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7 Stress Management None of the topics treated in this volume has received more attention than the management of stress. Its popularity is due at least in part to the more general environment in which we live, referred to by some as the Age of Anxiety. Its importance is due to observed effects on performance. The costs of stress have been widely documented in terms of losses in work time and efficiency. Clearly, techniques that effectively reduce stress are likely also to improve performance. One purpose of this chapter is to review programs and approaches to stress reduction. The review has been aided by a thorough survey of stress reduction programs in the military prepared for the committee by Raymond Novaco (Appendix B). The discussion of techniques is preceded by a more general treatment of the nature of stress. Drawing on a large literature, this section summarizes what we have come to understand as the stress response. Seymour Levine's background paper (Appendix B) provided the committee with a comprehensive review of literature in several disciplines on the relations among stress, arousal, and performance. Research on stress has resulted in a number of compelling insights. Most notable perhaps is the finding that different techniques for reducing stress are likely to succeed to the extent that they focus on the reduction of uncertainty about, and an increase in control over, important events in a person's environment. To the extent that any technique reduces stress, it will help a person think more clearly, increasing his or her chances of coping with challenging situations. However, the implications of these findings must be developed in the context of institutional constraints. Most efforts to reduce stress in nonmilitary settings are based ~5

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6 ENHANCING HUMAN PERFORMANCE on the presumption that it is functional to be relieved of stress. This may not be as clearly the case in the military. A soldier's stress may be seen as legitimate and even valuable. Reducing it to very low levels may reduce combat effectiveness. This suggests the larger issue of distinguish- ing between what one can do and what one ought to do, a dilemma that is discussed in the chapter. STRESS IN THE MILITARY That stress management should be of concern to the military is no surprise; in many ways the experiences of a soldier are a paradigm for what behavioral scientists know about stress in both human beings and animals. For a soldier, there is little control over and much uncertainty about events; life is sometimes threatened or, when not actually threat- ened, endangered in analogous ways; tolerance for error is minimal; and mistakes are generally followed by harsh reprimands and other punish- ments. Although stress is generally equated with fear or anxiety, it is useful to remember that other affects are probably part of the stress response in human beings, for example, anger, guilt, shame, and depression or sadness. Boredom might also be mentioned, in light of the fact that considerable amounts of military time, even during war, are spent idly. Our focus in this chapter is on the deleterious effects of stress. We are mindful of the need for soldiers at work to be motivated and aroused and of the need to introduce stressful conditions during training in order to acclimate the novice to the demands of a new life. Thus, basic training will necessarily have elements that mimic battle and other working military conditions. Soldiers have to get used to arduous, stressful situations. But stress has its costs. We discuss these costs as well as means that have been employed to assist people in coping with stress, even if some of the research and methods may not be readily implemented in military settings. It is generally believed by the military and rightly so-that the learning and performance capabilities of soldiers who are under stress are less than they could be if they were not under stress. Moreover, since Selye's (1936) classic work on stress and the more recent acceptance by both the psychological and medical communities of the role of stress in physical illness (e.g., Rahe and Lind, 1971), the military has good reason to be concerned about the losses in work time and efficiency of task performance that arise from ongoing stress, medical leaves, and sick call. A notable feature of the stressfulness of Army life is the so-called zero defect rule: a single mistake can have lasting negative consequences on a career, both for noncommissioned and for comissioned officers. The

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STRESS MANAGEMENT 117 anxiety that must be generated by this widely known management principle would seem neither to reduce stress nor to encourage the kind of independent problem solving and risk taking that are part of enhanced performance. Given this context, the Army is faced with a dilemma: the ultimate work of soldiers and officers is to inflict injury on the enemy or to be prepared to do so, as well as to ward off the enemy's efforts to do the same. The target situation, in other words, is an inherently stressful one. And to prepare young men and women for these unpleasant tasks, the Army intentionally creates conditions during training to get them used to noxious or at least noisome living and working conditions. The basic training that all members of the Army must experience, as well as the highly regimented and frequently uncomfortable living and working conditions, are often experienced as negative, if not actually stressful, by many soldiers. Recognizing, then, that the business of the armed forces is ultimately (if not always directly) to harm an enemy and that such preparation and readiness are not positive activities, how can one reasonably design interventions of a preventive, remedial, and quasi-therapeutic nature that stand some realistic chance of reducing stress reactions to a moderate level while allowing for effective and efficient learning and performance? We turn first to a consideration of the nature of stress, drawing on research on both animals and people. We then discuss stress management procedures in general, followed by stress management in military settings. We conclude with a note on ethical issues. THE NATURE OF STRESS Our focus is on stress as a psychobiological phenomenon that can and does impair performance, particularly in critical situations such as combat. In broad terms, some small degree of stress may well be a good thing. The time-honored inverted-U relation between arousal level and perform- ance indicates that some intermediate degree of arousal is optimal for performance, the degree dependent on the task and many other factors. Indeed, too little arousal (boredom) may well be an issue of concern for a peacetime army. Arousal and stress are to some degree related notions; arousal is a broad and ill-defined term, whereas stress at least has specific biological indicators (e.g., concentrations of cortisol in the blood, catecholamines; secretion of endorphins). In this chapter we use stress to refer to the right side of the inverted-U, that is, the degree of arousal that impairs performance. Using such a definition has made possible a much clearer characterization of the nature of stress. In the discussion that follows, . ..

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118 ENHANCING HUMAN PERFORMANCE selected examples are given; extensive documentation is provided in the papers prepared for the committee by Levine and Novaco (see Appendix B). Stress and anxiety are core concepts in the field of psychopathology and are implicated in the full range of disorders, from psychophysiological disorders such as essential hypertension and asthma, to the several anxiety disorders, to the affective disorders and schizophrenia. Indeed, a prevalent general model, or paradigm, is termed diathesis-stress; it assumes that most disorders arise from a complex interaction between environmental stressors and (usually) biological predispositions that make a given individual more prone to break down under a given stressor. There is a good deal of evidence that stress and physical illness are related, in both animals and human beings. Considerable correlational research has been and is being done on measuring stress in people (since one is constrained ethically from employing true experimental designs). One example is the Social Readjustment Rating Scale of Holmes and Rahe (19671. Subjects are given a list of life events (e.g., death of spouse, being fired from a job, changes in responsibilities at work, vacation, Christmas) and are asked to indicate those that have occurred recently. High scores have been related to heart attacks (Rahe and Lind, 1971), onset of leukemia (Word, 1968), and colds and fevers (Holmes and Holmes, 19701. With due caution given to the correlational nature of the findings-being sick could lead to dismissal from a job, for example the relations are striking enough to encourage similar research, some with improved instruments. Indeed, a succession of small stressors can also lead to disruption and breakdown. How might stress of a psychological nature negatively affect the physical (in addition to the psychological) health of a person? The immune system has been implicated; Jammot et al. (1983) have shown lower levels of immunoglobin (la A) in people after great stress than under little stress. Since lower levels of lg A are associated with certain infections, an explanatory link may emerge. A moderating factor that is being researched is hardiness, a constellation of behaviors and attitudes that Kobasa, Maddi, and Kahn (1982) find to be associated with resistance to the deleterious effects of stress. People high in commitment (rather than being alienated), control (rather than feeling helpless), and challenge (rather than viewing challenges as a threat) get sick less often. Hardiness may thus moderate the relation between stress and illness. There is a growing consensus in the vast animal and human research literatures. Earlier, in the classic studies of Selye (1936), stress was seen primarily as physical trauma tissue damage, blood loss, shock, exposure to cold. Selye identified major categories of response to stress: activation

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STRESS MANAGEMENT 119 of the autonomic nervous system and pituitary-adrenal axis, impairment of the immune system, gastrointestinal disturbances, and impairment of behavioral performance (Levine; Novaco). All these aspects (and more) of the stress response have been studied at length in the animal and human literature, with an initial focus on the adrenal gland and behavior; the immune system has only recently become a focus, engendering the new field of psychoneuroimmunology (Levine paper). It is now clear that stress cannot be identified simply with physical trauma: stress is in the eye of the beholder. The extent to which situations are stressful is determined by appraisal-how the individual understands, interprets, sees, and feels about a situation (Lazarus, 1966; Baum, Singer, and Baum, 19811. It is fundamentally a cognitive phenomenon, depending more on how the individual construes the situation than on the nature of the situation itself. The key aspects are uncertainty and control the less knowledge the individual has about a potentially harmful situation, the less control he or she feels can be exerted, and the more stressful the situation is. Conversely, the more understanding and certainty the individual has about a situation, the more he or she feels in control, and the less stressful it becomes. Another way to put this is that stress arises ". . . in the face of demands that tax or exceed the resources of the system or ... demands to which there are no readily available or automatic adaptive responses" (Lazarus and Cohen, 1977:1091. We and other mammals appear to be driven by nature toward certainty. This may in fact be the basis for the existence of various belief systems A person firmly committed to such a belief system does in fact "under- stand" the world and the nature of the controls that operate, even though this understanding may be fallacious. The anthropologist Malinowski (1948) made a similar point years ago in his classic book on magic, science, and religion. There are many examples from both the human and the animal literatures. The first time a person donates blood, for example, the concentration of cortisol in the blood (a measure of the adrenocortical response to stress) skyrockets. The second time, there may be no elevation, yet the physical trauma is the same (blood loss hemorrhag- ing is a traditional physical stressor) (Levine). In an early study of the Harvard boat race (Renold et al., 1951), a decline in eosinophil count was marked in the crew four hours after the race. This decline could have been due entirely to the physical stress of the race, but the coxswains and coaches had similar eosinophil drops, even though their stress was purely psychological. A classic study was conducted on human beings in parachute training (Ursin, Baade, and Levine, 19781. In that study, the hormonal and behavioral responses of a group of Norwegian paratroop trainees were

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120 ENHANCING [I UMAN PERFORMA NCE examined after repeated jumps off a 10-meter tower on a guide wire. After the first jump there was a dramatic elevation of cortisol in the blood, but as soon as the second jump there was a significant drop to basal levels; basal levels persisted on subsequent jumps. It is also important to note that the fear ratings changed dramatically following the first and second jumps: there was very little fear expressed after the second jump, even though there had been a very high rating of fear prior to the first jump. To take a simple example from the animal literature (Dess et al., 1983), dogs were subjected to a series of electric shocks that were either unpredictable or predictable. The predictable condition involved pre- senting the animal with a tone prior to the onset of shock. In the unpredictable condition, no such tone was presented. The adrenocortical response observed on subsequent testing of these animals clearly indicated the importance of reducing uncertainty by predictability. Animals that did not have the signal preceding the shock showed an adrenocortical response that was two to three times that observed in animals with previous predictable shock experiences. It should be noted that the procedures used in this experiment are typical of those used in experiments examining learned helplessness (Seligman, 1975~. Learned helplessness refers to the protracted effects of prolonged exposure to unpredictable and uncontrollable stimuli of an aversive nature. It has been observed that organisms exposed to this type of experimental regimen show long-term deficits in their ability to perform appropriately under subsequent testing conditions. Furthermore, these animals show a much greater increase in adrenocortical activity when exposed to novel stimuli (Levine et al., 1973) than do control animals. Thus, an organism exposed to an uncontrollable and unpredict- able set of aversive stimuli shows not only a dramatic increase in adrenocortical activity while exposed to these conditions but also long- term deficits in other, unrelated test conditions. The key element in these examples and in virtually all recent work on stress is uncertainty (Mason, 1968; Levine). This applies also to positive or rewarding events. In animal studies, frustration, with the attendant elevation of serum corticosterone (an animal hormone comparable to human cortisol), can be induced by changing the conditions of reward so that previously learned expectancies no longer hold. The key is that the uncertainty exists in the organism. Situations are stressful if the organism views them as being unpredictable and uncon: trollable. Studies of troops in Vietnam seem consistent with this view (Bourne, 1970, 1971; Levine). Members of an experienced combat unit of Special Forces enlisted personnel, upon being informed of an impending attack, were enthusiastic and spent much time in task-oriented activities

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STRESS MANAGEMENT 121 such as fortifying defenses. The concentration of a cortisol metabolite, 17 OHCS, in their urine did not rise on the day of the expected attack. Although they could not directly control the behavior of the enemy, they felt in control of the situation. Their young captain, by contrast, was in a state of uncertainty about whether the orders he would receive would be considered inappropriate by his experienced soldiers. Concentrations of 17 OHCS in his urine were markedly higher on the day of the expected attack. This research on stress implies that successful strategies for coping involve increased predictability, understanding, knowledge, and a sense of control. It may even be helpful sometimes to simply be able to do something, even if that something does not really control the situation. Rats allowed to fight after receiving strong, unpredictable shock showed far less elevation of serum corticosterone than rats given the same shocks but not allowed to fight (Levine). STRESS REDUCTION: GENERAL APPROACHES AND CONSIDERATIONS A useful way to organize our discussion of stress management is to distinguish between techniques that focus on intrapsychic and individual change versus those that aim to change the environment. For example, if a person feels too warm, he or she can either attempt to cool off (by drinking cool liquids, removing clothing, and so on) or attempt to alter the environment (turning on the air conditioner, and so on). Since environmental change is often very difficult to achieve, behavioral scientists have devoted most of their energies to devising procedures for reducing individuals' stress reactions to negative events. TNDIVIDUAL AND INTRAPSYCHIC APPROACHES Intrapsychic approaches can be discussed under the following rubrics: arousal reduction, cognitive restructuring and problem solving, and behavioral skills training. Arousal Reduction Relaxation Training. Given the fact that stress reactions are frequently marked by elevations in such physiological indexes as heart rate, muscle tension, and blood pressure, training in relaxation has prima facie relevance. There is in fact an extensive literature on teaching people to quiet themselves when physiologically aroused. These techniques have

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122 ENHANCING HUMAN PERFORA'IANCE in common a reduction in external stimulation, a focus on internal stimuli (such as the state of one's muscles or a mental image), slowed and regular breathing, and a letting go of one's muscles. In general, the instructor speaks in a reassuring, soothing, sometimes soporific voice. Best known are the procedures of and variations on the work of Edmund Jacobson (1938), a physician who believed that emotional states could not exist in the absence of muscle tension. For years he conducted workshops for teaching health professionals his very detailed, painstaking techniques for relaxing the striate musculature. Abbreviations of Jacobson's proce- dures were developed by Joseph Wolpe in the 1950s (Wolpe, 1958) as part of his systematic desensitization, fear-reduction technique; they were modified still further by Lazarus (Wolpe and Lazarus, 1966) and Paul (19661. Some persons have gone even further by putting the instructions on audiotapes for practice at home (Goldfried and Davison, 1976~. Independently developed was autogenic training (Schultz and Luthe, 1969), procedures that rely on passive concentration and suggestions of looseness and warmth in the muscles. These approaches are in many ways similar to Eastern practices of meditation. Of considerable interest in the 1970s was the work of Benson (1975), a Harvard professor of medicine who developed what he called `'the relaxation response," which was really a westernized version of transcendental meditation. Biofeedback. It is important to distinguish between feedback in general (knowledge about outcomes) and biofeedback as a specific technology. The former is an integral part of the general proposition that increased understanding, including feedback about a situation (i.e., reduced uncer- tainty) reduces stress. Classic animal studies illustrate this point (Weiss, 1971a, 1971b, 1971c). Rats given inescapable and unpredictable shocks followed immediately by a sound developed fewer stomach ulcers than animals not given the sound but treated identically otherwise. Levine interprets the Norwegian paratrooper study in part in this context: "Although the situation (second 10-meterjump) was potentially dangerous and threatening, the trainees had gone through the experience and suffered no bad consequences. Thus, a maximum amount of feedback about the absence of danger in a potentially threatening situation became quickly obvious" (Levine paper: 19-201. Although we discussed biofeedback in Chapter 5 in terms of motor skills, here we discuss it as a technique that has been applied to stress reduction. While the most common paradigm uses EMG recordings, EEG recordings are also used to determine the percentage of time EEG alpha occurred, providing subjects with visual or auditory cues (see Chapter 5 for definitions). The subjects goal is to reduce EMG or increase the

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STRESS MANAGEMENT 123 proportion of EEG alpha waves. This literature has been reviewed in several volumes (Beatty and Legewie, 1977; Schwartz and Beatty, 1977) and more recently by Lawrence (19841. The work raises several issues relating to the ubiquitous questions of reliability and validity: Are subjects able to decrease the amplitude of recorded EMG (or increase EEG alpha)? 2. If so, does this mean they are learning to become more relaxed? 3. If so, does this have any significant effect on stress reduction and on performance? The answer to question 1 is mixed; some studies report significant change in the actual physiological measure used (EMG reduction, in- creased percentage EEG alpha), others do not. Similarly, the answer to question 2 is mixed. EMG is often recorded from the frontalis muscle, but EMG reduction in this muscle does not always correlate with EMG changes in other muscles (Arnarson and Sheffield, 1980; Suarez, Kohlen- berg, and Pagano, 1979~. Perhaps most critical, the answer to question 3 is generally no. There is no evidence to indicate that biofeedback training- induced reduction of EMG activity or increased percentage of EEG alpha has any effect on stress or on performance under conditions of stress (Lawrence, 1984~. The strongest conclusion that can be drawn in a positive vein is that some studies do report decreased EMG activity in the muscle or muscles being recorded from as a result of biofeedback training, so under some conditions biofeedback training may be a useful adjunct to relaxation training. To the extent that learning to relax can in fact enhance performance under stress, then biofeedback training may be of some limited use; but given the time and instrumentation required, and its relatively low reliability and validity, biofeedback would seem far less useful than the more general cognitive approaches to stress manage- ment, to which we now turn. Cognitive Restructuring We all accept that the way we look at things, including ourselves, matters. If one mistakes a person standing some distance away for a long-lost friend, ones emotions and behavior will be different than they would have been had that person not reminded one of a friend. Beyond such commonplace understanding is the assumption of Ellis (1962) and Beck (1976) that severe emotional and behavioral disorders can be favorably affected by altering a person's perception or conception of the situation. Great faith is placed, then, on intellectual capacities to influence one's affect and actions. (Not all clinicians have such faith in our intellectual capacities. Clinicians as different from one another as Freud

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/24 ENHANCING HUMAN PERFORMANCE and Wolpe, for example, place little reliance on the power of the conscious mind to change the way one feels and behaves when in bad psychological shape.) Ellis's '`rational emotive therapy" (RET) holds that people are unhappy and worse because they "catastrophize" about what is merely annoying or inconvenient, blow it out of proportion, and respond to their exagger- ated conception of the situation (Ellis, 19621. Thus, to fail an examination is, in Ellis's words, "a pain in the ass," but it does not have to be construed as a catastrophe, for it is irrational to demand that one succeed in everything one attempts or that one never incur the disapproval of others. There is a growing body of reasonably controlled research confirming the usefulness of this general therapeutic approach in alle- viating a wide range of anxiety-based disorders (see Haaga and Davison, in press). Beck's "cognitive therapy" (1976) focuses more on the data of expe- rience and one's inferences therefrom. Thus, for example, I conclude that, because Dorothy has rejected me, no one likes me. Beck involves the patient in a collaborative empirical testing of the generalization that no one likes me based solely on the experience of one rejection. Beck has worked primarily with depressives, although in recent years his efforts have been directed toward the anxiety disorders as well (Beck and Emery, 19851. There is considerable and very strong evidence that Beck's general approach (which is considerably more complicated than just summarized) is effective with even severe and long-standing depres- sion (e.g., Rush et al., 1977; Blackburn et al., 19811. A third approach is exemplified by the early work of Meichenbaum (1977), who advocated an emphasis on self-instructions to guide overt behavior. Meichenbaum and his co-workers have been successful in helping impulsive children control their behavior and thereby improve their problem-solving abilities and in helping college students who are anxious about taking tests improve their performance by talking them- selves through their activities (e.g., "OK, take it slow. Let's see, what's the formula for figuring time and distance in travel? I won't worry if I don't get it right the first timed. A fourth cognitive approach is social problem solving, a way to approach the inevitable difficulties in life and overcome them. The core of this approach, as presented by D'Zurilla and Goldfried (1971), is the concep- tualization of human distress as problems to be solved. Several stages are posited, consisting of (1) a general orientation or set (that, indeed, my distress arises from specific, solvable conundrums); (2) problem definition (translation of what may appear to be a hopeless mess into a problem that is conceivably amenable to a solution); (3) generation of alternatives (sometimes referred to as brainstorming, the free and easy

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STRESS MANAGEMENT 125 production of possible solutions but without evaluation just yet as to their utility or practicality); (4) decision making (deciding on a solution to explore first); and (5) verification (attempting the solution or at least developing it abstractly to check out whether the benefits and costs are what one finds acceptable at a given time and in a given place). Evidence is beginning to accumulate confirming the usefulness of this approach. For example, depressed older adults in a nursing home were relieved of much of their depression after they were trained in this fashion (Hussian and Lawrence, 1980), and other adult problems can be amelio- rated with such an approach (D'Zurilla and Nezu, 19821. Though not formally recognized as a cognitive change method, the simple provision of information is a rational way to reduce uncertainty and increase a person's sense of control over an upcoming challenge. Early work was conducted by Janis (1951), who found a beneficial effect on the emotional impact of an impending stressor (air attacks) when information about it was provided in advance. This work had previously been reported in the American Soldier project (Stouffer, 19491. Similar results come from work with surgery patients (Janis, 1971~. A risk to be considered and avoided in this approach is the possibility of overloading a person on the aversiveness of an upcoming situation, lest he or she become traumatized by the information. By the same token, however, if advance information on a stressor is going to be traumatic, chances are the actual stressor will be also. This provision of realistic information was subsequently incorporated into a "stress inoculation training" pack- age (Meichenbaum and Cameron, 1983) and is described below in connection with the Novaco-Sarason project with Marine drill instructors. The implication of this approach for the military is that individuals should be given maximum knowledge and understanding of potentially harmful situations and as much control over them as possible. This conclusion seems just the opposite of the accepted military philosophy of giving the individual the least amount of information necessary for a given task or situation. In a combat situation it would seem that each soldier should be given as much information as possible about his situation and that of the enemy to help him manage stress levels and maintain arousal at a useful motivational level. Behavioral Skills Training Chapter 5 of this report discusses the learning of motor skills. It is important to allude to this in the context of stress, because people's stress levels will be high if they correctly perceive themselves to be deficient in the behavioral skills necessary to accomplish a task. To find it stressful, for example, to be in the driver's seat of a Bradley tank is

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26 ENHANCING HUMAN PERFORMANCE not unreasonable and is, one hopes, impossible to become acclimated to unless one has the skills to operate it safely and effectively. In our focus in most of this chapter on the reduction of arousal and the acquisition of adaptive cognitive strategies, one should not lose sight of the importance of having in one's behavioral repertoire the skills it takes to do the job. One example of a useful behavioral skill commonly employed in the corporate sphere is time management. Especially for high achievers, learning to avoid excessive obligations can be difficult. Lakein (1973) outlines a systematic approach to time management that entails a goals statement, a priority list of tasks, and a schedule. He distinguishes between tasks that require concentration and tasks that involve dealing with people and suggests that, for the former, one needs "internal prime time'' and for the latter "external prime time." Interruptions should be avoided during internal prime time so that the mind can concentrate on a particular task that does not require the involvement of other people. Anyone who has worked as a secretary or who has one working for him or her can appreciate the stress created by the need to monitor the phone and greet visitors to the office while having as an important task the typing of a complex manuscript. The secretarial example brings us to the next major section, environ- mental change as an approach to stress reduction, for what comes to mind is the difficulty a secretary usually has in shutting out external distractions in order to create internal prime time for working on the manuscript. The work environment itself may proscribe or at least make extraordinarily difficult the structuring of the context that would be most conducive to the reduction of stress and thereby the enhancement of performance. In psychology, the focus on environmental change for the betterment of the human condition is generally the bailiwick of community psychologists, who, it has been pointed out (Davison and Neale, 1986), are inherently political and therefore sometimes revolutionary in their perspective. What follows is doubtless problematic in as complex and tradition-rich an environment as the military, but it is important to present the issues at least briefly. STRATEGIES FOR CHANGING THE ENVIRONMENT Earlier we mentioned that for a person who is uncomfortably warm the options include environmental change, such as leaving the hot area for a cooler one or cooling the hot area with air conditioning. The discussion of the nature of stress at the beginning of this chapter suggests that greater levels of certainty (or predictability and of control reduce stress on both the psychological and physiological levels in human beings and animals. While reduction of uncertainty and increase in control can

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STRESS MANAGEMENT 127 be achieved by working intrapsychically, a community psychology or environmental orientation would look to contextual change as a powerful avenue to stress management. Some examples of behavioral research already exist or are under way in the armed forces, and we discuss them below in connection with the Novaco-Sarason work with drill instructors in Marine boot camp. Such research, aimed at teaching anger control and other strategies to drill instructors, is intrapsychic in nature vis a vis the drill instructors being trained, but it is effectively environmental change as far as the "grunts', are concerned, for as a result they are confronted with a training environment that is likely to be different from the typically more aggressive atmosphere prevalent in Marine boot camps. Desired changes produced in an individual are successful insofar as they enhance his or her skill in dealing with environmental demands. If stress is reduced by the acquisition of a relaxation skill or of a less catastrophic way to construe one's behaviors, then one's interaction with the environment is likely to change in a positive way. A soldier who is less anxious can concentrate better on M-1 training exercises. A drill instructor who is not depressed can meet his leadership obligations better and continue career-long learning. These overt behaviors, whether already in the person's repertoire or yet to be acquired, will have a favorable impact on the environment. In a constantly reciprocal fashion, the improved environment will present a picture to the person that is different from that which would have been presented had he or she continued to be stressed and less functional. Success builds on success; evaluating one's efforts and building a sense of self-efficacy (Bandura, 1977) em- boldens one to forge ahead, doing so with less and less stress, even though the tasks undertaken are likely to be increasingly complex and challenging. Though the foregoing approaches have attracted a great deal of research attention, there is a paucity of published research on stress management in military settings; the few examples are discussed in the next section. This is not to say that military people have not from time to time attempted to relax soldiers, encourage positive outlooks, or suggest problem solv- in~-rather that systematic inquiry, which would be persuasive to most ~ . social scientists, is lacking. STRESS REDUCTION IN MILITARY SETTINGS There are basically two points at which one can intervene in matters of stress: before (much) damage has been done and afterward. We are concerned in this chapter primarily with the former, but any discussion

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28 ENHANCING HUMAN PERFORMANCE of stress in military settings must also include the nature and treatment of posttraumatic stress disorder. POSTTRAUMATIC STRESS DISORDER* Symptoms and Diagnosis In posttraumatic stress disorder (PTSD) a traumatic event or catastrophe of the worst order, such as rape, combat, or a natural disaster, brings in its aftermath difficulties with concentration and memory, an inability to relax, impulsiveness, a tendency to be easily startled, disturbed sleep, anxiety, depression, and above all a psychic numbing. Activities previously enjoyed lose their appeal. There is a feeling of estrangement from others and from "the passing parade" and, if the trauma was shared and took the lives of companions, a deadening sense of guilt for having survived. As for the experience itself, the person has great difficulty keeping it out of mind. Flash- backs vivid and intrusive recollections of the painful event and recurring nightmares and dreams of it are common. Posttraumatic ~ , ~ ~ ~ t ~ . ~ _ 1 - _ _ _1 . _ 1 stress disorder may be acute, chronic, or delayed. It Is believed to be more severe and longer-lasting after a trauma caused by human beings, as in war, physical assaults, or torture, than after a catas- trophe of nature, such as a flood or an earthquake. Symptoms often worsen when the individual is exposed to situations that resemble the original trauma: a thunderstorm may remind a soldier of the firings and rumbles of battle. People diagnosed as having posttraumatic stress disorder, although surely different from one another in countless ways before trauma, do have in common in their lives a major, salient, and powerful happening in the words of the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (1980:236), "a psychologically traumatic event that is generally outside the range of usual human experience." The manual goes on to state, as .. ____O_ the literature on trauma has for years, that "the stressor producing this syndrome would evoke significant symptoms of distress in most people" (p. 2361. Current thinking is that PTSD symptoms can also arise from a series of subtraumatic events. Although clinicians had written about a disorder that they called traumatic neurosis, the previous edition of the manual lacked a specific category for stress disorders of some duration. That posttraumatic stress disorder is *Most of the discussion of PTSD is taken from Davison and Neale (1986:13~143).

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STRESS MANAGEMENT 129 listed in the third edition represents no small change in overall point of view, for it constitutes a formal recognition that, regardless of premorbid history, many people may be adversely affected by overwhelming catastrophic stress and that their reaction should be distinguished from other disorders. The newly listed disorder can be seen, then, as shifting the "blame" for the problem from the survivor to the event. Instead of implicitly concluding that a person would be all right were he or she made of sterner stuff, the third edition of the manual acknowledges the onerousness of the traumatizing circumstances (Haley, 19781. Treatment of PTSD There is very little controlled research on the treatment of PTSD in the military, although there are many case reports of therapeutic interventions with personnel suffering from the disorder (formerly called shell shock or battle fatigue). The classic book by Grinker and Spiegel (1945) described the treatment of PTSD in World War II personnel, and this and related work have more recently been discussed by Lifton ( 19761. In general, the treatment of combat- related stress is guided by three principles: immediacy, proximity, and expectancy. Treat the soldier as soon as possible when signs of breakdown (e.g., sleeplessness and great anxiety) are detected; do so as close to the battle situation as possible; and do so while conveying the expectation that he will soon return to his unit. Treatment has generally involved a review with the affected person of the traumatizing situation. The assumption has been that the person needs to face up to the frightening situation and work through his anxiety about it. Sometimes hypnosis or drugs are used to facilitate the emotional recall. The aftermath of the Vietnam War has been different from the periods following the two world wars and the Korean War, primarily because of society's rejection of Vietnam veterans for some years after their discharge from the military. It was not until 1982 that the now highly regarded and much-visited Vietnam War Memorial was established and both official and nonofficial welcomes were accorded the veterans of this conflict. It took several years for the Veterans Administration (VA) to gear itself up for the postwar trauma problems of many of the Vietnam veterans: Indeed, prior to large-scale governmental efforts in the late 1970s to bring more Vietnam veterans into the VA system, veterans them- selves, with the assistance of Robert Jay Lifton, an academic psychi- atrist at Yale, established self-help ''rap groups'' that had a twofold

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130 ENHANCING HUMAN PERFORMANCE purpose: a therapeutic one of healing, by talking through their concerns with strong mutual group support; and a political one of forcing the American public to understand the human costs of this exceedingly unpopular war. The focus of the rap groups has been the residual guilt and rage felt by the veterans: guilt over what their status as soldiers required them to do in fighting a guerilla war in which enemy and ally were often impossible to distinguish; and rage at being forced to risk their lives in a cause to which their country was not fully committed. Group discussions have also encouraged traumatized veterans to confront in vivid recollections their negative wartime experiences. Whether the treatment be psychoanalytic, behavioral, or human- istic-existential, exposure to the trauma is deemed to be the most powerful curative factor, bringing to mind an ancient Chinese proverb, '~Go straight to the heart of danger, for there you will find safety." PREVENTIVE PROGRAMS Dealing responsibly with PTSD is generally regarded as therapy, even when conducted by the participants themselves, and it is remedial in nature; that is, it attempts to fix something that has been broken. The Army is concerned, however, with preventing breakdown and reducing stress in soldiers at large so that they can learn and perform at optimal levels. Especially in peacetime, the challenge with regard to stress is not to heal the scarred veteran, but to maintain the soldier's arousal level at the middle of the inverted-U function, where it is known that the best learning and performance take place. The earliest and perhaps most crucial period for the soldier is basic training, or boot camp, that unique period of four to ten weeks when a young civilian is turned into a military person through a carefully planned and closely supervised regimen of highly demanding physical and psy- chological challenges. Beds are to be made only one way, answers to questions delivered in just a certain way, posture maintained in a certain way, and many complex skills acquired, from shooting a ride to pitching a tent. It is appropriate, then, that the few stress management programs whose procedures and results have been published concern primarily this first stage of a military person's development, when important learning must take place. Studies by Beach, Prince, and Klugman (1977) at Fort Dix, by Datel and Lifrak (1969) at Fort Ord, and by Homer, Meglino, and Mobley (1979) are difficult to interpret because of sampling and other methodo- logical problems, but they do have in common attempts to provide

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STRESS MANAGEMENT 131 realistic information to recruits of what lies in store for them. A more recent study by Novaco, Cook, and Sarason (1983) with Marine recruits in San Diego is more comprehensive than the earlier work. It entailed a 35-minute videotape called "Making It," which depicted skills necessary for coping with the rigors of boot camp. The tape contained positive expectancies of success while at the same time informing recruits of the difficulties of the training and their likely distress, worry, and confusion. Details of the ingredients of successful performance were also provided. Results suggested that recruits viewing this film manifested higher ex- pectations of personal control and efficacy than did recruits seeing a control film. It is worth commenting that this tape may have reduced uncertainty and enhanced a sense of personal control by providing factual information while at the same time explicitly telling recruits what it takes to make it. The extreme physical stressor that is boot camp, therefore, came to be viewed and reacted to as less of a stressor, consistent with our earlier observations about the cognitive core of stress. A study being done by Novaco and Sarason at both Parris Island and San Diego endeavors to impart to drill instructors coping information and encouragement regarding anger control, evaluation anxiety, the virtues of patience, and the utility of supportive social relationships. Model coping strategies are presented in conjunction with typical problem situations. It is hoped that the findings will provide clues to how stress can be reduced in drill instructors and how their performance can be enhanced, as indexed by, among other things, lower recruit attrition. CONCLUSION AND AN ETHICAL NOTE We can relate all these stress management procedures to each other and to our earlier discussion of the nature of stress by focusing on the reduction of uncertainty and the increase in control that would seem to follow from any of them. The amelioration of stress by any means is going to help people think more clearly and thereby increase the chances that they can cope with a challenging situation. Stress reduction will also improve learning capacities and thereby add to their ability to acquire new adaptive skills (which, in turn, will increase control and lessen uncertainty about a situation). Since the abuses of the Nazi doctors in World War II and the establishment of human subjects committees in research settings in the United States, scientists have become more sensitive to the moral dimensions of their work. When it comes to matters of stress in an organization whose mission is inextricably bound up with destruction, it is only at our risk that we ignore the ethics of stress reduction. A clinician

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132 ENHANCING HUMAN PERFORMANCE consents to help a patient reduce stress caused by a set of circumstances only if that stress is jointly agreed to be inappropriate. In other words, one has to believe that it is morally right not to be stressed (so much) by those circumstances. At what point should one view a soldier's stress reaction as legitimate and even valuable? Should we be concerned with the long-term effects of any interventions that permit us to teach more efficiently and more effectively the various arts of war? What role should civilian oversight play, if any at all, in the determination by the military of what the goals of training should be? These and related questions should be raised in any effort to change people's behavior. We do not mean to single out the military for exclusive attention and implied criticism. At the same time, however, the moral dimensions of stress reduction should be mentioned in order to sensitize social scientists, policymakers, and the military to the distinction between what one can do and what one ought to do.