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OCR for page 115
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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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.
Representative terms from entire chapter:
stress reduction
