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Stress Reduction ~9 testing (Novaco, Sarason, Cook, Robinson, ~ Cunningham, 1979; Sarason, Novaco, Robinson, & Cook, 1981). These studies pointed to the social environment established by drill instructor teams as a key factor determining attrition, adjustment, and performance. STRESS REDUCTION Both individuals and organizations act become victims of it. as architects of stress as well as The objective, traditions, and policies of organizations shape the work social environment, affecting the demands and contingencies that impinge on its members. Correspondingly, the goals, habits, and expectancies of individuals create recurrent behavioral contexts and activate events that cause stressful dimensions. Because of these proactive and transactional aspects of person-environment relationships, strategies of stress reduction should not be preoccupied with after-the-fact intervention. While empirical research on this point is grossly lacking, stress reduction theoretically and pragmatically can be achieved by optimizing environments and behavior patterns. Comprehensively, stress reduction entails remediation procedures, regulatory techniques, and preventive strategies. Remediation Procedures are interventions implemented to curtail and treat stress reactions. Various psychological and medical procedures are available for such therapeutic action. Regulatory techniques are psychological coping tactics utilized to counteract precursors or elements of stress reactions, particularly with regard to tension, emotion, and cognition predisposed to stress. Behavior patterns linked with recurrent stress episodes might also be modified in a self-regulatory effort. Preventive strategies involve proactive personal and oganizational action design Lo reduce exposure to stressors, to develop skills
Strew Reduction ~0 for dealing with environmental demands, social resources that promote well-being. and to augment environmental and The following section will expand upon these stress reduction methods, using less abstract categories. The various procedures, techniques, and strategies can be alternatively grouped in terms of (a) arousal reduction, (b) cognitive restructuring, (c) problem-solving skills, (d) behavioral coping skills, and (e) environmental modification. In addition, a model known as stress inoculation represents an attractive aggregate of available methods and can usefully be applied to military populations. Arousal Reduction Since physiological activation constitutes a core component of stress reactions, procedures designed to reduce arousal are commonly part of stress management programs. Both mental as well as physical relaxation are emphasized. As Davison (1967; 1969) observed, relaxation procedures teach cognitive as well as somatic lessons, teaching that tension can be controlled and regulated. Jacobson's (1938) progressive relaxation procedure of systematically tensing and then relaxing sequential sets of skeletal muscles was the first structured approach in the medical/psychological literature, although it is widely recognized that ancient Eastern religions predated the more contemporary clinical approaches. While practices such as yoga and Tai Chi perpetuated the philosophical and spiritual elements of Taoism and Buddhism among secular populations, it was not until the emergence of Transcendental Meditation cults in the 1960s and 70s with Hindu origins that Eastern ideas about relaxation gained considerable popularity. Highly significant degrees of arousal reduction across many physiological channels were found to be associated with TM practice (Wallace, 1970). In a study of corporate
Stress Reduction _1 businessmen, Frew (1974) fount higher levels of job satisfaction, productivity, and work relationships among those who meditated on a regular basis. Benson's (1975) study of meditation, however, led to a demystified view of the process, and he devised a simplifies set of instructions to elicit what he termed, "the relaxation response." Basically, in the Benson technique, the person sits comfortably in a quiet place, closes his eyes, focuses on breathing, and repeats the word "one" silently to himself. This is practiced for ten to twenty minutes, once or twice daily. Peters, Benson, and Peters (1977) reported that significant decreases in blood pressure were found under experimental conditions to be associated with tally relaxation practice in a corporate environment. Another relaxation induction procedure is autogenic training, developed by Schultz and Luthe. Autogenic training was conceived by Schultz, a German psychiatrist, as a form of self-hypnosis that could be used to create mental resolve for behavior change, as well as to modify physiological conditions in specific organ areas. The techniques.emphasizes smooth, rhythmic breathing, self instructions of calmness, and the use of suggestions of "heaviness" and "warmth' for body regions' especially limbs. There are a few reports of the use of arousal reduction procedures with military persons. Herrell (1971) successfully used systematic desensitization in treating a 19 year old private who became uncontrollably angry whenever he was given orders. This was a lifelong problem, often accompanied by acts of aggression. He had received four nonjudicial punishments prior to the start of treatment and one other early in the treatment period (for kicking his sergeant during a game of pool). After eight weeks of therapy (18 sessions)' the client's self-reported improvement was verified by his commenting
Stress Reduction 42 officer. Another arousal reduction intervention was that of Brooks and Scarano (1985) who used an experimental design to study transcendental meditation as a treatment for Vietnam veterans with PTSD. They randomly assigned 18 male veterans to either a TM or a psychotherapy condition for a three month treatment period. The TM group, compared to the psychotherapy group, was significantly more improved on degree of PTSD, emotional numbness, anxiety, depression, alcohol consumption, insomnia, and family problems. There was also a trend toward improvement on physiological arousal to noise (called a stressful stimulus by the authors, that a bit doubtful). Those in the IM group they no longer felt the intensity of tension, had practiced their mediation twice daily for weekly follow-up meetings with the instructor. While arousal reduction procedure are for treating stress disorders. it should but the 85 decibel level makes reported that after meditation rage, and guilt inside. They 20 minute periods and also had the intuitively sensible approach be added that counter-intuitive methods have also been used. Fairbank and Keane (1982) sequentially treated Two Vietnam veterans having PTSD by using imaginal flooding. In the first case the flooding decreased SUDS ratings and flashbacks. For the second case, physiological recordings were also made for skin conductance ant heart rate. Again SUDS ratings and flashbacks were decreased considerably, and the physiological measures for the anxiety scenes decreased to non-anxiety baseline levels or lower. Cognitive Interventions Various procedures are being extensively used in clinical work to modify cognitive dimensions of stress disorders. Changing belief systems, modifying perceptions, altering attentional focus, eliminating intrusive thoughts, and adjusting expectations are among the tactics utilized to help clients
Stress Reduction restructure how they view the world and themselves. The treatment efficacy of such procedures has been extensively documented in edited volumes by Kendall and Hollon (1979) and Kendall (1982). The problems of impulsive children, delinquents, anxiety disorders, depression, assertivenss, pain, eating disorders, anger, alcoholism, and smoking have each had multiple treatment studies produce successful results with cognitively based behavioral programs. Cognitive-behavioral interventionists have built upon the work of Meichenbaum (1977), Beck (1976), and Ellis (1962), their precursor. The field has reached a point of maturity, becoming a major form of psychotherapy that has been extended to many field settings. An important element of cognitive-behavioral interventions is problem- solving. D'Zurilla and Goldfried (1971) outlined five stages of problem- solving as (1) general orientation or "set," (2) problem definition, (3) generation of alternatives, (4) decision making, and (5) verification. The components of alternative thinking and the means-end aspects of decision making have been developed by Platt and Spivak (1975). A variety of problem- solving approaches have been successfully utilized with delinquents (Little & Kendall, 1979), and social problem-solving treatments have produced effective outcomes with a wide range of adult clinical problems (D'Zurilla & Nezu, 1982), although there are difficulties with control groups and outcome measures. With regard to stress, the process of coping effectively involves the ability to ascertain the nature of problems, think of alternative solutions, identify steps to solution, anticipate obstacles, and utilize feedback from coping efforts. However, as Lazarus and Folkman (1984) point out, this suggests a mastery model, and not all sources of stress are amenable to mastery. Natural disasters, aging, disease, and the death of loved ones are
Stress Reduction examples of such conditions. The concept of coping, however, acknowledges that there may well be constraints on possible outcomes and the availability of means. Effective coping entails the ability to gather information, analyze the problem situation, weigh alternatives, and then select and implement an action plan. The armed forces have incorporated such ideas in their officer training programs by the use of problem situations presented to candidates as "What Now, Lieutenant?" scenarios. One promising cognitive technique that is getting extensive use in the area of sports psychology is vi-quo-motor behavioral rehearsal (VEER). Suinn (1972) developed this technique as a way of removing emotional obstacles to performance and has used the procedure with Olympic skiers with favorable results. The technique involves relaxation, visualization of performance, and performance in a simulated stressful situation. Other investigators (Noel, 1980; Weinberg, Seabourne, ~ Jackson, 1981) have experimentally evaluated this technique with tennis players and karate competitors in tournament situations. Although results across dependent measures are not always significant, there is some evidence for performance enhancement. Studies of basketball players by Hall and Erffmeyer (1983) and DeWitt (1980) also showed positive effects. In the use of this procedure, it is important that the person have an accurate mental image of optimum performance and be able to visualize the details of the behavioral sequence. Behavioral Coping Skills The transactional qualities of stress first emphasized by Lazarus (1966) and intrinsic to the present view of stress reduction is the importance of behavioral competencies in coping. Pearlin and Schooler (1978) presented a view of coping that directed attention away from exceptional people dealing with unusual problems in rare situations and toward "persistent hardships
Stress Reduction :: experienced by those engaged in mainstream activities within major institutions" (p. 3). They distinguished three major types of coping responses: (1) responses that modify the situation, (2) responses that control the meaning of the problem, and (3) response that manage existing stress. Their second category is clearly a cognitive appraisal function. They sought to distinguish coping from personal characteristics (what one does, as opposed to who one is). In an analysis of coping data from home versus occupational domains, they concluded that coping (what one does) has more of an impact in the context of marriage and parenting, while personal characteristics have more sway in financial and job arenas. However, they also found that the greater the scope and variety of the person's coping repertoire, the more protection coping affords. Their conclusion about the relative ineffectiveness of coping in occupation is, however, misleading and is a result of their self-report questionnaire methodology which asked about how people usually coped with general sources of stress. This can be seen as at variance with their objective to distinguish what people do (behavior) from who people are (traits). In contrast, Folkman and Lazarus (1980) did a more differentiated analysis of both forms of coping and stressful encounters. They found that work contexts favored problem focused coping, while health contexts favored emotion-focused coping. Pearlin and Schooler (1978) did point out that, for impersonal strains arising from economic and occupational experiences, the most effective forms of coping involve the modification of goals and values. Goal setting is a cognitive-behavioral skill that has been incorporated into many stress reduction approaches and other enterprises concerned with performance effectiveness. It involves an assessment of personal values, the development of short-term versus long-term goals, and a clear specification of them. A time table with realistic expectations is a useful tool.
S=e" Reduction to In the field of sports psychology, for example, an athlete who may be experiencing stress from competitive pressures and a strong desire to achieve high levels of success can be helped, hypotheticially, by a goal setting strategy. The athlete should be helped to map the performance requirements of the sport component, using a quantitative approach, and correspondingly do a realistic assessment of his or her capabilities. Using measureable performance criteria, present performance level can be arrayed against the goals or desired improvement levels. In conjunction with this analysis training steps can be designed including diet, strenYth-buildinv conditioning that remain to be behaviorally enacted. goals, behaviorally achieved, can be a useful adjunct. an ,,, and The visualization of Quick and Quick (1984) present a model for understanding the stress reducing functions of goal setting programs which have dyadic involvement of managers and employees, thus leading to reduced role stress. This results from employee participation in setting task goals and frequent managerial performance feedback. Acquiring new behavior patterns and modifying old ones are essential to goal setting as a stress management strategy. Their review of limited work in this area finds mixed results in empirical evaluations. Time management is another commonly used component of stress programs, especially in the corporate sphere. Temporal factors have been studied with regard to stress among military populations, such as research done on naval watch schedules and experimental simulation studies pertaining to aerospace crews (Alluisi ~ Morgan, 1982). This work has sought to determine optimum work-rest cycles, and it has applicability to unusual situations. For example, Chiles, Alluisi, and Adams (1968) found in a continous 30 day study of air force officers working around the clock on schedules of 4 hours work, 4 hours rest (4-4), maintained consistently better levels of performance than
Stress Reduction 4~ those in 4-2 schedules. Curiously, during periods of confinement (four days), subject preference and performance is better on a 4-4 schedule than for 6-6 or 8-8 (Alluisi & Morgan, 1982). These studies on work-rest cycles, and others on vigilance and watch-keeping deal with temporal variables as fatigue factors. Time management, alternatively, looks as temporal matters in terms of workload regulation. There is general agreement in the idea of human beings as multichannel information processing systems with limits on their channel capacity (Schneider & Shiffrin, 1977). The concept of overload has been central to analyses of adaptation in urban environments (Milgram, 1970) and is fundamental to Cohen's (1978) stress model. Among Cohen's basic assumptions are that when demands exceed attentional capacity, priorities are set, and that prolonged demands cause depletion in capacity. Intense, unpredictable, and uncontrollable stressors create demands on attention capacity, as does task multiplicity. Available capacity shrinks ("cognitive fatigues) when demands on attention are prolonged. Task priorities, if not proscribed, will be generated by an operator (Chiles, 1982). Subjects strive to prevent decrements on what they regard as high priority tasks when workload is increased, and this of course is contextually determined. A pilot, for example, will carefully monitor air speed on landing approach regardless of other inputs, while attending to air speed might receive a lower priority enroute. Work demands, however, may well be generated by unrealistic expectations of personal capacity, thus creating conditions of overload. Job pressures themselves may require very efficient allocation of attention. In these regards, time management becomes an important stress coping skill.
Stress Reduction 48 The first step in effective time management is overload avoidance. Learning to avoid excessive obligations can be difficult for high achievers, but realistic goal setting can pave the way. Systematic approaches to time management have been outlined by Lakein (1973), who advocates a goals statement, a priority list of tasks, and a schedule. He emphasizes a written listing of things to do with a three tier ranking system. "Internal prime time" and "external prime time" are distinguished to designate periods best for concentration versus dealing with other people. Interruptions should be minimized during internal prime time, and limits must be set on meetings, calls, and various time drains. The core idea is to assure that high priority, high value items are accomplished first. Charlesworth and Nathan (1984) advocate taking a time inventory, charting one's activities as one goes through a normal day, using 15 minute segements. In a corresponding chart, they suggest making a satisfaction column indicating degree of satisfaction associated with each time segment. Summary tabulations will be informative about areas in need of adjustment. This charting technique is a form of self-monitoring, which is a cognitive-behavioral skill that is fundamental to coping with stress. Self- monitoring requires accurate observation and attention, but procedurally involves behavioral habits of charting physical states, psychological states, and behavioral activities. Kanfer (1970) set forth a view of self-monitoring as an initial step in self-directed behavior change, "a crucial trigger for self-adjustive behaviors" (p. 151). The self-observation of a specific behavior, thought, feeling, or sensation becomes a discriminative stimulus for a self-control response. Alternatively, the process can be viewed as a component of a feedback loop in a self-regulatory system whereby either disturbances in homeostasis are sensed and then activate deviation counter-
S=e" Reduction 4~ acting processes or inputs function as alarms that direct the system to avoid disturbances. An example of this perspective is that of Notterman and Trumbull (1950) who speculated about systems theory as a framework for stress research and viewed self-regulation as presupposing processes of detection, identification, and response availability. The organism must sense a disturbance, identify its nature, and be able to make the necessary correction. Curiously, they describe anxious individuals as having excessive feedback requirements (send out excess "feelers" or inquires to establish the identity of the disturbance) and use hyperventilation among Naval Aviation cadets as an example. They called the anxious hyperventilation, "Radar Robert, for his high need for feedback. S.cress Inoculation A cognitive-behavioral approach to clinical problems, particularly stress-related disorders of anxiety, anger, and pain, is the stress inoculation model, first developed by Meichenbaum (1975). The "inoculation" concept is a medical metaphor, and the treatment approach involves exposing the client to graduated dosages of a stressor that challenge but do not overwhelm coping resources. The client is taught a variety of cognitive and behavioral skills, which are then applied to conditions of stressor exposure. The approach was elaborated by me to deal with problems of anger, Is tested successfully in a series of studies with various client populations (cf. Novaco, 1985). Extensions to the area of chronic pain have been made primarily by Turk (1978). The treatment approach is conceptualized as having a sequence of phases, namely (a) cognitive preparation, (b) skill acquisition, and (c) application training. It is viewed as both a treatment and a preventive approach (Meichenbau~ & Novaco, 1978). The volume by Meichenbaum and Jaremko (1983) presents :he theoretical foundation and wide range of client problems and populations -a which the approach has been applied.
Stress Reduction :0 The historical precursors of the stress inoculation model, as mapped by Epstein (1983), include classic work concerned with the mastery of stress such as Freud's observations about wartime traumatic neuroses and Pavlov's laboratory experiments with dogs that were discussed earlier. Epstein argues that there is a natural process of graded stress inoculation, a sort of adaptive defense system that seeks to pro-actively master stress. Janis (1951), who discovered that preparatory information for impending stressors had a beneficial effect on their emotional impact when he studied reactions to air attacks (this is the forerunner of the Cognitive preparation" stage of the SI model), had previously written about fear and battle inoculation" in his work on the American Soldier project (Stouffer et al., 1949). He had suggested that trainees be given battle inoculation not only to acquire combat skills but to develop personal techniques for coping with emotional reactions, such as techniques we would now refer to as attentional refocusing, task orientation, and self-verbalizations of confidence enhancement. Janis (1971) extended these ideas to working with hospitalized surgical patients to help them cope with the impending stress of surgury by giving them a form of "emotional inoculation." Curiously, he first used this term to describe a preparedness training for the emotional reactions of relief workers in an A- bomb disaster (Janis, 1951). Among his suggestions were exposure to realistic color-sound films of disaster scenes and tours of the local morgue. For surgical patients, this was a three part counseling procedure that included a realistic assessment of the situation, reassurance about coping resources to counteract helplessness, and encouragement to develop a personal coping plan. Among the applications has been to recruits in Marine Corps basic training (Novaco et al., 1983), although this particular intervention did not entail a full implementation of the three phased approach. Pragmatic
S=e" Reduction :1 constraints simply did not allow for the use of the full procedure with entire recruit cohorts in a tightly scheduled training regimen. Consequently, we only utilized the cognitive preparation and skill acquisition components and even abbreviated those. The program and its results, along with an account of a much more elaborate intervention with drill instructors, is given in the subsequent section. Meichenbaum (1985) has recently written a clinical handbook or practitioners guide which reviews the full range of stress inoculation work. My own perspective differs from his by placing greater emphasis on environmental determinants of stress and on physiological activation, both of which are often ignored by Meichenbaum, despite my attempts to influence him (Meichenbaum & Novaco, 1984). The divergence is rooted in my interest and research in naturalistic settings, as well as in presuppositions about the involvement of arousal in stress - related disorders . UTILIZATION OF STRESS REDUCTION IN MILITARY CONTEXTS There is very little published. research on stress reduction in the military. There are a few clinical cases, mostly concerning PTSD described earlier as arousal reduction treatments, and very few experimental programs. My search has included technical report information sources, as well as books and journals. Clinical Interventions Several case reports on treatment of PTSD were given in the arousal reduction section earlier. In addition, some other reports on psychotherapy and psychopharmacology exist. Amen (1985) described work with a 43 year-old army first sergeant who had been a POU in Vietnam, and like a number of others, had PTSD symptoms when the Unknown Soldier from the Vietnam War was
