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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

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Stress Reduction :2 buried at Arlington. The treatment was psychoanalytically oriented with medication, and it was still in progress at the time the article was written. The PTSD symptoms were interpreted as metaphors for other life stresses, as well as war experiences. Psychodynamic treatments of war trauma and war neuroses rely on "abreaction" or the reliving of the traumatic experiences in order to gain mastery over them (cf. Milgram, 1982). A case report of abreactic treatment for a traumatic neurosis from the Yom Kippur War is given by Weisman (1982) who, for this case, found guilt to integrate the whole treatment process. Other reports of pharmacology treatments of PTSD have involved the use of lithium carbonate in low dosage (Kitchner & Greenstein, 1985) with 'five outpatients previously considered Treatment resistant" and considered serious cases of PTSD. All patients had problems of anger ant depression. One patient disengaged from treatment after being given lithium, one patient worsened and required hospitalization, and three showed some improvement. No quantitative outcome data were provided. - Several reports on the use of phenelzine in comparison with other medications inspired Birkhimer, DeVane, and Muniz (1985) to study the medical records for a one-year period of a 440 bed VA hospital. Fifteen cases of primary diagnosis PTSD were identified and studied for their clinical characteristics, as well as medication treatment. They found high variability in symptoms. Strikingly, they found that these patients received an average of 12 different psychoactive agents over the course of hospitalizations, none of which effectively achieved symptom remission. Anti-depressants had particularly poor results, especially imipramine -- in contrast to a case report by Burns tein (1983). Amen (1984) had to discontinue imipramine when it produced impotence. Birkhimer et al. also found weak results for anti-anxiety

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S=e" Reduction :3 medications, but there were generally effective outcomes for sleep disturbances. Mixed results were found for lithium treatment of anger- irritability problems. A pharmacotherapeutic treatment center that emphasized abreactic cathartic techniques often with chemical induction was established in the wake of the Yom Kippur War in a non-military atmosphere (Benyaku, Dasberg, & Plotkin, 1982). This center, which also used medications freely for anxiety, depression, and sleep disorders, was contrasted by Benyakur et al. with an alternative center in a military camp that relied on group therapy and personal responsibility to facilitate recovery and return to active duty. The latter approach was reported as being far more successful, while the medical approach resulted in continued dependency on therapeutic personnel and external blaming. War injury itself becomes a condition of stress, and Geron and Dunkelman (1982) give an abbreviated account of an intervention with paraplegic war veterans in Tel Aviv that made use of a sport rehabilitation program. They compared two groups, participants versus non-participants, and also had a control group of war veterans who were able-bodied. The war injured men were indeed more depressed, suspicious, and poorly oriented to reality. After a 3 year treatment period, the sports rehabilitation program participants were found to be better adjusted than the non-participants. Geron and Dunkelman's conclusions, however, must be qualified by the fact that program participation was a matter of personal choice, and their data analyses are not rigorous. The use of cognitive therapy interventions is even more rare in case reports. Stevens (1979) did three single subject studies using a Rational Emotive Therapy treatment for Air Force security service personnel and reported significant improvement on self-ratings for 10 stressful situations

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Stress Reduction :- two weeks after treatment. He also found significant changes in an overall life events coping measure. Experimental Programs There are a handful of stress management programs that have been implemented in military settings. Some dissertations on cognitive modification and arousal reduction have been conducted with dissertation-size samples, but there are a few larger projects at Army and Marine Corps bases. A comparison of relaxation training, cognitive restructuring, and wait- list control was done by Seegert (1984) with 52 military students at the Defense Language Institute. Self-report anxiety was the key stress measure in evaluating this six session program, which also looked at grades. Marginal effects were found for the treatment, with relaxation subjects reporting lowest anxiety, and no effects were found for grades. The dependent measures, as well as the treatment are transparently weak in Seegert's study. A better project was done by Marra (1981) who examined stress and performance in a study of attention during a military medical examination that incorporated a treatment comparison. - His two treatments were a deep-breathing arousal reduction procedure and a cognitive modification approach that taught subjects to recognize dysfunctional thoughts and to replace them with task-focused self instructions and thoughts of self-confidence. Compared to a non-treatment control group, these treatment groups were significantly better on measures of both stress and attention. While attention measures did not discriminate the treatment groups, the behavioral observation measures of stress did find 25% less stress behavior for the cognitive modification condition compared Lo the arousal reduction condition. An interesting implementation of arousal reduction procedures was done by Burke (1980), utilizing procedures of Walter Fenz in the Jumpmaster Course at

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Stress Reduction ~ Ft. Benning. Officers and enlisted men from several Army Airborne units, some Marines, and an Air Force officer participated in a study of respiration control as a stress management technique. They were taught deep breathing as a coping technique, and assessments were made of heart rate, perceived stress, and performance. Randomly assigned treatment and control groups constituted the experimental design. Significant treatment effects were found for heart rate only, although there were trends for perceived stress and graded jump at night. Reflecting on the treatment, Burke speculated that the respiratory control technique may have been too complex (it involved intake, pressing down the diaphram, holding for 8 seconds, release over 4 seconds, hold without breathing 4 seconds, one regular breath, and repeat). This probably weighed against its utilization in the stress situation. Several stress management programs have been implemented at basic training facilities. Beach, Prince, ant Klugman (1977) conducted a project at Fort Dix, Datel ant Lifrak (1969) did one at Fort Ord, Homer, Meglino, and Mobley (1979) tested a program at Parris Island, and Novaco and Sarason (Novaco et al., 1983) evaluated an intervention at San Diego. Each of the latter three programs utilized a film or videotape to deliver the intervention. Beach et al. (1977) sought to reduce administrative discharges through the prevention of stress reactions. Their program was multifaceted ant involved (a) presentations by chaplains at the reception station that aimed to prepare recruits for impending stressors, (b) discussion groups ("I want out of the Army a) run weekly by chaplains, (c) group consultations in the training unit day room with mental health staff for designated trainees, and (d) a stress management therapy group by mental health staff. Other company level and-battalion level didactic presentations were done by the mental health

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Stress Reduction :6 staff. Presentations were also given at the Drill Sergeant Academy regarding how to manage the marginal recruit. Within 48 hours after arrival at Ft. Dix, the new recruits were given a presentation by the chaplain on stress and adjustment. They were told to expect stress and that it was something natural. They were given an opportunity to ask questions and generally were afforded accurate information about basic training so as to reduce anxiety about their new surroundings. Several suggestions on how to cope with the impending stress were also given, these being: (1) to anticipate stress, (2) to be objective, (3) to recall how they had coped with stress in the past, (4) to seek information, (5) to help each other, and (6) to practice difficult.tasks, imaginally and in viva. The chaplains also ran a "I want out of the Army. group each Wednesday evening, which was a pre-existing program that allowed recruits the chance to ventilate feelings and discuss ways of dealing with basic training. The mental health staff consultations were a type of secondary prevention program for trainees who were experiencing difficulties ant involved group discussions on the unit day room. This was done on an nas needed" basis, and the mental health staff did large group presentations similar to that done by the chaplains at the reception station. After these unit consultations, meetings were held with the commander and first sergeant to provide feedback and recommendations regarding certain recruits. The stress management therapy groups had an open group format, but the authors provide no information about the therapeutic process or framework. Similarly, the company and battalion level interventions are not described in any detail. Beach et al. portray an intervention program that has many components, but the variation lacks structure and focus. Moreover, in the absence of dependent measures tailored to the program components, it is impossible to know what ingredients are efficacious.

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Stress Reduction This varied intervention was evaluated by assessment of discharge rates for January-June of 1977 in comparison with those for the same period the previous year, and significant reductions were found (9.09% versus 13.22% overall, and 4.26% versus 8.13% for administrative discharges). Comparisons with other Army training facilities for the same periods, however, reveals considerable fluctuations in discharge rates across facilities. Another depot, Fort Jackson also had reductions in discharges, but they also had a social work service program underway with similar goals. The Fort Jackson discharge reductions were not as large as those at Fort Dix. My point about fluctuations is that Fort Gordon had an administrative discharge rate of 6.01% in 1976 and 10.53% in 1977. - Datel and Lifrak (1969) developed an experimental film for Army basic training recruits at Fort Ord for the purpose of creating realistic expectations about the demands of boot camp. They had previously found that recruits underestimate the distress they will experience in training, and the authors sought to reduce stress through emotional preparedness. Datel and Lifrak actually edited an existing Army training film for their experimental condition and also had a control film in the design. The editing removed gratifying or rewarding aspects of the existing film, nThis Is How It Is." As expected, distress was increased after the film, but hypothesized stress preparation had no effect on distress during training. While the authors concluded that the negative results were due to omitting material on the "culture shock" elements of basic training, it seems unlikely that depiction of Goffman-like phenomena of identity-stripping, etc., would achieve the desired goals. Instead, the missing ingredient would seem to be information about coping skills.

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Stress Reduction ,5 An analogous intervention with Marine Corps recruits at Parris Island was conducted by Homer et al. (1979), using a "realistic preview" film. Their intervention was directed at recruit expectations, inspired by research in organizational psychology on management of employee turnover. They reported an experiment consisting of a treatment (80 minute videotape), placebo and control conditions, which found reductions in attrition that were a~ctributed to the experimental film. However, recruits were not randomly assigned to conditions which are seriously confounded by training unit effects that were unnoticed by the investigators. Oddly, the absence of significant effects on any manipulation check variable is ignored by the investigators in explaining differential group outcomes, nor were the authors struck by the implausibility of a 14% reduction in attrition reported for postgraduation enlistment as being due to an 80 minute videotape. Another Marine Corps recruit training intervention was conducted by Novaco and Sarason at San Diego (Novaco et al., 1983). Our intervention was a videotape called "Making It" that concerned stress coping skills. It had two key themes: the self-control regulation of emotion and task performance effectiveness. It sought to promote an adaptive cognitive orientation and provide information about the demands of training and the roles of training personnel. Consistent with the cognitive preparation phase of the stress inoculation model, recruits were told about their likely distress, worry, and confusion, and they were also informed about the ingredients of successful performance. Successful coping behavior was modeled for use in stress situations. Our goal with this 35 minute module was to beneficially affect recruit cognitions during the processing phase at the start of training. The experimental evaluation was conducted by randomly dividing 530 recruits among

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Stress Reduction :- five treatment conditions which included the Parris Island realistic preview film (as remade for San Diego). Details of the design and procedure are given in Novaco et al. (1983). Importantly, we randomized within platoons and had a pre-post design. The analyses indicated that the coping skills module significantly increased efficacy expectations across a range of training tasks and also enhanced perceptions of personal control. These effects were not obtained for the comparison film. Moreover, we found that the recruits who profit most are those in greatest need (cf. Cook et al., 1982). External locus of control recruits gain the most in efficacy from the intervention. Presently underway is a very extensive project designed to teach stress coping skills to Marine Corps drill instructors. This intervention program is being conducted at both the San Diego and Parris Island depots. It is based in their Drill Instructor Schools where it is part of the curriculum, entailing about eight hours of instruction distributed over the training schedule. The program is taught by each school's leadership instructor and is conveyed by- videotape modules and vignettes. There are six modules concerned with central themes (such as anger, evaluation anxiety, personal relationships, recruit evaluation) and which portray the utilization of a set of stress coping skills with regard to the problem domain. The coping skills are (1) self-monitoring, (2) task-orientation, (3) having a constructive outlook on others, (4) having a balanced view of oneself, (5) acting naturally, (6) being patient and learning from mistakes, and (7) utilizing supportive social relationships. The module videotapes are about 15-18 minutes in length. The vignettes are 5-7 minute tapes on concrete problem situations, and there are eight of these, which deal with various problem recruit situations, work relationships, and personal relationships. The vignettes dissect the problem situation and model effective coping strategies.

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Stress Reduction 60 The drill instructor project developed from longitudinal research on the stressful nature of drill field duty (Novaco, Sarason, Robinson, & Cunningham, 1982; Novaco, Sarason, Robinson, & Parry, 1983), which had been initiated after studies on recruit attrition and adjustment found strong effects for training unit influences (Novaco & Sarason, 1986). The drill instructor intervention program has just entered the evaluation phase. Data are being gathered on a multitude of cognitive, personality, behavioral, and physiological variables to evaluate the effectiveness of the intervention. PROSPECTS FOR IMP~ENTATION As stipulated by the conceptual model given earlier, stress must be understood in terms of contextual conditions. The mechanisms by which environmental demands operate to produce stress reactions are linked to features of the physical ant loci-cultural milieux that affect stressor salience and signification, mitigating factors, resources, and coping processes. For example, not everyone who has a long commute to work on congested roadways is going to experience stress that is manifested by elevated blood pressure, negative mood, lowered frustration tolerance, impairments in cognitive functioning, and health problems. Indeed, such stress reactions are significantly influenced by conditions of the residential and work environments, between which one commutes, as well as by cognitive- behavioral characteristics of the individual and their efforts to cope with commuting stress (Stokols & Novaco, 1981). Similarly, whether a drill instructor exhibits stress reactions will depend on contextual conditions such as workload (which is phasic and greatest in summer months of high accessions), company and battalion policies, types of supervision received, the social climate of the drill instructor team, unexpected pressures, and his