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PART IV. Stress Management
Stress and Performance Seymour Levine Stanford University School of Medicine
page ~ The literature concerning stress is extensive and complex, extending through fields as varied as clinical applied psychology, anthropology, sociology, psychosomatic medicine, industrial relations, and epidemiology. Not included in this list are, of course, the extensive studies dealing with the biochemical and physiological of the responses to stress. These responses have been involved in mechanisms as basic as immunological function, metabolic function, and fundamental psychological processes, such as memory and learning. Since one of the primary problems in stress research is conceptual, and this problem takes many forms, there is a great deal of confusion in the field. Because stress researchers lack a common vocabulary, each writer must define his/her own terms, and the reader must scrutinize each article carefully in order to understand the writer's vocabulary. The lack of a uniform and consistent vocabulary is a substantial impediment to progress and adds materially to the confusion in the field. Although the term "stress" is used throughout the literature, it is apparent that this term has multiple meanings, depending upon the particular field in which the concept is being investigated. Within the context of this report, we shall attempt to use one set of operational definitions to define stress, and at least to be consistent with our own definitions of the primary psychological variables that induce many of the profound long-term effects commonly attributed to stress. Stress can be approached from a purely behavioral perspective, and it effects studies on primarily behavioral outcomes. However, stress has also been viewed predominantly as a physiological and psychosomatic process, and the outcomes arestudies on either pathophysiological processes or basic biological processes. This report, however, will focus on an integration of these two perspectives and present a psychobiological view of stress.
Page 3 It is important to note that, historically, the concept of stress has been predominantly implicated with changes in the endocrine systems. Initially, the changes were specifically related either to increased secretion of catecholamines or to activation of the pituitary-adrenal system. The problems are best illustrated by examining the concept of stress beginning with Selye's (1936) early work in which he defined a general adaptation syndrome (GAS) in rodents. This nonspecific response occurred after diverse noxious agents, such as exposure to cold, surgical injury, spinal shock, and muscular exercise. The essential argument was that the response did not depend upon the type of agent that produced it; rather, like inflammation, it was deemed as nonspecific. GAS was divided into three stages: an alarm reaction, a stage of resistance, and a stage of exhaustion. The initial stage included activation of the pituitary-adrenal system and eventually resulted in adrenal hypertrophy, thymicolymphatic involution, and gastric ulceration if the noxious stimuli persisted. If the response to the aversive situation was sustained, physiological resistance ultimately developed, and it was hypothesized that stressed subjects would enter a third stage--exhaustion--which occurred 1-3 months after the initial exposure. Problems with this view have occurred at several levels. First, there was an early emphasis on the physical and chemical aspects of the stressful stimuli, and we now know that psychosocial stimuli are also potent elicitors of the stress response. Second, Selye has received much criticism for the "nonspecificity" view because, with modern hormone assays, it is now possible to detect differential endocrine responses to certain stimuli. Further, the importance of the final stage of exhaustion has been questioned. Diseases due to exhaustion of this syndrome are rare, and, with the exception of a few animal models (e.g.,
Page 4 intruders in wild rat colonies ), have not been demonstrated as a response deco psychosocial stimuli (Allen, 1972). Moreover, a number of physicians have studied moribund patients and have found that adrenal exhaustion did not occur even at death. Rather, there is usually increased adrenal output immediately before and after death (Sandberg et al., 1956~. The dramatic picture described by Selye is emphatically different from the present day concept of stress in the lay literature, which includes the daily troubles and anxieties of commuters and executives. The broader use of the term has resulted in an urgency to reduce or eliminate stress in both personal and professional arenas, even though Selye (1974) himself has minimized the significance of this type of stress and stated that its absence occurs only after death. This paradoxical situation reveals that we do not have a clear and generally accepted definition. As a consequence, there is a serious communication problem and increasing talk about a crisis in stress research (Wolf et al., 1979). At the very least, there is a growing impatience with the present state of vagueness in an area so vitally important for issues of health and quality of life. We believe that much of the controversy over stress theory can be eliminated through clarification of the "afferent limb," that is, by focusing on the nature of the stimuli that provoke physiological responses rather than on the physiological responses themselves. This type of investigation requires an unusual integration of physiology and psychology--disciplines which have traditionally been separated--and puts the major emphasis on psychological variables.
Page 5 One of the purposes of this report is to examine the importance of psychological variables that have been determined to have profound endocrinological consequences both in animals and humans. In fact, the major conceptual framework pervading this report is that one of the primary aspects of stressful stimuli eliciting an endocrine response is psychological in nature. This perspective is derived from Mason's (1968, 1975a,b) review of psychoendocrine research, particularly involving the pituitary-adrenal cortical system. As mentioned above, much of the early stress research had emphasized the nonspecificity of the organism's response to a wide variety of physical stressors (Selye, 1950). However, even in the 1950s, it was becoming increasingly apparent that psychological factors were importantly involved. For example, in one study, Renold et al. (1951) examined the physiological response of participants in the Harvard Boat Race. Utilizing a traditional measure of that period, the decline in eosinophils following stress, they found that eosinophils in the crew members were markedly lower 4 hours after the race. This decline could have been attributed solely to the exercise and physical strain, but the investigators also discovered that the coxswains and coaches had similar eosinophil drops, even though their stress was purely psychological. In Mason's major review of the stress literature in 1968, he pointed out that much of the prior work, including the experiments on physical stimuli, shared one important characteristic, namely, that a typical aspect of the stressful experience was exposure to novel, strange, or unfamiliar environments. Therefore, the common thread that may have explained the animals' response was the psychological dimension of the stimuli, rather than the particular physical trauma to which they had been exposed. In subsequent research, Mason (1975a,b) was able to show that when animals are exposed to the
Page 6 stimuli in such a way that they do not experience distress or novelty, then typical stressors such as heat or fasting do not necessarily result in activation of the pituitary-adrenal system. The concept that psychological variables can activate, and inhibit, the endocrine system has subsequently received much support in experimental studies on both animals and humans. PITUITARY-ADRENAL SYSTEM Although the response to stress can best be defined as a syndrome, which includes many changes in neurochemical and metabolic processes, for the purposes of this report we will focus on the response of the pituitary-adrenal system. It is important to remember, however, that we are utilizing this as a model system. There is abundant evidence indicating that the hormone function of other endocrine systems--including insulin, growth hormone, and prolactin--can also be influenced by psychological variables. In addition, it has been demonstrated recently that the endorphins are also extremely responsive to stress. In fact, it appears that almost all of the stimuli capable of eliciting an ACTH response from the pituitary are also capable of releasing beta endorphins (Guillemin et al., 1977). There are two reasons for focusing on the pituitary-adrenal system in illness. First, there is an extensive data base showing the effects of psychological variables on the pituitary-adrenal system. Second, and perhaps more important, is the profound influence that adrenal hormones have on many basic functions related to health. There have been many attempts in recent years to resolve the issue of the primary stimuli that elicit the endocrine response, in particular pituitary-adrenal responses, which occur under conditions of stress. As Mason
Page 7 (1975a) pointed '.Ut , when the psychologically threatening or arousing aspects of the situation were altered, classical stresses such as fasting and heat no longer activated the pituitary-adrenal system. In the case of heat, there was, in fact, a reduction in the corticoids when the mode of presentation was gradual. The importance of the rate of presentation of a particular stimulus was also demonstrated in another experiment that used a potent physiological insult to induce adrenocortical activity. Hemorrhage in the magnitude of 10 ml/kg at the rate of 6.6 ml/kg/min actively stimulates the adrenal cortex of the dog. In contrast, if the same ultimate volume of blood loss is achieved at a much-slower rate of hemorrhage (i.e., 0.3 ml/kg/min), the pituitary-adrenal system does not activate (Gann, 1969). That rapid hemorrhaging induces adrenocortical activity, while slow rates of hemorrhaging do not, once again indicates that the rate of stimulus change is one important parameter for the induction of pituitary-adrenal activity. The fact that dexamethasone blocks the pituitary-adrenal response at a high rate of hemorrhaging clearly indicates that neuroendocrine systems are involved and that the effect was not mediated peripherally. Regardless of the specific explanation that accounts for these results, their general significance cannot be underestimated. More recent studies on psychoendocrine responses have indicated further that it may be possible to use adrenal activity as a measure of specific emotional responses, rather than simply as a reflection of undifferentiated arousal (Hennessy and Levine, 1979; Mason, 1975a,b). In addition, studies on psychological stress bring out one point quite clearly; the great individual differences typically observed in response to a given stressor can best be explained in terms of cognitive mechanisms . For example, a sub, echo s perception
Page 8 of a stressor AS Z three_, or the coping responses that are available to the subject, may well determine the physiological response. It may be insufficient, therefore, to merely describe the stimulus operations involved in producing a stressor. A psychobiological approach to understanding endocrine function cannot escape making reference to cognitive processes. In his new description of arousal theory, Berlyne (1960, 1967) provides a framework for the description of the processes by which stimulators of arousal (and thus, activators of the pituitary-adrenal response) operate. Novelty, uncertainty, and conflict are considered primary determinants of arousal. These have been labeled by Berlyne as collative factors, because in order to evaluate them, it is necessary to compare similarities and differences between stimulus elements (novelty), or between stimulus-evoked expectations (uncertainty). The basic cognitive process involved in stimulation of the pituitary-adrenal system, then, is one of comparison. To a large extent, the cognitive processes of comparison can be best understood by adding the concept of uncertainty, although there are some differences between uncertainty and novelty. Uncertaintv seems to be a major factor underlying many psychological responses. The processes involving neuroendocrine activation under conditions of uncertainty are best explained by a model elaborated by Sokolov (1960) to account for the general process of habituation. The pattern of habituation is familiar to most people. A subject is presented with an unexpected stimulus and shows an alerting reaction. Physiological components of this orienting reaction are well known--general activation of the brain, decreased blood flow into the extremities, changes in electrical resistance of the skin, and increases in both adrenomedullary and cortical hormones. If the stimulus is frequently repeated,
Page 9 all of these reactions gradually dominion and eventually disappear, and the subject is said to be habituated. It does appear, however, that physiological responses may habituate more slowly than the observed behavioral reactions. Sokolov's model, in essence, is based on a matching sys~ce~n in which new stimuli or situations are compared with a representation in the central nervous system of prior events. This matching process results in the development of expectancies whereby the organism is either habituated or gives an alerting arousal reaction (Pribram and Helges, 1969~. Thus, the habituated organism has an internal representation of prior events with which to deal with the environment--expectancies--and if the environment does not contain any new contingencies, the habituated organism no longer responds with the physiological responses related to the alerting reaction. Activation of the pituitary-adrenal system by any change in expectancy can also be accounted for by invoking the powerful explanatory capacity of the Sokolov model. NOVELTY AND UNCERTAINTY Exposure of an animal to novelty is one of the most potent experimental conditions leading to an increase in pi~cuitary-adrenal activity. Novelty can be classified as a collative variable, since the recognition of any stimulus situation as being novel requires a comparison between present stimulus events and those experienced in the past. Increases in pituitary-adrenal activity in response to novelty have been demonstrated in humans as well as animals. For example, increased adrenocortical activity, as evidenced by elevated levels of circulating cortisol, are observed in individuals during their first exposure to procedures involved in drawing blood at a blood bank. However, if they have had
Page 10 prior blood bank experience, there are SIG SUC'i- increases (Mendoza and Barchas, 1982). Further, in an experiment to be discussed in detail later, young adults experiencing their first jump off a tower during parachute training also show a dramatic elevation of adrenocortical activity, which is not observed on subsequent jumps from the tower (Levine, 1978). Studies on animals also indicate another important characteristic of the cognitive process which results in pituitary-adrenal activation, that is, the ability of the animal to discriminate similar vs. unfamiliar stimulus elements. In a series of experiments on rats and mice it was demonstrated that if novelty was varied along a continuum with increasing changes in the stimulus elements, there was a graded adrenocortical response according to the degree to which the environment represented a discrepancy from the normal cage living environment of the organism (Hennessy and Levine, 1977; Hennessy et al., 1979). Thus, minor changes, such as placing the animal in a different cage, but one identical with its home cage, resulted in an elevation of plasma corticosterone, but one that was significantly less than when the animal was placed in a totally novel cage containing none of the elements of its familiar living conditions. This capacity to make fine discriminations resulting in graded elevations of pituitary-adrenal activity are clearly demonstrative of the remarkable capacity of the central nervous system to regulate the output of pituitary-adrenal response. Novelty, according to the theory presented by Sokolov, should indeed be one of the most potent variables that elicits increases in pituitary-adrenal activity. Insofar as an organism has no expectations about an unfamiliar environment, that environment should represent a degree of uncertainty that should lead to increases in neuroendocrine activity.
Page 11 Although novelty can be subsumed under the general concept of uncertainty, not all conditions which create uncertainty are novel. Uncertainty can also be evoked by insufficient information concerning the nature of upcoming events. Uncertainty can be seen to vary along the continuum from highly certain, predictable events to highly uncertain, unpredictable events. The presentation of a novel stimulus is likely to lead to an increase in uncertainty because, by definition, there is little information the organism can use to predict forthcoming events. However, uncertainty can also be defined in terms of contingencies between environmental events. Experimentally, the dimension of uncertainty can be controlled by limiting the amount of information available to the organism to predict the occurrence of a specific event. Thus, one would hypothesize that if an organism is given information about the occurrence of either an appetitive or an aversive stimulus, such predictability should lead to a reduction in the pituitary-adrenal response. Further, situations in which there is an absence of predictability should lead to a dramatic increase. There are many experiments that illustrate the value of predictability in modifying the pituitary-adrenal response to a variety of stimuli (Weinberg and Levine, 1980). One illustration of the effects of reducing uncertainty by providing predictability can be seen in a study by Dess et al. (1983). Dogs were subjected to a series of electric shock which were either controllable or predictable. The predictable condition involved presenting 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
Page ;2 an adrenocortical response which 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 utilized in experiments examining learned helplessness (Seligman, 1975). Learned helplessness refers to the protracted effects resulting from prolonged exposure to unpredictable and uncontrollable stimuli of an aversive nature. It has been observed that organisms exposed to this type of an experimental regimen show long-term deficits in terms of their inability to perform appropriately under subsequent testing conditions. Further, these animals show a much greater increase in adrenocortical response when exposed to novelty (Levine et al., 1973) than do control animals. Thus, an organism exposed to an uncontrollable and unpredictable set of aversive stimuli not only shows a dramatic increase in adrenocortical activity while exposed to these conditions, but there is also a long-term effect in other unrelated test conditions. The concept of control is particularly important in understanding these long-term effects, and it will be dealt with later when the issue of coping is discussed. There is yet another series of experiments related to the issue of uncertainty. These do not utilize aversive stimuli typical of stress research, but are more directly related to a psychological response commonly described as frustration. Frustration can be evoked when the organism fails to achieve a desired goal following a history of successful fulfillment of these goals. Experimentally, the operations utilized to produce frustration involve either preventing an animal from making the appropriate response to achieve a desired object, or not reinforcing the animal for a response that has had a prior history of reinforcement. In a broader sense, frustration involves the failure of an
pa.gn. 1.3 animal to fulfill expectancies developed in previous experiences and, thus, car. be subsumed under the larger heading of uncertainty. For example, rats trained to press a lever for water, in which each lever-press delivered a small amount of water, showed a dramatic elevation of plasma corticosterone when the water was no longer available following the lever-press response (Coe et al., 1983b). Elevations of plasma corticosterone have been shown to be a robust and reliable phenomenon occurring under many experimental conditions in which reinforcement contingencies are altered. Thus, not only is an elevation of plasma corticosterone observed when reinforcement is eliminated, but if the animal receives less reinforcement than it has previously become accustomed to, then elevations of plasma corticosterone also occur. A similar phenomenon can be observed when using aversive stimuli. If an animal has learned to make an appropriate avoidance response that eliminates the occurrence of an electric shock, and this animal is then prevented from making the response, an increase in pituitary-adrenal activity occurs even when no electric shock is delivered (Coover et al., 1973). These experiments have led to the belief that one of the primary conditions to activate the neuroendocrine mechanisms leading to a subsequent adrenal response is a change in expectancies concerning well-established behaviors. In the case of the appetitive learning situation when reinforcement is eliminated, as well as in the avoidance experiment, activation of the pituitary-adrenal system occurred following disruption of ongoing behavior which had once let to a predictable set of outcomes. This can best be understood if one assumes that, under conditions whereby frustration is evoked, the absence of reinforcement represents a condition in which uncertainties are introduced.
Page 14 COPING Since the time of Bernard and Cannon, the importance of maintaining physiological homeostasis has been well known. The consequences of inappropriate adrenal secretion are evident from the effects of both hyper- and hypo-adrenal output. Organisms deprived of adrenal corticoids are clearly in jeopardy and unable to effectively deal with even minor stressors that are of little consequence to an intact organism, such as water or salt restriction. Conversely, excessive secretion of the pituitary-adrenal system is also maladaptive. Prolonged elevations of adrenocortical hormones can have high biological cost, leading to increased susceptibility to psychosomatic illnesses as well as other pathophysiological processes, through their effects on the immune system. It would follow, therefore, that there must have evolved a set of mechanisms available to the organism whereby it could regulate and modulate excessive output of adrenocorticoids. We believe that these mechanisms are predominantly psychological and should be classified under the general rubric of cop 1ng . Coping differs from habituation in one profound sense. In the case of habituation, it is presumed that the organism has changed its evaluation of the stimulus through repeated experience and has developed a set of expectancies concerning the benign characteristics of the stimulus or environment. Coping, on the other hand, is a more active process and can be defined in terms of the absence of a physiological response even under conditions in which the aversive stimulus continues to be present. In the case of coping, cognitive and behavioral processes are actively involved in determining whether an individual does or does
not respond to a specific stressful situation. Page 15 It is not just the aversive nature of the stimuli, per se, that determines the physiological response, but rather the individual's evaluation of these stimuli. We can regard this as a filter or gating function. An organism can alter its evaluation of potential! threatening or aversive stimuli if it can avoid, alter, or master the stress-inducing aspects of the situation. In a previous context, we have discussed the importance of predictability. There are two other psychological processes also involved in the process of altering an organism's evaluation of stressful events: control over aspects of the situation, and feedback about the efficacy of its actions. Perhaps the most important single determinant of the ability of the organism to reduce its hormonal responses to aversive stimuli is control. Control can best be defined as the capacity to make active responses during the presence of an aversive stimulus. These responses are frequently effective in allowing the animal to avoid or escape from the stimulus, but they may also function by providing the animal with the opportunity to change from one set of stimulus conditions to another, rather than to escape the aversive stimulus entirely. Control, in and of itself, can reduce an organism's physiological response to such noxious stimuli as electric shock. It has been observed that rats able to press a lever to terminate shock show less severe physiological disturbances (e.g., weight loss and gastric lesions) than yoked controls which cannot respond, even though both animals receive the identical amount of shock. Similarly, animals able to escape from shock show a reduction in plasma corticosterone following repeated exposures of shock (Davis et al., 1977). The effects of control have also been demonstrated in an experiment by Hanson et al. (1976~.
Page 16 These investigators studied rhesus monkeys that were exposed to another noxious stimulus--a loud noise. One group of monkeys were permitted to control the duration of the noxious stimulus by making a lever-press response to terminate the noise. A comparable group of monkeys were given the identical amount of noise, but were not permitted to regulate the duration. The animals that were allowed control procedures showed identical levels of plasma cortisol as those which were not exposed to the noise at all, compared to the yoked controls that showed extremely high levels of plasma cortisol. The effect of control on plasma cortisol levels was also demonstrated very clearly in a recent experiment on dogs (Dess et al., 1983~. These animals were subjected to a standard procedure used to produce learned helplessness. They were placed in a hammock and given uncontrollable and unpredictable shock. Other dogs were allowed to control the shock and terminate it by making a panel-press response with their heads. We have previously discussed the role of predictability within the context of this experiment. The results further indicated that controllability also affected the magnitude of the cortisol response to the shock. Having neither control nor predictability elicited the maximum cortisol response; having both minimized the impact of the shock. However, the capacity to control the stimuli appeared to have a greater effect in reducing the cortisol response to shock. Rodin (1980) has presented an elegant series of studies with profound implications for the importance of control in human situations. As others had previously suggested (Birren, 1958; Gould, 1972), Rodin hypothesized that the transition from adulthood to old age may represent a loss of control. She further argued that the ability to sustain a sense of personal control in old age
Page 17 may be greatly influenced by societal factors, and that this, in turn, could affect the physical well-being of an aged individual. In order to investigate this problem, she introduced a program of "coping skill trainings in a nursing home population, which was intended to reintroduce control to a group of individuals who felt a high degree of helplessness about their situation as a function of being institutionalized. There were two impressive aspects of the cortisol data presented in this study. First, among the aged in institutions, cortisol levels appear to be chronically elevated, similar to those observed in depressed individuals. Perhaps more important, however, was that individuals who were trained in certain aspects of coping skills (including control) showed a marked and significant reduction of their elevated cortisol levels. The concept of control in reducing stress in humans can be observed in other situations as well, such as the work environment. Rose and associates (Rose et al., 1982a,b,c) investigated a variety of endocrine parameters, including growth hormone and cortisol, in a large group of air traffic controllers during and after the work day. The job demands placed upon air traffic controllers have been considered to be extremely stressful. Blood samples were obtained automatically at 20-minute intervals over a 5-hour period from a large group of working air traffic controllers in their routine occupational environment. The data indicated that cortisol and growth hormone levels were not appreciably elevated and that both hormones showed a lack of consistency across repeated studies in terms of average levels or measures of episodic secretory activity. Thus, there appeared to be little in the way of an increased stress physiology under working conditions which were presumed to be stressful. It is important to note, however, that the population selected for study was composed of highly
Page 18 exre_ier.ced individuals who had been on the job an average of 11 years. One could conclude, therefore, that as a consequence of their extensive work experience these individuals had developed adequate coping mechanisms, particularly in their ability to exercise control over the environment, which enabled them to minimize the psychological consequences of their stressful occupation. FEEDBACK Although it is clear that control is a major factor involved in coping, the ability or efficiency with which an organism can cope is also dependent upon another factor--feedback. Feedback refers to stimuli or information occurring after a behavioral response has been made in reaction to an event. These stimuli may be used to convey information to the responding organism indicating that it has made the correct response to a noxious event, for example, or that the aversive event is terminated for at least some interval of time. According to Weiss (1971a,b,c), the amount of stress an animal actually experiences when exposed to noxious stimuli depends upon the number of coping attempts the animal makes (control) and the amount of relevant information the coping response produces (feedback). As the required number of coping responses increase and/or the =mount of relevant feedback decreases, the amount of stress experienced increases. In an extensive series of studies, Weiss demonstrated that if two groups of rats were subjected to the same amount of electric shock, the severity of the ulceration was reduced if the animal could respond--avoid and escape--and if the situation had some feedback information, i.e., a signal following the termination of shock. Although feedback information usually occurs in the
Page 19 contexc of co;lLrol, namely, information about the efficacy of a response, it has been reported that feedback information, per se, even in the absence of control, can reduce the pituitary-adrenal response to noxious stimuli. Hennessy et al. (1977) reported that the presence of a signal following the delivery of shock resulted in a reduced adrenocortical response even in the absence of control. In contrast, the pituitary-adrenal response of animals given a random signal was not significantly different from those animals that had no signal at all. Although the human data concerning the role of feedback are not abundant, there is one large study (Ursin et al., 1978) that investigated the coping process in humans following repeated experience with parachute training. In that study, the hormonal and behavioral responses of a group of Norwegian paratroop trainees were examined following repeated exposure to jumping off a 10-meter tower on a guide wire. After the first jump experience, there was a dramatic elevation of plasma cortisol, but as early as the second jump, there was a significant drop to basal levels; thereafter, basal levels persisted on subsequent jumps. It is also important to note that the fear ratings changed dramatically following the first and second jumps, so that 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. We believe that both aspects of the coping model presented by Weiss can be applied to this situation. The individuals were able to make appropriate responses; that is, after the first experience they had already improved their performance of the task. However, since the individuals were jumping on a guide wire, performance was probably not the critical factor. The second aspect of the coping model, feedback, may be more important in this context. Although the situation was potentially dangerous
Page 20 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. When one closely examines the three factors--control, predictability, and feedback--that have been shown to be involved in the coping process, they all have common elements which can be viewed within the framework of the determinant of the stress response proposed earlier--uncertainty. Each of these factors, either acting alone or more probably in concert, appear to have the capacity to reduce uncertainty. Control provides the organism with the capacity to eliminate, or at least to regulate, the duration of the stimuli. Thus, the uncertainty involved in unpredictable and uncontrollable situations is reduced. We have discussed predictability in a previous section of this report, and by definition, it serves to reduce uncertainty. Feedback can also be viewed in terms of reducing uncertainty, since feedback provides information to the organism about the efficacy and success of the response being emitted. We can therefore speculate that any set of operations that reduces uncertainty, whether they be passive such as habituation, or active such as the utilization of control, predictability, or feedback, can lead to an amelioration or elimination of adrenal activation. SOCIAL SUPPORT There are now ample behavioral and physiological data which point to the importance of social relationships in determining an individual's ability to cope with stress. Hamburg and Adams (1967) emphasized the great need for the continuity of personal relationships when individuals are involved in crisis.
Page 21 There have been several studies that have pointed directly to social support as a major determinant in specific health-related issues. Nuckolls et al. (1972) studied the relationship between social stress, as measured by the cumulative life-change scores of Holmes and Rahe (1967), and psychological assets relating it to the prognosis of pregnancy. These studies showed that women with high life-change scores before and during pregnancy had an excessive incidence of complications if their social support was low, while a high level of social support appeared to be protective against adverse outcomes. Cobb (1976) discussed further evidence showing that social support affected the length of hospitalization and the rate of recovery from illness, minimized the effects of retirement and bereavement, and helped one to endure the threat of catastrophe. Cobb also studied the effects of social support on the effects of job termination. One hundred men whose jobs were abolished were vis ted by public health nurses before and after their jobs had terminated, and periodically up to 24 months after being unemployed. The results showed a tenfold increase in arthritis (with two or more swollen joints) in men who had low social support, as compared to men who had a great deal of social support. The effects of social support on the pituitary-adrenal system have been inferred in the now highly cited studies of Bourne (1970, 1971) conducted during the Viet Nam war. There are two studies that are relevant to this discussion. In the first study, Bourne (1970) measured urinary levels of corticoids in helicopter medics who were involved in medical evacuation flights. The striking finding was that when 17-OHCS levels on flight days were compared to output on those days when the medics remained on base, there were no significant differences. In fact, their overall levels tended to be lower than comparable
Page 22 levels of recruits and of the general population of men in the United States. Although this study was not experimental, so that social factors could not be manipulated, Bourne hypothesized that a strong support group was an important social asset, and that one of the defenses being used by these helicopter medics was a deep belief that their task was worthwhile, as observed by the gratitude of the men they rescued. This feeling, combined with a sense of personal worth, was socially validated by the frequent medals and the additional merit pay they received. In the second study (Bourne, 1971), a group of men in the Special Forces who had intercepted a message that their isolated camp was to be attacked by the Viet Cong in a few days, were evaluated. Again, 24-hour urine samples were obtained from the men in camp, both before the expected attack and several days following. Although the attack actually did not occur, anticipation of the attack resulted in different levels of urinary 17-OHCS excreted in some of the men. Most of the Special Forces enlisted personnel were enthusiastic about the impending attack and spent much of their time in task-oriented activities, such as bringing extra ammunition, fortifying their defenses, etc. Their behavior and attitude was in sharp contrast to the captain and the radio operator, who spent much of their time communicating with the commanding officer at battalion headquarters, the captain under considerable pressure to perform well. Both the radio operator and the captain showed sharp increases in corticoid excretion on the day of the expected attack, compared to the days preceding and following this day. In contrast, most of the enlisted men actually showed a suppression of adrenocorticoids on the expected day of attack, which returned to basal levels in the following days. According to Bourne, the problem confronting the radio
_ Page 23 operator and the captain was that the orders being issu~d~mi&ht not be relevant to the present situation, so that the officer had to compromise between satisfying his superiors and not disturbing the experienced soldiers with orders that they would regard as inappropriate. Bourne noted that the officer's duty did not permit him to keep busy with emotionally satisfying manual chores of the camp. In addition, the demands made upon the young officer to maintain his role as an authority figure over the older and experienced enlisted men was a tension-inducing influence that could have elevated his adrenal output. Once again, according to Bourne, the most important asset is the group consensus as to how a stimulus should be perceived. Although Bourne implicated social variables in the modulation of the adrenocortical response under these extremely stressful conditions, it is clear that the data are open to other interpretations. One could argue that in the case of both the helicopter medics and the enlisted men, they were able to exercise a large degree of control, and that this control may be the more important determinant of their low level of adrenal activity under these circumstances. There are available experimental data that clearly implicate the role of social factors both in accentuating and modulating the pituitary-adrenal - response. In order to study the influence of social behavior on hormonal systems, it is of course essential to investigate an animal whose predominant way of life is social. There are many forms of social organization and social behavior among animals, but it is in the primate species that the most striking feature of adaptation appears to be living in groups. Hans Kummer, a leading primatologist, has stated, "...primates seem to have only one unusual asset in coping with their environments: a type of society which, through constant
Page 24 association of young and old and through a long life duration, exploits their large brains to produce adults of great experience. One may, therefore, expect to find some specific primate adaptations in the way primates do things as groups" (1971, pp. 37-38). In several experiments using a small South American primate, the squirrel monkey, we have found that group living can serve to reduce the individuals hormonal responses to events outside the group (Vogt et al., 1981~. Animals in groups communicate, and communication about available resources facilitates the survival of all group members. In addition, one of the primary adaptive functions served by groups is that gregarious animals are better at discovering, mobbing, and chasing a predator than single individuals. Further, by existing in a stable social situation in which it is possible to rely on the reactions of familiar social partners, the individuals may also show a reduced stress response. Nonhuman primates generally exhibit strong behavioral reactions indicative of fear when exposed to a snake or snake-like object (Vogt et al., 1981). In order to determine whether a group could serve as an effective modulator of stress responses, we exposed squirrel monkeys to a live boa constrictor, which was presented above their cage in a wire mesh box. Monkeys living in social groups consisting of males and females were exposed to the snake for 30 minutes while in a group, and also after being removed from the group and placed in an individual cage. An empty box, similar to the one containing the snake, was placed on top of the monkeys' cage on different days to control for the effects of general disturbance. All of the monkeys showed increased vigilance, agitated activity, and total avoidance of the stimulus box when the snake was presented in either the group or individual condition. However, while the presence of the snake
Page 25 consistently produced a behavioral response, it did not elicit adrenal activat on in the monkeys when they remained in the group. Thus, it did appear that the social group could reduce the physiological response to a potentially threatening stimulus. Of equal importance was the fact that when the monkeys were separated from the group and placed in an unfamiliar cage, they showed striking elevations in plasma cortisol which were as great as those produced by exposure to the snake while alone. Whether these elevations in plasma cortisol following removal from the social group represent a response to loss of social partners or a response to novelty was difficult to specify in this experiment, but it is clear that-the individual is much more prone to stress following disruption of group integrity. In additional experiments, we have subjected animals living in social groups to a variety of potentially stressful stimuli, such as a strange mobile robot, an unfamiliar nonspecific, loud noise, etc. In none of these conditions while the animals were living as a group in their home environment were we able to elicit a pituitary- adrenal response . In a further study, social buffering, the apparent capacity of group membership to reduce adrenocortical responses to stress, was investigated in squirrel monkeys using a conditioning paradigm which involved classical conditioning or cortisol secretion. Adult males were assigned to two groups: one group received pairing of conditioned stimulus (CS) with footshock; a control group received the conditioned stimulus without shock. All animals were then tested with presentations of the conditioned stimulus without shock under three social housing conditions. In four successive phases of the experiment they were tested either individually, as dyads, or within a social group, and then retested when housed individually. Neither group showed a cortisol response to the CS
Page ~5 prior to training. Following training, CS-evoked elevations of cortisol were found only in individually-housed animals. Animals housed in a group did not show the cortisol response elicited when individually housed. These results are consistent with the findings discussed above that the presence of familiar conspecifics can ameliorate a neuroendocrine response to psychological stress (Stanton et al., 1985~. One of the important aspects of social support systems which differs from ordinary coping mechanisms is that these systems do not require the organism to deal directly with the aversive event, per se. How then is it possible to fit the data on social support within the general context of the propositions that uncertainty leads to an activation of the pituitary-adrenal response, and that reduction of uncertainty reduces or eliminates this response? Cobb (1976) discusses social support as a moderator of life stress and sees it as providing information that falls into three categories. The first leads the subject to believe that he is loved and cared for. The second leads a person to have higher self-esteem as a result of public expression of approval. The third is the perception of social congruity derived from a shared network of information and mutual obligation in which each member participates, and the common knowledge is shared and accepted by all. It is possible to speculate that all three types of information derived from social support serve to minimize an individual's level of uncertainty about the situation. Thus, the availability of stable and familiar social relationships can provide a set of predictable outcomes due in part to the long history of previous interaction and experience.
Page 27 These hypotheses would lead to the prediction that an unfamiliar social group would provide none of these beneficial features and, in fact, would constitute a condition of high uncertainty and therefore lead to an elevation of pituitary-adrenal activity. In adult organisms, we have also found that one of the most reliable elicitors of increased pituitary-adrenal activity is the formation of new social groups. We have demonstrated in several experiments that there is a a striking elevation of plasma cortisol when animals are placed in a new social group and, in fact, this elevation of cortisol can continue for several months (Coe et al., 1983a; Gonzalez et al., 1981~. CATECHOLAMINES Thus far, we have emphasized the importance of psychological factors in regulating one of the major stress responses to the pituitary-adrenal system. However, there is extensive literature on changes in peripheral and central noradrenergic systems during exposure to various stressors. The purpose of this report is not to review the data on catecholamines, but to attempt to further develop the hypothesis that various physiological systems respond specifically to psychological conditions, and that the psychological conditions required for the elaboration of one endocrine response are not the same as those required for other endocrine responses. The only way to examine specificity is when several hormone systems are examined within the same experimental paradigm. Thus, it becomes possible to determine whether both hormone systems are responding to the same stimuli or whether there are different responses depending on the psychological conditions.
Page 28 Several experiments have examined both plasma catecholamine and corticosterone changes. In a recent study, Swenson and Vogel (1983) studied these systems in rats that were exposed to footshock under two conditions. In the first condition the animals were able to escape the footshock, whereas in the second condition the shock was inescapable. Several measures were taken in this study, which included peripheral and central catecholamines as well as corticosterone. For this report, however, we will examine only the corticosterone response and the plasma epinephrine response during shock and only for the 30 minutes the animals remained in the apparatus after the shock was terminated. In this particular experiment, both plasma epinephrine and corticosterone were elevated after footshock. The only significant difference between these two measurements was that, while the catecholamine response was diminished 30 minutes after the termination of shock, plasma corticosterone tended to remain elevated. Based on this experiment, catecholamines and plasma corticosterone appear to reflect, with only a minor difference, similar response characteristics to the presence of footshock. However, there are several studies indicating that the pituitary-adrenal response and the catecholamine response are indeed very different. In the study of men going through paratrooper training (Ursin et al., 1978), both plasma cortisol and urinary epinephrine were examined during the course of the training. The plasma cortisol was rapidly reduced to basal levels after the first jump off the tower. However, although the magnitude of the epinephrine response was also diminished after repeated jumps, there was still a significant elevation of epinephrine even at the last jump, whereas the response of the pituitary-adrenal system had long ceased to be significant. Utilizing different
Page 29 experimental paradigms, Frankenhaeuser (1980) studied urinary catecholamines and cor~cisol in subj ects who performed a choice reaction task at Ache individual ' s preferred pace. The data indicated that under these conditions, both epinephrine and norepinephrine were significantly elevated above baseline, whereas cortisol was significantly reduced. Thus, as in the study on paratroopers, a presumed dissociation between the pituitary-adrenal response and the response of the catechol~mine system is evident. Finally, Dantzer and Mormede (198S) demonstrated once again a dissociation between indices of catecholamine activity and the activity of the pituitary-adrenal system. Thus, animals exposed to footshock were compared with animals that were permitted to exhibit aggressive behavior when the footshock was presented. Weinberg and Levine (1980) previously reported that the ACTH response in animals that were shocked and fought, compared with those only shocked, was significantly reduced in the fighting animals. Dantzer and Mormide report that plasma corticosterone was also significantly reduced in animals tested after a repeated series of electric shocks when fighting was permitted. The animals not permitted to fight (controls) showed no such reduction. However, when catecholamine activity was examined via tyrosine hydroxylase, the tyrosine- hydroxylase was significantly elevated in fighting animals compared with control animals. Although Dantzer and Morm~de present these data as an apparent paradox, T believe this can be resolved if the catecholamine response is based on a set of psychological events different from those regulating the corticosterone response. Thus the catecholamine response seems to be more in tune with processes related to attention and vigilance; i.e., when the task requires the subject (human or animal) to be vigilant and attentive to specific stimulus
Page 30 events, the c.atecholamine response appears to be elicited. On the other hand, due to the reduction of uncertainty in response to the information gained by repeated exposures, the cortisol response tends to be diminished. How then do we resolve the results of the above-described experiments with the results reported by Swenson and Vogel (1983)? It can be argued that during the initial phases of any stressful experience (those closely related to the alarm reaction of Selye, 1936), many systems operate simultaneously. Thus, arousal is increased as a result of uncertainty and, in the case of catecholamines, attention and vigilance are hypothetically increased. However, when the subject is given repeated experiences in which feedback information is presented and coping mechanisms are evoked, the response of the pituitary-adrenal system either diminishes or ceases. In contrast, it is assumed that these systems still require some attention and vigilance on the part of the subject, and therefore the catecholamine system continues to be responsive. STRESS AND PERFORMANCE Any attempt to discuss the broad range of effects of stress on performance, both in animals and humans, would clearly represent a limited view of what is an extensive area ranging from performance in laboratory animals to industrial productivity. Any discussion of the effects of stress and performance must discriminate between two classes of events: those which involve the proactive effects of stress on performance, that is, the effects of some prior stressor on subsequent performance characteristics, and those which are inherent in the task itself. Although we can arbitrarily view these as different phenomena, they do have many characteristics in common. The notion that continued exposure to a
Page 31 stressor may produce effects that appear only after the stimulation is terminated have been prevalent in the stress literature for many years. This assumption is derived principally from an adaptive cost hypothesis which suggests that, although humans and animals can often adapt to extreme conditions, there are cumulative costs to that adaptation. An early form of this hypothesis which emphasizes the biological cost of these adaptive processes was offered by Selye (1956), who proposed that after prolonged exposure to a stressor, one's adaptive reserves are drained, resistance breaks down, and exhaustion sets in. Others (Basowitz, et al., 1955; Dubos, 1965; Milgram, 1970; Wohlwill, 1966) make-similar points with regard to the poststressor effects on behavior. Dubos states, "Although man is highly adaptable and can therefore achieve adjustments to extremely undesirable conditions, such adjustments often have...indirect effects that are deleterious" (1968, p. 139~. Consistent with our previous views concerning the importance of control in reducing uncertainty, and thus resulting in effective coping, one common characteristic which pervades the literature on the aftereffects of stress is that the stress normally involves prior exposure to uncontrollable noxious events. Thus, if control is biologically important to organisms, its absence may be viewed as deleterious. The most important contribution to this hypothesis has derived from relatively recent literature which has been conducted within the framework of the Learned helplessness hypothesis. In this section, we will attempt to review the effects upon subsequent learning and performance "proactive effects which have been pursued within the context of testing learned helplessness theory. In the classic proactive interference experiment, Overmier and Seligman (1967) studied the effects of exposure to inescapable shock on subsequent avoidance
Page 32 learning in dogs. They- began by placing naive animals in a restraining hammock enclosed in a sound-attenuated cubicle. The dogs received 64 5-second electric shocks of moderately high intensity delivered on the average of 1/minute. After 24 hours the animals were then placed in a standard two-way shuttle-box apparatus (designed to test conditioned avoidance learning) and given signal avoidance training. The basic observation was that the dogs pretrained in the hammock with inescapable shocks later failed dramatically in this avoidance task, a task which is learned relatively easily by animals not preexposed to the uncontrollable stress. There were three features prominent in this failure to learn: (1) in addition to not learning to avoid, these animals also did not learn to escape a moderately intense shock; (2) even when the occasional escape response or avoidance response did occur, it did not lead to an increased probability of future escape-avoidance behavior, contrary to a pattern observed in normal dogs; (3) the dogs appeared passive, showing much less persistence in struggling and vocalization in the continued presence of the shocks than did naive dogs. However, it became very clear that this was a robust phenomenon and one which not only was specific to the failure to avoid an electric shock, but appeared to have much more general effects on performance. What was important in these studies was that the prior exposure to shock was uncontrollable. Seligman and Maier (1967) demonstrated that uncontrollability of the pretreatment shocks caused the interference effect by comparing two groups. One group received a series of escapable shocks; the second group received a series of inescapable shocks, the duration of which was determined by the first group, i.e., this group was "yokedn to escape subjects. The addition of a third group, naive with respect to shock, into the treatment phase constituted what is now called the triadic design. It
Page 33 was determined that the group which received inescapable shock, even though the duration of the shock was identical to those that escaped, were the group which showed the most profound proactive interference. Thus far the discussion has been limited to instances of exposure to inescapable shock in one situation and disrupting shock-produced Performance in another. One concern is how general such phenomena might be with respect to other combinations of both aversive and positive events. We can observe that four classes of interaction may exist. The shock-shock interaction is a special case of one of these; in particular, of the interaction between the experience of one aversive event, and learning based on the second aversive event. If one substitutes events of two different hedonic qualities, positive or negative, for either the first or the second event, four classes of interaction can be obtained in which the exposure to uncontrollability might modulate subsequent performance. These are shown in Table 1. Furthermore, within the aversive-aversive category, similar effects of uncontrollability can be found when stimuli other than electric shock are utilized. This is clearly relevant to the human performance field, where most of the stressful events would indeed not be restricted to the laboratory model of stress-shock. An example of the substitutability of uncontrollable aversive events on performance under different aversive conditions was provided by Altenor et al. (1977). In this experiment, a group of rats were initially exposed to either footshock or submerged in very cold water. For half the rats exposed to each aversive condition, the event was either escapable or inescapable. Ultimately, half of each of these groups were tested in an avoidance task for shock-escape learning, while the other half were tested in an underwater maze for water-escape
Page 34 learning. The subjects from each of the inescapable treatment conditions were significantly impaired for performance on the test task than the corresponding escapable pretreatment groups. Of more importance is the fact that the magnitude of the aftereffects appeared no smaller when the aversive stimuli were different in the pretreatment tests than when they were the same. Rosellini (1978) has reported an experiment which demonstrates the aversive-appetitive interaction. In two experiments, prior exposure of rats to inescapable shock interfered with the subsequent learning to press a lever to earn food in the second chamber. With respect to the appetitive-appetitive class of interactions, Welker (1976) and Wheatley et al. (1977) have presented two examples, the first with pigeons, and the second with rats. In both experiments, three groups differing in their initial treatments were used: (1) a response-dependent reinforcement group; (2) a matched group which received reinforcers independently of behavior; and (3) a naive control group. After several sessions with the initial treatment, all groups were required to perform a different task to obtain reinforcers. In both experiments the group initially exposed to the response-independent uncontrollable food presentations were very much slower to learn the required response. Even recognizing the powerful effects that stem from exposure to noncontrollable events, the class of interactions that has produced the most surprising results is the appetitive-aversive one. Rosellini and Bazerman (1976), for example, found that rats exposed to 17 days of noncontingent food deliveries were significantly impaired relative to control groups in shock-escape responding in a shuttle-box. Others have obtained results congruous with these (Goodkin, 1976; Wight and Katzev, 1977~. The effects of experience on controllability must be powerful indeed for initial appetitive treatments to result in interference with escape from life-threatening stimuli.
Page 3 5 STRES S AND PERFORMANCE IN TITANS That the effects of uncontrollable events are obtainable across all classes and combinations of both positive and aversive events attests to the broad generality ant biological significance of uncontrollability as a behaviorally debilitating experience. It is not surprising, therefore, that a phenonemon which has such a broad generalization within the animal literature should also have received substantial verification in the human literature under both experimental and naturalistic conditions. However, it is relatively recently that the first experimental studies of the post-exposure effects of stress on behavior were reported (Glass and Singer, 1972). Based on previous research which demonstrated that the ability (or perceived ability) to predict or escape an aversive event reduced both the aversive quality of the stimulus (Corah and Boffa, 1970; Pervin, 1963) and the resultant physiological response (Champion, 1950; Corah and Boffa, 1970; Stotland and Blumenthal, 1964), these workers hypothesized that performance following stress exposure may be similarly mediated by stressor predictability and perceived control over stressor determination. Glass and Singer's original work was influenced by the adaptive cost hypothesis. They suggested that detrimental effects on performance following exposure to unpredictable uncontrollable stressors, (which occur due to the substantial effort required to adapt to these aversive events) would leave one less able to cope with subsequent demands and frustrations, because predictable and controllable stresses were viewed as less aversive adaptations of these stresses, would presumably require less effort and, therefore, would be less likely to impair post-stimulation performance. Although the adaptive cost hypothesis did
. Page 36 not prove to be tenable, Glass and Singer did conclude on the basis o. their work that exposure to unpredictable uncontrollable stress produces post-et maiation deficits in performance on a number of tasks, and that the ability to predict and control stressors ameliorates these deficits. It is not the purpose of this report to comprehensively review all of the studies that have shown deficits in some aspect of performance as a consequence of prior exposure to uncontrollable and unpredictable stress. However, some examples of the type of research conducted in this area and a review of the findings would suffice. Using noise as a stressful stimulus, Glass and Singer (1972) reported a number of studies that examined post-stimulation effects after exposure to unpredictable uncontrollable noise (pp. 47, 50, 52, 55, 80). These studies typically involve approximately 25 minutes exposure to 108-110 dB random intermittent bursts of broad band conglomerate noise made up of a number of typical urban sounds. During noise exposure, the subjects worked on simple cognitive tasks. Autonomic response was monitored during stressor exposure. Immediately after noise exposure, one or more of three measures were administered to the subject: tolerance for frustration tasks (Feather, 1961), a proof-reading task (Glass and Singer, 1972), and the Stroop (1935) Color-Word task. The Feather test requires a subject to work on two soluble and two insoluble line puzzles for 15 minutes. The subject can only work on one puzzle at a time and cannot return to a puzzle after moving on to the next. The puzzles are presented so that the first and third are insoluble and the second and fourth are soluble. The criterion measure for amount of tolerance of frustration is the number of trials, puzzle cards, or amount of time spent on insoluble puzzles. The proof-reading task involves correcting misspellings, grammatical mistakes,
Page 37 incorrect punctuations, transpositions, and typographical errors. Each subject is usually given 8-15 minutes, and the quality of performance is measured as the percentage of errors not found out of the total number of errors that could have been detected at the point the subject was told to stop. In the S troop task, the stimuli are names of four colors--green, red, orange, and blue--each of which is printed in one of the other three colors. For example, the word green may be printed in red, orange, or blue. The four color words are randomly presented over a series of trials, and the subject is asked to name the color and the word which is printed. The control version of the task, in which the subject is required to name the colors of a set of asterisks or zeros, is also administered to each subject. Stroop interference scores on accuracy and speed are obtained by subtracting the subject's score on the control stimuli from the subjects's Stroop scores. Post-stimulation deficits in performance occurred in all of the studies in all three of the tasks. The data presented by Glass and Singer appear to be highly reliable and have been replicated by several other authors (Gardner, 1978; Rot ton et al., 1978; Wohlwill et al., 1976). Although the Glass and Singer research suggests that post-stimulation effects occur only following unpredictable noise, at least two studies reported similar deficits following exposure to high intensity steady-state continuous noise. Such steady-state continuous noise presumably does not have unpredictable components (Broadbent, 1979; Hartley, 1973). Thus, the data on post-stimulation effects of noise producing deficits on performance appear to be consistent for variable continuous and steady-state continuous noise, as well as for unpredictable noise. .
Page ~ 8 Although noise has received a cons iderable amount of attention in the experimental literature (due to the ability to control this particular variable more closely than others), there is evidence that other stressful conditions do produce post-exposure effects. Studies have indicated that subjects who have experienced high taskload perform more poorly following task completion than those who have been exposed to low taskload. Cohen and Spacapan (1978) found in a forced reaction time experiment that those required to respond to 100 lights/minute had less tolerance for frustration following task completion than those responding to 50 lights/minute. Hartley (1973) reports that those required to perform a serial reaction time task for the first 20 minutes of an experiment perform more poorly on the same task in the last 20 minutes than those who simply read during the initial phase of the study. Rotton et a1. (1978) found that the subjects who expected to be required to recall a speech, even though never actually required to do so, showed lower tolerance for frustration following task completion than those subjects not expecting a recall test. Crowding also appears to effect subsequent performance and to produce post-exposure deficits. Studies on the effects of crowding on human behavior have found it necessary to distinguish two kinds of crowding conditions: spatial density and social density. Spatial density is manipulated by varying available space but keeping the number of people constant; social density is manipulated by varying the number of people occupying a fixed quantity of space. As an example of the aftereffects of spatial density, Sherrod (1974) had groups of female high-school students perform a number of tasks in either a large or a small room. After 1 hour of exposure the subjects were moved into a larger area. Each student was then tested at her own desk on tolerance for frustration at a
Page 39 proof-reading task. Those subjects who had been working in a high-density small room showed less tolerance for frustration than did their low-density large room counterparts. However, there were no differences on the proof-reading task. Some of the post-crowding deficits varying spatial density have been reported by Evans (1979) and Aiello et al., (1977). The existing studies in which spatial density was varied indicate that exposure to high-density conditions produced post-exposure deficits on the limited number of tasks investigated. However, the few studies which have varied social density provide evidence indicating that, although social density may produce post-stimulation deficits on performance, these effects interact with a number of other variables. Saegert et al. (1975) required male and female subjects to do a number of tasks in a railway station during crowded and uncrowded times of the day. Whereas females who had been exposed to high levels of density performed more poorly on the Stroop test than did their low-density counterparts, males performed better after high than after low density. Glass and Singer also have reported that there are post-exposure deficits in performance following a variety of other stressful conditions, which include electric shock, a frustrating experience with a bureaucracy, and an experience of arbitrary or sex discrimination. The previously cited studies provide evidence for both the reliability and generality of the post-exposure effects of stress on performance. These effects have appeared in the vast majority of studies and these studies have used a wide range of stressors. The data suggest that the effect is most likely to occur when the stressor is clearly unpredictable and when a sensitive aftereffects measure is used. Moreover, the factors that might mediate the stressfulness of the situation, i.e. , subject gender, perception of
Page 40 control, individual need for personal space, all appear to be important determinants of whether a particular manipulation will produce a significant deficit in subsequent performance. Within the context of coping theory, control, predictability, and feedback are considered to be important psychological dimensions which lead to a reduction in the psychological and biological responses to stress. The data in the stress and performance field are almost unanimous in supporting the role of both perceived and implemented control in ameliorating the post-exposure effects of the stressful experience. In some cases, groups with control performed as if they were not exposed to a stressor (Gardner, 1978; Glass et al., 1973); whereas in others, Sherrod et al. (1977) control provided some improvement in the post-stress task performance but did not completely ameliorate the effect. What does appear to be particularly cogent is the control, or perceived control, over the termination of the stress. There is a single study that indicates that initiation control, that is, the ability to control the onset of the stress, similarly produces an amelioration of the post-stress performance deficits. Providing someone with more than one kind of control does appear to be more effective than only having control over termination of the stressors. The role of predictability in reducing the aftereffects of stress has not received much attention, although the existing evidence does indicate (Glass and Singer, 1972) that the post-exposure deficits in performance are more likely to occur following exposure to an unpredictable, rather than to a predictable stress. In view of the abundance of data produced experimentally indicating post-exposure effects on subsequent performance, it is not surprising that investigators have also studied the effects of these stressful experiences in
Page 41 more naturalistic settings. Several investigators have studied the effects of long exposure to community noise on the performance of elementary school students. In one exemplar study, Cohen et al. (1973) tested children living in an apartment building built on bridges spanning a busy expressway. When tested in a quiet setting, children who lived in noisier apartments showed greater impairment of auditory discrimination and reading ability than those who lived in quieter apartments. The length of time in residence increased the magnitude of the correlation between noise and auditory discrimination. A subsequent study of children attending school in the air corridor of a busy metropolitan airport (Cohen et al., 1980) indicated that children living and attending school in the air corridor were poorer on both a simple and a difficult problem-solving task and were more likely to give up the task than their quiet-neighborhood controls. There are several studies which have also investigated the naturalistic effects of crowding. Rodin (1976) reported that 6- to 9-year-old children from high-density apartments of a low-income housing project were less likely than children from less dense homes in the same-project to control (choose) their own outcomes on a reward task. In a subsequent study, 8th grade children from high-density apartments were more adversely affected by a learned helplessness pretreatment (insoluble puzzles) than were their low-density counterparts. These effects persisted even after statistical control for social class and race were used. Although these naturalistic studies on crowding do not specifically address the issue of stress on performance, they do indicate chronic effects of crowding on certain aspects of human behavior.
Page 42 1'~ summary, the following conclusions can be generated from the material weigh we have just reviewed on the post-exposure effects of stress on performance. (1) The post-exposure effects of unpredictable uncontrollable stress on performance have been replicated in many different laboratories and with a variety of subject populations. They occur as a result of a wide range of stressors, such as noise, electric shock, social density, etc. Interventions that increase control and predictability are effective in reducing these effects. However, it is important to note that the laboratory research has used a limited number of tasks with which to measure the post-exposure effects on performance. (2) Post-exposure effects of environmental stresses occur following prolonged exposure in naturalistic settings. These studies have suggested that the effects are mediated by helplessness. However, the studies in naturalistic settings--particularly those related to crowding--are not specifically directed toward performance deficits. (3) There is evidence that various forms of control have ameliorative effects similar to those of perceived control over the termination of the stressor. These include termination control, in which one actually performs a coping response, as well as initiation, choice, and information control. There is some evidence to suggest that combining more than one form of control will further improve post-exposure performance. This improvement, of course, cannot exceed the performance level reached by the no-stress conditions. Thus far, most of the data we have presented in this report on the relationship between stress and performance indicates that stress has a negative effect and results in performance decrements. However, it would be erroneous to conclude that there is always a negative relationship between stress and
Page 43 performance. Hennessy and Levine (1979) presented a comparison between the concepts of stress and arousal and concluded that the concept of stress might be subsumed under the umbrella of arousal theory. Both stress and arousal can be considered as representing a "state phenomenon" referring to the tonic nature of the effects. A distinction has been drawn between stimulus response (SR) or motor systems with direct pathways through the brain, and "state" or arousal systems with diffuse central nervous system connections (Groves and Thompson, 1970; Thompson and Spencer, 1966). This proposition was derived from the results of studies of response plasticity within SR systems; when a motor response is evoked, SR and arousal systems are activated. The two types of systems appear to be independent, yet interaction is possible. One of the most pervasive findings in the literature with relationship to arousal and performance is that these relationships are curvilinear--that the relationship between arousal and performance is characterized by a U-shaped function, rather than being monotonic. One of the earliest studies to show an inverted U-shaped curve between stress and performance was that of Yerkes and Dodson (1908) who found that when animals are exposed to electric shock of medium intensity, they made fewer errors in learning than they did when exposed to weaker or stronger shocks. Finan (1940) also found that equated groups of rats deprived of food for 1, 12, 24 and 48 hours showed differences in conditioning strength in a Skinner apparatus when conditioning strength was measured in terms of extinction. The optimal deprivation interval was 12 hours. Conditioning strength was less for intervals shorter and longer than the optimal. Levine (1966) also reported a study in which, as electric shock increased in an avoidance learning paradigm, the ability of the animals to learn declined beyond
Page 44 optimal levels of the unconditioned stimulus electric shock. Within the human literature, Freeman (1940) studied reaction time in palmer conductance, an index of autonomic activity. Over a period of many days, 100 measures of palmer conductance and reaction time were taken. When the pairs of values were plotted, an orderly function appeared. Low palmer conductance (thus, less autonomic activity) was associated with slow reaction times, and high conductance was associated with fast reaction times. However, beyond the optimal range of palmer conductance, reaction time once again became slower. Thus, we have the classic demonstration of the relationship between arousal and performance, in this instance reaction time, resulting in the U- or inverted U-shape function. Reviewing all of the literature on U- or inverted U-shaped functions would represent another volume. The inverted U-function has been one of the most robust in the psychological literature. Classical activation theorists, such as Duffy, Lindsley, and Hebb have all stressed the importance of this curvilinear function. It is of interest that Pavlov in his writings contained reference to this phenomenon: "For every one of our animals [dogs] there is a maximum stimulus, a limit of harmless functional strain, beyond which begins the intervention of inhibition [the rule of the limit of intensity of excitation]. A stimulus, the intensity of which is beyond that maximum, instantly elicits inhibition, thus distorting the usual rule of the relationship between the magnitude of the effect and the intensity of excitation; a strong stimulus may produce an equal and even smaller effect, than a weak one..." (Pavlov, 1930, p. 213, quoted by Malmo, 1958). Given the robust relationship between arousal (stress) and performance, it would certainly be erroneous to assume that stress invariably leads to a decrement in performance. There is clearly some optimal
Page 45 level of arousal which is required for organisms to perform. What is also apparent, however, is that beyond this optimal level of arousal, performance decrements are indeed the rule. However, perhaps the most difficult issue concerning the relationship between stress and performance emerges from the U-shaped relationship between arousal and performance. Individual differences in response to stress, both physiological and behavioral, emerge throughout all of the studies on stress and performance. It would appear, therefore, that what would be an optimal arousal level for one individual may indeed be detrimental to another. The number of variables which contribute to the marked individual differences in optimal arousal levels are perhaps the most difficult to specify. As mentioned previously, there are gender differences. In addition, prior experiences with either controllable or uncontrollable stressful events certainly appear to affect the relationship between stress and performance. There is a large literature which indicates that experiences occurring early in development can also markedly affect the relationship between stress and performance. Further, there is recent evidence that indicates that there may be strong genetic factors determining the response characteristics of individual organisms to stressful stimuli. Perhaps the only generalization that one can make is that individual differences pervade every step in the process of stress arousal/reduction. Lazarus (1974) has repeatedly stated that at the level of a specific individual, the problem is to determine what kind of stress evokes what kind of stress response in what kind of person. What does emerge from the theoretical considerations presented here and from the experimental data on the biological and behavioral consequences of stress, is that control is a major mechanism by which organisms can effectively deal with
stressful conditions; and that the absence of control or loss of control can indeed have profound and pe.~'anent effec variety of tasks. Page 46 ts on individual performance on a wide
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Page 6i TABLE 1 Classes of Proactive Interaction Experiments, Including Exemplars (Overmier et al., 1980) Controllable Event in Learning Test Uncon- trollabie Event in Pretreat- ment . .. ~ Avers ~ ve Appetitive Porsolt, Le Pichor~ Rosellini (197B) and Jalfre ~1977 Altenor, Kay and Richter (1977) Payne, Anderson and Mercurio ~1970) ~ _ Wight and Katzev Rhue and Brown (1978 (1977) Walker (1~976) Rose llini arid Bazerman ~1976 _ Goodkin ~ ~ 976) Aversive Appeti tive ....
- ~~ Stress Reduction Programs Raymond W. Novaco University of California, Irvine
Table ofContents 1. Inwoduc~on.... 2. O,re~ew of the Stress Field 3 A . H u m an Stress: C onceptual Fra ~ e w ark . . . . . . . . . . . ..... . . . 4 B . S tress R esponses C. S=ess as a Concern for the ~i~itary 8 .13 3. Military Soci~1i~a~on and the Ethos of Trainis~g 16 4. Determinanes and Media~cors of Stress in Mi~itary See~ngs A. Environ m ental C ontex~c .20 B. Cogni~ve Processes ~ 25 C . B ehawor P a~cte rns and C oping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 0 D. SocL~ Condi~ons . E. Organiza~onal Factors. 5. S=ess Reduc~on A . Arousal R educ~on . 31 B. Cogni-veInterven~ons C . B eha~rioral C oping S~i'3 ~ . D. S=essInocula~on 6. U~li~ation of Stress Reduction in blilitary Con~cex~cs A. C~nicalLntervenaons 51 B. Expe~men ~ Pro~rams 7. Prosptc" forImplementa~on. ~ _ 8. References.
Stress Reduction 2 reduction methods, such as deep muscle relaxation (which has a distinct effect in lowering blood pressure), have limited, if any, utility for recruits in boot camp. Recruits, who have virtually every minute of the day programmed and very little privacy at any time, do not have the opportunity to engage in muscle relaxation procedures. Similarly, a principal means of stress reduction is to limit one's exposure to environmental demands. Recruits, however, have little control over the demands placed upon them and furthermore have a narrow range of behavioral options for responding to those demands. Such constraining conditions in training environments do not only affect recruits. The duty requirements for drill instructors and unit officers will curtail the extension of stress reduction strategies that are otherwise useful for civilians. This is not to say that methods of tension reduction have no applicability, to clarify the point of this example. Indeed, they may be quite valuable. But instead of muscle relaxation, hypnosis, or biofeedback procedures, something more suitable to the context and population must be formulated. This might involve training groups how to self-monitor physiological arousal and disruptive emotion, combined with their physical fitness routine and methods. Although we know a considerable amount about the determinants of stress and a fair amount about how to remediate stress (the causal processes do remain a puzzle), the implementation of interventions in a complex organization with idiosyncratic characteristics requires recognition of the circumstances that will limit the utilization of the advocated procedures. When it can be recognized that behavioral coping options are restricted, as they surely are in military organizations and on military missions, then emphasis must be placed on cognitive coping strategies. Likewise, when it can supplemented with deep breathing and usual imagery )
Stress Reduction in Military Settings Problems of stress, coping, and adaptation are highly relevant to the performance of military personnel. Military environments from recruit training to conditions of warfare engender stress and require adaptive coping skills to ensure optimum performance. Stress reduction strategies, therefore, offer the prospect of enhanced performance under circumstances of adversity, as well as promoting the health and well-being of military personnel. The topics of stress, performance, and well-being are engaging not only because they are prominent topics of contemporary psychological research, but also because they have become preeminent concerns of work organizations. Many volumes have appeared on the subject of occupational stress, which vary from edited scholarly collections to practical guidebooks on how to cope with stressful jobs. Moreover, abounding programs have been sold to corporate industry on "stress management" (The Wall Street Journal, 1982). Unfortunately, the many formulas offered for reducing job stress are much stronger in marketing accomplishment than in substantive product. Yet, the contemporary sensitization to stress is more than faddish self-indulgence by our society. There is ample evidence linking occupational demands and circumstances of strain to health impairments and performance decrements. However, while much is also known about stress reduction, its programmatic application in an organizational context presents multiple challenges. The unique aspects of military life and the special characteristics of military environments, such as recruit training and officer training, call for careful thought in applying knowledge about stress and stress reduction. Strategies and procedures that are appropriate for civilian life may not at all be feasible or useful in military contexts. For example, tension
Stress Reduction 2 reduction methods, such as deep muscle relaxation (which has a distinct effect in lowering blood pressure), have limited, if any, utility for recruits in boot camp. Recruits, who have virtually every minute of the day programmed and very little privacy at any time, do not have the opportunity to engage in muscle relaxation procedures. Similarly, a principal means of stress reduction is to limit one's exposure to environmental demands. Recruits, however, have little control over the demands placed upon them and furthermore have a narrow range of behavioral options for responding to those demands. Such constraining conditions in training environments do not only affect recruits. The duty requirements for drill instructors and unit officers will curtail the extension of stress reduction strategies that are otherwise useful for civilians. This is not to say that methods of tension reduction have no applicability, to clarify the point of this example. Indeed, they may be quite valuable. But instead of muscle relaxation, hypnosis, or biofeedback procedures, something more suitable to the context and population must be formulated. This might involve training groups how to self-monitor physiological arousal and disruptive emotion, combined with their physical fitness routine and supplemented with deep breathing and usual imagery methods. Although we know a considerable amount about the determinants of stress and a fair amount about how to remediate stress (the causal processes do remain a puzzle), the implementation of interventions in a complex organization with idiosyncratic characteristics requires recognition of the circumstances that will limit the utilization of the advocated procedures. When it can be recognized that behavioral coping options are restricted, as they surely are in military organizations and on military missions, then emphas is must be placed on cognitive coping strategies . Likewise ~ when it can )
Stress Reduction 3 be determined that modifiable factors in the social environments of organizational units have powerful stress-inducing effects, it is not prudent to rely on person-based, intrapsychic stress reduction approaches. The organizational mission of the military is combat. That, of course, involves stressful conditions. Consequently, it might seem odd to suggest that stress be lowered for military personnel in their training. A critic here might ask, "How can soldiers be prepared for combat if they do not know how to deal with stress, and how can they learn how to deal with stress if they are not exposed to it?" The succinct reply involves a conceptual clarification, namely that stress can be understood as a state of imbalance between environmental demands and resources for coping. Therefore, stress can be mitigated by augmenting coping skills. When environmental demands or pressures are a given inevitability, stress can be reduced nonetheless by enhancing the person's cognitive, behavioral, and social resources for coping with the stressors. An overview of the stress field and an elaboration of the above concept will be set forth in the next section, which will discuss determinants and mediators of stress in environmental, cognitive, behavioral, and social domains. Given the scope of this paper, coverage of these areas will necessarily be abbreviated. The aim will be to provide a basic conceptual background for what is to be presented on stress diagnostic procedures, stress reduction, and prospects for implementation in military settings. OVERVIEW OF THE STRESS FIELD Contemporary research on human stress tracks a number of main areas of investigation, these being (a) conditions of the physical and social environment that function as stressors, (b) stressful life events and the
Stress Reduction 4 moderating influences of supportive relationships, (c) physiological processes and health impairments that accompany and follow from the experience of stress, (d) cognitive and personality mediators of stress, (e) processes of coping and adaptation; and (f) stress reduction strategies. Each of these areas is relevant to military settings and the well-being of military personnel. In order to present a coherent synopsis of this vast literature in such a broad field, a theoretical framework will be set forth witch its guiding concepts . Human S tress: Conceptual Framework The field of human stress contains many contextually focused theories or models. Some examples are those concerned with stressful life crises (Dohrenwend, 1978), attention overload and task performance (Cohen, 1978), perceived controllability of stressors (Glass & Singer, 1972), person- environment congruence (Stokols, 1979), physiological mechanisms and disease (Levi, 1974; Selye, 1976), the regulation of emotion (Novaco, 1979), and coping processes (Lazarus & Launier, 1978; Pearlin & Schooler, 1978). Although there is no single, all-embracing theory of stress to adequately represent and explain the diversity of phenomena studied in stress research, a basic model can be set forth that is compatible with the preponderance of existing theory. This was attempted by Novaco and Vaux (1985), ant the basic propositions of that model will guide this paper. The concept of stress, as a condition of the organism or system that constitutes a state of imbalance between demands and resources, is defined by relationships between environmental demands (stressors) and adverse health and behavioral consequences (stress reactions) resulting from exposure to those demands. The association between stressors and stress reactions is not l )
Stress Reduction ~ uniform, as it is mediated by cognitive, behavioral, and social factors which influence whether environmental demands function as stressors and also influence the course of stress reactions. Importantly, environmental conditions and person characteristics/behaviors are thought to be reciprocally related in ongoing processes of stress and adaptation. The general model of stress (Novaco ~ Vaux, 1985) can be understood in terms of its basic postulates given below with brief elaborations. The central propositions pertain to the sources of stress, impact mechanisms, mediational factors, and transactional influence processes. 1. Stress is induced by environmental demands that exceed coping resources, thus disturbing homeostatic balance. Environmental demands or nstressorsn are elements or conditions of environmental fields that require an adaptive response from the organism or system. The stress inducing potential of environmental demands is a function of their potency and persistence. Potency refers to the degree of disturbance caused to homeostatic balance as a result of a stressor's intensity, severity, and multiplicity. Persistence refers to the temporal exposure to the stressor in terms of its frequency and duration. 2 . S tress is manifested by adverse cognitive, behavioral, and physiological consequences resulting from the exposure to environmental demands . Stress reactions consist of physiological disturbances, negative affect, and impairments to cognitive and behavioral functioning. Stress reactions vary in their magnitude and extension, which determine their severity. Magnitude refers to the degree of homeostatic disturbance and impairment to functioning. Extension refers to the temporal duration of the disturbance or impairment.
Strew Reduction 6 3. Environmental demands operate in transaction with the behavior of persons or systems. Stress is viewed in terms of dynamic influence processes involving reciprocal causal relationships between persons and environments. Transactionality assumes that the organism and the environment are interconnected components of a system in motion over time. 4. The effects of exposure to specific environmental demands are not uniform across individuals or systems but are mediated by cognitive, behavioral, and social factors. 4.1 The cognitive representation of environmental demands and of response capabilities, on an initial and ongoing basis, is a primary determinant of stress. The human organism primarily responds to cognitive representations of the environment, not to the environment per se. Attention to environmental demands and response sensitivity to them are a function of expectation and appraisal structures pertaining to both environmental demands and coping resources. 4.2 Behavioral transactions with the environment influence the probability and degree of exposure to environmental demands and the course of stress reactions. While stressors vary in their controlability, some proportion of stressor exposure is a result of the person's behavior. Conditions of stress are often the products of ache person's own activities. Similarly, the experience of stress inevitably leads to coping behavior which may be directed at the environmental circumstances or at the stress reactions resulting from them. 1
Stress Reduction 7 4. 3 Social relationships moderate stress by reducing exposure to en~riror~mental demands, by decrees ing sens itivity to them, increas ing resources for dealing with them, and by containing sub j entire distress . Supportive social relationships mi Ligate ache impact of environmental demands. Social support insulates the person from otherwise debilitating forces in the environment and facilitates coping with life crises. The importance of social support is such that the loss of supportive relationships is stress-inducing. Stress is a product of contextually linked person-environment impact mechanisms which determine how en~riron~nental demands are experienced. S tress arises in conj unction with clus ters of s ituationally- relevant factors. Behavior occurs in context, and its understanding requires analysis of the ecological setting, identifying the network of variables that are functionally related to the behaving organism or system. The mechanisms by which stress is induced and ameliorated are contextually linked. The implications of this model for the sub; ect of stress reduction are that stress can be prevented, mitigated, regulated, and remedied in a number of ways. In simplified form, the strategies principally involve (1) modifying environmental demands and their context of occurrence, (2) enhancing cognitive-behavioral skills so as to prevent exposure to stressors or moderate their influence, and (3) regulating stress reactions once they have become manifest. It should be noted that this way of understanding stress represents it as an undesirable condition. By definition, it avoids the confusion and inconsistencies routinely found in ideas of positive stress and negative stress. The latter concepts fol lowed from Selye's (1976) late-career notions
Stress Reduction 8 of "eustress~ and "distress," ironic in their ambiguity, because Selye began his distinguished career by advocating clarity in stress concepts. Despite its appeal to management consultants, no one has ever substantively developed the concept of "eustress." Quick and Quick (1984), for example, advocate the dual concept, but then throughout their book use the term "stress" to refer almost exclusively to adverse conditions and consequences. This is not to be fussy about definitions, which tell us nothing about the nature of things. Definitions inform us about rules for the use of words, but once the language rules are given, it is important to follow them. Moreover, concept labels like "stress" and "aggression" are shorthand designations for an otherwise long story that cannot be told in a definitional format. The quandary over whether stress can be positive as well as negative results from several conceptual errors: (1) failure to differentiate the concepts of stress and arousal, (2) mixing referents that are categorically different (job demands may be positive, but heart disease is not), and (3) taking a static perspective instead of a transactional one, which would recognize that coping skills can be learned during stressful life experiences. The stress literature is, of course, enormous in volume, and there is an abundance of research in elements of the physical, psychological, and social environment that operate as stressors. Those elements that have direct relevance to military settings will be discussed in the next section. As part of this introductory overview, however, it will be useful to give a brief account of key stress responses that are often studied in stress research. Stress Responses Four main classes of reaction were identified by Lazarus (1966) as stress indexes, these being physiological arousal, emotional distress, motor behaviors, ant cognitive functioning, although the emphasis of his work was on !
Stress Reduction 9 cognitive processes. In the time since his landmark book, these general categories still hold true. A central component of stress reactions is physiological arousal. While it is not always the case that arousal is assessed in stress research, it is routinely assumed that patterns of physiological activation underlie illness process. Selye's (1956) formulation of the stress response as a tri-component cluster of bodily reactions and his concept of the general adaptation syndrome are cornerstones of stress research. His conceptualization of stress is that it constitutes the "non-specific response of the body to any demand, a physiological common denominator, if you will, representing a condition of "wear and tear" in the body. Importantly, he identified adrenocortical enlargement, shrinkage of lymphatic structures, and gastrointestinal disturbances as the triparte response cluster that constitute the stress response. His non-specificity thesis has been strongly criticized by psycho- endocrinologists' especially Mason (1975). However, Selye's research directed investigators to activation in the autonomic nervous system and to impairments in immunological function. Classic research in the area of psychosomatic medicine by Ax (1954), Schachter (1957), Funkenstein, King, and Drolette (1957), and Wolf and Wolff (1952) directed attention to physiological processes in the study of stress and its mastery. Frankenhauser (1975) was also instrumental in turning attention to catecholamines in particular. Interest in physiology is routine among stress researchers, and military populations have often been studied because they are exposed to extreme environments. For example, an entire volume has been written on physiological processes associated with parachute jumping (Ursin, Basde, & Levine, 1978). Scientific interest in the physiology of stress was sparked by Cannon ( 1929 ), who called attention to bodily states associated with emotional arousal
S=e" Reduction 10 and also to conditions relevant to military environments, such as cold, lack of oxygen, and blood loss. Since the time of Cannon, the autonomic nervous system (ANS) is generally recognized as central to stress responses. This system regulates the heart and smooth muscles of the body, the digestive system, sweat glands, and certain endocrine functions. While the sympathetic system component of the ANS is activated to mobilize the body's resources in response to threat, the parasympathetic component is also important because of its relevance to digestion, recuperation, and relaxation. Cannon's work on ANS functions and its activation in conjunction with physical and psychological conditions was extended by Seyle, who proposed a general adaptation syndrome (GAS) for stress responses. His non-specificity thesis regarding its activation has not been generally accepted, but he directed attention to sympathetic-adrenocortical activity. Interest in sympathetic- adrenomedullary functions that Cannon had pioneered soon followed. Research on catecholamine excretion has been studied with regard deco many stressful situations, and a leading researcher in this area is Frankenhauser (1975~. In her laboratory in Stockholm, epinephrine and norepinephrine output has been linked to physical work, mental strain, and emotional states. Among those doing psychoendocrine research has been Mason (1975) at the Walter Reed Army Institute, whose work in basic training and combat environments will be discussed later. However, here it can be noted that his laboratory-based research demonstrates that Selye's non-specificity concept does not hold when psychological states (e.g., novelty, apprehension, appraisal) are controlled during stressor exposure. He argued strongly against the view of an indiscriminate action of the pituitary-adrenal cortical system in response to nonpsychological stimuli or stressors as Selye had proposed. Across a large set of laboratory studies, he has found no uniform
Stress Reduction 31 pattern for psychoendocrine responses (epinephrine, norepinephrine, 17-OHCS) to a range of stimulus conditions (Mason, 1975~. The significance of physiological arousal as a stress response is threefold. First, pronounced physiological activation constitutes a disturbance of homeostatic balance. The continued onset of arousal, and its prolongation is thought to be related to disease processes that affect the heart, gastro-intestinal system, kidneys, and pancreas, as well as pain and discomfort in the skeletal musculature. For example, acute psychophysiologic reactivity has been linked to cardiovascular disease risk (Krantz & Manuck, 1984). Second, heightened arousal has been found to impair performance. The empirical generalization that the relationship between arousal and performance is an inverted U function often appears in stress literature and related fields (e.g., sports psychology). This concept originated with Duffy (1932 & 1957) and has been associated with Hebb (1955), as well as being adopted by Spence and his co-workers in their anxiety-drive research. While Duffy focused on muscle tension-performance relationship, Hebb discussed the arousal function in terms of information processing. Importantly, Easterbrook (1959) explained the arousal-caused impairment of performance in terms of cue utilization. Arousal acts to narrow the range of cues that can be used. Hence, for complex tasks, arousal will have a disorganizing effect on performance. Regarding the empirical generalization of an inverted U function, the problems are that "arousal" is not a unitary phenomenon (various indices have low intercorrelation) and that strong arguments have been made for dissociations of electrocortical, autonomic, and behavioral arousal (Lacey, 1967). Moreover, the way in which a particular level of arousal will affect performance will very much depend on the nature of the task and the individual's skill level.
Stress Reduction 12 A third aspect of the significance of physiological arousal as a stress response component is its involvement in disruptive emotion and its maladaptive consequences. Fear (anxiety) and anger constitute emotional states, defined in part by physiological activation. While these emotional states themselves are unpleasant, they are linked to maladaptive behavior patterns, such as recurrent avoidance and disorganization in the case of anxiety and aggression in the case of anger. Because we are architects as well as victims of our stress experiences (transactionality postulate), these disruptive emotions potentiate continued stress and weigh against adaptive recovery from transitory stress experiences. Emotional states that constitute functional disturbances are indeed a major category of stress reactions. In addition to fear/anxiety and anger, guilt, shame) and sadness are relevant stress responses. Conditions of depression and grief are frequently studied by stress researchers in association with processes of coping. Anxiety is of course strongly involved in combat stress, and depression is a prominent feature of wartime -bereavement. Motoric functioning in the sense of behavioral performance, as well as flight and attack responses, are important aspects of stress responses, although attention to overt behavior has been less than to physiology, emotion, or cognitive functioning. Concerns about matters of productivity, work performance on complex tasks, ant behavioral components of problem soldering must give attention deco meteoric dimensions. The adequacy of cognitive functioning is strongly entailed in human performance concerns. There is an abundance of work pertaining to effects of stress on perception, information processing, social judgment, and cognitive elements of coping. Tests of reasoning, signal detection' puzzle-solving) !
Stress Reduction 13 perceptual-motor skills, and memory have long been part of human performance research, and personality-oriented studies have made ample use of measures of expectation, intentions, appraisals, and attributions. With this overview and theoretical framework, the determinants of stress relevant to military contexts will be discussed. Attention will be given to environmental factors, cognitive processes, behavioral performance and coping styles, and social conditions that shape the experience of stress. Among the relevant issues pertaining to the general topic of stress vis-a-vis the military are themes of military socialization. Stress as a Concern for the Military The purpose of the military is obviously to fight wars, and the business of war is the destruction of the enemy and of their will to fight. At times, it is naively thought that soldiers are simply taught to follow orders and to be mechanically brutal. Oddly enough, such ideas do seem to underlie Soviet military training philosophy (Gabriel, 1986). But all wars involve being immersed in a hostile atmosphere, where the soldier is enveloped by the sounds, sights, and smells of destruction. Combat environments entail multiple sources of stress that have cumulative effects. As developed in Novaco, Cook, & Sarason (1983), warfare stressors can be thought to fall into two principal classes: (1) harsh physical circumstances that affect tissue needs, and (2) the threatening psychological ambiance of combat. The ability of combat personnel to cope with these powerful stressors has an important bearing on their performance effectiveness. The stress associated with exposure to the extreme environments of warfare has been studied extensively. Among the most notable works are those of Grinker and Spiegel (194S) on air combat units, Kardiner and Spiegel (1947)
Stress Reduction regarding traumatic neuroses, Bourne (1969 & 1970) on psychological and physiological stress reactions in Vietnam, and Figley (1978) on combat-related stress disorders among Vietnam veterans. The adverse consequences of stress and the psychiatric casualties that may eventuate are a concern for United States military organizations not only because of the humanistic values at the foundation of our society but because the effectiveness of combat units is seriously impaired. This was a salient lesson of World War II, as reflected in a highly regarded analysis of military behavior by Marshall (1947), who found that less than one-fourth of the men in combat fired their weapons. Going back to the American Civil War Battle of Gettysburg, over 18,000 muskets were found on the battle field that unmistakably had not been fired. The evidence for this conclusion was that 12,000 had two charges, both undischarged, rammed down the barrel; and another 6,000 had three to ten packed charges. The men had panicked and were loading their weapons purposelessly, or they deliberately wanted to appear as though they were firing (Kars ten, 1978). Considering such observations, it must be kept in mind that for World War II the Army rejected about three of every ten men it screened for induction--5 1/4 million out of 18 million. Ginzburg (1959a; 1959b) provided a critical review of this ambitious screening operation and the factors associated with the discharge of 470,000 men between 1942 and 1945 for performance ineffectiveness. To be sure, it was not simply a matter of poor initial screening, because "...many educated and strongly motivated men who were properly trained and properly assigned also broke down. The cause of their failure can be found neither within themselves nor within the military organization; but it lies rather, in the excessive stresses to which they were exposed as a result of the exigences of war" (Ginzburg, 1959b, p. 7). Despite i \ 1
Stress Reduction induction screening of unstable individuals, the Army came to recognize that even emotionally stable men could become ineffective. Problems at home, casualties in the combat unit, and the strain of protracted battle, such as the Normandy invasion or the push through Italy, could precipitate breakdown (Ginzburg, 1959b, l959c). Looking at contemporary conflict, Israel is a natural laboratory for the study of warfare-related stress (Milgram, 1982). Since its formal existence nearly 40 years ago, as well as the 75 years of settlement that preceded the establishment of the state, the Israelies have monitored and treated psychological disabilities induced by warfare. Their concerns were made salient by the Yom Kippur War (1973), which in contrast to the Six Day 'War (1967) had much higher casualties and an unsatisfactory conclusion. The initial success of the Egyptian and Syrian armies was shocking and brought about the realization that the shadow of war and terrorist attack would be perpetual (Milgram, 1982). Coping with war-related psychological distress became a matter for the national consciousness. Moreover, general concern about the disabling effects of combat stress have risen with observations about the recent Lebanon war, as the Israeli army lost nearly twice as many soldiers to "battle shock" as were killed by the enemy (Gabriel, 1986~. Despite the nuclear era, conventional warfare continues, and the Soviet's themselves are concerned with how to improve the soldier's ability to withstand stress and trauma. Gabriel's (1986) states that, since the Brezhnev years, the Soviets have believed that conventional operations could be conducted in a nuclear environment and that when nuclear arsenals were exhausted, the conventional forces would be decisive. Soviet behavior in World War II showed a proclivity to continue attacks until the units were nearly decimated -- a willingness to accept staggering numbers of casualties. Gabriel reports that units often fought down to 30% strength. 1` ~ J
Stress Reduction ;6 Major causes of stress are the harsh physical circumstances of warfare that affect tissue needs, such as conditions of deprivation (food, sleep, or oxygen), extreme stimulation (temperature and noise), disease-engendering conditions, and trauma-inducing wounds. But it is the threatening psychological ambiance of combat that is so pervasive. Every soldier must cope with the fear of death. Fear has been found to be greatest before going into action and to be reported by 7 of 10 men (Dollard & Horton, 1944; Stouffer, Lumsdaine, Lumsdaine, Williams, Smith, Janis, Star, & Cottrell, 1949). In the Vietnam War, the clandestine nature of the fighting exacerbated the psychological strain, as American troops developed "a sense of helplessness at not being able to confront the enemy in set piece battles. The spectre of being shot at and having friends killed and maimed by virtually unseen forces generated considerable rage which came to be displaced on anyone or anything available" (DeFazio, 1978, p. 30). The psychological ambiance of combat associated with the Vietnam War had a particularly negative effect on veterans, who in large numbers manifested "delayed stress responses" (Horowitz & Solomon, 1975). MILITARY SOCIALIZATION AND THE ETHOS OF TRAINING Despite variations across branches of the armed services, military recruit training has a relatively homogeneous process. Basic training is a period of rapid resocialization and enculturation, occurring under conditions of relative isolation and confinement (Novaco et al., 1983). Ranging from seven to eleven weeks across service branches, young men are expected to develop new behavior confined to a narrow range of acceptability as shaped by heavy doses of reward and punishment. In a certain sense, boot camp can be thought to habituate recruits to the unpredictable stresses likely to be encountered in combat. According to Gabriel (1986), Soviet military training 1
Stress Reduction explicitly attempts to achieve the approximation. Whatever the nation state, the goals of basic training are discipline, motivation, physical conditioning, and weapon skills. The latter two are more readily achieved than the former. Conditions of war are unpleasant and preparing soldiers for war inevitably involves a degree of nastiness. In the United States, we so fortunately lack the totalitarian ideologies (whether it be Soviet or Khomeni- guided Shtite fundamentalism) and are also fortunate to live in a land relatively insulated from attack. Therefore, the idea of boot camp as an analog to combat strikes discordant notes. It is often difficult for social scientists having little military exposure to view recruit training as anything other than negative and dehumanizing. At first glance, it may appear that the sole purpose of training is to break the person psychologically, to render them helpless in the face of the system's desires, and to instill a reflexive conformity to the warrior ethic. At times, harsh criticism has come from combat veterans (e.g., Eisenhart, 1975) and others experienced in the military (Dyer, 1985). Various authors taking an adversarial stance have discussed recruit training in ways that dwell on themes of the warrior ethic and masculinity. For example, Arkin and Dobrofsky (1978) look at military socialization as a manufacturing of the "traditional masculine blueprint" that aims to reinforce fundamental archetypes about male sex roles. Their article, published in a highly visible academic publication, selectively focuses on unflattering elements of basic training constructed from limited behavior samples and overplays sexuality (phallic) themes. Very similar points had been made by Eisenhart (1975), a Marine Corps Vietnam veteran, in his "You Can't Hack It, Little Girl" portrayal of basic training as brutal and emotionally conflictual. He contrasts the intensely instilled masculinity of boot camp
Strew Reduction TS with the war conditions that denied its expression. Vietnam combat was often passive, had no honorable encounters, and had no wartier grandeur. While he recounts some of his own basic training experiences, which were graphically harsh, he provides no evidence of the generalizability of these experiences. The portrayal of basic training as a dehumanizing, social control process aimed at shaping the warrior ethic and punctuated by themes of male sexuality, is taken a step further by Dyer (1985). He sees basic training as nearly homogeneous across nations and as being a process that gets young men to believe that they like combat. Dyer's analysis, although cynical and occasionally slanted, is nonetheless insightful about the instilling of motivation and primary group loyalty. "The DIs 'stress' the recruits, feet them their daily ration of synthetic triumphs over apparent obstacles, and bear in mind all the time that the goal is to instill the foundations for the instinctive, selfless reactions and the fierce group loyalty that is what recruits will need if they ever see combat. They are arch- manipul~tors, fully conscious of it, and utterly unashamed. These kids have signed up as Marines, and they could well see combat; this is the way they have to think if they want to live." (p. 115~. Dyer writes with a flair and, despite the cynical edge throughout, there is a probing quality to his presentation. He does, however, give a distorted view of drill instructor competence, getting too locked into his portrait of them as harsh manipulators grinding out masculine warrior themes. Marine Corps commanders at the battalion, regimental, depot, or Headquarters level do not endorse the archetypal "DI" personification, nor do the NCO supervisors of drill instructors, nor is such an image cast in Drill Instructor School. In extensive research that I have conducted with Irwin 1
Stress Reduction 19 Sarason, we have consistently found organizational policy to be at variance with the image of a drill instructor as a harsh, punitive, individual without empathy for recruits. The Drill Instructor Schools at San Diego and Parris Island emphasize positive leadership approaches and the concept of being firm but fair. Moreover, our evaluation data in drill instructor performance show that the angry, impatient, highly activated drill instructor performs poorly and receives low ratings from NCO and officer supervisors. A sanguine view of military socialization can also be found in the longitudinal research of Elder (1986). Tracking a cohort of Berkeley men born in 1928-1929 who entered military service in the 1940s and l9SOs. Elder found that military service was a constructive turning point in the lives of most men. Particularly for the disadvantaged person with perceived self- inadequacy, the service brought opportunity and new directions. Those who entered the service young, despite a background that favored low achievement and disorganization in marriage and family,instead were found to have the highest levels of family stability and have dramatic gains in health and competence. Elder's extensive findings that veterans of World War II and Korea had more stable marriages than did non-veterans certainly is at odds with the characterization of military socialization as a dehumanizing, manipulative, and coercive process that breeds maladjustment. Boot camp necessarily involves a transition from civilian to military culture. "The process is fundamentally one of acculturation in which the recruit is subjected to a forced change of reference groups, and the skills he learns are basically those necessary for sur~ri~ral and successful adaptation under these circumstances" (Bourne, 1967, p. 187~.
S=e" Reduction 20 "Training is seen as the intentional disruption of civilian patterns of adjustment, replacement of individual gratifications witch group goals, inculcation of unquestioning acceptance of authority and development of conformity to official attitudes and conduct" (Yar~olinsky, 1975, p. 158~. These authors, along with Arkin and Dobrofsky (1978) and Dyer (1980), represent basic training as a conversion process that promotes socialization to military norms. Stress has an integral function in this process, but the exposure to this environmental context results in the acquisition of stress coping skills. As one develops commensurate resources for coping, environmental demands that once functioned as stressors can then be appraised as "challenges" that can be handled effectively. In the face of "humanist" criticisms about the nature of basic training, researchers and other social scholars must bear in mind that military institutions indeed have intrinsic defense functions and that training involves preparation for combat with the objective being the destruction of the enemy. Military organizations must therefore utilize methods and techniques of training which provide a realistic test of stress tolerance. "It is more prudent and ultimately more humane, to provide this screening and learning under conditions in which the probability of death due to error is very low than it would be to send ill-prepared troops into combat. This assumption underlies both the process and content of training and is one often overlooked in discussion of the efficacy of methods used by the military" (Novaco, et al., 1983, p. 392). DETERMINANTS AND MEDIATORS OF STRESS IN MILITARY SETTINGS Those who function in military settings are at high risk for exposure to stressors. Military objectives and the nature of the tasks involved in 1
Screw Reduction 2i achieving them necessarily entail stress. The concept of stress reduction set forth in this paper, however, asserts that despite the inevitability of stressor exposure, psychological dysfunction and performance impairment can be attenuated if suitable coping skills have been developed and are utilized. So as to better establish this assertion, stress in military settings will be discussed in terms of determinants and mediators. This will be organized in terms of key rubrics in the stress fields, namely environmental context, cognitive factors, behavior patterns/coping, social conditions, and organizational factors. Environmental Context . As elaborated in Novaco et al., (1983), combat environments entailed multiple sources of stress that have cumulative effects. Exposure to harsh elements in various environmental fields require an adaptive response from the soldier, including (a) deprivation of food, sleep, or oxygen, (b) extreme stimulation involving aversive temperatures and noise, (c) disease-engendering conditions linked to inadequacies in diet, hygiene, and medical care, and (d) wounds and injuries that induce trauma and confirm the soldiers most basic fear. However, in addition to these harsh physical circumstances that affect tissue needs, there is another pervasive dimension of stress in warfare, which is the threatening psychological ambiance of combat. This psychological dimension has several components: the continuous threat of death and injury, the loss of friends, and the recognition of one's own destructive capacity. Psychological dysfunction in war settings will of course vary with the intensity and duration of combats as well as with organizational factors such as experience, leadership, unit cohesion, and psychiatric management. Yet it has been estimated that in a high intensity war, approximately one-third of all non-death casualties will be psychiatric (Small' 1984). Such estimates
Strew Reduction 22 extrapolate from World War II, Korea, Vietnam, and the Arab-Israeli wars, and some estimates run much higher. Battlefield psychiatric disorders include psychoses, psychosomatic syndromes, and acute anxiety reactions. Various forms of withdrawal may also occur, such as drug use and unexcused absences. Treatment policies of immediacy, proximity, and expectancy to return to combat have formed the basis of psychiatric case management (Hilber, 1984; Kormos, 1978). Regarding psychosis, Ginzburg (1959) found that combat exposure did not increase the rate of psychosis among U.S. soldiers, although neuroses rates were clearly affected. Often overlooked in accounts of battlefield psychiatric dysfunction, however, are manifestations of stress in the form of anger, hostility, and aggression. In the earliest work on psychopathy resulting from combat, Kardiner and Speigel (1947) wrote about aggressive impulses as one of the most common aspects of traumatic neuroses. These believed that it was related to the irritability and hypertoxicity of the entire muscular system... Easily aroused to anger, these patients are very prone to motor expression. They -either break or tear objects in these fits of temper, or strike the people who happen to be around them" (pp. 212-213). This is an impulsive aggressiveness related to an incapacity to process information properly. Explosive irritability and unwarranted rage were identified by Kardiner and Spiegel as a stage in the progressive development of incapacitating breakdowns, which begin with poor appetite ant carelessness, then involve irritability and exaggerated reactions of rage, and culminate in freezing, sleep disturbances, and being terrified of one's own artillery. While observations during the first and second World Wars led to these ideas of traumatic neuroses as progressive disorders, it was learned in subsequent wars that combat stress reactions are not necessarily progressive and are more dynamic (Bourne, 1970~. )
S Mess R eduction 2 3 Phys iological acti~ra~cion, however, should not automatically be expected in combat situations, because psychological defenses can operate to suppress reactivity. Bourne (1969), for example, found in studies of helicopter ambulance crews and of special forces teams of enlisted men that urinary 17- hydroxycorticosteroid (OHCS) levels were relatively low, compared to recruits in basic training, to the population at large, and to the officers in the units. He attributed the low excretion levels to affective denials and the self-perception of invincibility. Recruit training, while hardly analogous to combat' can be seen as having parallel dimensions of stress exposure. That is, the training regimen entails difficult physical challenges and also involves psychological shock associated with isolation, low autonomy, time pressures, ego threat, social comparison, and authoritarian control. To a large extent, boot camp can be viewed as a stress inoculation procedure. Recruit training occurs in an intentionally aversive environment designed to prepare personnel to function effectively under the conditions of overstimulation found in combat (Novaco & Robinson, 1984). The intense demands of the recruit training environment have been found to be associated with both adverse health reactions and psychoendocrine effects. Voors, Stewarts, Gutekunst, Moldow, and Jenkins (1968) identified stress as a precipitant of respiratory infection among Marine recruits, and Poe, Rose, and Mason (1970) viewed stress as one determinant of 17-OHCS excretion among National Guard recruits. Bourne (1967), examining Marine Corps recruit training, reviewed research indicating that during the period of induction, the degree of psychological stress is reflected by 17-OHCS levels comparable to those of patients measured during incipient psychosis.
Stress Reduction 24 Following up a study by Rose, Bourne, & Poe (1969) on basic training and soldiers anticipating combat in Vietnam which found suppressed androgen levels, Kreuz, Rose, and Jennings (1972) studied officer candidates at the Army Infantry School at Fort Benning, Georgia. These authors found significantly lower plasma testosterone levels during the stressful part of Officer Candidate School, confirming the hypothesis about androgen suppression as a result of stress. Comparisons were made with non-stressed samples and with the same subjects under conditions of low stress. They also found significant elevations of plasma cortisol during the stressful phase of the training program. Psychiatric interview ratings and questionnaire self- ratings buttressed the analyses. - Specialized training, such as for the Navy Underwater Demolition Team, has been found to be highly stressful, with pronounced adrenal cortical activity (Rubin, Rahe, Arthur, and Clark, 1969). The high failure rate in this program (30 to 70 percent) is seen to be stress related, and stressful life events have been found to add to the strain that induces dispensary visits and then training drops. Symptomatology measures of emotional distress have been found to be strongly correlated within dispensary visits among those who ultimately drop voluntarily from training (Rahe, Biersner, Rymen, & Arthur, 1972). The phasic nature of stress during basic training is easily observed and is commonly reported by training personnel. Empirical studies certainly support such observations. Stewart, Voors, Jenkins, Gutekunst, & Moldow (1969) found that sick calls peak during the second and third week of training for Marine recruits. Similarly, Novaco, Sarason, Cook, Robinson and Cunningham (1979) found that the majority of psychologically categorized attrition occurs during the first two weeks of Marine Corps training. ) i}
Stress Reduction 9: Findings by McCabe and Board (1976) for psychiatric admissions among airmen in basic training are also that more than two-thirds of admissions occur during the first 10 days of training. When these authors examined prior illness history, they also found that those airmen having prior illnesses actually completed more training than those who had no illness history, thus supporting a stress reaction view. Cognitive Processes When intense environmental demands are inevitable, as in the case of combat, captivity, or military training, the most accessible form of coping is cognitive. The relatively low levels of cortical steroid excretion found by Bourne (1969) among helicopter ambulance crews and special forces teams in Vietnam was interpreted as a consequence of defensive denial and perceptions of invulnerability. Easily recalled in this regard are the classic experiments by Lazarus and his colleagues (Lazarus, 1966) on denial and intellectualization as cognitive appraisal moderators of anxiety, as reflected in physiological and self-report indices. However, classic military research can be cited here also. Janis' (1951) review of adjustment mechanisms to recurrent air raids found that complete denial of impending danger and "reversion" to beliefs of personal omnipotence were typical psychological defenses. The illusion of personal invulnerability is thought to become reinforced by "remote-miss" as opposed to "near-miss" experiences. While the remote-miss survived emerges unscathed from an intact shelter, the near-miss survivors have had a shocking contact with destruction that shatters their confidence and exposes w lnerability. Assuming that the Vietnam units had some near-misses, they seem remarkably to have become inoculated against fear stimuli and solidified the perceptions of invincibility. Unlike civilians exposed deco air raids, combat personnel are engaged in the warfare, and the ir
S=e" Reduction 26 duties may have attention refocusing and task-orienting qualities thee facilitate coping with fear, but they also are more recurrently exposed to danger. We have seen that the basic training regimen is an intentional disruption of civilian patterns of adjustment (Yarmolinsky, 197S) and has been described in various ways as a conversion process. O'Neill and Demos (1971) described how stress can operate to effect an ideological conversion. One element is that the recruit becomes aware that overt rewards are rare, while punishment and negative reinforcement (cessation or avoidance of aversive consequences) are the predominant contingencies. Stressors such as yelling and "incentive training" (rigorous calisthenics) are often used to shape attitudes-behavior. In this "conversion process," stress contributes to perceptual "tunnel vision" and cognitive rigidity. Lazarus (1966) noted that there is a constriction of the perceptual field under stress and argue t from existing research that anxiety resulting from stressor exposure interferes with learning and performance by narrowing the range of attention and by limiting perceptual cue utilization. As discussed earlier with regard to arousal effects, this is Easterbrook's (1959) theory. With regard to basic training environments, stress can be thought to reduce the capacity for critical thinking and for intellectual reflection about the recruit's experience. A third aspect of stress in training regimens is that it heightens suggestibility and thereby can increase receptivity to institutional influences. O'Neill and Demos (1971) make this point as a generalization of Pavlov's principle of transmarginal inhibition. Pavlov discovered that deviation from previously established response tendencies (the "inhibition" of conditioned behavior) resulted whenever the stimulus situation was sufficient to exceed the "margin" for effec t ice response.
Stress Reduction 2, Pavlov's (1927; 1928) conditioning experiments had been disrupted by the Leningrad flood (Petrograd, September 23, 1924) which threatened the lives of his caged dogs who subsequently failed to exhibit their conditioned responses. His idea of "transmarginal inhibition" was that the animal's upper limit of cortical excitation had been exceeded and the inhibition occurred to protect the brain from overstimulation. Stimuli which had at one time elicited the strongest conditioned responses consequently elicited the weakest ones as the response hierarchy was reversed (Pavlov's "ultraparadoxical phase"). As the transmarginal inhibition dissipated, the original response gradient was restored, and as the overexcited cortex recovered, it could learn to tolerate increasingly greater levels of stimulation. Epstein (1983) speculated that Pavlov's observations of traumatized dogs are related to what Freud saw in traumatized soldiers who exhibited "repetition compulsion," but Pavlov (1941) actually made similar extensions of his concept to war neuroses. For Freud the traumatic neurosis occurred due to excessive stimulation, and the repetition compulsion was an attempt to retroactively master the stressful experience. Returning to the association with recruit training suggested by O'Neill and Demos (1971), it can be seen that some conditions noted by Pavlov (1928) for the occurrence of transmarginal inhibition are prolonged anticipation of rewards under stress, confusion or inconsistency in the conditions necessary for effective response, and fatigue in the responding subject. Such conditions are indeed part of the early stages of basic training, and stress may thus be utilized to "recondition" civilian behavior (previously established response tendencies). Novaco et al. (1983) presented a cognitive behavioral analysis of recruit training adjustment that suggests a different perspective on the basic
Stress Reduction 28 training experience. Their analysis was organized around the concepts of expectations and appraisals which can be seen to undergo considerable modification as training proceeds. The.initial states of disequilibrium and disorientation from unexpected events and stimulus overload are coupled with low efficacy expectations. Similarly, the appraisal systems are commonly those of threat, antagonism, and failure which correspondingly are linked to states of anxiety, anger, and demoralization. Over the course of training, however, these cognitive conditions undergo dramatic change. Repeated exposure to the environment elements over time, success experiences, and the coping efforts utilized by recruits work to alter the expectation and appraisal systems. Recruits have been shown to have strong shifts towards internal locus of control expectancies (Cook, Novaco, ~ Sarason, 1982) and develop stronger efficacy expectations as they succeed on training tasks. They learn to reappraise their drill instructors' behavior, their pain experiences in physical training, and their role in the social unit. Importantly, they learn to develop a task-orientation and not be distracted by irrelevant stimulation and preoccupation. Very little appears to be known about the cognitive characteristics of successful soliders. The extensive study by Ginzberg et al. (1959) primarily addressed demographic, archival, and managerial factors. More recent works such as the Sarkesian (1980) volume on combat effectiveness, which addresses the Vietnam experience, says little about cognitive dimensions beyond some amorphous reference to the will to fight. While considerable work was done to understand the stress disorders of Vietnam veterans (e.g., Figley, 1978) there is a virtual absence of information about cognitive pre-conditions that heighten susceptibility to trauma. A recent study by Foy, Sipprelle, Rueger, and Carroll (1984) which looked at promilitary adjustment (along with other i
Strew Reduction ^c military and combat factors) in the etiology of postraumatic stress disorder (PTSD) found no effects for promilitary measures. This index consisted of items covering family stability, parent relationships, school achievement, disciplinary problems, and social activity. Of course, post-hoc analyses do not lend themselves to the assessment of pre-existing cognitive structures and processes, but given that stress reactions are to a significant degree a function of cognitive mediation, there would seem to be much value in obtaining measures that identify cognitive risk factors. Studies that have sought to differentiate PTSD cases from normal and clinical controls have made physiological and psychometric assessments (Fairbank, Keane, & Malloy, 1983; Malloy, Fairbank & Keane, 1983) but have ignored cognitive dispositions. Prisoner of war studies might also be informative about cognitive determinants of stress, but this work as well has given little attention to cognitive dimensions as preconditions. Deaton, Berg, Richlin, and Litrownik (1977) examined the coping activities of Navy POWs in solitary confinement in Jie~cnam and found that the most useful activities were associated with ache captor-captive relationship. This involved the prisoners attempting deco stay one step ahead of the captor by anticipating his next move and formulating contingencies for new situations. Communication loaded high on this factor and was accomplished by a variety of methods. Similar accounts were given in the press by interview with those held hostage in Tehran after our embassy was taken over in November, 1979. Nardini (1952) reported that survival in Japanese POW camps was related to strong motivation to live, intelligence, a sense of humor, controlled fantasy life, and controlled emotional sensitivity. The latter points relate to Spaulding and Ford's (1972; 1977) account of the Pueblo crew's captivity in North Korea, which reported that the men who best tolerated stress were bright, able to isolate their emotions, and able to entertain themselves with fantasy.
Stress Reduction 30 Behavior Patterns and_Coping One of the key factors that has emerged in stress research is the coronary prone behavior pattern known as Type A behavior. Characterized by time urgency, competitive drive, and hostility, the behavior pattern has been found to be associated with risk for coronary artery disease. Recent research in this area (cf. Chesney & Rosenman, 1985) has given increased attention to the involvement of anger and hostility as the key risk factor. Longitudinal research by Barefoot, Dahlstrom and Williams (1982) and Williams et al. (1980) linked anger/hostility to subsequent disease and mortality. Coupled with experimental research showing heightened catecholoamine responses among Type As when faced with challenge or provocation (Krantz & Manuck, 1984), the involvement of anger has surely been identified, although the nature of the association remains to be untangled. This behavior pattern should concern the military and its training institutions. Each of the three demarcating dimensions has relevance to military training, particularly for those whose duty it is to train recruits. Longitudinal studies conducted by me and my colleague Irwin Sarason have consistently found significant increases in Type A characteristics among Marine Corps drill instructors. We have found that those men who successfully complete Drill Instructor School are significantly lower on Type A characteristics than are those who are dropped, as well as being low on a variety of other stress risk factors. However, after graduation from Drill Instructor School and when the tour of duty begins, drill instructors progressively increase in Type A behavior, particularly the speed/impatience and anger components. Importantly, these dimensions are inversely related to performance evaluations by their supervisors. The impatient, irritable drill instructors are given poor evaluations. These relationships are both syncronous and predictive (No~raco, Sarason, Cook, Robinson, & Parry, 1983 ~ . . )
Stress Reduction 31 One manifestation of stress and poor coping skills related to anger is child abuse. While military families are not much different than civilian families with regard to abuse (Dubanoski ~ McIntosh, 1984), several types of stress were found to be related to abuse in military families: family discord, new baby and continuous child care, and relocation/isolation. Loss of control and lack of tolerance were two major reasons for abuse given by members of the military studied in Hawaii. A study of spousal violence at the Naval Regional Medical Center in San Diego (Wasileski, Callaghan-Chaffee, & Chaffee, 1982) found a high level of reported stress in the families in the preceding twelve months. Low pay, housing problem, and hardship separations are routine characteristics of military life that impose stress on families and have been linked to child abuse and neglect among the military (Roth, 1980). Social Conditions In the stress field, the topic of social support has become a major sub- area. It has involved studies of (1) social resources, including measures of social networks and participation, (2) social behaviors, such as the actual provision of aid, giving advice, or socializing, and (3) perceptions of support that is the individual's assessment of the quality of relationships, of being cared for and esteemed, and of satisfaction with social relationships. A good example of the measurement of social support and its study in experimental contexts is Saras on, Levine, Basham, and Sarason (1983). It is unclear from considerable research how social support operates in ameliorating stress, but it is a good bet that it has both direct effects on stressor exposure and buffering effects in enhancing coping resources. Curiously, in the vast literature accumulating on social support, there is little if any reference to its relevance to military contexts. Given the research done at the time of the second World War, this is indeed suprising.
Stress R education 3 ~ Interpersonal strain undermines military organiza~cions, because it is weil-eseablished that group cohesion, group identification, and loyalty motivate men to fight. Interpersonal conflict linked to race, gender, or economic class can be a source of organizational stress, but the fact that it disrupts processes of social support constitutes a double risk condition. The concept of teamwork is nowhere emphasized more than in the military, where supportive social relationships indeed have life preserving functions. The importance of social bonds for military functioning is nowhere better emphasized than in Grinker and Spiegel (1945), whose work on air combat units is indeed a historic milestone in the stress field -- e.g., they had a strong influence on Lazarus (1966~. Their account of human functioning and psychological adjustment under extreme environmental conditions portrayed the struggle to master the environment, as well as the failures of adaptation. They worked with combat soldiers in theaters of battle ant in hospital rehabilitation settings where soldiers were treated for "war neuroses." Regarding the value of social relationships they stated: "It is an interesting fact that, although the members of combat crews are thrown together only by chance, they rapidly become united to each other by the strongest bonds while in combat. he character of these bonds is of the greatest significance in determining their ability to withstand the stresses of the combat s ituation" (p . 22 ~ . The mutual dependence for protection, the family circle of the combat group, and the stress associated with the loss of one' s brothers-in-arms are vividly described by Grinker and Spiegel, who stance that the loss of friends in combat .. is a major source of emotional stress . ! i
Stress Reduction 33 "The men suffer not only from a sense of bereavement, but from having seen the anguish of a bloody and painful death. . . the grief persists and, though it is dulled by time, new losses may be added to it. In addition, the loss of friends stimulates anxiety. . . This double load of grief and anxie~cy is part of the heritage o f emotional stress incidental deco combat" (Grinker & Spiegel, 1945, p. 35~. Rachman (1978) in his review of studies on combat fears, including a 17 volume report by Flanagan on U.S. combat air crews during World War II, states that the information testifies to the overwhelming importance of social bonds. "It seems that the most important source of motivation was the small social group of which each soldier or airman became a part" (p. 50~. It is the identification with a group and it history ache provides moti~ra~cion for combat, and a fighting unit' s morale is dependent upon faith in leadership and faith among unit members. "There is general agreement that a major factor protecting the individual soldier from being overwhelmed by war- related stress is the group cohesiveness of the military unit to which he belongs, the mutual trust of men and officers, and the high morale and confidence in themselves" (Milgram, 1982, p. 134~. In a comparison of Yom Kippur War combat units, Steiner and Neumann (1982) attributed differences in posttraumatic stress reactions to differences in cohesiveness of the units, although they did not control for pre-combat variables. Several studies of PTSD Vietnam Veterans have found impairments in social support for this population. Keane, Scott, Chavoya, Lamparski, and Fairbank (1985) compared PTSD veterans to well-adjusted veterans and to VA medical service inpatients. The PTSD group had significant reductions after military
Stress Reduction 34 service in their social network size and in various qualitative dimensions of social support, particularly emotional support. The comparison groups reported either maintained or strengthened support systems. Because pre- military adjustment and support did not differ across groups, Keane et al. speculate that the combat stress and the low levels of subsequent support interact to produce gradual increases in symptomatology. In a less elegant study, Stretch (1985) found significant regressions for returning social support on PTSD symptoms. The retrospective nature of these studies does curtail inferences about causal relationships, especially since it has also been found (Carroll, Rueger, Fry, & Donahue, 1985) that PTSD veterans are less self-disclosing and expressive to their partners, have greater difficulty adjusting to dyadic relationships, and are more prone to hostility than are PTSD-negative combat veterans. An interesting extension is that Stretch, Vail, and Maloney (1985) report PTSD among Army nurses was very significantly attenuated by social support during Vietnam and upon return home. Given that supportive relationships promote adjustment during and after wartime, it is surely a topic that merits attention by the military. Indeed, promoting social bonding, team-work, and group morale receive extensive attention by the military, beginning in basic training. However, it is questionable whether this emphasis gets beyond the "band of brothers" notion that is functionally associated with combat perfo, dance. Effective combat units operate with a sense of brotherhood, psychological adjustment is tied to more spheres of activity and responsibility than combat, and the value of supportive relationships in these other domains may be too often ignored or taken for granted. but a person's overall 1 )
Stress Reduction 3: Organizational Factors Analyses of stress that are associated with stress reduction strategies often ignore conditions in the social environment that potentiate stress, as well as counteracting forces that can moderate stress reactions and even reduce exposure to stressors. Organizational -factors represent contextual conditions that importantly bear on what stress is experienced, how it is experienced, and what is done about it. As Novaco and Robinson (1984) delineate, attention to organizational variables might begin with organizational conflict at an institutional level, dealing with conflict between military and civilean organizations. This, however, is too broad in scope here, but as Novaco and Robinson indicate, the ambivalent attitudes toward the military prevailing throughout large segments of society create a backdrop for tension among military personnel. Members of the armed forces are beset with economic frustrations due to military pay scales, a relatively low social status for enlisted personnel that provides no tradeoff for economic shortcomings, and the fact that a distinct appearance makes soldiers easy targets for the expression of negative sentiment. These conditions of the social fabric were prevalent during the Vietnam era and were the cause of much bitterness. As is well-known, the Vietnam veterans carried the burden of the war's unpopularity, and their resentment followed from their belief that they had been manipulated and betrayed (Bourne, 1970; Shatan, 1978). Such frictions and social strain are by no means unique to Americans. French officers who had spent much of their time after World War II in Indochina began to resent the French people for their lack of sacrifice and support, including criticism in the French press (Hauser, 1973). As Perlmutter (1977) has observed, the military is by no means a cohesive, coherent, monolithic group. There are many divisions and disputes
Stress Reduction 36 between and within military ranks and hierarchies. However, within a given organizational unit, we can identify stress as arising from at least three sources: task generated stress, role-based stress, and stress arising from interpersonal relationships (Novaco ~ Robinson, 1984~. To summarize briefly about these stress origins, task stress occurs when task demands exceed resources or abilities. This may result from a misfit between job and worker or because of task multiplicity or because workload is exacerbated by fatigue and debilitating emotional states. Demands of a given task may be within a person's capabilities, but the overall job context (workload and responsibility) and particular exigencies may deplete resources and thus induce stress. A good example of task-generated stress can be observed in the work of basic training personnel. Drill instructors are responsible for recruits over training cycles of 9-11 weeks. During this period, the drill instructor must cope with the strain imposed by (1) a rigorous training cycle in which activities are tightly programmed, (2) extremely long working hours over extended periods, (3) myriad difficulties associated with managing the behavior of 60-90 eighteen-year-olds, (4) family strain resulting from the heavy workload and recent relocation, (5) the presence of constant supervision and evaluative scrutiny, and (6) competitive pressures among peers and between units. Longitudinal research with Marine Corps drill instructors (Novaco, Sarason, Robinson, & Cunningham, 1982) found stress levels to escalate significantly as a function of length of time as a drill instructor. Our assessments were made prior co the start of duty, after three months, and after one year. Self-report. physiological, and performance assessment coverage to confirm the stress increases. Moreover, performance evaluations )
Strew Reduction by supervisors are inversely related to job stress, as is a more catastrophic outcome, namely being relieved of duty for maltreatment, drug use, or poor judgment. Role-based stress, which was found by Kahn, Wolfe, Snoek, and Rosenthal (1964) to affect five of six men in a national labor force sample, often occurs with regard to conflicts with organizational superiors. In the military, the rank structure, coupled with authoritarian discipline, embodies a system of sharply-defined status differentials. The hierarchical structure of military authority is predicated on the ultimate need to direct troops in battle. Orders emanating from higher organizational levels are presumed to reflect superior information and strategy. Yet role conflict emerges in battle and after fighting has ended, as combat veterans at times are hostile to the military and its leaders (Grinker ~ Spiegel, 1945; Cartright, 1975). The killing of unpopular officers by their own troops occurred not only in Vietnam but has been recorded in the American Revolution and the Civil War (Walton, 1973). More commonly, role-based stress arises when a set of role demands contain internally contradictory expectations, such as between military obedience and the sense of professional competence or ethics. Another role conflict arena involves the conflicting demands of occupational roles and family roles. Relocations and other routine disruptions of family life constitute very significant sources of stress. The organizational environment of recruit training has been studied with regard to psychological variables of expectations, intentions, role attractiveness, job satisfact on. and motives related to employee turnover. Studies of attrition in recruit training, such as Mobley, Hand, Baker, and Meglino (1979), have generated multiple regression models that account for
S=e" Reduction 38 small but significant proportions of variance. Studies focused on person- centered variables have ignored environmental conditions that may be important determinants of an individual's desire to disengage from the military and/or the organizational actions chat result in separa~cion or discharge. The stress perspective leads itself to accounting for environmental factors, and this of course has guided my work with Irwin Sarason which was concerned with Marine Corps recruit attrition, performance, and adjustment. We assumed that the nature of environmental demands or stressors in recruit training are determined not only by the rigorous tasks and challenges specified by Marine Corps training standards but also by the particular way in which the training regimen is operationalized by training unit personnel, specially the drill instructor team. Our conjecture was simply that some training personnel, especially drill instructors, may intensify the stressful nature of recruit training beyond the demands inherent in the training regimen and chat this amplification of stress would result in higher rates of attrition, as well as impairment in performance and psychological adjustment. This general proposition involves a complex set of hypotheses about training unit social climates, drill instructor characteristics, unit performance, and recruit psychological variables. The testing of this proposition also involved the evaluation of alternative hypotheses in accounting for attrition, namely one concerning pretraining variables and unit composition, and another which specified the standards of unit leaders as the reason for variation in attrition. Our analyses found virtually no support for the initial composition or the training standards hypotheses, but considerable support was found for our training unit environment hypotheses. This was achieved in several archival inves tigations and in the tes tiny and tracking of a month's cohort, which was then replicated by a second cohort- i i 1
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 as architects of stress as well as become victims of it. 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 to reduce exposure to stressors, to develop skills
Stress Reduction u0 for dealing with environmental demands, and to augment environmental and social resources that promote well-being. 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. Arous al Reduc t ion . 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 IM practice (Wallace, 1970). In a study of corporate i
Stress Reduction businessmen, Frew (1974) found higher levels of job satisfaction, productivity, and work relationships among those who meditated on a regular basis. Benson's (197S) study of meditation, however, led to a demystified view of the process, and he devised a simplified 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 daily 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 commanding
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 ache authors, but ache 85 decibel level makes that a bit doubtful ~ . Those in ache TM group reported that after meditation they no longer felt the intensity of tension, rage, and guilt inside. They had practiced their mediation twice daily for 20 minute periods and also had ee'~cly follow-up meetings witch the instructor. While arousal reduction procedure are the intuitively sensible approach for treating stress disorders, it should 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 and heart rate. Again SUDS ratings and flashbacks were decreased cons iderably, 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 tac~cics utilized to help clients . !
S Mess R e Tucson ~ 3 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 deco many field settings. An important element of cognitive-beha~rioral 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 FolLman (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 4. 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 (VMBR). 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 4: 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. .
Strew 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, strength-building, and- The visualization of training steps can be designed including diet , conditioning that remain to be behaviorally enacted. goals, behaviorally achieved, can be a useful adjunct. Quick and Quick (1984) present a model for understanding the stress reducing functions of goal setting programs which have dyedic 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 s imulation 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 beater 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 fatigue") 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 times 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" Reduc~on -- 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. Stress 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, Us 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 to which the approach has been applied.
Stress Reduction DIG 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 j
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 guise 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 (Meichenba~m & 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 POW in Vietnam, and like a number of others, had PTSD symptoms when the Unknown Soldier from the Vietnam War was
Stress Reduction 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 ache 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 Ueisman (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 Kirchner & 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 pheneizine 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 en al. also found weak results for an~ci-anxiety
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
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 to 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
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, and Klugman (1977) conducted a project at Fort Dix, Datel and 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 ache latter three programs utilized a film or videotape to deliverer ache intervention . Beach et al . ( 1977) sought to reduce administrative discharges through the prevention of stress reactions. Their program was multifaceted and involved (a) presentations by chaplains at the reception station that aimed to prepare recruits for impending stressors, (b) discussion groups ~ nT want out of the Army") 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 ~cherapy group by mental health staff. Other company level and battalion level didactic presentations were done by the mental health
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 and 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.
S tress R educcion ~ ,~ This varied intervention was evaluated by assessment of discharge races for January-June of 1977 in comparison with those for the same period the previous year, and significant reductions were found (9.o9% 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 ache 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, "This Is How It Is." As expected, distress was increased after the film, but hypothesized stress preparation hat 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.
Stress Reduction ,3 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 condi~cions, which found reductions in attrition that were attributed 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 Its 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 Starr of training . The experimental evaluation was conducted by randomly dividing 530 recruits among
Stress Reduction tic 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, (S) 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 relet ionships , and personal relationships . The vignettes dissect the problem situation and model effective coping strategies.
Stress Reduction 60 The drill instructor project developed from longitudinal research on the stressful nature of drill field duty (Novaco, Saras on, 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 & Saras on, 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 IMPLEMENTATION 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 and 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
Stress Reduction ci own leadership style and personality. This is not to say that "it all depends," but to state that relevant contextual factors and their interaction can be identified, and importantly we must understand when prevailing conditions impose constraints or limitations on the degree to which certain stress coping strategies can be utilized. At the outset, a fundamental set of stress coping skills can be identified which might be considered to be a distillation of a broad range of research on stress and stress reduction practices. These are (1) self- monitoring of somatic states, thoughts, feelings, and behavior patterns, (2) arousal reduction with regard to both general arousal levels and Darticular occasions of activation, (3) task-orientation, which is the ability to focus on the task at hand and engage in behavior instrumental to achieving identified goals, (4) setting realistic expectations for oneself and others, (5) constructive thinking about situations, the behavior of others, and one's own behavior, especially with regard to setbacks and thwartings, (6) behavioral competence in dealing with recurrent environmental demands or problems, and (7). utilizing supportive social relationships. For the most part, these coping skills have been the basis of the intervention that Irwin Sarason and I have undertaken with Marine Corps drill instructors, with the exception of arousal reduction, which seemed less feasible in that context. On the basis of the present review, the prospects for stress reduction can be seen with regard to training environments and the provision of remedial services through mental health units. Training facilities from recruit training depots to specialized schools, such as those for drill instructors, officer candidates, NCO academies, recruiters, airborne jumpmaster , underwater demolition, etc . , are prime arena for stress coping curricula as a preventive intervention. The receptivity of
Stress Reduction e2 the audience to stress reduction messages, however, will depend upon their perception of its relevance. If the audience is experiencing stress and is looking for remedial ideas then conditions of receptivity are optimum. But when the person is either not currently stressed or does not perceive the severity of the impending stress associated with the future duty assignment, then the perceived value of the stress reduction program will be attenuated. Therefore, it will be important to not only give the audience a realistic picture of impending stress but also to tie the ideas about stress coping skills to performance enhancement. The program audience needs to see that augmenting their stress coping ability will lead to improvement in their performance, as well as in their well-being. In this regard, it is essential that such messages be delivered by highly credible sources. Whenever possible, high status role models should be the vehicle for the instructional material. As several studies indicate, training environments have stressful regimens, but the stressful conditions are phasic, with stress being higher in the early weeks. This was demonstrated by the physiological and health studies on Marine recruits, Army Officer candidates, Navy underwater demolition training, and airmen in basic training. Attrition research with Marine recruits (Mobley et al., 1979; Novaco & Sarason, 1986) also finds that the majority of attrition occurs early in training. From a standpoint of secondary prevention, this facilitates early detection and the provision of remedial assistance. For example, Conrad, Barry, and Patterson (1976) in a study at West Point found that the effectiveness of treatment in returning cadets to duty was related to early identification of stress symptoms. A more impressive study in this regard but concerning the enlistment period was performed by Steinberg and Durell (1968) who reviewed the service records of
Stress Reduction 63 every uncommissioned soldier in the U.S. Army who had been hospitalized for schizophrenia from 1956-1960. They found that the rate of hospitalization is markedly increased in the early months of service and that chronic cases account for only a small fraction of this high incidence. They viewed the initial period of service as that having the greatest demand for social adaptations accompanied by psychological stress. The implementation of secondary prevention hinges on early detection of signs that are empirically related to some outcome criteria. It is far from clear what the stress diagnostic protocol might be. Mental health screening with standardized instruments such as the MMPI is routinely done in some specialized schools, but it is unclear how general such practices are or what their utility indeed is. Physical health assessments are probably done infrequently, and I would speculate that military personnel often avoid getting physicals. I suspect that the flight surgeon is one of the last persons that a pilot would like to see. Existing stress assessment devices such as life events scales, hassle scales, symptom checklists, Type-A behavior scales, or measures of job tension might be examined as a predictive battery, but it is likely that contextual conditions can easily override personological indices. For example, in my research with Irwin Sarason on Marine Corps drill instructors, we have found that the Speed/Impatience component of Type-A behavior (assessed by the Jenkins Activity Survey) is indeed associated with stress during drill field duty and is predictive of supervision evaluations of job performance (inverse relationship). Yet a more striking discovery was that when we examined a person's rank at graduation from Drill Instructor School, we found that those who were corporals had a 50% chance of being relieved of duty for maltreatment or drug use. A relatively small percentage of DI School candidates were corporals, but these men had been selected
Stress Reduction 6" because they showed promise and indeed they performed very well in DI School. After graduation ant the training of their first platoon, they typically were promoted to sergeant. However, our speculation is that these men adopted poor leadership styles on the drill field and probably were too intense in their approach, trying to prove themselves and rise above the two stripes conspicuously on their sleeves. By the time trouble was noticed, their rank was sergeant or above, hence the relationship of high incidence escaped attention. Our research with four DI School cohorts did receive attention by base commanders, and corporals are no longer sent to Drill Instructor School. Our consistent findings of training unit environment effects in recruit training appear also to extend into the first term of enlistment, although analyses on those recruit longitudinal data are not complete. We do know that the social environment established by drill instructors is a key factor determining attrition, adjustment, and performance. This also has effects on recruit cognitions, such as expectations for control of reinforcement (Cook, Novaco, & Sarason, 1982). Drill instructors who adopt a "firm but fair" approach as opposed to a more coercive' harassing approach, are likely to produce service men that are better adjusted and indeed perform better in the Fleet Marine Force. Preliminary analyses of archival data and ratings of E1IF company commanders of our longitudinal subj ects so indicate . Among the patterns that we have found is that low attrition drill instructors (those whose platoons remain relatively intact from forming to graduation) foster increases in efficacy expectations and personal control among their recruits. In contract high perceptions of _ ~ _ _ In contrast, high attrition drill instructors (those whose platoons have high discharge rates) cause decreases in efficacy and lowering of perceptions of control. These findings echo the
Stress Reduction 6: efficacy themes of Rachman's (1978) analysis of fear in combat. He argues that degrees of fear are associated with controllability and confidence and that combatants having appropriate competence and confidence will be less disrupted by fear. Military organizations obviously aim to build personal efficacy, but how well particular training units achieve that objective is an open question. When there are identifiable variations in the effectiveness of training personnel, something can be learned about the proficiencies of the more successful leaders. As Bandura (1977) has delineated, efficacy expectations derive from four main sources, namely performance accomplishments, vicarious experience, verbal persuasion, and physiological states. Training unit leaders can enhance efficacy, therefore, through modeling and suggestion. They can also structure training activities to maximize personal mastery experiences for trainees. Physiological arousal is thought to be a source of efficacy expectations because if arousal is low in a stressful situation, the person will perceive themselves as less vulnerable and the potentially debilitating effects of arousal on performance will be minimized. The arousal reduction approaches reviewed earlier can be employed to promote self-regulatory skills. They must, however, be suited to the context of their application and provisions must be made for the practice of arousal reduction techniques. The study by Burke (1980) with Army Airborne trainees, for example, fell short on both of these aspects. The breathing control procedure was too complicated, and there was no monitoring of practice. In general, arousal reduction procedures require time in skill acquisition and application training. Perhaps they are tees; utilized by mental health specialists in the treatment of stress cases when there is an explicit personal reason for their use. Training in self-
Stress Reduction So monitoring' on the other hand, is more simplified and has a broader range of application. Keeping tabs on somatic states, thought, feelings, and behavior is a fundamental skill of stress management, the point of departure for doing anything to remediate stress. When it has been estimated that in a high intensity war, one-third of the non-death casualties will be psychiatric, the value of stress coping skills should gain sway. Because stress has direct effects on performance, as well as on health and adjustment. the ability to regulate stress can be a significant asset to troops and commanders. While research on stress reduction is in its nascency, there already is a core of basic principles and techniques that can be utilized both in training and in treatment units.
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Influence Strategies Dean G. Pruitt, Jennifer Crocker, and Deborah Hanes State University of New York at Buffalo