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Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
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OCR for page 117
S=e" Reduction :1
constraints simply did not allow for the use of the full procedure with entire
recruit cohorts in a tightly scheduled training regimen. Consequently, we
only utilized the cognitive preparation and skill acquisition components and
even abbreviated those. The program and its results, along with an account of
a much more elaborate intervention with drill instructors, is given in the
subsequent section.
Meichenbaum (1985) has recently written a clinical handbook or
practitioners guide which reviews the full range of stress inoculation work.
My own perspective differs from his by placing greater emphasis on
environmental determinants of stress and on physiological activation, both of
which are often ignored by Meichenbaum, despite my attempts to influence him
(Meichenbaum & Novaco, 1984). The divergence is rooted in my interest and
research in naturalistic settings, as well as in presuppositions about the
involvement of arousal in stress - related disorders .
UTILIZATION OF STRESS REDUCTION IN MILITARY CONTEXTS
There is very little published. research on stress reduction in the
military. There are a few clinical cases, mostly concerning PTSD described
earlier as arousal reduction treatments, and very few experimental programs.
My search has included technical report information sources, as well as books
and journals.
Clinical Interventions
Several case reports on treatment of PTSD were given in the arousal
reduction section earlier. In addition, some other reports on psychotherapy
and psychopharmacology exist. Amen (1985) described work with a 43 year-old
army first sergeant who had been a POU in Vietnam, and like a number of
others, had PTSD symptoms when the Unknown Soldier from the Vietnam War was
OCR for page 118
Stress Reduction :2
buried at Arlington. The treatment was psychoanalytically oriented with
medication, and it was still in progress at the time the article was
written. The PTSD symptoms were interpreted as metaphors for other life
stresses, as well as war experiences. Psychodynamic treatments of war trauma
and war neuroses rely on "abreaction" or the reliving of the traumatic
experiences in order to gain mastery over them (cf. Milgram, 1982). A case
report of abreactic treatment for a traumatic neurosis from the Yom Kippur War
is given by Weisman (1982) who, for this case, found guilt to integrate the
whole treatment process.
Other reports of pharmacology treatments of PTSD have involved the use of
lithium carbonate in low dosage (Kitchner & Greenstein, 1985) with 'five
outpatients previously considered Treatment resistant" and considered serious
cases of PTSD. All patients had problems of anger ant depression. One
patient disengaged from treatment after being given lithium, one patient
worsened and required hospitalization, and three showed some improvement. No
quantitative outcome data were provided.
- Several reports on the use of phenelzine in comparison with other
medications inspired Birkhimer, DeVane, and Muniz (1985) to study the medical
records for a one-year period of a 440 bed VA hospital. Fifteen cases of
primary diagnosis PTSD were identified and studied for their clinical
characteristics, as well as medication treatment. They found high variability
in symptoms. Strikingly, they found that these patients received an average
of 12 different psychoactive agents over the course of hospitalizations, none
of which effectively achieved symptom remission. Anti-depressants had
particularly poor results, especially imipramine -- in contrast to a case
report by Burns tein (1983). Amen (1984) had to discontinue imipramine when it
produced impotence. Birkhimer et al. also found weak results for anti-anxiety
OCR for page 119
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
OCR for page 120
Stress Reduction :-
two weeks after treatment. He also found significant changes in an overall
life events coping measure.
Experimental Programs
There are a handful of stress management programs that have been
implemented in military settings. Some dissertations on cognitive
modification and arousal reduction have been conducted with dissertation-size
samples, but there are a few larger projects at Army and Marine Corps bases.
A comparison of relaxation training, cognitive restructuring, and wait-
list control was done by Seegert (1984) with 52 military students at the
Defense Language Institute. Self-report anxiety was the key stress measure in
evaluating this six session program, which also looked at grades. Marginal
effects were found for the treatment, with relaxation subjects reporting
lowest anxiety, and no effects were found for grades. The dependent measures,
as well as the treatment are transparently weak in Seegert's study. A better
project was done by Marra (1981) who examined stress and performance in a
study of attention during a military medical examination that incorporated a
treatment comparison. - His two treatments were a deep-breathing arousal
reduction procedure and a cognitive modification approach that taught subjects
to recognize dysfunctional thoughts and to replace them with task-focused self
instructions and thoughts of self-confidence. Compared to a non-treatment
control group, these treatment groups were significantly better on measures of
both stress and attention. While attention measures did not discriminate the
treatment groups, the behavioral observation measures of stress did find 25%
less stress behavior for the cognitive modification condition compared Lo the
arousal reduction condition.
An interesting implementation of arousal reduction procedures was done by
Burke (1980), utilizing procedures of Walter Fenz in the Jumpmaster Course at
OCR for page 121
Stress Reduction ~
Ft. Benning. Officers and enlisted men from several Army Airborne units, some
Marines, and an Air Force officer participated in a study of respiration
control as a stress management technique. They were taught deep breathing as
a coping technique, and assessments were made of heart rate, perceived stress,
and performance. Randomly assigned treatment and control groups constituted
the experimental design. Significant treatment effects were found for heart
rate only, although there were trends for perceived stress and graded jump at
night. Reflecting on the treatment, Burke speculated that the respiratory
control technique may have been too complex (it involved intake, pressing down
the diaphram, holding for 8 seconds, release over 4 seconds, hold without
breathing 4 seconds, one regular breath, and repeat). This probably weighed
against its utilization in the stress situation.
Several stress management programs have been implemented at basic
training facilities. Beach, Prince, ant Klugman (1977) conducted a project at
Fort Dix, Datel ant Lifrak (1969) did one at Fort Ord, Homer, Meglino, and
Mobley (1979) tested a program at Parris Island, and Novaco and Sarason
(Novaco et al., 1983) evaluated an intervention at San Diego. Each of the
latter three programs utilized a film or videotape to deliver the
intervention.
Beach et al. (1977) sought to reduce administrative discharges through
the prevention of stress reactions. Their program was multifaceted ant
involved (a) presentations by chaplains at the reception station that aimed to
prepare recruits for impending stressors, (b) discussion groups ("I want out
of the Army a) run weekly by chaplains, (c) group consultations in the training
unit day room with mental health staff for designated trainees, and (d) a
stress management therapy group by mental health staff. Other company level
and-battalion level didactic presentations were done by the mental health
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Stress Reduction :6
staff. Presentations were also given at the Drill Sergeant Academy regarding
how to manage the marginal recruit.
Within 48 hours after arrival at Ft. Dix, the new recruits were given a
presentation by the chaplain on stress and adjustment. They were told to
expect stress and that it was something natural. They were given an
opportunity to ask questions and generally were afforded accurate information
about basic training so as to reduce anxiety about their new surroundings.
Several suggestions on how to cope with the impending stress were also given,
these being: (1) to anticipate stress, (2) to be objective, (3) to recall how
they had coped with stress in the past, (4) to seek information, (5) to help
each other, and (6) to practice difficult.tasks, imaginally and in viva. The
chaplains also ran a "I want out of the Army. group each Wednesday evening,
which was a pre-existing program that allowed recruits the chance to ventilate
feelings and discuss ways of dealing with basic training.
The mental health staff consultations were a type of secondary prevention
program for trainees who were experiencing difficulties ant involved group
discussions on the unit day room. This was done on an nas needed" basis, and
the mental health staff did large group presentations similar to that done by
the chaplains at the reception station. After these unit consultations,
meetings were held with the commander and first sergeant to provide feedback
and recommendations regarding certain recruits.
The stress management therapy groups had an open group format, but the
authors provide no information about the therapeutic process or framework.
Similarly, the company and battalion level interventions are not described in
any detail. Beach et al. portray an intervention program that has many
components, but the variation lacks structure and focus. Moreover, in the
absence of dependent measures tailored to the program components, it is
impossible to know what ingredients are efficacious.
OCR for page 123
Stress Reduction
This varied intervention was evaluated by assessment of discharge rates
for January-June of 1977 in comparison with those for the same period the
previous year, and significant reductions were found (9.09% versus 13.22%
overall, and 4.26% versus 8.13% for administrative discharges). Comparisons
with other Army training facilities for the same periods, however, reveals
considerable fluctuations in discharge rates across facilities. Another
depot, Fort Jackson also had reductions in discharges, but they also had a
social work service program underway with similar goals. The Fort Jackson
discharge reductions were not as large as those at Fort Dix. My point about
fluctuations is that Fort Gordon had an administrative discharge rate of 6.01%
in 1976 and 10.53% in 1977. -
Datel and Lifrak (1969) developed an experimental film for Army basic
training recruits at Fort Ord for the purpose of creating realistic
expectations about the demands of boot camp. They had previously found that
recruits underestimate the distress they will experience in training, and the
authors sought to reduce stress through emotional preparedness. Datel and
Lifrak actually edited an existing Army training film for their experimental
condition and also had a control film in the design. The editing removed
gratifying or rewarding aspects of the existing film, nThis Is How It Is." As
expected, distress was increased after the film, but hypothesized stress
preparation had no effect on distress during training. While the authors
concluded that the negative results were due to omitting material on the
"culture shock" elements of basic training, it seems unlikely that depiction
of Goffman-like phenomena of identity-stripping, etc., would achieve the
desired goals. Instead, the missing ingredient would seem to be information
about coping skills.
OCR for page 124
Stress Reduction ,5
An analogous intervention with Marine Corps recruits at Parris Island was
conducted by Homer et al. (1979), using a "realistic preview" film. Their
intervention was directed at recruit expectations, inspired by research in
organizational psychology on management of employee turnover. They reported
an experiment consisting of a treatment (80 minute videotape), placebo and
control conditions, which found reductions in attrition that were a~ctributed
to the experimental film. However, recruits were not randomly assigned to
conditions which are seriously confounded by training unit effects that were
unnoticed by the investigators. Oddly, the absence of significant effects on
any manipulation check variable is ignored by the investigators in explaining
differential group outcomes, nor were the authors struck by the implausibility
of a 14% reduction in attrition reported for postgraduation enlistment as
being due to an 80 minute videotape.
Another Marine Corps recruit training intervention was conducted by
Novaco and Sarason at San Diego (Novaco et al., 1983). Our intervention was a
videotape called "Making It" that concerned stress coping skills. It had two
key themes: the self-control regulation of emotion and task performance
effectiveness. It sought to promote an adaptive cognitive orientation and
provide information about the demands of training and the roles of training
personnel. Consistent with the cognitive preparation phase of the stress
inoculation model, recruits were told about their likely distress, worry, and
confusion, and they were also informed about the ingredients of successful
performance. Successful coping behavior was modeled for use in stress
situations.
Our goal with this 35 minute module was to beneficially affect recruit
cognitions during the processing phase at the start of training. The
experimental evaluation was conducted by randomly dividing 530 recruits among
OCR for page 125
Stress Reduction :-
five treatment conditions which included the Parris Island realistic preview
film (as remade for San Diego). Details of the design and procedure are given
in Novaco et al. (1983). Importantly, we randomized within platoons and had a
pre-post design. The analyses indicated that the coping skills module
significantly increased efficacy expectations across a range of training tasks
and also enhanced perceptions of personal control. These effects were not
obtained for the comparison film. Moreover, we found that the recruits who
profit most are those in greatest need (cf. Cook et al., 1982). External
locus of control recruits gain the most in efficacy from the intervention.
Presently underway is a very extensive project designed to teach stress
coping skills to Marine Corps drill instructors. This intervention program is
being conducted at both the San Diego and Parris Island depots. It is based
in their Drill Instructor Schools where it is part of the curriculum,
entailing about eight hours of instruction distributed over the training
schedule. The program is taught by each school's leadership instructor and is
conveyed by- videotape modules and vignettes. There are six modules concerned
with central themes (such as anger, evaluation anxiety, personal
relationships, recruit evaluation) and which portray the utilization of a set
of stress coping skills with regard to the problem domain. The coping skills
are (1) self-monitoring, (2) task-orientation, (3) having a constructive
outlook on others, (4) having a balanced view of oneself, (5) acting
naturally, (6) being patient and learning from mistakes, and (7) utilizing
supportive social relationships. The module videotapes are about 15-18
minutes in length. The vignettes are 5-7 minute tapes on concrete problem
situations, and there are eight of these, which deal with various problem
recruit situations, work relationships, and personal relationships. The
vignettes dissect the problem situation and model effective coping strategies.
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Stress Reduction 60
The drill instructor project developed from longitudinal research on the
stressful nature of drill field duty (Novaco, Sarason, Robinson, & Cunningham,
1982; Novaco, Sarason, Robinson, & Parry, 1983), which had been initiated
after studies on recruit attrition and adjustment found strong effects for
training unit influences (Novaco & Sarason, 1986). The drill instructor
intervention program has just entered the evaluation phase. Data are being
gathered on a multitude of cognitive, personality, behavioral, and
physiological variables to evaluate the effectiveness of the intervention.
PROSPECTS FOR IMP~ENTATION
As stipulated by the conceptual model given earlier, stress must be
understood in terms of contextual conditions. The mechanisms by which
environmental demands operate to produce stress reactions are linked to
features of the physical ant loci-cultural milieux that affect stressor
salience and signification, mitigating factors, resources, and coping
processes. For example, not everyone who has a long commute to work on
congested roadways is going to experience stress that is manifested by
elevated blood pressure, negative mood, lowered frustration tolerance,
impairments in cognitive functioning, and health problems. Indeed, such
stress reactions are significantly influenced by conditions of the residential
and work environments, between which one commutes, as well as by cognitive-
behavioral characteristics of the individual and their efforts to cope with
commuting stress (Stokols & Novaco, 1981). Similarly, whether a drill
instructor exhibits stress reactions will depend on contextual conditions such
as workload (which is phasic and greatest in summer months of high
accessions), company and battalion policies, types of supervision received,
the social climate of the drill instructor team, unexpected pressures, and his
Representative terms from entire chapter:
coping skills
