Donald Meichenbaum

Stress reduction and prevention

I: The Stress Literature: Implications for Prevention and Treatment.- 1. A Model for Stress Research with Some Implications for the Control of Stress Disorders.- 2. Natural Healing Processes of the Mind: Graded Stress Inoculation as an Inherent Coping Mechanism.- 3. Stress Inoculation in Health Care: Theory and Research.- Concluding Comments to Section I.- II: Guidelines for Training.- 4. Stress Inoculation Training: Toward a General Paradigm for Training Coping Skills.- III. Applications.- 5. Stressful Medical Procedures: Cognitive-Behavioral Strategies for Stress Management and Prevention.- 6. Stress Inoculation in the Management of Clinical Pain: Applications to Burn Pain.- 7. A Cognitive-Behavioral Approach to Psychophysiological Disorders.- 8. Stress Management For Type A Individuals.- 9. Coping with Terrorism: The Israeli Case.- 10. Stress Management for Rape Victims.- 11. Military Recruit Training: An Arena for Stress-Coping Skills.- 12. Stress Inoculation Training for Social Anxiety, with Emphasis on Dating Anxiety.- 13. Stress Inoculation Training for Adolescent Anger Problems.- Concluding Comments.- Author Index.

STRESS INOCULATION TRAINING: A PREVENTATIVE AND TREATMENT APPROACH

This is the fourth time I am presenting at an Evolution of Psychotherapy Conference. Each time I feel honored and privileged to be included with such esteemed psychotherapists from whom I have learned so much and whom I admire. But, I am also challenged, as are the participants in this conference, to determine what distinguishes this group of “experts,” and moreover to determine what they have in common. I have always been fascinated by the nature of expertise. In fact, my colleague Andrew Biemiller and I have recently written a book on educational expertise entitled, Nurturing Independent Learners, in which we reviewed the literature on expertise (Meichenbaum & Biemiller, 1998). Psychologists have studied experts in such varied areas as sports, artists, writers, computer programmers, jugglers, chess players, waiters, and psychotherapists. What do these various expert groups have in common and what is the relevance to understanding expert psychotherapist? The research indicates that experts differ from novices and from experienced nonexperts in terms of their:1 Clinicians who seek to provide help to stressed individuals, either on a treatment or on a preventative basis, are confronted with a major challenge. As Elliott and Eisdorfer (1982) observed, stressful events come in diverse forms that include exposure to: 1) acute time-limited stressors, including such events as preparing for specific medical procedures (e.g., surgery, dental examination) or for invasive medical examinations (e.g., biopsies, cardiac catherization) or having to confront specific evaluations (e.g., a PhD defense) 2) a sequence of stressful events that may follow from the exposure to traumatic events, such as a terrorist attack, a rape, a natural disaster that results in a major loss of resources, or exposure to stressors that require transitional adjustments due to major losses (e.g., death of a loved one, becoming unemployed), each of which gives rise to a series of related challenges 3) chronic intermittent stressors that entail repeated exposures to stressors such as repetitive evaluations and ongoing competitive performances (e.g., musical or athletic competitions), recurrent medical tests or treatments, or episodic physical disorders such as recurrent headaches, as well as the exposure to intermittent stress that accompanies certain occupational roles, such as military combat 4) chronic continual stressors such as debilitating medical or psychiatric illnesses, physical disabilities resulting from exposure to traumatic events (e.g., burns, spinal cord injuries, traumatic brain injuries), or exposure to prolonged distress, including marital or familial discord, urban violence, poverty, and racism, as well as exposure to persistent occupational dangers and stressors in professions such as police work, nursing and teaching. 2 These varied stressful events may range from those that are time-limited and require situational adjustments to those chronic stressful events that are persistent and that require long-term adaptation. Stressors may also differ between those that are potentially controllable (i.e., can be lessened, avoided, or eliminated by engaging in certain behaviors) and those judged to be uncontrollable (i.e., an incurable illness, exposure to ongoing threats of violence, caring for a spouse with severe dementia) and whether they are predictable or unpredictable; of short duration living in a racist society, being exposed to poverty, having a stressful job); intermittent or recurrent; current versus distant in the past. Distant stressors are traumatic experiences that occurred in the distant past yet that have the potential to continually affect on ones well-being and even modify the individuals immune system because of the long-lasting emotional, cognitive, and behavioral sequelae (Segerstrom …

The developmental control of operant motor responding by verbal operants

Abstract The developmental control of operant motor responding (tapping response) by the verbal operants “faster” and “slower” was examined with 54 kindergarten and 30 first grade children. The effects of the verbal operants on motor behavior were assessed under three conditions: E verbalized the verbal operants; S said the verbal operants to themselves aloud; S whispered the verbal operants using only lip movements (approximating a covert condition). The major finding was an interaction between age and mode of delivery in controlling motor behavior. Kindergarten childrens motor performance approximated first grade children when self-verbalizations were overt, but covert self-instructions had minimal functional control over motor behavior. First-grade childrens self-verbalizations had more functional control over motor behavior when covert than overt. The results suggested a developmental sequence of the functional interaction between speech-for-self and nonverbal operants.

The work of worrying in children undergoing surgery

This study examined the relationship involving childrens level of anxiety, defensiveness, and play patterns 1 week prior to, during, and 1 week after hospitalization for minor surgery. A 7-month follow up was also conducted in order to assess the childrens recall for hospital events and coping style. The results suggested that two classes of children could be identified. The children in one group distinguished themselves in terms of their disposition to engage in the “work of worrying” (i.e., were low defensive prior to hospitalization, actively played with stress-related toys prior to hospitalization, and reported minimal distress and anxiety following surgery). Those in the second group were highly defensive, avoided playing with stress-related toys, and reported most anxiety following surgery. The parallel between children and adult patterns of dealing with surgery was considered in terms of Janiss (1958) model of coping with psychological stress.

Teaching Children Self-Control

An author of a chapter on self-control has to demonstrate just such self-control. In my own case this was necessary for two reasons. The first reason is that I was on sabbatical leave at the University of Hawaii (escaping the Canadian winter) when the completion date for this chapter was approaching. Can you think of a better illustration of a situation that calls for “self-control”?

Changing Conceptions of Cognitive Behavior Modification: Retrospect and Prospect

A retrospective analysis of cognitive behavior modification reveals that 3 major metaphors have been offered to explain the role that cognitions play in behavior change. These metaphors include cognition as a form of conditioning, information processing, and, currently, narrative construction. The implications of using each of these metaphors are discussed.

The effects of instructions and reinforcement on thinking and language behavior of schizophrenics

Abstract Six experimental groups and 2 control groups ( N =48) were used to investigate the relative effectiveness of prolonged training of schizophrenics with contingent social and token reinforcement on (a) the level of abstraction as measured on a proverbs task, (b) the percentage of “sick talk” (% ST) emitted in a structured interview, (c) both verbal response classes of proverb abstraction and % ST. Prior to treatment, schizophrenic Ss compared with 20 nonpsychiatric hospitalized medical patients were significantly inferior on the proverbs task and emitted five times more ST in a structured interview. The results indicated that the experimental treatments were effective in decreasing % ST and increasing abstraction to proverbs with token reinforcement being most effective. Evidence for response and stimulus generalization was obtained.

Aversive and cognitive factors in the modification of smoking behaviour.

Abstract This study investigated the role of verbalization and behavioural rehearsal procedures in an aversive conditioning behaviour therapy for smokers. Experimental conditions, contrasted with an insight control condition, featured combinations of overt or covert verbalizations describing the smoking act and the use or omission of behavioural rehearsal of the smoking act concomitant to an avoidance conditioning procedure. Substantial improvement was obtained, and continued in the follow-up, from a particular combination of behavioural rehearsal and covert verbalization. In this condition S s were trained to smoke a cigarette while imagining themselves to be in a social situation, and while making a sub-voca description of their smoking behaviour. These results have led to the speculation that the manipulation of covert events and behavioural rehearsal of the deviant act may be important adjuncts of the aversive paradigm by virtue of the greater generalizability of the self-generated cues to extra-therapy situations.

Toward a Cognitive Theory of Self-Control

For the last 10 years we have been conducting research designed to bring together the clinical concerns of semantic, or cognitive, therapists (e.g., Aaron Beck, Albert Ellis, Jerome Frank, George Kelley) and the technology of behavior therapy (e.g., procedures such as operant and aversive conditioning, desensitization, modeling, and behavioral and imagery rehearsal). This marriage of somewhat strange bedfellows has bred a set of therapy procedures that we have come to call cognitive-behavior modification. At one time we tended to call the procedures self-instructional training, but this title was too delimiting, not permitting ample recognition of imagery- and fantasy-based factors in the change process. This program of research has been described elsewhere (Meichenbaum, 1973, 1975b; Meichenbaum and Cameron, 1974). These studies have indicated the promising outcome, in terms of generalization and persistence of treatment effects, that follow from the alteration of “standard” behavior-therapy procedures to include self-instructional and imagery processes. For example, the efficacy of behavior-therapy procedures such as modeling (Meichenbaum, 1971), desensitization (Meichenbaum, 1972), operant conditioning (Meichenbaum and Goodman, 1971), and aversive conditioning (Steffy, Meichenbaum, and Best, 1970) was enhanced by the focusing of treatment of the client’s cognitive processes. See Mahoney’s (1974) recent book for a review of the cognitive-behavior modification literature.

Adherence to Self-Care Regimens

Early in the history of medicine, Hippocrates (On Decorum, 1923 translation) cautioned against relying on patient’s self-reports of their compliance with medical regimens because he believed that patients typically do not tell the truth. He suggested that patients try to avoid recriminations, embarrassment, or rejection by the practitioner by responding in a socially desirable manner.