**The Potential of Stress Management Training as a Coping Strategy for Stressors Experienced in Theater of Operation: A Systematic Review**

Stéphane Bouchard1, Tanya Guitard2, Mylène Laforest3, Stéphanie Dumoulin2, Julie Boulanger1 and François Bernier4 *1Université du Québec en Outaouais, Gatineau, Québec, 2Université du Québec à Montréal, Montréal, Québec, 3Defence Research and Development Canada - Valcartier, Valcartier, Québec, 4Ottawa University, Canada* 

#### **1. Introduction**

This chapter provides a literature review on Stress Management Training (SMT) as a potential tool to help military personnel cope with stressors experienced in the theater of operations. It is hoped that SMT techniques can be used to prepare soldiers for potential highly stressful situations in an effort to diminish their negative reactions to stress. The ultimate long-term prospective benefits would be that training military personnel with SMT would increase resilience and lower the incidence of post-traumatic stress disorder (PTSD).

There are several definitions of stress, but essentially it can be considered an affective state that occurs in response to perceived demands and challenges in the environment with which one feels unable to cope [1]. A variety of stress management techniques have been developed over the years in order to help individuals prevent, eliminate or cope with stress. All these techniques have the objective to modify factors associated with stress (behavioral, cognitive, physiological, emotional and environmental).

Early references to SMT date back to the work of Gottlieb, Strite and Koller et al. [2] who applied stress reduction strategies in behavioral medicine. SMT now represents an extremely diverse set of strategies and our literature review confirmed that notion several times. Authors include almost any available techniques, from Yoga [3] to prayer [4], along with exposure to feared situations [5], cognitive restructuring [6], problem solving [7], etc.

In general, SMT can be defined as the application of any set of techniques aiming to improve the way people cope with stress. Coping represents efforts to manage demands, conflicts and pressures that drain, or exceed, a person's resources [1]. Murphy and Sauter [8] offered to better integrate the applications of SMT strategies to contemporary notions of prevention by dividing SMT into primary, secondary and tertiary interventions. Primary interventions focus on changing the sources of the stress response (e.g., by modifying the environment) before stress becomes a problem, while secondary interventions aim at reducing the severity of symptoms associated with stress (much like secondary prevention, before non-clinical

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A search for scientific papers was conducted using the Scopus database (which includes the following databases and more: PsychLit, PsychInfo, Medline, PubMed) with the following search terms (written without quotes): stress management training, stress inoculation training and anxiety management training. To reduce the risk of missing relevant papers the search was not limited to keywords but open to keywords, title and abstract. The search was performed with publication date ranging from 1950 (the oldest paper found in our search dates from 1958) up to 2009. Information available only from websites, dissertations and conferences were not considered. Taking into account the fact that some papers included two or more of the search terms SMT, SIT and AMT, the literature search resulted in 3 611

As intended, a manual examination of each of these results showed that our search strategy was extremely broad. The majority of the 3 611 papers (89.5%) were rejected because they either: (a) were irrelevant to SMT, SIT or AMT (usually because the search terms were not written within quotes), (b) did not include any1 quantitative or qualitative data (e.g., theoretical paper, description of projects yet to be realized, clinical descriptions, policy position papers), (c) were in languages other than English or French, and (d) were limited to the development of psychometric tests. Meta-analyses and literature reviews based on systematic search of published papers were not rejected. However, their reference lists were crossed-checked to confirm we had not missed any relevant articles. The tedious process of systematic paper selection led to 350 articles, 200 falling under the general umbrella of SMT, 55 on the variation or subtype of SMT called SIT and 95 on the variation or subtype of SMT

After reading the 350 papers addressing the broad definition of SMT techniques, they were divided into five categories, presented in increasing order of relevance to the purpose of helping military personnel to cope with acute stressors such as those experienced in theater of operations (see Table 1): (a) improving physical and medical conditions, (b) treatment of anxiety disorders and other mental disorders, (c) control of already existing stress-related issues (i.e., not clinical diagnoses), (d) preventing the consequences of traumatic events, and (e) development of strategies to cope more efficiently with future stressful situation (i.e., primary prevention). In reviewing the articles, special attention was devoted to studies on

The following pages will present the results of this extensive search on SMT. Given the extremely wide variety of SMT techniques, SIT and AMT are considered to fit in the broad inclusive description of SMT. Results for all these techniques will thus be presented together. For the sake of brevity and clarity, in the first four categories only the most relevant studies will be discussed or cited as examples (for an exhaustive list of the studies compiled in this chapter, contact the first author). Category five includes studies that are clearly relevant to the purpose of our work on mental readiness training to cope with acute stress. Due to their relevance to the aim of our endeavor on preventing psychological

<sup>1</sup> This criterion was relaxed for papers applying SMT with populations similar to military personnel (see

military personnel and similar populations (e.g., police SWAT teams, firefighters).

injuries, studies in category five will be described in more details.

**2. Method** 

called AMT.

Category 5).

papers published in peer-review journals.

symptoms crystallize into disorders). Finally, tertiary interventions represent the application of SMT to treat mental and physical disorders. According to Murphy and Sauter [8], the most common stress management interventions are secondary programs aimed at the individual level and involve instruction in techniques to manage and cope with the stress associated with current problems.

Since the breath of SMT encompasses such techniques as relaxation, cognitive restructuring, problem solving, social skills training, planning behavioral changes and exposure to stressful situations, other stress management programs relying on these techniques also fall under the broad definition of SMT, such as Stress Inoculation Training [9] and Anxiety Management Training [10]. As opposed to SMT, where there is no coherent set of techniques and official definition, SIT and AMT are far from umbrella categories of various psychological techniques. SIT and AMT represent consistent intervention programs with a number of defining strategies that are carefully selected among those usually found in SMT. We therefore decided to include AMT and SIT in our literature review since they represent subtypes of SMT.

Stress inoculation training is a set of cognitive-behavioral techniques developed as a treatment by Donald Meichenbaum around the same years as SMT was gaining popularity [9]. The aim of SIT is to help individuals cope with the consequences of being exposed to stressful events and on a preventative basis to "inoculate" individuals to current and future stressors. Although it is made to be tailored to the client's need, the application of the SIT program follows a semi-structured and clearly outlined format [11] that unfolds in three distinct phases: (a) conceptualization, (b) skills acquisition and rehearsal, and (c) application and follow through. The term inoculation is used to simulate the concept of immunization through progressive exposure. The individual uses techniques such as imagery and behavior rehearsal, role play, modeling and progressive exposure to stressful situations. Techniques for relapse prevention and attribution of success to one's own efforts are also used.

Anxiety management training was developed by Richard Suinn [12] and research on its use was blooming at the same time as SMT and SIT [13]. It is therefore not surprising that, as cognitive-behavior techniques, they share common roots and principles. However, its focus on learning relaxation and generalizing it to daily stressors is much stronger. AMT was first developed for the treatment of what was defined at the time as "free floating anxiety". It was geared more toward clinical anxiety than was SMT and SIT. Suinn's basic philosophy was that patients could be taught to: (a) detect emotional, cognitive and physical signs associated with the onset of anxiety, and (b) react to these signs in manners that would make them disappear. One specific aspect of AMT is that patients are not required to find the causes or stimuli that precipitate their anxiety; they are essentially taught to focus on recognizing the presence of anxiety and its symptoms. Once anxiety-related cues are felt, the patient learns to use relaxation skills in order to alleviate the anxiety. Later on in therapy, the patient learns to identify the cognitive and physiological signs of anxiety arousal sooner. Even if AMT has been created to treat patients suffering from an anxiety disorder, it has been used in other contexts, such as enhancing performance and reducing general stress, and therefore deserves to be included in the current literature review.

This chapter sets out to report an extensive search in peer-reviewed scientific journals, analyze the published empirical data, and organize the results in such a way that studies could be examined based on their relevance to confirm with empirical evidences that SMT, or some of its strategies, is an effective approach to cope with acute stressors such as those encountered in theater of operations.
