**4. Discussion**

Overall, studies on the application of the broad strategies used in SMT show that it is most of the time effective and for an extensive category of difficulties. For instance, it sometimes has a physical impact on medical conditions and is clearly effective to help patients cope with associated psychological reactions. Most studies, but not all, support the effectiveness of SMT. When it comes to dealing with chronic physical illness, strategies having an enduring impact on patient's life and coping style might also be more effective than brief interventions.

The same can be said when looking at mental disorders. Our literature review showed that SIT and AMT are effective tools for PTSD and, to some extent, for other disorders such as generalized anxiety disorder. The broad set of SMT intervention are powerful enough to treat mental disorders, as long as they are structured an include ingredients at the core of SIT and AMT like exposure, cognitive restructuring and homework assignments. Softer techniques often included in SMT, like relaxation and basic coping skills, can be learned and mastered effectively by people who suffer from significant life impairment like schizophrenia or alcoholism in order to deal with stress-related issues instead of treating the disorder itself.

As for the control of non-clinical anxiety symptoms, a large number of studies successfully used SMT to train people to control their stress. These studies represent a secondary prevention approach, where people are already dealing with stress that has not yet reached a clinical level of significance. Broadly defined SMT interventions are effective to deal with stress in the workplace, with academic stressors and for healthcare professionals. Structured approaches like SIT and AMT, as well as biofeedback, appear to be superior. Adapting the coping strategies and how they are presented to the trainees may be inevitable when it comes to applying them to specific contexts such as school and police work. Along those lines, some authors have noted the need to also adapt SMT programs to attitudes of trainees towards stress and emotion regulation.

On another application of SMT, the studies analyzed almost invariably mention that people attending debriefing programs appreciated the experience and were under the subjective impression that it had been beneficial to them. However, empirical data, especially when collected in rigorously designed studies, do not support its efficacy. The selection criteria for the articles were not designed to target debriefing, therefore our analysis may be incomplete. Nevertheless, the limited efficacy of debriefing to reduce the incident of PTSD has been confirmed several times and in other more comprehensive reviews [73, 86] and the consensus is that debriefing trauma victims is not an effective approach, at least when the goal is to reduce the incidence of mental disorders.

Finally, a few interesting studies could be used to appraise the usefulness of SMT in the training of military personnel to cope with acute stressors. Their results suggest that broadly defined SMT strategies could be effective in preparing individuals to cope with a highly specific upcoming stressor. Studies with military personnel and other people facing lifethreatening stressors are scarce, and the breadth of stressors they are likely to experience might be too great to provide effective training options for some of the training programs (e.g., SIT). However, the existing research does suggest that some SMT strategies could be effective, even for life-threatening situations. Their efficacy might be increased if the SMT strategies are structured, sufficiently long to be well learned, and practiced until they are well mastered in stressful situations. Attitudes towards using such coping skills may be a

Overall, studies on the application of the broad strategies used in SMT show that it is most of the time effective and for an extensive category of difficulties. For instance, it sometimes has a physical impact on medical conditions and is clearly effective to help patients cope with associated psychological reactions. Most studies, but not all, support the effectiveness of SMT. When it comes to dealing with chronic physical illness, strategies having an enduring impact on patient's life and coping style might also be more effective than brief

The same can be said when looking at mental disorders. Our literature review showed that SIT and AMT are effective tools for PTSD and, to some extent, for other disorders such as generalized anxiety disorder. The broad set of SMT intervention are powerful enough to treat mental disorders, as long as they are structured an include ingredients at the core of SIT and AMT like exposure, cognitive restructuring and homework assignments. Softer techniques often included in SMT, like relaxation and basic coping skills, can be learned and mastered effectively by people who suffer from significant life impairment like schizophrenia or alcoholism in order to deal with stress-related issues instead of treating the

As for the control of non-clinical anxiety symptoms, a large number of studies successfully used SMT to train people to control their stress. These studies represent a secondary prevention approach, where people are already dealing with stress that has not yet reached a clinical level of significance. Broadly defined SMT interventions are effective to deal with stress in the workplace, with academic stressors and for healthcare professionals. Structured approaches like SIT and AMT, as well as biofeedback, appear to be superior. Adapting the coping strategies and how they are presented to the trainees may be inevitable when it comes to applying them to specific contexts such as school and police work. Along those lines, some authors have noted the need to also adapt SMT programs to attitudes of trainees

On another application of SMT, the studies analyzed almost invariably mention that people attending debriefing programs appreciated the experience and were under the subjective impression that it had been beneficial to them. However, empirical data, especially when collected in rigorously designed studies, do not support its efficacy. The selection criteria for the articles were not designed to target debriefing, therefore our analysis may be incomplete. Nevertheless, the limited efficacy of debriefing to reduce the incident of PTSD has been confirmed several times and in other more comprehensive reviews [73, 86] and the consensus is that debriefing trauma victims is not an effective approach, at least when the

Finally, a few interesting studies could be used to appraise the usefulness of SMT in the training of military personnel to cope with acute stressors. Their results suggest that broadly defined SMT strategies could be effective in preparing individuals to cope with a highly specific upcoming stressor. Studies with military personnel and other people facing lifethreatening stressors are scarce, and the breadth of stressors they are likely to experience might be too great to provide effective training options for some of the training programs (e.g., SIT). However, the existing research does suggest that some SMT strategies could be effective, even for life-threatening situations. Their efficacy might be increased if the SMT strategies are structured, sufficiently long to be well learned, and practiced until they are well mastered in stressful situations. Attitudes towards using such coping skills may be a

**4. Discussion** 

interventions.

disorder itself.

towards stress and emotion regulation.

goal is to reduce the incidence of mental disorders.

factor to take into account when designing the training protocols. In the case of Hytten et al.'s [79] work, it is possible that the use of SIT may not have been optimal. SIT involves strategies that should be learned over many sessions, accompanied with extensive practices and includes several techniques that may be more appropriate for dysfunctional primary and secondary appraisal than dealing with the adequate appraisal of an objective lifethreatening stressors. In any case, Hytten et al.'s [79] paper suggests that a brief, one hour, SMT training is probably not sufficient to learn how to cope effectively with objective lifethreatening stressors. Longer programs, with extensive practice, may be required.

Overall, our goal was to assess whether or not SMT could be used to help military personnel develop effective coping skills while in the theatre of operation. Studies reported in the present chapter point towards a positive answer. Many specific strategies have been shown to be useful, from tactical breathing [87] to cognitive restructuring [10] and exposure [11].

However, a challenge may reside in the low motivation of soldiers in using and practicing psychological tools that are viewed as making a person weak or unmanly. It would therefore be strategic to find ways to help military personnel apply SMT without the negative perceptions. One way of accomplishing that could be to combine SMT with virtual reality [88,89,90]. Although virtual reality is sometime viewed as requiring considerable technological equipment, studies are being conducted to assess the capability of video games and a television screen in helping soldiers control their anxiety. With this technology, it is believed that the negative perception would be reduced and soldiers could then benefit from stress management training in a way that would prove beneficial for their health and mission without appearing weak.
