**2. Method**

272 Post Traumatic Stress Disorders in a Global Context

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

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

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

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,

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

prevention and attribution of success to one's own efforts are also used.

and therefore deserves to be included in the current literature review.

encountered in theater of operations.

associated with current problems.

subtypes of SMT.

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 papers published in peer-review journals.

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 called AMT.

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

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

<sup>1</sup> This criterion was relaxed for papers applying SMT with populations similar to military personnel (see Category 5).

Stress Management Training 275

not to treat existing anxiety disorders. Nevertheless, one cannot ignore that we found 61 scientific papers on that topic. Among all SMT techniques, AMT has clearly been the tool most often studied in regard to the treatment of anxiety disorders and other mental disorders found in the DSM-IV [38], with 39 papers. Most studies (n = 29) were conducted with people suffering from an anxiety disorder: a third of them targeted generalized anxiety disorder [39- 41], while others were conducted with patients suffering from all types of anxiety disorders, ranging from posttraumatic stress disorder [6, 42] to specific phobias [43, 44]. For most of these disorders, at least one randomized controlled trial was conducted with reliably diagnosed patients and long-term follow-up. There is strong evidence to claim that AMT can have a favourable impact on anxiety disorders, including PTSD. AMT has also been used with patients suffering from other mental disorders, such as schizophrenia [45, 46] and alcoholism

SIT has been used in 15 published studies to treat anxiety disorder or symptoms of anxiety in people suffering from mental disorders such as schizophrenia (e.g., in comparison with drug treatment [48]) or addictions [49]. Ten studies were conducted on the treatment of PTSD [50-52] and five on specific phobia [53, 54]. For example, in a randomized controlled trial Foa, Rothbaum, Riggs and Murdock [42] compared SIT to prolonged exposure, minimal support (active control condition) and waiting list (passive control condition) for rape victims suffering from PTSD. Results were statistically superior to the other two control conditions at post-treatment and gains were maintained at follow-up. There are only a limited number of outcome studies using SIT with clinical populations, but their results clearly support the efficacy of this approach to psychological injuries that are severe enough

Much less research has been conducted on the use of more vaguely defined sets of SMT strategies. Our literature search found seven studies conducted on learning stress management skills in different populations suffering from schizophrenia [55-57], substance abuse [58, 59], attention deficit disorder [60], and ambulatory psychosomatic patients [61]. Four of these studies are randomized controlled trials with rigorous designs, acceptable sample and long-term follow-up. For example, it can be safely stated that for people with chronic schizophrenia, training in stress management clearly provides skills for coping with acute work and daily-life stressors and reduces the likelihood of subsequent acute exacerbation of symptoms with needs for hospitalization. It is also useful for substance

**3.3 Category 3: Control of already existing stress-related issues (i.e. non clinical** 

pre/post data and thus were not excluded from our literature search.

Intervening on general, non pathological, anxiety symptoms is the most frequent application of the broad set of SMT techniques. Researchers have published 136 studies on controlling already existing stress-related problems and non-clinical anxiety. Some of these studies did not focus on efficacy but even if it was not the aim of their study, they collected meaningful

A total of 33 studies have focused on using the broad range of SMT strategies with student populations, with 11 studies using essentially the AMT protocol for school related or exam stressors [62, 63]. In a classic experiment, Suinn and Richardson [12] successfully treated 24 students suffering from math anxiety. Additional studies were conducted with university students, seven studies used the SIT protocol [64, 65] and 15 studies used various other SMT

[47], with statistically significant impact on associated anxiety symptoms.

to warrant the clinical diagnosis of PTSD.

abuse and ADHD as tools to better regulate stress.

**diagnoses)** 

strategies, mostly relaxation.


Table 1. Number of peer-reviewed papers found in the literature search on SMT.
