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Stress inoculation training, type A behaviour, and irrational beliefs in medical, dental, and graduate… Wyne, Monica A. A. 1991

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STRESS INOCULATION TRAINING, TYPE A BEHAVIOUR, AND IRRATIONAL BELIEFS IN MEDICAL, DENTAL, AND GRADUATE STUDENTS By Monica A.A.Wyne B.A., The Unversity of British Columbia, 1986 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Counselling Psychology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA March, 1991 © Monica A. A. Wyne, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, 1 agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of C o u n s e l l i n g P s y c h o l o g y The University of British Columbia Vancouver, Canada Date March 19. 1991  DE-6 (2/88) ii Abstract This study examined the effects of a stress inoculation training program on self-reported Type A behaviour pattern (TABP) and irrational beliefs in a sample of female medical, dental, and graduate students. Thirteen female medical students from the first, second, and third years of medical school, one female dental student from the first year of dental school, and 16 female graduate student volunteers were assigned to a 6-week stress inoculation group (SI; n_ = 14) or a 4-hour brief treatment group (BT; n = 16) in a repeated measures (pre, post, 11-week follow-up) quasi-experimental design. Participants completed the Rational Behavior Inventory, the Irrational Beliefs Test, the Type A Irrational Beliefs Test, and the Framingham Type A Scale (modified) in order to assess treatment effects. Price's (1982) cognitive social learning model proposes that TABP is elicited and maintained, in part, by specific beliefs and the fears and anxieties that they engender. Following this model, it was hypothesized that self-reported TABP, irrational beliefs, and Type A irrational beliefs would significantly decrease, and rational behaviour, or general rational thinking, would significantly increase, from pre- to post-test and these changes would be maintained at 11-week follow-up in the SI group, compared with the BT group. Repeated measures MANOVAs with pre-planned contrasts indicated that SI was effective in significantly reducing TABP from pre-to post-test. Both SI and BT were effective in significantly decreasing irrational beliefs and Type A irrational beliefs, as well as significantly increasing rational behaviour, or general rational thinking, from pre-iii to post-test. These changes were maintained at follow-up and provide further insight into the relationship between TABP and irrational beliefs. This study provides partial support for Price's model and implicates the use of stress inoculation training in the treatment of TABP in female medical, dental, and graduate students. Implications of these findings and suggestions for future research are discussed. iv Table of Contents page Abstract ii List of Tables vi i i List of Figures ix Acknowledgements x Dedication xi Introduction 1 Hypotheses 6 Literature Review 9 Cognitive Social Learning Theory of TABP 10 Cognitive Therapy and TABP 11 Stress Inoculation Training 21 Measurement Issues 22 Method 27 Participants 27 Design and Procedures 30 Dependent Measures 32 Irrational Beliefs Test 32 Rational Behavior Inventory 33 Type A Irrational Beliefs Inventory 34 Framingham Type A Scale (modified) 34 Ancillary Measures 35 Thought Listing Technique 35 Trait Anxiety Inventory 35 Expectancy Questionnaire 35 Treatments 36 Leaders 36 Stress Inoculation Treatment 37 Brief Treatment 38 Program Evaluation 38 Data Analysis 39 Results : 41 Preliminary Analyses 41 Group Comparability and Pretreatment Differences 41 Expectations of Treatment Effectiveness 42 Outcome Analyses 42 Type A Behaviour Pattern (TABP) and Irrational Beliefs 42 Rational Behaviour and Type A Irrational Beliefs 47 Additional Questions 49 Trait Anxiety and Thought Listing 49 Pearson-Product Moment Correlation Matrix 50 Clinical Change 50 Program Evaluation and Additional Stress Management 51 Discussion 54 Type A Behaviour Pattern and Irrational Beliefs 54 Rational Behaviour and Type A Irrational Beliefs 56 Trait Anxiety and Thought Listing 58 Relationships Between Dependent Measures 60 Brief or Minimal Treatments 61 Clinical Change 63 Theoretical Model 65 Program Evaluation and Additional Stress Management 67 Limitations 68 Conclusions and Recommendations 69 References 71 Appendix A 81 Representative Advertisements and Announcement.... 82 Interview Protocol 84 Informed Consent Form 85 Stress Management Checklist 86 Appendix B 87 Demographic Questionnaire 88 Appendix C 90 Dependent Measures 90 Rational Behavior Inventory 91 Type A Irrational Beliefs Inventory 92 Appendix D 94 Ancillary Measures 94 Thought Listing Form 95 Expectancy Questionnaire 98 Mid-Way Evaluation Questionnaire 99 Post Evaluation Goal Attainment Questionnaire 101 Post Evaluation Cognitive Stress Management Questionnaire and Means and Standard Deviations (Stress Inoculation Group) 102 Follow-up Questionnaire 105 Examples of Program Evaluation Responses 106 Appendix E 108 Pearson Product-Moment Correlation Matrix of Outcome Measures 109 List of Tables page 1. Participant Characteristics 28 2. Means and Standard Deviations of Outcome Measures 43 3. Means and Standard Deviations of Expectancies Scores.... 44 4. Multivariate and Univariate Results for Outcome Measures 45 5. Multivariate and Univariate Results for Ancillary Measures 46 6. Clinical Change of Outcome Measures 52 List of Figures 1. Pre-Test, Post-Test, and Follow-Up Group Means for TABP X Acknowledgements I wish to express my gratitude to my supervisor, Dr. Bonita Long, for her expertise, guidance, and support throughout the duration of my research and its documentation. I also wish to express my appreciation to my other committee members, Dr. Carol Herbert, and Dr. Richard Young, for their advise, support, and patience. Finally, I wish to thank Ms. Colleen Haney for her contribution as co-leader, Dr. Robert Conry and Dr. Robert Schutz for their assistance and advice, and my husband, Mr. Quentin Wyne, for his support and encouragement. XI Dedication I wish to dedicate this thesis to my greatest supporter, my mother, Mrs. Klara Kovacs, for her ubiquitous faith in my abilities, and her constant support and encouragement in the pursuit of my aspirations. 1 Introduction Female medical students have been identified as an at risk subgroup in a profession marked by elevated incidences of distress and impairment (Roeske, 1981), anxiety (Vitaliano et al., 1988), psychiatric problems including suicide, drug and alcohol abuse (Gapen, 1980; Richlings, Khara, & McDowell, 1986) and interpersonal difficulties (Spiegel, Smolen, & Jonas, 1985). Medical students have traditionally had to contend with an anxiety-provoking school environment characterized by performance demands, information overload, intense time pressure, feelings of inadequacy, and a lack of personal support (Lloyd & Gartrell, 1983). Female medical students may be faced with the additional stresses of gender bias (Zeldow, Daugherty, & McAdams, 1988), role conflict (Gaensbauer & Mizner, 1980), and a paucity of female role models, as a result of their participation in a non-traditional career. Studies suggest that female medical students report significantly higher levels of anxiety (Russo, Miller, & Vitaliano, 1985), stress (Clark & Rieker, 1986), and stress symptoms (Spiegel, Smolen, & Hopfensperger, 1986), compared with male medical students. In addition, they have been found to report more depression and somatic symptoms (Lloyd & Gartrell, 1981), and to seek more psychological assistance (Davidson, 1978) than their male counterparts. A recent study (Lloyd & Musser, 1989) suggests that dental students are very similar to medical students, reporting higher levels of distress, including anxiety, than a general sample. Again, female dental students 2 were found to report a significantly higher level of psychiatric symptomatology, including anxiety, and depression, than their male classmates. Although information is limited, it appears that graduate students in general, also report high levels of stress and anxiety (e.g., Heins, Fahey, & Leiden, 1984). Recently, the Type A behaviour pattern has been identified in medical students (Wolf, Kissling, & Burgess, 1986), and several studies have found it to increase across the preclinical years (e.g., Jones, 1984; Jones & Lebnan, 1988), presumably as an attempt to control the stressful medical school environment (Vitaliano et al., 1988; Wolf & Kissling, 1983). Although the Type A behaviour pattern may be construed as an adaptive behaviour within the demanding context of medical school, the association between this behaviour and academic achievement is controversial (e.g., Jones & Lebnan, 1988). However, self-reported anxiety and distress have been found to be higher in medical students than in general samples, and to be associated with higher self-reported Type A behaviour pattern (Vitaliano et al., 1988). A study by George, Whitworth, Sturdevant, and Lundeen (1987), has provided preliminary support for the association between higher levels of stress and higher levels of TABP in dental students. In addition, there is some evidence to suggest that female graduate students report higher levels of TABP than male graduate students (Burke, 1983). The Type A behaviour pattern (TABP) has been described by Friedman and Rosenman (1974) as, ...an action-emotion complex that can be observed in any person who is aggressively involved in a chronic, 3 incessant struggle to achieve more and more in less and less time, and if required to do so, against the opposing efforts of other things or other persons. " (p. 67) Central elements of this pattern include a sense of time urgency or "hurry sickness," aggression, and hostility, as reflected in the propensity to challenge or compete, and competitive achievement striving (Rosenman, 1978). However, it has been contended (Price, 1982) that TABP may be expressed differently by women, particularly with regard to the aggressive component, which may have an inward focus. Although TABP research previously focused primarily on white middle-class executive males, it has been found that women report Type A levels comparable to men when age, education, and marital status are controlled for, and higher Type A levels when work hours are also controlled for (Sorensen et al., 1987). Although the Type A construct has received considerable research attention to date, only a handful of theorists and researchers have addressed the cognitive aspects of this pattern. Price (1982) has put forth a comprehensive conceptual model to attempt to explain the factors involved in the development and maintenance of TABP. In her cognitive social learning model, Price has proposed that specific dysfunctional beliefs and the fears and anxieties which they engender form the core of this pattern. Empirical support for this model has been limited to some extent by poor methodology and the use of unvalidated measures of beliefs (Burke, 1984; Burke & Deszca, 1984; Matteson, Ivencevich, & Gambie, 1987), yet these studies suggest a positive 4 relationship between dysfunctional or irrational beliefs and selected measures of Type A. Studies by Smith and his colleagues (e.g., Smith & Brehm, 1981), have supported this relationship utilizing standardized and validated measures of irrational beliefs and Type A. Taken together, Price's theoretical model and empirical support for the proposed relationships between TABP, irrational beliefs, and anxiety suggest that cognitive behavioural interventions may be effective in the treatment of this behaviour pattern. Several investigations have found such treatments to be effective in reducing TABP (e.g. Levenkron, Cohen, Mueller, & Fisher, 1983; Roskies et al., 1986), and TABP in conjunction with irrational beliefs (e.g. Thurman, 1983; Thurman, 1985 a,b), and trait anxiety (e.g. Jenni & Wollersheim, 1979; Kelly & Stone, 1987). Haaga (1987), in his review of TABP treatments, concluded that rational emotive therapies, a form of cognitive behavioural modification, are apparently effective in reducing self-reported TABP and related beliefs in an enduring manner. In addition, cognitive behavioural treatments are indicated as effective in reducing self-reported and interviewer-observed TABP, and are evidently superior to minimal or educational treatments. These conclusions are consistent with the model put forth by Price. However, due to methodological inadequacies and inconsistencies, these conclusions may be overly decisive. Conclusions at this stage warrant tentativeness due to the lack of concensus regarding targets of intervention, outcome measures, 5 duration of treatments and screening criteria. In addition, studies have combined healthy and coronary heart diseased participants, as well as men and women. Little is known of the effects of such interventions on subgroups, including women, young adults, and at-risk populations. Methodological flaws pervade the area and include high attrition rates, a lack of follow-up measures, and small sample sizes. Therapist bias, via the use of a single therapist, has been introduced in many cases, and the use of different measures, as well as those which have been developed and normed utilizing strictly male samples, may have reduced the validity of some findings. Finally, many programs have failed to include attention placebo control groups to examine expectancy, history, maturation, and testing effects. The need for stress management programs for medical students and female medical students in particular is apparent. Female dental and graduate students appear to also be at risk and thus in need of these programs as well. Investigations into which cognitive change methods reduce TABP, stress, and anxiety, and the use of well defined, and empirically evaluated interventions in standardized programs, are warranted. In addition, conceptual cohesion between theory, interventions, and dependent measures should be pursued. Stress Inoculation Training (SI; Meichenbaum, 1988) is an empirically supported, cognitive behavioural intervention that has been applied in the prevention and treatment of stress, anxiety, and related conditions in a variety of populations (Jorgensen, Houston, & Zurawski, 1981; Long, 1982; Wernick, 1984). The main assumption underlying both SI and Price's model of TABP is that stress is 6 transactional, or is the result of the reciprocal interaction between behaviour, environment, physiology and cognitions. Both frameworks place cognitive mediation or appraisal at the centre of this transaction, indicating this process to be the target for change methods. SI attempts to modify cognitions, including irrational beliefs, and negative thinking, through cognitive restructuring and self-instructional training. The purpose of this study was to assess the efficacy of a cognitive behavioural stress management program, stress inoculation training (SI), on reducing levels of self-reported TABP as well as modifying faulty or irrational beliefs in healthy female medical, dental, and graduate students, compared with a brief treatment (BT). Because this form of therapy, and SI in particular, has been supported as an effective treatment compared with other therapies, it was contended that a BT group was an adequate comparison to control for the effects of participation in a group. It was concluded that this treatment was ethically superior to a waitlist group given the apparent need of the population sampled. Hypotheses It was hypothesized that self-reported TABP, as measured by the Framingham Type A Scale (modified; Haynes et al., 1978), would decrease significantly from pre- to post-test and this change would be maintained at follow-up in the stress inoculation group, compared with the brief treatment group. This would be consistent with previously reported reductions in self-reported TABP following cognitive 7 behavioural interventions (e.g., Jenni & Wollersheim, 1979; Kelly & Stone, 1987). It was also hypothesized that self-reported irrational beliefs, as measured by selected items of the Irrational Beliefs Test (IBT; Jones, 1969), would decrease significantly from pre- to post-test and this change would be maintained at follow-up in the stress inoculation training group, compared with the brief treatment group. This outcome was suggested by previous studies that have found specific types of irrational beliefs, as measured by the IBT to significantly and positively correlate with the Framingham Type A Scale (FTAS; Haynes, Levine, Scotch, Feinleib, & Kannel, 1978; Smith, Houston, & Zurawski, 1983) and trait anxiety (Deffenbacher, Zwemer, Whisman, Hill, & Sloan, 1986). In addition, specific beliefs, as measured by the IBT, have been found to differentially decrease following a cognitive behavioural intervention in a sample of undergraduate university students (Thurman, 1983). It was further hypothesized that self-reported Type A irrational beliefs, as measured by the Type A Irrational Beliefs Inventory (TAIBI; Thurman, 1984), would decrease significantly from pre- to post-test, and this change would be maintained at follow-up in the stress inoculation training group, compared with the brief treatment group. This outcome was suggested in a study by Thurman (1985a,b), which found self-reported Type A beliefs, as measured by the TAIBI, to decrease significantly following a cognitive behavioural intervention with Type A university faculty. Finally, It was hypothesized that self-reported rational behaviour, 8 or general rational thinking, as measured by the Rational Behavior Inventory (RBI; Shorkey, & Whiteman, 1977), would increase significantly from pre- to post-test and this change would be maintained at follow-up in the stress inoculation training group, compared with the brief treatment group. This outcome was suggested in a study by Shorkey and Whiteman (1977), which found rational thinking, as measured by the RBI, to increase significantly following cognitive behavioural interventions in a sample of undergraduate university students and a sample of mental health professionals. Furthermore, as confirmation of cognitive treatment effects, it was expected that the ratio of negative thoughts to positive thoughts, as measured by the thought-listing technique (Cacioppo & Petty, 1981), would decrease significantly over time in the stress inoculation training group, compared with the brief treatment group. It was also expected that anxiety, as measured by the Trait Anxiety Inventory (TAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983), would show greater decrease over time in the stress inoculation group, compared with the brief treatment group. Although trait anxiety is defined as a relatively stable characteristic by the author of this measure (Spielberger et al., 1983) several studies have found trait anxiety to decrease as a result of cognitive behavioural interventions (e.g. Long, 1984). 9 Literature Review Female medical students are vulnerable to distress in the form of TABP, anxiety, and stress symptoms. Female dental students, and female graduate students appear to be affected similarly. However, little is known about the effects of interventions for TABP and related components in these groups. Traditional perspectives of TABP have been limited by an excessive focus on the behavioural and physiological outcomes, and disease end points of this pattern. The generally atheoretical approach towards the pattern has restricted understanding into factors underlying its development and maintenance, and subsequently, its treatment. Price's (1982) cognitive social learning model contends that specific irrational beliefs and their related fears or anxieties are central to the development and maintenance of the TABP pattern. This model implicates cognitive therapies for TABP, particularly those which implement strategies to help Type A individuals cope with stress as a transactional phenomena, through physical and cognitive coping techniques, in addition to cognitive restructuring. Within this literature review, Price's model is described and empirical support for the proposed relationships between TABP, irrational beliefs, and trait anxiety are summarized. Research assessing the impact of cognitive behavioural therapies for healthy individuals at risk for the development of, or exhibiting TABP, is also reviewed. Stress inoculation training is described, and support for SI as a viable cognitive behavioural treatment for TABP is cited. Finally, issues regarding the measurement of TABP, irrational beliefs, and anxiety are 10 examined. Cognitive Social Learning Theory of TABP Price (1982) has contended that the dysfunctional beliefs underlying TABP are the product of direct instruction and observational learning of predominant sociocultural values, transmitted to the individual through family, social groups, institutions, and the media. Type A irrational beliefs are defined, in the present analysis, as cognitive structures or constructs which elicit fears, anxieties, and other negative affective states in the individual and manifest in overt TABP behaviours. Price contends that Type A individuals believe that their self-worth is a function of their accomplishments, and is therefore variable, leading such persons to constantly strive to prove themselves, for fear of being appraised as unworthy or unsuccessful. Concomitant to this is the belief that no global moralism exists, which engenders the fears that good intentions will not necessarily lead to favourable outcomes and that good may not dominate. Finally, Type A individuals are thought to believe that tangible and intangible resources are limited and consequently fear that they will not attain enough of these resources. These beliefs and associated anxiety are thought to reciprocally interact with the environment, physiology, and behaviour, manifesting in TABP. Studies utilizing standardized measures to test Price's theory have provided preliminary support for the purported relationships between irrational beliefs, TABP, and anxiety. In one such study, Smith and Brehm (1981) found Type A behaviour, as measured by the student 11 version of the Jenkins Activity Survey (Glass, 1977), and the activity subscale of the Thurstone Temperament Survey (Thurstone, 1953), to correlate significantly with items of the Irrational Beliefs Test (IBT; Jones, 1969). A second study (Smith et al., 1983) provides support for the association of selected beliefs on the IBT and higher levels of anxiety with TABP, as measured by the trait scale of the State-Trait Anxiety Inventory (STAI; Spielberger et al., 1970) and the Framingham Type A Scale (FTAS; Haynes et al., 1978), respectively. These findings suggest an association between self-reported TABP, irrational beliefs, and trait anxiety. Cognitive Therapy and TABP A study by Jenni and Wollersheim (1979) compared the effects of a stress management program (SMT) versus cognitive therapy (CT) on reducing stress related to Type A behaviour. Participants were recruited via physician referrals and newspaper advertisements on a volunteer basis and further screened by the structured interview (SI; Rosenman et al., 1964) for the presence of the pattern. Twenty-seven male and 15 female participants (n = 42; M_ = 42.5 yrs.) were matched for sex and randomly assigned to SMT, which employed progressive relaxation and visualization, CT, which utilized rational emotive therapy, or a waiting list control group (WL). Two graduate students in clinical psychology acted as therapists. Those in the treatment groups participated in 6 (90-minute) sessions over a period of 6 weeks. Pre-, post-, and 6-week follow-up measures included the Bortner (Type A) Self-Rating Scale (BSRS; Bortner, 1969) (modified), the Spielberger 12 State-Trait Anxiety Inventory (STAI; Spielberger et al., 1970), and physiological indices. Repeated measures analyses of variance (ANOVA) supported both treatments as equally effective in decreasing levels of self-reported trait and state anxiety, as compared with the waiting list control group. In addition, it was found that CT was more effective than both SMT and WL in reducing self-reported TABP in those subjects who were highest on TABP at pre-test. This finding was replicated when the control group received CT. The statistical conclusion validity of this preliminary study is limited by the use of both healthy and non-healthy (coronary heart diseased) participants, a relatively small sample size, and possibly differential mortality. The validity of this study is limited by the lack of controls for therapeutic expectancy, as well as the use of an unvalidated instrument to measure TABP. In an investigation by Levenkron, Cohen, Mueller, and Fisher (1983), - comprehensive behaviour therapy (CBT), including cognitive behavioural modification training, was compared to group support (GS) and brief information (BI; minimal treatment) to assess the relative efficacy of these treatments in modifying TABP. Volunteer participants responded to announcements at two corporations. Thirty-eight males (M = 35.6 yrs.) met the screening criteria of age (25-50), the absence of coronary heart disease, a minimum of two years college, management level employment and the lack of psychological and pharmacological treatment. In addition, participants had to demonstrate a score greater than zero on the Jenkins Activity Survey (JAS; Jenkins, Zyzanski, & 13 Rosenman, 1979). Participants completed pre- and post-testing on the JAS, the Framingham Type A scale (FTAS; Haynes et al., 1978), the activity scale (modified) of the Thurstone Temperament Schedule (TTS; Thurstone, 1953), and a measure of anger. Ancillary measures included the STAI. Subjects were stratified, on the basis of their JAS and STAI scores, into blocks of three which were subsequently randomly assigned to either CBT, GS, or BI. Those in active treatment groups participated in 8 weekly (90-minute) sessions conducted by a doctoral student, while those in the BI group participated in a single (2 hour) session. Repeated measures multivariate analyses of variance (MANOVA) and correlational analyses revealed that both the CBT and GS were superior to BI in reducing self-reported Type A behaviour. In addition, CBT significantly reduced all measured components of the pattern, while GS demonstrated this efficacy on only 4 components (not including anger and job involvement). The BI treatment significantly reduced only the JAS job involvement scale. No significant changes were found for trait anxiety or for the additional measures. Potential methodological flaws include experimenter bias, introduced through the use of a single therapist, and a 20% attrition rate in the CBT group. The inclusion of 34 of 38 subjects from one corporation limits the generalizabilty of this study to middle age, management level males who are healthy and work for a single corporation. In addition, the sample reported low levels of anxiety at pre-test, thereby reducing the probability of a significant change 14 occurring from the treatment and limiting the generalizability of these findings. Finally, the lack of follow-up measures leaves the durability of any treatment effects unknown. Thurman (1983) investigated the effects of a rational emotive (RET) treatment on TABP in college students. Volunteers were recruited via advertisements and screened for scores of 10 or higher on the Type A scale of the JAS (student version; Glass, 1977). Twelve males and 10 females (n = 22; M. = 23.5 yrs.) from undergraduate and graduate levels completed pre-, post-, and 8-week follow-up measures on the JAS, the Irrational Beliefs Test (modified) (IBT; Jones, 1969), the STAI, and other unvalidated measures. Participants were randomly assigned to either RET or waiting list control groups and matched for sex. Those in the RET group participated in 6 weekly (2-hour) sessions conducted by a psychologist. ANOVAs indicated that those in the RET group reported significantly reduced levels of Type A, speed and impatience, hard-driving and competitive behaviours. Significant reductions in irrational beliefs, in general, and irrational beliefs regarding high self-expectations, anxious overconcern about the future and perfectionism were also reported by the RET group. These findings were maintained at follow-up. The absence of a placebo attention control group and the use of a small sample size limits the validity of these findings. A second study by Thurman (1985a,b) compared the relative efficacy of cognitive behaviour modification (CBM) versus CBM plus assertiveness training (CBM/AT) in reducing TABP in Type A university 15 faculty. Thirty male and 9 female (n = 39; M_ = 46.6 yrs.) faculty who had scores at or above the 60th percentile on the JAS participated. Participants were randomly assigned to either CBM, CBM/AT, or minimal treatment (MT) groups and matched for sex. CBM and CBM/AT sessions were held for one (2-hour) session per week over 8 weeks, while MT consisted of a single (1-hour) session. All groups were conducted by a doctoral counselling psychology student. Pre-, post- and 3-, 6-, and 12-month follow-up measures included the JAS (minus the job involvement scale), the BSRS, the Rational Behavior Inventory (RBI; Shorkey & Whiteman, 1977), the Type A Irrational Beliefs Inventory (TAIBI; Thurman, 1984), measures of anger, and physiological indices. Repeated measures MANOVAs and ANOVAs supported CBM and CBM/AT as effective in significantly reducing self-reported and significant other reported Type A behaviour, as measured by the JAS Type A scale, and the BSRS, as well as self-reported irrational beliefs on the TAIBI, compared with MT. No significant difference was found on the RBI. These findings were maintained at 3-, 6-, and 12-month follow-ups, and extended to include the JAS speed and impatience scale. In addition, participants' scores decreased from the 85th and 90th percentiles at pretreatment, to the 65th percentile at the one year follow-up, as indicated by the JAS. These findings must be viewed in light of the use of a single therapist, which may have introduced experimenter bias into the findings and thus may have lessened the validity of the study. The small sample size, the absence of an attention placebo control group, and the use of an unvalidated measure of 16 irrational beliefs may have also limited the validity of this investigation. Finally, the 20.5% attrition rate in the treatment group may have limited the generalizability of the findings. In a study by Roskies et al. (1986), cognitive behavioural stress management (SM) was compared to aerobic exercise (AE) and weight training (WT; minimal treatment) in modifying physiological and behavioural reactivity to laboratory stressors in Type A men. Participants were recruited via invitations sent to two corporations. Screening criteria included 'physiological reactivity' and the presence of the Type A pattern, as indicated by the speech component of the Structured Interview (SI; Rosenman et al., 1964). One hundred and seven male managers (M. = 37 yrs.) participated on a volunteer basis. Participants were randomly assigned to SM, WT, or AE, the former two of which consisted of 20 sessions, while the latter included 30 sessions, all across a period of 10 weeks. Participants completed pre- and post-test measures, including the SI and physiological measures, following laboratory stress tasks. MANOVAs and repeated measures MANOVAs indicated that behavioural reactivity, as measured by the SI, was reduced significantly in the stress management group. These findings must be interpreted cautiously in view of the lack of comparability of the groups, i.e., the SM group was supportive in nature compared to the other groups, and thereby possibly introduced the Hawthorne effect. In addition, the number of leaders varied from 2 in the SM group to 1 in the WT and AE groups. It is unclear as to whether the laboratory stressors sufficiently mimicked those in real life (experimental realism) and elicited realistic responses (mundane 17 realism). Generalizability is limited to healthy male managers from these two corporations. Diffusion may have occurred between groups, thereby lessening the internal validity of the findings. Finally, the lack of follow-up measures leaves the durability of treatment effects unknown. Kelly and Stone (1987) compared the efficacy of anxiety management training (AMT) alone, to AMT plus cognitive behaviour therapy (AMT/CBT), to AMT plus values clarification training (AMT/VCT) in reducing TABP. Participants were recruited via newspaper announcements and screened for health (the absence of coronary heart disease), and the presence of the TABP (above the 80th percentile on the JAS, and as indicated by the SI). Thirty-six participants were blocked on self-monitoring and randomly assigned to AMT, AMT/CBT or AMT/VCT. Due to attrition, 31 participants (n_= 16 male; n = 15 female) completed the study. Pre- and post-treatment measures included the JAS, the STAI, and the Thought-Listing procedure (Cacioppo & Petty, 1981). Groups were conducted according to the following schedules: AMT: one (1-hour) session per week over 6 weeks; CBT/AMT and VCT/AMT: one (1-hour) session twice per week for 3 weeks (AMT), plus one (90-minute) session per week for 6 weeks. All groups were conducted by a doctoral student. ANCOVAs and correlational analyses found all three treatments to be equally effective in reducing TABP. State and trait anxiety were significantly reduced in the CBT/AMT group, compared to the AMT group. No significant differences were found on thought 18 listing. The statistical conclusion validity of these findings may have been limited by the small sample size and participant attrition. Delivery of treatments was by a single therapist, thereby possibly confounding treatment effects. The lack of follow-up measures, and the differing schedules between treatments also make conclusions and comparison difficult. Finally, the sample consisted of extreme Type A individuals, thus limiting conclusions to this highly homogenous group. A study by Kelly, Bradlyn, Dubbert, and St. Lawrence (1982) evaluated the effects of a cognitive behavioural stress management program on reducing self-reported stress, including TABP, and increasing coping skills in medical students. Participants volunteered in reponse to announcements and were assigned in intact groups to the stress management (SM) program (n = 34) or the waiting list group (n = 14). Groups were composed of 65% first year, 12% second year, and 3% fourth year medical students, in addition to 20% residents and nurses. Thirty-two males and 16 females completed pre- and post- measures on the JAS, the STAI, as well as unvalidated measures of stress, and self-monitoring logs. Those in the SM group participated in 6 (60- 90 minute) sessions across 3 weeks, conducted by 4 coleaders. MANOVAs and ANOVAs revealed decreases on the JAS speed and impatience, and hard driving scales. However, no significant difference was found on the STAI. These findings must be interpreted with caution considering several methodological flaws. In the context of the literature in this 19 area, it is apparent that a 3-week cognitive behavioural intervention may be insufficient to allow for the application and habituation of learned skills and may account for the lack of a significant change on the STAI. In addition, the lack of a placebo attention control group limits the validity of these findings. The high attrition rate in the SM group and the unequal sample sizes limits the generalizability of these findings. No follow-up measures were pursued, leaving the durability of the effects unknown. Finally, the lack of random assignment of subjects lessens the statistical power of this study considerably. In a study by Gill et al. (1985), a cognitive behavioural program for TABP in Type A military officer students was compared to a no-treatment control group. One-hundred and sixteen male and 2 female Type A participants (M_ = 42.9 yrs) were randomly assigned to receive Type A counselling or to the control group. All participants completed pre- and post-test measures including a Type A questionnaire (Friedman et al., 1982), and the Videotaped Structured Interview (VSI; Friedman & Powell, 1984), as well as physiological and dietary measures. Those in the treatment group participated in a 90-minute session per week for three months, followed by one session every three weeks for five months, for a total of 21 sessions. Statistical analysis revealed significant reductions on all Type A assessments in the treatment group, compared with the control group. These findings must be tempered by group attrition (treatment group, 15%; control group, 10%), which may have been differential, and the use of a high Type A sample. No follow-up data were collected, leaving the durability of treatment effects unknown. Finally, 20 generalizations must be limited to the highly homogeneous sample. St. Lawrence, McGrath, Oakley, and Suit (1983), investigated the effects of a cognitive behavioural stress management intervention for law students. Volunteer participants were assigned in an intact group (n_ = 10) to the treatment group, while students randomly selected from the law student body were assigned in an intact group to the control group (n_= 11). Participants completed pre- and post-test measures including the JAS (minus the job involvement scale), the Stress Knowledge Inventory (Kelly et al., 1982), an unvalidated measure of stressful situations ratings, and self-monitoring logs. Those in the treatment group attended 6 (60-90 minute) sessions, very similar in content and process, to SI. A MANOVA and ANOVAs revealed significant differences only on the Stress Knowledge Inventory and stressful situations ratings in the treatment group, compared with the control group. No significant differences were found on the JAS. These findings must be viewed in light of the small sample sizes utilized, the lack of a placebo attention control group, the different selection and assignment procedures implemented with the two groups, and the unjustified and disproportionate use of 4 co-leaders. No follow-up assessment was made, thereby limiting information regarding the durability of treatment effects. A study by Tisdelle, Hansen, St. Lawrence, and Brown (1984) examined the effects of a cognitive behavioural stress management program for dental students. Twenty-eight male and 4 female 21 volunteers were randomly assigned to a treatment group (n=17) or to a waiting-list control group (n_=15). All participants completed pre-test, post-test, and follow-up measures including the JAS, the STAI, the Stress Knowledge Inventory, and measures of stressful situations ratings, symptomatology, and physiological indices. Those in the treatment group participated in 6 (60-90 minute) weekly sessions co-led by two graduate students. MANOVAs revealed no significant differences from pre- to post-test. However, trait anxiety, JAS speed and impatience, and stressful sitations ratings were found to significantly decrease, and knowledge of stress was found to increase significantly, in the treatment group at follow-up, compared with the control group at post-test. No significant differences were found on the JAS Type A or hard driving scales between the two groups. These findings must be interpreted with caution because of the lack of a placebo attention control group, and the different testing points compared, i.e., post-test data in the control group were compared to follow-up data in the treatment group. Extraneous factors, for example, those related to changes in academic pressures at these times, may have contributed to the observed effects. Stress Inoculation Training Stress inoculation training (ST, Meichenbaum, 1988), is a cognitive behavioural therapy which incorporates cognitive restructuring, in addition to cognitive and physical coping strategies, to assist individuals in their stress management. These components derive from a 22 transactional model of stress which implicates the interaction between stressors in the environment, cognitive appraisal, physiological reactions, and behavioural outcomes. The treatment consists of three phases which gradually introduce individuals to increasing levels of coping which they implement with increasing levels of stress. A treatment rationale and information regarding the components and effects of stress comprise the first, or the conceptualization or educational phase. The second phase, the skills acquisition and rehearsal phase, consists of cognitive restructuring, as well as cognitive and physical coping techniques. The final phase, the application and follow-through phase, involves the gradual implementation of coping methods through imagery, role-playing, and in real life situations. Stress inoculation has previously been supported as effective in reducing TABP (Levenkron et al., 1983; St. Lawrence et al., 1983) and trait anxiety (Long, 1984; Sharp & Forman, 1985). Measurement Issues Measures were selected for use in this study after a careful weighing of both empirical and theoretical factors within the developing contexts of research in TABP and irrational beliefs. This section will review these concerns while presenting rationales for the use and modification of selected instruments. The Irrational Beliefs Test (IBT; Jones, 1969) was selected as a dependent measure because of previous findings of significant correlations between the high self-expectations, blame proneness, frustration reactive, and anxious overconcern IBT scales, with the 23 Framingham Type A Scale (Smith et al., 1983). These correlations suggest a relationship between specific beliefs and overt Type A behaviours consistent with the model outlined by Price (1982). In addition, the IBT is the most frequently used measure of irrational beliefs in the published literature, and has demonstrated sensitivity as a change or outcome measure in cognitive behavioural intervention studies with TABP (e.g., Thurman, 1983). The issue of discriminant validity has been raised regarding the distinctiveness of the construct of irrational beliefs from the construct of general anxiety. Sutton-Simon (1981), for example, has contended that the IBT may be viewed as an additional measure of anxiety which focuses on cognitive aspects. Smith (1982) and others have criticized the IBT on the basis of its use of affective language, and have contended that this overlap may artificially inflate the association between the IBT and measures of anxiety. This was supported in a study by Smith and Zurawski (1983), which found the IBT not to demonstrate discriminant validity against some measures of anxiety, including the TAI. Clearly, some degree of overlap exists and may be viewed as a specific and unique patterning of the constructs of interest, rather than the redundant assessment of a unitary phenomenon. An investigation by Deffenbacher, Zwemer, Whisman, Hill, and Sloan (1986) supports this contention in finding specific belief scales on the IBT to be related to different types of anxiety. A regression analysis for trait anxiety found the IBT scales of perfectionism, frustration reactive, anxious overconcern, and helplessness to be predictive of trait anxiety. 24 This pattern was similar to that reported by Zwemer and Deffenbacher (1984) who found anxious overconcern, problem avoidance, frustration reactive, and perfectionism to enter a regression analysis for trait anxiety. If the IBT simply measured trait or general anxiety, then it follows that high trait anxiety would be associated with high scores on all irrational belief scales, and would therefore account for a high proportion of variance. However, this pattern has not been demonstrated, and correlations between associated scales leave a significant proportion of variance unaccounted for. Items which were selected for use in the analyses of this study were those common to the factor analyses of Jones (1969), Lohr and Bonge (1982), and Cramer (1985). As a result, items which were found not to represent the beliefs they were purported to, cited at 48% by Cramer, were not included in analysis. Therefore, although the frustration reactive scale of the IBT should logically have been included, following Price's model, it has been omitted due to the lack of representative items. The Rational Behavior Inventory (RBI; Shorkey & Whiteman, 1977) was selected for use in this study because of its demonstrated discriminant validity against measures of anxiety, including the TAI, in addition to its utility as an outcome measure in studies of cognitive behavioural interventions (Shorkey & Whiteman, 1977). Although the RBI has been criticized as potentially being a measure of R.E.T. language acquisition (Sutton-Simon, 1981), this was not a factor in the present study, as R.E.T. techniques were not implemented. In addition, the RBI 25 rationality index, utilized in this study, has been found to significantly negatively correlate with several anxiety scales, including the TAI (Himle, Thyer, & Papsdorf, 1982). The RBI is the second most widely used beliefs measure in the literature and was used in this study to confirm findings on the IBT. The Framingham Type A Scale (FTAS; Haynes et al., 1978) was selected for use because of its unique association with measures of anxiety, including the TAI (Houston, Smith, & Zurawski, 1986; Smith et al., 1983; Smith & O'Keefe, 1985). Although the relationship of the FTAS with anxiety has been construed as "contamination with neuroticism" (Smith & O'Keefe, 1985), the FTAS has demonstrated discriminant validity against measures of anxiety (Smith et al., 1983). In addition, the FTAS has been found to correlate significantly with the high self-expectations, blame proneness, frustration reactive, and anxious overconcern scales of the IBT scales, which are indicated by Price's model. The FTAS has demonstrated convergent validity by classification agreement of several items with assessments made by other Type A measures (Chesney, Black, Chadwick, & Rosenman, 1981; MacDougall, Dembroski, & Musante, 1979). The FTAS has been criticized for the limited number of items (10), and the ability of the instrument to discriminate successfully between self-reported Type A versus Type B (TABP absent) individuals, particularly in light of the scoring procedure utilized, which assigns type on the basis of a median split procedure. In this study, a modified continuous scoring procedure (Levenkron et al., 1983) was used resulting in a Type A/B continuum, 26 thereby eliminating the artificiality of an arbitrary split. Finally, the FTAS was selected on the basis of the standardization sample used in its development, which was unique to Type A measures in the inclusion of females. Furthermore, the FTAS has been used in studies of medical students, and as an outcome measure in a cognitive behavioural intervention for TABP (Levenkron et al., 1983) indicating the FTAS as the appropriate Type A measure in this study. In conclusion, Price's (1982) cognitive social learning theory of TABP provides a comprehensive framework which links the underlying mechanisms in TABP to targets for assessment and treatment. Cognitive behavioural interventions, and SI in particular, are implicated by this model and are empirically supported as viable interventions for TABP and its related components. However, information regarding the effects of such treatments on TABP in at-risk subgroups, including female medical, dental, and graduate students is limited. 27 Method Participants Thirteen female medical students, one female dental student, and 16 female graduate students from the University of British Columbia were recruited via class announcements, posters and student newspaper advertisements (see Appendix A) on a volunteer basis during the 1989-1990 academic year. Participants were screened according to an absence of previous stress inoculation stress management training and their agreement to be randomly assigned to either the SI or the BT groups. No participants were screened out. The two groups were similar in age, the SI group ranged from 21 to 49 years, with a mean age of 28.7 (SD = 7.6), and the BT group ranged from 22 to 40 years, with a mean age of 29.9 (SD = 5.1). The SI group was comprised of 57% medical and dental students, and 43% graduate students, whereas the BT group had 37.5% medical and dental students, and 62.5% graduate students. The groups were also very similar with regard to marital status, 43% of the SI group were married or in a common-law relationship, and 57% were single, divorced or separated, whereas 44% of the BT group were married or in a common-law relationship, and 56% were single, divorced or separated. Both groups exhibited substantial trait anxiety as revealed in their pre-test TAI scores. The SI group mean 42.9 (SD = 9.6), and the BT group mean 45.8 (SD = 10.5), were both higher than the mean of 40.4 (SD = 10.15) reported by Spielberger et al. (1983) for female college students. Additional demographic information is summarized in Table 1. 28 Table 1 Participant Characteristics Demographics (N_ = 30) SI (n = 14) BT (n = 16) %. %. Year of Program Year 1 29 31 Year 2 43 38 Year 3 14 25 Other 14 6 Educational Qualifications University prerequisites 28 19 University degree 36 62 Masters degree 36 19 Marital Status Married/Commonlaw 43 44 Single/Div./Sep. 57 56 Health Satisfaction (mean, standard deviation) (range 1 - 7) 5.3 1.1 5.1 1.1 Cigarette Smoking 0 6 Diagnoses Blood Pressure 0 6 Diabetes 0 0 29 Angina 0 0 Ulcers 14 13 Migraine Headaches 7 25 Coronary Heart Disease 0 0 Asthma/Allergies 21 6 Other 7 0 No Diagnoses 64 56 30 Design and Procedures Volunteers attended small information group meetings, at which time the leaders introduced themselves and described their credentials and training backgrounds. Requirements for participation in, and the purpose of the groups were then described. Participants then completed informed consent forms, as well as a checklist of previous stress management (see Appendix A). Participants were assigned to two stress inoculation groups (SI; nls = 7, 7) and two brief treatment groups (BT; nls. = 7, 9) in a repeated measures (pre, post, 11-week follow-up) quasi-experimental design. Female medical student participants were randomly assigned to the first SI group and BT groups, based on the random selection of an envelope containing their respective assignments, however, based on the limited number of volunteers, the decision was made to broaden the sample to include female dental and graduate students, and to assign participants to the second SI and BT groups in intact groups. Participants were then provided with the dates, times, and location of their respective groups. Those assigned to the SI groups participated in a modified treatment based on a standardized program (Long, 1982), for one (90-minute) session per week for a period of 6 weeks (one group completed two sessions on two separate days in one week due to time constraints) in the fall of 1989. This duration is typical of investigations of cognitive behavioural interventions with TABP (e.g., Jenni & Wollersheim, 1979). Participants assigned to the BT group participated in a one session, 4-hour educational program on stress management 31 between pre- and post-testing in the fall of 1989 (n_= 7), and in the winter of 1990 (n_= 9). Participants completed a demographic questionnaire (see Appendix B), as well as pre-test, post-test, and 11-week follow-up measures including the IBT (Jones, 1969), the RBI (Shorkey & Whiteman, 1977), and the TAIBI (Thurman, 1984) to assess changes in self-reported irrational beliefs, Type A irrational beliefs, and rational behaviour, or general rational thinking; the FTAS (modified; Haynes et al., 1978) as an indice of self-reported TABP (see Appendix C), the TAI (Spielberger et al., 1983) as a measure of trait anxiety, and the TLT (Cacioppo & Petty, 1981), to assess changes in internal dialogue (see Appendix D). Measures were administered immediately prior to the first SI session, immediately following the last SI sessions and the BT sessions, and at 11-week follow-up meetings. Participants in both groups completed an expectancy/treatment credibility questionnaire immediately prior to, and following, the treatment overviews and rationales, in order to assess therapeutic expectancy and perceived credibility of the programs, as well as midway and postgroup evaluation forms. All participants attended follow-up group meetings 11 weeks after the final SI session (n = 21) and 11 weeks following BT (n = 9). Participants met in their original groups to complete follow-up measures in addition to a follow-up questionnaire assessing their need to seek additional stress management resources, and requesting their comments and suggestions regarding the groups (see Appendix D). Participants were encouraged to provide the group leaders with verbal feedback, and to ask any questions they may have 32 had regarding the programs and the study. Only the last group (BT, n = 9) was informed of the general research questions because at follow-up the investigation was ongoing for the other three groups. Finally, participants were provided with a stress management reference and resource list. Dependent Measures Irrational Beliefs Test. The Irrational Beliefs Test (IBT, Jones, 1969) was used to assess participants' self-reported agreement with irrational beliefs. The IBT is a 100-item questionnaire containing 10 10-item scales purported to represent the irrational beliefs originally proposed by Ellis (1961) as well as an overall scale for general irrational thinking. Items common to three independent factor analyses of the IBT (Cramer, 1985; Jones, 1969; Lohr & Bonge, 1982), and deemed consistent with the beliefs proposed by Price (1982) were utilized in analysis. Participants responded to the items on a 5-point Likert scale, ranging from "strongly disagree" to "strongly agree". Scores on selected items were summed to provide an overall index, with higher scores indicating greater endorsement of selected irrational beliefs, resulting in a range of 18-90. Selected items included items 6, 16, 36, 56, 66, 76, and 86 from the anxious overconcern scale, items 11, 41, and 61 from the demand for approval scale, items 3, 13, 23, and 93, from the high self-expectations scale and items 20, 50, 70, and 100 from the perfectionism scale. Scale selection was supported by a study by Smith et al. (1983), which found the high self-expectations, blame proneness, and anxious overconcern 33 IBT scales to significantly and positively correlate with the FTAS. In addition, the use of scale items was supported by significant reductions in the high self-expectations, anxious overconcern, and perfectionism IBT scales following a cognitive behavioural (R.E.T.) intervention (Thurman, 1984). Test-retest reliability has been reported at 0.92 (Jones, 1969) for the total score. Validity of the IBT subscales has been demonstrated by their association with other measures of irrational beliefs (Smith & Zurawski, 1983). Rational Behavior Inventory. The Rational Behavior Inventory (RBI, Shorkey & Whiteman, 1977) was used to assess participants' self-reported rational behaviour, or general rational thinking. The RBI is a 37-item questionnaire consisting of 11 scales which are purported to represent different components of rationality, as well as an overall index purported to measure general rational thinking. Each item is represented by a 5- point Likert scale anchored with "strongly agree" and "strongly disagree", with higher scores indicating greater rationality. The rationality index was used for the purposes of the study with a modified scoring format. Scores on individual items were summed to provide a continuous score, for the purposes of statistical analysis, and ranged from 37-185. Test-retest reliabilities for the total score of this measure have been reported at 0.82 (3-day interval), and 0.71 (10-day interval), while split-half reliability has been reported at 0.73 (Shorkey & Whiteman, 1977). Discriminant validity has been demonstrated by the higher correlation of the RBI with the IBT than with measures of anxiety (Smith & Zurawski, 1983), and its sensitivity as 34 an outcome measure in cognitive behavioural interventions (e.g., Shorkey & Whiteman, 1977), respectively. Type A Irrational Beliefs Inventory. The Type A Irrational Beliefs Inventory (TAIBI, Thurman, 1984) was utilized to measure self-reported Type A irrational beliefs. The TAIBI is a 25-item questionnaire purported to measure irrational beliefs specific to TABP. Each item is represented by a 5-point Likert scale ranging from "strongly agree" to "strongly disagree", with higher scores representing greater endorsement of Type A irrational beliefs, and providing a range of 25-125. Although no reliability data are available for this measure, its validity has been demonstrated by its correlation with measures of TABP and the RBI, as well as its sensitivity to treatment outcome (Thurman, 1984). Framingham Type A Scale. The Framingham Type A scale (Haynes et al., 1978) was used to measure participants' level of self-reported TABP. The FTAS is a self-administered measure which has been found to correlate with other measures of Type A. The 10-item measure was modified to a 4-point Likert scale, from "1" representing "not at all" to "4" representing "very well", with higher scores indicating the greater presence of TABP. Scoring was modified for the purposes of statistical analyses to a continuous score attained by summing each item for an overall range of 10 to 40. Due to the nature of the sample, the word "work" was replaced with the word "school" on FTAS items. Validity has been demonstrated in previous investigations utilizing the FTAS (Haynes et al., 1980), and an internal consistency reliability 35 estimate of 0.70 has been reported in a sample of women by the authors of this measure (Haynes et al., 1978). Ancillary Measures Thought-Listing Technique. The Thought-Listing technique (TLT, Cacioppo & Petty, 1981) was used to identify the polarity (positive, neutral, or negative) dimension of participants' cognitions or self-statements. Positive self-statements, as judged by the participants, accounted for a score of +1 each, while negative self-statements accounted for a score of -1 each. The ratio of positive to negative self-statements was utilized as the final score. Split-half reliability of the Thought-Listing Technique has been estimated at 0.78, and an average test-retest reliability of 0.64 has been reported (Cullen, 1968). The validity of this measure has been established in several studies (e.g., Petty, Wells, & Brock, 1976). Trait Anxiety Inventory. The Trait Anxiety Inventory (TAI; Spielberger et al., 1983) was used to assess general anxiety, or the characteristic and relatively enduring tendency to react with anxiety to a variety of situations. Test-retest reliability coefficients have been reported from 0.76 (20 day interval) to 0.77 (104 day interval) in female college students and support for the validity of this measure has been demonstrated (Spielberger et al., 1983). Expectancy/Credibility Questionnaire. Participants in both groups completed an expectancy/treatment credibility questionnaire (Long, 1982), to assess therapeutic expectancy and perceived credibility. A 6-point Likert scale was utilized, ranging from "1" representing "not at all" to "6" representing "very much so" in a 3-item format. Scores were 36 summed to provide a range from 3 to 18. Treatments Both treatments (SI and BT) were designed to educate participants in the basic concepts of stress recognition, i.e., appraisal, self-statements, physiological responses, and behavioural responses, to provide participants with a rationale for the reappraisal of potentially stressful situations, and to educate participants about the various phases of a stress reaction. Participants were encouraged to discuss and explore their experiences and to practice implementing reappraisal in a supportive, therapeutic environment. Group size was relatively small, although consistent with studies of a similar nature (e.g., Levenkron et al., 1983; Thurman, 1983), however, previous studies have typically utilized fewer that 50% female participants (eig., Kelly & Stone, 1987). Although attrition rates are typically considerable, no attrition was experienced in the groups. Participants were encouraged to attend all sessions and to contact the group leaders to arrange for half-hour, in-depth make-up sessions if they were unable to attend the scheduled session. Participants in the SI groups averaged 5.6 of the 6 sessions in their attendance, whereas all BT participants attended the full single session. Leaders. Both treatments were administered by two co-leaders, the author, a masters student, and a doctoral student, both in the Department of Counselling Psychology at the University of British Columbia. Both leaders were trained in group dynamics and had previous experience in implementing stress inoculation training both in student and 37 community groups. Leaders met prior to the first session of each group to discuss protocol, and had meetings throughout the programs to further discuss and debrief sessions and progress. Stress Inoculation Treatment. The stress inoculation program included three major phases, described by Meichenbaum (1988) as the conceptualization or education phase, the skills acquisition and rehearsal phase, and the application and follow-through phase. During the first phase, a rationale and overview for SI as a method of stress managment were provided. Components common to all SI sessions included review, exploration, and discussion of individual stressors, stress reactions, coping techniques, and their perceived effectiveness. Participants were then instructed in the analysis of stressful situations, i.e., their cognitive, physiological and behavioural aspects, and phases of stress, as well as in cognitive and physical coping techniques (e.g., progressive relaxation, visualization), and the necessity of their consistent review and practice. As a large group, participants would initially practice each technique and in later sessions, would be encouraged to practice and roleplay the strategies in smaller groups, dyads, and individually, gradually progressing to application in real-life situations. Each session included group discussions evaluating participants' experiences of the various coping strategies and the group itself, successes and non-successes, and an emphasis on utilizing strategies which they found to be personally effective. Participants were encouraged to complete homework exercises and to practice and/or implement the strategies on 38 a daily basis. Brief Treatment. The brief treatment consisted of the initial SI phase (conceptualization), as previously described, as well as minimal information, exploration, discussion, and practice of the cognitive coping strategy of modifying internal dialogue, i.e., the cognitive restructuring component of the skills acquisition and rehearsal phase of SI. The rationale and overview for BT were similar to that presented in SI, without the emphasis on coping strategies and continued group participation. In a large group, participants were instructed in the analysis of stressful situations and the different aspects and phases of stress. Participants then evaluated individual stressors in terms of the described aspects. In smaller groups, individuals were instructed in cognitive modification of internal dialogue and briefly practiced this strategy. In a large group, participants were encouraged to review, discuss, and process their experiences. Practice and implementation were once again emphasized. Training manuals for the stress inoculation treatment and the brief treatment are available for research purposes from the author. Program Evaluation. Participants in both groups completed a 4-item midway evaluation questionnaire (Long, 1982) at mid-treatment, in order to provide feedback to the leaders as to the progress of the groups. In addition, participants completed a 9-item goal-attainment questionnaire (Long, 1982) at post-treatment (one BT group, n = 7, completed this questionnaire at follow-up), in order to evaluate their success in achieving personal stress management goals as a result of 39 the treatments. Participants in the SI group also completed a 16-item program evaluation questionnaire (Long, 1982) at post-test, in order to assess their ability to manage stress as a result of the program, as well as their experience of the program. Participants in both groups also completed a 2-item questionnaire assessing their need to seek additional stress management resources or assistance and requesting feedback regarding the programs and the study itself (see Appendix D). Data Analysis Initial group (SI vs. BT) differences on dependent variables and demographic variables were tested with one-way ANOVAs (between group). Hypotheses were tested with three repeated measures 2 x 3 (Group x Time) multivariate analyses of variance (MANOVAs) with pre-planned (nonorthogonal) contrasts (pre- to post-test; post-test to follow-up) using Dunn's test for significance at .025 to assess differences between groups and across time on the dependent variables: (a) TABP and irrational beliefs, (b) rational behaviour and Type A irrational beliefs, and on the variables of (c) trait anxiety and thought listing. Significant overall F's were followed by tests of univariate F's. Preplanned contrasts were tested on the time factor (e.g., pre- to post-; post- to follow-up). In cases where data were missing the mean of the respective subscale or scale for that individual was substituted. Clinical change was calculated utilizing the two-fold criteria set forth by Jacobsen, Follette, and Revenstorf (1984). This method stipulates that participants scores must fall 2 standard deviations above or below a calculated cut-off point (or the pretest mean of the sample when appropriate norms are unavailable) in order to be considered improved or declined, respectively. In addition, the magnitude of change must be deemed reliable, i.e., non-random, using a reliable change index, which must exceed 1.96. Because of the exploratory nature of the present study, a less stringent cut-off point of one standard deviation was utilized in determining whether an individual had experienced clinical change and the standard error of measurement for the sample was substituted for the calculated standard error of measurement where appropriate norms were unavailable. 41 Results Preliminary Analyses Group comparability and pretreatment differences. One-way analyses of variance (ANOVAs) computed for the two stress-inoculation treatment groups (n's = 7, 7) and the two brief treatment groups (n's = 7, 9) revealed no significant group differences on the demographic variable of age, however, a significant difference was found for year, F(3,26) = 3.65, g_ = .026. No differences were found on pre-test means for the dependent variables of TABP, Type A irrational beliefs, rational behaviour, irrational beliefs, or for the variable of trait anxiety. A significant difference was found for the variable of thought listing, F(3,26) = 4.91, p. = .008. In view of these findings, in addition to the exploratory nature of the study and the small sample sizes in each treatment group, the four groups were collapsed into one stress inoculation group (SI; n = 14) and one brief treatment group (BT; n = 16). One participant, who was originally assigned to the brief treatment group and who completed pre-test measures withdrew prior to receiving treatment and was therefore not included in the analyses. All other participants in both groups completed all phases of the study. One-way ANOVAs computed on pre-test means for the two collapsed groups revealed no significant pre-treatment differences between the SI and BT groups on the demographic variables of year and age. No ANOVA group differences were found on the dependent variables of TABP, F(l,28) = 0.55, p. = .46, Type A irrational beliefs, F(l,28) = 0.56, p. = .46, rational behaviour, F(l,28) = 0.35, p. = .56, and irrational beliefs, F(l,28) = 1.07, p_ = .31, or for the variable of trait anxiety, F(l,28) = 0.61, p_ = .44. A significant difference was found for the variable of thought listing, F(l,28) = 4.54, p_ = .042. Means and standard deviations of dependent variables are presented in Table 2. Expectations of treatment effectiveness. A one-way ANOVA revealed no significant differences in expectations of treatment effectiveness prior to treatment, although the group differences on this measure approached significance, F(l,28) = 3.81, p. = .061. Upon examination of group means it appears that the SI group had higher expectations than the BT group (See Table 3). Outcome Analyses Three repeated measures 2 x 3 (Group x Time) MANOVAs with pre-planned (nonorthogonal) contrasts (pre- to post-test; post-test to follow-up) using Dunn's test for significance at .025 were conducted to assess differences between groups and across time on the dependent variables: (a) TABP and irrational beliefs, (b) rational behaviour and Type A irrational beliefs, and on the variables of (c) trait anxiety and thought listing. Multivariate and univariate results are presented in Tables 4 and 5. Only the preplanned contrasts are presented below when discussing the Time effect. Type A Behaviour Pattern (TABP) and Irrational Beliefs. Multivariate analyses revealed a nonsignificant Group main effect, F(2,27) = 2.44, p. = .11, on these variables. A significant pre- to post-Time effect, F(2,27) = 5.45, p_ = .01, was found on TABP and irrational beliefs. The follow-up univariate pre- to post-Time effect was significant for irrational beliefs, F(l,28) = 10.11, p_ = .004. An Table 2 Means and Standard Deviations of Outcome Measures TABP IB RB TAIB TL TA Group M SD M SD M SD M m M SD M SD Stress Inoculation (n = 14) Pre 28.3 4.6 50.3 7.7 121.0 13.4 65.3 8.7 0.38 0.20 42.9 9.6 Post 26.8 3.9 45.7 7.4 127.9 11.2 58.6 8.1 0.60 0.22 41.4 10.1 Follow-up 26.6 4.5 45.9 6.5 131.8 12.5 58.6 8.3 0.67 0.21 41.1 9.1 Brief Treatment (n = 16) Pre 26.7 6.4 53.0 6.7 123.8 12.7 62.6 10.9 0.25 0.12 45.8 10.4 Post 27.9 5.6 51.1 8.9 125.0 10.7 59.9 12.7 0.47 0.28 48.1 11.2 Follow-up 25.8 6.3 50.1 8.0 127.0 12.6 59.6 10.3 0.49 0.26 43.2 8.8 Note. TABP=Type A Behaviour Pattern, IB=Irrational Beliefs, TAIBI=Type A Irrational Beliefs, TA=Trait Anxiety, TL=Thought Listing (higher scores indicate higher levels of variable), RB=Rational Behaviour (lower scores indicate higher levels of variable). 44 Table 3 Means and Standard Deviations of Expectancies Scores M SD Group Stress Inoculation (n_ = 14) Pre 13.1 2.4 Post 14.0 3.0 Brief Treatment (n = 16) Pre 10.9 3.4 Post 11.2 3.6 45 Table 4 Multivariate and Univariate Analysis of Variance Results for Outcome  Measures Effects Multivariate (F, p.) df Univariate (F, rj) df 2,27 TABP IB 1,28 Group 2.44 0.11 <1 0.84 2.64 0.12 Time (pre-post) 5.45 0.01* < 1 0.76 10.11 0.004* Group by Time 5.12 0.01* 6.74 0.01* 1.66 0.21 Time (post-fol) 2.79 0.08 5.72 0.02* <1 0.66 Group by Time 1.98 0.16 3.81 0.06 <1 0.49 2,27 1,28 RB TAIB Group < 1 0.87 <1 0.69 < 1 0.97 Time (pre-post) 7.38 0.003* 6.07 0.02* 15.14 0.001* Group by Time 1.82 0.18 3.04 0.09 2.78 0.11 Time (post-fol) 2.21 0.13 4.43 0.04 < 1 0.91 Group by Time < 1 0.76 <1 0.51 <1 0.84 Note: TABP=Type A Behaviour Pattern, IB= irrational Beliefs, RB= Rational Behaviour, TAIB=Type A Irrational Beliefs. * p. < .025. Table 5 Multivariate and Univariate Analysis of Variance Results for Ancillary  Measures Effects Multivariate (F, p.) d_f Univariate (F, rj) d_f 2,27 1,28 TA TL Group 3.41 0.05 1.22 0.28 7.05 0.01* Time (pre-post) 10.00 0.001 <1 0.71 19.02 0.001* Group by Time 2.30 0.12 4.61 0.04 < 1 0.96 Time (post-fol) 6.63 0.005* 9.50 0.005* 1.23 0.28 Group by Time 3.86 0.03 7.97 0.01* < 1 0.55 Note: TA=Trait Anxiety, TL=Thought Listing. * p. < .025. 47 examination of the means indicated a decrease in irrational beliefs from pre- to post-test for both groups. There was a significant Group by Time (pre to post) effect, F(2,27) = 5.12, p_ = .01, on these variables. Follow-up univariate interactions were significant, F(l,28) = 6.74, p_ = .01, for TABP, but not for irrational beliefs, F(l,28) = 1.66, p_ = .20. Upon examination of group means, it appears that the SI group reduced their TABP significantly from pre- to post- test, compared with the BT group, who increased their TABP (see Figure 1). The post- to follow-up Time effect, F(2,27) = 2.79, p_ = .08, was nonsignificant. The Group by Time (post- to follow-up) effect was nonsignificant F(2,27) = 1.98, p_ = .16, indicating the groups did not change differentially from post- to follow-up on either variable. Thus, the pre- to post-test decrease experienced by the SI group was maintained from post-test to follow-up, however, group means reflect a small decrease in TABP in the BT group. Rational Behaviour and Type A Irrational Beliefs. A nonsignificant multivariate Group effect was found, F. < 1, however, a significant pre- to post-Time effect, F(2,27) = 7.38, p. = .003, was found on these measures. The follow-up univariate tests were significant for Type A irrational beliefs, F(l,28) = 15.14, p_ = .001, and for rational behaviour, F(l,28) = 6.07, p. = .02. Group means indicate an increase in rational behaviour and a decrease in Type A irrational beliefs for both groups. The Group by Time (pre to post) effect was nonsignificant, however, due to the limited research available, particularly that 48 35 30 h ft < H « 25 CD S 20 L SI o BT x I PRE POST FOLLOW-UP Figure 1: Prc-Tcst, Post-Test, and Follow-up Group Means for TABP 49 utilizing female samples, the univariate results were examined in an exploratory fashion. The follow-up univariate test for rational behaviour approached significance, F(l,28) = 3.04, p_ = .09, reflecting the greater increase in rational behaviour, or general rational thinking, experienced by the SI -group, compared with the BT group, as indicated by group means. The post-to follow-up Time effect, F(2,27) = 2.21, p_ = .13, was also nonsignificant. It should be noted that the follow-up univariate test approached significance, F(l,28) = 4.43, p_ = .04, for rational behaviour. The means indicate an increase in rational behaviour, or general rational thinking, from post-test to follow-up in both groups. The Group by Time (post to follow-up) effect was nonsignificant. Thus, the Type A irrational beliefs of both groups remained relatively constant during the post-test to follow-up time interval. Additional Questions Trait Anxiety and Thought Listing. The Group effect, F(2,27) = 3.41, p_ = .05, approached significance for these variables. A significant pre-to post-Time effect, F (2,27) = 10.00, p_ = .001, was also found. The follow-up univariate test was significant for thought listing, F(l,28) = 19.02, p. = .001. The means indicate that thought listing, or positive internal dialogue, increased in both groups. A nonsignificant Group by Time (pre to post) effect was found, F(2,27) = 2.30, p. = .12. However, due to the considerations previously described, the univariate results were examined in an exploratory fashion. The follow-up univariate test for trait anxiety approached 50 significance, F(l,28) = 4.6, p_ = .04. Group means reflect a small decrease in trait anxiety in the SI group from pre- to post-test, in contrast to an increase in trait anxiety in the BT group. In addition, a significant post-to follow-up Time effect, F(2,27) = 6.63, p. = .005, was found. The follow-up univariate test was significant, F(l,28) = 9.50, p_ = .005, for trait anxiety. This Time main effect must be interpreted with regard to the interaction effect. The Group by Time (post to follow-up) effect approached significance, F(2,27) = 3.86, p_ = .03. The follow-up univariate test for the Group by Time (post to follow-up) effect was significant, F(l,28) = 7.97, p_ = .01, for trait anxiety, reflecting the larger decrease in trait anxiety experienced by the BT group from post-test to follow-up, compared with the SI group, whose trait anxiety remained relatively constant. Correlation matrix. A Pearson product-moment correlation was calculated in order to examine correlations between outcome variables (see Appendix E). Correlations were moderate to moderately high (Huck, Cormier, & Bounds, 1974), ranging from r(30) = 0.46 to r(30) = 0.69 and are examined in the discussion section. Clinical change. Clinical change (Jacobson et al., 1984) was calculated in order to determine the proportion of individuals in each group who improved, were unchanged, or deteriorated as a result of the treatments. Because of the exploratory nature of the study, a less stringent cut-off point of one standard deviation and the standard error of measurement of the sample were utilized with those measures for which norms were unavailable. Overall, the trends of clinical change from pre- to post-test were consistent with the hypotheses. The SI 51 group experienced a greater proportion of clinical improvement on TABP, rational behaviour, Type A irrational beliefs, irrational beliefs, and trait anxiety, compared with the BT group. These trends were maintained or enhanced from post- to follow-up in the SI group, compared with the BT group, with the exception of clinical improvements on TABP and Type A irrational beliefs experienced by the BT group. Clinical change results are presented in Table 6 and are examined in greater detail in the discussion section. Program evaluation and additional stress management. Means and representative responses for the program evaluation questionnaire are presented in Appendix D. Twenty-one percent of the SI group and 31% of the BT group pursued additional stress management assistance in the form of readings, exercise, counselling, and other resources, concurrent with or following their participation in the groups. Both groups commented, in general, that they found the groups to be helpful, supportive and normalizing. In addition, the SI group stated that they found the specific techniques to be useful in their stress management. Both groups suggested that future endeavors might benefit from a longer program format, including both individual and follow-up group meetings, as well as greater specificity with regard to the examination and discussion of stressors, issues, and interventions. Finally, the SI group suggested a more comprehensive approach to education about stress management interventions, information on time management techniques, and the implementation of such programs at the beginning of the academic year because the time commitment Table 6 Clinical Change of Outcome Measures Group Stress Inoculation (n= =14) Brief Treatment (n= 16) improved n / c declined improved n / c declined % % % % % % Pre-Post TABP 7 93 0 0 100 0 RB 7 93 0 0 100 0 IB 29 71 0 19 75 6 TAIB 50 43 7 13 87 0 TAI 7 93 0 0 100 0 Post-Follow-up TABP 0 100 0 19 81 0 RB 7 93 0 0 100 0 IB 7 93 0 19 68 13 TAIBI 7 93 0 0 100 0 TAI 7 93 0 0 100 0 Note. TABP=Type A Behaviour Pattern, IB=Irrational Beliefs, TAIB=Type A Irrational Beliefs, TA=Trait Anxiety, RB=Rational Behaviour. Improved=clinical improvement, n/c=no clinical change, declined=clinical decline. created a conflict for some students. Discussion The results of this study indicate that participation in a 6-week stress inoculation treatment (SI) is more effective in significantly reducing Type A Behaviour Pattern (TABP) than is participation in a 4-hour brief treatment (BT) for female medical, dental and graduate students. In addition, there was a significant decrease in irrational beliefs (IB) and Type A irrational beliefs (TAIB), and a significant increase in rational behaviour (RB) for both treatment groups. In general, with the exception of TABP, no significant group differences were found, suggesting that participants responded to SI and BT similarly. As confirmation of treatment effects, it was expected that SI would significantly decrease trait anxiety (TA), and increase positive thinking (thought listing; TLT), compared with BT, but these effects were not evident. Positive thinking increased for both groups, although only slight reductions in trait anxiety were found. Type A Behaviour Pattern (TABP) and Irrational Beliefs TABP was found to decrease significantly from pre- to post-test in the SI group, compared with the BT group, whose TABP increased over this time period. This finding is consistent with a study by Levenkron et al. (1983), which found cognitive behavioural therapy and group support treatments to be superior to a brief information treatment in reducing TABP in Type A males. A study by Thurman (1985a,b) also found a cognitive behavioural treatment to reduce TABP significantly compared to a minimal, or brief treatment, in predominantly male Type A university faculty. It should be noted that these studies utilized 55 samples pre-screened for the presence of TABP, whereas the present study did not. This is important in light of the finding by Jenni and Wollersheim (1979) that a cognitive behavioural treatment was equally as effective as a stress management treatment (consisting of progressive relaxation and visualization) in reducing TABP, yet was more effective than the latter treatment in those subjects highest on TABP at pretest. The increase in TABP experienced by the BT group from pre- to post-test corroborates trends found in studies of medical students (Jones, 1984; Jones & Lebnan, 1988), which suggest that TABP increases across the preclinical years. The present findings suggest that these trends may also be present in female dental and graduate students. A possible alternative explanation for the findings may be the placebo effects of participating in an ongoing group (SI), compared with a one-session group (BT). This explanation is supported by a study by Levenkron et al. (1983), which found group support to be as effective as a cognitive behavioural treatment in reducing many TABP components in Type A men. However, comparisons are limited by the different samples and treatment programs utilized. The BT group experienced a larger decrease in TABP from post-test to follow-up than the SI group, although the interaction effect only approached significance, p_ = .06 (see Figure 1). The decrease in TABP experienced by the BT group may be explained by the timing of follow-up testing, which for the majority of the BT group (n = 9) occurred at the end of the academic year, compared to the remaining participants (BT, n = 7; SI, n = 14) who completed follow-up testing mid-term, during 56 times of high academic pressure. Contrary to expectation, irrational beliefs regarding anxious overconcern, demand for approval, high self-expectations, and perfectionism did not change differentially in the SI group from pre-to post-test, compared with the BT group. However, group means indicate that irrational beliefs decreased in both groups, and this decrease was maintained at follow-up. A study by Thurman (1983) found that irrational beliefs about high self-expectations, anxious overconcern, and perfectionism were decreased significantly in male and female Type A university students following a cognitive behavioural (rational emotive therapy; R.E.T.) treatment, compared with a waiting list control group. The lack of a significant group by time difference in the present study may be due to the different modifications to the Irrational Beliefs Test (IBT; Jones, 1969) implemented in the two studies. In the Thurman study, six complete scales of the IBT were utilized, although the present study utilized only those items in selected scales that were supported by previous factor analyses. In addition, the lack of a placebo attention group in the study by Thurman, the different treatments implemented, and the small sample sizes utilized in both studies may have contributed to the difference in results. Finally, the lack of a significant group by time difference in the present study may have been due to the lack of specificity of the SI treatment with regard to the beliefs held by the groups sampled. Rational Behaviour and Type A Irrational Beliefs Rational behaviour, or general rational thinking, did not increase 57 significantly from pre- to post-test in the SI group, compared with the BT group, although group means indicate increases in both groups from pre- to post-test, and from post-test to follow-up. These results indicate that both the SI and BT groups were effective in increasing rational behaviour, or general rational thinking. This finding is consistent with results of a study by Thurman (1985a,b) which failed to differentially increase rational behaviour as a result of a cognitive behavioural treatment, compared with a minimal treatment, in a sample of male and female Type A university faculty. Type A irrational beliefs did not decrease significantly in the SI group from pre- to post-test, or from post-test to follow-up, compared with the BT group. Both groups experienced decreases in Type A irrational beliefs from pre- to post-test. This finding is in contrast to the results of the study by Thurman (1985a,b) which found a R.E.T. treatment to reduce Type A irrational beliefs significantly, compared with a minimal treatment. It is important to note that the present sample began treatment with lower means on Type A irrational beliefs (SI, M. = 65.3; BT, M. = 62.6) than the sample utilized in the Thurman study (treatment, M = 78.8, 74.7; MT, M = 74.6). Therefore a floor effect may have limited the magnitude of decreases in Type A irrational beliefs that could be expected. These inconsistencies may be due to the small sample sizes utilized in both studies, the different populations sampled, or the different treatments implemented. 58 Trait Anxiety and Thought Listing As confirmation of treatment effects, trait anxiety and thought listing results were examined. Unexpectedly, trait anxiety did not decrease significantly from pre- to post-test in the SI group, compared with the BT group. However, the univariate group by time test approached significance, p_ = .04, and group means indicate that the SI group experienced a small reduction in trait anxiety, compared with the BT group, which experienced an increase in trait anxiety during this time interval. One interpretation is that SI participants were able to prevent what may have been an inevitable increase in their trait anxiety, in response to the increase in academic and other demands as the school year progressed. These results are similar to those of previous studies (e.g., Holtzworth-Munroe, Munroe, & Smith, 1985; Kelly et al., 1982; Levenkron et al., 1983), which did not find trait anxiety to significantly decrease as a result of cognitive behavioural interventions with medical student, and Type A samples, respectively. This is contrasted by other studies (e.g., Long, 1984) which have found trait anxiety to significantly decrease as a result of cognitive behavioural therapies for chronically anxious adults. However, these differences may be due in part, to the use of control or waitlist control groups, with the exception of the present study and Levenkron et al., 1983, which utilized minimal or brief treatment comparison groups. One interpretation of these findings is that female medical, dental and graduate students differ considerably from samples in previous studies on trait anxiety. This is supported by an examination of pretreatment group means. Jenni and Wollersheim (1979), for example, 59 reported pretreatment means of 39.4 and 40.7. Levenkron et al. (1983) reported these means at 35.9 and 36.7. Pretreatment group means for trait anxiety were higher at 42.9 (SI) and 45.8 (BT) in the present study. These means are more comparable to those previously documented in a study with medical students by Kelly et al. (1982), which reported pretreatment means for trait anxiety at 42.5 and 42.8, and also failed to find significant pre- to post-test reductions in trait anxiety. In light of the pre- to post-test increase in trait anxiety experienced by the BT group in the present study, it may be that significant reductions on this variable as a result of treatment are unrealistic in the context of the increasing pressures and demands faced by these students during the academic year. Preventing what may be predictable increases in trait anxiety in these groups may be of greater utility and should be pursued by future research. Contrary to expectation, trait anxiety decreased significantly in the BT group from post-test to follow-up, compared with the SI group. This result may be related to the timing of follow-up testing as previously described. Trait anxiety was relatively unchanged in the SI group during this time interval, possibly reflecting the durability of the treatment effects. Contrary to expectation, the ratio of positive to negative self-statements did not change differentially in the SI group from pre- to post-test, or from post-test to follow-up, compared with the BT group. However, both groups experienced significant increases in positive thinking from pre-to post-test, indicating the effectiveness of both 60 treatments. In addition, a pre-treatment group difference on thought listing indicated that the SI group began treatment with a higher proportion of positive thoughts, compared with the BT group. Therefore, a ceiling effect, i.e., a limit to how positive one's thoughts can become, may account for the lack of a significant finding. Relationships Between Dependent Measures Due to the measurement issues previously described and the exploratory nature of the study, the results of Pearson product-moment correlations between dependent measures are discussed. Correlations revealed consistent and significant relationships in the expected directions between all dependent measures (see Appendix E). These results suggest that higher levels of irrational beliefs, and Type A irrational beliefs are associated with higher levels of TABP. In addition, increased levels of rational behaviour, or general rational thinking appear to be associated with decreased levels of TABP. These findings provide additional support for the relationship between irrational beliefs and TABP delineated by Price (1982). Of particular interest is the association demonstrated between irrational beliefs and TABP, r(n=30) = .46, p_ = .005, which was larger than that found by Smith et al. (1983), r(n=143) = .20, p. < -01, in a sample of female and male undergraduate students. The higher correlations found in the present study implicate potential differences in the association between irrational beliefs and TABP in female medical, dental, and graduate students, compared to female and male undergraduate students. 61 The suggestion that gender differences exist in the association between TABP and specific irrational beliefs is consistent with the results of a study by Smith and Brehm (1981), which found TABP to be correlated with different beliefs in women, compared with men. However, it should be noted that the Smith et al. study utilized a larger, undergraduate sample, and a different measure of TABP, the JAS. An alternative explanation is that the items selected from the IBT have a greater association with TABP, as measured by the FTAS, than the original measure. Given that the selected items were those found to be representative of the irrational beliefs scales, and consistent with Price's (1982) model, it may be argued that they offer a more accurate measure of these beliefs, and thus these results are a more accurate assessment of the association between TABP and irrational beliefs. Brief or Minimal Treatments The lack of differential effects on a number of the variables may have been due to the potency of the BT in effecting change. Although the BT was comparable to previous minimal treatments (e.g., Levenkron et al., 1983), in its limited scope and duration, the inclusion of certain components may have made the BT a more "active" treatment. Brief or minimal treatments offer simulations of active treatments, attempting to elicit equivalent expectations of treatment, while controlling for treatment effects (O'Leary & Borkovec, 1978). Previous studies of TABP utilizing minimal treatments have offered brief, generalized informational presentations. In the study by Levenkron et al. (1983), participants in the minimal treatment group were provided with information and practical suggestions regarding 62 TABP and stress in a 2-hour group format. Thurman (1985a,b) offered a similar program, in a 1-hour group format. In contrast, the brief treatment utilized in the present study implemented components of an active treatment (SI) in a 4-hour program. The BT consisted of the educational phase, as well as the cognitive restructuring component of the skills acquisition and rehearsal phase, of SI. It has been suggested that the educational phase alone is an effective treatment (e.g., Jaremko, Hadfield, & Walker, 1980), but consensus has not yet been reached (e.g., West, Horan, & Games, 1984). However, cognitive restructuring is viewed by many to be the central component of SI (e.g., Goldfried, Linehan, & Smith, 1978). Thus it may be speculated that the BT utilized in the present study is less comparable to a minimal treatment than to an active treatment in its contents. Alternatively, the at-risk status of the participants may have contributed to the effectiveness of this treatment, in that some treatment for stress management was needed and useful. These considerations support the utility and necessity of stress management treatments which are more comprehensive than simple lectures and basic information. Levenkron et al. (1983) have previously emphasized the importance of including minimal treatment controls in outcome studies of TABP, due to their noteable effects. This is underscored by the results of the present study. Investigations into which components of minimal, or brief, treatments are effective for TABP, as well as the relative contributions of non-specific treatment effects should be pursued. On this latter issue, Kelly and Stone (1987) have contended that the effect of 63 having one's experiences normalized in a group may be of significance in explaining the impact of minimal treatments in TABP studies. Clinical Change Clinical change trends from pre- to post-test generally supported the expected decreases in TABP, Type A irrational beliefs, irrational beliefs, and trait anxiety, as well as the expected increase in rational behaviour, or general rational thinking, in the SI group, compared with the BT group (see Table 6). Both groups experienced clinical changes indicating decreases in irrational beliefs and Type A irrational beliefs. These findings provide additional support for the effectiveness of SI, not only for the reduction of TABP, but also for improvements on Type A irrational beliefs, irrational beliefs, trait anxiety, and rational behaviour, or general rational thinking. The improvement experienced by the BT group on irrational beliefs and Type A irrational beliefs suggest that BT was also somewhat effective in the modification of irrational beliefs and Type A irrational beliefs. This further supports the utility of even brief programs composed of educational and cognitive restructuring components in these groups. Overall, 50% of the SI participants experienced clinical improvement on at least one outcome variable, compared with 19% in the BT group. An examination of those demographic variables which appeared to be associated with clinically significant change revealed that from pre- to post-test those individuals who were clinically improved on irrational beliefs (n = 7; M = 27.0 years) were younger than the average for both groups and most (n = 5) were medical students. 64 Those who experienced clinical improvement on Type A irrational beliefs (n = 9; M_ = 30.5 years) were older than the average participant. Those participants who were clinically improved from post-test to follow-up on irrational beliefs were younger (n = 4; M_ = 27) than the average participant and most (n = 3) were single. These findings may reflect complex relationships between age, marital status, and irrational beliefs, as well as the specificity of irrational beliefs held by medical students, which should be addressed in future research. Those who improved on TABP were older (n =4; M = 31.3 years) than the average participant. This finding may reflect a greater awareness of the deleterious effects of TABP and the need to modify this behaviour pattern in older students. Of particular interest is the finding that of the individuals who either improved (n = 6) or declined (n = 2) from post-test to follow-up, most (n = 4) were medical students who were referred for additional counselling during the course of the program, or were participants in the final BT group (n = 4) which completed follow-up testing at the end of the academic year. These findings may reflect the influence of the neediness of the medical students who were given referrals and the treatments which they received, as well as the potential decline in academic and other stressors at the time of follow-up testing in the final BT group. Jacobsen et al. (1984), among others, contend that traditional statistical significance methods are limited in that they fail to account 65 for changes in specific individuals as a result of treatment. Therefore, clinical change, defined as the number of individuals who clinically improve, decline, or who are unchanged following treatment, may provide valuable additional information in determining which treatments are effective in which specific individuals. However, there are some important limitations in applying this method to the present study. Of primary relevance is the distinction made by Jacobsen et al. (1984) and Jacobsen and Revenstorf (1988) between "functional" and "dysfunctional" populations, based on the assumption that those receiving treatment fall primarily into the latter category. Based on this assumption, clinical change would be more appropriate in previous outcome studies which utilized Type A samples (e.g., Levenkron et al., 1983; Thurman, 1985a,b), than in the present study, which utilized a sample not screened for the presence of the pattern. In addition, the use of a discrete cut-off point fails to take into consideration those individuals who begin treatment below this point, indicating their "functionality" prior to treatment. In the present study, the number of participants for whom this occurred was substantial, 57% in the SI group and 44% in the BT group. In light of these considerations, these findings must be interpreted with caution, and in the context of the statistical findings. Theoretical Model Taken together, these findings provide additional support for Price's (1982) cognitive social learning model of Type A behaviour, which implicates specific irrational beliefs and their associated fears and anxieties as central in the development and maintenance of this 66 pattern. From this perspective, the significant reductions in TABP, irrational beliefs, and Type A irrational beliefs, as well as the significant increase in rational behaviour, or general rational thinking, experienced by the SI group from pre- to post-test, may be explained by the emphasis on in-depth cognitive restructuring in the SI program. Although the BT group experienced similar changes on most of these variables, the absence of a significant decrease in TABP in this group, who received minimal instruction and opportunity to practice cognitive restructuring, may indicate that in order to be effective, this strategy must be practiced and implemented over a prolonged period of time, with continuing reinforcement and development. This explanation fits well with the conception of beliefs as enduring cognitive structures, which have been developed over a substantial time period (Price, 1982), and thus may be quite resistant to change, particularly in light of the perceived benefits to be derived from the behaviour pattern which they elicit and sustain. Alternatively, it may be argued that because both treatments were effective in reducing irrational beliefs, presumably through education and cognitive restructuring, that both groups should have experienced significant reductions in TABP as well. It may be that other components of SI (e.g., physical and cognitive coping skills training, or non-specific treatment effects such as group support and reinforcement) may be responsible for the changes on TABP. It may be argued that the modifications to the Irrational Beliefs 67 Test (Jones, 1969) implemented in this study may have served to remove those items which were associated with TABP, or the additional irrational beliefs measures utilized may not have been sensitive enough to tap the highly specific beliefs associated with TABP. These considerations, together with the use of an unvalidated instrument (TAIBI; Thurman, 1984), with unknown psychometric properties, may have contributed to the lack of significant group differences. An alternative explanation for the lack of group differences on many of the variables may be the need for psychological intervention and stress management in the sample, and perhaps in these populations. This is supported by the levels of trait anxiety present at pretest, and by the substantial number of participants in both groups who pursued additional stress management resources or assistance concurrent with or following treatment. Finally, these additional stress management resources may have exerted unknown influences on treatment effects. Program Evaluation and Additional Stress Management Overall, the responses and comments of participants in both groups suggest that female medical, dental and graduate students are receptive to stress management interventions and view them to be useful. Of particular interest were comments made by participants in the SI group which positively evaluated the ongoing group format, and comments made by individuals in the BT group expressing their desire for such an ongoing group. This is significant in light of the high attrition rates documented in previous studies of TABP, and the considerable time pressures experienced by female medical, dental and 68 graduate students. Those in the SI group reported that education about stress and its components, cognitive restructuring, cognitive techniques (e.g., visualization) and normalization were the most helpful and change producing elements of the program. Participants indicated a desire for greater attention to the specific stressors, beliefs, and demands particular to these groups. Limitations The generalizability of these results must be tempered by a number of limitations regarding the design and the sample utilized. Participants were volunteers and thus may have been more receptive to the treatments than other female medical, dental and graduate students. It may be speculated that those individuals who did not volunteer may have been those most in need of intervention and highest in TABP. These individuals may have perceived the time constraints inherent to participation in the groups as too great, in spite of the potential benefits to be derived. In addition, the small sample size (n = 30) and the lack of complete random assignment may have acted to select and assign non-representative samples to the respective treatments. However, preliminary analyses of pretreatment means indicate that group differences were minimal. Diffusion between groups was informally assessed and determined not to be a significant influence, however, some diffusion may have occurred, thus possibly affecting participants' beliefs about and motivation in the programs. The exclusive use of self-report paper and pencil measures may have introduced the influence of socially desirable responding, as well as under- or over-reporting of 69 measured phenomena. Finally, the effects of concurrent additional stress management may have acted as a potential influence on the variables of interest. Conclusions and Recommendations In conclusion, SI appears to be an effective treatment for TABP in some female medical, dental, and graduate students. In addition, SI and BT are supported as effective treatments for irrational beliefs, Type A irrational beliefs, rational behaviour, and positive thinking in these individuals. Finally, a greater proportion (50%) of the SI group experienced clinical improvement, compared with the BT group (19%), suggesting that SI may be more effective, in general, on an individual basis. Future investigations should include assessments, both of the idiosyncratic beliefs held by various Type A populations (Thurman, 1985a), as well as their specific needs with regard to stress management and other psychological interventions. In addition, further studies should investigate the statistical and clinical effects of SI and other cognitive behavioural treatments on different levels of TABP, as well as in relation to demographic variables. These findings, in turn, may facilitate the development and validation of more precise and multimodal measures as well as specialized treatment programs for specific populations, including female medical, dental, and graduate students. Stress management interventions with these groups may prove more satisfactory both in terms of the time limitations faced by these 70 students and the ability of such programs to reach those most in need, who may be the least likely to volunteer for such programs, if offered as a part of the academic curriculum. This has previously been suggested by Holtzworth-Munroe et al. (1985) and is supported by the high attrition rates in previous studies of TABP and of stress management with medical students, as well as the difficulty experienced in the present study in recruiting female medical students. A more comprehensive approach based on the specific needs of these groups may also contribute to compliance with, and the success of such programs. Finally, long term follow-up of treatment effects must be pursued in order to provide information about the durability of treatment effects and factors influencing this durability. Follow-up meetings aimed at reinforcement of treatment principles, and strategies should also be included. This study provides several contributions to the study of TABP, central factors in the initiation and maintenance of this pattern, as well as potential interventions for its modification. More specifically, it provides some support for the utility of stress inoculation training in the treatment of this pattern. It demonstrated the effects of such an intervention in an at-risk subgroup in an area where information is limited. In addition, findings provide partial support for Price's cognitive social learning theory of TABP. Finally, the study provides additional information about the relationship between TABP and irrational beliefs. 71 References Bortner, R. W. (1969). A short rating scale as a potential measure of pattern A behavior. Journal of Chronic Diseases, 22, 87-91. Burke, R. J. (1983). Early parental experiences, coping styles, and Type A behavior. The Journal of Psychology, 113, 161-190. Burke, R. J. (1984). Beliefs and fears underlying Type A behavior: What makes Sammy run - so fast and aggressively? Journal of Human Stress, 10, 174-182. Burke, R. J., & Deszca, G. (1984). What makes Sammy run - so fast and aggressively? Beliefs and fears underlying Type A behavior. Journal of Occupational Behavior, 5, 219-227. Cacioppo, J. J., & Petty, R. E. (1981). Social psychological procedures for cognitive response assessment: The thought-listing technique. In T.V. Merluzzi, C.R. Glass, & M. Genest (Eds.), Cognitive Assessment (pp. 308-342). New York: Guilford Press. Chesney, M. A., Black, G. W., Chadwick, J. H., & Rosenman, R. H. (1981). Psychological correlates of the Type A behavior pattern. Journal of Behavioral Medicine, 4(2), 217-228. Clark, E. J., & Rieker, P. P. (1986). Gender differences in relationships and stress of medical and law students. Journal of Medical Education, 61, 32-40. Cramer, D. (1985). An item-factor analysis of the Irrational Beliefs Test. British Journal of Cognitive Psychotherapy, 3(1), 70-76. Cullen, D. M. (1968). Attitude measurement by cognitive sampling. Unpublished doctoral dissertation, The Ohio State University. Davidson, V. A. (1978). Coping styles of women medical students. 72 Journal of Medical Education, 53, 902-907. Deffenbacher, J. L., Zwemer, W. A., Whisman, M. A., Hill, R. A., & Sloan, R. D. (1986). Irrational beliefs and anxiety. Cognitive Therapy and Research, 10(3), 281-292. Ellis, A. (1961). A guide to rational living. Englewood Cliffs, NJ: Prentice-Hall. Friedman, M., & Powell, L. H. (1984). Diagnosis and quantitative assessment of Type A behavior: Introduction and description of the videotaped structured interview. Integrative Psychiatry, 2, 123-136. Friedman, M., & Rosenman, R. H. (1974). Type A behavior and your heart. New York: Knopf. Friedman, M., Thoresen, C. E., Gill, J. J., Ulmer, D., Thompson, L., Powell, L., Price, V. A., Elek, S. R., Rabin, D. D., Breall, W. S., Piaget, G., Dixon, T. R., Bourg, E., Levy, R. A., & Tasto, D. L. (1982). Feasibility of altering Type A behavior pattern after myocardial infarction. Recurrent Coronary Prevention Project Study. Methods, baseline results and preliminary findings. Circulation, 66, 83-92. Gaensbauer, T. J., & Mizner, G. L. (1980). Developmental stresses in medical education. Psychiatry, 43, 60-70. Gapen, P. (1980). Stress: Medical school's perilous rites of passage. New Physician, 29, 18-22. George, J. M., Whitworth, D. E., Sturdevant, J. R., & Lundeen, T. F. (1987). Correlates of dental student stress. Journal of Dental Education, 51(8), 481-485. 73 Gill, J. J., Price, V. A., Friedman, M., Thoresen, C. E., Powell, L. H., Ulmer, D., Brown, B., & Drews, F. R. (1985). Reduction in Type A behavior in healthy middle-aged American military officers. American Heart Journal, 110(3), 503-514. Glass, D. (1977). Behavior patterns, stress, and coronary disease. Hillsdale, NJ: Erlbaum. Goldfried, M. R., Linehan, M. M., & Smith, J. L. (1978). Reduction of test anxiety through cognitive restructuring. Journal of Consulting and Clinical Psychology, 46, 32-39 Haaga, D. A. (1987). Treatment of the Type A behavior pattern. Clinical Psychology Review, 7, 557-574. Haynes, S. G., Feinleib, M., & Kannel, W. B. (1980). The relationship of psychosocial factors to coronary heart disease in the Framingham Study. III. Eight year incidence of coronary heart disease. American Journal of Epidemiology, 111(1), 37-58. Haynes, S. G., Levine, S., Scotch, N., Feinleib, M., & Kannel, W. B. (1978). The relationship of psychosocial factors to coronary heart disease in the Framingham study: I. Methods and risk factors. American Journal of Epidemiology, 107(5), 362-383. Heins, M., Fahey, S. N., & Leiden, L. I. (1984). Perceived stress in medical, law, and graduate students. Journal of Medical Education, 59, 170-179. Himle, D., Thyer, B., & Papsdorf, J. (1982). Relationships between rational beliefs and anxiety. Cognitive Therapy and Research, 6, 219-223. 74 Holtzworth-Munroe, A., Munroe, M. S., & Smith, R. E. (1985). Effects of a stress-management program on first- and second-year medical students. Journal of Medical Education, 60, 417-419. Houston, B. K., Smith, T. W., & Zurawski, R. M. (1986). Principal dimensions of the Framingham Type A scale: Differential relationships to cardiovascular reactivity and anxiety. Journal of Human Stress, 12(3), 105-112. Huck, S., Cormier, W. H., & Bounds, W. G. (1974). Reading statistics and research. NY: Harper & Row. Jacobson, N. S., Folette, W. C, & Revenstorf, D. (1984). Psychotherapy outcome research: Methods for reporting variability and evaluating clinical significance. Behavior Therapy, 15, 336-352. Jacobson, N. S., & Revenstorf, D. (1988). Statistics for assessing the clinical significance of psychotherapy techniques: Issues, problems, and new developments. Behavioral Assessment, 10, 133-145. Jaremko, M., Hadfield, R., & Walker, W. (1980). Contribution of an educational phase to stress inoculation of spech anxiety. Perceptual and Motor Skills, 50, 495-501. Jenni, M. A., & Wollersheim, J. P. (1979). Cognitive therapy, stress management training, and the Type A behavior pattern. Cognitive Therapy and Research, 3, 61-73. Jenkins, C. D., Zyzanski, S. J., & Rosenman, R. H. (1979). Jenkins Activity Survey Manual. New York: The Psychological Corporation. Jones, K. V. (1984). Type A as a challenge-induced response: Two year follow-up. Psychological Reports, 55, 262. Jones, K. V., & Lebnan, V. (1988). A 6-year follow-up of the Type A behavior pattern in medical students. Medical Education, 22, 211-213. Jones, R. G. (1969). The Irrational Beliefs Test. Wichita, KS: Test Systems. Jorgensen, F., Houston, B., & Zurawski, R. (1981). Anxiety management training in the treatment of essential hypertension. Behavior Research and Therapy, 19, A61-A1A. Kelly, J. A., Bradlyn, A. S., Dubbert, P. M., & St. Laurence, J. S. (1982). Stress management training in medical school. Journal of Medical Education, 57, 91 -99. Kelly, K. R., & Stone, G. L. (1987). Effects of three psychological treatments and self-monitoring on the reduction of Type A behavior. Journal of Counseling Psychology, 34(1), 46-54. Levenkron, J. C., Cohen, J. D., Mueller, H. S., & Fisher, E. B. (1983). Modifying the Type A coronary-prone behavior pattern. Journal of Consulting and Clinical Psychology, 51, 192-204. Lloyd, C, & Gartrell, N. K. (1981). Sex differences in medical student mental health. American Journal of Psychiatry, 138, 1346-1351. Lloyd, C, & Musser, L. A. (1989). Psychiatric symptoms in dental students. The Journal of Nervous and Mental Disease, 177(2), 61-69. Lohr, J. M., & Bonge, D. (1982). The factorial validity of the Irrational Beliefs Test: A psychometric investigation. Cognitive Therapy and 76 Research, 6(3), 225-230. Long, B. C. (1982). A comparison of aerobic conditioning and stress inoculation as stress-management interventions. Unpublished doctoral dissertation, University of British Columbia, Vancouver. Long, B. C. (1984). Aerobic conditioning and stress inoculation: A comparison of stress management interventions. Cognitive Therapy and Research, 8(5), 517-541. MacDougall, J. M., Dembroski, T. M., & Musante, L. (1979). The structured interview and questionnaire methods of assessing coronary-prone behavior in male and female college students. Journal of Behavioral Medicine, 2, 71-83. Matteson, M. T., Ivancevich, J. M., & Gambie, G. O. (1987). A test of the cognitive social learning model of Type A behavior. Journal of Human Stress, 13, 23-31. Meichenbaum, D. (1988). Stress inoculation training. Toronto: Pergamon Press. O'Leary, K. D., & Borkovec, T. D. (1978). Conceptual, methodological, and ethical problems of placebo groups in psychotherapy research. American Psychologist, 33, 821-830. Petty, R. E., Wells, G. L., & Brock, T. C. (1976). Distraction can enhance or reduce yielding to propaganda: Thought disruption versus effort justification. Journal of Personality and Social Psychology, 34, 874-884. Price, V. A. (1982). Type A Behavior Pattern: A model for research and practice. Toronto: Academic Press. Richlings, J. C, Khara, G. S., & McDowell, M. (1986). Suicide in young doctors. British Journal of Psychiatry, 149, 475-478. Roeske, N. C. A. (1981). Stress and the physician. Psychiatric Annals, 11, 245-258. Rosenman, R. H. (1978). The interview method of assessment of the coronary-prone behavior pattern. In T. M. Dembroski, S. M. Weiss, J. L. Shields, S. G. Haynes, & M. Feinleib. (Eds.), Coronary-prone behavior (pp. 55-69). NY: Springer-Verlag. Rosenman, R. H., Friedman, M., Straus, R., Wurm, M., Kusitchek, R., Hahn, W., & Werthessen, N. T. (1964). A predictive study of coronary heart disease. Journal of the American Medical Association, 189, 15-22. Roskies, E., Seraganian, P., Oseasohn, R., Hanley, J.A., Collu, R., Martin, N., & Smilga, C. (1986). The Montreal Type A intervention project: Major findings. Health Psychology, 5, 45-69. Russo, J., Miller, D., & Vitaliano, P. P. (1985). The relationship of gender to perceived stress and distress in medical school. Journal of Psychosomatics in Obstetrics and Gynecology, 4, 117-127. Sharp, J. J., & Forman, S. G. (1985). A comparison of two approaches to anxiety management for teachers. Behavior Therapy, 16, 370-383. Shorkey, C., & Whiteman, V. (1977). Development of the Rational Behavior Inventory: Initial validity and reliability. Educational and Psychological Measurement, 37, 527-534. Smith, T. W. (1982). Irrational beliefs in the cause and treatment of emotional distress: A critical review of the rational-emotive model. Clinical Psychology Review, 2, 505-522. Smith, T. W., & Brehm, S. S. (1981). Cognitive correlates of the Type-A coronary-prone behavior pattern. Motivation & Emotion, 5(3), 215-223. Smith, T. W., Houston, B. K., & Zurawski, R. M. (1983). The Framingham Type-A scale, anxiety, irrational beliefs, and self-control. Journal of Human Stress, 9(2), 32-37. Smith, T. W., & O'Keefe, J. L. (1985). The inequivalence of self-reports of Type A behavior: Differential relationships of the Jenkins Activity Survey and the Framingham Scale with affect, stress, and control. Motivation and Emotion, 9(3), 299-311. Smith, T. W., & Zurawski, R. M. (1983). Assessment of irrational beliefs: The question of discriminant validity. Journal of Clinical Psychology, 39(6), 976-979. Sorensen, G., Jacobs, Jr., D. R., Pirie, P., Folsom, A., Luepker, R., & Gillum, R. (1987). Relationships among Type A behavior, employment experiences, and gender: The Minnesota Heart Study. Journal of Behavioral Medicine, 10(4), 323-336. Spiegel, D. A., Smolen, R. C , & Hopfensperger, K. A. (1986). Medical student stress and clerkship performance. Journal of Medical Education, 61, 929-931. Spiegel, D. A., Smolen, R .C, & Jones, C. K. (1985). Interpersonal conflicts involving students in clinical medical education. Journal of Medical Education, 60, 819-829. Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for 79 the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press. Spielberger, C. D., Gorsuch, R. L., Lushene, R. E., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the State Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press. St. Lawrence, J. S., McGrath, M. L., Oakley, M. E., & Suit, S. C. (1983). Stress management training for law students: Cognitive-behavioral intervention. Behavioral Sciences and the Law, 1(4), 100-110. Sutton-Simon, K. (1981). Assessing belief systems: Concepts and strategies. In Kendall, P. C, & Hollon, S. D. (Eds.), Assessment strategies for cognitive-behavioral interventions (pp. 59-83). Toronto: Academic Press. Thurman, C. W. (1983). Effects of a rational-emotive treatment program on Type A behavior among college students. Journal of College Student Personnel, 24, 411-423. Thurman, C. W. (1984). Cognitive-behavioral interventions with Type A faculty. Personnel and Guidance Journal, 62, 358-362. Thurman, C. W. (1985a). Effectiveness of cognitive-behavioral treatments in reducing Type A behavior among university faculty. Journal of Counseling Psychology, 32(1), 74-83. Thurman, C. W. (1985b). Effectiveness of cognitive-behavioral treatments in reducing Type A behavior among university faculty -One year later. Journal of Counseling Psychology, 32(3), 445-448. Thurstone, L. (1953). Thurstone Temperament Schedule. Chicago: 80 Science Research Associates. Tisdelle, D. A., Hansen, D. J., St. Lawrence, J. S., & Brown, J. C. (1984). Stress management for dental students. Journal of Dental Education, 48(4), 196-201. Vitaliano, P. P., Maiuro, R. D., Russo, J., Mitchell, E. S., Carr, I. E., & Van Citters, P. L. (1988). A biopsychosocial model of medical student distress. Journal of Behavioral Medicine, 11 (4), 311-331. Wernick, R. (1984). Stress management with practical nursing students: Effects on attrition. Cognitive Therapy and Research, 8, 543-550. West, D., Horan, J., & Games, P. (1984). Component analysis of occupational stress inoculation applied to registered nurses in an acute care hospital setting. Journal of Counseling Psychology, 31, 209-218. Wolf, T. M., & Kissling, G. E. (1983). Type A behavior and achievement of freshman medical students. Journal of Medical Education, 58, 820-822. Wolf, T. M., Kissling, G. E., & Burgess, L. A. (1986). Change in Type A behavior among medical students: A four-year longitudinal study. Medical Education, 20, 176-180. Zeldow, P. B., Daugherty, S. R., & McAdams, D. P. (1988). Intimacy, power, and psychological well-being in medical students. The Journal of Nervous and Mental Disease, 176(3), 182-187. Zwemer, W. A., & Deffenbacher, J. L. (1984). Irrational beliefs, anger and anxiety. Journal of Counseling Psychology, 31, 391-393. Appendix A Representative Advertisements and Announcement Interview Protocol Informed Consent Form Stress Management Checklist 82 Advertisement Stress Management for Female Graduate Students Female graduate student volunteers are invited to participate in a free one day group stress management program. This program may help participants deal with stress related to exams, academic experiences and other graduate school stressors in more effective and productive ways. Volunteers will be contributing to knowledge of graduate student stress and stress management. The program will be co-led by Monica Wyne, masters student, and Colleen Haney, M.A., doctoral student, Department of Counselling Psychology and is sponsored by the Department of Counselling Psychology at U.B.C. (Supervisor: Dr. Bonita Long, Associate Professor). Those students interested in this program should contact Monica Wyne or Colleen Haney at (telephone number). 83 Announcement/Advertisement Female medical student volunteers from years 1, 2 and 3 are invited to participate in two free group stress management programs to take place this fall. These programs have been designed specifically for medical students and may halp participants deal with stress related to exams, clinical experiences and other medical school stressors in more effective and productive ways. In addition, the programs may facilitate medical students in assisting their patients in their stress management, for example, that related to surgical and medical procedures and acute pain. In addition, participants will have an opportunity to discuss and explore their own stressors, both academic and personal. Volunteers will be contributing to knowledge of medical student stress and stress management. Two program formats will be offered. One program will be held (dates listed), for one 90-minute session per week for six weeks, while the other will be held (date listed) for four hours. Participants must be willing to be randomly assigned to either program. Both programs will be co-led by Monica Wyne, masters student, and Colleen Haney, M.PE., doctoral student, Department of Counselling Psychology. Both are short-term programs and are being offered as part of a masters thesis sponsored by the Department of Counselling Psychology at U.B.C. (supervisor: Dr. Bonita Long, associate professor). Those students interested in these programs should attend group meetings on (dates, times and locations listed) and take a copy of this announcement. Those interested in more information now can contact Monica Wyne at (phone number). 84 Interview Protocol In response to advertisements and class announcements, potential participants attended group information meetings. Those requiring additional information prior to these meetings left their names and telephone numbers on a telephone answering machine in the Department of Counselling Psychology. All calls were returned by the principal investigator within one week. Procedure: At the group meetings, the principal investigator and her assistant introduced themselves and described their qualifications to the potential participants. In addition, the study was identified as a masters thesis. Potential participants were asked to complete a checklist of previous stress management group experience, prior to which they were informed that the information was for descriptive purposes only, would be confidential, and they may have elected not to complete it. The investigator and her assistant then described the requirements for participation as follows: The purpose of this intervention is to offer stress management programs to first, second and third year female medical students (this was subsequently extended to include female dental students and female graduate students). Two programs will be offered and participants will be randomly assigned to one or the other group. All participants will be asked to complete questionnaires for approximately 1 hour at the beginning and end of the six week program, and at a group meeting 12 weeks later (this was subsequently adjusted to 11 weeks). Both groups will be co-led by one masters student and one doctoral student in the Department of Counselling Psychology at U.B.C. Potential participants were then asked: Do you wish to participate? The informed consent form was then orally described and subsequently made available to the individuals to read and sign. Participants were then asked to randomly select an envelope which indicated the group they were assigned to and provided the place, time and date of the initial session, as well as the names and telephone number of the leaders. All participants were telephoned a few days prior to the initial session as a reminder. All participants were then asked if they had any questions or concerns, which were addressed. Individuals were thanked for their interest. Informed Consent Document 85 Title: Stress management for female medical, dental and graduate students. Purpose: This investigation is being conducted to assist female medical, dental and graduate students in their stress management. Investigators: Monica Wyne, M.A. student Colleen Haney, M.PE., Ed.D. student Telephone: Procedure: As a participant, you will be asked to complete questionnaires at the beginning and end of the study, as well as 12 weeks after the final session. These questionnaires will take approximately one hour to complete. If you have been assigned to the six week program, you will be asked to participate in six 90-minute group training sessions. If you have been assigned to the one day program, you will be asked to participate in a four hour program on a single day. This is to certify that I, , hereby agree to voluntarily participate in this study of stress management. I have been informed and I understand that I am not required to participate in this study, and that I am free to withdraw my consent and terminate my participation at any time, and this will not jeopardize my future participation in any programs sponsored by the Department of Counselling Psychology at U.B.C. I have been informed and I understand that my statements and any information which is collected will remain confidential with regard to my identity. Confidentiality will be ensured through a numerical coding system which identifies participants by a number only. A master list will be kept in a locked filing cabinet by the principle investigator and will be accessed only by the principle investigator and her assistant. All data will be destroyed upon the completion of the Final analysis of the study. I understand that I am free to omit any answer to specific questions or items in interviews or questionnaires or during the training sessions. I have received a copy of the consent form including all attachments. I have had the opportunity to ask any questions and clarify any concerns about this study and they have been answered to my satisfaction. I have also been informed that I will have the opportunity to ask any questions at any time during the study, and that they will be answered to my satisfaction. Date Participant's Signature Faculty Supervisor Dr. Bonita Long Investigator's Signature 86 Stress Management Checklist Directions: Please indicate if you have previously participated in a stress management group. If you have, please indicate the category which describes it best, as well as the number of sessions in the program. Autogenic Training Cognitive Behavioral Meditation Hypnosis Relaxation Other (please describe) Number of sessions Appendix B Demographic Questionnare Number: Date: Directions: For purposes of statistical analyses only, please indicate the response which best describes you and your situation. Your answers will remain anonymous and strictly confidential. However, this biographical data is crucial to the study. Please circle the appropriate response unless otherwise indicated. 1. Year of medical, dental or graduate school: year 1 year 2 year 3 other 4 Educational qualifications: college (2-3 year degree) 1 university (prerequisite ye ars) 2 university (degree completed) 3 graduate degree - masters 4 graduate degree - doctorate 5 other 6 Undergraduate major: Age: vears Marital status: married/remarried/common law 1 single 2 divorced/separated/widowed 3 Stress may affect our health, therefore, please indicate the response which best describes your health. 1. How satisfied are you with your health at the present time? extremely dissatisfied 1 2 3 2. Do you smoke cigarettes? 4 Yes No 3. Have you been diagnosed as having: High blood pressure Yes_ Diabetes Yes_ Angina Yes_ Ulcers Yes_ Migraine headaches Yes_ Coronary heart disease Yes_ Asthma/ Allergies Yes_ Other (please specify): extremely satisfied Number/day No_ No_ No_ No_ No_ No No Appendix C Dependent Measures Rational Behavior Inventory Type A Irrational Beliefs Inventory 91 SURVEY OF REACTIONS TO LIFE PROBLEMS AND SITUATIONS For each o f the f o l l o w i n g q u e s t i o n s , p l e a s e c i r c l e the numbered re s p o n s e w h i c h most c l e a r l y r e f l e c t s y o u r o p i n i o n . Work q u i c k l y and answer each q u e s t i o n . Strongly Agree Ag ree Neutral Disagree Strongly Disagree I 1. H e l p i n g o t h e r s i s the v e r y b a s i s o f l i f e . 1 2 3 4 5 2. I t i s n e c e s s a r y t o be e s p e c i a l l y f r i e n d l y t o new c o l l e a g u e s and n e i g h b o r s . ! 2 3 4 5 3. P e o p l e s h o u l d o b s e r v e moral laws more s t r i c t l y t h a n t h e y do. 1 2 3 4 5 4. 1 f i n d i t d i f f i c u l t t o t a k e c r i t i c i s m w i t h o u t f e e l i n g h u r t . 1 2 3 4 5 5. 1 o f t e n spend more t i m e t r y i n g t o t h i n k o f ways o f g e t t i n g out o f t h i n g s t h a n i t w ould t a k e me t o do them. , 2 3 4 5 6. 1 t e n d t o become t e r r i b l y u p set and m i s e r a b l e when t h i n g s a r e not the way 1 w o u l d l i k e them t o be. 2 3 4 5 7. I t i s i m p o s s i b l e at any g i v e n time t o change one's e m o t i o n s . 1 2 3 4 5 8. I t i s s i n f u l t o doubt the B i b l e . 1 2 3 4 5 9. Sympathy i s the most b e a u t i f u l human e m o t i o n . 1 2 3 4 5 10. 1 s h r i n k from f a c i n g a c r i s i s o r d i f f i c u l t y . 1 2 3 4 5 11. 1 o f t e n get e x c i t e d o r u p s e t when t h i n g s go wrong. 1 2 3 4 5 12. One s h o u l d r e b e l a g a i n s t d o i n g u n p l e a s a n t t h i n g s , however n e c e s s a r y , i f d o i n g them i s u n p l e a s a n t . , 2 3 4 5 13. 1 get upset when n e i g h b o r s a r e v e r y h a r s h w i t h t h e i r l i t t l e c h i l d r e n . 1 2 3 4 5 14. I t i s r e a l i s t i c t o e x p e c t t h a t t h e r e s h o u l d be no i n c o m p a t i b i l i t y i n m a r r i age. 2 3 4 5 15. 1 f r e q u e n t l y f e e l unhappy w i t h my a p p e a r a n c e . 1 2 3 4 5 16. A p e r s o n s h o u l d be t h o r o u g h l y competent, a d e q u a t e , t a l e n t e d , and i n t e l l i g e n t i n a l l p o s s i b l e r e s p e c t s . 2 3 4 5 17- What o t h e r s t h i n k o f you i s most i m p o r t a n t . 1 2 3 4 5 18. O t h e r p e o p l e s h o u l d make t h i n g s e a s i e r f o r u s , and h e l p w i t h l i f e ' s d i f f i c u l t i e s . , 2 3 4 5 19. 1 t e n d t o l o o k t o o t h e r s f o r the k i n d o f b e h a v i o r t h e y a p p r o v e as r i g h t o r wronq. 2 3 4 5 20. 1 f i n d t h a t my o c c u p a t i o n and s o c i a l l i f e t e n d t o make me unhappy. 1 2 3 4 5 21. 1 u s u a l l y t r y t o a v o i d d o i n g c h o r e s w h i c h 1 d i s l i k e d o i n g . 1 2 3 4 5 22. Some o f my f a m i l y and/or f r i e n d s have h a b i t s t h a t b o t h e r and annoy me v e r y much. , 2 3 4 5 23- 1 tend t o w o r r y about p o s s i b l e a c c i d e n t s and d i s a s t e r s . 1 2 3 4 5 24. 1 l i k e t o bear r e s p o n s i b i l i t y a l o n e . 1 2 3 4 5 25. 1 get t e r r i b l y u p s e t and m i s e r a b l e when t h i n g s a r e not t h e way 1 l i k e them t o be. , 2 3 4 5 26. 1 w o r r y q u i t e a b i t o v e r p o s s i b l e m i s f o r t u n e s . 1 2 3 4 5 27. P u n i s h i n g o n e s e l f f o r a l l e r r o r s w i l l p r e v e n t f u t u r e m i s t a k e s . 1 2 3 4 5 28. One can b e s t h e l p o t h e r s by c r i t i c i z i n g them and s h a r p l y p o i n t i n g o u t the e r r o r o f t h e i r ways. 2 3 4 5 29. W o r r y i n g about a p o s s i b l e danger w i l l h e l p ward i t o f f o r d e c r e a s e i t s e f f e c t s . 2 3 4 5 30. 1 w o r r y a b o u t l i t t l e t h i n q s . 1 2 3 4 5 31. C e r t a i n p e o p l e a r e bad, w i c k e d , o r v i l l a i n o u s and s h o u l d be s e v e r e l y blamed and p u n i s h e d f o r t h e i r s i n s . , 2 3 4 5 32. A l a r g e number o f p e o p l e a r e g u i l t y o f bad s e x u a l c o n d u c t . 1 2 3 4 5 33- One s h o u l d blame o n e s e l f s e v e r e l y f o r a l l m i s t a k e s and w r o n g d o i n q s . 1 2 3 4 5 34. I t makes me v e r y u n c o m f o r t a b l e t o be d i f f e r e n t . 1 2 3 4 5 35- 1 w o r r y o v e r p o s s i b l e m i s f o r t u n e s . 1 2 3 4 5 36. 1 p r e f e r t o be i n d e pendent o f o t h e r s i n making d e c i s i o n s . 1 2 3 4 5 37- Because a c e r t a i n t h i n g once s t r o n g l y a f f e c t e d one's l i f e , i t s h o u l d i n d e f i n i t e l v a f f e c t i t . 1 2 3 4 5 92 BELIEFS INVENTORY For each of the f o l l o w i n g questions, please c i r c l e the numbered response which most c l e a r l y r e f l e c t s your opinion. Work q u i c k l y and answer each question. Strongly Disagree Disagree Neutral Agree Strongly Agree 1. I get upset when things do not get done as q u i c k l y as they should. 1 2 3 4 5 2. While both are d e s i r a b l e , quantity of output i s more important than q u a l i t y of output. 1 2 3 4 5 3. One can e a s i l y increase t h e i r work load without l o s i n g any q u a l i t y i n t h e i r performance. 1 2 3 4 5 4. Winning or l o s i n g a corapetiton i s a r e f l e c t i o n of your basic worth as a human being. 1 2 3 4 5 5. Non-achievement or i e n t e d a c t i v i t i e s are u s u a l l y a waste of time. 1 2 3 4 5 6. Speeding up the pace of my l i f e i s one of the best ways to have or regain c o n t r o l of i t . 1 2 3 4 5 7. One i s only as good as t h e i r accomplishments. 1 2 3 4 5 8. People should do things f a s t e r than they do. 1 2 3 4 5 9. I u s u a l l y must get everything p o s s i b l e done i n order to f e e l that I have accomplished something. 1 2 3 4 5 10. People should not be l a t e f o r appointments. 1 2 3 4 5 11. I t d i s t u r b s me to compete and l o s e . 1 2 3 4 5 12. I t i s b e t t e r to achieve a l o t of medium-quality things than a small number of high q u a l i t y t h i n g s . 1 2 3 4 5 13. People w i l l think l e s s of you i f they beat you at something. 1 2 3 4 5 14. Periods of r e s t are necessary but less important than a c t i v i t i e s that produce something. 1 2 3 4 5 15. Most things that slow me down are avoidable. 1 2 3 4 5 16. Each new competitive s i t u a t i o n i s a challenge to prove myself to others 1 2 3 4 5 17. One can have almost complete c o n t r o l over t h e i r l i f e . 1 2 3 U 5 93 BELIEFS INVENTORY (continued) For each of the f o l l o w i n g questions, please c i r c l e the numbered response which most c l e a r l y r e f l e c t s your o p i n i o n . Work q u i c k l y and answer each question. Strongly Disagree Disagree Neutral Agree Strongly Agrre 18. Faster i s u s u a l l y b e t t e r . 1 2 3 4 19. The only way to get ahead i s to achieve a maximum number of goals i n a minimum amount of time. 1 2 3 4 5 20. Not being i n c o n t r o l i s a sign of weakness. 1 2 3 4 J 21. An endless s t r i n g of accomplishments increases my worth as a human being. 1 2 3 4 5 22. Anger i s an acceptable way to deal wi:h people or things that get i n the way of what I want. 1 2 3 -* 5 23. S e t t i n g e a r l y deadlines for the completion of v a r i o u s tasks i s a good way to insure that things w i l l get done. 2 3 4 5 24. I f e e l g u i l t y when r e l a x i n g . 1 2 3 4 5 25. The success I have enjoyed i s p r i m a r i l y due to my a b i l i t y to get things done f a s t e r Chan other people. 1 2 3 4 5 Appendix D Ancillary Measures Thought Listing Form Expectancy Questionnaire Midway Evaluation Questionnaire Post-Evaluation Cognitive Stress Management Questionnaire Means and Standard Deviations (SI) Follow-up Questionnaire Examples of Program Evaluation Responses 95 Number: Date: Directions: Please imagine a stressful situation and list the thoughts or images which come to mind, as they occur, whether they relate to yourself, the situation, and/or others, and whether they are positive, neutral, and/or negative. IGNORE SPELLING, GRAMMAR, AND PUNCTUATION. You will have 2 and 1/2 minutes to write. We have deliberately provided more space than we think people will need to insure that everyone will have plenty of room. Please be completely honest. Your responses will be anonymous. The next page contains the form we have prepared for you to use to record your thoughts and idea. Simply write down the first thought you had in the first space, the second in the second space, etc. Please write only one idea or thought in a space provided. 96 97 Directions: Please turn back to the page on which you wrote down your thoughts. We would like you to go back and rate each of the ideas that you wrote down. In the left margin beside each idea you wrote down, we would like to know if that idea was (+) positive or favorable, (-) negative or unfavorable, or (0) neither favorable nor unfavorable. If the idea that you wrote down seemed to be favorable, place a "+" (plus) in the left margin beside the idea; if the idea you wrote down seems unfavorable, you should place a "-" (minus) in the left margin beside that idea; and if the idea was neither favorable nor unfavorable, you should put a "0" (zero) in the left margin. Please go back now and rate each idea listed by putting a "+", or "0" in the left margin. Be sure to rate each thought that you wrote down. Please also be honest with your rating. Number: Date: 98 1. How confident are you that this program will be successful in reducing your stress reactions? Q 1 2 2 4 5. 6. Not at all Very much so 2. How logical does this type of program seem to you as a stress management technique? Q 1 2 2 4 5. 6. Not at all Very much so 3. How confident are you in recommending the program to a friend who is extremely anxious? Q 1 2 3 4 5 6 Not at all Very much so MID-WAY EVALUATION STRESS MANAGEMENT PROGRAM 9 9 EVALUATION. Please take a few minutes to complete t h i s form and thus help us to improve t h i s program. Please check (V) . 1. What aspect of the program i s most re levant to your needs? Changing Sel f -Statements Muscle r e l a x a t i o n Imagery Breathing 2. What aspect of the program i s l e a s t re levant to your needs? Changing Sel f -Statements Muscle r e l a x a t i o n Imagery Breathing 3. How do you f e e l about the amount of information? Too much Right amount Too l i t t l e 4. How do you f e e l about the way i t i s presented? Boring So-so I n t e r e s t i n g 5. To what extent have you learned things that w i l l a f f e c t the way you manage s tress? Name: Number: Not at a l l Some A g reat d e a l 100 6. How do you fee l about the hand-outs and tasks? Waste of time So-so Very useful 7. To what extent is the program helping you meet the goals you set at the beginning of the program? Not at a l l Some A great deal 8. What would you l i ke to see done differently? 9. Any other comments? Date* No. : POST EVALUATION GOAL ATTAINMENT 101 A. To what extent have you been able to achieve the goals you identified (see cards) at the beginning of this program? Please circle the number that corresponds most closely to how you feel. 3. Not at a l l Minimally Somewhat A great deal Completely 2. Not at a l l Minimally Somewhat A great deal Completely Not at a l l Minimally Somewhat A great deal Completely Not at a l l Minimally Somewhat A great deal Completely Not at a l l Minimally Somewhat A great deal Completely 6. Not at a l l Minimally Somewhat A great deal Completely Did your goals change or did any additional goals emerge during the program? Yes (If so, please l i s t and indicate to what extent they were achieved) No Not at a l l Minimally Somewhat A great deal Completely 2. Not at a l l Minimally Somewhat A great deal Completely 1 2 3 4 5 Not at a l l Minimally Somewhat A great deal Completely Date: No. : POST EVALUATION COGNITIVE STRESS MANAGEMENT 102 Means and Standard Deviations for Stress Inoculation Group (n = 14) To what extent have you been able to put to use the following concepts and s k i l l s in order to cope better with s t r e s s f u l situations? 1. Challenging negative self-statements. M 3.6 SD 0.75 not at a l l minimally somewhat 4 5 a great deal almost always 2. Replacing negative self-statements with p o s i t i v e self-statements and ins t r u c t i o n s . not at a l l minimally somewhat 3.4 0.64 a great deal almost always 3. Mentally rehearsing coping behaviors. not at a l l minimally somewhat 2.9 0.95 a great deal almost always 4. Inducing muscle rel a x a t i o n . not at a l l minimally somewhat 2.4 0.84 a great deal almost always 5. Slow down breathing (deep breathing) not at a l l minimally somewhat 2.9 0.86 a great deal almost always 6. Becoming task oriented (planning) 0.83 not at a l l minimally somewhat a great deal almost always Please l i s t any other s k i l l s you have used and indicate to what extent you implement them. 7. 1 2 3 4 5 not at a l l minimally somewhat a great deal almost always 103 8. 1 2 n o t a t a l l m i n i m a l l y 9. 1 2 3 4 5 n o t a t a l l m i n i m a l l y s o m e w h a t a g r e a t d e a l a l m o s t a l w a y s 1 0 . W h a t do y o u d £ d i f f e r e n t l y a s a c o n s e q u e n c e o f t h i s p r o g r a m ? 1 1 . I n w h a t way d o y o u f e e l d i f f e r e n t l y a s a c o n s e q u e n c e o f t ' i s p r o g r a m ? 3 4 5 s o m e w h a t a g r e a t d e a l a l m o s t a l w a y s 1 2 . W h a t a s p e c t o f t h i s p r o g r a m was m o s t u s e f u l ( h e l p f u l ) t o y o u i n l e a r n i n g how t o b e t t e r c o p e w i t h s t r e s s ? 1 3 . W h a t w o u l d y o u h a v e u s c h a n g e o r d o d i f f e r e n t l y i n t h i s p r o g r a m ? 1 4 . A n y o t h e r c o m m e n t s ? 104 A. How many sessions did you attend ? ; How may make up sessions did you attend? . B. I f you missed any of the sessions, please indicate the factors that affected your attendance. C o n f l i c t i n g work/course schedules Family r e s p o n s i b i l i t i e s D i s s a t i s f a c t i o n with the program ( i . e . , boredom) D i f f i c u l t y i n getting to l o c a t i o n D i s s a t i s f a c t i o n with leadership of program General lack of energy or enthusiasm Program did not meet expectations Holidays c o n f l i c t e d 111 health Other (please explain): 105 Number: Date: Directions: For purposes of statistical analyses only, please answer the following questions. Your answers will remain anonymous and strictly confidential. However, this biographical data is crucial to the study. 1. During the course of the program, or since its completion, did you find it necessary to seek additional sources of stress management assistance? If the answer is yes, please indicate the type of assistance you received, the number of sessions involved, and if you are still receiving these services. 2. We would appreciate any information which would assist us in improving the program in the future. In addition, we are interested in your experience as a participant in the program. Please write your comments in the space below. Thank you very much for your participation. 106 Examples of Program Evaluation Responses "Please list any other skills you have used and indicate to what extent you implement them." Normalizing Visualization/Imagery Recognizing I am reacting stressfully - avoid situation (for as little as a few seconds) until I can react better. Talking to classmates Fantasizing self into a relaxing, pleasant situation Distraction - see a movie, go out and visit Talking about stressors, accepting criticism/advice on how to react better Sharing how I'm feeling Giving myself 'free time' (e.g., enough sleep (important) reading a novel, etc. to relax Exercise "What do you do. differently as a consequence of this program?" I do not get as uptight...I have more confidence in myself and I'm not as easily intimidated...I'm not as absent minded. I don't think I react quite so quickly to others in a bad way -tend to wait so I'm not so emotional. I try to recognize and correct negative self-statements. I set more realistic goals for myself, value my effort more. Use positive self-statements - recognize the negative self-statements at the very least. "In what way do you feel differently as a consequence of this program?" I feel better about myself, more assured. Don't feel "alone"; feel less overwhelmed. I feel that my stresses are not unique - everyone is in the same boat. More positive about my efforts - and my stress! More in control much less panicky. "What aspect of this program was most helpful to you in learning how to better cope with stress?" Talking, being shown how to catch negative self-statements, 107 being given real examples. Recognizing the stress and my reaction so I could change the reaction to be more effective. I reinforced in my own mind that stress is a very complex entity -that I have a ways to go before I identify some of mine. Analyzing how stress is generated and developed. 108 Appendix E Pearson Product-Moment Correlation Matrix of Outcome Measures Pearson Product Moment Correlation Matrix of Outcome Measures E=30 IB RB TAIB TA TL TABP .46 -.69 .57 .65 -.18 p. = .005 p. = .001 p = .001 E =.001 £ = .173 IB -.67 .48 .54 -.41 p = .001 E= .004 E = .001 E = .011 RB -.64 -.76 .06 E = .001 E = .001 E = .369 TAIB .48 -.20 E = .004 .147 Note: TABP=Type A Behaviour Pattern, IB=Irrational Beliefs, RB=Rational Behaviour, TAIB=Type A Irrational Beliefs, TA= Trait Anxiety, TL=Thought Listing. o 

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