A stress inoculation training program for adolescents in a high school setting: a multiple baseline approach

Journal of Adolescence 1992, 15,163-175

A stress inoculation training program for adolescents in a high school setting: a multiple baseline approach ANTHONY

A. HAINS

This study examined the effectiveness of stress inoculation training with adolescents in a high school setting using a multiple baseline approach. Through this intervention procedure, youths were trained in cognitive restructuring, anxiety management, and problem solving skills. Selfreports of state and trait anxiety were gathered during baseline and each training session. Five of the six youths displayed improvement on state and trait anxiety scores with the initiation of treatment. In addition, significant improvements were noted on pre- to post-assessments of state and trait anxiety and trait anger. Non-significant decreases were evident on self-reports of total, daily, and major negative stress events. No changes occurred on measures of depression, self-esteem, and anger expression. Similar patterns were obtained at a 3 month follow-up.

INTRODUCTION Recent

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problems

in adolescents

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1987; The

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1986).

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more psychologically salient than major events Williams and Ledoux, 1989). The influence of

to increase if youths experience multiple daily manner or in combinations (Compas, Davis and 1986).

The evidence for the negative impact of stress on adolescents indicates a need for stress management programs for this populations (Johnson, 1986). For those youths who have difficulty managing stress, the training *Reprint Psychology,

requests should be addressed to Anthony A. Hains, Department P.O. Box 413, University of Wisconsin-Milwaukee, Milwaukee, WI

0140-1971/92/020163+13

$03.00/O

0

1992 The

Association

for the Psychiatric

of Educational 53201, U.S.A.

Study

of Adolescents

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A. A. HAINS

of various cognitive and behavioral coping strategies as part of intervention packages would likely have a positive impact in terms of alleviating the negative consequences of stress reactions (Johnson, 1986; Feindler, 1990). While interventions have been developed to help youths cope with specific events such as school transitions (Jason and Burrows, 1983) and divorce (Pedro-Carroll and Cowen, 1985), very few cognitive behavioral procedures to help adolescents manage stress reactions have been developed, and this area has not seen much in the way of systematic attention (Kane and Kendall, 1989; Segal, 1983). The development of programs which teach cognitive behavioral coping skills would be useful for adolescents who already experience negative stress reactions or as a prevention procedure for coping with future stress events (Johnson, 1986). A procedure that might prove useful for helping adolescents cope with both major life stress events and daily stressors is Stress Inoculation Training (Meichenbaum, 1985). Most stress inoculation interventions have been successfully applied to adults (Johnson, 1986; Meichenbaum, 1985). However, since other similar cognitive-behavioral procedures have been used effectively with adolescents (Feindler, Ecton, Kingsley and Dubey, 1986; Hains and Szyjakowski, 1990), a stress inoculation training package may be a valuable approach for teaching adolescents a variety of cognitive and behavioral skills for coping with stress (Johnson, 1986). Stress inoculation training has three overlapping phases. The first phase is an educational one in which the therapist and client collaborate in a reconceptualization process. This process involves the client conceptualizing his or her negative emotional arousal problem in terms that are addressable rather than overwhelming or uncontrollable (Meichenbaum and Deffenbacher, 1988). In the second phase, interventions are developed to deal specifically with newly developed conceptualizations of the client’s problem. These interventions typically involve cognitive procedures such as cognitive restructuring, problem solving, or self-instructions to address the cognitive components which contribute to stress. Also, behavioral interventions such as relaxation training are often used to cope with physical and emotional tension (Meichenbaum and Deffenbacher, 1988). The third phase involves rehearsal and application of skills to stress provoking situations (Meichenbaum and Deffenbacher, 1988). This comprehensive training procedure, which integrates various cognitive coping skills and relaxation skills, seems to hold more promise than the training of individual skills (Meichenbaum and Deffenbacher, 1988). The purpose of this project was to examine the effectiveness of a stress inoculation training program with adolescents using a multiple baseline

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procedure. The impact of the training was measured on self-reports of state and trait anxiety, anger, depression, and self-esteem. Since anxiety, anger, and depression can be viewed as cognitively mediated reactions to stress, a reduction in these areas was expected. Furthermore, the youths were expected to show improvement in self-esteem because this domain is influenced by cognitive processes (e.g., personal self-statements) (Pope, McHale and Craighead, 1988). In addition, treatment effectiveness on reports of major life stress events and daily stressors was examined. METHOD

Subjects Six adolescent males, 15-17 years old, participated in the study. The project was conducted at a college preparatory, parochial high school for boys in a midwestern city. Admission to this school is based on competitive examinations taken by students from over 100 elementary schools in the surrounding area. In recent years, 98% of the graduates enrolled in college. The nature and purpose of the project was described to sophomores, juniors, and seniors by the head guidance counselor, and interested students were asked to sign up. Initially, there were 55 students who expressed interest. Because of the multiple baseline nature of the study, a maximum of eight students were to be selected for participation. Selection of youths was based on scheduling. That is, those youths who had a free period at the same time twice a week that was consistent with the experimenter’s schedules were selected. Eight youths meeting these stipulations were selected, however, two of these dropped out of the study right after training was begun after reconsidering the time commitment required. Unfortunately, no other youth schedules fit the session schedules. Five youths were white and one was Asian American. Dependent

measwes

Assessment The youths were given pre-, post-, and 3-month follow-up assessments within group sessions. The assessment instruments measured anxiety, anger, self-esteem, depression, and self-reports of daily and major life event stressors. In addition, anxiety assessments were made during baseline assessment periods and at each training session. Anxiety Anxiety

was measured

by the

State-Trait

Anxiety

Inventory

(STAI;

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Spielberger, 1983). The STAI is a 40 item instrument, 20 of which measure state anxiety and 20 of which measure trait anxiety. State anxiety indicates the presence of anxiety an individual is feeling at the time of assessment. Trait anxiety indicates the overall level of anxiety that an individual generally feels. Scores on both scales range from 20 to 80 with higher scores indicating higher levels of anxiety. Internal consistency estimates range from 0.86 to 0.95, with the stability estimates of the trait subscale ranging from 0.65 to 0.86 and the State subscale ranging from 0.16 to 0.62 (Chaplin, 1984). Validity scores, which have been estimated for the Trait scale by correlating it with other anxiety inventories (e.g., the Manifest Anxiety Scale), ranged from 0.52 to 0.80 (Chaplin, 1984). Anger

Anger was measured by the State-Trait Anger Expression Inventory (STAXI; Spielberger, 1988). The STAXI is a 44-item inventory which forms six scales and two subscales. For this study, only three of these scales were examined: State Anger; Trait Anger; and Anger Expression. The State Anger (S-Anger) scale is a lo-item scale which measures the intensity of angry feelings at the time of assessment. The Trait Anger (TAnger) scale is a lo-item scale which measures general feelings of anger or the disposition to experience anger. The Anger Expression (AX/EX) scale is based on the combined responses to three 8-item scales: the Anger-In scale (which measures the frequency with which angry feelings are suppressed), the Anger-Out scale (which measures how often an individual expresses anger toward people or objects in the environment), and the Anger Control scale (which measures the frequency with which an individual attempts to control the expression of anger). Therefore, the Anger Expression scale provides a general index of anger expression, regardless of the direction of expression. Scores on the State and Trait scales can range from 10 to 40, and the range for the Anger Expression scale is 0 to 72. Higher scores indicate greater levels of anger. Alpha coefficients computed for male adolescents were 0.87 and 0.82 for State and Trait anger, respectively. Reliability information is not available for male adolescents on the Anger Expression scale (Spielberger, 1988). Validity was estimated for the Trait Anger scale by correlating it with the Buss-Durke Hostility Inventory and the hostility and overt hostility scales of the MMPI using a college sample. Significant correlations ranging from 0.32 to 0.71 for males were found (Spielberger, 1988). For the Anger Expression scale, significant correlations ranges from 0.46 to 0.49 were found between AX/EX scores and male students’ responses to anger-provoking situations (Spielberger, 1988).

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Self-esteem

Self-esteem was measured by the Coopersmith Self-Esteem Inventory (CSE; Coopersmith, 1981). The CSE is a 25-item instrument that measures self-evaluative attitudes that an individual holds within his or her is meapersonal realm of experience (e.g., family, social). Self-esteem sured as an expression of approval or disapproval of the items, which indicates the degree to which the individual’s self-perception in competent, successful, or worthwhile. Scores range from 0 to 100 with higher scores indicating positive self-esteem. Reliability estimates are in excess of 0.80 (Adair, 1984). Adair (1984) also reviewed validity data for the CSE and concluded that the predictive validity was quite high, and that the instrument could be used with confidence. Depression

Depression was measured by the Reynolds Adolescent Depression Scale (RADS; Reynolds, 1987). The RADS is a 30-item instrument that uses a four point Likert-type response format. The adolescent endorses the extent to which each item describing depressive symptomatology has ever occurred. Scores range from 30 to 120 with higher scores indicating greater levels of depression. Reynolds (1987) reports an alpha coefficient across all adolescent age groups (grades 7-12) of 0.92. Validity of the RADS was estimated by correlating it with other self-report measures of depression (e.g., the Beck Depression Inventory), with significant correlation coefficients ranging from 0.68 to 0.76 being obtained (Reynolds, 1987). Daily and major life stress events

The occurrence of stress events was measured by the Adolescent Perceived Events Scale (APES; Compas, Davis, Forsythe and Wagner, 1987). The APES is a 200-item self-report instrument comprising major life events and negative and positive daily events occurring during adolescence, Youths read each item and indicate whether or not the event has occurred within the last 3 months. For those events that have occurred within 3 months, youths rate these events on 9-point Likert scales for desirability of the event (-4 = extremely undesirable; +4 = extremely desirable), impact of event (1 = no impact at all, 9 = very extreme impact), and frequency of event (1 = only once in your life; 9 = every day). Separate negative and positive scores can be calculated for a total events score (daily and major events, combined), a major stress event score, and a daily event score. However, as past research (e.g., Wagner, Compas and Howell, 1988) has shown that negative events on the APES (those rated -1 to -4 on the desirability scale) and not positive events are associated

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with psychological symptoms of stress, only scores related to negative events were included in this study. Thus, only three stress events scores were used: total negative events score, major negative events score, and daily negative events score. Major events are defined as those events rated 6 (much impact) or above in impact and 4 (several times a year) or below in frequency. Daily events are defined as those events rated 5 (about once a month) or above in frequency, regardless of impact. Those events rated low in frequency and impact were not included as daily or major events (Wagner et al., 1988). Compas et al. (1987) report excellent test-retest reliability of event occurrence (89% agreement over 2 weeks) and concurrent validity (82% agreement in corroboration that events have occurred through reports of close friends) with older adolescents. Design A multiple baseline design across subjects was used (Baer, Wolf and Risley, 1968). Treatment was initiated after baseline assessment periods (using the State-Trait Anxiety Inventory) of one, two, or three sessions. In addition to these baseline assessments, the STAI was used for the pretreatment, post-treatment, and 3 month follow-up assessments. The other measures were used only at the pre-, post-, and follow-up assessments . Treatment

procedure

The stress inoculation training procedure paralleled a three phase stress inoculation model developed by Meichenbaum (1985) for adults: the conceptualization phase; the skill acquisition and rehearsal phase; and the application phase. The author and a clinical psychology doctoral student served as therapists for the project. Each youth was seen twice a week in individual sessions which lasted 40 min. Sessions were set up such that the youths alternated between therapists. However, there were a small number of occasions when a youth saw the same therapist twice in a row due to scheduling conflicts (e.g., absenteeism because of illness, holidays). The details of the 15 session training program were specified in a treatment manual. Conceptualization phase Sessions 1 and 2 comprised this phase. During these sessions, the youths were educated on the impact of cognitions on emotions and behavior. They were taught how to identify irrational cognitions (referred to as selfdefeating cognitions throughout the course of the project) which promote forms of emotional arousal such as stress and anger. A self-monitoring

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procedure was introduced to help youths learn how to identify and monitor self-defeating thoughts. Self-monitoring sheets (labeled “Daily Thought Record”) were distributed to the youths to record daily stressful situ-ations, the type and extent of emotional arousal, and the accompanying self-defeating cognitions as soon as possible after the situations occurred. Youths were asked to return at least one completed sheet each session. In addition, the youths practised filling out a sheet each session after recalling and imagining as recent stress situation. Skill acquisition and rehearsal phase

This phase involved the training of cognitive restructuring, anxiety management training, and problem solving. During sessions 3-5, the youths were shown how to challenge and restructure their self-defeating cognitions which they learned to identify during the conceptualization phase. The youths were trained to question their identified self-defeating thoughts by examining the evidence for and against these thoughts and looking for alternative explanations for stress experiences. Practice of cognitive restructuring was accomplished through an imagery procedure. Using imagery to recall a previous stressful event, the youths reported self-defeating cognitions that they recognized while imagining the event. At this point, the therapist and the youths discussed useful rational responses that could be used as substitutes for the self-defeating thoughts in this situation. The youths were then instructed to imagine themselves in the same situation, this time restructuring the self-defeating cognitions as they arose by replacing them with the prepared rational responses. Cognitive restructuring attempts between sessions were recorded on the Daily Thought Record. Anxiety management training (Suinn, 1986), which involves the acquisition of self-controlled relaxation skills, took place in sessions 6-8. The youths received training in progressive muscle relaxation, deep breathing as cued relaxation, relaxation without tensing muscles, and relaxation through visualization of a personally relaxing image. The youths were trained to visualize past events or scenes which tend to bring on stress in order to practise reducing or managing the stress through the application of the relaxation procedures. The initiation of the stress scene was always under the control of the therapist, but the control of relaxation initiation was gradually shifted from the therapist to the youths as the sessions progressed. Homework assignments were given whereby the youths practised relaxation skills in situations of increasing levels of anxiety. Daily Thought Records were still collected at the beginning of these sessions. Sessions 9-10 involved a combination of cognitive restructuring and anxiety management training. Youths recounted examples of recent or

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current stress events, and cognitive restructuring was practiced in imagery. Then, these same images were used as the stress scenes in an abbreviated anxiety management training procedure. Relaxation homework and Daily Thought Record collection continued. Problem solving training occurred in session 1 l-l 2. Youths were taught a four-step problem solving strategy which involved: (a) defining the problem; (b) considering alternative solutions to solve the problem; (c) anticipating consequences; and (d) making a decision. During these sessions, the youths practised problem solving by applying this strategy to reported stress related problems. Relaxation homework and Daily Thought Record collection continued. Application

phase

This phase, which occurred in sessions 13-15 involved further practise of skills and application of intervention procedures in anticipation of a stressor. The youths disclosed likely stressful events that they would encounter before the next session. This stressful event was explored and discussed, and the therapist and the youths discussed which acquired skill (cognitive restructuring, anxiety management training, or problem solving) would be appropriate for this stressor. If cognitive restructuring was chosen, then the youth imagined the anticipated stressor and applied cognitive restructuring while in imagery. If anxiety management training was chosen, then the image of the anticipated stressor was used as the stress scene to which self-controlled relaxation skills were applied. If problem solving was chosen, then the therapist and the youths dealt with the issue using the problem solving strategy, and the youths then imagined themselves coping with the problem using the selected solution in imagery. Each successive session was used to discuss how well the selected stress inoculation procedure helped the youth prepare and cope with the anticipated stressor.

RESULTS

Figure 1 displays the youths’ self-report of state and trait anxiety from the STAI. Five of the six youths showed a decrease in anxiety in comparison to their baseline data after treatment was introduced across the multiple baseline procedures. The pattern of decrease differed, however, across the youths. Youth 1 showed an immediate decrease in both state and trait anxiety with the initiation of the conceptualization phase. Youth 3 displayed a sharp decline in scores with the introduction of the skill acquisition phase. Youths 5 and 6 showed a more gradual decrease than the

STRESS

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INOCULATION

and their decrease may reflect a cumulative effect of skill acquisition. The anxiety scores of Youth 4 which were very low during baseline, others,

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across baseline

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172

Table 1. Means and standard deviations for state (STATE) and trait (TRAIT) anxiety, self-esteem (CSE), state (S-ANG) and trait (T-ANG) anger, Anger expression (AXIEX), Depression (RADS), total negative events (TOT/N), major negative events (MAJIN), and daily negative events (DA YIN). Pre

Post

Follow-up

Measure

M

S.D.

M

S.D.

M

S.D.

STATE TRAIT CSE S-ANG T-ANG AX/EX RADS TOT/N MAG/N DAY/N

41.00 43.17 78.00 13.67 21.33 30.33 54.17 401.50 63.17 276.83

IO.79 7.76 19.39 8.02 5.96 6.12 9.02 189.39 60.88 121.89

30.00 31.67 79.33 11.83 1X.50 28.17 50.17 316.00 45.83 228.17

5.93 8.04 17.78 4.02 4.76 5.42 10.57 139.70 56.60 133.19

32.40 31.20 84.80 II.20 18.60 30.40 49.80 298.00 35.20 247.00

6.69 8.47 8.47 2.17 7.44 7.83 8.82 178.53 35.03 169.92

showed a decrease with advent of the conceptualization phase, despite the near floor effect pattern of his scores. With the exception of Youth 5, the youths who showed improvement as a result of training maintained these effects during the application phase. The increase of anxiety scores of Youth 5 during the application phase deserves comment. This youth attended school and training sessions during the application phase even though he was sick with the flu. A review of the therapists’ notes for this youth revealed that he was released early from these sessions because he was not feeling well. Consequently, he may not have retained much from these sessions. Finally, Youth 2 did not show any clear intervention effects. Considerable variability exists in his scores across the sessions. Three month follow-up data were gathered on all youths except Youth 6, who had left school and for whom no data were obtained. Anxiety scores remained at lower levels for Youths 1, 3 and 4. The follow-up scores for Youth 5 were not maintained at the improved levels evidenced during skill acquisition, suggesting that his limited opportunity for skill application due to illness had adverse effects. Table 1 displays the means and standard deviations for the youths’ responses to all the measures. Pre- to post-comparisons (one-tailed) were conducted to assess change on each of the measures. Significant improvement was obtained on state anxiety, t(5) = 3.08, p < 0.05, trait anxiety, t(5) = 4.55, p < O-01, and trait anger, t(5) = 3.11, p < 0.05. The remaining preto post-comparisons were not significant. However, noticeable, but non-

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significant, pre- to post-decreases in negative stress events (total negative events, major negative events, and daily negative events) were observed. Significant pre- to follow-up comparisons on trait anxiety, t(4) = 2.81, p < 0.05 and trait anger, t(4) = 2.18, p c 0.05 were obtained which suggested maintenance of training. Noticeable, but non-significant, differences were observed on state anxiety, total negative events, major negative events, and daily negative events at follow-up.

DISCUSSION

Despite the preliminary nature of the results, this study suggests that stress inoculation training is a viable form of intervention for adolescents. A decrease in both state and trait anxiety was evident in five of the six youths with initiation of training across the multiple baseline procedures. Significant improvements were noted on state and trait anxiety and trait anger from pre- to post-assessment. A non-significant trend for the negative events scores suggested that the youths reported experiencing a decrease in negative daily events, negative major events, and negative total events. These findings suggest that the acquisition of cognitive restructuring, anxiety management, or problem solving skills may have allowed the youths to cope in an effective manner with negative events when they occurred, and the impact of these events may have been subsequently lessened. The follow-up data indicated maintenance of training gains and improvement trends for three of the five youths for whom data were available (as indicated, the decline in performance in one of these youths appeared to be related to his inability to fully participate in the application phase due to illness). Cautions and limitations for this study should be noted. Youth selfreports were the only method of assessment used. In addition, a waiting list comparison control group with multiple assessment measures would enhance the investigation of training effectiveness on pre-, post-, and follow-up assessments. The participants in this study were non-clinical volunteers within a high school setting. Indeed, the lack of change on the depression, self-esteem, and some anger measures (and the indication that the youths’ scores were within normal ranges on these measures) might suggest that there was little room for improvement. Therefore, application of these procedures with youths who have more serious stress concerns or a clinical sample might further illustrate the efficacy of the procedures. The lack of female participants and the fact that these youths were considered college-bound may limit the general&ability of the findings. No significant changes were obtained on the negative events scores,

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which may be related to the small number of participants and sizeable variance within the sample. Yet, the trends were in the expected direction. These results are promising because of the deleterious effects that stress events do have on adolescents, both in terms of psychological functioning and physical health (Johnson, 1986).

ACKNOWLEDGEMENTS

The author gratefully acknowledges Elizabeth O’Laughlin for her participation and assistance, and Rev. Chuck Burns of Marquette University High School for his support and co-operation in this project.

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