The equitable life assurance society program

PREVENTIVE

MEDICINE

12, 658-662

The Equitable

(1983)

Life Assurance

Society Program’

JAMES S. J. MANUSO James

S. J. Manuso

and Associates,

50 East Tenth Street,

New

York, New

York 10003

There is increasing interest in biofeedback and self-regulatory approaches to health enhancement. The movement has not gone unnoticed by business and industry. At this point, there are adequate data to demonstrate the effectiveness of different forms of stress management intervention. Using the experience of the Equitable Life Assurance Society of the United States as an example, an individualized stress management training program utilizing biofeedback is described. The effects of this intervention on employee performance, health behavior, and cognitions are examined. A cost-benefit analysis of the program suggests that, for each dollar invested, there is a $5.52 return. A group program, employing audiovisual techniques for employees at risk, is also described. Suggestions are given for maximizing program effectiveness and success.

INTRODUCTION In recent years, stress management programs in the workplace have become quite popular, but there is still relatively little information available on their effectiveness. The trainer, the trainees, the setting, and the expressed purpose of the program all influence effectiveness and outcome. Recently, the Wall Street Journal published an article entitled “Stress-Management Plans Abound, But Not All Programs Are Run Well” (September 30, 1982), bringing some of the critical questions to the attention of the businessreader. Still, many issuesthat should be considered by managers in planning a stress management program for their company have received insufficient coverage. In this article I will present the results of my research at The Equitable Life Assurance Society of the United States, examining the effectiveness of two types of stressmanagementprograms: an individualized, biofeedback program intended for employees already suffering from the common stress-related disorders of muscle-tension headache and generalized anxiety; and a group-administered, audiovisual program for employees presumed to be at risk. Some of the variables critical to the successof such programs will be reviewed. THE INDIVIDUALIZED PROGRAM The individualized Stress Management Program employed a four-stage model, as follows: A. Intake Employees with a long-term history of a stress-related disorder, such as headache, muscle tension, or generalized anxiety, were referred for evaluation. They were screened medically, neurologically, and psychologically, to assuresuitability t From a presentation at the University of Connecticut Symposium on Employee Health and Fitness, May 12-13, 1983, Farmington, Conn. 658 0091-7435/83

$3.00

Copyright Q 1983 by Academic Press, Inc. All rights of reproduction in any form reserved.

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for treatment. An employee who is motivated for treatment, who is willing to become involved in the treatment process, and who is sufficiently compulsive to do the homework and to practice is likely to succeed. The intake phase was conducted in two or three visits, usually over a 2-week period. B. Baseline Requiring one session per week for two consecutive weeks, the baseline phase involved a determination of digit (hand) temperature and forehead muscle tension during a “relaxed” and a “stressed” condition. Part of the purpose of this phase was to determine realistic treatment goals. Employees filled out a daily log of symptom activity (describing intensity and frequency), and symptom interference (i.e., the extent to which the symptom interferes with functioning on the job and elsewhere). Typically, high symptom activity correlated with high interference. C. Treatment During the treatment phase, the employee came to the biofeedback lab for training in self-regulation and deep-muscle relaxation. Visits were scheduled two to three times a week over a 5-week period; during this time, employees continued to till out the daily log. To help them learn autonomic self-regulation, employees were given audiovisual feedback of hand temperature and of forehead-muscle tension. Gradually, over the treatment phase, client employees were weaned from dependency on the feedback devices and learned to control stress responses using self-generated verbal instructions. Clients were given a variety of home tasks in order to assure that learning was transferred to their everyday lives: audio tapes on relaxation strategies, information on biofeedback training, a self-hypnosis guide, and a series of isometric, breathing, and cognitive techniques were provided. A 3-month period elapsed between the completion of treatment and the first follow-up. D. Follow-up The final phase was a combination of the “Intake” and “Baseline” phases and was used to assess the effects of treatment and to give advice on maximizing the effects of training in everyday life. From this point on, employees were evaluated once or twice per year to assure that they were doing well. Table 1 presents a typical course for an individualized stress management program using forehead-muscle (EMG) and digit temperature (DT) biofeedback. A comparison of status before and after treatment for 15 headache subjects and 15 anxiety subjects indicates the following: clients were able to decrease foreheadmuscle tension by 50% (variance decreased 600%), suggesting that regulation had improved; symptom activity decreased from a high-moderate to a low category; interference of symptoms with ability to function on the job decreased from 18 to 4%, suggesting increased work efficiency; medication intake decreased from 7 to 2 “pills” (Valium, fiorinal, etc.) per week, suggesting diminished dependence on palliatives; monthly visits to the corporate health center decreased from two to less than one, suggesting that behavioral self-control was taking the place of

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JAMES S. J. MANUSO TABLE 1 BIOFEEDBACK TREATMENT Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 3 Months

Baseline Baseline Treatment Treatment Treatment Treatment Treatment Treatment Treatment Treatment Treatment Treatment Follow-up Follow-up

1 15 min, 3 simulated stages 2 10 min relaxation 1 Audio and video feedback 2 Audio and video feedback 3 Audio and video feedback 4 Audio only 5 Audio only 6 Audio only 7 3 Trials, no feedback 8 No feedback, alternate trials 9 Half trials, no feedback 10 No feedback 1 No feedback 2 No feedback

LISix weeks, two sessions per week; EMG and DT readings; homework;

tapes and daily logs

“revolving door” medical care; and finally, 75% of subjects completing the program continued to retain the gains they made. Cumulative cost-benefit ratios demonstrate that for each dollar invested in the program, there was a $5.52 return on the investment, in terms of decreased health care utilization, less time away from the job to use health care services, and increased efficiency in performing job requirements. If the probability of longrange illness and death is lessened by such a program, then related insurance costs may well increase at a lower rate or even decrease. THE GROUP

PROGRAM

A group-administered, audiovisual program for people “at risk” of developing a stress-related disorder was also offered (2). The Type A personality, characterized by a sense of time urgency, competitiveness, and hostility, is believed to be more likely to be associated with the development of coronary heart disease than the complementary personality, the Type B (1). We recruited a sample of 37 Type A’s and 10 Type B’s, offering them the 6-week, group program summarized in Table 2. This research, also conducted at The Equitable (5), showed that, after completion of this program, subjects decreased use of the health care services by about 50%. Perceived stress levels (analogous to symptom activity, as defined earlier) decreased by 45% following treatment. The fact that Type B subjects showed nearly as much improvement from the program leads us to speculate that Type B’s may not be well suited to the “Type A” environment of a large corporation in an urban setting. Although it is too early to tell, future research may demonstrate that treating subjects “at risk” can decrease the likelihood of stress-related disorders, as well as the need for expensive health care services along the way. The lessons learned from this preliminary work have been applied to larger scale, health-risk intervention programs (3).

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2 SUMMARY

OF SIX

SESSIONS

I Overview of stress Physiological/emotional/cognitive consequences II Type A behavior pattern Learning the “Quieting response” (6) III Nutrition, substance abuse, exercise IV Self-monitoring and self-regulation 10 irrational beliefs V Stress inoculation technique Assertiveness VI Occupational stressors Time management strategies

MAXIMIZING

THE PROBABILITY

OF PROGRAM SUCCESS

Americans have always wanted a “quick fix,” especially when it comes to health-related issues. However, for retraining cognitive, behavioral, and physiological patterns acquired over a lifetime (to say nothing of inherited predispositions), there are no shortcuts. There are four features of a successful program that should be taken into account in the evaluation of a proposed program. First, a distinction must be made between entertainment, education, skill acquisition, and behavioral change. The l- to 2-hr lecture on stress may be considered entertainment. The 2-day stress seminar can be entertaining, but it also typically involves the communication of specific knowledge and is, therefore, educational. Some aspect of such seminars may provide skill acquisition, but the offering usually falls short of reaching the goal of stable behavioral change. It is the stress management program that is sustained over a period of weeks, requires home practice, and has a follow-up phase that maximizes the probability of enduring change. Second, appropriate staff should be chosen to deliver the program to selected corporate employees. The preferred stress management trainer is a health professional, such as a licensed psychologist or physician (psychiatrist, neurologist), with previous, relevant experience. Sometimes, a health professional with extensive corporate experience can be found. An understanding of the unique stressors and special conditions of the work environment improves the credibility of the program and increases its potential for achieving behavioral change. The selection of participants should take into account the following: employees with existing stress-related disorders should be given more intensive, individualized programs, whereas employees believed to be at risk should be given group-administered programs. Participants may be differentiated by whether they experience cognitive vs physical manifestations of stress, by whether they are Type A’s (who appear to prefer group interaction) vs Type B’s (who appear to do best in a oneon-one program), or by whether they have supervisory vs staff or managerial vs professional responsibilities. Whatever the criteria chosen, the optimal trainertrainee match should be sought.

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Third, objectives should be specified in measurable, quantitative terms. For example, decreased health care utilization, less symptom activity (or less selfperceived stress), heightened work effectiveness, increased efficiency, etc. There should be some documented history of success in preliminary testing or in other settings before implementation. All too often, a “slick” marketing job is preferred to a genuine program. Fourth, the elements of the stress management program should be examined. A well-run program will offer baseline and post-treatment assessments of participants. It should convey information about the sources of stress and their expressions and should develop strategies for managing them. The participants should end up with improved self-awareness along with cognitive and behavioral tools for coping with stress. To summarize, the critical questions regarding a proposed stress management program are: (A) What exactly are you buying? (B) From whom? (C) For whom? and (D) Does the program meet your expectations, in terms of its elements, outcomes, and history of success elsewhere? CONCLUSION

There are many management development programs calling themselves programs for stress management. The potential purchaser should be wary. There is a growing literature on stress management in the workplace (e.g., (4)), and this should be consulted. The potential contribution of stress management to a corporation can be considerable, as research has shown. In today’s rapidly changing business environment, a manager who can handle stress in himself or herself and his or her employees is a better leader. An effective program can also help reduce the burden of rising employee health benefit costs. REFERENCES 1. Friedman, M., and Rosenman, R. “Type A Behavior and Your Heart.” Wildwood House, London, 1974. 2. Manuso, J. “Manage Your Stress” (Prod. Code 108000-7). CRM-McGraw-Hill Films, New York, 1980. 3. Manuso J. “Psychological services and health enhancement: A corporate model, in “Linking Health and Mental Health: Coordinating Care in the Community” (A. Broskowski et al., Eds.), Sage Annual Reviews of Community Mental Health, Vol. 2. Sage Publications, 1981. 4. Manuso J. “Occupational Clinical Psychology.” Praeger, New York, 1983. 5. Sherwood, M. Preventive health care in the work setting: The relative efficacy of two intervention strategies in ameliorating Type A coronary prone behavior pattern. Unpublished paper, 1982. 6. Stroebel, C. R. “QR-The Quieting Reflex: A Six-Second Technique for Coping with Stress Anytime, Anywhere.” Putnam, New York, 1982.