Applied Psychophysiology and Biofeedback, Vol. 23, No.

3,1998

Psychological Changes Accompanying and Mediating

Stress-Management Training for Essential Hypertension
Maria Paz Garcia-Vera,1,2 Jesus Sanz,1 and Francisco J. Labrador1

In a previous controlled study, 21 participants with essential hypertension were treated

with a program based on education, relaxation and D'Zurilla problem-solving training,
and another 21 participants were assigned to a waiting list control condition (Garcia-
Vera, Labrador, & Sanz, 1997). In this report, the pre-post-treatmentpsychological changes
accompanying those conditions were examined with the Jenkins Activity Survey, the
Rosenbaum Self-Control Schedule, the Spielberger State-Trait Anxiety Inventory, and the
D'Zurilla-Nezu Social Problem-Solving Inventory. Treatment yielded significant psycholog-
ical changes that included an increase of problem-solving abilities. Moreover, correlation
and multiple regression analyses revealed that, when clinic blood pressure (BP) values were
considered, increases in problem-solving abilities were correlated with systolic and dias-
tolic BP reductions for participants in the stress-management condition, and they mediated
partially the antihypertensive effects of stress-management training on BP. No significant
correlations were found between psychological changes and self-measured systolic or di-
astolic BP reductions.
KEY WORDS: essential hypertension; stress-management training; problem-solving skills; psychological
changes.

INTRODUCTION

Although there have been numerous studies concerning the use of behavioral proce-
dures in the treatment of essential hypertension (see the reviews of Jacob, Chesney, Williams,
Ding, & Shapiro, 1991;Linden & Chambers, 1994), few studies have assessed the relevance
of psychological changes accompanying treatment (for exceptions see Adsett, Bellissimo,
Mitchell, Wilczynski, & Haynes, 1989; Bali, 1979; Blanchard, McCaffrey, Musso, Gerardi,
& McCoy, 1987; Davison, Williams, Nezami, Bice, & DeQuattro, 1991; Hafner, 1982;
Irvine, Johnston, Jenner, & Marie, 1986; McGrady, 1994; Wadden, 1984), and, to our
knowledge, no study has evaluated appropriately whether those psychological changes me-
diate the antihypertensive effects of behavioral treatments for essential hypertension. This

1
Universidad Complutense de Madrid, Madrid, Spain.
2
All correspondence should be addressed to Maria Paz Garcia-Vera, Departamento de Personalidad, Evaluacion
y Psicologia Clinica, Universidad Complutense de Madrid, Campus de Somosaguas, 28223 Madrid, Spain.

159
1090-0586/98/0900-0159$15.00/0© 1998 Plenum Publishing Corporation
160 Garcia-Vera, Sanz, and Labrador

state of affairs is not surprising because the classical behavioral treatments for essential
hypertension, biofeedback and relaxation techniques, were considered to operate by low-
ering blood pressure (BP) directly through physiological means or by reducing the pressor
response to stress (Johnston, 1987).
Various reviews and meta-analyses published in the late 1980s and early 1990s have
concluded that stress-management training is the most effective psychological treatment
for essential hypertension to date (Jacob et al., 1991; Johnston, 1987; Linden & Cham-
bers, 1994). The label "stress management" encompasses many different interventions,
including relaxation plus other, varied components: health education, various biofeed-
back modalities, assertiveness training, cognitive restructuring, stress-inoculation training,
etc. All seem to share the aim of modifying persons' stress responses, especially their
emotional stress responses. The relevance of this aim has been supported by prior re-
search suggesting a relationship between hypertension and anger/hostility (Diamond, 1982;
Sommers-Flanagan & Greenberg, 1989), anxiety (Linden & Feuerstein, 1981; Markowitz,
Matthews, Kannel, Cobb, & D'Agostino, 1993) or emotional stability (Baer, Collins,
Bourianoff, & Ketchel, 1979; Spiro, Aldwin, Ward, & Mroczek, 1995). From this research,
changes in hypertension-related emotional responses would be the basis for the effects
of stress-management training on BP. Thus, these psychological variables are thought as
mediation variables in the causal chain that leads to lower BPs in the persons receiv-
ing behavioral treatment for essential hypertension. In other words, the effect of many
psychological treatments on BP is not direct, but is mediated by a third, psychological
variable.
Few studies have reported the effects of stress-management training on psychological
variables such as anxiety or anger, and their results have been inconsistent across them.
Bali (1979) and Wadden (1984) found that anxiety dropped following relaxation training
but this was not related to the reduction in BP. Irvine et al. (1986), Adsett et al. (1989),
Blanchard et al. (1987), and Davison et al. (1991) found no reductions in a variety of anxiety
and anger measures following different forms of relaxation training, although the latter two
group of investigators did find a reduction of trait anger and of anger/hostility cognitions,
respectively, for people receiving progressive muscle relaxation. Moreover, Davison et al.
(1991) showed that anger/hostility cognition reduction was correlated with BP reduction.
McGrady (1994) reported a reduction of state anxiety, but not of trait anxiety, in a group of
persons provided with relaxation training and thermal biofeedback.
In sum, it is clearly safest to conclude from literature that the view that stress-
management training works by reducing the negative emotional response to stress has
not found convincing support. Therefore, it may be fruitful to seek different kinds of evi-
dence concerning the psychological mechanisms of the antihypertensive efficacy of stress
management trainings. These trainings, except in their simplest forms, are complex treat-
ments that are likely to produce complex psychological changes and, in fact, many of them
are specifically designed to modify other, varied behavioral and cognitive variables. For
example, in a previous study (Garcia-Vera, Labrador, & Sanz, 1997), we examined the an-
tihypertensive effects of a stress-management training based on education, relaxation, and
D'Zurilla problem-solving training (PST). The assumption underlying PST is that problem
solving is a general coping strategy that can reduce or prevent emotional stress responses
by improving a person's ability to manage everyday problems and their emotional effects
(D'Zurilla, 1986, 1990). Although its goals are similar to the self-management objectives
Psychological Changes 161

of other cognitive-behavioral approaches, the general framework and specific instructional

strategies of PST differ, particularly in the emphasis on the process of problem solving
versus the content of specific coping techniques. For example, the first component of PST
is problem orientation, which includes training in problem perception and in the adoption
of a positive problem-solving cognitive set. Interestingly, Linden and Feuerstein (1981),
after reviewing personality studies as a psychological risk factor in essential hypertension,
suggested a link between a negative cognitive set and hypertension. In this line, Linden and
Feuerstein (1983) examined the cognitive reaction pattern to interpersonal stress in 18 mild
hypertensives and 20 normotensives. They found that, after an individualized high-stress
situation, hypertensives perceived less stress than normotensives and displayed a repressive-
defensive cognitive style. Therefore, psychological mediating processes such as cognitive
appraisals are as important as specific coping skills to understand hypertension; they are
concurrent with, and may have causal significance in, BP elevation or change, and, therefore,
they constitute, along with problem-solving skills, specific targets for a stress-management
training based on PST for essential hypertension.
In our previous work, we determined the antihypertensive efficacy of this form of stress-
management training comparing it with a waiting list control condition: at post-treatment,
mean reductions of clinic BP, percentages of participants who achieved at least a 5 mm Hg
reduction and percentages of participants who in addition achieved a normotensive level
were significantly higher in the treated group than in the control one for both systolic BP
(SBP) and diastolic BP (DBP). The effectiveness of the stress-management training was also
significant regarding BP measurements made by the participant, but the mean SBP/DBP
reductions and the percentages of participants who achieved 5 mm Hg SBP/DBP reductions
were lower than those obtained with clinic BPs. From these data, in the present study we
were interested in determining whether:
(1) Stress-management training favorably affects psychological characteristics in par-
ticipants with essential hypertension, especially those characteristics that con-
stitute the specific targets of this form of stress-management training, namely,
problem-solving variables.
(2) There are psychological changes associated with BP reductions for those hyper-
tensives who receive stress-management training.
(3) The psychological changes produced by the stress-management training mediate
its effectiveness in lowering BP. To evaluate the mediator status of the psycho-
logical changes we used statistical techniques involving regression modeling as
suggested by Baron and Kenny (1986).

METHOD

Subjects

Over a 3-year period 43 males diagnosed as having essential hypertension, by their

family physicians, volunteered to participate. Participants were referred if their BP was not
well-controlled (i.e., DBP greater than or equal to 90 mm Hg or SBP greater than or equal
to 140 mm Hg) despite having one or two medications. All participants were recruited from
two health centers near Madrid. Participants were considered for this research if: (a) the
diagnosis was confirmed by six to nine readings of either DBP above 90 mm Hg or SBP
162 Garcia-Vera, Sanz, and Labrador

Table I. Demographic and Clinical Data

Stress
Management Control
(n = 21) (n=21) F(1,40)a

Age (years) 45.5 ±10.1 45.1 ±7.8 .02

Duration of hypertension (months) 66.2 ±47.8 71.0±84.1 .05
Compliance with the medication (%)b 94.2 ±18.0 97.8 ±3.7 .52
Number of previous treatments 0.9 ±0.9 0.9±1.1 .02
Number of cigarettes per day 1.1 ±4.4 4.5 ±9.2 2.31
Regularity of meals (0-10 scale) 8.1 ±2.3 7.3 ±2.9 1.11
Discomfort by medication (0-10 scale)b 0.2 ±0.9 0.0 ±0.0 .81
Physical exercise (no. hours per day) 2.2 ±3.7 3.0±5.2 .33
Clinic SBP at pretreatment 150.5 ±7.6 149.7 ±9.5 .09
Clinic SBP at posttreatment 133.4 ±10.1 142.7 ±10.7 8.32**
Clinic DBP at pretreatment 99.2 ±7.7 99.5 ±6.3 .02
Clinic DBP at posttreatment 86.2 ±7.0 93.9 ±6.6 13.65***
Self-measured SBP at pretreatment 128.5 ±10.9 131.9±10.9 1.07
Self-measured SBP at post-treatment 123.3 ±11.2 132.0 ±12.3 5.74*
Self-measured DBP at pretreatment 82.8 ±7.2 85.0 ±8.1 .87
Self-measured DBP at post-treatment 79.5 ±7.4 85.6±8.1 6.38**
Note. Data are presented as mean ± SD. SBP: Systolic blood pressure; DBP: Diastolic blood pressure.
aValues of F tests; all of them were not significant for p < .05, except those marked with asterisks.
bOnly data from medicated participants (n = 17 and 14 for stress-management and control group, respectively);
therefore, for these variables F (1,29).
*p<.05.
**p<.01.
***p< .001.

above 140 during three consecutive casual BP measurement sessions occurring over a 2- or
3-month period in the clinic, (b) participant's physician agreed not to change participant's
dose of medication or participant's usual diet throughout the duration of the investigation,
and (c) they did not suffer severe psychiatric disturbances. After pretreatment assessment,
all participants were randomized into two groups: 22 to the stress-management group and
21 to the control group. One participant from the stress-management group did not return all
psychological questionnaires and, therefore, their data were discarded for the present study.
A break down of demographic and clinical characteristics of the final sample for the two
groups (stress management and control) is shown in Table I. Thirty one participants were
on antihypertensive medications at the beginning of the study, but there were no significant
differences on clinic or self-measured BP values between medicated and unmedicated
participants at pretreatment.

Procedure

The investigation consisted of three phases: (a) a pretreatment assessment of BP, and
of physiological and psychosocial hypertension-related variables; (b) a stress-management
training phase for the treated group and a waiting list for the control group, and (c) a
posttreatment assessment identical to the pretreatment assessment. Written informed con-
sent was obtained for each phase. Both assessments and treatments were conducted by
MPG.
Psychological Changes 163

Pretreatment and Post-treatment Assessments

Before a participant was referred to the study and over a 2- or 3-month period, three
clinic measurements of BP (each measurement being the average of two or three clinic BP
readings) were taken by a nurse in the health center participants attended regularly. The
measurement procedure followed the guidelines recommended by the Spanish Ministry of
Health and Consumer (Ministerio de Sanidad y Consumo). After a period of 5 min rest,
two readings of BP with an interval of 2 min between each were taken; if the difference
between the two readings was below or equal to 5 mm Hg, the mean of the two readings
was considered as the clinic BP measurement for the session; if the difference between two
readings was above 5 mm Hg, a third reading of BP was taken and the mean of the three
readings was considered the clinic BP measurement for the session (Ministerio de Sanidad
y Consumo, 1990, p. 29).
After being referred by their physicians, participants were invited to an individual as-
sessment of their hypertension, composed of two 60-min sessions. The first session was held
in the health center the participant attended regularly. Participants completed an interview
that assessed several variables related to their hypertension problem (duration of hyperten-
sion, adherence to medication, etc.). Then, participants were carefully instructed on how to
self-measure and self-record correctly BP readings, and were asked to self-measure their
BP on three occasions per day for 16 days: two times at home (getting up in the morning and
before bedtime) and one at work. Self-measured BP was the average of 48 home and work
readings. Finally, participants received the Jenkins Activity Survey and the D'Zurilla-Nezu
Social Problem-Solving Inventory to be completed at home. The study therapist reviewed
the specific instructions of those questionnaires with participants, and participants were
then asked to schedule a time during the following week to complete both instruments in
a quiet room, free from interruption, "so that you can give your entire concentration to fill
out the questionnaires."
The second session of the pretreatment assessment was held 8 days after the first one,
in the laboratories of the Faculty of Psychology of the Universidad Complutense de Madrid.
After completing a psychophysiological assessment, participants received the Rosenbaum
Self-Control Schedule and the Spielberger State-Trait Anxiety Inventory, and instructions
for BP self-measurement and for completing questionnaires at home were reviewed. Two
weeks after the end of stress-management training, participants underwent a post-treatment
assessment identical to that mentioned above. Thus, participants visited the health center
another three times over a 2- or 3-month period for the purpose of clinic BP readings,
self-recorded their BP on three occasions per day for 16 days, and completed again the
questionnaires in the same order at home. Both at pretreatment and post-treatment, nurses
who evaluated clinic BPs were blind to the experimental condition of participants.

Stress-Management Training

The control group did not receive any intervention during the two months that the stress-
management training lasted. Stress-management training involved three basic components:
(a) information about the hypertension problem, (b) relaxation training following closely
Bernstein and Borkovec's (1983) adaptation of Jacobson's progressive muscle relaxation,
164 Garcia-Vera, Sanz, and Labrador

and (c) PST following D'Zurilla's (1986, 1990) procedure. See Garcia-Vera et al. (1997)
for a more detailed description of the stress-management training.

Materials

Devices for BP Measurement

Clinic BP readings were taken with a RIESTER NOVA mercury sphygmomanome-

ter. Each participant was given an OMRON HEM-403C digital BP monitor to self-record
his/her BP.

Jenkins Activity Survey, Form C

The JAS (Jenkins, Zyzanski, & Rosenman, 1979) is a 52-item multiple-choice indi-
cator of Type A-related behaviors. Its four scales measure Type A tendency, hard-driving
behaviors/competitiveness, speed and impatience, and job involvement. We used the Span-
ish version of the JAS (Jenkins et al., 1992) whose psychometric properties are similar to
those showed by the original one. Regarding the reliability of the Spanish version of the
JAS, its manual reports internal consistency indices of .86 (Type A), .84 (Hard-Driving
Competitive), .87 (Speed and Impatience), and .80 (Job Involvement), for a sample of 5275
persons; in addition, it reports test-retest correlations over seven months of .69 (Type A),
.67 (Speed and Impatience), .69 (Job Involvement), and .61 (Hard Driving Competitive),
for a subsample of 787 persons (Jenkins et al., 1992). Regarding its criterion validity, Type
A scores and Hard Driving Competitive scores have been found to discriminate between
persons with heart disorders and healthy persons (Jenkins et al., 1992).

Social Problem-Solving Inventory

This is a multidimensional self-report measure of social problem-solving ability that is

based on the problem-solving model of stress and coping developed by D'Zurilla (D'Zurilla,
1986). The SPSI (D'Zurilla & Nezu, 1990) consists of 70 5-point Likert-type items and can
be scored for the total inventory, the Problem Orientation scale and the Problem-Solving
Skills scale. In addition, the first scale contains three subscales (Cognition, Emotion, and
Behavior) designed to reflect the cognitive, emotional and behavioral response sets that a
person brings to a new problem-solving situation, whereas the second scale includes four
subscales (Problem Definition and Formulation, Generation of Alternative Solutions, Deci-
sion Making, and Solution Implementation and Verification) designed to measure the four
skilled tasks that, according to D'Zurilla's model, enable a person to solve a particular
problem successfully. We used the Spanish version of the SPSI translated by M. Munoz and
M. Crespo. Although the psychometric properties of this version have not been examined
yet, it showed adequate indices of reliability for the present sample of essential hyperten-
sives. At pretreatment, the alpha coefficients for the Problem Orientation, Problem-Solving
Skills, and Total scales were .90, .89, and .91, respectively, whereas for the subscales were
as follows: .63 (Cognition), .84 (Emotion), .77 (Behavior), .81 (Problem Definition and
Formulation), .73 (Generation of Alternative Solutions), .67 (Decision Making), and .69
(Solution Implementation and Verification). These values are similar to those found by
Psychological Changes 165

D'Zurilla and Nezu (1990) with the original SPSI. In addition, D'Zurilla and Nezu (1990)
have reported test-retest (approximately 3 weeks) reliabilities for the scales (Total, Prob-
lem Orientation, and Problem-Solving Skills) of .87, .83 and .88, respectively, and for the
subscales between a high of .86 (Problem Definition and Formulation) and a low of .73
(Cognition). Regarding criterion validity, the original SPSI has been found to be related in
middle-aged and elderly community residents to psychological stress, personal problems,
state and trait anxiety, depression, and general severity of psychological symptoms (Kant,
1992). Finally, the original SPSI has been shown to be sensitive to problem-solving training
effects in high-stressed community residents (D'Zurilla & Maschka, 1988).

State-Trait Anxiety Scale

The STAI (Spielberger, Gorsuch, & Lushene, 1970) is comprised of separate 20-item
self-report scales for measurement of two distinct anxiety concepts: trait anxiety and state
anxiety. High scores in the Trait Anxiety scale indicate a greater tendency to respond to
situations perceived as threatening with anxiety, whereas high scores in the State Anxiety
scale reflect the presence of perceived feelings of tension and apprehension at the particular
moment of test administration. We used the Spanish version of the STAI (Spielberger et al.,
1988). Although this version uses for each item a 0-3 response scale instead of the 1-4
response scale of the original, this change does not affect the reliability or validity of the
STAI. In fact, the Spanish version shows satisfactory psychometric properties. For exam-
ple, with adult samples from the Spanish general population, KR-20 coefficients ranging
between 0.92 and 0.93 and between 0.84 and 0.86 have been reported for the State Anxiety
scale and the Trait Anxiety scale, respectively, indicating adequate internal consistency for
both scales. Correlations with measures of related constructs (the anxiety subscale of the
Eight State Questionnaire, and the C—emotional unstableness—, O—apprehensiveness—
and QII—anxiety—factors of the 16PF) support the convergent validity of the Spanish
version of the STAI. As happens in American studies (e.g., Spielberger, Vagg, Barker, Don-
ham, & Westberry, 1980; Vagg, Spielberger, & O'Hearn, 1980), two studies of the factor
structure of the Spanish version of the STAI have yielded distinctive state and trait anxiety
factors (Spielberger et al., 1988). In addition, the Spanish version of the STAI has been
shown to be sensitive to behavioral treatment effects in different clinical samples (e.g., per-
sons with headaches, anxiety disorders, stress; for a review see Rosa, Olivares, & Sanchez,
1998).

Self-Control Schedule

The SCS (Rosenbaum, 1980) consists of 36 items, rated on a —3-to-3 point scale, that
measure "learned resourcefulness." This term refers to an acquired repertoire of behaviors
and skills by which an individual self-regulates internal events (e.g., emotions and cog-
nitions) that interfere with the smooth execution of behaviors aimed to resolve everyday
problems. High scores on the SCS are obtained by persons who have a general repertoire
of self-control skills that include the use of cognitions and self-statements to regulate emo-
tional and physiological responses, the use of problem-solving strategies, the ability to delay
gratification, and the presence of general expectations for self-efficacy. We used the Spanish
version of the SCS translated by M. A. Fernandez-Ruiz, which is essentially identical to
166 Garcia-Vera, Sanz, and Labrador

the Spanish version translated by A. Capafons and P. Barreto. The psychometric proper-
ties of this last Spanish version have been examined in several studies (for a review see
Capafons, 1989). Alpha coefficients between .78 and .85 have been reported indicating sat-
isfactory internal consistency. The test-retest correlation over 24 weeks (r = .81) indicates
that SCS scores are fairly stable. Convergent and discriminant validity indices are adequate.
The Spanish version of the SCS has statistically significant correlations with measures of
related constructs (Rotter's I-E locus of control scale) and no correlations with measures
of unrelated constructs (Extraversion and Lie scales of the Eysenck Personality Question-
naire). Correlations with behavioral indices (success in behavioral programs to lose weight)
also support the validity of the Spanish version of the SCS. These psychometric data are
similar to those obtained with the original version of the SCS (for a review see Rosenbaum,
1988).

RESULTS

Psychological Changes

Table II presents psychological measures for the stress-management and control groups
at the pretreatment and posttreatment. Correlation analyses revealed that, except for SCS
scores, there were significant interrelations among psychological measures from different
instruments in addition to intercorrelations among psychological measures from the same
instrument. Therefore, a 2 x 2 MANOVA was performed on all the psychological variables
except for SCS scores and for the linearly dependent scores of the SPSI (Problem-Solving

Table II. Changes in Psychological Variables

Stress Management Control
M SD M SD
Social Problem-Solving Inventory
Problem orientation
Pre 81.95 (19.67) 76.62 (19.91)
Post 89.09 (20.29) 76.61 (19.71)
Cognition
Pre 29.38 (6.96) 27.85 (8.13)
Post 32.00 (7.94) 27.62 (7.89)
Emotion
Pre 23.71 (7.85) 22.09 (7.01)
Post 26.42 (7.81) 22.81 (7.63)
Behavior
Pre 28.85 (6.48) 26.86 (7.28)
Post 30.66 (6.36) 26.00 (6.84)
Problem-solving skills
Pre 98.71 (15.78) 106.81 (20.97)
Post 111.09 (16.58) 107.14 (20.98)
Problem definition and formulation
Pre 26.28 (4.61) 27.47 (5.31)
Post 28.52 (5.05) 27.85 (5.42)
(Continued)
Psychological Changes 167

Table II— (Continued)

Stress Management Control
M SD M SD
Social Problem-Solving Inventory
Generation of Alternative Solutions
Pre 26.19 (4.82) 28.14 (5.32)
Post 28.09 (4.30) 29.76 (10.36)
Decision making
Pre 24.09 (5.11) 25.52 (6.81)
Post 27.71 (4.63) 25.81 (6.19)
Solution implementation and verification
Pre 22.61 (4.94) 25.95 (5.53)
Post 26.76 (5.05) 25.52 (5.72)
Total SPSI
Pre 181.14 (31.27) 183.33 (32.38)
Post 200.19 (32.53) 183.76 (32.51)
Jenkins Activity Survey
Type A
Pre 4.05 (7.93) 1.73 (10.53)
Post .80 (7.10) -.44 (10.81)
Hard driving competitive
Pre -3.24 (9.37) 2.08 (10.91)
Post -3.33 (9.49) 2.58 (11.53)
Speed and impatience
Pre 1.89 (8.44) 2.60 (10.25)
Post -3.99 (9.01) 1.45 (9.86)
Job involvement
Pre -6.14 (8.35) -11.62 (9.39)
Post -6.07 (6.86) -10.48 (9.84)
State-Trait Anxiety Scale
State anxiety
Pre 17.24 (6.65) 19.85 (8.52)
Post 19.43 (10.05) 19.90 (6.53)
Trait anxiety
Pre 19.38 (7.99) 24.40 (11.67)
Post 15.85 (6.72) 22.05 (10.29)
Self-Control Scale
Pre 47.09 (16.34) 38.62 (14.08)
Post 70.52 (46.33) 38.43 (14.13)
Note. SPSI: Social Problem-Solving Inventory.

Skills, Problem Orientation and Total scores). This MANOVA used group of participants
(stress management vs. control) and period of the study (pretreatment vs. posttreatment) as
between-subjects factor and within-subjects factor, respectively. Separate 2x2 ANOVAs
were performed on SCS scores and on each of the linearly dependent scores of the SPSI.
Given that the MANOVA indicated a significant interaction effect [Exact F(13,27) = 3.38,
p < .004], individual 2x2 ANOVAs were also conducted on each of the remaining psycho-
logical measures. To control the experiment-wise error rate, alpha levels for these ANOVAs
were adjusted by the Bonferroni technique (.05/17 = .003). When interaction effects were
significant, correlated t tests were also performed on the pre- to post-treatment changes
168 Garcia-Vera, Sanz, and Labrador

within each group of participants. These t tests were also conducted with the adjusted alpha
level.
A visual inspection of Table II reveals that, in general, the treated group exhibited
pretreatment-posttreatment increases in all problem-solving measures obtained from the
SPSI, whereas the control group did not change essentially their SPSI scores from pretreat-
ment to posttreatment. Thus, the interaction of Group x Period was significant in 3 out of
10 SPSI scales: Problem-Solving Skills [F(l, 40) = 14.90, nonadjusted p < .001], Deci-
sion Making [F(l, 40) = 11.13, nonadjusted p < .002], and Solution Implementation and
Verification [F(1, 40) = 20.05, nonadjusted p < .001]. In these scales, the increase of SPSI
scores for the stress-management training participants reached significance [t(20) = 4.15,
4.03, and 4.31, respectively, all nonadjusted p < .001], whereas there were no significant
differences from pretreatment to post-treatment for control participants [t(20) = .37, .65,
and 1.25, respectively, all n.s.]. In addition, ANOVA analyses revealed a trend toward a sig-
nificant interaction in total SPSI scores [F(l, 40) = 8.93, nonadjusted p < .005]; thus, the
increase of total SPSI scores for the treated group almost reached significance [t(20) = 3.10,
nonadjusted p < .006], whereas there were no significant differences from pretreatment to
posttreatment for the control group [t (20) = .20, n.s.].
Concerning the remaining psychological variables measured in this study, we did not
find any significant interaction for the adjusted alpha level of .05. Nevertheless, ANOVA
analyses revealed a trend toward a significant interaction in SCS scores [F(l,40) = 4.03,
nonadjusted p < .05]. Within-group correlated t tests revealed that the stress-management
training participants showed, from pre- to post-treatment, a trend toward a significant in-
crease in self-control skills [t(20) = 2.14, nonadjusted p < .05]., whereas the control partic-
ipants exhibited similar levels of self-control skills both at pretreatment and post-treatment
[t(20) = .34, n.s.].

Relationship Between Psychological Changes and BP Reductions

Table III displays correlations coefficients of psychological changes (pretreatment

scores minus posttreatment scores) with SBP reductions (pretreatment SBP minus posttreat-
ment SBP) and with DBP reductions (pretreatment DBP minus posttreatment DBP) for the
stress-management group. Decreases in clinic SBP were positively correlated with increases
in two problem-solving measures: Problem Orientation and Emotion, whereas decreases
in clinic DBP were positively correlated with increases in five out of ten problem-solving
measures: Problem Orientation, Cognition, Behavior, Decision Making, and the total SPSI.
The correlations of clinic SBP decreases and of clinic DBP with other SPSI variables were
all in the predicted direction (except one), albeit not statistically significant. In addition,
decreases in clinic DBP were positively correlated with reductions in STAI trait anxiety and
negatively correlated with decreases in JAS job involvement, whereas decreases in clinic
SBP were positively correlated with reductions in JAS type A measure.
In contrast, we did not find any significant correlations between decreases in self-
measured SBP or in self-measured DBP and psychological changes, except for a posi-
tive correlation between decreases in self-measured DBP and SPSI Behavior reductions.
This last finding was contrary to our predictions and is countered by a lack of significant
correlations between self-measured SBP/DBP reductions and the remaining SPSI scales,
suggesting that it was a chance finding due to multiple testing.
Psychological Changes 169

Table III. Correlations Between Changes in Psychological Variables and Reductions in Blood Pressure (BP) for
the Stress-Management Group (n = 21)
Reductions in BP
Clinic Self-Measured
SBP DBP SBP DBP
Jenkins Activity Survey
Type A .37* .13 -.02 -.18
Hard driving competitive .35 -.09 -.03 -.14
Speed and impatience .22 -.21 -.05 -.16
Job involvement -.06 -.46* -.03 -.05
State-Trait Anxiety Scale
State anxiety .13 .16 -.13 -.25
Trait anxiety .24 .52** -.16 -.02
Self-Control Scale .16 -.22 -.11 -.19
Social Problem-Solving Inventory
Problem orientation -.36* -.43* .11 .19
Cognition -.24 -.40* -.13 -.07
Emotion -.48** -.34 .05 .16
Behavior -.20 -.36* .35 .40*
Problem-Solving Skills -.09 -.30 .01 .18
Problem Definition and Formulation -.19 -.04 -.07 .16
Generation of Alternative Solutions .06 -.27 .18 .26
Decision Making -.14 -.47* -.13 -.02
Solution Implementation and Verification -.12 -.25 .15 .27
Total SPSI -.27 -.40* .08 .21
Note. SBP: Systolic blood pressure; DBP: Diastolic blood pressure; SPSI: Social Problem-Solving Inventory.
*p < .05; **p < .01; one-tailed significance.

Mediator Status of Psychological Changes

in the Stress-Management Training

To evaluate whether any psychological variable could be a mediator that reflected

the psychological mechanisms for the effects of stress-management training on BP, we
performed a series of multiple regression analyses with treatment predicting psychologi-
cal changes (Equations A), treatment predicting BP reduction (Equations B), and, finally,
treatment and psychological change predicting BP reduction (Equations C). To receive the
designation of mediator, the following conditions must be met (Baron & Kenny, 1986):
(1) treatment must be significantly related to psychological change; (2) treatment must
be significantly related to BP reduction; and (3) psychological change must be signifi-
cantly related to BP reduction in the Equation C, that is, there must be a reduction in the
magnitude of the relation between treatment and BP change in the last equation (Equa-
tion C) relative to the value of the relation in the second equation (Equation B). Accord-
ing to first condition, we restricted regression analyses to those psychological variables
that had showed a significant change from pretreatment to post-treatment in the stress-
management training group in comparison to the control group, and separate analyses were
conducted using each of them. Likewise, separate analyses were conducted using the re-
duction in clinic SBP, in clinic DBP, in self-measured SBP, and in self-measured DBP.
In these analyses, treatment was coded as 1 for stress-management training and as 0 for
control.
170 Garcia-Vera, Sanz, and Labrador

Table IV. Regression Analyses for Testing Mediational Effects Among Treatment, Changes in Psychological
Variables and Reductions in Blood Pressure (BP)
Conditions To Be a Mediator
Regression Equations: Predictors -»• Criterion R R2 Fa B
1 . Treatment predicts psychological changes
(A) Treatment-* SPSI-DM .46 .22 11.13** -3.33
(A) Treatment ->• T-SPSI .41 .17 8.15** -18.62
(A) Treatment -> SPSI-PS .52 .27 14.89*** -12.04
(A) Treatment -» SPSI-SIV .58 .33 20.05*** -4.57
2. Treatment predicts BP reductions
Systolic blood pressure (SBP)
(B) Treatment -» clinic SBP .48 .23 11.91*** 10.06
(B) Treatment -> self-measured SBP .41 .17 8.19** 5.23
Diastolic blood pressure (DBP)
(B) Treatment -» clinic DBP .42 .18 8.57** 7.48
(B) Treatment -> self-measured DBP .45 .20 10.27** 3.85
3. Psychological changes predict BP reductions
Systolic blood pressure
SPSI Decision Making
(C) T + SPSI-DM -»• clinic SBP .50 .25 1.21 8.37 + (-.50)
(C) T + SPSI-DM -> self-measured SBP .45 .20 1.59 4.02 + (-.36)
Total SPSI
(C) T + T-SPSI -*• clinic SBP .53 .28 2.66 7.96 + (-.11)
(C) T + T-SPSI -» self-measured SBP .42 .17 .16 4.89 + (-.02)
SPSI problem-solving skills
(C) T + SPSI-PS -»• clinic SBP .50 .25 .96 8.31 +(-.14)
(C) T + SPSI-PS ->• self-measured SBP .42 .17 .22 4.70 + (-.04)
SPSI-SIV
(C) T + SPSI-SIV -»• clinic SBP .50 .25 .98 8.01 +(-.45)
(C) T + SPSI-SIV -> self-measured SBP .41 .17 .08 5.60 + (.08)
Diastolic blood pressure
SPSI Decision Making
(C) T + SPSI-DM -»• clinic DBP .59 .35 10.39** 3.57 + (-1.17)
(C) T + SPSI-DM -» self-measured DBP .45 .21 .12 4.07 + (.06)
Total SPSI
(C) T + T-SPSI -»• clinic DBP .52 .27 5.14* 4.99 + (-.13)
(C) T + T-SPSI -»• self-measured DBP .48 .23 1.42 4.49 + (.03)
SPSI Problem-Solving Skills
(C) T + SPSI-PS -> clinic DBP .47 .23 2.51 5.06 + (-.20)
(C) T + SPSI-PS -* self-measured DBP .48 .23 1.53 4.75 + (.07)
SPSI-SIV
(C) T + SPSI-SIV -*• clinic DBP .46 .22 2.01 4.94 + (-.55)
(C) T + SPSI-SIV -> self-measured DBP .49 .24 1.98 5.03 + (.26)
Note. T: Treatment; SPSI: Social Problem-Solving Inventory; SPSI-DM: Decision Making subscale of the SPSI;
T-SPSI: Total score of the SPSI; SPSI-PS: Problem-Solving Skills scale of the SPSI; SPSI-SIV: Solution
Implementation and Verification subscale of the SPSI. Mediator Status: (A) significant, (B) significant, and
mediator must affect BP in (C), that is, decrease in Treatment regression coefficient in (C) relative to (B).
a
In (C), F values test whether the second variable of the equation accounts for a significant proportion of the
variance in BP beyond the variance accounted for by Treatment (T).
* p < .05.
**p<.01.
*** p<.001.

Table IV shows regression analyses results for the four psychological variables that
met the first condition to be a mediator (see Equation A). Table IV also shows that the
second condition to speak about mediators was met, namely, treatment was shown to affect
the clinic and self-measured SBP/DBP reductions (see Equation B). The third condition
Psychological Changes 171
Table V. Pearson Correlations, Partial Correlations, Squared Part Correlations and Beta Coefficients
of Psychological and Treatment Variables in the Regression Equations Predicting Reductions
in Clinic Blood Pressure
Regression Equations: Predictors -> Criterion r Partial r Part r2 Beta

Systolic blood pressure (SBP)

Treatment + SPSI Decision Making -> clinic SBP
Treatment .48" .38** .12 .40
SPSI Decision Making -.36** -.17 -.02 -.17
Treatment + Total SPSI -» clinic SBP
Treatment .49** .38** .11 .38
Total SPSI -.40** -.25 -.05 -.24
Treatment + SPSI-PS -» clinic SBP
Treatment .48** .36" .11 .39
SPSI Problem-Solving Skills -.37** -.15 -.02 -.16
Treatment + SPSI-SIV ->• clinic SBP
Treatment .48** .34* .10 .38
SPSI Solution Implementation and Verification -.39** -.16 -.02 -.17
Diastolic blood pressure (DBP)
Treatment + SPSI Decision Making -» clinic DBP
Treatment .42** .21 .03 .20
SPSI Decision Making -.56** -.46** -.18 -.47
Treatment + Total SPSI -» clinic DBP
Treatment .42** .29* .06 .28
Total SPSI -.45** -.34* -.10 -.34
Treatment + SPSI-PS -»• clinic DBP
Treatment .42** .26* .06 .28
SPSI Problem-Solving Skills -.41** -.24 -.05 -.26
Treatment + SPSI-SIV -» clinic DBP
Treatment .42" .25 .05 .28
SPSI Solution Implementation and Verification -.41" -.22 -.04 -.24

Note. SPSI: Social Problem-Solving Inventory.

*p < .05.
**p < .01; one-tailed significance.

was met only for two variables, decision making skills and problem-solving ability, and
only for reductions in clinic DBP (see Equation C). Indeed, regression analyses revealed a
significant relation between these two psychological variables and clinic DBP reductions
in the third equation (see F values in Table IV, and partial and part correlations coefficients
in Table V).
However, an examination of the treatment regression coefficients displayed in Table IV
indicates that the other two psychological variables could also meet the third condition to
be mediators: problem-solving skills and solution implementation-verification skills. Baron
and Kenny (1986) have advised investigators to examine not only the significance of cor-
relations but also their absolute size, because multicollinearity (treatment and those SPSI
measures were correlated; see Equation A in Table IV) reduces power in the tests of sig-
nificance in the third equation. As shown in Table IV, decreases in treatment regression
coefficients in the third equation (C) relative to the second equation (B) were found for both
psychological variables concerning both clinic BP measures (DBP and SBP), and, in fact,
there was a reduction of the relation between treatment and clinic SBP or DBP reduction
when the effects of those psychological variables were controlled (compare Pearson corre-
lation and partial correlation coefficients of treatment in Table V). Likewise, decreases in
172 Garcia-Vera, Sanz, and Labrador

treatment regression coefficients in the third equation (C) relative to the second equation (B)
were found for decision making skills and problem-solving ability concerning clinic SBP,
and, again, there was a reduction of the relation between treatment and clinic SBP reduc-
tion when the effects of those psychological variables were controlled (compare Pearson
correlation and partial correlation coefficients of treatment in Table V).
A visual inspection of Table II reveals that, in comparison to the control group, the
stress management group had lower (albeit not statistically significant) initial values on the
problem-solving skills measures, which were key predictors. Nevertheless, the predictions
did not seem to be based on regression on the mean. We did not find any significant
correlation between the initial values on SPSI variables and the changes in clinic SBP/DBPs.
For example, for the key predictors, that is, Decision Making, Total SPSI, Problem-Solving
Skills, and Solution Implementation and Verification, the correlations ranged from —.07 to
.11 for the stress-management group, and from —.15 to .11 for the whole sample.

DISCUSSION

Psychological Changes Accompanying Stress-Management Treatment

The results of the present study show that there are psychological changes in partici-
pants receiving stress-management training for the lowering of BP in essential hypertension.
Following treatment these participants increased their problem-solving abilities, especially
their skills related to decision making and to solution implementation-verification, and they
also tended to increase their self-control behaviors. In contrast, participants in the control
group did not change significantly their levels on these psychological variables from pre-
treatment to post-treatment. Given that the stress-management training administered in this
study was based on D'Zurilla PST, it is significant to note that pre-post-treatment changes
were found in those psychological variables specifically targeted by this form of treatment:
problem-solving skills. Interestingly, self-control, a psychological variable not directly tar-
geted by the treatment and not empirically correlated with problem-solving ability measures,
was also affected favorably. The importance of essential hypertension for the population at
large lies in its association with an increased risk of cardiovascular disease. Cardiovascular
diseases are determined by the interaction of many risk factors including psychological
factors such as stress or particular behavior patterns. The results of this study suggest that
stress-management treatments may have pervasive effects that spread across several risk
factors apart from high BP, especially across psychological factors (e.g., self-control behav-
iors that determine dietary and related lifestyle habits known for their direct effects on BP
control; Lindquist, Beilin, & Knuiman, 1997). In some cases, these wide-ranging effects
may be preferable to the more powerful effects of antihypertensive medication which are
restricted to one risk factor (see Kostis, Rosen, Cosgrove, Shindler, & Wilson, 1994, for
consistent data evidencing the generalized effects of behavioral treatments in cardiovascular
disorders).
Although in this study most participants received medication, psychological changes
found in the stress-management group can be safely attributed to stress-management training
rather than to pharmacological therapy or to its interaction with this latter. First, we did not
find those psychological changes in the control group, in spite of the fact that this group also
Psychological Changes 173

received medication. It should be emphasized that medication was constant throughout the
study. Second, although emotional variables such as anxiety may be altered by medication,
we are not aware of any theoretical or empirical relationship between antihypertensive
medication and the psychological variables that showed pre-posttreatment changes in this
study.
Concerning the other psychological variables assessed in the present study, our failure
to find significant reductions in anxiety following stress-management training is consistent
with the results found by most previous studies on relaxation training for essential hyper-
tension (e.g., for trait anxiety see Adsett et al., 1989; Blanchard et al., 1987; Davison et al.,
1991; Irvine et al., 1986; McGrady, 1994; for exceptions see Bali, 1979; Wadden, 1984; for
state anxiety see Adsett et al., 1989; Blanchard et al., 1987; for exceptions see McGrady,
1994).
Several explanations may been advanced to explain the lack of changes in anxiety.
First, given that our sample of essential hypertensives showed normal levels of anxiety
at the pretreatment assessment according to the Spanish norms for the STAI (the mean
STAI Trait/State scores for the stress-management and control groups were below the
50/40th and 70/50th percentiles, respectively; Spielberger et al., 1988), the lack of changes
in anxiety in previous literature and in this study might reflect the absence of elevations
on this variable at pretreatment (Blanchard et al., 1987). The same reasoning might be
made for the failure to find significant reductions on the Type A-related measures derived
from the JAS. At pretreatment, both stress-management and control groups showed nor-
mal levels on the JAS scales according to the Spanish norms (the mean Type A, Hard
Driving/Competitiveness, Speed/Impatience and Job Involvement scores for the stress-
management and control groups were below the 60/45/60/35th and 50/60/60/20th per-
centiles, respectively; Jenkins et al., 1992).
Nevertheless, this explanation is clearly insufficient. Blanchard et al. (1987) found a
reduction in Speed and Impatience scores from pretreatment to 6-month follow-up in essen-
tial hypertensives with normal pretreatment scores receiving either thermal biofeedback or
progressive muscle relaxation training. To make the issue more complex, inconsistent data
for the Speed and Impatience scale and for the remaining JAS scales have been also reported.
For example, Adsett et al. (1989) found a significant reduction in Type A behaviors, and
speed and impatient behaviors at 3-months follow-up for a group of essential hypertensives
receiving beta-blocker plus muscle relaxation training, but not at posttreatment and not for a
group receiving relaxation training plus placebo drug. In addition, they did not observe any
significant reduction in the remaining JAS scales. On the other hand, in the above-mentioned
study, Blanchard et al. (1988) did not find any significant reduction in the Type A and Hard
Driving Competitive scales and, in contrast, they found a very curious pattern of results for
the Job Involvement scale: the progressive muscle relaxation group showed an increase in
Job Involvement scores whereas the temperature biofeedback group exhibited the opposite
effect.
Another possibility is that the failure to find psychological changes in anxiety and Type
A-related measures in this study and in previous ones could have resulted from inadequate
statistical power. This does not seem to be the case. Recently, Rosa, Olivares, and Sanchez
(1998) carried out a meta-analytic review on the effectiveness of relaxation techniques on
anxiety problems in Spain (e.g., anxiety disorders, migraines and tension-type headaches,
asthma). They found that the standardized mean difference, that is, the mean effect size
174 Garcia-Vera, Sanz, and Labrador

for state anxiety and trait anxiety were, respectively, 1.13 and .93. Using these estimates
and usual levels of protection against Type I (two-tailed a = .05) and Type II (ft = .20)
errors, the number of participants needed to detect a clinically significant difference on
anxiety with a statistical power of 80% was estimated to be 40 and 28 participants for
trait anxiety and state anxiety, respectively. According to these estimates, both previous
studies and the present one have employed adequate sample sizes in spite of not finding
psychological changes in anxiety following behavioral treatments (e.g., N =47 in Adsset
et al., 1989; N =40 in Blanchard et al., 1987; N =58 in Davison et al., 1991; N = 101 in
McGrady, 1994). On the other hand, in the above-mentioned studies of Adsset et al. (1989)
and Blanchard et al. (1988), sample sizes of 40 or 47 participants were adequate to show
significance in Type A behaviors, in speed and impatient behaviors, or in job involvement
behaviors.
Other alternative explanations for the negative findings may be examined, especially
regarding the possible theoretical relationships between the treatment components and the
various psychological variables associated with hypertension, and regarding the validity
of procedures and instruments for measuring those psychological variables. For example,
it is possible that the administration procedure of the STAI State scale in this study (self-
administered at home) was not the best strategy to reveal treatment effects; perhaps, it
would be better to administer it after a potentially stressful situation in a way that allows
treated participants to show the coping and relaxation strategies learned during the stress-
management training. In addition, several studies have cast doubts about the psychometric
properties of the JAS, especially their validity to predict cardiovascular morbidity and
mortality (e.g., Edwards, Baglioni, & Cooper, 1990; Shipper, Kreitner, Reif, & Lewis, 1986;
for a review see Booth-Kewley & Friedman, 1987). For example, scores in Speed/Impatience
and Job Involvement scales of the Spanish version of the JAS do not discriminate between
persons with heart disorders and healthy persons (Jenkins et al., 1992). Furthermore, the
mixed and confusing results with the JAS reported by Blanchard et al. (1988) and Adsett et al.
(1989) and discussed earlier are consistent with the unexpected findings of the present study:
decreases in clinic DBF were negatively correlated with decreases in JAS job involvement.
Taken together, these data provide additional support to the claim that the JAS does not
show good validity indices and, therefore, further research should consider the use of other
measures for Type A behavior.

Psychological Changes Mediating Stress-Management Treatment

For participants in the stress-management training, increases in problem-solving vari-

ables as measured on the SPSI were significantly correlated with clinic SBP/DBP reductions.
We believe that this is the first demonstration of such an association, and it confirms the view
that increases in coping processes in everyday life may be a key to BP reduction (Johnston,
1988). In addition, it also suggests that a deficient problem-solving ability may be worth
studying as a candidate for explaining the development of essential hypertension.
Moreover, regression analysis results suggest that increases in problem-solving abil-
ities in general, and, in particular, increases in decision making, problem-solving and so-
lution implementation and verification skills, function as partial mediators between the
stress-management training and the reductions found in clinic BP at posttreatment. Indeed,
Psychological Changes 175

when those psychological variables were controlled, there was a significant reduction in
the relation between treatment and clinic DBP/SBP reductions. As expected, this reduc-
tion was not total and, therefore, it indicates that the form of stress-management training
used in this study also works through other mechanisms. However, this kind of data on
mediation adds to the important understanding of how behavioral treatments affect BP
reductions.
We also found that, in the stress-management group, reductions in trait anxiety and in
Type A behaviors were significantly correlated with clinic DBP reductions and with clinic
SBP reductions, respectively. These data suggest that trait anxiety and Type A behavior
may be useful to predict what types of persons will respond to stress-management training
(McGrady & Higgins, 1989). However, the reductions in trait anxiety and in Type A behavior
could not be attributable to stress-management training. In addition, the relationship of
decreases in trait anxiety with reductions in clinic DBP contrasts with the negative findings
reported by Bali (1979) and Wadden (1984) in their studies with essential hypertensives
receiving relaxation training, whereas the relationship of decreases in Type A behavior with
reductions in clinic SBP is weakened by the questionable psychometric properties of the
JAS. Further research is needed to clarify the role of anxiety reductions and of Type A
behavior reductions in the treatment of essential hypertension.
Unfortunately, we did not find any significant relationships between psychological
changes and self-measured BP reductions. As reported in our previous study (Garcia-Vera
et al., 1997), stress-management training produced changes of smaller magnitude for self-
measured BPs than for clinic BPs. The small variance change scores, therefore, would be
expected to attenuate any possible correlations with changes in psychological variables and
may partially explain the pattern of results found in this study. On the other hand, to rule out
alternative explanations related to demand characteristics or therapist expectancy effects, it
is important to recall that clinic BP measurements were conducted by independent nurses
who were blind both to the experimental condition of participants and research hypotheses.
Nevertheless, other explanations may be possible. As reported elsewhere (Garcia-Vera,
Labrador, & Sanz in press; Garcia-Vera & Labrador, 1998), we found very low correlations
between clinic and self-measured readings of BP at pretreatment in the sample of this
study (a significant .38 for SBP and a nonsignificant .19 for DBP), and we also found that
self-measured readings were consistently lower than clinic ones and that more than 40%
of the sample could be considered as participants with white coat hypertension taking the
borderline hypertension criteria obtained by Mejia et al. (1990) for BP self-determination
(131/83 mm Hg for men). Furthermore, the correlations between the changes in clinic BP
and the changes in self-measured BP for the stress-management group were not statistically
significant: —.23 for SBP and —.08 for DBP. Therefore, it may be that treatment was most
effective in lowering clinic BP because of state anxiety based elevations and, in this vein,
that the problem-solving predictors correlated with clinic BPs, but not necessarily with
self-measured BPs. If this was the case, sustained hypertensive participants should show
lower BP reductions than white coat hypertensive participants. Nevertheless, we found
similar reductions in clinic BPs for the whole sample and for the subsample of sustained
hypertensive participants (Garcia-Vera et al., 1997). On the other hand, although the validity
of the state anxiety measure in this study should be taken with reservations due to the
administration procedure, it needs to be pointed out that we did not find, in general, any (one-
tailed) significant correlation between changes in state or trait anxiety and changes in social
176 Garcia-Vera, Sanz, and Labrador

problem-solving skills for the stress-management group.3 In addition, partial correlations

between changes in social problem-solving variables and reductions in BPs for the stress-
management group when controlling for state and trait anxiety variables were very similar
(or even greater) in magnitude to Pearson correlations displayed in Table III.4
In sum, we have no convincing hypothesis to explain why psychological factors me-
diated change in clinic BPs but did not do so at all with self-measured BPs. Therefore,
there is a need for future studies to examine the relation between psychological changes
and reductions in BPs measured outside the clinic, especially given that self-measured or
ambulatory BP measurements appear to be more reliable estimate of a person's true BP
than clinic BP measurements (cf. Pickering, 1991).
In the last decade several well-publicized reports have cast serious doubts about the
effectiveness of behavioral treatments for essential hypertension (e.g., Jacob et al., 1991;
JNC, 1993, 1997). After reviewing the evidence, other investigators have arrived at more
positive conclusions (e.g., Linden & Chambers, 1994; McGrady, 1996). It is clear that, to
settle this debate in favor of behavioral therapies, further controlled studies that demonstrate
clinically and statistically significant decreases in BP are required as well as analyses of
what types of hypertensives respond to behavioral therapies (McGrady, 1996). However,
given the psychological nature of the treatment, there is also a need for studies that reveal
the psychological changes accompanying and mediating behavioral therapies, and link the-
oretically these changes to the specific goals and components of treatment. In this line, our
findings indicate that a stress-management training based on D'Zurilla PST has effects on
psychological variables specifically targeted by the treatment, and that these changes are
correlated with and mediate its antihypertensive effects in a sample of males with essen-
tial hypertensive. Of course, further research should determine whether the psychological
characteristics of the present sample of essential hypertensives are representative of the
general population of persons with essential hypertension. In addition, given that the SPSI
was the only instrument that yielded reliable results in the present study, further studies
should examine in a thorough manner the psychometric properties of this instrument for the
population of essential hypertensives. In fact, a limitation to this study is that, except for in-
ternal consistency, the psychometric properties of the Spanish version of the SPSI have not
been examined yet. Finally, it would be interesting to examine whether the antihypertensive
effects of the pharmacological therapies are also accompanied by psychological changes,
and whether these changes play some role in those effects.

ACKNOWLEDGMENTS

This article was based on the doctoral dissertation carried out by the first author under
the direction of the third author and with the support provided by a FPI Grant from the
Comunidad Autonoma de Madrid.

3
Only 2 out of 20 correlations among changes in SPSI scores and changes in STAI scores were (one-tailed
significant: the correlation between changes in the Behavior subscale and changes in the State Anxiety scale
(r = -.36, p < .05), and the correlation between changes in the Problem Definition and Formulation subscale
and changes in the Trait Anxiety scale (r = .42, p < .05).
4
Following the order of SPSI variables displayed in Table III, the partial correlations between changes in social
problem-solving variables and reductions in clinic BPs for the stress-management group were: —.47, -.45, -.35,
-.38, -.44, -.35, -.34, -.50, -.41, and -.50, for clinic DBP, whereas for clinic SBP they were: -.34, -.22,
-.47, -.17, -.12, -.35, .06, -.11, -.16, and -.27.
Psychological Changes 177

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