Jouraal of Coiuulliiil and CBmoJ Piydwlo»y Copyright 1987 by the American Psychological AnocialiOfi, Inc.

1987, Vol. 55. No. 6,919-922 0022-006X/87/J00.7S

Efficacy of Stress-Inoculation Training in Coping

With Multiple Sclerosis

Frederick W. Foley and Jeffrey R. Bedell Nicholas G. LaRocca and Labe C. Scheinberg
Department of Psychiatry Medical Rehabilitation Research and
Sound View Throgs Neck Community Mental Health Center Training Center for Multiple Sclerosis
Albert Einstein College of Medicine Albert Einstein College of Medicine
Marvin Reznikpff
Fordham University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Forty multiple sclerosis (MS) patients were randomly assigned to one of two treatment conditions:
stress inoculation training (SIT) or current available care (CAC). The SIT treatment included cogni-
tive-behavioral psychotherapy and progressive deep-muscle relaxation training adapted for MS pa-
tients. The CAC treatment provided the usual clinic services, and the CAC group was told the SIT
treatment would be available in 5 weeks. At posttest, it was found that the SIT group was significantly
less depressed, anxious, and distressed than the CAC group and that they were utilizing more prob-
lem-focused coping strategies than CAC control subjects.

Multiple sclerosis (MS) is a common demyelinating disease
that affects the central nervous system. Clinical symptoms vary
widely and affect sensory-tactile, motor, visual, bladder, and
bowel functioning. Multiple sclerosis has profound social and
psychological consequences. Disruptions in schooling, employ-
ment, sexual and family functioning, friendships, and activities
of daily living occur. Psychological distress includes anxiety, de-
pression, poor body image, and low self-esteem (VanderPlate,
1984). Because of these challenges to the MS patient's ability to
cope, the need to develop efficacious psychological interven-
tions is paramount.
The literature on psychological interventions in MS primar-
ily comprises case reports and uncontrolled group studies of
hypnotherapy (Brunn, 1966), biofeedback (LaRiccia, Katz, Pe-
ters, Atkinson, & Weiss, 1985), psychodynamic therapy (Day,
Day, & Hermann, 1953), psychoeducational programs (Barnes,
Busse, & Dinkin, 1954), and support (Hamburg & Adams,
1967). Controlled studies of psychological intervention in MS
are scarce. Crawford and Mclvor (1985) found that long-term
psychodynamic group therapy improved depression. Likewise,
Larcombe and Wilson (1984) found that short-term group cog-
nitive-behavioral treatment improved depressive symptoms.
The current treatment study offers the first controlled study
of an individual treatment approach (stress inoculation train-
This work was supported in part by Grant G008200040 from the
National Institute on Disability and Rehabilitation Research and Grant
R G1459-A-7 from the National Multiple Sclerosis Society.
Correspondence concerning this article (and requests for an extended
report) should be addressed to Frederick W. Foley, Department of Psy-
chiatry, Sound View Throgs Neck Community Mental Health Center,
Albert Einstein College of Medicine, 2527 Glebe Avenue, Bronx, New
York 10461.
ing) in MS. The current study also measures disease variables
that could easily confound outcome findings (disease duration,
severity, and current exacerbation status). In addition, coping
measures were assessed that tap both coping outcome (e.g., de-
pression, state anxiety, psychological distress) and coping medi-
ators (e.g., locus of control, trait anxiety, problem-focused
coping).
The current study utilized a stress inoculation training (SIT)
program that was specially adapted to augment coping in MS
by increasing psychological symptom control and by modifying
potential coping mediators. The SIT is a short-term, cognitive-
behavioral psychotherapeutic intervention that seeks to
enhance coping by ameliorating affective distress and by pre-
venting maladaptive psychological responses to stress
(Meichenbaum, 1977). It was predicted that, compared with a
current-available-care (CAC) control group, the MS patients
who received the SIT would demonstrate significantly less de-
pression, anxiety, and perceived distress and would utilize more
problem-focused coping strategies than the control group fol-
lowing treatment. Locus of control was not expected to change
due to the brevity of the intervention (5 weeks).
Method
Subjects
Subjects were 41 MS outpatients at the Albert Einstein College of
Medicine. Criteria for subject inclusion required that patients have (a)
a confirmed MS diagnosis, (b) a level of disability no greater than 8
(restricted to wheelchair) on the 10-point Disability Status Scale (Kurt-
zke, 1955), and (c) no major cognitive deficits (e.g., severe dementia).
Subjects were selected following a careful chart review. Five subjects
failed to complete the self-reports at either pretest or posttest and were
excluded from the analysis. The remaining 36 subjects constituted the
final sample upon which results were based.

919
 920 BRIEF REPORTS
The typical subject was female (85%), 38.8 years old, separated or
divorced (55%), and unemployed (57.5%). Patients' disability levels
ranged from a Kurtzke classification of 1 (minimal neurological signs)
to 8 (restricted to wheelchair and unable to manipulate it}, with a mean
level of 6 (assistance required to ambulate: e.g., crutches). Most patients
were experiencing clinical exacerbations at the time of entry into the
study (60%), at posttest (58%), and at 6-month follow-up (60%).
Assessment
Measures of coping evaluated psychological symptoms (depression,
state anxiety, perceived distress) and coping mediators (locus of control,
trait anxiety, and problem-focused coping). Included were the Beck De-
pression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erhaugh.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
1961), the Slate-Trait Anxiety Inventory (STAI; Spielberger, 1983), the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Hassles Scale (Kanner, Coyne, Schaefer, & Lazarus, 1981), and Rotter's
(1966) Internal-External Locus of Control Scale. Problem-focused cop-
ing includes strategies that are directed at altering or managing sources
of stress and was evaluated via the Ways of Coping Checklist (WCC;
Folkman& Lazarus, 1980).
In addition, patients' disease-related (duration, clinical status, sever-
ity of disability) information was collected. Severity of disability was
assessed by neurologists' ratings on the 10-point Kurtzke Disability Sta-
tus Scale for Multiple Sclerosis (Kurtzke, 1955), which ranges from 1
(minimal signs of disease) to 10 (death due to MS). Although little reli-
ability data exists for this scale, interrater agreement between two neu-
rologists who evaluated patients in the current study was found to be
quite high, with an intraclass correlation coefficient on a sample of 20
MS patients of .98. Clinical status (whether patients were currently ex-
periencing an exacerbation of symptoms) was recorded as well.
Treatment
Patients who met the subject-inclusion criteria were pretested and
randomly assigned to either the SIT or CAC group. Patients assigned to
the CAC control condition were informed that the SIT would be pro-
vided after a 5-week delay. However, for ethical reasons, all of the stan-
dard hospital services were available. The CAC patients received a vari-
ety of psychotherapeutic and medical interventions during the waiting
period. All CAC patients received a minimum of 2 hr of supportive
psychotherapy. In addition, 2 control patients received antidepressan!
therapy, 2 received family counseling, and 3 others received individual
counseling during the waiting period. Patients were posttested following
the SIT intervention or the 5-week CAC period.
For the SIT, a six-session cognitive-behavioral procedure was inte-
grated with a shortened version of progressive deep-muscle relaxation
that obviated dysfunctional muscle groups for each patient. (A com-
plete treatment manual may be obtained from the first author.) Briefly,
Session 1 trained patients to self-monitor daily stressors and concommi-
tant cognitive, behavioral, affective, and physiological responses. Ses-
sion 2 included feedback to enhance self-monitoring and the construc-
tion of a personalized progressive deep-muscle relaxation (PDMR) tape.
Session 3 evaluated cognitive self-statements in response to daily stres-
sors. Session 4 identified stress cues to augment the in vivo use of cogni-
tive reinterprctations, relaxation imagery, and PDMR. Sessions 5 and 6
focused on role playing bow to cope with potentially distressing situa-
tions while integrating the self-monitoring, self-cueing, cognitive-be-
havioral, and physiological coping skills.
The control group therapists consisted of hospital staff who utilized
standard methods in treating patients. In the SIT condition, the thera-
pist was an advanced clinical psychology graduate student who was su-
pervised thrice weekly by two licensed clinical psychologists. A random
sample of 24 SIT sessions was audiotaped and reviewed by the supervi-
sor to confirm that all sessions were conducted according to treatment
protocol.
Results and Discussion
To evaluate for the treatment-efficacy hypotheses, a repeated-
measures multivariate analysis of variance {MANOVA) was con-
ducted using the BDI, the STAI, the Hassles Scale, and the Ways
of Coping Checklist as dependent variables, with treatment type
(SIT vs. CAC) and pre-post treatment as independent variables.
The MANOVA yielded a significant main effect of pre-post treat-
ment, t\5, 30) = 6.20, p < .001, and the interaction of Treat-
ment Type X Pre-Post Treatment, fl(5, 30) = 4.99, p < .002,
indicating that overall the experimental intervention had statis-
tical efficacy. Because this research was interested in differential
pre-post changes for the SIT and CAC treatments, the interac-
tion effect of Treatment Type X Pre-Post Treatment was of
principal interest in this analysis.
Repeated-measures analyses of variance (ANOVA) were then
conducted on the individual dependent variables to evaluate the
differential effects of the two treatment interventions over time.
The means for the SIT and CAC groups before and after treat-
ment are shown in Table 1. The results of the ANOVAS are also
shown in Table 1, where it may be seen that significant effects
of the Treatment Type x Pre-Post interaction in the predicted
direction were found for depression, state anxiety, hassles, and
problem-focused coping. There were no significant differences
between groups for trait anxiety. Means associated with the in-
teraction effects were evaluated using a Duncan multiple-range
test. These comparisons indicated that there were no significant
differences between the SIT and CAC groups at pretreatment,
but at posttreatment the SIT subjects showed significant im-
provement whereas the CAC subjects did not change signifi-
cantly. Thus, SIT resulted in greater improvements in depres-
sion, state anxiety, coping with daily stressors, and problem-
focused coping efforts relative to CAC treatment. Because locus
of control was hypothesized to be unaffected by the brief treat-
ment, a separate repeated-measures ANOVA was conducted,
and results revealed no significant main effects or interaction,
which confirmed this hypothesis.
It is possible that the current results were attributable to
differential changes in MS symptoms between the SIT and CAC
groups during the treatment period. To evaluate this potential
bias, a chi-square statistic comparing the posttest presence or
absence of an exacerbation of medical symptoms and a one-
tailed I test that compared posttest disability levels (Kurtzke
scores) was conducted to compare the experimental and control
groups. Results indicated no significant differences between the
two groups on disease severity and current disease activity.
Six month follow-up evaluations utilized the same dependent
measures previously administered. Six month follow-up data
were only collected from the first 10 participants (50%) of the
experimental group due to unavoidable changes in staff that
obviated continued data collection. Six months after treatment,
subjects in the experimental group reported mean coping mea-
sures that were mostly unchanged from posttest. A Hotelling's
 BRIEF REPORTS 921

Table 1
Means, Standard Deviations. Analyses of Variance, and Post Hoc Comparisons Across Groups

SIT CAC

Pretest Posttest Pretest Posttest

Measure M SD M SD SD M SD ft 1,34)

BDI 24.4. 13.0 13.2,, 10.5 21.7. 15.0 21.6. 14.2 18.54 6.5
STAI-S 51.8. 15.6 37.2b 13.8 54.6. 16.9 50.5. 13.0 6.54 6.5
STAI-T 53.6. 12.8 46.26 13.1 54.5. 13.1 51.9.b 13.4 3.31 4.2
Hassles 88.1. 44.0 57.5b 37.6 90.2. 49.5 89.2. 67.1 5.78 5.2
RFC 12.6. 4.7 16.2b 4.8 12.2. 5.7 11.8. 4.6 7.39 6.0

Note. SIT = stress inoculation training group; CAC = current available care group; BDI = Beck Depression Inventory; STAI-S = State-Trait Anxiety
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Inventory, State; STAI-T = State-Trait Anxiety Inventory, Trait; Hassles = Hassles Scale Intensity Score; PFC = Problem-Focused Coping score from
This document is copyrighted by the American Psychological Association or one of its allied publishers.

the Ways of Coping Checklist. Means with different subscripts differed significantly at p < .01. Duncan q scores listed compare posttest scores.

r-square statistic that was conducted on posttest minus follow-
up change scores was not significant, indicating that posttreat-
ment scores were maintained for 6 months. These results were
generally reconfirmed by a series of one-tailed, dependent t sta-
tistics that were computed on the change scores for each out-
come variable. Thus, the treatment gains observed were main-
tained at follow-up for depression, state anxiety, perceived dis-
tress, and locus of control, whereas problem-focused coping
scores decreased, «(8) = 1.79,p<.05.
The current findings suggest that a brief, six-session SIT pro-
cedure can significantly assist patients with chronic illness to
cope more efficaciously with subjective stress. Coping was facili-
tated by developing increased ability to control psychological
symptoms and by altering the process that was generally used
to cope. Patients utilized more problem-focused coping strate-
gies in which they focused on ameliorating stressful aspects of
the person-environment relation.
The fact that patients in the CAC control group did not sig-
nificantly improve on any of the measures of coping at posttest
suggests that the improvement in the experimental group was
not simply due to naturally occurring remission processes or to
the effects of short-term nonspecific psychologic intervention.
Also, the differences between groups cannot be attributed to
differences in disease status either pre- or posttest. The superior
improvement of the treatment group is also significant because
the individuals in the CAC group received a variety of psycho-
logical interventions and support during the waiting period.
However, the relative amount of intervention time received be-
tween groups and patients' expectations of the efficacy of the
relative interventions offered were not controlled for and could
have influenced the current results. Future researchers should
use placebo control conditions and measure expectancy.
Two recent controlled studies of psychodynamic and cogni-
tive-behavioral group intervention in MS have also demon-
strated effectiveness, at least for depression (Crawford &
Mclvor, 1985; Larcombe & Wilson, 1984). Thus, even if de-
pression in MS is in part biologically based, a variety of psycho-
therapeutic approaches can be used to enhance coping. The cur-
rent study demonstrates that improvement can be obtained in
wide range of symptoms beyond depression relatively quickly
when an SIT intervention is used.
The results revealed that the SIT was no better than the CAC
in affecting subjects personality traits of locus of control and
trait anxiety. To the extent that modification of these traits
would provide a buffer for stress and would aid in coping, other
therapeutic procedures are needed.
The finding that problem-focused coping decreased signifi-
cantly 6 months after treatment may indicate that, once there
is improvement in psychological symptoms, subjects are less
motivated to engage in active problem-oriented coping. On the
other hand, it is also possible that the decrease observed in pro-
blem-focused coping represents a failure to maintain the new
skills rather than a failure to apply them. If so, these patients
may be vulnerable to future psychological distress when faced
with new disease exacerbations.
Instrumentation limitations of the current study include the
reliance on self-reports and the acquisition of follow-up data
from only 10 subjects. Future research in the training of coping
skills should continue to focus on developing better methods to
assist those with chronic medical illness to cope with the pro-
found psychosocial changes they frequently experience.
References
Barnes, R., Busse, E., & Dinken, H. (1954). The alleviation of emo-
tional problems in multiple sclerosis by group psychotherapy. Group
Psychotherapy. 6,193-201.
Beck, A., Ward, C., Mendelson, M., Mock, T, & Erbaugh, J. (1961). An
inventory for measuring depression. Archives of General Psychiatry,
4. 561-571.
Brunn, J. T. (1966). Hypnosis and neurological disease: A case report.
American Journal of Clinical Hypnosis, 8, 312-320.
Crawford, J. D., & Mclvor, G. P. (1985). Group psychotherapy: Benefit
in multiple sclerosis. Archives of Physical Medicine and Rehabilita-
tion, 66, 810-813.
Day, M., Day, E., & Hermann, R. (1953). Group therapy in patients
with multiple sclerosis. Archives of Neurology and Psychiatry, 69,
193-201.
Folkman, S., & Lazarus, R. (1980). An analysis of coping in a middle-
 922
aged community sample. Journal of Health and Social Behavior, 21,
219-239.
Hamburg, D. A., & Adams, J. E. (1967). A perspective on coping: Seek-
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eral Psychiatry, 17,227-284.
Kanner, A., Coyne, J., Schaefer, C., & Lazarus, R. (1981). Comparisons
of two modes of stress measurement: Daily hassles and uplifts versus
major life events. Journal of Behavioral Medicine, 4,1-39.
Kurtzke, J. F. (1955). A new scale for evaluating disability in multiple
sclerosis. Neurology, 5, 580-583.
Larcombe, N. A., & Wilson, P. H. (1984). An evaluation of cognitive
behavior therapy for depression in patients with multiple sclerosis.
British Journal of Psychiatry, 145, 366-371.
LaRiccia, P. J., Katz, R. H., Peters, J. W., Atkinson, G., & Weiss, T.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
BRIEF REPORTS
(1985). Biofeedback and hypnosis in weaning from mechanical venti-
lators. Chest, 87,267-269.
Meichenbaum, D. (1977). Cognitive behavior modification: An integra-
tive approach. New \brk: Plenum Press.
Rotter, J. (1966). Generalized expectations for internal versus external
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Spielberger, C. (1983). Manual for the State-Trait Anxiety Inventory
(rev. ed.). Palo Alto, CA: Consulting Psychologists Press.
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Received August 20,1986
Revision received March 16,1987
Accepted March 24,1987 •

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