Excerpt From

A DAY TOO LONG

A Novel of 100000 Words

By

Harry Lee Mills

Static was the prelude to the dispatcher’s intrusion into the silence within Biloxi Police Car 23: “All cars we have a 10-71 at 1488 Croesus Street. All cars in the vicinity. We have a Code 3. Repeat.  Repeat. Code 3. Gunshot. A man down.”

“Ten four,” Sergeant Polowski responded, “Ten four and we have a Code 3.”

He did a U turn at Division and Lameuse Streets, while his partner switched on the siren. The tires on the ’60 Ford Fairlane squealed. Several cars stopped abruptly to avoid near collisions in the intersection.

“I think that is where that nigger civil rights doctor lives.” Patrolman Lott remarked, as the car straightened out and headed west on Division Street.

Polowski did not reply. He rarely spoke. Seemed not to feel the need to do so. Patrolman Lott spoke enough for both. He had been assigned Lott while his regular partner recovered from a heart attack and found Lott a royal pain in the ass. Never shut up. Always rattling on about something. Polowski found if he ever replied, it was like opening the floodgates. Lott would go on and on and on.  So he made a policy of never replying. Finally, it began to work. Lott shut up. Some of the time, anyway.

Their car was the first police car at the scene. “Car 23 here. We have 10-97. Repeat 10-97.”

“Ten four, Car 23. Ambulance has been called and confirms en route. Ambulance is on the way.” The dispatcher came back, comments punctuated by static.

The police car pulled partially onto the front lawn and turned off the siren. Sergeant Polowski exited his car and walked over to the woman, the little girl and the black man lying face down in a pool of blood

The Sergeant glanced back over his shoulder and saw the door to his car swing open with such force that the entire car swayed. Out came Lott with his 38 revolver pulled. He ran across the lawn and with both hands he pointed the revolver at the shadow on the porch while shouting: “Drop the weapon or you’re dead! Drop the gun now! I will shoot! Drop the gun!” The figure hesitated at first, and then placed the shotgun on the ground. “Now on the ground face down. Drop to the ground. Now!” The figure complied. Lott had neglected to notice that the man on the porch was just a boy, and that boy was crying uncontrollably. The sergeant was just a few steps behind Lott; he reached around and pushed Lott’s revolver so it pointed toward the ground.

“Brilliant, Lott, this is just a boy, you just arrested the son I think. You idiot!  You want to arrest the wife too? Put your weapon up and go over and stand by the car.” The Sergeant said, embarrassed and angry. Lott was the stupidest partner he had ever had.

When the boy, Matthew, the oldest son, had seen his father shot, he ran into the house, grabbed the twelve gage shotgun that his father had taught him to use for protection, loaded it, and took up guard on the porch waiting to kill the assassin. His eyes scanned the lot across the street from which he had seen a flash. He saw nothing except a green pick-up pull away fast from the Dairy Queen. There were no more shots. Matthew stayed on the porch because he knew his father would expect him to protect his mother. Besides, if he looked now at his father’s face would lose control. He could kill any white man around. Instead he stood guard and cried hot, burning angry tears.

The Sergeant put his hand on Matthew’s shoulder and said: “It’s OK son, he made a mistake. See, he is over by the patrol car now. Take it easy son.”

Matthew shrugged away the Sergeant’s hand, and pulled himself to a sitting position. His face the face of rage.

The ambulance parked behind the family Buick. Its siren gradually fell silent. The flashing red light continued, creating bazaar lighting effects. The neighbors seemed to flash on and off, as the lights on top of the ambulance created a strobe effect, making the scene all the more nightmarish.

Other Biloxi Police cars were arriving. Detective Lieutenant Petrello was in one of the cars. He was now in command of the crime scene. Sergeant Polowski reported in. Lott was sulking over by the car. Just as well, thought the Sergeant, that way he could stay out of trouble.

Polowski had discerned that the shots came from the lot with the large oak tree across the street and he so informed Petrello as he turned the crime scene over to him.

Lieutenant Petrello orchestrated a move of the vehicles in the area, so that they could focus their lights on the vacant lot. One car was placed at the nearest cross streets to Croesus Street, to stop reporters and sightseers. Another car circled the corner and parked at the Dairy Queen on the other side of the vacant lot. In a matter of ten minutes, the area was secure. To add to the surrealistic quality, with the circulating and flashing red lights spotlighted the crowd, police radios squawking, the juke box at the Dairy Queen blared out Mitch Miller’s version of  “Dixie”.

The ambulance attendants stood aside for the police photographers to complete the series of flash photos of the body as it fell in the driveway. They knew to wait for the coroner’s OK before moving the body.  They had checked for life signs and found no pulse, no respirations and no heartbeat. The coroner arrived, asked some questions of the attendants and then motioned with his right arm to move the patient to the hospital for an autopsy.

When they lifted the body onto the gurney, put a sheet over the body and then pulled it over Sam’s face, Connie let out an agonized cry. The neighbors supported her at each elbow. A very large black woman held Tina, whose clothes were bloody, in her arms. Tina nestled up against the neighbor, whimpering.  Sam’s two boys would not accept support. They stood close together, alone, at the top of the driveway. Finally, Lieutenant Petrello nodded, and they lifted the gurney into the ambulance. In spite of the neighbors gentle efforts to discourage her, Connie entered the ambulance and sat beside her husband. She would not leave his side. Not yet.

The ambulance started its siren and drove to Biloxi Hospital.

“I don’t want nobody in that lot over there but my investigators. Last thing we need is idiots traipsing all over all the evidence.” Petrello shouted.

“Sergeant Polowski,” Petrello motioned as he called, “Would you get on the radio and have the patrol put out an APB. Watch for suspicious persons on Highway 49 and on Highway 90 to the east and west. Several people at the Dairy Queen saw a green pick up leaving quickly. Look for a green pick up.”

He quickly organized the interrogation of the neighbors and a search of the house. The assigned officers began to interrogate the spectators.  He waited for the Sergeant to complete the call and then assigned the family to him. Petrello would have to go to the hospital and talk with the man’s wife. That required a real pro.

Out of the corner of his eye the Lieutenant saw Lott walking toward the perimeter and shouted: “You stay over here! I only want my forensics people and my officers there. You patrol the neighborhood. Walk up that way then down there.” He pointed down the street in both directions, a useless assignment clearly designed to keep him out of the way. He agreed with Polowski that Lott was a fool.

He motioned to another uniformed officer and then instructed him to immediately contact Bill Friedman, the District Attorney. The Lieutenant thought to himself; this investigation had best be done by the book. No blade of grass should be touched without the DA.

There was a commotion at the corner of Division Street and Croesus. The Black and White pulled back and the Harrison County Sheriff’s car cut through to Croesus. The Lieutenant recognized it immediately as Sheriff  Budreaux’s Cadillac. “Grumpf,” was the sound that came from Lieutenant Petrello’s  throat, as he thought to himself that the politicians were already going to start getting in the way. Mumbling to himself that the Sheriff and his Deputies could screw up a two car parade, he composed himself then stepped forward to meet the car, opened the back door and said, “Hello. What can we do for you Sheriff?”

As he unfolded his large frame and pulled himself out of the back seat, with his big stogie leading the way out of the car, the Sheriff asked, “Is Bill Friedman here yet?”

“No. But he is on his way. We have cordoned off the area. The body was viewed by the coroner and then taken away for autopsy. My men are interrogating the neighbors.”

The Sheriff adjusted his pants beneath the overhang of his beer belly, scanned the scene, looking irritated and said: “We got a big problem here Lieutenant. We depend on tourists here in Biloxi, and this will hurt us. This is the last kind of thing we need. I’m very sorry it had to happen in Biloxi. It will hurt a lot of businesses. Have you put out an all-points bulletin?” Budreaux paused for a reply.

“Yes we have.” Lieutenant Petrello answered.

“We need to solve this and get it over with. The longer it goes on the more we will be hurt.” What the Sheriff did not say is that many of the establishments on the coast were owned by Carlos Marcello or his mafia henchmen. They would be very upset at any loss of business. He also did not say that a loss of business from tourists would mean less money from the black market tax for him. Then the Sheriff walked over and began to work the crowd. After several handshakes and tentative greetings to the neighbors, it seemed to sink in, probably based on the indifferent response, that this might not be a good time for running for office. He then noticed his cousin, Patrolman Lott, walking toward him. The sheriff stopped and had an intense discussion with Lott, the content of which was beyond hearing. Since Lott kept looking defensively back over his shoulder at him, the Sergeant thought Lott was complaining about how the crime scene was being handled. Polowski walked toward the perimeter mumbling discontentedly to himself. He was pleased to see Bill Friedman arrive. Competent fellow. He walked over to greet him.

*****

Susan was just back home for summer break and to her summer job after a two week trip to France with her mother. They had toured many of the places Natalie remembered from the war. She stopped her car at the barrier and introduced herself to the officer guarding the Division Street entrance to Croesus. He waived her through, and moved the barrier out of her way. She had very mixed feelings about being at the scene of the murder so soon after the shooting. However, Bill Friedman had called her at home and made clear that he wanted her at the scene with files he needed for the investigation. She spotted Bill in a cluster of detectives and uniformed officers and parked nearby. Susan picked up the brief case with the files for Bill and exited the car.

As was often the case, the heads of most of the men in the area turned when Susan got out of the car. She wore a simple white blouse and dark blue skirt that came to the top of the knee. She stood nearby and waited until she could catch Bill’s eye and then deliver the files. His back was to her and he was involved in an argument with one of the detectives from BPD. The other men cast glances her way, but Bill continued talking.

“Don’t decide the results of the investigation before we really begin. It may look like one nut was here, but we need to keep our options open.” Bill Friedman asserted.

“We have tracks of one man. We have one green truck reported. We have one witness who saw one man go into the bushes. We have two shells that are probably from one weapon.” Detective Gautier argued giving emphasis to the word one.

“Yes, but we have been here only twelve hours and we have no weapon. We have no witness to the shooting itself, who saw one man pull the trigger. There are probably a hundred green trucks on the coast and we have yet to match the tire tracks with any known vehicle and any one owner. And we have no reason to think even one killer acted alone.” Bill said, finally noticing that Susan was there. She held up his brief case. He stepped out of the cluster and took it from her.

He turned back to the BPD and said: “Go find the kids at the Dairy Queen and see what they saw or did not see and why. Go back to the girl who says she saw one man enter the lot. Take her down to the station and ask her lots of very good questions. See if the feds can help us match those tire tracks. Above all look for that green pickup truck. Put out a bulletin on it right now. That should have been done last night.” Bill’s instructions broke up the cluster. Each took the assignment deemed most appropriate to their roles in the investigation.

Turning to Susan he asked: “Did you bring the list of local Klansmen?”
“Yes here it is.” Susan replied.

“Good.” He said, fingering the labels on the files then said: “Lieutenant Petrello, could you take this list and begin to work it. Contact them all. Find out where they were at 10:30 last night and who can corroborate that they were where they say they were. Start with the ones with an asterisk beside their names. They have an arrest record. Check with Judge Petrangelo on the others.”  Bill handed the file to the man he thought was the best cop on the force.

Bill knew that he was overstepping the boundaries of his office. Frankly, he did not give a damn. He thought the BPD was corrupt and, with the exception of men like Petrello, incompetent. They would screw this case up, and his office would have to clean it up when he went to trial. Nepotism was the rule rather than the exception in the BPD. The locals said the department was the best place for the most juvenile delinquent of Biloxi youth, as long as they had relatives in the right place.

“Susan, I need your help. I need someone who is good with kids. You have been babysitting my own kids for years. I need someone to interview the Henry kids. Let’s see…” He took out a note pad, and read: “ Matthew is 14. Martin is 9 and Tina is 6. They have been over at that neighbor’s house since the murder. I will assign a police woman to you, but I don’t have any cops that can handle a matter this sensitive without screwing it up. So I nominate you. OK? Come back first thing in the morning.”

Susan was not at all sure she could handle it but she also knew that it was impossible to change Bill Freidman’s mind, once he made it up.

Bill Friedman was Jewish. He was also the DA. Newcomers wondered how a community like Biloxi, with more than its share of bigots, could produce a Jewish DA. While Biloxi was geographically located in Mississippi , it readily embraced other cultures. A look at the phone book revealed names with a variety of national origins, unlike other Mississippi cities. It was primarily a Catholic community. The priests made every effort to moderate the racist beliefs that were tolerated, or even embraced, in other parts of Mississippi, by the fundamentalist clergy. But even with all that Bill would not have been the DA if he had not been quarterback at Biloxi High School. He went on to quarterback at Tulane. Not good enough for the NFL, he took the consolation prize of a law degree from Tulane.  His social ticket had been punched by football excellence, which, some believed, meant more than religion in Biloxi.

She woke up at six and started her drive to the murder scene at 7:30. What could she say to three kids who had just seen their father murdered? She would do as Bill asked. Intuitively, she knew what to say to the children. Nothing. In the beginning she would say nothing at all. Let them get used to her.

The neighbor, who had been introduced to Susan as Alma Miller, offered Susan a cup of coffee. Susan accepted. She asked if Susan had breakfast and she said yes. Alma was a very round woman.  Her skin was very dark and when she smiled her toothy smile, it set her whole face aglow. She hugged everybody and everybody seemed to like it. There was nothing phony in it. Touching and hugging were as natural for Alma as talking and eating. And she liked those too, particularly the eating.

“Would you like some apple pie with that coffee?” She turned back to Susan, as she reached the kitchen door, “I make the best apple pie in Biloxi, honey. You look like a little pie wouldn’t hurt you none.”

“Sure, I’d love some pie, Alma.” Susan said, hoping that she would not seem too familiar.

She walked over to where the three children were on the floor playing some kind of card game. “What are you playing?” She asked.

The boys did not answer, but Tina said: “Poker. I want to play Old Maid. Matthew won’t play anything but poker. Always poker.”

Alma brought in the coffee and the pie. She sat the coffee down on an end table near the card players and offered Susan the pie, and a fork.

Susan sat down and took a bite of the pie. “This is great,” she said and would have praised the pie as a matter of courtesy, but in fact it was exceptionally tasty, so there was enthusiasm in her voice.

“There’s plenty more where that came from, honey, so just holler if you want another piece.” Alma responded, as she sat down on the floor. Alma discerned that she needed to keep these kids as busy as possible.

Susan finished the pie and watched the game progress. Matthew was clearly winning. Tina would occasionally ask Alma for help in reading her hand. The boys seemed to accept coaching of their little sister. They were using poker chips and Matthew raked in another pot after showing an aces-and-queens full house. He seemed pleased with himself, in spite of minimal competition. He and his father had played cutthroat poker games. That was one of the many things he would miss. Many things. He paused and seemed to be staring a thousand miles away. Alma noticed.

“Boy, what you got there, some cards up your sleeves?” Alma asked. That did the trick. Matthew almost smiled. Almost, but not quite. Then she added: “What we need is a new hand. How ‘bout we invite this lady to join us on the floor.”

Matthew looked at her for the first time: “You play poker?”

“I’ve played a little.” She replied.

“Then come on down here, girl.” Alma said patting the rug next to her.

Susan did so. She had been playing poker with her dad since she was 4 or 5. She was dealt the next hand of draw poker. She looked at her cards. Two aces, a nine, a five and a deuce. She called Matthew’s bet and then drew three. As she fanned out her hand she discovered that she drew a pair of jacks. She called Matthew’s bet again and won the pot with two pair. She continued and won the next five pots in a row. Matthew’s eyes, as he glanced at her, changed from indifference to grudging admiration, to ungrudging admiration. This white woman could play a mean game of poker. For the rest of the game it was one on one. The others were turned into an audience. Once he began to concentrate, he won some pots. Then it was back and forth. Back and forth, for much of the afternoon.

A knock at the door stopped the poker game. A black man with gray hair and beard stood in the doorway, when Alma opened it. All three kids immediately reacted, stood up, and ran to the man. With tears returning to her eyes Tina said: “Uncle Charlie, you know what they did to my daddy?” Charlie Fountain said nothing but embraced them all, one at a time. Suddenly Susan felt like an intruder. She excused herself and let ‘Ol Charlie sit down on the couch with his niece and nephews. She shook Charlie’s hand and then left. She would come back in the afternoon. Let the family grieve.

*****

The table that the Biloxi District Attorney used regularly, at Fayard’s Warf Restaurant, was ready when Bill Friedman and his party arrived. The restaurant sat out on a pier near Point Cadet. The owner, Tiny Fayard, greeted them and ushered them to the table with the best view of the sound and Deer Island. Tiny was not tiny. He weighed in at nearly 300 pounds on a five foot seven inch frame. As he waddled toward the table, the floor boards creaked with complaint. With a dramatic waive wave of the arm, he invited them to seat themselves and then handed them the menus.

“We have Pompano and Red Snapper as our fresh catch today gentlemen. Could I get you a cocktail ?”

“Not for us. We have work to do.” Bill Friedman replied for himself and all the staff. Tiny returned to his station near the door.

“Let’s start by welcoming Susan Forrest back. This is her first investigative conference. ” Bill Friedman said and the group gave her applause.

The Warf’s gumbo was delicious, as usual. The entrees were also superb. Biloxi cuisine was influenced by the same Creole and Cajun traditions that made New Orleans restaurants world famous but with the addition of Spanish and eastern European traditions. Biloxi was a good place for aspiring chefs to practice on their way to New Orleans. The lawyers continued their discussion as the plates were removed and the coffee, with chicory, was delivered in heavy mugs.

Bill Friedman returned to the discussion: “The press has given little attention to this murder. Dr. Henry was not well known, and such killings in the South are all too common now. That is sad to say. The novelty is wearing off. They killed Medger Evers in exactly the same way. All the attention is there. This is a copy cat crime. So they are not swarming about as much as I had feared they would be doing.  The Pols are staying off our backs for right now. But they will be back. They will push us to trial as soon as possible. Probably sooner than is best. So we must get a witness either to the murder or a murder weapon we can trace to him.  Even better– both.”

Swetman responded: “I am going to talk with Hailey of the bureau this afternoon. I talked with him by phone yesterday. He said they had a man inside this local Klan group. But he did not say whether they had gotten any inside stuff before the killing. The feds always play this stuff close to the chest. Hoover does not like organized crime or racial cases. He says organized crime is a myth and race relations are a problem only because of the commies. They don’t trust us. Anyway, he said he would do some checking on the plant and might have something for us by the afternoon.”

“Check ‘um out this afternoon.” Bill said, tossing the tip on the table. Then he led his staff out of the restaurant and into the June sunshine and heat. As he reached one of the two cars that brought them there, he turned and said: “See you at our law library in fifteen minutes. We’ll stay as long as we need to for the case review to be complete even if that’s midnight.”

Back at the office, the attorneys and the investigators gathered with their latest cup of caffeine at the mahogany conference table surrounded on all side by law books in mahogany book cases . The room smelled of stale smoke. At one end of the room, near the chair occupied by Bill Friedman, was an easel with notes from the morning’s conference.

“OK Chuck,” said Bill to Charles Swetman, “We have been over the two other suspects. We have a good follow up plan for those. But Let’s go back to what we know about Leo Ladner.”

Swetman rose and walked over to the easel. He began by saying:  “As I pointed out this morning, our man was born November 12, 1923. We ran through his childhood this morning. Father was a drunk and Mom was a hard shell Baptist. We are up to December 1941 in our review of major life events. He had just turned eighteen when the Japs attacked Pearl Harbor. He joined the Marine Corps on December 16, 1941. Any questions before I go on?” Heads were down. Without questions, Charles continued. “He had a checkered service record. He was classified as a marksman for his skill with an M-1 but he had a hot temper and was busted four times. Got all the way up to Sergeant First Class once but was busted down to private for hitting his CO. Could not follow orders. Spent most of the war on a garbage detail or a chain gang. But to hear his tales after the war, he was Audie Murphy. From childhood he could tell tall tales.  Never concerned about the truth getting in the way of a good story. He told his family and anyone who would listen that he was in the Pacific and landed on Guam, Guadalcanal, the Philippines and Iwo Jima. In fact he spent the war in Louisiana. Was able to father his first child out of wedlock in 1944 with a stripper he met in the French Quarter in New Orleans. She managed to get him to marry her in 1945 and they moved to Laurel Mississippi. He went to work selling farm equipment, seeds, fertilizer and just about anything. He had his own Bible sales on the side. Quite a combination. Bibles and fertilizer.”

“He has the gift of gab. And is known for a certain charm. An avid hunter and gun collector, he began his Klan affiliation some time in the fifties when the Klan resurgence took place after the Supreme Court decision on school desegregation. He was a deacon in his Baptist Church in Laurel. Even did some preaching in the small fundamentalist churches in rural areas around Laurel. Preacher on Sunday, salesman on Monday. Beat his wife on Tuesday. Repented in time for Prayer Meeting on Wednesday. But the loss of more and more farms and farmers finally put him out of business. So he moved to Biloxi in 1952 and began a series of jobs selling anything he could sell. Sold Kirby vacuum cleaners door to door, cutlery and the old stand by Bibles. Even tried his hand at selling used cars. His wife waited tables and then another gig taking off her clothes, until gravity set in and sagging took its toll. His father left him some money and he was able to buy five acres of land on Bayou Keegan in 1953. That is where he lives still.”

“What happened to his wife?” Asked Bill Friedman, while he scraped the tobacco out of his pipe, knocking it gently against the heavy ash tray on the table.

“They had a stormy relationship from the beginning. But about two years ago she began to have an affair with a small time criminal and bouncer on the strip and Leo beat the hell out of her when he caught them naked as Jaybirds in the den of his home. She packed up and moved in with the lover in Pass Christian. Leo was always mean as hell but this seemed to make him meaner. Her promiscuity was well known to everyone but Leo. That was ’60 and he became more and more involved with the Klan after that. In his salesmanship he seemed to specialize in racist jokes, so he was well known as a bigot. He had gone to Klan meetings in the past to hobnob and tell tall tales but he did nothing of substance ‘til 1960. All we know for sure is that he began traveling more and more and seemed to have a way of showing up in places when Klan things were happening. Also we cannot tell who he has been working for. He seems to have money, but we cannot tell that he is selling anything in particular.

“We think he was with several night raids including the bombing of the synagogue in Jackson in November of ’61 and at least three Negro churches. But we have a lot more work to do on that. He makes regular trips to New Orleans and stays at an apartment on Dumaine Avenue in the Quarter. We are checking on the owner now. Some of the people he has contact with on those visits are known henchmen for Carlos Marcello. That is a connection we need more help from the Feds to check out. In fact you can see we keep bumping into areas that the FBI is into up to J. Edgar’s backside. We need ‘um.”

“What do we have on the night of the murder?” Bill asked, growing impatient with the narrative.

“Nothing. Absolutely nothing.” Was Swetman’s frustrated  reply. “We know he was in New Orleans the night before and we have a witness from D’Iberville, Randy Polivich, who came forward and says he saw him at the Chez Joy, a strip joint on Bourbon  street. We have no one who can place him anywhere on the next day, the day of the murder.”

“Damn, we got a lot of work to do. Look this has gone as far as it needs to go for today. We would be in much better shape to adjourn and see if the Feds have anything that will help us. If we went into court with this Judge Petrangelo would throw the whole thing out in a heartbeat.” Bill Friedman lectured pointedly. “Do you guys agree?”

Heads nodded affirmatively. The meeting was adjourned.

Harry Lee Mills

Appeared in LifeHub

Dr. William A. Cohen was a Major General in the U.S. Air Force who saw combat in both the American and Israeli armies. Along with Peter Drucker, a renowned author and professor of management, he believes that we can all learn from leadership in life-threatening combat situations. He surveyed more than 200 former combat leaders and interviewed hundreds more. He published his results in the book, The Stuff of Heroes: The Eight Universal Laws of Leadership. The eight principles of leadership are:

1. Maintain absolute integrity
2. Know your stuff
3. Declare your expectations
4. Show unconditional commitment
5. Expect positive results
6. Take care of your people
7. Put duty before self
8. Get out in front

Let’s take a look at these principles one at a time as they apply in business settings.

Maintain Integrity

Stephen Covey, author of The 7 Habits of Highly Successful People, develops this idea well in Principle-Centered Leadership. People are more likely to follow a person who has values and behaves accordingly, which is the definition of integrity. In his autobiography, It Does Not Take A Hero, General Norman Schwarzkopf says that much of his success as a military leader was based on the integrity built first from the honor code at West Point. He believes that integrity is the most important attribute.

Michael J. Smith was CEO of billion dollar catalogue giant Lands End, Inc. when they were in trouble and profits were falling 60%. His accountants advised laying off staff to boost stock prices. But for Smith, it was an integrity issue. His view was that his most valuable capital was his people, so he did the opposite. He added benefits and kept the staff. He added Adoptive Assistance as a Work/Life benefit and an Employee Assistance Program. He gave health care benefits to part-time employees. In the following quarter, profits tripled to $4.4 million and share prices increased 85%.

Know Your Stuff

The best leaders get the job done. Generally, people who claw their way into leadership through office politics find themselves with few followers. The most effective leaders know the job. If the company does computer programming, the leaders know enough about computer programming to have credibility. If the company flies airplanes, the most effective leaders know something about flying airplanes. If the company does health care, the most effective leaders know about health care. Some leaders come from other industries, but if so, they learn a lot. The pointy-haired boss in the Dilbert cartoons is a beautiful portrayal of an anti-leader: one who does not know his stuff and is uninterested in learning.

Declare your Expectations

The worst leaders play “Guess what I am thinking” and leave it up to subordinates to read their minds about what they want. Good leaders declare their expectations with clarity and do so frequently. Communication of goals is a major part of communicating expectations. Poor leaders communicate expectations only after the supervisees have failed to meet the undisclosed expectancy. In the recent war in Iraq, the strategic goal was the taking of Baghdad and removal of Saddam Hussein from power. Leaders made that expectancy clear and repeated it regularly. It is through clarification of expectations that the people in an organization align themselves with the purposes of the organization.

Show Uncommon Commitment

If you want commitment, you must show commitment. If you are not committed to the goals of the organization, or if you cannot influence those goals, you might consider another organization. You show commitment not just by what you say but by what you do. If you expect long hours you had best work long hours. If you want others to be concerned about quality, you had best show that concern yourself.

Expect Positive Results

People are more likely to follow optimists than pessimists. If the leader expects positive outcomes, followers are more likely to deliver. Harper Collins is a major New York publisher. After profits had plunged 80%, the company suffered layoffs and cancellation of book contracts. Jane Friedman was made the new CEO. She entered the organization with an upbeat attitude and communicated a clearly positive expectation for the future of the company. She communicated an expectancy of a positive future. Within a year, operating income tripled in spite of being in a slumping industry.

It is also important to maintain a positive attitude. One of the best examples of this was by Winston Churchill in World War II. Throughout 1940 and most of 1941, England stood alone and most people felt their situation was hopeless. But not Churchill. He continued to believe that England would prevail. And it did.

Take Care of Your People

Effective leaders must be viewed as taking care of the people who report to them. There is no better example in business than Howard Schultz, who took over as CEO of Starbucks when it was a chain of just a few stores in Seattle. He grew it into 1,300 stores across the nation and 25,000 employees. His philosophy was if you take good care of your people, they will take good care of customers. That same philosophy was expressed by J.W. Marriott, founder of one of the world’s finest hotel companies. He has said: “We take care of our people and they take care of our guests.”

Put Duty Before Self

For the most effective leaders, the mission is more important than their own needs. In combat, there is no more dramatic an illustration than that involving a submarine commander named Howard Gilmore while on patrol in the South Pacific in 1943. When the sub surfaced to recharge batteries, he and others came under fire on the deck. He ordered the others below, but before he could get to the hatch, he was shot several times. He could not reach the hatch, but he knew that his sub would be sunk if they did not dive. So he ordered his sub to dive. They did and they made it back to Pearl Harbor. Captain Gilmore sacrificed himself for the sake of his men and the mission.

Get Out Front

Patton said that leadership is like a spaghetti noodle. You can pull it, but you can’t push it. The best leaders lead from the front and not from behind. At the battle of Fort Danielson in Tennessee during the Civil War, Ulysses S. Grant was away when a Confederate attack began. When he arrived, his right wing was collapsing and they were on the brink of a total defeat. He drew his saber and galloped out in front, shouting that they must move quickly or the enemy would escape. His soldiers followed and they won the battle.

In a literal sense, businesses and their leaders do not face the life-and-death situations that armed forces leaders do. But metaphorically, business leaders are locked in combat with their competition, fighting for the success and even survival of their organizations. Success, victories and comebacks depend on effective leadership, and many of the principles and attitudes that carry officers to victory in battle can be adopted by business leaders for success.

Summary: The same leadership principles that bring victory on the battlefield can be applied by business leaders for the success of their organizations.

Harry Lee Mills

Appeared in LifeHub

Yesterday’s companies were bossed; today’s companies require leaders with a new set of skills.

No one would argue that gone are the days of the ruthless, dictatorial boss lording over a rigid hierarchy of managerial layers. However, as obsolete as this type of leadership is today, we occasionally see it influencing leadership philosophies and decisions. To fill the void and finish pushing out the remnants of the old style, we’ll take a look at the six skills that today’s managers and leaders need.

The Six Areas of Competency

Peter R. Scholtes, a disciple of quality guru W. Edwards Deming, suggested in his book The Leader’s Handbook:

“All of the empowered, motivated, teamed-up, self-directed, incentivized, accountable, and reinvented people you can muster cannot compensate for a dysfunctional system. When the system is functioning well, these other things are all just foofaraw. When the system is not functioning well, these things are still empty, meaningless twaddle.” (page 17)

That is quite a challenge to many of the latest leadership fads. The only area of life where you will find more fads is in dieting. And in both dieting and leadership, the effectiveness of the latest tricks tends not to be well supported. In contrast, Scholtes recommends an approach to leadership in the new global economy which is founded on sixty years of work by Deming. Both Deming and Scholtes agree that competency in these areas is essential for the new leader:

· Understanding systems thinking

· Understanding of variability

· Understanding how people learn

· Understanding why people behave as they do

· Understanding of behavior within systems

· Understanding importance of vision and focus to alignment

Understanding Systems Thinking

We are used to thinking of organizations in terms of two-dimensional boxes on an organizational chart. However, such charts do not reflect reality and never have. Instead of viewing an organization as a collection of individual units or people, today’s leader needs to think of it more as a system.

What is a system? A system is a set of components that work together for the overall objective of the whole. Your automobile is a system. Its purpose is to provide you with transportation. Each part of the system contributes in its unique way to achieving the purpose. You do not drive the tires or the steering wheel, you drive the car. Teams, organizational units, and organizations as a whole, are best viewed as systems.

Systems Thinking allows the new leader to avoid overly simplistic solutions to complex problems. Slogans and scapegoats often produce more new problems than they solve. Above all, however, a systems approach assures that leaders look at problems in the context of the marketplace and that solutions to problems do not address internal issues at the risk of going out of business.

Understanding of Variability

Things change. When they do, they don’t change in a straight line. One of the challenges for any leader is to look at certain sets of data and figure out what they say about the direction the organization or marketplace is heading. Misreading data can have catastrophic consequences, including:

· Seeing trends where there are no trends

· Missing trends when there are trends

· Misreading the real cause of problems

· Giving credit where it does not belong

· Failing to recognize needs for improvement

Because change occurs so rapidly in today’s competitive global economy, it is more important than ever for the new leader to understand how data varies in order to make good decisions. When data is presented in a managerial meeting or a board meeting, the new leader must be able to ask probing questions. Statistics, well-understood, do not lie; but it is common for people to use statistics to lie, or at least to misdirect or mislead. Perhaps it is only to make their department look good. The purpose of statistics is to understand variables and to employ that understanding in making better decisions.

Understanding How People Learn

In today’s economy, lifelong learning and performance improvement of employees is a necessity, not an option, for the success of an organization. If employees do not possess or develop necessary skills, they will not be able to achieve the goals set by their leaders and to pursue the organization’s vision.

But it’s not as simple as offering training courses or buying materials. Leaders must have an appreciation of how people change their behavior and learn new skills. Leaders do not have to be experts in the area. But they need to find people who do have that expertise in order for the training and learning to be effective.

One key to that understanding is that there are differences in the way people learn. Some are visual learners, some auditory learners, and some kinesthetic learners. While one type may dominate, all of us learn best when all these perceptual channels are employed. Above all, today’s leader must appreciate that the outcome of learning must be changes in performance. A good leader evaluates training programs by how they result in changes in performance.

Understanding why people behave as they do

The new leader must understand what motivates people. Too many leaders assume that what motivates them motivates others. Money motivates some but may be less relevant for others. The best leaders understand that the key to motivation is the relationships they have with their people. But it is also important to understand that employees have relationships with other employees; and those relationships are also important to understanding why people behave as they do.

Although the carrot-and-stick motivational model works on a jackass, it’s not the best way to treat employees. In an article on motivating employees, Frederick Herzberg called this the KITA approach, which stands for kick-in-the-“pants”. The problem with the approach is:

· It does not work, in spite of short-term appearances that it does.

· It is bad for relationships between the motivator and the one so motivated.

In Hollywood’s version of military motivation, KITA is primary for inspiring the troops to victory. Coaches like Bobby Knight use KITA to win games. However, these victories come in spite of the kicks, not because of them.

Understanding of Behavior Within Systems

New leaders understand that the behavior of employees is influenced by the system in which they work, and at the same time their behavior influences the system. It is a two-way street. Leaders who think only in one direction are very likely to fail when time calls for big changes.

Understanding Importance of Vision and Focus To Alignment

For an organization to be successful, all of its members need to know:

1. Who are we?

2. What business are we in?

3. What business are we not in?

4. Where are we headed in the long view?

5. What are the priorities for the short term?

6. What are our values and principles?

7. What is my job and where does it fit?

8. What is expected of me?

9. How can I improve what I do?

10. Where can I get performance feedback?

When all employees – not just the leaders — know the answers to all the questions, then a culture of success and achievement is created.

Harry L. Mills, Ph.D.

Appears in Cohealth

SCREEN ONE

Dr. Andrew Armour has described the complex network of neurons, neurotransmitters and even hormones, with which the heart sends and receives signals to and from the brain and other parts of the body. In fact, in 1983 the heart was reclassified as an endocrine gland when it was discovered that it produces a hormone called atrial natriuretic factor or ANF. This led cardiologist Dr. Mimi Guarneri to assert that “…the ten ounce heart is much more powerful than we ever imagined—functioning as a sensory organ, hormone-producing gland, and information processing center.”

We tend to think of the heartbeat as being as mechanically rhythmic and regular as what we see on an ECG readout. That is a much simplified signal and a product of the measurement method. Actually the heartbeat can vary greatly from moment to moment as we experience emotions. By measuring heart-rate variability (HRV) researchers have been able to analyze how the heart responds to stress and emotions. They have found that negative emotions like rage and frustration lead to increased disorder and a chaotic HRV while positive emotions such as appreciation and love produce a coherent harmonic rhythm. And it seems other organs in the body oscillate in synchronicity with the signals the heart sends out. One emergency cardiologist who rode regularly with heart attack patients on the way to the hospital began to have them talk about the things they loved the most and he watched the heart rate and blood pressure fall. All this more recent evidence about the heart has led cardiologists to say that low heart-rate variability can be as important as cholesterol levels.

SCREEN TWO

The heart is such an integral part of the emotional life of all patients. Robert Allen, who is with Cornell Medical Center points out that conditions or psychological characteristics which tend to elevate sympathetic reactivity and arousal promote development of atherosclerosis and psychological intervention can be of great value. Disease managers must address emotional issues in the management of cardiac rissk factor and should include these:

Help the patient learn to manage their anger

Help reduce anxiety through such methods as Benson’s relaxation response

Help the patient reduce risk factors like smoking, hyperlipidemia, obesity and a sedentary lifestyle

Help the patient develop resiliency to depression

Provide emotional support particularly after a major cardiac event such as a heart attack or bypass surgery

Help the patient strengthen social support

Help the patient deal with existential and spiritual issues by exploring their life and their values

SCREEN THREE

The heart is much more than a robotic mechanical pump that beats on average 72 times a minute or 100,000 times a day. It is intimately involved in our experience of life and works in harmony with the rest of the body in regulation of our emotional responses to the world around us. Our heart begins to flutter about the sixth week of pregnancy and continues to work until its last beat signals the end of life. It works tirelessly, not only supporting life, but as an integral part of our experience, as when we graduate from school, get married, welcome the birth of our first child or sit at the bedside as someone we love dies.

A study involving 774 older white men (average age 60) indicated that high hostility levels were more predictive of developing coronary heart disease than risk factors like high cholesterol, alcohol intake, cigarette smoking. Older men with the highest levels of hostility were at the greatest risk for developing coronary heart disease, independent of the effects of BMI, waist-to-hip ratio, fasting blood-sugar levels, triglyceride levels, and blood pressure.

In a series of studies in Japan it was discovered that older men with high hostility levels have weaker parasympathetic nervous systems than men with low hostility levels. An effective PNS can help counter the effects of the SNS, which results in the heart working less hard and lowering the risk for developing heart disease. This suggests that combining anger management and relaxation training can be particularly effective as complementary interventions.

SCREEN FOUR

The Recurrent Coronary Prevention Project (RCPP) was a 4.5 year clinical trial aimed at reducing recurrent cardiac events in patients after they had one heart attack. One of the strategies came to be known as the Hook. The goal was to create an immediate cognitive shift that would allow the patient to dampen arousal and mobilize an alternative response. A Hook is anything that might make the patient angry. Hooks can include these:

The perception that we have been victimized or harmed

The belief that the provoking person meant to deliberately harm us

The belief that the OTHER person was wrong and they should have behaved differently and that they were evil to harm us.

Hook themes include:

People do not pay enough attention to our needs; they do not care about us.

People demand/expect too much

People are rude or inconsiderate.

People take advantage or use us

People are selfish; they think only of themselves.

People criticize, shame, or disrespect us

People are cruel or mean.

People are incompetent or stupid.

People are thoughtless and irresponsible.

People do not help us.

People are lazy and refuse to do their share.

People try to control or manipulate us.

People cause us to have to wait.

SCREEN FIVE

It is suggested that the patient create a Hook Book. Each day they review events and identify the Hooks, whether they bit the hook or not. They should be specific about what was going on when they began to notice that they were angry. What happened that gave pain or increase stress? What was the exact provocative situation? What trigger thoughts (or themes) were going through their mind? On a scale of 0-100 how angry did they feel? What did they do? What was the effect of their behavior on others? They share the Hook Book with the therapist.

Cardiac Psychologist Robert Allen teaches his patients a three step anger management process:

Identify the hook; note it, but DO NOT BITE IT. Do not express anger.

Identify which of the patients needs are not being met (e.g. respect or personal space)

Find a way to meet the need or decide to adjust to the fact that the need cannot be addressed.

By doing the Hook Book the patient learns to identify the most common hooks. In therapy strategies can be developed to identify the underlying needs that are involved in the anger, learn methods like deep breathing to dampen the arousal and then mobilize more constructive alternative ways to meet the need.

SCREEN SIX

Dr. Herbert Benson, a Harvard cardiologist, has made a study of the counterbalancing mechanisms of the body’s stress reaction. He discovered that while the fight-or-flight response is part of the hard wired response to stress, there is an opposite response, he called the relaxation response. The relaxation response causes the body to calm itself. Metabolism decreases, heart rate decreases, blood pressure decreases, breathing rate decreases and muscle tension decreases.

There are the basic steps in learning to elicit the relaxation response:

A mental focusing device, such as attending to breathing, or repeating a word, phrase, prayer, sound, to help shift your mind from everyday worries. He suggests using the word ‘one’ or ‘calm’ as a device.

Tell the patient to gently direct the mind back to the mental or physical relaxation exercise when getting caught up in a train of thought. It seems important to keep a passive attitude toward distractions.

The basic steps necessary to elicit the relaxation response are:

Step 1: Picking a focus word, phrase, image, or prayer.

Step 2: Sitting quietly in a comfortable position.

Step 3: Closing the eyes.

Step 4: Relaxing muscles.

Step 5: Breathing slowly and naturally repeating the focus word or phrase when exhaling.

Step 6: It seems important to instruct the patient to not be critical of their ‘performance’ and when other thoughts come to mind they should say: "Oh well," and gently return to the repetition.

Step 7: Continue for ten to twenty minutes.

SUMMARY PAGE: THE HOOK AND THE RELAXATION RESPONSE

Have the patient create a Hook Book. Each day they review events and identify the Hooks, whether they bit the hook or not. Hooks may include:

The perception that we have been victimized or harmed

The belief that the provoking person meant to deliberately harm us

The belief that the OTHER person was wrong and they should have behaved differently and that they were evil to harm us.

They should be specific about what was going on when they began to notice that they were angry. What happened that gave pain or increase stress? What was the exact provocative situation? What trigger thoughts (or themes) were going through their mind? On a scale of 0-100 how angry did they feel? What did they do? What was the effect of their behavior on others? They share the Hook Book with the therapist.

Teach the patient the three step anger management process:

Identify the hook; note it, but DO NOT BITE IT. Do not express anger.

Identify which of the patients needs are not being met (e.g. respect or personal space)

Find a way to meet the need or decide to adjust to the fact that the need cannot be addressed.

By doing the Hook Book the patient learns to identify the most common hooks. In therapy strategies can be developed to identify the underlying needs that are involved in the anger, learn methods like deep breathing to dampen the arousal and then mobilize more constructive alternative ways to meet the need.

Dr. Herbert Benson, a Harvard cardiologist, has made a study of the counterbalancing mechanisms of the body’s stress reaction. He discovered that while the fight-or-flight response is part of the hard wired response to stress, there is an opposite response, he called the relaxation response. The relaxation response causes the body to calm itself. Metabolism decreases, heart rate decreases, blood pressure decreases, breathing rate decreases and muscle tension decreases.

There are the basic steps in learning to elicit the relaxation response:

A mental focusing device, such as attending to breathing, or repeating a word, phrase, prayer, sound, to help shift your mind from everyday worries. He suggests using the word ‘one’ or ‘calm’ as a device.

Tell the patient to gently direct the mind back to the mental or physical relaxation exercise when getting caught up in a train of thought. It seems important to keep a passive attitude toward distractions.

The basic steps necessary to elicit the relaxation response are:

Step 1: Picking a focus word, phrase, image, or prayer.

Step 2: Sitting quietly in a comfortable position.

Step 3: Closing the eyes.

Step 4: Relaxing muscles.

Step 5: Breathing slowly and naturally repeating the focus word or phrase when exhaling.

Step 6: It seems important to instruct the patient to not be critical of their ‘performance’ and when other thoughts come to mind they should say: "Oh well," and gently return to the repetition.

Step 7: Continue for ten to twenty minutes

Harry L. Mills, Ph.D.

Appeared in Cohealth

SCREEN ONE

Diabetes is a silent killer that steals away life and well-being. Its impact is evident by looking behind the curtains of heart disease, strokes, kidney disease and other illnesses, that might have happened, but much later, if at all, were it not for the impact of high blood glucose on the human body. In SNFs diabetics have an average of 6.4 diagnoses in contrast to 2.4 for non-diabetics. They are much sicker than other residents. In fact one of the best predictors of eventual placement in a SNF may very well be poorly controlled diabetes. A person with diabetes can expect to lose ten years of life. Before it kills, through its proxies, diabetes can rob patients of their sight and even their limbs. Variations in blood glucose levels can lead to mental confusion and increase the instability of mood. In addition, the patient faces an emotional dilemma which can give the patient the Sisyphean choice of choosing between compromising health rapidly today, by risking hypoglycemia, or compromising health slowly tomorrow, as hyperglycemia ravages their body.

SCREEN TWO

Hyperglycemia is a condition of too much glucose in the blood. This can be a product of either the pancreas’ loss of capacity for production of insulin, as is the case in type 1 diabetes, or resistance that prevents the insulin from being used as effectively and efficiently in its role of moving glucose into the cells to create energy, as is the case with type 2 diabetes. Hypoglycemia is the opposite. In hypoglycemia there is too little glucose in the blood to maintain bodily functions. Type 1 diabetics require insulin for life itself since the pancreas no longer produces it. However, the traditional distinction between insulin dependent and non-insulin dependent diabetes has been dropped. Type 2 diabetics may also need insulin. Elderly type 2 diabetics are more likely to require insulin as a management tool. Most type two diabetics are older and of those with diabetes 90% are type 2.

The primary medical treatment goal for both types of diabetes is to normalize blood sugar levels. Poorly controlled diabetes accelerates the aging process. There is evidence that it not only speeds coronary artery disease but may very well accelerate dementia.

There is strong evidence that lowering hyperglycemia can have a very positive effect in delaying the onset of complications, even in seniors.

SCREEN THREE

The goals of any nutritional aspects of diabetes care are:

To approximate normal blood sugar levels

Optimum serum lipid levels

Maintain appropriate body weight

Prevent acute and chronic complications

While diabetics may check their own blood level when living in the community, or nurses may check the level in SNFs, the gold standard measure is called the Hemoglobin A1c. The red blood cells of the body actually keep a record of glucose levels and those levels can be measured to determine the history of blood sugar levels over that last 3 to 4 months. Normal levels for the HbA1c is below 7% in general and below 5% to 6% for tight management.

Even under close supervision, as few as 5% keep blood sugar within prescribed limits. If hyperglycemia is so damaging, and diabetics know that is the case, then why is adherence such a problem? One reason is that the medical regimen is very complex and it intrudes into so many spheres of life. Still another reason is diabetic burnout, a diagnosis specific form of depression. Characteristics include:

The patient feels diabetes is in control of life

They feel overwhelmed with the demands of the medical regimen

Experiences bitterness and anger over diabetes

Feels alone in their battle. Others do not understand.

Feels resigned to poor glycemic control

Avoids discussing the illness or symptoms with health professionals

Ambivalence about increasing self-care role

Too often in LTC they turn over all responsibility to the staff

SCREEN FOUR

Hypoglycemia is considered a blood sugar level below 70 mg/dl (normal is from 90 to 114). With mild hypoglycemia symptoms appear such as shaking, sweating and slowed thinking, but the patient can still treat themselves by eating. With severe hypoglycemia neuroglycopenic symptoms, such as lethargy, mental stupor and unconsciousness can occur, and the person must have help from others. It is an aversive experience and can be a source of embarrassment for the patient. Thus some patients avoid hypoglycemia by remaining hyperglycemic. To understand how patients could develop a fear of this condition, that can take on many characteristics of a phobia, consider these autonomic symptoms of very low blood sugar:

Pounding heart

Fast pulse

Flushed face

Trembling and shaking

Sweating

Queasy stomach

Temperature changes

Weakness

Tingling

Headache

Rapid breathing

These mood changes can occur:

Nervousness

Irrational

Worried

Frustrated

Angry

Sadness

Giddy

Euphoric

Jittery

At very low levels these neuroglycopenic symptoms can really scare a patient:

Slowed thinking

Dizziness

Trouble concentrating

Slurred speech

Blurred vision

Difficulty reading

Sleepiness

Numbness

Lack of coordination

These kinds of symptoms can occur from too much insulin and too little food intake in type 1 or from skipping meals for type 2. Most type 1 diabetics have some experience with this condition. Unfortunately one way to avoid the negative experience is to stay hyperglycemic, in spite of the long term risks, by eating foods that keep sugar levels high. It is a short term solution with severe longer term consequences. Those with a history of anxiety disorders are particularly susceptible.

SCREEN FIVE

False alarms can also play a negative role. Some of the symptoms of low blood sugar are also products of exercise. Like many panic patients, diabetics may avoid exercise for fear of the symptoms. Since losing even a small amount of weight can be of great value in controlling diabetes this fear can also have a very negative impact. The fact that exercise can indeed produce hyperglycemia makes solutions more of a challenge. By staying in what seems the safe territory of hyperglycemia and avoiding exercise such patients are creating the conditions for maximizing complications.

Some patients experience symptoms at 70 mg/dl and others do not do so until it falls below 50 mg/dl. So one of the first things that must happen is to find the risk point for particular patients. The key to finding the risk points is frequent checks by the patient or by the nursing staff. The minimum number of checks is four per day. Six to eight checks a day is not uncommon particularly if there is a history of high risk episodes. Patients learn to better discriminate changes by checking their blood sugar when they have what they believe are symptoms. In a successful program called Blood Glucose Awareness Training (BGAT) patients keep a diary that compares their estimates of blood glucose with actual numbers. Type 1 diabetics can learn to better recognize and react to variations in blood glucose fluctuations and such training has sustained, sustained, and broad ranging benefits.

SCREEN SIX

Fear of hypoglycemia is not a totally irrational fear. There is risk. So the goal is to attenuate the fear while realistically managing the risk. All type 1 diabetics and those type 2 diabetics who are on a tight control regimen should carry items like crackers, glucose tablets or gels with them at all times. Once they have learned how to recognize the symptoms they can easily resolve any symptoms by eating or perhaps drinking a little orange juice. Have the patient learn deep relaxation and set up a hierarchy that steps through the symptom experiences, and not just the external conditions. Some patients are more fearful in some circumstances than others and thus the desensitization should give emphasis to those. Always include in the imagery actually treating the symptoms with some food intake and have the symptoms fade away after that, replacing the tension with calm and relaxation.

Any time a diabetic presents as depressed it is useful to evaluate whether that depression is a manifestation of diabetic burnout. And it is essential to include in the assessment of a diabetic an exploration of the history of hypoglycemic episodes and the patient’s perceptions of that aspect of the illness.

SUMMARY PAGE: SYMPTOMS OF HYPOGLYCEMIA

Hypoglycemia is considered a blood sugar level below 70 mg/dl (normal is from 90 to 114). With mild hypoglycemia symptoms appear such as shaking, sweating and slowed thinking, but the patient can still treat themselves by eating. With severe hypoglycemia neuroglycopenic symptoms, such as lethargy, mental stupor and unconsciousness can occur, and the person must have help from others. It is an aversive experience and can be a source of embarrassment for the patient. Thus some patients avoid hypoglycemia by remaining hyperglycemic. Consider these autonomic symptoms of very low blood sugar:

Pounding heart

Fast pulse

Flushed face

Trembling and shaking

Sweating

Queasy stomach

Temperature changes

Weakness

Tingling

Headache

Rapid breathing

These mood changes can occur:

Nervousness

Irrational

Worried

Frustrated

Angry

Sadness

Giddy

Euphoric

Jittery

At very low levels these neuroglycopenic symptoms can really scare a patient:

Slowed thinking

Dizziness

Trouble concentrating

Slurred speech

Blurred vision

Difficulty reading

Sleepiness

Numbness

Lack of coordination

These kinds of symptoms can occur from too much insulin and too little food intake in type 1 or from skipping meals for type 2. Most type 1 diabetics have some experience with this condition. Unfortunately one way to avoid the negative experience is to stay hyperglycemic, in spite of the long term risks, by eating foods that keep sugar levels high. It is a short term solution with severe longer term consequences. Those with a history of anxiety disorders are particularly susceptible.

Harry L. Mills, Ph.D.

Appeared in Cohealth

SCREEN ONE

Effective disease management requires addressing emotional issues. While survival rates have improved, for many patients and their families cancer means death. Patients and their families must make many decisions under intense stress. Treatment for cancer can be an emotional rollercoaster. Surgery, chemotherapy, radiation and immunotherapy and such treatments as bone marrow transplantation can have significant intrapersonal and interpersonal impact, and the trauma of diagnosis and treatment may persist for sometime.

Two important forms of coping are essential for cancer patients: problem-focused coping and emotion-focused coping. Problem-focused coping involves changing the objective problem situation or modifying the external environment. Emotion-focused coping is internally focused and involves changing the reaction or emotional response. Good disease management programs should include methods that involves teaching a set of skills valuable to resolving complex problems under stress like those associated with illnesses, while ensuring that both these approaches to coping are used in a balanced way.

SCREEN TWO

Project Genesis, funded by the National Cancer Institute under the leadership of Arthur Nezu, had the following goals:

Improve cancer patients overall problem-solving abilities and skills

Decrease their current emotional distress

Increase control by teaching them a set of generalizable coping skills

Improve the overall quality of life.

Findings from a variety of studies support the validity of the model in general, as well as its application to cancer patients. Thanks to modern medicine patients live longer with cancer, but they are living longer under significant stress and the emotional disruption that attends such stress. The goal is to help the patient direct their coping efforts toward altering the situations, their reactions to their situations, or both, when helpful.

A problem is viewed as specific life circumstances (e.g., diagnosis of cancer) that demands an adaptive response. However, problems in illness are all the more of a challenge because of ambiguity, uncertainty, conflicting demands or conflict over resources. The natural human desire for health and well-being is compromised and a discrepancy is created. The most effective solution to such problems is not only to modify the situation, or one’s reaction to it, but also maximize other positive consequences and minimize negative consequences.

SCREEN THREE

Cancer related problems include:

Physical Problems – such as pain, trouble walking, difficulty in completing routine tasks

Psychological distress – such as trouble sleeping, increased worry, feeling sad and being ashamed of physical changes

Medical interaction – such as trouble getting answers to questions, communication with medical staff, and understanding technical language

Family – change in roles with family, too little affection, intrusions by well-meaning family members

The orientation of the patient to problems and problem solving is a major factor in success or failure. What is the dominant response of the patient when confronted with a problem? A positive orientation involves optimism and lower levels of anxiety and depression. A negative orientation involves negative affect (e.g., anger, fear), impulsive behavior and avoidance or denial. Thus the first step is to address those issues and provide an orientation to the patient in structured problem solving.

Personal control beliefs are also a major issue. Effective problem involves viewing common life problems, including illness, as being caused by controllable factors. Primary control involves belief that one’s actions can have a direct impact on the illness. Secondary control involves one’s acceptance of a lack of control but a willingness to change the emotional reaction to the illness. An overly rigid stance is problematic. Flexibility is a key. Some problems do not permit a change in the objective situation. For example, the diagnosis itself must be accepted and emotion-focused approaches become essential. It is important to communicate the value of adaptability and flexibility and the risks of knee-jerk automatic solutions particularly when driven by anger, fear or dread.

SCREEN FOUR

It is preferable to discuss each of the common beliefs that can be counterproductive openly with the patient and counter each one. Discuss and counter each of these misconceptions:

Most people do not have problems coping with illness.

All my problems are caused by my cancer.

It is better to avoid problems. They disappear on their own.

The first solution is always the best solution.

There is one perfect solution to all problems.

Nobody can understand unless they have cancer.

People cannot change.

Since a problem well defined is half-solved, the first step in structured problem-solving is Problem Definition and Formulation. Patients should be trained that the best way to start is to:

Seek all available facts and information about a problem

Describe such facts in clear language

Differentiate relevant from irrelevant information and objective facts from assumptions

Identify the facts and circumstances that make the situation a problem

SCREEN FIVE

Leaping too quickly to solutions that are driven by negative emotions is significant risk with cancer patients. Training in generating alternatives is most valuable. In highly stressful situations, with high levels of emotionality, the first alternative that comes to mind may very well prove to be dead wrong. So the rules of brainstorming apply. The three principles are:

Quantity principle

Deferment of judgment principle

Strategies and tactics principle

The quantity principle suggests that the more alternative solutions that are generated, the more likely it will be that the list includes the best ideas for a solution. Patients should be taught to defer judgment and avoid premature evaluation and conclusions. The distinction between a strategy and a tactic should be taught. Strategies are the general ways to solve a problem, and tactics are the specific steps used to accomplish those strategies. Once completed the list should be reviewed to find ways to contrast ideas, modify or improve them or elaborate on the ideas. Patients should keep alternatives on the table until the effort to compare and contrast or elaborate have been completed. Often that process produces the best ideas for solutions. Yet it is too often skipped when trying to make decisions under stress.

SCREEN SIX

Once a wide range of alternatives are on the table, the cancer patient must learn how to evaluate each solution and select the most effective for implementation. There are two major concerns:

Estimation of value

Estimation of likelihood of effects

In making judgments about value there are four categories of consequences that must be considered:

Short-term or immediate consequence

Long-term consequence

Personal consequences

Social consequences

All must be considered. Considering just short-term or immediate consequences is all too common under stress. Require all four categories.

Estimating the likelihood of effect means asking the question: “Will it work?” We must look at each option that remains on the table to determine the likelihood that each alternative will actually solve the problem.

In the final step the cancer patient implements the selected solution. There is more to it than meets the eye. The patient must carry out the solution, evaluate the effectiveness of the solution and, if necessary resume the problem solving process to search for a more effective alternative.

SUMMARY PAGE: TEACHING PROBLEM SOLVING

Since a problem well defined is half-solved, the first step in structured problem-solving is Problem Definition and Formulation. Patients should be trained that the best way to start is to:

Seek all available facts and information about a problem

Describe such facts in clear language

Differentiate relevant from irrelevant information and objective facts from assumptions

Identify the facts and circumstances that make the situation a problem

The rules of brainstorming must be applied. The three principles are:

Quantity principle

Deferment of judgment principle

Strategies and tactics principle

The quantity principle suggests that the more alternative solutions that are generated, the more likely it will be that the list includes the best ideas for a solution. Patients should be taught to defer judgment and avoid premature evaluation and conclusions. The distinction between a strategy and a tactic should be taught. Strategies are the general ways to solve a problem, and tactics are the specific steps used to accomplish those strategies. Once completed the list should be reviewed to find ways to contrast ideas, modify or improve them or elaborate on the ideas. Patients should keep alternatives on the table until the effort to compare and contrast or elaborate have been completed. Often that process produces the best ideas for solutions. Yet it is too often skipped when trying to make decisions under stress.

Once a wide range of alternatives are on the table, the cancer patient must learn how to evaluate each solution and select the most effective for implementation.

In making judgments about value there are four categories of consequences that must be considered:

Short-term or immediate consequence

Long-term consequence

Personal consequences

Social consequences

Estimating the likelihood of effect means asking the question: “Will it work?” We must look at each option that remains on the table to determine the likelihood that each alternative will actually solve the problem. In the final step the cancer patient implements the selected solution. There is more to it than meets the eye. The patient must carry out the solution, evaluate the effectiveness of the solution and, if necessary resume the problem solving process to search for a more effective alternative.

Harry L. Mills, Ph.D.

Appeared in Cohealth

SCREEN ONE

Allostatic Load

As we age there is increased susceptibility to a wide variety of chronic illnesses and those illnesses are both a source of greater stress and are exacerbated by stress. This is all the more true of those seniors who become part of long-term care. A stressor can be defined as any event that challenges a person and the stress response is the body’s compensatory reaction to the challenge. There are many challenges associated with aging such as the loss of loved ones, decline in vigor and health, economic hardship and the necessity of caring for family with illnesses. We are all familiar with the concept of homeostasis. Less familiar use the term allostasis. When a demand has not been neutralized or removed maintaining homeostasis may be a source of ongoing wear and tear on the system. The concept of allostatic load has been a special utility when we take into account a persistent, though often not immediately life-threatening, stress unique to growing older. When stresses go on for months and years they can have a devastating impact on both physical health and psychological well-being of seniors. We know now that chronic stress compromises the effectiveness of the immune system in combating variety of illnesses and us it becomes critically important in working with seniors that we understand the impact of stress and emotions on health and illness.

SCREEN TWO

Hans Selye and Stress

The father of the modern scientific concept of stress was an immigrant physiologist named Dr. Hans Selye. While studying the physical reaction of the body to disturbances, he found a pattern that seemed to occur over and over. The body undergoes a generalized physiological response as it tries to adapt to the demands and pressures and he called that response the General Adaptation Syndrome or GAS. The first step is the initial alarm reaction followed by resistance, as the body tries to adapt and, if the disturbance continues, a final stage of exhaustion sets in. He labeled the response the body makes to any demand that is taxing as stress and coined another word, stressor, to describe the events that produce the stress reaction.

To Selye stress is part of life. If you are alive, you have it. It is neither good or bad. Stress just is. You cannot hide from it. Trying to avoid it can lead to boredom which in it self is a stressor. However, Selye was a pioneer in pointing out that stress could result in diseases of adaptation. In the 1950s that was a revolutionary notion. Germs were viewed as the cause of disease. Selye pointed out that stress could weaken resistance and thus make it more likely a germ would lead to disease. Much later researchers actually injected cold germs into the nostrils of groups of subjects under high stress levels and groups under no significant stress. Guess who caught the colds? The subjects under stress. Hans Selye was right.

SCREEN THREE

Physiology of Stress

We are built to respond to stress. However, we are designed for a different kind of stress than the type that we experience in our modern technological society. Our bodies are the same as it was for our prehistoric ancestors, but the world has changed greatly over during that same period. We have the same automatic reaction that our tribal ancestors possessed. We are “wired” to respond to threats with what physiologists call the fight-or-flight response. If we encounter a rattle snake while hiking along a trail our bodies prepare us to react by either trying to kill the snake or trying to get away from the dangerous situation. Our nervous system orchestrates these changes to prepare for either event. Click to find out why:

Digestion slows Pop up: So blood may be directed to muscles and the brain in preparation for trying to avoid and get away from the snake.

Breathing gets faster Pop up: To supply more oxygen to muscles to speed our movement.

The heart speeds up and blood pressure soars Pop up: Forces blood to the parts of the body that enable you to fight or run.

Perspiration increases Pop up: To cool the body while we exert ourselves.

Muscles tense Pop up: Prepare for jumping away and running.

Chemicals are released Pop up: To promote blood-clotting in case of injury.

Sugars and fats are poured into the blood Pop up: to provide fuel for quick energy as you try to kill the snake or avoid contact with it.

SCREEN FOUR

Fight-or-Flight Response

Psychologists who conduct research on stress say there are three basic ways we respond to stress: (1) we fight; (2) we flee; or, (3) we freeze. Fighting is the power response, we try to influence the source of stress by attack or counter attack. Sometimes it is better to escape–to run away and fight another day. When the threat is overwhelming, flight may be the wiser option. When fighting or running is not appropriate we may simply freeze. In sports this is called choking.

The flight-or-fight response is an automatic alarm. How we respond, when the alarm sounds is critical to health and happiness. We may fall into mindless reactions that become a destructive, vicious cycle. External events of biological, social, physical or economic origin impinge on us from outside our bodies. These events may be highly predictable or they may be unpredictable. These lead to activation of changes in your nervous system, as well as your cardiovascular, musculoskeletal, immune and digestive systems.

However, we are not mechanical robots. Our response to stress is not hard wired. In over 30 years of research Dr. Richard Lazarus at University of California at Berkley found that it is our lightening fast appraisal of the nature of the environmental event that determines whether we experience stress. First we ask is this event a threat to me? Then we ask, do I have the resources to cope with it? If the event threatens our well-being or exceeds our ability to respond then we experience psychological stress.

SCREEN FIVE

The Nervous System and Stress

If events are appraised as threatening, the changes in the body come about because of the activation of a particular branch of the autonomic nervous system (ANS). This branch is called the sympathetic nervous system (SNS), and it functions to prepare us for action. The other branch, called the parasympathetic nervous system (PNS) acts as a brake. Its function is to slow things down — to calm the body. The hypothalamus, a master control switch, controls the activity of both branches.

The opposing functions of the two branches is summarized in these functions:

One dilates the pupils while the other constricts the pupil

One inhibits salivation while the other stimulates salivation

One accelerates heartbeat while the other slows heartbeat

One inhibits digestion while the other stimulates digestion

It is the SNS that kicks into action in situations we find threatening. It serves the goals of vigilance, arousal, activation and mobilization. The PNS provides for body maintenance. It promotes growth, energy storage and other activities important for longer term survival.

The hypothalamus is part of a region in the brain called the limbic system and it is the limbic system that is thought of as the seat of our emotions. There are complex interconnections between the limbic system and the higher cortical centers, where we do our thinking and problem solving, as well as, the endocrine system and our musculoskeletal system. Mobilization of our response to stress involves magnificent orchestration of all of these systems.

SCREEN SIX

The Amygdala and Neocortex

The seat of our emotions is a small almond shaped part of the brain called the amygdala. There are two, one on each side of the head. The amygdala is like a psychological sentinel that examines each event in our lives for its emotional meaning. It asks basic questions like: Is this demeaning? Do they intend to hurt me? Depending on the answer the amygdala sends out an alarm. The amygdala can start our reactions in motion before the neocortex, or the thinking brain, can check on the reasonableness of our actions. The amygdala can hijack the rest of the brain. This has led neuroscientist Joseph LeDoux to point out that the emotional system can act independently of the neocortex. Some emotional reactions and emotional memories can be formed without any conscious cognitive participation at all. That often happens with anger.

Fortunately, the part of our brain just behind the forehead, the prefrontal lobes, can modulate these emotional impulses. The left prefrontal area can switch off emotions. The thinking brain can serve an executive role. Unfortunately executive control does not always prevail. The emotional brain can and does surge out of control. Harmony between thought and emotion is thus lost. One of the keys to anger control is to develop and understand the best ways to facilitate that prefrontal executive control. There are two essential elements:

Reduce the arousal level with relaxation

Use cognitive control techniques

It is important, therefore, to improve self-calming skills to avoid an emotional high jacking and learn to use thinking skills to regain executive control.

SCREEN SEVEN

Stages of Stress

It is useful to view stress as having four stages:

Stage 1- Environmental demand

Stage 2- Perception or appraisal of the demand

Stage 3- Physical and psychological response to stress

Stage 4- Behavioral consequence or performance

An event in the environment makes a demand on the person. That demand is not automatically a source of stress unless the person views the event as a threat or that an adequate response may stretch the capacity of the person. In Stage 3 the body may show signs of increased tension and arousal (e.g. increased heart rate, perspiration, rapid breathing) and a flood of thoughts. Finally the person acts in a way that may either reduce the level of tension or increase it further, and the cycle renews at Stage 1. If the behavior succeeds in meeting the demand, the person will approach similar demands in the future with greater confidence. Learning is very important in determining our response to stress.

SCREEN EIGHT

Stress and Health

There is growing evidence that stress is a major factor in maintaining health and well-being. Health means more than the absence of illness. In China and in ancient Greece health was thought of as being in balance with nature. The vital task was seen as maintaining equilibrium in the face of extensive demands. The World Health Organization (WHO) definition of health is a state of complete physical, mental and social well being.

It seems increasingly clear that the naive notion that a germ automatically leads to illness is no longer acceptable, although much of the lay public subscribes to the theory. Today we know that the idea of a single external cause, such as a germ, is oversimplified. The presence of the germ does not always cause the illness. The vulnerability of the person or the host animal is a major factor and that vulnerability is influenced by such factors as immunity and stress levels. So the cause of illness is not quite as simple as we once thought.

Another important distinction that came out of the seminal work of Hans Selye is between stress and distress. Both involve demands on the person to adapt to a challenging event. However, when we appraise the situation as being something we can handle it can be an exhilarating experience. When a person appraises the event as beyond their ability or as exceeding resources the situation is experienced as distress. Another way to look at it is that stress is positive and distress is negative.

SCREEN NINE

Diathesis-stress Theory

The diathesis-stress theory of the origin of certain illnesses holds that we are born with certain biological predispositions but that whether or not an illness manifests itself is dependent on the level of stress one experiences and the resources one can use to overcome the stress. For example, although a person may have inherited a genetic deficiency in metabolizing alcohol, whether that person becomes an alcoholic or not also depends on the types and levels of stress they experience. Another person may have inherited a problem with glucose metabolism; however, it is factors such as the level of stress, or a sedentary life style or a combination of the two that result in development of type 2 diabetes. We may be born with certain vulnerabilities; it is stress that tips us into active illness.

Certain ailments have been recognized for some time as being influenced by stress. The most common example is intestinal distress such as indigestion and colitis. Other disorders like migraine, tension headaches, high blood pressure, arthritis and certain skin disorders may also be influenced by stress. In some instances, stress emotions seem to make an ailment worse, while in others stress may be a factor in bringing on illness. Research increasingly supports the hypothesis that stress may have at least some impact on many diseases.

SCREEN TEN

Stress and Development of Disease

There are several reasons for believing that stress contributes to the development of cardiovascular disease. First, stress emotions increase the level of low-density blood cholesterol and this leads to clogging of the arteries of the heart. Second, stress emotions result in maladaptive coping behaviors such as smoking, drinking and overeating, which can damage the heart and surrounding vessels. Finally, stress emotions result in the release of powerful hormones which result in increases in heart rate and blood pressure. One of these stress emotions is anger, and anger expressed in the form of hostility is known to increase the risk of cardiovascular disease.

Several hypotheses are being explored in the role of emotions in cancer. Again stress emotions may play an indirect role leading the person to smoke or drink excessively. More direct influence is attributed to a tendency to suppress or deny emotions. There is some evidence that those who suppress emotions are more susceptible to cancer. Again the mediating factor is hormonal activity.

SCREEN ELEVEN

Stress and Diabetes

At the 2002 meeting of the American Psychological Association a group-based stress management study was presented that indicated that group stress management training could lower blood glucose levels in Type 2 diabetes. Patients that received instruction regarding the health consequences of stress and instruction in the use of cognitive and behavioral skills such as deep breathing and recognition of major life stresses as well as instruction in progressive muscle relaxation lowered their glucose levels more than patients that did not have stress management training. Thirty-two percent of the patients receiving stress management lowered their A1C glucose levels by one percent or more as compared to 12% of the patients who did not receive this training. This modest change is larger than the half percent change that has been associated with significant reduction in microvasclar complications that can accompany out of control diabetes. While this change might move someone with tightly controlled diabetes to near normal levels; even those diabetics with poorer control would benefit from the reduction in glucose levels with fewer diabetic complications. Learning how to manage stress can be of great benefit to type 2 diabetics.

SCREEN TWELVE

Stress and the Immune System

The immune system has been called our liquid nervous system. With our growing knowledge of the human body has come an increasing conviction that stress may be a factor in susceptibility to colds, flu, mononucleosis and other infectious illnesses. It appears that some of the hormones secreted in the presence of stress emotions impair or weaken the immune process by reducing the number of disease-fighting components such as lymphocytes (white cells) thus leaving us more vulnerable to infection. This may be one of the reasons why so many people die within a year or so of their spouse’s death. Recently there has been research into why some HIV positive patients develop full blown AIDS while others do not. One interesting finding is that patients with a more effective style of coping with stress seem to have stronger resistance as a result. It is now reasonable to hypothesize that stress emotions increase secretion of certain hormones. These hormones weaken the immune system and that weakness results in an increased likelihood of infectious illness.

Recent research indicates that brief time-limited stress that may be viewed as a challenge (e.g. passing an exam, good performance in sports, solving a difficult puzzle under pressure) may actually enhance the body’s immune response. However, chronic stress seems to reduce the effectiveness of the immune system and thus make the person more susceptible to diseases.

SCREEN THIRTEEN

Anger and Hostility

Stress has its impact on health through emotions. Afflictive emotions are those that torment a person. Anger, anxiety and depression are the afflictive emotions with the strongest link to health problems. If we are exposed long term to these afflictive emotions we increase our vulnerability to disease, worsen physical symptoms and impede recovery from illness or disease.

Right hemisphere activity is associated with negative emotions. The right side of the brain also influences bodily structures that secrete stress hormones. If the right side of the brain is chronically overactive there appears to be a relationship between negative emotions and the secretion of stress hormones. Chronic feelings of anger, hostility and aggression have been linked with raising the risk for developing arteriosclerosis and coronary heart disease as much as five times the normal rate. The health risks from hostility appear to be more significant in men than in women because of their higher levels of testosterone. Higher levels of testosterone are often associated with a person liking to control situations which can lead to their being argumentative or even engaging in physical fighting.

Depression has adverse health consequences. Research suggests that depression is more likely to hamper the ability to recover from severe illness. For example, depressed women suffering from breast cancer have been found to have fewer natural killer cells then breast cancer sufferers who are not depressed. The job of these natural killer cells is to search for tumors as they begin to grow. Since depressed patients have fewer killer cells they are more likely to have tumors spread quickly to other parts of the body than patients who are not depressed.

SCREEN FOURTEEN

Anxiety and Depressive Reactions

At Mt. Sinai Medical School in New York City research indicated that elderly patients who are not depressed were three times more likely to walk again after breaking a hip and nine times more likely to regain their previous state of health than those who were depressed.

A study at the University of Minnesota indicated that patients who were seriously depressed before their bone marrow transplant were significantly more likely to die in the first year following their transplant than non-depressed bone marrow transplant recipients. A University of Montreal study found that patients treated for a first heart attack who were seriously depressed were five times more like to die than a comparable group of patients who were not depressed.

People who lived near the Three Mile Island nuclear power plant after a meltdown in 1979 were very anxious and apprehensive. In a research study they were determined to have fewer T-cells and B-cells than people living in a similar neighborhood more distant from the plant. Fear and worry seemed to have a negative impact on the immune system.

A collaborative study between a special colds research unit in England and researchers at Carnegie-Mellon University found that when volunteers were exposed to cold viruses not everyone got sick. The critical factor appeared to be stress and anxiety. Only 27 percent of the people who were experiencing little stress developed a cold as compared to 47 percent of those who were under high stress.

SCREEN FIFTEEN

Impact of Negative Emotions

Emotions contain two components: bodily sensations that usually involve lower brain centers and a secondary physiological response in the cerebral cortex.

Positive emotions, such as happiness, tend to move people toward something they seek or prefer. Negative emotions, such as fear and disgust, tend to make people move away or withdraw. Emotions are signals for action.

Positive emotions have been described as nourishing emotions. This is because emotions such as joy seem to have beneficial effects on health. In studies classifying people on the basis of their brain activity, people who had the greatest activation of the left anterior region of the brain reported more positive emotions in their daily lives and when faced with life challenges. People with more active right hemispheres reported more negative emotions.

Are there health consequences associated with persistent negative emotions, such as anger? In one study people were selected based on the results of a test of brain wave activity, called an EEG. In addition to the EEG participants also had blood drawn in order to test for differences in their immune systems. The group with more left hemisphere activity had immune system killer cells which were more effective in destroying foreign elements than the group with more right hemisphere activity.

Negative emotions are those that torment a person. Anger, anxiety and depression are the afflictive emotions with the strongest link to health problems. If we are exposed long term to these afflictive emotions we increase our vulnerability to disease, worsen physical symptoms and impede recovery from illness or disease.

SCREEN SIXTEEN

Emotional Resilience and Stress

The American Psychological Association defines emotional resilience as the process of adapting well to life’s challenges. These challenges include trauma, tragedy, adversity, threats or other significant sources of stress. While the initial response to these experiences may be a flood of powerful emotions and a sense of uncertainty, many people bounce back in spite of the obstacles. Resilience is the characteristic that makes such adaptation possible.

Emotionally resilient individuals have a set of assumptions about themselves and their world that influences their response. Emotionally resilient people tend to:

Feel like they are in control of their lives

Learn how to strengthen their ability to handle stress

Be empathetic to other people

Be effective communicators and have good people skills

Have good problem-solving and decision-making skills

Develop realistic expectations and goals

Learn not only from their successes but also from their failures

Be contributing and compassionate members of society

Live responsibly based on thoughtful values

Feel worthwhile as a person, without being self-centered, and have the capacity to help others feel the same way about themselves.

Each of us has the capacity to become more stress resilient, learn how to successfully cope with problems and perhaps make assets out of liabilities.

SCREEN SEVENTEEN

Appraisal and Coping

Richard Lazarus conducted research on stress and emotions for four decades. He found a link between appraisals and stress. An appraisal is an evaluation of the significance of what is going on between the person and the environment in terms of that person’s well being. Appraisals establish the meaning of an encounter for us. At its simplest level, it is a quick assessment of what is going on and then what we can do about it. If we confront a snake, the first appraisal may be that it will harm us (e.g. it kills) and quickly, on the heels of that appraisal, we evaluate what we can do about it (e.g. move quickly away). These appraisals are instantaneous and automatic.

In understanding the role of emotions in regulation of stress the distinction between a primary and a secondary appraisal is most helpful. A primary appraisal is an evaluation of whether something (e.g. a snake) is of relevance to our well-being. What is our stake in the event (e.g. not being bitten)? A Secondary appraisal is an evaluation of our options for coping and expectations about what will happen.

Another key concept in understanding our capacity for self-regulation is coping. It is defined as activity to manage demands that tax or exceed our resources. When demands exceed our resources we experience stress. There are two important types of coping:

Action-focused – which involves making changes in the environment (e.g. killing a snake

Emotion-focused – which involves changing the way we interpret or we experience the event (e.g. “Oh, it’s not poisonous.”)

SCREEN EIGHTEEN

Importance of Control

Ellen Langer is one of the pioneers in the study of perceived control and stress. Some of her most important findings come from field experiments with collaborator Judith Rodin which were conducted in nursing homes for the elderly. These studies pointed out the significant physical and mental gains that can be achieved in elderly people in institutional settings if they are given a sense that they are at least partially in control of their own lives by being able to choose some of their daily activities. According to Langer and her colleagues there are two kinds of control:

Primary control involves changing a situation. Owning our behavior and becoming more resilient requires that we realize that we are the authors of our lives. Instead of always trying to change everyone else we should ask what is it that I can do to change the situation? The elderly in nursing homes can benefit from feeling like they have some control. Research supports the importance of personal control as a major factor in our physical and emotional well-being. A sense of control fosters optimism and optimism can be protective. Primary control means changing the situation

Secondary control involves how we view a situation. Even in situations that we cannot directly change we can determine how we think about it. Even when faced with major life challenges like serious illness, death of a loved one, divorce, loss of employment and natural disasters a lot of what happens to us emotionally and physically is determined by how we look at the situation. Secondary control means changing the way we view the situation and how we feel about it.

SCREEN NINETEEN

Stress Hardiness

Research by Dr. Suzanne Kobasa and her colleagues has suggested three elements which appear to be essential for a stress hardy mindset. These are: commitment, challenge and personal control. Challenge is critical when dealing with adversity. Stress hardy people view difficult situations as challenges which can teach them important life lessons rather than opportunities to feel failure. It is not easy to look for these life lessons but if you do not look for benefits you might receive you will likely experience a sense of pessimism and stress.

Dr. Kobasa explains commitment as a person being involved with life rather than being alienated from it. Another way to look at commitment is to consider it as part of a greater purpose in life. Purpose gives us a reason for getting up in the morning. It demands that we meet life challenges and it requires that we be devoted to not only our work but also to our personal relationships. Purpose also obligates us to service to others and to our philosophical and religious ideals. If a person has no purpose in life they will not be able to lead a resilient life. On the other hand resilient people find meaning in their activities even when faced with significant stress.

Effective disease management programs must include elements that help patients manage their stress levels, improve emotional resilience and develop a stress hardy way of thinking.

SCREEN TWENTY

Buffering the Effects of Stress

There is promising research that suggests that while negative emotions compromise immune functioning there may be parallel enhancements of immune functioning associated with positive emotions and positive behavioral states. Research studying the impact of laughter found that viewing the humorous film leads to lowered epinephrine and cortisol levels and this is suggestive that immune cells and organs may have been affected. In another study an eight week course of mindfulness meditation was found to improve immune system response to influenza vaccine. It has been found that patients who express their emotion about the impact of traumatic stress had better lymphocyte activity. A ten week cognitive behavioral stress management program for HIV patients at lower evidence of viral reactivation and improved complements of T cells suggestive of improved immune system functioning. Such results are preliminary and at this point we have an increasingly appealing case that emotions and cognitions can alter the function of the immune system. Whether these can alter short term or long term health is less certain of but the findings are encouraging.

To pursue this promising area of research on the relationship between emotions and illness a new field of study with a very long name, psychoneuroimmunology, has developed. It is the study of interactions among behavior, neural and endocrine functioning, and immune processes. Results of studies in years to come will give us more clues about better management of illness and the maintenance of health.

Appears in Concept Health Web Site

Harry L. Mills, Ph.D.

Diabetes in older Americans

Diabetes is of epidemic proportion among older Americans. There is growing evidence that high blood sugar actually accelerates the aging process. Unfortunately in spite of the risks, ageism leads to a significant undertreatment in seniors even in nursing homes. Symptoms are often confused with the process of aging and dismissed. Too often, the myth that type 2 diabetes is a milder form, helps to reinforce the pattern of undertreatment. The prevalence of type 2 diabetes increases with age to the point that 90% of older adults with diabetes have type 2. Seventy percent of those who have diabetes are over the age of 55. The prevalence of diabetes in nursing homes is remarkable, with at least 20%, or one out of five residents having diabetes. Estimates are that the disease processes reduces lifespan by approximately 10 years. The disease process can actually lead to memory loss and may actually accelerate dementia. With diabetes, there is a decline in complex cognitive skills and an increase in the incidence of depression and anxiety, which may in turn complicate other acute and chronic illnesses. Disability rates are much higher when diabetes complicates the medical presentation. Treatment of diabetes is much more complicated in seniors. Medications may not work as well or may have diminished effectiveness, in the context of the multiple medications common to seniors. The use of insulin, even in type 2 diabetes is much more likely to be required in the older population.

The disease process

Diabetes involves the inability to effectively metabolize glucose, which leads to chronic hyperglycemia or high blood sugar. Over a prolonged period of time, this leads to vascular disease, among other complications. Type 1 diabetes is an autoimmune disease in which beta cells of the pancreas or destroyed and thus cannot produce insulin. In type 2 diabetes there is resistance to insulin at the cellular level. There is a myth that one type of diabetes is insulin-dependent and the other does not require insulin. That is not the case, in fact among seniors, insulin is much more likely to be required. The cause of disease is still the subject of research, but it appears that there is a genetic predisposition which is activated by environmental factors. Symptoms of type 2 diabetes, which accounts for 90% of diabetics, include:

• Extreme fatigue
• Weight change
• Blurred vision
• Drowsiness
• Unwarranted hunger
• Frequent urination
• Excessive thirst

Diagnosis, measures and goals of disease management

Diagnosis of diabetes involves any blood glucose level greater than 200 mg/dl and the presence of symptoms. A fasting blood glucose level greater than 126 mg/dl, with or without symptoms, may be considered a diagnostic indicator. The diagnostic gold standard is the A1c or glycosylated hemoglobin test. There is some variability in the target level depending on age and other factors. The A1c measures blood glucose levels over a period of time and is better than a snap shot.

There must be some variability in targets for the disease management process based upon assessment of the individual by a physician, however, the goals should include:

• Abolish diabetic symptoms
• Reduce risk of metabolic complications
• Increase life expectancy
• Restore quality of life

It is important to point out, with regard to restoration quality of life, that 40% of diabetics are significantly depressed and 40% have elevated anxiety. An effective disease management program, particularly with seniors, must address the emotional conditions that are most common.

Essential goals for disease management

Disease management program for seniors, as with younger diabetics, must seek to reduce complications. Optimal control of blood sugar requires regular readings. Even diabetics in nursing homes should be involved in their own self-care. If they are not taking their own readings daily they should be informed about them, and preferably keep some records of their own. There are some similarities and differences in the management of type 1 versus type 2 diabetes. Concern about avoiding hypoglycemia is much greater in type 1 but will also be concerned on a type 2 diabetics who require insulin. For both type 1 and type 2, the goal should be avoiding symptomatic hyperglycemia. In both, we want to promote normal blood glucose levels. It is also important to monitor and manage lipid metabolism and prevent vascular complications that can lead to major heart disease. A combination of diabetes and hypertension can be a deadly duo. So any program should include the management of high blood pressure. Any effective disease management program must also address weight management with appropriate nutrition and dietary behavior change. This must involve an appropriate exercise program in keeping with the health status of the senior. Sustained weight management requires attention to both diet and exercise. Adherence to the prescribed medication requirements, including either insulin or hyperglycemic medication, or both must be addressed. Finally, but of equal importance, stress management and the control of depressive symptoms cannot be ignored.

Major studies on the value of tight control

In 1993, the National Institute of Health, completed the Diabetes Control and Complications Trial (DCCT). The study involved 1441 patients with type 1 diabetes. The study compared intensive versus conventional therapy methods. Patients were followed up for seven years after completion of the study. Intensive treatment involves keeping very tight control of blood glucose levels with more frequent monitoring and then more frequent insulin based on the findings of the blood glucose readings. Patients in the study had access to a nurse consultant and to a psychologist is a routine part of treatment. They found that improvements in blood glucose levels, with more intensive monitoring and variation in insulin, resulted in a significant reduction in risk of complications. The United Kingdom Prospective Diabetes Study reported in 1998 confirmation that tight glycemic control reduces risk of complications from type 1 diabetes. Many physicians believe that, given the characteristics of the disease in seniors, disease management with seniors should emphasize these elements:

• Frequent monitoring of blood glucose
• Optimum involvement in self-care
• Variation in insulin based on findings
• Appropriate consultation with a nurse knowledgeable in diabetes
• Motivational interviewing and coaching
• Appropriate psychological services

The most common elements left out of such programs can make a great deal of difference. Those are motivational interviewing and coaching as well as addressing emotional concomitants.

Seniors with diabetes in skilled nursing facilities

Poor treatment of diabetes among seniors in skilled nursing facilities should be a matter of major concern. It appears that diabetes accelerates the process of aging and the disabilities that are associated with aging. This in turn increases the cost of care for a variety of medical conditions. Appropriate diagnosis is imperative and under diagnosis, in skilled nursing facilities, is common. Research suggests that inadequately treated diabetes accelerates atherosclerosis and may very well accelerate the downward trajectory in dementia. Acute illnesses, common in the aging population, can precipitate hyperglycemic episodes, making monitoring all a more important. Type 2 diabetics report more memory problems, and other cognitive deficits, and these problems can be a source of anxiety even in the absence of the primary dementing process. Anxiety disorders are much more common among diabetic patients and diabetic patients are much more prone to the onset of depression. It also seems to be the case that diabetes compromises the seniors capacity to recover from anxiety attacks and depressive episodes. Fear of hypoglycemia can be debilitating and can damage the patient’s motivation to persist with the type of tight control and seems to be most beneficial. The management of other medications, needed by the senior, can become more complicated for patients with poorer control of their diabetes. Given the risks inherent in diabetes, every skilled nursing facility should implement a disease management program to ensure that the residents diabetes have good control.

Catastrophic complications of diabetes

One of the devastating effects of poorly controlled diabetes is its effect on the vascular system. High blood sugar increases the probability of all of the following:

• Coronary artery disease
• Angina
• Myocardial infarction
• Strokes with a high mortality risk
• Transient ischemic attacks
• Peripheral vascular disease
• Amputations
• Microvascular complications
• Blindness
• Cataracts
• Nephropathy (End stage renal disease)
• Neuropathy (Pain)

All of these are found in skilled nursing facilities, and all of these, are at increased risk levels in diabetics who are not aggressively treated by the staff in the facility.

Diabetic coma and insulin shock

Diabetic coma and insulin shock are also risks of poorly controlled diabetes in skilled nursing facilities. The onset of diabetic coma may be gradual. The patient becomes confused, drowsy and then they slip into unconsciousness. They have difficulty breathing, experienced nausea and vomiting. They may exhibit dehydration. The breath as a fruity odor. The treatment for diabetic coma is insulin and fluids. Insulin shock is the opposite of diabetic coma. It is a product of too much insulin for the amount of glucose in the blood stream. Insulin shock may result from injecting too much insulin, too much exercise or too little food. The process begins with the patient feeling hungry, weak and nervous. Even though they are perspiring, the skin feels cold. There is confusion and the person may very well begin to behave in ways that are inconsistent with their personality. There may be angry outbursts or an extended crying episode. In skilled nursing facilities, were dementia is a common, symptoms related to confusion may be ignored, unless the staff is taught to look carefully for changes in behavioral baselines as an index of possible difficulty. Since exercise is very important, it is essential with diabetics, particularly those on insulin, to test blood sugar levels before and after exercise. Staffing shortages being what they are in SNFs, this may very well not be done, in spite of its importance. If the condition is not treated the patient may lapse into unconsciousness. If the patient is conscious, a piece of candy or orange juice can be quite effective. However, if the patient is unconscious and injection of intravenous glucose will be necessary.

Stress and diabetes

All too often, one aspect of any good disease management program for diabetes, particularly in skilled nursing facilities, is ignored and the price is paid by the patient. Stress impairs blood sugar control and leads to a number of changes that may even sabotage the rest of the disease management program. We know that stress increases adrenal secretion of an epinephrine and cortisol. Epinephrine causes the pancreas to decrease insulin production and this may cause a diabetic crisis. Cortisol, on the other hand, causes the liver to increase glucose production in this may also lead to a diabetic crisis. Under stress, tissues decrease the use of glucose, and that may lead to higher levels in the bloodstream. In short, stress can be a major factor in wrecking a disease management program which is seeking better control. These physiological changes are important, but of equal importance, is the impact of stress on emotional regulation. Stress may lead to depression and depression, that is prolonged, can have a major negative effect on the patient’s motivation to help manage their disease. They need to be active, and depression tends to make us passive. Another motivational factor is that stress reduces the sense of personal control that may be very important in maintaining the motivation to manage the disease. Keep in mind that stress mobilizes glucose as part of the body’s natural fight or flight response. In general, it seems that type 2 diabetics are more stress reactive thus making this a troubling vicious cycle.

More on stress anxiety and diabetes

Anxiety and stress increase epinephrine, which breaks down glycogen into glucose and the stress hormone cortisol increases resistance to insulin at the cellular level. This essentially means that stress can produce a temporary version of type 2 diabetes in virtually anyone. In addition, stress robs the body of essential nutrients that are needed to effectively manage hyperglycemia. It contributes to the development of obesity, and obesity, in turn, makes the management of diabetes all the more difficult. Stress tends to demand a person’s attention, and tends to disrupt execution of self-care habits and the learning of new habits which may be essential for the management of diabetes. Paradoxically, the variability in blood glucose, produced by stress, tends to multiply the stress level once again. When readings are outside the expected range, that alone can be demoralizing and stressful. Therefore any good disease management program for diabetes must include a component that is tailored to the unique needs of diabetics. It should include a cognitive component in which the person learns to improve the kind of coping that focuses specifically on the problem that caused the stress, and on the kind of coping that improves the person’s ability to attenuate the emotional responses that amplify the level of stress. It must include an element that improves the person’s skills in deep relaxation, such as body scanning method, deep abdominal breathing and the use of visual imagery to attenuate anxiety.

Challenges of tight control

The primary concern, in any disease management program for senior diabetics must be to keep blood glucose levels as close to normal as possible. Research supports the notion that tight control can significantly reduce complications, and while home testing devices can be valuable, the A1c measure remains the best. Sadly, research suggests that only 5% of diabetics maintain the targeted A1c. And, while tight control is valuable, it also increases the risk for hypoglycemia, low blood sugar by a factor of three. Thus, in any disease management program, fear of hypoglycemia becomes a major motivational issue. One of the major reasons for failure of disease management programs for diabetes, is the relative complexity and difficulty of the regimen. Studies have indicated that type 1 diabetics must think about the management of their diabetes every 15 minutes of the day and can spend as much as five hours a day trying to manage the disease. The dietary and nutritional aspects of such disease management programs represent a significant challenge. Often physicians prescribe rigid dietary requirements without regard to individual differences. And unfortunately such rigid diets have a tendency to fail. Patients stick with the diets for a period of time and then almost invariably drifts from the diets into prior habits. To succeed diets must be individualized, and take into account personal preferences.

Factors in successful adherence that you

Research into the effectiveness of adherence or compliance programs, suggests that simplicity is best. The simpler the regimen the greater the compliance. Unfortunately the medical regimen of the management and diabetes is inherently complex, involving many different areas of life and many different patterns of behavior. Generally speaking, adherence is better for type 1 diabetes because failure can actually result in death. However only 39% of patients monitor their blood glucose levels more than twice a day. That means that 61% of patients do not monitor their blood sugar often enough for tight control. Only 29% of type 1 patients adjust their insulin based on variations in blood sugar levels as seems to be required for optimal self-regulation according to the research. Even a modest weight loss of 10% can make a big difference, and yet such weight reductions are all too rare. The most common pattern seems to be that adherence is disrupted when stress enters the patient’s life, to a degree or of a type for which they have been too poorly prepared. Disease management programs, must be individually tailored based upon understanding of the health beliefs of the patient regarding the seriousness of their diabetic condition, their own vulnerability to side effects of a failure to adhere to a reasonable medical regimen, the relative benefits as well as the costs associated with adherence and finally, and most importantly, perhaps, their sense of self-efficacy. If a patient does not appropriately understand their own vulnerability, and the seriousness of their condition and if they do not judge the benefits as outweighing the costs, they are at risk for failure. Above all, however, if they do not relieve themselves capable of maintaining the regimen, they are likely to fail. Self-efficacy is critical.

Managing the emotional aspects

It is all too common for disease management programs with diabetics to devote too little attention to the affective or emotional aspects. Diabetes patients is use a denial is an emotional defense. They have an awareness of the risks of complications but they tend to believe that that will not apply to them. Without individual interviews as part of the disease management program, it is difficult, if not impossible, to address such denials. Another pattern that is common is an overly compulsive approach to to the efforts at control. A very rigid and inflexible patterns are all the harder to maintain over a longer period of time. Some patients become hypervigilant, and overreact or catastrophize the slightest signs of blood sugar variations. Patterns such as these are difficult to manage, unless there is one on one attention given, in the disease management program. Even those patients who have success, are prone to problems as they experience such things as anger at the unfairness of having to live their lives with such complex medical requirements. This may alternate with equally damaging inappropriate guilt as they blame themselves, completely, for even the slightest failures in the medical regimen. Depression is much more common in diabetes than in many other chronic illnesses, and seems, in many cases to be precipitated by what psychologist Martin Seligman called learned helplessness. Frequent lapses and failures can lead to diabetic to a sense of helplessness which, in and of itself, can turn into chronic depression. These, and other emotional characteristics, require personal attention and support.

Depression and anxiety

For a variety of reasons, depression tends to promote poor glycemic control. A regimen which requires very active role for the patient, can be devastated when depression promotes inactivity and passivity. Therefore one key element in a successful disease management program for diabetics may very well be appropriate treatment for depression. Research supports two major methods of intervention which are complementary. Those are antidepressant medications and Cognitive Behavior Therapy. Given the risk that are involved, it is surprising that this need is often ignored. The most common anxiety disorder in diabetics is what is called Generalized Anxiety Disorder or GAD. This disorder involves an elevated pattern of worry and a consistently high level of anxiety. It is a perfect companion, in an ironic way, for a complicated medical regimen. Patients suffering from GAD tend to do more useless worrying and too little constructive problem solving. Generally, anxiety levels are higher with type 2 diabetics, than with the general population. Exacerbations of the symptoms of these emotional disorders are much more common when glycemic control is poor or highly variable. Patients predisposed to anxiety, are much more likely to develop fear of hypoglycemia, which can drive them to keeping blood sugar levels higher than is appropriate, in order to avoid the uncomfortable feelings, often mistaken for anxiety, that are common as blood sugar levels become too low.

Heart disease and diabetes

Diabetic patients are very likely to die of heart disease. The numbers are staggering. Approximately 80% of diabetics die of heart disease. Diabetes is a major risk factor. In diabetics atherosclerosis develops earlier, progresses more rapidly and is more virulent. This is one reason that a disease management program for diabetics must be accompanied by an effort at controlling cholesterol levels. Diabetics have a three to five times risk level of congestive heart failure. They are much more susceptible to silent myocardial infarction and thus are at greater risk for sudden death from a heart attack. While more research is needed, it appears that vacillation between hypoglycemia and hyperglycemia is very damaging indeed. Thus, the goal in a disease management program must be stability a blood sugar levels within the normal range. Research on the mechanisms is strongly suggestive that chronic hyperglycemia creates a kind of adhesive process that increases lipid deposits in blood vessels. At the risk of oversimplification, hyperglycemia seems to glue fat to the walls of the arteries. Hypoglycemia, lower blood sugar levels, can actually mimic the stress of a heart attack on the patient’s heart. In order to overcome denial, disease managers must be very specific in educating the patient, not only broadly about the risks, but specifically about the likely mechanisms so that there is a greater understanding of the relationship between wide variations in blood sugar levels in addition to chronically high or chronically low levels.

Individually tailored programs

In individually tailored disease management program for seniors with diabetes should begin with individualized goal setting. It is essential that the program began by helping the patient set realistic goals based on an examination of previous patterns of success and failure. Putting the patient at ease, to a sufficient degree, that they can share failures, and not just successes, is imperative. One of the models of constructive problem solving should be the focus of training. Because of the emotional aspects of managing the diabetic regimen, the patient must learn to avoid impulsive decision-making and learn to be very methodical, in the approach to solving problems, related to adherence issues. It is useful to help the patient learn to accept those aspects of the disease which are unchangeable and therefore require acceptance. A good example of this is the necessity for regular blood sugar tests. Diabetics who succeed,approach this with a calm acceptance rather than with anger and frustration. The program should include stress management methods as stated previously. Because of the complexity of the adherence process, social support from family and friends must be mobilized as part of the disease management program. This may require education of a spouse not only about the medical requirements but about the emotional roller coaster that is involved in managing diabetes. While not mandatory, a disease manager who works with diabetics, particularly seniors, would be wise to learn about the methods of motivational interviewing which can be a very valuable tool.

Diabetic burnout

Diabetic burnout is a special form of depression, unique to the effort to manage diabetes. At its root it is a sense of helplessness, and hopelessness, as well as low self- efficacy. Essentially patients give up on the prospect of control and A1c readings go up. The patients begin to feel that diabetes is more in control of their lives than they are. They become overwhelmed with the self-care regimen and often express strong negative emotions about diabetes as the 800 pound gorilla in their lives. They feel alone, and that no one, particularly non-diabetics, understand. They admit to poor self-care and often exhibit a lackadaisical attitude about it. It is during this phase that they grow ambivalent about the prospect of ever improving and thus may minimize contact with all health care providers, including the person who may have been assigned the role of disease manager. There is no choice for a disease manager, other than to go back to the beginning with the patient again, and help them take baby steps if necessary. In helping the patient out of the burnout phase, it is critical to engage the patient in the process and not expect a return to all aspects of the adherence regimen. It is better to start with some simple dietary changes than to ask them to return completely to all aspects of a diabetic diet. It may be useful to return to one or two blood glucose level checks a day then to the full complement that may be the eventual goal.

Avoiding hypoglycemia

Disease managers must help diabetic patients in avoiding hypoglycemia because of its damaging effects on motivation. The experience of hypoglycemic symptoms is much more variable than some think. The standard cut off is at 70 but some patients may show symptoms and 60 men still others not until 50. For disease managers therefore it is important for them to know that patients and their history of hypoglycemia. Patients must be encouraged to check blood glucose levels after exercise, all the time. It is important to emphasize accurate measurements of insulin and knowledge of the different types of insulin, since hypoglycemia can be produced by too much insulin. In mild hypoglycemia there is shaking, sweating and slowed thinking. Patients can treat themselves with glucose intake, and thus should be encouraged to have glucose tabs or other options available at all times. On the other hand, with severe hypoglycemia, there may be lethargy, mental stupor and possibly unconsciousness. In such cases help from others is required. It is important to remember that hypoglycemia results in mood changes. It may simply intensify current mood or it may result in nervousness, irritability, worry, frustration, anger, sadness, giddiness or even euphoria. These episodes are easy for patients to remember because they are scary, and therefore, it is useful for disease manager to ask the patient about the earliest symptoms and to help them define their own unique configuration of symptoms. Then help the patient plan appropriate responses.

Chapter Five

Adolescent Dysfunctional Behavior

Sage Press

©1996

In 1980 when the American Psychiatric Association published DSM-III (1980) anxiety disorders for both adults and children were formally withdrawn from the theoretically overburdened territory of neurosis. The definition of anxiety became “apprehension, tension or uneasiness that stems from the anticipation of danger whether internal or external…It may be focused on an object, situation or activity which is avoided (phobia) or unfocused (free floating anxiety)” (American Psychiatric Association, 1980, p.354). DSM-III-R (APA, 1987) included a subclassification of disorders characterized as Anxiety Disorders of Childhood and Adolescence. Three distinct disorders were considered as unique to children: Separation anxiety disorder, avoidant disorder and overanxious disorder. DSM-IV (1994) eliminated the separate category leaving only Separation Anxiety Disorder as part of disorders unique to infancy, childhood and adolescence. In DSM-IV the Anxiety Disorders section is applicable to children and teens as well as adults.

While a clinically derived classification system holds popular appeal, empirically derived schemes such as those proposed by Achenbach (Achenbach, 1985; Achenbach & McConaughy, 1987) and Quay (Quay, 1972; 1977; 1979) are of significant value in understanding anxiety disorders. From extensive factor analytic studies of childhood disorders two broad band classifications have emerged: overcontrolled or internalizing disorders and undercontrolled or externalizing disorders. Anxiety manifests itself in problems of over control. Employing the Child Behavior Checklist and other scales Achenbach and McConaughy (1987) have identified broad band characteristics, that they characterize as internalizing disorders. This group includes problems within the self such as unhappiness and fears. Syndromes that fall under the internalizing dimension include: social withdrawal, depression, somatic complaints, and depressed withdrawal, depending on the age and sex of the child (Achenbach and McConaughy, 1987). The externalizing syndromes seem to involve little anxiety and include: aggressive, destructive, delinquent, cruel and hyperactive behavior patterns. One dimension seems to involve too much control, anxiety and attendant dysphoria and the other dimension, too little anxiety, self control and attending social dysfunction.

DEFINITIONS

Both anxiety and fear are experienced subjectively as dysphoric and aversive. Both involve the same types of physiological reactions but fear is seen as a response to a genuine threat that disappears once the threat as removed. Anxiety represents a more enduring response to internal cues without obvious external threat. However, anxiety may become associated with external objects or situations and lead to fear for no apparent reason. (Reed, et. al, 1992)

The disorder specific to childhood in DSM-IV (APA, 1994) is separation anxiety disorder. The core feature is excessive anxiety concerning separation from significant others to whom the child is attached. When separated the level of anxiety may reach the point of panic. The chid exhibits unrealistic worry about harm to the attachment figure or a major calamity that results in permanent separation. School refusal and refusal to go to sleep as well as persistent avoidance of being alone may be part of the presentation. Nightmares, somatic complaints and clinging may also be present. The pattern described must take place well after developmentally expected stranger anxieties which occurs at approximately eight months and separation anxiety which is common at 18 months. (APA, 1987; Reed et al, 1992)

In DSM-III-R (1987) avoidant disorder was under Anxiety Disorders of Children and Adolescence. It involved shrinking from contact with unfamiliar people, while seeking contact with family or other familiar persons (e.g., peers). Such youngsters avoid contact with people they do not know to the point that social functioning and development were impaired. Anxiety with strangers may be so great that they become uncommunicative and mute. In DSM-IV children manifesting such symptoms must meet criteria for social phobia. In social phobia the person is said to be fearful of situations in which they are evaluated by others or that they may do something humiliating or embarrassing. Criteria have been modified to include children (APA, 1994; Kendall et al, 1992)

Generalized excessive anxiety and unrealistic worry were the hallmark feature of overanxious disorder in DSM-III-R. Individuals may worry about the future or the past and tend to be extremely self conscious. Routine visits to the doctor may lead to excessive worry. The adolescent is often very anxious about competence and about meeting the expectations of others. Somatic complaints (e.g. headaches or stomachaches) are very common and no physical basis can be found (APA, 1987). Kendall et al. (1992) point out the overanxious youngster’s worry about cleanliness, keeping the rules, making appointments and inquiry about situation danger create an illusion of maturity that can mask the distress they experience. In DSM-IV such symptoms are classified under generalized anxiety disorder.

Panic disorder may also occur in children and adolescents. It is characterized by at least one panic episode that is unexpected and is not triggered by situations in which the person is the focus of attention (e.g. social phobia). Shaking, dyspnea, dizziness, palpitations, sweating, nausea or abdominal distress and choking may be experienced during a panic attack. While agoraphobic symptoms are very rare in children they may develop in adolescence. Those symptoms include fear of being in places or situations from which escape might be difficult or embarrassing when away from home (APA, 1994).

According to Reed et al. (1992) simple phobia and obsessive-compulsive disorders are seen more frequently in children and adolescents than the other anxiety disorders. The hallmark of simple phobia is disproportionate fear directed at a specific and well circumscribed situations. The person is likely aware that the fear is out of proportion and yet the reaction interferes with usual and appropriate functioning. (Kendall et al., 1992; Reed et al., 1992).

While obsessive-compulsive disorders (OCD) are thought to be comparatively rare in children and adolescents, it can be a severe disorder when it presents itself. Milby and Weber (1991) define the key terms:

¨ Obsession – an intrusive, repetitive thought, image or impulse. It is unacceptable, associated with subjective resistance and usually produces distress.

¨ Compulsions – a repetitive, stereotypical act, completely or partly unacceptable but regarded as excessive exaggerated by the patient. It is accompanied by a subjective need to perform the act, often provokes long-term distress but usually reduces, immediate distress ( Milby & Weber, 1991, p.10).

Children and teens with post traumatic stress disorder (PTSD) have experienced events that are outside the range of usual human experience that would be distressing to anyone. Physical and sexual abuse, natural disasters, invasive medical procedures and domestic violence are common examples. The victim tends to reexperience the event or events in recurrent dreams, memories or play themes. There may be a numbing of general responsiveness or active avoidance of stimuli associated with the original trauma. High arousal manifests itself in hyposomnia, angry outbursts and startle responses (Reed et.al 1992). While considered an anxiety disorder PTSD is beyond the scope of this chapter.

INCIDENCE, PREVALENCE AND COMORBIDITY

Children often experience short-lived, transitory and developmentally appropriate fears and anxieties that do not require professional intervention. However, the age of the child or developmental stage must influence interpretation of an anxiety based presentation. What is appropriate at one age may be a precursor to serious adjustment problems at another. These developmental issues often cloud interpretation of prevalence data (Kendall et. al, 1992).

Much of the research on incident rates of children’s fears is quite old and precedes the criterion referenced diagnostic system (DSM-III-R) that arose in the 1980′s. Recent studies by Ollendick and his associates (e.g. Ollendick, 1983; Ollendick, Matson & Helsel, 1985) report an average of 11 fears for children between 8 and 11 years of age and 13 for children and adolescents between 7 and 18 years of age. Graziano and Mooney (1984) report that girls generally obtain higher fear scores than boys. Werry and Quay (1971); Richman, Stevenson and Graham (1975) and Earls (1980) report from 12.8% to 16.5% of their sample with significant fears. Based on these studies one might make the risky inference that from 5% to 16% of children experience intensive fears. Much more research is required.

Obsessive-Compulsive Disorder in children is rare. The highest incidence rates seem less than 2% of cases studies (Milby and Weber, 1991). A 1.2% incidence in 405 children seen in inpatient and outpatient settings was reported by Judd (1965). In a pool of 2500 children Adams (1972) also found a 1.2% incidence. Flament et. al (1985) studied an entire school population of a New Jersey County and found a prevalence rate of .33% of the general adolescent population.

While clinicians report that anxious youth often report depressive symptoms, studies of the comorbidity with large samples is rare. Last et. al (1987) found that one third of 22 children who presented with separation anxiety had a coexisting major depression. Bernstein and Garfinkel (1986) reported that of a sample of 26 teens with chronic school refusal, 16 were diagnosed with an anxiety disorder and of that group 81% had a coexisting major depression. Berney et. al (1981) found 45% of school phobic children exhibited signs of significant depression. However, DSM-III criteria were not used in that study. Strauss, Last, Herson & Kazdin (1988) reported in the best designed study to date, that 28% of the children with anxiety disorder also met DSM-III criteria for major depressive disorder.

Much more research will be required on incidence and prevalence using DSM-III-R criteria before generalizations can be made with confidence.

CONTRIBUTING FACTORS

Infants have been observed to fear loud, unpredictable, sudden stimuli, loss of support and high places (Ball and Tronick, 1971). Fear of strange people and novel objects becomes more evident as the child approaches the end of the first year. (Bronson, 1972). Bowlby (1969) points out that infants show distress at separation from their caretaker. At around six months the infant manifests anxiety to novel stimuli. At six months fears of masks, dogs and jacks-in-the box also begin to emerge. These fears increase until 18 to 24 months and then decrease. Scarr and Salapatek (1970) found that children rated high on such fears at one point in time tend to be higher at a later date. This suggests that perhaps intensity of fear may be stable. Unlike earlier research (e.g. Agras, Chapin & Olivean, 1972), more recent research suggests fears and anxieties may be persistent (Reed et. al, 1992) and they report the following sources of anxiety at designated stages of development:

¨ From birth to six months fears of excessive or unexpected sensory stimuli, loss of support and loud noises are prevalent.

¨ From six to nine months fears of strangers and novel stimuli predominate.

¨ At the end of the first year fears of separation, injury or toilets are common.

¨ At the end of the second year monsters, imaginary creatures, death, robbers are dominant.

¨ By the end of the third year dogs, large animals and being alone arouse fearfulness.

¨ The end of the fourth year brings fears of darkness.

¨ School, injury, natural events and social anxiety are predominant from ages six to twelve.

Factor analysis of fears in children and adolescents yielded a five factor structure according to Ollendick, Matson and Helsel (1985):

(1) Fear of failure and criticism

(2) Fear of the unknown

(3) Fear of injury and small animals

(4) Fear of danger and death

(5) Medical fears.

Kendall et. al (1992) suggest that humans respond with fear to naturally occurring signs of danger such as loud noises and that this might be seen as having adaptive value. Furthermore, survival may be entranced by attachment to familiar figures while fearing strangers. However, what may be normative or even adaptive at one age may be maladaptive at later stage. Such a developmental conceptualization suggests that child and adolescent anxiety disorders, and even their adult derivatives, may represent natural survival mechanisms gone awry. While such speculation is intriguing longitutional research has yet been conducted to support such notions.

EARLY EXPERIENCES

Speculation about prenatal influence in developing anxiety disorder far exceeds sound research, and thus no conclusions are clear. However, the level of influence and the types of parent-child interactions that are influential at different stages of development has begun to be researched. Campbell (1986) provides an excellent summary of the interaction between development and parenting patterns; pointing out that caretaking behavior of key attachment figures play an influential role. Bowlby (1973), among others, has speculated that when the attachment figure is available and responsive, the infant develops a sense of security and trust. Conversely lack of availability and responsivity lead to heightened levels of anxiety and distress. Children’s anxieties and fears are seen as developing normally out of biologically determined species-specific responses that lead to avoidance of possible hazards and to approach of protective figures (Campbell, 1986). As the youngster develops cognitive skills the types of fears are transformed. However, at each stage fears have survival value. They signal the need to protect oneself from harm. However, it is naive to assume that such fears unreel themselves developmentally without influence from caretaker responses. The preschooler’s fears of animals, the dark or imaginary creatures are communicated to caretakers and the caretaker response is likely to have influence. Furthermore, complex fear reactions, such as fear of strangers, are very much influenced by the way in which the stranger approaches (Rheingold & Eckerman, 1973). Females are less fear evoking than males (Brooks & Lewis, 1976). In short there is variability in the level of the child’s reaction to situations and strangers, there is variability in the social context and also in the nurturing reassuring response of attachment figures. Maternal responsiveness and accessibility have been shown associated with secure attachments and securely attached infants are less anxious when exposed to events such as separation (Stayton and Ainsworth, 1973). While it seems likely that parental influences on development of adolescent or adult anxiety disorder begins very early in development, the lack of longitudinal research leaves such contributions in the realm of intriguing speculation.

GENETIC

Gittelman (1986b) summarized evidence indicating that anxious behavior can be bred selectively in animals and she reviewed available evidence supporting genetic influences in the development of anxiety disorders. Weissman et. al (1984) studied the psychiatric states of children of normal and depressed women and found the rate of anxiety symptoms much higher among the children of depressed/anxious individuals than among pure depressive and normal controls. The most common anxiety symptoms among the children was separation anxiety. The type of anxiety disorder in the parent seemed a factor with the offspring of patients with panic disorder showing greater risk. Two additional studies by Berg et. al (1974) and Gittelman-Klein (1975) gave mixed support to the influence of heredity with the Gittleman-Klein (1975) research lending limited support. There is also evidence supporting genetic influence in OCD. Elkins, Rapopart and Lipsky (1980) reviewed the twin studies and found four that examined a total of 30 sets of twins of which 24 showed concordance for OCD. Gittelman (1986) pointed out that there are enough positive results to warrant systematic inquiry. However, much more research is required.

ENVIRONMENT

Learning and conditioning theories about anxiety disorders have undergone considerable change since Watson’s early formulations (Watson & Rayner, 1920). Demonstration of the simple respondent conditioning paradigm with Albert and furry objects has been challenged by subsequent failures at replication (Gray, 1971; Marks, 1969; Seligman, 1970) and by the clinical observation that many individuals with anxiety disorders do not present with history that justifies the theory. In addition the following observations challenge traditional respondent conditioning theory:

(1) Seligman (1970, 1971) has interpreted findings as an indicator that natural selection has led humans to be genetically “prepared” to develop certain type of fears. All conditional stimuli are not the same. Furry objects, snakes and spiders are more likely to evoke fear than flowers and wooden blocks.

(2) Fear can be transmitted vicariously without direct experience with the object of fear (Bandura and Rosenthal, 1966).

(3) Rachman (1977) cities surveys, epidemiological studies and observations by anthropologists that fears do not occur in patterns expected by traumatic interactions with objects and situations.

(4) Rachman (1977) also points out conditioned stimuli (CS) and unconditioned stimuli (UCS) pairings often do not result in acquired fear reactions. The CS being, for example, a furry, white rabbit and the UCS being a loud noise.

(5) Eysenck (1976) has pointed out that fear responses don’t diminish with repeated CS-only presentations.

In an excellent review of learning approaches to anxiety Delprado and McGlynn (1984) propose a multifaceted framework for anxiety disorders. Anxiety is said to refer to an intricate composition of action modes, developmental origins and maintaining conditions all of which must be taken into account. Such a conceptualization runs counter to a unitary concept of fear and is much more compatible with research findings. Anxiety manifests itself within three distinct response systems: (1) overt motor behavior, (2) physiological, and (3) cognitive. An understanding of a given patients symptoms must be understood by its presentation within each of the three systems. Unlike traditional learning theory Delprato & McGlynn (1984) insist that the developmental origins of an anxiety disorder may be in complex interaction that involves respondent or operant conditioning, modeling and/or information transmission (e.g. instruction). And regardless of its origin the disorder may be maintained though respondent, operant, modeling or information learning processes.

Kendall et. al. (1992) proposed a model for cognitive aspects of the development of an anxiety disorder in children and adolescents across time. In their formulation the disorder begins with a behavioral event that is magnified because of heightened emotional intensity. At the culmination of the behavioral event an explanation of the event is formulated. This is referred to as an attribution and is conceived as a relatively short lived event. However, when multiple behavioral events and event outcomes follow the initial event, the youngster begins to develop a more precise anticipatory cognition or expectancy. Bandura (1977) described expectancies as of two types: outcome expectancies and self-efficacy expectations. Expectancies develop, including expectation of catastrophic outcomes and expectation of an inability to cope with events when situations of concern (e.g. phobic object) present themselves. Without corrective experiences the pattern may become something of a vicious cycle and the expectations evolve into consistent cognitive patterns (e.g. schemata) and attributional styles that are counterproductive. If this is the case therapy must become a learning process to reduce support for dysfunctional schemas and construct new schema.

FAMILY INTERACTION

The influence of parenting and family interaction patterns on the development of anxiety disorders has been the product of more speculation and clinical lore than research. Bowlby (1961) has suggested that separating from the mother early in life makes children vulnerable to later anxiety states. However, research has not borne this out (Shepherd, Oppenheim and Mitchell, 1971). In the case of obsessive compulsive disorder, Rachman and Hodgson (1980) have observed that parental reaction to OCD are of two types: rejection and overindulgence. Studies of family characteristics of OCD youth have included Adams (1973) study in which certain family characteristics were noted: These families:

(1) were highly verbal

(2) placed positive emphasis on etiquette

(3) valued social isolation or withdrawal

(4) emphasized cleanliness

(5) adhered to an instrumental morality

(6) derogated maleness

(7) practiced limited commitment – - religion, politics and social views

(8) had a hoarding orientation toward money

Other researchers (e.g. Tseng, 1973 and Manchanda and Sharma, 1986) have presented intriguing findings about the families of youngsters with OCD. Ambiguity characterizes research on family characteristics and other anxiety disorders.

RESEARCH ON EFFECTIVENESS OF CLINICAL INTERVENTION

There remains a dearth of information on the value and effectiveness of the various forms of treatment for anxiety disorders in children and adolescents (Reed et. al, 1992). As is the case with many other disorders, behavioral approaches represent the exception. Because of this the primary focus of the remainder of this chapter will be on those approaches. Effective methods of intervention for child and adolescent anxiety disorders can and will be categorized as follows:

¨ exposure

¨ modeling

¨ contingency management

¨ cognitive-behavioral techniques

¨ pharmacotherapy

¨ family therapy

Representative research will be examined in each category.

Exposure Techniques

There are a variety of behavioral techniques that involve the key element of exposure. Systematic desensitization (Lazarus, 1959), and implosion therapy (Blagg and Yule, 1984) are among the common techniques appropriately included. Response prevention (Mills et al., 1973) is another. Exposure therapies have in common the presentation of the anxiety provoking situation in imagination or in vivo, in either a graduated or intensive fashion with or without incompatible or alternative coping responses such as relaxation. The supposed theoretical underpinnings for the approaches are far less important than an understanding of the clinical operations encompassed by the strategy or technique.

Research on the role of relaxation training as a discrete techniqiue has been neglected. It was introduced as a counter conditioning element as part of a desensitization procedure (Wolpe & Lazarus, 1966). However, it can also be viewed as a coping device that provides for more intensive exposure and the cognitive changes that may attend such exposure. Regardless of the theoretical purpose it should be an important starting point for effective clinical intervention. Morris (1973) and Cautela and Groden (1978) have reported a shaping procedures to teach gradually longer periods of eye closing and methods of tensing or relaxing appropriate muscle groups. They also suggest use of toys of various types to promote effective learning. Morris and Kratochwill (1983) outline a detailed relaxation program for treatment of fears based on Jacobson’s (1938) pioneering work. Once the child or adolescent develops basic proficiency in the office, practice homework is ordinarily given (Bergland & Chal, 1972; King et. al., 1988). The level of proficiency required depends in part on the use that relaxation is to be put during subsequent treatment. Its use as a coping device in exposure to intensive anxiety provoking situations requires a high level of skill. Koeppen (1974) originally reported and Ollendick (1978) revised relaxation techniques for children that is often called the “Turtle Techniques” because it employs imagery and a story involving a turtle. The scripts can be found in their entirety in Ollendick and Cerny (1981).

The first step in development of any exposure treatment is the development of an anxiety hierarchy. As Morris and Kratochwill (1991) point out this is often done using index cards on which the parent, child or adolescent writes the situations that provoke anxiety. The level of anxiety is then rated and the situations are placed in hierarchical order.

When desensitization is the selected strategy the hierarchy is presented in imagination from the least distressing to the most distressing while the child tries to remain relaxed. Taylor (1972) and Miller (1972) have reported successful use of desensitization with school related fears. Other successful uses of desensitization have been reported Kushner (1965) with a fear of driving; Saunders (1976) with motion sickness; Obler and Terwilliger (1970) with fears of dogs or use of a public bus.

In vivo desensitization involves exposing the child or adolescent to progressively more distressing situations in reality rather than in imagination. Wilson and Jackson (1980) and Waranch, Iwata, Wohl and Nidiffer (1981) and Freeman, Roy & Hemmick (1976) have reported successful use of in vivo desensitization with childhood fears.

One of the key factors in selection of imaginal vs in vivo desensitization is the age of the child. Morris and Kratochwill (1983) point out that children cannot form visual images until they are approximately nine years of age. They suggest that imaginal desensitization should not be used until the children have reached at least that age.

There are a number of variations of systematic desensitization. Kondas (1967) and Barabsz (1973) have reported successful use of desensitization in small groups. Self directed desensitization has been reported successful by Baker, Cohen & Saunders (1973) and Rosen (1976). A creative variation that involves anxiety-inhibiting images in children called emotive imagery was first reported by Lazarus and Abramovitz (1962).

In treatment of OCD exposure and response prevention has become a treatment of choice. Mills and his associates (Mills, Agras, Barlow and Mills, 1973) were among the first to apply the technique to children. The child or teen is exposed to anxiety arousing situations in vivo while the ritual provoked by the situation is prevented in some fashion. Foa et. al (1980) and Steketee, Grayson and Foa (1981) have demonstrated that response prevention is essential in conjunction with the exposure.

Flooding is a variation of exposure treatment described effectively by Marks (1975). Ollendick and Gruen (1972) describe a case study of flooding using imaginal stimuli associated with monster movies. Screenivasan, Manocha and Jain (1979) treated a severely dog phobic 11 year old using in vivo stimuli. However, the lack of adequate supporting research has led investigators like Graziano (1978), Ollendick (1979) and Ollendick and Cerny (1981) to caution against indiscriminate use of these procedures. Given the lack of empirical support the risks that attend such procedures are unacceptable.

MODELING

Treatment that results from the observation of another person performing the desired behavior has been referred to as modeling (e.g. Bandura, 1969; Kazdin and Wilson, 1978). In treatment of anxiety disorders the paradigm involves a fearful observor who observes a model aged in the behavior the person has a history of avoiding. Most agree with Bandura (1971) that the model should perform the avoided behavior in a graduated fashion.

Bandura, Grusec and Menlove (1967) studied the effects of live modeling on the fear of dogs in children from three to five years of age. The children in modeling groups showed significantly more approach behavior than control groups. White and Davis (1974) examined the relative effectiveness of live modeling, observation/exposure only and no treatment on dental treatment avoidance in children four to eight years of age. Both the live model and exposure groups were significantly superior after treatment. Others have also reported success (Mann and Rosenthal, 1969; Ritter, 1968).

Symbolic modeling involves the presentation of the model through film, videotape or imagination. Bandura and Menlove (1968) reported on the effects of filmed modeling on the dog avoidant behavior of 48 children ages three to five. Symbolic modeling was as effective as live modeling. Melamed and Siegel (1975) studied the effectiveness of symbolic modeling on reducing the anxiety level of youngsters facing hospitalization and surgery. Filmed modeling significantly reduced all measures of situational anxiety and differences were maintained at follow up. Melamed and her associates have demonstrated effectiveness of symbolic modeling in a variety of situations (Melamed, Hawes, Heigy and Glick, 1975; Melamed, Weinstein, Howes and Katin-Borland, 1975; Melamed, Yurcheson, Fleece, Hutcherson and Hawes, 1978). An interesting variation on symbolic modeling involves reading stories to children on topics related to their particular fear. (Fasser, 1985; Mikulas, Coffman, Dayton, Frayne and Maier, 1985). While discussion of the relative contribution of model characteristics, client characteristics and modeling setting factors is beyond the scope of this chapter (See Melamed and Siegel, 1980 or Perry & Furukawa, 1986), it is important to distinguish between a coping vs a mastery performance by the model. While research findings are hardly conclusive most agree with Perry and Furukawa (1986) that the coping approach should receive primary consideration. This involves the model moving gradually from a performance that is similar to the patient/ observor to the competency level which is the goal.

Variations on modeling procedures include covert modeling in which the child imagines that he is interacting with the feared stimulus, participant modeling in which the child observes the model and then actually practices the behavior pattern observed and graduated modeling in which the complex behavior is broken down into its components by the model. (Morris and Kratochwill, 1991).

Positive reinforcement has been used alone and in combination with other behavioral therapy procedures to reduce various fears in a variety of settings (Conger and Keane, 1981; King et. al, 1988; Leitenburg (Leitenburg and Callahan, 1973) employed a procedure called reinforced practice to reduce children’s fear of darkness. Feedback was given regarding the exact time the children spent in a darkened room and praise was given. Vaal (1973) reported on the use of a contingency contracting system in successful treatment of a school phobia. Various privileges and activities of choice were made dependent on meeting criterion/target behaviors. Other variations on the use of positive reinforcement have also been reported (Ayllon et.al, 1970; Kellerman, 1980; Lazarus, Davison and Polefka, 1965; and Luiselli, 1977).

Shaping was reported used successfully to reduce school phobia in a 13 year old girl by Tahmisian and McReynolds (1971). A variation on stimulus fading, in which the mother was gradually faded from the preschool setting for treatment of separation anxiety was reported by Neisworth, Madle and Goeke (1975). An extinction procedure, in which reinforcing conditions are removed has been reported successfully used by Boer and Sipprelle, 1970; Herson, 1970 and Piersel and Kratochwill, 1981.

Contingency management has been employed successfully with school phobia. However, controlled studies have been rare and the generalizability of the findings to more severe clinical presentations remains questionable. Little has changed since Carlson et. al, 1986 concluded that the apparent promise of reinforcement procedures has yet to be satisfactorily demonstrated in controlled research. However, the use of such procedures as a part of a treatment package continues to be common.

COGNITIVE BEHAVIORAL

Kendall and Braswell (1985, p. 2) have pointed out that congitive-behavioral approaches encompass a variety of techniques that build on a basic set of assumptions:

¨ Cognitive mediational processes are essential to assure learning

¨ Behavior, feelings and thoughts are causally interrelated

¨ Cognitive events such as expectations, self statements and attributions are important in understanding and predicting psychopathology

¨ Behavioral and cognitive approaches are compatible

¨ The key therapeutic tasks are to assess cognitive processes and design new learning experiences to remediate dysfunctional patterns.

One of the first cognitive behavioral approaches, rational-emotive therapy (RET), was developed by Albert Ellis. While it began as an adult application it has more recently been extended to children and adolescents (Ellis, 1962, 1984). He presented the view that emotional difficulties were a result of irrational thoughts or beliefs. Several books have been published on applications of RET with children and adolescents (Bernard and Joyce, 1984; Ellis and Bernard, 1983). However, research has been sparse. Bernard, Kratochwill and Keefauver (1983) applied RET and self instruction to reduce high-frequency hair pulling. Van de Ploeg-Stapert and Van der Ploeg (1986) evaluated a group treatment approach employing RET for reducing test anxiety in adolescents. Results showed significant reduction in anxiety.

Kanfer and his associates (Kanfer and Gaelick, 1986; Kanfer and Schefft, 1988) have formalized a self control strategy that combines behavioral intervention with cognitive approaches. The child or adolescent received as having the capacity of learning to regulate their own behavior with the help of a therapist who acts in the role of instigator or motivator. The therapist teaches the client how, when and where to use various cognitions to facilitate the learning of a new behavior pattern in relation to particular feared stimuli events or objects.

Kanfer, Koroly and Newman (1975) compared the effectiveness of two types of verbal controlling responses on the reduction of children’s fear of the dark. The competence treatment group learned sentences that emphasized their competence (e.g. I am a brave boy). A stimulus group learned sentences that reduced the aversive qualities of the fear situation (e.g. the dark is a fun place to be). The results suggested that learning to improve one’s sense of competency with the help of a therapist outreacts in the role of instigator and motivator. Th therapist teaches the client how, when and where to use various cognitions to facilitate the learning of a new behavior pattern in relation to particular feared stimuli events or object.

Another early contribution by Lazarus and Abramovitz (1962) has been characterized as emotive imagery. The child or adolescent is taught to focus on cognitive images that inhibit anxieties. Fictional characters (e.g. Superman) and fictional events (e.g. conquering the fear) are common materials for the imagery. For example, Jackson and King (1981) used the technique with a child whose fears of the dark, noises and shadows followed a break in by a prowler. The child’s favorite character, Batman, was employed as a fantasy helper when the child was home in his room at night. Treatment was successful at termination and at 18 month follow up. Meichenbaum and his associate pioneered the use of self-instruction training as a cognitive treatment strategy (e.g. Meichenbaum and Goodman, 1971). Treatment involves having the therapist model cognitive strategies. Meichenbaum (1986) describes the treatment as follows:

¨ An adult model performs the task while talking to themselves out loud

¨ Child or adolescent carries out the same task under the model’s instruction

¨ Child or adolescent then performs task while instructing herself out loud

¨ Child or adolescent then whispers instructions to self

¨ Child or adolescent finally performs the task while using silent self instruction.

The self instruction model has been employed successfully in treatment of children’s fears by Fox and Houston, 1981 and Genshaft, 1982.

Kendall (1985) has proposed distinguishing between cognitive distortions and cognitive deficiencies. Deficiencies involve an absence of thinking (e.g. in impulsive youngsters) while distortions refer to dysfunctional thoughts (e.g., If I fail my mother will die). Anxious children and adolescents seem preoccupied with concerns about evaluations by self or others and they seem to misperceive the demands of the environment. Thus they add to their own stress level.

Kendall et. al., 1991 described an integrated cognitive behavioral strategy that attempts to teach children and teens to recognize signs of anxious arousal and then to let these signs serve as cues for alternative anxiety management strategies. The overall strategy at Temple University’s Child and Adolescent Anxiety Disorder clinic involve the following elements:

¨ coping modeling

¨ identification and modification of anxious self talk

¨ exposure to anxiety-provoking situations

¨ role playing and contingent reward procedures

¨ homework assignments (show that I can or STIC)

¨ affective education

¨ awareness of bodily reactions and cognitive activities when anxious

¨ relaxation procedures

¨ graduated sequence of training tasks and assignments

¨ application and practice of newly acquired skills in increasingly anxiety-provoking situations.

The overall approach to intervention is described in Anxiety Disorders in Youth: Cognitive-Behavioral Intervention by Kendall et. al., 1992. The book describes the sessions in some detail and thus can serve as something of a manual for clinicians seeking a comprehensive cognitive behavioral approach to intervention.

PHARMACOTHERAPY

Agents that have been tried in children and adolescents with anxiety disorders include neuroleptics, psychostimulants, antihistamines, anxiolytics and antidepressants. While neuroleptics have been used in anxiety states Gittleman-Klein (1978) reviewed the literature and concluded there was little support for the use of neuroleptics in child and adolescent anxiety disorders. Since then it is generally conceded that neuroleptics are not a viable class of drugs for anxiety disorders due to irreversible side effects and the availability of safer alternatives. While stimulants have been tried, Gittleman and Koplewicz (1986) pointed out that there is no evidence stimulants are effective, and there is some evidence they may be contraindicated. The same authors go on to point out that evidence for the effectiveness of antihistamines is clearly wanting.

Antianxiety agents or anxiolytics are commonly used for anxiety symptoms in clinical settings. However, they are not useful for some patients (e.g. anxious manics) and may be inferior to alternatives such as tricyclic antidepressants for some types of anxiety disorder (e.g. panic disorder). While barbiturates are the oldest of the sedatives, Gittleman and Koplewicz (1986) point out that they are no longer a part of modern psychopharmacology. They have been replaced by the safer benzodiazepines. While there is a large amount of information on treatment of adult anxiety disorders, the available literature on applications with children and adolescents is severely limited. This led Gittleman and Koplewicz (1986) to conclude that documentation of usefulness is lacking. This does, however, not rule out possible efficacy.

Antidepressants, on the other hand, have shown significant promise. Two tricyclic antidepressants have shown particular promise: Imipramine and Clomipramine. Imipramine has been found effective in inducing a return to school, in reducing other anxious symptomology and in providing for improvement in depressive symptoms. Gittelman-Klein and Klein (1971, 1973, 1980) and Bernstein, Garfinkel and Borchardt (1987) studied the effects of Alprazolam and Caripramiase on overanxious disorder and found Alprazolam significantly superior. Klein and Last (1989) have more recently questioned the efficacy of tricyclic medications with separation-anxious children in light of more recent unpublished research.

A newer drug that is chemically related to imipramine, clomipramine (Prozac) has found use with children and adolescents with obsessive-compulsive disorder. Rapoport, Elkins and Mikkelsen, 1980 and Flament et.al, 1985 have obtained results supportive of the use of clomipramine in relieving obsessive-compulsive symptomatology.

Gittelman and Koplewicz (1986) have concluded that tricyclics seem to play a legitimate role in management of some severe, early anxiety disorders. However only two diagnoses, separation anxiety and obsessive-compulsive disorder have been subjected to systematic scrutiny.

Family Therapy

Cognitive-behavioral approaches are quite compatible with systems models that posit that children are part of a network of activity. Family involvement is an essential element in treatment of anxiety disorders in children and adolescents. Mills, Agras, Barlow and Mills (1973) found that parental involvement was an important element in a successful response-prevention program. Kendall et. al. (1992) enlist parental cooperation in the application of their cognitive behavioral intervention. However, the focus of treatment remains on the anxiety of the youngster. Kendall’s approach (Kendall et. al, 1992) is to encourage a spirit of collaborative problem solving in which family members can look at their behavior patterns, expectations and attributions and how those may be contributing to the youth’s presentation and the methods that must be developed. Within any family this may include changing:

¨ parent’s unhelpful expectations of their child or adolescent

¨ the child or adolescent expectations about themselves

¨ the child’s or adolescent maladaptive beliefs

¨ patterns of attribution about the causes of behavioral outcomes

Within the framework of family intervention Kendall et. al, 1992 engage in role playing, family brainstorming and problem solving, family relaxation training and evaluation and reinforcement of appropriate patterns of behavior.

More traditional family therapy may also be an adjunct to effective treatment of anxiety disorders (e.g. Haley, 1976; Minuchin, 1974). Anxiety disorder symptoms may be conceived as part of a disturbed family system. For example Harbin (1976) described strategic family therapy with a 16 year old with a compulsion to redo homework. Treatment included a change in parental discipline and alteration of a hostile relationship between the child and the mother.

The lack of systematic research on the effectiveness of family therapy with anxiety disordered children leaves the matter in the hand of the individual clinician and their level of comfort level with these approaches. However, experienced clinicians and Mills et. al (1973) caution that to leave the family out of treatment may increase the risk of relapse.

PREVENTION

Like the weather, prevention is something about which there is a great deal of talk and pitifully little action. This, and the lack of methodological rigor, led Peterson, Zink and Farmer (1992) to conclude that preventive efforts have a small constituency, continue to be underfunded and to be under researched. Also, the lack of understanding of the specifics of etiology make preventive programs for specific problems (e.g. anxiety disorders) a highly speculative matter. The distinction between primary, secondary and tertiary prevention in the medical sciences has been applied to mental health (Winett et.al., 1989). Primary prevention involves reducing the incidence of new cases of the target disorder, secondary prevention involves reducing the duration and severity of the disorder and tertiary prevention involves reducing the severity and disability of the disorder. While the community mental health centers were to have addressed prevention as one of its primary missions, serious applications were few and results were disappointing.

Winett et.al (1989) have proposed an integration of community psychology and concepts of public health in addressing prevention on the heels of the failure of the original goals of community mental health. They propose that prevention intervention can take place at several levels including at the level of the individual, at an interpersonal level (e.g. families or groups), at an organizational level (e.g. school) or an institutional level (e.g. day care licensing or entire school systems). They also point out that at any given level the approach may be either a passive waiting mode or an active interventionist mode.

Unfortunately the state of research on the conditions that lead to psychological disorders makes an aquisition-oriented (Chassin, Presson & Sherman, 1985) approach to prevention difficult. The same set of conditions (e.g. high stress and social isolation) may contribute to a wide variety of specific disorders (e.g.depression, anxiety, child abuse or alcoholism). This makes some of the more general approaches to prevention applicable to anxiety disorders. Specific approaches remain extremely rare.

Affective education is one area for primary prevention that could influence both development of depression and the development of anxiety disorders. Examples of such programs are the Human Development Program (Bessell & Palomares, 1970) and Developing Understanding of Self and Others or DUSO (Dinkmeyer, 1970). Provided at an organizational level in elementary school such programs have targeted improved self esteem, peer relationships and motivation.

In addition, such affective education programs could be more effective in prevention of anxiety disorders if they addressed such skills as:

¨ Developing cue controlled relaxation skills

¨ Conquering fear (e.g. what to do when you are scared)

¨ Developing self control

¨ Facing criticism constructively

¨ Stress management skills

¨ Thinking and feeling

¨ Problem solving under stress

¨ Improving self esteem

¨ Going to sleep

¨ Worry vs solving problems

Major stressful life events may be assured to contribute to an exacerbation of the symptoms of anxiety disorders. Parental divorce is clearly one such stress. Two of the best known models are the Divorce Adjustment Project: Children’s Support Group (CSG) (Stolberg & Garrison, 1985) and the Children of Divorce Intervention Project (Pedro-Carroll & Caven, 1985). Such programs are delivered in groups and often involve teaching and practicing cognitive behavioral skills such as relaxation, problem solving, communication and self control. The gamelike approach often stimulates motivation for both children and parents.

Proposals made by Winett et al and others that might contribute to prevention of anxiety disorders include:

¨ Improving parenting skills (e.g. love and support)

¨ Improving family support skills

¨ Training for child care workers

¨ Training for teachers

¨ Improving child care resources

¨ Programs for preparation for medical or dental procedures

¨ After school programs

¨ Improved television programs for children

¨ Early identification of anxiety disorders and early intervention

¨ Early development of stress management skills.

Without more research on the effectiveness of such programs it must be said that prevention holds much in the way of promise that has yet to be realized. In the meantime the attempt to correctly diagnosis and treat child and adult anxiety disorders continues.

References available on request.

Harry L. Mills, Ph.D.

Managing in healthcare is not the same as managing a widget factory even if advocates of the generic-all-purpose-managers, who can manage anything at all, would claim otherwise. Healthcare organizations are part businesses but that is not the whole story. The lives of people are at stake in organizations delivering healthcare services. Making a profit is less impressive when dead people or ruined lives are a byproduct. Quality must be programmed into the service systems. It is not a product of committee meetings or those notebooks loved by auditors. Quality is a moral imperative in healthcare. Thus is requires a new kind of leader.

The New Knowledge

Leaders in healthcare can depend on knowledge that has accumulated and been tested repeatedly since World War II. In WWII the fate of the world depended on the development of management techniques and methods of quality control that were certain to work. Among those who stepped up to the plate was a man with a doctorate in mathematical physics named W. Edwards Deming. During World War II our soldiers were brave, but so too were the soldiers of our enemies. It was our industrial might that beat the Nazis and Japanese. Rafael Aguayo points out in his book The Metaknowledge Advantage, that industrial success in WWII was the first confirmation of the new approach to management based on the revolutions in science that took place in the first half of the century. New knowledge based on new science.

The second substantiation of the new knowledge came after WWII when General Douglas Macarthur was struggling to help lift Japan from its ashes. At the time the term ‘Made in Japan’ was synonymous with very poor quality. Macarthur remembered the miraculous transformation of American industry during the war and invited people such as Deming to Japan to work with industry leaders. The Japanese embraced the techniques wholeheartedly because they believed that it was the might of American industry that defeated them. The recovery of Japan and its transformation into an industrial power that would become dominant over the US in industry after industry, from cars to televisions, was the second testimony to the new knowledge.

By the 1980s American industry could no longer rest on its laurels, as it was able to do just after WWII. Competition in the marketplace led to the rediscovery of Deming and the proponents of the new knowledge and the new approach to leadership. Companies as diverse as Harley Davidson, Ford and Motorola began to apply these methods to regain their share of markets by producing better products. By the 1990s even skeptics like Jack Welch of GE were applying the proven methods under a new name, Six Sigma. Same information with a new name. The successes of companies like Ford and GE were the third proof of the new knowledge which provides the foundation for the new leadership.

The new leader can turn to knowledge that builds on the foundation of the scientific transformations of the first half of the 20^th century. However, to succeed it must be built on three commitments:

1. Insisting on an intense focus on the patient and development of ways to bring the voice of the patients into the health organization.
2. Insisting on an intense focus on the methods (a.k.a. processes) that produce high quality services to patients.
3. Insisting on a continuous effort to innovate and further improve the way services are delivered.

With these key commitments and a continuing effort to develop and grow in the ten areas introduced in this program, you can begin to build your leadership on a solid foundation.

The New Leadership

Bookshelves are filled with texts on how to become a better leader. Some books suggest imitating leaders from the distant past, including such figures as Attila the Hun and Robert E. Lee. While one may glean snippets of knowledge from such sources, the modern workplace is very different from the plains of Mongolia or the hills of Gettysburg. Modern workers are highly educated, tuned into the world through CNN and capable of voting against a bad boss with their feet. Modern organizations are very complex and the production of products and services requires increasing levels of technical knowledge. Above all there has been an explosion of information and the world is now connected, and made one community, by electronic marvels like the internet. Waving swords and battle flags is more likely to lead to arrest than to success.

Leading healthcare professionals, who are called knowledge workers because we need what is their head more than we need their muscles, is a little like herding cats. Healthcare professionals expect communication and prefer participation. Even the modern Marine Corps requires a much more sophisticated form of leadership than a shouting drill instructor. It is doubtful that Attila the Hun or Robert E. Lee would be a great leader in any modern company. To succeed they would require all of these:

1. The ability to think of organizations as systems.

2. The ability to understand that real events exhibit high levels of variability.

3. An understanding that change is constant and that no organization can stand still without going backwards.

4. The ability to build and manage teams that have a laser-like focus.

5. The ability to be a performance manager and coach for individuals and for teams.

6. The capacity to formulate a vision for the future of the organization (or team).

7. The ability to analyze trends, solve problems and make appropriate decisions.

8. The continuing refinement of emotional competency.

9. The ability to communicate to superiors, peers and followers.

10. Continually building resilience to adversity and thus the ability to bounce back from disappointment.

For the new leader, pursuit of excellence, in these ten areas, must be a continuing effort. The goal is mastery, so as each new skill is developed there will always be a higher level to which the leader can strive.

In no area is this more important than in healthcare. There has been a trend since the 80s to turn healthcare into a commodity and to sell life and death like beads in a bazaar.

Systems Thinking

Ask about an organization and you may be handed an organizational chart with boxes in neat little columns and rows. While most people know, intuitively, that a page of boxes does not conform to workplace reality, few are aware of the degree to which such notions damage managerial effectiveness. Hierarchies of boxes promote silo thinking and that is the opposite of systems thinking. Departments can, and often do, become silos (those tall, thin windowless structures that are great for storage of grain). Organizational silos in healthcare promote terrible patterns of organizational behavior and declines in the quality of care. Windowless walls tend to retard essential communication and inhibit cooperation. Each silo, or department, tends to optimize itself, often at the expense of the organization as a whole. Leaders in such organizations spend much of their time passing information from silo to silo and resolving the conflicts that must arise from silo thinking. Too little time is spent ensuring that work processes are being done in a way that impact patients positively. Such organizations tend to place customer satisfaction way down on the priority list, because they are too busy with fights between silo managers and playing games that are a product of poor communication and limited cooperation.

While discussions of systems often drift into lofty abstractions, it is actually a very practical concept. Peter Sholtes, a disciple of quality guru W. Edwards Deming, says these are characteristics of a system:

1. A system is a whole composed of many parts. He suggests a car as a concrete example of a system.

2. Each unit, or part, of the system has a different purpose in relation to the overall purpose of that car providing transportation.

3. Each unit or part contributes to the overall purpose, but no part can do so by itself. You can’t drive the brakes to the airport, but just try driving to the airport without brakes.

4. The parts are dependent on one another, or interdependent, in fulfilling the goal of transportation. You will not get where you need to go without an accelerator pedal. but it must be connected to the fuel injection system

5. To understand a unit, or part, you must understand how it is dependent on other parts and how it fits into the whole system (e.g. to provide transportation).

6. To understand why the system works you must look to the larger systems of which it is a part. Having a steering wheel on the right will work in some countries but not others.

7. To understand the system you must understand the purpose, its interactions and its interdependencies. Spreading the parts out on the floor tells you very little.

Any organization is a system with social and technical components. There are interdependent parts (e.g. departments, divisions, teams, individuals) each of which has interests and purposes which should, but do not always, contribute to the primary goals of the organization. The new leader must look at the system as a whole, understand the importance of interdependencies and ensure all parts contribute to the whole.

Variability and Process Control

Is the temperature in the room where you sit with your computer always exactly the same? Does it always take the same amount of time to drive to work? Does the sun rise and set at the same time each day? There is variation, right? That is the way the world is, and yet leaders often pretend the business world is not that way. The delusion that it is a black and white world and that any single number (e.g. last quarter profits) represents reality is a source of a great deal of foolishness. Too many leaders try to manage in the 21^st century with 18^th century thinking. The new leader must not do so.

Leaders who disregard variability are much like B.F. Skinner’s pigeon in the famous Skinner box. When pellets of food were presented at random, the pigeons foolishly linked the food with various body movements. If their heads were rocking when the pellet appeared, they rocked their heads. If they were turning around they turned around. These movements had nothing to do with the food. However, the world is full of leaders who are dancing around like pigeons. They are operating in a world of superstition.

When a leader fails to understand variation, or fails to even acknowledge its existence, these kinds of mistakes are made:

• Seeing trends when there are actually no trends
• Missing trends when there are real trends
• Leaping to blaming individuals or groups of individuals who had no real influence
• Giving credit to individuals or groups who were simply lucky
• Launching disruptive programs for improvement when no improvement is needed
• Failing to identify areas for improvement when improvement is needed

The leader who fails to recognize the importance of variation is likely to leap to conclusions from too little data. Can you predict the temperature of your room three hours and twenty minutes from now, based on one measure, such as the temperature right now? Can you specify to the second, or even the minute, how long your drive to work will take tomorrow based on the time it took this morning? Unlikely. Can you predict what next quarter’s profit will be based on the last quarter? No. You cannot interpret such numbers without understanding variation. One number by itself is never enough.

The new leader must place as much emphasis on the statistics of variation as on the profit and loss statement. In any business there are key processes which determine whether customers will pay for the product or service, and the new leader must be a wise student of those processes. The new leader cannot afford to become a superstitious pigeon. If the business requires a telephone response, and the length of time required for an answer determines customer satisfaction, then the leader must understand those processes well in order to determine if, and when, those processes require change. The new leader cannot know when changes need to be made without understanding variation. Superstition costs money.

Leading Change

The new leader knows that tomorrow will not be like yesterday. Change is a constant fact of life. The new leader seeks to work with the forces of change. The surfer seeks to ride the waves and not to stop them. A leader in the global economy must be a change surfer. The old leader mutters platitudes like “people don’t like change” when faced with the fact that up to 75% of corporate change programs do not yield desired results. To find out why most change programs fail, the leader should look in the mirror.

Actually life, by its nature, is about adapting to change. Of all the species on earth, humans are the most adaptable. People don’t like being changed, but they find change, when properly managed, exciting and exhilarating. The key is leadership.

When there is resistance to change, it is because change is viewed as having risks. Actually not changing may carry more risks, but we tend to get comfortable when things stay the same. Often the old leadership shoves all the risks to subordinates while taking few, if any, themselves. The new leader is willing to absorb risk and help employees appraise their own risks. In fact, the new leader realizes that if you are not risking your job, you are not doing your job. Followers will risk more when the leader is already willing to do the same. The new leader is a risk taker. You cannot steal second base with your foot still on first.

John P. Kotter in his excellent book, Leading Changes, identifies an eight stage process for creating major change:

1. Establishing a sense of urgency – the new leader must define the market reality that compels change, and do so with clarity

2. Creating the guiding coalition – putting together the groups that have the power and know how to bring about the changes

3. Developing a vision and a strategy – the vision must be shared and must be clear enough, in defining the end product

4. Communicating the change vision – the new leader keeps the desired ends in front of people

5. Empowering broad-based action – there will be obstacles and those obstacles must be systematically removed

6. Generating short-term wins – the new leader defines shorter term milestones on the way to the goal, each of which can be celebrated.

7. Consolidating gains and producing more change – other systems, structures and policies that no longer fit must be changed also

8. Anchoring new approaches in the culture – the new changes must be tied to the values and patterns of the culture to be sure the changes endure

Leading change is one of the biggest challenges for the new leader. Improving skills in planning and leading change is a continuing process. It is best to begin now.

Building and Managing Teams

Teams work. That fact, and the flexibility required for organizations to adapt to the constant changes of the global market place, are reasons why the new leader must develop skills in creating and managing teams. The rigid old organizational structures are being replaced with more fluid designs that can better serve customer needs. Teams will do more of the work that used to be done through the hierarchy. However, teams are only as good as the leadership. The good news is that teams can reduce costs and provide better solutions. The bad news is that teams can be a real challenge for leadership. Teams can be useful in these ways:

• To save time and costs by cutting through layers of hierarchy
• To integrate the work of people with different competencies and points of view
• To arrive at more innovative solutions through the synergy of diversity
• To generate high levels of involvement by giving a group of people with a clear focus, authority, responsibility and accountability
• To free leadership to focus on the customer

What is a team? In general, a team is a group of individuals with a common purpose. The common purpose of a professional football team is to win games. However, teams in the workplace are groups of people who are collectively responsible for achieving a specific outcome. A team may suggest improvements in the way a product is created or a service delivered. If properly selected, from different parts of the organization, a team can bring a unique perspective to problems that would not be possible from inside the hierarchy.

Because of increasing pressures for high levels of performance, organizations use teams to bring multiple perspectives to a problem, or program, a set of customers or an important work process. With creative leadership there may be an unlimited number of purposes for the use of teams. Susan Mohrman and Allan Mohrman in Designing and Leading Team-Based Organizations suggest these five types of teams:

1. Work teams – which perform the core work of the organization. They employ resources (e.g. labor and raw materials) to produce the products or services of the organizations

2. Integrated teams – which coordinate and integrate the work of different parts of the organization to add value to products or services

3. Management team – which makes authoritative decisions about strategy, priorities, services, allocations and organization for a business unit

4. Involvement teams – which perform tasks that were once the domain of management such as Six Sigma performance teams.

5. Improvement teams – which plan and introduce changes that improve the quality of products or services.

When properly managed teams can be a major asset. When poorly managed, as is often the case, they can be counterproductive. The new leader will face the challenge.

Performance Management and Coaching

Far too often leaders conclude that the employee is the problem and the leader must train, transfer, threaten, discipline or replace them. Assuming that defective people are the root of all performance problems is as illogical as assuming that bad batteries are the root of all automobile malfunctions. There may be need for changes by the employee. The problem may very well be the battery. But good leaders, and good mechanics, realize that batteries and employees are part of a system. If the mechanic is only interested in assigning blame, then blaming the battery is easy. If, on the other hand, the goal is to fix the car, the mechanic had best conduct a more careful assessment. The goal of the new leaders should be to fix performance and to succeed performance must be carefully analyzed.

Geary Rummler and Alan Brache in Improving Performance point out these elements must be involved in any analysis of performance, if change, rather than blame is the goal:

1. Performance specification

2. Task support

3. Consequences

4. Feedback

5. Skills/knowledge

6. Individual capacity

To clarify we should look at each stage in the analysis a little more closely.

The first phase of analysis addresses the question of whether performance standards exist and if so, are they clear? If they are clearly stated, does the employee understand them? If the standards are vague or if the employee does not understand them, the review might very well end there. The solution may be clarification and not elimination.

The second area of analysis requires a review of the flow of resources. Did the material arrive on time? If there are problems upstream those problems should be addressed. Leaders must explore whether there was sufficient support for performance.

The third area of analysis is to examine the consequences of performance. What happens if employees do things right? What consequences are wired in to support positive performance? It is essential for the new leader to examine the timeliness of feedback about employee performance. Feedback on performance should be frequent, relevant, accurate, specific and understandable.

Whenever there is a performance problem the new leader must ask if the employee has the knowledge and skills needed to perform the tasks in question. If not, coaching or training may be the right solution

Finally, does the person have the individual capacity physically, mentally and emotionally to perform. Even good people have performance problems under great stress. The new leader does not leap to blaming, rather, they solve problems.

Vision, Inspiration and Motivation

A vision is a doable dream, or a simple, easy to comprehend and possible goal toward which you would like your business to work. Visions are important to the extent that they channel motivational energy. A vision of a feast is likely to energize a starving man. A vision trigger is a statement, slogan or picture that reminds people of the ultimate goal. But the energy to achieve the goal comes from the match between the inner striving of those led and the vision and not from the vision itself. Going away for a weekend with a consultant to write a vision statement is likely to be a waste of time and money. Energizing visions must arise between the leader and those who are led.

The primary purpose of a vision is to keep the goal in mind. But to be transforming a vision must be appropriate to the organization and its time. It must be consistent with the values, culture and history of the organization. There must be a match. The vision of a personal computer on each desk did not thrive at IBM. Good vision. Bad match.

A good vision should be uplifting. It should set standards of excellence and reflect high ideals. A vision can be about what is possible even when it is not highly probable. The vision should clarify purpose and direction. It should define what the organization wants to make happen and define legitimate aspirations for people in the organization.

A vision should inspire enthusiasm and commitment. Done properly a vision can recruit diverse followers for the leader. The vision should be well articulated and readily understood. It will not inspire if it is not understood.

Even a well articulated vision will not energize an organization unless the new leader waves the flag regularly and thus ensures that the mission, goals and objectives for the organization serve the vision. The alignment of energies does not automatically follow. The leader should use the vision like the sailor uses the North Star. The sailor must constantly review their direction and their progress in relationship to the star. The leader should track progress in relation to the vision.

The popular press has created a myth that successful companies begin with a vision and are headed by charismatic visionaries. Not true. Successful visions often evolve even when they are not defined at the outset. James Collins and Jerry Powers of Stanford University Graduate School of Business have studied successful organizations, and they find that this is not the case. Their examples are interesting. Bill Hewlett and Dave Packard, who created Hewlett-Packard, did not have the slightest notion of where they were going when they started the company. Masaru Ibuka, who built Sony, started out with bean paste and miniature golf equipment. Sam Walton started out with a Ben Franklin franchise and later told the New York Times, “I had no vision of the scope of what I would start.” J. Willard Marriott just wanted to be in business for himself, but he had no idea what that business might be.

Business success requires the evolution of a vision, though it may not be perfectly clear at the outset.

Analysis, Problem Solving & Decision Making

The first job of a leader is to make decisions. To fail to make decisions is to abdicate leadership. There is no simple formula for decision making. Leaders face making decisions in a pressure-packed environment of inadequate input, conflicting recommendations, scarce resources, and budget constraints that limit options.

How can the new leader be thorough and methodical in analysis and problem solving, without falling into analysis paralysis? President Kennedy had an advisor from Harvard who droned on and on saying, “On the on hand…on the other hand… or on the other hand.” JFK stopped him and said, “Please pick a hand.” When the advisor looked at him quizzically JFK simply said, “Now is the time for you to pick a hand.”

Paul Hersey, Ken Blanchard and Dewey Johnson in Management in Organizational Behavior point out that there is no one decisional style that fits all circumstances. The new leader does not get locked into a single style, no matter how comfortable that style may be. There are four major approaches:

• Authoritative
• Facilitative
• Consultative
• Delegative

Authoritative decision making applies in situations in which the leader has information and experience to make a decision, makes the decision and then and announces that decision to subordinates. In crisis situations and in situations in which subordinates have little to offer, this is an appropriate style.

Consultative decision making also involves the leader making the final call but only after knowledgeable and willing followers offer their input. When others can increase the likelihood of a good decision, the leader is a fool not to ask. However, the leader should make it very clear that she will make the final decision and may not follow the advice given.

Facilitative decision making is a cooperative effort in which the leader and the followers reach a shared decision. In this case the leader actually shares authority so it is very important that those followers have both knowledge and the positive motivation to help make the best decision.

Delegative decision making is used when followers have the knowledge and experience to make a decision and then recommend a course of action to the leader. The leader throws the ball to others, and stands back to let them make the shot to the basket. The new leader realizes that, with the educated staff found in the modern workplace, one style does not work. The new leader is flexible.

Emotional Competency

Leadership is as much about the heart as the head. It is emotions that energize followers and motivate them. It is passion that inspires. Followers often match their emotions to the emotion of the leader. It is much like the two tuning forks in high school science. Tap one to get it vibrating and place it near another. Shortly the second will vibrate at the same frequency. The new leader must recognize that emotional resonance is part of effective leadership. Passion recruits passion. Joy recruits joy. Anger may very well recruit anger. A leader who is unable or unwilling to exhibit emotion will be short of followers.

The new leader must be emotionally intelligent. The concept of emotional intelligence was popularized by Daniel Golman based on the pioneering work of Peter Salovey at Yale. Emotions play a role in orchestrating our responses to events. Fear leads to running away from danger which can be a very intelligent thing to do. Anger leads to social or even physical aggression that can be very valuable for survival. Emotions help organize our reactions and, in fact, work in full partnership with thinking. Effective leaders appeal to both the head and the heart.

Salovey believes that emotions actually help us prioritize, by directing attention to options that have higher survival value. Happiness can actually facilitate reasoning and creativity. Changes in mood can signal a need to review what is happening around us. Emotions help us remember and can help us in making judgments. In short, according to Salovey, the notion that thinking is good and feelings are bad is pure nonsense. We need both.

The emotionally intelligent leader is able to recognize and properly identify emotional states in themselves and in others. Those who cannot recognize emotional states in others are very likely to make big mistakes in judgment about people and motivation.

The ability to manage emotion in oneself, by moderating negative emotions and enhancing positive ones, is essential to effective leadership. Leaders who cannot control the experience and expression of anger are condemned to be significantly less effective. Emotionally intelligent leaders can regulate their negative emotions.

Emotional intelligent leaders are capable of empathy. They can appreciate what other people are feeling and identify with those feelings. They can use that understanding to develop strategies for influencing that person in the service of the organization. A lack of empathy renders the leader much less effective. Empathy helps the leader make better judgments.

Daniel Goleman, Richard Boyaters and Annie McKee have applied the concept of emotional intelligence in a book entitled Primal Leadership. They say that the emotional task of the leader is primal, or first, and is “…the most important act of leadership.” They make a persuasive argument that, throughout history, leadership is effective because it was emotionally compelling. The new leader recognizes this.

Effective Communication

The best way for the new leader to improve skill in communication is to be quiet. Shut up. Then listen. As Stephen Covey has suggested in The Seven Habits of Highly Effective People seek first to understand, and only then, to be understood. If the new leader can do only one thing, listening is certainly likely to have the most immediate impact. While a good beginning, it will not be enough because there is a communication revolution under way, and the new leader must ride the wave of that revolution. The global economy makes new demands for better communication.

After becoming a better listener, the next most important thing to understand about communication is that we do not know whether we have succeeded until we find out what the person or persons, to whom we sent the message, actually received and understood. A presentation, whether before a group, by phone or by email cannot be judged successful until we probe to determine how our message is being received. The new leader cannot stop to do formal studies after each communication; however, they can do spot checks. This alone makes them more sensitive to the audience and to the fact that, if the message was not received, there was no communication. It is the audience or receiver who determines success is communication, and not the sender.

In the past the leader could learn writing, reading, speaking and listening skills and be satisfied with their skills. With the advent of the internet and new telecommunication options, the new leader has to develop more specialized skills like researching on the net, writing an email, and reading from a computer screen. They must add these new skills to other basic skills such as speaking in public and listening on the phone. In the future, with technological improvements in video, the new leader will have to make the best use of electronic conferencing. However, none of these will eliminate the need for writing clearly, reading quickly for comprehension or speaking to groups of various sizes.

The new leader seeks to continually improve their writing skills. While there are similarities, writing a memo to be distributed on paper is not the same as writing an email. While both require attention to spelling and grammar, an email must be brief while a memo can contain greater elaboration within the basic document. An email is also considered to be less formal than a memo. Improvement in presentation skills is also imperative. Talking to three people in your office will tap different skills than presenting to a thousand stock holders. But both sets of skills can be essential for effectiveness.

The worst method of communication for leaders is “guess what I am thinking.” Mind reading is not a skill that should be expected in employees. Some leaders justify their mistakes in communication by saying they like to play it ‘close-to-their chest’ or they use a ‘need-to-know’ criteria. No matter what the rationalization may be, the inability or unwillingness to communicate renders such leaders far less effective.

The new leader must become a great communicator.

Resiliency and Optimism

Martin Seligman, the author of Learned Optimism, and psychologist at Penn, made a study of the elections for president in the United States since 1948. Do voters tend to vote for optimists? In his lab they created a way to score the campaign presentations of the candidates and develop a score. The higher the score the more pessimistic the candidate. The lower the more optimistic. In every election from 1948 to 1984, except one, the more optimistic candidate won. The only exception was the Nixon-Humphrey race which followed the disastrous convention in Chicago. In the 1988 election they rated the candidates, before the primaries, and then stored their predictions until the conventions. Optimism predicted the outcome in every race. People prefer fellow optimists. Optimists give hope, and hope is powerful.

The new leader must build the kind of resilience that seems a product of optimism. The good news is that research by Dr. Seligman, and others, about optimism suggests we inoculate ourselves against adversity in a variety of ways. Success is based on the way we explain the world around us to ourselves and others. We can learn how to do that better and thus increase our ability to bounce back.

Resilience refers to how well a leader can respond to stress. How much resistance does the person have to being overwhelmed by stress? There is a dimension called hardiness that has been studied extensively. Research on leaders in a wide variety of organizations and found that hardiness was based on three characteristics:

• Control
• Commitment
• Challenge

The leaders least likely to be overwhelmed by adversity have a belief that they have a significant measure of control over events in their work life. The key was the belief and not necessarily the reality. Even when they would prefer to have more influence over events the hardiest leaders believed in their capacity to control. Hardy leaders were committed to their work and their workplace. They tended to consistently reassert that commitment in the face of disappointments. Leaders who can bounce back see negative events in the workplace as a challenge. Barriers are seen as challenges that must be overcome.

Paul Stoltz, author of Adversity Quotient, points out that those who bounce back are better able to limit the adversity and do not let it spread to other areas of their work or home life. They also see the adversity as limited and not enduring. They quarantine the stress and prevent it from spreading. The new leader continues to work on their ability to manage stress and adversity. They learn to convert the negative events into positive energy for performance. New leaders must continually build their resilience to stress.

Recommended Books For The New Leader

One way to jump start your personal development is to select the areas in which you would like to begin and read one of our recommended books. The URL for Amazon is included:

The New Knowledge- Read The Metaknowledge Advantage by Rafael Aquayo. Published in 2004 by Free Press.

http://www.amazon.com/exec/obidos/tg/detail/-/0743216954/qid=1076075157/sr=1-1/ref=sr_1_1/103-1252748-5183004?v=glance&s=books

The New Leader- Read Leadership and the New Science by Margaret Wheatley. Published in 2001 by Berret-Koeler.

http://www.amazon.com/exec/obidos/tg/detail/-/1576751198/ref=pd_sim_books_4/103-1252748-5183004?v=glance&s=books

Systems Thinking- Read The Fifth Discipline by Peter Senge. Published in 1994 by Currency Press.

http://www.amazon.com/exec/obidos/ASIN/0385260954/qid=1076075699/sr=2-2/ref=sr_2_2/103-1252748-5183004

Variability and Process Control- Read The Leaders Handbook by Peter Sholtes. Published in 1997 by McGraw-Hill.

http://www.amazon.com/exec/obidos/tg/detail/-/0070580286/qid=1076075377/sr=1-1/ref=sr_1_1/103-1252748-5183004?v=glance&s=books

Leading Change- Read Leading Change by John P. Kotter. Published in 1996 by Harvard Business School.

http://www.amazon.com/exec/obidos/ASIN/0875847471/qid=1076076392/sr=2-1/ref=sr_2_1/103-1252748-5183004

Building and Managing Teams- Read The Team Handbook by Barbara Streibel et. al. and published in 2003 by Oriel Inc.

http://www.amazon.com/exec/obidos/ASIN/1884731260/qid=1076076634/sr=2-1/ref=sr_2_1/103-1252748-5183004

Performance Management and Coaching- Read Improving Performance by Geary Rummler and Alan Brache, Published in 1995 by Jossey-Bass.

http://www.amazon.com/exec/obidos/tg/detail/-/0787900907/qid=1076077234/sr=1-1/ref=sr_1_1/103-1252748-5183004?v=glance&s=books

Vision Inspiration and Motivation- Read Full Steam Ahead by Ken Blanchard and Jesse Stoner. Published in 2003 by Berret-Koehler.

http://www.amazon.com/exec/obidos/tg/detail/-/1576752445/qid=1076077500/sr=1-1/ref=sr_1_1/103-1252748-5183004?v=glance&s=books

Analysis, Problem Solving and Decision Making- Read Management of Organizational Behavior by Paul Hersey et. al. published in 2000 by Prentice Hall.

http://www.amazon.com/exec/obidos/ASIN/0130175986/qid=1076078238/sr=2-2/ref=sr_2_2/103-1252748-5183004

Emotional Competency- Read Primal Leadership by Daniel Goleman et. al. published in 2002 by Harvard Business School.

http://www.amazon.com/exec/obidos/ASIN/157851486X/qid=1076078673/sr=2-1/ref=sr_2_1/103-1252748-5183004

Effective Communication- Read Listen Up by Larry Lee Barker. Published in 2000 by St Martin’s Press.

http://www.amazon.com/exec/obidos/tg/detail/-/0312242654/qid=1076078866/sr=5-1/ref=cm_lm_asin/103-1252748-5183004?v=glance

Resiliency and Optimism- Read Learned Optimism by Martin Seligman. Published in 1998 by Free Press.

http://www.amazon.com/exec/obidos/ASIN/0671019112/qid=1076081536/sr=2-1/ref=sr_2_1/103-1252748-5183004