Copyright 1986 by the American Psychological Association, Inc.

0022-006X/86/500.75

Journal of Consulting and Clinical Psychology

1986, 1. 54, No. 6,831-835

Presurgical Anxiety and Postsurgical Pain and Adjustment:

Effects of a Stress Inoculation Procedure
Judith K. Wells and George S. Howard
University of Notre Dame

Manuel J. Vargas
Merrillville, Indiana

William F. Nowlin
Saint Mary Medical Center

The present study designed and tested a method for preparing surgical patients to actively cope
with the stress of hospitalization and surgery. Specifically, this study examined the effects of a stress
inoculation procedure on patients' anxiety, pain, and postoperative adjustment. Twenty-four surgery
patients were randomly assigned either to a stress inoculation intervention or to a standard hospital
instructions control. The results demonstrated the utility of stress inoculation training in providing
surgical patients with a self-regulation technique to reduce their experiences of anxiety and pain and
improve their postoperative adjustment, including the reduction of reliance on analgesia and number
of postoperative recovery days.

is in the preliminary testing stage and has, to date, resulted in

Behavioral principles have been applied to the prevention,

assessment, and treatment of a variety of physical disorders for

equivocal findings.

which psychological influences can prevent or relieve dysfunc-

Wernick, Jaremko, and Taylor (1981) applied stress inocula-

tion or distress. Perhaps the newest area of application is that

tion to burn patients to aid them in coping with bathing and

of treatment reaction. Here interventions are administered to

dressing changes. Patients received the educational component

modify psychological and physiological reactions to aversive

(describing the nature of stress and pain), the skills acquisition

and stressful medical examination and treatment procedures.

component (deep breathing, relaxation, cognitive reappraisal,

Reactions to these procedures include avoidance, anxiety, fear,

and attention diversion), and the application component (bath-

depression, discomfort and pain, and even the production of

ing and dressing of burns). In addition, the therapist accompa-

new physiological or behavioral pathology.

nied the patient during the application phase to provide coach-

Often patients react to an aversive procedure with not one

ing when necessary. The procedure was successful in aiding pa-

but a number of responses. In these situations, it has been rec-

tients to cope with pain-inducing treatments. However, the

ommended that a combined cognitive-behavioral approach be

authors cautioned that the study was a preliminary investiga-

used because it contains the widest spectrum of aids and would

tion and described methodological limitations: Coaching by the

likely appeal to the largest number of patients (Kaplan, Metzgcr,

therapist was a confounding variable. Furthermore, neither rat-

& Jablecki, 1983). Stress inoculation, as conceptualized by

ers obtaining behavioral measures nor patients were blind to

Meichenbaum and his colleagues, is just such an approach

subject condition.

(Meichenbaum & Cameron, 1983; Turk, Meichenbaum, &

Genest,

1983). This multidimensional program

Tan, Melzack, and Poser (1980) evaluated the efficacy of

has been

stress inoculation for the attenuation of pain experienced dur-

proven helpful in a number of problematic situations. It has

ing a noxious X-ray procedure. Here no differences were ob-

been successful in the treatment of social anxiety (Jaremko,

served among the stress inoculation, attention-placebo, and no-

Myers, & Jaremko, 1979), speech anxiety (Meichenbaum, Gil-

treatment control groups on measures of pain. In explanation,

more, & Ffedoravicius, 1971), and test anxiety (Hussain & Law-

the authors noted that pain was relatively mild and of somewhat

rence, 1978). It has also been applied to hypertension (Patel &

short duration. It may be that although patients learn skills to

North, 1975), anger (Novaco, 1977), and chronic pain (Hart-

attenuate pain, the experience must be of sufficient quality (in-

man & Ainsworth, 1980).

tensity and duration) to elicit the use of those skills.

Although the success of stress inoculation in attenuating

The present study tested the efficacy of a stress inoculation

acute pain has been demonstrated in controlled laboratory

program in preparing patients for surgery. It sought to measure

studies (Genest, 1980; Turk, 1977), the external validity of

the effects on patient anxiety (pre- and postsurgical) and pain.

stress inoculation for the reduction of more severe clinical pain

The design allowed for (a) patients' sole reliance on skills taught
in a 1-hr training session nearly 1 week prior to surgery; (b)
raters and interviewers who were blind to patient condition; and
(c) the experience of severe, acute clinical pain (resulting from

Correspondence concerning this article should be addressed to

George S. Howard, Department of Psychology, University of Notre
Dame, Notre Dame, Indiana 46556.

surgical incision) of longer duration (lasting 3 days) than in previous studies.

831

832

WELLS, HOWARD, NOWLIN, AND VARGAS

Method
Subjects
Participants were 24 patients in two northwest Indiana hospitals.
Their ages ranged from 14 to 62 years with a mean age of 41 years. For
inclusion patients had to be scheduled for elective surgery within 1 week
for which recovery was expected to take at least 3 days and medical
prognoses were favorable. The surgical category was general and included such operations as debridement of decubitis ulcer and skin graft,
abdominal hysterectomy, cholecystotomy, fasciectomy and evacuation
of hematoma, resection of cavernous hemangioma, and repair of arterial vensus fistula.

Procedure and Materials

Patients were first contacted by their surgeon and informed of the
general purpose of the study and the voluntary and confidential nature
of their participation. To allay fears that they were being singled out
because of special problems, each was informed that all of his or her
surgeon's patients meeting the selection criteria were being asked to participate. Participants read and signed a description of research and a
consent form.
Patients were then referred to the experimenter for an initial interview and for pretesting. The experimenter, blind to subjects' conditions
throughout the study, conducted all assessment sessions. The assessment began with a biographical and health questionnaire that included
items pertaining to demographics and medical history.
State and trait anxiety levels were assessed with the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, 1970). The SAnxiety scale is a sensitive indicator of changes in transitory anxiety.
The T-Anxiety scale is useful for identifying relatively stable individual
differences in anxiety-proneness.
Following the pretest session, patients were randomly assigned either
to the stress inoculation or to the control condition. The experimental
treatment group received instruction in stress inoculation as well as
standard hospital preparatory instructions; the control group received
only standard hospital preparatory instructions. Patients in the treatment condition were then met by the instructor of the stress inoculation
procedure, who was a PhD-level clinical psychologist.
Stress inoculation. The conceptualization phase of the stress inoculation training began with an introduction asserting that hospitalization
and surgery can be stressful and that many people are somewhat nervous before an operation.' Patients were informed that research has
shown that people can prepare themselves for a stressful event by learning ways to control their reactions to it. Specifically, they were warned
about two feelings typically experienced about surgery: feeling anxious
before surgery and feeling discomfort or pain after surgery. Patients
were provided a simplified version of the Schachter-Singer (Schachter &
Singer, 1962) theory of emotion and of the Melzack and Wall (Melzack
& Wall, 1965) theory of pain. These theories were provided as aids to
reconceptualize the experiences of anxiety and pain and as rationales
for understanding the emotional and behavioral components of these
experiences.
The skills acquisition phase of training included instruction in (a)
monitoring cognitive and physical cues for stress reactions (e.g., increased heart rate, negative self-statements); (b) deep breathing; (c) general, passive muscle relaxation; (d) induction of pleasant images; (e) substitution of coping self-statements for negative self-statements; and (f)
application of positively reinforcing self-statements following the successful completion of the procedure. The complete procedure was rehearsed by each patient with the instructor.
The application phase of training included instructions for rehearsing
the procedure and for applying it when stress cues were present. Patients

were encouraged to practice the skills a number of times each day prior
to surgery and to use the skills whenever they perceived the cognitive or
physical stress cues.
Presurgical postinoculation testing. On the day before surgery, all
patients met with the experimenter for a presurgical interview. Patients
again completed the STAI for measures of state and trait anxiety.
Postswgical testing. Adjustment measures were taken postoperatively beginning the day patients returned to their rooms (i.e., released
from recovery or intensive care units). On the 1st day patients rated
their pain with a visual analogue scale (Keefe, Brown, Scott, & Ziesat,
1982). This scale consists of a line with endpoints anchored by descriptive terms such as no pain and pain as bad as it can be. The patient
placed a mark along the line indicating the current level of pain. Pain
ratings were again taken on the 2nd and 3rd day at approximately the
same time to control for patient activities.
On the 3rd day patients responded to the Hospital Anxiety Scale (Lucente & Fleck, 1972). This scale was developed for measuring anxiety
specifically related to the experience of hospitalization and includes the
rating of such statements as "While in the hospital I feel that I am under
a great deal of strain."
On the day of discharge from the hospital the charge nurse, blind
to subjects' experimental conditions, rated each patient's adjustment
during hospitalization relative to other patients in his/her experience
who had the same or similar surgery. Questions included items regarding patient adherence to treatment regimen, general cooperation, exhibition of signs of anxiety, and behaviors of general adjustment.
Following each patient's discharge from the hospital, type and dosage
of analgesic medication as well as number of patient requests for medication were noted from the medical chart. Using this information, two
physicians, also blind to subject condition, rated each patient's use of
analgesics relative to other patients in their experience who had the
same or similar surgery. This scaling procedure allowed for differences
in drug potencies and dosages, which were confounding variables in
previous research.2 Finally, the number of days following surgery till
discharge were recorded from patients' medical charts.

Results
Phase 1: Presurgical Measures
The initial equivalence of the two groups was tested by a oneway multivariate analysis of variance (MANOVA) on pretest state
and trait anxiety scores. There was no significant effect for
groups, suggesting that the random assignment procedure
achieved the desired effect of initial group equivalence. The correlation between the ratings of analgesic use by the two physicians was, r(23) = .81, suggesting an acceptable level of interrater reliability.
To test the effect of the stress inoculation treatment on presurgical anxiety, a one-way multivariate analysis of covariance
(MANCOVA) was performed on measures of state and trait anxiety. Pretest measures of anxiety were used as covariates to adjust for patients' initial scores on these dimensions. Justification

1
The Stress Inoculation Training Manual, which contains a complete transcript of the training procedure, can be obtained upon request
from George S. Howard.
2
The analgesic usage variable was formed by obtaining the linear
combination of the standardized scores of the two judges. Scores were
standardized to prevent scaling differences from biasing the mean calculations.

833

STRESS INOCULATION

Table 1

in the control group. Also, nurses' ratings of patient adjustment

to hospitalization were significantly more positive for patients
receiving stress inoculation training than for patients in the con-

Means and Standard Deviations of Pretest and

Presurgical Assessments of Anxiety

trol group, F(l, 22) = 4.84, p < .05. Patients in the treatment
Treatment group
Variable
S-Anxiety
Pretest
Presurgical
T-Anxiety
Pretest
Presurgical

SD

Control group

SD

group reported lower pain intensity after surgery than did patients in the control group, f{ 1,22) = 13.21, p < .01. Moreover,
members of the treatment group were rated by physicians to
demonstrate a marginally significant lower usage of analgesics,

43.17
37.50*

11.12
10.58

41.92
46.42

14.05
14.48

F(l, 18) = 4.29,p=.08.

33.58
33.58

7.13
7.13

36.58
36.92

14.24
13.81

sess the relations between postsurgical measures of adjustment

Note. S-Anxiety and T-Anxiety are scales on the State-Trait Anxiety

Inventory.
*p<.OS.

Pearson product-moment correlations were calculated to asand measures of pain intensity and analgesic usage. Patients'
levels of hospitalization anxiety during the recovery period were
significantly correlated with both their reports of pain, r(23) =
.63, p < . 01, and their use of analgesics, r(23) - .60, p< .01. In
addition, nurse ratings of adjustment had a significant, negative
correlation with patient reports of pain, r(23) = -.58, p< .01,

for the use of the covariates is evidenced by a significant multivariate effect for the covariates, F(\6,46.46) = 48.78, p < .0001.
The MANCOVA demonstrated a highly significant treatment

and analgesic usage, r(23) = -.52, p < .01. Pearson productmoment correlations calculated between presurgical and postsurgical variables demonstrated that the only significant relation was a positive correlation between subjects' presurgical

effect, F(4, 15) = 10.61, p < .0003. Table 1 presents pretest and
Presurgical (postinoculation) means and standard deviations

p<m.

for measures of anxiety.

Univariate analyses revealed that presurgical S-Anxiety
scores for patients in the treatment group were significantly
lower than for those in the control group, F(l, 8)-21.51, p<
.0002. One might expect that the state anxiety measures of patients in both treatment and control groups would increase as
they approached surgery (although the treatment group's measures might be expected to be lower than the control group's).
In fact, patients in the treatment group experienced a decrease
in their state anxiety as they approached surgery, whereas patients in the control group experienced an increase.

state anxiety and postsurgical hospital anxiety, r(23) = .63,

Relations among biographical variables and presurgical and
postsurgical dependent measures were also probed. For the
most part, biographical variables were not strongly related to
dependent variables. However, patients' age was negatively correlated with S-Anxiety such that older patients reported significantly less situational anxiety than did younger patients,
r(23) = -.42, p < .05. Education was negatively correlated with
anxiety such that those patients possessing greater education
reported less situational anxiety, r(23) = ~.S2,p < .01, and less
trait anxiety, r(23) = -.49, p < .05. And marriage was related
to anxiety in that patients who were single tended to report

As expected, there was no treatment effect on the scores of TAnxiety. Thus, although there was a difference in the levels of

greater trait anxiety, r(23) = .40, p< .05.

It has been demonstrated that as patients approach surgery

state anxiety just before surgery between treatment and control

groups, levels of trait anxiety did not differ.

their levels of anxiety increase, reaching maximum levels in the

24 hr prior to surgery (e.g., Auerbach, 1973; Chapman & Cox,
1977). Such an increase was predicted for participants in this
study. As expected, the state anxiety levels of control subjects

Phase 2: Postsurgical Measures

To test for the effect of the stress inoculation treatment on
postsurgical pain and adjustment, a one-way MANOVA was performed on the five postsurgical dependent variables: the Hospital Anxiety Scale (HAS), nurse ratings of hospital adjustment,

Table 2
Means and Standard Deviations on Postsurgical Measures
for Treatment and Control Groups

cumulative patient ratings of pain intensity for the 3 days following surgery, physician ratings of analgesic usage, and number of days from surgery to discharge. The analysis yielded a
significant treatment effect overall, F(5, 18) - 5.68, p < .01.
Univariate analyses disclosed that significant differences on several dependent variables existed. See Table 2 for means and
standard deviations on postsurgical measures for both treatment and control groups.
As hypothesized, patients in the treatment group obtained
significantly lower scores on the HAS than did patients in the
control group, F(l, 18) = 26.60, p < .0001. That is, patients
receiving stress inoculation training reported less anxiety in
hospitalization during their recovery period than did patients

Treatment group

Control group

Variable

SD

SD

HAS3
Nurse rating of
adjustment"
Surgical pain
Analgesic
Days to discharge

6.58**

4.50

24.83

11.40

1.07
2.22
0.73
5.15

8.58
7.17
1.75
11.25

2.54
3.66
0.96
5.77

10.33*
2.67"
1.00
7.75

Note. HAS = Hospital Anxiety Scale.

Higher score indicates greater anxiety in hospitalization.
* Higher score indicates better adjustment.
*p<.05. **p<.01.

834

WELLS, HOWARD, NOWLIN, AND VARGAS

did increase from pretesting (M = 41.92, SD = 14.05) to posttesting (M = 46.42, SD = 14.48). However; this mean increase
of only 4.50 does not seem particularly remarkable. A possible
explanation for this negligible increase in anxiety, compared
with patients in previous investigations, is the effect of the primary surgeon himself. Patients in the present study frequently
reported positive perceptions of, and reactions to, their primary
surgeon that seemed to assuage worry and nervousness. In at
least one previous study particular physicians were shown to
have a powerful influence on patients' experiences of hospitalization and treatment (MacDevitt, 1983). Future research must
clarify the role of the physician in influencing patients' experi-

creases in state anxiety they were not simply acquiescing to demands of the experimental situation or reacting to other response-style effects because these effects might also have been
expected to influence self-report measures of trait anxiety.
As expected, the stress inoculation procedure also had a positive effect on patients' experience of pain. Patients who received
training reported significantly lower levels of pain than patients
who did not receive training. In support of the self-report measure of pain intensity we note that treatment subjects also requested and received significantly fewer analgesics for alleviating the pain that they did experience. Although the success of
stress inoculation in attenuating the pain experience has been

ences, especially in influencing negative experiences like anxiety.

The possibility of the physician as an influence notwithstand-

demonstrated in controlled laboratory studies (e.g., Genest,

1980; Hackett & Koran, 1980), the external validity of stress

ing, patients receiving stress inoculation training evidenced

in equivocal findings. The present study corrected some methodological problems from previous work and successfully demonstrated the utility of stress inoculation training in providing

even lower levels of presurgical anxiety. In fact, as treatment

subjects approached surgery, their presurgical anxiety levels
(M = 37.50, SD - 10.58) fell below their pretest anxiety levels
(M = 43.17, SD = 11.12). That is, as surgery approached, treatment subjects became less anxious. This treatment effect on
presurgical anxiety was mirrored in postsurgical anxiety where
the treatment group again reported significantly lower levels of
anxiety (M = 6.58, SD = 4.50) than did the control group (M =
24.83, SD= 11.40).
Treatment subjects were discharged from the hospital an average of 3.5 days earlier than their control group counterparts.
By a conservative estimate, the average cost of 1 day in a hospital is currently $300. Thus, net savings in hospital bills to treatment subjects is estimated at $ 12,600 (3.5 days x 12 subjects x

inoculation for the reduction of severe clinical pain has resulted

patients with methods for reducing the intensity of their pain

and their reliance on pain medication. As demonstrated, these
effects exist even when the training period is relatively brief and
the pain is severe in quality and duration.
In conclusion, the results of the present investigation demonstrate the utility of stress inoculation for reducing individuals'
preoperative and postoperative distress. Trained in stress inoculation, patients can effectively decrease their anxiety as they approach surgery. They can also decrease the anxiety that they
experience during hospitalization in the recovery period. In the
present investigation patients so trained were also viewed by

$300 per day). The stress inoculation procedures in this study

required a total of 12 therapist-contact hours. Even if one
claims that a therapist contact hour costs $100, the resulting
cost/benefit ratio of $l,200/$ 12,600 is extremely impressive.
Added to other program benefits (e.g., reduction of pain, lower

care givers as more cooperative in response to treatment. Stress

inoculation training may also be utilized as an aid to help individuals cope with the discomfort and pain they experience after
surgery. As a result they may rely on this form of self-regulation
and have less need of analgesic medication.
Stress inoculation as a psychological strategy serves as a

analgesic medication use), the value of the program appears

great indeed. Of course, further replication of these program

framework for cognitive-behavioral procedures that teach people to prepare for and actively cope with stressors incurred dur-

benefits is needed to establish the representative nature of effect

ing medical treatment. People need not be passive recipients of

interventions by outside agents when disorder or dysfunction

sizes in the present study.

Discussion
The present study examined the effects of a stress inoculation
procedure on patients' anxiety, pain, and postoperative adjustment. The results demonstrate the utility of stress inoculation
training in providing surgical patients with self-regulation techniques that have powerfully positive effects on these variables.
Both the presurgical measure of anxiety (STAI S-Anxiety
scale) and the postsurgical measure of anxiety (Hospital Anxiety Scale) are self-report measures, and as such they are vulnerable to subject response-style effects (Millham & Jacobson,
1978). However, although group differences were reported in
state and situational anxiety, they were not reported in the measurement of trait anxiety. (No change as a result of stress inoculation was predicted for trait anxiety because this is believed to
be a relatively stable individual-difference variable not affected
by situational factors or by this particular intervention.) Therefore, it is suggested that when treatment subjects reported de-

occurs. They can actively collaborate with their health care providers in a holistic approach to treatment.

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