J o u r n a l of Religion and Health, Vol. 26, No. 1, Spring 1987

Modifying the Type A Behavior Pattern LONNIE YODER A B S T R A C T : The Type A behavior p a t t e r n (TABP), a complex of personality traits characterized by insecurity of status, hyperaggressiveness, sense of time urgency, free-floating hostility, and a tendency toward self-destruction, has been linked to coronary h e a r t disease in both prospective and clinical studies. Attempts to modify the TABP are complicated by conceptual u n d e r s t a n d i n g s of the behavioral complex. However, intervention studies, such as the San Francisco Recurrent Coronary Prevention Project, have shown t h a t modification is possible. Both psychological and religious factors need to be t a k e n into consideration when exploring the modification of the TABP.

Introduction And he said to them, "Take heed, and beware of all covetousness; for a man's life does not consist in the abundance of his possessions." And he told them a parable, saying, "The land of a rich man brought forth plentifully; and he thought to himself, "What shall I do, for I have nowhere to store my crops?" And he said, "I will do this: I will pull down my barns, and build larger ones; and there I will store all my grain and my goods. And I will say to my soul, Soul, you have ample goods laid up for many years; take your ease, eat, drink, be merry." But God said to him, "Fool! This night your soul is required of you; and the things you have prepared, whose will they be?" So is he who lays up treasure for himself, and is not rich toward God. (Luke 12:15-21) 1 This a d m o n i t i o n and p a r a b l e from t h e Gospel of L u k e deals p r i m a r i l y w i t h t h e issue of covetousness. H o w e v e r , viewed from the perspective of one familiar w i t h t h e T y p e A b e h a v i o r p a t t e r n (TABP), t h e covetous m a n in this p a r a b l e m i g h t also be diagnosed as a T y p e A p e r s o n a l i t y . It is hoped t h a t this p a p e r , which explores t h e T A B P a n d e x a m i n e s both p s y c h o t h e r a p e u t i c and r e l i g i o u s implications for its modification, will m a k e t h e u n u s u a l c o n n e c t i o n b e t w e e n a covetous m a n in t h e biblical era and a r e l a t i v e l y r e c e n t d e v e l o p m e n t in t h e s t u d y of c o r o n a r y h e a r t disease s o m e w h a t m o r e a p p a r e n t , if not e v e n obvious. In 1974 M e y e r F r i e d m a n a n d Ray R o s e n m a n , two S a n F r a n c i s c o cardiologists, published a book e n t i t l e d Type A Behavior and Your Heart in w h i c h t h e y a r g u e d t h a t t h e r e is a definite association b e t w e e n a n o b s e r v a b l e b e h a v i o r a l p a t t e r n , t h a t is, T y p e A b e h a v i o r p a t t e r n (TABP), a n d c o r o n a r y h e a r t disease. T h e y f u r t h e r s p e c u l a t e d t h a t if one could modify this TABP, t h e n t h e i n c i d e n c e of c o r o n a r y h e a r t disease would p r o b a b l y also be lowered. In the decade since Lonnie Yoder, B.A., M. Div., an ordained minister in the Mennonite Church, is a doctoral student in Religion and Personality at the University of Iowa in Iowa City, Iowa. 57

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the publication of this seminal work, num erous epidemiological and clinical studies have explored the relationship between the TABP and coronary h e a r t disease (CHD). We will examine these studies and their relevance for modification of the TABP; but let us first begin with a definition of the TABP and a b r ief survey of some of the conceptual issues related to a definitive understanding of this behavior pattern.

The Type A behavior pattern The phrase "Type A behavior pat t er n " came into existence in an unusual man n er . In 1958 Meyer F r i e d m a n and Ray Rosenman were seeking research grants from the National H e a r t Institute to study the emotional dimension of coronary h e a r t disease. In their first two requests, which were refused, t hey used the t e r m "emotional stress" to describe their area of interest. Fri edm an traveled to Washington, D.C., to discover the reason for the grant refusals. A doctor th er e indicated t h a t t he r e was some feeling t hat cardiologists were illequipped to study emotional m at t er s and suggested t hat Fri edm an and Rosenm a n rephrase t hei r subject of interest and suggested they label it "Type A behavior pattern." A third gr ant request using this terminology was funded! ~ F r o m t h a t interesting genesis, the Type A behavior pat t ern has experienced n u mer o u s definitions and analyses. Most definitions understand the TABP as a complex of personality traits, including such items as time urgency, excessive aggressiveness, free-floating hostility, deep-seated insecurity, etc. Rosenm a n defines the TABP as follows: TABP is an action-emotion complex exhibited by increasing numbers of individuals in their interactions with others and against opposition of time, persons, and things. It is not a personality typology but is a behavioral syndrome that is correlated with enhanced neurohormonal responses. It includes behavioral dispositions such as ambitiousness, aggressiveness, competitiveness, and impatience; specific behaviors such as muscle tenseness, mental alertness, rapid and emphatic speech stylistics, and rapid pace of most activities; and emotional responses such as irritation, hostility and anger that is usually covertJ Friedman, in his most recent book, Treating Type A Behavior and Your Heart, lists five components of the TABP: 1. 2. 3. 4. 5.

insecurity of status, hyperaggressiveness, sense of time urgency, free-floating hostility, and a tendency toward self-destruction.

He sees the interrelatedness of these five components as follows: Type A behavior is above all a continuous struggle, an unremitting attempt to accomplish or achieve more and more things or participate in more and more events

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in less and less time, frequently in the face of opposition--real or i m a g i n e d - from other persons. The Type A personality is dominated by covert insecurity of status or hyperaggressiveness, or both. It is one or both of these two basic components that generally cause the struggle to begin. The struggle itself sooner or later fosters the emergence of a third personality ingredient, that sense of time urgency we have designated hurry sickness. As the struggle continues, the hyperaggressiveness (and also perhaps the status insecurity) usually shows itself in the easily aroused anger we term free-floating hostility. Finally if the struggle becomes severe enough and persists long enough, it may lead to a fifth component, a tendency toward self-destruction. 4 T h e T y p e B p e r s o n a l i t y is considered to be t h e opposite of T y p e A p e r s o n a l ity. F o r e x a m p l e , t h e T y p e B p e r s o n a l i t y would g e n e r a l l y be m o r e r e l a x e d , less h u r r i e d , a n d not e x h i b i t excessive a g g r e s s i v e n e s s a n d f r e e - f l o a t i n g hostility. I t is i m p o r t a n t to n o t e the distinction b e t w e e n the T A B P a n d t h e concept of stress. S t r e s s is u s u a l l y defined w i t h r e s p e c t to a s t r e s s o r s i t u a t i o n or a dist r e s s e d response. T h e TABP, on t h e o t h e r h a n d , is u n d e r s t o o d as a style of beh a v i o r e x h i b i t e d b y s o m e p e r s o n s w h e n confronted w i t h a r e a l or p e r c e i v e d c h a l l e n g e 2 V i r g i n i a Price p u s h e s t h e u n d e r s t a n d i n g of t h e T A B P a step furt h e r w h e n she s u g g e s t s it would be helpful to v i e w it as a profile, v a r y i n g f r o m i n d i v i d u a l to i n d i v i d u a l w i t h i n t h e l a r g e r c o n s t r u c t of a t y p e or style. She r e a sons as follows: If we were to divide any population into A and B types, we would find considerable heterogeneity within each type. In fact, individual differences would be apparent in regard to many different factors, including (a) specific components of the pattern that are exhibited, (b) their intensity, (c) their frequency, (d) the number and kinds of different situations that elicit them, and even (e) the mode in which the behaviors are expressed2 T h e p o s s i b i l i t y of i n d i v i d u a l differences w i t h i n the T A B P r a i s e s t h e issue of s e v e r i t y or degree. While some would d i a g n o s e a n i n d i v i d u a l on a s p e c t r u m w i t h T y p e A a t one end a n d T y p e B a t t h e other, F r i e d m a n is a d a m a n t t h a t a n i n d i v i d u a l is e i t h e r a T y p e A or not. E v e n if a n i n d i v i d u a l e x h i b i t s o n l y one t r a i t of t h e T A B P , F r i e d m a n would classify t h a t p e r s o n as a T y p e A. F o r F r i e d m a n t h e s p e c t r u m exists w i t h i n t h e T A B P , f r o m v e r y m i l d ( e x h i b i t i n g o n l y a few t r a i t s ) to v e r y s e v e r e ( e x h i b i t i n g m o s t , if not all, of t h e traits). 7 I n t h i s r e g a r d , F r i e d m a n a s s e r t s " . . . t h a t t h e s e v e r i t y of y o u r T y p e A b e h a v i o r is dir e c t l y p r o p o r t i o n a l to t h e t r i v i a l i t y of t h e s t i m u l i t h a t m a k e it b l o o m openly. ''8 F i n a l l y , F r i e d m a n p o s t u l a t e s t h a t t h e T A B P m a y lie d o r m a n t in a g i v e n indiv i d u a l u n t i l he or she is confronted w i t h e n v i r o n m e n t a l s t i m u l i t h a t a c t i v a t e it. 9 In 1974 F r i e d m a n a n d R o s e n m a n s p e c u l a t e d t h a t t h e U n i t e d S t a t e s p o p u l a tion w a s divided n e a r l y 5 0 - 5 0 w i t h r e g a r d to T y p e A a n d T y p e B occurrence. I n F r i e d m a n ' s m o r e r e c e n t book (1984) he e n v i s i o n s t h e T A B P as m o r e p e r v a sive, s u g g e s t i n g t h a t 75% of t h e U n i t e d S t a t e s a d u l t m a l e s a r e T y p e A. I n t h i s regard, Friedman asserts that the TABP has always been more prevalent a m o n g m a l e s t h a n f e m a l e s in t h i s c o u n t r y o w i n g to c u l t u r a l a n d e n v i r o n m e n -

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tal circumstances. However, he has observed an alarming increase in the rate of the TABP among women in the last num ber of years. This is attributed primar ily to the changing role of women in United States society. 1~ Two primary i ns t r um e nt s have been used to diagnose and assess the TABP. The first is the structured interview developed by Fri edm an and Rosenman. The interview is conducted with a standard questionnaire t h a t the interviewer uses to observe the style of the response as well as its content. The structured interview " . . . takes into account stylistics of speech, content of answers to the questions asked, and overt psychomotor and other nonverbal behaviors t hat subjects exhibit during the interview. ''H The second i n s t r u m e n t used to assess the TABP is the J e n k i n s Activity Survey (JAS), a written questionnaire. The JAS works only with the content of the answer given. One advantage the JAS offers is th at it rates several components of the T A B P - - t h a t is, 1. speed and impatience, 2. job involvement, and 3. hard-driving. '~ Diagnosis is complicated by the fact t h a t certain components of the TABP are more or less covert in the individual's behavior. Fr i e dm an divides his five basic components in this respect. He views hyperaggressiveness, free-floating hostility, and a sense of time urgency as overt and therefore helpful in diagnosis. On the other hand, insecurity of status and a tendency toward self-destruction tend to be covert. F r i e d m a n concludes: "For all practical purposes, the easiest and quickest way to detect the presence of Type A behavior in an individual is to look for psychomotor signs and biographical manifestations of a sense of time urgency and free-floating hostility. ''~3 Before we proceed with an analysis of the components of the TABP and an examination of conceptual problems related to it, it would be well to look at the association between the TABP and coronary heart disease. Two major prospective studies have shown a relationship between the TABP and an increased incidence of coronary h e a r t disease. The Western Collaborative Group study, which followed 3,500 he a l t hy men for 8 1/2 years, concluded t h a t " . . . Type A men were, over the course of the study, shown to be two-three times more prone to h e ar t attacks t han men classed as Type B. ''14 The F r a m i n g h a m study, as well as numerous smaller prospective and respective studies, has shown similar results. 1~ In addition, various clinical studies have been conducted to ascertain the physiological and biochemical relation or relations between the TABP and coronary h e a r t disease. Fr i edm a n has observed the following phenom ena in persons exhibiting the TABP: 1. a relative inability to rid their blood of fat absorbed from food, t hat is, a process known as "sludging"; 2. a high level of norepinephrine, the so-called "struggle hormone," in the blood; 3. an excess secretion of ACTH, an adrenal-stimulating hormone, which can cause the eyelids and the skin above and below the eyes to appear deeply tanned; and 4. an inadequate a m o u n t of pituitary growth hormone. TM

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Other studies have shown elevated levels of serum cholesterol and serum triglyceride, as well as reduced blood-clotting time, in individuals exhibiting the TABP. 17Of these clinically documented relationships, F r i e d m a n believes t h a t the excess secretion of norepinephrine is the key to the hi gher incidence of coronary h e a r t disease in the Type A person: We believe that it is the e x c e s s discharge of norepinephrine--the hormone manufactured by the sympathetic nervous system, and employed as its messenger agent to control the correct functioning of the heart and the degree of constriction and dilation of the body's large and small arteries--that is chiefly responsible for the development of arterial diseases. 18 F r i e d m a n concludes t h a t the excess secretion of norepinephrine can lead to coronary h e a r t disease in at least three different ways: 1. the deterioration of the atherosclerotic plaques present in the coronary arteries, 2. sludging, and 3. v en tr icu lar fibrillation. TM In view of this epidemiological and clinical documentation of t he relation between th e T A B P and the increased incidence of coronary h e a r t disease, it behooves us to examine the various components of the TABP more closely in anticipation of exploring some helpful psychotherapeutic and religious interventions to modify the TABP. As noted earlier, F r i e d m a n sees five basic components in the TABP. Insecurity of status and hyperaggressiveness are most basic. T hey issue forth in a sense of time urgency characterized by chronic haste, polyphasic activity, difficulty in relaxing, and stereotyped t h i n k i n g and action. 2~ The fourth component, free-floating hostility, tends to evolve out of the Type A's excessive aggression. T here is also an e l e m e n t of fear associated with this hostility. It leads to a frustrated longing for love and affection. In the words of Friedman: This hostility, of course, makes it difficult for its possessor either to attract or to accept pure affection. It is because of the essential incompatibility of hostility and love that so many Type A's find it very difficult to receive or give love gracefully.~1 This dynamic at work in a Type A individual can lead to a lonely, solitary existence. The fifth component of the TABP, a tendency toward self-destruction, has only recently been added to the TABP by Friedman. He sees it as an unconscious drive at work in m a n y or most severe cases of the TABP. For Friedman: This covert drive toward self-destruction rarely surfaces in the form of an open suicide attempt. Instead, it usually takes such indirect forms as overeating, heavy drinking, failure to exercise, and a forced-draft working schedule involving as many as 20 hours a day, month after month. Type A's guilty of these practices are quite aware of the danger they pose, but seem unwilling to changeY Finally, F r i e d m a n sees t hr ee secondary aspects of the TABP. T hey are: "1. a tendency to use num be r s and quantities when t h i n k i n g and speaking, 2. a fail-

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ure to use metaphors and similes in thought and speech, and 3. a relative inability or unwillingness to develop various kinds of imagery. ''~3 Other components mentioned, in addition to Friedman's basic five, include: ambition and lack of well-defined goals, setting excessively high performance standards, hard-driving behavior, competitiveness, impatience, etc. 24 This proliferation of components or characteristics of the TABP raises problems with regard to intervention in an attempt to modify the TABP. For example, should one try to modify all components equally? Or should one concentrate on select components of the TABP? Virginia Price, a collaborator with Meyer Friedman in the San Francisco Recurrent Coronary Prevention Project, published a book (Type A Behavior Pattern: A Model for Research and Practice) in 1982 which deals with the conceptual problems surrounding the TABP. She notes in her preface that the " . . . failure to develop a coherent conceptual model of Type A grounded in contemporary psychological theory seems to be responsible for the rather slow accumulation of generalizable and replicable empirical findings in Type A research. ''2~ Her listing of 31 different characteristics of the TABP found in research literature from 1959 to 1979 highlights the need for a coherent conceptual framework. A number of researchers in the field have hypothesized regarding this unifying factor. Friedman views the TABP primarily as a struggle against other persons, objects, and time. David C. Glass understands the TABP as an attempt to gain and maintain control over one's environment. Dembroski and colleagues view the TABP as a psychological response to challenge. '2~Given these attempts at finding a unifying theme in the TABP, Price goes on to develop her own. She uses an expanded cognitive social learning theory as a conceptual framework. This perspective views the TABP as developing from the interaction of behavioral, environmental, cognitive, and physiological factors. 27 Given this comprehensive framework, Price first looks at antecedents to the TABP. Social and cultural antecedents include both beliefs and contingencies t h a t encourage the TABP. Price lists the following social and cultural beliefs as ones t h a t encourage the Type A personality: 1. "an open economy is good"; 2. "there is no ultimate conscience or universal moral principle to provide a regulating influence on the process and outcome of h u m a n endeavors"; and 3. "progress is best defined in terms of material, or tangible, achievements and related status." Social contingencies listed are: socioeconomic factors, religion, educational system, urbanization, and the electronic revolution. Personal antecedents to the TABP include the family, school, and television as transmitters of beliefs and expectations. 28 Within the framework of these environmental antecedents to the TABP, Price proceeds to develop her own underlying theme for the TABP. She first asserts t h a t cognitions, particularly personal belief, are at the core of the TABP. She uses the analogy of an iceberg to explain this cognitive core. The tip of the Type A iceberg is the speech and psychomotor behaviors one observes in the TABP. Underlying this overt behavior are certain psychological and interpersonal characteristics, such as ambition, competitiveness, hard-driving behavior, etc. At the base of the icerberg we find certain beliefs and fears t h a t are the basis for the TABP. These beliefs and fears issue forth in behavior t h a t is clas-

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sifted as Type A. Price lists three beliefs and their accompanying fears as the basis for the TABP. They are: 1. the belief that one must constantly prove oneself a) fear of insufficient worth 2. the belief t h a t no universal moral principle exists a) fear t h a t good may not prevail b) fear t h a t justice may not triumph 3. the belief t h a t all resources are scarce a) fear of insufficient supply. Price concludes that the first belief, the need to p r o v e oneself, is the unifying theme in the TABP. 29 Viewed from still another perspective, Price sees the TABP as a pattern of immoderation. She states t h a t "many of the discrepancies in the Type A literature can be explained by considering the Type A behavior pattern as a pattern of perceptual and behavioral immoderation. ''3~ Price then goes on to list some possible mediating factors between the TABP and coronary heart disease. They include: 1. other coronary heart disease risk factors (for example, cigarette smoking, high blood pressure, elevated serum cholesterol), 2. cognitive factors, 3. major stressful life events, 4. perceived social support, and 5. coping actions for reducing the impact of the behavior pattern on one's personal well-being21 Price's inclusion of both antecedents and mediating factors in her conceptual framework points to the importance of one's environment (personal and cultural) in the development of the TABP. In this regard, one's early childhood experience m a y play a crucial role in the development of the TABP. Friedman has discovered in his studies t h a t m a n y Type A individuals did not perceive t h a t they received adequate parental love and support during their childhood. This, in turn, leads to the development of the status insecurity which is at the core of his understanding of the TABP. In the course of the San Francisco Recurrent Coronary Prevention Project Friedman asked 120 random Type A individuals whether they felt t h a t they had received sufficient love and affection from their parents. Over 70% of them responded in the negative. Friedman concludes: "We now believe t h a t one of the most important influences fostering status insecurity is the failure of the Type A person in his infancy and very early childhood to receive u n c o n d i t i o n a l love, affection, and encouragement from one or both of his parents. ''32 Mark Laaser, in the process of interviewing a group of extreme Type A's, found a similar lack of positive affirmation from parents and role models23 Studies have also shown t h a t one's cultural environment m a y play a crucial role in the development and/or exacerbation of the TABP.

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For example, Rosenman and Friedman, in a study of the psychological makeup of Japanese-Americans, found that Japanese living in the United States who remained true to their cultural customs and family ties were similar to Japanese living in Japan in terms of the preponderance of Type A's and Type B's, with Type A's being quite rare. Correspondingly, these Japanese have a lower incidence of coronary heart disease than the American average. On the other hand, Japanese who have adopted Western-style living and customs approached distribution between Type A's and Type B's similar to that of United States natives, with a high incidence of heart disease and heart attacks? 4 Rosenman also contends t h a t urbanization and technological progress contribute to the exacerbation of the TABP. 35 Several attempts have also been made to ascertain w het her there are any genetic factors at work in the TABP. However, these studies have proved to be inconclusive. For example, two different studies of identical twins have produced contradictory results. 3~ It remains to be seen w het her heredity plays a crucial role in the development of the TABP.

Modifying the Type A behavior pattern: Psychotherapeutic indications A v ar iety of intervention studies have been done in an a t t e m p t to modify the TABP. Richard Suinn, in an overview of these intervention studies, concludes t h a t most of t hem have produced some reduction in the TABP. In general, he sees a trend in which behavior t her a py is proving to be more effective t han psychoanalysis? 7 Among the intervention studies done, a n u m b e r have been of a comparative nature. Roskies compared psychoanalysis and a stress manag emen t approach in at t em pt i ng to modify the TABP and found the stress m a n a g e m e n t t r a i ni ng to be the more effective?s A study by J e n n i and Wollersheim compared stress m a n a g e m e n t t rai ni ng with Ellis's rational-emotive t h e r a p y (RET). They found RET to be significantly more effective among severe Type A individuals? 9 A third comparative study by Levenkron contrasted comprehensive behavior t her a py (emphasizing self-control behavioral techniques), group support (emphasizing group therapy), and brief information (emphasizing the encouragement and instruction one ordinarily receives in a p r i m a r y health care setting). Both comprehensive behavior t h e r a p y and group support were found to be superior to the brief information with the comprehensive behavior t h e r a p y slightly more effective.4~ In addition to the comparative studies, there have been several studies evalu atin g the effectiveness of particular therapies in modifying the TABP. Thurman discovered t h a t rational-emotive t h e r a p y was effective in reducing the TABP among a small group of college students? 1 Muskatel found t h a t clinically standardized meditation was effective in reducing certain components of the TABP among a group of college u n d e r g r a d u a t e s ? 2 A Dutch study with 69 post-myocardial infarction patients showed t h a t relaxation t rai ni ng had positive effects, particularly with Type A individuals? 3 Stern and Elder used a biofeedback approach to reduce the h e a r t rate of Type A individuals. They accomplished this aim by using certain challenge incentives (competition, excel-

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lence-seeking, and time urgency) which exploited certain Type A behavioral characteristics .44 Despite the positive results of these intervention studies, most of them share certain methodological problems. For example, most of them were of a short duration and their long-term effectiveness is questionable. Andrew Razin questions whether they can be generalized from the experimental setting to real-life situations. Most of these studies tend to focus on only one or two components of the TABP. 4"~ With regard to these methodological problems, one study stands out in its large-scale long-term attempt to explore the modification of the TABP and its subsequent effect on the incidence of coronary heart disease. The San Francisco Recurrent Coronary Prevention project (RCPP) was a three-year study, begun in 1979, which sought to answer two questions: 1. could the TABP be modified in post-myocardial infarction patients? and 2. if so, would it significantly influence the recurrence of cardiac episodes? Nearly 1000 post-myocardial infarction patients volunteered to become part of one of two groups: 1. a control group of 270 patients who received group cardiologic counseling (counseling dealing with diet, exercise, and drug regimens) or, 2. an experimental section of 592 patients who received group Type A behavioral counseling in addition to the group cardiologic counseling. The group Type A behavioral counseling involved the following dimensions: Briefly, it consisted of instruction in progressive muscle relaxation, behavioral learning (e.g. recognition of causes and modification of exaggerated emotional reactions and instruction in self-observation and self-assessment techniques), restructuring of some environmental situations and, most important of all, cognitive affective learning (e.g. modification of some earlier held beliefs, assumptions, and attributes, establishment of new and realistical internally constructed values and goals, and self-instruction and self-management).~6 This t r e a t m e n t was based on the expanded cognitive social learning model which deals with the interaction of behavioral, environmental, cognitive, and physiological factors. Results of the three-year study showed the following: 1. Reduction of the TABP was significantly greater in the experimental section t h a n in the control section (43.8% of the participants in the experimental section experienced reduced Type A behavior compared to only 25.2% in the control section); 2. the cumulative cardiac recurrence rate was significantly lower in the experimental section t h a n in the control section (7.2% compared to 13%); and 3. all patients regardless of section who showed significant reduction in Type A behavior at the end of one year experienced only one fourth as m a n y cardiac recurrences as those who showed little or no reduction in Type A behavior at the end of the first year. 47 The study also found t h a t the overt behavior associated with the TABP changed more quickly than the covert beliefs and attitudes underlying it. For example, "The overt behavior associated with time urgency and hostility (e.g., slowed speech, impatience while waiting, irritation while driving) were found

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to have changed the most by the second year, whereas the more cognitive and intractable areas (e.g., egocentrism, the belief t h a t Type A leads to success, and family-marital conflicts) were found to have changed the least. ''48 This finding of the study suggests t h a t symptomatic overt behavioral change in the TABP m a y occur without assurance t h a t underlying beliefs and attitudes will also change. The RCPP, under the direction of Meyer Friedman, has shown t h a t the TABP can be significantly modified and t h a t this modification is associated with a substantial reduction in cardiac recurrences. It has also shown t h a t a comprehensive approach to treatment is essential to success. Treating the behavioral dimension without addressing the underlying cognitive and emotive realities does not lead to lasting change. Any significant t r e a t m e n t model should address at least three dimensions: behavioral, cognitive, and emotive. Friedman uses this multidimensional approach when he attempts to modify various components of the TABP. In examining a given component (for example, the sense of time urgency) he calls first for the Type A individual to recognize its presence and ascertain its cause, t h a t is, insecurity of status. This initial step addresses the emotional dimension of the TABP. Second, he challenges the Type A individual to replace old beliefs with new ones. For example, he may challenge the belief that one's sense of time urgency has helped one succeed socially and economically. Third, he invites the Type A individual to change his or her behavior. In the case where the sense of time urgency is a problem, he would challenge the Type A individual to engage in any number of the following behavioral activities: 1. recover the use of memory, 2. recover the use of verbal imagery in daily thought (read books, visit museums and galleries, write letters, etc.), 3. take interest in the lives of others, and 4. pay attention to the things of lasting worth (culture, religion, myths, legends, traditions, rituals, etc.). In addition, he suggests specific behavioral drills t h a t can enable one to begin to modify the TABP. 49 In addition to a comprehensive approach (behavioral, cognitive, and emotive) to psychotherapeutic intervention, a number of other factors need to be taken into account for effective modification of the TABP. First, the Type A individual will often deny the existence of the TABP in his or her life. This denial needs to be challenged, and the individual needs to accept the responsibility for change if he or she so desires. Second, a continual emphasis on "being" versus "doing" or "having" can correct the Type A's relentless tendency to "do" or "have" more and more. Third, one study has shown t h a t time-limited counseling and goal specificity are especially helpful in treating the Type A individual. ~~ Fourth, analysis of the environmental antecedents and mediating factors of the TABP needs to be part of a comprehensive assessment and treatment program. In addition to the environmental factors mentioned earlier, recognizing sex differences (that is, socializing influences on men and women) in

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the TABP may be crucial in developing an effective modification program?' Fifth, prevention, opposed to the current emphasis on the modification of the TABP, may develop into a useful goal as more is learned about the causes of the TABP. For example, Price argues for interventions to reduce or prevent Type A behavior among children. ~2 Given these guidelines for psychotherapeutic intervention, what specific psychotherapies might prove effective for modifying the TABP? The San Francisco Recurrent Coronary Prevention Project has shown that a comprehensive behavior therapy can be quite effective. The emphasis on cognitive and emotive dimensions, as well as altering overt behavior, seems to be the key to success. Rational-emotive therapy has also proven effective, probably for similar reasons (that is, cognition is emphasized). Adlerian psychotherapy and transactional analysis may yet prove effective in dealing with the status insecurity of the Type A individual which has been shown to have its roots often in early childhood experience. Likewise, a Rogerian approach may provide the unconditional positive regard (frequently found lacking in the Type A individual's childhood experience) which will enable significant change. Existential psychotherapy's emphasis on "being" and confronting existential anxiety m a y elicit new emotive and cognitive dimensions in the experience of the Type A individual. Finally, reality therapy may challenge the reluctant Type A individual to accept responsibility for modifying the TABP. In any case, a comprehensive intervention approach emphasizing behavioral, cognitive, emotive, and environmental factors seems to hold forth the most promise for modifying the TABP.

Modifying the Type A behavior pattern: Religious indications Few studies have been conducted exploring the relationship between religion and the TABP. Bernard Caffrey, in a comparative study between Benedictine and Trappist monks, discovered that the incidence of coronary heart disease among the Benedictines was three times higher than that among the Trappists. When he classified the monks (whether Benedictine or Trappist) into Type A and B categories, he discovered that Type A monks experienced coronary heart disease five times more frequently than Type B monks. The difference in coronary heart disease incidence between the two orders was attributed to different vocational identities. The Benedictines dedicated their lives to teaching, whereas the Trappists are engaged in agriculture. Yet the Type A-Type B classification, irrespective of group membership, seemed to be a more powerful indicator of incidence of coronary heart disease? 3 Mark Laaser, in a study of Type A and Type B men in a large suburban Presbyterian church, found that the extreme Type A individuals often experienced a conflict between cognition (what they believed) and emotion (what they actually felt) with regard to religion. These extreme Type A individuals tended to spend more time in religious thought and meditation and were heavily involved in the social activities of their church. Yet they experienced a deepseated anxiety which Laaser attributes to their need to control both their tem-

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poral and n o n - t e m p o r a l world. T h e y were successful in using t h e i r religion to control t h e i r world cognitively but were u n a b l e to do so in the e m o t i o n a l realm. On the o t h e r hand, e x t r e m e Type B individuals often had developed the ability to s u r r e n d e r control and hence were able to h a v e a religious experience which b r o u g h t both release and a sense of peace. L a a s e r s u m m a r i z e s his theory as follows: Religion, as it is believed and practiced, may be both positively and negatively associated with heart disease . . . . It is not so much the nature and definition (theological interpretation) of non-temporal ultimate concerns that is important to the avoidance of the Type A behavior pattern, but the ability of the individual to participate (and perhaps surrender) to some system of religious concern that is ultimate (as opposed to pen-ultimate concerns) and which provides in its participation a sense of peace about one's own worth and salvation. 54 T h e k e y for L a a s e r is the role t h a t one's religion plays in d e a l i n g w i t h the control of existential a n x i e t i e s and f e a r s - - d o e s it c o n t r i b u t e to t h a t struggle or does it become involved in the process of freeing oneself from t h a t struggle? P a u l Insel, in a s t u d y of the r e l a t i o n b e t w e e n blood pressure levels in school age children (aged 10-16) and c e r t a i n psychosocial factors, c o m p a r e d a group of c h i l d r e n a t t e n d i n g a S e v e n t h - d a y A d v e n t i s t parochial school w i t h children att e n d i n g a public school. H e discovered a positive r e l a t i o n b e t w e e n such factors as f a m i l y support and stability and blood p r e s s u r e level. In particular, he found a strong r e l a t i o n b e t w e e n religious o r i e n t a t i o n and h i g h e r blood pressure levels. In Insel's words: Religious Orientation and Control have emerged as showing the strongest association with diastolic blood pressure. This is particularly true for SDA families who are more likely to be concerned about their child's deviation from the SDA lifestyle than non-SDA's. Both of these factors have elements of social pressure. A lifestyle with a religious emphasis requires the child to attend to a number of regular or consistently disciplined processes such as reciting from the Bible, attending church regularly, sitting quietly and being attentive for long periods of time2 5 In addition to t h e s e few studies, a n u m b e r of o t h e r r e l e v a n t factors m u s t be i n t r o d u c e d before we explore religious indications for modifying the TABP. First, one m u s t be a w a r e of a possible r e l a t i o n b e t w e e n the c h a n g i n g role of religion in our society and the incidence of the TABP. F r i e d m a n alludes to this possibility w h e n he discusses the g r a d u a l demise of religious faith and symbols in our society. 56 Price is even more specific w h e n she states t h a t "a godless P r o t e s t a n t work ethic combined w i t h the lack of e m p h a s i s on guiding moral principles appears to c o n s t i t u t e i m p o r t a n t social and cognitive a n t e c e d e n t s of Type A behavior. ''57 However, the studies of Caffrey and L a a s e r e n c o u r a g e us to look at the q u a l i t y of religion as well as its q u a n t i t y . In this regard, one m u s t be concerned about the f r e q u e n t occurrence of emotional a n d spiritual m a l n u t r i t i o n in t h e lives of Type A individuals. F r i e d m a n points to this r e a l i t y in both of his major works. In t h e course of t h e R C P P s t u d y he found t h a t

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5 0 - t o - 6 0 year-old men and women can and do recover their religious beliefs (particularly if they had been believing Catholics) and in doing so, lose some of their most troublesome Type A traits. Our participants did not find the process at all easy. Their sense of time urgency frequently made them feel that meditating about the numinous was a sheer waste of time. Nor was it easy at first for them to read the Bible, because the Bible did not speak to them in numbers and equations but in stories, metaphors, and images. But with great resolve, drilling; and in some cases a sort of personal revelation, quite a few of our participants found their way back to the religious beliefs that they had held earlier in their lives2 s 9

In t h e same m a n n e r , L a a s e r found t h a t T y p e B individuals t e n d e d to experience a m o r e i n t u i t i v e , sensitive, a n d a e s t h e t i c d i m e n s i o n of religion t h a n did Type A's. ~ This r e a l i t y can be a t t r i b u t e d in p a r t to the T y p e A individual's e m p h a s i s on doing and h a v i n g as opposed to being. A n o t h e r d i m e n s i o n of the T A B P t h a t has religious implications is t h e comp o n e n t of free-floating hostility. S p e a k i n g to t h e Type A individual, F r i e d m a n says: The fierceness of your hostility can best be assuaged by affection and love. However, it is not easy for Type A individuals to accept affection and love. Acceptance of affection requires an element of passivity and dependency, traits most Type A subjects have rejected. Nevertheless, it is never really too late to begin to learn how to accept affection and love2~ P e r h a p s the T y p e A individual has so m u c h t r o u b l e giving a n d r e c e i v i n g love and affection because of his or h e r concept of God. L a a s e r discovered t h a t T y p e B individuals t e n d to view God "as loving a n d caring, n u r t u r i n g and protective. ''G1 On t h e o t h e r hand, F r i e d m a n found in a s u r v e y of f o u r t e e n T y p e A w o m e n t h a t only one of t h e m (a n u n ) viewed God "as a loving, t o t a l l y forgiving, and accepting F a t h e r . ''~2 It is not surprising, t h e n , t h a t F r i e d m a n s o u g h t counselors for the R C P P s t u d y who e x p r e s s e d both care and love for t h e participants. In fact, he found t h a t D i a n e U l m e r , field director of t h e R C P P s t u d y , b e c a m e a " s u r r o g a t e m o t h e r " for h u n d r e d s of t h e m a l e p a r t i c i p a n t s in t h e massive study23 Finally, one m u s t be a w a r e of t h e possible effects of a n a r r o w , rigid religious s t a n c e on t h e d e v e l o p m e n t of the TABP. Price, in h e r s u r v e y of possible a n t e cedents to the T A B P , concludes t h a t " . . . it m a y be t h a t b e l i e f in a God who rewards s t r i v i n g and p u n i s h e s a n y t h i n g less t h a n c o n s t a n t l y s u s t a i n e d effort m a y also function as a Type A a n t e c e d e n t . ''~4 L a a s e r comes to a s i m i l a r conclusion in his reflection on t h e religious e x p e r i e n c e of e x t r e m e T y p e A a n d B men. 65 G i v e n t h e s e factors, t h e r e are a n u m b e r of religious concepts t h a t m i g h t prove helpful in m o d i f y i n g t h e TABP. First, a n e m p h a s i s on God as a loving, caring, a c c e p t i n g B e i n g would be a p p r o p r i a t e in c o u n t e r i n g the d e e p - s e a t e d ins e c u r i t y and hostility of the T y p e A individual 9 If the T y p e A i n d i v i d u a l c a n cognitively a n d e m o t i o n a l l y e x p e r i e n c e this reality, he or she m a y be able to overcome fears and a n x i e t i e s r e g a r d i n g self-worth 9 An e m p h a s i s on t h e concept of grace would also be helpful in this regard. T h e Type A i n d i v i d u a l does not h a v e to be perfect or does not c o n s t a n t l y h a v e to achieve m o r e a n d m o r e to be accepted by God.

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Second, am emphasis on the concept of providence, whereby we believe t h a t we have a benevolent God who always has our best interests in mind, can be helpful in modifying the TABP. The Type A individual's need to struggle constantly, to be in control, and to prove oneself is probably exacerbated when the individual does not experience a sense of a benevolent Supreme Being or a guiding moral principle. Likewise, an understanding of creation and nature which elicits a meaningful rationale for one's own existence and station in life will, we hope, enable the Type A individual to escape from the snare of constantly needing to struggle, control, and/or prove oneself. Third, an emphasis on the h u m a n response to God's love and providence may provide a helpful framework for the Type A individual to live more meaningfully. If this response is first of all one of trust and faith, the Type A individual can be empowered to give up deep-seated insecurity as well as constant fears and anxieties about life (for example, the need to control and the need to prove oneself). In the context of this trusting, faithful response to God's love and care, the concept of surrender proves to be helpful. Can the Type A individual give up the need to control, the need to struggle constantly, and the need to prove oneself?. The Anabaptist concept of Gelassenheit captures this capacity to give up or surrender. Robert Friedmann defines Gelassenheit as "self-surrender, resignation in God's w i l l . . . , yieldedness to God's will, self-abandonment, the (passive) opening to God's willing, including the readiness to suffer for the sake of God, also peace and calmness of mind . . . . -66 This theological construct is found as well among the mystics of the Middle Ages, the Pietists, and the Quakers. Among the "Stillen im Lande" (for example, the Amish), it is understood as "aloofness from the turmoil of life and strife. ''~7 It comes as no surprise, then, t h a t the Amish of Lancaster County, Pennsylvania, have a very low incidence of coronary heart disease. 68 In addition to any environmental factors at work, it would be reasonable to assume t h a t their emphasis on and practice of Gelassenheit enables them to stay relatively free of the TABP. Fourth, an emphasis on the contemplative side of one's religion might serve as an antidote to the TABP. Friedman discovered that "Type B's generally indulge in periods of contemplation. This may range from sheer cerebration to spiritual musing or meditation. ''~ We have already noted how the Type A individual tends to resist this side of religious experience. Fifth, an emphasis on the resources of the religious community itself may be helpful in modifying the TABP. One can imagine how the component of freefloating hostility in the Type A individual quickly leads to a sense of isolation and loneliness. The Type A individual needs to experience a sense of belonging and of being cared for in the context of the religious community. Experiences of love, acceptance, and forgiveness (those elements often found lacking in the Type A individual's childhood) may prove to be a key in modifying the TABP. Sixth, an understanding of repentance as a willingness to change may prove crucial for the Type A individual who denies t h a t he or she has a need or insists t h a t modifying the TABP is impossible. Those who have worked intensively with Type A individuals often find them quite resistant to change, t h a t is, not repentant. However, if the Type A individual is willing to accept his or her need and also willing to work at changing behavior, the individual is well on the road to modification of the TABP.

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S e v e n t h , a n e x a m i n a t i o n o f o n e ' s r e l i g i o u s b e l i e f s y s t e m for b e l i e f s t h a t might exacerbate the TABP can prove helpful. For example, one might believe that "more good works makes one a more religious person." This belief could t e n d to r e i n f o r c e t h e T A B P . I t a n d o t h e r b e l i e f s l i k e i t s h o u l d b e c h a l l e n g e d o r put in a proper perspective in the life of the Type A individual, thus enabling modification of the TABP. We began this paper with the biblical account of a rich man who exhibited several components of the TABP. We conclude, as well, with another familiar b i b l i c a l a c c o u n t . W e l e a v e i t to t h e r e a d e r to d i a g n o s e w h o is T y p e A a n d w h o is T y p e B! Now as t h e y w e n t on t h e i r way, he entered a village; and a woman n a m e d M a r t h a received h i m into her house. A n d she had a sister called Mary, who sat at the Lord's feet and listened to his teaching. But M a r t h a was distracted with much serving; and she went to him and said, "Lord, do you not care t h a t m y sister h a s left me to serve alone? Tell h e r t h e n to help me." But the Lord answered her, " M a r t h a , M a r t h a , you are anxious and troubled about m a n y things; one t h i n g is needful. M a r y h a s chosen the good portion, which shall not be t a k e n a w a y from her." (Luke 10:38-42)

References

1. All scripture quotations are from Revised Standard Version, Division of Christian Education of the National Council of Churches in the United States of America, 1972. 2. Friedman, M., and Ulmer, D., Treating Type A Behavior and Your Heart. New York, Alfred A. Knopf, 1984, p. 6. 3. Rosenman, R., Psychological Problems Before and After Myocardial Infarction. Basel, S. Karger AG, 1982, pp. 81-82. 4. Friedman and Ulmer, op. cit., p. 31. 5. Gentry, W , and Williams, R., Psychological Aspects of Myocardial Infarction and Coronary Care. St. Louis, The C.V. Mosby Company, 1979, p. 6. 6. Price, V., Type A Behavior Pattern: A Model for Research and Practice. New York, Academic Press, 1982, p. 168. 7. Friedman and Ulmer, op. cir., p. 61. 8. Ibid., p. 163. 9. Friedman, M., and Rosenman, R., Type A Behavior and Your Heart. New York, Alfred A. Knopf, 1974, p. 68. 10. Friedman and Ulmer, op. cit., p. 61. 11. Rosenman, op. cir., p. 81. 12. Laaser, M., "Religion and Heart Disease: An Investigation of Their Association as Expressed in the Religious Dimensions of the Coronary-Prone Behavior--Type A," doctoral dissertation, University of Iowa, 1981, p. 59. 13. Friedman and Ulmer, op. cit., pp. 55-56. 14. Ibid., p. 10. 15. Razin, A., "Psychological Intervention in Coronary Artery Disease: A Review," Psychosomatic Medicine, September 1982, 44, 366. 16. Friedman and Ulmer, op. cit., pp. 12-14. 17. Price, op. cit., pp. 121-123. 18. Friedman and Ulmer, o19.cit., pp. 66-67. 19. Ibid., pp. 67-69. 20. Price, op. cit., pp. 103-104. 21. Friedman and Ulmer, o19.cir., p. 36. 22. Ibid., p. 235. 23. Ibid., p. 42. 24. Price, op. cir., pp. 80-111. 25. Ibid., p. xiii.

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26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46~

Ibid., Ibid., Ibid., Ibid., Ibid., Ibid.,

pp. 17-19. p. 36. pp. 41-53. pp. 63-72. p. 177. pp. 149-161. F r i e d m a n and Ulmer, op. cit., p. 45. Laaser, op. cit., p. 129. Kezdi, P., You and Your Heart: How to Take Care of Your Heart for a Long and Healthy Life. New York, Atheneum/SMI, 1977, p. 94. Rosenman, op. cir., p. 81. F r i e d m a n and Ulmer, op. cit., p. 43. Suinn, R., "Intervention with Type A Behaviors," J. Consulting and Clinical Psychology, December 1982, 50, 935-942. Johnston, D., "Behavioral T r e a t m e n t in the Reduction of Coronary Risk Factors: Type A Behavior and Blood Pressure," British J. Clinical Psychology, November 1982, 21,282. Ibid., 283. Levenkron, J., "Modifying the Type A Coronary-Prone Behavior Pattern," J. Consulting and Clinical Psychology, April 1983, 51,194-195,201. T h u r m a n , C., "Effects of a Rational-Emotive Treatment Program on Type A Behavior Among College Students," J. College Student Personnel, September 1983, 24,421. Muskatel, N., et al., "Effect of Meditation Training on Aspects of Coronary-Prone Behavior," Perceptual and Motor Skills, April 1984, 58, 515. van Dixhoorn, J., et al., "Contribution of Relaxation Technique Training to the Rehabilitation of Myocardial Infarction Patients," Psychotherapy and Psychosomatics, November 1983, 40, 137. Stern, G., and Elder, R., "The Role of Challenging Incentives in Feedback-Assisted H e a r t Rate Reduction for Coronary-Prone Adult Males," Biofeedback and Self-Regulation, March 1982, 7, 65. Razin, op. cir., 367-372. Friedman, M., et al., "Alteration of a Type A Behavior and Reduction in Cardiac Recurrences in Post Myocardial Infarction Patients," Amer. Heart J., August 1984, 108, 239. Ibid., 237, 247.

47. 48. P•well• L.• et al.• ``Can the Type A Behavi•r Pattern Be Altered after Myocardial Infarcti•n? A Second Year Report from the Recurrent Coronary Prevention Project," Psychosomatic Medicine, August 1984, 46, 311. 49. F r i e d m a n and Ulmer, op. cit., pp. 169-201. 50. Kelly, K., and Stone, G., "Effects of Time Limits on the Interview Behavior of Type A and B Persons Within a Brief Counseling Analog," J. Counseling Psychology, September 1982, 29, 457-459. 51. Price, op. cit., p. 263. 52. Ibid., pp. 264-266. 53. F r i e d m a n and Ulmer, op. cir, pp. 22-23. 54. Laaser, op. cir., p. 39. 55. Insel, P., et al., "Psychosocial Factors and Blood Pressure in Children," J. Psychosomatic Research, 1981, 25, 510. 56. Friedman and Rosenman, op. cir., p. 169. 57. Price, op. cir., pp. 4 5 - 4 6 . 58. F r i e d m a n and Ulmer, op. cit., p. 186. 59. Laaser, op. cir., p. 105. 60. F r i e d m a n and Rosenman, op. cit., p. 192. 61. Laaser, op. cit., p. 104. 62. F r i e d m a n and Uhner, op. cit., p. 97. 63. Ibid., pp. 121-122. 64. Price, 0]9. cir., p. 46. 65. Laaser, op. cit., pp. 179-180. 66. Friedmann, R., "Gelassenheit," The Mennonite Encyclopedia, 1956 edition, 2, pp. 448-449. 67. Ibid., p. 449. 68. F r i e d m a n and Ulmer, op. cit., pp. 113-114. 69. Ibid., p. 74.