20Q: Overview of The Stress Management Questionnaire

Welcome Dr. Franklin Stein, Contributing Editor for 20Q!

As Managing Editor of OccupationalTherapy.com, it is my pleasure to introduce an exciting new series on OccupationalTherapy.com – 20Q: Salute to the OT Leaders. Each edition of 20Q will focus on a different OT leader and follow a 20-question interview format to allow OTs to learn more about these leaders, their history, their research, and their thoughts on the future of OT.

The first edition of 20Q, illuminates the work of Dr. Franklin Stein, his 59-year legacy, and in particular, his role in the development of the Stress Management Questionnaire (SMQ). The Stress Management Questionnaire (SMQ) is a great tool for occupational therapists. It can help to guide the development of individualized stress treatment programs utilizing purposeful activity and coping strategies. 

As we look forward to future issues of 20Q, Dr. Stein will shift into the role of Contributing Editor to give us an inside look at some of other top leaders in our field. 

Without further ado, let's meet our future Contributing Editor, Dr. Stein!

Fawn Carson, MS, OTR/L, ATP
Managing Editor

Salute to OT Leaders Series

20Q: Overview of the Stress Management Questionnaire

Editor's note: This content is not available for continuing education credits at this time.

 Franklin Stein, PhD

History

1. Where did you grow up and how did that affect your career?

I grew up in a working class neighborhood in Brooklyn, New York, and I was the first in my family to go to college.  I supported myself with part time jobs in high school and college by working in department stores as a sales clerk, and in hotels during the summer as a waiter, bellhop and bus boy. I was lucky enough to receive scholarships as a student that enabled me to complete undergraduate and graduate education in Brooklyn College and New York University. During my college years, I identified with the humanistic movement in psychology and felt strongly regarding a career in a social service profession. I wanted to be involved in a career that enabled an individual to overcome a handicap whether it was from a disadvantaged home or a medical disability. An older brother, who was a casualty of the Korean War, was an inspiration for me to become an occupational therapist. 

2. How did you become interested in occupational therapy?

When I completed my degree at Brooklyn College with a major in psychology in 1952, I learned from the counselor at Brooklyn College of a job opening at Brooklyn State Hospital for an occupational therapy instructor to work with the psychiatric patients. The job requirements included an undergraduate degree. I went for the job interview with the director of occupational therapy at the State Hospital, Edith Weingarten, who told me I had the degree requirements, but I needed skills in industrial arts, such as woodworking and ceramics. She mentioned that there were courses available at New York University (NYU) where I could take craft and industrial arts courses. I set up an appointment with the director of the occupational therapy program, Freida Behlen, who discussed with me the field of occupational therapy. In the meantime, I took a full-time position at New York City Department of Welfare as a social worker, while I took evening courses in jewelry making, ceramics and woodworking at NYU. During these two years, I became interested in becoming an occupational therapist and I formally applied to NYU as a certificate student, equivalent to a MOT or first professional degree. 

3. Where did you attend school?

I went to Brooklyn College, which is part of the City University of New York, for an undergraduate degree in psychology. At that time, students paid no tuition and commuted from their home. Most of the students were from working class backgrounds. I then completed an Occupational Therapy Certificate Program at NYU in 1959, went on to complete a MA degree in occupational therapy in 1963, and a PhD degree in Counseling Psychology in 1968. As a graduate student, I was offered a full-time scholarship from the New York State Department of Mental Hygiene. The scholarship paid all tuition expenses at NYU and a stipend. I also received support from the New York State Scholar Incentive Program, American Occupational Therapy Association, and Vocational Rehabilitation Services to complete my Master’s and Doctoral degrees. Upon receiving my PhD in counseling psychology, I received the New York University Founder’s Day Award for high scholastic performance.

4.  What was your first position in occupational therapy?

My first position in occupational therapy was at New York Psychiatric Institute (NPI). This was a teaching hospital affiliated with Columbia University. It was a great opportunity to learn about mental health treatment and to attend lectures that were available to the staff. I also had the opportunity to work alongside Gail Fidler, who was a pioneer in psychosocial occupational therapy. I worked in an adolescent treatment unit where I used group therapy techniques combined with arts and crafts activities. I was exposed to psychoanalytic techniques and intensive psychotherapy. I also worked very closely with the psychiatrists in the adolescent unit. After working two years in NPI, I became the supervising occupational therapist at the Brooklyn Day Hospital. I enjoyed this position very much and I learned the importance of a holistic approach in rehabilitating individuals with mental illness.

Career

6. What are your most important strengths as a leader in occupational therapy?

I feel my most important quality is to recognize the strengths of others and to encourage their success. For example, when I was the chair of occupational therapy at the University of Wisconsin Milwaukee, most everyone on the faculty I hired, during my 12-year tenure, completed their doctoral degree while they were teaching, and later many of them became leaders in occupational therapy and fellows in AOTA. My other strength is to maintain my integrity as a leader and not to compromise my values for either money or power. 

7. What are your daily work habits?

I am a morning person, arising usually at 6:30 AM every morning. I spend 30 minutes on a stationary bike before breakfast. I start working on my computer at 9 AM. I tend to be very self-disciplined in my daily work habits. I check my e-mails and then set a "to do" list for the day. It includes all my priorities, such as my work as an editor for the Annals of International Occupational Therapy, revision of the 6th edition of the book Clinical Research in Occupational Therapy, and other work assignments, such as the keynote speaker at the Symposium sponsored by the Institute of Occupational Therapy in Mexico City or planned lectures and workshops. I take a walk in my neighborhood in Madison, Wisconsin everyday, and I do stretching exercises in the afternoon for 20 minutes. I usually have a book that I am reading in non-fiction and a novel beside my bed. I also try very hard to keep up with OT journals.

8. How would you describe your leadership style?

I see myself as an active listener, and I try very hard to set standards for others that try to accomplish myself. I think it is important to have high expectations for oneself and colleagues. To me an academic position is composed of three layers: excellence in teaching, research and clinical practice. In my career at Boston University, University of Wisconsin, University of Manitoba and University of South Dakota, I tried to serve as an academic role model.

9. What motivated you to succeed in occupational therapy?

At first I was appreciative to have an opportunity to work with patients and later on to teach at a university level. The motivation has always come from within. I have to admit that I am ambitious, and I push myself to achieve at my highest level. I ascribe to Maslow’s concept of self-actualization where I believe that we have capabilities that can come to fruition if we persevere and work hard. I think of where I came from and how much I have accomplished in my career. I take an existential view of life that each individual has the capacity to an extent to shape one’s own destiny. The decisions we make in life, such as whom we marry, what jobs we select and where we live, are within our means. In other words, we need to be goal directed and carry forward with our dreams.

10. When did you publish your first manuscript? What was the experience like?

I published my first manuscript in 1964. The title was Work Adjustment of the Former Psychiatric Patient. It was first presented at the World Federation of Occupational Therapists Conference in Philadelphia and then published in book form. In 1964, I was the Director of Occupational Therapy at the Brooklyn Day Hospital where I prepared patients for community living and employment. It was a very satisfying position, and there were concrete successes. The experience of presenting at a conference and then publishing a manuscript was very positive and started me on a research career in occupational therapy.

11. What was one of your biggest challenges during your career as an occupational therapist?

One of my biggest challenges came when I was Director of the School of Medical Rehabilitation at the University of Manitoba in Canada. I wanted very much during my four-year tenure there to establish a program in speech pathology and audiology. I worked very closely with the speech pathologists in Manitoba and the Health Commissioner. I was able to secure a grant of $100,000 for the development of the program. With this grant, I recruited a speech pathologist academic from Florida, who was hired to develop a curriculum and proposal to be approved by the Dean of the School of Medicine and the President of the University. We both worked hard on the proposal, but it ran into opposition from the physical therapy and occupational therapy faculty. It was a lesson in leadership. I did not have the grass roots support for the project, and ultimately, it failed.

12. What is your best piece of research that you have accomplished in occupational therapy?

I consider the work that I have done on the development of the Stress Management Questionnaire (SMQ), with occupational therapy students, as my best piece of research. The SMQ was initially developed at the University of Wisconsin-Milwaukee in 1986. Data was generated from a large number of participants from open-ended questions related to:

a) What symptoms do you experience when you are stressful?
b) What are the stressors in your life that trigger symptoms of stress?
c) What are the coping activities that you have used in the past to minimize or control your stress?

From the original research, the specific symptoms and problems, resulting from stress, were organized into four factors:

1.    Physiological: such as headaches, tremors, and neck/low back pain
2.    Cognitive: such as difficulty concentrating, remembering, and decision-making
3.    Emotional: such as feeling angry, hopeless, tense, and sad
4.    Behavioral: such as difficulty sleeping, eating, and speaking.

The second set of descriptor choices on the SMQ identifies situations that cause the stress response. Everyday stressors precipitating stress reactions were grouped under nine factors:

1.    Interpersonal: such as arguments with family members
2.    Intrapersonal: such as low self-esteem
3.    Time demands: such as meeting a deadline at work
4.    Mechanical breakdown: such as dealing with a broken household appliance
5.    Performance: such as taking a test
6.    Financial pressures: such as loss of income
7.    Illness: such as having the flu
8.    Environmental disturbance: such as excessive noise
9.    Complex situations: such as raising a child alone

The third section of the SMQ lists coping responses, and everyday activities such as exercise, listening to music, and talking to a friend that manage or reduce stress. These “copers” were organized in the SMQ into nine factors:

1.    Creative: such as writing a poem
2.    Construction: such as knitting a sweater
3.    Exercise: such as walking
4.    Appreciation: such as listening to music
5.    Self-care: such as taking a bath
6.    Social: such as talking to friends
7.    Plant and animal care: such as having a pet
8.    Performance: such as singing in a choir
9.    Sports: such as swimming

The paper and pencil version of the SMQ usually takes about 20 to 45 minutes to complete. Individuals completing the questionnaire are asked to check yes or no to a list of symptoms, stressors and “copers”. The SMQ consists of 73 items describing symptoms, 37 items describing stressors, and forty-eight items describing “copers”. There is also space for individuals to list other items in each of the three categories.

A graduate student in occupational therapy, at the University of South Dakota, developed a computer version. It follows the same 158-item format as the paper and pencil version of the SMQ, using a mouse click to identify the person’s individual symptoms, stressors and “copers”. This allows the client to take the SMQ within the privacy of one’s home or office. The results, of a study in 1995, indicated that the computer version has good reliability and validity.

With graduate students in occupational therapy at the University of South Dakota, I developed a card version of the SMQ during 1998-2002. The card version was intended to be used in a clinical setting in a face-to-face interview with the client. It takes about 10 to 15 minutes to complete the card version of the SMQ as compared to 20 to 45 minutes to complete the original version. In the card version the participant is asked to sort through three packets of cards, for symptoms, stressors and “copers”. The participant places the individual descriptors that pertain to oneself into a yes, no, or maybe pile.  The participant is then asked to rank order the top five responses. A reliability and validity study was completed in 2001-2002 and the results indicated that the card version is a highly valid and reliable instrument as compared to the long version of the SMQ. 

13. How do you think your research on the SMQ has shaped practice in occupational therapy?

The SMQ is taught in many occupational therapy curriculums, and I feel it has had an impact on clinical practice. I think the instrument has potential especially in working with veterans diagnosed with posttraumatic stress disorder. The SMQ incorporates purposeful and meaningful activities in helping clients to self-regulate stress in their lives.

14. How do you motivate students or staff to do research and publish in occupational therapy?

The concepts of self-discipline, perseverance, and wanting to achieve are important for anyone trying to publish a manuscript in occupational therapy. First, I try to help the individual identify a content area that they would like to spend a lifetime researching. Then they need to immerse themselves in the area by reading books and manuscripts related to their area of expertise. In order to publish research you need to have the knowledge and skills of a researcher such as objectivity, curiosity, persistence, self-discipline, and ability to work in teams and to be self-critical.

15. What is your approach to making decisions regarding career choices and engaging in new projects in occupational therapy?

I have been fortunate in my career that I have had opportunities in applying to a number of positions. When I left New York City in 1967, I was in the process of completing my doctorate in psychology from NYU, and I was awarded a PhD in 1968. At that time, I had applied for a university position as an assistant professor. When I received an offer to apply for the position at Boston University in the graduate program in occupational therapy, I was extremely delighted. I wanted to teach occupational therapy and to continue my clinical interests. I was able to work as a consultant to an early intervention program in cerebral palsy and as a psychologist for a residential school program for delinquent youth. My career decisions have always involved the opportunities to teach, do clinical practice, and to engage in clinical research and publication. I have liked every place that I have lived since I enjoy symphony, art, libraries, hiking paths and sports. The places where I have lived have been very satisfying.

16. How would you define occupational therapy?

As someone who has been an occupational therapist for almost 60 years, I have seen the definition of occupational therapy change over the years as occupational therapy has evolved and matured as a research based healthcare profession. Occupation and activities are an essential part of the occupational therapist’s role. To me, the application of meaningful (to the client) and purposeful (goal directed) occupation to achieve client independence and self-actualization is the essence of what we do as occupational therapists whether we are working in a neonatal unit, hand therapy clinic, or working with clients who have a cognitive deficit in a nursing home. The three main roles for an occupational therapist are: ergonomist, adapting the environment so that the client is most functional; healer, when we help clients to overcome or lessen disabilities, such as depression, addiction or autism; and teacher, as we instruct our clients on healthy living by prescribing meaningful exercise programs, beneficial diets, and stress management programs.

Future Reflections

17. What do you see as the major issues in healthcare that is impacting on clinical practice in occupational therapy?

In the United States, we have a healthcare system that seems like a patchwork. Care, by health professionals, is dependent upon the client’s ability to pay and/or insurance coverage. We are one of the few countries of the industrialized nations where healthcare is viewed as a privilege rather than as a right, such as the right to public education. Because of the political decisions made, occupational therapy is dependent upon the arbitrariness of the system. The major issues in the US are providing excellent healthcare to the disadvantaged, using health resources efficaciously, incorporating humanism and personal care at time when computers dominate practice, and using evidence-based practice that uses the results of research in practice as an occupational therapist.

18. How do you foresee the future of occupational therapy in your specialty area and on this topic?

The future of healthcare is tied to the concepts of evidence-based practice and prevention. Most of the breakthroughs in medicine have been in the prevention of diseases through public health measures, such as smoking cessation, clean water, food protection and vaccinations against communicable diseases. In medicine, we have expanded longevity through surgical techniques and chemotherapy. Illnesses, such as osteoarthritis, Parkinson’s disease, Alzheimer’s disease, alcohol and drug addictions, and severe mental illness are examples of health problems that do not have simple solutions and depend upon a multi-varied approach. Occupational therapy has expanded its areas of practice since its beginning 100 years ago. During the early years of occupational therapy, most occupational therapists worked in hospitals and long-term institutions, such as chronic disease hospitals and state mental institutions. Occupational therapists now work in the public school systems, outpatient clinics, forensic facilities, and in the community, to name a few. The concepts of habilitation and primary prevention will continue to attract occupational therapists. Other areas, such as occupational justice, homelessness, and chronic poverty, in the future, will be considered health and societal problems where occupational therapists will contribute their expertise through meaningful and purposeful occupation to help in alleviating these problems.

19. What are some other thoughts regarding the future of occupational therapy?

As an occupational therapist that has had the opportunity to lecture internationally and to be an editor of an international journal of occupational therapy, I foresee occupational therapy as an expanding healthcare profession. In 1959 when I became an occupational therapist, there were only 10 countries in the world that had educational programs for occupational therapy. They were the United States, Great Britain, Canada, Australia, South Africa, India, Israel, Denmark, Sweden and New Zealand. There were perhaps 5,000 occupational therapists total in the world. Now in 2017, there are over 80 countries that have educational programs in occupational therapy with about 400,000 occupational therapists. Occupational therapy is one of the fastest growing healthcare professions in the world. The definition of occupational therapy has been expanding, and of course, it has become diverse reflecting the national interests of a country and their unique healthcare concerns. It is exciting to see the development of occupational therapy, its prominent place in the healthcare system, and its role in increasing the well being of millions of people.

20. Summarize your contributions to the profession of occupational therapy up to this point in your career?

I am pleased that I have spent my full life career as an occupational therapist clinician, professor, researcher, author and editor. I am the first author with Martin Rice and Susan Cutler of the textbook, Clinical Research in Occupational Therapy, 5th edition (2013); Occupational Therapy and Ergonomics, with Ingrid Soderback, Susan Cutler and Barbara Larson (2006); Psychosocial Occupational Therapy: A Holistic Approach, 2nd ed. with Susan Cutler (2002); Pocketguide to Treatment in Occupational Therapy, Becky Roose (2000); and Stress Management Questionnaire, (2003); and over 40 articles in journals and books related to rehabilitation and psychosocial research. I have also presented at more than a hundred seminars, workshops, institutes, short courses, and research papers at national and international conferences. I have taught courses in occupational therapy, ergonomics, and research and statistics on an undergraduate and graduate level, to students at Boston University, University of Wisconsin-Milwaukee, University of Manitoba, New York University, Wayne State University, Institute of Occupational Therapy in Mexico City, University of Toronto, University of Montreal, Osteopathic School of Montreal, University of Texas El Paso, Brown-Mackie College in Tucson, University of South Dakota, and most recently, in December 2016, at the University of Minais Gerais in Belo Horizonte in Brazil.

Summary

Franklin Stein as an occupational therapist, clinician, researcher, teacher and author has distinguished his career as an internationalist where he has had the opportunities to present lectures and workshops throughout the world. His most noted work is in developing the Stress Management Questionnaire, an assessment tool to help clients self-regulate stress by identifying symptoms, stressors and coping activities.

In closing, at the end of this course, the reader should be able to discuss how the author developed the Stress Management Questionnaire (SMQ) and describe the components and three versions of this tool. The reader should also be able to explain how the author defines occupational therapy and the three major roles of the occupational therapist, and the major traits of a researcher. Lastly, the reader will be able to discuss the major issues in healthcare impacting on the practice of occupational therapy.

References

Stein, F. (1964). Work adjustment of the former psychiatric patient as a function of occupational therapy, Jones, Mona (ed.) Proceedings of the Third International Congress World Federation of Occupational Therapists, (1962). Study Course V. Dubuque, Iowa: W.C. Brown Book Company.

Stein, F. (1986). Reliability and validity of the stress management questionnaire. Unpublished manuscript: University of Wisconsin, Milwaukee.

Stein, F. (2008). Stress Management Questionnaire. In B. Hemphill-Pearson (Ed.), Assessments in occupational therapy mental health: An integrative approach (2nd Ed.). Thorofare, N.J.: SLACK.

Stein, F., & Cutler, S. (2002). Psychosocial occupational therapy: A holistic approach. (2nd ed.). Clifton Park, NY: Thomson Delmar Learning.

Stein, F., Grueschow, D., Hoffman, M., Natz, M., Taylor, S., & Tronback, R. (2003). Stress Management Questionnaire: An instrument for self-regulating stress, individual version. Clifton Park, NY: Thomson Delmar Learning.

Stein, F., Grueschow, D, Hoffman, M, Taylor, S, & Tronback, R. (2003). The Sorting Out Stress Cards—a version of the SMQ: A reliability study. Occupational Therapy in Mental Health, 19, 41-59.

Stein, F., & Neville, S.A., (1987). Biofeedback, locus of control and reduction of anxiety in alcohol dependent adults. Unpublished manuscript. University of Wisconsin-Milwaukee.

Stein, F., & Nikolic, S. (1989). Teaching stress management techniques to a schizophrenic patient. American Journal of Occupational Therapy, 43,162-169.

Stein, F., Rice, M., & Cutler, S. (2013). Clinical research in occupational therapy (5th ed.). New York: Cengage/Delmar.

Stein, F., & Roose, B. (2000). Pocketguide to treatment in occupational therapy. San Diego: Singular Publishing Group, Inc.Stein, F., Soderback, I., Cutler, S., & Larson, B. (2006). Occupational therapy and ergonomics. London: John Wiley and Sons.

Stein, F., & Smith, J. (1989). Short-term stress management program with acutely depressed in-patients. Canadian Journal of Occupational Therapy, 56, 185-192.