The major questions asked in attempting to modify the Type A behaviour pattern have been whether the behaviour pattern is modifiable and, if so, whether modification will reduce the
incidence of CHD. Friedman, Thoresen and Gill (1981)
hypothesized that the Type A behaviour pattern can not be altered in healthy individuals since they would not be
sufficiently motivated. Therefore, a great deal of attention was originally directed towards patients suffering from CHD. Although as early as 1974 modification programmes have been used with Type A patients (Suinn, 1974; Thompson, 1976), the most ambitious attempt to alter Type A behaviour pattern among heart patients has been the Recurrent Coronary Prevention Project (RCPP) initiated by Friedman and his colleagues in 1982. Type A subjects who had had an HI at least six months before the beginning of the programme were recruited. All subjects were under 65 years of age, had been non-smokers for at least six months, and had never shown signs of diabetes. Subjects were divided into three
sections: Section I (n=270) subjects were given detailed medical advice about CHD and strict control of traditional risk factors such as diet and smoking for a period of three years. Patients met regularly to discuss anxieties with a psychologist. Section II (n=592) patients were taught how to modify the Type A behaviour pattern in addition to medical
advice. Patients in Section II were a) taught how to control physiological variables that could increase the risk of
were exhibiting and alternative strategies for handling situations that elicit Type A behaviour were developed, c) were taught how to change their environment. For example, patients were taught how to seek help from their children or spouses to bring about changes in the environment, and d) treatment concentrated on cognitive or philosophical factors which encourage and sustain the Type A behaviour pattern. Patients in Section III (n=151) were given no treatment at all.
The results of the RCPP show that among subjects who
completed the treatment, a new self report measure showed significantly greater reductions of the Type A behaviour pattern in Section II treatment group (from an average of 2.74 on a 1 to 5 scale to 2.14, more than one SD) than by the Section I group (2.69 to 2.40) (Friedman etal 1984). Furthermore, reports by spouses and co-workers and
continuous assessment using a videotaped structured
interview (Friedman and Powell, 1984) largely confirmed the results. More importantly, the three year cumulative rate of a recurrent cardiac event was lower among Section II
patients (7.2%) than among Section I (13.2%) and Section III (14.0%) participants (Powell etal 1984).
The results of the RCPP are impressive. However, it is not known whether the changes effected during treatment will be maintained after the termination of the treatment programme
(Haaga, 1987). Furthermore, there is no indication of what aspects of the treatment programme were responsible for the effects observed. Further research should attempt to answer these questions.
The results of the RCPP have prompted many researchers to initiate modification programmes for healthy Type A
individuals. Various techniques such as meditation
(Muskatell etal 1984), Rational-Emotive therapy (Thurman, 1983; Woods, 1987), and Anxiety Management Training (Hart 1984) have generally reported limited success in reducing aspects of the Type A behaviour pattern. For example,
hostility and anger have been successfully reduced in some Type A populations. Recent attempts at modification in
healthy subjects has been reported by Ethel Roskies and her associates who have proposed a stress management programme for the modification of the Type A behaviour pattern in healthy individuals. This programme is comprised of twenty sessions during which subjects are taught deep muscle
relaxation and are encouraged to keep records of variations in physical tension. Subjects are given "home work"
assignments and are taught coping skills (Roskies, 1987). The use of this programme was reported in the Montreal Type A Prevention Project (Roskies etal 1986) where significant reductions in overall Type A scores were found. Subjects also reported greater life satisfaction at the end of the programme. However, there were no significant changes in
physiological responsivity. In fact, unlike studies
conducted with Type A heart patients, research on healthy Type A individuals has been unsuccessful in reducing
physiological activity, thought to be a major precursor to CHD (Haaga, 1987).
The hypothesis put forward by Friedman, Thoresen, and Gill (1981) suggesting that the Type A behaviour pattern can not be modified in healthy subjects is therefore rejected by the above studies. However, on the basis of some of the studies reporting failure to modify physiological responses, it may be argued that Type A is much more difficult to change in the healthy population than in patients already suffering from the adverse effects of Type A. This, however, does not mean that altering the Type A behaviour pattern in a
clinical population is free of problems. As the researchers in the RCPP point out (Thoresen etal 1985; Friedman etal 1984) a major problem in any modification programme is the fact that subjects are reluctant or unable to change. This may be due to the fact that by the time a person has reached middle age, the behaviour pattern is established to such an extent that change becomes extremely difficult. Price (1983) has therefore suggested that modification programmes should aim at a much lower age group and attempt to educate
children and adolescents about the negative consequences of the Type A behaviour pattern.
The modification programmes directed at healthy Type As have only been successful in terms of reducing self reported Type A behaviour and increasing life satisfaction in subjects. The danger of relying on self report measures as the only index of Type A will be discussed in future sections. Nevertheless, there are some problems with these studies. Firstly, there have been no follow up studies to indicate a) whether the effects of Type A change are sustained long term
after the termination of the programme, and more importantly b) whether these modification programmes have any clinical utility in terms of reducing the incidence of CHD.
Furthermore, most of these studies have failed to show reductions in actual physiological reactivity in subjects.
Since it has been argued that the Type A behaviour pattern is maintained in part by lack of awareness of its long term negative consequences (Price, 1983; Rosenman, 1978),
repeatedly drawing subjects' attention to the physiological processes that may be associated with the behaviour pattern might go far to help motivate people to reduce their Type A behaviour. The most successful studies which have reported
significant reductions in physiological activity of healthy type As have used biofeedback training as part of the
modification programme (Prior etal 1983; Stern and Elder, 1982). It must therefore be noted here that any modification programme designed for healthy Type As should consider the following points: a) there should be follow up studies to
clarify the effects of altering Type A in terms of
subsequent incidence of CHD, b) emphasis should be placed on physiological as well as cognitive factors, and c) because healthy Type As are unwilling to alter their behaviour
pattern and may even be unaware of the consequences of their behaviour, new challenges and incentives should be provided to motivate them, and d) programmes should be designed to alter the type A in the younger population before the behaviour pattern becomes fully established.