First, we will continue the process which Avrom began in his concluding comments to my previous article by taking a more in-depth look at the components of Hardiness and their meaning.Second, I'll examine the relationship between Hardiness and other stress--related personality characteristics of dentists. Finally, we will look at Hardiness from an interactive perspective which takes into consideration the context in which the Hardy person functions. This will help us to better understand the relationship of Hardiness to stress, illness and career satisfaction. Of course, the context we are primarily concerned with in this report is the world of dentistry.
To review briefly, the Hardy person was described as an individual who possessed three personality characteristics: control, commitment and challenge. Avrom's response to my previous discussion of these concepts underscores the necessity of thoroughly understanding the meaning of these terms if the Hardiness concept is to be fully appreciated.
 To review briefly, the Hardy person was described as an individual who possessed three personality characteristics: control, commitment and challenge. 
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The word CONTROL as it is used in personality theory has typically referred to an individual's perception of power or influence over the events in one's life. The word conveys a deterministic sense. That is, a person with a high sense of control (in the typical way the term is used) believes that the things which happen to us are attributable to our own will and actions rather than to forces outside of ourselves such as fate, luck or powerful others. Obviously, persons with a high need to feel they are in control of events in their lives will experience great stress when confronted with those inevitable circumstances over which they have little or no control.
In her original discussion of Hardiness, psychologist Suzanne Kobasa presents an expanded model of the concept of control which itself has three components:
• Cognitive control --- the ability to adaptively interpret, appraise and/or incorporate potentially stressful events into an on-going life plan.• Decisional control --- the capability of autonomously choosing among various courses of action in response to life events.
• Coping skills -- having a large repertory of suitable methods for handling the stressful outcomes of given situations.
The sense of control inherent in this conceptual view is adaptively interactive with the environment. It is contrasted to the sense of helplessness often experienced by those individuals, including many dentists, who see themselves as victimized by people and influences over which they have little or no control. Such a win/lose concept of control obviously predisposes the individual to high levels of stress and its deleterious consequences. (See Comment #1.)
COMMITMENT, the second component of Hardiness, refers to a sense of purpose, mission and involvement with one's self and one's social context which tends to mitigate the stress--inducing aspects of life events. By social context, I am referring to family, friends, other interpersonal relationships, work and important social institutions in one's life.
The polar opposite of commitment is alienation which can take many forms including lethargy and indifference, disengagement from one's work and social support systems, negativism, nihilism and even inappropriately escapist adventures. Unfortunately, most dentists do not have to look very hard to see examples of all of these attitudes and behaviors, either in their personal experience or among their professional colleagues. The most important area of commitment, in terms of stress resistance, appears to be commitment to one's self.
This really involves a sense of personal value and worth, both of which are essential components of self-esteem. Self--commitment means an understanding, acceptance and appreciation for one's own values, goals, priorities, abilities and uniqueness. It is only when an appropriate commitment to self exists that individuals can truly become committed to an interdependent involvement with the world around them: an involvement which both gives meaning to and buffers the effects of potentially stressful life events. (See Comment #2.)
The third component of the Hardy personality is CHALLENGE by which is meant the anticipation of change as an exciting opportunity for further learning and development rather than the perception of change as threatening. Persons high in this characteristic tend to be change-seekers who not only cope well with change, but who often are catalysts of change. These individuals seek change not merely as an escape from currently difficult or painful circumstances, but rather because they value the enriching and personally rewarding growth that results from continually stretching as a person. These are flexible and adaptive individuals who are calculated risk--takers and who often transform unexpected demands from potentially overwhelming hardships into productive opportunities.
It must be pointed out that the change-seeking referred to here is not the same as the relentless search for happiness and self--fulfillment experienced by those whose quest keeps them searching for external solutions to their perceived life dilemmas. For the perpetually dissatisfied searcher, "the answer" seems to eternally lie "just over the next hill". Instead, the high challenged individual is able to act upon a set of value-centered processes which, in turn, create opportunity for personal growth and development. (See Conmment #3.)
Kobasa, in her work with executives, lawyers and career Army officers, was interested in Hardiness as a mediator between stress and physical illness or psychiatric symptoms. She found that scores on the various Hardiness indices did discriminate between those individuals who would or would not get sick under conditions of high stress as measured by life events. She acknowledged that other mediating factors were undoubtedly involved.
For example, physiological predisposition, early childhood experiences and social resources. But the significance of her work has been the repeated empirical substantiation of the relationship between personality, stress and illness.
In my work with practicing dentists, I asked a somewhat different research question: "To what extent are Hardiness and other personality characteristics related to the tendency of dentists to perceive their life events or professionally related situation to be stressful?" As previously reported in NEXUS, the results of my study with over 300 dentists strongly supported the hypothesis that dentists who scored low on the Hardiness components of control, commitment and challenge would perceive dentistry as more stressful, experience more symptoms and be less satisfied with their choice of dentistry as a career.
In addition, two other personality or attitudinal measures were used with participating dentists. One was a scale which measured the degree to which the dentists agreed with beliefs that have been identified by psychologist Albert Ellis to be "irrational" and that lead to inappropriate emotions and behaviors.
The beliefs measured by this scale dealt with various aspects of the participants' perception of themselves and the world including their demand for approval from others, high self-expectation, frustration reactivity, anxious overconcern, dependency and perfectionism. The third attitudinal measure used in the study was a scale composed of similar problematic beliefs, but in this case, beliefs unique to dentistry. The "dental irrational beliefs" were gathered from the literature on stress among dentists, from my own experience as a practicing dentist and from my experiences with other dentists through the years. A few examples will gave you the flavor of the Dental Attitude Scale: -
"The quality of my dental work is almost never as good as it should be .' "There's no reason with today's advanced techniques that the dentistry I do should ever be painful."
"People who value their boats and color TVs over good dentistry have the wrong priorities in life."
"The only way I can be sure something gets done right in my office is to do it myself."
Sound familiar? The statements comprising this scale are beliefs that we all have been exposed to in our experiences as dentists. The significance of such beliefs in the lives of dentists was demonstrated by our findings that the total number of these beliefs to which dentists ascribe and the magnitude of their adherence was directly, positively and strongly related to the level of perceived stress and career dissatisfaction among the 300 dentists studied. The general irrational beliefs were also found to be significantly related to the stress measures, but the strength of the relationship was somewhat less than the relationship between stress measures and the dental beliefs. (See Comment #4.)
In contrast to the above mentioned findings, the relationship between stress measures and situational variables within the dentists' practices were of little significance. Of 18 situational variables measured for each participant in the study (i.e., age, income, size of staff, number of patients seen per week, etc.) there were but a few statistically significant correlations to measurements of perceived stress and almost no consistent pattern of relationships.
However, frequency of exercise and the number of weeks per year that the dentist was out of the office were both associated with decreased stress and increased career satisfaction. The overall impact of these findings was to strongly support a position that the perception of stress on the part of practicing dentists is almost entirely attitudinal, not situational.
In other words, the degree of stress in dentistry appears not to be a function of characteristics of dentistry, but rather a function of the characteristics of the person who is practicing dentistry.
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In other words, the degree of stress in dentistry appears not to be a function of characteristics of dentistry, but rather a function of the characteristics of the person who is practicing dentistry. (See Comment #5.)
To be more precise and more fair, it should really be said that stress is a function of the interaction of the person and the situation. An ecological or systems approach to the problem of stress in dentistry must deal with what psychologists call the person--environment fit. For instance, in her study of career Army officers, Kobasa found that the combat officer who thrived on high challenge usually suffered an increase in stress when faced with prolonged exposure to the less exciting administrative demands required of a peace--time command position.
Similarly, Avrom has often discussed the idea that the very traits for which dental students are selected and rewarded during training are precisely those traits which are often responsible for much of the stresses experienced by practicing dentists. The verbal, technical, analytic (left brain) attributes rewarded in dental school are often of little help, or may, in fact, interfere, with the level of behavioral sensibilities required of the practicing dentist who is fully capable of responding appropriately to the interpersonal transactions of daily practice.
A second environmental issue which must be addressed is that of the "professional ideology" which surrounds the concept of stress in various occupational fields. Kobasa found that within the legal profession there is a belief that lawyers perform best in times of great change and under a lot of pressure. Thus lawyers have been socialized to confront stress as a challenge which they should be capable of meeting. In contrast, the current focus in business and dentistry is on programs and articles which emphasize the idea that "stress kills" or is otherwise very detrimental. Interestingly, but perhaps not so surprisingly, lawyers were the only professional group studied by Kobasa who did not tend to get sick under conditions of high stress as measured by life change scores.
A second and perhaps more insidious point concerning the "stress mythology" of dentists, also previously made by Avrom, is that there appears to be a perverse side to the attitude of dentists towards the degree of stress purported to exist in the practice of dentistry. It is as if we dentists wear the stress statistics as our "red badge of courage" to let an otherwise unappreciative world know "how hard we have it". Perhaps the truly Hardy dentist has found a better way to view the world and its potential stressors. (See Comment #6.)
Another researcher interested in why some people stay healthy and others do not in the face of stress is medical sociologist Aaron Antonovsky. In his book "Health, Stress, and Coping" (highly recommended for serious students who wish to deepen their philosophical and conceptual understanding of the relationship between life stress, health and disease) , Antonovsky presents the concept of a sense of coherence which, evidently, is part of the self--concept of those individuals who are resistant to stress. He generally defines the sense of coherence as a "global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that one's internal and external environment are predictable and that there is a high probability that things will work out as well as can reasonably be expected".
Antonovsky points out that such a perspective, in its best form, is neither naive nor dogmatic. The sense of coherence does not imply that one is in control of all factors, but that one is a participant in the processes shaping one's destiny. Perhaps, ultimately, it might be said that Hardy dentists have a much greater sense of coherence than do those lacking Hardiness. (See Comment #7.)
Regardless of the descriptive label or conceptual framework, a personal lifestyle and perspective which facilitates coping with a rapidly changing world seem imperative for the successful Tier III dentist. In the next part of this series on the Hardy dentist, we will look at some of the compoients of a stress-resistant lifestyle and consider some possibilities for developing a more Hardy personality.
Avrom King's COMMENTS
#1 --- Please re--read the two underlined sentences in this section (page 1). It seems to me that these sentences describe the internalized personal trauma which many dentists are now enduring as they witness the transformation of their profession. Here is the real explanation for the pandemic apathy that now confronts dental societies and dental school continuing education programs. Large numbers of dentists are withdrawing in response to their self-perceived loss of control. Some re-emerge after being enticed by the siren song of Tier I [Closed panel clinics (CAK)] or Tier II [retail, store-front, corporate-owned (CAK)]. This creates an immense opportunity in Tier III for the dentist who's bright enough to grasp the principles of health-centered dentistry and courageous enough to attain them.
#2 --- Cliff's insight is brilliant. "Commitment to one's self" is the key to "interdependent involvement" and, of course, self--esteem. What Cliff here describes is healthy; the contrary of it is sick. That's why the health-centered model absolutely requires a dentist and staff who manifest self-esteem. People who lack self--esteem and who, therefore, are sick cannot promulgate health in others.
#3 --- Please note the underlined sentence. Writing from the somewhat different perspective of an ego psychologist, Dr. Charles M. Sorenson interprets this manifestation of compulsiveness as a search for worthiness. See his discussion, "Beyond Self ism: A Manager's Imperative", which appeared in NEXUS on September 17, 1979. Let me also refer you to the audio-cassette program, "Personal and Professional Growth", which he and I together produced. This behavior is clearly seen in the addictive performance of the "continuing education junkie" who is driven by a need to validate self rather than a desire to better prepare self for helping others.
#4 ---- Cliff's point can be quickly summarized: Stress in dentistry is attitudinal, not occupational. Our 1976--77 study of stress in dentistry demonstrated that of the 18 most common stresses, none are intrinsic to dentistry. All are attitudinal and relational.
#5 -- This paragraph exploits the distinction of the previous paragraph in a very important way. The size of the practice, however that's measured, is not a cause of stress. That is completely consistent with our data and observations. Indeed, some of the least stressed and most happy dentists are extraordinarily productive. And, as a generalization, I think that the dentists who exhibit the highest level of stress tend to be economically unproductive. But the explanation for both sides of this observation is not economic. In my opinion, there is a mosaic of attitudes --- all of which are related to self--esteem ---- that predictably determine whether a dentist is stressed. The same attitudes which permit a relatively low level of stress also permit a relatively high level of productivity.
#6 --- The "It Hurts So Good Syndrome" is a major obstacle to behavior change in dentists. Unquestionable, a remnant of our Puritan heritage still tells many of us that good things will not happen in the absence of suffering. The premise is flawed ---- theologically and psychologically. It's OK to enjoy our work.
#7 -- over the years I've discussed the phenomenon of the health-centered dentist as an entrepreneurial risk--taker. For me, the quotation from Antonovsky is beautiful and meaningful. It encapsulates the essence of what perhaps we can call "enlightened entrepreneurial behavior". This is very different than the behavior of the compulsive gambler or hunch player who, by various references to "lady luck" or reliance on such talismans as a "lucky shirt", are acknowledging a locus of control outside of themselves. The flip side of this is what I have sometimes called "the devil theory". Here failure (real or expected) is explained by the presence of a devil -- the Supreme Court, the ADA, advertising dentists or whatever. The key distinction, in Cliff's words, is whether "one is a participant in the processes shaping one's destiny". Either an individual does --- or does not ---- accept responsibility for self.
To read the first and third part of this series go to: In Search of The Hardy Dentist, How to Become a Hardy Dentist
To find out more about Cliff, go to: Cliff Katz DDS, PhD
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