Stress and Health

Frank L Collins Jr, Kristen H Sorocco, Kimberly R Haala, Brian I Miller, William R Lovallo. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.

Although stress may not cause disease, it has been established that stress may be a risk factor for the development of disease, may aggravate an existing disease, and may reduce a compliance and treatment success. As a result, many health professionals frequently refer clients to clinical health psychologists for help in dealing with stress-related issues. Clients referred in this manner frequently have a basic understanding that emotional and psychological factors influence health (often seen as the mind influencing the body); however, they frequently do not understand the mechanisms involved in this process. Likewise, clinical health psychologists may have an in-depth understanding of effective treatment methods for reducing stress while having only an elementary understanding of the physiological foundations that can help to guide a more sophisticated conceptualization and treatment for these disorders. The major goals of this chapter are to (a) provide health professionals with a model to use with clients, (b) review the literature on models of coping, and (c) provide information assessment and treatment strategies.

What Exactly is Stress?

To understand the complexities of the construct we call stress, it is important to have a basic understanding of how the body is organized. The body is a complex machine that functions in a hierarchical manner. At the most basic level, individual organs and tissues have self-regulating properties that allow the body to maintain normal function (homeostasis) when external conditions are constant. However, individual organs and tissues are not able to respond to rapid changes (challenges) in the environment or coordinate their responses with other bodily systems. Therefore, higher levels in the nervous system modulate the self-regulation of tissues and organs when homeostasis is threatened. Modulation in self-regulatory functioning is achieved through the receipt of sensory inputs, integrated control over target tissues, endocrine outflow, and autonomic function. This process is discussed in further detail later in this chapter.

In its simplest form, stress involves a stressor and stress response that challenge the body’s ability to maintain homeostasis. A stressor is any physical or mental challenge to the body that threatens homeostasis. Physical stressors are events that challenge the body to function beyond normal capacity (McEwen, 2000). Examples of physical stressors include bodily injury, physical exertion, noise, overcrowding, and excessive heat or cold. Physical stressors are generated through internal mechanisms and are a bottom-up process. Alternatively, psychological stressors are top-down processes that challenge an individual’s mental capacity. Psychological stressors include challenges such as time-pressured tasks, speech tasks, mental arithmetic, interpersonal conflict, overcrowding, isolation, and traumatic life events. Therefore, both a physical stressor, such as being trapped outside in below-freezing temperatures, and a psychological stressor, such as participating in a public speaking task, can challenge the homeostasis of the body.

A stress response may consist of both a behavioral response and physiological response. A behavioral response is any action taken on the environment, such as quickly leaving a dangerous situation or implementing a coping skill, whereas a physiological response is an alteration in physiological functioning that serves to restore an imbalance in homeostatic functioning. Examples of physiological responses include an increase in blood pressure, elevated heart rate, impaired memory and decision-making abilities, and altered metabolism. Both behavioral and physiological responses to a stressor may be associated with a negative affective state for the individual.

Most individuals can identify stressors they experience in their daily lives as well as how they experience the negative effects of stress. However, what goes on between the stressor and the stress response in terms of physiology is less clearly understood by clients with whom health professionals come into contact. By educating clients on the psychological and physiological mechanisms of stress, health professionals can teach clients the adaptive role of the stress response to episodic stressors and the detrimental physical and psychological effects caused by chronic long-term stress.

Physiology of the Psychological Stress Response

After any external event occurs, sensory information related to the event is processed within the corticolimbic system. In general, the corticolimbic system is responsible for threat appraisals and the processing of emotions. The corticolimbic system is composed of multiple brain structures, including the thalamus, sensory cortex, prefrontal cortex, memory system, and amygdala. As an individual experiences an external event in the environment, sensory information is relayed from the thalamus to the sensory cortex. From the sensory cortex, the information is relayed to the prefrontal cortex, which is responsible for decision making and planning. Interestingly, the prefrontal cortex is tied to the person’s memory system, so incoming information is evaluated based on his or her prior memories. The appraisal process is completed in the prefrontal cortex, which communicates with the amygdala, the region in the brain where emotions are processed.

One of the main functions of the corticolimbic system during the stress response is the appraisal of potential threats in the environment. Lazarus and Folkman’s (1984) model of coping distinguishes between two types of appraisals that occur during a stress response. A primary appraisal is responsible for determining the magnitude of the threat such as immediate danger. If a threat appraisal is made, secondary appraisals help an individual to evaluate ways in which to cope with the stressor. For example, if a threat appraisal indicates immediate danger, the corticolimbic system immediately activates the peripheral nervous system to signal the body to engage in behaviors that initiate movement.

After primary and secondary appraisals have been made indicating a threat, the corticolimbic system also sends a message to the hypothalamus in addition to the message that was sent to the peripheral nervous system signaling the body to move. The hypothalamus is responsible for coordinating the nervous system and controls the autonomic nervous system via the brain stem. The autonomic nervous system is divided into three main branches: the sympathetic nervous system, the parasympathetic nervous system, and the entric nervous system. For the purposes of this chapter, only the sympathetic and parasympathetic nervous systems are discussed. Both the sympathetic and parasympathetic nervous systems are involved in maintaining homeostasis. The sympathetic nervous system is usually responsible for increasing the activation of bodily systems (flight-fight response), whereas the parasympathetic nervous system is responsible for feeding, energy storage, and reproduction. The brain stem itself can initiate changes in the autonomic nervous system in single organs and tissues but is not efficient at coordinating across organs or between systems. The role of the autonomic nervous system in the stress response is to prepare the body to respond to the stressor.

The hypothalamus, as a coordinator between systems, also communicates with the endocrine system during a stress response. There are two main endocrine functions during a stress response: the adrenocortical response and the adrenomedullary response. The adrenocortical response releases cortisol into the body during a stress response. Cortisol is released through multiple steps. First, the paraventricular nucleus of the hypothalamus releases corticotropin-releasing factor (CRF), which travels to the pituitary gland. CRF causes the secretion of adrenocorticotropin in the anterior pituitary gland and the secretion of cortisol in the adrenal cortex. Cortisol is then released from the adrenal cortex. Cortisol as a hormone is always present in the body, indicating its importance in normal functioning, but the levels vary due to both time of day (diurnal pattern) and current stressors. Cortisol is responsible for increasing sympathetic nervous system function, releasing stored glucose and fats for energy, and suppressing immune function.

Another stress hormone that is important to the stress response is epinephrine, also known as adrenaline. The adrenomedullary response releases epinephrine into general circulation in response to the increase in sympathetic nervous system activity caused by the release of cortisol. Epinephrine increases relative to the stress response and assists in coordinating bodily systems to make both behavioral and metabolic changes necessary to deal with the stressor. More specifically, epinephrine stimulates heart muscles, increasing heart rate and oxygen levels to prepare the body to respond to the stressor.

After the first three components of a stress response occur, regulation of the autonomic nervous system and endocrine system is maintained by negative feedback. Information on cortisol and epinephrine output is sent from tissues and organs to the brain stem, hypothalamus, and corticolimbic system, where the decision to continue production of cortisol and epinephrine is made. If production of these hormones is no longer needed, messages are sent to the pituitary and adrenal glands to discontinue output.

Negative Physiological Impacts of Chronic Stress

Walter Cannon, a physiologist who first introduced the term stress, distinguished between short-term and long-term stressors (Carlson, 1999). He discussed the fact that physiologically we were built to deal with episodic stressors rather than chronic stressors. The stress response is designed to deal efficiently with episodic stressors; however, there are negative physiological and psychological consequences when an individual is under chronic stress. The negative physiological consequences resulting from chronic stress are due to the prolonged activation of the stress response, which cannot be easily eliminated by behavioral and psychological mechanisms.

If we reexamine the physiology of the stress response, some of the negative consequences of chronic stress become evident. To begin with, cortisol and epinephrine, the hormones released during the stress response, have detrimental effects when they are released continuously. For example, one of the roles of cortisol is to suppress the immune function, which episodically is fine but which over a long period of time leaves an individual susceptible to illness (Lovallo, 1997). Chronic stress also increases the amount of time it takes for a wound to heal. For example, Kiecolt-Glaser, Marucha, Malarkey, Mercado, and Glaser (1995) examined the length of time it took for punch biopsy wounds to heal in individuals caring for a relative with Alzheimer’s disease and found that wounds took significantly longer to heal in caregivers under chronic stress in comparison with control participants. The continuous release of cortisol also might be related to the sleep problems commonly reported among individuals experiencing chronic stressors. As was mentioned earlier, cortisol is released diurnally two times per day: once during the morning and then again after lunch. Researchers have found that the continuous release of cortisol decreases rapid eye movement (REM) sleep, which is essential to normal sleep cycles (Vgontzas, Bixler, & Kales, 2000).

In addition, the release of epinephrine during the stress response can put individuals experiencing chronic stress at risk for cardiovascular disease (Pollard, 2000). Epinephrine stimulates cardiac muscles, resulting in an increased heart rate and potentially hypertension. Epinephrine also is involved in increasing blood platelet adhesiveness and in reducing clotting time, both of which are risk factors for myocardial infarctions and cerebrovascular accidents (Markovitz & Matthews, 1991).

Chronic stressors also can negatively affect individuals psychologically. As discussed previously, the second stage in the stress response after experiencing a stressor is the appraisal process. During the appraisal process, emotions are generated, and emotions in turn influence an individual’s mood. Chronic stress can lead to a negative mood state such as depression or anxiety. Negative mood states can influence how a person appraises situations by serving as a filter through which he or she interprets information from the environment. How the person appraises environmental events influences the duration of the stress response because it can be considered the highest level of control over homeostatic functioning (Lovallo, 1997).

Although the human body is designed to deal with episodic stressors, chronic stress can negatively affect both the physiological and psychological functioning of an individual. However, individual differences resulting from both genetics and life experiences influence how individuals respond to stressors. In fact, two individuals who experience the same traumatic event might react to the stressor completely differently depending on each individual’s access to coping resources. By studying how individuals respond to stress, researchers have been able to develop coping models for stress and to identify effective treatment interventions designed to help individuals develop coping skills.

Models of Stress

As noted previously, at the most basic level, stress involves two processes: an environmental event (stressor) and a physiological response (stress response). Over the years, models of stress have differentially focused on these two components, with most contemporary models focusing on stress as a transactional process (Cassidy, 1999). A comprehensive review of the strengths and weaknesses of each model is beyond the scope of this chapter; however, clinical health psychologists need to have familiarity with these major approaches and how these models are translated into treatment options.

Stimulus Models

Stimulus models focus on environmental events that produce demand on the organism. Early research in this area (cf. Brown & Harris, 1978; Holmes & Rahe, 1967) led to a focus on negative life events as a major source of stress. Intervention efforts focused on learning to deal more effectively with these demands (coping) or on learning to predict and (where appropriate) minimize exposure to negative life events. Cassidy (1999) argued that these models primarily served a classification role, providing researchers and clinicians with necessary tools for identification of individuals experiencing stress. Intervention, particularly stress management strategies, has moved beyond stimulus models.

Response Models

Stress is frequently identified by the presence of specific symptoms that include overt behavioral, physiological, and cognitive symptoms. These symptoms are the natural consequences of demand, and although one cannot separate stress responses from stressors, focus on response models has played a major role in the development of treatment strategies typically labeled “stress management” (cf. Lehrer & Woolfolk, 1993).

These models use a bottom-up explanation rather than a top-down basis as in the appraisal models. Much of the theory behind these models comes out of biofeedback and relaxation research as well as from Eastern philosophy. The basic premise of these models is that stress can be influenced by a person’s level of autonomic arousal. In other words, if a person is experiencing high levels of arousal, the person will feel as though he or she is under more stress. If the arousal is reduced, the person will subjectively experience lower amounts of stress. This may occur even if the demands on the person have not been reduced or changed.

In relation to this, it is believed that the perception of controllability of arousal may also influence stress levels. People who experience high levels of arousal and do not feel as though they can control that arousal may report more stress than do people who experience the same levels of arousal but feel as though they have control over their arousal.

Appraisal Models

Appraisal models view psychological stress as a process whereby an individual interprets or views environmental events and perceived coping ability that in turn shapes his or her emotional, behavioral, and physiological responses to events. Appraisal theories suggest that the person “appraises” an event in an attempt to discern its meaning in the context of his or her experiences. These appraisals lead to decisions regarding whether or not the event is viewed as threatening or harmful and what actions would be appropriate under the circumstances.

Appraisal models are a natural outgrowth of stimulus and response models. Appraisal of an event by definition requires that an event occur. Thus, it should be no surprise that many events that would be labeled as stressors are in fact appraised as high demand. Likewise, when a person appraises an event as high demand, the natural consequence of such an appraisal is behaviors, emotions, and/or cognitions that fit the definition of a stress response.

Lazarus’s model (Lazarus, 1966, 1999; Lazarus & Folkman, 1984) is the most widely accepted stress model. As noted previously, Lazarus divided the appraisal process into two distinct parts: primary and secondary. Primary appraisals are intended to determine the threat value of an event. They take into consideration the familiarity of the event, the beliefs of the person, and commitments. An event can be perceived as stressful or benign. Stress appraisals, whether positive or negative, lead to autonomic arousal.

Lazarus proposed three types of stress appraisals: harm/loss, threat, and challenge. Harm/loss appraisals occur in cases where damage has already occurred. For instance, a harm/loss appraisal would occur when a person has become ill or injured, lost a loved one, or suffered a blow to his or her self-esteem. Threat appraisals occur when harm or loss can be anticipated but has not yet occurred. These are different from harm/loss appraisals mainly in that threat appraisals allow the person to plan and adapt to minimize or alleviate some of the harm before it occurs. The third type of stress appraisal is challenge. Challenge appraisals are more positive in that the focus is on opportunity to achieve growth or to gain something from the event. These categories are not necessarily exclusive. There may be, and often are, situations in which threat and challenge appraisals are experienced from the same event.

Once primary appraisal determines that an event is stressful, a person must choose what he or she is going to do about the situation. This is where secondary appraisals come in. Secondary appraisals evaluate the person’s available options for coping with a stressful event and the possible consequences of those actions. These appraisals take into account personal resources and the limitations of the environment.

Appraisals rarely occur in this linear fashion. Rather, primary and secondary appraisals may occur almost simultaneously, and changes in the event, new information, and/or changes in the level of perceived threat may alter a person’s appraisals. Lazarus referred to these new appraisals as reappraisals. A person reappraises an event when there are changes that may affect the stressfulness of the event or his or her ability to cope with it.

Coping responses are generated from the appraisal process. According to Lazarus, coping refers to constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person. Coping can be divided into two types of responses: problem focused and emotion focused. Problem-focused responses operate directly on the situation itself and may include behaviors aimed at increasing personal resources, altering the event, and/or generating alternative solutions. Emotion-focused coping is directed at lessening the emotional distress caused by the event. Little or no effort is devoted to changing the event that caused the distress. This type of coping includes strategies such as avoidance, reappraising the situation, distancing, and selective attention. As with the division between types of appraisals, the boundary between problem-focused coping and emotion-focused coping is somewhat blurred. People often engage in a coping strategy that serves both purposes or use more than one strategy at the same time to serve both purposes.

Problem-focused strategies can be costly early on because of the energy and time that they require. However, they can lead to alterations in the event that lessen its stress value and so lessen the amount of coping that continues to be needed. Emotion-focused strategies are not as costly early on, but if the situation remains stressful, these coping responses can lead to a continued drain on resources. Once a coping response has been used, the situation is reappraised taking into account changes a person has made to the situation or his or her response to it. In this way, the appraisal process is circular and recurrent.

Symptoms of Chronic Stress

Chronic exposure to stress can lead to a variety of impairments in many domains. People who are under chronic stress report a number of symptoms. Some of these symptoms are vague and do not greatly affect their functioning, whereas others can be quite severe and troubling to patients. Stress can lead to emotional impairments such as inappropriate crying, nervousness, edginess, anger, and irritability. In addition, patients experiencing chronic stress may feel overwhelmed, powerless, and isolated. They may report general feelings of unhappiness and dissatisfaction. They may report feeling that life has no meaning anymore. Some patients may appear cynical or apathetic. They may report that they feel empty or directionless, and they may have a strong urge to try to prove themselves.

People experiencing chronic stress often exhibit cognitive problems such as foggy thinking, distractibility, and forgetfulness. They often say that they cannot stop worrying. Some patients report that they cannot seem to be creative anymore or have no sense of humor. Chronic stress can also lead to behavioral problems and trouble in relationships. Stressed people may be bossy and critical of others and themselves. They may take up alcoholism or smoking, or they may begin to eat or chew gum compulsively. Spouses or partners of stressed individuals often report that their significant others grind their teeth in their sleep, have a lowered sex drive, and have “clammed up.” Stressed people may also seem resentful or intolerant of others and may isolate themselves.

In addition to these impairments in a wide range of functioning, people experiencing chronic stress may experience a number of physical symptoms. Patients commonly report headaches, fatigue, restlessness, and sleep disturbances. Patients also report unexplained backaches, painful muscle tension, and gastrointestinal discomfort such as stomachaches and indigestion. Patients may also have an increased heart rate and increased blood pressure.

Effects of Stress on Health

As noted earlier, stress increases the risk of disease. This can occur via the numerous symptoms just described or through the effects of stress on the immune system. In addition, stress can exacerbate already existing disease states or can impede recovery from an illness. Although the effects of stress on health have been widely studied, there has been little conclusive evidence on the mechanism by which these effects occur.

Immune Function. The immune function is very complex, involving many different antibodies and activities. One of the acute effects of stress is to suppress immune functioning and thereby increase infection susceptibility. Stress leads to increased adrenaline secretion, which suppresses the production of some antibodies, decreases macrophage activity, and decreases interleukin production. Reduced immune function can increase a person’s chances of viral and bacterial infection, which may lead to illnesses such as the common cold and mononucleosis. For instance, Cohen, Tyrrell, and Smith (1991) placed a cold virus in the nasal passages of participants. They found that participants who had reported high levels of stress within the past year were much more likely to become infected than were those who reported low levels of stress.

Cardiovascular Disease. Stress may also exacerbate or lead to cardiovascular disease. Chronic stress elevates blood pressure and serum cholesterol levels. In addition, some evidence suggests that chronic central nervous system hyperactivity reduces the body’s sensitivity to insulin, and this also increases blood pressure.

Gastrointestinal Disorders. Stress also affects the gastrointestinal tract. It can increase colonic contractions or can lead to spasms in the colon. There may also be increased muscle tension in the abdominal area as well as throughout the body. Stress may also increase pain sensitivity. Consequently, people who experience chronic stress may be seen for disorders such as irritable bowel syndrome, Chron’s disease, and general gastric discomfort.

Sleep Disorders. As listed previously, some of the symptoms of stress include nervousness and constant worrying. These symptoms, as well as other stress effects, can lead to interruptions in sleep patterns. Stress often leads to insomnia and frequent nighttime waking. Sleep efficiency is usually lowered, and people may report feeling tired and worn out even after receiving a full night’s sleep.

Anxiety and Depression. As can be seen from the list of symptoms earlier, stress often leads to feelings of anxiety and depression, and this can become a problem in itself for some patients.

Substance Abuse. Some substances have a stress-relieving effect, and some patients may resort to substance abuse as a way of coping with their high stress levels.

Assessment of Stress and Treatment of Stress

The exclusion of “stress disorders” from the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition [American Psychiatric Association, 1994]) as a distinct category has led to a wide variety of methods used in the measurement of stress. From the clinical health psychologist’s perspective, the most important criterion for diagnosing a given complaint as a clinical stress problem is the judgment that it is amenable to improvement by changing the way in which the person perceives or manages his or her transactions with the immediate environment. Therefore, the diagnosis of a clinical stress problem has less to do with the etiology or severity of the problem itself than with the prediction of its responsiveness to the teaching of coping skills.

Assessment

One of the primary ways in which the physician assesses preliminary signs of stress is the patient’s self-report via questionnaires and/or a clinical interview. Self-report questionnaires typically allow the patient to rate whether a symptom is present or absent as well as the severity of the symptom. Clinical interviews are often designed to allow the physician to use a checklist format for quick and efficient diagnoses.

Two of the more frequently used scales to assess stressors are the Life Events Survey (Sarason, Johnson, & Siegel, 1978) and the Daily Hassles and Uplifts Scale (Kanner, Coyne, Schaefer, & Lazarus, 1981). The Life Events Survey consists of 57 items, and the client checks each event that has ever happened to him or her. Then the client rates each of these items positively or negatively in terms of desirability and impact at the time the event occurred. Each item is rated on a 7-point scale from -3 to +3, with the sum indicating the client’s life events experience. Sarason and colleagues (1978) noted that negative scores are the best predictor of health problems.

The Daily Hassles and Uplifts Scale was developed to address more minor events in a person’s life. This 143-item survey has generated enormous numbers of research studies focusing on the types of stressors found for individuals with various disease states (e.g., VanHoudenhove et al., 2002) as well as on differences in stressful experiences of particular high-risk populations (e.g., McCallum, Arnold, & Bolland, 2002). In addition, psychometric research evaluating the questionnaire indicates that for some populations, the order in which items are presented influences ratings. Specifically, events are rated as less uplifting when they follow hassle items than when they precede hassle items (Mayberry et al., 2002).

Life events can also be measured as part of a structured or unstructured interview. Brown and Harris (1978) developed a structured interview format called the Bedford College Interview for Life Events and Difficulties, which has been found to be both reliable and potentially more useful because it allows trained raters to evaluate contextual factors surrounding specific life events. For example, someone who lost a parent following a prolonged illness that preceded the death may view the “loss of a parent” event quite differently from someone who lost a parent in an unexpected accident.

Symptoms of stress can be measured using common emotional scales, including the Spielberger anxiety (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) and anger (Spielberger, 1996) scales (for a review, see Spielberger, Sydeman, Owen, & Marsh, 1999), the Beck inventories (Beck Depression Inventory-II [Beck, Steer, & Brown, 1996] and Beck Anxiety Inventory [Beck, 1990]), and broad-based measures such as the Symptom Checklist 90-Revised (Derogatis, 1975).

Treatment

The treatment of stress disorders often falls into one of two types: treatments aimed at reducing central nervous system activation and treatments designed to address problems in appraisal or coping skills. Treatment techniques that involve the alteration of appraisals often incorporate cognitive strategies to alter and improve the competitiveness-readiness level, whereas central nervous system activation reduction techniques focus on lowering or controlling physiological arousal, anxiety, and muscular tension. It should be noted that the term stress management is typically used to describe a number of treatment techniques designed to reduce stress rather than referring to any one specific method. Lehrer and Woolfolk provided detailed chapters on the methods and approaches that fit this broad category of “stress management” (Lehrer & Woolfolk, 1993; Woolfolk & Lehrer, 1984). In the current chapter, several of the most common methods are merely outlined. Training in these individual techniques should be done under close supervision as part of a formal training program.

Treatments That Focus on Central Nervous System Reduction

Relaxation methods encompass a range of techniques, each with unique properties; however, all share the goal of creating a relaxation response. This response is designed to activate the parasympathetic nervous system, resulting in a decrease in oxygen consumption, heart rate, respiration, and skeletal muscle activity along with an increase in skin resistance and alpha brain waves. Four factors have been identified as important for eliciting a relaxation response: a mental device (a word, a phrase, or an object to shift attention inward), a passive attitude, decreased muscle tonus, and a quiet environment. The ultimate goal of relaxation training is to evoke the relaxation response to counter situational stress.

Progressive Relaxation. Modern progressive relaxation techniques were derived from Edmond Jacobson’s work during the early part of the 20th century. The main premise of his approach was that it is impossible to be nervous or tense when skeletal muscles are completely relaxed. Jacobson noted that relaxation is a fundamental physiological occurrence that consists of systematically learning to elongate muscle fibers. For this reason, the use of suggestion by the progressive relaxation instructor should be abandoned given that the perception of relaxation is not so important as actual physiological relaxation (McGuigan, 1993).

Jacobson’s full progressive relaxation procedure involves systematically tensing and relaxing specific muscle groups in a predetermined order and was described in great detail by McGuigan (1993). The individual is instructed to tense a muscle before relaxing it to help him or her recognize the difference between tension and relaxation. To first become familiar with the sensation of tension, the learner is instructed to lie on his or her back with arms at the sides and to bend the wrist up at a 90-degree angle. The learner perceives tension in the forearm. Next the learner performs much of the same task except that this time the wrist is bent at a 45-degree angle, producing less tension. This method is repeated again at increasingly smaller angles. Using this method of diminishing tensions teaches the learner to detect not only high tension but even the most minute tension.

Relaxation begins with the instructor explaining the basic physiology of neuromuscular circuits and the nature of tension and relaxation. The learning environment can be quite varied; classrooms, gymnasiums, and conference rooms all provide learners with something soft to lie on such as mats, blankets, or thick carpets. In clinical treatment, individual rooms with cots, pillows, and blankets are often provided. It should be noted that complete elimination of external distraction is not desired because the normal environment in which the individual will be relaxing can be quite noisy. Relaxation starts with the muscles of the left arm and proceeds to the right arm, left and right legs, abdomen, back, chest, and shoulder muscles and then concludes with the neck and face muscles. The starting position is with the learner lying on his or her back, with the arms by the sides. Only one position is practiced each hour. The control signal, which for the position with the hand bent back is the vague sensation in the upper surface of the forearm, is observed three times during each period. This is the critical signal that the individual is to learn and recognize. The tensed position is held for a minute or so, and then the “power goes off” (relaxing the signal away) for a few minutes.

During this initial session, the learner will make a few common mistakes, and it is the instructor’s crucial job to catch and correct mistakes. These include misidentifying a control signal as a strain and making an effort to relax by working the hand down to a “resting” position, which is merely adding more tension, instead of allowing the hand to simply collapse.

The amount of time required to learn progressive relaxation may seem excessive from a naive learner’s point of view. Attempts to shorten the process have not yielded satisfactory results. Jacobson explained that a body that has been practicing overtension for decades will not be able to reverse the process in brief sessions. Children, however, have been shown to learn progressive relaxation quite rapidly, probably because they have not had as many years practicing maladaptive tension habits.

Abbreviated Progressive Relaxation Training. Condensed versions of progressive relaxation have been linked to the work of Wolpe (1958), who developed a “short” version of progressive relaxation for treating phobias (Bernstein & Carlson, 1993). Abbreviated progressive relaxation was standardized and popularized by Bernstein and Borkovec (1973) in their classic text, Progressive Relaxation Training, and is the source citation for many clinical intervention studies using progressive relaxation (Hillenberg & Collins, 1982).

Bernstein and Carson (1993) provided a detailed review of abbreviated procedures, which are summarized here. In the initial training session, 16 muscle groups are the focus of tension release procedures. The client is typically asked to recline during the introduction. The order in which the muscle groups are taught is standardized, and the therapist demonstrates the tensing methods and then paces the client through the series of tension release procedures. The client is encouraged to practice relaxation skills twice a day, 15 to 20 minutes each time, with continued training in sessions paced by the therapist.

Autogenic Training. Autogenic training was developed by Johannes Heinrich Schultz following his own observations of individuals under hypnosis and Oskar Vogt’s observations in brain research (Linden, 1993). Schultz noticed that hypnotized patients would report a heaviness of the limbs and a warmth sensation. Hypnosis was believed to be something that patients allowed to happen to themselves, not something that the therapist did to them. The objective of autogenic training is to permit self-regulation in either direction (deep relaxation or augmentation of a physiological activity) through “passive concentration,” also described as “self-hypnosis.” Training can be taught individually or in groups. The ideal setting should be one at room temperature, slightly darkened, with a couch or exercise mats and pillows.

Biofeedback Methods. In general, biofeedback systems operate by detecting changes in the biological environment and conveying this information to the client in the form of visual and auditory signals (Stoyva & Budzynski, 1993). The client then synthesizes this information with a trial-and-error strategy to cause the signals to change in the desired direction; thus, the client learns how to control the biological response system. It is further intended that the client will be gradually weaned away from the biofeedback signal, allowing for the transfer of control into everyday life.

The most common form of biofeedback used in stress management is electromyo-graphic (EMG) feedback. EMG feedback operates by detecting biological signals and providing visual or auditory signals linked to this biological system via amplification of the psychophysiological measures. This immediate feedback is thought to facilitate learning to control or reduce arousal through trial-and-error strategies designed to produce changes in the signal in a desired direction (Stoyva & Budzynski, 1993).

EMG feedback offers a number of specific advantages as compared with traditional non-biofeedback relaxation therapies in that it provides a direct measure of client learning through the monitoring of muscular activity rather than depending on the client’s verbal report of relaxation. EMG data quantify physiological relationships and operationalize the concept of relaxation. Some drawbacks associated with biofeedback are that the client may become dependent on the machine and that it provides minimal training in coping strategies for reducing tension.

Yoga-Based Stress Management. Yoga methods have had the most popularity in the treatment of hypertension (Patel, 1993). This technique appears to reduce stress in part by helping the client to reframe the stressor in a nonthreatening fashion. Yoga, which means “union,” is an Indian philosophy that presents various values, techniques, and disciplines to teach ways of establishing harmony by developing the mind among the various sides of life. The sides of human life are both material (body) and nonmaterial (mind and soul). Different techniques or combinations are used depending on whether one’s intellect, emotions, or actions dominate. The main components of yoga include 14 breathing exercises (which facilitate regulation of the mind and body), 200 balanced physical postures (which help to prevent musculoskeletal deterioration), and exercises for awakening “kundalini” (the energy reservoir at the base of the spinal cord). Yoga is based on a belief that life can be conceptualized as a gaseous exchange that takes place between “inspired” (oxygenated) air and the blood circulating in the lungs. Deep muscle relaxation, visualization, and meditation all are components of yoga-based therapies, further illustrating yoga’s emphasis ranging from the physical to the spiritual in nature. For a more in-depth review of yoga methods, the reader is referred to Patel (1993), who provides a detailed summary of these methods.

Meditation. Although meditation is often viewed as a yoga-based technique, Carrington (1978) introduced a “clinically standardized meditation procedure” that appears to be useful for reducing stress symptoms in a range of health-related disorders (see also Carrington, 1993). Meditation can be divided into two distinct forms: concentrative and nonconcentrative. The concentrative forms of meditation are simple to learn. The techniques are often practiced in a quiet environment, with the object of the meditator’s attention being a mentally repeated sound, the meditator’s breath, or some other appropriate focal sound (e.g., running water). If attention is found to be wandering, the meditator is directed back to the attentional object in an unforceful manner. A nonconcentrative technique expands the meditator’s attentional field to include as much of his or her conscious mental activity as possible. In this sense, the specific techniques of meditation are secondary to the actual experience of meditation in bringing about therapeutic change.

In summary, there are many paths to the reduction of sympathetic nervous system activation, producing a shift toward lower arousal characterized by parasympathetic nervous system dominance. Because the stress response is characterized by a heightened sympathetic tone, shifting autonomic dominance to the parasympathetic nervous system should be effective in moderating stress and anxiety reactions regardless of the methods used. Schwartz (1993) pointed out that although numerous methods are available for stress management, client characteristics may lead the therapist to consider alternative strategies that might best fit clients’ life histories and experiences and that might be more appealing to clients. Therapists who develop skills in multiple methods will be in a better position to provide clients with methods that are both evidence based and philosophically consistent with client expectations.

Cognitive Approaches to Stress

Cognitive approaches conceptualize stress as the result of an active cognitive set that includes successive appraisals of environmental demands and the risks, costs, and gains of specific coping responses. When an individual’s vital interests appear to be challenged, cognitive processes provide a selective conceptualization of what is occurring. Beck (1993) provided an in-depth review of cognitive approaches to stress management that are summarized in the current chapter.

The initial appraisal of an event can be considered a quick scan to determine whether it is pleasant, neutral, or noxious. When the vital interests (harm or enhancement) of an individual (egocentric view) are assessed to be affected, a critical response ensues. An emergency critical response is activated when the individual perceives a threat to his or her survival, domain, individuality, or status. This response is critical to the development of stress reactions. At the same time the situation is evaluated as a threat, the individual is assessing his or her resources for dealing with the ensuing problem. This assessment is labeled “secondary appraisal” (Lazarus, 1966).

The basic rationale behind the treatment of stress from a cognitive perspective is that certain idiosyncratic cognitive patterns become hyperactive and lead to the overmobilization of the voluntary nervous system and autonomic nervous system. When this occurs, the protective buffers and adaptive functions (e.g., objectivity, perspective, reality testing) are rendered ineffective against the cognitive constellation that has been triggered. This overmobilization directly results in reactive syndromes (e.g., anxiety, hostility) or psychosomatic syndromes. In the long term, these physical effects can lead to dysfunction of specific systems or organs (e.g., musculoskeletal, cardiovascular, gastrointestinal). Therefore, the ultimate goal of therapy is to reduce the dominance of the controlling constellation of cognitions and to allow the protective buffers’ adaptive functions to take over.

An initial treatment approach often includes directly reducing the exposure of the stressful stimuli to the individual. This serves to reduce the intensity of the cognitive constellations, reduce the mobilization of the neuromuscular endocrine system, and increase perspective and objectivity. This sets the stage for the individual to now reflect on his or her reactions, test other options, and adopt a broader and more realistic view of the situation. The specific terms for the previously described treatment are as follows: identifying automatic thoughts (“What am I thinking now?”), recognizing and correcting cognitive distortions (“It does not have to mean this; it is probably that”), and identifying the broad beliefs and assumptions that underlie the hyperactive constellations (“I’m a bad person and I don’t deserve good things”). The process described previously outlines the process known as cognitive restructuring or the ABC approach. The premise is that the antecedent or event leads to thoughts and feelings that ultimately drive the individual’s behavior. By changing the way in which the individual thinks about the events, the person will be able to change his or her behavior. In respect to this chapter, the individual will be able to reduce the stress response by “seeing the problem in another light” using this systematic approach.

Stress Inoculation Training

Stress inoculation training is based on the premise that bolstering (inoculating) an individual’s repertoire of coping responses to milder stressors can serve to defuse responses to major life stressors (for a more extensive review, see Meichenbaum, 1993). This is accomplished with the use of an overlapping three-phase intervention approach. The goal of the initial phase is to establish a relationship between the trainer and the client to help the client better understand the nature of stress and its effects on emotions and behavior. Similarly to the cognitive approach, this initial phase focuses on getting the client to appreciate how he or she appraises both events and on his or her ability to cope with the events. In addition, alternative explanations and alternatives are explored. At the end of the initial phase, a reconceptualization of the client’s problems is made.

The second phase focuses on coping skills acquisition and rehearsal of these skills. Attention is paid to removing factors that may interfere with adequate coping such as maladaptive beliefs and feelings of low self-efficacy. The skills are practiced initially in the training setting, with gradual introduction in vivo.

The final phase of stress inoculation training calls for the client to apply the variety of learned coping skills across increasing levels (“inoculation”) of stressors on a graduated basis. This is accomplished by imagery and behavioral rehearsal, modeling, role-playing, and graded in vivo exposure. Attention is also allocated to relapse prevention. The client is taught how to handle a lapse and not allow for it to become a relapse. In summary, stress inoculation training combines client self-monitoring, cognitive restructuring, problem solving, self-instructional and relaxation training, behavioral and imagined rehearsal, and environmental change, with the goal of enabling the client to be flexible in his or her coping repertoire and to have the confidence to cope resourcefully.

Summary

As this brief review illustrates, there are many approaches to stress management. Cognitive approaches focus on a “top-down” method, with the primary goal being the reduction of cognitions that, if unchecked, begin a cascade of behavioral and biological processes that include autonomic nervous system arousal and endocrine activation. Through the modification of appraisal processes, an individual is able to minimize threat and demand, thereby reducing levels of the stress response. Treatments that focus on central nervous system reduction directly can be conceptualized as “bottom-up” methods that directly influence behavioral and biological processes. In addition, some central nervous system reduction methods have been shown to directly influence cognitive processes that show up as enhanced coping and reduced perception of demand based on the individual’s “knowing” that he or she now has the skill to reduce arousal directly. The following case study illustrates this point.

Conclusions

This chapter has provided an overview of the biological and psychosocial factors related to stress. A great deal of attention was given to the biological mechanisms involved in the stress response because this is an aspect of training that is often lacking. As the case study illustrates, assessment and treatment may at times focus on behavioral and cognitive factors; however, knowledge of the biology of stress may help clients to accept psychological treatment.

The treatment methods presented in this chapter were, by necessity, merely summarized. Therapists who have not used relaxation or other anxiety reduction methods should seek out supervised experiences before using these with clients. What at times seems very easy to do can in fact be much more complicated than it appears. As should be noted from both the case study and the early work of Jacobson, it takes a great deal of therapist time to successfully train relaxation skills. Merely sending clients home with a taped session is not sufficient. Likewise, the cognitive interventions require systematic training and should not be attempted without supervised experiences.

Case Study

“Jane M.” was referred by her physician for treatment of stress that was thought to be linked to her frequent headaches. Jane had recently been promoted to a managerial position with her company, and the new position required that she visit regional offices in nearby states on a frequent basis. She was on the road several days each week, and for the past 6 months she reported constant fatigue and frequent headaches. While fatigued and tired, she found it difficult to relax at night while on the road.

Baseline assessment included the Daily Hassles and Uplifts Scale, the Spielberger State-Trait Anger Inventory, the Beck Depression Inventory-II, and a clinical interview. Results indicated mild levels of depression and moderate to severe levels of anger. The anger appeared to be most linked to Jane’s dissatisfaction with the staff at many of the hotels where she stayed and her inability to be “treated with the respect that she deserved” when problems arose. There were few life events rated as positive, with many minor annoyances receiving very negative ratings.

Although it seemed clear that Jane’s stress levels were at times generated by her perceptions of events and expectations that she “should” be treated more respectfully, it was also obvious from early sessions that she was physiologically very tense and quite concerned that her physician believed her problems were all “mental.” The therapist spent a great deal of time discussing how negative events start a chain of physiological processes that lead to heightened arousal that for some people result in headaches or other physical problems. For some clients, merely learning to reduce this arousal can be useful. Jane showed a strong interest in learning how to reduce physical arousal, and a treatment plan was developed that initially focused on learning relaxation skills.

The relaxation method used was a form of abbreviated progressive relaxation training developed by Charles R. Carlson (Carlson, Collins, Nitz, Sturgis, & Rogers, 1990; Carlson, Ventralla, & Sturgis, 1987; Kay & Carlson, 1992) called stretch-based relaxation. Stretch-based relaxation focuses on stretching of muscles, facilitating a differentiation of muscle sensations that contributes to a recognition of muscle tension and fosters relaxation of the muscles.

Training was conducted over an 8-week period, with in-session relaxation training taking between 30 and 40 minutes of each session. The remaining time was spent discussing the application of stretch-based relaxation to Jane’s daily routine and fine-tuning home practice. Her initial response was that she could not produce the levels of relaxation at home that she experienced in sessions, and these concerns and expectations were addressed with a reminder that she would improve with continued practice. At Session 5, she reported feeling much more effective at home, and in-session training switched from being therapist-led training to client-paced training with the therapist observing Jane’s performance.

At Session 6, Jane reported a critical incident where she was checking into a hotel and the night clerk could not find her reservation. It took some time for the clerk to come up with a suitable room, and in the past she would have become physically tense and extremely angry and would have developed a headache that would keep her from sleeping well. She remembered thinking to herself that if she got tense from this “incompetent clerk,” she would just use her relaxation skills to calm down once she was in her room and could avoid getting a headache. Not only did she not get a headache that evening, she did not even feel tense while waiting. Discussion with her therapist indicated that the knowledge that she “knew what to do if she got tense” seemed to ward off feelings of tension. She began to entertain the idea that it was not merely the situation that “got her tense”; rather, it was her reaction to the situation (including the expectancy that a headache would ensue) that contributed to her tension.

Sessions 7 and 8 involved a minor review of stretch-based relaxation, with a great deal of the sessions devoted to discussion of how Jane planned to implement this new skill in her life to keep herself more relaxed. Readministration of the Daily Hassles and Uplifts Scale indicated that the number of situations did not change but that the perception of the situations as negative was greatly improved. Headaches had dropped off significantly with more relaxed sleep and energy. Jane was encouraged to continue formally practicing relaxation on at least a weekly basis.