Pyschological & physiological methods of stress management

Stress is the term we use to refer to a state of mental or emotional strain or suspense. Causes of stress include financial worries, phobias, confusion, work overloads and many other everyday situations.

These can lead to symptoms such as dizziness to depression or sickness.

Psychological approaches to managing stress are many & vaired. the current concept of stress involves appraisal processes; these are cognitive evaluations of the demands caused by faulty or mistaken appraisalesl for instance, over estimating the difficulty of the exam, combined with underestimating your level of prep. if high levels of stress are encountered they lead to the bodily arousal. Negative effects of stress have been linked to these high levels of physiological arousal.

These broad characteristics of stress can immediately provide ways of tackling harmful levels of stress:

• if stress is caused by faulty appriasal & evaluation, one approach to stress management might be to target those faulty cognitions

• another approach would be to target the symptoms of stress, such as increased levels of physiological arousal

The aim is to challenge irrational and dysfunctional thought processes. Two examples of this approach are Beck’s cognitive therapy for depression and Ellis’s rational-emotive therapy (RET). Although both developed independently they follow the same assumptions and share many similarities.

Beck (1967) believed that negative schemata lead to pessimistic thoughts about the self, the world and the future. These in turn lead to the sort of cognitive biases that maintains negative thoughts. The aim of Beck’s approach is to challenge these irrational cognitions and replace them with more realistic appraisals.

• The therapist helps the client identify particular negative thoughts; to do this the client is encouraged to keep a record of their thoughts and anxieties in possibly a diary. These than could be reviewed with the therapist and negative automatic thoughts are recognised.

• Using this material the therapist challenges the dysfunctional cognitions by drawing attention to positive incidents or examples, however trivial, which contradict the client’s negative assumptions.

• This is a form of reality testing (key component in cognitive therapy- it is technique where the therapist encourages the client to compare the irrational cognitions against reality)

• Along with challenging the client’s negative thoughts & showing them to be irrational & unrealistic, Beck also uses behavioural techniques to encourage more positive behaviour.

• Another aspect can be training in problem solving skills, if there are particular situations that trigger negative thoughts. However the focus of the therapy is very much on cognitive restructuring and behavioural change without cognitive change is unlikely to alter the depressed state.

Ellis’s (1962, 1991) approach is similar to Beck’s. He believed that people maintain negative and self-defeating beliefs by constantly telling themselves how inadequate they are, constantly looking to confirming evidence for this. The therapy is similar to Beck’s however he developed a more confrontational approach to therapy, challenging the client’s self-defeating beliefs in intense debates.

However a key issue for both approaches to cognitive therapy is that some negative thoughts are based on rational & accurate perception of reality; and that dealing with this depressive realism was as important as correcting dysfunctional thoughts.

• As a combination of behavioural & cognitive elements, CBT is a structured approach to therapy but acknowledges that complex cognitive processes are important in psychological disorders.

• Depression may sometimes be based on a perfectly rational and accurate perception of reality. It is important that the therapist acknowledges this & does not give the impression that depression is always unjustified.

• It is effective as a treatment for depression & social anxiety. There is evidence that the beneficial effects of CBT in depression may last longer than those with antidepressant drugs.

• There are some conditions where CBT seems less effective. Behavioural therapies are more effective in treating phobias; while more sever conditions such as schizophrenia are not obviously suited to CBT. However, some therapists believe that where the person with schizophrenia has some insight into their condition CBT can have beneficial effects in coping with the disorder, and research in this area is rapidly increasing.

• The cognitive approach ignores genetic & biological factors in states such as depression
  

• The idea of schemata lacks detail & in particular there is no clearly described mechanism for how negative schemata develop in the first place.

• Courses of CBT are generally limited to a number of sessions over a few weeks; it is therefore less time consuming & more cost effective than psychoanalytic therapies.

• Although it requires a degree of insight on the part of the client, it avoids the in-depth probing associated with psychoanalysis and which might be unpleasant or even damaging for some clients. However it should be acknowledged that some people might still find the self-monitoring & analysis associated with CBT threatening.

It consists of 3 stages:

1. Conceptualisation: in this stage the client works with the therapist to identify the sources of stress in their lives. This may involve thinking back to stressful encounters & trying to identify key features of these encounters. In addition, they would be encouraged to keep a diary to record stressful experiences during the daytime. The therapist may also challenge some of the client’s appraisals of stressful situations if they seem exaggerated.

 2. Skills training and rehearsal: For a number of stresses in people’s lives it is possible for them to acquire specific skills to address those situations.

For instance, a common source of stress is social anxiety, that is, interacting with other people either at work/ socially. These types of situation can be addressed by specific training in relevant skills:

• People with social anxiety often have poor non-verbal communication, for example not making eye contact or appearing unapproachable. They can be shown how to improve their social communication through skills training & practise.

• A background issue in most stressful situations is physiological arousal. Therefore, regardless of the particular source of stress, training in relaxation is always useful. So whether it is entering a room full of people, or the examination hall, the individual will have a relaxation technique hey can use to keep their bodily arousal under control

3. Application in the real world: After practising specific skills and relaxation     techniques in the therapeutic setting the client is then encouraged to apply them in the real world. That is not the end of the story as the client & the therapist continue monitoring the success/ failure of the therapy. A key approach is that the client is should learn from experience, by reflecting on the success / failure of their new skills. If necessary there would be opportunities for further training & rehearsal.

• The first stages in managing stress involve identifying the sources of stress in one’s life and assessing how well you have dealt with them in the past. SIT is a cognitive-behavioural approach that focuses on exactly these elements

• Stress exists where there is a gap between perceived demands and the resources you have to cope with them. The cognitive element of SIT is aimed at producing a realistic appraisal of demands, while the training in relevant skills is aimed at increasing recourses to cope with those demands. This training is an example of problem-focused coping.

• Training in relaxation techniques gives clients some control over any stressful situation. It can be seen as emotion-focused, in that it reduces the emotionally arousing effects of stress.

• SIT, like most CBT programmes, takes time, commitment and money. It is no, therefore, suitable or available for everyone.

• However it has been shown to be effective in managing in a variety of situations, including examination stress in students (Berger 2000) and as a treatment for the stress associated with snake phobia (Meichenbaum 1985)

The hardy personality type was characterised by high levels of commitment, challenge and control. She purposed that these characteristics were not fixed but could be increased through training. Hardiness training is another form of CBT and has similarities with stress inoculation training.

There are 3 stages:

1. Focusing: in this stage the therapist encourages the client to focus on the physiological symptoms associated with stressful situations. Thus helps them identify sources of stress. The therapist will also help them acquire new skills & strategies for coping with stress.

1. Reconstructing stressful situations: Here the client is encouraged to think about recent stressful situations, and in particular how they might have turned out better and how they might have turned out worse. This is a cognitive strategy to encourage the client towards a realistic appraisal of life stress and how they cope with it. Realising that things could have been worse should help them feel more positive and optimistic

1. Self-improvement: to improve the client’s sense of self-efficacy (the sense of personal effectiveness and control over one’s life): the therapist will suggest taking on manageable sources of stress. This may involve skills training similar to stage 2 of stress inoculation training. The experience of coping with these will increase the sense of self-efficacy, and even though there will always be stressors around the client should feel more optimistic about dealing with them.

• As with any CBT approach, hardiness training targets both the appraisal of sources of stress and, through training, the resources available dealing with them. In this way it theoretically reduces the gap between demands and coping resources.

• It should provide the client with an increased sense of self-efficacy and this should enable them to deal with future stressful situations more effectively.

• Hardiness training involves time, commitment and money. It is therefore not appropriate for everybody.

• Studies have shown the effectiveness of hardiness training in improving health and performance in working adults and in students (Maddi, 1987; Maddi et al., 2002).

Physiological methods

Drugs

Stressful situations are usually associated with feelings of anxiety. Up to the 1960’s anxiety was treated with drugs from the barbiturate family. Although these could be effective, they were lethal in overdose and also produce high levels of physical dependency. In 1960’s a class of drugs called the benzodiazepines (BZs) as introduced, and these rapidly took over the barbiturates in the treatment of stress & anxiety.

Benzodiazepines have become the most prescribed of the drugs used to treat clinical disorders. The best-known examples of these drugs are: Librium, Valium and Mogadon. 1 reason for the popularity of this group its that some BZs such Librium and Valium can be effective anti-anxiety drugs (or anxiolytics- drugs used in the treatment of anxiety states & stress), while others such as Mogadon are effective sleeping pills.

BZs act in the brain. They increase the action of the neurotransmitter GABA; GABA is an inhibitory neurotransmitter meaning that its role is to reduce the activity of other neurotransmitter pathways throughout the brain. By increasing this inhibitory action of GABA, benzodiazepines therefore produce greater inhibition of neurotransmitter activity in the brain, and there is some evidence that the inhibition f noradrenaline & serotonin is particularly important for the anti-anxiety & antistress effects of BZs.

Librium & Valium are successful ant-anxiety drugs and are often prescribed for the stress and anxiety associated with life events such as bereavement. However as, with all drug treatments for psychological conditions, there are weaknesses as well as strengths associated with the use of BZs.

• Compared with barbiturates BZs are relatively safe in overdose.

• BZs do have a range of side effects. They can produce feelings of tiredness & sedation, and impaired motor coordination. There is also evidence for memory impairment, especially during long-term treatment.

• The major problem with BZs is that they can lead to a state of physical dependence. This means that if the drug is stopped the person goes into withdrawal syndrome. The symptoms of withdrawal include sleeping problems, sweating, tremors & raised heart rate. This has led to the recommendation that they are only prescribed for short periods.

• BZs do not target the sources of stress or help the individual develop more effective coping strategies. They may help people recover from specific life vents such as marriage break-up or bereavement, but even then a psychological grieving / mourning process has to be gone through.

• Effective stress management should specifically target sources of stress in one’s life and/ or one’s available coping resources. This reduces the gap between perceived demands and perceived resources. The use of BZs is most effective if combined with psychological and alternative methods that address the causes of stress.

• There are ethical issues associated with the use of BZs. Because they can lead to dependence and may also have a range of distressing side effects, fully informed consent should be obtained before they are prescribed. It is possible with severe stress-related anxiety would not be full competent to gie informed consent.

This group includes drugs such as Propranolol & Alprenolol. These drugs act directly on the heart & circulatory system of the body. They reduce activation of the cardiovascular system by sympathetic fibres of the autonomic nervous system. In this was they directly reduce increases in heart rate & blood pressure that are associated with stressful situations, and are also used in them management of chronic hypertension (raised blood pressure).

In this way beta-blockers are useful in controlling bodily arousal. It is interesting to note that they are sometimes prescribed for musicians and snooker players whose smooth motor-control can be upset by high levels of arousal.

• Beta-blockers act directly to reduce heart rate & blood pressure. They can act rapidly & have a life-saving function in people with life-threatening hypertension (hypertension is not always related to stress; there may be genetic/ lifestyle factors that are equally / even more important!).

• Although they can interact with other drug treatments, especially those for asthma, beta-blockers do not have severe side effects, partly because their main action is in the body and they do not penetrate the brain easily.

• Beta-blockers are clearly targeting the physiological stress response. They can reduce this response in stressed individuals and lower stress-related bodily arousal. They are not targeting the sources of stress but only the physical symptoms. Therefore they are inappropriate for the long-term management of stress-related arousal, which more effectively treated with psychological needs.

Altenerative methods

• biofeedback
• progressive muscle relaxation & mediation
• physical exercise
  

It is a technique that combines both physiological and psychological techniques. The individual; is wired up to machines that provide feedback on their physiological processes. For instance, heart rate might be recorded & displayed on a monitor. Or a buzzer might sound if heart rate goes above a certain level. The person is then helped to develop techniques for reducing physiological arousal, such as the progressive muscle relaxation or visualisation of calm scenes & meditation. The aim is for the individual to develop their own psychological techniques to lower heat rate & blood pressure, using the biofeedback as a guide as to when they are successful.

After training they should then be able to apply these techniques in real life, and be confident that even without immediate biofeedback they are reducing their physiological arousal.

• There is evidence that biofeedback if effective controlling heart rate & in the treatment of headaches caused by muscle tension (Attanasio et al., 1985). Biofeedback on breathing patterns has been found to be effective in people with panic disorder (Meuret et al., 2004). The biofeedback helps them maintain a regular breathing pattern.

• Attanasio et al. (1985) showed that biofeedback for tension headaches was especially effective in children, probably because of the exciting machinery involved.

• Biofeedback is harmless & has no side effects but It does require motivation & commitment for the training programme to be successful.

• As biofeedback involves relaxation, a stress management technique in itself, it is possible that biofeedback may be no more effective than relaxation techniques used on their own (Masters et al., 1987)

Muscle relaxation is not seen as a stress management technique in its own right, but is a common component of, for instance, CBT approaches. One of the main features of the body’s stress response is an increase in general physiological arousal. One way to exert some control over this is to have available a reliable technique for relaxing body muscles & reducing general arousal.

The most common procedure taught is based on Jacobson (1983). Muscles are alternately tensed & relaxed in a systematic fashion, i.e. beginning with toes and feet and working up to the arms and hands, shoulders and muscles of the lips and forehead. As the person becomes more practised they should be able to achieve a state of relaxation without going through the full tense/relax procedure.

Once acquired, this fairly rapid method of achieving bodily relaxation can be used in times of stress. Along with cognitive reappraisal taught through CBT, this gives the individual an increased sense of control over stressful situations.

Meditation has similarities with muscle relaxation, in that it has the immediate effect of reducing bodily arousal. There are a number of different approaches, but they all essentially involve focusing away from the immediate situation & instead dwelling on neutral/ relaxing stimuli. This may be helped by having a mantra- a single word / sound repeated over & over- and concentrating on steady & deep breathing. As with muscle relaxation, meditation works against the bodily arousal associated with stress. Studies have shown (Murphy 1996) that meditation can be an effective stress management technique in the workplace, leading to reductions in blood pressure and anxiety.

• Both of these techniques reduce the arousal associated with stress, & give the individual an increased sense of control over stressful situations.

• Neither technique targets the sources of stress, or provides specific skills for dealing with stress.

• They can extremely useful in combination with more systematic & focused methods.

One of the issues in modern society is that physical activity is rarely appropriate response to modern day stressors. However, anxieties about examinations, relationships / paying the mortgage, still arouse these systems.

As a result of long-term / chronic stress can result in high levels of energy reserves such as glucose & fatty free acids in the bloodstream. This contributes to the development of circulatory problems such as atherosclerosis. It would seem logical that physical exercise would help burn these energy reserves & prevent these stress-related conditions developing. The evidence is actually quite mixed & it is not clear that regular exercise does reduce physiological reactivity to stressors. However there is evidence that regular exercise reduces resting levels of heart rate & blood pressure, so that while stress-related increases may occur, they are starting from a lower level & should not be so harmful.

In contrast to research physiological reactivity, there is clear evidence that exercise can lower levels of stress & have very positive effects on mood (Biddle, 2000). Throne et al. (2000) found that regular exercise reduced levels of stress in fire fighters. Besides reducing stress levels, exercise makes people feel better & can lead to reductions in clinical states such as depression (Mutrie, 2000). In relation to personality & stress, negative mood states are associated with vulnerability to stress-related illness, & so the positive effects of exercise on mood may indirectly help in coping with stress.

There is no clear explanation for the effects of exercise on mood. It may be the effect of taking positive action & exerting some control over this area of life, so increasing self-efficacy. Alternatively it has been proposed that chemicals called enkephalins (neurotransmitters in the brain involved in emotion circuits, their release may be associated with improvement in mood) are released during exercise & act in the brain to directly improve mood. However this is v. little direct evidence.

• Physical exercise lowers resting heart rate & blood pressure, but may not affect physiological reactivity to stress.

• It has positive effects in raising mood, possibly through actions of enkephalins in the brain.

• It can also reduce reported levels of stress & depression

• There is some risk of injury, especially if exercising too vigorously /when starting an exercise programme.

Social support is not technically a method of stress management. However many studies over the last 40 years have shown that the level of social support can be a critical factor in reactions to the stress. These studies cover a variety of different situations, ranging from physiological reactions to stress, to patients coping with life-threatening illnesses such as cancer & heart disease.

On a commonsense level, social support simply refers to the network of family, friends and co-workers on whom you rely in times of stress:

The functions of social support can be divided into 4 main categories:

• Emotional support: this is where your social network shows concern for your situation and provides reassurance.
• Practical or instrumental support: this is where your support group may provide practical advice or help, for instance lending you money.
• Informational support: your support group may be a source of valuable advice on how to deal with particular stressors. Some of the groups may have been through the same situation previously and you can benefit from the experience.
• General network support: being part of a network of people provides a sense of belonging & social identity, and improves self-esteem.

• Research has consistently shown that social support reduces vulnerability to stress-related arousal.

• Mortality from heart disease has shown to be closely related to social support (as rated by size of network & number of categories covered; Vogt et al., 1992)

• Social support in the workplace reduces job-related stress (Constable & Russell, 1996)

• Uchino, Cacioppro & Kiecolt-Glaser 1996 reviewed studies of social support & the body’s physiological processes, they concluded that:

• Across 28 different studies degrees of social support showed a consistent relationship reduced blood pressure.

• Across 19 studies there was a significant association between level of social support & immune function, for instance carers for dementia patients showed reduced immune function, and this was particularly marked in those reporting the lowest levels of social support.
• The conclusions are supported by a variety of other studies.

• In a lab experiment heart rate & blood pressure during a difficult arithmetic task were lower in women with a companion that those who did the task alone (Kamar et al. 1998)

• Cohen et al., 1997 found that vulnerability to the common cold was greatest in p’s who reported having the fewest special roles (i.e. friend, brother etc) and hence the smallest social networks.

• Overall it is clear that social support is a key factor in dealing with stressful situations.

• One study, Allen et al. 2002, even found that the presence of a pet lowered heart rated during the performance of stressful tests!

• Social isolation in monkeys leads to increases in heart rate & blood pressure and eventually heart disease (Watson et al., 1998), so it appears that the importance of social support is not limited to humans.