Stress Management

From Basic Science to Better Practice

Wolfgang Linden

• Publisher: SAGE Publications, Inc
• Year: 2004
• Print ISBN: 9780761929468
• eBook ISBN: 9781452238661
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Praise for Stress Management

"The author is correct in saying that the stress management field is a ?soft? one, lacking a strong theoretical foundation, and therefore lacking good studies of efficacy and long term outcome. Certainly any publication that would improve on this situation is to be welcomed. . . . Strengths are the systematic approach to the topic. The attempt to ground scientifically the issue of stress management will appeal greatly to the more discerning student of clinical psychology and applied health psychology. It will provide a sufficiently academic approach to the topic that it will find acceptance in courses on the topic."

-William R. Lovallo, University of Oklahoma Health Sciences Center & Director, Behavioral Sciences Laboratory, VA Medical Centers, Oklahoma City

Most of the literature on stress management describes and evaluates individual stress responses but lacks a critical view of the scientific foundation of stress. In order to truly comprehend stress management, there needs to be clear understanding on the phenomenon that is "to be managed."

Stress Management: From Basic Science to Better Practice examines documented pathways between stress and health and develops the scientific foundations for sound interventions. The book begins with a broad review of the term ?stress? and its importance for health. The text then provides a critical examination of the elements of the stress process, extracts supporting research for a rationale of stress management and describes various stress management techniques and their effectiveness.

In Stress Management, author and renowned stress researcher Wolfgang Linden reviews the literature on intervention outcomes, noting weaknesses that include an overemphasis on individual rather than societal responsibility for stress and coping and disregard of the emerging field of positive psychology. The author concludes the text with a proposed distinction between psychotherapy and stress management, and he proposes the need for three distinguishable subtypes of stress management programs-a systematic-preventative approach; a broad-based stress vaccination and prevention type of protocol; and a reactive, problem-solving type of stress reduction intervention.

Key Features

• Begins with a firm groundwork in defining stress and examining conceptual models of stress to set the stage for rational, science-based thinking on how to manage it
• Introduces a unique three-step process model for stress management
• Considers physiological and sociocultural influences on stress and health
• Offers an objective analysis of existing literature and includes extensive personal, clinical experiences of the author to make the science of stress come alive for the reader
• Includes coverage of positive psychology and how the creation of social support and positive emotional states can ease experiences with stress

Stress Management is an excellent textbook for advanced undergraduate and graduate courses, such as Stress Management, Stress & Coping, Stress & Health, and Stress & Wellness, in the fields of Psychology and Health. The book is also a valuable resource for researchers and clinicians within the behavioral sciences interested in understanding and alleviating stress.

1

Stress

Definitions and Pathways to Disease

Stress is essentially reflected by the rate of all wear and tear caused by life.

—Hans Selye, 1956

Scientific and Popular Definitions

It makes little sense to write about stress management (SM) unless there is clarity about the phenomenon that is to be managed. For this reason, a broad but by no means exhaustive review of the term stress and its importance for health is provided first. In this chapter, the meaning of the terms stress and management is explored, and research is described that reveals how they can be connected.

“Stress” has become so ubiquitous and so much a part of everyday language that, at first glance, there appears to be no need for a definition. Selye (1976), a pioneer of stress research, points out that “stress is a scientific concept which has suffered from the mixed blessing of being too well known and too little understood.” Consistent with Selye's view, it is argued here that when concepts from basic science become popularized, there is potential for oversimplification or alteration of the term that may ultimately belie its origins and add to confusion.

When seeking definitions, the general populace does not read scientific journals. People are much more likely to refer to other “gold standards” of definition like Webster's Dictionary. Ideally, definitions contained therein are in full accord with scientists’ definitions but just appear in a simpler or broader language. What, then, can one learn from consulting a dictionary?

Webster's dictionary (Webster's Illustrated Encyclopedic Dictionary, 1990) gives six definitions, ranging from a generic definition to more specific ones depending on areas of application. The first, most generic, one is: “Importance, significance, or emphasis placed on something.” The second, third, and fourth deal with stress as a feature of spoken language and sound: “The degree of force with which a sound or syllable is spoken”; “The relative emphasis given a syllable or word in verse in accordance with a metric pattern”; and finally, “an accent” in music. The next definition relates stress to physics: “An applied force or system of forces that tend to strain or deform a body, measured by the force acting per unit area.” Finally, a definition is given that is more psychological in nature: “A mentally or emotionally disruptive or disquieting influence, or alternatively, a state of tension or distress caused by such an influence.” One can easily see differences in these many definitions such that only the definitions used for physics and psychology contain elements of an action and a result, a challenge and a response. The novelty of the term stress also provided a considerable challenge for translation into other languages; for example, there are no equivalent terms in French or German, and in the end it was largely decided to use the word stress in the same way across many different languages. Given that Selye (1976, p. 51) saw stress as the result of a process, he further felt a need to label the beginning of the process in a manner distinct from the outcome and coined the term stressor to refer to a causative agent, a trigger for this process.

A two-step sequence of “stress” is also reflected in definitions found in psychological textbooks. Girdano, Everly, and Dusek (1993, p. 7) state, “Stress is the body reacting. It is psychophysiological (mind-body) arousal that can fatigue body systems to the point of malfunction and disease.” Hence, popular and scientific definitions see “stress” as a process in which external and internal stimuli, forces, or systems interact, where triggers activate a response system that may lead to exhaustion and vulnerability (Wheaton, 1996).

My definition of stress, as applied to stress management, is this:

Stress is a mediational process in which stressors (or demands) trigger an attempt at adaptation or resolution that results in individual distress if the organism is unsuccessful in satisfying the demand. Stress responding occurs at physiological, behavioral, and cognitive levels. Stress is more than just acute subjective or physiological activation and has its potentially most deleterious health effects when it becomes chronic.

Before delving further into the history and basic research on the stress concept, it should be clarified that, consistent with my definition of stress, the emphasis is going to be on chronic stress and its health consequences rather than on a singular, traumatic kind of stress exposure. Exposure to a traumatic event, like witnessing or being subjected to violence, is a profound event with potentially grave and long-lasting psychological sequelae; in their most severe form, these sequelae qualify for posttraumatic stress disorder, which can be quite debilitating. Little is known about the long-term physical health consequences of traumatic stress (with the exception of early life exposure to trauma, discussed below) and the treatment techniques embraced by stress management (Ong, Linden, & Young, 2004) are not treatments of choice for posttraumatic stress disorder (Taylor, Lerner, Sherman, Sage, & McDowell, 2003).

Also of importance is the recent introduction of the term “acute stress disorder” (American Psychiatric Association [APA], 1994), which was meant to describe initial reaction to trauma that in turn predicts posttraumatic stress disorder. There is considerable debate whether science and clinical practice are well served by having two disorders that are so closely interlinked, and that are really distinct only in the time period required for their manifestation (2 days to 4 weeks relative to at least 1 month post trauma; Harvey & Bryant, 2002). Notwithstanding this debate, neither acute stress disorder nor posttraumatic stress disorder will receive much attention here.

How Can Stress Be Measured?

Having a clear definition of a construct is a useful and necessary precursor for its measurement. In the case of stress, which was defined as a multistep process, the answer to the question posed in the title of this section is anything but simple. The great majority of what has been written about the measurement of stress is really the measurement of the stress response, that is, the result of the stress process. Because stress responding can occur at behavioral, cognitive, and physiological levels, measures of stress responses at each level would ideally correlate highly with each other, meaning that they would be synchronous. Unfortunately they are often desynchronous, and some observations made in my laboratory and a brief anecdote may serve as illustrations of the relative desynchrony among various stress measures.

When exposing individuals to controlled laboratory stressors, we routinely request participants to provide a rating of the stressfulness of the experience, primarily to serve as a validation check. This method has been very effective in showing that a mild stressor like exposure to white noise receives a mean rating of 3 on a 10-point scale whereas an arithmetic challenge with interjected harassing feedback is likely to rate on average of 7 out of 10, thus validating the anticipated differences of the severity of the stressors. However, irrespective of the type of stressor used, and provided that a large sample was tested, some participants rated the exact same stressor 1 out of 10 whereas somebody else rated it 10 out of 10. What accounts for such whopping differences in perception? It is posited that these often greatly varying ratings of the same stimulus reflect a blend of (a) stable, natural response tendencies toward repressing or sensitizing toindividually relevant affective information; (b) the subjective, idiosyncratic meaning of the stressor; (c) possible differences in the ability to perceive simultaneous physiological activation; and (d) possible mood priming via pleasant or unpleasant daily events that preceded participation in the research study.

A researcher who sees such great variability in the judgment of the exact same stressor develops great doubt about the comparability of subjective stress ratings across individuals, and develops a cautiousness that outsiders may not readily share. Along these lines, I had been approached by a TV reporter who was aggregating information from “experts” and the lay public about the presumably growing level of stress in the Canadian populace. The TV production team wanted to measure the absolute level of “stress” by conducting a representative telephone survey and using self-reported stress levels as the index of “real population stress.” When I told the reporter that in my opinion this method of assessment was not an adequate way of measuring “population stress,” he was quite surprised and asked for an explanation. The analogy I used was that measuring “stress” was a lot like measuring “winter.” We all (especially we Canadians) know what winter is, but it is also clear that there is no single defining characteristic of “winter.” That notwithstanding, people know and even agree on a number of features that jointly characterize winter, including below-freezing temperatures, reduced daylight, snowfall (or increased rain in some climate zones), a time epoch in the calendar ranging from December to March, and so forth. My position with this reporter was that the more of these features we measure, the more we capture the global phenomenon “winter,” and that measuring “stress” is very much the same.

An attempt at applying this reporter's crude definition to a real-world problem may further serve to strengthen the point. If one accepted that self-reported stress by one individual was a fully satisfactory definition of stress, then workers’ compensation boards and various insurance companies would likely go bankrupt as a consequence of the resulting number of “stress disability” claims they would have to pay out on. In a variety of jurisdictions, workers’ compensation boards already have to deal with these issues and have categorically decided that subjective self-report is clearly not sufficient for a stress-related disability.

In principle, reliance on self-report of stress would make sense if there were a close correlation (with high sensitivity and specificity) of self-reported stress with the biological markers that are known to play a critical role in the process of activation, failure of recovery, and exhaustion. Unfortunately, the literature indicates that biological changes and self-reported stress, even under relatively transparent circumstances, are at best moderately correlated, as research on acute physiological reactivity in the laboratory shows. Even in well-controlled laboratory environments with reduced stimulus complexity, physiological and parallel mood changes rarely show correlations exceeding r = .3. Self-reported distress rarely explains more than 10% of the variance in physiological change (Linden, 1987). While disappointing, this is not really surprising because (a) there are few direct pathways between central nervous system activity and conscious awareness, (b) researchers have observed marked individual differences in ability and willingness to sense and report physiological changes (Pennebaker, 1982), and (c) people rely heavily on contextual clues for inferring physiological changes from mental representation of environmental events (“This is an important test and I know that I am ill-prepared, so whatever I feel must be ‘stress’ and my fast-beating heart confirms this”). At the level of sensation, there is inherently limited awareness of biological markers, ranging from complete inability to sense, for example, lipid changes or platelet aggregation in the blood, to a rather modest awareness of blood pressure or heart rate changes, to reasonably accurate knowledge of breathing rates or rising blood alcohol levels (although even in the latter cases false feedback studies show that only large changes are accurately perceived). Understanding the relationships between context use and accurate physiological sensing requires delving into basic psychological research that differentiates sensation from perception.

The problems that are endemic to people's relative inability to accurately sense stress-related biological changes, and to the unavoidable influence of context variables on self-reports of stress, are particularly worrisome when important decisions with long-term impact have to be made and objective indices are hard to come by (see the discussion above on the workers’ compensation systems that process claims for stress-related disability).

Is there an answer to the question, “Can stress be measured?” In an absolute sense, the answer has to be emphatically “no.” Given that stress is not a fixed state but a process with multiple phases and with interacting cognitive, behavioral, and physiological processes, we cannot readily index stress and should not even attempt to draw inferences from it from any single index, whether subjective or physiological. We can, however, aggregate information from self-reported distress, observe behavior, and determine physiological activation that is known to be relevant to the stress arousal and exhaustion process. Grossi and his collaborators (Grossi, Perski, Evengard, Blomkvist, & Orth-Gomer, 2003), for example, have compared people with self-reported high and low burnout and found a reasonably high level of parallel self-reported stress and physiological marker activity in neuroendocrine and immune systems. Self-reported stress levels were also sufficient to predict significantly greater mortality risk over 5 years in a cohort of 6,920; this effect held true even after controlling for sociodemographic and known cardiovascular risk factors (Rasul, Stansfield, Hart, Gillis, & Smith, 2004). No class of measurable phenomena that are correlates of stress (and certainly not any single index within each class) can be accepted as absolutely reflecting “stress”; any inference needs to involve understanding of the context and needs to establish the concordance of various stress markers. One can take, for example, cortisol and its precursor ACTH, which are widely considered to be good markers of the stress response. In addition to reflecting varying stress levels, they are also influenced by naturally occurring diurnal patterns, individual differences, and random fluctuations that prevent absolute inferencing of cortisol activity to mean “stress.”

Nevertheless, I do believe that it is meaningful to study subjective reports of stress in the same individual over time (as is done in diary studies) and then relate them to parallel occurring objective events, given that the individual difference variables in stress reporting are presumably stable over time. This claim needs to be tempered, however, with the fact that reactive situations (like stress and pain reports in claimants for a disability) threaten the trustworthiness of subjective stress reporting.

A History of Models for Stress and Health

The decision to start with a chapter on the history of stress should not be taken to mean that an exhaustive review and discussion will follow; the intent here is to focus on those features of previous theorizing that have most prominently contributed to shaping this book and its objectives. Readers who want more in-depth reviews of theories and proposed biological pathways from stress to disease can seek out a large number of books and review articles. As such, there are many excellent undergraduate textbooks in health psychology that provide broad overviews, and for greater depth of facts and discussion, I recommend Lovallo's (1997) excellent discourse, Stress and Health, as well as McEwen's (1998), Ray's (2004), and Kelly, Hertzman, and Daniels's (1997) review articles.

These caveats notwithstanding, some background on major theories and empirical findings needs to be presented early in this text so that sound, empirically based psychophysiological rationales for stress management interventions can be offered, and so that my criticisms of extant thinking and writing on stress management can be solidly grounded.

What may appear to be modern approaches to understanding stress have roots in ancient views of health and disease that can be traced to beliefs and practices of Oriental (around 2600 B.C.) and Greek physicians (around 500 B.C.) who advocated moderation, avoidance of excess, and concepts of balance and harmony. The current practices of acupuncture, meditation, yoga, biofeedback, self-hypnosis, and Autogenic Training can be traced back to these ancient views of health as a state of good balance.

Cannon (1928) can be credited with describing a view of physiological balance sthat at once reconnects medicine with historical views of a healthy balance and also represents a sound approach to physiology that is actually measurable and quantifiable. His work underscored that the autonomous nervous system response to challenges needs to be understood as a dynamic interplay of sympathetic and parasympathetic activation in the autonomous nervous system. These two regulatory forces of the nervous system have opposing actions and both need to be strong and responsive to achieve or maintain health.

Selye's (1956) general adaptation syndrome can be seen as an elaboration of Cannon's work in that he showed conditions and pathways for nervous system activity to become unbalanced. The general adaptation syndrome describes stress as a potential 3-step sequence of events in which a challenge (like the appearance of an aggressor—step 1) precedes the body's activation of its innate coping abilities to deal with the challenge: fight, flee, or otherwise adapt (step 2). Frequently, the whole process of challenge and response ends right there because the challenge has been effectively met, and the constructive arousal that accompanied the stress resistance and that allowed active responding is no longer needed and can return to a physiological resting state. Consistent with Cannon's work, it can be seen that after initial sympathetic activation, the body's natural inhibitory systems “kick in” in the form of counterregulatory, de-arousing, parasympathetic activation. However, not all challenges are of time-limited nature and/or allow quick, decisive responding, and the body continues to resist, becoming by necessity exhausted at some point (step 3). This physiological exhaustion is considered to carry disease potential because the body is now weak and unable to resist. Interestingly, the term exhaustion found in Selye's work has been carried forward into other researchers’ work and, for example, a Dutch research group has coined the term vital exhaustion, which they have shown as critically preceding myocardial...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Preface
• About the Author
• 1. Stress: Definitions and Pathways to Disease
• 2. Elements of the Stress Process and Implications for Stress Management
• 3. Descriptions, Rationales, and Outcomes of Stress Management Interventions
• 4. Now What? A Summary, Reflections, and Recommendations
• References
• Author Index
• Subject Index