Stress Management

An Integrated Approach to Therapy

Dorothy H.G. Cotton

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134849734
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

A guide for clinicians from all disciplines to help conceptualize and control stress in clients in a clinical setting. Presents a definition of stress that is operational in a therapeutic context, and suggests ways of translating this understanding into effective counseling.

1

An Overview

The client settles back in her chair, in apparent relief, having described a litany of problems, including family pressures, work conflict, sleep disturbance, irritability, stomach upset, and crying jags. The therapist silently ponders these problems, attempting to fit them into a straightforward diagnostic category such as anxiety or depression. Such a categorical diagnosis might aid the therapist in establishing a clear direction for treatment. The problem is neither simple nor straightforward, however. As with so many other clients the therapist has seen recently, the problem is stress, and the answer is complex.

As the silence continues, many different therapeutic modalities come to the therapist's mind—relaxation, cognitive therapy, assertiveness, time management. The list is long and all are appropriate interventions. Yet the therapist is torn by the competing demands of the situation. On the one hand, there are immediate practical measures which may offer some degree of relief from the acute aspects of the situation, but which seem stopgap and short-sighted. On the other hand, there are longer term introspective approaches which work toward the eventual goal of maximizing personal strength and awareness, but without providing the immediate relief that the client seems to need.

“I think you have a problem with stress.”

STRESS MANAGEMENT: WHAT IS IT?

According to the American Academy of Family Physicians, two-thirds of office visits to family doctors are prompted by stress-related symptoms. The effects of stress on health may be major and life-threatening, or merely annoying and inconvenient. There is little doubt, however, that stress is a significant problem in contemporary society. A number of factors may contribute to the increasing prevalence of stress problems. Television, and the media in general, bring us into daily contact with situations and conflicts which would have been outside of our experience at another time in history. Changes, conflicts, and upheavals in some of society's basic values also contribute to the general experience of stress. Part of the perceived increase in levels of stress may derive simply from the development of a vocabulary and a literature which describe the phenomenon. An increasing number of individuals are actively seeking assistance in dealing with stress-related problems.

The individual seeking help is frequently relieved to find that he or she is not “going crazy” nor is he or she suffering from an elusive (and surely fatal!) medical problem. The simple act of identifying the problem as stress-related opens the door to a wide variety of approaches and techniques subsumed under the heading “stress management techniques.”

What is stress management? Everything—and nothing. There are probably few individual psychotherapeutic or counseling techniques which cannot be used to help manage stress. Unfortunately, there are also no magic answers or unique solutions to the problem of stress. Many books and authors zealously advocate the use of one particular technique to manage stress. Perhaps the answer is in a little-known form of Eastern meditation? Perhaps jogging will do the trick? Stress formula vitamins? Maybe—but maybe not. It seems unlikely that any problem as complex and pervasive as stress may be addressed comprehensively by a single technique.

In the present volume, the term “stress management” refers to the identification and analysis of problems related to stress, and the application of a variety of therapeutic tools to alter either the source of stress or the experience of stress. These therapeutic tools are utilized within an integrated and conceptually meaningful framework. The major goal of managing stress is simply to enable the individual to function at his or her optimal level, in a healthy and positive manner.

The first step in this process is to identify and describe stress-related problems. It is easy to ascribe to stress all the perils and misfortunes of life. It may even be likely that most perils and misfortunes do contain a stress-related component. However, if stress management approaches are to be employed, it is essential to assess and clearly delineate the exact role of stress in the individual's current status. The client seeking help with a specific medical problem (e.g. headaches) may not readily perceive or accept that the problem is stress-related. Conversely, a busy working mother may attribute her symptoms to stress when in fact a relatively straightforward medical problem may exist. There is some danger of stress management being viewed as a panacea. In order for stress management techniques and a stress management perspective to be effective, they must be applied to problems which are in fact significantly related to stress.

The source of stress, as will be discussed later, can be internal or external to the individual. What exactly accounts for the individual's symptomatology? Individual pathology? Discrete external events? Systems? Social psychological contradictions? Only with a thorough and comprehensive analysis of the presenting problem can the role of stress as a precipitating factor be identified. Without accurate identification, effective intervention is unlikely.

The goal of intervention is to achieve a balance between the client's individual resistance to stress and the amount of stress in his or her environment. This balance can be achieved in a variety of ways—through change in the individual, through change in specific stressors, or by altering the interaction between the individual and the environment.

Balance is a key concept in an integrated approach to stress management. A common misconception among both therapists and clients is that the goal of stress management is to minimize or eliminate stress. Although this may be appropriate in some instances, a more general concern is that of achieving the proper balance of stress. As mentioned above, one must balance the individual's personal resources against the demands made upon him or her. To do so requires a balance between too little stress—which engenders apathy and boredom—and too much stress—which leads to anxiety and burnout. Even when the desirable amount of stress has been achieved, there is a further need for balance between good or positive stress (sometimes called “eustress”) and bad or negative stress (“distress”). If lowering the level of stress further disrupts the balance between the individual's personal resources and the demands made upon him or her, a simpleminded goal of eliminating stress may actually potentiate the problems of a stressed individual. Consider, for example, the plight of a healthy, fit, college-educated individual who, for some reason, is performing a monotonous, sedentary, and repetitive job for eight hours a day. In this case, the level of stress may need to be increased in order to achieve balance. Or consider the middle-aged worker who has been in the same job for many years, but who feels that, at present, family pressures are too great to allow a job change at this time. The absolute amount of stress in this individual's life may be appropriate, but the balance between eustress and distress has not been achieved.

One way of achieving balance is to alter the level and type of stress in the individual's environment. However, this may be difficult, impossible, or undesirable. Balance may also be achieved by altering the individual. Individuals may learn to alter their physiological, cognitive, or behavioral responses to stress. Learning to control or offset the physiological arousal accompanying stress may allow the individual to endure higher levels of stress in an adaptive fashion. Similarly, changes in cognitive interpretation may change a routine task into a challenge, thus allowing the individual to function well in circumstances which may formerly have been regarded as understimulating. Regardless of the specific mechanism of change, the end result is to achieve balance between the individual and his or her environment.

There is, of course, no meaningful “normal” amount of stress or “average” amount of tolerance. The optimal level is that level at which the individual client is able to maintain physiological homeostatis, mental well-being, and behavioral stability.

STRESS MANAGEMENT AS THERAPY

As was mentioned earlier, the practice of stress management requires that the therapist be familiar and experienced with the basic tenets of a psychotherapy or counseling relationship. Like other types of therapy, stress management relies on factors such as the release of tension, through catharsis or through expectancy; cognitive learning and insight; overt or covert operant conditioning; identification or alliance with the therapist; and reality testing (Sloane et al., 1975). What distinguishes stress management from other forms of psychotherapy is the reliance on the dissemination of information. There is a significant didactic component to stress management. The therapist and the client together must “learn” what stress is (for that client), how it is experienced, and how it may be dealt with adaptively. The therapist brings to therapy a knowledge of the literature and research in the area; knowledge based on his or her own personal experience of stress; and knowledge gleaned from others during the experience of being a therapist. The client, on the other hand, comes to therapy with knowledge of his or her own personal experiences of stress; knowledge of previously tried coping methods which may or may not have been successful; and knowledge of the general circumstances and limitations of daily life which may have implications for stress management. Thus, each individual (client and therapist) comes to the relationship with a specific body of knowledge, to be shared and reinterpreted jointly. Occasionally, the client will have labeled his or her problem as a stress problem prior to seeking help, but

Copyrighted Material more often the client enters treatment seeking a remedy for a specific problem, whether it be headaches, insomnia, depression, or poor performance at work. Thus, the initial work of therapy revolves around the development of a common conceptualization for therapy. If the client thinks that he or she has simple headaches, for which a medical cure is indicated, and the therapist thinks that the client has a stress problem, for which “stress management techniques” would be useful, then the therapy is temporarily at a stalemate. No active treatment can be initiated until the client and the therapist agree on the nature of the problem.

Formulation

This first phase of stress management is referred to as the “formulation phase.” The Concise Oxford Dictionary defines the verb “to formulate” as meaning “to set forth systematically.” Slater and Roth (1977) describe formulation in psychiatry as the “detailed statement of the diagnosis in multidimensional terms. It will contain a classification of the disorder and a specification of the factors, physical, constitutional and psychogenic, which have contributed to its appearance ... a short plan for further investigation and for treatment” (p. 35).

In the case of stress management, the tasks of the formulation phase are to define the problems and to set forth systematically the goals, procedures, and mechanisms of change which are to be employed in therapy. The definition provided by Slater and Roth (1977) is perhaps too reminiscent of the medical model to be employed literally. The term “diagnosis” might better be replaced by “problem identification,” and along with the physical, constitutional, and psychogenic factors are interpersonal, behavioral, cognitive, and social factors. Nevertheless, the intent of the process is the same: to describe and to plan.

Formulation is, of course, an integral part of any therapeutic process. In the stress management process, however, the role of formulation is particularly significant for several reasons. First, and most importantly, in stress management (unlike in psychiatry in general, as described by Slater & Roth), formulation is a joint effort of the therapist and the client. Each attempts to consider and evaluate the information presented by the other, in order to incorporate that evidence into his or her own schema. Rather than the therapist formulating a diagnosis which is then superimposed upon the client, client and therapist jointly reach an agreement as to the nature of the problem. The therapist may surmise that the client has trouble coping with stress; the client considers that he or she has a headache. In order for the client to establish the legitimacy of the “head-ache” as a problem, he or she must explain, collect data, and otherwise describe such features as intensity, duration, frequency, situational determinants, adverse effects, and impact on functioning (for example). In order for the therapist to establish the legitimacy of “stress” as a problem, he or she must explain, collect data, and otherwise describe such factors as the physical, cognitive, and behavioral aspects of stress, and its relation to illnesses such as headaches. Throug...

Table of contents

• Front Cover
• Half Title
• Brunner/Mazel Psychosocial Stress Series
• Title Page
• Copyright
• Dedication
• Series Note
• Contents
• Introduction: Stress and Gender
• Acknowledgment
• 1. AN OVERVIEW
• 2. FORMULATION AND DEFINITION IN STRESS MANAGEMENT
• 3. STRESS AND ILLNESS
• 4. ASSESSMENT OF STRESS: TOOLS AND METHODS
• 5. PLANNING INTERVENTIONS
• 6. PHYSIOLOGICAL APPROACHES TO MANAGING STRESS PART I: THE RELAXATION THERAPIES
• 7. PHYSIOLOGICAL APPROACHES TO MANAGING STRESS PART II: LIFE-STYLE MANAGEMENT
• 8. COGNITIVE APPROACHES TO MANAGING STRESS
• 9. BEHAVIORAL STRATEGIES FOR MANAGING STRESS
• EPILOGUE
• References
• Name Index
• Subject Index