ABS 200

4 Addressing Stress and Coping in the Mental Health Field By Christopher J. McCarthy, University of Texas at Austin, and Colleen Jaimie McCarthy, University of Oregon Tommy Flynn/Getty Images Learning Objectives After reading this chapter, you should be able to • Explain the relationship between stress and well-being.

• Differentiate between the major models of stress.

• Describe the types of interventions used to reduce stress and promote coping used by mental health professionals.

• Describe settings in which stress interventions take place.

• Identify hot topics, trends, and controversies related to stress and coping.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.1 Stress and Its Connection to Well-Being Vanessa is in her second year of college. She is the first person in her family to attend a 4-year college. She is both proud of that and a little bit scared; she wants to live up to her parents’ expectations but also feels a tremendous weight every day in meeting the lofty expectations she has for herself. Her parents made great sacrifices to send her to school, and the most important thing in the world to her is that she not waste this opportunity. Unfortunately, Vanessa is struggling right now. She chose biology as a major, with the hope that she would become a doctor and make her parents proud. But she is finding her studies hard, mainly because they are not as interesting as she had hoped.

Lately, Vanessa has started having trouble sleeping and has found it hard to concentrate. She is constantly worrying about her grades and what will happen if her GPA is too low for medi - cal school. She has tried studying extra hard and cutting out social activities, but that has left her feeling even more anxious and isolated.

Her roommate thinks she is simply stressed out, but Vanessa is not even sure what the term stress means. Of course she is anxious; she is under a lot of pressure! How is that going to change? Her parents worked very long hours in custodial jobs all their lives, and they never complained about stress. How could she? But last week, Vanessa was so anxious she decided to visit her university counseling center to see if they could help with her stress. Vanessa is not really sure what to expect. What is stress, anyway? And what can a mental health profes - sional do to help her?

4.1 Stress and Its Connection to Well-Being Stress is a widely acknowledged phenomenon. Mental health practitioners have many clients reporting stress symptoms (Ivey & Ivey, 2015), but what exactly is meant by the term? Does it refer to a feeling, such as when we are “stressed out”? Or does it refer to events in our lives, such as taking a “stressful” exam? Or should we think about stress in terms of what it does to us emotionally and physically, such as causing anxiety or high blood pressure?

While the term has been used in many ways by theorists, today stress is understood as a trans- action between a person and his or her environment. More specifically, stress results from an imbalance between an individual’s perceived demands and perceived resources. For example, Vanessa’s perceived demand is that she do well in college and make her parents proud. If she questions her ability to do so (i.e., her perceived resources), she will likely experience stress.

Once people become stressed, they experience negative emotions, such as anger or distress. Emotions represent physiological arousal, feelings, thoughts, and behaviors in response to people and events. Given their physiologi- cal expression, negative emotions experi- enced in the long term can cause wear and tear on the body. Perhaps the best way to conceptualize stress, however, is as an umbrella term for a broad and complex phenomenon. Over the past several decades, researchers in Gino Santa Maria/iStock/Thinkstock The term stress encapsulates various responses and phenomena. Therefore, the definition is still expanding.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.1 Stress and Its Connection to Well-Being medicine, psychology, and related fields have increasingly come to understand the many con- nections between the mind and the body and the significant role that stress plays in over - all well-being. It is now universally recognized that stress plays a significant role in causing or aggravating both physical and mental disorders. The 21st century has seen an increased emphasis on the positive role that stress can play in people’s lives, energizing them to meet challenges and live life to its fullest. This shift is part of the positive psychology movement, which was discussed briefly in Chapter 1 and will be discussed at the end of this chapter.

It is important to note that there are functional aspects of stress, as every emotion exists for a reason. Stress can serve to motivate (such as to study for an important exam), it helps our brain focus when things are important, and it creates adrenaline to increase our reactions and reflexes. However, stress becomes a problem when it is experienced more often than not and interferes with individuals’ ability to get things done. The focus of this chapter will be on the stress that is unhelpful and bad for our health. We will also look at some of the ways mental health professionals address stress experienced by their clients.

Basic Terminology Terminology about the stress process has changed as the field has developed. Until fairly recently, the term was utilized in so many different ways that its scientific use was somewhat limited. Stress originally was borrowed from the field of engineering, and it referred to the amount of pressure placed on an object. For engineers, stress was important to understand (for example, they needed to know how much pressure [weight] a bridge could take before collapsing). Stress researchers then used this term to describe what happens to people expe- riencing life’s pressures, which can lead them to weaken and eventually “snap.” Unlike bridges, humans have the capacity to reflect on the impact of the events in their lives. There is a com- plex relationship between our perceptions of events and how our bodies respond to being under pressure. People have cognitive, emotional, behavioral, and physiological responses that culminate in different reactions to stress, and so each person has different experiences that can create pressure and weaken his or her ability to persevere.

In recent decades, researchers and practitioners have become more precise in defining what is meant by the term stress. Stress is an umbrella term associated with all aspects of the phe - nomenon. However, there are three important constructs that define different aspects of the stress experience: stressors, the stress response, and stress symptoms . Stressors are environ- mental or internal events that have the potential to cause us harm. They may come from external sources, such as work or relationships, or internal sources, such as perfectionism or negative thinking. What separates us from most other living things on earth is that our brains have evolved to have the ability to imagine future events based on past experiences.

This wonderful capacity that helps us plan and negotiate the outside world can also add to our stress level, however, as we tend to forecast and worry about many things that may never materialize.

The stress response is the cascade of physiological, cognitive, and emotional changes that result once a stressor has been experienced (Matheny & McCarthy, 2000). Once triggered, the stress response results in negative emotions, such as anger, frustration, and sadness. Negative emotions can also affect our bodies, with reactions such as neck tension, an unsettled stom- ach, and worrisome thoughts, to name a few. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.1 Stress and Its Connection to Well-Being Finally, in response to stress, people experience stress symptoms, which are emotional and physical responses to stress such as feeling anxious, stomachaches, the grinding of teeth, or feelings of worthlessness. Figure 4.1 illustrates the relationships among these factors (Matheny & McCarthy, 2000).

Figure 4.1 uses the example of a person who has just learned his company is laying him off.

Learning this news would certainly qualify as a stressor, or something that threatens this individual’s well-being. The encounter with the stressor is immediately followed by the stress response, which may include increased heart rate, higher blood pressure, and emotions such as anxiety. Anxiety is a feeling that often accompanies stress and is characterized by feelings of worry, nervousness, or uneasiness. Stress symptoms are the consequences of being under stress and can occur fairly soon after experiencing a situation, or over time. In the case of the person who has lost his job, he may worry about finances, lose sleep due to anxiety, and lash out at others. These reactions are normal, but they are also unpleasant, could harm the per - son’s health, and are often counterproductive because they interfere with being able to focus on finding a new job. Additionally, continued experiences of stress symptoms (e.g., lack of sleep, anxiety, frustration) can lead to health problems such as sleep issues, depression, and digestive problems.

Figure 4.1: Overview of stress terms In the stress experience, stressors lead to a stress response, which leads to stress symptoms.

Source: Adapted from Write Your Own Prescription for Stress , by K. B. Matheny and C. J. McCarthy, 2000, Oakland, CA: New Harbinger.

The Relationship Between Stress and Well-Being Not only is stress frequently an unpleasant experience, but it can also make us sick. Wal - ter B. Cannon was an early pioneer in exploring the link between the mind and the body, though this idea was not accepted by other medical professions at the time. In 1936, Cannon wrote, “A highly important change has occurred in the incidence of disease. Serious infec- tions have markedly decreased or almost disappeared, . . . meanwhile, conditions involving strain in the nervous system have been greatly augmented” (1936, p. 4). Today, those of us living in countries with advanced health care systems may take for granted that many infec- tious diseases are relatively under control, whereas 100 years ago they ravaged large num- bers of people and led to fear and panic when outbreaks occurred. As the field of medicine has reduced the prevalence of infectious diseases and allowed for longer lifespans, diseases linked to unhealthy lifestyles have increased. Hypertension, coronary heart disease, ulcers, cancer, arthritis, headaches, lower back strain, and many other illnesses are linked to how \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.1 Stress and Its Connection to Well-Being people live their lives—and how they manage stress is a key ingredient in lifestyle. Some people handle stress by eating a nutritious diet, keeping an active lifestyle, and maintaining healthy social relationships, which can act as buffers against stress. However, some people eat fast food, drink too much alcohol, and spend countless hours sitting in front of the television.

These individuals increase their risk of having mental and psychological health issues and are vulnerable to all manner of health complications in the long run.

The American Psychology Association (APA) conducts an annual survey that documents the many ways in which stress affects the lives of people in the United States. The 2014 Stress in America survey found that Americans report money and finances as a particular source of stress, and money has consistently been at the top of the list of stressors since the first survey, in 2007. Here are some of the most significant findings from the 2014 survey:

• On a 10-point scale, where 1 is “little or no stress” and 10 is a “great deal of stress,” the average American rates his or her stress level as a 4.9. In 2007, the average American stress level was reported as a 6.2. Although current levels appear to have decreased since 2007, stress levels are still higher than what is desired, as Ameri- cans believe a 3.7 is a healthy stress level.

• Adults struggle in how they manage their stress, as 42% report not doing enough or are not sure how to manage their stress, and 20% state that they are not engaging in any stress-reducing activities to manage stress levels.

• There are many sources of stress that adults experience. On average, American adults reported these as consistent stressors: money (64% report that this is a very or somewhat significant source of stress), work (60%), the economy (49%), family responsibilities (47%), and personal health concerns (46%).

• Adults experience a wide range of stress-related symptoms. When asked about symptoms of stress in the last month, adults reported feeling irritable or angry (37%), feeling nervous or anxious (35%), having a lack of interest or motivation (34%), fatigue (32%), feeling overwhelmed (32%), and being depressed or sad (32%).

• Stress affects how people interact with others. Of adults who are married or living with a partner, 41% reported losing patience or yelling at their spouse or partner in the last month because of stress. Additionally, within the last month, 18% also reported snapping at or being short with a coworker (APA, 2014).

Stress and Coping as a Focus of Mental Health Interventions Mental health professionals will undoubtedly find themselves working with clients for whom stress is a concern, whether it is labeled as such or not. It is important for people in the men- tal health field to help their clients cope. Coping represents a person’s attempts to manage, mitigate, and prevent stress. In order to understand current research and stress management techniques, it is important to consider the history of the identification and understanding of stress.

The mental health field has made great strides in recent decades in understanding the many links between the mind and the body. Sigmund Freud, who established the earliest form of talk therapy (psychoanalysis), pioneered the idea of hysteria (Freud & Breuer, 2004) in describing his approach to psychotherapy. Hysteria referred to nervous system symptoms \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.1 Stress and Its Connection to Well-Being (such as paralysis and blindness) that could not be explained by medical factors. Freud postulated that the cause was psychological in nature, specifically feelings and impulses that the person had repressed.

While groundbreaking, this view of the mind and body seemed to suggest physical manifestations of emotional turmoil are “all in our head.” During Freud’s time, medical researchers had not yet docu- mented the many connections between the mind and the body. Scientists today have begun to look at the mind-body connection, not only as a whole, but also in relation to stress. In response to stress, our bodies send out hormones. Although the release of hormones is not always bad, when it continues too long, as with stress, the hormones begin to weaken the immune system and it becomes harder to fight disease. Additionally, chronic stress can aggravate existing health issues such as heart problems and asthma and affect nerves and muscles, causing tense muscles and headaches (Reus, 2001). Thus, knowledge of how the mind and body can affect one another helps us better under- stand the struggles people face psychologically and physically and better equip mental health profession- als when working with clients.

While stress management is not itself a career track for mental health professionals, stress is almost always a concern for people seeking professional help. It is therefore important that mental health professionals understand the latest stress interventions and be able to either use them or refer clients to someone who can. It is also important for mental health profes - sionals to be aware of evidence-based interventions, which are treatments that have been proven to be effective through rigorous research of their outcomes. Knowledge of evidence- based interventions allows mental health professionals to know they are using techniques that have proven, positive outcomes in order to best help their clients. Examples of evidence- based interventions are discussed later in this chapter.

Another important role for mental health professionals is educating clients about what stress is. Many people still have a hard time accepting that their attitude, lifestyle, emotions, and ways of thinking could affect their emotional and physical well-being. Stress may seem like an excuse, and they may think labeling their stress means they are not tough enough.

But there is an overwhelming amount of evidence that indicates stress is real and that it can affect our well-being in many ways (DeLongis, Folkman, & Lazarus, 1988; Lupien, McEwen, Gunnar, & Heim, 2009; McEwen, 2009). Mental health professionals now have many tools for helping clients manage stress effectively; however, a foundational knowledge about the psychological and physiological origins of stress is vital to understanding how to best address stress. Science and Society/SuperStock Psychoanalyst Sigmund Freud, 1910.

Freud believed that the mind and the body operate as separate entities.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.2 Emerging Models of Stress 4.2 Emerging Models of Stress Stress researchers and theories have added considerably to our understanding of stress over the past several decades. Early research on stress helped establish the foundations for stress interventions that are commonly used today. The following sections trace the major ways of thinking about stress that have emerged as research has developed.

Biological Perspectives on Stress While Freud saw the mind and body as distinct and separate, today we know that both are interconnected. In particular, we know much more about how the brain processes informa- tion about threats to our well-being. The brain’s reaction to stress seems to play a key role in the physiology of stress. One important brain structure is the thalamus , which is involved in sensory perception and the regulation of motor functions. When potentially threatening stimuli are registered by our senses, an alerting signal is sent to the thalamus and then to the brain’s cortex, which is a kind of executive board in the brain that evaluates the signal and helps direct the body’s response. The cortex includes a giant reservoir of memories and experiences, which is used to evaluate the potential stressor. If potential harm seems likely, the message is sent to the amygdala, which plays a central role in emotional reactions such as the stress response. The hypothalamus then swings into action. This is a small structure in the center of the brain, which links the nervous system to the pituitary gland, a master gland that controls the functions of other glands. The pituitary gland causes the release of adreno- corticotropic hormone (ACTH), a stress hormone that is involved in the stress response.

The presence of ACTH in the bloodstream causes the adrenal glands, which are located above the kidneys, to produce hormones that reduce inflammation in the body and allow for improved muscle function, as well as raise sugar levels in the liver, helping fuel the body.

The hypothalamus also stimulates the adrenal glands to produce catecholamines, which are organic compounds that increase the heart and breathing rates and accelerate brain activ - ity. The body is thus equipped with a powerful system to prepare us for action when threats arise; the entire process can be understood as part of the stress response.

While this process describes how humans react to a wide range of life events, the startle response activates specifically when emergencies arise. When immediate action is called for, the startle response enables the body to spring into action without needing the thinking brain.

Joseph LeDoux (1984) discovered that the thalamus and the amygdala have a direct neural connection, allowing for the stress response to be triggered in the body before the brain has fully processed an event. The amygdala is also known to work in concert with a section of the brain called the orbitofrontal cortex, which stores emotional memories, or emotions affiliated with an event. Examples include excitement, grief, or anger. The orbitofrontal cortex then assesses any associations with previous events that might be used to regulate responses by the amygdala. In other words, the amygdala has two pathways in the brain when assessing a situation: the low road and the high road. The low road transmits a faster, less detailed sig- nal to the thalamus, then to the amygdala to trigger a fear response in the body. The high road is slower, as it carries nerve impulses to the thalamus, then to the sensory cortex of the brain to assess and send the most appropriate signals to the amygdala. This model of the chain of physiological events leading to the stress response is presented in Figure 4.2. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.2 Emerging Models of Stress Figure 4.2: Overview of brain structures involved in the stress response In the stress response, the cortex receives information about potential stressors internally or externally from the thalamus. However, note that the thalamus has a direct connection to the amygdala, which allows (in concert with the orbitofrontal cortex) for an instant response if needed.

The hypothalamus then swings into action.

The cortex receives information about potential stressors from two main sources: internally, when mental events are generated (“I just remembered I have an exam tomorrow!”), or exter - nally, when external stressors are registered by the senses and information is received from the thalamus (“Who is that person lurking in my yard?”). As noted previously, direct connec- tions between the thalamus and the amygdala can allow for an instant response when needed, and the amygdala and the orbitofrontal cortex can work in concert to establish whether this is necessary.

We have just discussed how the various brain structures process information that can trigger and maintain the stress response. The next section describes what happens once the stress response occurs. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.2 Emerging Models of Stress The Fight or Flight Response The evolutionary purpose of the stress response is to prepare humans to survive threats in the environment. This response was labeled fight or flight in the 18th century by Claude Ber- nard, who pioneered the field of experimental medicine. He observed that healthy organisms seek to maintain a state of constancy despite changes in the outside environment, a process that was later labeled homeostasis by Cannon (1932). Anything that disrupts this constant state triggers the fight or flight response, now called the stress response.

It is more accurate, though perhaps less catchy, to call this phenomenon freeze, flight, or fight. As was noted in the discussion of the brain, threatening signals bypass the cortex and immediately trigger us to stop and further scan the environment—in other words, our first reaction to danger is to freeze. Consider the example of a hiker who encountered a rattlesnake on a desert trail in West Texas. The rattling sound emanating from the coiled viper seemed to occur simultaneously with the hiker stopping dead in his tracks and scanning frantically to find its location. The sound triggered an instant recognition in the hiker’s brain that this was a sound to pay attention to. When the rest of his brain and body caught up, he quickly realized he needed to warn the others in his party and take a wide route around the rattler.

This example also illustrates that after freezing, it is often better to flee rather than fight—in other words, live to fight another day. Often, the wisest course is to avoid danger whenever possible. So the likely way that most people cope with extreme danger is to freeze, flee if necessary, and only as a last resort to fight (Schmidt, Richey, Zvolensky, & Maner, 2008). Of course, the freeze, flight, or fight response is only the beginning of the story when it comes to our reaction to stress.

The General Adaptation Syndrome The stress response may have been necessary at one point in human evolution, but it prob- ably does not always serve us well in modern society. Although some stress is necessary for our continued survival in dangerous situations, as well as to maintain motivation for school, work, and life, it can become unhelpful when it is debilitating. The stress response can inter - fere with responding to more modern demands, such as exams, demanding bosses, or finan- cial difficulties. When our mind is racing, and our heart pounding, it is difficult to take a test.

However, it is important to understand that our body really has only this way of coping, which was labeled the general adaptation syndrome by Hans Selye (1976).

Selye was an endocrinologist who conducted experiments with rats under stress (such as injecting their skin with fluids) and discovered that under a wide range of conditions, they exhibited the same set of physiological reactions—the stress response. He extrapolated that the same was true for humans, which meant that whether we are confronted with an onrush- ing tiger or losing a job, the same neurological, hormonal, and immunological responses occur.

While subsequent research has suggested the body’s response is not quite as general as Selye believed (Denson, Spanovic, & Miller, 2009), it does appear to be a very generic response across a wide range of triggering events.

There are three stages to the general adaptation syndrome: the alarm stage, in which the body and mind ramp up to a state of alarm (freeze, flight, or fight); the resistance stage, in which only some of the physiological components of the alarm stage remain (such as tension, worry, \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.2 Emerging Models of Stress and lack of sleep); and the exhaustion stage, which is marked by a wearing down of the body’s defenses. These three stages help us understand the symptoms and process of stress.

The Perceptual Nature of Stress: Appraisals of External Events The preceding sections described models of stress based on physiological reactions associ - ated with the stress response. Another important model of stress was introduced when two medical doctors named Thomas Holmes and Richard Rahe discovered that certain experi- ences in life were predictive of one’s vulnerability to physical disease. The Social Readjust- ment Rating Scale (SRRS; Holmes & Rahe, 1967) is an assessment that measures incidences of various stressful life events, such as death, divorce, and other major life transitions. Based on the accumulation of these experiences, they were able to document a relationship between their accumulation and illness. Also, they discovered that not all events are equal: Some events, such as divorce or the death of a significant other, exact a much greater toll than do more minor events, such as a change in sleeping habits. There is also some evidence that accumulating a great many minor stressors, called hassles, can also affect our health (Kanner, Coyne, Schaefer, & Lazarus, 1981).

While it is important to understand the brain’s role in processing stressors, the body’s reaction to stress, and the link between life events and illness, there is one piece missing: the role of perception, which refers to an individual’s subjective evaluation of the outside world and his or her resources for coping with it. As thinking creatures, humans do not all view events the same way. A family vacation may be wonderful for parents who pick the destina- tion and itinerary, but it can be unpleasant for children who feel they are being dragged along to see relatives they hardly remem- ber. Research has demonstrated that per - ceptions play a key role in the relationship between life events and illness. As an example, Matheny and Cupp (1983) used the SRRS to predict health, but they also asked participants if they could foresee each event, if they could control it, and if it was desirable. They found that if people had anticipated and prepared for life events indicated on the SRRS, the events were not as predictive of illness. The same effect was true for desirable events. However, control seemed to have the most important moderat - ing effect on illness—if a person reported no control over an event, its value in predicting ill - ness increased 400%. Such research strongly indicates that the type of events matter in how stress affects us, and that perception can play an important role. This understanding is a key part of the transactional model of stress, which is reviewed next.

Transactional Model of Stress Currently, the predominant model of stress describes it as the result of a transaction between the individual and the environment (Lazarus & Folkman, 1984). This theory is founded on the idea that stress is mainly a function of our perceptions, namely, what we perceive to be the Westend61/SuperStock Perception and control both play an important role in health and how people react to life’s stressors.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.2 Emerging Models of Stress demands in a given situation and what we perceive as our resources. Lazarus (2001) noted that the word appraisal seemed the most accurate way to describe the cognitive evaluation that takes place whenever we encounter a life demand. According to Lazarus, whenever we encounter demands in our life, we appraise them according to their significance to our well- being, which he labeled a primary appraisal . We then conduct a secondary appraisal of whether we have the resources to cope successfully with the demand. Lazarus (2001) also noted that this appraisal involves two complementary processes: We attempt to view situa- tions realistically but also look for reasons to be optimistic about our chances for success. As he put it, “Appraisal is a compromise between life as it is and what one wishes it to be, and efficacious coping depends on both” (p. 41). Depending on the results of the appraisal pro- cess, we will determine either that demands are roughly equal to resources, meaning that we will view the situation as a challenge that is within our capacities, or that the demand exceeds our resources, which can trigger the response (Lazarus, 2003). This process is depicted in Figure 4.3.

Figure 4.3: Overview of transactional models The appraisal process determines whether we see a demand as a stressor or a challenge.

Source: Adapted from “Factor Structure of the Preventive Resources Inventory and Its Relationship to Existing Measures of Stress and Coping,” by C. J. McCarthy, R. G. Lambert, L. M. Beard, and A. P. Dematatis, in G. S. Gates, M. Wolverton, and W. H. Gmelch (Eds.), Research on Stress and Coping in Education (pp. 3–37), 2002, Greenwich, CT: Information Age Publishing, Inc.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.2 Emerging Models of Stress To demonstrate the processes of primary and secondary appraisal, imagine that two different students, Nico and Angela, have an upcoming class assignment in which they have to give a 15-minute presentation in their public speaking class. The following is a brief description of the event. Demand Self-statement Nico Required to give a 15-minute presentation “I knew I’d have to give a speech! But now it’s real! How I am ever going to talk that long? I know I’m going to fail this course now.” Angela Required to give a 15-minute presentation “Uh oh, I guess this is what I signed up for. This will be scary, but I know I can do it, and I’ll probably learn a lot.” In this example, Nico is appraising the demands of making a speech as being too much for his resources. Angela is appraising this situation differently. Her primary appraisal seems to be that the assignment is important, but not a life or death matter. Her secondary appraisal of her resources is likely that the situation can be handled with them—that by preparing and using course materials, the task will be manageable.

Appraisals are a critical part of the transactional model of stress. For two people, the same event can be interpreted very differently. And subsequent attempts at coping with the stimuli causing stress will likely be very different. Nico might be so overwhelmed with stress about the assignment that he procrastinates and puts something together at the last minute, which is not an ideal coping strategy. Angela appraises the event as a challenge, not a stressor. There- fore, she might be more likely to take on the task with enthusiasm and deliberation, thus mak - ing it more likely the speech will be a success.

Conservation of Resources Model of Stress Alongside Lazarus and Folkman’s (1984) transactional model, Stevan Hobfoll’s (1989) con- servation of resources (COR) theory is the other dominant model for understanding stress.

COR theory defines stress as “a reaction to the environment in which there is: (a) the threat of a net loss of resources, (b) the net loss of resources, or (c) a lack of resource gain following the investment of resources” (Hobfoll, 1989, p. 516). Like transactional models, Hobfoll’s COR theory emphasizes the role of perception in stress; however, COR departs from transactional models in two important ways. First, whereas the transactional theory emphasizes the sub- jective nature of appraisals of both demands and resources, COR theory gives primacy to our perceptions of threats to our resources. Hobfoll believed the fundamental human drive toward pleasure, self-esteem, and connections with others was not sufficiently emphasized in stress models, which seemed to focus only on how humans avoid harm. Instead, Hobfoll attempted to view stress from a strengths-based model, rather than a deficit-based model. COR focuses on the positive, sustaining, and protective power of people’s demands and resources.

The second major way in which Hobfoll’s (2011) theory departs from the transactional model is its ecological perspective, as COR theory emphasizes common appraisals held jointly by people who share a biology or culture, or even workplace (Hobfoll, 1989, 2011). In other words, appraisal of resources is located not just within the individual, but also in the broader \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.3 Interventions context in which the individual lives. Hobfoll further expanded this idea with his notion of resource caravans, the idea that families, communities, and organizations can invest in col- lective resources that are broadly shared by everyone. These investments create pathways for individuals to accumulate resources that protect against stress.

While offering some contrasting propositions, the transactional and COR models of stress can be thought of as addressing different, and perhaps equally valid, aspects of the stress process.

Hobfoll (2011) noted that COR theory was originally devised to focus on major life stress, and its central tenets seem consistent with that emphasis. Major catastrophes such as war and floods do not seem subjective to those involved—they are very real and cause actual loss of one’s resources. However, aside from such major stressors, it can be argued that much of life is lived in a gray area of daily events that are often ambiguous, and that individual perception can be an important element of how such experiences are judged, which is consistent with Lazarus and Folkman’s (1984) transactional theory. Equipped with an understanding of how individuals experience and process stress, let’s now turn our attention to the interventions used to help people cope with stress.

4.3 Interventions The models of stress reviewed in the previous section form the foundation for the interven- tions that mental health professionals use with clients. Over the years, stress interventions have emerged as one of the most commonly practiced techniques in a counseling setting.

There are also many self-help books for managing stress written for the general public (see, for example, Davis, Eshelman, & McKay, 2008).

While there are many mental health special- izations that have a specified career trajec- tory for entering the field (see Chapter 2 on the various counseling professionals tracks), stress management techniques are not really associated with a specific coun- seling specialty. Instead, they are incorpo - rated into the interventions used by almost every branch of the helping profession.

The pervasiveness of stress interventions does not mean that they are easy to imple- ment. Stress and coping interventions that are administered under the guidance of a trained helper are far more effective than are those attempted by individuals on their own. Because there is a great number of stress management techniques and interventions in existence today, providing a compre- hensive review is outside the scope of this chapter. In the following sections, we will review two general categories of interventions to provide a sense of which ones are used most fre- quently due to their effectiveness. Physical stress interventions are targeted at reducing the symptoms of the stress response, while cognitive stress interventions are aimed at altering Fuse/Thinkstock Though there is not a specialization dedicated to stress management, stress interventions are used across the helping professions.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.3 Interventions the thinking patterns that produce stress. Both categories are consistent with the models reviewed in the previous section.

Physical Stress Interventions Once the stress response is triggered, it prepares us for freeze, fight, or flight. In most of every - day life, this response is not helpful, and it can actually interfere with the ability to confront the demands of modern life. A variety of physical stress interventions has been developed to essentially cool down the stress response, so individuals can focus instead on addressing stress. These are listed in the following sections.

Breathing Exercises The fight or flight response accelerates breathing and physically indicates to the body and mind that something is wrong. Breathing patterns are often disrupted by changes in emotion.

For example, when anxious, people tend to hold their breath and speak in a higher-pitched voice when exhaling. On the other hand, when sad or down, people tend to sigh and speak in lower-pitched tones as they exhale. Simple breathing exercises can be used to regulate disruptions in the breathing pattern and help in the short term with managing the stress response and promoting relaxation (Jensen, 2003; Loehr & Migdow, 1999).

Practitioners measure stress by evaluating an individual’s cortisol levels. Breathing exercises have been shown to decrease cortisol levels, thereby reducing stress (Cea Ugarte, Gonzalez- Pinto Arrillaga, & Cabo Gonzalez, 2010). The following are breathing exercises that many practitioners use in their practice.

Rhythmic breathing: Breathing that is short and hurried can be slowed down by taking long, slow breaths. People are instructed to inhale slowly and then exhale slowly, count slowly to five while inhaling, and then count slowly to five while exhaling. During exhalation, people are instructed to pay attention to how the body naturally relaxes. Recognizing this change can help them to relax even more.

Deep breathing: People are instructed to imagine a spot just below the navel. They are then encouraged to imagine breathing in through the spot, filling the abdomen with air. Then, they are to let the air fill from the abdomen up, then let it out, like deflating a balloon. With every long, slow exhalation, a person should notice feeling more relaxed. Breathing deeply and slowly floods the body with oxygen and other chemicals that work on the central nervous system and improve comfort. Deep breathing exercises have been shown to decrease heart rate, increase cognitive functioning, and increase executive functioning (Busch et al., 2012; Prinsloo, Derman, Lambert, & Laurie Rauch, 2013).

Visualized breathing: With this exercise, people are encouraged to find a comfortable place, close their eyes, and combine slow breathing with the imagination. Individuals visualize the air coming in through the nostrils, going into the lungs, and expanding the chest and abdo- men. Then, they visualize the breath going out the same way. They then continue breath- ing, but with each inhalation, they imagine breathing in relaxation, and with each exhalation imagine breathing out the tension. These types of instructional breathing exercises can help reduce respiratory rate (Conrad et al., 2007), which can reduce tension and anxiety (Wilhelm, Gevirtz, & Roth, 2001). \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.3 Interventions Progressive Muscle Relaxation Progressive muscle relaxation (PMR) is a technique that involves concentrating on relax - ing every muscle in the body, beginning at the toes and working all the way up to the head.

Research has shown that PMR techniques are effective in managing anxiety (e.g., Carlson, Bacaseta, & Simanton, 1988; Carrington et al., 1980; Pawlow & Jones, 2002), decreasing cor - tisol levels (Pawlow & Jones, 2002), reducing pain (Gada, 1985), regulating physiological pro- cesses (Carlson et al., 1988), and increasing overall quality of life (Carrington et al., 1980).

Progressive muscle relaxation is a two-step process. First, the individual deliberately applies tension to certain muscle groups. Then, the tension is released and the individual focuses on how the muscles relax as the tension flows away. Following are the steps to using progressive muscle relaxation:

• St ep 1: Tension—First, focus your mind on a muscle group, for instance, the mus- cles in your hand. As you inhale, squeeze the muscles in your hand (by making a tight fist) as hard as you can for about 8 seconds.

• St ep 2: Releasing the tension—Now, as you exhale, quickly open your hand and let the pain and tightness go. Feel the muscles relax and become loose and limp as the tension flows away. You would repeat this tension-relaxation process for all the major muscle groups in your body, beginning with the muscles in your feet and mov- ing upward all the way to your face (Mayo Clinic, 2014).

Biofeedback Biofeedback is a technique that entails learn- ing how to relax and better cope with stress by altering behavior, thoughts, and feelings.

According to the Biofeedback Certification International Alliance (2012), biofeedback enables the user to alter physiological activ - ity to help with health and performance.

Using specialized equipment, biofeedback methods measure and utilize various sig- nals from the body, including brain activity, blood pressure, muscle tension, heart rate, skin temperature, and sweat gland activity (Mayo Clinic, 2009). Biofeedback is a three- step process that involves (a) becoming aware of a physiological response, (b) learn- ing to control the response, and (c) transfer- ring control of the response to everyday life (Calderon & Thompson, 2004). Thus, a bio- feedback unit processes the electronic signals and feeds back the information to the user in the form of sounds or graphs on a computer screen.

Biofeedback allows people to learn how their bodies react to stressful situations, how to control certain physiologic functions that cause tension and physical pain, and how to create a state of total body relaxation. When people notice they are starting to experience unhelpful amounts of stress, they can use biofeedback to alleviate the stress before it becomes unmanageable. Francesco Ruggeri/Getty Images Understanding and learning to control physiological responses is key to managing stress. Biofeedback supports this process.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.3 Interventions There are many other interventions that have been developed to combat stress symptoms.

Davis et al.’s 2008 book The Relaxation and Stress Reduction Workbook offers a comprehen- sive list.

Cognitive Behavioral Therapy While physical stress interventions can be used quite effectively to manage the symptoms of the stress response, the modern transactional and COR stress theories emphasize the percep- tual nature of stress. Unless people can change the way they think about events, they are likely to repeat the stress response over and over, potentially damaging their health in the long run.

Changing their thinking has the potential to prevent stress, which is preferable to putting out fires through the use of physical stress interventions. This section focuses on approaches to stress management aimed at changing thinking patterns. As people change the way they think, their brains change neurologically, suggesting that when people experience anxiety or depression, dysfunctional neural activity is taking place (Porto et al., 2009; Rachman, 2015).

Cognitive Approaches to Stress Intervention Given the role of perception suggested by transactional and COR models of stress, the use of cognitive approaches in addressing stress has increased. Cognitive approaches in coun- seling have been adapted to stress interventions, which is an approach to counseling based on changing irrational or maladaptive thoughts. Cognitive approaches are part of cognitive behavioral therapy (CBT), which you may recall is a form of psychotherapy aimed at changing unhelpful thinking and behavior. They can be used both by mental health professionals who identify as cognitive behavioral therapists and by mental health professionals who are using them as one part of their work.

Cognitive therapists gather information about their clients’ lives and how they respond to stress and help create a plan to better manage stress (Beck, 1991; Matheny et al., 1996; Rush, Beck, Kovacs, & Hollon, 1977). The stress management plan often involves approaches to modifying thoughts that create stress, identifying ways to use thoughts to manage stress, and helping people develop tools to cope. For example, if a person is a perfectionist and thinks, “I’m not good enough,” a cognitive interventionist may work with the client to reduce unre- alistic expectations of self, teach and practice relaxation exercises, and incorporate useful coping strategies, such as exercise. Another person may suffer from catastrophic thinking, such as “I’m going to fail all of my finals!” and watch TV to avoid studying. This person may benefit from exercises that challenge his or her automatic thoughts (examining the evidence for and against failing). It may also be helpful to set up designated times to study, as well as break times where he or she can practice relaxation techniques. Stress management is most effective when it is tailored to a person’s specific needs, issues, and resources.

Acceptance and Commitment Therapy (ACT) Acceptance and commitment therapy (ACT) is a form of CBT that incorporates mindfulness to increase a client’s ability to engage in flexible thinking. Especially when stressed, people often struggle to think about things from a different perspective and deal with disappointment, such as failing a test, a fight with a loved one, or social rejection. ACT helps people use cogni- tive defusion and acceptance to increase their willingness to experience unpleasant things. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.3 Interventions Cognitive defusion is a technique that encourages a person to approach his or her thoughts as a detective and see them as hypotheses rather than facts. This can help create some emo- tional and cognitive distance from the thoughts so the person can identify how accurate and believable a thought is. Acceptance involves both becoming aware of and embracing a private feeling or experience. For example, those who experience anxiety may be encouraged to fully feel and experience the anxiety, rather than push it away. The use of acceptance and cogni- tive defusion can help people make decisions based on their values and wants in life. ACT has been shown to increase effective courses of action; reduce unhelpful thoughts, feelings, and behavior; and decrease stress.

There are six core processes to ACT (Hayes, Strosahl, & Wilson, 1999; Wolitzky-Taylor, Arch, Rosenfield, & Craske, 2012):

1.

A cceptance of private experiences (i.e., willingness to experience odd or uncomfort- able thoughts, feelings, or physical sensations) 2.

Cogniti ve defusion or emotional separation/distancing (i.e., observing one’s own uncomfortable thoughts without automatically taking them literally or attaching any particular value to them) 3.

Being pr esent (i.e., being able to direct attention flexibly and voluntarily to pres- ent external and internal events rather than automatically focusing on the past or future) 4.

Self as cont ext (i.e., recognizing that thoughts and feelings are ever changing depending on one’s perspective and context) 5.

Identification of v alues that are personally important 6.

Commitment t o action for achieving the personal values identified Studies have shown that ACT can help with a wide variety of distress people experience. For example, ACT has been used to reduce symptoms of depression, decrease the severity of the obsessions and repetitive behaviors/mental acts of OCD, and improve overall mental health in coping with workplace stress (Hayes et al., 1999; Wolitzky-Taylor et al., 2012).

Mindfulness-Based Stress Reduction (MBSR) Mindfulness is a skill that emphasizes moment-to-moment, nonjudgmental aware- ness, and it has been shown to promote well- being. It has been adapted into numerous interventions, including mindfulness-based stress reduction (MBSR). MBSR is a form of training for people who experience both mental and physical distress. MBSR pro- grams typically focus on increasing the skill of mindfulness by practices such as medita- tion and body scan, which is then incorpo- rated into everyday life to cope (Fjorback, Arendt, Ornbol, Fink, & Walach, 2011).

MBSR has been shown to reduce stress and anxiety symptoms, negative mood-related Poike/iStock/Thinkstock Mindfulness is the process of becoming consciously aware of oneself.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.4 Roles and Settings in Which Stress and Coping Interventions Take Place feelings, and depression; increase self-esteem; and improve overall functioning (Birnie, Specca, & Carlson, 2010; Cordon, Brown, & Gibson, 2009; Kabat-Zinn, 1990). MBSR is based on mindfulness, a mental state in which individuals purposefully manage their awareness of the present and what is happening in the moment. This intervention helps people develop a mindful state, in which they focus on the moment, and incorporate it into everyday life as a coping resource to deal with stressors. There are three core elements when teaching MBSR:

• Mindfulness meditation, a formal daily practice of introspection and self-observation without judgment. In the most common forms of this meditation, the person men- tally focuses on the process of breathing or on the movement of the feet while slowly walking without looking down.

• Body scan, which focuses one’s awareness on one’s body. While lying down or sit- ting, a person directs attention to each part of the body, noticing any pain, tension, lack of sensation, or sense of comfort, becoming more at ease by focusing on the body instead of the mind.

• Gentle yoga, a mental focusing through movement that creates a calming of the mind’s continuous and ruminative thinking. People use yoga postures to quiet the mind and strengthen concentration (Jazaieri, Goldin, Werner, Ziv, & Gross, 2012; Kabat-Zinn, 1990).

4.4  R oles and Settings in Which Stress and Coping Interventions Take Place There are few if any clearly defined career paths in stress and coping interventions. Mental health professionals can become proficient in stress interventions and conduct research in the field, but job titles including “stress management expert” are rare. Instead, stress and coping interventions tend to be part of the repertoire of mental health professionals work - ing in settings where such approaches are needed. The following sections describe some mental health professional roles and settings where stress and coping interventions typi- cally take place.

K–12 Schools Both students and teachers in K–12 settings commonly experience stress and its symptoms, particularly in recent years as accountability measures and high stakes testing have added more pressure to the educational environment (Goldstein, 2014). School mental health pro- fessionals are often called upon to help students with stress (see Voices From the Field) and, in some settings, teachers as well. Social anxiety, which refers to fears about social situa- tions, is one example, and empirically supported group interventions have been developed to address this issue with students (Vassilopoulos, Brouzes, Damer, Mellou, & Mitroploulou, 2013). More generally, adolescence has been described as a time of “storm and stress,” and any interventions that can teach younger people coping skills can be useful to their growth and development. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.4 Roles and Settings in Which Stress and Coping Interventions Take Place Voices From the Field: Kaitlyn, School Mental Health Professional Working With Stress I work in a high school where I counsel students who are at risk of dropping out or not gradu- ating on time. My students often have chaotic home lives and are also battling mental health issues. They know I have an open door policy and that they are welcome to come see me when they’re having a tough day. When students come in, I ask them if they want to talk, or if they want to find something from my bucket of self-soothing items and take some time to work on regulating their emotions. The bucket includes, among other things, coloring pages of manda- las and crayons, spearmint- and eucalyptus-scented lotion that prompts relaxation, a stuffed animal, and instructions for breathing exercises. If students are not ready to talk and prefer to find a self-soothing item, I allow them to sit at my table and do some emotional regulation while I keep working quietly. When students are ready to talk, I open a dialogue about what brought them to me, and how they can get through the rest of the day. Often, I will do a breath- ing exercise with students before they return to class. I will also ask them about the coping mechanisms they use when they are at home (e.g., art, music, exercise). If students cannot identify any coping mechanisms to employ, I work with them to determine some things that they find calming, and we talk about how they can use those mechanisms when they are feel- ing stressed. Higher Education College can be a time when many people experience increased stress levels as they navi- gate a completely unfamiliar setting with new expectations, relationships, and living situ- ations. Many college students experience stress due to academic demands, changes in family relations and social life, being away from home, and making decisions indepen- dently that may have long-lasting effects (e.g., substance use, choice of major, romantic relationships).

Campuses usually have a counseling center that provides a wide range of services to help students cope with stress, including individual counseling, group counseling, and workshops targeting those dealing with stress. Individual counseling may involve some of the interven- tions discussed earlier to help students create a plan to tackle their stress (see Voices From the Field). Group counseling for stress is often skill based and focuses on helping students develop strategies for overcoming stress and anxiety symptoms and related problems such as excessive worry, feeling overwhelmed, insomnia, perfectionism, and excessive self-criticism.

College campuses may also offer workshops about the good and bad of stress and ways to cope, overcoming test anxiety, and building positive coping strategies to nourish one’s mind and body.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.4 Roles and Settings in Which Stress and Coping Interventions Take Place Voices From the Field: Duane, Mental Health Professional at a University Counseling Center I work at a counseling center within a large West Coast university, where the vast majority of students I counsel describe their main concern as “stress.” For college students, stress typi- cally represents a secondary symptom of a multitude of primary concerns: academic achieve- ment, adjustment, anxiety, disordered eating, mood, relationships, substance use, etc.

I adapt the interventions I use to best fit the individual’s unique context, symptom presen- tation, and stage of change. These core components affect the way I interact with students who are experiencing stress. For example, I typically use a combination of cognitive behav - ioral therapy (CBT) and acceptance and commitment therapy (ACT) techniques to combat stress. Both of these strategies encourage mindfulness practice (e.g., diaphragmatic breath- ing, progressive muscle relaxation, and meditation), which are incredibly useful to decrease physiological symptoms of stress as well as the racing thoughts that typically stem from being emotionally overwhelmed.

For stressful situations, thoughts, and symptoms that are within the student’s control, I start with CBT. Strategies such as challenging thoughts and assumptions put the individuals in the driver’s seat by encouraging them to consider the evidence for and against their stressful thoughts. For most people, the evidence indicates that their worried thought is unlikely to be true. We work together to find an alternative thought they could offer themselves when feeling stress.

In other situations, a stressful thought may be difficult to challenge because it is true (e.g., “I have a lot of finals this year”). In this situation, I would start with an ACT strategy called cogni- tive defusion. This technique encourages the individual to accept the worried thought he or she is having, notice that it is unhelpful, and let it go; this process may take several repetitions.

Cognitive defusion is usually associated with imagery such as clouds passing in the sky or leaves floating down a stream. These images can help the individual metaphorically let go of his or her stressful thought.

Differentiating between when to use these two strategies is important to facilitating successful coping. For instance, if students are experiencing test anxiety, I ask them how they typically do on tests. If the students indicate that they always do well (i.e., they can challenge the thought because it is likely inaccurate), I usually direct them toward changing how they think about test taking. Alternately, if the students have experienced poor grades subsequent to feeling stressed about test taking (i.e., they have strong evidence that their worried thought is accu- rate), I would lead them toward cognitive defusion. With both of these strategies, I highlight that the brain is flexible, changeable, and able to be rewired.

Learning and practicing these strategies is difficult for students at first, but it gets easier and easier as the brain learns to anticipate alternative thoughts or the process of letting thoughts go. For most people, stress responses are innately wired in the brain after years of practice. My job is to help students create new pathways in the brain for managing stress by learning new ways of thinking and interacting with their environment.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.5 Hot Topics, Trends, and Controversies in Stress and Coping Health Care Stress management interventions are an important compo- nent of health care delivery. It is not uncommon for people to go to their doctors to talk about stress or stress-related symptoms. As part of medical training, health care profes - sionals receive some training in assessing and assisting patients with stress. Stress management interventions are an important component of health care delivery, as stress is connected to health and using our knowledge about the connection between stress and health can help us best treat people. The health care and mental health commu- nities increasingly recognize that behavioral health—the full range of mental well-being—needs to be integrated with medical health care. Integration is necessary because medical personnel simply do not have the time or training to address the many psychological issues associated with health care.

Behavioral specialists can use stress interventions in a number of ways to improve patient health. First, they can teach patients coping skills they can utilize when encoun- tering stress. Second, behavioral specialists can help patients understand how their lifestyle plays a role in their health, such as the negative effects of a high-fat diet or smoking. In addition to helping patients identify things to eliminate from their lifestyle, behavioral specialists can also encourage positive change, such as exercise, to improve their health. Another role is providing community resources such as individual counseling, support groups, and other services when needed.

Workplaces Many people experience stress in the workplace, and the strategies reviewed in this chapter can help people cope with this stress. Employee assistance programs (EAPs) are intended to improve the health and well-being of an organization’s employees. The programs are designed to help employees and their families deal with personal issues that inhibit job functioning and potentially threaten their health, well-being, and job. They provide assessment, short-term counseling, and referral for additional behavioral health care. Typically, employers pay for the program with no cost to the employee (Horgan, Garnick, Merrick, & Hodgkin, 2009; Merrick et al., 2011).

4.5  Hot T opics, Trends, and Controversies in Stress and Coping Despite the increasing number of studies related to stress and coping, researchers still do not agree on exactly how to define and conceptualize the terms. Nor have they determined effective ways to measure them. While scholarly debate about how to understand stress and Davor Pavelic/Ikon Images/Getty Images Both the health care and mental health communities agree that behavioral health, and the promotion of mental wellness, ought to be incorporated into medical health care.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Section 4.5 Hot Topics, Trends, and Controversies in Stress and Coping coping can be beneficial for the field in spurring research and new ways of thinking, it can present a problem if researchers cannot use common terminology to communicate with each other and with those in the field who might benefit from their research. With this in mind, current hot topics in the field will next be reviewed.

Areas of Emerging Research Early in the study of stress, physicians informally noticed that certain illnesses seemed to be connected to personality (Matheny & McCarthy, 2000), which is defined as differences in the way people think, feel, and behave. One important area of research published in the 1970s was that of Friedman and Rosenman (1974), who identified the coronary prone personality, or Type A behavior pattern. They hypothesized that individuals exhibiting this personality type are driven by the belief that their worth is dependent mainly on their productivity, and that such productivity stems from being able to do more in less time than other people. This area of research supported the idea that Type A personalities are more likely to develop coro- nary disease later in life, because their behavior is linked to constant arousal of the stress response. Research on the links between personality and stress is complicated by the multidi- mensional nature of both personality and coping. Friedman and Booth-Kewley (1987) reviewed 101 research studies examining links between emotional responses and specific diseases. They reported evidence that people with certain personality types, including those who exhibit hostility and anxiety, were predisposed to illness. The five-factor model (FFM) of personality explains individual differences on the basis of five characteristics:

1.

e xtraversion—enjoying interac- tions with others 2.

neur oticism—being more likely to experience negative emotions 3.

conscientiousness—being thor ough and organized 4.

agr eeableness—being cooperative 5.

openness t o experience—including sources such as new ideas, information gained from the senses, and imagination (Costa & McCrae, 1992) Segerstrom and O’Connor (2012) have noted that a substantial amount of research links the FFM of personality to health and longevity. Given the current consensus for the FFM, future research may help further clarify links between personality, stress, and coping (Reevy & Frydenberg, 2011). Science Photo Library/SuperStock There is research that suggests a connection between personality and stress. However, the complexity of both personality and coping leave much to be discovered.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Summary and Resources The Changing Landscape of Health Care As health care models continue to evolve and as mental health care efforts are increasingly integrated into health care services, stress interventions will likely change as well. As one example, mindfulness-based interventions are increasingly being utilized in health care set- tings. Models of health care services are changing rapidly in the United States, and mental health care providers continue to play an expanded role in many such systems (Novotney, 2010). The older “pay as you go” model of health care delivery, where patients pay out of pocket for most care, is increasingly being recognized as impractical for today’s health care climate, and integrated health care systems are increasingly being utilized, in which profes- sionals with a wide variety of health care expertise coordinate their efforts to meet the needs of their clientele. It is likely that incorporating stress interventions into health care delivery will be an area of high interest to both researchers and practitioners.

Positive Psychology and Thriving As discussed briefly in Chapter 1, positive psychology is a newer branch of psychology that shifts the focus from what is going wrong with people to what is going well and what contrib- utes to happiness and emotional resilience (Seligman & Csikszentmihalyi, 2000). The field of positive psychology focuses on the strengths of people, what makes life fulfilling, and build - ing on positive experiences to repair negative experiences. It is concerned with psychological health and growth, as opposed to the more traditional emphasis in psychology on explain - ing psychological disorders (Seligman, 2011; Seligman & Csikszentmihalyi, 2000). It has long been recognized that stress can have an energizing and healthy effect; in fact, the term eustress was coined by Selye (1976) to describe this very phenomenon. However, stress and coping research has focused on the negative aspects of how stress affects our health and how we can cope to offset the negative effects of stress. Less attention has been devoted to the positive effects of stress—eustress—and how responding to challenges in life can actually add to our health and vitality. It is important to note that positive psychology does not recom - mend ignoring or dismissing problems, such as stress, but instead seeks to complement the more dominant, problem-focused approaches within psychology (Seligman & Csikszentmi - halyi, 2000). While researchers are beginning to explore how responding to life challenges can actually improve our welfare, much more research is needed to better understand and develop models for the positive models of health.

Summary and Resources Chapter Summary Everyone experiences stress in life; however, it becomes a problem when stress levels are so high that it becomes hard to function and ultimately affects physical health and well-being.

The impacts of stress are far reaching, and the effects of stress, or stressors, refer to external events and self-generated demands that trigger the stress response. Stress can be an unpleas - ant experience that may affect our emotional and physical well-being in the long term. It is important for those entering the mental health field that stress interventions are used in many different settings; however, an understanding of the history of the knowledge and research of stress is necessary. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Summary and Resources Research on stress began with examining links between the mind and the body. Sigmund Freud’s groundbreaking writings on hysteria, which referred to nervous system symptoms (such as paralysis and blindness) that could not be explained by medical factors, led to the creation of psychoanalysis but seemed to reinforce the idea that the mind was separate from the body. We know now that while our psychology can affect our physical well-being, the links are very real, not imagined. Many different brain structures are involved in processing threats to our well-being, which help determine whether the body’s stress response will be triggered.

This response was labeled fight or flight in the 18th century by Claude Bernard and was later refined to include “freeze,” which is our initial reaction to potential threats. The general pat- tern of responses associated with stress was labeled the general adaptation syndrome by Hans Selye. There are three stages to the general adaptation syndrome: alarm (freeze, flight, or fight), resistance (ongoing physiological changes to deal with stress), and exhaustion (wear- ing down of the body’s defenses). Two medical doctors, Thomas Holmes and Richard Rahe, discovered that the clustering of life events was predictive of one’s vulnerability to physical disease, furthering our understanding of how external events are connected to well-being.

Our current understanding of the stress process comes from researchers who see stress as the result of a transaction between the individuals and the environment. Two important researchers in this area are mental health professionals Richard Lazarus and Susan Folkman (1984). They maintained this transaction is largely a function of our perceptions. Alongside Lazarus and Folkman (1984)’s transactional model, Stevan Hobfoll’s (1989) conservation of resources (COR) theory is the other dominant model for understanding stress. Like the trans- actional model, Hobfoll’s COR theory also emphasizes the role of perception in stress, but COR theory gives primacy to our perceptions of threats to our resources.

While there are many mental health specializations that have a specified career trajectory for entering the field and certificating who is able to provide that service, stress management techniques are not really associated with a specific counseling specialty. Instead, they are incorporated into the interventions used by almost every branch of the helping profession and are available to the general public in the form of self-help books and website resources.

Based on the emerging understanding of stress, two general types of interventions have been developed for use by mental health professionals: physical stress interventions targeted at reducing the symptoms of the stress response, and cognitive stress interventions aimed at altering the thinking patterns that produce stress. Each category of intervention has a num- ber of different techniques and approaches that can be used by professionals or by the public in cases where a self-help approach has been developed. It is critical for mental health pro- fessionals to be aware of evidence-based interventions, as they have demonstrated effective outcomes that will be useful to best help clients.

Mental health professionals can clearly become proficient in stress interventions and conduct research in the field, but job titles including “stress management expert” are rare. Instead, stress and coping interventions tend to be part of the repertoire of mental health professionals working in settings where such approaches are needed. Because stress and its symptoms are prevalent for both students and teachers in K–12 settings, school mental health professionals and other professionals in the school often use stress interventions. Similarly, professionals \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Summary and Resources working in higher education provide a range of stress interventions as part of individual, group, and campus-wide services. Given widespread changes in the health care system and the increased understanding of links between the mind and physical health, such interven- tions are common in medical settings, often under the title of behavioral health. Workplaces are also common settings for stress interventions.

Even though much has been learned about stress, there are many emerging areas and con- troversies in the field. First, debate continues about how best to define both stress and cop- ing. Second, a better understanding of the links between personality, stress, and coping is a growing field. Models of health care services are changing rapidly in the United States, and mental health care providers continue to play an expanded role in many such systems. Finally, the positive psychology movement, emphasizing health and growth as opposed to illness and disease, has become a trend in the field of stress and coping.

Resources for Future Exploration APA: Division 17: Positive Psychology ht tp://w w w.div17pospsych.com/ Website with additional information about events, student membership, and conferences.

Evidence-Based Interventions Network ht tp://ebi.missouri.edu/ The Evidence-Based Interventions Network was developed to provide guidance in the selec- tion and implementation of evidence-based interventions.

Mindfulness Training ht tp://w w w.umassmed.edu/cfm/ Website of the Center for Mindfulness at the University of Massachusetts Medical School, where mindfulness-based stress reduction began.

www.thinkmindfully.com This website provides information about mindfulness-based stress reduction.

Positive Psychology ht tp://w w w.positivepsycholog y.org/ Website through the University of Pennsylvania that has resources on research, training, and education on positive psychology.

Stress and Anxiety Research Society (STAR) www.star-society.org STAR is a multidisciplinary organization for stress, coping, and anxiety research.

Stress and Coping in Education Special Interest Group, American Educational Research Association http://www.aera.net/tabid/11093/First/R/Last/Z/Default.aspx This organization promotes research and exchange of ideas concerning stress and coping in education.

\251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Summary and Resources Key Terms acceptance Becoming aware of and embracing private events occasioned by one’s history without unnecessary attempts to change their frequency or form, especially when doing so would cause psychological harm.

adrenal glands Located above the kidneys, glands that produce hormones that facilitate the stress response.

adrenocorticotropic hormone (ACTH)  A stress hormone involved in the stress response.

alarm stage A phase of the general adapta- tion syndrome in which the body and mind ramp up to a state of alarm (freeze, flight, or fight).

amygdala A part of the brain that plays a central role in emotional reactions such as the stress response.

anxiety A feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome.

appraisal  The cognitive evaluation that takes place whenever a life demand is encountered.

catecholamines Organic compounds that increase the heart and breathing rates and accelerate brain activity.

cognitive approaches A system of counsel- ing, based on changing irrational or mal- adaptive thoughts, that is often applied to treating stress.

cognitive defusion Consists of encourag- ing clients to detect their thoughts and to see them as hypotheses rather than objec- tive facts about the world.

cognitive stress interventions  Approaches to stress management aimed at altering the thinking patterns that produce stress.

conservation of resources (COR)  A theory that perceived or actual threat to resources is what causes stress.

coping Attempts to manage, mitigate, or prevent stress.

cortex A kind of executive board in the brain that evaluates a signal and helps direct the body’s responses.

emotional memories  Emotions affiliated with an event, such as excitement, grief, and anger.

emotions  A complex pattern of changes, including physiological arousal, feelings, cognitive processes, and behavioral reac- tions, made in response to a situation per- ceived to be personally significant.

eustress Positive stress, that is, how responding to challenges in life can actually add to one’s health and vitality.

evidence-based interventions Treat- ments that have been proven effective (to some degree) through outcome evaluations.

exhaustion stage  A phase of the general adaptation syndrome that is marked by a wearing down of the body’s defenses.

fight or flight The body’s physiological response to stress, which enhances the abil- ity to either fight or flee from threats in the environment.

freeze, flight, or fight A refinement of the idea of fight or flight, including the idea that an individual’s first reaction to stress is to stop and assess the situation.

general adaptation syndrome The uni- versal response of the body to stress. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. Summary and Resources hassles Minor stressors that accumulate to affect a person’s stress level.

homeostasis The tendency of healthy organisms to maintain a state of constancy despite changes in the outside environment.

hypothalamus  A small neurostructure in the center of the brain that links the nervous system to the pituitary gland.

hysteria  A term developed by Freud that refers to nervous system symptoms (such as paralysis and blindness) that could not be explained by medical factors during his time.

orbitofrontal cortex A part of the brain that stores emotional memories and serves to help assess any associations with previ- ous events that might be used to regulate responses by the amygdala.

perception The subjective nature of evalu- ations of the outside world and a person’s resources for coping with it.

personality  Individual differences in the way people think, feel, and behave.

physical stress interventions Treatment targeted at reducing the symptoms of the stress response.

pituitary gland A master gland that con- trols the functions of other glands.

primary appraisal A psychological process that occurs when an individual evaluates events according to their significance to his or her well-being.

resistance stage A phase of the general adaptation syndrome in which only some of the physiological components of the alarm stage remain (such as tension, worry, and lack of sleep). resource caravans The idea that families, communities, and organizations can invest in collective resources that are broadly shared by everyone.

secondary appraisal  Following pri- mary appraisal, a psychological process that occurs when an individual evaluates resources according to their sufficiency in meeting a life demand.

startle response  When immediate action is called for, the startle response allows the body to spring into action without needing the thinking part of the brain.

stress A transaction between the person and the environment, and more specifi- cally as the result of an imbalance between perceived demands and perceived resources that has the potential to cause negative emotions and physical wear and tear on the body.

stressors Environmental or internal events that have the potential to cause individuals harm and that trigger the stress response.

stress response  The cascade of physiologi- cal, cognitive, and emotional changes that result once a stressor has been experienced.

stress symptoms The consequences of the stress response upon functioning, such as feeling anxious or becoming physically ill.

thalamus  A brain structure that is involved in sensory perception and the regulation of motor functions.

transaction An important component of stress models emphasizing that stress results from the interaction of the person with his or her environment. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. \251 2016 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution.