Problems
Repression, rationalisation, projection, suppression, denial, displacement.
Confrontive coping - standing one's ground or expressing one's anger
Planful problem solving - having a plan of action or doubling effort
Basically, you can try to solve the problem that has become a stressor or you can deal with the emotion.
Billings and Moos (1981) see table 3.1 p35
Items on questionnaire take account of `method of coping', as well as `focus of coping'.
The method that works best, depends on the individual, but generally active strategies work better than avoidance strategies.
Cairns and Wilson (1984) found the opposite in Northern Ireland. If stress is prolonged then it may be better to deny that there is much violence (in the case of Northern Ireland). People who denied the level of violence were less stressed than those that had a realistic appraisal of the situation.
Wilson and Cairns (1992) found most people were using `distancing' as a coping strategy. This was not true of Enniskillen, that had had a bomb aimed at civilians. here the coping strategy became one of positive reappraisal.
Suls and Fletcher (1985) pooled the results of a large number of studies in a meta--analysis to clarify the effects of avoidance and attention strategies. Their analysis led to two conclusions.
A 1-year study compared people who differed in their reported use of avoidance coping approaches. Of the subjects who experienced a high degree of stress during the intervening year, those who had reported a greater tendency to use avoidance methods had, at the end of the study, more psychosomatic symptoms-for example, headaches and acid stomach (Holahan and Moos, 1986).
Developing methods of coping
Young children are very poor at coping with stress. Middle-aged people tend to use more problem-focused forms of coping, whereas elderly people tend to use emotion-focused forms of coping. For example a middle-aged person might say "I stood my ground and fought for what I wanted", whereas an elderly individual might say "I went on as if nothing happened". The difference in coping strategies between middle-aged people and elderly people could be due to the different sorts of problems that they face. Middle-aged people experience stress from work and raising a family whereas elderly people may experience stress from home maintenance, for example.
Support that gives the above resources
Although men tend to have larger social networks than women, women seem to use theirs more effectively for support.
People who report that they are coping well with stressful events in their lives are more likely to be regarded as attractive by others and less likely to be avoided than those who indicate that they are having some difficulties coping. The implications of these results are depressing, because they suggest that those in greatest need for social support may be least likely to get it (Wortman & Dunkel-Schetter, 1987).
Network size is related to social prestige, income, and education: the lower the prestige, income, and education level of individuals, the smaller their social networks tend to be.
Perceived support is a more accurate predictor of coping than actual support (Johnson et al, 1995) It is easier to observe actual support. Low levels of social relationship is associated with increased risk of mortality, using the social network list (Stokes, 1983) An alternative measure - Social Support Questionnaire (Sarason et al, 1983) - size of social networks and perceived qualities of social relationships.
Wexler - Morrison et al (1991) 133 women diagnosed as suffering from breast cancer. Major factor - social support, leads to longer survival. Social support works for 2 reasons
One approach teachers can use is to have children engage in cooperative games that promote prolonged interaction with one another. There are four types of specific behaviours teachers can help children learn:
Isolated people of all ages, especially the elderly, can be encouraged to join suitable organisations.
Employers can help improve support systems on the job (Quick and Quick, 1984). They can do this in many ways, such as:
A supportive boss discusses decisions and problems with employees, compliments subordinates and gives them credit for good work, and stands behind reasonable decisions they make (Kobasa,1986).
Social support can also be ineffective if the recipient interprets it as a sign of inadequacy, feels uncomfortable about being unable to reciprocated, or believes his or her personal control is limited by it (Cohen and McKay, 1984).
Asthma - over-protective and over-concerned parents makes the matter worse. Coronary heart disease - social support for unhealthy life style. Back pain - supportive family members doing too much for sufferer, so providing positive reinforcement. Being in a relationship reduces the number of complaints a person can suffer from. A study of German Women found that single women suffered the following complaints more often: Hiccups, Toothache, Heartburn, Colds, Flatulence, Nausea, Stomach-ache, and Headache. Whereas, women in relationships suffered more backache and insomnia!
Improving one's personal control and hardiness
Hardiness (Kobasa and Maddi 1977)
The concept of 'hardiness' is taken to mean resistance to illness, or ability to deal with stress. From studies of highly stressed executives, Kobasa et al were able to identify the characteristics of those who handled stress well from those who did not. Those who reported the fewest illnesses showed three kinds of hardiness.
Kobasa found that the most important of these factors was the first, openness to change. Those who perceived change (such as the loss of a job) as a challenge rather than a devastatingly person event, were more likely to interpret the event positively and show fewer signs of stress. Kobasa proposed three ways in which hardness could be improved.
People following this course tend to score higher on a test of hardiness, report feeling less distress, and have lower blood pressure.
Enhancing hardiness in children
Parents, teachers, and other caregivers can show a child their love and respect, providing a stimulating environment, encourage and praise the child's accomplishments, and set reasonable standards of conduct and performance that he or she can regard as challenges, rather than threats. Doing these things is likely to enhance the child's hardiness, and Hardy individuals tend to use coping strategies to manage their stress effectively (Holahan & Moos, 1985).
Hardiness at work
Employers can help by giving workers some degree of control over aspects of their jobs (Quick and Quick, 1984). One approach involves having employees working in groups to make certain managerial decisions or solve problems, such as how to improve the quality of the product they manufacture. Other approaches include allowing workers to have some control over their work hours, which tasks to work on, and the order in which they do them.
Hardiness and the elderly
Elderly people in nursing homes and families can be allowed to do things for themselves and have responsibilities, such as in cleaning, cooking, and arranging social activities.
Evaluation of hardiness
Time management
Physical exercise
Most studies use correlational or retrospective methods, and show that people who exercise or are physically fit often reported less anxiety, depression, and tension in their lives than do people who do not exercise or are less fit (Blumenthalof & McCubbin, 1987). Unfortunately, causality cannot be established with such techniques.
An experiment by Goldwater and Collis (1985) examined the effects of exercise on cardiovascular fitness and feelings of anxiety in males between 19 and thirty years of age. These subjects were randomly assigned to one of two groups after they were shown to be in good health by a medical examination. In one group, the subjects worked out five days a week in a vigorous fitness programme. Subjects in the second group had a more moderate fitness programme. Both groups participated in their programmes for six weeks and were tested for cardiovascular fitness and anxiety before and after participating. Those in the vigorous programme showed greater gains in fitness and reductions in anxiety.
Jennings S. L. (1986) conducted an experiment with healthy 19 to 27-year-old individuals who had sedentary occupations and had not regularly engaged in vigorous physical activity in the previous year. Over the next four months, the subjects spent one month at each of four levels of activity:
Each exercise period lasted 40 minutes.
Measurements of heart rate and BP were taken after each month. The results demonstrated that regular exercise lowers heart rate and both systolic and diastolic blood pressure.
Preparing for stressful events
Parents can help prepare a child for starting day care by taking the child there in advance to see the place, meet the teacher, and play for a while (Sarafino, 1986).
Janis (1958) studied the need for people to prepare for stressful life events, such as surgery. He found those patients with moderate levels of anxiety before the surgery showed better adjustments after the operation compared with those with very high or very low anxiety. Janis proposed that some degree of anticipatory worry about a stressful event is adaptive because it motivates coping via the process he called the "work of worrying". There are three steps in this process:
Subsequent research has confirmed that Janis may be correct about high levels of anxiety impairing the patient's success in coping with or recovery from surgery. There is no evidence to support the view that low levels of anxiety could impair recovery, in fact the opposite has been found (Anderson & Masur, 1983).
Other ways of improving people's preparedness for stressful events is by using psychotherapy, in which patient's express their worries and receive emotional support. Another method would be hypnosis, but much would depend upon the person's ease of suggestibility. Another method would be enhancing the patient's feelings of control. Patients can be taught behavioural control by teaching them how to reduce discomfort or promote rehabilitation through specific actions, such as by doing exercises to improve strength or deep breathing exercises to reduce pain. Another method enhances cognitive control, by instructing people on ways to concentrate on the pleasant or beneficial aspects of the surgery. Another method would use informational control, in which patients received information about the procedures and/or sensations they will experience.
Care has to be taken over how much information one should give when trying to provide informational control. Los Angeles City Council placed cards in the city lifts assuring passengers that they should stay calm, since "there is little danger of the car dropping uncontrollably or running out of air". The Council had to remove the cards in the end because many passengers were becoming anxious after reading the message; they had not thought about the dangers until they saw the cards! (Suzanne Thompson, 1981).
Young children become more anxious if given too much information about medical procedures (Miller and green, 1984).
Kubler - Ross (1969) 5 stages of psychological adjustment to death.
Heavily quoted - became the 'natural' way to approach death.
Wortman and Silver (1987) - response of parents following death of infant (Sudden Infant Death Syndrome) (SIDS). It was found that although the level of sadness was high, happiness was just as high. They also found that it's not true that if you cry a lot just after a death it is better later. In fact the parents who grieved most at three weeks also grieved most at 18 months
Edmund Jacobson (1938) developed a device to measure electrical activity in muscle fibres. Using this device, he found that subjects would reduce the tension in their muscles when simply asked to "sit and relax." He then went on to teach subjects how to pay attention to the sensations in their muscles in order to have some control over them and to be able to relax them.
Patients are required to relax muscles in a sequence. For example, the person might start with the hands, then in the forehead, followed by the lower face, the neck, the stomach, and, finally, the legs. For each muscle group, the person first tenses the muscles for about ten seconds, and then relaxes them for about 15 seconds, paying attention to how the muscles feel. This would be repeated two or three times before moving on to the next muscle group. One whole session should last about 25 minutes. The person should be lying down on comfortable furniture in a quiet room.
After mastery of the relaxation procedure subjects can apply a quick version at times of stress. An example of such a quick version might be:
Take a deep breath and let out whilst saying to oneself, "relax, feel nice and calm," and then think about a pleasant thought for a few seconds.
Progressive muscle relaxation is frequently used in conjunction with systematic desensitisation.
During the relaxation state, stress response mechanisms are inactive and the parasympathetic nervous system is dominant.
Evaluation
It is fairly easy to practice relaxation, even in unusual situations. These techniques may also involve cognitive strategies that help reduce arousal in unpleasantly arousing circumstances. Although relaxation techniques can be useful by reducing the levels of stress response, the action is non-specific. Effective long-term stress reduction requires focused intervention on the source of the stress.
Biofeedback is a technique in which an electromechanical device monitors the status of a persons physiological processes, such as heart rate, blood pressure or muscle tension, and immediately reports that information back to the individual. The person is able to then gain voluntary control over these processes through operant conditioning. The feedback from the device becomes the reinforcement.
An experiment was conducted with patients suffering from chronic muscle-contraction headaches (Budzynski et al., 1973). Those who were given biofeedback regarding muscle tension in the forehead later showed less tension in those muscles and reported having fewer headaches than subjects in control groups. These benefits were found at a follow-up session after three months. Biofeedback seems to be as effective as progressive muscle relaxation methods for treating headache (Blanchard and Andrasik, 1985).
Limitations of biofeedback techniques
It is claimed that biofeedback techniques can have significant positive effects in the reduction of generalised anxiety disorders. The use of this technique and the related efforts to reduce heart rate in sufferers of anxiety disorders has had only limited success.
Biofeedback may be no more effective than muscle relaxation in the absence of biofeedback. This is a critical issue as biofeedback can be expensive as a technique.
Virginia Attanasio, et al. (1985) gave three reasons why biofeedback is particularly suitable for use with children:
The problems with using biofeedback with children are:
Modelling
Children watched a short film showing a five-year-old boy's reactions to figures of the cartoon characters Mickey Mouse and Donald duck (Venn and Short, 1973). In the film, when the boy's mother showed him the Mickey Mouse figure he screamed and withdrew; but when she showed him the Donald duck figure he remained calm and displayed no distress. While the subjects watched the film physiological measures of stress were taken, confirming that the children were more aroused while watching the episode with Mickey Mouse (fearful) than while watching the one with Donald duck. After the film they tended to avoid a Mickey Mouse figure (the stressful one) in favour of Donald duck. The effect only lasted for one or two days.
Modelling is useful in reversing this learning and in helping people to cope with stressors. The procedure is rather like desensitisation: the person relaxes while watching a model calmly perform a series of activities arranged as a stimulus hierarchy. The stimulus can be presented using films or video tapes, or by using real life models and events. Barbara Melamed et al., 1983, found that by showing children video tapes she was able to reduce the stress of being in hospital and improve their recovery from surgery. However, children under the age of 8 who had had previous surgery experienced increased anxiety!
Bridge et al (1988) Imagery used on a group of women undergoing radiotherapy. Moods were better than a group that had physical training or a control group that just met and talked.
Post-traumatic Stress Disorder
This method is based on the view that fears are learned by classical conditioning. Desensitisation is a classical conditioning procedure that reverses this learning by pairing the feared object or situation with either pleasant or neutral events. The method uses a stimulus hierarchy. The patient is given the opportunity to get used to something that is similar to their fear, for example in order to overcome a fear of dentists the patient might be asked to imagine waiting with a friend, who is to have treatment, in the dentists waiting room. After the patient gets used to this idea they can be introduced to something a little more like the real situation. After a series of 10 to 15 steps the patient might be able to imagine having their tooth extracted. As an exercise think of a phobia and plan a series of steps that could be used in applying the systematic desensitisation technique.
In one study with dental-phobic adults who simply imagined each step in a hierarchy, the procedure successfully reduced their fear in six one and a half hour sessions (Gatchel, 1980). Sessions with children tend to be shorter because of their short attention span.
Cognitive restructuring and Rational Emotive Therapy
Cognitive restructuring - developed by Arnold Lazarus (1971). Faulty, irrational thinking. These irrational thoughts are replaced by more constructive or realistic ones.
Rational-emotive therapy (RET) is based on cognitive restructuring and was developed by Albert Ellis (1962).
Commonly used irrational ways of thinking include:
RET involves patients reading materials about irrational believes or doing desensitisation exercises. RET has been found to be successful in treating anxiety and depression (DiGiuseppe & Miller, 1977).
We are not sure whether there are any long term effects of RET.
Preparing people for stress. Just like an injection to prevent a disease.
Michenbaum and Cameron (1983)
Zeigler et al (1982) found cross-country runners found stress inoculation useful in reducing stress and in improving running performance.
Evaluation of Meichenbaum's stress-inoculation training
Meichenbaum's model focuses on both the nature of the stress problem (enabling clients to more realistically appraise their life) and the ways of coping with stress giving clients more understanding of the strengths and limitations of specific techniques).
The combination of cognitive strategies and behavioural techniques makes stress-inoculation a potentially effective way of managing stress. Despite this potential, few controlled studies have confirmed its predictions.
Stress inoculation has been effective in a variety of stressful situations, ranging from anxiety about mathematics in college students, managing hypertension in all age groups and stress management in general. It has been successfully combined with other treatment methods to alleviate stress. For example, Kiselica et al. (1994) used a combination of stress inoculation, progressive muscle relaxation, cognitive restructuring and assertiveness training to significantly reduce trait anxiety and stress related symptoms among adolescents. These results however, did not extended to their improving academic performance, suggesting that other factors may also be involved here. Interventions cannot necessarily rule out the possibility of placebo or expectancy effects.
Multimodal therapy
Arnold Lazarus (1981) suggests that many different approaches could be used on one patient depending upon the nature of their problems. For example patients may have a problem with their behaviour, such as eating excessively. They might also have an affective problem, such as frequent anxiety. In addition to these problems the patient might have difficulty with interpersonal relationships, for example, in exhibiting hostile behaviour.
Meditation
Transcendental meditation is a method in the practice of yoga that was promoted by Maharishi Mahesh Yogi. The method is a way of improving physical and mental health and reducing stress (Benson, 1984). people using this procedure are instructed to practise it twice a day, sitting upright but comfortably relaxed with eyes closed, and mentally repeating a word or sound (such as "om"), called a mantra. The mantra is to prevent thoughts from occurring.
Reviews of studies into the effectiveness of transcendental meditation have found that the levels of rest produced are not that profound. There are no consistent differences in blood pressure, heart rate, or respiration rate between the meditating and resting control subjects (Holmes, 1984). However Buddhist monks in South-East Asia can dramatically alter their bodies metabolism and their brains electrical activity through meditation (Benson et al., 1990).
Evaluation
Hypnosis is considered to be an altered state of consciousness that is induced by special techniques of suggestion and leads to varying degrees of responsiveness to directions for changes in perception, memory, and behaviour (Orne, 1989).
Only 15 to 30% of the population is easily and deeply hypnotisable (Evans, 1987). Children between the ages of seven and 14 are the most suggestible (Hilgard, 1967). People can learn to hypnotise themselves, this is called self-hypnosis.
There are two problems with doing therapy and research with hypnosis:
However, studies have found that hypnosis can be helpful in stress management, but it is not necessarily a more effective method than other relaxation techniques (Tapp, 1985).
Using stress management to reduce coronary risk
Modifying type A behaviour
Ethel Ruskin et al. (1978) began a research and therapy programme in the 1970s to modify type A behaviour. The patients studied were type A male subjects who were healthy and employed in professional or managerial positions. The subjects were assessed for type A behaviour with the structured interview method and given a physical examination. The healthy type a men were randomly assigned to two therapy groups:
A third group was formed from type A individuals who showed signs of chronic heart disease; these men received the progressive muscle relaxation therapy.
Each group had weekly therapy sessions over 14 weeks, during which time the subjects were asked to maintain their usual habits. Psychological and physiological measures taken before, immediately after and six months after the treatment phase began. All three groups improved with respect to their feelings of time pressure, blood cholesterol levels, and BP. Six-months later, the two relaxation groups maintained their improvements better than the psychotherapy group did.
The programme was revised by using a multimodal approach (Roskies, 1983). The revised programme included progressive muscle relaxation and most aspects of RET and stress inoculation training. The multimodal approach was used to control the individuals physical tension through relaxation, emotional outbursts through RET, and interpersonal friction through stress inoculation training in problem-solving and communication skills.
This revised programme was tested in a study with men who were employed in managerial jobs, had passed a physical examination, and exhibited the type A pattern in the structured interview (Roskies et al., 1986). They were randomly assigned to either the revised multimodal programme or to one of two physical exercise groups (aerobic training or weight training). All subjects attended two or three sessions a week for ten weeks. The men were tested at the end of the training period using the structured interview, and their blood pressure and heart rate reactivity were assessed in response to stressors, such as doing mental arithmetic. None of the three treatments reduced the men's physiological reactivity, but the multimodal programme was more successful than either of the exercise programmes in reducing the three components of type a behaviour.
Raymond Novaco (1975) has demonstrated the usefulness of stress inoculation training and relaxation in helping people to control the anger. He trained patients who were both self identified and clinically assessed as having serious problems controlling anger. The subjects learnt about the role of arousal and cognitive processes in feelings of anger. Then they learned muscle relaxation along with statements, for example:
|
Preparing for a provocation |
This could be a rough situation; I have the know-how to deal with it. I can work out a plan to handle this. Easy does it. Remember, stick to the issues and don't take it personally. There won't be any need for an argument. I know what to do. |
|
Impact and confrontation |
As long as I keep my cool, then I am in control of the situation. You don't need to prove yourself. Don't make more out of this than you have to. There is no point in getting mad. Think of what I have to do, look for the positives and don't jump to conclusions. |
|
Coping with arousal |
Muscles are getting tight. Relax and slow things down. Time to take a deep breath. Let's take the issue point by point. My anger is a signal of what I need to do. Time for problem-solving. He probably wants me to get angry, but I'm going to deal with it constructively. |
|
Subsequent reflection Conflict unresolved |
Forget about the aggravation. Thinking about it only makes you upset. Try to shake it off. Don't let it interfere with your job. Remember relaxation. It is a lot better than anger is. Don't take it personally. It's probably not so serious. |
|
Subsequent reflection Conflict resolved |
I handled that one pretty well. That's doing a good job. I could have got more upset than it was worth. My pride can get me into trouble, but I'm doing better at this all the time. I actually got through that without getting angry. |
The subjects practiced the techniques while imagining and role playing realistic anger situations arranged in a hierarchy from least to most provoking. The subjects were able to control their anger as measured by self reports and their blood pressure when provoked in the laboratory.
Beta blockers have been found to reduce type a behaviour and to lower cardiovascular reactivity (Schmeider et al., 1983). This approach may be useful for individuals who are at coronary risk and do not respond to behavioural and cognitive interventions (Chesney et al, 1985).
Treating hypertension
Patients can be treated with diuretics, which lower blood pressure by decreasing blood volume. In addition, doctors generally try to get all hypertensive patients to reduce their body weight, exercise regularly, and reduce their intake of sodium, cholesterol, caffeine, and alcohol (Herd & Weiss, 1984).
It is sometimes counter-productive for doctors to ask patients to relax as un-trained people often increase their blood pressure when trying to relax (Suls, et al. 1986).
BP can be reduced with certain stress management techniques, such as progressive muscle relaxation, biofeedback, and meditation (McCaffrey & Blanchard, 1985). But many of these studies have flawed methodologies (Jacob et al., 1991), and asking people who suffer from high levels of anger simply to use just relaxation techniques is unlikely to succeed (Larkin, et al. 1990). Diuretic drugs are more effective in controlling BP than stress management techniques (McCaffrey & Blanchard, 1985).
The multimodal programme technique is more successful in treating BP in mildly hypertensive type a men (Bennett,et al., 1991). Psychological approaches to treating blood pressure work best in conjunction with drugs. This would allow a reduction in dosage. Psychological approaches would be suitable for patients who suffer from drug side-effects.
Discrepancies between the findings of research into chronic heart disease could be explained by differences in methodological details, such as the duration of the intervention, the specific stressors used, and whether the participants believed in the particular intervention they received (Seraganian et al., 1987). Without intervention people appear to adapt to repeated exposure to the same stressor, showing decreased reactivity over time (Frankish & Linden, 1991).
Even though many employees run voluntary stress management programmes for the workers many type a individuals will not join. Many type a individuals don't see any connection between chronic heart disease and a hard-driving lifestyle (Roskies, 1983). Many people with high blood pressure either don't know they have it will say they feel okay. Many people who do join such schemes tend to drop out before completing programmes or don't adhere closely to their recommendations, such as to practise relaxation techniques at home (Alderman, 1984).
Point to ponder
Should workers be given stress counselling or should they take up trade union activity for a reduced work load?
Acknowledgements
Cardwell. M., Wadeley. A., and Murphy. M. 2000. Revision Express, A level Study Guide, Psychology, Pearson Education Limited. ISBN 0-582-43170-0. An excellent study guide currently £12.99.
Curtis. A.J., (2000), Health Psychology, Routledge. ISBN 0-415-19273-0. Great value. Covers most of the OCR syllabus. Recommended as an affordable class text book