1. Cognitive-Behavioral Approaches
   1. Cognitive Restructuring
   2. Coping Skills Therapies
   3. Problem-Solving Therapies
2. Relaxation
3. Exercise
4. Diet and Nutrition
5. Medication

VI. Stress Management

To avoid the problems associated with stress, people need to manage their stress. Before they can manage their stress, however, they need to decide whether they need professional help or whether self-help is enough. Once people decide on a source of help, regardless of the source of the help and the stress management techniques involved, a series of steps are involved in the process of change.

A. Professional Help or Self-Help?

When trying to manage stress, it is often difficult for people to decide whether self-help will be enough or whether they should seek professional help. In practice, people usually turn to self-help instead of professional help. The public appears to be very accepting of self-help resources ^{(128; 169)}. Self-help is not always the best way to manage stress, though. Sometimes professional help is necessary. Professional help is probably necessary if self-help fails or does not offer any worthwhile solution or if the problems associated with stress develop into mental disorders or physical illness.

When people realize that they do in fact need to seek professional help, how do they know what type of professional to turn to? A wide range of professionals is available to people with stress-related problems, ranging from medical doctors to mental health professionals. A medical doctor, such as a general practitioner or a specialist, is a good choice when stress leads to symptoms that may indicate physical illnesses. A mental health professional, such as clinical psychologist or a psychiatrist, is a good choice when stress leads to symptoms that may indicate a mental disorder. Clinical psychologists and psychiatrists along with other mental health professionals like counseling psychologists can also provide assistance with stress management in general, not just with mental disorders that may accompany stress. Other mental health professionals like marriage and family counselors, social workers, nurses, clergypersons, and telephone crisis counselors may also be able to provide some assistance with stress management.

Clinical or counseling psychologists usually earn a Ph.D., doctor of philosophy, (or sometimes a Psy.D., doctor of psychology, or Ed.D, doctor of education.) in psychology. Psychiatrists earn an M.D., medical doctor, degree. Compared to psychiatrists, clinical psychologists tend to focus more on the aspects of mental disorders that involve problematic thoughts, feelings, and actions and problems with relationships with other people. They also usually receive more extensive training in therapy. Psychiatrists, however, tend to view mental disorders as medical problems that should be treated with drugs and typically receive less training in actual therapy ^{(13; 99)}. Whether a clinical psychologist or a psychiatrist or both is more appropriate, depends on a person's specific problems. Whereas clinical psychologists and psychiatrists often deal with mental disorders, counseling psychologists customarily deal with adjustment issues and issues related to employment that are encountered by relatively healthy people ⁽¹³⁾.

It is also important to realize that, if people need to seek professional help from a mental health professional, it does not necessarily mean that they are "crazy." Although many mental health professionals do treat people with mental disorders that people generally associate with being "crazy," such as schizophrenia, many mental health professionals help people with other problems associated with stress. In fact, some mental health professionals specialize in stress management and see people who only need help with stress. Furthermore, it is important to remember that any legitimate professional is also a great resource for a person who wants advice on how to avoid the problems associated with stress.

B. The Process of Change

Five stages are involved in changing behaviors that contribute to health-related problems, such as the problems associated with stress:

1. Precontemplation: People do not notice a problem and have no intention of changing it any time soon.
2. Contemplation: People realize they have a problem behavior that should be changed and are seriously thinking about changing it.
3. Preparation: People have a strong intention to change it, have specific plans for changing it, and have already taken preliminary steps toward changing it.
4. Action: People are successfully working on changing the problem behavior.
5. Maintenance: People take steps to make sure the new behavior remains and the problem behavior does not return ⁽¹³¹⁾.

Although progress through these stages may appear simple and straightforward, it usually is not. People usually cycle through these stages several times before they are able to stay in the maintenance stage ⁽¹³⁰⁾. Whether people are able to move from one stage to the next depends a great deal on decisional balance, the relative impact of the advantages and disadvantages on the decision about whether to change a behavior or leave it as it is ⁽¹³²⁾.

C. Stress Management Techniques

Countless stress management techniques have been used for stress management. These techniques usually involve cognitive-behavioral approaches, relaxation, exercise, diet and nutrition, and/or medication.

1. Cognitive-Behavioral Approaches

Cognitive-behavioral approaches to stress management attempt to change stress-related thoughts, feelings, and actions. Cognitive-behavioral techniques traditionally have been used within the context of three types of therapies: cognitive restructuring, coping skills therapies, and problem-solving therapies ^{(Mahoney & Arnkoff, as cited in 44)}. More recently, however, the same principles have been incorporated into self-help methods.

a. Cognitive Restructuring

The goal of cognitive restructuring is to establish patterns of thinking that are more adaptive ⁽⁴⁴⁾ and less stress provoking. Examples of cognitive restructuring are rational-emotive therapy ⁽⁵⁰⁾, rational behavior therapy ⁽¹⁰⁴⁾, cognitive therapy ^{(16, 18, 19, 20)}, self-instructional training ^{(Meichenbaum, as cited in 44, 111, 112)}, and structural psychotherapy ⁽⁷⁴⁾.

A fundamental concept in rational-emotive therapy is the ABC model. According to this model, consequences (C; i.e., stress responses) occur as a result of beliefs (B; i.e., appraisals) about antecedents (A; i.e., stressors). The main purpose of rational-emotive therapy is to is identify irrational beliefs (i.e., stress-provoking appraisals) and reveal why they do not make sense ⁽⁵⁰⁾. A unique feature of rational-emotive therapy is the philosophical emphasis of its major goals ⁽⁴⁴⁾:

• Self-interest
• Social interest
• Self-direction
• Tolerance of self and others
• Flexibility
• Acceptance of uncertainty
• Commitment to vital interests
• Self-acceptance
• Scientific thinking
• Realistic expectations in life ⁽⁵¹⁾.

Rational behavior therapy is essentially the same as rational-emotive therapy, but it lacks the obvious philosophical emphasis of rational-emotive therapy and focuses on neuropsychophysiology (psychological relevance of brain functioning) and learning theory ⁽⁴⁴⁾. A central concept in rational behavior therapy is that rational self-talk, which originates in the left hemisphere of the brain, is converted by the right hemisphere of the brain into appropriate emotional behavioral reactions ⁽¹⁰⁴⁾.

Both rational behavior therapy and self-instructional training involve self-talk, but self-instructional training involves a specific type of self-talk, self-instruction. The idea behind self-instructional training is that commands made to oneself can be used in basic behavioral modification processes like reinforcement (receiving a reward for desired behavior) ^{(Meichenbaum, as cited in 44)}. Clients are taught six types of skills:

• Problem definition
• Problem approach
• Attention focussing
• Coping statements
• Error-correcting options
• Self-reinforcement ^{(Kendall & Bemis, as cited in 44)}

In cognitive therapy, people learn to replace distorted appraisals of events with more realistic appraisals ⁽⁴⁴⁾. Ten principles underlie cognitive therapy:

• Principle No. 1: It is based on a continuously developing description of the client and his or her problems.
• Principle No. 2: It requires a good relationship between the therapist and the client.
• Principle No. 3: It emphasizes that the therapist and the client should work together and actively participate.
• Principle No. 4: It is goal orientated and problem focused.
• Principle No. 5: It initially emphasizes the present, focussing on current problems and current stressful situations.
• Principle No. 6: It strives to teach the client to be his or her own therapist and emphasizes relapse prevention.
• Principle No. 7: It aims to be time limited, involving a limited number of sessions.
• Principle No. 8: The sessions are structured.
• Principle No. 9: It teaches clients to identify, evaluate, and respond to dysfunctional thoughts and beliefs.
• Principle No. 10: It uses a variety of techniques to change thoughts, feelings, and actions ⁽²⁰⁾.

In particular, clients are taught the following skills:

• Monitoring automatic thoughts
• Recognizing the relations between thoughts, feelings, and actions
• Testing the validity of automatic thoughts
• Substituting more realistic thoughts for distorted thoughts
• Learning to identify and change the underlying assumptions or beliefs that make themselves more likely to engage in faulty thinking patterns ^{(Kendall & Bemis, as cited in 44)}

Structural psychotherapy is similar to cognitive therapy, but requires that an understanding of the development of and current role of the clients knowledge of himself or herself and the world be established ⁽⁷⁴⁾.

b. Coping Skills Therapies

The goal of coping skills therapies is to develop a set of skills designed to help people cope with a variety of stressful situations ⁽⁴⁴⁾. Examples of coping skills therapies are systematic rational restructuring ^{(68; 69)}, anxiety-management training ⁽¹⁵⁹⁾, and stress inoculation training ^{(111; 112; Meichenbaum, as cited in 44)}.

The purpose of systematic rational restructuring, an extension of systematic desensitization (reducing fears through gradual exposure to feared stimuli paired with positive coping experiences ⁽¹³⁾), is to provide clients with more effective coping abilities by teaching them how to change the thoughts that occur automatically in anxiety-provoking situations. Systematic rational restructuring consists of five stages:

1. Exposure to anxiety-provoking situations through imagery or role-playing
2. Self-evaluation of anxiety level
3. Monitoring of anxiety-provoking thoughts
4. Rational reevaluation of the anxiety-provoking thoughts
5. Self-evaluation of anxiety level following the rational reevaluation ^{(Godfried, as cited in 44)}

Though anxiety-management training, clients learn to use relaxation and competency skills to control anxiety without paying any attention to the anxiety-provoking stimuli ⁽¹⁵⁹⁾. Clients visualize anxiety-provoking scenes that may be unrelated to their specific problem and then practice relaxation skills and imagine responding intelligently ⁽¹⁵⁸⁾.

The rationale for stress inoculation training is that, if clients can learn how to cope with mild levels of stress, they will be prepared for or "inoculated" against uncontrollable levels of stress ⁽⁴⁴⁾. Stress inoculation training consists of three stages:

1. Conceptualization phase: Therapists establish a working relationship with clients and help them understand the nature of stress.
2. Skills acquisition and rehearsal phase: Clients develop and rehearse a variety of coping skills, such as relaxation, cognitive restructuring, problem solving, and self-instruction.
3. Application and follow-through phase: Clients practice using their coping skills in response to real or imagined stressors ⁽¹¹²⁾.

c. Problem-Solving Therapies

The goal of problem-solving therapies is to develop general strategies for solving a wide range of problems. Problem-solving therapies are essentially a combination of cognitive restructuring and coping skills therapies ⁽⁴⁴⁾. In general, problem-solving therapy involves fives stages:

1. General orientation or "set": a vague familiarity with the problem
2. Problem definition and formulation: determining exactly what the problem is
3. Generation of alternatives: coming up with several possible ways to try to solve the problem
4. Decision making: deciding which method to use to try to solve the problem
5. Verification: evaluating how well the chosen method worked to solve the problem ⁽⁴⁷⁾

Examples of problem-solving therapies are personal science ^{(Mahoney, as cited in 44)} and self-control therapy ^{(65; 133)}.

Personal science teaches clients to use the skills used by researchers to solve problems. The mnemonic SCIENCE represents seven basic skills:

• S: Specify general problem area
• C: Collect data
• I: Identify patterns or sources
• E: Examine options
• N: Narrow and experiment
• C: Compare data
• E: Extend, revise, and replace ^{(Mahoney, as cited in 44)}

Self-control therapy uses a variety of techniques to teach clients how to correct six potential deficits in self-control behavior across three phases of self-control that relate to depression. In the self-monitoring phase, potential deficits include selectively paying attention to negative events and selectively paying attention to immediate instead of delayed consequences of behaviors. In the self-evaluation phase, potential deficits include being overly critical of oneself and inaccurate conclusions about responsibility. In the self-reinforcement phase, potential deficits include not rewarding oneself sufficiently and punishing oneself too much ^{(65; 133)}.

2. Relaxation

The purpose of relaxation techniques is to reduce stress responses. Sometimes it is easy to relax just by getting a massage, listening to calming music, or admiring peaceful works of art. Similarly, simple environmental or ergonomic changes in people's lives can be relaxing by allowing their interactions with specific objects and their surroundings in general to be less strenuous. Other times, however, people have trouble relaxing and need to learn relaxation techniques. Relaxation techniques include progressive muscle relaxation, autogenic relaxation, meditation, the relaxation response, diaphragmatic breathing, biofeedback, self-hypnosis.

Progressive muscle relaxation is accomplished by focusing on muscle groups one at a time and tensing them for a few seconds, releasing the tension, and focusing on the resulting feelings of relaxation ^{(23; 83)}.

Autogenic relaxation is accomplished by focusing on blood flow and tense muscle groups and suggesting to oneself that he or she is becoming more relaxed and warm ⁽¹³⁾.

In most types of meditation, people use special techniques to focus their attention on one thing until they stop thinking about anything and experience nothing but "pure awareness" ⁽²¹⁾. People who meditate seem to have fewer problems associated with stress, such as general anxiety, high blood pressure, and insomnia ⁽¹⁵⁾. The relaxation response is a stripped-down version transcendental meditation, a form of mediation in which attention is focused on softly repeating a specific vocalization (the mantra). The relaxation response isolates this aspect of transcendental meditation ⁽¹³⁾, and has been shown to reduce the stress hormones levels ^{(21; 22)}

Diaphragmatic breathing is sustained, slow, rhythmical, breathing that emphasizes the use of the diaphragm ⁽⁵⁴⁾. It can be thought of as a special way of breathing with your stomach area instead of your chest area.

With biofeedback, special equipment records stress-related physiological activity in people like heart rate, blood pressure, and muscle tension and relays this information back to them as a tone that changes frequency or a meter reading. The person uses this information to learn to control these physiological processes and reduce the stress responses ^{(Budzynski & Stoyva, as cited in 23)}

Self-hypnosis is exactly what it sounds like, hypnotizing oneself. Self-hypnosis can be used to give oneself suggestions of relaxation. Hypnosis is a highly relaxing state in which people are more responsive to suggestions ⁽⁹⁰⁾. People display five main changes while under hypnosis:

• Reduced planfulness: They do not initiate actions as much.
• Attention is redistributed: They tend to pay attention exclusively to the voice of the hypnotist (which is their own voice during self-hypnosis).
• Improved ability to fantasize: They are better able to vividly imagine scenes or to relive remembered events.
• Better role-taking ability: It is easier for them to act like other types of people, such as people of different ages or the opposite sex.
• Reduced reality testing: They are less likely to question the truthfulness of statements and are more willing to accept apparent distortions of reality ^{(77; 78)}.

3. Exercise

Aerobic exercise, weight lifting, yoga, and tai chi are examples of forms of exercise that can help with stress.

Aerobic exercise uses the large muscle groups in continuous, repetitive motions and involves increased oxygen intake and increased breathing and heart rates. Aerobic exercises include the following types of exercise:

• Running
• Swimming
• Brisk walking
• Bicycling
• Rowing
• Jumping rope ⁽¹⁷⁷⁾

An exercise program aimed at improving physical fitness should include aerobic exercise 3 to 4 times a week for 20 to 30 minutes preceded and followed by a 5- to 10-minute warm-up and cool-down period, respectively ^{(6; 152)}.

Weight lifting can be used to enhance muscular strength or muscular endurance. Muscular strength is how much force muscles can exert, and muscular endurance is how long muscles can work before getting too tired ⁽¹⁰⁾. Strength training involves lifting heavier weights for fewer repetitions. Endurance training involves lifting lighter weights for more repetitions ⁽⁴²⁾. An exercise program aimed at improving physical fitness should include strength training with 8 to 12 repetitions of 8 to 10 types of lifts at least twice a week ^{(American College of Sports Medicine, as cited in 10)}.

Yoga involves aspects of meditation and special physical and breathing techniques used to control bodily processes like heart rate and blood pressure ⁽⁹⁹⁾. It is one of the six orthodox systems of Indian philosophy ⁽¹³⁶⁾. Yoga is not a religion, though; it is a way of life, combining the body, mind, and spirit ⁽⁵⁴⁾.

Tai chi (also called tai chi chuan) is a style of martial art based on the Chinese philosophy of Taoism. According to tai chi principles, everything in the universe is made up of two opposing yet united forces, yin and yang. Tai chi movements are intended to build up the Qi, the intrinsic energy that runs throughout the body along pathways know as meridians. The object is to harmonize the body and mind and become aware of internal conflicts that may be causing tension ^{(54; 102)}.

4. Diet and Nutrition

Switching to a diet that is healthier can relieve stress for people who do not already have a healthy diet already, especially for people who are overweight. No dietary secrets or miracle diets can lead to long-term stress reduction (or weight loss). People just need to eat right ⁽⁵⁴⁾. The following recommendations may be helpful for people who want to improve their diet:

• Eat more fresh fruits and vegetables, enough so that fresh fruits and vegetables make up 50% to 75% of your diet.
• Avoid processed foods and all foods that are stressful for the body, such as artificial sweeteners, carbonated soft drinks, chocolate, eggs, fried foods, junk foods, pork, red meat, sugar, white flour products, foods containing preservatives or heavy spices, and chips and similar snack foods.
• Try getting rid of dairy products from your diet for 3 weeks. Then, slowly add them back into your diet and see if stress responses coincide with them.
• Avoid caffeine.
• Avoid alcohol, nicotine, and mood-altering drugs.
• Follow a monthly fasting program, but make sure you know what you are doing! ⁽¹¹⁾

Additionally, the following herbs are useful for relief from stress and problems associated with stress:

• Lemon balm is a general remedy for stress and helps with stress-related digestive problems.
• Damiana is a general remedy for stress and helps with anxiety and depression after long-term stress.
• Skullcap is a general remedy for stress and helps with headaches and panic attacks.
• St. John's wort is a general remedy for stress, depression in particular.
• Motherwort helps with panic attacks.
• Linden helps with panic attacks and a fast or irregular heart beat.
• Dan shen help with a fast or irregular heart beat.
• Valerian helps with chronic anxiety and hyperactivity.
• Codonopsis helps with nervous exhaustion, muscle tension, and headaches.
• Ginseng (also called panax ginseng) and Siberian ginseng help with short-term stress.
• Withania helps with long-term stress and recovery from illness and fatigue. ⁽³⁴⁾
• Catnip causes drowsiness.
• Chamomile is a gentle relaxant and helps with stress-related digestive problems.
• Hops helps with nervousness and restlessness.
• Kava kava relaxes the mind and the rest of the body.
• Passionflower is calming.
• Polygala root is soothing and calming.
• Sour jujube seed is soothing and calming. ⁽¹¹⁾

Regarding herbs, it is important to remember that they can interact with medications that people may be taking and may have adverse sideeffects for some people. Advice from a professional, such as a physician or an herbalist, should be sought before taking herbs.

5. Medication

Over-the-counter pain relievers are used frequently by many people to relieve the pain of some problems associated with stress ⁽¹³⁾. Regarding prescription drugs for stress, amitriptyline, an antidepressant drug, has been used to treat tension headaches ⁽¹¹³⁾. Additionally, a wide variety of prescription drugs are used to treat mental disorders and physical illnesses associated with stress. Anxiety and depressive disorders, for instance, are often treated with antianxiety agents and antidepressants, respectively. Examples of antianxiety agents are as follows:

• Benzodiazepines
• Buspirone
• Clomipramine
• Clonidine
• Hydroxyzine
• Meprobamate (and other beta-blockers)
• Propranolol

Examples of antidepressants are as follows:

• Heterocyclic (or multicyclic) antidepressants (HCAs): tricyclic antidepressants (TCAs), maprotiline, and amoxapine
• Selective serotonin reuptake inhibitors (SSRIs)
• Monoamine-oxidase inhibitors (MAOIs)
• Atypical antidepressants: bupropion, nefazodone trazodone, venlafaxine ⁽¹⁰⁵⁾

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