Stress Management Programs Research Paper

1. Introduction

Stress is generally considered a major impediment to individual health and well-being and to social and societal functioning. Stress is associated with psychological symptoms, diminished well-being, acute and chronic health problems, and impaired performance in work and social settings. To alleviate such stress related problems, theory-based stress management programs have been developed whose aim is to improve personal skills in dealing more effectively with stressful conditions and to cultivate a personal sense of self-efficacy and control in problem situations. In the next section of this research paper, the main theories and key concepts that underlie stress management interventions will be delineated. Subsequently, program designs, intervention techniques, and the range of application of stress interventions will be discussed. The fourth section presents results of the evaluation of stress management programs across different outcome measures. Moreover, methodological aspects of intervention studies will be examined. Finally, prospects for future research and program development will be considered.

2. Rationale And Theoretical Background

The majority of stress management programs are based on the following theories: (a) transactional theories of stress and coping, and (b) theories for cognitive-behavioral psychotherapy developed in clinical psychology. In addition to these psychological theories, knowledge of the physiology of stress and the physiological systems activated by stress has resulted in the view that relaxation must be a major objective in healthy stress management. Relaxation techniques have since been advocated that are aimed at reducing heightened arousal and at preventing its short and long-term deleterious effects.

2.1 Transactional Theories Of Stress And Coping

The most influential theory of stress and coping was developed by Lazarus and Folkman (1984) who defined stress as resulting from an imbalance between perceived external or internal demands and the perceived personal and social resources to deal with them. According to Lazarus and Folkman, two cognitive appraisal processes can be distinguished. The initial appraisal, defined as primary appraisal, involves the analysis of whether an event is personally relevant. Events perceived as personally relevant can be appraised as either positive or stressful (the latter including possible harm, threat, or challenge). If individuals perceive events as stressful, they evaluate their own resources to deal with the demands. This constitutes the process of secondary appraisal. Stress occurs when the demands are perceived as either exceeding or taxing the resources and coping responses become activated. Lazarus and Folkman (1984) defined coping as cognitive and behavioral efforts to deal with situations appraised as stressful. Generally, cognitive appraisal and coping processes are influenced by personality factors, personal and social resources, characteristics of the situation, and other variables.

A very similar stress model has been developed by Palmer (1997) to guide health professionals in the selection of appropriate stress interventions. It incorporates Arnold Lazarus’ seven interacting response modalities comprising behavior, affect, sensory, imaginal, cognitive, interpersonal, and drugs/biology. According to this multimodal–transactional model, stress and coping proceed in five stages. In Stage 1, an external or internal stressor is perceived by the individual to be emerging either from an external source or from internal bodily sensations. In Stage 2, the individual appraises his or her capacity to deal with the stressor. The person then decides whether he or she has the resources to cope. If the individual perceives that he or she cannot cope, stress may be experienced, and stress responses are likely to become activated. Appraisal of coping capacity is influenced by social and cultural beliefs and attitudes that determine the importance of an event. An example is the belief that one must meet every deadline. If individuals perceive that they cannot cope, they progress to Stage 3. In this stage, stress responses occur that include behavioral, affective, sensory, imaginal, cognitive, interpersonal, and physiological changes. In Stage 4, the individuals appraise the effectiveness of the coping strategies they have used. If they perceive themselves to have been successful, they return to a state of equilibrium. If they believe, however, that they have failed to cope with the situation, this perceived failure exacerbates existing problems and turns into an additional strain. Stage 5 relates to the continuing process and long-term consequences. If an individual uses strategies that alter the situation and reduce stress, he or she will return to a state of equilibrium. If the problems persist, however, eventually the person’s health may be negatively affected.

In sum, transactional theories of stress and coping focus on the cognitive and affective aspects of an individual’s interactions with the environment and the coping strategies he or she uses or lacks.

2.2 Cognitive Approaches To Psychotherapy

Many of the techniques adopted in stress management programs have their origin in clinical psychology. In addition to the stress and coping theories, stress management is an explicit goal of intervention in cognitive and cognitive-behavioral approaches to psychotherapy. The basis of this form of clinical intervention is the belief that negative thoughts and cognitive distortions (e.g., ‘catastrophizing’ and overestimating negative outcomes) play a causal role in many clinical disorders. Cognitive interventions seek to modify biased and maladaptive beliefs by cognitive reeducation. The most influential cognitive therapies are Beck’s cognitive therapy (Beck 1976) and Ellis’ rational emotive behavior therapy (Ellis 1962, Ellis et al. 1997). Within the framework of his rational emotive behavior therapy, Ellis has developed the ABC model, which posits that an emotional, behavioral, or physiological reaction (C, for consequence) to an activating event (A) is influenced mainly by the beliefs (B) pertaining to an event and not so much by the activating event per se. According to Ellis, irrational beliefs such as ‘awfulizing’ or dogmatic and absolutist beliefs will lead to self-defeating behavioral and emotional consequences. In psychotherapy, such beliefs are challenged by asking logical, empirical, and pragmatic questions. Generally, cognitive interventions are employed in combination with behavioral techniques and the acquisition of problem solving and social skills.

3. Program Designs

3.1 Intervention Techniques

The importance of transactional theories of stress (Lazarus and Folkman 1984, Palmer 1997) and cognitive therapy approaches (Beck 1976, Ellis 1962, Meichenbaum 1985) lies in their recognition that the subjective interpretation of events plays a critical role in the experience of stress. Moreover, lack of appropriate skills in dealing with problem situations or inappropriate or rigid use of coping strategies may exacerbate stress. Thus, stress intervention now focuses on two aspects: dysfunctional cognitive appraisal such as cognitive distortions and irrational beliefs, and inefficient coping attempts and deficits in a wide range of personal and social skills. Furthermore, in accord with the physiology of stress, reducing the level of physiological arousal is acknowledged as a major objective in stress management. Based on this theoretical framework, the main intervention techniques employed in stress intervention include: (a) relaxation techniques that can be used to achieve short-term, in situ relaxation, as well as prolonged relaxation in the private setting (e.g., progressive muscle relaxation, meditation, breathing exercises, biofeedback, and autogenic training); (b) cognitive re-education and cognitive restructuring, mainly by challenging maladaptive cognitions and negatively biased beliefs; and (c) skills training in areas such as problem solving, time management, negotiation, assertive behavior, and the activation of social support (Bunce 1997, Murphy 1996, Palmer 1996, 1997).

According to reviews of stress intervention studies, combinations of individual techniques, especially the combination of relaxation and cognitive-behavioral skills training, are the most frequently used forms of intervention (Bunce 1997, Kaluza 1997, Murphy 1996). A very influential composite stress management program that represents the multicomponent approach is ‘stress inoculation training’ (Meichenbaum 1985). The stress inoculation procedure typically includes three stages. The first stage, education, focuses on the assessment of an individual’s problems, the identification of strategies usually adopted to deal with stressful situations, and reconceptualization of the individual’s responses to stressors. Thus, the client learns to become aware of how he or she habitually responds to stressful situations. In the second stage, rehearsal, the client learns and practices various coping-skill techniques such as relaxation, problem solving, and cognitive restructuring. During the third stage, application, the newly acquired coping skills are practiced under simulated conditions and transferred into everyday life.

In sum, stress management programs seek to reduce physiological arousal, and to provide the individual with a positive perception of stressful situations that is more conducive to well-being. Moreover, the pro- grams aim to teach a wide range of coping skills to be used in a flexible, situation-appropriate way. Above all, the goal of stress interventions lies in promoting a sense of control and self-efficacy in coping with problem situations.

3.2 Range Of Application

Stress management programs have been implemented in a variety of settings. They are usually prevention oriented and focus on psycho-education and cognitive behavioral skills training. Accordingly, most programs are offered to all who seek such forms of intervention for themselves (Murphy 1996). In contrast to psychotherapeutic approaches, stress management programs are primarily developed for subclinical populations. However, these programs may also address high-risk groups such as hypertension patients, persons suffering from coronary heart disease (Bennett and Carroll 1990, Dusseldorp et al. 1999), or individuals with specific psychological problems such as high levels of stress, anxiety (Murphy 1996), or anger (Novaco 1975). For these groups, there may be no clear distinction between preventive stress management programs and psychotherapy. Moreover, stress management programs are offered to persons coping with specific stressors or chronically difficult living conditions; this may include caregiving or chronic financial problems (Kaluza 1997). Modified stress interventions are also offered to children and adolescents (Wolchik and Sandler 1997).

Stress management programs are particularly prevalent within work settings (Bunce 1997, Murphy 1996). The high frequency of stress interventions that target the workplace and occupational stress is a result of the recognition that stress is a major cause of problems such as absenteeism, accidents, poor work performance, and burnout. Coping with chronic illness is another important domain for which stress management programs have been developed and applied (Devins and Binik 1996, Dusseldorp et al. 1999). The most common forms of stress interventions for patients are education, behavioral training, relaxation, cognitive restructuring, and support groups. Usually, these interventions are part of composite intervention or self-management programs. Such interventions are generally designed to assist the patients to engage in active coping, to change risk behavior, and to feel less hopeless and helpless.

3.3 Formats

Though stress management programs can be administered individually, most programs are implemented in small groups. Typically, a number of weekly training sessions which may last one hour or longer are either conducted over a number of weeks or condensed into block sessions. Learning theories see advantages in both formats (Brown et al. 1998). Interest in working with large groups which meet for ‘massed learning’ format workshops may increase in the future, however, as preventive psycho-education and skills training become part of general health promotion. Brown et al. (1998) have shown that large-scale, day-long stress management workshops are just as effective as the traditional programs consisting of one weekly session. The value of large-scale stress management programs lies in their potential to make preventive training accessible to the general public and to induce more persons to avail themselves of psychological intervention measures.

4. Program Evaluation

4.1 Outcome Measures

In the studies that evaluate the effects of stress management interventions, a wide range of health outcome measures were used to assess program effectiveness. Frequently employed measures include in- dices of subjective well-being (which, for the most part, are negatively defined as distress reduction, e.g., anxiety, anger/hostility, depression), perceived strain associated with different life domains, self-reported somatic symptoms and complaints, control and self-efficacy beliefs, and physiological measures. Moreover, some studies rely on biochemical measures (Kaluza 1997, Murphy 1996). According to a meta-analysis of 36 intervention studies, only five studies assessed coping strategies (Kaluza 1997). This is especially noteworthy in light of the fact that the acquisition of adaptive coping strategies is the primary focus of stress intervention. Obviously, the existing program evaluations have major shortcomings. In workplace intervention studies, organizational outcome measures such as job satisfaction, work performance, absenteeism, and turnover were additionally assessed (Murphy 1996). Evaluations of programs aimed at coping with chronic illness frequently assess illness- related knowledge, illness-related behavior and cognitions, and disease-related outcomes in addition to measures of subjective well-being (Devins and Binik 1996, Dusseldorp et al. 1999).

4.2 Results

There are several systematic and comprehensive reviews of studies which evaluate the success of stress management programs (Devins and Binik 1996, Murphy 1996). While there exist only a few metaanalyses of preventive stress management interventions, especially of primary preventive programs, they clearly attest to positive treatment effects (Kaluza 1997, Lipsey and Wilson 1993; for secondary preventive programs see Dusseldorp et al. 1999). In their review of meta-analyses of psychological treatment effects, Lipsey and Wilson (1993) reported two studies of stress management programs, with the two mean effect sizes indicating positive treatment results. Similarly, a more recent meta-analysis of 36 studies (31 of them conducted in the US) reported small to medium effect sizes found in randomized control studies. Positive effects were found for different outcome measures such as subjective well-being, anger/Type A behavior, coping strategies, physiological measures, and cognitions (Kaluza 1997). Notably, mean effect sizes were greater for follow-up measures assessed between one and six months after the intervention. Particularly remarkable is the increase in mean effect size found in five studies that assessed subjective wellbeing more than six months after post-test. These results suggest that the effectiveness of stress management programs may be stable or may even increase over time, at least in regard to subjective well-being.

According to a systematic review of 64 studies on workplace management programs (Murphy 1996), stress interventions were generally found to be effective, but the effectiveness varied with the outcome measure used. Cognitive-behavioral techniques were more effective with respect to psychological and cognitive outcomes, mainly anxiety, whereas relaxation was more effective in regard to physiological outcomes, predominantly assessed by blood pressure measurements. Meditation was used in only six studies, but produced the most consistent results across outcome measures. Generally, composite programs which used a combination of techniques proved to be more effective than single-technique programs. Job and organizational outcome measures, mainly job satisfaction, were employed in only 40 percent of the studies. According to Murphy, the low frequency of organizational outcomes may reflect the fact that stress management programs target the individual worker, not the organization. Of the studies reviewed, two-thirds reported no increase in job satisfaction. It appears that the interventions had a greater effect on subjective well-being and physiological arousal, which are subject to personal control, than on outcomes such as job satisfaction and somatic complaints, which are more influenced by external working conditions. The conclusion may be that workplace stress management needs to be more comprehensive and should address personal coping skills as well as the work environment (Murphy 1996).

In sum, meta-analyses and systematic reviews attest to the general effectiveness of stress management programs, especially with regard to psychological and physiological well-being. The programs had less of an effect on outcomes that may be heavily influenced by external factors. Inconclusive are the results for coping skills, which were seldom assessed. However, in interpreting the results one has to bear in mind that studies examining the success of stress management programs face the problem that it is more difficult to demonstrate a significant effect in participants who enter the training with subclinical levels of complaints than it is in participants who enter with high levels of stress. For example, in the review of Murphy (1996), 79 percent of the prevention-oriented studies yielded positive effects, compared with 94 percent of the treatment-oriented studies that involved persons complaining of high stress or anxiety.

4.3 Methodological Aspects

The variety of different intervention techniques raises the question of whether some techniques are more effective than others. Results for contrasting different intervention techniques are equivocal. Murphy (1996) reported technique-specific effects, whereas other reviewers came to the conclusion that seemingly different techniques appear to have similar outcomes, which is generally known as the ‘equivalence paradox’ (Bunce 1997, Palmer 1996). According to Bunce (1997), outcome equivalence may be due to two factors. First, methodological and design weaknesses may underlie outcome equivalence. Second, all the different intervention techniques or combinations of techniques may have common features which are responsible for change. The methodological shortcomings that could add to outcome equivalence include: (a) combining techniques even if only one technique is used so that it is not possible to identify which specific components are responsible for the changes that are observed; (b) small sample sizes that may be associated with insufficient statistical power to detect techniquespecific effects even if they exist; (c) inappropriate or unspecific outcome measures; and (d) participant heterogeneity.

The second interpretation suggested by Bunce to explain outcome equivalence is that nonspecific factors common to distinct contrasting techniques produce similar effects. Such nonspecific factors may be the experience of being in a group and meeting people with similar problems, expectancy effects, or insights gained by participation in respect to the self, others, and one’s environment. Indeed, studies that controlled for placebo effects, e.g., with a control group directed to sit quietly or to passively receive information, have demonstrated nonspecific effects (Bunce 1997, Murphy 1996). One may argue, however, that nonspecific effects are no less valuable. In fact, nonspecific effects may be constituent parts of psychological treatment, involving mechanisms of social interaction, expectations, and changes in beliefs and attitudes (Lipsey and Wilson 1993).

The quality of the studies that evaluate intervention effects has been a point of severe methodological critique in the past. Recent reviews, however, reveal increasing methodological rigor (Ivancevich et al. 1990, Kaluza 1997, Murphy 1996). According to a recent review of 64 intervention studies in the workplace, just over half of the studies were true experiments with random assignment to a training or control group (Murphy 1996). However, about 25 percent of the studies did not use a control or comparison group, and 25 percent did not randomly assign participants to training and control groups. Generally, the studies involving randomized groups yielded lower effects, which underscores the importance of randomized control trials. Of the 36 studies that were included in the meta-analysis of Kaluza (1997), 61 percent were true experimental studies with random assignment to training and control groups. In the remaining studies, participants were not randomized into an intervention or control condition. In addition to post-treatment assessment, 53 percent of the studies reported results for a follow-up between one and over six months after post-test.

5. Prospects For Future Program Development

Stress management programs are designed for a wide range of possible stressors and chronically difficult living conditions. Most of them are preventive in nature and open to all persons who wish to improve their skills in dealing with stressful situations and enhance their feelings of control. Unspecific and stressor-specific stress management programs provide an invaluable service for health promotion by offering psycho-education, skills training, and adaptive perceptions of problem situations. Generally, systematic reviews and meta-analyses of intervention studies attest to the effectiveness of preventive stress management programs. Clearly, however, further research is needed, especially with nonclinical populations attending preventive stress management programs (Kaluza 1997, Palmer 1996). Future research should focus on the following four problems.

(a) Studies on stress intervention should seek to identify the factors that are responsible for change and the mechanisms of change. Such mediators by which changes may be engendered could be psychological variables such as personal sense of control and self-efficacy, the use of adaptive coping strategies, and insights into self, others, and work (Bunce 1997).

(b) Outcome measures should be used that reflect the specific goals of stress management intervention such as realistic and adaptive stress-related cognitions, increased skills for dealing with everyday stress, and improved social competencies (Kaluza 1997). Currently, most outcome measures pertain to subjective well-being, which may indicate improvement in coping skills, but does not clearly reflect actual changes in stress-related interactions between the individual and his or her environment. Moreover, the effectiveness of stress intervention should be evaluated by long-term follow-up assessments in order to ascertain whether the interventions guard against future stress experiences.

(c) Biographical and psychological individual differences such as age, gender, self-esteem, or locus of control may systematically influence changes effected by stress interventions (Bunce 1997). According to Bunce, future research must consider individual differences and should examine how these factors might act as moderators and mediators of outcome variance. Matthews and Wells (1996) assert that intervention is likely to be most successful when it is based on systematic analyses of individual styles of attention and coping. Miller has shown that interventions may be more effective when matched with the dispositional information-processing style (e.g., Miller and Mangan 1983).

(d) In the development of stress intervention programs, cultural aspects should be taken into consideration in addition to biographical and psycho-logical individual differences. For instance, minority groups in work or social settings may experience stress due to racial prejudices that could become the target of special stress intervention measures (Palmer 1996). Generally, cultural differences may play an important role in successful health promotion. Matching stress interventions with cultural beliefs and models of health and illness is a challenging task for multicultural societies (Devins and Binik 1996).

There is every reason to believe that stress will continue to be a salient problem in the near future. Increasingly, individuals and organizations will seek effective interventions to improve coping skills and reduce stress-related problems. Providing methodologically sound and effective unspecific and stressor-specific stress management programs will remain a predominant task for all who are involved in health promotion.

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