Motivation and emotion/Book/2014/Stress inoculation

Overview
Psychological stress appears to have become a permanent condition of modern society. Some individuals may see stress as a good thing and use it constructively to propel them towards a successful outcome (Lazarus, 2006). Others view stress in a negative light and consequently experience stress in its destructive form, which often has an adverse effect on the person’s health and well-being (Lazarus, 2006).

The ways in which people experience stress varies from person to person and can take many forms. Psychological responses to negative stress events can include, but are not limited to anxiety, fear, anger, depression, panic attacks, and post-traumatic stress disorder (PTSD; Lazarus, 2006; Rice, 2012). Adverse physical manifestations of stress can include conditions such as chronic headaches, high blood pressure, and cardiovascular disease (Dimsdale, 2008; Steptoe & Kivimäki, 2012). These undesirable responses to stress can have a devastating effect on peoples’ lives. Effective empirically supported stress management strategies are therefore needed to help people cope more successfully with stress and, in turn, minimise its devastating consequences. Stress inoculation is a particular stress management strategy that has been reported to be effective in helping people cope successfully with stress (Lyons & Parker, 2007; Meichenbaum, 2007; Saunders, Driskell, Johnston, & Salas, 1996).

The current chapter discusses the concept of stress inoculation, underlying theories, the phases of stress inoculation training (SIT), and how stress inoculation can be applied.

What is stress inoculation?
Stress inoculation is a type of cognitive-behavioural therapy (CBT) that is based on the concept of inoculation. Inoculation, in a medical sense, involves artificially inducing immunity to a particular harmful pathogen by exposing the body to small amounts of that pathogen. In a similar way, stress inoculation prepares an individual to be more resistant to the effects of stress through prior exposure to milder forms of stress (Meichenbaum, 2007).

The theory of stress inoculation is well supported by empirical evidence. For example, in a meta-analysis of the literature on stress inoculation, Saunders et al. (1996) found that stress inoculation, as an intervention strategy, effectively reduced anxiety under stress. The study further revealed the robust nature of stress inoculation as an intervention showing small to moderate beneficial effects with as little as one stress inoculation session. A study by Katz et al. (2009) investigated the impact of stress inoculation on the brain using squirrel monkeys. Their results suggested that the brain seem to have its own innate stress inoculation process, which appears to provide a biological foundation for formal stress inoculation interventions to build on. Other studies, again, have focussed on how exposure to low-to-moderate levels of stress early in life impacted on coping with stress in later life (e.g., Forest, Moen, & Dempster-McClain, 1996; Khoshaba & Maddi, 1999; Lyons & Parker, 2007). The results of these studies would suggest that exposure to lower levels of stress early in life may foster resilience and successful coping with higher levels of stress later in life.

History and theoretical foundations
Stress inoculation as an intervention strategy was first developed by Meichenbaum (2007) in the early 1970’s under the label stress inoculation training (SIT). The approach initially focussed on the Schachter-Singer (1962) two-factor model of emotion, cognitive appraisal (as espoused by Lazarus, 1966) and learning principles (Meichenbaum, 1972, 1977). The Schachter-Singer model proposes that emotion includes both physiological and psychological factors. That is, an event causes a heightened physiological state of arousal in an individual who then experiences certain thoughts and feelings about that event. The thoughts and feelings are subsequently appraised (or interpreted) and then labelled and experienced as a particular emotion. For example, an angry barking dog creates a physical arousal in the form of a rapid heartbeat and trembling. The rapid heartbeat and trembling is interpreted (appraised) as a physical reaction to fear, resulting in fear being instantly experienced on a conscious level. Cognitive appraisal theory (Lazarus, 1966, 1980), in addition, views stress as the result of negative evaluations of thoughts and feelings, as well as the negative evaluation of the ability to cope. These theories not only formed part of the basis of the early SIT intervention strategy, but were also employed as an educational tool with clients.

The above theories were typically introduced to the client(s) at the onset of the SIT program (Meichenbaum & Deffenbacher, 1988). The aim thereof was to help clients understand that their stress-engendering emotions were as a result of physiological arousal and negative self-statements (Meichenbaum & Deffenbacher, 1988). SIT further facilitated the acquisition and application of effective coping skills, such as positive self-statements and self-directed relaxation, to ameliorate the effects of stress-engendering thoughts and feelings (Meichenbaum & Deffenbacher, 1988). SIT has since evolved to incorporate many other stress reduction strategies, resulting in it becoming an effective stress management intervention that can be widely applied across different contexts (Meichenbaum, 2007, 1993).

The current SIT model
The current SIT approach (Meichenbaum, 2007) embraces the Lazarus and Folkman (1984) transactional model of stress and coping. This model focusses on the role of cognitive-emotional appraisal and coping behaviour, and how it relates to the experience of psychological stress. Transactional refers to the ever-changing bidirectional relationship that exists between the individual and the environment. This means that the environment and the individual have a mutual influence on each other in a great variety of ways over the course of time. The transactional model, therefore, supposes that psychological stress is experienced when the person evaluates their relationship with the environment as being overly demanding, beyond their ability to cope with and as posing a threat to their well-being.

In addition, the current SIT model has adopted a constructive narrative perspective (CNP; Meichenbaum, 2007). According to this perspective people construct "stories" about themselves and the world around them. These stories (or narratives) that people tell themselves greatly influence their ability to cope with stressful situations. By incorporating the CNP into the SIT model, clients can be assisted in constructing more adaptive life narratives while building valuable coping skills in the process. The SIT program, overall, provides a generic approach for the management and prevention of a wide range of stress-related disorders. Meichenbaum (2007) has described the SIT intervention as a flexible multi-faceted program that can be uniquely tailored to suit the client’s needs.

How does stress inoculation work?
The goal of SIT (Meichenbaum, 2007) is not only to impart a broad range of coping skills that could be applied flexibly by the individual in different situations, but also to boost the individual’s confidence in their ability to cope with demanding situations. SIT can be used on both a preventative basis (i.e., by inducing ‘inoculation’ against future stress) and a treatment basis.

SIT, as described by Jaremko (1984), Meichenbaum (2007), and Saunders et al., (1996), typically comprises of three overlapping phases: A conceptual educational phase (which is the initial phase); a skills acquisition and consolidation phase (the second phase); and an application and follow-through phase (the final phase).

During the initial conceptual education phase the client is provided with information about the nature of stress and the impact it can have on a person. The transactional model of stress and coping (Lazarus & Folkman, 1984) is furthermore presented to the client in order to help the client understand how maladaptive coping behaviours could influence the level of stress they are experiencing. Various clinical techniques (e.g., Socratic-probing/questioning, self-monitoring, modelling, etc.) are also applied to help the client become more aware of their ability to solve problems, while fostering hope, self-confidence and self-control. This, in turn, encourages the client to think adaptively.

During the second phase, new stress management/coping skills are learned and practiced. The types of skills that are learned usually depends on the client’s unique needs. However, the aim is to provide the client with a broad arsenal of techniques, which he or she can then draw from and flexibly apply when coping with stressful circumstances. Some of the skills that are oftentimes acquired during this phase include relaxation training, cognitive restructuring, emotional self-regulation, problem-solving and communication skills training. These newly acquired skills are then practiced through role-playing exercises and mental imagery. The third and final phase involves application and follow-through. During this phase the client is provided with an opportunity to apply their newly acquired skills, while gradually being exposed to higher levels of stress. This consequently induces inoculation and prepares the client for becoming more stress resistant. That is, through gradually exposing the client to increasing levels of stress (systematic desensitization), the client becomes more familiar with the stressful situation without being overwhelmed. This in turn fosters a sense of control and self-confidence when faced with demanding life events. Newly acquired coping skills are initially practiced using imagery, role-play, and modelling. Eventually the skills are practice in a real-life situations. To deal with and prevent relapse, high-risk situations and warning signs are identified, and relapse recovery strategies are devised to deal with unsuccessful coping attempts. Follow-up booster sessions (this is where follow-through comes into play) are also provided to assist the client in fine-tuning his or her stress management/coping strategies.

SIT oftentimes also takes a systems approach when addressing a client’s distress. That is, it looks beyond the client at the bigger picture and may decide to include significant others and/or the wider community in the therapeutic process in order the address additional sources of stress (e.g., behaviours and attitudes of others) that could be contributing to or worsening the client’s distress (Meichenbaum, 2007).

How can stress inoculation be used?
The flexible and generic nature of the SIT approach lends it a great deal of versatility and allows it to be applied to virtually any stressful situation (Jaremko, 1984; Meichenbaum, 2007). SIT can effectively be used with individuals, couples and small to moderate sized groups. It is noted that as the size of the group increases, the effectiveness of the SIT intervention decreases (Saunders et al., 1996). One possible reason for this phenomenon could be that being in a larger group may cause group members to feel "lost in the crowd", leading to a reduction in motivation and effort, and subsequently results in decreased effectiveness of SIT (see Mullin, 1991, as cited in Saunders et al., 1996). SIT can be used in both a preventative and treatment capacity for various stress related issues.

Click here to watch a video by Dr Donald Meichenbaum on stress inoculation

For various reasons individuals oftentimes do not end up seeking help from a clinical professional in dealing with their stress issues. Self-management strategies (self-help) can, therefore, offer a low-cost stigma-reducing alternative in preventing or reducing stress.

In recent years SIT has been combined with modern electronic technologies (e.g., virtual reality or mobile phone) to create cyber stress inoculation interventions (cyber-SIT; Serino et al., 2014). A review of the literature by Serino et al. (2014) revealed that cyber-SIT effectively reduced stress, anxiety and maladaptive anger, and increases relaxation across different contexts. However, cyber-SIT is still in its infancy and is currently mainly used as part of the formal therapeutic process (Serino et al., 2014). Cyber-SIT may become readily available to the general public in future as a self-help stress inoculation tool; however, this may still be a long way off.

Moreover, in reviewing the literature it would appear that there are currently no structured self-help stress inoculation procedures or guidelines available that do not form part of the formal therapy process and that does not require a trainer-trainee relationship. Nonetheless, most people in today’s fast-paced society are subjected to varying degrees of stress and need to address their stress issues on a daily basis. A need, therefore, exists for guidelines that would explain to an individual how to go about engaging in self-directed stress inoculation. Also, such guidelines would have to be based on theory and research. Even though no formal self-directed stress inoculation guidelines exist at this point, which are readily accessible by the public at large, the author of this article believes that it is still possible to engage in some sort of self-directed stress inoculation procedure by following some of the general guidelines suggested in the literature and utilising existing self-help procedures (e.g., Davis, Eshelman, & McKay, 2008; Watson & Tharp, 2012).

Looking at the research, a meta-analysis by Saunders et al. (1996) revealed that a single stress inoculation session sufficiently reduced stress. They also found that the phenomenon of stress inoculation was fairly robust, and one did not have to be a qualified clinician to successfully present the stress inoculation program to others. It would therefore be reasonable to infer that even if a self-directed stress inoculation intervention is not designed and presented on a trainer-trainee basis, it should still be effective in reducing and/or preventing anxiety and stress.

Devising a self-directed stress inoculation intervention
Due to a lack of formal guidelines for engaging in self-directed stress inoculation, individuals who want to self-administer a stress inoculation intervention for the reduction/prevention of their stress will have to devise their own strategies.

Things to consider when deciding to devise and self-administer a stress inoculation intervention:

In presenting a framework and basic procedures for a SIT program, Meichenbaum and Deffenbacher (1988) recommended that a stress inoculation intervention should at least include


 * all three phases of SIT (as described above);


 * acquiring relaxation skills (e.g., progressive muscle relaxation and meditation);


 * acquiring cognitive coping skills (e.g., task-oriented self-instruction, restructuring of negative cognitions, and self-reward/self-efficacy statements);


 * combining SIT with skill acquisition when necessary; and


 * strategies for generalizing coping skills to other problem areas.

Meichenbaum and Deffenbacher (1988) further pointed out the importance and value of the first phase (conceptual education phase) of SIT. Therefore, by becoming familiar with the transactional model of stress and coping and appraisal processes (as espoused by Lazarus & Folkman, 1984) it could greatly increase the effectiveness of a self-directed stress inoculation intervention.

Moreover, existing self-help procedures—such as those explained in The Relaxation and Stress Reduction Workbook (RSRW; Davis, Eshelman, & McKay, 2008), and Self-directed Behavior: Self-modification for Personal Adjustment (Watson & Tharp, 2014)—could be combined with the SIT guidelines and procedures discussed above, to devise an effective self-directed stress inoculation intervention.

Conclusion
Stress inoculation (i.e., artificially inducing stress hardiness through prior exposure to milder forms of stress) appears to be a robust phenomenon, and is well supported by research in both the applied clinical and neuroscience arenas. The research further reveals SIT to be an effective way to prevent, reduce and treat stress related disorders. However, for various reasons, individuals oftentimes do not end up seeking help from a clinical professional in dealing with their stress issues. Self-management strategies (self-help) can be used in such cases to provide a low-cost, stigma-reducing alternative in preventing or reducing stress. Cyber-SIT may also be able to assist in offering such a self-help intervention. However, at present cyber-SIT is in its infancy and mainly available to supplement the formal therapeutic process. This is not ideal as most people in today’s fast-paced society are subjected to varying degrees of stress and need to address their stress issues on a daily basis. A need, therefore, exists for guidelines that would explain to an individual how to devise and engage in a self-directed stress inoculation program. This may be a possible area for future research to focus on.