Course Sample of the Diploma Course in Stress Management Training
This is Session One of our diploma course in Stress Management Training.
This is the first of the eight sessions in the Training Course.
This is a training course in the techniques of Stress Management. The course is designed to teach you how to better manage the stresses in your life. It does not attempt to eliminate stress altogether, as we need a certain amount of stress in our lives in order to achieve our goals. Too much stress, however, can lead to illness or unnecessary restrictions on our lives. Today, more people suffer from stress than ever before. The pace of life is stressful in itself. We expect to manage the major life changes and crises, such as marriage, parenthood, unemployment, bereavement, overwork or ill health, without the network of support that previous generations relied upon. For some, stress may not be related to such specific events, but may have developed in early childhood as an anxiety response to difficult situations. This response may have been carried into adult life as the characteristic way of dealing with difficulties.
Stress affects us in many different ways. Some people develop stress related illnesses, such as asthma, hypertension, ulcers, irritable bowel syndrome and a host of others. Some suffer from free-floating anxiety, panic attacks, muscular tension and hyperventilation. Some people respond with obsessive or compulsive thoughts and behaviours, and many suffer from a variety of phobias, notably agoraphobia and social phobia. It is estimated that one in four people suffer from anxiety at some time in their lives and it is one of the most common symptoms treated by doctors in the Western world.
So what exactly is stress? Our bodies react to stress in a similar way that they react to fear. We experience fear when we have cause to be concerned about our well-being or safety. We experience stress when we are in situations where we feel under threat but are not actually in any immediate danger. When we feel under threat in this way our bodies respond with the Fight or Flight Syndrome. This Syndrome, which prepares our bodies to fight or flee, involves a number of physical changes. Our heartbeat increases, our breathing becomes shallow, all of our senses work better, we may have a desire to defecate, our muscles tense to fight or flee, our hands and feet become colder and we begin to sweat to cool ourselves, as all of these changes make us hot.
This Fight or Flight Syndrome is our instinctive reaction to danger. This response, however, can be set off by many situations that are not really dangerous or life-threatening. However, our bodies are reacting as if our lives were actually threatened, and the reaction to such a threat is a powerful one. When there is no enemy to fight or run from, the physical feelings created by the Fight or Flight Syndrome have no release, and so we begin to build up stress. This stress will eventually find an outlet in chronic fatigue, anxiety and a variety of minor physical illnesses.
Stress Management Training works by breaking down the Fight or Flight Syndrome into three inter-related systems: Firstly; our thoughts. Secondly; the physical changes which take place in our bodies, and thirdly; the behaviour which results from these. When we experience stress our thoughts are of perceived danger. Such thinking creates the physical changes we associate with fear or panic. This, in turn, may result in behaviour which causes more stress, or in the avoidance of the stress-provoking situation. With training in Stress Management techniques, we can learn to create relaxed and positive habits of thought and we can learn techniques of physical relaxation. These two changes together will result in relaxed and appropriate behaviour enabling us to achieve our desired goals in life.
This course achieves these results by a logical sequence of training in the areas of muscular and mental relaxation, deep breathing and breath control techniques, discovering and challenging negative thinking patterns, positive thinking, the development of self-confidence and the elimination of unwanted behaviours.
Each session of the course includes an Information Giving and a Stress Management Relaxation exercise. The Information Giving describes the origins and expressions of the symptoms of stress, and explains how we can learn to control, or manage, these symptoms. Research shows that the greater the understanding that individuals have about stress, the better they are able to manage it effectively. The Stress Management exercise should be practised daily until the next session.
Stress Management Training really can help you to change, but, like any other skill worth learning, it takes practise, hard work and commitment.
Relaxation Training for Stress
There are three major approaches to relaxation training; the physiological approach, which includes simple and progressive muscular relaxation techniques; the meditative approach, which includes visualisation techniques; and the hypnotic approach, which includes autogenic training. Mental relaxation techniques can enhance the ability to focus and give a feeling of peace and well being. Physical relaxation can reduce the breathing and heart rates and lower muscle tension.
However there is a correlation between mental state and muscular tension, over 90% of headache sufferers hae a marked sustained contraction in the muscles of the neck and that such tension is associated with emotional strain, dissatisfaction, apprehension and anxiety.
Jacobson developed the technique of progressive relaxation (from which the active relaxation exercise in this course has been developed) to lower muscular tension. He believed that contraction and relaxation of muscle groups induces relaxation and trained his clients to relax forty-four different muscle groups in turn to induce relaxation and mental health. Wolpe's procedures were similar and he incorporated muscular relaxation into systematic desensitisation programmes to modify behaviour when treating phobic clients. Research shows that muscular relaxation training can improve general health and job performance, lower blood pressure, breathing rates and muscle tension.
Autogenic training was developed in the 1950s to induce relaxation and we use similar techniques in the relaxation exercise in session 6 of the course. Autogenic training is a hypnotic technique focusing on the use of suggestive phrases to induce a relaxed state. Clients need to be relaxed to some degree to be able to respond to the suggestions.
Relaxation training is most useful for clients who suffer from high tension levels which interfere in performance and behaviour. Some people suffering from stress also suffer from varying degrees of depression as well (see depression questionnaire in session 4). Goleman argues that relaxation training, which puts the body in a low arousal state works well for anxiety which is a high arousal state, but not so well for depression because it is already a low arousal state. He suggests that exercise or sport which stimulates the body into high arousal may be a better form of relaxation for depressed clients. Relaxation training can be inappropriate for clients who suffer from psychotic illness such as schizophrenia, as visualisations may trigger hallucinations. It is possible for a client to be physiologically calm while experiencing anxious thoughts, thus relaxation training should always be accompanied by cognitive therapeutic techniques.
Teaching Relaxation Training Using Guided Fantasy
Teaching muscular relaxation skills is the second task in Stress Management Training, the first being Therapeutic Information Giving. For stressed clients, who may spend most of their waking, and some of their sleeping hours in a very tense condition, Relaxation Training can bring great relief and a gain in self-confidence, and a belief that they will be able to cope in future with the stresses in their lives.
Muscular relaxation reduces the effects on the body of stress and tension and, once relaxed, guided fantasy can help to create a more positive and confident state of mind for the client. For those clients who are experiencing long-term stress, it may be the case that their body seems to have become the enemy. Learning to relax helps them to accept their body again and to work with it, instead of against it.
Since relaxation is a skill that can be learned, and can be improved upon, clients will find it increasingly easy to enter into a relaxed state, and the more they practise the Relaxation Exercises, the easier this will become. Guided fantasy can aid relaxation and also help in changing behaviour. We can use images to lessen the stress and tension by creating the image that the desired change has already occurred. Such fantasy work has been successful in the treatment of cancer.
Learning to use guided fantasy to produce relaxation helps to strengthen the belief that clients can use their minds to support their body. Relaxation Training and guided fantasy can enhance the immune system so that those clients at risk from stress-related illness, and those already suffering from stress-related illness can alter the course of the disease or prevent the disease from occurring. Guided fantasy works in inducing deeper relaxation because the mind and body react in much the same way to imaginary experiences as to real experiences, which is in fact why stress often builds up in the first place. We can use this same process to induce relaxation instead of stress. All the Relaxation Exercises in this course focus on awareness of internal states. This change in a client's perspective entails a learning process that must include a new and healthier degree of self-awareness in the client, and an acceptance of the possibility of change.
This course introduces eight Relaxation Exercises digitally or on CD and also includes a script for each exercise, in order that you may develop your skills in this area if you wish. When first doing Relaxation Training if you wish to deliver your own exercise, it is perfectly acceptable to read from a script. This will not disturb the Client at all, in fact, they will probably be unaware of it. I still frequently use a script as a reminder.
In time, if you wish, you may make up your own Relaxation Exercises using words and phrases that come more naturally to you. However, if you wish to continue to use our exercises throughout your career as a stress management trainer, it is perfectly acceptable to do so, in both your individual and group training sessions. When practising Relaxation Training with clients, you must ensure that you will be free from interruption, including interruptions from the telephone, as these can be very disturbing to the client. You need not worry about external noise affecting the client, just give them an instruction to ignore it. The room where you work needs to be warm; cold is the one thing that will interfere with a client's ability to relax.
If possible, the client should be lying down. However, sitting in a comfortable chair is permissible. The Trainer should sit fairly near to the client. Tone of delivery should be fairly monotonous, as this helps to produce relaxation. Repetition of key words and phrases also helps to produce relaxation, as well as emphasising ideas of relaxation. Because it is almost certain that a client's attention will drift, it is useful to include this in the Relaxation exercise, so that the client will accept your suggestion that they can bring their attention easily back to the exercise.
When working with individual clients, the Trainer may match her own breathing with the client's and gradually slow down her breathing and her delivery. The client's breathing will begin to match the Trainer's and deeper relaxation will occur. Pauses in the delivery are very important, as it is during these pauses that clients drift deeper into relaxation. Quite long pauses should occur at points when you are asking clients to imagine a place or situation. However, a new client should be told that the exercise is not over until you actually say so. It is anxiety-provoking for clients if they are not sure whether or not a long pause is the end of the exercise or not, and this interferes with their ability to relax.
Images of moving downward are very useful for deepening the relaxation, and I use images of going down a hill, going down steps and going down an escalator to this end. Some clients, however will dislike some images, for example, lifts can be an unpopular image - possibly due to a fear of getting stuck in one. Deepening is a technique which we use once the client becomes familiar with relaxation and guided fantasy. Deepening helps the client to relax much more deeply. We use this technique in the exercise in Session Four. We begin with a Passive Progressive Muscular Relaxation and extend the, now familiar, exercise to include counting down in tens from one hundred, which will produce a deeper relaxation, and an image of time passing rapidly, which also produces a very deep relaxation.
Whether or not you have any physical contact with the client will depend on your own 'style' as a trainer. (Though in a brief therapy such as Stress Management Training I would generally advise against it). However, once the client has begun to relax, you should never touch them without warning, this, together with unexpected silence, can be disturbing to the client.
Some clients may suffer from jerking, muscle spasms and rapid blinking as they begin to let go of tension. They may feel strange, experience tingling, or go to sleep. If they do sleep, just wake them gently at the end of the Relaxation exercise. Holding on to tension is very tiring and clients dropping off to sleep is not uncommon when working with stressed individuals.
Occasionally, clients may feel in distress as they begin to relax. It may be possible to include what is happening in your script, but if not, just reassure the client that these feelings are normal and will soon pass. Sometimes clients will continue to feel sad after the exercise, as relaxation may have loosened rigid control over a situation of past pain. In this instance clients allow the feelings to occur because they are ready to let them go. Again, reassurance that the feeling will soon pass is necessary. On rare occasions clients may suffer a strong emotional reaction as they relax. In this case, reassure the client of your continued presence, and suggest they slowly discharge the distress within the session without any attempts at further exploration, unless you are qualified to undertake such work. Sometimes it is useful to get a distressed client to lie on their tummy for a short period, as this feels 'protected'. It may also be useful to do an awareness shifting exercise to bring a client out of distress. For example, ask their name, age, address, favourite colour, song, film etc. in order to distance them from painful feelings.
Although a closeness can develop between the Trainer and the client during stress management training, transference and counter-transference are less likely to occur, with the co-operative effort that is necessary between Trainer and client in this type of work, than in some therapies.
If you do decide to make your own CDs for clients, it is worthwhile practising the style of your delivery. When clients are taking a CD away to practise at home, it is useful if you can manage to inject 'empathy' into your voice. Deep relaxation always involves some degree of regression, and clients need to feel supported. Another way of providing support is to use the word 'good' often in your delivery, as though you were praising the client. It can also be very relaxing for the client if you are able to make your relaxation exercises include relaxing music.
Some of the techniques presented in this course are similar to techniques used in hypnotherapy. The main difference is in terms of the way we use Relaxation Training. Normally, the only suggestions we make to relaxed clients are those relating to feelings of relaxation and self-confidence. Hypnotherapy has a much wider agenda, involving suggestion and regression therapy which would be inappropriate in Stress Management Training, and unethical for unqualified practitioners to use.
Therapeutic Information Giving as a Treatment for Stress
It is important that clients understand how a build up of stress can cause problems, and that they are given as much information about their condition as possible. This is known as 'therapeutic information giving' and forms an important part of any treatment for stress and related conditions. If clients can understand stress in terms of the three interrelated systems of physiology (the physical changes they experience), cognition (their anxious thoughts) and their behaviour, this may be the first step in breaking the stress spiral.
We have seen how the physical symptoms of stress are caused by the activation of the Fight or Flight Syndrome: The heartbeat increases to pump blood carrying oxygen and nutrients to cells and clearing away waste. This causes the blood pressure to rise. Breathing becomes rapid and shallow. The liver releases stored sugar into the blood to meet increased need. The pupils dilate to let in more light. The other senses are more receptive. Muscles tense ready for movement. Blood flow to digestive organs and the hands and feet is constricted, but is increased to the brain and major muscles. The increased metabolism generates more heat, so sweating occurs.
Thus people may become pale, suffer palpitations, dizziness, breathlessness, tingling, cold hands and feet, nausea, diarrhoea, blurred vision, chest pains and muscular tension. Breathlessness and overbreathing may in turn result in an altered blood chemistry which gives rise to numbness, tingling and cramps. Panic attacks can result form catastrophic interpretations of these physical symptoms of stress, and this can contribute to the development of a phobic response, particularly agoraphobia. It is common for sufferers to believe that they are seriously ill, physically or mentally. This is the 'second fear', being additional to the 'first fear' of the symptoms themselves.
In order to allay clients' 'second fear' of illness and insanity, it is useful to describe the Fight or Flight Syndrome in relation to their individual symptoms of stress. A detailed explanation enables people not only to gain awareness of their condition, but also to develop a confidence that they will be able to cope effectively with the symptoms. Such findings are shared by many psychological treatments and are not special to stress management. Clients rating individual components of stress management training rated Information Giving as significantly higher than some other parts of the treatment.
Work Related Stress - Roger
Description of the Individual
Roger is in his late forties. He is divorced and has two children who live with his ex-wife. Roger sees little of his children and currently lives alone, though he has a girlfriend. Roger is employed as a Sales Executive, earns a good salary and has a comfortable lifestyle.
Nature of the Problem
Roger has difficulty in concentrating on his work which is suffering as a result. He has increasingly regular unbidden thoughts about 'how worthless' he feels he is, particularly these thoughts come when he is driving. This anxious thinking appears to be a result of Roger's high level of tension and low self-esteem rather than the development of an Obsessive-Compulsive Disorder (See Session Three). Since Roger's wife left him three years ago, he has begun to drink heavily.
Effects of the Problem - Lack of concentration - Work adversely affected - Poor work performance -Lowers self-esteem.
Low self-esteem - Anxious thoughts - Alcohol abuse - Panic Attacks -Fear of madness -Health at risk.
Past Attempts to work on the Problem
Roger has not seen his doctor about these difficulties and does not wish to. He is sceptical about Stress Management training, but willing to try it.
Duration of the Problem
Roger's poor concentration has been a problem for about nine months. His anxious thinking pattern developed about three months ago. However, the build up of stress appears to have begun five years ago when he was promoted to his present post, and may have contributed to the break-up of his marriage.
I made a contract with Roger to meet weekly for eight weeks.
Holmes and Rahe Scale
Roger scored 230 on the scale, which is high enough to put him at risk of developing a stress related illness. I talked to Roger about this but he did not see himself as at any such risk.
Subjective Level of Stress
Roger felt this to be 8 out of 10.
Three Things Contributing most to Stress at Present
1. Failure to achieve targets at work.
2. Lack of concentration.
3. Living alone.
Subjective measure of change
"To do my job properly again".
Coping with Stress - Score and Strengths and Weaknesses
Roger scored in the moderate range overall, with a good knowledge of stress, good assertiveness skills, a moderate ability to set and achieve goals, manage time and be decisive. Roger scored low on self-esteem, fitness and healthy habits.
Response to Therapeutic Information Giving
We discussed Roger's problems relating them to the build up of stress over the past five years, when worries at work may have led to the activation of the Fight or Flight Syndrome many times every day, resulting in a chronic stress response. I reassured him that his anxious thinking pattern was a common reaction to stress.
Response to Muscular Relaxation Training
Roger found the first Stress Management Relaxation Exercise on Passive Progressive Muscular Relaxation very difficult to do. He felt he could not find the time to practise. I told him if he didn't take the time to practise the Relaxation Exercises then he was wasting his time and money in coming to see me. At our next meeting he had mastered Passive Progressive Relaxation and begun to use it as a coping skill, helping him to relax while driving. Although Roger tried to learn Active Progressive Relaxation, he found it caused pain to his over-tensed muscles and I advised him to stick to the passive method.
Roger scored highly on this test, emerging as Type A at high risk of developing cardiac illness, I advised him of this and reminded him that his score on the Holmes and Rahe scale was also predictive of an illness risk. Roger was not inclined to take this seriously enough to make any changes.
Breaths per minute
Roger breathed 12 breaths per minute when tested, a low normal and healthy. score
Depression Questionnaire Score
Roger showed as suffering from mild depression, due, I felt, to his lonely living situation. I hoped that the depression would improve by the end of the Training.
Response to Deep breathing and Breath Control
Roger's breathing was in the normal range of six to ten breaths per minute. At first Roger felt little benefit from the Exercises, but after several weeks reported feeling calmer as a result of regular deep breathing and breathing techniques.
Response to 'triggers'
Roger's good response to deep breathing techniques was due to his use of 'triggers'.
Response to Cognitive Techniques
Roger was able to understand how the process of negative thinking was contributing to stress, and was able to use the Negative/Positive Mood Log to this end. Roger greatly benefited from using the STOP technique, and was able to use this to stop his negative thinking pattern.
Roger was not interested in making any changes to his diet or in beginning to take more exercise. He was, however, able to make a start on cutting down on his use of alcohol.
Subjective Level of Stress
This changed from 8 out of 10 in Session Two to 4 out of 10 in Session Eight.
Three Things Contributing most to Stress at Present
Roger now feels more able to achieve targets at work, and his concentration has improved. The things he feels contribute most to stress now are:
1. Living alone.
2. Not enough money.
3. Excessive alcohol.
Subjective Measure of Change
Achieved by Session Seven.
Client's Evaluation of the Training
Roger best liked cognitive techniques aimed at uncovering unconscious negative thinking patterns. He was very impressed with the simplicity and effectiveness of the STOP technique. Roger liked least any discussion on changes in diet and exercise.
Results of the Daily Relaxation Log
In Session Two Roger was reporting a level of tension at No. 8 on the scale of 1-8 before the Relaxation Exercise and of No. 4 on the scale after the Exercise. By Session Eight Roger was reporting a level of tension at No. 4 on the scale before the Relaxation Exercise and of No. 2 on the scale after the Exercise.
Results of the Breathing Log
In Sessions Four to Eight Roger reported breathing 8 breaths per minute before relaxing and 6 breaths per minute after relaxing.
After a slow start, Roger began to feel the benefit of the Training. We met for eight Sessions. By Session Seven he had achieved his Subjective Measure of Change, due largely to the improvement in his concentration brought about by muscular relaxation and deep breathing. Roger was able to use the STOP Technique to change his negative thinking patterns and his Subjective Level of Stress fell from 8 to 4. Roger was generally calmer, as can be seen by the results of the Daily Relaxation Log, and he seemed to be far less angry than at the outset. There seems to be little chance of major life-style changes, which means that his health continues to be at risk, but Roger seems more open to looking at other parts of his life that he might need to change.