# Presentation: 062965

## Less Stress Please......

**Richard Harvey, Ph.D****.**
**VA National Center for Health Promotion and Disease Prevention (NCP)**

**Notes:**
Today we will talk about stress- something we all feel from time to time and don’t really want to have much to do with.  We’ll go over a bit about the risks of excessive stress, treating excessive stress, and what to do about it personally.

## Stress is Risky

**Stress is the “Hidden” risk factor**

**Notes:**
Although we all know about risk factors for our health such as smoking, high blood pressure, obesity, sedentary lifestyle and so on, we don’t very often talk about stress in the same breath.  However, stress might be labeled “The hidden risk factor” for several reasons,   Even though it may be hidden, the fact remains that over time excessive stress adversely affects our health.

## Stress as a “hidden” risk factor

**It may or may not be an independent risk factor; may co-vary with smoking, unhealthy diet, sedentary lifestyle.**
**Stress is often associated with exacerbation of disease states rather than being the primary etiology.**

**Notes:**
We know that stress adversely affects health.  In some cases it may act as an independent risk factor and in others it may simply increase the effect of other risk factors.  It virtually all such situations it makes existing disease states worse.

## Stress as a “hidden” risk factor

**Patients don’t often complain about stress until it reaches crisis levels; it may be socially frowned upon and may imply personal weakness.**
**Physicians may not get as much training on stress as a risk factor as other behaviors.**

**Notes:**
So why is it a hidden risk factor?  For one thing, patients don’t often complain about it for a variety of reasons, but come in instead complaining of headaches, “nerves”, fatigue, depression, or other related maladies.  Studies have suggested that 60-70% of medical complaints in primary care settings may be related to stress in some way.  Also, stress as a medical condition is not typically emphasized in medical training to the same extent as other risk factors are.  There are reasons for that of course...

## Stress as a “hidden” risk factor

**Stress is transitory**
**Stress is not easily measured; it is “hidden” because you can’t see it**
**“****Objective” psychological assessment takes time**

**Notes:**
Stress is exceedingly difficult to pin down.  It comes and goes and because of that isn’t something easily diagnosed.  Although there are physiological indications such as cortisol levels, they too are transitory so that a lab test taken this morning may not reflect the stress felt yesterday.  It isn’t easy to measure and it can’t be seen, so the erroneous conclusion is that it doesn’t exist.  Or at least it gets ignored.  And treatment isn’t simple and many physicians don’t know what to do about it so they don’t want to deal with it as a health problem.  There are psychological tests available that are presumably “objective”, but they are all self-report and take time to administer, score, and interpret.  

## Treatment of Stress Problems

**Physical Methods:**
**	**
**Medications- antidepressants & anxiolytics**
**Relaxation training/Meditation/hypnosis**
**Exercise**
**Nutrition**
**Rest/sleep hygiene**
**Massage**

**Notes:**
But there are treatments.  Antidepressant and anxiolytic medications will often help.  Various forms of relaxation training and similar treatments have also been shown to provide substantial help.  We know that exercise is also effective in ameliorating mild to moderate depression and anxiety.  There are questions about the role of nutrition in stress, but eating a healthy diet will often give people a sense of greater energy, which can’t hurt, especially when a person is feeling helpless or too tired to deal with stressors.  Clearly, getting enough sleep contributes to a feeling of well-being, and energy to deal with the sources of stress.  Massage has, of course, been used for centuries to relieve the muscular tension that accompanies felt stress.

## Treatment of Stress Problems

**Cognitive Methods:**
**“****Cognitive restructuring”**
**Systematic desensitization**
**Stress innoculation **
**Flooding**

**Notes:**
Insofar as stress results from one’s interpretation of life events and conditions, cognitive interventions are known to be effective.  So called “cognitive restructuring” involves identifying stress-enhancing thoughts and substituting more positive, practical, and adaptive thoughts in their place.  Repeated practice with this technique results in the more positive thinking patterns prevailing.  People can also be desensitized to fearful stimuli, as occurs in phobias and other irrational fears, through a process of graded gradual cognitive exposure to the stressor(s).  Stress innoculation involves helping a person to reconceptualize  stressful events and  their reactions to those events in a more benign fashion , to learn new coping skills, and then to utilize those tools to effectively deal with situations that are less threatening at first, and then more threatening as confidence is gained.  Flooding is an uncomfortable process in which a person is cognitively exposed to a flood of highly stressful stimuli until the accommodation process occurs to the extent that they no longer react with maladaptive stress responses.

## Treatment of Stress Problems

**Behavioral skill training:**
**Assertive skills, social skills**
**Problem solving skills**
**Time management skills**
**Pleasuring skills**

**Notes:**
There are certain skills that help ameliorate or neutralize stress.  For dealing with stressors coming from interactions with other people, learning to communicate assertively and learning effective social skills are helpful interventions.  People often feel stressed because they feel helpless to deal with stressful situations.  It this case, certain skills at solving problems can be taught.  Stress related to time pressure often responds to improvements in time management skills.  And stress can be relieved with pleasurable experiences.  There are also skills involved with the experience of pleasure, and these can be taught.

## Treatment of Stress Problems

**Miscellaneous methods:**
**Arranging for getting some help with caretaking duties, financial problems, etc.**
**Changing one’s situation (e.g., leaving one’s job, divorce, getting away for a while, etc.)**

**Notes:**
Many times stress can be relieved by simpler actions such as getting some help with overly burdensome tasks, or just getting out of the stressful situation.

## STRESS - UGH!  Don’t Want it, Don’t Need it!

**Life is just too short for this.**
**“****God only gives us one thing, and that is time.....   It is how we spend that time, with whom we spend that time, and how we share that time that makes life worth living.”**
**“****Whatever you do, do it with a sense of joy...”**
**From the film “Dimensions”**

**Notes:**
So what shall we do about stress for ourselves?  Here are some thoughts that may help us think in a less stress-engendering way.  The ones in quotes come from a short film about living life to its fullest called “Dimensions” that was sponsored by a life insurance company.  These might be the kind of thoughts one would use to replace worrying or other forms of stress-engendering thinking.

## Five Critical Stress Skills

**Thought control skills**
**Relaxation Skills**
**Assertiveness skills**
**Pleasuring skills**
**Time management skills**

**Notes:**
As mentioned previously when we talked about treatment methods, here are some critical skill areas for stress control.  These address different facets of coping with stress.

## What Can We Do about Stress?

**“****KNOW THINE ENEMY!”**
**Monitor yourself with the **
**   “****Stress-o-meter”.   Be aware of your stress level on a scale of 1-10.**

**Notes:**
One problem people have is that they may not be consciously aware of how stressed they are, even though they are not feeling good.  Instead, they may be complaining frequently, feel exhausted, having headaches, difficulty sleeping, and so on.  A person can only do something about that which they are aware of.  One way to prompt awareness is to make your own “Stress-o-meter” by stopping to consider your stress level and rating it on  a scale from 1 to 10.   A numerical rating gives you some kind of anchor to objectify felt stress. Again, if you are aware of it you can then do something about it.

## What Can We Do about Stress? (Cont.)

**Take internal control of your thinking.  Get rid of ****“**_**Stinking**_** **_**Thinking**_**”!**
**Recognize that you always have a **_**choice**_** about what to think.  You are the only one that has control of your mind!**

**Notes:**
Perhaps a good first step is to get rid of our “stinking thinking”, that is, get rid of all the negative thoughts that lead to increased stress.  That involves recognizing that we actually do have control of what goes on in our head.  We can decide what we want to be thinking.

## What Can We Do about Stress? (Cont.)

**Identify your negative, exaggerated, over-reactive, unrealistic, and self-defeating thoughts.   Ask yourself “**_**Exactly**_** **_**WHAT**_** am I thinking?”.**
**Ask yourself “How realistic, sensible, accurate, and helpful are these thoughts?”.**

**Notes:**
In this process there are several questions to ask ourselves.  First, in order to identify the thoughts that increase our stress, we must stop for a moment and ask ourselves exactly what thoughts are going on in our mind.  Look for negative, over-reactive, unrealistic, self-defeating, and exaggerated thoughts.  And then, ask yourself honestly how sensible, accurate, and helpful these thoughts are.

## What Can We Do about Stress? (Cont.)

**Ask yourself “What evidence do I have for this thought?”**
**Ask yourself “Am I just making this up?”**
**Ask yourself “Is this thinking good for me?”**

**Notes:**
Also, what’s the evidence?  Is it real or am I making it up for some reason?  And perhaps most importantly, is this thinking good for me?

## What Can We Do about Stress? (Cont.)

**Recognize the error in your thinking.**
**Make yourself substitute sensible, realistic, accurate, and positive thoughts in their place.  Do this again and again, as often as needed!**

**Notes:**
The answers to these questions make us realize that our thinking is off, so what we must do is to banish those stressful thoughts in favor of more sensible, realistic, accurate, positive, constructive, and adpative thoughts.  We can start this by thinking of a counteractive thought- one that contradicts the negative one.  For example, instead of thinking “I can’t do anything right anymore”, think “Actually, I’m just like everybody else.  I have my strengths and my weaknesses.  The reality is that I’m not right all the time but I’m not wrong all the time either”.  The key here is to keep doing this until the habit of negative thinking is essentially gone.  Negative thinking is a habit, and can be changed just like other habits.

## Examples of sensible, positive thoughts

**“****If I allow myself to feel stressed, its **_**ME**_** who suffers!  So hey, drop it....”**
**“****I don’t have to like everything that happens- I just have to get through it.   I can get through this.”**

**Notes:**
Here are some example of sensible, constructive thoughts we can use in place of “stinking thinking”.

## Examples of sensible, positive thoughts

**“****I am going to keep my dignity...., not make a fool of myself”.**
**“****Nobody promised that life would be fair”.**
**“****I CHOOSE to live each day to the fullest and enjoy that day”.**

**Notes:**
Here are some more...

## Examples of sensible, positive thoughts

**“****I CANNOT CONTROL other people’s behavior!  I just have to deal with my own reactions...”**
**“****My life is too short for this”.**
**Think The Serenity Prayer.**

**Notes:**
And more.  Note particularly the one about our having virtually no control over other people.  The fact is, we don’t.  People more or less do whatever they want.  Even though we may think we can control our kids or our spouse, that’s really a fallacy.  In the end they do whatever they personally choose to do.  Our job is to control our reaction to others’ behavior.  And most of you know the Serenity Prayer about accepting the things you can’t change, having the courage to change the things you can, and the wisdom to know the difference.

## What Can We Do about Stress? (Cont.)

**Instead of beating yourself about mistakes, vow to **_**learn **_**from them.**
**Believe that “life is what I make it”.**
**Act accordingly.**

**Notes:**
Here are some other things that relate to our thinking.  Vowing to learn from our mistakes moves us along into the future rather than wallowing in the past.  And indeed, we make our own bed so to speak, and can turn that to our advantage by realizing that we are in control of our well-being, and acting accordingly.

## What Can We Do about Stress? (Cont.)

**Do not “SHOULD” on yourself, or others.**
**Avoid “Awfulizing”.**
**Strive to have a positive optimistic attitude!**

**Notes:**
Thinking that “I should do that”, “I shouldn’t have done that”, or “He/she/they should (or shouldn’t) do such and such” leads us right into negative thinking and feeling stressed and pressured.  “Should” amounts to a guilting operation, and “should-ing” on others just begets anger and resentment.  The better rule is to just do your best, don’t stress over others’ actions, learn from mistakes, and move forward.  “Awfulizing”  refers to our tendency to always think the worst.  For example, if the boss criticizes something you did, you may start thinking that you are going to get fired for sure, default on your mortgage and lose your home and car, your spouse will divorce you and take the kids since you have no income... you get the picture.  And strive to be positive at all times!

## What Can We Do about Stress? (Cont.)

**Use “Calming Thoughts”.  E.G., “I am at peace with myself and the world around me”, or “My mind is quiet and still”.**
**Use “Self-Instructions” like “Slow down, just relax”, “breathe slowly”, or “Just forget it”.**

**Notes:**
Here are some thinking things you can do to mentally and physically relax.

## What Can We Do about Stress? (Cont.)

**Use “Mental Rehearsal”.**
**Find things to laugh about.  Be with people who laugh!   Read humorous books, rent funny videos....”laughter is the best medicine”.**

**Notes:**
Rehearsing things mentally before you have to do them is an effective practice to reduce the stress associated with various kinds of performance.  For example, you can rehearse how you want to say something, how you want to appear, how you want to act, and how you intend to feel.  And laughter- it is so good!  Need I say more?

## What Can We Do about Stress? (Cont.)

_**EXERCISE**_**!   **_**EXERCISE**_**!  **_**EXERCISE**_**!**
**Get enough rest....**
**Eat a healthy low fat, high fiber diet.**
**Have someone give you a massage.**

**Notes:**
We mentioned these before with regard to treatments, but they apply to us too.  Exercise stimulates the release of endorphins- those natural substances that make us feel really good.  Exercise also relaxes the muscles and relieves tension. It is a good thing.  So is sleep, a healthy diet, and massage.  

## What Can We Do about Stress? (Cont.)

**Take a hot bath or shower when feeling stressed.**
**Take a few slow, deep breaths.**
**“****Put on a happy face”  “Fake it ‘til you make it!”**

**Notes:**
A hot bath or shower reduces blood pressure, relieves tense muscles, and relieves stress.   We may not often think of a hot bath as a stress reduction tool, but it is.  An easy stress reducer is to take a few slow deep breaths using abdominal breathing, that is, breathing in which your stomach protrudes when you inhale.  This technique works quite well and can be done almost anywhere.  And even though it seems counterintuitive, just making yourself act happy and relaxed even though you aren’t will start to make that happy and relaxed feeling come to be.  There isn’t much research to date on that one, but it does work.

## What Can We Do about Stress? (Cont.)

**Escape from stressful situations for a while.  Take a break!**
**Have some quiet time for yourself each day.**
**Learn the relaxation response and practice it daily.**

**Notes:**
One obvious way to reduce stress is to just get away from it!  That may involve a momentary break such as stretching at your desk or taking a bathroom break, or a temporary getaway such as a day or two off of work or a vacation.  Alternatively, it may be that getting out of a bad relationship, stressful living situation, or stressful job is necessary.  Assuredly, doing things like that have their own associated stressors, but may be the better choice overall in some situations.  Of course, making some quiet time each day or even several times each day is intuitively relaxing.  We can also learn the “relaxation response”, which is a state of deep bodily relaxation.  It is an extremely pleasant state, and we know that doing a daily relaxation session reduces stress and appears to have some health benefits as well.  There are relaxation recordings available at most bookstores and on the web.

## What Can We Do about Stress? (Cont.)

**Act assertively.  Speak your mind- respectfully, with your thoughts, feelings, ideas, beliefs, needs, and wants.**
**   **
**Talk with someone you respect about your worries and concerns- do not hold all that inside.**

**Notes:**
Communication skills help us deal with stressful interactions with other people.  Assertive skills can be very effective in situations involving people close to us, people in consumer circumstances, in job situations, and so on.  There are books on assertive skills available, and occasional courses offered.  Another age old technique for reducing stress is to talk your concerns and problems over with someone you respect.  Or sometimes, expressing those thoughts to a stranger relieves some of the pressure, and may be an opportunity to receive an objective opinion.

## What Can We Do about Stress? (Cont.)

**Make SURE you plan time to do things you enjoy.   Have a “passion”.   Put lots of **_**PLEASURE**_** into your daily life!**
**Plan pleasurable experiences.**
**Become acutely aware of numerous small daily pleasures.  “Stop & smell the roses”.**

**Notes:**
We mentioned pleasure before as well.  When people feel too stressed, many times they forget to “lighten up” by putting some pleasure in their daily or even weekly life.  There are two aspects to this.  One is to make actual plans for pleasurable experiences.  Examples might include going out for a special meal, going fishing, going to a movie, visiting friends or loved ones, going bowling, working on a hobby, and so on.  But one can only do those things every so often.  An often overlooked source of pleasure are those things one encounters every day.  A hot shower, a nice meal, a pleasant drive, sleep, a nice stretch, seeing beautiful flowers, trees, parks and the like, having a pleasant conversation with someone, and so on.  The list is endless.  The trick is stopping long enough to make oneself acutely aware of the pleasure inherent in each of those experiences rather than rushing blindly through the day.  It just requires reminding yourself to do that and noting that “this is really pleasurable!”

## What Can We Do about Stress? (Cont.)

**Listen to music.**
**Write out what you are thinking and feeling.   Make a “stress diary”.**
**Pray, if that helps you feel relief.**

**Notes:**
Music “soothes the savage beast” for many people, although perhaps not for others.  Making an effort to include music in one’s environment may help reduce some of the stress.  Another technique which has been researched for effectiveness is actually writing down all the thoughts and feelings associated with either a particular event, person, or situation, or more generally about one’s overall situation.  Sometimes writing a letter to someone who is a source of stress is therapeutic, but in most situations, DON”T MAIL IT!  And of course prayer has been used for centuries for comfort.

## What Can We Do about Stress? (Cont.)

**Write out a daily priority list of things you want/need to do.**
**Write out a plan each day for your time.**
**Plan ahead to avoid stress about being late by allowing more time than you expect to need.**

**Notes:**
These are techniques for better management of one’s time.  (Go over each one, using common examples)

## What Can We Do about Stress? (Cont.)

**Break big tasks into little ones.**
**Get started with stuff!  Do not procrastinate and let things pile up on you..**

**Notes:**
People get stressed when facing a big job, a major undertaking, or something that seems endless.  The appropriate strategy in these situations is to break the task down into small manageable parts, and then just get started!  And the get started rule applies to any situation in which there is lots to do.  Once started, the stress often seems to just melt away!

## Is There More We can Do about Reducing Stress?

**YES...**

**Notes:**
There is more...

## The Relaxation Response

**Notes:**
We have mentioned the relaxation response before, and it is an important aspect of stress management. 

## The Relaxation Response

**Has no doubt been a part of human experience since the beginning of time.**
**Was first written about by Dr. Edmund Jacobson in 1938 ****(Jacobson, Progressive Relaxation, 1938)**
**Was popularized through research and writing by Dr. Herbert Benson from Harvard in 1976 ****(Benson, The Relaxation Response, 1976)**** **

**Notes:**
Relaxation is a very basic physiological phenomenon, so ways to produce that state have no doubt been practiced for centuries.  But Dr Edmund Jacobson first called attention to it in modern times in his 1938 book about the topic, and more recently, Dr. Hebert Benson has written extensively about it and made it a popular topic.

## The Relaxation Response

**The “relaxation response” is very simply a state of reduced autonomic (sympathetic) arousal.**
**Blood pressure, heart rate, muscle tension, etc. all attenuate during relaxation.**

**Notes:**
The relaxation response is a state of reduced physiological arousal in which the parasympathetic nervous system predominates.  All our activation responses attenuate during relaxation.  And it feels good!

## The Relaxation Response

**It is probably a useful technique for dealing with all stress-mediated physiological and psychological problems.**
**Among those problems where relaxation has been shown to have effectiveness are:**

**Notes:**
The effectiveness of “relaxation therapy” has been researched quite extensively and found to be helpful with the stress component of many problems.  

## The Relaxation Response

**Tension headache**
**Migraine headache**
**Mild hypertension**
**Insomnia**

**Notes:**
Here are some of the maladies for which relaxation training (along with regular daily practice) has been found to be beneficial. 

## The Relaxation Response

**Chronic pain**
**Irritable bowel syndrome**
**Performance anxiety**
**Other anxiety disorders**
**(From Goldberger & Brenitz, Handbook of Stress, 1993)**

**Notes:**
Here are others.  So indeed, it is a helpful thing to learn and practice daily.

## Various Methods to Induce Relaxation

**Progressive muscle relaxation**
**Biofeedback, of various sorts**
**Hypnosis**
**Yoga**
**Meditation**

**Notes:**
There are several ways to induce relaxation, the most common of which is probably so-called progressive muscle relaxation.  This involves alternately tensing and relaxing various muscles until the entire body is relaxed.  It is often combined with soothing words, images, and perhaps sounds as well.  Biofeedback utilizes sensors that measure muscle tension and provide feedback so that the person can do whatever it is that makes their muscle tension decrease.  Hypnosis is very similar to the progressive muscle relaxation procedure, but is done entirely mentally.  Yoga is known to relax the body, as are various meditation techniques.

## Let’s Relax

**So now.....**
**Sit back, get comfortable, let go.....**
**And ***** ******RELAX.......***

**Notes:**
So now let’s experience relaxation for ourselves.  We will do a brief relaxation exercise for your enjoyment.  (Conduct a relaxation exercise either yourself, or using a recording.  One available recording is on the NCP internet website www.prevention.va.gov under the Wellness Toolkit.  The same recording is also available on the NCP VA intranet website under the Wellness Toolkit.) 

## That is All

**Go in Peace...**