Coping With Stress What is Coping

5 COPING WITH AND REDUCING STRESS Coping With Stress What is Coping? Functions and Methods of Coping

Reducing the Potential for Stress Enhancing Social Support Improving One’s Personal Control Organizing One’s World Better Exercising: Links to Stress and Health Preparing for Stressful Events

Reducing Stress Reactions: Stress Management Medication Behavioral and Cognitive Methods Massage, Meditation, and Hypnosis

Using Stress Management to Reduce Coronary Risk Modifying Type A Behavior Treating Hypertension

PROLOGUE One morning while taking a shower before going to psychology class, Cicely felt a small lump in her breast. She was sure it had not been there before. It didn’t hurt, but she was momentarily alarmed—her mother had had breast cancer a few years before. ‘‘It could be a

pimple or some other benign growth,’’ she thought. Still, it was very worrisome. She decided not to consult her physician about it yet because as she thought, ‘‘it may not be anything.’’ Over the next several days, she anxiously examined the lump daily. This was a very stressful time for her, and she slept poorly. After a week without the lump changing, she decided to take action and see her physician.

Another young woman, Beth, had a similar experi- ence. Finding a lump on her breast alarmed her, but she didn’t deal with the stress as rationally as Cicely did. Beth’s initial fright led her to reexamine her breast just once, and in a cursory way. She told herself, ‘‘There isn’t really a lump on my breast, it’s just a rough spot,’’ and convinced herself that she should not touch it because, she thought, ‘‘That will only make it worse.’’ During the next few months, Beth worried often about the ‘‘rough spot’’ and avoided touching it, even while washing. She became increasingly moody, slept poorly, and developed many more headaches than usual. Beth finally men- tioned the ‘‘rough spot’’ to a friend who convinced her to have her physician examine it.

People vary in the ways they deal with stress. Sometimes people confront a problem directly and rationally, as Cicely did, and sometimes they do not. For these two women, the way they dealt with their stress had the potential for affecting their health. Because Beth did not face up to the reality of the lump, she delayed seeking medical attention and experienced high levels

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Chapter 5 / Coping With and Reducing Stress 111

of stress for a long time. If the lump were malignant, delaying treatment would allow the cancer to progress and spread. As we have seen, prolonged stress can have adverse health effects even in healthy people.

In this chapter we discuss the ways people can and do deal with stress. Through this discussion, you will find answers to questions you may have about the methods people use in handling stress. Are some methods for coping with stress more effective than others? How can people reduce the potential for stress in their lives? When people encounter a stressor, how can they reduce the strain it produces?


Individuals of all ages experience stress and try to deal with it. During childhood years, people learn ways to manage feelings of stress that arise from the many fearful situations they experience (Sarafino, 1986). For instance, psychologist Lois Murphy (1974, p. 76) has described the progress and setbacks a 4-year-old named Molly had made in dealing with the terror she felt during thunderstorms. In her last steps at gaining control over her fear, she experienced two storms a few months apart. During the first storm, she awoke and didn’t cry, ‘‘but I just snuggled in my bed,’’ she said later. In the second storm, she showed no outward fear and comforted her frightened brother, saying, ‘‘I remember when I was a little baby and I was scared of thunder and I used to cry and cry every time it thundered.’’ Like most children, Molly became better able to cope with the stress of storms as she grew older. What’s more, in the last steps of her progress she showed pride in having mastered her fear.

WHAT IS COPING? Because the emotional and physical strain that accom- panies stress is uncomfortable, people are motivated to do things to reduce their stress. These ‘‘things’’ are what is involved in coping.

What is coping? Several definitions of coping exist (Lazarus & Folkman, 1984). We’ll use a definition based on how we defined stress in Chapter 3, when we saw that stress involves a perceived discrepancy between the demands of the situation and the resources of the person. Coping is the process by which people try to manage the perceived discrepancy between the demands and resources they appraise in a stressful situation. Notice the word manage in this definition. It indicates that coping efforts can be quite varied and do not necessarily lead to a solution of the problem. Although coping efforts can be

aimed at correcting or mastering the problem, they may also simply help the person alter his or her perception of a discrepancy, tolerate or accept the harm or threat, or escape or avoid the situation (Lazarus & Folkman, 1984; Carver & Connor-Smith, 2010). For example, a child who faces a stressful exam in school might cope by feeling nauseated and staying home.

We cope with stress through our cognitive and behavioral transactions with the environment. Suppose you are overweight and smoke cigarettes, and your physician has asked you to lose weight and stop smoking because several factors place you at very high risk for developing heart disease. This presents a threat—you may become disabled or die—and is stressful, especially if you don’t think you can change your behavior. How might you cope with this? Some people would cope by seeking information about ways to improve their ability to change. Other people would simply find another doctor who is not so directive. Others would attribute their health to fate or ‘‘the will of God,’’ and leave the problem ‘‘in His hands.’’ Still others would try to deaden this and other worries with alcohol, which would add to the risk. People use many different methods to try to manage the appraised discrepancy between the demands of the situation and their resources.

The coping process is not a single event. Because coping involves continuous transactions with the envi- ronment, the process is best viewed as a dynamic series of appraisals and reappraisals that adjust to shifts in person–environment relationships. And so, in coping with the threat of serious illness, people who try to change their lifestyles may receive encouragement and better relationships with their physician and family. But individuals who ignore the problem are likely to expe- rience worse and worse health and relations with these people. Each shift in one direction or the other is affected by the transactions that preceded it and affects subse- quent transactions (Lazarus & Folkman, 1984).

FUNCTIONS AND METHODS OF COPING You have probably realized by now that people have many ways for coping with stress. Because of this, researchers have attempted to organize coping approaches on the basis of their functions and the methods they employ. (Go to .)

Functions of Coping According to Richard Lazarus and his colleagues, coping can serve two main functions (Lazarus, 1999; Lazarus & Folkman, 1984). It can alter the problem causing the stress or it can regulate the emotional response to the problem.

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112 Part II / Stress, Illness, and Coping


Your Focuses in Coping Think about a very stressful personal

crisis or life event you experienced in the last year—the more recent and stressful the event, the better for this exercise. How did you handle this situation and your stress? Some of the ways people handle stressful experiences are listed below. Mark an ‘‘X’’ in the space preceding each one you used.

Tried to see a positive side to it Tried to step back from the situation and be more objective Prayed for guidance or strength Sometimes took it out on other people when I felt angry or depressed Got busy with other things to keep my mind off the problem Decided not to worry about it because I figured everything would work out fine Took things one step at a time

Read relevant material for solutions and considered several alternatives Drew on my knowledge because I had a similar experience before Talked to a friend or relative to get advice on handling the problem Talked with a professional person (e.g., doctor, clergy, lawyer, teacher, counselor) about ways to improve the situation Took some action to improve the situation

Of the first six ways listed, count how many you marked; these are examples of ‘‘emotion-focused’’ ways. How many of the second six—‘‘problem-focused’’—ways did you mark? When you read the upcoming text material entitled Functions of Coping, answer these questions: Did you use mostly emotion- or problem- focused methods? Why, and what functions did your methods serve? (Based on material in Billings & Moos, 1981.)

Emotion-focused coping is aimed at controlling the emotional response to the stressful situation. People can regulate their emotional responses through behavioral and cognitive approaches. Examples of behavioral approaches include using alcohol or drugs, seeking emotional social support from friends or relatives, and engaging in activities, such as sports or watching TV, which distract attention from the problem. Cognitive approaches involve how people think about the stressful situation. In one cognitive approach, people redefine the situation to put a good face on it, such as by noting that things could be worse, making comparisons with individuals who are less well off, or seeing something good growing out of the problem. We can see this approach in two statements of women with breast cancer (Taylor, 1983):

What you do is put things into perspective. You find out that things like relationships are really the most important things you have—the people you know and your family—everything else is just way down the line. It’s very strange that it takes something so serious to make you realize that. (p. 1163)

The people I really feel sorry for are these young gals. To lose a breast when you’re so young must be awful. I’m 73; what do I need a breast for? (p. 1166)

People who want to redefine a stressful situation can generally find a way to do it since there is almost always

some aspect of one’s life that can be viewed positively (Taylor, 1983).

Other emotion-focused cognitive processes include strategies Freud called ‘‘defense mechanisms,’’ which involve distorting memory or reality in some way (Cramer, 2000). For instance, when something is too painful to face, the person may deny that it exists, as Beth did with the lump on her breast. This defense mechanism is called denial. In medical situations, individuals who are diagnosed with terminal diseases often use this strategy and refuse to believe they are really ill. This is one way by which people cope by using avoidance strategies. But strategies that promote avoidance of the problem are helpful mainly in the short run, such as during an early stage of a prolonged stress experience (Suls & Fletcher, 1985). This is so for individuals who are diagnosed with a serious illness, for instance. As a rule of thumb, the effectiveness of avoidance-promoting methods seems to be limited to the first couple of weeks of a prolonged stress experience. Thereafter, coping is better served by giving the situation attention.

People tend to use emotion-focused approaches when they believe they can do little to change the stressful conditions (Lazarus & Folkman, 1984). An example of this is when a loved one dies—in this situation, people often seek emotional support and distract themselves with funeral arrangements and

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Chapter 5 / Coping With and Reducing Stress 113

chores at home or at work. Other examples can be seen in situations in which individuals believe their resources are not and cannot be adequate to meet the demands of the stressor. A child who tries very hard to be the ‘‘straight A’’ student his or her parents seem to want, but never succeeds, may reappraise the situation and decide, ‘‘I don’t need their love.’’ Coping methods that focus on emotions are important because they sometimes interfere with getting medical treatment or involve unhealthful behaviors, such as using cigarettes, alcohol, and drugs to reduce tension. People often use these substances in their efforts toward emotion-focused coping (Wills, 1986).

Problem-focused coping is aimed at reducing the demands of a stressful situation or expanding the resources to deal with it. Everyday life provides many examples of problem-focused coping, including quitting a stressful job, negotiating an extension for paying some bills, devising a new schedule for studying (and sticking to it), choosing a different career to pursue, seeking medical or psychological treatment, and learning new skills. People tend to use problem-focused approaches when they believe their resources or the demands of the situation are changeable (Lazarus & Folkman, 1984). For example, caregivers of terminally ill patients use problem-focused coping more in the months prior to the death than during bereavement (Moskowitz et al., 1996).

To what extent do people use problem-focused and emotion-focused approaches in coping with stress in their lives? Andrew Billings and Rudolf Moos (1981) studied this issue by having nearly 200 married couples fill out a survey. The respondents described a recent personal crisis or negative life event that happened to them and then answered questions that were very similar to the ones you answered in the self-assessment exercise. The outcomes of this research revealed some interesting relationships. Both the husbands and the wives used more problem-focused than emotion-focused methods to cope with the stressful event. But the wives reported using more emotion-focused approaches than the husbands did. People with higher incomes and educational levels reported greater use of problem- focused coping than those with less income and education. Last, individuals used much less problem- focused coping when the stress involved a death in the family than when it involved other kinds of problems, such as illness or economic difficulties.

Can problem-focused and emotion-focused coping be used together? Yes, and they often are. For instance, a study had patients with painful arthritis keep track of their daily use of problem- and emotion-focused coping (Tennen et al., 2000). Most often, they used the two types of coping together; but when they used only one

Sometimes people don’t cope effectively with stress. Reprinted courtesy of Bunny Hoest.

type, three-quarters of the time it was problem-focused coping. We can see an example of both types of coping in a man’s experience when a coworker accused him of not sending out the appropriate letters for a job. In describing how he reacted to this stressful situation, he said he first confirmed that the coworker’s accusation

was not true, that everything [letters] had gone out. There’s always a chance you might be wrong so I checked first. Then I told him. No, everything had gone out. My immediate reaction was to call him on the carpet first. He doesn’t have any right to call me on something like this. Then I gave it a second thought and decided that that wouldn’t help the situation. (Kahn et al., cited in Lazarus & Folkman, 1984, p. 155)

This example shows problem-focused coping in confirm- ing that the letters had gone out, and emotion-focused coping in controlling his angry impulse ‘‘to call him on the carpet.’’

Coping Methods and Measurement What specific methods—that is, skills and stra- tegies—can people apply in stressful situations to alter the problem or regulate their emotional response? Researchers have described about 400 methods and incorporated sets of them into dozens of instruments to assess overall coping and categories of coping types

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114 Part II / Stress, Illness, and Coping

Table 5.1 Methods of Coping with Stressful Situations (listed alphabetically) Assistance seekingp Hiding feelingse Positive reappraisale

Avoidancee Humore Prayinge

Confrontive assertionp Increased activitye Resigned acceptancee

Deniale Information seekingp Seeking meaninge

Direct actionp Intrusive thoughtse Self-criticisme

Discharge (venting)e Logical analysisp Substance usee

Distraction (diverting attention)e Physical exercisee Wishful thinkinge

Emotional approache Planful problem solvingp Worrye

Note: Superscripted letters refer to the method’s most likely function, p = problem-focused and e = emotion-focused coping, but some methods may serve either function. Source: Skinner et al., 2003, Table 3.

(Skinner et al., 2003). Table 5.1 lists two dozen coping methods that are easy to conceptualize, without stating definitions, to give you a sense of the great variety of possible methods people can use.

Unfortunately, instruments to measure coping haven’t been very useful so far. They were typically developed with the expectation that the scores would predict mental or physical health, but they don’t (Coyne & Racioppo, 2000; Skinner et al., 2003). And they don’t seem to be very accurate in measuring people’s cop- ing. Most measures of coping are retrospective, asking respondents about the methods used in the past week, month, or more. Do you remember exactly how you coped 2 weeks ago with a stressful event, such as a poor grade on a test or an argument with a close friend? A study tested the accuracy issue by having people report daily for a month on the coping strategies they used with the most negative event that occurred that day (Todd et al., 2004). The subjects used a list with descriptions of 16 strategies that comprise a widely used coping survey for the daily reports; at the end of the study they filled out the survey to report on the whole month. Comparisons of daily and full-month reports showed weak correspon- dence for about half of the coping methods, suggesting that assessments of coping pertaining to more than the past week or so are inaccurate for many methods.

Researchers are currently working to identify the coping methods that are most important—those that can be measured accurately and are related to psychological and health outcomes, such as people’s development of and recovery from illnesses. Let’s look at some directions that look promising (Folkman & Moskowitz, 2004; Carver & Connor-Smith, 2010).

1. Engaging positive emotions. One approach for coping with stress involves the use of positive emotions to soften or balance against feelings of distress. For instance, Susan Folkman (1997; Folkman & Moskowitz, 2004) has found that individuals who were caring for a dying spouse or partner and then lost that person report both positive and negative emotions occurring

together during times of great stress. As an example, a gay man described the difficulty of tending for his partner during the extreme sweating episodes he, like many AIDS patients, had many times each day and noted that he feels ‘‘proud, pleased that I can comfort him … . We are still making our love for each other the focal point’’ (Folkman, 1997, p. 1213).

2. Finding benefits or meaning. People who are trying to cope with severe stress often search for benefits or meaning in the experience, using beliefs, values, and goals to give it a positive significance (Folkman, 1997; Sears, Stanton, & Danoff-Burg, 2003). They find benefits or meaning in many ways, such as

when people whose loved ones have died from a disease become advocates for research on that disease; finding that new or closer bonds with others have been formed because of having experienced or survived a natural disaster together; or finding that the event has clarified which goals or priorities are important and which are not (Folkman, 1997, p. 1215).

A meta-analysis of over 80 studies found partial support for a role of benefit finding in coping: it was associated with less depression and greater feelings of well-being, but was not related to anxiety and self-reports of physical health (Helgeson, Reynolds, & Tomich, 2006).

3. Engaging in emotional approach. In emotional approach, people cope with stress by actively processing and expressing their feelings (Stanton et al., 2000). To assess emotional approach, people rate how often they engage emotional processing (in such activities as, ‘‘I take time to figure out what I’m really feeling’’ and ‘‘I delve into my feelings to get a thorough understanding of them’’) and emotional expression (‘‘I take time to express my emotions’’). Emotional approach probably includes the method of disclosure of negative experiences and feelings we discussed in Chapter 4 as a way of reducing stress and enhancing health.

4. Accommodating to a stressor. Another way to cope is to adapt or adjust to the presence of the stressor and

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Chapter 5 / Coping With and Reducing Stress 115

carry on with life (Carver & Connor-Smith, 2010, Morling & Evered, 2006). For instance, people with chronic pain conditions may come to accept that the pain is present and engage in everyday activities as best as they can.

Research has found psychological and health ben- efits for each of these of coping methods (Folkman & Moskowitz, 2004). For example, researchers tested women with breast cancer for emotional approach soon after medical treatment and for psychological and health status 3 months later (Stanton et al., 2000). They found that high levels of emotional expression were associated with improved self-perceived health, increased vigor, fewer medical visits for cancer-related problems, and decreased distress. But high levels of emotional process- ing were linked with increased distress. It may be that emotional processing includes or leads to rumination, in which people have intrusive thoughts and images that per- petuate their stress (Baum, 1990). For example, people may think repeatedly about how they or others are to blame for their problems or have ‘‘flashbacks’’ of painful or angry events. People who often ruminate take longer for their blood pressure to decrease after starting to think about arousing events and report having poorer health habits and health than individuals who seldom have such thoughts (Gerin et al., 2006; Nowack, 1989).

Using and Developing Methods of Coping No single method of coping is uniformly applied or effective with all stressful situations (Ilfeld, 1980; Pearlin & Schooler, 1978). Four issues about people’s patterns in using different coping methods should be mentioned. First, people tend to be consistent in the way they cope with a particular type of stressor—that is, when faced with the same problem, they tend to use the same methods they used in the past (Stone & Neale, 1984). Second, people seldom use just one method to cope with a stressor. Their efforts typically involve a combination of problem- and emotion-focused strategies (Tennen et al., 2000). Third, the methods people use in coping with short-term stressors may be different from those they use under long-term stress, such as from a serious chronic illness (Aldwin & Brustrom, 1997). Fourth, although the methods people use to cope with stress develop from the transactions they have in their lives, a genetic influence is suggested by the finding that identical twins are more similar than fraternal twins in the coping styles they use (Busjahn et al., 1999).

Psychologists assume that coping processes change across the life span. But the nature of these changes is unclear because there is little research, espe- cially longitudinal studies, charting these changes

(Aldwin & Brustrom, 1997; Lazarus & Folkman, 1984). Some aspects of the changes in coping that occur in the early years are known. Infants and toddlers being examined by their pediatricians are likely to cope by try- ing to stop the examination (Hyson, 1983). We saw earlier in the case of Molly that young children develop coping skills that enable them to overcome many of their fears, making use of her expanding cognitive abilities. Over the next several years, children come to rely increasingly on cognitive strategies for coping (Brown et al., 1986; Miller & Green, 1984). So, for example, they learn to think about something else to distract themselves from stress. More and more, they regulate their feelings with emotion-focused methods, such as playing with toys or watching TV, especially when they can’t do anything to solve the problem, such as a serious illness in their parents (Compas et al., 1996).

Few studies have examined changes in methods of coping from adolescence to old age. One study used interviews and questionnaires to compare the daily hassles and coping methods of middle-aged and elderly men and women (Folkman et al., 1987). The middle- aged individuals used more problem-focused coping, whereas the elderly people used more emotion-focused approaches. Why do adults use less problem-focused and more emotion-focused coping as they get older? These changes probably result at least in part from differences in what people must cope with as they age. The elderly individuals in this study were retired from full- time work and reported more stress relating to health than did the middle-aged people did, who reported more stress relating to work, finances, and family and friends. The stressors encountered in middle age are more changeable than those in old age. But the age groups also differed in outlook: regardless of the source of stress, the elderly people appraised their problems as less changeable than the middle-aged individuals did. As we saw earlier, people tend to use problem- focused approaches when they believe the situation is changeable, and rely on emotion-focused coping when they do not.

Because most adults are married or partnered, adults’ coping strategies usually operate and develop jointly as a system, with each member’s coping processes being shared by and influencing the other’s (Berg & Upchurch, 2007). This sharing and social influence in coping may be clearest when a couple copes with long- term major stressors, such the diagnosis, treatment, and future course of a life-threatening or disabling illness in one or both of them. Their psychological adjustment to the stressors will depend on the type of illness, whether their joint coping strategies are effective, and the quality of their relationship.

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116 Part II / Stress, Illness, and Coping

Gender and Sociocultural Differences in Coping Studies of gender differences in coping have generally found that men are more likely to report using problem- focused strategies and women are more likely to report using emotion-focused strategies in dealing with stress- ful events (Marco, 2004). But when the men and women are similar in occupation and education, no gender differences are found (Greenglass & Noguchi, 1996). These results suggest that societal sex roles play an important role in the coping patterns of men and women.

Billings and Moos (1981) found that people with higher incomes and educational levels report greater use of problem-focused coping than those with less income and education. This finding suggests that the social experiences of disadvantaged people lead many of them to believe they have little control over events in their lives. In general, disadvantaged individuals—a category that typically includes disproportionately more minority group members—are more likely to experience stressful events and less likely to cope with them effectively than other people are (Marco, 2004). Thus, people in Asian cultures and African- and Hispanic-Americans tend to use more emotion-focused and less problem-focused coping than White Americans do.

We have examined many ways people cope with stress. Each method can be effective and adaptive for the individual if it neutralizes the current stressor and does not increase the likelihood of future stressful situations.

In the next section, we consider how people can reduce the potential for stress for themselves and for others.


Can people become ‘‘immune’’ to the impact of stress to some extent? Some aspects of people’s lives can reduce the potential for stressors to develop and help individuals cope with problems when they occur. Efforts taken that prevent or minimize stress are called proactive coping, and they typically use problem-focused methods (Carver & Connor-Smith, 2010). We will look at several

proactive coping methods. (Go to .)

ENHANCING SOCIAL SUPPORT We have all turned to others for help and comfort when under stress at some time in our lives. If you have ever had to endure troubled times on your own, you know how important social support can be. But social support is not only helpful after stressors appear, it also can help avert problems in the first place. Consider, for example, the tangible support newlyweds receive, such as items they will need to set up a household. Without these items, the couple would be saddled either with the financial burden of buying the items or with the hassles of not having them.


Does Religiousness Reduce Stress and Enhance Health?

Here’s an intriguing finding: religiousness—that is, people’s personal involvement in a religion—is associated with lower anxiety and depression, better physical health, and longer life (Chida, Steptoe, & Powell, 2009; Mas- ters, 2004). Some reasons for this link have been proposed—for instance, some religions promote healthy lifestyles, such as by preaching against smoking, and religious meetings provide social contact and support. To the extent that these processes happen, they are likely to reduce stress and enhance health. But keep in mind three issues. First, some people are involved in a reli- gion for utilitarian reasons, such as to promote status or political goals, and their stress reactions do not seem to benefit from their involvement (Masters et al., 2004). Second, social contact appears to play a strong role

in health benefits of religious involvement (Nicholson, Rose, & Bobak, 2010). Third, the link between religious- ness and lower mortality applies to people who were initially healthy, not to individuals who were already sick (Chida, Steptoe, & Powell, 2009).

One other reason for the link between religiousness and health that some people have proposed is that religious people may receive direct help from their God, especially if others pray for their health. This idea has been disconfirmed. A meta-analysis on data from 14 studies on the role of people’s praying to help another person found no impact of that prayer on the object person’s health or life condition (Masters, Spielmans, & Goodson, 2006). The health or life conditions of people who are or are not the objects of prayer are not different.

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Chapter 5 / Coping With and Reducing Stress 117

Although people in all walks of life can lack the social support they need, some segments of the population have less than others (Antonucci, 1985; Broadhead et al., 1983; Ratliff-Crain & Baum, 1990). For instance:

• Men tend to have larger social networks than women, but women seem to use theirs more effectively for support.

• Many elderly individuals live in isolated conditions and have few people on whom to rely.

• Network size is related to social prestige, income, and education—the lower these variables are for individuals, the smaller their social networks tend to be.

Furthermore, the networks of people from lower socioeconomic classes are usually less diverse than those of people from higher classes—that is, lower- class networks contain fewer nonkin members. In contemporary American society, the traditional sources of support have shifted to include greater reliance on individuals in social and helping organizations. This is partly because extended family members today have different functions and live farther apart than they did many decades ago (Pilisuk, 1982).

Social support is a dynamic process. People’s needs for, giving of, and receipt of support change over time. Unfortunately, people who experience high levels of chronic stress, such as when their health declines severely, often find that their social support resources deteriorate at the same time (Kaplan et al., 1997; Lepore, 1997; Wortman & Dunkel-Schetter, 1987). These results are disheartening because they suggest that people whose need for social support is greatest may be unlikely to receive it.

Teachers can help enhance children’s social support by having them work together.

People can enhance their ability to give and receive social support by joining community organizations, such as social, religious, special interest, and self- help groups. These organizations have the advantage of bringing together individuals with similar problems and interests, which can become the basis for sharing, helping, and friendship. In the United States, there are many widely known self-help groups, including Alcoholics Anonymous and Parents without Partners, and special-interest groups, including the American Association of Retired People and support groups for people with specific illnesses, such as arthritis or AIDS. Although groups like these are helpful, we don’t yet know which ones work best for specific problems (Hogan, Linden, & Najarian, 2002). People are most likely to join a support group for a serious illness if it is embarrassing or stigmatizing, such as AIDS or breast cancer (Davison, Pennebaker, & Dickerson, 2000). Isolated people of all ages—especially the elderly—with all types of difficulties should be encouraged to join suitable organizations.

Communities can play a valuable role in enhancing people’s resources for social support by creating pro- grams to help individuals develop social networks, such as in occupational and religious settings, and by provid- ing facilities for recreation and fitness, arranging social events, and providing counseling services. But social support may not be effective if the recipient interprets it as a sign of inadequacy or believes his or her personal control is limited by it. Providing effective social support

requires sensitivity and good judgment. (Go to .)

IMPROVING ONE’S PERSONAL CONTROL When life becomes stressful, people who lack a strong sense of personal control may stop trying, thinking, ‘‘Oh, what’s the use.’’ Instead of feeling they have power and control, they feel helpless. For instance, people with a painful and disabling chronic illness may stop doing physical therapy exercises. When seriously ill patients who feel little personal control face a new severe stressor, they show more emotional distress than others who feel more control (Benight et al., 1997). The main psychological help such people need is to bolster their self-efficacy and reduce their passiveness and helplessness (Smith & Wallston, 1992). A pessimistic outlook increases people’s potential for stress and can have a negative effect on their health.

How can a person’s sense of control be enhanced? The process can begin very early. Parents, teachers, and other caregivers can show a child their love and respect, provide a stimulating environment, encourage and praise the child’s accomplishments, and set reasonable standards of conduct and performance that he or she can

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118 Part II / Stress, Illness, and Coping


The Amish Way of Social Support in Bereavement The Amish people in North America

form a conservative religious sect that settled in Pennsyl- vania in the 18th century. Amish families generally live in colonies that now exist in many states and Canada. These families have a strongly religious orientation and a seri- ous work ethic that revolves around farming. Their way of life is quite distinctive: they wear uniquely simple and uniform clothing; speak mainly a Pennsylvania-German dialect; and reject modern devices, using horse-driven buggies instead of automobiles, for example. Their social lives require their adherence to strict rules of conduct and obedience to patriarchal authority.

One feature of Amish life is that community members give assistance to one another in all times of need. Their way of dealing with death provides a good example, as Kathleen Bryer (1986) has studied and described. Before death, a person who is seriously ill receives care from his or her family. This generally occurs at home, rather than in a hospital. The Amish not only expect to give this care, but see it as a positive opportunity. A married woman who was asked about caring for a dying relative replied, ‘‘Oh yes, we had the

An Amish funeral procession. The Amish provide social support to one another in many ways, particularly after a member dies.

chance to take care of all four of our old parents before they died. We are both so thankful for this’’ (p. 251). Death typically occurs in the presence of the family.

Upon someone’s death, the Amish community swings into action. Close neighbors notify other members of the colony, and the community makes most of the funeral arrangements. The family receives visits of sympathy and support from other Amish families, some of whom come from other colonies far away and may not even know the bereaved family. In contrast to the social support most Americans receive in bereavement, Amish supportive efforts do not end shortly after the funeral—they continue at a high level for at least a year. Supportive activities include evening and Sunday visiting, making items and scrapbooks for the family, and organized quilting projects that create fellowship around a common task. Moreover, Amish individuals often give extraordinary help to bereaved family members. For instance, the sister of one widower came to live with him and care for his four children until he remarried. The community encourages widowed individuals to remarry in time, and they often do so.

regard as challenges, rather than threats. At the other end of the life span, nursing homes and families can allow elderly people to do things for themselves and have responsibilities, such as in cleaning, cooking, and arranging social activities. One woman described the prospect of living with her children in the following way: ‘‘I couldn’t stand to live with my children, as much as I love them, because they always want to take over my life’’ (Shupe, 1985). For people with serious illnesses, health psychologists can help patients with little control by training them in effective ways to cope with stress (Thompson & Kyle, 2000).

ORGANIZING ONE’S WORLD BETTER ‘‘Where did I put my keys?’’ you have surely heard someone ask frantically while running late to make an

appointment. People often feel stress because they are running late or believe they don’t have enough time to do the tasks of the day. They need to organize their worlds to make things happen efficiently. This can take the form of keeping an appointment calendar, designating certain places for certain items, or putting materials in alphabetized file folders, for instance. Organizing one’s world reduces frustration, wasted time, and the potential for stress.

An important approach for organizing one’s time is called time management. It consists of three elements (Lakein, 1973). The first element is to set goals. These goals should be reasonable or obtainable ones, and they should include long-term goals, such as graduating from college next year, and short-term ones, such as getting good grades. The second element involves

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Chapter 5 / Coping With and Reducing Stress 119

making daily To Do lists with priorities indicated, keeping the goals in mind. These lists should be composed each morning or late in the preceding day. Each list must be written—trying to keep the list in your head is unreliable and makes setting priorities difficult. The third element is to set up a schedule for the day, allocating estimated time periods to each item in the list. If an urgent new task arises during the day, the list should be adjusted to include it.

EXERCISING: LINKS TO STRESS AND HEALTH You have probably heard from TV, radio, magazine, and newspaper reports that exercise and physical fitness can protect people from stress and its harmful effects on health. These reports cite a wide range of benefits of exercising, from increased intellectual functioning and personal control to decreased anxiety, depression, hostility, and tension. Do exercise and fitness reduce the potential for stress and its effects on health?

Correlational and retrospective studies of this question have found that people who exercise or are physically fit often report less anxiety, depression, and tension in their lives than do people who do not exercise or are less fit (Dishman, 1986; Holmes, 1993). Although these results are consistent with the view that exercise and fitness reduce stress, there are two problems in interpreting them. First, the reduction in self-reported stress and emotion may have resulted partly from a placebo effect—that is, the subjects’ expectations that psychological improvements would occur (Desharnais et al., 1993). Second, the results of correlational research do not tell us what causes what. Do exercise and fitness cause people to feel less stress? Or are people more likely to exercise and keep fit if they feel less stress and time pressures in their lives? Fortunately, there is stronger evidence for the beneficial effects of exercise and fitness on stress and health.

An experiment by Bram Goldwater and Martin Collis (1985) examined the effects of 6-week exercise programs on cardiovascular fitness and feelings of anxiety in healthy 19- to 30-year-old men who were randomly assigned to one of two groups. In one group, the men worked out 5 days a week in a vigorous fitness program, including swimming and active sports, such as soccer; the second group had a more moderate program with less demanding exercise activities. Compared with the men in the moderate program, those in the vigorous program showed greater gains in fitness and reductions in anxiety. Other experiments have shown similar beneficial effects of exercise on depression and anxiety with men and women, particularly if the programs last at least 2 or 3 months (Babyak et al., 2000; Phillips, Kiernan, & King, 2001).

Research has also assessed the role of exercise on stress and cardiovascular function. Although most studies were correlational, finding that people who exercise or are physically fit show less reactivity to stressors and are less likely to be hypertensive than individuals who do not exercise or are less fit, some used experimental methods (Blumenthal, Sherwood et al., 2002; Dimsdale, Alpert, & Schneiderman, 1986). We’ll consider two experiments. First, healthy young adults who had sedentary jobs and had not regularly engaged in vigorous physical activity in the previous year were recruited (Jennings et al., 1986). During the next 4 months, these people spent 1 month at each of four levels of activity, ranging from below normal (which included 2 weeks of rest in a hospital) to much above-normal activity (daily vigorous exercise for 40 minutes). Heart rate and blood pressure were measured after each month. The much above-normal level of activity reduced heart rate by 12% and systolic and diastolic blood pressure by 8% and 10% compared with the normal sedentary activity level. Below-normal activity levels did not alter heart rate or blood pressure. Second, researchers had undergraduates experience a stress condition and then engage in moderate exercise or sit quietly for 3 minutes (Chafin, Christenfeld, & Gerin, 2008). Measures taken soon after revealed that exercise enhanced recovery from stress: the individuals who exercised had lower blood pressure levels than those who sat.

Do exercise and fitness prevent people from develop- ing stress-related illnesses? The results of several studies suggest they do (Phillips, Kiernan, & King, 2001). For example, one study used prospective methods by first assessing the subjects’ recent life events and fitness, and then having them keep records concerning their health over the next 9 weeks (Roth & Holmes, 1985). The results revealed that individuals who reported high levels of stress had poorer subsequent health if they were not fit; stress had little impact on the health of fit subjects. Overall, the evidence is fairly strong that engag- ing in regular exercise can promote health by reducing stress.

PREPARING FOR STRESSFUL EVENTS In this and previous chapters we have discussed many types of stressful events, ranging from being stuck in traffic, to starting day care or school, being overloaded with work, going through a divorce, and experiencing a disaster. Preparing for these events can reduce the potential for stress. For instance, parents can help prepare a child for starting day care by taking the child there in advance to see the place, meet the teacher, and play for a while (Sarafino, 1986).

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120 Part II / Stress, Illness, and Coping

Irving Janis (1958) pioneered the psychological study of the need to prepare people for stressful events, such as surgery. In general, research on preparing for surgery indicates that the higher the patients’ preoperative fear, the worse their postoperative adjustment and recovery tend to be, as reflected in the following measures (Anderson & Masur, 1983; Johnson, 1983):

• The patient’s self-reported pain

• The amount of medication taken to relieve pain

• Self-reported anxiety or depression

• The length of stay in the hospital after surgery

• Ratings by hospital staff of the patient’s recovery or adjustment

These outcomes suggest that preparing patients to help them cope with their preoperative concerns should enhance later adjustment and recovery. The most effective methods for preparing people psychologically for the stress of surgery attempt to enhance the patients’ feelings of control (Anderson & Masur, 1983; Mathews & Ridgeway, 1984). To promote behavioral control, for example, patients learn how to reduce discomfort or promote rehabilitation through specific actions they can take, such as by doing leg exercises to improve strength or deep breathing exercises to reduce pain. For cognitive control, patients learn ways to focus their thoughts on pleasant or beneficial aspects of the surgery, rather than the unpleasant aspects. And for informational control, patients receive information about the procedures and/or sensations they will experience.

Although receiving preparatory information is usu- ally helpful, sometimes it can have the opposite effect—for instance:

The Los Angeles City Council had placed cards in the city elevators assuring riders that they should stay calm, since ‘‘there is little danger of the car dropping uncontrollably or running out of air.’’ … A year later the cards had to be removed because of complaints from elevator riders that the message made them anxious. (Thompson, 1981, p. 96)

Also, having too much information can be confusing and actually arouse fear. Young children often become more anxious when they receive a great deal of information about the medical procedures they will undergo (Miller & Green, 1984). With children in dental or medical settings, it is generally best not to give a lot of detail. Describing some sensory experiences to expect is especially helpful, such as the sounds of equipment or the tingly feeling from the dental anesthetic.

In summary, we have discussed several methods that are helpful in reducing the potential for stress

and, thereby, benefiting health. These methods take advantage of the stress-moderating effects of social support, personal control, exercise, being well organized, and being prepared for an impending stressor. In the next section, we consider ways to reduce the reaction to stress once it has begun.


People acquire coping skills through their experiences, which may involve strategies they have tried in the past or methods they have seen others use. But sometimes the skills they have learned are not adequate for a current stressor because it is so strong, novel, or unrelenting. When people cannot cope effectively, they need help in learning new and adaptive ways of managing stress. The term stress management refers to any program of behavioral and cognitive techniques that is designed to reduce psychological and physical reactions to stress. Sometimes people use pharmacological approaches under medical supervision to reduce emotions, such as anxiety, that accompany stress.

MEDICATION Of the many types of drugs physicians prescribe to help patients manage stress, we will consider two: benzodiazepines and beta-blockers, both of which reduce physiological arousal and feelings of anxiety (AMA, 2003; Kring et al., 2010). Benzodiazepines, which include drugs with the trade names Valium and Xanax, activate a neurotransmitter that decreases neural transmission in the central nervous system. Beta-blockers, such as Inderal, are used to reduce anxiety and blood pressure. They block the activity stimulated by epinephrine and norepinephrine in the peripheral nervous system. Beta- blockers cause less drowsiness than benzodiazepines, probably because they act on the peripheral rather than central nervous system. Although many people use drugs for long-term control of stress and emotions, using drugs for stress should be a temporary measure. For instance, they might be used during an acute crisis, such as in the week or two following the death of a loved one, or while the patient learns new psychological methods for coping.

BEHAVIORAL AND COGNITIVE METHODS Psychologists have developed methods they can train people to use in coping with stress. Some of these techniques focus mainly on the person’s behavior, and

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Chapter 5 / Coping With and Reducing Stress 121

some emphasize the person’s thinking processes. People who use these methods usually find them helpful.

Relaxation The opposite of arousal is relaxation—so relaxing should be a good way to reduce stress. ‘‘Perhaps so,’’ you say, ‘‘but when stress occurs, relaxing is easier said than done.’’ Actually, relaxing when under stress is not so hard to do when you know how. One way people can learn to control their feelings of tension is called progressive muscle relaxation (or just progressive relaxation), in which they focus their attention on specific muscle groups while alternately tightening and relaxing these muscles (Sarafino, 2001).

The idea of teaching people to relax their skeletal muscles to reduce psychological stress was introduced many years ago by Edmund Jacobson (1938). He found that muscle tension could be reduced much more if individuals were taught to pay attention to the sensations as they tense and relax individual groups of muscles. Although today there are various versions of the progressive muscle relaxation technique, they each outline a sequence of muscle groups for the person to follow. For example, the sequence might begin with the person relaxing the hands, then the forehead, followed by the lower face, the neck, the stomach, and, finally, the legs. For each muscle group, the person first tenses the muscles for 7–10 seconds, and then relaxes them for about 15 seconds, paying attention to how the

muscles feel. This is usually repeated for the same muscle group two or three times in a relaxation session, which generally lasts 20 or 30 minutes. The tensing action is mainly important while the person is being trained, and can be eliminated after he or she has mastered the technique (Sarafino, 2001). Relaxation works best in a quiet, nondistracting setting with the person lying down or sitting on comfortable furniture.

Stress management is applied mainly with adults, but children also experience stress without being able to cope effectively. Fortunately, many behavioral and cognitive methods are easy to learn and can be adapted so that an adult can teach a young child to use them (Siegel & Peterson, 1980). Relaxation exercises provide a good example. An adult could start by showing the child what relaxing is like by lifting and then releasing the arms and legs of a rag doll, allowing them to fall down. Then, the adult would follow a protocol, or script, giving instructions like those in Table 5.2. When children and adults first learn progressive muscle relaxation, they sometimes don’t relax their muscles when told to do so. Instead of letting their arms and legs fall down, they move them down. They may also tense more muscles than required—for example, tightening facial muscles when they are asked to tense hand muscles. These errors should be pointed out and corrected.

Often, after individuals have thoroughly mastered the relaxation procedure, they can gradually shorten the procedure so they can apply a very quick version in times of stress, such as when they are about to give a

Table 5.2 Progressive Muscle Relaxation Protocol for Children

1. ‘‘OK. Let’s raise our arms and put them out in front. Now make a fist with both your hands, really hard. Hold the fist tight and you will see how your muscles in your hands and arms feel when they are tight.’’ (hold for 7–10 seconds)

‘‘That’s very good. Now when I say relax, I want the muscles in your hands and arms to become floppy, like the rag doll, and your arms will drop to your sides. OK, relax.’’ (about 15 seconds)

2. ‘‘Let’s raise our legs out in front of us. Now tighten the muscles in your feet and legs, really hard. Make the muscles really tight, and hold it.’’ (7–10 seconds)

‘‘Very good. Now relax the muscles in your feet and legs, and let them drop to the floor. They feel so good. So calm and relaxed.’’ (15 seconds)

3. ‘‘Now let’s do our tummy muscles. Tighten your tummy, really hard—and hold it.’’ (7–10 seconds) ‘‘OK. Relax your tummy, and feel how good it feels. So comfortable.’’ (15 seconds)

4. ‘‘Leave your arms at your side, but tighten the muscles in your shoulders and neck. You can do this by moving your shoulders up toward your head. Hold the muscles very tightly in your shoulders and neck.’’ (7–10 seconds)

‘‘Now relax those muscles so they are floppy, and see how good that feels.’’ (15 seconds) 5. ‘‘Let’s tighten the muscles in our faces. Scrunch up your whole face so that all of the muscles are tight—the muscles in

your cheeks, and your mouth, and your nose, and your forehead. Really scrunch up your face, and hold it.’’ (7–10 seconds) ‘‘Now relax all the muscles in your face—your cheeks, mouth, nose, and forehead. Feel how nice that is.’’ (15

seconds) 6. ‘‘Now I want us to take a very, very deep breath—so deep that there’s no more room inside for more air. Hold the air in.

(use a shorter time: 6–8 seconds) ‘‘That’s good. Now slowly let the air out. Very slowly, until it’s all out … . And now breathe as you usually do.’’ (15


Source: From Sarafino, 1986, pp. 112–113.

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122 Part II / Stress, Illness, and Coping

speech (Sarafino, 2001). This quick version might have the following steps: (1) taking a deep breath, and letting it out; (2) saying to oneself, ‘‘Relax, feel nice and calm’’; and (3) thinking about a pleasant thought for a few seconds. In this way, relaxation methods can be directly applied to help people cope with everyday stressful events.

Research has demonstrated that progressive muscle relaxation is highly effective in reducing stress (Carlson & Hoyle, 1993; Jain et al., 2007; Lichstein, 1988). What’s more, people who receive training in relaxation show less cardiovascular reactivity to stressors and stronger immune function (Lucini et al., 1997; Sherman et al., 1997).

Systematic Desensitization Although relaxation is often successful by itself in helping people cope, it is frequently used in conjunction with systematic desensitization, a useful method for reducing fear and anxiety (Sarafino, 2001). This method is based on the view that fears are learned by classical conditioning—that is, by associating a situation or object with an unpleasant event. This can happen, for example, if a person associates visits to the dentist with pain, thereby becoming ‘‘sensitized’’ to dentists. Desensitization is a classical conditioning procedure that reverses this learning by pairing the feared object or situation with either pleasant or neutral events, as Figure 5-1 outlines. According to Joseph Wolpe (1958, 1973), an originator of the desensitization method, the reversal comes about through the process of counterconditioning, whereby the ‘‘calm’’ response gradually replaces the ‘‘fear’’ response. Desensitization has been used successfully in reducing a variety of children’s and adults’ fears, such as fear of dentists, animals, high places, public speaking, and taking tests (Lichstein, 1988; Sarafino, 2001).

An important feature of the systematic desensitiza- tion method is that it uses a stimulus hierarchy—a graded sequence of approximations to the conditioned stimulus, the feared situation. The purpose of these approxima- tions is to bring the person gradually in contact with the source of fear in about 10 or 15 steps. To see how a stimulus hierarchy might be constructed, we will look at the one in Table 5.3 that deals with the fear of dentists. The person would follow the instructions in each of the 14 steps. As you can see, some of the steps involve real-life, or in vivo, contacts with the feared situation, and some do not. Two types of non–real-life contacts, of varying degrees, can be included. One type uses imaginal situations, such as having the person think about calling the dentist. The other involves symbolic contacts, such as by showing pictures, films, or models of the feared situation.

Reverse Conditioning

CS Dentist

US Pain


CS Dentist

US Pleasant or neutral



Classical Conditioning of Fear

UR Fear

UR Calm

Figure 5-1 Classical conditioning in learning to fear dental visits and in reversing this learning. In conditioning the fear, the unconditioned stimulus (US) of pain elicits the unconditioned response (UR) of fear automatically. Learning occurs by pairing the dentist, the conditioned stimulus (CS), with the US so that the dentist begins to elicit fear. The reverse conditioning pairs the feared dentist with a US that elicits calm.

The systematic desensitization procedure starts by having the person do relaxation exercises. Then the steps in a hierarchy are presented individually, while the person is relaxed and comfortable (Sarafino, 2001). The steps follow a sequence from the least to the most fearful for the individual. Each step may elicit some wariness or fear behavior, but the person is encouraged to relax. Once the wariness at one step has passed and the person is calm, the next step in the hierarchy can be introduced. Completing an entire stimulus hierarchy and reducing a fairly strong fear can be achieved fairly quickly—it is likely to take several hours, divided into several separate sessions. In one study with dental-phobic adults who simply imagined each step in a hierarchy, the procedure successfully reduced their fear in six 11/2-hour sessions (Gatchel, 1980). Individual sessions for reducing fears in children are usually much shorter than those used with adults, especially for a child who is very young and has a short attention span.

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Chapter 5 / Coping With and Reducing Stress 123

Table 5.3 Example of a Stimulus Hierarchy for a Fear of Dentists

1. Think about being in the dentist’s waiting room, simply accompanying someone else who is there for an examination. 2. Look at a photograph of a smiling person seated in a dental chair. 3. Imagine this person calmly having a dental examination. 4. Think about calling the dentist for an appointment. 5. Actually call for the appointment. 6. Sit in a car outside the dentist’s office without having an appointment. 7. Sit in the dentist’s waiting room and hear the nurse say, ‘‘The hygienist is ready for you.’’ 8. Sit in the examination room and hear the hygienist say, ‘‘I see one tooth the dentist will need to look at.’’ 9. Hear and watch the drill run, without its being brought near the face.

10. Have the dentist pick at the tooth with an instrument, saying, ‘‘That doesn’t look good.’’ 11. See the dentist lay out the instruments, including a syringe to administer an anesthetic. 12. Feel the needle touch the gums. 13. Imagine having the tooth drilled. 14. Imagine having the tooth pulled.

Biofeedback Biofeedback is a technique in which an electromechani- cal device monitors the status of a person’s physiological processes, such as heart rate or muscle tension, and immediately reports that information back to the indi- vidual. This information enables the person to gain voluntary control over these processes through operant conditioning. If, for instance, the person is trying to reduce neck-muscle tension and the device reports that the tension has just decreased, this information reinforces whatever efforts the individual made to accomplish this decrease.

Biofeedback has been used successfully in treat- ing stress-related health problems. For example, an experiment found that patients suffering from chronic

headaches who were given biofeedback regarding muscle tension in their foreheads later showed less tension in those muscles and reported having fewer headaches than subjects in control groups (Budzynski et al., 1973). What’s more, these benefits continued at a follow-up after 3 months. Biofeedback and progressive muscle relaxation are effective for treating headache and many other stress-related disorders (Gatchel, 2001; Nestoriuc, Rief, & Martin, 2008). Both biofeedback and progressive muscle relaxation techniques can help reduce stress, but some individuals may benefit more from one method than the other.

According to Virginia Attanasio, Frank Andrasik, and their colleagues (1985), children may be better candidates for biofeedback treatment than adults. In treating recurrent headache with biofeedback, these

A biofeedback procedure for forehead muscle tension. One way to give feedback regarding the status of the muscles is with audio speakers, such as by sounding higher tones for higher levels of tension.

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124 Part II / Stress, Illness, and Coping

researchers noticed that children seem to acquire biofeedback control faster and show better overall improvement than adults. Part of this observation has been confirmed in research: the headaches of children and adults improve with biofeedback, but children’s headaches improve more (Nestoriuc, Rief, & Martin, 2008; Sarafino & Goehring, 2000). Why? Attanasio and her coworkers have offered some reasons. First, although a small proportion of children are frightened initially by the equipment and procedures, most are more enthusiastic than adults, often regarding biofeedback as a game. In fact, some children become so interested and motivated in the game that their arousal interferes with relaxation if the therapist does not help them remain calm. Second, children are usually less skeptical about their ability to succeed in biofeedback training and to benefit from doing so. Adults often say, ‘‘Nothing else I’ve ever tried has worked, so why should biofeedback?’’ This difference in skepticism may reflect differences in experience: adults are likely than children to have had more failure experiences with other treatments. Third, children may be more likely than adults to practice their training at home, as they are instructed to do.

Although children have characteristics that make them well suited to biofeedback methods, they also have some special difficulties (Attanasio et al., 1985). For one thing, children—particularly those below the age of 8—have shorter attention spans than adults. If biofeedback sessions last more than 20 minutes or so, it may be necessary to divide each session into smaller units with brief breaks in between. A related problem is that children sometimes perform disruptive behaviors during a session, disturbing the electrodes and wires or interrupting to talk about tangential topics, for instance. The therapist can reduce the likelihood of these unwanted behaviors, such as by providing rewards for being cooperative. Clearly, the difficulties some children have in biofeedback training can usually be overcome.

Modeling People learn not just by doing, but also by observing. They see what others do and the consequences of the behavior these models perform. As a result, this kind of learning is called modeling, and sometimes ‘‘observational’’ or ‘‘social’’ learning. People can learn fears and other stress-related behavior by observing fearful behavior in other individuals. In one study, children (with their parents’ permission) learned to fear a Mickey Mouse figure by watching a short film showing a 5-year-old boy’s fear reaction to plastic figures of Mickey Mouse and Donald Duck (Venn & Short, 1973). This learned fear reaction was pronounced initially—but declined a day or two later.

Since people can learn stressful reactions by observ- ing these behaviors in others, modeling should be effective in reversing this learning and helping people cope with stressors, too. A large body of research has confirmed that it is effective (Sarafino, 2001; Thelen et al., 1979). The therapeutic use of modeling is similar to the method of desensitization: the person relaxes while watching a model calmly perform a series of activities arranged as a stimulus hierarchy—that is, from least to most stressful. The modeling procedure can be pre- sented symbolically, using films or videotapes, or in vivo, with real-life models and events. Using symbolic pre- sentations, for example, researchers have shown that modeling procedures can reduce the stress 4- to 17-year- old hospitalized children experience and improve their recovery from surgery (Melamed, Dearborn, & Hermecz, 1983; Melamed & Siegel, 1975). But the child’s age and prior experience with surgery were also important fac- tors in the results. Children under the age of 8 who had had previous surgery experienced increased anxiety rather than less. These children may benefit from other methods to reduce stress, such as activities that simply distract their attention. (Go to .)

Approaches Focusing on Cognitive Processes Because stress results from cognitive appraisals that are frequently based on a lack of information, mis- perceptions, or irrational beliefs, some approaches to modify people’s behavior and thought patterns have been developed to help them cope better with the stress they experience. These methods guide people toward a ‘‘restructuring’’ of their thought patterns (Lazarus, 1971). Cognitive restructuring is a process by which stress- provoking thoughts or beliefs are replaced with more constructive or realistic ones that reduce the person’s appraisal of threat or harm.

What sorts of irrational beliefs do people have that increase stress? Two leading theorists have described a variety of erroneous thought patterns that some people use habitually and frequently that lead to stress; we’ll consider two from each theorist. The beliefs described by Albert Ellis (1962, 1977, 1987) include:

• Can’t-stand-itis—as in, ‘‘I can’t stand not doing well on a test.’’

• Musterbating—for instance, ‘‘People must like me, or I’m worthless.’’

And the beliefs described by Aaron Beck (1976; Beck et al., 1990) include:

• Arbitrary inference (drawing a specific conclusion from insufficient, ambiguous, or contrary evidence). For example, a husband might interpret his wife’s bad mood

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Chapter 5 / Coping With and Reducing Stress 125


The Case of ‘‘Bear’’ We’ve seen that people’s thought pro-

cesses can affect their stress. Appraisals of stress are often based on thoughts that are not rational. To illus- trate how irrational thoughts can increase stress and lead to psychological problems, consider the case of a college baseball player, nicknamed ‘‘Bear,’’

who was not hitting up to expectations, and was very depressed about his poor performance. In talking with Bear, it quickly became apparent that his own expectations were unrealistic. For instance, Bear wanted to hit the ball so hard that it would literally be bent out of shape (if someone happened to find it in the next county!). After a particularly bad batting session, he would go home and continue to practice until he was immobilized with exhaustion. Simply put, he believed that if an

athlete was not performing well, this could only mean he was not trying hard enough. (Rimm & Masters, 1979, p. 40)

Bear’s therapy involved progressive muscle relax- ation and cognitive methods to help him realize two important things: First, although motivation and desire increase performance, they do so only up to a point, after which additional motivation impairs performance. Second, although hitting very well is ‘‘nice,’’ hitting moderately well is not ‘‘terrible’’ or ‘‘intolerable.’’ These realizations restructured Bear’s thinking about his per- formance, and his batting average increased dramati- cally. Similar methods can help people reduce irrational thoughts that lead to their debilitating feelings of anxiety and depression (Sarafino, 2001).

as meaning she is unhappy with something he did when she is actually just preoccupied with another matter.

• Magnification (greatly exaggerating the meaning or impact of an event). For instance, a recently retired per- son diagnosed with arthritis might describe it as a ‘‘catastrophe.’’

These ways of thinking affect stress appraisal pro- cesses, increasing the appraisal of threat or harm because the perspectives are so extreme. The circumstances that are the bases of these thoughts are not ‘‘good,’’ but they’re probably not as bad as the thoughts imply.

A widely used cognitive restructuring approach to change maladaptive thought patterns is called cognitive therapy (Beck, 1976; Beck et al., 1990). Although it was developed originally to treat psychological depression, it is also being applied today for anxiety. Cognitive therapy attempts to help clients see that they are not responsible for all of the problems they encounter, the negative events they experience are usually not catastrophes, and their maladaptive beliefs are not logically valid. For instance, the following dialogue shows how a therapist tried to counter the negative beliefs a woman named Sharon had.

THERAPIST: … what evidence do you have that all this is true? That you are ugly, awkward? Or that it is not true? What data do you have?

SHARON: Comparing myself to people that I consider to be extremely attractive and finding myself lacking.

THERAPIST: So if you look at that beautiful person, you’re less?


THERAPIST: Or if I look at that perfect person, I’m less. Is that what you’re saying? …

SHARON: Yeah. I always pick out, of course, the most attractive person and probably a person who spends 3 hours a day on grooming and appearance… . I don’t compare myself to the run-of-the-mill… . (Freeman, 1990, p. 83)

One technique cognitive therapy uses, called hypoth- esis testing, has the person treat an erroneous belief as a hypothesis and test it by looking for evidence for and against it in his or her everyday life. Research has shown that cognitive therapy is clearly effective in treating depression (Hollon, Shelton, & Davis, 1993; Robins & Hayes, 1993) and appears to be a very promising approach for treating anxieties (Chambless & Gillis, 1993).

Another cognitive approach is designed to help clients solve problems in their lives. By a ‘‘problem’’ we mean a life circumstance, such as being stuck in traffic or feeling a worrisome chest pain, that requires a response based on thinking and planning. People experience stress when they face a problem and don’t know what to do or how to do it. In problem-solving training, clients learn a strategy for identifying, discovering, or inventing effective or adaptive ways to address problems in everyday life

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126 Part II / Stress, Illness, and Coping

(D’Zurilla, 1988; Nezu, Nezu, & Perri, 1989). They learn to watch for problems that can arise, define a problem clearly and concretely, generate a variety of possible solutions, and decide on the best course of action. Evidence indicates that problem-solving training reduces anxiety and other negative emotions (D’Zurilla, 1988; Elliott, Berry, & Grant, 2009).

Stress-inoculation training is an approach that uses a variety of methods that are designed to teach people skills for alleviating stress (Meichenbaum & Cameron, 1983; Meichenbaum & Turk, 1982). The training involves three phases in which the person (1) learns about the nature of stress and how people react to it; (2) acquires behavioral and cognitive skills, such as relaxation and seeking social support; and (3) practices coping skills with actual or imagined stressors. The methods used in stress-inoculation training are well-thought-out, include a number of well-established techniques, and are useful for people who anticipate a stressful event, such as surgery (Dale, 2004). (Go to .)

Multidimensional Approaches The coping difficulties individuals have are often multi- dimensional and multifaceted. As a result, one particular technique may not be sufficient in helping a client, and the most effective intervention usually draws upon many techniques. When designing a multidimensional approach, the program for helping an individual cope better with stress would be tailored to the person’s spe- cific problems (Sarafino, 2001). The program may make use of any of the methods we have considered, many methods that would take this discussion too far afield, and the methods we are about to examine.

MASSAGE, MEDITATION, AND HYPNOSIS Three additional techniques have been used in stress management. The first two we will consider—massage and meditation—are often classified as relaxation meth- ods. The third technique—hypnosis—seems to produce an altered state of consciousness in which mental functioning differs from its usual pattern of wakefulness. Some peo- ple believe that meditation and massage are other ways by which we can alter consciousness.

Massage Massage has several forms that vary in the degree of pressure applied. Some forms of massage use soothing strokes with light pressure, others involve a rubbing motion with moderate force, and others use a kneading or pounding action. Deep tissue massage uses enough pressure to penetrate deeply into muscles and joints. Infants seem to prefer light strokes, but adults tend to prefer more force (Field, 1996). When seeking a massage therapist, it is a good idea to ask about licensing and certification.

Massage therapy can reduce anxiety and depression (Moyer, Rounds, & Hannum, 2004). It also increases the body’s production of a hormone called oxytocin that decreases blood pressure and stress hormone levels (Holt-Lunstad, Birmingham, & Light, 2008). And it helps reduce hypertension, some types of pain, and asthma symptoms; and some evidence indicates that it may bolster immune function (Field, 1996, 1998).

Meditation Transcendental meditation is a method in the practice of yoga that was promoted by Maharishi Mahesh Yogi as a means


Treating Insomnia Insomnia often results from stress, as

when people can’t sleep because they worry about their jobs or health. People who show evidence of maladaptive behaviors or arousal that persistently interfere with sleep, thereby leading to daytime distress or impaired function, are candidates for cognitive–behavioral therapy for insomnia (Smith & Perlis, 2006). Many people with insomnia have a medical condition, such as cancer or arthritis, which is stressful because of its prognosis or the disability or symptoms it produces. A meta- analysis on data from 23 experiments found that cognitive–behavioral therapy is very effective in treating

insomnia (Irwin, Cole, & Nicassio, 2006). Using sleep medication for the first few weeks of treatment enhances the long-term success of this therapy (Morin et al., 2009).

What methods do cognitive–behavioral approaches use for insomnia? Behavioral methods include relaxation and sleep restriction, which involves setting a regular routine for sleeping and not using the bed as a place for reading or working. Cognitive methods include restructuring beliefs, such as that not sleeping will ‘‘wreck tomorrow,’’ and using fantasies about being in a relaxing place, such as on a beach or in a forest.

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Chapter 5 / Coping With and Reducing Stress 127

of improving physical and mental health and reducing stress (Benson, 1984, 1991; Nystul, 2004). Individuals using this procedure are instructed to practice it twice a day, sitting upright but comfortably relaxed with eyes closed, and mentally repeating a word or sound (such as ‘‘om’’), called a mantra, to prevent distracting thoughts from occurring.

Psychologists and psychiatrists have advocated sim- ilar meditation methods for reducing stress. For example, Herbert Benson has recommended that the person:

Sit quietly in a comfortable position and close your eyes … . Deeply relax all your muscles … . Become aware of your breathing. As you breathe out, say the word one silently to yourself … . Maintain a passive attitude and permit relaxation to occur at its own pace. Expect other thoughts. When these distracting thoughts occur, ignore them by thinking, ‘‘Oh well,’’ and continue repeating, ‘‘One.’’ (1984, p. 332)

The purpose of this procedure is to increase the person’s ability in the face of a stressor to make a ‘‘relax- ation response,’’ which includes reduced physiological activity, as an alternative to a stress response. According to Benson, the relaxation response enhances health, such as by reducing blood pressure, and may be achieved in many different ways. For example, a religious person might find that a meditative prayer is the most effective method for bringing forth the relaxation response.

Although meditation helps people relax, it has a broader purpose: to develop a clear and mindful awareness, or ‘‘insight’’ regarding the essence of one’s experiences, unencumbered by cognitive or emotional distortions (Hart, 1987; Solé-Leris, 1986). Jon Kabat-Zinn (1982; Kabat-Zinn, Lipworth, & Burney, 1985) has emphasized the mindful awareness component of meditation to help individuals who suffer from chronic pain to detach

themselves from the cognitive and emotional distortions they have with their pain. He trains patients to pay close attention to their pain and other sensations without reacting toward them in any way, thereby enabling the people to be aware of the pain itself with no thoughts or feelings about it. Using this technique leads to a reduction in the patients’ reports of physical and psychological discomfort.

Many people believe that meditation enables people to reach a state of profound rest, as is claimed by popular self-help books (for example, Forem, 1974). Some studies have found lower anxiety and blood pressure among meditators than nonmeditators, but the research was quasi-experimental (Jorgensen, 2004). Other research findings are more important here. First, Buddhist monks in Southeast Asia can dramatically alter their body metabolism and brain electrical activity through meditation (Benson et al., 1990). Second, people’s blood pressure decreases while they meditate (Barnes et al., 1999). Third, stress management interventions using meditation alleviate stress effectively in people’s daily lives (Chiesa & Serretti, 2009; Jain et al., 2007; Jorgensen, 2004; Williams, Kolar et al., 2001). Fourth, practicing meditation on a regular basis appears to reduce blood pressure and enhance immune function (Barnes, Treiber,

& Johnson, 2004; Davidson et al., 2003). (Go to .)

Hypnosis The modern history of hypnosis began with its being called ‘‘animal magnetism’’ and ‘‘Mesmerism’’ in the 18th and 19th centuries. The Austrian physician Franz Anton Mesmer popularized its use in treating patients who had symptoms of physical illness, such as paralysis, without a detectable underlying organic disorder. Today, hypnosis is considered to be an altered state of consciousness


Can Increasing Positive Emotions Enhance Health? Did you know that, on average, winners

of the Nobel Prize and Academy Award live longer than their colleagues who don’t receive these honors? Maybe the reason for the winners’ longer lives is that they experience more positive emotions because of the respect and prestige their work receives. People who have relatively high levels of positive affect experience less negative emotion when under stress (Ong et al., 2006) and better health: they have fewer illnesses and live longer than people who have low levels of positive emotions (Pressman & Cohen, 2005).

We’ve seen that stress management can reduce negative emotions, but can it increase positive emo- tions? Some evidence indicates that it can (Chesney et al., 2005). Interventions that include training in relaxation, meditation, and methods to enhance social support, stress-appraisal processes, and problem- and emotion-focused coping with stress reduce people’s negative emotions and increase their positive affect, and the effects on positive emotions last for at least a year.

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128 Part II / Stress, Illness, and Coping

that is induced by special techniques of suggestion and leads to varying degrees of responsiveness to directions for changes in perception, memory, and behavior (Moran, 2004).

People differ in suggestibility, or the degree to which they can be hypnotized. Perhaps 15–30% of the general population is easily and deeply hypnotizable (Evans, 1987; Hilgard, 1967). Suggestibility appears to change with age, being particularly strong among children between the ages of about 7 and 14, and then declining in adolescence to a level that remains stable throughout adulthood (Hilgard, 1967; Place, 1984). People who are reasonably suggestible can often learn to induce a hyp- notic state in themselves—a process called self-hypnosis. Usually they learn to do this after they have experienced hypnosis under the supervision of a skilled hypnotist.

Because individuals who have been hypnotized usually claim that it is a relaxing experience, researchers have examined whether it can reduce stress. These studies have generally found that hypnosis is helpful in stress management, but not necessarily more effective than other relaxation techniques (Moran, 2004; Wadden & Anderton, 1982). Other research has revealed that people who received training in and practiced regularly either hypnosis or relaxation showed enhanced immune function weeks later (Kiecolt-Glaser et al., 2001; McGrady et al., 1992).

In summary, we have seen that many different behavioral and cognitive methods, massage, meditation, and hypnosis offer useful therapeutic approaches for helping people cope with stress. Research is also revealing more and more clearly the important benefits of stress management in preventing illness.


Of the many risk factors that have been identified for CHD, a few of them—such as age and family history—are beyond the control of the individual. But many risk factors for CHD are directly linked to the person’s experiences and behavior, which should be modifiable. One of these risk factors is stress, and stress management interventions appear to produce cardiovascular improvements and prolong life in CHD patients (Orth-Gomér et al., 2009). Let’s now consider how stress management methods can be applied to reduce the risk of developing CHD.

MODIFYING TYPE A BEHAVIOR When the Type A behavior pattern was established as a risk factor for CHD, researchers began to study

ways to modify Type A behavior to reduce coronary risk. One approach used a multidimensional program that included progressive muscle relaxation, cognitive restructuring, and stress-inoculation training (Roskies, 1983; Roskies et al., 1986). An experiment randomly assigned Type A men to the multidimensional program or to one of two physical exercise programs, aerobic training (mostly jogging) or weight-training, each lasting 10 weeks. Then the men were tested for Type A behavior and cardiovascular reactivity (blood pressure and heart rate) to stressors, such as doing mental arithmetic, to compare with measures taken earlier. One finding can be seen in Figure 5-2: the hostility component of Type A behavior decreased markedly in the multidimensional program but not in the exercise groups. These benefits can be quite durable: another study found that improvements in Type A behavior with a similar intervention were maintained at a 2-year follow- up (Karlberg, Krakau, & Undén, 1998).

Other research has demonstrated the usefulness of stress-inoculation training and relaxation in helping people control their anger (Novaco, 1975, 1978). The subjects first learned about the role of arousal and cognitive processes in feelings of anger. Then they learned muscle relaxation along with statements—like those in Table 5.4—they could say to themselves at different times in the course of angry episodes, such as at the point of ‘‘impact and confrontation.’’ The program improved the subjects’ ability to control their anger, as measured by self-reports and their blood pressure





3.8 Weight-training




H os

ti lit

y sc

or e

Before treatment

Timing of structured interview

After treatment

Figure 5-2 Hostility of Type A men measured by the Structured Interview method before and after a 10-week multidimensional, aerobic exercise, or weight-training treat- ment program. (Data from Roskies et al., 1986, Table 4.)

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Chapter 5 / Coping With and Reducing Stress 129

Table 5.4 Examples of Anger Management Self-Statements Rehearsed in Stress-Inoculation Training

Preparing for Provocation This could be a rough situation; but I know how to deal with it. I can work out a plan to handle this. Easy does it. Remember, stick to the issues and don’t take it personally. There won’t be any need for an argument. I know what to do.

Impact and Confrontation As long as I keep my cool, I’m in control of the situation. You don’t need to prove yourself. Don’t make more out of this than you have to. There is no point in getting mad. Think of what you have to do. Look for the positives and don’t jump to conclusions.

Coping with Arousal Muscles are getting tight. Relax and slow things down. Time to take a deep breath. Let’s take the issue point by point. My anger is a signal of what I need to do. Time for problem solving. He probably wants me to get angry, but I’m going to deal with it constructively.

Subsequent Reflection

a. Conflict unresolved. Forget about the aggravation. Thinking about it only makes you upset. Try to shake it off. Don’t let it interfere with your job. Remember relaxation. It’s a lot better than anger. Don’t take it personally. It’s probably not so serious.

b. Conflict resolved. I handled that one pretty well. That’s doing a good job. I could have gotten more upset than it was worth. My pride can get me into trouble, but I’m doing better at this all the time. I actually got through that without getting angry.

Source: From Novaco, 1978, p. 150.

when provoked in the laboratory. Many studies have confirmed the success of interventions using cognitive and behavioral methods in decreasing anger (Del Vecchio & O’Leary, 2004; DiGiuseppe & Tafrate, 2003), and research has shown that such interventions reduce both hostility and diastolic (resting) blood pressure in patients with CHD and mild hypertension (Gidron, Davidson, & Bata, 1999; Larkin & Zayfert, 1996).

Does decreasing Type A behavior with stress man- agement techniques decrease the incidence of CHD? Researchers studied this issue with over 1,000 patients who had suffered a heart attack and who agreed to par- ticipate in the study for 5 years (Friedman et al., 1986; Powell & Friedman, 1986). The patients were not selected on the basis of their exhibiting Type A behavior, and they continued to be treated by their own physicians through- out the study. The subjects were randomly assigned to two intervention groups and a control group. One inter- vention, called cardiac counseling, presented information, such as about the causes of heart disease and the impor- tance of altering standard coronary risk factors, such as cigarette smoking (Type A behavior was not discussed). The other intervention, called the Type A/cardiac group, included the same cardiac counseling plus a multidimen- sional program, including progressive muscle relaxation and cognitive restructuring techniques, to modify Type A behavior. The results revealed that the Type A/cardiac group showed a much larger decrease in Type A behavior (measured with Structured Interview and questionnaire methods) than those in the other groups and had substantially lower rates of cardiac morbidity and mortality (Friedman et al., 1986). For example, subse- quent heart attacks occurred in about 13% of the Type A/cardiac subjects, 21% of the cardiac counseling sub- jects, and 28% of the control subjects during the 41/2-year follow-up.

Research has shown that pharmacological approaches can reduce hostility and Type A behavior (Kamarck et al., 2009; Schmieder et al., 1983). Although using drugs may not be the treatment of choice for most people with high levels of anger or Type A behavior, it may be appropriate for those who are at coronary risk who do not respond to behavioral and cognitive interventions (Chesney, Frautschi, & Rosenman, 1985).

TREATING HYPERTENSION As we discussed in Chapter 4, essential hypertension is an important risk factor for CHD. Patients with diagnosed hypertension usually receive medical treatment that includes a prescription drug, such as a diuretic, and advice to control their body weight, exercise regularly, and reduce their intake of cholesterol, sodium, caffeine, and alcohol (AHA, 2010). Sometimes physicians and others urge hypertensive patients ‘‘to try to relax’’ when hassles occur, but untrained people who make an effort to relax often end up raising their blood pressure rather than lowering it (Suls, Sanders, & Labrecque, 1986).

Because the development of essential hypertension has been linked to the amount of stress people expe- rience, researchers have examined the utility of stress management techniques in treating high blood pressure. The findings suggest three conclusions. First, using a sin- gle technique, such as relaxation, to lower blood pressure often provides only limited success; stress management methods are more effective when combined in multidi- mensional programs (Larkin, Knowlton, & D’Alessandri, 1990; Spence et al., 1999). Second, if an intervention uses a single technique, meditation seems to be more effective than other methods (Rainforth et al., 2007). Third, a meta- analysis by Wolfgang Linden and Laura Chambers (1994)

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130 Part II / Stress, Illness, and Coping

of dozens of studies found that multidimensional programs consisting of behavioral and cognitive methods for stress management are highly effective—as effective as diuretic drugs—in reducing blood pressure. It is now clear that psychological approaches have considerable value in treating hypertension, making effective treatment possi- ble without drugs or with lower doses for most patients.

In an effort to improve the health of employees, many large companies have introduced voluntary stress management programs for their workers. Studies of these programs have found that they produce improve- ments in workers’ psychological and physiological stress (Alderman, 1984; Richardson & Rothstein, 2008;

Sallis et al., 1987). Despite the success of stress management programs in reducing coronary risk by modifying Type A behavior and lowering blood pressure, they are not yet widely applied—partly because the evidence supporting the use of these programs is relatively new, and partly because they cost money to run. Also, many people who could benefit from stress management programs don’t join one when it is available, drop out before completing the program, or don’t adhere closely to its recommendations, such as to practice relaxation techniques at home (Alderman, 1984; Hoelscher, Lichstein, & Rosenthal, 1986).


Coping is the process by which people try to manage the real or perceived discrepancy between the demands and resources they appraise in stressful situations. We cope with stress through transactions with the environment that do not necessarily lead to solutions to the problems causing the stress.

Coping serves two functions. (1) Emotion-focused coping regulates the person’s emotional response to stress—for example, by using alcohol or seeking social support, and through cognitive strategies, such as denying unpleasant facts. (2) Problem-focused coping reduces the demands of a stressor or expands the resources to deal with it, such as by learning new skills. People tend to use emotion-focused coping when they believe they cannot change the stressful conditions; they use problem-focused coping when they believe they can change the situation. Adults report using more problem-focused than emotion- focused coping approaches when dealing with stress. People tend to use a combination of methods in coping with a stressful situation.

Coping changes across the life span. Young children’s coping is limited by their cognitive abilities, which improve throughout childhood. During adulthood, a shift in coping function occurs as people approach old age—they rely less on problem-focused and more on emotion-focused coping. Elderly people tend to view the stressors they experience as less changeable than middle-aged individuals do.

People can reduce the potential for stress in their lives and others’ lives in several ways. First, they can increase the social support they give and receive by joining

social, religious, and special-interest groups. Second, they can improve their own and others’ sense of personal control and hardiness by giving and taking responsibility. Also, they can reduce frustration and waste less time by organizing their world better, such as through time management. And by exercising and keeping fit, they can reduce the experience of stress and the impact it has on their health. Last, they can prepare for stressful events, such as a medical procedure, by improving their behavioral, cognitive, and informational control.

Sometimes the coping skills individuals have learned are not adequate for dealing with a stressor that is very strong, novel, or unrelenting. A variety of techniques are available to help people who are having trouble cop- ing effectively. One technique is pharmacological, that is, using prescribed drugs, such as beta-blockers. Stress man- agement methods include progressive muscle relaxation, systematic desensitization, biofeedback, modeling, and several cognitive approaches. Cognitive therapy attempts to modify stress-producing, irrational thought patterns through the process of cognitive restructuring. Stress- inoculation training and problem solving training are designed to teach people skills to alleviate stress and achieve personal goals. Beneficial effects on people’s stress have been found for all of the behavioral and cognitive stress management methods, particularly relaxation. Mas- sage, meditation, and hypnosis have shown promise for reducing stress, too. Stress management techniques can reduce coronary risk by modifying Type A behavior and by treating hypertension.


coping emotion-focused coping problem-focused coping time management

stress management progressive muscle

relaxation systematic desensitization

biofeedback modeling cognitive restructuring

cognitive therapy problem-solving training stress-inoculation training

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/ENU (Use these settings to create Adobe PDF documents for quality printing on desktop printers and proofers. 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