Counselling for Stress Problems

Books

Stephen Palmer & Windy Dryden

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  • Counselling in Practice

    Series editor: Windy Dryden

    Associate editor: E. Thomas Dowd

    Counselling in Practice is a series of books developed especially for counsellors and students of counselling which provides practical, accessible guidelines for dealing with clients with specific, but very common, problems.

    Counselling Couples

    Donald L. Bubenzer and John D. West

    Counselling Survivors of Childhood Sexual Abuse

    Claire Burke Draucker

    Counselling with Dreams and Nightmares

    Delia Cushway and Robyn Sewell

    Counselling People with Communication Problems

    Peggy Dalton

    Counselling for Depression

    Paul Gilbert

    Counselling for Anxiety Problems

    Richard Hallam

    Career Counselling

    Robert Nathan and Linda Hill

    Counselling for Post-traumatic Stress Disorder

    Michael J. Scott and Stephen G. Stradling

    Counselling for Family Problems

    Eddy Street

    Counselling for Alcohol Problems

    Richard Velleman

    Copyright

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    Dedication

    To Maggie and Louise

    Foreword

    Stephen Palmer and Windy Dryden have written a splendid book! By stressing the need for a multimodal approach (instead of the more usual uni-modal, bi-modal or, at best, tri-modal orientations so widely practised), they clearly demonstrate how it is possible to employ a wide range of strategies in a rational and flexible manner for combating the ravages of stress. The systematic framework endorsed by multimodal practitioners enables one to embrace a series of methods that, as Professor Dryden has emphasized in many places, is ‘challenging but not overwhelming’. The methods endorsed in this book are easy to understand, easy to apply and easy to remember.

    The multimodal approach (Lazarus, 1989a) rests on the assumption that unless seven discrete but interactive modalities are assessed, treatment is likely to overlook significant concerns. Initial interviews and the use of a Multimodal Life History Inventory (Lazarus and Lazarus, 1991) provide an initial overview of a client's significant Behaviours, Affective responses, Sensory reactions, Images, Cognitions, Interpersonal relationships and the need for Drugs and other biological interventions. The first letters yield BASIC ID, an acronym that is easy to recall. These modalities exist in a state of reciprocal transaction and flux, connected by complex chains of behaviour and other psychophysiological processes.

    The counsellor or therapist, usually in concert with the client, determines which specific problems, across the BASIC ID, are most salient. Whenever possible, the choice of appropriate techniques rests on well-documented research data but, as this book illustrates, multimodal counsellors remain essentially flexible and are willing to improvise when necessary.

    The multimodal approach is essentially psycho-educational and contends that many problems arise from misinformation and missing information. Thus, as Palmer and Dryden indicate, with most outpatients, ‘bibliotherapy’, the use of selected books for home reading, often provides a springboard for enhancing the treatment process and content.

    An assiduous attempt is made to tailor the therapy to each client's unique requirements. Thus, in addition to mastering a wide range of effective techniques, multimodal counsellors or clinicians address the fact that different relationship styles are also necessary. Some clients require boundless warmth and empathy; others prefer a more austere business-like relationship. Some prefer an active trainer to a good listener (or vice versa). Because the therapeutic relationship is the soil that enables the techniques to take root, it is held that the correct method, delivered within, and geared to, the context of the client's interpersonal expectancies, will augment treatment adherence and enhance therapeutic outcome.

    In essence, this book contains an enormous amount of useful clinical information that can readily be translated into effective and efficient treatment and counselling procedures. I think it deserves a very wide readership.

    Arnold A.LazarusDistinguished Professor of Psychology Rutgers University

    Preface

    Stress counselling and stress management has become a new growth industry. Often in counselling or training settings the practitioner only uses one approach, such as non-directive counselling or relaxation training. Alternatively, an eclectic approach involving a confusing mish-mash of techniques is used. Either way, clients receiving stress counselling are not always given the most effective help for their individual problems (see Palmer and Dryden, 1994).

    This book has been written to provide practitioners with a technically eclectic and systematic approach to stress counselling and stress management. The approach is technically eclectic as it uses techniques taken from many different psychological theories and systems, without necessarily being concerned with the validity of the theoretical principles that underpin the different approaches from which it takes its techniques. It agrees with London (1964: 33) who stated: ‘however interesting, plausible and appealing a theory may be, it is techniques, not theories, that are actually used on people. Study of the effects of psychotherapy, therefore, is always the study of the effectiveness of techniques.’

    The techniques are applied systematically, based on data from client qualities, the counsellor's clinical skills and specific techniques. The approach is underpinned by social learning theory, general systems theory, group and communications theory (Lazarus, 1987), and is based on the extensive work of Arnold Lazarus (1973b, 1981). It has been adapted to the field of stress by the authors (Palmer, 1992a; Palmer and Dryden, 1991). Experienced counsellors may be able to integrate this approach within their own working model.

    Our approach to stress counselling and stress management incorporates Lazarus' thorough and comprehensive multimodal assessment procedures. These procedures involve the counsellor assessing a client from seven discrete modalities which Lazarus believes comprise the entire range of personality: Behaviour, Affect, Sensation, Imagery, Cognition, Interpersonal, Drugs/biology. Hence the approach's ‘Multimodal’ perspective. It uses techniques pioneered by Carl Rogers, Aaron Beck, Albert Ellis, Donald Meichenbaum and others.

    This book will introduce counsellors, psychotherapists and trainers to multimodal assessment procedures and show them how these methods logically lead to the application of interventions for use with individual clients. Real examples are taken from the authors' clinical practice to show the model in action. In Chapter 1, we discuss a working model of stress; in Chapter 2, we explain the multimodal assessment procedures and therapeutic approach. From Chapter 3 we describe the different techniques that can be used in a multimodal approach to stress counselling. Chapters 38 each feature a different modality. Lazarus' seventh modality, Affect (emotion), has been integrated into the other chapters as Lazarus has argued that you cannot change affective reactions without using methods derived from the other six modalities (Lazarus and Lazarus, 1990a).

    This book takes a pragmatic and empirical approach to stress counselling and can be used as a handbook of multimodal techniques. Even if counsellors, psychotherapists or trainers do not use the multimodal approach we describe in this book, it may nevertheless stimulate their thinking about how to approach stress counselling in a broad and comprehensive manner.

    A note about pronouns: where no specific sex is intended, the use of ‘he’ and ‘she’ has been alternated for clients.

  • Postscript

    This book has included a wide range of different techniques and interventions, some of which may be quite new for many counsellors. We therefore recommend that counsellors receive adequate supervision when using this approach. For those counsellors with insufficient experience in the application of these techniques, further training is available in Britain at the Centre for Multimodal Therapy (address below). In the United States of America training is available at a number of centres.

    Although the Multimodal Life History Inventory is not essential for stress counselling, we have found that it helps the counsellor to develop an individual stress programme for each client. In Britain counsellors can purchase copies from the Centre for Multimodal Therapy. In America they can be purchased from Research Press. Counsellors experiencing any difficulty obtaining biofeedback instruments, biodots, client handouts or other items mentioned in this book can write to the authors for further information and advice.

    The authors would be interested to hear your views and experience of multimodal stress counselling and stress management. Please write to:

    Centre for Multimodal Therapy

    156 Westcombe Hill

    London SE3 7DH

    Appendix: Handouts and Information

    Throughout this book we have included boxed information which can be used as handouts to clients in stress counselling or stress management workshops. Here we offer additional sample materials, which the multimodal stress counsellor or trainer may find useful, followed by a section on recommended manuals and audio-visual materials.

    Handout 1: Definitions

    The following definitions will be helpful to you as you begin to learn about how you might best cope with stress in your life.

    Stress
    • Bodily reaction to some stimuli in the environment.
    Anxiety
    • Learned. Pairing of stimuli and response.
    • Emotional response to a threatening situation or object.
    • Prepares body for fight or flight.
    • Normal reaction to stresses of life; no one is anxiety free.
    • Can be useful to us by causing increased alertness, taking important things seriously, and motivating change and development.
    Distress
    • Unmanaged stress and anxiety.
    • Anxiety is a problem when it occurs in response to non-threatening stimuli or events and/or is an unrealistic fear of failing at tasks.
    Possible Consequences of Distress
    • Impaired health.
    • Blood pressure increases in response to stress.

    Increased blood pressure can increase incidence of hardening of arteries, heart attacks and strokes.

    Combined with other factors, such as heredity, diet and exercise, high blood pressure and associated disorders account for almost half of all deaths in the United States and the United Kingdom.

    Source: Ross and Altmaier, 1994
    Handout 2: What is Stress?

    Too much or too little pressure leads to stress

    Handout 3: Daily Log

    Handout 4: Distress Symptoms or Signals

    As a way to begin to evaluate how much distress you are experiencing in your life, consider the list of symptoms below. Place a tick next to all the symptoms that describe you currently.

    • ____ Expression of boredom with much or everything
    • ____ Tendency to begin vacillating in decision-making
    • ____ Tendency to become distraught with trifles
    • ____ Inattentiveness or loss of power to concentrate
    • ____ Irritability
    • ____ Procrastination
    • ____ Feelings of persecution
    • ____ Gut-level feelings of unexplainable dissatisfaction
    • ____ Forgetfulness
    • ____ Tendency to misjudge people
    • ____ Uncertain about whom to trust
    • ____ Inability to organize self
    • ____ Inner confusion about duties or roles
    • ____ Physical changes such as:
      • ____ Sudden, noticeable loss or gain of weight
      • ____ Sudden change of appearance
      • ____ Decline or improvement in dress
      • ____ Sudden changes of complexion (sallow, reddened, acne)
      • ____ Difficult breathing
      • ____ Sudden change in smoking habits
      • ____ Sudden change in use of alcohol
      • ____ Allergies or new allergies
      • ____ Sudden facial expression changes
      • ____ Sudden changes in social habits
      • ____ Not going to work or home according to past schedule
      • ____ Change of life situation or style (for example, marriage, birth of baby, divorce, death of spouse)
    Source: Ross and Altmaier, 1994
    Handout 5: Relaxation Diary

    Handout 6: Three Basic Musts

    1 Demands about self

    I must do well

    And be approved by significant others

    If I'm not, then it is awful

    I can't stand it

    And I am a damnable person to some degree when I am not loved or when I do not do well

    Leads to stress, anxiety, depression, shame and guilt

    2 Demands about others

    You must treat me well and justly

    And it's awful and I can't bear it when you don't

    You are damnable when you don't treat me well

    And you deserve to be punished for doing what you must not do

    Leads to anger, rage, passive-aggressiveness and violence.

    3 Demands about the world/life conditions

    Life conditions under which I live absolutely must be the way I want them to be

    And if they are not, it's terrible

    I can't stand it, poor me

    Leads to self-pity, other pity, hurt, procrastination and addictive behaviour

    Flexible beliefs, desires, wants, preferences v. absolute/dogmatic musts, shoulds, oughts

    Self-esteem v. self-acceptance (of fallibility)

    Statements of toleration (it's bad but not awful)

    Always and never thinking (always will fail, never succeed)

    Handout 7: Stability Zones

    Stability zones can be considered as those physical areas where an individual may be able to relax, feel safe and be able to forget about worries. However, this is different for every individual but some examples may be:

    • Home with or without the family
    • Holiday home/caravan
    • Park
    • Room
    • Bath
    • Beach
    • Favourite pub, restaurant, café, chair, country walk, old car, old clothes

    Rituals are enjoyable regular or irregular habits or routines that individuals may have in their repertoire of adaptive behaviour. However, these rituals are not to the point of obsession. Some examples may be:

    • Walking the dog
    • Morning cup of tea
    • Hobbies
    • Weekend breaks
    • Eating out on Friday nights
    • Reading book on the way to work
    • Sunday outings
    • Holidays
    • Watching old films
    • Talking/meeting old friends

    Often stability zones and rituals are linked together, e.g. drinking a cup of tea while sitting in a favourite chair and listening to one's favourite radio programme. Stability zones and rituals are one way of coping with stress and when used in moderation they act as buffers. However, if applied inappropriately or to excess, they can inhabit creativity and change.

    Source: Palmer, 1989
    Handout 8: Value of Various Exercises

    Handout 9: Role Demands

    Handout 10: Constructive Self-Talk
    SituationNegative self-talkConstructive self-talk alternative
    Handout 11: Assignment Task Sheet

    Handout 12: Homework Diary for Exposure Programme

    Handout 13: Stress Management Plan

    Handout 14: Assertiveness Problem Hierarchy form

    Handout 15: Assertiveness Behaviour Diary

    Handout 16: Thought Form to Help Clients to Dispute Irrational Beliefs
    ABCDE
    Activating event/problemSelf-defeating beliefsEmotional/behavioural consequencesDisputing beliefsEffective new beliefs, emotions and behaviours
    Instructions: Write your problem or activating event in column A. Note in column C your unhealthy and unhelpful emotion(s). These are anger, depression, anxiety, guilt, shame. The healthy alternatives are annoyance, sadness, concern, remorse, regret. Irrational beliefs consist of dogmatic musts, shoulds, have tos, ‘I can't stand it’, ‘it's awful’ statements which are placed in column B. Disputes are logical (how does it follow?), empirical (where is the evidence?) and pragmatic (where is holding on to this belief going to get me?). These are written in column D. Rational alternatives consist of wishes, desires and wants and are placed in column E. Effective behaviours help you deal with the situation in a helpful manner.
    Handout 17: Stress Mapping

    A stress map is a visual means of representing the sources of stress in your life. The central box represents yourself and the other boxes represent people you are in contact with. The other boxes can represent other potential stessors too, such as new computers or internal demands you place on yourself e.g. perfectionist beliefs.

    Complete the boxes and then rate the amount of stress each other potential stressor can cause you on a scale of 1 to 10, where 10 represents high levels of stress. Place the score next to the appropriate stressor. Then ask yourself how much stress you may cause the other people on your stress map. Also note these scores down.

    Once the exercise is completed, note down any insights that you may have gained from undertaking stress mapping.

    Source: Palmer, 1990b

    Training Materials

    Bailey, R., (1989) 50 Activities for Managing Stress. Hampshire: Gower (trainer's manual).
    BBC (1991) Managing Pressure at Work. London: BBC Training Videos (useful video for stress management workshops).
    Clarke, D. and Palmer, S. (1994) Stress Management. Cambridge: National Extension College (a trainer's manual and self-help book for clients or course participants).
    HMSO (1987) Understanding Stress, part 3. London: HMSO (trainer's manual).
    Howell, M. and Whitehead, J. (1989) Survive Stress: a Training Guide. Cambridge: Cambridge Health Promotion (trainer's manual).
    Lazarus, A.A. (1975) Learning To Relax. New York: Institute for Rational-Emotive Therapy (cassette).
    Lazarus, A.A. (1995) Personal Enrichment through Imagery. London: Centre for Multimodal Therapy (cassette).
    Lazarus, A.A. (1995) Multimodal Training Aids: Insomnia, Tension, Headache and Smoking. London: Centre for Multimodal Therapy (cassettes).
    Palmer, S. (1988) Personal Stress Management Programme. London: Centre for Stress Management (handouts for completion by clients or course participants).
    Ross, R.R., and Altmaier, E.M. (1994) Intervention in Occupational Stress: a Handbook of Counselling for Stress at Work. London: Sage (book with 25 useful sample handouts for clients).
    Wycherley, R.J. (1990) Stress at Work. East Sussex: Outset (trainer's manual).

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