The treatment of stress is divided into three phases (Stanley, Norman & Burrows, 1999). Firstly, the medical, psychiatric and psychological conditions that are the outcome of the stress experience are treated in their own right. Anxiety, depression or the effects of attempts to manage their psychological distress by alcohol or drug use require appropriate clinical management first. Secondly, the chronic hyperarousal is treated, and this 'arousal management' contributes to controlling the secondary psychological distresses. In the third phase, the patient is assisted with stress prevention by developing more effective strategies for dealing with life stressors as well as changing attitudes, habitual thought processes and learned behavioral patterns.
Hypnosis as a therapeutic approach contributes to all three of these components of stress management. The part hypnosis may play in cognitive/attitudinal change, arousal management and in the treatment of the psychological and physical consequences of stress, will be reviewed and the management of anxiety disorders that may result from chronic stress will be outlined.
PHASE ONE: MEDICAL, PSYCHOLOGICAL AND PSYCHIATRIC TREATMENT
Medical illnesses contributed to by the stress process require the same medical interventions as those conditions where stress has not contributed. In treating the condition the contribution of stress as a precipitant and exacerbating factor is noted. So cardiovascular disease is treated as cardiovascular disease is usually treated, respiratory disorders as any respiratory disorder.
The same applies to depression or anxiety disorders. With the diagnosis of a psychiatric or psychological disorder the treatment of choice may be either pharmacological or psychological or both. The nature and severity of the presenting condition will be considered in making this decision. Effective antidepressant medication or the judicious use of benzodiazepines may have a part to play in treating the outcome of the stress.
The psychological treatment of stress-related and anxiety disorders may involve a wide variety of techniques based on psychotherapeutic, behavioral and cognitive principles. Cognitive, behavioral and other psychotherapies are applied on the basis of their proven effectiveness in treating the particular presenting condition. If the treatment of choice for the particular condition precipitated by the stress experience is psychotherapy, this may be used with or without drug therapy. Hypnosis may enhance treatment as a result of being a particularly persuasive form of communication. Some of the phenomena of hypnosis may be used directly to enhance the psychological treatment.
PHASE TWO: COGNITIVE AND ATTITUDE CHANGE
This phase focuses on lowering stress-proneness and involves individualized treatment. Cognitive and attitude change takes into account personality characteristics, flexibility, life experiences, ongoing problem situations, the availability of suitable coping strategies to resolve problem situations and the patient's confidence in coping strategies. It may also need to consider the patient's ability to tolerate partial solutions to challenging situations. Stress prevention programmes are also individualized on the basis of the aetiological contributions to the particular stress responses the patient shows, or if carried out in a group setting they need to cover the full range of likely contributors. Patient education, concerning the nature of stress and the variety of stress responses, is an essential part of the programme. The patient is assisted in recognizing what events result in stress, including what is the impact of their lifestyle. Many are unwilling or unable initially to identify the events, interpretations or lifestyle contributions, and require encouragement to do so.
Interpretation of events and situations as threatening, an essential cause of attitudinal and cognitive causes of stress, requires the sufferer to be encouraged to challenge their assumptions about the nature of their current experiences. This is done using the common cognitive-behavioral therapy approaches (Beck, 1995). Inappropriate interpretations are dealt with by the cognitive-behavioral approach of challenging automatic thoughts. When the process involves problem-solving strategies which are ineffectual, treatments focus on developing effective problemsolving strategies and on making them habitual. These approaches involve appropriate labelling of the problem as a challenge to be overcome, identifying the range of solutions available, choosing the solution that has the potential most likely to minimize discomfort and effect a resolution, and evaluating the outcome if the solution is not as desired. Passivity and problem avoidance must be overcome, and rather than seeing problems as threats, the patient must be encouraged to see them as part of the range of life's challenges.
Because personality characteristics such as perfectionism and obsessiveness get in the way, patients need to be encouraged to be flexible in evaluating the situation. They need to develop the ability to perceive the range of complete or partial solutions. They need to be assisted to choose between the possible solutions, in the knowledge that while they may desire to get it right, if they do not they will simply make another choice or consider it a learning experience. They need to see that their self-esteem or self-worth is not related to finding the perfect solution. Indecision and passivity are presented as being worse than trying an inadequate solution that can be changed later if unsuccessful. The realistic recognition that life is problematic and challenging is encouraged. Some experiences such as the death of a loved one are to be coped with and survived as part of the vicissitudes of life. A willingness to deal with the unsolvable is a necessary part of coping with the inevitable challenges life throws at us all.
Self-esteem and confidence in their ability to find and effect solutions need to be encouraged. Low self-esteem may reflect long-standing personal difficulties that require more extensive interventions. If necessary, psychotherapy may be recommended to free the patient from the 'ghosts' of the past that continue to colour the way they deal with their present life and therefore to sensitize them to exhibit stress responses in the present.
PHASE THREE: AROUSAL MANAGEMENT
The exaggerated physiological response to the particular difficulties and/or a habitually increased basal level of arousal may be treated in the initial phase with appropriate medication.
Longer term it is desirable that the patient can manage the exaggerated phasic and tonic arousal via other strategies such as relaxation, meditation, self-hypnosis, biofeedback or exercise programmes. Relaxation/meditation techniques if practised regularly have been shown to progressively lower the basal physiological arousal. There are many different approaches to meditation and relaxation (Jacob-son, 1929; Benson, 1975), but they essentially involve similar principles. The patient needs to be motivated to persist as it is the alteration of a habitual basal or phasic response that is being sought. Practice may be needed daily for 6-12 months and regularly after that time (maybe 2-3 times a week).
The modern use of hypnosis is a very effective technique in reducing inappropriate or prolonged arousal. Self-hypnosis can be used to alter the phasic responses or the habitual elevation in basal arousal levels (Stanley, Norman & Burrows, 1999). If the patient can use hypnosis and the therapist is properly trained in its use, it not only speeds up treatment (perhaps by as much as one-third) but also enhances the sense of self-control and problem resolution in the future, thereby becoming part of stress prevention as well. There are contraindications to the use of hypnosis and its inappropriate use can worsen the patient's condition (Stanley, 1994). Effective training is essential for the use of hypnosis to be safe (Stanley, Rose & Burrows, 1998).
Exercise and the maintenance of physical fitness also reduce the inappropriate arousal responses to stressful life events. The effects are reported immediately after exercise and following a regular exercise programme (Markoff, Ryan & Young, 1982; Ransford, 1982). Both basal and phasic physiological responses are reduced as a result of increased physical fitness. Once more motivation of the patient to maintain this programme is difficult even after the rationale is explained.
Where stress is not the result of challenges being turned into threats, stress management may need to consider lifestyle changes. Constant, ongoing stimulation (even positive stimulation) may accumulate to manifest itself in a hyperarousal stress response. The patient needs to accept the requirement for restoration of biological and psychological homeostasis, or in other words the reduction of basal arousal back into the middle of the range. Lifestyle and behavioral changes of this sort are difficult to achieve and maintain. It is rarely easy for patients to make the connection between constant stimulation of their lifestyle and the stress-related disorders they suffer or may likely suffer. They are often deriving such benefits from their current lifestyle, that they are ambivalent if not downright resistive to change. Even if they do make significant changes, they have difficulty in maintaining them as the pay-off is not clear (and the habitual behaviors that have more evident rewards return). Ongoing tangible or self-administered rewards for suitable lifestyle change may need to be built into the stress management. Effective time management, exercise programmes, relaxation, recreation, changes in diet, alcohol use and other drug use (including smoking) need to be considered. These are difficult to achieve until the patient makes the connection (and not just intellectually) between their lifestyle and their health. Even with this connection being made, motivation to change must be present or be cultivated. Hypnosis may be used to develop the individual motivation.
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