Stress

Monday, September 18, 2006

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Friday, September 01, 2006

Evaluation Points You Should Know for Stress

Point 1: Compare and contrast Kanner's hassles and up-lifts measures with Holmes and Rahe's social readjustment rating scale (SRRS).

Comparisons; They both try to measure stress and both provide us with quantitative data.

Differences; measuring major life events (Holmes and Rahe) or measuring everyday events (Kanner).

Kanner argues, and has provided evidence, that measuring everyday hassles is a better predictor of stress related illness than measuring life events.

Point 2: Methodology.

Problems with fixed choice self-report measures (SRRS and/or Hassles and Uplifts). All the data is quantitative; lacks insight, lacks descriptive power. May ellicit oversimplified responses from Ps. If the participant's test-taking attitude is poor, the results will be unreliable and, more importantly, less valid.

In regards to the SRRS many of the stressors can be interpreted in many different ways. For example, the death of a spouse may vary significantly in regards to the level of stress as a life event; sudden death of a spouse will probably very stressful however the death of a spouse who had been chronically ill would probably not be half as stressful as originally thought.

Further, stressors are culturally specific and historically specific. For example, not everyone is married. Many of the life events may only be relevant to certain groups within a society and not to all, e.g. a mortgage. This means that as a measure of stress the SRRS may not be applicable to all people within a nation.

It doesn't allow us to look at how individual's cope with stress. Being fired from different jobs will present a range of different reactions; e.g. if you hated the job, you wouldn't care that much and therefore probably would not be as stressed. However, if it was a high-powered and well paid job, a lot of stress could be incurred, especially if you were fired suddenly for a questionable reason. thus individual differences are somewhat overlooked by this approach. Their method was trying to make the self report measures objective. Marriage for example, could be seen as an uplift, but on their test it is automatically marked as a stressor.

Finally some people may not be able to use such approaches to measuring stress - children are automatically excluded, and those who are introverted and may be put off by the test. Those with learning disabilities, and at the later stages of old age dementia. These all affect the usefulness of such approaches.

Point 3: Determinism

Holmes and Rahe's approach only measures one aspect of stress that might contribute to ill health. This is an example of determinism. If they wanted a better approach, they should include more variables, e.g. does the individual smoke, do they do much exercise etc. by measuring these other variables are they would gain it a more valid picture of how stressful life events affect the individual. The adoption of a deterministic approach to this topic leads us to only gaining a partial, incomplete and potentially invalid understanding of stress. Determinism in psychology in regards to stress assumes a very simplistic relationship between stressor and stress. Whereas this relationship needs to be seen as mediated through age, sex, ethnicity, socio-economic factors and individual differences.

Point 4: Modernist & Post-modernistic Views.

Modernist approaches are ones which assume that laws, facts and causal relationships can be found if the correct approach is adopted. Holmes and Rahe's approach can be seen as modernist because it assumes that if an individual experiences too many critical life events in the previous year they are highly susceptible to illness. However a post modernist approach would argue that a it is only by investigating the numerous factors that contribute to stress and how they interact together in complex and unpredictable ways, would we gain a valid understanding of the experience of stress and what contributes to this experience. Kanner's work starts to address this issue with it's emphasis on the same daily event as being both a potential hassle and potential uplift.

Causes/Sources of Stress

What is Stress?

There are three main theoretical ways of answering this question and they all have something to say in regards as to what the causes of stress are. Simply put, how we define stress will lead us to certain understandings as to what the causes are.

Stimulus Models of Stress

This approach argues that stress should be understood as a repsonse to certain environmentla stimuli, such as exposure to excessive noise, loss of a job, etc. Holmes and Rahe (1967) were the first researchers to attempt to investigate this model of stress in a seemingly scientific fashion. They began by choosing 43 probably stressful life events, and then asked 400 US adults to rate the relative amount of readjustment that they judged would be required by each of the 43 events. Holmes and Rahe then used their results to construct a social readjustment rating scale (SRRS) that assigns points values to different stressors and which has subsequently been used in research on the relationship between stress and physical illness. Such that if an individual experiences a number of high scoring stressful events in the previous year they are more prone to various forms of illness.

Some researchers felt dissatisfied with the SRRS because many of the events listed in it occur relatively rarely in anyone's life. There was a desire for a scale that reflected to a greater degree the day-to-day variation experienced by people in levels of the stress to which they are exposed. This led Kanner et al. (1981) to devise, using similar techniques to those of Holmes and Rahe, two further scales, a hassles scale consisting of everyday events that cause annoyance or frustration, and an uplifts scale consisting of events that make them feel good. For these researchers it is the everyday stressors that are the primary source of stress rather than significant major life events.

A further development in this line of research has been that we need to understand the nature of the stimulus to gain more insight into the reaction to it. One approach has been to distinguish between qualitatively different types of stressor and a useful fourfold classification has been put forward by Elliot and Eisdorfer (1982):

1 Acute, time-limited stressors: examples could be being threatened in the street or taking the driving test.

2 Stressor sequences: examples could be selling one's house or losing one's job.

Chronic, intermittent stressors: examples could be deadlines for journalists or premenstrual tension.

4 Chronic stressors: examples could be medical emergencies for doctors or living in cramped and overcrowded conditions.

A further distinction, introduced by Spielberger (1966, 1972), can be made between physical threats and ego threats (threats to our sense of self, such as bullying). Spielberger argues that everyone reacts in much the same way to physical threats, while only individuals high in anxiety experience large increases in stress in response to ego-threats.

Other souces of stress within this model are -

Crowding: Unquestionably, density and crowding affect human behavior. Sundstrom (1978), in a review of the literature, revealed that both laboratory and field studies have found density and crowding to be associated with increased aggression, withdrawal from interpersonal relations, increased crime rates, and a number of other negative factors. However because the experience of density and crowding are affected by our perception of the stimulus, this means that not all crowded conditions will create stress. For example, Mitchell (1971) found that, when the factor of poor housing was statistically controlled, high population density in Hong Kong for the most part had little adverse effect. However, when psychological variables were examined, some consistent and significant findings began to emerge. One was that, when nonrelated families occupied the same dwelling unit, stress increased. In other words, the number of people or families living in a house was not so important as the people's perceptions of one another. When people are forced to live with lonrelatives, the conditions are likely to be seen as crowded. Increased stress is the result.

Noise: Because noise is a subjective interpretation of sound, we can expect that not all sound will be percieved as noise. However when sound is interpreted as noise, often when we have no control over the sound, then stress is a common reaction. For example, A study by Glass and Singer (1972) indicated that personal control was an important factor in appraising the stressful effects of noise. Two groups of subjects were exposed to loud, distracting, bothersome noise. Subjects in one group were told that they could control the noise if it was too distracting, but those in the other group were given no such option. A third group was not exposed to noise. All groups worked on a task that required attention and vigilance. The performance of the group exposed to uncontrollable noise was worse than that of the other twc groups. This finding indicates that noise does not necessarily cause performance problems. Rather, the cause seems to be the lack of control that often accompanies loud sounds.

Occupation: The popular impression is that executives suffer from a high level of stress, but research indicates that other occupations are more stressful (Smith, Colligan, Horning, & Hurrel, 1978). Using stress-related illnesses as a criterion, the jobs of construction worker, secretary, laboratory techmcian, waiter or waitress, machine operator, farm worker, and painter are among the most stressful. These jobs all share a high level of demand combined with a low level of control. Another highly stressful job is middle-level manager, such as foreman or supervisor. Middle managers must meet demands from two directions: their bosses and their workers. Thus they have more than their share of stress-related illnesses (Smith et al., 1978). Most executives have jobs in which the demands are high but so is the level of control. The ime is true of physicians, who have jobs that include a very high level of demands but also a high degree of control. Medical students, however, are typically burdened with the undesirable combination of high demands and low control. Vitaliano et al. (1988) found that medical students were subject to high levels of stress and insiderably higher than average levels of anxiety. Furthermore, their anxiety was persistent, with no significant let-up over the nine-month school term.

Response Models of Stress

Because of the endless problems of identifying what stimuli people find stressful another approach has been to understand the response that people have to stress. Thus if we know you are responding to stress we can also then try to identify causes. In a sense the cause of stress is how your body responds to external stimuli.

Research on the physiology of stress originated in the work of Walter Cannon in the first half of the twentieth century. Cannon's theories revolve around the concept of homeostasis, whereby the physiological mechanisms of the body are considered as feedback systems functioning as far as possible to maintain a steady state. Homeostatic balance is disrupted not only by basic bodily needs, as in the case of hunger and thirst, but by any environmental stimulus which disrupts the body's state of equilibrium (e.g. excessive heat or cold, bacterial and virus infections, emotion provoking stimuli), thereby causing a reaction which has the function of reestablishing the inner balance. Anything which disrupts equilibrium may be regarded as a stressor (Cannon, 1932).

Under Cannon's influence, Hans Selye began a programme of animal experimentation into the physiological effects of noxious stimuli and other environmental stressors from the early 1930s until shortly before his death in 1982 (Selye, 1956, 1976). He argued for the existence of a generalized response, known as the general adaptation syndrome (GAS), which occurs whenever the body defends itself against noxious stimuli. The GAS occurs primarily in the pituitary-adrenocortical system and consists of three stages, an alarm reaction in which the body's defences are mobilized, a resistance stage in which the body adapts to the stressor, and an exhaustion stage in which the body's capacity to resist finally breaks down. The GAS may be likened to the process whereby an individual, confronted by sudden unexpected financial demands, takes out a bank loan (alarm reaction), and uses it to meet these demands (resistance stage) until further income is received and the loan repaid (recovery) or bankruptcy results (exhaustion stage). Selye particularly drew attention to the abnormal physiology of the animal during the resistance stage which, if protracted, could lead to what he called the diseases of adaptation. These include ulcers, cardiovascular disease and asthma. Thus anything which creates this kind of response can be viewed as a source of stress.

Interactional Models of Stress

A number of theorists have sought to overcome the problems of stimulus and response models by conceptualizing stress as a relationship between the individual and the environment and developing interactional models. The most influential of these was first put forward by Lazarus (1966). In this model psychological stress is defined as 'a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being'. A distinction is made between primary appraisal whereby an event may be perceived as benign and non-threatening, potentially harmful, threatening to one's self-esteem, or challenging, and secondary appraisal in which an assessment is made of one's ability to cope with the threat or challenge. Stress occurs whenever there is a mismatch between perceived threat and perceived ability to cope. Thus the source of stress is in the interaction between these variables.

Several studies have examined the effect of appraisal on stress and have evaluated the role of the psychological state of the individual on their stress response. In an early study by Speisman et al. (1964), Ps were shown a film depicting an initiation ceremony involving unpleasant genital surgery. The film was shown with three different sounds tracks. In condition one, the trauma condition, the sound track emphasized the pain and the mutilation. In condition two, the denial condition, the sound track showed the participants as being willing and happy. In condition three, the intellectualization condition, the sound track gave an anthropological interpretation of the ceremony. The study therefore manipulated the subjects' appraisal of the situation and evaluated the effect of the type of appraisal on their stress response. The results showed that subjects reported that the trauma condition was most stressful. This indicates that it is not the events themselves that elicit stress, but the individuals' interpretation or appraisal of those events.

Recently, theories of stress have emphasized forms of self-control as important in understanding stress. This is illustrated in theories of self-efficacy, hardiness and feelings of mastery.

1 Self-efficacy. In 1987, Lazarus and Folkman suggested that self-efficacy was a powerful factor for mediating the stress response. Self-efficacy refers to an individual's feeling of confidence that they can perform a refers to an individual's feeling of confidence that they can perform a desired action. For example, the belief 'I am confident that I can succeed in this exam' may result in physiological changes that reduce the stress response. Therefore, a belief in the ability to control one's behaviour may relate to whether or not a potentially stressful event results in a stress response.

2 Hardiness. This shift towards emphasizing self-control is also illustrated by Kobasa's concept of 'hardiness' (Kobasa et al. 1982; Maddi and Kobasa 1984). Hardiness was described as reflecting (a) personal teelings of control, (b) a desire to accept challenges and (c) commitment. It has been argued that the degree of hardiness influences an individual's appraisal of potential stressors and the resulting stress response. Accordingly, a feeling of being in control may contribute to the process of primary appraisal.

3 Mastery. Karasek and Theorell (1990) defined the term 'feelings of mastery', which reflected an individual's control over their stress response. They argued that the degree of mastery may be related to the stress response.

According to these recent developments, stress is conceptualized as a product of the individual's capacity for self-control. Successful coping and nanagement eradicates stress, failed self-regulation results in a stress aonse and stress-related illness is considered a consequence of prolonged failed self-management.

Measures of Stress

SRRS

One approach many scales have used is to develop a list of life events—major happenings that can occur in a person's life that require some degree of psychological adjustment. he scale assigns each event a value that reflects its stressfulness. The most widely used scale of life events has been the Social Readjustment Rating Scale (SRRS) developed by Thomas Holmes and Richard Rahe (1967). To develop this scale, these researchers constructed a list of events they derived from clinical experience. Then they had hundreds of men and women of various ages and backgrounds rate the amount of adjustment each event would require, using the following instructions:

Use all of your experience in arriving at your answer. This means personal experience where it applies as well as what you have learned to be the case for others. Some persons accommodate to change more readily than others; some persons adjust with particular ease or difficulty to only certain events. Therefore, strive to give your opinion of the average degree of readjustment necessary for each event rather than the extreme. (P. 213)

The researchers used these ratings to assign values to each event and constructed the scale shown below (not all the scale is shown) -

Rank Life Event Mean Value
1 Death of a spouse 100
2 Divorce 73
3 Marital separation 65
4 Jail term 63
5 Death of a close family member 63
6 Personal injury and illness 53
7 Marriage 50
8 Fired at work 47
9 Marital reconciliation 45
10 Retirement 45
11 Change in health of family 44
12 Pregnancy 40
13 Sex difficulties 39
14 Gain of new family member 39
15 Business readjustment 39
16 Change in financial state 38
17 Death of close friend 37
18 Change to different line of work 36
19 Change in number of arguments with spouse 35
20 Mortgage over $10,000 31
21 Foreclosure of mortgage or loan 30
22 Change in responsibilities at work 29
23
29
24
29
25
28
26
26
27
26
28
25
29
24
30
23
31
20
32
20
33 Change in schools 20
34 Change in recreation 19
35 Change in church activities 19
36 Change in social activities 18
37 Mortgage or loan less than $10,000 17
38 Change in sleeping habit 16
39 Change in number of family get-togethers 15
40 Change in eating habits 15
41 Vacation 13
42 Christmas 12
43 Minor violations of the law 11

To measure the amount of stress people have experienced, subjects are given a survey form listing these life events and asked to check off the ones that happened to them during a given period of time, usually not more than the past 24 months. The values of the checked items are then summed to give a total stress score.

Other life events scales-

The Life Experiences Survey (LES) contains 57 items that are stated relatively precisely, for example, "major change in financial status (a lot better off or a lot worse off)" Subjects rate each event on a 7-point scale, worse off"). Subjects rate each event on a 7-point scale, ranging from extremely negative (—3) to extremely positive (+ 3). The items perceived as positive or as negative can be examined separately or combined for a total change can be examined separately or combined for a total change score (Sarason et al , 1978)

The Unpleasant Events Schedule (UES) contains 320 items and takes an hour to complete (although a shorter, 53-item form is also available). The items are divided into a number of categories, such as sexual/marital/ friendship and achievement/academic/job, and stated relalively precisely, for example, "being fired or laid off from work." The subjects rate each item on a 3-point scale twice, first for frequency and then for aversiveness. These two ratings are multiplied, and a total score is summed for the entire schedule (Lewinsohn, Mermelstein, Alexander, & MacPhillamy, 1985.)

Hassles and Uplifts

Not all of the stress we experience comes from major life events. Lesser events can also be stressful, as when we give a presentation, misplace our keys during a busy day, or have our quiet disrupted by a loud party next door. These are called daily hassles.

Richard Lazarus and his associates have con>tructed a scale to measure people's experiences with day-to-day unpleasant or potentially harmful events (Kanner, Coyne, Schaefer, & Lazarus, 1981). This instrument—called the Hassles Scale—lists 117 of these events that range from minor annoyances, such as "silly practical mistakes," to major problems or difficulties, such as "not enough money for food." The subjects indicate which hassles occurred in the past month and rate each event as having been "somewhat," "moderately," or "extremely" severe. These researchers tested 100 middle-aged adults monthly over a 9-month period. The half-dozen most frequent hassles reported were:

  • Concerns about weight
  • Health of a family member
  • Rising prices of common goods
  • Home maintenance
  • Too many things to do
  • Misplacing or losing things

In the course of developing the Hassles Scale, these researchers proposed that having desirable experiences makes hassles more bearable and reduces their impact on health. So they developed another instrument, the Uplifts Scale, which lists 135 events that bring peace, satisfaction, or joy. This instrument was administered along with the Hassles Scale to the ) indicated which uplifts they experienced in the past month and whether each event had been "somewhat," "moderately," or "extremely" strong. Some of the most frequently occurring uplifts were "relating well to your spouse or lover," "completing a task," and "feeling healthy."

COPE

One consequence of the emergence of interactional models of stress (as discussed above) has been the development of checklists designed to assess the individual's predominant coping strategies. An example is the COPE questionnaire y Carver et al. (1989) which consists of 14 subscales each consisting of a number of items for which the individual tested indicates agreement or disagreement on a four-point scale.

In the COPE scale, you are asked how you respond when confronting 'vents in your life. To each item you use the following rating system:

  1. I usually don't do this at all.
  2. I usually do this a little bit.
  3. I usually do this a medium amount.
  4. I usually do this a lot.

The 14 COPE subscales with an example of a checklist item from each (the complete version contained four items per subscale) are:

  1. Active coping: I take additional action to get rid of the problem.
  2. Planning: I try to come up with a strategy about what to do.
  3. Suppression of competing activities: I put aside other activities in order rate on this.
  4. Restraint coping: I force myself to wait until the right time to do something.
  5. Seeking social support for instrumental reasons: I ask people who have had similar experiences what they did.
  6. Seeking social support for emotional reasons: I talk to someone about how I feel.
  7. Positive reinterpretation and growth: I look for something good in what is happening.
  8. Acceptance: I leam to live with it.
  9. Turning to religion: I seek God's help.
  10. Focus on and venting of emotions: I get upset and let my emotions out.
  11. Denial: I refuse to believe that it has happened.
  12. Behavioural disengagement: I give up the attempt to get what I want.
  13. Mental disengagement: I turn to work or other substitute activities to take my mind off things.
  14. Alcohol-drug disengagement: I drink alcohol, or take drugs, in order to think about it less.

Physiological Measures

Stress produces physiological arousal, which is refleeted in the functioning of many of our body sysOne way to assess arousal is to use electrical/ mechanical equipment to take measurements of blood pressure, heart rate, respiration rate, or galvanic skin response (GSR). Each of these indexes of arousal can be measured separately, or they can all be measured the polygraph. Miniaturised versions of can fit in a pocket, thereby allowing assessments during the person's daily life at home, at work, or in a stressful situation, such as while flying in an airplane or receiving dental treatment (Carruthers, 1983). Using one of these devices, researchers have shown that paramedics' blood pressure is higher during ambulance runs and at the hospital than during other work situations or at home (Goldstein, Jamner, & Shapiro, 1992).

Another way to measure arousal is to do biochemical analyses of blood or urine samples to assess the level of hormones that the adrenal glands secrete. Using this approach, researchers can test for two classes of hormones: corticosteroids, the most important of which is cortisol, and catecholamines, which include epinephrine and norepinephrine. The analysis is done by a chemist using special procedures and equipment. For example, a series of field studies undertaken in Sweden on commuter trains have found that negative physiological reactions increase as density (a stressor) increases. This was measured from urine samples given by commuters! (Lundenberg 1976).

Management of Stress

Social Support

There is little doubt that social support does help us to cope with stress, even though at times our social networks can be a source of stress. For example, In 1986 Lisa Berkman looked at previous studies on social support and concluded that soart clearly helps men cope against stress that might be related to mortality, especially death from heart disease. One reason for this is that socially isolted people will be less likely to have friends and acquaintances who encourage them to protect their health or go to the doctor when they are sick. Perhaps the most frequently suggested explanation is that social support lessens or eliminates the harmful effects of stress and therefore protects against disease and death. This buffering hypothesis assumes, of course, some physlological consequences of stress, an assumption well supported by research (Zegans, 1982). Some evidence exists to support this buffering hypothesis. In one study, women who had a close, intimate relationship were largely unaffected by severely stressful events, whereas those with no strong social supports experienced a substantial disturbance when faced (Brown et al, 1975).

Relaxation Training

With progressive muscle relaxation, patients are first given a rationale for the procedure, including an explanation that their present tension is mostly a physical state resulting from tense musles. While reclining in a comfortable chair with no distracting lights or sounds, patients are asked to breathe deeply and then to exhale slowly. After this, the series of deep muscle relaxation exercises begins. Because patients must have some sense of how relaxation feels, they are instructed to tense a particular muscle group (for example, the hand) and to hold the tension for ibout 10 seconds (Jacobson, 1938). Then they are asked to slowly release the tension, concentrating on the relaxing, soothing sensations in their hand as tension gradually drains away. Once the hand is relaxed, patients go through the same tensing and relaxing sequence with other muscle groups, including the arms, shoulders, neck, mouth, tongue, forehead and eyes, toes, calves, thighs, back, stomach, and other muscle groups.

Patients may repeat the breathing exercises until they achieve a deep feeling of relaxation. Frequently, patients are also encouraged to focus on the pleasant feeling of relaxation, which restricts their attention to internal events and away from external sources of anxiety and stress. They can rate their level of relaxation on a scale of 1 to 10 or can signal by raising an index finger when tension begins to increase.

Once patients learn the relaxation technique, they may practice independently at home. If independent practice is too difficult, prerecorded audiotapes are available that allow patients to lisnothing voice of a professional inithout returning to the clinic. The if relaxation training programs varies, 1 and about 10 sessions with :ructor are usually enough to allow patients itly enter into a state of deep relaxation (Blanchard and Andrasik, 1985).

Biofeedback

In biofeedback, biological responses are measured by electronic instruments, and the status of those responses is immediately available to the person being tested. In other words, a person gains information about changes in biological responses as they are taking place. This feedback allows the person to alter physiological responses that cannot voluntarily be controlled without the biofeedback information. The type of biofeedback most commonly in clinical use is electromyograph (EMG) biofeedback. EMG biofeedback reflects the activity of the skeletal muscles by measuring the electrical discharge in muscle fibers. The measurement is taken by attaching electrodes to the surface of the skin over the muscles o be monitored. The level of electrical activity reflects the degree of tension or relaxation of the muscles. The machine responds with a signal that varies "with the electrical activity of the muscle. The electrodes may be placed over any muscle group, but the forehead is the most common placement site.

A review by Andrasik, Blanchard, and Ediund (1985) indicated that research in this area has been quite consistent. Ps are able to significantly reduce muscle tension during EMG biofeedback training. These authors remained unconvinced, however, that these reductions resulted in significant clinical benefit and concluded that EMG feedback may not be better than alternative procedures, including relaxation training. Biofeedback therapy can be an effective mode of stress management for certain patients, but because it produces relaxation, some of its positive effects may be attributable to increases in relaxation rather than to the precise control of the physiology involved with responses to stress.

Stress Inoculation Techniques

One way of preventing illness is to inoculated against certain diseases. Meichenbaum and Cameron (1983) have argued that stress inoculation (being prepared for stress) can work in a similar way. Their theraputic intervention uses 3 stages -

The first stage, conceptualization, is oriented toward identifying the sources of the problem and enhancing the client's ability to do the same. Interviewing the client is one way of gathering information, but it is not the only technique used. Specific experiences may be created using guided imagery so the therapist can anayze the client's reaction. Direct behavioral observation and the client's written accounts of stressful events are also frequently used.

The second stage in stress inoculation uses both cognitive and behavioral techniques. Meichenbaum and Cameron call this stage skills acquisition and rehearsal. The client learns new coping skills and practices those already acquired. One of the goals of this stage is to improve self-instruction by changing cognitions. This process includes monitoring one's internal monologue (talking to oneself). The therapist develops a list of self-statements. For a student with test anxiety, for example, the therapist might suggest this self-statement: "Take this test one item at a time. I know the material, so I can answer these questions." The list ofselftements is to be repeated in the problem situation. Initially, the therapist may model this behavior, demonstrating how to repeat the statements and in what situations. Then the ;at these self-statements and work on internalizing the procedure, so that they will more readily appear when the therapist is not present, for example, when the student is taking a test.

The final stage of stress inoculation is application and follow-through. This stage is behavioral, and Meichenbaum and Cameron consider it essential to the completion of stress inoculation training. They do not assume that outcomes of therapy will be transfered into the client's everyday life. To achieve behaviour change the P needs to use techniques such as role playing under simulated stress situations.