Health and Clinical Psychology Unit

Area 2 = Stress

OCR Specification

Stress

Stress appears to be a major factor in the health of people, with psychologists interested in improving the health of the nation by identifying causes, and trying to encourage stress management techniques

Causes of stress and supporting evidence

• Work (e.g. Johansson 1978); • Hassles and life events (e.g. Kanner 1981); • Lack of control (e.g. Geer & Meisel 1973).

Methods of measuring stress and supporting evidence

• Physiological measures (e.g. Geer & Meisel 1973); • Self report (e.g. Holmes & Rahe 1967); • Combined approach (e.g. Johansson 1978).

Techniques for managing stress and supporting evidence

• Cognitive (e.g. SIT, Meichenbaum 1975); • Behavioural (e.g. biofeedback, Budzynski 1973); • Social (e.g. social support, Waxler-Morrison 2006).

Section = Causes Of Stress And Supporting Evidence

Subsection = Worke.g.Johansson et al. (1978)

Stress In The WorkplaceAim: to investigate whether work stressors such as repetitiveness, machine-regulated pace of work and high levels of responsibility increase stress-related physiological arousal and stress related illnessProcedure: The researchers identified a high-risk group of 14 “finishers” in a Swedish sawmill. Their job was to finish off the wood at the last stage of processing timber. The work was machine-paced, isolated, very repetitive yet highly skilled, and the finishers’ productivity determined the wage rates for the entire factory. The 14 “finishers” were compared with a low-risk group of 10 cleaners, whose work was more varied, largely self-paced, and allowed more socialising with other workers.

A combined approach was taken to measure the ppts’ stress: Each participant had to give a urine sample when they arrived at work

and at four other times a day so that their levels of stress-related hormones (adrenaline and noradrenaline) could be measured.

Their body temperature was recorded at the same time as this can give an indication of how alert a person is.

These two physiological measures were combined with self report where each participant had to say how much caffeine and nicotine they had consumed since the last urine test. They also had to report on a range of emotions and feelings as well as sleepiness, well-being, calmness, irritation and efficiency etc. They had to scale these feelings on a continuum from minimum to maximum using a scale with millimetres. The score was how many millimetres from the base point the participants had marked themselves to be feeling.

This combined approach gave a range of stress measurements enabling Johansson to compare the two groups of workers and understand the impact of higher stress levels on the participants.

Results: - The high risk group had significantly higher stress hormone levels, with

levels increasing throughout the day.- Self reports showed that the high risk group felt more rushed and

irritated than the control group. They also rated their well-being as lower than that of the control group.

Conclusions:A combination of work stressors- especially repetitiveness, machine-pacing of work and high levels of responsibility – lead to chronic (long-term) physiological arousal. This in turn leads to stress-related illness and absenteeism.If employers want to reduce illness and absenteeism in their workforce, they need to find ways of reducing these work stressors, for example by introducing variety into employees’ work and by allowing them to experience some sense of control over the pace of their work.

Evaluation:Some important variables, such as individual differences, were not controlled in this study; it may be that certain people who are vulnerable to stress (e.g. those exhibiting Type A behaviour) may be attracted to high-risk demanding jobs, such as finishing in a sawmill. In addition, the study does not identify which of the various work stressors may be the most stressful. The high risk group was exposed to low levels of control through repetitive machine-paced work, physical isolation and high levels of responsibility.

To separate out the effects of these different factors, a more controlled experimental study would have to be carried out, but this would be at the expense of ecological validity.

Section = Causes Of Stress And Supporting Evidence Subsection = Hassles and Life EventsBackground: Life events and stress - Holmes and Rahe's SRRS (Social Readjustment Rating Scale) Holmes and Rahe (1967) were two psychiatrists who noticed that many of the patients that they visited on their rounds had suffered stressful life events causing disruption to their lives in the previous year.  They decided to construct a questionnaire to examine the possible link between life changing events (stress) and physical ill-health. They examined the medical records of over 5000 patients and from this they they compiled a list of 43 "life events".

The events were rated in relation to the time it would take to get your life back to some semblance of normality following the event (how much "readjustment" would be needed). This was done by getting approx 400 adults to give each item a score out of 100 in comparison to the baseline score they were given of 100 for "death of a spouse". Averages from the standardisation sample were used to give numerical values to each of the 43 events, for example: The scale starts at 100 LCUs (Life Change Units) for ‘death of a spouse' and ends with 11 LCUs for ‘minor violation of the law.’

TASK - COMPLETE THE SRRS QUESTIONNAIRE FOR YOU FOR THE LAST 12 MONTHS AND ADD UP YOUR STRESS SCORE

The scale was tested on different groups of people to determine its relevance.  Patients would add up the scores for each life event they had experienced in the last 12 months and this would be their total LCU.  Holmes and Rahe predicted that the higher the score, the more likely the person would be to develop an illness (as they would have experienced more stress in their lives).They noted that people who scored between 200 and 300 over a given year were statistically likely to develop health problems the following year. People scoring over 400 were likely to develop a major illness.The SRRS has its problems, however including:

Major life events are quite rare and many people will score close to zero Some of the items on the list are vague and ambiguous Some of the items will have greater value for some groups I society than

others There are large individual differences in our ability to cope with stressful

life events There are large cultural and subcultural differences in our experiences

of events The values of events changes with time, and changing social customs,

such that the original 1967 SRRS has had to be adapted as the original has lost validity over time.

In addition, the SRRS is a self-report qre which can be falsified by respondents

e.g. Kanner et al . (1981)Hassles and life events – which is the most valid way to measure

the causes of stress?As a result of the fact that major life events are rare and many people might score low on the SRRS , Kanner et al (1981) theorised that a better (more

valid) measure of stress might be to measure not the major life events that a person experiences but instead to measure the minor everyday hassles that they experience. They argued that hassles were a cause of stress that we all experience and on a daily basis.

Aim: to see whether the daily hassles and uplifts scales are more accurate in predicting stress than a life events scale.Procedure: Some 100 participants (52F 48M, all white, well-educated and comfortably well off) were selected from a sample of 7000 ppts who were already in a study in Alameda County, California USA. Each ppt was asked to complete questionnaires once a month for ten months including a life events qre (similar to Holmes and Rahe’s) and the Daily hassles and Daily Uplifts scale developed by Kanner et al. and scales to measure psychological well-being.Findings:Kanner et al found that the hassles scale was a better predictor of psychological symptoms than the life events scores.Conclusions: from this study it seems that daily hassles are a cause of stress and that they are a more valid way of measuring stress than the life events scale.

Example item from Kanner et al’s Daily Hassles Scale (1981)

Kanner et al(1981) –TEN MOST FREQUENTLY EXPRESSEDHASSLES OF MIDDLE-AGED ADULTS:

1. Concerns about weight

2. Health of a family member

3. Rising prices of common goods

4. Home maintenance5. Too many things to do

6. Misplacing or losing things

7. Outside home maintenance

8. Property investment or taxes9. Crime

10. Physical appearance

Section = Causes Of Stress And Supporting Evidence

Subsection = Lack of Control

e.g. Geer & Meisel (1973) = the effect ofcontrol in reducing stress reactions.

Aim: To see if perceived control or actual control can reduce stress reactions to aversive stimuli.Procedure: A laboratory experiment was conducted in which participants were shown photographs of dead car crash victims (the “aversive stimuli”) Their stress levels were measured by GSR (galvanic skin response) and heart rate was measured through ECG monitoring.

Key concept: GSR [galvanic skin response]Your galvanic skin response is the level of electrical current which is

conducted by your skin. This varies according to moisture on the skin.

Anxiety/stress causes sweating and so increases the moisture on the skin and its conductance

Participants were 60 undergraduate students enrolled in a psychology course at a New York university.An independent measures design was used with participants randomly assigned to three conditions:

- Group 1: were given control over how long they looked at the images for. They could press a button to terminate the image and were told a tone would precede each new image. [= the group given control]

- Group 2: Were warned the photos would be 60 seconds apart they would see the picture for 35 seconds and a 10 second warning tone would precede each photo. The group had no control but did know what was happening.

[= the predictability group]- Group 3: were told that from time to time they would see photos and

hear tones but were not given timings or any control.Each participant was tested individually, seated in a sound proofed room and wired up to the GSR and ECG machines. The machine was calibrated for 5 minutes while the participant relaxed and a baseline measurement was then taken. Instructions were read over an intercom. Each photo was preceded with a 10 second tone and then flashed up for 35 seconds (only members of group 1 could terminate the photo and move on). The GSR was taken at the onset of the tone and during the second half of the tone and in response to the picture.Results: The predictability group showed most stress with the tone, probably as they knew what would happen but had no control over it. Group 1 (the group given control) had the lowest GSR reactions. ECG recordings were discarded as they appeared inaccurate.Conclusions: The group given control over the photos showed least stress, as they could reduce the impact of the negative images by moving quickly on from them.Having control over your environment can reduce stress responses.

Section = Methods of measuring stress and supporting evidence

N.B – the methods of measuring stress and supporting evidence that you need to know about are all included in the studies covered in the CAUSES OF STRESS AND SUPPORTING EVIDENCE

Subsection = Physiological MeasuresPhysiological measures of stress measure the body’s response to stress by measuring levels of physiological arousal. There are a number of indexes of arousal, e.g. heart rate, GSR level (skin conductance), blood pressure, and respiration rate. These four indexes of arousal are measured by a Polygraph machine, for example:

Arousal can also be measured biochemically by analysing the levels of stress hormone in saliva, urine or blood samples. The adrenal gland secretes stress hormones and levels of cortisol and adrenaline and noradrenaline levels can be analysed in order to measure stress levels.

In their study of whether level of control can reduce stress to aversive stimuli, Geer and Meisel (1973) used

GSR (skin conductance) as a measure of arousal (stress):A Beckman Model RB Polygraph was used to collect the data. The machine converts the data from a voltmeter to a graphical printout.Each recording was carried out in a sound and electrically shielded room to ensure no audio or visual imput from the projector interfered with the data collection.The GSR electrodes were placed between the palm and forearm of the participant’s non-preferred arm (i.e. the left arm for right-handed people)

Task: What are the strengths and weaknesses ofphysiological measures of stress?

Section = Methods of measuring stress and supporting evidence

Subsection = Self Report

Holmes and Rahe’s (1967) SRRS is an example of a self-report measure of stress (see background to Hassles and Life Events as causes of stress).

Task 1. Look at the SRRS again. Identify five challenges to the validity of the SRRS as a measure of stress.2. What type of data does the SRRS produce? Identify the strengths of this kind of data.3. What are the strengths of using self report measures to assess stress levels?

Section = Methods of measuring stress and supporting evidence

Subsection = Combined Approach

Johansson’s (1978) study of work related stress used a combined approach to measure stress, including

- Physiological measures – urine samples were taken five times a day to analyse for stress hormone levels

- Self report measures - each participant had to say how much caffeine and nicotine they had consumed since the last urine test. They also had to report on a range of emotions and feelings as well as sleepiness, well-being, calmness, irritation and efficiency etc. They had to scale these feelings on a continuum from minimum to maximum using a scale with millimetres. The score was how many millimetres from the base point the participants had marked themselves to be feeling.

TaskWhat advantages are there in taking a

COMBINED APPROACH to measuring stress?

Section = Techniques for managing stress and supporting evidence

Subsection = Cognitive

Key Concept: Stress Inoculation Therapy [SIT]

“Some medical treatments give people weak versions of a disease in order to encourage the body to develop defences against the full-blown versions.

This is called inoculation. A form of cognitive therapy uses a similar idea as a preparation for a stressful event and it is called, not surprisingly, stress inoculation therapy.

It was developed by Meichenbaum and it is designed to prepare people for stress and to help them develop skills to cope with that stress. The inoculation programme involves three stages:

Stage 1 - Conceptualisation- the trainer talks with the patient about their stress response, and during

this phase the patient learns to identify and express feelings and fears. The patient is also educated in lay terms about stress and its effect.

Stage 2 - Skill acquisition and rehearsal

- The patient learns some basic behavioural and cognitive skills that will be useful for coping with stressful situations. For example, they might be taught how to relax and use self-regulatory skill. The patient then practises these skills under supervision

Stage 3 - Application and follow-through- The trainer guides the patient through a series of progressively more

threatening situations (a bit like the hierarchy in the behavioural therapy called systematic desensitization). The patient is given a wide range of possible stressors to prepare them for real life situations”.

Phil Banyard, Applying Psychology to Health

Standard behavioural measures, such as systematic desensitization, have tried to help people become desensitised to stress. Meichenbaum compared these standard behavioural methods with cognitive ones.

e.g. Stress Inoculation Therapy – Meichenbaum (1975)

Aim: To see if cognitive therapy sessions aimed at enabling people to identify their stressors and change their mental processes when under stress [SIT] work better than strategies simply aimed at changing their behaviours.Procedure: 21 students ages 17 – 25 responded to an advert about treatment of test (examination) anxiety. It was a field experiment with participants put into three groups, (matched in threes)- Group one received SIT, - Group 2 received standard desensitisation with no cognitive element- and group 3 acted as a control group (waiting list group-told they would

receive therapy in the future)

The SIT group received 8 therapy sessions giving them insight into their thoughts before tests. They were then given some positive statements to say and relaxation techniques to use in test situations.The systematic desensitisation groups were also given 8 therapy sessions with only progressive relaxation training whilst imagining stressful situations.The control group were told they were on a waiting list for treatment.

Each participant was tested using a test anxiety questionnaire. Each person did an IQ test as a baseline score and were tested again after the interventions

Findings: Performance in tests in the SIT group improved the most, although both therapy groups showed improvement over the control group.

Those in the SIT group reported the most improvement in their anxiety levels, although both therapy groups showed overall improvement compared with the control group

Conclusions: SIT is an effective way of reducing anxiety in students who are prone to anxiety in test situations and is more effective then behavioural techniques such as systematic desensitization as it adds a cognitive element to the therapy.

Section = Techniques for managing stress and supporting evidence

Subsection = Behavioural

e.g. BIOFEEDBACK - Budzynski et al. (1973) EMG Biofeedback and Tension Headache: A Controlled Outcome Study

Key Concept : the principle of BiofeedbackThe principle of biofeedback is to make a person aware of their physiological responses. Many of our physiological responses are normally beyond our conscious control, e.g. heart rate, blood pressure, muscle tension, as we are not aware of what is happening. Some of these, e.g. muscle tension, can have an adverse effect on the body. With biofeedback the idea is that we give a person physiological readings in real time so that they can become aware of what their physiological responses are, and then train them to take control of their physiological responses and thus reduce/remove any adverse effects.

Aim: To see if biofeedback techniques work to help reduce tension (stress induced) headaches or whether any observed effect is due to a placebo effect (a placebo effect is a positive psychological effect that can occur even when there is no actual treatment).Procedure: Participants: 18 replied to a newspaper advert in the USA. They were screened by telephone and then had psychiatric and medical examinations to ensure there were no other reasons for their headaches. There were 2 males and 16 females aged 22-44 with a mean age of 36. The experimental method was used with the first stage being to train patients in the laboratory. Data was collected using muscle tension measurements by use of an EMG machine (electromyography). The EMG machine gives feedback by a graph through electrodes applied to the muscles in the forehead. Patients were also given a psychometric test for depression (MMPI) and asked to complete questionnaires on their headaches. It was an independent measures design with participants randomly assigned to one of three groups.

Group A had real biofeedback training with relaxation using the EMG machine

Group B had biofeedback training but with false (pseudo) feedback, and were also trained in relaxation

Group C (no training) were used as a control groupAll groups kept a diary of their headaches for two weeks, rating them from 0 mild to 5 severe. Groups A and B were told to practice relaxation after the training for 15 – 20 mins each day.

Results: After 3 months Group A’s muscle tension was significantly lower than the other two groups. Reporting of headaches in Group A also fell significantly compared to their baseline which it did not in the other two groups.

Conclusions: Biofeedback is an effective way to reduce stress levels by reducing tension.

Section = Techniques for managing stress and supporting evidence

Subsection = Social

e.g. Waxler-Morrison et al 2006, social relationships and cancer survival

Aim: To investigate how a woman’s social relationships influence her response to breast cancer and survival.

Procedure: - A quasi experiment was carried out with women who were diagnosed with breast cancer. Women were fitted into categories (experimental conditions) based on their social support network, giving an independent measures design with women of different pre-existing levels of social support. Participants were 133 women under 55 yrs (pre-menopausal) who had been referred with breast cancer in Canada. The women were sent a questionnaire to fill in about their social support including questions on education and family responsibilities, friends, their perception of their support from others, marital status and church memberships etc. Their diagnoses were taken from medical records (June 1980-May 1981) which were again checked 4 years later (January 1985). This was a prospective study that identified a group of women to study and then followed them up, avoiding the problems associated with retrospective studies which would have depended on women accurately recalling what had happened in the past.

Results: qualitative data from questionnaires showed that practical help given by others for cleaning, child care, cooking etc was essential for support. Jobs were seen as important for support and most survivors reported supportive husbands, although problems were often reported with children who may also need support. There was a significant relationship between the amount of support reported and survival rates.

Conclusion: The study concluded that the more social networks and support, the higher the chance of survival. The assumption is that the support received reduces the level of stress.However, it was also noted that the most important factor in survival is still the state of the cancer at the time of diagnosis.