Description
The field of stress management has changed appreciably during the past decade. Advances have been made in the way that we understand the psychophysiology of stress; more has been found out about previously popular stress management methods, and a respectable body of empirical evidence has accumulated for some methods that previously were primarily of speculative interest.
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82
Biofeedback
Volume 35, Issue 3, pp. 82-84
©Association for Applied Psychophysiology & Biofeedback
www.aapb.org
This article presents a view of progress in the stress
management ?eld during the past decade, gleaned from
work on a revision of the previous edition of Principles
and Practice of Stress Management. In addition to better
validation of existing stress management techniques, much
has been learned about the psychobiology of stress, and new
stress management techniques have been developed and
have gained wide popularity.
Principles and Practice of Stress
Management
A Review of Advances in the Field
The ?eld of stress management has changed appreciably
during the past decade. Advances have been made in the
way that we understand the psychophysiology of stress;
more has been found out about previously popular stress
management methods, and a respectable body of empirical
evidence has accumulated for some methods that previously
were primarily of speculative interest. During the past
several years, I and my co-editors, Wes Sime and Robert
Woolfolk, have been working on an update of the widely
used book Principles and Practice of Stress Management,
whose third edition will soon appear. Here I will share some
of what I have learned in the process.
In redoing our volume, we had two aims: (a) to present
each method in the voice of an originator or de?nitive
contributor to the method and (b) to emphasize methods
having a reasonable degree of empirical validation. We
then describe each method; evaluate its validity; describe its
applications, side effects, and contraindications; and present
case examples. The revised edition was written with the
interests of the biofeedback and applied psychophysiology
community speci?cally in mind. We also wanted to present
a general understanding of the psychophysiology of stress
and outline the applications and limits of stress management
methods in general.
Continuity Amid Change
Meditation. It is interesting to note areas of change as well
as continuity in the ?eld of stress and stress management.
For example, interest in meditation methods remains strong,
yet a shift has occurred in topics of empirical study, not
necessarily because older methods have proven less useful but
more likely because of changes in fashion and the popularity
of particular methods. Thus, relatively few additional studies
have appeared on the topic of mantra meditation, whereas
many studies have been performed on mindfulness. Interest
in mindfulness has grown dramatically, prompted no doubt
by the in?uential writings of Thich Nhat Hanh and Jon Kabat
Zinn. Mindfulness has become a major goal in a variety of
methods, including mindfulness meditation and the widely
used acceptance and commitment therapy, best described by
the work of Steven Hayes. In our view, it may be particularly
useful for treating borderline personality, as described by
Marsha Linehan, and eating disorders, as researched by
Jean Kristeller. It speci?cally helps people to experience and
accept their own feelings and their own bodies. Kristeller has
prepared a new chapter on this method for our book.
Empirical validation of new methods. Methods that have
more recently developed a body of empirical validation
research include heart rate variability (HRV) biofeedback,
EMDR, and neurofeedback. I have personally been involved
in HRV biofeedback research. It differs from some other
biofeedback techniques in that rather than aiming to
decrease the level of arousal or changing the sympathetic/
parasympathetic balance, it works by exercising the
barore?ex, one of the important homeostatic re?exes
governing autonomic stability. In this way, its mechanism
overlaps with that of aerobic exercise as a stress management
method. Physical exercise also strengthens modulatory
re?exes. The theory behind HRV biofeedback is more similar
to that behind autogenic training than that of progressive
relaxation. The aim of autogenic training is to free the body
to allow endogenous modulatory re?exes to do their work
with less encumbrance from inhibitory processes. The aim
of progressive relaxation is to decrease sympathetic arousal,
a very different mechanism.
Facilitation of human performance. Also, a body of
literature has developed on the facilitation of human
performance by stress management, made possible by
SPECIAL ISSUE
Principles and Practice of Stress Management:
Advances in the Field
Paul Lehrer, PhD
Department of Psychiatry, UMDNJ–Robert Wood Johnson Medical School, Piscataway, NJ
Keywords: biofeedback, meditation, relaxation, heart rate variability, neurofeedback
83
Lehrer
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advances in the design and availability of equipment for
ambulatory physiological monitoring and expansion of data
on the relationship between emotion and sport performance,
facilitating as well as debilitating levels and aspects of
stress, the effects of various coping styles, and speci?c
stressors experienced by athletes. Human factors research
on the relationships among work load, psychophysiological
responsiveness, and performance accuracy also has expanded,
particularly in aerospace applications (e.g., among airplane
pilots and air traf?c controllers).
Neural pathways of the human stress response. In
addition, we have learned a considerable amount about
neural pathways for the stress response beyond the
autonomic nervous system and the ?ght-or-?ight reaction
(including interactions with the immune system and
in?ammatory activity) and the important role of the
parasympathetic nervous system in both modulating and
expressing the stress response. For example, knowledge of
how the hypothalamic-pituitary-adrenal axis is regulated
has greatly expanded. Research is also beginning to appear
using the technology of functional magnetic resonance
imaging. We now have evidence for ways that stress may
in?uence thinking by stimulation of brain centers involved
in higher mental processing. We also now know that
serum levels of some of the in?ammatory cytokines (e.g.,
interleukin 1 and interleukin 6) are particularly in?uenced
by chronic stress, that serum levels of catecholamines and
cortisol seem to be particularly responsive to acute stress,
and that susceptibility to infectious illness increases after a
period of chronic stress.
Understanding the role of stress in illness. Further
evidence has also accumulated on the effects of stress on
chronic respiratory, gastrointestinal, and cardiovascular
illness. Considerable research has been done on the
regulation of stress-related cardiovascular changes
through mediation of the barore?ex, one of the important
mechanisms for regulating both blood pressure reactivity
and, through central nervous system projections, the limbic
system and emotional reactivity. The development of new
technologies for the functional assessment of various
physiological systems has increased our ability to study
these various effects, so new information is accumulating
exponentially. We also now have better documentation on
how the parasympathetic nervous system can be directly
stimulated by stress, through parasympathetic rebound
effects and direct parasympathetic effects of responses
involving a passive coping orientation (e.g., the “playing
dead” response) or anticipation of blood loss and perhaps
preparation for shock (as in the response of blood phobia or
exposure of most people to blood and gore).
The Treatment of Stress and Stress-Related Disease
Advances in newer techniques and treatments. In drug
therapy, the proliferation and widespread use of selective
serotonin reuptake inhibitors has produced major changes
in the treatment of stress and stress-related diseases.
Comprehensive biofeedback methods have developed
that draw on a variety of feedback modalities and have
been applied to a variety of newly de?ned and better
understood conditions, particularly to patients with multiple
unexplained somatic symptoms. Jan van Dixhoorn’s
method of breathing retraining has had a major impact
on cardiac rehabilitation and is now a standard medical
intervention in many parts of the world. He now provides
a lucid English-language description of the method. Various
systems of conceptualization have appeared to integrate the
understanding and practice of various stress management
methods. Previously, our emphasis was on the speci?city of
effects for applications emphasizing, respectively, cognitive,
psychophysiological, and behavioral components. Although
we believe that treatment speci?city remains a robust ?nding,
we are intrigued by the work of people such as Jonathan
Smith, who has done considerable research on nuances of
differences among relaxation methods and implications for
their individual and sequential use.
More information on past methods of stress management.
Many of the more venerable methods have long had a body
of validation research, but the volume of recent research has
reinforced previous knowledge and extended the range of
applications to which the methods have been put. This seems
particularly true for progressive muscle relaxation, autogenic
training, cognitive therapies, music therapy, aerobic exercise,
and hypnotherapy. For example, there is considerably
more information available about muscle spindle activity
and its relationship to the sympathetic nervous system (a
pathway for the effects of muscle relaxation therapies), the
application of such therapies to treating chronic pain, and
the effects of muscle relaxation on the autonomic nervous
system. Additional research has appeared on the effects of
autogenic approaches to motion sickness and airplane pilot
performance and the effects of individualized autogenic
approaches to treating hypertension, as well as stress
symptoms in general.
There is much more information available about speci?c
effects of music therapy on various individuals, and this
approach is now ?nding much wider application in various
hospitals and medical clinics: Musicians are increasingly
found strolling the patient ?oors, and recorded music
is often available in operating theaters, dental of?ces,
and so forth. Major cardiovascular effects have been
documented for singing and chanting, which sometimes
84
Principles and Practice of Stress Management
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produce cardiorespiratory effects similar to those achieved
through heart rate variability biofeedback, perhaps through
entrainment of endogenous modulatory biorhythms. More
information is available about neural substrates of the
hypnotic state as well as applications to chronic pain and
psychiatric disease. Research on cognitive substrates of
stress and cognitive treatment approaches has also greatly
expanded in the past decade.
The Future
Stress management, as a ?eld, is seeing increasingly more
applications. Recent research on coronary artery disease,
for example, has shown that acute as well as chronic stress
contributes to changes in the arteries that can be pathogenic
and even dangerous in the short run in susceptible people.
Research is needed on the best methods for inoculating
people to stresses in ways that reduce vulnerability to
cardiovascular events. Many other mental as well as somatic
diseases are also known to be exacerbated by stress; indeed,
for some, stress may even be a causative factor. Finding the
most effective stress management methods for each problem
is a task for the future. Recent research on performance
similarly indicates that stress plays an important role in
highly complex tasks, from music instrumental performance
to athletics to ?ying an airplane. Adapting particular stress
management methods for these purposes is a growing
enterprise.
Unfortunately, much of the stress management ?eld is
driven more by popular interest than by scienti?c data. It
is possible that some stress management methods may
be better for some disorders than for others, perhaps
for psychobiological reasons as well as for reasons of
patient acceptance. However, various religious and ethnic
communities, as well as various entrepreneurs and even
scholars and clinicians, have promoted their own particular
stress management methods. A ?urry of research and
interest often accompanies the latest method, often driven
in large part by the charisma of the founders and number
of adherents to various philosophical or religious doctrines.
The moderating voice of science needs to play a more
important role in this process. Particularly, research needs
to be done on underlying mechanisms of highly complex
methods, such as mindfulness medication, yoga, and qi gong.
Effects of speci?c elements comprising these methods need
to be better understood, so that they may work together
in particular disciplines. On a psychological plane, such
elements certainly include muscle relaxation, breathing
alterations, and mental focus. Research on cardiorespiratory
effects and neuropsychological function will also be helpful.
Despite the needs for future research, the amount of
scienti?c information about stress management is large. It
has grown exponentially in the past three decades. We now
know a huge amount about how psychophysiology interacts
with disease, sense of well-being, and human performance.
Indeed, one of the major shortcomings in modern teaching of
psychology and psychotherapy is the relative super?ciality of
training in applied psychophysiology and stress management;
many psychotherapists tend to stick to methods in which
they have been trained rather than change with new
developments in the ?eld. Although the former Association
for Advancement of Behavior Therapy has changed its name
to the Association for Cognitive Behavior Therapy, even
this empirically oriented group of scienti?c practitioners
ignores the role of psychophysiology in its basic charter. By
comparison, how would we feel about physicians who used
only medicines and surgical procedures that were in vogue
20 or 30 years ago? Data are fast accumulating to the point at
which, from my perspective, it is tantamount to malpractice
to treat people psychotherapeutically without having a good
grounding in the various methods of stress management.
Correspondence: Paul Lehrer, UMDNJ–Robert Wood Johnson Medical School,
Department of Psychiatry, 671 Hoes Lane, Piscataway, NJ 08854, email: lehrer@
umdnj.edu.
Paul Lehrer
doc_892253680.pdf
The field of stress management has changed appreciably during the past decade. Advances have been made in the way that we understand the psychophysiology of stress; more has been found out about previously popular stress management methods, and a respectable body of empirical evidence has accumulated for some methods that previously were primarily of speculative interest.
F
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Ô
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82
Biofeedback
Volume 35, Issue 3, pp. 82-84
©Association for Applied Psychophysiology & Biofeedback
www.aapb.org
This article presents a view of progress in the stress
management ?eld during the past decade, gleaned from
work on a revision of the previous edition of Principles
and Practice of Stress Management. In addition to better
validation of existing stress management techniques, much
has been learned about the psychobiology of stress, and new
stress management techniques have been developed and
have gained wide popularity.
Principles and Practice of Stress
Management
A Review of Advances in the Field
The ?eld of stress management has changed appreciably
during the past decade. Advances have been made in the
way that we understand the psychophysiology of stress;
more has been found out about previously popular stress
management methods, and a respectable body of empirical
evidence has accumulated for some methods that previously
were primarily of speculative interest. During the past
several years, I and my co-editors, Wes Sime and Robert
Woolfolk, have been working on an update of the widely
used book Principles and Practice of Stress Management,
whose third edition will soon appear. Here I will share some
of what I have learned in the process.
In redoing our volume, we had two aims: (a) to present
each method in the voice of an originator or de?nitive
contributor to the method and (b) to emphasize methods
having a reasonable degree of empirical validation. We
then describe each method; evaluate its validity; describe its
applications, side effects, and contraindications; and present
case examples. The revised edition was written with the
interests of the biofeedback and applied psychophysiology
community speci?cally in mind. We also wanted to present
a general understanding of the psychophysiology of stress
and outline the applications and limits of stress management
methods in general.
Continuity Amid Change
Meditation. It is interesting to note areas of change as well
as continuity in the ?eld of stress and stress management.
For example, interest in meditation methods remains strong,
yet a shift has occurred in topics of empirical study, not
necessarily because older methods have proven less useful but
more likely because of changes in fashion and the popularity
of particular methods. Thus, relatively few additional studies
have appeared on the topic of mantra meditation, whereas
many studies have been performed on mindfulness. Interest
in mindfulness has grown dramatically, prompted no doubt
by the in?uential writings of Thich Nhat Hanh and Jon Kabat
Zinn. Mindfulness has become a major goal in a variety of
methods, including mindfulness meditation and the widely
used acceptance and commitment therapy, best described by
the work of Steven Hayes. In our view, it may be particularly
useful for treating borderline personality, as described by
Marsha Linehan, and eating disorders, as researched by
Jean Kristeller. It speci?cally helps people to experience and
accept their own feelings and their own bodies. Kristeller has
prepared a new chapter on this method for our book.
Empirical validation of new methods. Methods that have
more recently developed a body of empirical validation
research include heart rate variability (HRV) biofeedback,
EMDR, and neurofeedback. I have personally been involved
in HRV biofeedback research. It differs from some other
biofeedback techniques in that rather than aiming to
decrease the level of arousal or changing the sympathetic/
parasympathetic balance, it works by exercising the
barore?ex, one of the important homeostatic re?exes
governing autonomic stability. In this way, its mechanism
overlaps with that of aerobic exercise as a stress management
method. Physical exercise also strengthens modulatory
re?exes. The theory behind HRV biofeedback is more similar
to that behind autogenic training than that of progressive
relaxation. The aim of autogenic training is to free the body
to allow endogenous modulatory re?exes to do their work
with less encumbrance from inhibitory processes. The aim
of progressive relaxation is to decrease sympathetic arousal,
a very different mechanism.
Facilitation of human performance. Also, a body of
literature has developed on the facilitation of human
performance by stress management, made possible by
SPECIAL ISSUE
Principles and Practice of Stress Management:
Advances in the Field
Paul Lehrer, PhD
Department of Psychiatry, UMDNJ–Robert Wood Johnson Medical School, Piscataway, NJ
Keywords: biofeedback, meditation, relaxation, heart rate variability, neurofeedback
83
Lehrer
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advances in the design and availability of equipment for
ambulatory physiological monitoring and expansion of data
on the relationship between emotion and sport performance,
facilitating as well as debilitating levels and aspects of
stress, the effects of various coping styles, and speci?c
stressors experienced by athletes. Human factors research
on the relationships among work load, psychophysiological
responsiveness, and performance accuracy also has expanded,
particularly in aerospace applications (e.g., among airplane
pilots and air traf?c controllers).
Neural pathways of the human stress response. In
addition, we have learned a considerable amount about
neural pathways for the stress response beyond the
autonomic nervous system and the ?ght-or-?ight reaction
(including interactions with the immune system and
in?ammatory activity) and the important role of the
parasympathetic nervous system in both modulating and
expressing the stress response. For example, knowledge of
how the hypothalamic-pituitary-adrenal axis is regulated
has greatly expanded. Research is also beginning to appear
using the technology of functional magnetic resonance
imaging. We now have evidence for ways that stress may
in?uence thinking by stimulation of brain centers involved
in higher mental processing. We also now know that
serum levels of some of the in?ammatory cytokines (e.g.,
interleukin 1 and interleukin 6) are particularly in?uenced
by chronic stress, that serum levels of catecholamines and
cortisol seem to be particularly responsive to acute stress,
and that susceptibility to infectious illness increases after a
period of chronic stress.
Understanding the role of stress in illness. Further
evidence has also accumulated on the effects of stress on
chronic respiratory, gastrointestinal, and cardiovascular
illness. Considerable research has been done on the
regulation of stress-related cardiovascular changes
through mediation of the barore?ex, one of the important
mechanisms for regulating both blood pressure reactivity
and, through central nervous system projections, the limbic
system and emotional reactivity. The development of new
technologies for the functional assessment of various
physiological systems has increased our ability to study
these various effects, so new information is accumulating
exponentially. We also now have better documentation on
how the parasympathetic nervous system can be directly
stimulated by stress, through parasympathetic rebound
effects and direct parasympathetic effects of responses
involving a passive coping orientation (e.g., the “playing
dead” response) or anticipation of blood loss and perhaps
preparation for shock (as in the response of blood phobia or
exposure of most people to blood and gore).
The Treatment of Stress and Stress-Related Disease
Advances in newer techniques and treatments. In drug
therapy, the proliferation and widespread use of selective
serotonin reuptake inhibitors has produced major changes
in the treatment of stress and stress-related diseases.
Comprehensive biofeedback methods have developed
that draw on a variety of feedback modalities and have
been applied to a variety of newly de?ned and better
understood conditions, particularly to patients with multiple
unexplained somatic symptoms. Jan van Dixhoorn’s
method of breathing retraining has had a major impact
on cardiac rehabilitation and is now a standard medical
intervention in many parts of the world. He now provides
a lucid English-language description of the method. Various
systems of conceptualization have appeared to integrate the
understanding and practice of various stress management
methods. Previously, our emphasis was on the speci?city of
effects for applications emphasizing, respectively, cognitive,
psychophysiological, and behavioral components. Although
we believe that treatment speci?city remains a robust ?nding,
we are intrigued by the work of people such as Jonathan
Smith, who has done considerable research on nuances of
differences among relaxation methods and implications for
their individual and sequential use.
More information on past methods of stress management.
Many of the more venerable methods have long had a body
of validation research, but the volume of recent research has
reinforced previous knowledge and extended the range of
applications to which the methods have been put. This seems
particularly true for progressive muscle relaxation, autogenic
training, cognitive therapies, music therapy, aerobic exercise,
and hypnotherapy. For example, there is considerably
more information available about muscle spindle activity
and its relationship to the sympathetic nervous system (a
pathway for the effects of muscle relaxation therapies), the
application of such therapies to treating chronic pain, and
the effects of muscle relaxation on the autonomic nervous
system. Additional research has appeared on the effects of
autogenic approaches to motion sickness and airplane pilot
performance and the effects of individualized autogenic
approaches to treating hypertension, as well as stress
symptoms in general.
There is much more information available about speci?c
effects of music therapy on various individuals, and this
approach is now ?nding much wider application in various
hospitals and medical clinics: Musicians are increasingly
found strolling the patient ?oors, and recorded music
is often available in operating theaters, dental of?ces,
and so forth. Major cardiovascular effects have been
documented for singing and chanting, which sometimes
84
Principles and Practice of Stress Management
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produce cardiorespiratory effects similar to those achieved
through heart rate variability biofeedback, perhaps through
entrainment of endogenous modulatory biorhythms. More
information is available about neural substrates of the
hypnotic state as well as applications to chronic pain and
psychiatric disease. Research on cognitive substrates of
stress and cognitive treatment approaches has also greatly
expanded in the past decade.
The Future
Stress management, as a ?eld, is seeing increasingly more
applications. Recent research on coronary artery disease,
for example, has shown that acute as well as chronic stress
contributes to changes in the arteries that can be pathogenic
and even dangerous in the short run in susceptible people.
Research is needed on the best methods for inoculating
people to stresses in ways that reduce vulnerability to
cardiovascular events. Many other mental as well as somatic
diseases are also known to be exacerbated by stress; indeed,
for some, stress may even be a causative factor. Finding the
most effective stress management methods for each problem
is a task for the future. Recent research on performance
similarly indicates that stress plays an important role in
highly complex tasks, from music instrumental performance
to athletics to ?ying an airplane. Adapting particular stress
management methods for these purposes is a growing
enterprise.
Unfortunately, much of the stress management ?eld is
driven more by popular interest than by scienti?c data. It
is possible that some stress management methods may
be better for some disorders than for others, perhaps
for psychobiological reasons as well as for reasons of
patient acceptance. However, various religious and ethnic
communities, as well as various entrepreneurs and even
scholars and clinicians, have promoted their own particular
stress management methods. A ?urry of research and
interest often accompanies the latest method, often driven
in large part by the charisma of the founders and number
of adherents to various philosophical or religious doctrines.
The moderating voice of science needs to play a more
important role in this process. Particularly, research needs
to be done on underlying mechanisms of highly complex
methods, such as mindfulness medication, yoga, and qi gong.
Effects of speci?c elements comprising these methods need
to be better understood, so that they may work together
in particular disciplines. On a psychological plane, such
elements certainly include muscle relaxation, breathing
alterations, and mental focus. Research on cardiorespiratory
effects and neuropsychological function will also be helpful.
Despite the needs for future research, the amount of
scienti?c information about stress management is large. It
has grown exponentially in the past three decades. We now
know a huge amount about how psychophysiology interacts
with disease, sense of well-being, and human performance.
Indeed, one of the major shortcomings in modern teaching of
psychology and psychotherapy is the relative super?ciality of
training in applied psychophysiology and stress management;
many psychotherapists tend to stick to methods in which
they have been trained rather than change with new
developments in the ?eld. Although the former Association
for Advancement of Behavior Therapy has changed its name
to the Association for Cognitive Behavior Therapy, even
this empirically oriented group of scienti?c practitioners
ignores the role of psychophysiology in its basic charter. By
comparison, how would we feel about physicians who used
only medicines and surgical procedures that were in vogue
20 or 30 years ago? Data are fast accumulating to the point at
which, from my perspective, it is tantamount to malpractice
to treat people psychotherapeutically without having a good
grounding in the various methods of stress management.
Correspondence: Paul Lehrer, UMDNJ–Robert Wood Johnson Medical School,
Department of Psychiatry, 671 Hoes Lane, Piscataway, NJ 08854, email: lehrer@
umdnj.edu.
Paul Lehrer
doc_892253680.pdf