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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Illness Management and Recovery Workbook

Handout 3:
Stress-Vulnerability Model and Treatment Strategies

“For me it’s been vital to be aware of when I am under stress. Because of my illness, I’m extra sensitive to stress. It has also been vital for me to take the lead role in my treatment, since I believe that I know best what is going on inside my head.”

David Kime: artist, writer, floral designerIntroduction

This handout describes a model for understanding the nature of psychiatric disorders, including factors which can influence the course of these disorders. According to this model, the stress-vulnerability model, psychiatric illnesses have a biological basis. This biological basis or vulnerability can be made worse by stress and substance use, but can be improved by medication and by leading a healthy lifestyle.

The stress-vulnerability model can help you understand what influences your disorder and how you can minimize the effects of the disorder on your life.

Appendix 1 contains a diagram which summarizes the stress-vulnerability model. The components of the diagram are described in detail in this handout.

What causes psychiatric symptoms?

Scientists do not yet understand exactly why some people have symptoms of mental illness and others do not. They also cannot predict who will have several episodes of symptoms and who will have one or only a few. One theory that has received strong support is called the “stress-vulnerability model.” According to this theory, both stress and biological vulnerability contribute
to symptoms.

What are the biological factors in mental illness?

The term “biological vulnerability” refers to people who are born with, or who acquire very early in life, a tendency to develop a problem in a specific medical area. For example, some people have a biological vulnerability to developing asthma, and other people have a biological vulnerability to developing high blood pressure or diabetes. Similarly, it is thought that people can have biological vulnerabilities to develop schizophrenia, bipolar disorder, or depression.

In diabetes, the part of the body that is affected is the pancreas, which keeps the level of insulin in balance. In mental illness, the part of the body that is affected is the brain, which is made up of billions of nerve cells (neurons) containing different chemicals (neurotransmitters). Scientists believe that mental illnesses are caused by imbalances in these neurotransmitters in the brain.

As with other disorders, such as diabetes, hypertension, and heart disease, genetic factors play a role in the vulnerability to mental illness. The chances of a person developing depression, bipolar disorder, or schizophrenia are higher if a close relative also has the disorder. Many scientific studies, including the international human genome project, are researching the genetic factors related to mental illness.

Genetic factors, however, do not explain everything about why some people develop mental illness. For example, for many people with mental illness, there is no history of anyone else in their family who experienced psychiatric symptoms. It is widely believed that non-genetic factors may also contribute to people developing mental illnesses. For example, early biological factors, such as exposure to a virus when the baby is in the womb, may be important.

There is little scientific evidence that alcohol use or drug use causes people to develop a biological vulnerability to mental illness in the first place. However, when someone already has a biological vulnerability, alcohol and drug use may trigger symptoms or make them worse.

Questions:

Are you aware of any of your family members who have had (or might have had) a mental illness?

Have you had experience with alcohol or drugs that seemed to make your symptoms more severe?

What are the stress factors in mental illness?

Scientists believe that stress also plays an important part in psychiatric symptoms. Stress can trigger the onset of symptoms or make them worse. Stress may play a particularly strong role in increasing the biological vulnerability to depression. For example, if someone has lost a loved one, been the victim of a sexual or physical assault, witnessed a tragic event or experienced other examples of extraordinary stressors, he or she may be more likely to become depressed.

How people experience stress is very individual. In fact, what is stressful to one person may not be stressful at all to someone else. The following list, however, includes examples of situations that are commonly experienced as stressful:

• Too much to do, such as being expected to complete several tasks in a short period of time.
• Too little to do, such as sitting around all day with no meaningful activities.
• Tense relationships, where people are often arguing or expressing angry feelings or criticizing each other.
• Major life changes, such as losing a loved one, moving away from home, starting a new job, getting married or having a child.
• Financial or legal problems.
• Being sick or fatigued.
• Abusing drugs or alcohol.
• Being the victim or a crime.
• Poverty or poor living conditions.

There is no such thing as a stress-free life, so you can’t avoid all stress. In fact, to pursue important goals in your life, it is essential to be willing to take on new challenges, which can be stressful. But it is helpful to be aware of times when you’re under stress and to learn strategies for coping with it effectively. The educational handout “Coping with Stress and Common Problems” will go into more detail about this subject.

Question: Have there been times when you were under stress and experienced more symptoms?

What are the goals of treatment?

Because both biological vulnerability and stress contribute to symptoms, treatment for psychiatric symptoms needs to address both of these factors. The main goals of treatment are:

• Reducing biological vulnerability
• Reducing stress
• Coping with stress more effectively

Reducing biological vulnerability

Medications help correct the chemical imbalances which lead to symptoms. There are different medicines to treat different types of symptoms. The educational handout “Using Medication Effectively” provides more specific information about medications and how to get the best results from them.

It is your decision whether to take medication. Medications are not perfect: they don’t cure mental illness and they have side effects. Medications also help some people more than others. However, medications are one of the most powerful tools we have for reducing or eliminating symptoms and preventing relapses and rehospitalizations.

Another way to reduce biological vulnerability is to avoid alcohol and drug abuse. Alcohol and drug use affect neurotransmitters in the brain, which can lead to worse symptoms and relapses. Alcohol and drug use can also lead to legal, financial, and health problems, resulting in stress that can trigger symptoms. In addition, using alcohol and drugs can interfere with the beneficial effects of medication.

Questions:

Have medications helped you to reduce symptoms?

Has avoiding (or decreasing) drug and alcohol use helped you to reduce symptoms?

Reducing stress

Each person experiences stress in his or her own individual way. In addition, what is stressful to one person may not be stressful to another. For example, some people feel stressed by going to a large family gathering, whereas others enjoy it.

In general, the following guidelines are helpful in reducing common sources of stress:

• Identify situations that caused stress for you in the past. Think of ways to handle the situations so they won’t be as stressful.
• Set reasonable expectations for yourself—try not to do too much or too little.
• Find activities that are meaningful to you—whether working or volunteering or pursuing hobbies.
• Maintain good health habits by eating well, getting enough sleep, and exercising regularly.
• Seek out supportive relationships where you feel comfortable telling people what you are feeling and thinking.
• Avoid situations where people argue with you or criticize you.
• Give yourself credit for your talents and strengths; don’t be hard on yourself.

Question: What do you do to reduce stress? You can use the following checklist to answer the question.

Reducing Stress Checklist

Coping with Stress

Stress is a natural part of life, and everyone experiences it. When stress occurs, however, it is helpful to have some strategies for dealing with it, so it will have a less harmful effect on you. Consider using some of the following strategies for dealing with stress:

• Talk to someone about your feelings.
• Use relaxation techniques, such as deep breathing, meditation, picturing a pleasant scene, progressive muscle relaxation.
• Use “positive self-talk,” by saying things to yourself such as “This is a challenge, but I can handle it.”
• Keep your sense of humor and try to look at the lighter side. Seek out a funny movie or a book or cartoons.
• Use religion or another form of spiritual inspiration.
• Take a walk or do some other kind of physical exercise.
• Write your thoughts and feelings down in a journal.
• Draw or create other kinds of artwork.
• Think of the situation as a problem to solve, then work on solving the problem.
• Engage in a hobby such as cooking, gardening, reading, or listening to music.

Try to keep an open mind, and experiment with new ways of coping with stress. The more strategies you have, the better you can cope.

Question: What strategies do you use for coping with stress? You can use the following checklist to answer the question.

Coping with Stress Checklist

What kinds of treatment options are there to choose from?

There are many reasons for you to be as active as possible in your treatment:

• You are the expert about your own symptoms and what makes you feel better or worse.
• You need to be able to make informed choices about treatment.
• You have a lot to gain by receiving effective treatment.

Depending on your own individual situation and what is available in your community, you can choose among several different treatment options to best serve your needs. Some people choose one or two options; others choose several. A lot depends on your recovery goals.

The following chart lists some of the common recovery goals and the treatment options that may help you move towards achieving your goals. This is only a partial list. The educational handout, “Getting Your Needs Met in the Mental Health System” will cover more options.

Treatment Options

Questions:

Which treatment options fit with your recovery goals?

Which of the options are you currently using?

Which would you like to try?

What are some examples of people whose treatment choices work well for them?

Even when people have the same disorder, they may experience symptoms very differently. Therefore, treatment choices vary widely depending on the individual and what works for them. The following are some examples of people whose treatment choices have worked well for them. Your choices may be very different—the important thing is that they work for you.

Example 1:

“I work part-time, and I’ve noticed that I need to take regular breaks or I start to feel stressed out. I always eat breakfast because if I skip it I start to feel irritable. Exercise helps me relax, so I try to jog every other day, before dinner. Just for 15-20 minutes, but it makes me feel good. I enjoy my life.”

“It took a long time to find a medication that worked well for me. But now I take it regularly and it helps me to concentrate better and not feel down all the time. I belong to a support group, which meets twice a month. It helps me to talk to people who have gone through some of the same things I have.

Example 2:

“When I first started to have symptoms and was toId the diagnosis, I learned everything I could about it. It helped me to make sense of what was happening, and it also made me feel like I wasn’t the only one. I also went to a recovery group that was led by someone who had mental illness. It gave me a lot of hope.

“I’ve gone to several different doctors, and I think the one I have now is good. She suggested trying one of the newer medicines because it has fewer side effects. I’m considering it. But I don’t want to change anything fast.

“I’ve been seeing a counselor every week to talk about some of the stress I’m under. He taught me how to do some yoga exercises to relax myself after the kids go to bed. I never thought I was the yoga type, but it does make me feel more relaxed.”

Example 3

“I go to group therapy every week. A couple of times each week I go to the clubhouse, where I can be with other people and have something fun to do. I’ve applied for a supported employment program, and I’m really excited about that.

“When I get stressed out, it helps me to sit down with my sketch pad and colored pencils and do some drawing. I put the best drawings up on my wall. I also like to go to the art museums and see paintings and drawings. It takes my mind to a calmer place.”

Summary of the main points about the stress-vulnerability model and strategies for treatment

• Both stress and biology contribute to symptoms.
• Biology plays a part in whether someone is vulnerable to developing a mental illness.
• Biological factors contribute to the chemical imbalance in the brain that scientists have associated with psychiatric symptoms.
• Stress can make symptoms worse or may even trigger the onset of symptoms.
• The goals of treatment are to reduce biological vulnerability, reduce stress, and improve the ability to cope with stress.
• Medications and avoiding drug and alcohol use can reduce biological vulnerability.
• Reducing stress can help reduce symptoms.
• Developing coping strategies for dealing with stress can help reduce symptoms.
• The more you learn about treatment, the better choices you can make.
• It’s important to choose treatment options that work for you as an individual.

Appendix

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