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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Illness Management and Recovery Workbook

Handout 7:
Coping with Stress

Exercise helps me elevate my mood. My writing is a great distraction and helps me get my mind off the pressures of work and life in general. My sculpture also helps me to escape. Believing that there is a God and that He doesn’t hate me and that I can turn to Him also helps. I also like music and find listening to it helpful.

“What helps you? God? Medication? Therapy? Art? Exercise? TV? Music? Reading? What?”

David Kime, artist, writer, floral designer

Introduction

This handout describes different ways of coping effectively with stress. In order to cope effectively, it is first important to know what situations you find stressful and what the experience of stress is like for you. Specific strategies for dealing with stress are suggested, such as using relaxation techniques, talking with others, exercising, and creative expression.

What is stress?

“Stress” is a term people often use to describe a feeling of pressure, strain, or tension. People often say that they are “under stress” or feel “stressed out” when they are dealing with challenging situations or events.

Everyone encounters stressful situations. Sometimes the stress comes from something positive (like a new job, new apartment, or new relationship) and sometimes from something negative (like being bored, having an argument with someone, or being the victim of crime).

Question: What is it like when you experience stress?

Why is stress relevant to mental illness?

According to the stress-vulnerability model, stress is an important factor in mental illness because it can worsen symptoms and lead to relapses. If you can decrease stress, you can decrease symptoms.

Nobody has a stress-free life and probably nobody would want to! Stress is a natural part of life. In fact, to pursue important personal goals, you need to be willing to take on new challenges, which can be stressful. Being able to cope effectively with stressful situations can minimize the effects of stress on you and your symptoms. This can enable you to continue to pursue your goals and enjoy life.

What makes you feel under stress?

Different people find different things stressful. For example, some people enjoy the hustle and bustle of a big city, while others don’t like the crowds and noise and find it stressful. Some people enjoy going to a party and meeting new people; others find it stressful. Knowing what you personally find stressful will help you cope better.

There are two main types of stress: life events and daily hassles.

Life events refers to experiences such as moving, getting married, the death of a loved one, or having a baby. Some life events are more stressful than others; for example, getting a divorce is usually more stressful than changing jobs.

To see how many life events you have experienced in the past year, complete the following checklist:

Life Events Checklist

Put a check mark next to each event that you have experienced in the past year.
___ Moving
___ Getting married
___ New baby
___ Divorce or separation
___ Injury
___ Illness
___ New job
___ Loss of a job
___ Inheriting or winning money
___ Financial problems
___ Injury or illness of a loved one
___ Death of a loved one
___ Victim of a crime
___ Legal problems
___ New boyfriend or girlfriend
___ Broke up with a boyfriend or girlfriend
___ Stopped smoking
___ Went on a diet
___ New responsibilities at home
___ New responsibilities at work
___ No place to live
___ Hospitalization
___ Drinking or using street drugs caused problems
___ other:______________________________

___ Total number of life events checked off.

moderate stress=1

event high stress=2-3 events

very high stress=more than 3 events

Daily hassles are the small daily stresses of everyday life that can add up if they occur over time. Examples of daily hassles include dealing with long bus rides, working with unpleasant or critical people, having conflicts with family members or close friends, living or working in a noisy chaotic place, and being rushed to do things.

The following checklist will help you evaluate how many daily hassles you are dealing with:

Daily Hassles Checklist

Place a check mark next to each event that you have experienced in the past week:
___ not enough money to take care of necessities
___ not enough money to spend on leisure
___ crowded living situation
___ crowded public transportation
___ long drives or traffic back ups
___ feeling rushed at home
___ feeling rushed at work
___ arguments at home
___ arguments at work
___ doing business with unpleasant people (sales clerks, waiters/waitresses, transit clerks, toll booth collectors)
___ noisy situation at home
___ noisy situation at work
___ not enough privacy at home
___ minor medical problems
___ lack of order or cleanliness at home
___ lack of order or cleanliness at work
___ unpleasant chores at home
___ unpleasant chores at work
___ living in a dangerous neighborhood
___ other:__________________________

___ Total number of hassles in the past week

moderate stress=1 or 2 daily hassles

high stress=3-6 daily hassles

very high tress=more than 6

Questions:

What is the most stressful life event you have experienced in the past year?

What are the most stressful daily hassles you have experienced in the past week?

What are the signs that you’re under stress?

When people are under stress, it affects them physically and emotionally. It also affects their thinking, mood, and behavior. Some people show only physical signs of stress, such as muscular tension, headaches or sleep problems. Others have trouble concentrating or become irritable, anxious or depressed. Still others may pace or bite their nails. Each person’s response to stress is individual.

Being aware of your own personal signs of stress can be very helpful, because once you realize that you’re under stress you can start to do something about it.

You can use the following checklist to identify your own personal signs of being under stress.

Signs of Stress Checklist

Put a check mark next to the signs you notice when you are under stress:
___ headaches
___ sweating
___ increased heart rate
___ back pain
___ change in appetite
___ difficulty falling asleep
___ increased need for sleep
___ trembling or shaking
___ digestion problems
___ stomach aches
___ dry mouth
___ problems concentrating
___ anger over relatively minor things
___ irritable
___ anxious
___ feeling restless or “keyed up”
___ tearful
___ forgetful
___ prone to accidents
___ using alcohol or drugs (or wanting to)
___ other:__________________________
___ other:__________________________
___ other:__________________________

Question: Have you noticed any signs of being under stress in the past week?

How can you prevent stress?

Putting energy into preventing stress can pay off. If you eliminate some of the avoidable stress in your life, it frees you up to enjoy yourself more and to accomplish more of your goals.

Most people find it helpful to be familiar with a variety of prevention strategies, like the ones described below and listed in the “Strategies for Preventing Stress Checklist.” Choose the strategies that best suit you.

Be aware of situations that caused stress in the past. If you found a situation stressful before, it will probably cause problems again. Knowing that a situation has been stressful will allow you to think of different ways to handle it so it won’t be as stressful. For example, if you notice that you become irritable whenever you catch the bus at rush hour, try catching it at a less busy time. Or try practicing deep breathing if you become tense on a crowded bus.

If large holiday gatherings with your extended family make you feel tense, try taking short breaks away from the larger group. Or try getting together with family members at times other than holidays, in smaller groups.

Schedule meaningful, enjoyable activities. Having activities that you enjoy makes a significant difference in reducing stress. For some people, their work is meaningful and enjoyable. Other people look to volunteering, hobbies, music, sports or art for meaning and enjoyment. It all depends on what the individual finds most meaningful.

Schedule time for relaxation. It’s important to take time to relax each day, to refresh your mind and body from the tensions of the day. Some people find exercise relaxing, while others find reading or doing a puzzle or some other activity to be relaxing.

Have balance in your daily life. Being active and involved is important to keeping stress low. However, too much activity can lead to stress. It’s important to leave time for sleep and for restful, relaxing activities, such as a reading or taking a walk.

Develop a support system. Seek out people who are encouraging and supportive, rather than critical and pressuring. It’s very helpful to have relationships with people you feel comfortable with. Common support systems include, friends, family members, peer support, professionals and members of one’s religious or spiritual group. See the handout “Building Social Supports” for more information on this subject.

Take care of your health. Eating well, getting enough sleep, exercising regularly, and avoiding alcohol or drug abuse helps prevent stress. These healthy habits are not easy to maintain, but they really pay off.

Talk about your feelings or write them down in a journal. Holding in your feelings can be very stressful. It helps to have an outlet for your feelings so that you don’t keep them bottled up. These may be positive feelings, like being excited about a new job or negative feelings, such as being angry at how someone else has behaved. Having someone to talk to, such as a family member, friend, or professional, can help. Or you might find it helpful to keep a journal of your thoughts and feelings.

Avoid being hard on yourself. Some people increase their stress by being critical of themselves and what they are accomplishing. Try to be reasonable about what you expect from yourself, and give yourself credit for your talents and strengths. It can be helpful to identify some positive features about yourself and remind yourself of these features when you are feeling negatively about yourself.

Strategies for Preventing Stress Checklist

Question: Which prevention strategies would be most helpful to you?

How can you cope with stress effectively?

Coping effectively with stress is a key to living a successful and rewarding life and being able to pursue your personal goals. Some examples of strategies for coping with stress include:

Talking to someone about the stress you are experiencing
“When I was packing up my stuff to move to a new place, I started having headaches and trouble sleeping. I called my sister and told her how stressed out I felt. She told me she felt the same way when she moved the last time. She even offered to help me pack. It made a huge difference.”

Using relaxation techniques
“If I’ve had a stressful day, it helps me to do some deep breathing. I put on some relaxing music, and sit in my favorite chair. Then I start by taking ten deep, slow breaths. Then I let my breath out very slowly. As I exhale, I try to imagine that when I let out my breath, I’m letting out the tension in my body. Then I take about 20 or 30 more breaths. Sometimes I try to imagine a peaceful scene, like the ocean, when I’m breathing. I usually feel more relaxed after that.”
The Appendix to this handout contains some relaxation techniques that you can try.

Using positive self-talk
“Before when I was under stress, I used to blame myself and think that there was no way out. Now I try to think more positively. I say to myself, ‘This is hard, but I can do it,’ or ‘If I take this one step at a time, I’ll be able to handle it.’ It’s hard to do sometimes, but it makes me feel better about myself.”

Maintaining your sense of humor
“For me ‘laughter is the best medicine.’ When I’ve been on a subway ride that lasted two hours instead of 45 minutes, I feel very tense and agitated. I have some funny videos at home, and I’ll pull one out and have a good laugh. Believe it or not, it helps me to watch a Monty Python movie or one starring Adam Sandler.”

Participating in religion or spiritual activity
“I grew up in a religious home. Although I’m not sure I believe every aspect of that religion, I still find it comforting to go to services. And sometimes instead of going to services I go for a walk in the park and see how beautiful nature can be. That’s very spiritual for me.”

Exercising
“I like to ‘work off’ my stress by getting some exercise. Sometimes I go for a run and sometimes I just do some jumping jacks until I calm down.”

Writing in a journal
“I’ve started keeping a journal to write down my thoughts and feelings. I don’t care about the grammar or spelling—I just write down what comes into my head. Sometimes I write about stressful things and that seems to help. Writing helps me think things through.”

Making or listening to music
“I’m a music person. I put on my headphones and blow away the stress of the day. I can even do it on the train, to distract myself on the long ride.”

Doing art or going to see art
“I like to sketch. I especially like drawing cartoons. I must admit I sometimes make some unflattering cartoons of people who are bugging me.”

Playing games or developing a hobby
“I like playing card games. When I don’t have anyone to play with, I like solitaire. It’s relaxing to me.”

Questions:

What strategies do you use to cope with stress?

What strategies would you like to try or develop further?

You can use the following checklist to record your answer to these questions.

Strategies for Coping with Stress Checklist

Examples of coping effectively with stress

People develop different strategies for coping with stress, depending on what works for them. The following individuals have recognized what kinds of situations are stressful to them and have worked out strategies that help them cope effectively with these situations.

Leticia

“For me, it’s very stressful to rush to get somewhere on time. I start to feel anxious and irritable. Sometimes I even get a headache. So I try to plan ahead as much as possible, and allow myself plenty of time. On the nights before I go to work, I lay out my clothing for the next day. I get up at least an hour before I have to leave the house to catch the bus. Then I don’t feel anxious. I can relax on my way to work and start the day feeling fresh.

“Of course, I can’t plan for everything. Sometimes the bus is late or the road conditions are bad. When I feel myself starting to get anxious, I do some deep breathing to slow myself down. Sometimes I use ‘positive self-talk.’ I tell myself, ‘I have an excellent record at work of arriving on time and doing my job well. It’s O.K. if I’m late once in a while. My boss has always told not to worry about this. Just relax.’ It works for me.”

Daniel

“Recently I’ve been under stress because my mother has been ill and in the hospital. I visit her almost every afternoon and I think I’m doing all I can to help her. But sometimes I have trouble sleeping. I lie in bed worrying, so it takes me longer to fall asleep. Then I end up tired in the morning and have a hard time getting up.

“It helps me to talk to someone about my worries. I talk to my sister and it helps a lot. I also try to do something relaxing in the evening, to take my mind off Mom’s illness. If it’s not too dark, I take a walk in the neighborhood. Or I might read a travel magazine or watch a nature show on TV. It helps me to feel more calm and to be able to fall asleep more easily.”

Ching-Li

“I feel tense when there is a lot of noise. I try to avoid those kinds of situations. But there are times when it’s unavoidable, like at my apartment. I have roommates, and sometimes they watch television shows or make noise when they are cooking dinner. I like my roommates and I don’t think they are being excessive. Noise is just part of having roommates.

“It helps me to take a break and go to my room. I like to listen to my music on headphones; it drowns out the noise and takes me to a more quiet place.

How to develop a plan for coping with stress

This handout included checklists to help you identify the following: stressful situations, signs of stress, strategies for preventing stress, and strategies for coping with stress. It may be helpful to put this information together as an individual plan for coping with stress using the following form:

Individual Plan for Coping with Stress

Stressful situations to be aware of:

1.

2.

3.

Signs that I am under stress:

1.

2.

3.

My strategies for preventing stress:

1.

2.

3.

My strategies for coping with stress:

1.

2.

3.

Summary of the main points about coping with stress

• Stress is the feeling of pressure, strain, or tension that comes from responding to challenging situations.
• Being able to cope effectively with stress can help you to reduce symptoms and pursue your goals.
• Life events and daily hassles are both sources of stress.
• Being aware of signs of stress can help you take steps to prevent it from getting worse.
• You can avoid stress by using strategies such as scheduling enjoyable activities and developing a support system.
• Using coping strategies, such as listening to music, exercising, watching videos, or participating in a hobby, can help you manage stress effectively and enjoy your life.
• You can develop an individual plan for coping with stress that works for you.

Appendix: Relaxation Techniques

Three types of relaxation techniques are described below:

• Relaxed breathing
• Muscle relaxation
• Imagining a peaceful scene

Relaxation techniques are most effective when they are practiced on a regular basis. When you are first learning a technique, you usually concentrate on doing the steps according to the instructions. As you become familiar with the instructions, you will be able to concentrate more on the relaxation you are experiencing. Choose one of the following techniques and try practicing it daily. After a week, evaluate whether you think the technique is effective for you.

Relaxed Breathing

The goal of this exercise is to slow down your breathing, especially your exhaling.

Steps:

1. Choose a word that you associate with relaxation, such as CALM or RELAX or PEACEFUL.
2. Inhale through your nose and exhale slowly through your mouth. Take normal breaths, not deep ones.
3. While you exhale, say the relaxing word you have chosen. Say it very slowly, like this, “c-a-a-a-a-a-a-l-m” or “r-e-e-e-l-a-a-a-x.”
4. Pause after exhaling before taking your next breath. If it’s not too distracting, count to four before inhaling each new breath.
5. Repeat the entire sequence 10 to 15 times.

Muscle relaxation

The goal of this technique is to gently stretch your muscles to reduce stiffness and tension. The exercises start at your head and work down to your feet. You can do these exercises while sitting in a chair.

Steps:

• Neck rolls. Drop your head to one side. Gently roll it around in a wide circle. Repeat 3-5 times. Then reverse directions, and gently roll your head in a wide circle the other way. Repeat 3-5 times.
• Shoulder shrugs. Lift both shoulders in a shrugging motion. Try to touch your ears with your shoulders. Let your shoulders drop down after each shrug. Repeat 3-5 times.
• Overhead arm stretches*. Raise both arms straight above your head. Interlace your fingers, like you’re making a basket, with your palms facing down (towards the floor). Stretch your arms towards the ceiling. Then, keeping your fingers interlaced, rotate your palms to face upwards (towards the ceiling). Stretch towards the ceiling. Repeat 3-5 times.
• Knee raises. Reach down and grab your right knee with one or both hands. Pull your knee up towards your chest (as close to your chest as is comfortable). Hold your knee there for a few seconds, before returning your foot to the floor. Reach down and grab your left knee with one or both hands and bring it up towards your chest. Hold it there for a few seconds. Repeat the sequence 3-5 times.
• Foot and ankle rolls. Lift your feet and stretch your legs out. Rotate your ankles and feet, 3-5 times in one direction, then 3-5 times in the other direction.

  *If it is not comfortable to do step #3 with your arms overhead, try it with your arms reaching out in front of you.

Imagining a peaceful scene

The goal of this technique is to “take yourself away” from stress and picture yourself in a more relaxed, calm situation.

Steps:

1. Choose a scene that you find peaceful, calm and restful. If you have trouble thinking of a scene, consider the following:
   • at the beach
   • on a walk in the woods
   • on a parkbench
   • on a mountain path
   • in a canoe or sailboat
   • in a meadow
   • traveling on a train
   • in a cabin
   • beside a river
   • next to a waterfall
   • in a high rise apartment overlooking a large city
   • riding a bicycle
   • on a farm
2. After choosing a peaceful scene, imagine as many details as possible, using all your senses.
3. What does the scene look like? What are the colors? Is it light or dark? What shapes are in the scene? If it’s a nature scene, what kinds of trees or flowers do you see? What animals? If it’s a city scene, what kind of buildings? What kind of vehicles?
4. What sounds are in your peaceful scene? Can you hear water or the sounds of waves? Are there sounds from animals or birds? From the breeze? From people?
5. What could you feel with your sense of touch? Are there textures? Is it cool or warm? Can you feel a breeze?
6. What smells are there in your peaceful scene?
   Could you smell flowers? The smell of the ocean? The smell of food cooking?
7. Disregard any stressful thoughts and keep your attention on the peaceful scene.
8. Allow at least five minutes for this relaxation technique.

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