For any stress management program to be effective, it must address the issue from  several perspectives: the physical, the emotional or spiritual, and the mental. As we  have seen, human beings are not just bodies or minds existing in separate compartments. We are biopsychosocial and spiritual creatures; wellness depends on achieving a balance in all of those areas. The body can be perfectly healthy from the biomedical standpoint, but if the person is experiencing emotional discomfort from some issue in  his life, true wellness is not possible. To be well means to be whole; to feel a sense of unity within yourself. Let's review some of the effects of stress on each of the overlapping systems by looking at the diagram on the next page. 

           As you can see, no part of the mind or body is untouched by the effects of stress. Any approach to stress management must be a multi-faceted approach to overall life management.

Getting in Touch
           Many of the methods for handling stress which we will study involve getting in touch with our body: learning to listen to it more closely. Whether you are practicing  progressive relaxation techniques, or movement meditations, or exploring the  therapeutic applications of music-all of these stress reduction modalities involve  both the mind and the body. You will essentially be performing a dance with yourself,  learning how to balance and move in harmony with your own rhythms. The steps are  your own. The goal is not to imitate any other dancer, but to increase your awareness of who you are, to learn how your body reacts

MIND poor judgment, difficulty learning new information, poor decision making, forgetfulness, difficulty concentrating BODY Fatigue, frequent colds, back pain, muscle tension, chest pain, high blood pressure, palpitations, dry mouth, sweaty cold hands, diarrhea or  constipation SPIRIT-PSYCHE anxiety, depression, fear, nightmares, feeling threatened or trapped, alcohol or drug abuse, eating disorders

to stressful thoughts and events, and to learn how to modify that reaction to move to a higher level of wellness. 

         As you read through this chapter and work on the exercises, you may think to yourself that learning how to reduce the stress in your life is a lot of work. It can be! Making lifestyle changes may not be easy, but it is worth it. Why? 

         We have already seen the negative effects of stress on the body: high blood pressure, decreased immune function, cardiac symptoms, headaches, muscle tension, etc. We know from our own experience that stress and worry makes us feel bad, depressed, "uptight," or whatever. But what about the effects of stress on our mental health and ability to function successfully in our lives? 

          Some stress, such as the normal day-to-day stress of getting out of bed in the morning is good for us: it motivates us to do things. It is predictable, we can usually control it to some extent. 

High Levels of Stress
         The problems arise when a threatening event, such as an illness, divorce, job change, or the like arises. This is when the body tries to kick into high gear to fight whatever the threat is. Not only is our body affected, but also our mind. When we are under high stress, our perception of the world narrows-we may not see events or people in a realistic fashion. We may get moody, or easily aggravated. Anxiety tends to interfere with our performance of normal duties-such as our jobs. High levels of stress decrease productivity.

         Severe states of stress and panic have a major impact on how we cope with the world. Coping mechanisms, or the way we usually get through our lives, may fail. We may find ourselves in a state of crisis, requiring professional crisis intervention.

         For health care workers, we may encounter clients at any place along the continuum from relaxation to total panic. We may find ourselves in similar situations. Illness is a significant stressor, which often involves a sense of hopelessness and loss of control on the part of the client. By assisting clients to learn simple stress management techniques, we empower  them to try and regain control over some  portion of their lives.

         If we are feeling highly stressed, helpless, and out of control, we can do the same for ourselves. Each of us, regardless of profession, encounters numerous stressful situations over the course of a lifetime.

         If we are to achieve optimal wellness, we need to know how to handle these situations in an effective, adaptive manner. 

Perception and Reality
        One of the ways to deal with stress, and to manage it, is to change how we experience it. Change the way we look at any given event or situation.

        We create our own subjective reality to a great extent; we have a lot of control over how our mind perceives the world around us.

        The mind is an incredibly powerful tool, as we have seen. One of the first lessons of stress management is that we can change our perception of the stressor: we can transform an experience from one of negativity and discomfort to a piece of information to be processed and dealt with. Each of us can change how we interpret events. For example, a problem can become an opportunity for change or improvement. If we can transform stressful situations into controllable opportunities, we can turn negatives into potential positives. Stress itself can be transforming because it can force you to change, and change is the key to growth.

        This is not to say that problems do not exist. If the house is on fire, that is a very real cause for stress and an excellent reason to let the body react with the full "fight or flight" response. Our friend with the tiger had a very legitimate reason to have his blood pressure go up. But not all situations are this clear cut: worrying about the meaning of 'somebody-not-calling-when-you-thought-they-might-call-at-a certain-time-even-though-they-never-promised-to' may not be a realistic thing to do.  Thinking that they did not call because they had an accident and died would not necessarily be a valid perception of the event. This is the type of thinking that can be controlled, with commitment and practice. If you really think about it, worrying is something that happens inside your head-it may or may not have a connection with the reality outside.

        The importance of the mind-body connection is also not to imply that it a sick person caused himself to be sick. Blaming the victim accomplishes nothing.  While attitude has been shown to have a dramatic impact on the functioning of the immune system and other body systems, it would be highly unlikely that a person would deliberately "think", himself into getting cancer or having a heart attack!

        What is useful is to recognize that there is a connection between how we think and how we feel. Appositive outlook can help a sick person get through rigorous experiences with a greater sense of wholeness and control 

Exercises
           You have already noticed that this book combines a lot of information or didactic material teaching you about what stress is, how the concept developed,  and the effects of stress on the body. It also gives you space to put that information into practice-to make it real in your own life through the self-assessment exercises.

           By deciding to read the book, you demonstrated an interest in stress management, and [I hope] a commitment to yourself to use this knowledge to improve your own health.  By learning more about yourself, by learning how to employ a variety of stress management  tools, you will be able to teach others-your clients, family, friends, or co-workers..

           The next section deals with coping. What it is; how it fits into the stress management picture. This section will include a variety of different exercises for you to complete.

           A reminder for health care professionals: any of these self-assessment tools or relaxation exercises can be adapted for your patients or clients. You can change the words, change some of the approaches; do whatever you need to do to be most helpful to those individuals. It is essential that you work through these exercises yourself first for two reasons: it will assist you in your own growth and understanding of the subject, and it will provide you with insight into what you think will work within your practice setting.

          Do not just go to work tomorrow and try one of the drawing exercises with one of your anxious patients: explore it yourself first and use your professional judgment on how to apply the technique. 

Coping Skills: Keys to Life Management
      We all use the word "coping" quite freely. We talk of "coping" with life, "coping" with deadlines, "coping" with screaming kids, "coping" in general. What is coping? How can we define it in order gain a better grasp of what stress management really means?

         To cope means to be able to deal with something-anything. Some of us cope well, using what are called "adaptive coping skills." Others may use less helpful strategies, such as drugs or excessive alcohol to assist them. These would be examples of "maladaptive coping skills."

        How we cope, or deal with any given situation, is a complex mixture incorporating our perceptions, our emotions, and how we react to those events. The way we approach problems also depends on what types of examples or role models we have had throughout our lives; we may draw from the coping skills we saw our parents use-both good and bad. We learn how to cope with life from a variety of sources. There is no one set pattern.

        Coping is a process in which we constantly draw upon multiple resources and skills which we have acquired throughout the course of our lives. Personal resources combine with social resources and other factors, as shown in the table below:

personal resources + social resources sense of self-worth + friends/family faith + church/religious groups innate hardiness + support groups self-confidence + monetary resources adaptability + community assistance previous experience + occupational background

Resources
        Better resources lead to better coping skills .

        Merely having the resources available, however, does not guarantee a good outcome. It is how a person engages with these resources which determines in part  how effectively he or she will cope in a stressful situation,.

        As health care professionals, our goal should be to serve as facilitators, helping our clients to learn ways to enhance their own coping abilities. We I should empower that person to believe in his own inner resources, along [ with directing him to the various social and personal resources which may assist him in his journey to ward wellness.

        We must also remember that no one exists as an isolated being. Each of us is part of a family and social network. That network can be a major source of support, and an important enhancer of a person' scooping skills. As the most crucial social unit, the family is key to an overall life [ management/wellness promotion program.      Friends and support groups are also very important. This has been demonstrated  by studies of cancer patients and other persons living with serious illnesses. The  people who have been involved in supportive group situations tend to live longer  and report a higher quality of life than those who are not involved. As health care  professionals, we need to remember that our clients may benefit from appropriate  referrals to community and professional support networks.

        Whatever our profession, the importance of having a good support network as part of our overall commitment to our own wellness cannot be ignored. Stress management programs are most effective if they can address both the needs of the individual as a distinct being and his or her needs as member of a broader familial network.

        As human beings trying to learn more about what stress is and how it impacts on our lives, we are empowering and enabling our serves to reach new and higher levels of wellness. We are empowering ourselves to explore; to learn how to cope more effectively with whatever stressors we may encounter. We are learning how to adapt-to bend without breaking. To ride the waves without sinking, and without timidly treading water. We are empowering ourselves to draw from a collection of personal and social resources to learn how to avoid maladaptive coping behaviors which can be harmful to us, such as excessive consumption of alcohol, smoking, food, or drugs. Think of this book as your guide to inner discovery of new and better ways to be well. 

Self-Assessment Tool: Coping Skills
     In order to better understand how you are currently coping with the stress of day-to-day life, take a few minutes to answer the following questions. Once again, no one will see your answers but you, so be honest with yourself. 
      

1.	What do you do when you are feeling tense? Please answer yes or no to each  question:
	Go for a walk? _______________
	Drink a cup of coffee?  _______________
	Smoke a cigarette?  _______________
	Have a drink?  _______________
	Get drunk?  _______________
	Take some sort of drug?  _______________
	Eat?  _______________
	Exercise?  _______________
	Take a nap?  _______________
	Talk to a friend or family member?  _______________
	Other?  _______________
2.	For those actions to which you answered "yes," estimate how often you do that  particular action.
	Every day? Week? Ten times a day?
	Now have a little chat with yourself. The space below is for you to write down any  thoughts or responses which come to your mind as you ask yourself the following  questions:
	Do you think the ways you are responding to stress now is helping you  or hurting you? Why?
	Have any of your family or friends said anything to you (good or bad) about how you  respond to stress?
	___________________________________________________________________________________
	Of the behaviors that you marked yes above, which, if any, do you want to change?
	___________________________________________________________________________________
	Are there any specific new ways of coping that you would like to learn more about?
	___________________________________________________________________________________

Coping Skills: Practical Applications  

Basic Relaxation Exercise
        Many researchers and health care practitioners have built upon the work of physician Edmund Jacobsen. Jacobsen developed the technique known as Progressive Muscular Relaxation, which involves using the power of your mind and mental imagery to reduce muscle tension and some of the uncomfortable physical effects of stress.

        Basically, you learn to train yourself to relax by using a tool which is always with you: your breath. The "script" which you are about to read is designed to assist you to relax your entire body within a short period of time. The technique of Progressive Muscular Relaxation can be used any place and any time-at your desk, while sitting in a chair, while lying in bed, or wherever. Although listening to a recorded "script" can be very useful as you are learning this method, it is not essential as long as you have grasped the basic principles. One caution: Never practice this relaxation technique while you are driving or operating machinery. 

Using the Script  
        While you are learning how to relax using the powers of imagery, it is helpful to have a guide. The scripts in this book are just that: guides. They are here to assist you feel free to modify the text or use selected sections as you prefer. You have several options on how  to use them. The first way is to read them to yourself, get the basic idea and body sequence, and then work through the process without any particular words directing you. Another option is to have a friend or partner read the script out loud to you; this is very effective even in group stress management sessions. Be sure that the person reading the script has a voice which you find soothing to hear, that does not automatically trigger any strong emotions (especially negative emotions) when you hear it.

        A third option, which I recommend highly, is to record your own voice reciting the script and listening to that recording as you go through the relaxation process. This method is valuable for several reasons. First, having the taped script frees you from struggling to remember what  to do next. Secondly, hearing your own voice as your relaxation 'coach' reinforces the idea that you have the power and the ability to train yourself to relax. You are empowered to heal yourself from the negative effects of stress. You will internalize the sound of your voice telling you how to relax your body, limb by limb, muscle by muscle, until such time that you will have conditioned yourself to do so very quickly and effectively. You will hold the key to your own relaxation and stress reduction. In essence, you will become an active participant in the maintenance of your own wellness. One of the situations which can cause the greatest degree of stress is the feeling that one is "out of control," or helpless to direct one's own life. This is part of the reason why catastrophic illnesses such as cancer and AIDS are so stressful for those experiencing them: the person feels disemboweled by the disease process, and oftentimes by the demands of the treatment. The act of being in a hospital or health care setting is in itself a disemboweling experience. Any person who has had to wear a hospital gown or the little paper coverlets used in most doctors' offices can attest to that statement!

        A similar experience can also happen in the business world. We may be given assignments and deadlines over which we have no control or choice. This is often stressful. Think of how  you have felt when your boss or co-worker gives you a new assignment with very little time to complete it, and very little decision-making power in the entire process. Was this type of event stressful? How did your body react?

       The technique you are about to learn will help you in future encounters by giving you an internal resource: a way to de-escalate the physical reaction which your body will mount in response to the stressful stimulus. If you are a health care worker, you may be able to teach this technique to your clients to assist them through times of illness. Whatever your profession, it will be of value to you.

      As with all the exercises in this book, you may find some of more help than others. That's OK: the goal is to explore a variety of different methods of stress management to see which ones "fit" you the best. You will learn from each one, and will become more aware of how your mind and body "work" together. Enjoy the process of self-discovery.

       Do not feel discouraged if you don't feel totally "at ease" with this technique the first time  you try the exercise. Deep relaxation is a process which involves both the mind and the  body. Like any other skill, it takes practice.

      You will learn how to do the progressive relaxation step-by-step. The first step is to learn the importance of the breath.

      Before you can begin to relax the different parts of your body, you need to get your mind into a calmer, slower state. The first lesson to learn is the healing power of the breath. [Note: Martin Rossman'sbook Healing Yourself: A Step-by-Step Programfor Better Health Through Imagery  provides a more extensive discussion of this subject; please see the bibliography for the full reference].

      All relaxation exercises begin with what I am calling the Healing Breath, so it is essential to practice this first exercise until you feel comfortable with the technique. 

Preparation
     Sit or he down in a comfortable position. Loosen any tight clothing, take off your shoes, etc. Make sure that you will not be interrupted for at least 10minutes. You are now ready to begin the relaxation process. Give your self permission to take time  for your self, to care for yourself and to be however you need to be at this moment.

Breathing Exercise: The Healing Breath  This first exercise is the most important, most basic of all: you are going to begin the  process of training your body to relax. It may take a little practice, but it is well worth the effort.          As with all relaxation exercises, begin by making yourself comfortable, whether sitting or lying down. Place one hand on your abdomen, one on your chest. Close your eyes if you wish.          Now, just breathe normally-trying to do so in an unconscious fashion, letting your body breathe itself.          Which hand is moving up and down more? The one on your abdomen or the one on your chest?           To be most healing and most relaxing, we need to learn how to breathe deeply and  fully. This is done by learning to let your diaphragm expand fully. You may have heard of ''breathing from the diaphragm," if you are a singer, or you may have heard of  "belly breathing." Whatever you call it, the goal is to let your lungs expand fully by letting your abdomen move in and out. Don't feel self-conscious about your tummy looking fat: the fuller the breath, the more healing power it carries.          Focus on your breathing, and try to see how much you can make the hand on your  abdomen rise and fall. Don't exaggerate the movement, just relax and let it flown  naturally-breathing in and out through your nose. Slowly and deeply.          Feel your body start to relax as you let your self breathe. Each time you breathe in you inhale healing oxygen which rushes to every cell in your body. Each time you breathe out, you let go of some tension, some unnecessary thoughts, some discomfort. Let your breath help you to heal, to become whole.          Continue breathing, feeling your abdomen gently rise and fall. As you prepare to end  this exercise, you will tell yourself that your breath is your partner in healing. By taking  in a slow, deep breath-letting your lungs expand fully and your abdomen rise and fall- you are giving your body a signal to begin the relaxation process.

        Congratulations! You have just completed the first and most important exercise in the process of learning how to manage your reaction to stress: you have learned how to use your breath as a healing tool. You can now move on to the full process of muscular relaxation. Once again, we will  provide you with a script to help you get started. It is a good idea to make one tape  which includes both the Healing Breath script and the one for Muscular Relaxation- that way you can work through the entire process without worrying about changing tapes. 

        The preparation for the exercise is the same as before: make yourself comfortable, loosen any tight clothing, arrange for ten minutes or so of uninterrupted time. Then sit  or he back, close your eyes, and let the script assist you to relax.

Muscular Relaxation Script   Once you are comfortable, begin the relaxation process by focusing on your breathing. Breathe slowly and deeply, feeling your abdomen gently rise and fall with each breath. As you draw air in, you draw in the healing oxygen which nourishes every cell in your body. As you breathe out, you let go of the tensions and stresses of the day. Just take a few minutes to let your breath assist you into a state of quiet and calmness.           Good. Now begin to tune in to your body. Tune out any external noises or destractions. Give your self permission just to be . Listen to your body-take "inventory" of what sensations your are feeling from your toes to the top of your head. Where are you feeling stress? Pain? Discomfort?           Begin with your feet. Continue to breathe slowly and gently, and as you breathe in imagine the healing oxygen circulating down to the very tip s of your toes. Healing and cleansing any areas which feel tired or uncomfortable. As you let the breath go out, let the fatigue go with it.         Release and relax.         Slowly move up your feet to your ankles. Once again, breathe in the healing, calming oxygen. Breathing out any discomfort or tension. Continue moving up your calves to your knees, your thigh muscles, your hips. Breathe in slowly and deeply; breathe out  with a sense of letting go of all tension, all stress. Release and relax.                 Continue to focus on one area at a time, using your breath as a healing tool, until your body feels fully relaxed.         Next turn your attention to your back. Many of us carry a great deal of tension in the muscles of our backs; many of us have had back injuries which are aggravated by stress and tension. You can use your breath to help these muscles to let go of the  tension, the tightness. Take in a deep slow breath, and let it blow out all the discomfort,  the tension. Repeat this several times until you feel your back softening, relaxing.         Move up to your shoulders. Shrug your shoulders a few times, raising them up as  you breathe in-letting them drop as you breathe out.         Imagine the feeling of relaxation spreading down your arms and out to your fingertips. Your hands, tired from a day of work or activity, soften and become relaxed.         Release and relax. Let the tightness, the tension, and the stress blow away with your breath. Let your breath carry you up to your neck, letting your head gently flop around  if it feels right to you. Let your breath bring healing oxygen to all the tiny muscles in your  face, your scalp, your eyelids, all around your face. Release and relax.  Let go of all the tension as you let your breath out. Now that you have moved up your body, relaxing each area along the way, take a moment to re-check yourself: Are any areas still feeling tense? If so, take in some full, deep breaths and send that healing force to those areas. Blow out the tension as you blow out your breath. Take some time to enjoy this pleasant state of muscular relaxation. Notice how soft and comfortable your body feels.          Prepare to conclude the exercise by starting to move your body-wiggle your toes, your  fingers. Gently start to come back into your body, back into the room. Take in a few nice, deep breaths.        When you are ready, open your eyes. Feel refreshed and relaxed, and know that you can return to this pleasant state of relaxation anytime you wish by using the healing power of your breath....