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7 Stress management and counselling in primary care
Jane Turner and Beverley Raphael Stress management begins with actively listening to the patient and proceeds through a detailed assessment of the patient's needs |
Short course-->
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Synopsis - Introduction - Response to stress - Assessment in general practice - Stress management - Traps and pitfalls - When to refer - References - Authors' details - Box 1: Common causes of stress - Box 2: Common symptoms of stress - Box 3: Eliciting other problems associated with stress - Box 4: Muscle relaxation - Case history: A common problem - Short course - Contents list | ||
Synopsis | |||
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Introduction | |||
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| The term "stress" is now interwoven into popular and professional language, yet there remains a lack of clarity about its precise meaning, and its impact on health and well-being. Stress is considered by many to comprise those factors in day-to-day life which adversely affect adjustment and coping, but stress as a challenge or pressure to perform also has the potential to contribute to enhanced performance and productivity. Many see stress as exerting a major, often undesirable, influence on health and well-being, reflected in the perceived link between stress and the development of cancer, despite the lack of supporting scientific evidence.1 Stress is seen as contributing to other conditions such as heart disease, and certainly recent studies implicate stress as a factor in the clinical course of coronary heart disease.2 | ||
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Response to stress | |||
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Research into the impact of adverse events is complex, and few studies
have addressed all three components of the issue: stressors (however
defined and measured), their biological effects, and consequent
changes in health status.3 Assessing the link between
stress and physical disorders such as hypertension highlights the
difficulties posed by the lack of standardised, validated,
objective measures of stress and the number of confounding variables
in lifestyle factors.4 Other research suggests
that the emotional impact of a major stress, such as divorce, may be
mediated in large part via the more minor subsequent stressors, such
as changes in work and financial situation,5 adding another layer of
complexity to the issue.
From a practical point of view, it is prudent to consider that the response of an individual to stress may be mediated by many factors, including the number of different stressors involved, personality style, cultural background, social circumstances, the symbolic meaning of the stress, past life experiences and the availability of supports. When stress is implicated in ill health, it is possible for the patient to present with either physical or psychological complaints (Box 2). Presentation to general practitioners with psychological complaints accounted for about 6% of general practice encounters in one large study.6 However, many people, by virtue of personality style, culture, age, or past experiences, will present with physical symptoms rather than complain of psychological distress. There is evidence that those who are experiencing distress and who tend to introspect are those who are likely to amplify somatic symptoms.7 Sex may also influence coping styles and presentation. The dictum that "men don't cry" remains very real in some sections of Australian society. Women may be more likely to use interpersonal networks for support when faced with adverse life circumstances. | ||
Assessment in general practice | |||
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Stress management has become mainstream, particularly in some
sections of industry, and there is often pressure on the doctor to
deliver a slick treatment package in immediate response to the
patient's expression of concern. However, most interventions will
fail if they are delivered as a uniform package without detailed
assessment of the patient's individual needs. For everyone who
presents, the doctor should try to answer the question "Why is this
person presenting with these symptoms at this
time?".
Active listening: The first, crucial step is listening to what the patient has to say. Active listening allows the general practitioner to clarify the nature of the patient's concerns, and may also allow patients to see more clearly the nature of their problems and devise their own strategies for dealing with them.8 In the case of the person who has presented with concerns about stress, it is best to encourage the patient to discuss these issues as they see them before asking very specific questions, or offering an opinion about their situation. The patient will often identify a particular aspect of their situation that is of most pressing concern (often not the one that you might have suspected), which may then provide a focus of more detailed questioning. Associated problems: It is important to consider the range of problems which may be associated with stress, such as escalation in smoking or alcohol use, marital conflict or domestic violence. These may in a circular fashion contribute to further dysfunction, in the person themselves, and in family members. Many patients are highly sensitive about these matters, and questioning needs to allow the patient a way of responding honestly without losing face (Box 3). With regard to such concerns as heavy smoking it is crucial to avoid engendering guilt or fear about the problem, as it appears that fear may be a major disincentive for behavioural change.9 Always bear in mind that the person who feels they are facing intolerable stress may have thoughts of suicide. Physical symptoms: In the case of the person who presents with physical symptoms that appear to be related to stress, assessment may take a different form. Although it is vital to assess the symptoms fully and to establish their cause, in many cases effective symptom management must incorporate psychological treatments. There are those who regard expression of emotional concern as a sign of personal weakness, resisting discussion about such matters. Assessment of stress may pose some difficulty in these cases, and taking a parallel history may be a fruitful technique. This simply involves asking the person in detail about life events, work, family events and so forth, without identifying these as stressors. Often patients can nominate particular events or concerns which can be "matched" temporally with problems in health or symptom control, even though they have never made the link themselves. | ||
Stress management | |||
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This is a poorly defined area, the proliferation of lay "stress
management" courses and consultants adding to the blurring of the
edges.4 In many sectors of the
workplace, stress management is seen as essential for the
occupational health of employees. However, there is often poor
documentation of the precise techniques used, the competence and
qualifications of their operators, nor any evaluation of their
efficacy or even detrimental effects.10 The concept of trauma
debriefing was originally developed to assist those who had
experienced disasters or severe life-threatening events, but it has
increasingly been generalised inappropriately to other settings.
Even in situations such as disaster, there is no evidence that trauma
debriefing effectively prevents subsequent problems, despite
often being perceived as helpful by the individuals
concerned.11 The generic application
of such techniques may in fact undermine the capacity of individuals
to deal with difficulty, establishing instead a sense of anger and
helplessness that their own way of coping is somehow considered
imperfect.
Primary health care practitioners should thus consider stress management as a range of techniques that must be tailored to the unique needs of a particular patient. The general practitioner is ideally placed to recognise the strengths, resources, and vulnerabilities of those who consult them about stress, and to incorporate these factors in their treatment plans. As well as being useful for patients with psychological symptoms, stress management techniques may benefit those who suffer from rheumatoid arthritis and irritable bowel syndrome,12,13 and be useful in cardiac rehabilitation.14 Their precise contribution to the management of hypertension remains unclear.15 The treatment setting: Some general practitioners may feel concerned that stress counselling will take more time than they can afford,16 but others acknowledge the necessity for extra time and advocate allowing a double appointment time.17 Discuss the need for follow-up appointments: if they can be arranged for a regular day and time it is often reassuring to distressed patients, who feel able to "hang on" because they know their next appointment. Getting started: Helping the patient recognise that they are under stress may in fact assist them in devising coping strategies.18 Education of the patient about the nature of stress, the physiological response to it, and the frequency of such complaints in the community is often reassuring. Most people will identify with common phrases such as "it took my breath away" or "sick with worry". Particularly for highly obsessional individuals, feeling stressed may be interpreted as a sign of personal weakness, and providing information is very beneficial. Giving the patient an overview of the treatment plan may instil confidence, and, furthermore, models the way that seemingly overwhelming problems can be tackled in stages. Physiological approaches: Discussion about the consequences of rapid shallow breathing or hyperventilation makes sense to most people, who are often also aware of their heart pounding and feeling shaky when stressed. Introduction of abdominal breathing techniques is simple, but they require regular practice. It may help to suggest an environmental cue for practising breathing techniques (e.g., whenever stopped at traffic lights).19 Progressive muscular relaxation is a key element in stress management. It is important to reinforce that, although the principle is simple, it requires regular practice before it can be employed at will in situations of stress. There are a variety of techniques, one of which is described in Box 4. Imagery and visualisation can be linked to muscle relaxation, but can also be employed independently. The patient is encouraged to think about a particularly pleasant and relaxing scenario, and to focus exclusively on this for several minutes. In abbreviated form, such a technique can be employed as "time out" from other concerns. Biofeedback involves the measurement of physiological responses (for example, by electromyograph and galvanic skin response) and immediate feedback to the individual. The aim is to enhance awareness of the physiological changes that may accompany stress, so that the individual can develop greater control over these changes via techniques such as muscle relaxation and imagery. Biofeedback is practised by some psychologists and, although useful in some cases, it is not considered an essential procedure in the management of most cases of stress. Cognitive strategies: Adopting a problem-solving approach often asserts a sense of some order over seemingly overwhelming problems. In the context of stress management this may involve identifying the stressors, classifying them (is this an important stressor or a minor "hassle"?) and reframing concerns. Exploring the extent to which events are under personal control and acknowledging the inability of any individual to be completely "stress-free" may allow the person to let go of some more minor concerns and focus on a smaller number of specific issues.20 Breaking down the high priority stressors into components may allow the person to see strategies for coping that were not apparent when confronted with the "big picture". Dealing with negative thoughts is an integral aspect of stress management.21 Most of us have negative thoughts about ourselves and our lives from time to time, but for the person who is enduring major stress these may become so pervasive as to reinforce their feelings of inadequacy and fear, and undermine any plans they develop to deal with the problem. Most people grasp the concept of "brain washing" -- whereby something forcibly repeated to a person comes to be believed -- and can readily understand how destructive their own negative thoughts can be. Encouraging the person to challenge their negative thoughts and to consider how they could reframe things is a useful technique. The key element underpinning these approaches is fostering patients' recognition of their own pattern of response to stress. This insight may empower patients to develop strategies for coping with stress, and even to recognise the potential benefits of stress in some circumstances. Lifestyle issues: Behaviours developed in response to stress may undermine the ability to cope. The person who drinks ten cups of coffee a day may find that reducing caffeine intake improves sleep and reduces anxiety and irritability. Sleep deprivation endured to "catch-up" on tasks may actually decrease performance. If lifestyle changes such as regular exercise can be portrayed as active management of stress, it may be that busy executives give themselves permission to engage in something they had previously seen as a luxury. | ||
Traps and pitfalls | |||
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The distinction between adjustment disorder (problems in coping
with stress) and psychiatric illness (e.g., anxiety disorder,
depression) is often unclear. It is easy to overlook the development
of a depressive illness in patients who talk in terms of stress rather
than depression. It is a common misperception that because depressed
mood or anxiety are understandable reactions to life events or
circumstances they do not merit treatment. Nothing could be further
from the truth. About 25% of episodes of depression are preceded by
some negative life event, such as loss of a job or bereavement. In these
cases, what is required is early recognition of the disorder,
appropriate pharmacological management, and counselling that
focuses on the prominent components of grief, loss, and
identification of strength and capability.
A further trap is viewing stress as inevitably deleterious rather than a potential stimulus for development and growth. There is evidence that the experience of success in one arena of life may lead to enhanced self-esteem, self-efficacy, and more successful coping patterns when faced with other life challenges.22 Other traps and pitfalls include:
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When to refer | |||
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In those cases where stress symptoms seem disproportionately severe
or prolonged, consideration should be given to referral for
specialist treatment. Many of those who suffer from stress may
benefit from treatment by a psychologist who has expertise in
cognitive behaviour therapy, for example.
It is crucial to recognise that in many instances stress may be the external manifestation of psychiatric illness, or bring into focus personality dysfunction which had previously been covert. In these cases, specialist psychiatric treatment should be considered. | |||
References | |||
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Authors' details | |||
| Department of Psychiatry, University of Queensland, Royal Brisbane
Hospital, QLD.
Jane Turner, FRANZCP, Senior Lecturer. Beverley Raphael, AM, MD, FRANZCP, Emeritus Professor. Correspondence: Dr Jane Turner, Department of Psychiatry, University of Queensland, K Floor, Mental Health Centre, Royal Brisbane Hospital, Herston, QLD 4029.
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