Stress Inoculation Training for Coping with Stressors

Donald Meichenbaum, Ph.D.

University of Waterloo, Ontario

Reprinted from:
Meichenbaum, D. (1996). Stress inoculation training for coping with stressors. The Clinical Psychologist, 49, 4-7.

I. Description of Treatment

Stress Inoculation Training (SIT) emerged out of an attempt to integrate the research on the role of cognitive and affective factors in coping processes with the emerging technology of cognitive behavior modification (Meichenbaum, 1977). SIT has been employed on a treatment basis to help individuals cope with the aftermath of exposure to stressful events and on a preventative basis to "inoculate" individuals to future and ongoing stressors.

SIT is a flexible individually-tailored multifaceted form of cognitive-behavioral therapy. In order to enhance individuals' coping repertoires and to empower them to use already existing coping skills, an overlapping three phase intervention is employed. In the initial conceptualization phase a collaborative relationship is established between the clients and the therapist (trainer). A Socratic-type exchange is used to educate clients about the nature and impact of stress and the role of both appraisal processes and the transactional nature of stress (i.e., how clients may inadvertently, unwittingly, and perhaps, even unknowingly, exacerbate the level of stress they experience). Clients are encouraged to view perceived threats and provocations as problems-to-be-solved and to identify those aspects of their situations and reactions that are potentially changeable and those aspects that are not changeable. They are taught how to "fit" either problem-focus or emotion-focus to the perceived demands of the stressful situation (e.g., see Folkman et al., 1991). The clients are taught how to breakdown global stressors into specific short-term, intermediate and long-term coping goals.

As a result of interviewing, psychological testing, client self-monitoring, and reading materials, the clients' stress response is reconceptualized as being made-up of different components that go through predictable phases of preparing, building up, confronting, and reflecting upon their reactions to stressors. The specific reconceptualization that is offered is individually-tailored to the client's specific presenting problem (e.g. anxiety, anger, physical pain, etc.). As a result of a collaborative process a more hopeful and helpful model is formulated; a model that lends itself to specific intervention.

The second phase of SIT focuses on skills acquisition and rehearsal that follows naturally from the initial conceptualization phase. The coping skills that are taught and practiced primarily in the clinic or training setting and then gradually rehearsed in vivo are tailored to the specific stressors clients may have to deal with (e.g., chronic illness, traumatic stressors, job stress, surgery, sports competition, military combat, etc.). The specific coping skills may include emotional self-regulation, self-soothing and acceptance, relaxation training, self-instructional training, cognitive restructuring, problem-solving, interpersonal communication skills training, attention diversion procedures, using social support systems and fostering meaning-related activities.

The final phase of application and follow through provides opportunities for the clients to apply the variety of coping skills across increasing levels of stressors (inoculation concept as used in medical immunization or in social psychology to prepare individuals to resist the impact of persuasive messages). Such techniques as imagery and behavioral rehearsal, modeling, role playing, and graded in vivo exposure in the form of "personal experiments" are employed. In order to further consolidate these skills individuals may even be asked to help others with similar problems (Fremouw & Harinatz, 1975; Meichenbaum, 1994). Relapse prevention procedures (i.e., identifying high risk situations, warning signs, and ways to coping with lapses), attribution procedures (i.e., ensuring clients take credit for and appropriate ownership by putting into their own words the changes that have taken place), and follow-through (i.e., booster sessions) are built into SIT.

SIT also recognizes that the stress an individual experiences is often endemic, institutional and unavoidable. As a result, SIT has often helped clients to alter environmental settings and or worked with significant others in altering environmental stressors (e.g., hospital staff for medical patients, Kendall, 1983; coaches for athletes, Smith, 1980; drill instructors for recruits, Novaco et al., 1983; and so forth). SIT recognizes that stress is transitional in nature and that there is a need to not only work with clients to bolster and nurture flexible coping repertoires, but it is also necessary, on some occasions, to go beyond individual and group interventions and to adopt a community based focus.

SIT has been conducted with individuals, couples, small and large groups. The length of intervention has varied from being as short as 20 minutes for preparing patients for surgery (Langer et al., 1975) to 40 one hour weekly and biweekly sessions administered to psychiatric patients or to individuals with chronic medical problems (Meichenbaum, 1994; Turk et al., 1983). In most instances, SIT consists of some 8 to 15 sessions, plus booster and follow-up sessions, conducted over a 3-to-12-month period.

II. Summary of Studies Supporting Treatment Efficacy

SIT has been employed in the treatment of:

acute time-limited stressors
such as in preparation for medical examinations (Jay & Elliot, 1990; Kendall, 1983; Kendall et al., 1979); surgery (Langer, et al., 1975; Ross et al., 1996; Wells et al., 1986) and performance evaluation (athletic competition, public speaking - Altmaier et al., 1982; Hussain & Lawrence, 1978; Jaremko, 1980, 1983; Smith, 1980);

chronic intermittent stressors
such as military combat (Meichenbaum, 1994; Novaco et al., 1983) and episodic physical conditions like recurrent headaches (Holroyd et al., 1977);

chronic continual stressors
such as medical illness (asthma, hypertension, Type A behavior, chronic pain, cancer, burns, rheumatoid arthritis - Moore & Altmaier, 1981; Randich, 1982; Roskies, 1983; Turk et al., 1983) and psychiatric illness (Holcomb, 1986; Long, 1984); prolonged occupational stress such as police work, teaching, combat (Forman, 1982; Meichenbaum, 1993; Novaco et al., 1983; Wemick et al., 1981).

stressor sequence
that results from exposure to stressful events (e.g., divorce, unemployment, rape - Meichenbaum, 1993; Foa et al., 1991; Vernon & Best, 1983). (With regard to SIT treatment of rape victims: SIT produced significantly more improvement on PTSD symptoms immediately after treatment but at follow-up prolonged exposure produced superior outcome in PTSD symptoms.)

Another clinical problem that has yielded positive results is the application of SIT to treatment of adolescents and adults who have problems with anger control (Deffenbacher et al., 1988; Feindler & Ecton, 1986; Hains & Szyakowski, 1990). In a review Meichenbaum (1993) has provided a comprehensive summary of how SIT has been used on a preventative and treatment basis and how SIT can be viewed from a constructive narrative perspective (Meichenbaum, 1994).

III. Clinical References Describing the Approach

Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press.

Meichenbaum, D. (1994). A clinical handbook/practical therapist manual for assessing and treating adults with post traumatic stress disorder. Waterloo, Ontario: Institute Press.

Meichenbaum, D., & Deffenbacher, J. L. (1988). Stress inoculation training. Counseling Psychologist, 16, 69-90.

Meichenbaum, D., & Jaremko, M. (Eds.) (1983). Stress prevention and management: A cognitive-behavioral approach. New York: Plenum Press.

Turk, D. C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: A cognitive-behavioral perspective. New York: Guilford Press.

Meichenbaum, D. (1977). Cognitive behavioral modification: An integrative approach. New York: Plenum Press.

IV. Resources for Training

There are no formal programs where professional can obtain specific training in SIT. Dr. Donald Meichenbaum often gives one, two and five day workshops on SIT and related cognitive-behavioral interventions. For information contact him at the

University of Waterloo
Department of Psychology
Waterloo, Ontario, Canada, N2L 3G I

V. References

Altmaier, E. M., Ross, S. L., Leary, M. R., & Thombrough, M. T. (1982). Matching stress inoculation's treatment components to client's anxiety mode. Journal of Counseling Psychology, 29, 331-334.

Deffenbacher, J., Story, D., Brandon, A., Hogg, J., & Hazeleus, S. (1988). Cognitive and cognitive relaxation treatment of anger. Cognitive Therapy and Research, 12, 167-184.

Feindler, E. & Ecton, R. (1986). Adolescent anger control: Cognitive-behavioral techniques. New York: Pergamon Press.

Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715-723.

Folkman, S., Chesney, M., McKusik, L., Ironson, G., Johnson, D. S., & Coates, T. J. (1991). Translating coping theory into an intervention. In J. Eckenrode (Ed.). The social context of coping. New York: Plenum Press.

Forman, S. (1982). Stress management for teachers: A cognitive-behavioral program. Journal of School Psychology, 20, 180-187.

Fremouv, W. & Harmatz, M. (1975). A helper model for behavioral treatment of speech anxiety. Journal of Consulting and Clinical Psychology, 43, 652-660.

Hains, A. A. & Szyakowski, M. (1990). A cognitive stress-reduction intervention program for adolescents. Journal of Consulting and Clinical Psychology, 37, 79-84.

Holcomb, W. R. (1986). Stress inoculation therapy with anxiety and stress disorders of acute psychiatric patients. Journal of Clinical Psychology, 42, 864-872.

Holroyd, K., Andrasik, F., & Westbrook, T. (1977). Cognitive control of tension headaches. Cognitive Therapy and Research, 1, 121-133.

Hussain, R., & Lawrence, S. (1978). The reduction of test, state, and trait anxiety by test specific and generalized stress inoculation training. Cognitive Therapy and Research, 2, 25-37.

Jaremko, M. (1980). The use of stress inoculation training in reduction of public speaking anxiety. Journal of Clinical Psychology, 36, 735-738.

Jaremko, M. (1983). Stress inoculation training for social anxiety with emphasis on dating anxiety. In D. Meichenbaum and M. Jaremko (Eds.) Stress reduction and prevention. New York: Plenum Press.

Jay, S. M. & Elliot, C. H. (1990). A stress inoculation program for parents whose children are undergoing medical procedures. Journal of Consulting and Clinical Psychology, 58, 799-804.

Kendall, P. (1983). Stressful medical procedures: Cognitive-behavioral strategies for stress management and prevention. In D. Meichenbaum and M. Jaremko (Eds.) Stress reduction and prevention. New York: Plenum Press.

Kendall, P. C., Williams, L., Pechachek, F. F., Graham, L. E., Shisslak, C., & Herzoff, N. (1979). Cognitive-behavioral patient education intervention in cardiac catheterization procedures: The Palo Alto Psychology Project. Journal of Consulting and Clinical Psychology, 47, 49-58.

Langer, T., Janis, I., & Wolfer, J. (1975). Reduction of psychological stress in surgical patients. Journal of Experimental Social Psychology, 11, 155-165.

Long, B. C. (1984). Aerobic conditioning and stress inoculation: A comparison of stress management interventions. Cognitive Therapy and Research, 8, 517-542.

Meichenbaum, D. (1993). Stress inoculation training: A twenty year update. In R. L. Woolfolk and P. M. Lehrer (Eds.), Principles and practices of stress management. New York: Guilford Press.

Moore, K., & Altmaier, E. (1981). Stress inoculation training with cancer patients. Cancer Nursing, 10, 389-393.

Novaco, R. W. (1975). Anger control: The development and evaluation of an experimental treatment. Lexington, Mass: Heath.

Randich, S. (1982). Evaluation of stress inoculation training as a pain management program for rheumatoid arthritis. Unpublished doctoral dissertation, Washington University, St. Louis.

Roskies, E. (1983). Stress management for Type A individuals. In D. Meichenbaum and M. Jaremko (Eds.), Stress prevention and reduction. New York: Plenum Press.

Ross, M. J., & Berger, R. S. (1996). Effects of stress inoculation training on athletes' post surgical pain and rehabilitation after orthopedic injury. Journal of Consulting and Clinical Psychology, 64, 406-410.

Smith, R. E. (1980). A cognitive-affective approach to stress management training for athletes. In C. H. Nadeau, W. R. Halliwell, K. M. Newell, and G. C. Roberts (Eds.), Psychology of motor behavior and sport. Champaign, IL: Human Kinetics Press.

Vernon, L. J., & Best, C. L. (1983). Assessment and treatment of rape-induced fear and anxiety. The Clinical Psychologist, 36, 99-104.

Wells, J. K., Howard, O. S., Nowlin, W. F., & Vargas, M. J. (1986). Presurgical anxiety and postsurgical pain and adjustment: Effects of a stress inoculation procedure. Journal of Consulting and Clinical Psychology, 54, 831-835.

Wemick, R. L., Jaremko, M. E., & Taylor, P. W. (1981). Pain management in severely burned adults: A test of stress inoculation. Journal of Behavioral Medicine, 4, 103-109.

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