Welcome to From Insults to Respect. Regular visitors know that on this blog, we often find suggestions for improving our stress management skills.

The evidence supporting learning these skills includes studies demonstrating that prolonged stress is related to adverse psychological and physical health effects, as well as an increased risk of premature mortality (See Keller, et al., 2012 for a review of this evidence). Other studies indicate that not everyone exposed to high levels of stress become sicker than individuals exposed to less stress. Perhaps this is because the more resilient individuals have learned to respond skillfully.

There is some support for the “more skillful” theory. For example, in the Keller, et al. article, most of the people that these researchers studied believed their stressful experiences could make them ill, and indeed these folks did often experience more illnesses when they faced high chronic stressful experiences. However a resilient subgroup of individuals tended to not support the stress-illness connection. When faced with high stress, they had learned to believe that the physical sensations they experienced with stress was their body’s way to help them to rise to the challenges that they face.

Although this type of evidence encourages some to learn skills that teach us to respond to stress in ways that are related to being resilient, for some, it is not quite sufficient. What more is needed?

The skeptics would like to see studies that first identified people who were having ill effects from too much stress, and then, after learning stress management skills, they ended up having better health outcomes than a randomly assigned control group who were not taught these skills. Without such studies, it can be argued that it is just a coincidence that those who appear to be skillful at dealing with stress happen to be individuals who are also healthier. These skeptics point out that there are already a few randomly controlled studies that have been completed that provided some brief stress-skill training to people experiencing heart problems. The results from these studies turned out to be discouraging.

But now, a new study has come out that has the very characteristics that skeptics have been calling for. The results lend considerable support that those who learn stress skills in a more intensive manner than the earlier studies, do have significantly improved health outcomes.

The Study

Circulation, one of cardiology’s premier journals, published an article on March 21, 2016 titled, “Enhancing Cardiac Rehabilitation With Stress Management Training: A Randomized Clinical Efficacy Trial.” There we find that 151 outpatients with coronary heart disease aged 36- to 84-years were randomized to 12-weeks of comprehensive cardiac rehabilitation (CR) or comprehensive CR combined with stress management training (CR+SMT). A matched sample of CR-eligible patients who did not receive CR or CR+SMT comprised another comparison group. All participants were followed for up to 5.3 years (median = 3.2 years) for clinical events.

Participants who had participated in the CR+SMT group exhibited lower rates of clinical events compared with those who had just participated in the CR program (18% vs. 33%, P = 0.035). The group that did not receive CR or CR+SMT had significantly more clinical cardiac events then the other two groups (47%, P < .001). Patients randomized to CR+SMT not only reduced their stress levels, but also nearly halved adverse cardiovascular events, including heart attacks, strokes, severe angina, revascularization procedures and death.

These findings are pretty impressive. Let’s take a close look at both the CR and the SMT interventions used in this study.

Comprehensive Cardiac Rehabilitation

Patients engaged in aerobic exercise three times a week for 35 minutes. Patients also received education about coronary heart disease, nutritional counseling, and two classes devoted to the role of stress in this disease.

The CR+SMT Program

Patients in CR+SMT received the identical comprehensive CR intervention plus SMT. The SMT program combines education, group support, and cognitive-behavior therapy. The intervention is delivered in 12 weekly one and a half hour sessions in groups of 4 to 8 participants. Strategies for reducing demands are presented including prioritizing, time management, establishing personal values, and avoidance. Participants are encouraged to apply the skills that they have learned to address their own everyday problems.

Subsequent sessions focus on modifying responses to situations that cannot be readily changed. Several sessions are devoted to training in progressive muscle relaxation techniques and the use of visual imagery to reduce stress. Emphasis is placed on the importance of cognitive appraisals in affecting stress responses, with recognition of irrational beliefs and cognitive distortions such as overgeneralization, catastrophizing, and all-or-nothing thinking.

Later sessions focus on the importance of effective communication, including topics of assertiveness and anger management. Instruction in problem solving strategies is also provided. Methods included brief lectures, group discussion, role-playing, and weekly ‘homework’ assignments.

Take Away Message

Hopefully, the above discussion will increase the chances that you will take up the challenge of mastering stress management skills. I can tell you that from my own experience it is possible to transform many old entrenched habits, which typically escalate stressful experiences, to new ones that leave me in a far more comfortable state of mind.

That said, I am concerned that some people will come away from the above discussion being misled. They may find themselves thinking that all they have to do is to get a list of the various stress management skills, and once they know them, they will be all set to begin to be far less at risk of becoming ill. They may think, for instance, that now that they know that it is better not to believe that challenging stressful experiences will lead them to be sick, they’ll just stop believing that. But, just cognitively changing your attitude to the more health promoting attitude is not enough to convince your body of this.

Consider an analogous situation. There are many studies that involve people who are terrified of harmless snakes that appear in their gardens. These people, when they first come into a treatment program to help with this, first learn that the snakes they come in contact with are indeed harmless. Many soon become cognitively convinced of this, and yet the next time they come in contact with such a snake their bodies still become as stressed as ever. Such individuals, with guided practice, and a little patience, do learn to become comfortable when they see nonpoisonous snakes.

Similarly, to learn to act wisely when you are in other stress arousing situations, it takes some additional steps beyond just coming to know cognitively what they are. It takes practice over an extended period of time in a supportive setting.

Unfortunately, the stress management program described in the study published in Circulation, is not typically included as part of a cardiac rehabilitation program picked up by insurance carriers. Therefore, if such patients want to participate in a similar program described in the above study, they will have to be willing to pay the cost, assuming that they can find in their area someone with the expertise to teach them.

I hasten to also add that I believe it is a mistake to think that people should wait until their first heart attack before learning these skills. It’s no fun having a heart attack, and it makes sense to learn skills that may very well decrease the chances of having one.

So, for those who can not afford the financial burden of accessing such a program, or can not find such a program in their area, what can they do? Fortunately, you can dramatically improve your stress management skills without costing you a dime. That is what this blog is all about.

At the bottom of this post is a set of instructions for going to the first blog post, and working your way through the program at your own pace. Moreover, I have written three novels that further reinforce the skills by providing a narrative of some charming characters utilizing the skills in some pretty challenging circumstances. The first of these novels, A Hero Grows in Brooklyn, can be downloaded for free HERE.

There is great value of going through this entire free program with a few other people who can support one another along the way. Preferably, a group of about 4 to 6 people can meet somewhere weekly for about an hour and a half.

I suggest the following format for such groups. Everyone in the group would come prepared having read the post that will be discussed for the week. After 5 minutes of greeting each other, take twenty minutes to have a group meditation. A simple form of meditation is described HERE. Then, each person  in the group is to describe in about 2 minutes how the the post that they read for this session can be connected in some way to their own lives.

When discussing particularly sensitive material that might embarrass either someone in the group or someone else if it ever was revealed, fake names are used. Moreover, the scenarios that are discussed are presented as something that may happen in the future.

For example, let’s say I had a nasty argument with my wife a few days ago. I want to get some feedback from group members about how this can be handled if a similar set of circumstances should arise. I would describe the scenario to the group like this: “Let’s say there is this couple, Ralph and Alice. Sometime in the future, this couple has a nasty argument….”

Now, of course the group members might guess that you are Ralph, but they would not be sure. After all, it is perfectly possible that you might be discussing someone else that you care about and you wish to offer him or her some guidance. Or you might want to prepare yourself if something similar did occur in the future. So by making up fake names to discuss various scenarios you want to discuss, it at least provides some privacy.

In most of the posts, there is a description of how you can handle a particularly stressful experience, such as someone criticizing you, or someone doing something else that is making you angry. Each member of the group would role-play one of the scenarios described in the post under discussion. After each role-play, group members would share their reactions. The group would then end with everyone taking a turn sharing something that they are looking forward to in the upcoming week.

Now, to form this group, if you can identify individuals you know who wish to participate, that’s great. If, however, you have trouble identifying at least 4 people to join the group, consider setting something up using one of the social networking groups such as meetup.com.

These groups can be lots of fun, and they may just save your life.

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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their stress management skills and their emotional and social intelligence. To begin at the very first post you can click HERE.

Anger managementCardiac rehabilitationHeart diseaseStress Management