Wellness Protocol: Stress Management

PHILOSOPHY:   Everyone has some strategies for managing stress that work for him or her. Guided self-help in this area encourages people to identify current stress management strategies that work well for them and to extend these to additional areas of their life and work. They also are encouraged to substitute health-building strategies for any habits they now have for dealing with stress which may create health risks in the long run, and to discover additional approaches to stress management that are consistent with their own personal style. The strategies introduced in this program help prevent more serious emotional disruption. They are not intended as a substitute for personal counseling or therapy for the more troubled employ. They may, however, be especially helpful for clients who are trying to change a health risk behavior (like smoking, over-eating or over-consumption of alcohol) which they have been using as a way to handle stress.

FORMAT:   The client and the counselor spend time together on an agreed upon schedule (usually weekly or bi-weekly at first) to review stress management materials and the uses a client is making of them to deal with stress. These materials should include information about stress and health behaviors that may be affected by stress, information about stress management techniques, as well as self-assessment sheet to help the client discover how all this applies to him or herself. The wellness counselor will help the client identify the nature of the stress problem and will help the client choose materials that can give additional information or ideas for dealing with the situation. The counselor makes sure that the client understands the materials and sees how they might apply to their own situation. The counselor then helps the client set goals for stress management. In addition, the counselor helps the client develop an eating and exercise program that is appropriate to the client's situation and that can help lessen stress. The counselor also helps the client decide whether social support is needed and, if so, how to get it. The counselor provides a check-in point and times for assessing how things are going. At each visit the wellness counselor monitors blood pressure, smoking behavior, weight or other health risks, and discovers which stress management techniques the client has been using are effective.

Session I. Getting Acquainted with the Client

1. Take the client's blood pressure and record on a wallet card and on standard follow-up form. Give wallet card to client and explain its use.



2. Ask client to identify areas of work and personal life that involve more than normal stress at the moment. What is it about the situations that make them stressful? Follow up with questions from the chart Signs of Stress: How do you know when you are under stress?



3. Point out that people vary a lot in the kinds of situations they handle well and what situations leave them upset. Yet, there are simple techniques for reducing stress that apply to a wide variety of situations. Some of the techniques give you a different way to act in a stressful situation. Others help you reduce the amount of stress you carry inside. Both sets of techniques help turn negative stress into a more positive emotional state that helps you concentrate on problem-solving.



4. Hand the client the booklet A Guide to Managing STRESS (Krames Communications) and read pages 2-5 together. Make sure these ideas are understood.



5. Ask client to finish reading the booklet before the next session and do the following:



• Put a checkmark next to the stress-managing techniques they already know and use.



• Select one additional thing to try from pages 6 and 7: Recognizing the Problem---Finding Solutions and see how it works.



• Select one or more of the relaxation methods introduced in pages 8-13 and see how it works.
  (Note: if the client does not seem to be reading the material easily, suggest he/she read this with a friend, and ask the client which friend might be interested in helping with the reading).



• If the client is using alcohol to handle stress, try using the relaxation method when (s)he feels the urge to drink.



6. Make an appointment for a follow-up session within 7-10 days. See how it is working. Indicate the appointment on the wallet card. Ask the client to bring the booklet when he or she returns to see you.



7. After the client leaves, fill out the standard follow-up form to record what happened at this visit. Indicate when the client is expected to return.

• Wallet Card (developed by the University of Michigan Worker Health Program)
• A Guide to Managing STRESS (Krames Communication, 1100 Grundy Lane, San Bruno, CA 94066-3030. 1-800-333-3032).
• Signs of Stress: How do you know when you are under stress? (developed by the University of Michigan Worker Health Program)

Session II. 7 to 10 Days Later

(Note: Clients will vary in how thoroughly they try the steps suggested in the stress management materials. Your task is not to get them to do everything, but to discover what is helpful to them, and then to start building this into their habits. The sessions which follow are built on the assumption that you are working with a client who is actively trying out each of the things agreed upon in the last session. At times it may be necessary to vary this format, repeating something that didn't get used the last time, and simply slowing down the sequence of activities. If this happens, it is important not to make the client feel guilty, which only adds further stress to the situation. Instead, acknowledge that it is hard to develop new habits when you are under stress, even if they would be helpful. Encourage the client in each session to choose at least one thing that they would like to do that week. Help them think through what it is they will do to make sure they are good to themselves in this way).

1. If the client returns at the appointed time, take their blood pressure and record it on the wallet card and on the standard follow-up form. If the client forgot the appointment, call to reschedule one. When the client shows up for this appointment, take the client's blood pressure and record as above.



2. Ask how things are going. (Be careful to avoid getting into a long discussion of the details of the stressful situation, however. As soon as it is tactfully possible, draw attention to the stress management implications of the client's answer).



3. Ask how the client liked the booklet A Guide to Managing STRESS. How much of it was familiar?



4. Did the client try any of the suggestions on pages 6 and 7? If so, how did it work? If not, look together at these pages and discuss whether any of these ideas are relevant for the situation. If client suggests that any of them might be useful, put a star next to the idea and suggest (s)he try it this week. (Note: use the client's booklet if it is there. Otherwise, show these pages in another copy in the office).



5. Ask whether any of the relaxation suggestions on pages 8-13 were hard to follow or unclear. If so, go through the page with them and help them. Ask how it feels.



6. Did the client try any of the relaxation methods this week? If so, what did (s)he think of them? How useful were they? (If relevant) Did trying this relaxation method lesson the urge to drink?



7. Does the client want to try anything else in the coming week? If not, try out one together that the client thinks might be useful.



8. Read page 14 together. Ask if the client has developed an action plan for dealing with the stressful situation. If there is an action plan, encourage the client to discuss it with you. Reinforce any parts of the plan that sound positive. Encourage the client to act as simply and as directly as possible.



9. Ask the client what kind of support from others is available. Is there anyone to talk to about this? Can anyone give helpful suggestions or help out in particular ways? Encourage the client to find at least one person other than the counselor to talk to.



10. Schedule a follow-up visit, with the timing mutually agreed upon. Write it on the wallet card.



11. As the client prepares to leave, ask What do you plan to do this week to take care of yourself? Is there one thing you want to try? Be sure to celebrate with the client any improvement in the situation, or in the client's handling of stress.



12. After the client leaves, fill out the standard follow-up form to record what happened. Indicate when the client is to visit again. If the client had to be called, note that you should call a day before as a reminder.

• Follow-up form
• A Guide to Managing STRESS (Krames Communications)

Session III.

1. If the client missed the second appointment, call client the day before as a reminder.



2. Ask client their weight at the beginning of the session. Explain that it is important to eat well when under stress. Make sure that weight stays under control so that you don't add to an already stressful situation. Then take client's blood pressure and ask about smoking, and alcohol consumption. Record this on the wallet card and on the standard follow-up form.



3. Ask how things are going and how the stress management strategies are working for the situation and for relaxing oneself. Reinforce any positive moves and changes. If there are problems, ask questions that encourage the client to think through ways to tackle those problems more creatively.



4. Suggest that it might be useful to look at a number of ways people handle stress in their lives. Which ones are they already using? Would additions thing be helpful? Fill out the Managing Stress chart with the client. When you have finished, look it over with client, asking the client to point out any areas that look useful. If the client chooses several, ask the client to choose one that seems worth trying immediately. Show the client any materials that are relevant to that choice and go over them briefly. Assessing Your Coping Habits will be a useful follow-up exercise with some clients. Then ask if (or what) they would like to try during the next few weeks. Ask client if they would like a copy of the chart to take home. Give the client a copy if desired.



5. Schedule a follow-up visit, with the time agreed upon. Write it down on the wallet card.



6. As the client prepares to leave, ask, "What do you plan to do this week to take care of yourself and deal with the situation?" Be sure to celebrate any improvement in the situation with the client.



7. After client leaves, fill out standard follow-up form for this visit and when client will return.

• Follow-up form
• A Guide to Managing STRESS (Krames Communications)
• Managing Stress Chart (available from Worker Health Program)
• Assessing Your Coping Habits (available from Worker Health Program)
• Kicking Your Stress Habits by Don Tubesing, Whole Person Associates, Box 3151, Duluth, MN 19791
• The Healing Power of Humor , by Allen Klein. JB Tarcher, Los Angeles, CA, 1989
• "The Laughter Connection," by Norman Cousins. In Head First: The Biology of Hope and the Healing Power of the Human Spirit. Penguin, NY, 1988

Session IV.

1. Weigh the client at the beginning of the session. Remind client that it is important to eat well when under stress. Make sure weight stays under control, so that this doesn't increase the stress. Then take client's blood pressure and ask about smoking. Record this on the wallet card and on the standard follow-up form.



2. Ask how things are going and how the strategies are working for the situation and for relaxing. Reinforce any positive moves and changes. If there are problems, ask questions that encourage the client to think through ways to tackle those problems more creatively.
   
   If this has not already come out, next ask the client about their action plan and whether any of it has been tried. Ask as well about their social support system. If there are problems, ask the client questions that help them think things farther. You might want to use the Setting Goals and Priorities assessment sheet.



3. If "2" takes up the available time, encourage the client to try these approaches during the coming week and to let you know they work.



4. Otherwise, read page 15 of A Guide to Managing STRESS together.



5. Ask how much alcohol, if any, the client is drinking. If drinking is occuring, express sympathy for the urge to calm oneself down and in a non-judgmental voice suggest that they might want to see whether this is making them more depressed.



6. Ask how much exercise the client is getting. If the client is not exercising, point out the advantages of letting some of the stress out through physical movement. Use beginning exercises from the Guided Self-Help Physical Fitness Program and from Some Easy, Energy-Freeing Exercises.



7. If the client already has a good exercise program, encourage the client to use it to release the tension that builds up from stressful situations. For these clients, there may be time to ask about nutrition. Point out the importance of eating regularly and well, and including foods or vitamin supplements rich in Vitamin B, when one is under stress. Show them Nutrition for the Fitness Challenge (AHA) and/or Nutritious Nibbles. Ask the client if it would be helpful to spend a session looking at nutrition and eating plans. If it would, make the next session, and use materials from the Weight Loss and Cholesterol Control Protocols in that session.

• Follow-up form
• A Guide to Managing STRESS (Krames Communications)
• Setting Goals and Priorities Assessment Sheet (available from the University of Michigan Worker Health Program)
• Physical Fitness Guided Self-Help Counselor's Guide (available from the University of Michigan Worker Health Program)
• Some Easy, Energy-freeing Exercises (available from the University of Michigan Worker Health Program)
• Nutrition for the Fitness Challenge (American Heart Association, National Center, 7320 Greenville Ave., Dallas, TX 75231)
• Nutritious Nibbles (AHA)

Session V.

1. Weigh the client, take blood pressure, and ask about smoking behavior if this is relevant. Record this information on the wallet card and follow-up form, and be sure to compliment the client if any improvements have been made.



2. Ask how the stressful situation is going. Has the client's action plan made any difference? How would the client like to extend or change this plan?



3. Ask about exercise patterns since you were last together. Have they worked? Reinforce the importance of exercising, and compliment the client on any positive changes.



4. Ask about eating patterns. If client has tried to change, ask whether their body liked the change. Encourage the client to use body cues (i.e., how they feel afterwards) as a guide to good things to eat and things to avoid.



5. Ask about alcohol consumption. If it has decreased, ask how the body feels with less alcohol. Is (s)he less depressed? If the client expresses any positive feelings about the change, reinforce this.



6. Ask about social support and how this is working.



7. Ask about use of other stress management techniques. Which ones are proving to be most helpful?



8. If there is time, ask how work is being affected by the stressful situation. Ask if the client would like to see another booklet from this same stress management series (Developing a Low Stress Workstyle). If the client would like this, and reading with a buddy has worked before, give the client the pamphlet. Check things the client already does and star things the client would like to try. If that kind of assignment didn't work well earlier, suggest it might be good to read through together at the next session.



9. Schedule a follow-up visit, with timing mutually decided. Write this down on the wallet card.



10. As the client gets ready to leave ask, "What do you plan to do this week to take care of yourself and to deal with the stressful situation?" Be sure to celebrate with the client any improvement in the situation or in the client's handling of stress reported in this visit.



11. After the client leaves, fill out standard follow-up form and indicate when client is to visit again.

• Follow-up form
• A Guide to Managing STRESS (Krames Communications)
• Developing a Low-Stress Workstyle (Krames Communications)

Session VI.

1. Weigh the client, take blood pressure, and ask about smoking if relevant. Record this information on the wallet card and follow-up form, and be sure to compliment the client on any improvements that have been made.



2. Ask how the stressful situation is going. Has the client's action plan made any difference? How would the client like to extend or change this plan?



3. Ask about exercise patterns since you were last together and how they have worked. Reinforce the importance of exercising, and compliment the client on any positive changes made.



4. Ask about eating patterns. If the client has tried to change this, ask whether their body liked the change. Encourage the client to use body cues (i.e., how they feel afterwards) as a guide to good things to eat and things to avoid.



5. Ask about alcohol consumption. If it has decreased, ask how the body feels with less alcohol. Is (s)he less depressed? If the client expresses any positive feelings about the change, reinforce this.



6. Ask about social support and how this is working.



7. Ask about use of other stress management techniques. Which ones are proving to be most helpful?



8. If there is time, ask how work is being affected by the stressful situation. Ask if the client would like to see another booklet from this same stress management series (Developing a Low Stress Workstyle). If the client would like this, and reading with a buddy has worked before, give the client the pamphlet. Check things the client already does and star things the client would like to try. If that kind of assignment didn't work well earlier, suggest it might be good to read through together at the next session.



9. Schedule a follow-up visit, with timing mutually decided. Write this down on the wallet card.



10. As the client gets ready to leave ask, "What do you plan to do this week to take care of yourself and to deal with the stressful situation?" Be sure to celebrate with the client any improvement in the situation or in the client's handling of stress reported in this visit.



11. After the client leaves, fill out standard follow-up form and indicate when client is to visit again.

• Follow-up form
• A Guide to Managing STRESS (Krames Communications)
• Developing a Low-Stress Workstyle (Krames Communications)

Session VII.

1. Weigh the client, take blood pressure, and ask about smoking if relevant. Record this information on the wallet card and follow-up form, and compliment the client on any positive changes.



2. Ask how the stressful situation is going. Has the client's action plan made any difference? How would the client like to extend or change this plan?



3. If the client feels that the strategies now in use are beginning to resolve the situation, encourage the continuation of these methods. If the client wants more help, ask if they know of other stress management approaches they would like to try. If not, suggest a more in-depth guide for creative problem-solving. Show the client the table of contents for Breaking Through:Creative Problem Solving that Lessens Stress and have the client choose areas they would like to explore. Plan future sessions to use 20 minute segments from these chapters.



4. For all clients, ask about exercise patterns since you last saw each other. How did these work? Reinforce the importance of exercising and compliment the client on any positive changes made.



5. Ask about eating patterns. If the client has tried to change, ask whether their body liked the change. Encourage the client to use body cues (i.e., how they feel afterwards) as a guide to good things to eat and things to avoid.



6. Ask about drinking behaviors and respond as is appropriate, similarly to responses suggested for earlier sessions.



7. Ask about social support and how this is working.



8. Ask about use of other stress management techniques. Which ones are the most helpful?



9. Check with client if future sessions would be useful. Schedule appropriately, gradually lengthening the time between sessions, with the understanding that additional times could be scheduled if special problems come up the need immediate attention.



10. As the client prepares to leave ask, "What do you plan to do this week to take care of yourself and to deal with the stressful situation?" Be sure to celebrate any improvement in the situation or in the client's handling of stress reported in this visit.



11. After the client leaves, fill out follow-up form and record what happened in this visit. Indicate when the client will return. If no future session is scheduled, mark a six-month check-up on the follow-up form, to be scheduled on the computer.

• Follow-up form
• A Guide to Managing STRESS (Krames Communications)
• Developing a Low-Stress Workstyle (Krames Communications)
• Breaking Through: Creative Problem-Solving that Lessens Stress. Max Heirich, Ph.D. (Worker Health Program, ILIR, University of Michigan)

Future Sessions as Needed

1. Repeat the general format of earlier sessions, checking to see how things are going. Ask questions that direct the client's attention to stress management techniques and health care methods already in use. Help the client continue to think through how to use these suggestions for the situation.



2. Use timed segments from Breaking Through:Creative Problem Solving that Lessens Stress Trainers Manual that are appropriate to this situation and that fit available time for this session.



3. Check with the client about whether future sessions would be useful or are needed. Schedule appropriately, gradually lengthening the time between sessions, with the understanding that additional times could be scheduled if special problems come up that could use immediate attention.



4. As the client gets ready to leave, ask what they plan to do this week to take care of themselves and deal with the situation. Be sure to celebrate any improvement in the situation or in their handling of the stress reported in this visit.



5. After the client leaves, fill our follow-up form for this visit and indicate when client will visit again. If no future session is scheduled mar a six-month check-up on the follow-up form, to be scheduled in the computer.

• Follow-up form
• Breaking Through: Creative Problem Solving that Lessens Stress Trainer's Manual by Max Heirich, Ph.D. (Worker Health Program, ILIR, UM)
• Worksheets for Breaking Through–Creative Problem Solving that Lessens Stress Trainer's Manual, by Max Heirich, Ph.D. (Worker Health Program, ILIR, UM)