Stress inoculation, what does it consist of?
The Stress Inoculation (IE) it is an intervention framework in which the person is trained in a set of specific skills to cope with stressful situations.
The peculiarity of this type of intervention is that the person learns to interpret their problem from a specific model, allowing them to select those techniques that best meet the demands of the problematic situation they are facing. In addition, EI works as a “vaccine”, that is, once the coping skills are acquired, the person is subjected to stressful situations similar to the problematic ones but of moderate intensity in which it is expected that they will put those skills into operation. The main skills to learn are all those that allow effective control of emotional tension or activation (physiological), as well as the modification of the most superficial cognitive contents (eg, self-verbalizations) that occur before, during and after the confrontation. with problem situations.
- Phases of stress inoculation
- Educational phase
- Training or skills acquisition phase
- Guidelines for carrying out attentional refocusing or distraction
- Scheme for the preparation of coping plans
- Preparing for a stressful situation
- Consequence analysis
- Implementation or implementation phase and follow-up
- Cognitive techniques to cope with stress
Phases of stress inoculation
The procedure consists of three phases: educational, training or acquisition of skills and application.
It is about providing information on the genesis and maintenance of problematic emotional phenomena. The goal is not to eliminate stress, but to view stressful situations as problems that can be solved. In this sense, an understandable model must be proposed that allows the person to recognize their elements in the problem situation, as well as to interpret the relationships between them appropriately. Figure 5 shows a model that can be used as an example.
It is important for the person to understand the transactional nature of their stress reactions. The explanation of the model should make clear the interactive nature of the elements included. Once the person has understood the model, it is necessary to collect as much information as possible about the morphology and functional relationships between the elements of the environment and the response. For this purpose, records can be used in problem situations, interviews with the person and close people, self-report instruments, etc. It is important to allow the person to tell "their story" or their view of the problem. From this raw information it is easy to inquire about the relevant components for an adequate psychological formulation of the problem. The initial statement of the problem can be useful in planning and setting goals and objectives in the short, medium and long term. Special emphasis should be placed on formulating realistic objectives.
As a result of this phase, the person should:
- Have an alternative model of maintenance of your stress reactions;
- Triggers should have been identified and clarified, distinguishing global stressors from specific or situational stressors and those that can be modified from those that are not;
- It should have been clarified whether the person's deficit is due to a lack of competence (skills) or performance (secondary benefits, dysfunctional beliefs, etc.).
Training or skills acquisition phase
The person must be able to clearly distinguish between modifiable situations from those that are not. In the former (modifiable) the person's efforts will be aimed at controlling situations (instrumental techniques), while in the latter (not modifiable), the efforts will be focused on the emotion that is experienced (palliative techniques). It is about acquiring the skills and abilities necessary to manage problematic physiological and cognitive responses as well as ensuring that the person is capable of putting them into practice. These two objectives give rise to the acquisition and testing phases..
The strategies to be trained can be grouped into four broad categories: cognitive skills, control of emotional activation, behavioral and palliative coping..
- Cognitive habilyties. Cognitive restructuring, thought stopping, and self-instructions are the main strategies to train. Self-instruction training consists of modifying the negative verbalizations present in the person's coping response for positive ones before, during and after the interaction with the problem situation. Self-instructions must have the following characteristics: a) they must be adapted to the specific needs of the patient (s); b) they must be constructed and written with the patient's words; c) they must be specific, not too general (can lead to mechanical repetition); d) they must be oriented towards control and competition and focused on the present or immediate future; e) They should be integrated naturally into situations and not consider them as an isolated mechanical ritual. It can also be useful to establish contracts to put them into practice and generate some type of mnemonic rule to facilitate their applicability. To facilitate the acquisition of this skill, cards can be used in which the person writes down the positive self-verbalizations trained. Imagination is also useful. A hierarchy of difficult situations can be built to reproduce in imagination, so that when the person imagines facing the problem situation, they put into action the trained self-instructions.
- Emotional control skills. The main strategy is relaxation. This can be obtained in different ways (eg, progressive muscle relaxation, by imagination, by breathing and by meditation).
- Behavioral skills. The main one is the exhibition8. Other strategies such as modeling or testing of behaviors are applied to modify morphological parameters of the problem responses..
- Palliative skills. The main ones are distraction, change of perspective, and social skills, such as the appropriate expression of affection and the management of available social support..
Guidelines for carrying out attentional refocusing or distraction
- Explain the meaning of the technique: it is not about escaping the problem, it is about not paying attention to stimuli (eg, ruminant thoughts) when doing so does not modify the problem and amplify the symptoms or the associated discomfort. The objective is to refocus or redirect attention to stimuli that at least produce a benefit in one of the two parameters (problem solving / emotional well-being).
- Select possible sources of distraction relevant to the person (counting cars of a brand, clothing, doing housework, etc.).
- The tasks used as distractors must involve significant behavioral involvement (eg, physical exercise), attention to external stimuli (eg, describing the environment), use of cognitive resources (eg, counting backward from a number) and social content (e.g., doing group activities).
- Once the problem situations and the distractors have been identified, the person must be actively involved in refocusing, moving their "mental flashlight" towards the agreed stimuli. Once the person is able to implement the main skills necessary for an adequate coping with the problem, They should be organized according to the four steps of coping: preparation, coping (real confrontation and management of emotional activation) and analysis of the self-reinforcing consequences of success. These principles should be used to build so-called coping plans. These plans intend to integrate everything learned and organize it in a way that allows the confrontation with problem situations. The control of one's own behavior during these situations is done through self-instructions. These self-instructions must direct the activity during the situation, for which they must fulfill the following functions: a) identify and define the situation; b) prepare for coping; c) coordinate coping and activate the implementation of the necessary skills; d) correct possible difficulties and failures; e) organize motivational processes and f) analyze the situation once it is finished.
Scheme for the preparation of coping plans
Preparing for a stressful situation
- Identify and label the situation
- Analysis of the possibilities of coping and preparation of the plan.
- implementation of the plan
- crisis prevention. It is important to have a way out in the event of a partial failure.
- reward (from positive self-manifestations to physical or social rewards)
- Coping with failures and relapses.
Implementation or implementation phase and follow-up
During this phase the person must put into practice what they have learned in real situations. To achieve this, it is subjected to moderate and controllable levels of stress (inoculation) as behavioral “vaccines”. This procedure is intended to activate the strategies learned as well as to check to what extent they are effective and if there are problems in their implementation. Table 10 shows the main objectives within this phase.
The main strategies are Imagination Rehearsal, Behavioral Rehearsal, and Graded Live Exposure.
- Modeling, metaphors and essay in imagination. A good way to strengthen what you have learned is to see someone do it. The use of observation of competent close people, films (eg, films), readings, metaphors or even the therapist in similar situations can be very useful. The models must be varied, similar to the person (sex, age, etc.), credible and with a level of competence slightly higher than that of the patient. Instructions can be used simultaneously with observing the model. Sustained attention should be kept on the model and the person should be asked to summarize or integrate what was observed after the session. It is preferable for the person to generate certain rules about the stimulus-response-consequences relationships shown by the model. To facilitate generalization to situations in the person's life, metaphors and imaginative essays can be used. A hierarchy is built with the most stressful situations that the patient faces. They are ordered from highest to lowest level of difficulty. The person must reproduce the situations in imagination allowing the appearance of the stress response and facing it with the learned skills.
- Behavioral essay. Role reversal (therapist-patient) can be used. The objective is for the person to face simulated or real situations at first more controllable and progressively with more unforeseen events. In these situations, the person will put their skills into practice while the therapist observes and gives feedback..
- Graduated in vivo exposure. The person has to progressively face the real situations of the previously constructed hierarchy, assessing the result obtained in each of them.
Cognitive techniques to cope with stress
These are some of the most used cognitive techniques for stress management. The most common barrier to cognitive stress intervention is the failure to fully utilize the imagination. In order to improve the ability to imagine it is recommended:
- Focus on other types of senses other than visual, such as touch, taste, hearing, and smell.
- Record a detailed description of the scene you want to imagine.
- Make a drawing of the original scene that you want to imagine, as a way to activate the visual details. See what objects and details give the scene its unique identity.
Another major hurdle is not believing in techniques. So is boredom, because many of these exercises are. But they work and that's what you have to believe in order to achieve stress reduction.
Finally, special emphasis should be placed on the risks of relapse and how to deal with them. The probability of relapse is especially high in extremely difficult, novel situations or in which a high number of problems occur simultaneously. Essentially, it is about conceiving evolution with relapses as one more learning process, in which the probability of small “slip-ups” or errors about what has been learned is high. The person must conceive these relapses as opportunities for learning and not as situations of defeat. Along with this attitude, training in the early detection of signs of relapse, as well as high-risk situations, will allow the person to anticipate and put in place skills necessary to resolve the situation. When failure has occurred, the most important thing is to analyze the possible reasons why it has occurred. Once the person is able to anticipate certain high-risk situations, “controlled relapses” can be programmed in which the person puts what they have learned into action.
When these controlled situations are difficult to carry out, imaginative trials can be used..
Once the training is finished, it is important to evaluate the immediate effects of the intervention. This evaluation should cover both the level of competence achieved in the techniques and the longer-term effect on the variables relevant to the patient. These evaluations can be done in scheduled follow-up sessions with the consent of the person that will be progressively spaced over time..