4Addressing Stress and Coping in the Mental Health FieldBy.docx

4Addressing Stress and Coping in the Mental Health Field
By Christopher J. McCarthy, University of Texas at Austin, and
Colleen Jaimie McCarthy, University of Oregon
Tommy Flynn/Getty Images
Learning Objectives
After reading this chapter, you should be able to
• Explain the relationship between stress and well-being.
• Differentiate between the major models of stress.
• Describe the types of interventions used to reduce stress
and promote coping used by mental health
professionals.
• Describe settings in which stress interventions take place.
• Identify hot topics, trends, and controversies related to
stress and coping.
© 2016 Bridgepoint Education, Inc. All rights reserved. Not for
resale or redistribution.
Section 4.1Stress and Its Connection to Well-Being
Vanessa is in her second year of college. She is the first person

in her family to attend a 4-year
college. She is both proud of that and a little bit scared; she
wants to live up to her parents’
expectations but also feels a tremendous weight every day in
meeting the lofty expectations
she has for herself. Her parents made great sacrifices to send
her to school, and the most
important thing in the world to her is that she not waste this
opportunity. Unfortunately,
Vanessa is struggling right now. She chose biology as a major,
with the hope that she would
become a doctor and make her parents proud. But she is finding
her studies hard, mainly
because they are not as interesting as she had hoped.
Lately, Vanessa has started having trouble sleeping and has
found it hard to concentrate. She
is constantly worrying about her grades and what will happen if
her GPA is too low for medi-
cal school. She has tried studying extra hard and cutting out
social activities, but that has left
her feeling even more anxious and isolated.
Her roommate thinks she is simply stressed out, but Vanessa is
not even sure what the term
stress means. Of course she is anxious; she is under a lot of
pressure! How is that going to
change? Her parents worked very long hours in custodial jobs
all their lives, and they never
complained about stress. How could she? But last week,
Vanessa was so anxious she decided
to visit her university counseling center to see if they could
help with her stress. Vanessa is
not really sure what to expect. What is stress, anyway? And
what can a mental health profes-
sional do to help her?

4.1 Stress and Its Connection to Well-Being
Stress is a widely acknowledged phenomenon. Mental health
practitioners have many clients
reporting stress symptoms (Ivey & Ivey, 2015), but what exactly
is meant by the term? Does
it refer to a feeling, such as when we are “stressed out”? Or
does it refer to events in our lives,
such as taking a “stressful” exam? Or should we think about
stress in terms of what it does to
us emotionally and physically, such as causing anxiety or high
blood pressure?
While the term has been used in many ways by theorists, today
stress is understood as a trans-
action between a person and his or her environment. More
specifically, stress results from an
imbalance between an individual’s perceived demands and
perceived resources. For example,
Vanessa’s perceived demand is that she do well in college and
make her parents proud. If she
questions her ability to do so (i.e., her perceived resources), she
will likely experience stress.
Once people become stressed, they experience negative
emotions, such as anger or distress.
Emotions represent physiological arousal,
feelings, thoughts, and behaviors in response
to people and events. Given their physiologi-
cal expression, negative emotions experi-
enced in the long term can cause wear and
tear on the body.
Perhaps the best way to conceptualize
stress, however, is as an umbrella term for
a broad and complex phenomenon. Over

the past several decades, researchers in
Gino Santa Maria/iStock/Thinkstock
The term stress encapsulates various
responses and phenomena. Therefore, the
definition is still expanding.
medicine, psychology, and related fields have increasingly come
to understand the many con-
nections between the mind and the body and the significant role
that stress plays in over-
all well-being. It is now universally recognized that stress plays
a significant role in causing
or aggravating both physical and mental disorders. The 21st
century has seen an increased
emphasis on the positive role that stress can play in people’s
lives, energizing them to meet
challenges and live life to its fullest. This shift is part of the
positive psychology movement,
which was discussed briefly in Chapter 1 and will be discussed
at the end of this chapter.
It is important to note that there are functional aspects of stress,
as every emotion exists for
a reason. Stress can serve to motivate (such as to study for an
important exam), it helps our
brain focus when things are important, and it creates adrenaline
to increase our reactions and
reflexes. However, stress becomes a problem when it is

experienced more often than not and
interferes with individuals’ ability to get things done. The focus
of this chapter will be on the
stress that is unhelpful and bad for our health. We will also look
at some of the ways mental
health professionals address stress experienced by their clients.
Basic Terminology
Terminology about the stress process has changed as the field
has developed. Until fairly
recently, the term was utilized in so many different ways that its
scientific use was somewhat
limited. Stress originally was borrowed from the field of
engineering, and it referred to the
amount of pressure placed on an object. For engineers, stress
was important to understand
(for example, they needed to know how much pressure [weight]
a bridge could take before
collapsing). Stress researchers then used this term to describe
what happens to people expe-
riencing life’s pressures, which can lead them to weaken and
eventually “snap.” Unlike bridges,
humans have the capacity to reflect on the impact of the events
in their lives. There is a com-
plex relationship between our perceptions of events and how our
bodies respond to being
under pressure. People have cognitive, emotional, behavioral,
and physiological responses
that culminate in different reactions to stress, and so each
person has different experiences
that can create pressure and weaken his or her ability to
persevere.
In recent decades, researchers and practitioners have become
more precise in defining what
is meant by the term stress. Stress is an umbrella term

associated with all aspects of the phe-
nomenon. However, there are three important constructs that
define different aspects of the
stress experience: stressors, the stress response, and stress
symptoms. Stressors are environ-
mental or internal events that have the potential to cause us
harm. They may come from
external sources, such as work or relationships, or internal
sources, such as perfectionism
or negative thinking. What separates us from most other living
things on earth is that our
brains have evolved to have the ability to imagine future events
based on past experiences.
This wonderful capacity that helps us plan and negotiate the
outside world can also add to
our stress level, however, as we tend to forecast and worry
about many things that may never
materialize.
The stress response is the cascade of physiological, cognitive,
and emotional changes that
result once a stressor has been experienced (Matheny &
McCarthy, 2000). Once triggered, the
stress response results in negative emotions, such as anger,
frustration, and sadness. Negative
emotions can also affect our bodies, with reactions such as neck
tension, an unsettled stom-
ach, and worrisome thoughts, to name a few.

Finally, in response to stress, people experience stress
symptoms, which are emotional and
physical responses to stress such as feeling anxious,
stomachaches, the grinding of teeth,
or feelings of worthlessness. Figure 4.1 illustrates the
relationships among these factors
(Matheny & McCarthy, 2000).
Figure 4.1 uses the example of a person who has just learned his
company is laying him off.
Learning this news would certainly qualify as a stressor, or
something that threatens this
individual’s well-being. The encounter with the stressor is
immediately followed by the stress
response, which may include increased heart rate, higher blood
pressure, and emotions such
as anxiety. Anxiety is a feeling that often accompanies stress
and is characterized by feelings
of worry, nervousness, or uneasiness. Stress symptoms are the
consequences of being under
stress and can occur fairly soon after experiencing a situation,
or over time. In the case of the
person who has lost his job, he may worry about finances, lose
sleep due to anxiety, and lash
out at others. These reactions are normal, but they are also
unpleasant, could harm the per-
son’s health, and are often counterproductive because they
interfere with being able to focus
on finding a new job. Additionally, continued experiences of
stress symptoms (e.g., lack of
sleep, anxiety, frustration) can lead to health problems such as
sleep issues, depression, and
digestive problems.
Figure 4.1: Overview of stress terms

In the stress experience, stressors lead to a stress response,
which leads to stress symptoms.
Source: Adapted from Write Your Own Prescription for Stress,
by K. B. Matheny and C. J. McCarthy, 2000, Oakland, CA: New
Harbinger.
The Relationship Between Stress and Well-Being
Not only is stress frequently an unpleasant experience, but it
can also make us sick. Wal-
ter B. Cannon was an early pioneer in exploring the link
between the mind and the body,
though this idea was not accepted by other medical professions
at the time. In 1936, Cannon
wrote, “A highly important change has occurred in the incidence
of disease. Serious infec-
tions have markedly decreased or almost disappeared, . . .
meanwhile, conditions involving
strain in the nervous system have been greatly augmented”
(1936, p. 4). Today, those of us
living in countries with advanced health care systems may take
for granted that many infec-
tious diseases are relatively under control, whereas 100 years
ago they ravaged large num-
bers of people and led to fear and panic when outbreaks
occurred. As the field of medicine
has reduced the prevalence of infectious diseases and allowed
for longer lifespans, diseases
linked to unhealthy lifestyles have increased. Hypertension,
coronary heart disease, ulcers,
cancer, arthritis, headaches, lower back strain, and many other
illnesses are linked to how

people live their lives—and how they manage stress is a key
ingredient in lifestyle. Some
people handle stress by eating a nutritious diet, keeping an
active lifestyle, and maintaining
healthy social relationships, which can act as buffers against
stress. However, some people eat
fast food, drink too much alcohol, and spend countless hours
sitting in front of the television.
These individuals increase their risk of having mental and
psychological health issues and are
vulnerable to all manner of health complications in the long run.
The American Psychology Association (APA) conducts an
annual survey that documents the
many ways in which stress affects the lives of people in the
United States. The 2014 Stress in
America survey found that Americans report money and
finances as a particular source of
stress, and money has consistently been at the top of the list of
stressors since the first survey,
in 2007. Here are some of the most significant findings from the
2014 survey:
• On a 10-point scale, where 1 is “little or no stress” and 10
is a “great deal of stress,”
the average American rates his or her stress level as a 4.9. In
2007, the average
American stress level was reported as a 6.2. Although current
levels appear to have
decreased since 2007, stress levels are still higher than what is
desired, as Ameri-
cans believe a 3.7 is a healthy stress level.

• Adults struggle in how they manage their stress, as 42%
report not doing enough or
are not sure how to manage their stress, and 20% state that they
are not engaging in
any stress-reducing activities to manage stress levels.
• There are many sources of stress that adults experience.
On average, American
adults reported these as consistent stressors: money (64% report
that this is a very
or somewhat significant source of stress), work (60%), the
economy (49%), family
responsibilities (47%), and personal health concerns (46%).
• Adults experience a wide range of stress-related
symptoms. When asked about
symptoms of stress in the last month, adults reported feeling
irritable or angry
(37%), feeling nervous or anxious (35%), having a lack of
interest or motivation
(34%), fatigue (32%), feeling overwhelmed (32%), and being
depressed or sad
(32%).
• Stress affects how people interact with others. Of adults
who are married or living
with a partner, 41% reported losing patience or yelling at their
spouse or partner
in the last month because of stress. Additionally, within the last
month, 18% also
reported snapping at or being short with a coworker (APA,
2014).
Stress and Coping as a Focus of Mental Health Interventions
Mental health professionals will undoubtedly find themselves

working with clients for whom
stress is a concern, whether it is labeled as such or not. It is
important for people in the men-
tal health field to help their clients cope. Coping represents a
person’s attempts to manage,
mitigate, and prevent stress. In order to understand current
research and stress management
techniques, it is important to consider the history of the
identification and understanding
of stress.
The mental health field has made great strides in recent decades
in understanding the many
links between the mind and the body. Sigmund Freud, who
established the earliest form of
talk therapy (psychoanalysis), pioneered the idea of hysteria
(Freud & Breuer, 2004) in
describing his approach to psychotherapy. Hysteria referred to
nervous system symptoms
(such as paralysis and blindness) that could not be
explained by medical factors. Freud postulated that
the cause was psychological in nature, specifically
feelings and impulses that the person had repressed.
While groundbreaking, this view of the mind and
body seemed to suggest physical manifestations of
emotional turmoil are “all in our head.” During
Freud’s time, medical researchers had not yet docu-
mented the many connections between the mind and

the body.
Scientists today have begun to look at the mind-body
connection, not only as a whole, but also in relation
to stress. In response to stress, our bodies send out
hormones. Although the release of hormones is not
always bad, when it continues too long, as with stress,
the hormones begin to weaken the immune system
and it becomes harder to fight disease. Additionally,
chronic stress can aggravate existing health issues
such as heart problems and asthma and affect nerves
and muscles, causing tense muscles and headaches
(Reus, 2001). Thus, knowledge of how the mind and
body can affect one another helps us better under-
stand the struggles people face psychologically and
physically and better equip mental health profession-
als when working with clients.
While stress management is not itself a career track for mental
health professionals, stress is
almost always a concern for people seeking professional help. It
is therefore important that
mental health professionals understand the latest stress
interventions and be able to either
use them or refer clients to someone who can. It is also
important for mental health profes-
sionals to be aware of evidence-based interventions, which are
treatments that have been
proven to be effective through rigorous research of their
outcomes. Knowledge of evidence-
based interventions allows mental health professionals to know
they are using techniques
that have proven, positive outcomes in order to best help their
clients. Examples of evidence-
based interventions are discussed later in this chapter.

Another important role for mental health professionals is
educating clients about what
stress is. Many people still have a hard time accepting that their
attitude, lifestyle, emotions,
and ways of thinking could affect their emotional and physical
well-being. Stress may seem
like an excuse, and they may think labeling their stress means
they are not tough enough.
But there is an overwhelming amount of evidence that indicates
stress is real and that it can
affect our well-being in many ways (DeLongis, Folkman, &
Lazarus, 1988; Lupien, McEwen,
Gunnar, & Heim, 2009; McEwen, 2009). Mental health
professionals now have many tools
for helping clients manage stress effectively; however, a
foundational knowledge about
the psychological and physiological origins of stress is vital to
understanding how to best
address stress.
Science and Society/SuperStock
Psychoanalyst Sigmund Freud, 1910.
Freud believed that the mind and the
body operate as separate entities.
Section 4.2Emerging Models of Stress
4.2 Emerging Models of Stress
Stress researchers and theories have added considerably to our
understanding of stress over
the past several decades. Early research on stress helped

establish the foundations for stress
interventions that are commonly used today. The following
sections trace the major ways of
thinking about stress that have emerged as research has
developed.
Biological Perspectives on Stress
While Freud saw the mind and body as distinct and separate,
today we know that both are
interconnected. In particular, we know much more about how
the brain processes informa-
tion about threats to our well-being. The brain’s reaction to
stress seems to play a key role
in the physiology of stress. One important brain structure is the
thalamus, which is involved
in sensory perception and the regulation of motor functions.
When potentially threatening
stimuli are registered by our senses, an alerting signal is sent to
the thalamus and then to
the brain’s cortex, which is a kind of executive board in the
brain that evaluates the signal
and helps direct the body’s response. The cortex includes a
giant reservoir of memories and
experiences, which is used to evaluate the potential stressor. If
potential harm seems likely,
the message is sent to the amygdala, which plays a central role
in emotional reactions such as
the stress response. The hypothalamus then swings into action.
This is a small structure in
the center of the brain, which links the nervous system to the
pituitary gland, a master gland
that controls the functions of other glands. The pituitary gland
causes the release of adreno-
corticotropic hormone (ACTH), a stress hormone that is
involved in the stress response.

The presence of ACTH in the bloodstream causes the adrenal
glands, which are located
above the kidneys, to produce hormones that reduce
inflammation in the body and allow
for improved muscle function, as well as raise sugar levels in
the liver, helping fuel the body.
The hypothalamus also stimulates the adrenal glands to produce
catecholamines, which are
organic compounds that increase the heart and breathing rates
and accelerate brain activ-
ity. The body is thus equipped with a powerful system to
prepare us for action when threats
arise; the entire process can be understood as part of the stress
response.
While this process describes how humans react to a wide range
of life events, the startle
response activates specifically when emergencies arise. When
immediate action is called for,
the startle response enables the body to spring into action
without needing the thinking brain.
Joseph LeDoux (1984) discovered that the thalamus and the
amygdala have a direct neural
connection, allowing for the stress response to be triggered in
the body before the brain has
fully processed an event. The amygdala is also known to work
in concert with a section of
the brain called the orbitofrontal cortex, which stores emotional
memories, or emotions
affiliated with an event. Examples include excitement, grief, or
anger. The orbitofrontal cortex
then assesses any associations with previous events that might
be used to regulate responses
by the amygdala. In other words, the amygdala has two
pathways in the brain when assessing
a situation: the low road and the high road. The low road

transmits a faster, less detailed sig-
nal to the thalamus, then to the amygdala to trigger a fear
response in the body. The high road
is slower, as it carries nerve impulses to the thalamus, then to
the sensory cortex of the brain
to assess and send the most appropriate signals to the amygdala.
This model of the chain of
physiological events leading to the stress response is presented
in Figure 4.2.
Figure 4.2: Overview of brain structures involved in the stress
response
In the stress response, the cortex receives information about
potential stressors internally or
externally from the thalamus. However, note that the thalamus
has a direct connection to the
amygdala, which allows (in concert with the orbitofrontal
cortex) for an instant response if needed.
The hypothalamus then swings into action.
The cortex receives information about potential stressors from
two main sources: internally,
when mental events are generated (“I just remembered I have an
exam tomorrow!”), or exter-
nally, when external stressors are registered by the senses and
information is received from
the thalamus (“Who is that person lurking in my yard?”). As
noted previously, direct connec-

tions between the thalamus and the amygdala can allow for an
instant response when needed,
and the amygdala and the orbitofrontal cortex can work in
concert to establish whether this
is necessary.
We have just discussed how the various brain structures process
information that can trigger
and maintain the stress response. The next section describes
what happens once the stress
response occurs.
The Fight or Flight Response
The evolutionary purpose of the stress response is to prepare
humans to survive threats in
the environment. This response was labeled fight or flight in the
18th century by Claude Ber-
nard, who pioneered the field of experimental medicine. He
observed that healthy organisms
seek to maintain a state of constancy despite changes in the
outside environment, a process
that was later labeled homeostasis by Cannon (1932). Anything
that disrupts this constant
state triggers the fight or flight response, now called the stress
response.
It is more accurate, though perhaps less catchy, to call this
phenomenon freeze, flight, or
fight. As was noted in the discussion of the brain, threatening

signals bypass the cortex and
immediately trigger us to stop and further scan the
environment—in other words, our first
reaction to danger is to freeze. Consider the example of a hiker
who encountered a rattlesnake
on a desert trail in West Texas. The rattling sound emanating
from the coiled viper seemed to
occur simultaneously with the hiker stopping dead in his tracks
and scanning frantically to
find its location. The sound triggered an instant recognition in
the hiker’s brain that this was
a sound to pay attention to. When the rest of his brain and body
caught up, he quickly realized
he needed to warn the others in his party and take a wide route
around the rattler.
This example also illustrates that after freezing, it is often
better to flee rather than fight—in
other words, live to fight another day. Often, the wisest course
is to avoid danger whenever
possible. So the likely way that most people cope with extreme
danger is to freeze, flee if
necessary, and only as a last resort to fight (Schmidt, Richey,
Zvolensky, & Maner, 2008). Of
course, the freeze, flight, or fight response is only the beginning
of the story when it comes to
our reaction to stress.
The General Adaptation Syndrome
The stress response may have been necessary at one point in
human evolution, but it prob-
ably does not always serve us well in modern society. Although
some stress is necessary for
our continued survival in dangerous situations, as well as to
maintain motivation for school,
work, and life, it can become unhelpful when it is debilitating.

The stress response can inter-
fere with responding to more modern demands, such as exams,
demanding bosses, or finan-
cial difficulties. When our mind is racing, and our heart
pounding, it is difficult to take a test.
However, it is important to understand that our body really has
only this way of coping, which
was labeled the general adaptation syndrome by Hans Selye
(1976).
Selye was an endocrinologist who conducted experiments with
rats under stress (such as
injecting their skin with fluids) and discovered that under a
wide range of conditions, they
exhibited the same set of physiological reactions—the stress
response. He extrapolated that
the same was true for humans, which meant that whether we are
confronted with an onrush-
ing tiger or losing a job, the same neurological, hormonal, and
immunological responses occur.
While subsequent research has suggested the body’s response is
not quite as general as Selye
believed (Denson, Spanovic, & Miller, 2009), it does appear to
be a very generic response
across a wide range of triggering events.
There are three stages to the general adaptation syndrome: the
alarm stage, in which the body
and mind ramp up to a state of alarm (freeze, flight, or fight);
the resistance stage, in which
only some of the physiological components of the alarm stage
remain (such as tension, worry,

and lack of sleep); and the exhaustion stage, which is marked by
a wearing down of the body’s
defenses. These three stages help us understand the symptoms
and process of stress.
The Perceptual Nature of Stress: Appraisals of External Events
The preceding sections described models of stress based on
physiological reactions associ-
ated with the stress response. Another important model of stress
was introduced when two
medical doctors named Thomas Holmes and Richard Rahe
discovered that certain experi-
ences in life were predictive of one’s vulnerability to physical
disease. The Social Readjust-
ment Rating Scale (SRRS; Holmes & Rahe, 1967) is an
assessment that measures incidences
of various stressful life events, such as death, divorce, and other
major life transitions. Based
on the accumulation of these experiences, they were able to
document a relationship between
their accumulation and illness. Also, they discovered that not
all events are equal: Some
events, such as divorce or the death of a significant other, exact
a much greater toll than do
more minor events, such as a change in sleeping habits. There is
also some evidence that
accumulating a great many minor stressors, called hassles, can
also affect our health (Kanner,
Coyne, Schaefer, & Lazarus, 1981).
While it is important to understand the
brain’s role in processing stressors, the

body’s reaction to stress, and the link
between life events and illness, there is
one piece missing: the role of perception,
which refers to an individual’s subjective
evaluation of the outside world and his or
her resources for coping with it. As thinking
creatures, humans do not all view events
the same way. A family vacation may be
wonderful for parents who pick the destina-
tion and itinerary, but it can be unpleasant
for children who feel they are being dragged
along to see relatives they hardly remem-
ber. Research has demonstrated that per-
ceptions play a key role in the relationship
between life events and illness. As an example, Matheny and
Cupp (1983) used the SRRS to
predict health, but they also asked participants if they could
foresee each event, if they could
control it, and if it was desirable. They found that if people had
anticipated and prepared for
life events indicated on the SRRS, the events were not as
predictive of illness. The same effect
was true for desirable events. However, control seemed to have
the most important moderat-
ing effect on illness—if a person reported no control over an
event, its value in predicting ill-
ness increased 400%. Such research strongly indicates that the
type of events matter in how
stress affects us, and that perception can play an important role.
This understanding is a key
part of the transactional model of stress, which is reviewed
next.
Transactional Model of Stress
Currently, the predominant model of stress describes it as the

result of a transaction between
the individual and the environment (Lazarus & Folkman, 1984).
This theory is founded on the
idea that stress is mainly a function of our perceptions, namely,
what we perceive to be the
Westend61/SuperStock
Perception and control both play an important
role in health and how people react to life’s
stressors.
demands in a given situation and what we perceive as our
resources. Lazarus (2001) noted
that the word appraisal seemed the most accurate way to
describe the cognitive evaluation
that takes place whenever we encounter a life demand.
According to Lazarus, whenever we
encounter demands in our life, we appraise them according to
their significance to our well-
being, which he labeled a primary appraisal. We then conduct a
secondary appraisal of
whether we have the resources to cope successfully with the
demand. Lazarus (2001) also
noted that this appraisal involves two complementary processes:
We attempt to view situa-
tions realistically but also look for reasons to be optimistic
about our chances for success. As
he put it, “Appraisal is a compromise between life as it is and
what one wishes it to be, and

efficacious coping depends on both” (p. 41). Depending on the
results of the appraisal pro-
cess, we will determine either that demands are roughly equal to
resources, meaning that we
will view the situation as a challenge that is within our
capacities, or that the demand exceeds
our resources, which can trigger the response (Lazarus, 2003).
This process is depicted in
Figure 4.3.
Figure 4.3: Overview of transactional models
The appraisal process determines whether we see a demand as a
stressor or a challenge.
Source: Adapted from “Factor Structure of the Preventive
Resources Inventory and Its Relationship to Existing Measures
of Stress
and Coping,” by C. J. McCarthy, R. G. Lambert, L. M. Beard,
and A. P. Dematatis, in G. S. Gates, M. Wolverton, and W. H.
Gmelch (Eds.),
Research on Stress and Coping in Education (pp. 3–37), 2002,
Greenwich, CT: Information Age Publishing, Inc.
To demonstrate the processes of primary and secondary
appraisal, imagine that two different
students, Nico and Angela, have an upcoming class assignment
in which they have to give a
15-minute presentation in their public speaking class. The

following is a brief description of
the event.
Demand Self-statement
Nico Required to give a 15-minute
presentation
“I knew I’d have to give a speech! But now it’s real! How
I am ever going to talk that long? I know I’m going to fail
this course now.”
Angela Required to give a 15-minute
presentation
“Uh oh, I guess this is what I signed up for. This will be
scary, but I know I can do it, and I’ll probably learn a lot.”
In this example, Nico is appraising the demands of making a
speech as being too much for his
resources. Angela is appraising this situation differently. Her
primary appraisal seems to be
that the assignment is important, but not a life or death matter.
Her secondary appraisal of
her resources is likely that the situation can be handled with
them—that by preparing and
using course materials, the task will be manageable.
Appraisals are a critical part of the transactional model of
stress. For two people, the same
event can be interpreted very differently. And subsequent
attempts at coping with the stimuli
causing stress will likely be very different. Nico might be so
overwhelmed with stress about
the assignment that he procrastinates and puts something
together at the last minute, which

is not an ideal coping strategy. Angela appraises the event as a
challenge, not a stressor. There-
fore, she might be more likely to take on the task with
enthusiasm and deliberation, thus mak-
ing it more likely the speech will be a success.
Conservation of Resources Model of Stress
Alongside Lazarus and Folkman’s (1984) transactional model,
Stevan Hobfoll’s (1989) con-
servation of resources (COR) theory is the other dominant
model for understanding stress.
COR theory defines stress as “a reaction to the environment in
which there is: (a) the threat
of a net loss of resources, (b) the net loss of resources, or (c) a
lack of resource gain following
the investment of resources” (Hobfoll, 1989, p. 516). Like
transactional models, Hobfoll’s COR
theory emphasizes the role of perception in stress; however,
COR departs from transactional
models in two important ways. First, whereas the transactional
theory emphasizes the sub-
jective nature of appraisals of both demands and resources,
COR theory gives primacy to our
perceptions of threats to our resources. Hobfoll believed the
fundamental human drive toward
pleasure, self-esteem, and connections with others was not
sufficiently emphasized in stress
models, which seemed to focus only on how humans avoid
harm. Instead, Hobfoll attempted
to view stress from a strengths-based model, rather than a
deficit-based model. COR focuses
on the positive, sustaining, and protective power of people’s
demands and resources.
The second major way in which Hobfoll’s (2011) theory departs
from the transactional model

is its ecological perspective, as COR theory emphasizes
common appraisals held jointly by
people who share a biology or culture, or even workplace
(Hobfoll, 1989, 2011). In other
words, appraisal of resources is located not just within the
individual, but also in the broader
Section 4.3Interventions
context in which the individual lives. Hobfoll further expanded
this idea with his notion of
resource caravans, the idea that families, communities, and
organizations can invest in col-
lective resources that are broadly shared by everyone. These
investments create pathways for
individuals to accumulate resources that protect against stress.
While offering some contrasting propositions, the transactional
and COR models of stress can
be thought of as addressing different, and perhaps equally valid,
aspects of the stress process.
Hobfoll (2011) noted that COR theory was originally devised to
focus on major life stress, and
its central tenets seem consistent with that emphasis. Major
catastrophes such as war and
floods do not seem subjective to those involved—they are very
real and cause actual loss of
one’s resources. However, aside from such major stressors, it
can be argued that much of life
is lived in a gray area of daily events that are often ambiguous,
and that individual perception

can be an important element of how such experiences are
judged, which is consistent with
Lazarus and Folkman’s (1984) transactional theory. Equipped
with an understanding of how
individuals experience and process stress, let’s now turn our
attention to the interventions
used to help people cope with stress.
4.3 Interventions
The models of stress reviewed in the previous section form the
foundation for the interven-
tions that mental health professionals use with clients. Over the
years, stress interventions
have emerged as one of the most commonly practiced
techniques in a counseling setting.
There are also many self-help books for managing stress written
for the general public (see,
for example, Davis, Eshelman, & McKay, 2008).
While there are many mental health special-
izations that have a specified career trajec-
tory for entering the field (see Chapter 2 on
the various counseling professionals
tracks), stress management techniques are
not really associated with a specific coun-
seling specialty. Instead, they are incorpo-
rated into the interventions used by almost
every branch of the helping profession.
The pervasiveness of stress interventions
does not mean that they are easy to imple-
ment. Stress and coping interventions that
are administered under the guidance of a
trained helper are far more effective than
are those attempted by individuals on their
own. Because there is a great number of

stress management techniques and interventions in existence
today, providing a compre-
hensive review is outside the scope of this chapter. In the
following sections, we will review
two general categories of interventions to provide a sense of
which ones are used most fre-
quently due to their effectiveness. Physical stress interventions
are targeted at reducing the
symptoms of the stress response, while cognitive stress
interventions are aimed at altering
Fuse/Thinkstock
Though there is not a specialization dedicated
to stress management, stress interventions are
used across the helping professions.
the thinking patterns that produce stress. Both categories are
consistent with the models
reviewed in the previous section.
Physical Stress Interventions
Once the stress response is triggered, it prepares us for freeze,
fight, or flight. In most of every-
day life, this response is not helpful, and it can actually
interfere with the ability to confront
the demands of modern life. A variety of physical stress
interventions has been developed
to essentially cool down the stress response, so individuals can
focus instead on addressing

stress. These are listed in the following sections.
Breathing Exercises
The fight or flight response accelerates breathing and physically
indicates to the body and
mind that something is wrong. Breathing patterns are often
disrupted by changes in emotion.
For example, when anxious, people tend to hold their breath and
speak in a higher-pitched
voice when exhaling. On the other hand, when sad or down,
people tend to sigh and speak
in lower-pitched tones as they exhale. Simple breathing
exercises can be used to regulate
disruptions in the breathing pattern and help in the short term
with managing the stress
response and promoting relaxation (Jensen, 2003; Loehr &
Migdow, 1999).
Practitioners measure stress by evaluating an individual’s
cortisol levels. Breathing exercises
have been shown to decrease cortisol levels, thereby reducing
stress (Cea Ugarte, Gonzalez-
Pinto Arrillaga, & Cabo Gonzalez, 2010). The following are
breathing exercises that many
practitioners use in their practice.
Rhythmic breathing: Breathing that is short and hurried can be
slowed down by taking long,
slow breaths. People are instructed to inhale slowly and then
exhale slowly, count slowly to
five while inhaling, and then count slowly to five while
exhaling. During exhalation, people
are instructed to pay attention to how the body naturally
relaxes. Recognizing this change can
help them to relax even more.

Deep breathing: People are instructed to imagine a spot just
below the navel. They are then
encouraged to imagine breathing in through the spot, filling the
abdomen with air. Then, they
are to let the air fill from the abdomen up, then let it out, like
deflating a balloon. With every
long, slow exhalation, a person should notice feeling more
relaxed. Breathing deeply and
slowly floods the body with oxygen and other chemicals that
work on the central nervous
system and improve comfort. Deep breathing exercises have
been shown to decrease heart
rate, increase cognitive functioning, and increase executive
functioning (Busch et al., 2012;
Prinsloo, Derman, Lambert, & Laurie Rauch, 2013).
Visualized breathing: With this exercise, people are encouraged
to find a comfortable place,
close their eyes, and combine slow breathing with the
imagination. Individuals visualize the
air coming in through the nostrils, going into the lungs, and
expanding the chest and abdo-
men. Then, they visualize the breath going out the same way.
They then continue breath-
ing, but with each inhalation, they imagine breathing in
relaxation, and with each exhalation
imagine breathing out the tension. These types of instructional
breathing exercises can help
reduce respiratory rate (Conrad et al., 2007), which can reduce
tension and anxiety (Wilhelm,
Gevirtz, & Roth, 2001).

Progressive Muscle Relaxation
Progressive muscle relaxation (PMR) is a technique that
involves concentrating on relax-
ing every muscle in the body, beginning at the toes and working
all the way up to the head.
Research has shown that PMR techniques are effective in
managing anxiety (e.g., Carlson,
Bacaseta, & Simanton, 1988; Carrington et al., 1980; Pawlow &
Jones, 2002), decreasing cor-
tisol levels (Pawlow & Jones, 2002), reducing pain (Gada,
1985), regulating physiological pro-
cesses (Carlson et al., 1988), and increasing overall quality of
life (Carrington et al., 1980).
Progressive muscle relaxation is a two-step process. First, the
individual deliberately applies
tension to certain muscle groups. Then, the tension is released
and the individual focuses on
how the muscles relax as the tension flows away. Following are
the steps to using progressive
muscle relaxation:
• Step 1: Tension—First, focus your mind on a muscle group,
for instance, the mus-
cles in your hand. As you inhale, squeeze the muscles in your
hand (by making a
tight fist) as hard as you can for about 8 seconds.
• Step 2: Releasing the tension—Now, as you exhale, quickly
open your hand and
let the pain and tightness go. Feel the muscles relax and become
loose and limp as
the tension flows away. You would repeat this tension-

relaxation process for all the
major muscle groups in your body, beginning with the muscles
in your feet and mov-
ing upward all the way to your face (Mayo Clinic, 2014).
Biofeedback
Biofeedback is a technique that entails learn-
ing how to relax and better cope with stress
by altering behavior, thoughts, and feelings.
According to the Biofeedback Certification
International Alliance (2012), biofeedback
enables the user to alter physiological activ-
ity to help with health and performance.
Using specialized equipment, biofeedback
methods measure and utilize various sig-
nals from the body, including brain activity,
blood pressure, muscle tension, heart rate,
skin temperature, and sweat gland activity
(Mayo Clinic, 2009). Biofeedback is a three-
step process that involves (a) becoming
aware of a physiological response, (b) learn-
ing to control the response, and (c) transfer-
ring control of the response to everyday life
(Calderon & Thompson, 2004). Thus, a bio-
feedback unit processes the electronic signals and feeds back
the information to the user in
the form of sounds or graphs on a computer screen.
Biofeedback allows people to learn how their bodies react to
stressful situations, how to control
certain physiologic functions that cause tension and physical
pain, and how to create a state of
total body relaxation. When people notice they are starting to
experience unhelpful amounts of
stress, they can use biofeedback to alleviate the stress before it
becomes unmanageable.

Francesco Ruggeri/Getty Images
Understanding and learning to control
physiological responses is key to managing
stress. Biofeedback supports this process.
There are many other interventions that have been developed to
combat stress symptoms.
Davis et al.’s 2008 book The Relaxation and Stress Reduction
Workbook offers a comprehen-
sive list.
Cognitive Behavioral Therapy
While physical stress interventions can be used quite effectively
to manage the symptoms of
the stress response, the modern transactional and COR stress
theories emphasize the percep-
tual nature of stress. Unless people can change the way they
think about events, they are likely
to repeat the stress response over and over, potentially
damaging their health in the long run.
Changing their thinking has the potential to prevent stress,
which is preferable to putting
out fires through the use of physical stress interventions. This
section focuses on approaches
to stress management aimed at changing thinking patterns. As
people change the way they
think, their brains change neurologically, suggesting that when
people experience anxiety or

depression, dysfunctional neural activity is taking place (Porto
et al., 2009; Rachman, 2015).
Cognitive Approaches to Stress Intervention
Given the role of perception suggested by transactional and
COR models of stress, the use
of cognitive approaches in addressing stress has increased.
Cognitive approaches in coun-
seling have been adapted to stress interventions, which is an
approach to counseling based
on changing irrational or maladaptive thoughts. Cognitive
approaches are part of cognitive
behavioral therapy (CBT), which you may recall is a form of
psychotherapy aimed at changing
unhelpful thinking and behavior. They can be used both by
mental health professionals who
identify as cognitive behavioral therapists and by mental health
professionals who are using
them as one part of their work.
Cognitive therapists gather information about their clients’ lives
and how they respond to
stress and help create a plan to better manage stress (Beck,
1991; Matheny et al., 1996; Rush,
Beck, Kovacs, & Hollon, 1977). The stress management plan
often involves approaches to
modifying thoughts that create stress, identifying ways to use
thoughts to manage stress, and
helping people develop tools to cope. For example, if a person
is a perfectionist and thinks,
“I’m not good enough,” a cognitive interventionist may work
with the client to reduce unre-
alistic expectations of self, teach and practice relaxation
exercises, and incorporate useful
coping strategies, such as exercise. Another person may suffer
from catastrophic thinking,

such as “I’m going to fail all of my finals!” and watch TV to
avoid studying. This person may
benefit from exercises that challenge his or her automatic
thoughts (examining the evidence
for and against failing). It may also be helpful to set up
designated times to study, as well as
break times where he or she can practice relaxation techniques.
Stress management is most
effective when it is tailored to a person’s specific needs, issues,
and resources.
Acceptance and Commitment Therapy (ACT)
Acceptance and commitment therapy (ACT) is a form of CBT
that incorporates mindfulness to
increase a client’s ability to engage in flexible thinking.
Especially when stressed, people often
struggle to think about things from a different perspective and
deal with disappointment,
such as failing a test, a fight with a loved one, or social
rejection. ACT helps people use cogni-
tive defusion and acceptance to increase their willingness to
experience unpleasant things.
Cognitive defusion is a technique that encourages a person to
approach his or her thoughts
as a detective and see them as hypotheses rather than facts. This
can help create some emo-
tional and cognitive distance from the thoughts so the person
can identify how accurate and

believable a thought is. Acceptance involves both becoming
aware of and embracing a private
feeling or experience. For example, those who experience
anxiety may be encouraged to fully
feel and experience the anxiety, rather than push it away. The
use of acceptance and cogni-
tive defusion can help people make decisions based on their
values and wants in life. ACT has
been shown to increase effective courses of action; reduce
unhelpful thoughts, feelings, and
behavior; and decrease stress.
There are six core processes to ACT (Hayes, Strosahl, &
Wilson, 1999; Wolitzky-Taylor, Arch,
Rosenfield, & Craske, 2012):
1. Acceptance of private experiences (i.e., willingness to
experience odd or uncomfort-
able thoughts, feelings, or physical sensations)
2. Cognitive defusion or emotional separation/distancing (i.e.,
observing one’s own
uncomfortable thoughts without automatically taking them
literally or attaching any
particular value to them)
3. Being present (i.e., being able to direct attention flexibly and
voluntarily to pres-
ent external and internal events rather than automatically
focusing on the past or
future)
4. Self as context (i.e., recognizing that thoughts and feelings
are ever changing
depending on one’s perspective and context)

5. Identification of values that are personally important
6. Commitment to action for achieving the personal values
identified
Studies have shown that ACT can help with a wide variety of
distress people experience. For
example, ACT has been used to reduce symptoms of depression,
decrease the severity of the
obsessions and repetitive behaviors/mental acts of OCD, and
improve overall mental health
in coping with workplace stress (Hayes et al., 1999; Wolitzky-
Taylor et al., 2012).
Mindfulness-Based Stress Reduction (MBSR)
Mindfulness is a skill that emphasizes
moment-to-moment, nonjudgmental aware-
ness, and it has been shown to promote well-
being. It has been adapted into numerous
interventions, including mindfulness-based
stress reduction (MBSR). MBSR is a form
of training for people who experience both
mental and physical distress. MBSR pro-
grams typically focus on increasing the skill
of mindfulness by practices such as medita-
tion and body scan, which is then incorpo-
rated into everyday life to cope (Fjorback,
Arendt, Ornbol, Fink, & Walach, 2011).
MBSR has been shown to reduce stress and
anxiety symptoms, negative mood-related
Poike/iStock/Thinkstock
Mindfulness is the process of becoming
consciously aware of oneself.

Section 4.4Roles and Settings in Which Stress and Coping
Interventions Take Place
feelings, and depression; increase self-esteem; and improve
overall functioning (Birnie,
Specca, & Carlson, 2010; Cordon, Brown, & Gibson, 2009;
Kabat-Zinn, 1990). MBSR is
based on mindfulness, a mental state in which individuals
purposefully manage their
awareness of the present and what is happening in the moment.
This intervention helps
people develop a mindful state, in which they focus on the
moment, and incorporate it into
everyday life as a coping resource to deal with stressors. There
are three core elements
when teaching MBSR:
• Mindfulness meditation, a formal daily practice of
introspection and self-observation
without judgment. In the most common forms of this
meditation, the person men-
tally focuses on the process of breathing or on the movement of
the feet while slowly
walking without looking down.
• Body scan, which focuses one’s awareness on one’s body.
While lying down or sit-
ting, a person directs attention to each part of the body, noticing
any pain, tension,
lack of sensation, or sense of comfort, becoming more at ease
by focusing on the
body instead of the mind.

• Gentle yoga, a mental focusing through movement that
creates a calming of the
mind’s continuous and ruminative thinking. People use yoga
postures to quiet the
mind and strengthen concentration (Jazaieri, Goldin, Werner,
Ziv, & Gross, 2012;
Kabat-Zinn, 1990).
4.4 Roles and Settings in Which Stress and Coping
There are few if any clearly defined career paths in stress and
coping interventions. Mental
health professionals can become proficient in stress
interventions and conduct research in
the field, but job titles including “stress management expert”
are rare. Instead, stress and
coping interventions tend to be part of the repertoire of mental
health professionals work-
ing in settings where such approaches are needed. The following
sections describe some
mental health professional roles and settings where stress and
coping interventions typi-
cally take place.
K–12 Schools
Both students and teachers in K–12 settings commonly
experience stress and its symptoms,
particularly in recent years as accountability measures and high
stakes testing have added
more pressure to the educational environment (Goldstein, 2014).
School mental health pro-
fessionals are often called upon to help students with stress (see
Voices From the Field) and,
in some settings, teachers as well. Social anxiety, which refers

to fears about social situa-
tions, is one example, and empirically supported group
interventions have been developed
to address this issue with students (Vassilopoulos, Brouzes,
Damer, Mellou, & Mitroploulou,
2013). More generally, adolescence has been described as a
time of “storm and stress,” and
any interventions that can teach younger people coping skills
can be useful to their growth
and development.
Voices From the Field: Kaitlyn, School Mental Health
Professional
Working With Stress
I work in a high school where I counsel students who are at risk
of dropping out or not gradu-
ating on time. My students often have chaotic home lives and
are also battling mental health
issues. They know I have an open door policy and that they are
welcome to come see me when
they’re having a tough day. When students come in, I ask them
if they want to talk, or if they
want to find something from my bucket of self-soothing items
and take some time to work on
regulating their emotions. The bucket includes, among other
things, coloring pages of manda-
las and crayons, spearmint- and eucalyptus-scented lotion that

prompts relaxation, a stuffed
animal, and instructions for breathing exercises. If students are
not ready to talk and prefer
to find a self-soothing item, I allow them to sit at my table and
do some emotional regulation
while I keep working quietly. When students are ready to talk, I
open a dialogue about what
brought them to me, and how they can get through the rest of
the day. Often, I will do a breath-
ing exercise with students before they return to class. I will also
ask them about the coping
mechanisms they use when they are at home (e.g., art, music,
exercise). If students cannot
identify any coping mechanisms to employ, I work with them to
determine some things that
they find calming, and we talk about how they can use those
mechanisms when they are feel-
ing stressed.
Higher Education
College can be a time when many people experience increased
stress levels as they navi-
gate a completely unfamiliar setting with new expectations,
relationships, and living situ-
ations. Many college students experience stress due to academic
demands, changes in
family relations and social life, being away from home, and
making decisions indepen-
dently that may have long-lasting effects (e.g., substance use,
choice of major, romantic
relationships).
Campuses usually have a counseling center that provides a wide
range of services to help
students cope with stress, including individual counseling,
group counseling, and workshops

targeting those dealing with stress. Individual counseling may
involve some of the interven-
tions discussed earlier to help students create a plan to tackle
their stress (see Voices From
the Field). Group counseling for stress is often skill based and
focuses on helping students
develop strategies for overcoming stress and anxiety symptoms
and related problems such as
excessive worry, feeling overwhelmed, insomnia, perfectionism,
and excessive self-criticism.
College campuses may also offer workshops about the good and
bad of stress and ways to
cope, overcoming test anxiety, and building positive coping
strategies to nourish one’s mind
and body.
Voices From the Field: Duane, Mental Health Professional at a
University Counseling Center
I work at a counseling center within a large West Coast
university, where the vast majority of
students I counsel describe their main concern as “stress.” For
college students, stress typi-
cally represents a secondary symptom of a multitude of primary
concerns: academic achieve-
ment, adjustment, anxiety, disordered eating, mood,
relationships, substance use, etc.

I adapt the interventions I use to best fit the individual’s unique
context, symptom presen-
tation, and stage of change. These core components affect the
way I interact with students
who are experiencing stress. For example, I typically use a
combination of cognitive behav-
ioral therapy (CBT) and acceptance and commitment therapy
(ACT) techniques to combat
stress. Both of these strategies encourage mindfulness practice
(e.g., diaphragmatic breath-
ing, progressive muscle relaxation, and meditation), which are
incredibly useful to decrease
physiological symptoms of stress as well as the racing thoughts
that typically stem from being
emotionally overwhelmed.
For stressful situations, thoughts, and symptoms that are within
the student’s control, I start
with CBT. Strategies such as challenging thoughts and
assumptions put the individuals in the
driver’s seat by encouraging them to consider the evidence for
and against their stressful
thoughts. For most people, the evidence indicates that their
worried thought is unlikely to
be true. We work together to find an alternative thought they
could offer themselves when
feeling stress.
In other situations, a stressful thought may be difficult to
challenge because it is true (e.g., “I
have a lot of finals this year”). In this situation, I would start
with an ACT strategy called cogni-
tive defusion. This technique encourages the individual to
accept the worried thought he or
she is having, notice that it is unhelpful, and let it go; this
process may take several repetitions.

Cognitive defusion is usually associated with imagery such as
clouds passing in the sky or
leaves floating down a stream. These images can help the
individual metaphorically let go of
his or her stressful thought.
Differentiating between when to use these two strategies is
important to facilitating successful
coping. For instance, if students are experiencing test anxiety, I
ask them how they typically do
on tests. If the students indicate that they always do well (i.e.,
they can challenge the thought
because it is likely inaccurate), I usually direct them toward
changing how they think about
test taking. Alternately, if the students have experienced poor
grades subsequent to feeling
stressed about test taking (i.e., they have strong evidence that
their worried thought is accu-
rate), I would lead them toward cognitive defusion. With both
of these strategies, I highlight
that the brain is flexible, changeable, and able to be rewired.
Learning and practicing these strategies is difficult for students
at first, but it gets easier and
easier as the brain learns to anticipate alternative thoughts or
the process of letting thoughts
go. For most people, stress responses are innately wired in the
brain after years of practice. My
job is to help students create new pathways in the brain for
managing stress by learning new
ways of thinking and interacting with their environment.

Section 4.5Hot Topics, Trends, and Controversies in Stress and
Coping
Health Care
Stress management interventions are an important compo-
nent of health care delivery. It is not uncommon for people
to go to their doctors to talk about stress or stress-related
symptoms. As part of medical training, health care profes-
sionals receive some training in assessing and assisting
patients with stress. Stress management interventions are
an important component of health care delivery, as stress
is connected to health and using our knowledge about the
connection between stress and health can help us best
treat people. The health care and mental health commu-
nities increasingly recognize that behavioral health—the
full range of mental well-being—needs to be integrated
with medical health care. Integration is necessary because
medical personnel simply do not have the time or training
to address the many psychological issues associated with
health care.
Behavioral specialists can use stress interventions in a
number of ways to improve patient health. First, they can
teach patients coping skills they can utilize when encoun-
tering stress. Second, behavioral specialists can help
patients understand how their lifestyle plays a role in
their health, such as the negative effects of a high-fat diet
or smoking. In addition to helping patients identify things to
eliminate from their lifestyle,
behavioral specialists can also encourage positive change, such
as exercise, to improve their
health. Another role is providing community resources such as
individual counseling, support
groups, and other services when needed.

Workplaces
Many people experience stress in the workplace, and the
strategies reviewed in this chapter
can help people cope with this stress. Employee assistance
programs (EAPs) are intended to
improve the health and well-being of an organization’s
employees. The programs are designed
to help employees and their families deal with personal issues
that inhibit job functioning and
potentially threaten their health, well-being, and job. They
provide assessment, short-term
counseling, and referral for additional behavioral health care.
Typically, employers pay for the
program with no cost to the employee (Horgan, Garnick,
Merrick, & Hodgkin, 2009; Merrick
et al., 2011).
4.5 Hot Topics, Trends, and Controversies in
Stress and Coping
Despite the increasing number of studies related to stress and
coping, researchers still do
not agree on exactly how to define and conceptualize the terms.
Nor have they determined
effective ways to measure them. While scholarly debate about
how to understand stress and
Davor Pavelic/Ikon Images/Getty Images
Both the health care and mental
health communities agree that
behavioral health, and the
promotion of mental wellness,
ought to be incorporated into
medical health care.

Section 4.5Hot Topics, Trends, and Controversies in Stress and
Coping
coping can be beneficial for the field in spurring research and
new ways of thinking, it can
present a problem if researchers cannot use common
terminology to communicate with each
other and with those in the field who might benefit from their
research. With this in mind,
current hot topics in the field will next be reviewed.
Areas of Emerging Research
Early in the study of stress, physicians informally noticed that
certain illnesses seemed to be
connected to personality (Matheny & McCarthy, 2000), which is
defined as differences in the
way people think, feel, and behave. One important area of
research published in the 1970s
was that of Friedman and Rosenman (1974), who identified the
coronary prone personality,
or Type A behavior pattern. They hypothesized that individuals
exhibiting this personality
type are driven by the belief that their worth is dependent
mainly on their productivity, and
that such productivity stems from being able to do more in less
time than other people. This
area of research supported the idea that Type A personalities are
more likely to develop coro-
nary disease later in life, because their behavior is linked to
constant arousal of the stress
response.

Research on the links between personality
and stress is complicated by the multidi-
mensional nature of both personality and
coping. Friedman and Booth-Kewley (1987)
reviewed 101 research studies examining
links between emotional responses and
specific diseases. They reported evidence
that people with certain personality types,
including those who exhibit hostility and
anxiety, were predisposed to illness. The
five-factor model (FFM) of personality
explains individual differences on the basis
of five characteristics:
1. extraversion—enjoying interac-
tions with others
2. neuroticism—being more likely to
experience negative emotions
3. conscientiousness—being thorough and organized
4. agreeableness—being cooperative
5. openness to experience—including sources such as new ideas,
information gained
from the senses, and imagination (Costa & McCrae, 1992)
Segerstrom and O’Connor (2012) have noted that a substantial
amount of research links the
FFM of personality to health and longevity. Given the current
consensus for the FFM, future
research may help further clarify links between personality,
stress, and coping (Reevy &
Frydenberg, 2011).
Science Photo Library/SuperStock

There is research that suggests a connection
between personality and stress. However, the
complexity of both personality and coping
leave much to be discovered.
Summary and Resources
The Changing Landscape of Health Care
As health care models continue to evolve and as mental health
care efforts are increasingly
integrated into health care services, stress interventions will
likely change as well. As one
example, mindfulness-based interventions are increasingly
being utilized in health care set-
tings. Models of health care services are changing rapidly in the
United States, and mental
health care providers continue to play an expanded role in many
such systems (Novotney,
2010). The older “pay as you go” model of health care delivery,
where patients pay out of
pocket for most care, is increasingly being recognized as
impractical for today’s health care
climate, and integrated health care systems are increasingly
being utilized, in which profes-
sionals with a wide variety of health care expertise coordinate
their efforts to meet the needs
of their clientele. It is likely that incorporating stress
interventions into health care delivery
will be an area of high interest to both researchers and
practitioners.

Positive Psychology and Thriving
As discussed briefly in Chapter 1, positive psychology is a
newer branch of psychology that
shifts the focus from what is going wrong with people to what is
going well and what contrib-
utes to happiness and emotional resilience (Seligman &
Csikszentmihalyi, 2000). The field of
positive psychology focuses on the strengths of people, what
makes life fulfilling, and build-
ing on positive experiences to repair negative experiences. It is
concerned with psychological
health and growth, as opposed to the more traditional emphasis
in psychology on explain-
ing psychological disorders (Seligman, 2011; Seligman &
Csikszentmihalyi, 2000). It has
long been recognized that stress can have an energizing and
healthy effect; in fact, the term
eustress was coined by Selye (1976) to describe this very
phenomenon. However, stress and
coping research has focused on the negative aspects of how
stress affects our health and how
we can cope to offset the negative effects of stress. Less
attention has been devoted to the
positive effects of stress—eustress—and how responding to
challenges in life can actually
add to our health and vitality. It is important to note that
positive psychology does not recom-
mend ignoring or dismissing problems, such as stress, but
instead seeks to complement the
more dominant, problem-focused approaches within psychology
(Seligman & Csikszentmi-
halyi, 2000). While researchers are beginning to explore how
responding to life challenges
can actually improve our welfare, much more research is needed
to better understand and
develop models for the positive models of health.

Chapter Summary
Everyone experiences stress in life; however, it becomes a
problem when stress levels are so
high that it becomes hard to function and ultimately affects
physical health and well-being.
The impacts of stress are far reaching, and the effects of stress,
or stressors, refer to external
events and self-generated demands that trigger the stress
response. Stress can be an unpleas-
ant experience that may affect our emotional and physical well-
being in the long term. It is
important for those entering the mental health field that stress
interventions are used in many
different settings; however, an understanding of the history of
the knowledge and research of
stress is necessary.
Research on stress began with examining links between the
mind and the body. Sigmund
Freud’s groundbreaking writings on hysteria, which referred to
nervous system symptoms
(such as paralysis and blindness) that could not be explained by
medical factors, led to the
creation of psychoanalysis but seemed to reinforce the idea that
the mind was separate from
the body. We know now that while our psychology can affect

our physical well-being, the links
are very real, not imagined. Many different brain structures are
involved in processing threats
to our well-being, which help determine whether the body’s
stress response will be triggered.
This response was labeled fight or flight in the 18th century by
Claude Bernard and was later
refined to include “freeze,” which is our initial reaction to
potential threats. The general pat-
tern of responses associated with stress was labeled the general
adaptation syndrome by
Hans Selye. There are three stages to the general adaptation
syndrome: alarm (freeze, flight, or
fight), resistance (ongoing physiological changes to deal with
stress), and exhaustion (wear-
ing down of the body’s defenses). Two medical doctors, Thomas
Holmes and Richard Rahe,
discovered that the clustering of life events was predictive of
one’s vulnerability to physical
disease, furthering our understanding of how external events are
connected to well-being.
Our current understanding of the stress process comes from
researchers who see stress as
the result of a transaction between the individuals and the
environment. Two important
researchers in this area are mental health professionals Richard
Lazarus and Susan Folkman
(1984). They maintained this transaction is largely a function of
our perceptions. Alongside
Lazarus and Folkman (1984)’s transactional model, Stevan
Hobfoll’s (1989) conservation of
resources (COR) theory is the other dominant model for
understanding stress. Like the trans-
actional model, Hobfoll’s COR theory also emphasizes the role

of perception in stress, but COR
theory gives primacy to our perceptions of threats to our
resources.
While there are many mental health specializations that have a
specified career trajectory
for entering the field and certificating who is able to provide
that service, stress management
techniques are not really associated with a specific counseling
specialty. Instead, they are
incorporated into the interventions used by almost every branch
of the helping profession
and are available to the general public in the form of self-help
books and website resources.
Based on the emerging understanding of stress, two general
types of interventions have been
developed for use by mental health professionals: physical
stress interventions targeted at
reducing the symptoms of the stress response, and cognitive
stress interventions aimed at
altering the thinking patterns that produce stress. Each category
of intervention has a num-
ber of different techniques and approaches that can be used by
professionals or by the public
in cases where a self-help approach has been developed. It is
critical for mental health pro-
fessionals to be aware of evidence-based interventions, as they
have demonstrated effective
outcomes that will be useful to best help clients.
Mental health professionals can clearly become proficient in
stress interventions and conduct
research in the field, but job titles including “stress
management expert” are rare. Instead,
stress and coping interventions tend to be part of the repertoire

of mental health professionals
working in settings where such approaches are needed. Because
stress and its symptoms are
prevalent for both students and teachers in K–12 settings,
school mental health professionals
and other professionals in the school often use stress
interventions. Similarly, professionals
working in higher education provide a range of stress
interventions as part of individual,
group, and campus-wide services. Given widespread changes in
the health care system and
the increased understanding of links between the mind and
physical health, such interven-
tions are common in medical settings, often under the title of
behavioral health. Workplaces
are also common settings for stress interventions.
Even though much has been learned about stress, there are many
emerging areas and con-
troversies in the field. First, debate continues about how best to
define both stress and cop-
ing. Second, a better understanding of the links between
personality, stress, and coping is a
growing field. Models of health care services are changing
rapidly in the United States, and
mental health care providers continue to play an expanded role
in many such systems. Finally,
the positive psychology movement, emphasizing health and

growth as opposed to illness and
disease, has become a trend in the field of stress and coping.
Resources for Future Exploration
APA: Division 17: Positive Psychology
http://www.div17pospsych.com/
Website with additional information about events, student
membership, and conferences.
Evidence-Based Interventions Network
http://ebi.missouri.edu/
The Evidence-Based Interventions Network was developed to
provide guidance in the selec-
tion and implementation of evidence-based interventions.
Mindfulness Training
http://www.umassmed.edu/cfm/
Website of the Center for Mindfulness at the University of
Massachusetts Medical School,
where mindfulness-based stress reduction began.
www.thinkmindfully.com
This website provides information about mindfulness-based
stress reduction.
Positive Psychology
http://www.positivepsychology.org/
Website through the University of Pennsylvania that has
resources on research, training, and
education on positive psychology.
Stress and Anxiety Research Society (STAR)
www.star-society.org
STAR is a multidisciplinary organization for stress, coping, and
anxiety research.

Stress and Coping in Education Special Interest Group,
American Educational Research
Association
http://www.aera.net/tabid/11093/First/R/Last/Z/Default.aspx
This organization promotes research and exchange of ideas
concerning stress and coping in
education.
Key Terms
acceptance Becoming aware of and
embracing private events occasioned by
one’s history without unnecessary attempts
to change their frequency or form, especially
when doing so would cause psychological
harm.
adrenal glands Located above the kidneys,
glands that produce hormones that facilitate
the stress response.
adrenocorticotropic hormone (ACTH)
A stress hormone involved in the stress
response.
alarm stage A phase of the general adapta-
tion syndrome in which the body and mind
ramp up to a state of alarm (freeze, flight,
or fight).

amygdala A part of the brain that plays a
central role in emotional reactions such as
the stress response.
anxiety A feeling of worry, nervousness, or
unease, typically about an imminent event
or something with an uncertain outcome.
appraisal The cognitive evaluation that
takes place whenever a life demand is
encountered.
catecholamines Organic compounds that
increase the heart and breathing rates and
accelerate brain activity.
cognitive approaches A system of counsel-
ing, based on changing irrational or mal-
adaptive thoughts, that is often applied to
treating stress.
cognitive defusion Consists of encourag-
ing clients to detect their thoughts and to
see them as hypotheses rather than objec-
tive facts about the world.
cognitive stress interventions
Approaches to stress management aimed at
altering the thinking patterns that produce
stress.
conservation of resources (COR) A
theory that perceived or actual threat to
resources is what causes stress.

coping Attempts to manage, mitigate, or
prevent stress.
cortex A kind of executive board in the
brain that evaluates a signal and helps direct
the body’s responses.
emotional memories Emotions affiliated
with an event, such as excitement, grief,
and anger.
emotions A complex pattern of changes,
including physiological arousal, feelings,
cognitive processes, and behavioral reac-
tions, made in response to a situation per-
ceived to be personally significant.
eustress Positive stress, that is, how
responding to challenges in life can actually
add to one’s health and vitality.
evidence-based interventions Treat-
ments that have been proven effective (to
some degree) through outcome evaluations.
exhaustion stage A phase of the general
adaptation syndrome that is marked by a
wearing down of the body’s defenses.
fight or flight The body’s physiological
response to stress, which enhances the abil-
ity to either fight or flee from threats in the
environment.
freeze, flight, or fight A refinement of the
idea of fight or flight, including the idea that

an individual’s first reaction to stress is to
stop and assess the situation.
general adaptation syndrome The uni-
versal response of the body to stress.
hassles Minor stressors that accumulate to
affect a person’s stress level.
homeostasis The tendency of healthy
organisms to maintain a state of constancy
despite changes in the outside environment.
hypothalamus A small neurostructure in
the center of the brain that links the nervous
system to the pituitary gland.
hysteria A term developed by Freud that
refers to nervous system symptoms (such
as paralysis and blindness) that could not
be explained by medical factors during his
time.
orbitofrontal cortex A part of the brain
that stores emotional memories and serves
to help assess any associations with previ-
ous events that might be used to regulate
responses by the amygdala.

perception The subjective nature of evalu-
ations of the outside world and a person’s
resources for coping with it.
personality Individual differences in the
way people think, feel, and behave.
physical stress interventions Treatment
targeted at reducing the symptoms of the
stress response.
pituitary gland A master gland that con-
trols the functions of other glands.
primary appraisal A psychological process
that occurs when an individual evaluates
events according to their significance to his
or her well-being.
resistance stage A phase of the general
adaptation syndrome in which only some of
the physiological components of the alarm
stage remain (such as tension, worry, and
lack of sleep).
resource caravans The idea that families,
communities, and organizations can invest
in collective resources that are broadly
shared by everyone.
secondary appraisal Following pri-
mary appraisal, a psychological process
that occurs when an individual evaluates
resources according to their sufficiency in
meeting a life demand.

startle response When immediate action
is called for, the startle response allows the
body to spring into action without needing
the thinking part of the brain.
stress A transaction between the person
and the environment, and more specifi-
cally as the result of an imbalance between
perceived demands and perceived resources
that has the potential to cause negative
emotions and physical wear and tear on
the body.
stressors Environmental or internal events
that have the potential to cause individuals
harm and that trigger the stress response.
stress response The cascade of physiologi-
cal, cognitive, and emotional changes that
result once a stressor has been experienced.
stress symptoms The consequences of the
stress response upon functioning, such as
feeling anxious or becoming physically ill.
thalamus A brain structure that is involved
in sensory perception and the regulation of
motor functions.
transaction An important component
of stress models emphasizing that stress
results from the interaction of the person
with his or her environment.

3Health PsychologyBy Gregory J. Privitera, St. Bonaventure
University
Fuse/Thinkstock
Learning Objectives
After reading this chapter, you should be able to
• Define health psychology, and describe the different areas
of interest of health psychologists.
• Identify the core models and psychological concepts used
in health psychology.
• Evaluate the occupational and educational opportunities in
the field of health psychology.
• Analyze current trends and opportunities in the field of
health psychology.

Section 3.1The Basics of Health Psychology
From a general perspective, health can be thought of as the
quality of life between birth and
death. People often think of being “healthy” as the absence of
illness. However, this is an over-
simplification of what health is, and of how people live their
lives. Consider the following
phrases we may use on occasion:
“Let’s just relax and watch a movie; it’s been a stressful day.”
“I take a multivitamin a day to stay healthy.”
“Seeing my best friend always cheers me up.”
“Exercising makes me feel healthy; I love that feeling.”
“I need to take my medication each day; the doctor says it’s
how I can get better.”
Each of these five statements is related to the pursuit of feeling
better or healthier, yet only the
last statement relates to illness. It is important to understand
that health is not relevant only
when we are ill. We all have the potential to become ill, so
naturally we may engage in health-
related behaviors, such as purchasing a gym membership or
dieting, even when we are not
sick. We also may engage in unhealthy behaviors despite the
consequences. According to the
American Cancer Society and the World Lung Foundation, more
than 55.8 million Americans
still smoked cigarettes as of 2013, leading to a total cost in
dollars spent treating tobacco-
related illnesses of approximately $10–$11 billion annually

(World Lung Foundation, 2015).
Understanding why people engage in health-related behaviors
and ways to prevent unhealthy
behaviors is important, not only to reduce the costs associated
with unhealthy behaviors such
as smoking, but also to enhance health and well-being.
This chapter will explore the diverse areas of research on which
professionals in this sub-
discipline focus, and how this understanding can promote a
better understanding of health.
3.1 The Basics of Health Psychology
Health psychology is the study of psychosocial and behavioral
processes related to health,
illness, wellness, and health care in order to understand how
such processes contribute to
the landscape of health across the lifespan. It is a relatively new
field of psychology that has
gained interest as the field of psychological medicine has
grown. Increasingly, we are rec-
ognizing that illness is not purely physical. Even when it is
physical, like when a person has
cancer, the psychology of how a person experiences that illness
can play an important role in
the progression of that illness. This is the psychosocial and
behavioral component of health.
Health psychology focuses on how our interactions in a
psychological, social, and behavioral
context affect our health and the health of others. In order to
make sense of the field of health
psychology, let’s break this definition down into the
fundamental components of the field.
Health
According to the World Health Organization, in a statement last

amended in 1948, health is
“a complete state of physical, mental and social well-being, and
not merely the absence of
disease or infirmity” (World Health Organization [WHO], 1948,
p. 100). At the time, this was
quite a progressive definition for health,
although it is not comprehensive of what we
now understand health to be. The definition
misses key elements of health, such as psy-
chological and social/cultural aspects,
which together are commonly referred to as
the psychosocial health factors.
To illustrate the everyday psychosocial fac-
tors of health, consider that it is very likely
that you do not eat the recommended five
fruits and vegetables a day. Why? For many,
these foods are too expensive (an economic
reason). For others, fruits and vegetables
may not be a staple food, and thus cultural
or familial customs make it unlikely that
these foods will be eaten five times a day. Similarly, health can
be related to religious prac-
tices (certain foods may be sacred), lifestyle factors (a busy
work life leads to poorer dietary
choices), bodily changes (pregnancy affects diet), or even
personal experiences (divorce may
lead to depression, which is related to weight gain). The

interplay between psychology and
society (or “the world we live in”) is a crucial part of the
definition of health.
As stated earlier in this chapter, health psychology is a field
with interests in the psychoso-
cial and behavioral processes related to health, illness,
wellness, and health care. When we
consider illness, health, and wellness, the latter terms should
not be used as synonyms. In
practice, health, illness, and wellness are treated as part of a
continuum. Figure 3.1 illustrates
how such a continuum can reveal these aspects of health. The
patient is often thought of as
“healthy” when he or she has no apparent illness, which is a
disease or sickness over any
length of time that can affect the body, mind, or both. “Healthy”
is the neutral point in the con-
tinuum, although this is, of course, not correct with regards to
how health is defined. Show-
ing enhanced wellness is not typically regarded as a necessary
condition for a patient to be
labeled as “healthy.” Wellness involves caring for the physical
self, while also attending to the
psychosocial self. The treatment approach is a model that
begins with illness, with the goal
of eradicating the illness. The wellness approach is the other
part of this continuum. In this
approach, someone who is not necessarily ill makes efforts to
promote wellness or become
more than just “healthy” as a way to minimize the need for
treatment.
The illness-wellness continuum varies across the lifespan; it is
not a static model. Moving
to the left in the continuum is a progressively worsening state

of health. The treatment
approach can help return the individual to the center of the
continuum (Baker, McFall, &
Shoham, 2009). An example of this is when doctors use drugs,
surgery, or psychotherapy to
treat patients. The treatment approach aims to alleviate
symptoms of illness. To the right
in the continuum is a progressively improving state of health or
wellness. The wellness
approach, which can be applied even during treatment, can help
people achieve optimal
wellness beyond simply not being ill, and it can help them cope
with or manage an ongoing
illness (Myers, 1992; Swarbrick, 2006). Regardless, throughout
our lives we will vary along
this continuum.
Fuse/Thinkstock
Culture, environment, and lifestyle all play a
role in a person’s health.
Figure 3.1: The illness-wellness continuum
Indicators below the star suggest illness, while indicators above
the star suggest wellness. The
wellness approach is typically applied on both ends of the
continuum, whereas the treatment
approach is typically applied only when indicators suggest
illness.

Source: Adapted from The Wellness Workbook (3rd ed.), by J.
W. Travis and R. S. Ryan, 2004, Berkeley, CA: Celestial Arts.
Notably, optimal wellness is more than just a physical state in
this continuum. Even if an
individual lacks physical symptoms of illness, the person may
still experience psychological
symptoms, often expressed as emotion (e.g., depression,
anxiety, or even general dissatisfac-
tion with life). Such emotional states can often affect mental
and physical health. For example,
excessive stress can weaken the immune system, leading to
increased likelihood of diseases
such as cancer (Corthay, 2014). Negative emotional states can
also influence health behav-
iors, leading to smoking, alcohol consumption, overeating, or
even suicide. Death may be a
natural part of life, and an individual’s place on the continuum
often cannot be controlled.
However, people can control which direction they are facing in
this continuum—and facing to
the right of this continuum points to wellness.
Wellness is an increasingly important area of research and
practice. Consider research from
positive psychologists on flourishing and flow (Seligman &
Csikszentmihalyi, 2000; Keyes
& Haidt, 2003). Flow, which was coined by Mihaly
Csikszentmihalyi, occurs when people
become so engaged in an activity that they become engrossed,
losing a sense of self and time
as a result. Csikszentmihalyi’s work fundamentally focuses on
what gives people enjoyment
and happiness in their lives. He found that even those activities
in which people experience

physical discomfort, such as training for an athletic event, can
be enjoyable and produce a
strong sense of gratification if they contribute to feelings of
happiness and well-being. Activi-
ties that can induce flow can vary from reading a book to
making friends to exercise and
sports. Any activity that is rewarding and motivating can induce
flow. Such research is lead-
ing the way to help practitioners understand how people can
flourish and find happiness,
thereby enhancing their wellness (Centre for Confidence and
Well-Being, 2006).
Keep in mind that health psychology, as a field, is interested in
the processes that contribute
to the full spectrum of health across the lifespan. To understand
those processes, or what are
also called the underlying mechanisms related to health
outcomes, health psychologists use
the scientific method to evaluate health outcomes. Health
psychology is a scientific endeavor,
and health psychologists, whether they are employed in a lab or
in an applied setting, are
scientists.
Areas of Interest and Focus Among Health Psychologists
Health psychologists often make significant contributions to the
following key areas across
the lifespan:

• The etiology or correlates of health, illness, and wellness
• The prevention and treatment of illness
• Health promotion and maintenance
• The impact of the health care system and health policy
Etiology
The etiology, or cause of a disease or ill-
ness, is more than just biological. Health
psychologists are just as interested in
health and wellness as they are in illness
and view etiology from a broader perspec-
tive by evaluating health, wellness, and
illness from a “health onion” perspective
(Dahlgren & Whitehead, 1991). The health
onion is a multilayered framework for
health psychology (Figure 3.2). From this
perspective, to understand health, well-
ness, and illness, the biological individual
(e.g., age, sex, heredity) is at the center.
From a traditional clinical perspective, the
biological individual is the primary focus
for etiology. Health psychologists look
beyond this layer and focus on the four lay-
ers of etiology:
1. Individual and lifestyle factors
2. Social and community networks
3. Living and working conditions
4. General socioeconomic, cultural,
and environmental conditions
Prevention
A central focus in health psychology is on more than just
treatment, which is an application

of the left side of the illness-wellness continuum; it is on the
prevention of disease as well,
which is an application of the continuum from left to right.
When applied to health, preven-
tion means to avoid a disease entirely by taking actions that can
stop a given disease from
developing. Broadly, prevention services can be categorized
into three types:
1. Primary prevention is aimed at stopping disease before it
occurs. An example of
primary prevention is the immunization program, which has all
but eradicated many
diseases that were epidemic in the early 1900s.
Figure 3.2: The health onion
The “health onion” perspective views etiology in
layers that when considered together can lead to
improved quality care and health outcomes. A key
feature of this perspective is that each layer is a
contributing factor and that no one layer can be
fully isolated when working to identify etiology, or
causes of disease.
2. Secondary prevention is aimed at the early diagnosis and
detection of treatable dis-
eases. This level of prevention aims to identify diseases early to
make them easier to

manage. An example of secondary prevention includes medical
screening tests such
as mammograms and colonoscopies.
3. Tertiary prevention is aimed at wellness for those with
chronic irreversible diseases.
An example of tertiary prevention is physical therapy for those
with arthritis. The
goal is to help patients manage their diseases to improve their
quality of life or
wellness.
Health Promotion
While prevention of disease is an important step toward healthy
living, health psychologists
further focus on the promotion and maintenance of good health.
Health promotion refers to
enabling people to have greater control over and improve their
health and well-being. Efforts
to promote positive health go beyond individual behavior to
include other factors. Examples
of health promotion include building community parks to
increase activity, opening grocery
stores in “food deserts” to make fresh fruit and vegetables more
available, and individual
efforts such as lifestyle changes to increase exercise.
Health promotion is a key initiative today, thanks in part to the
great work of health psycholo-
gists who have developed effective strategies to promote health
and wellness even among
those who are not ill. For instance, the Centers for Disease
Control (CDC) has made this a key
initiative, particularly as it pertains to health equity. One of its
key goals is to

increase health promotion efforts targeting social determinants
of health,
such as increased access to affordable healthy food options in
underserved
communities through the development of community gardens, as
well as tax-
ing and zoning policies that encourage the development of full-
service gro-
cery stores in neighborhoods where they are lacking. (CDC,
2009, p. 12)
Health Care and Policy
Many of the concepts and strategies described in this chapter
have implications for, and an
impact on, the health care system and health policy. Keep in
mind that the health care system
is informed by health policy. As researchers gather data that
affect the policies that health
care providers must adhere to, the health care system—which
includes any level of care from
hospitals to physician office visits—thus fundamentally changes
to adapt to new and chang-
ing policies. Health psychology is an applied field rooted in
evidence-based scientific think-
ing to develop knowledge of illness, health, and wellness, and it
certainly has an impact on
health policy, particularly for behavioral health. For example,
rates of depression and stress
are rising among American war veterans, and the need to serve
and treat this population has
become increasingly important (Taylor, Parkes, Haw, & Jepson,
2012). The health psychol-
ogy field is also a holistic approach to health that focuses on the
entire person and not just
the physical body. This has inspired efforts in health promotion
and prevention that have led

to fewer people getting sick and improved recovery from illness
in many cases. For exam-
ple, art therapy is a growing and cost-effective approach that
has successfully been used to
promote positive moods among those suffering from depression
(Privitera, Misenheimer, &
Doraiswamy, 2013a) and enhance communication among those
with dementia (American Art
Section 3.2Core Models and Psychological Concepts in Health
Psychology
Therapy Association, 2015). Many of these prevention efforts
often contribute to reducing
costs associated with health care.
While health psychology’s impact on health care certainly
relates to cost, it also relates to
outcomes such as efficiency, accessibility, utility, and the
potential ethical implications of pro-
viding health care. Health care is a complex ecosystem in that it
affects and is affected by the
work of health psychologists, medical professionals, and even
patients. It provides the essen-
tial applied framework that guides the activities of medical and
behavioral health profession-
als. From a broad perspective, the role or structure of the health
care ecosystem for providing
care can be described by the 6 P’s (adapted from the website for
the Center for Healthcare
Innovation, 2012):

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