Stress Inoculation Training

C. Jeffrey Terrell, Ph.D., M.Div. Psychological Studies Institute

Stress Inoculation Training

SIT is a flexible, individually tailored, multifaceted form of cognitive-behavioral therapy. Given the wide array of stressors that individuals experience, SIT provides a set of clinical guidelines for treating stressed individuals, rather than a specific treatment formula. A central concept underlying SIT is that of "inoculation" or "immunization," which has been used both in medicine and in socialpsychological research on attitude change.

 SIT was developed by Meichenbaum (1974) as an anxiety management treatment. Later Kilpatrick, Veronen, and Resick (1982) modified the program to treat rape victims, although this was prior to the widespread use of the PTSD diagnosis to describe post rape symptomatology. The modified SIT program included education, muscle relaxation training, breathing retraining, role playing, covert modeling, guided self-dialog, and thought stopping.

 Some applications did not include some of the original SIT strategies, such as assertiveness training, since these were included in treatments compared with SIT in the initial studies. Similarly, in some studies that have compared SIT with EX, clients are not given instructions to confront frightening situations, although this might otherwise be included within several SIT strategies, such as role playing.

 The rationale underlying SIT focuses on anxiety that becomes conditioned at the time of the trauma and generalizes to many situations. Clients learn to manage this anxiety by using these new skills, thus decreasing avoidance and anxiety. In order to enhance an individual's coping and to empower him or her to use already existing coping skills, an overlapping three-phase intervention approach is employed

Stress Inoculation Training-Phase 1: Conceptualization

In a collaborative fashion, identify the determinants of the presenting clinical problem or the individual's stress concerns by means of: Interviews with the client and significant others. The client's use of an imagery-based reconstruction and assessment of a prototypic stressful incident. Psychological and situational assessments. Behavioral observations.

Stress Inoculation Training-Phase 1: Conceptualization

Permit the client to tell his or her "story" Have the client disaggregate global stressors into specific stressful situations. Have the client appreciate the differences between changeable and unchangeable aspects of stressful situations. Have the client engage in self-monitoring of the commonalities of stressful situations stress engendering appraisals, internal dialogue, feelings, and behaviors.

 Have the client establish short-term, intermediate, and long-term behaviorally specifiable goals. Ascertain the degree to which coping difficulties arise from coping skills deficits or are the results of "performance failures" Collaboratively formulate with the client and significant others a reconceptualization of the client's distress. Debunk myths concerning stress and coping

Stress Inoculation Training-Phase 2: Skills acquisition and rehearsal

Ascertain the client's preferred mode of coping. Explore with the client how these coping efforts can be employed in the present situation. Examine what interpersonal or intrapersonal factors are blocking such coping efforts. Train problem-focused instrumental coping skills that are directed at the modification, avoidance, and minimization of the impact of stressors.

Stress Inoculation Training-Phase 2: Skills acquisition and rehearsal cont.

Select each skill according to the needs of the specific client or group of clients. Help the client to break complex stressful problems into more manageable subproblems that can be solved one at a time.

Stress Inoculation Training-Phase 2: Skills acquisition and rehearsal cont.

Skills training Help the client engage in problem-solving activities by identifying possibilities for change, considering and ranking alternative solutions, and practicing coping behavioral activities in the clinic and in vivo. Train emotionally focused palliative coping skills, especially when the client has to deal with unchangeable and uncontrollable stressors. Train clients how to use social supports effectively Aim to help the client develop an extensive range of coping responses in order to facilitate flexible responding. Nurture gradual mastery.

Stress Inoculation Training-Phase 2: Skills acquisition and rehearsal

Skills rehearsal Promote the smooth integration and execution of coping responses by means of behavioral and imagery rehearsal. Use coping modeling (either live or videotape models). Engage in collaborative discussion, rehearsal, and feedback of coping skills. Use self-instructional training to help the client develop internal mediators to self-regulate coping responses. Solicit the client's verbal commitment to employ specific coping efforts. Discuss possible barriers and obstacles to using coping behaviors.

Stress Inoculation Training-Phase 3: Application and follow-through

Encouraging application of coping skills Prepare the client for application by using coping imagery, together with techniques in which early stress cues act as signals to cope. Expose the client to more stressful scenes, including using prolonged imagery exposure to stressful and arousing scenes. Expose the client in the session to graded stressors via imagery, behavioral rehearsal, and role-playing.

Stress Inoculation Training-Phase 3: Application and follow-through

Use graded exposure and other response induction aids to foster in vivo responding. Employ relapse prevention procedures: Identify high-risk situations, anticipate possible stressful reactions, and rehearse coping responses. Use counter-attitudinal procedures to increase the likelihood of treatment adherence (i.e., ask and challenge the client to indicate where, how, and why he or she will use coping efforts).

Stress Inoculation Training-Phase 3: Application and follow-through

Bolster self-efficacy by reviewing both the client's successful and unsuccessful coping efforts. Insure that the client makes self-attributions for success or mastery experiences (provide attribution retraining).

Stress Inoculation Training-Phase 3: Application and follow-through

Maintenance and generalization Gradually phase out treatment and include booster and follow-up sessions. Involve significant others in training (e.g., parents, spouse, coaches, hospital staff, police, administrators), as well as peer and self-help groups. Have the client coach someone with a similar problem (i.e., put client in a "helper" role). Help the client to restructure environmental stressors and develop appropriate escape routes.

Stress Inoculation Training-Phase 3: Application and follow-through

Insure that the client does not view escape or avoidance, if so desired, as a sign of failure, bur rather as a sign of taking personal control. Help the client to develop coping strategies for recovering from failure and setbacks, so that lapses do not become relapses.