Michael H. Antoni, Roselyn Smith-Stress Management Intervention For Women With Breast Cancer - Participant's Workbook (2002) PDF

Contents
INTRODUCTION vii
Session 1
Rationale for Stress Management 1
Session 2
Stress and Awareness 11
Session 3
Automatic Thoughts and Cognitive Distortions 21
Session 4
Rational Thought Replacement 33
Session 5
Coping, Part I 45
v
vi C O N T E N T S
Session 6
Coping, Part II 57
Session 7
Social Support 65
Session 8
Anger Management 77
Session 9
Assertiveness Training 87
Session 10
Wrap-Up 99
A B O U T T H E A U T H O R 103
Introduction
W
elcome to the B-SMART program, a stress management intervention for
women with breast cancer. What’s in a name? SMART stands for Stress
Management And Relaxation Training (and the B refers to breast cancer).
This program is a group-based therapeutic intervention. You will meet
with three to five other women with breast cancer and two female group
leaders during weekly intervention sessions for the next 10 weeks. This
setting provides an environment of support and collegiality that should
help you more easily learn new stress-reducing techniques and will give
you a place to share your frustrations, inspirations, and ideas with other
people who have similar health issues. The SMART part of our name
refers to the content of the program, which is made up of a set of stress
management techniques and relaxation and imagery exercises that are
designed to support your efforts to cope with breast cancer and the chal-
lenges of daily life.
During each group session of the 10-week period, you will learn new
stress management techniques and new relaxation and imagery exer-
cises. These techniques are designed to increase your awareness of your
The B-SMART Workbook was created in collaboration with Susan Alferi, Pati Arena, Amy
Boyers, Charles S. Carver, Jennifer Culver, Suzanne Harris, Gail Ironson, Kristin Kilbourn,
Jessica Lehman, Bonnie McGregor, Alicia Price, and Susan Yount.
This workbook was adapted from GET–SMART (Group Experiential Therapy–Stress Man-
agement and Relaxation Training) by Michael H. Antoni, Susan Lutgendorf, Kathleen Starr,
Gail Ironson, Nancy Costello, Marc Zuckerman, and Neil Schneiderman. Development of this
workbook was funded by National Institute of Mental Health grants MH4355, MH49548,
MH18917, and National Cancer Institute grant RO1CA64710.
vii
viii I N T R O D U C T I O N
stress responses and teach you new ways to think about and act on stressful
demands. Some of these techniques focus more on your thought pat-
terns and emotional responses, whereas others focus on the ways you
cope and behave in response to stressful events. Still others involve the
ways you interact with other people during interpersonal exchanges and
in relationships—another very common source of stress!
In addition to the stress management techniques, each week you
will also learn exercises designed to decrease body tension and other
physical effects of stress. Some of these exercises will teach you to sys-
tematically reduce tension throughout all of your major muscle groups,
whereas others will teach you ways to use mental imagery to bring about
a total state of relaxation.
We have presented the exercises in a way that will help you gradu-
ally build your skills. We begin with simpler techniques during the initial
weeks and build on them to lead you into the more complex exercises
that are presented later. Some of these exercises involve audiotapes or
CDs that we will ask you to listen to at home.
A key element of the program involves the home practice schedule.
If you are able to consistently attend the group sessions, practice your
exercises at home, and use this workbook, you will be able to use the
techniques to improve your ability to manage stressful experiences,
achieve a greater state of relaxation, and develop interpersonal coping
strategies that have been shown to be effective in prior research studies.
Many of the activities in this workbook parallel the group session exer-
cises. We hope that you will use the group sessions as a place where you
ask questions about and share any of your reactions to the workbook
exercises. We also hope that you use the workbook to review all of the
materials covered in the group sessions—then you won’t have to take
notes. Welcome aboard!
One last thing before you get started. Although many of the tech-
niques presented in this workbook are designed to build personal skills,
they are more likely to be effective when they are learned in a supportive
group led by professionally trained group leaders. The efficacy of the B-
SMART program has been established only in the context of a group-
based format, and none of these techniques have been designed to be
taught or used as self-help techniques.
Session 1:
Rationale for
Stress Management
1
This program is designed to help you deal with breast cancer by provid-
ing you with the benefits of stress management techniques, new coping
strategies, and relaxation training. We will introduce new topics every
week using a series of 10 modules. Each module builds on the previous
week, so it is important to attend all sessions. Although each session
includes a lecture, the real heart of the meeting is the input you provide
about your experiences and feelings, not only as they relate to your diag-
nosis, surgery, and subsequent treatment but also as they relate to life
situations that existed before your diagnosis or changed as a result of
your diagnosis.
Each weekly meeting consists of two parts. One portion involves a
group discussion about stressful situations you may encounter; everyday
situations that people in the group may bring up; and issues related to
having breast cancer, such as recent medical information and social or
interpersonal issues. For this portion of the session to be effective, you
will need to complete certain tasks outside of the sessions. You will have
assignments every week, and it is very important that you do them—we
need your commitment. The tasks will be very practical assignments,
such as paying attention to your stress levels, noticing what you say to
yourself, and becoming aware of how you feel when you’re stressed.
Most people find these exercises interesting and useful. The weekly as-
signments are just as important as the group meetings and are necessary
for you to get the most benefit from the groups.
1
2 STRESS MANAGEMENT: PART I C I P A N T ’ S W O R K B O O K
Goals ❚ To introduce the goals and expectations of the 10-week stress

management intervention.
❚ To introduce the concept of self-monitoring.
❚ To discuss the relationship of stress and anxiety to biological
processes and understand the process and benefits of stress
management.
In the other portion of each session, you will learn different stress
management techniques that will enable you to reduce bodily tension
through muscle relaxation and mental imagery exercises. During each
weekly session, you will be trained in the use of these exercises and en-
couraged to practice each 20- to 30-minute exercise at least once a day at
home. By recording your exercise experiences at home (on forms that
we distribute to you), you will enhance your awareness of subtle changes
in body tension levels and improve your ability to engage a “ relaxation
response” after particularly stressful periods or in anticipation of stressful
challenges. You should feel free to change any of the imagery exercises
with which you are not comfortable. Some of the techniques being in-
troduced may already be familiar, especially to those of you who have
ever practiced relaxation or meditation. If you have, the group sessions
can refresh your knowledge and remind you to use the skills you already
have.
We now begin to discuss the meaning of stress, individual responses
to stressful events, and the effects of stress on the body in general and on
physiological systems of the body such as the immune system.
Generate a List
of Stressors
What makes you feel stressed? When? One way to increase your aware-
ness of your stress responses is to get in touch with some of the ways
you respond to some fairly common life experiences. Using the follow-
ing form, start out by recording some day-to-day examples—not big
things—just daily hassles that seem to occur regularly. Recall the events
of the past week or two, and in the left column make a list of the stress-
ful events that you experienced. In the right column, write the ways in
Session 1: Rationale for Stress Management 3
Event Experiences
Example: I was cut off in traffic. I was angry. I was frustrated.
I wanted to hit someone.
________________________ _________________________
________________________ _________________________
________________________ _________________________
________________________ _________________________
which you experienced the event as stressful (e.g., “ I sensed my anger,”

“ I was scared,” “ I felt frustrated,” “ My stomach was in a knot” ). Think
about any event.
Stress: What Is It?
Stress is the physical, mental, or emotional tension caused by an event.

When we feel this tension, we say we are feeling distressed or “ stressed
out.”
SYMPTOMS
Sometimes we are not aware that we are experiencing stress. Becoming
familiar with the physical cues that indicate stress is the first step in in-
creasing our awareness of our responses to the stress. Recognizing these
feelings may help us realize we are feeling stressed. We can then try to
identify the source of this stress, or the stressor. In addition, our knowl-
edge and awareness will help us select the appropriate relaxation tech-
nique for our individual symptoms.
Your group leaders will help you classify the different types of re-
sponses with which these symptoms are associated.
EFFECTS
Stress responses often fall into one or more of the following five classes:
1. Cognitive: anxious thoughts, fearful anticipation, poor concentra-
tion, difficulties with memory
2. Emotional: feelings of tension, worries, irritability, restlessness, an
inability to relax, depression
Following is a list of several symptoms of stress. Check the symp-

Symptoms toms that apply to you, and use a 10-point scale to rate each
of Stress for the degree of discomfort it causes you: 1 = little distress; 10 =

extreme distress. Disregard those symptoms you do not experi-
Checklist ence.
Hostility _____ Anger _____

Resentment _____ Phobias _____
Headaches _____ Muscle tension _____
Backaches _____ Indigestion _____
Ulcers _____ Constipation _____
Muscle spasms _____ Tics _____
Sleeping difficulties _____ Obesity _____
Depression _____ Low self-esteem _____
Alcohol or drug use _____ Chronic diarrhea _____
Irritability _____ Insomnia _____
Fears _____ Physical weakness _____
Neck aches _____ Withdrawal _____
Irritable bowel _____ Other _____
Note. Adapted from The Relaxation and Stress Reduction Workbook, 3rd ed., by M.
Davis, E. Eshelman, and M. McKay, 1988, Oakland, CA: New Harbinger. Adapted
with permission.
3. Behavioral: avoidance of tasks; sleep problems; difficulty complet-

ing work assignments; fidgeting; tremors; a strained face; ten-
sion; crying; changes in drinking, eating, or smoking behaviors
4. Physical: stiff or tense muscles, teeth grinding, fist clenching, sweat-
ing, tension headaches, faint feelings, choking feelings, difficulty
swallowing, stomachaches, loss of interest in sex, tiredness, an
awareness of heart beating
5. Social: avoidance of others, attempts at isolation, seeking out other
people, venting, easy irritation with others
Stress Management:
Why Do We Need It?
As we have discussed, stress affects us mentally, emotionally, behavior-

ally, physically, and socially. When a person encounters a stressful situa-
tion, various physiological responses occur. The first set of responses is

called the fight-or-flight response because it enables you to take quick
physical action in response to a stressor.
The following are some physical changes that you may experience
when you are under stress:
❚ dilation of pupils
❚ increase in respiration rate
❚ increase in heart rate
❚ increase in blood pressure
❚ blood flow toward muscles away from organs
This physiological reaction is harmful to our bodies and takes its toll
if repeated regularly. It may be associated with poor recovery from ill-
ness, exacerbation of symptoms of chronic disease, and impairment of
cardiac and immune functioning.
Cognitive–Behavioral Stress
Management Techniques
Many of the things you will be learning in the coming weeks involve a
set of psychological techniques collectively referred to as cognitive–behav-
ioral stress management (CBSM) techniques. These include “ cognitive” pro-
cedures designed to increase your awareness of the link between the
ways you think about stressors (i.e., your cognitive appraisals, or “ self-
talk” ) and your emotional responses to them (i.e., your feelings). This
awareness is central to and forms the starting point for CBSM. In addi-
tion to learning about the connections between your thoughts and feel-
ings, you will learn ways to change your thinking (a process referred to
as cognitive restructuring) so that you can modify your emotional responses.
The “ behavioral” aspect of CBSM refers to a focus on building effec-
tive coping strategies—that is, how you actually respond to stressors. You
will become more aware of inefficient and indirect strategies (e.g., smok-
ing, overeating, drinking, working too much) that you may have devel-
oped for dealing with painful or stressful challenges and learn to replace
these with more healthy, efficient, and direct strategies (e.g., active cop-
ing, planning, goal setting). Other behavior-based techniques, such as
anger management, will help you learn better ways to handle and ex-
press angry feelings, whereas other types of training, such as assertiveness
training, will help you develop more efficient strategies for confronting
others, preserving your personal rights, and expressing your needs within
the context of close relationships. Other techniques will help you be-
Instructions These instructions are a guide to help you remember the de-
tails of the PMR exercise you learned in your session this week.
for 1. Right hand, forearm, and biceps: Hold your arm at a 45-de-
gree angle, and make a fist as if making a muscle.
Progressive 2. Left hand, forearm, and biceps: Follow Step 1 instructions.
Muscle 3. Face: Raise eyebrows, squint eyes, wrinkle nose, bite down
lightly, and pull back the corners of your mouth. (If this
Relaxation: feels strange, you are on the right track. What we really
want you to feel is the tightness around your face and neck.)
Seven 4. Neck and throat: Pull head down until the chin almost rests
on but is not touching the chest. Be sure not to pull too far
Muscle in because it may strain your neck.
5. Chest, shoulders, upper back, and abdomen: Take a deep breath
Groups and hold it, and pull your shoulders back together—all the
while pushing your stomach out or pulling it in. Imagine
that you are trying to fit into a tight pair of pants.
6. Right thigh, calf, and foot: Lift foot off the floor or mat, flex
the foot slightly, and if you feel comfortable, turn the toe
inward. You will feel tension throughout your calf and
possibly in your thigh.
7. Left thigh, calf, and foot: Follow the Step 6 instructions.
come more aware of the available social resources that you may not be
using and provide you with ways to enhance the size and usefulness of
your existing social support network. Together, these techniques form
the basis of stress management in CBSM.
Relaxation and
Imagery Techniques
The portion of each session involving relaxation and imagery exercises

addresses the physiological aspects of physical and emotional responses
to stressors. First, you will learn a technique called progressive muscle relax-
ation (PMR) to help you to relax your muscles (as appropriate) whenever
you want to. Often, people go about their daily lives with excess tension
in their muscles. This tension is not necessary for daily activities and may
result in headaches, backaches, and other undesirable effects. The relax-
Activity If you have difficulty finding time to practice the relaxation

techniques, use this monitoring sheet to record your activities
Schedule for one day. It will help you identify a time slot for the exer-
cises.
Date: _________ _________
7:00–8:00 a.m. _________ _________
8:00–9:00 _________ _________
9:00–10:00 _________ _________
10:00–11:00 _________ _________
11:00–12:00 _________ _________
12:00–1:00 p.m. _________ _________
1:00–2:00 _________ _________
2:00–3:00 _________ _________
3:00–4:00 _________ _________
4:00–5:00 _________ _________
5:00–6:00 _________ _________
6:00–7:00 _________ _________
7:00–8:00 _________ _________
8:00–9:00 _________ _________
9:00–10:00 _________ _________
10:00–11:00 _________ _________
11:00–12:00 _________ _________
12:00–1:00 a.m. _________ _________
Note. Adapted from The Relaxation and Stress Reduction Workbook, 3rd ed., by M.
Davis, E. Eshelman, and M. McKay, 1988, Oakland, CA: New Harbinger. Adapted
with permission.
ation exercises will help you to get rid of most of this excess tension, and
in turn, you may feel better in general. Later in the program, you will
learn some relaxing mental imagery. Some of the latter sessions give you
the opportunity to practice the techniques at home using audiotapes,
which will enhance the relaxation experience. The program will provide
you with various techniques so that you can use the ones you prefer.
You will need to practice the relaxation exercises outside of the ses-
sions to benefit from them. Once we teach you a relaxation technique,
we will ask you to practice it daily at home, every day during the 10
weeks of the program. Most people find it enjoyable to take the time to
relax everyday, but some people have a hard time fitting it into their
schedule. If you do not make time to practice the relaxation exercises
each day, you will not get the full benefit of the techniques. Our research
from the past few years has shown that the extent of relaxation practice
was related to the intervention’s effectiveness. Use the Activity Schedule
on the previous page to help you locate an optimal time for daily
practice.
During the 10 weeks of this program, we will ask you to take a few
moments each day to record your stress level. This simply involves re-
cording a number on Stress Monitoring Sheets several times a day. We
will also ask you to monitor your sleeping patterns using the form dis-
cussed in group. A sample form is included here and is followed by other
materials that will be explained to you by your group leaders.
In addition to filling in the self-monitoring sheets daily and handing
them in at your weekly sessions, you will also be completing other writ-
ten work between sessions. These materials are contained in later sec-
tions of this workbook.
Stress and ID Number: ________ Week: _________

Relaxation Practice Stress Rating
Sleep Using the following scale, record the date, your stress level
before and after each relaxation session, and whether you used
Monitoring the tape.
Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Stress Stressed Stressed
Date Session 1 Session 2 Tape?
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________

Your Sleep the Night Before Group
Total hours of sleep: _______

Minutes to fall asleep: _______
Number of times awoken: _______
Sleep Comfort Rating
Use the following scale to rate the quality of your sleep the
night before group and how you felt when you woke up.
1 2 3 4 5 6 7
Extremely Good Average Extremely Poor
Quality of sleep:_______
How you felt on awakening: ______
Session 2:
Stress and Awareness 2
During last week’s session, you learned about many of the ways in which
we respond to stressful events. You learned that these stress responses
can include
❚ changes in thought patterns (cognitive appraisals)
❚ changes in your emotional state (becoming more depressed or
anxious)
❚ changes in your typical work and home behaviors
❚ changes in physical sensations, increased tension levels
❚ changes in the ways in which you relate to others around you
During the session, you participated in exercises to help you become
more aware of the connection between stressful events and some of these
changes. You can use your increased awareness of these stress effects as
an internal monitor of whether you are under stress and need to take
some sort of action.
➤ Stressful Situation
➤
➤
➤
➤
➤ ➤
➤
Cognitive Emotional Behavioral Physical Social
11
12 STRESS MANAGEMENT: PARTICIPANT ’S WORKBOOK
To introduce the concepts of stress management.

Goals ❚
❚ To increase your awareness of your physical responses to
stressors.
What Is Stress Management?
Stress management involves using strategies that help us become more aware
of situations that cause stress and using effective coping techniques. Stress
management techniques have been successfully used for many emotional
and physical problems, including anxiety, depression, insomnia, fear of
dental treatment, diabetes, high blood pressure, headaches, heart dis-
ease, genital herpes, arthritis, and side effects of cancer chemotherapy.
Often we have no control over the occurrence of stressful situations;
however, we do have control over the way that we respond, and the
responses often either increase or decrease our stress symptoms.
One goal of this stress management intervention is to help you be-
come more aware of
❚ the situations in which you are most likely to experience stress
❚ your typical reaction to stressful events
❚ how your thoughts regarding the situations are related to how
you feel emotionally
❚ the ways in which cognitive–emotional events shape your behav-
ior and sense of confidence and self-esteem
Exactly Why Is
Stress Bad for You?
As we discussed last week, when an event is interpreted as stressful, it

sets off a complex physiological response involving the body’s glands and
organs. This fight-or-flight response made a lot of sense for our cavemen
ancestors because their stressors were primarily physical challenges, such
as saber-toothed tigers. The response has several effects on our bodies.
In response to the need for physical action, our heart and respiration
rates increase, and more sugar and fatty acids are released into the body.
In anticipation of bodily damage, hormones (corticosteroids) are released
to reduce fever and inflammation and increase the amount of energy
available to the individual. In anticipation of pain from injury or exer-
Session 2: Stress and Awareness 13
Exercise Conduct a body scan from your toes to your head, including
high-tension areas such as your abdomen, shoulders, back, and
2.1: Body neck. Ask yourselves the following questions:

❚ Where are you tight?
Awareness ❚ How long has the tightness been there?
❚ Has anything happened that is connected with your ten-
sion?
tion, the body releases endogenous opiates, which act as analgesics to

lessen pain and thus allow us to continue to defend ourselves if we are
injured or help us if we are running away. Endogenous opiates can cre-
ate a sensation of well-being, a physical phenomenon also know as a
runner’s high.
However, as we discussed previously, in today’s world we tend to
deal with stressors in a less physical way. For example, it is generally not
in your best interest to punch a boss who is making excessive demands.
Still, your body responds as if fighting or fleeing are your only two viable
options. What does this mean?
The additional fatty acids in the bloodstream just stay there and can
eventually lead to arteriosclerosis. The additional adrenaline (for energy)
can also cause damage to the blood vessel walls. The increase in blood
pressure can result in hypertension, strokes, and even heart attacks in
vulnerable individuals. Because blood is diverted from the stomach to
the extremities, the lining of the stomach does not get enough oxygen
and nutrients, potentially leading to gastrointestinal problems and ul-
cers. An increase in the amount of stomach acid can also aggravate ul-
cers. In addition, when you are under stress, the immune system (which
fights viruses and tumors) does not work as well, which has been shown
in numerous studies. The hormonal and immunological changes also are
often accompanied by anxiety and depression.
Creating Heightened
Awareness
AWARENESS OF PHYSICAL TENSION

One of the first steps in stress management is to increase our awareness of
the obvious and subtle bodily signals of stress. Awareness of the signals of
stress and the associated automatic reactions and behaviors is an essen-

tial first step in making important changes. We want you to get to know
your sources of stress and be able to identify your body’s reaction as it is
developing so that you can nip it in the bud.
Discussion
❚ What are your typical sources of tension?

❚ In what parts of your body are you most likely to feel this tension?
❚ When are you most likely to feel tense?
❚ When are you most and least aware of bodily tension?
THE APPRAISAL PROCESS

The appraisal process consists of four components. To begin the process, an
event must take place—something must happen (i.e., something stress-
ful—a stressor). Then your mind becomes aware of the event, and the
event must be perceived or filtered. To experience an emotional state,
the event must be appraised through thoughts and self-talk for its impli-
cation for your personal well-being. After you have perceived the event,
you start to determine its impact. What you feel about the event is di-
rectly linked with how you appraise it. Emotions are the result of the set
The Appraisal Process
World: The world comprises a series of EVENTS.

➤
Thoughts and Appraisal: You interpret the events with a series of

THOUGHTS that continually flow through your mind. This series of
thoughts is called your internal dialogue.
➤
Mood: Your feelings are created by your thoughts, not only by events.
All experiences must be processed through your brain and given a
conscious meaning before you experience any emotional response.
Note: Adapted from Feeling Good: The New Mood Therapy, by D. Burns, 1981. New York: New
American Library. Adapted with permission.
Emotion, Feelings
Perception Thoughts Physical Changes
Situation (Becoming (Appriasal, (How you
(Event) aware) self-talk) feel or respond)
Example: You “ She was “ Something terrible Feelings of worry
are expecting supposed to has happened to Feelings of anger
a phone call call me. her. She must be Heart palipations
from your She’s half hurt or even Knot in stomach
child or friend, an hour dead.” “ She
The person late. What’s doesn’t have the
has not called. happening?” courtesy to
realize I’m
waiting for her
call. She is
being so selfish.”
of appraisals and are accompanied by behavioral and physical reactions.

How do you determine the impact of an event? Relevant issues would
include
❚ What is happening?
❚ Do you care about what is happening?
❚ Is it good or bad for you?
❚ Can you do anything about it?
❚ Can you cope with it?
❚ Will it get better or worse?
DEMONSTRATION OF THE APPRAISAL PROCESS

Recall the example from this session that illustrates the link between
situation and perception, perception and thoughts, and thoughts and
feelings.
Appraisals, Emotions,
and Awareness
It is important to become aware of the relationships among what you

think (appraisal), what you feel (emotion), and how you react (physical
and behavioral responses). At times, this may be difficult because the
appraisal process is very, very, very fast!
Example Think about improving your swimming skills. To improve your

style, you first have to be aware of what you are doing wrong.
Because you have been swimming in a certain way for so long,
the process is automatic; it is very hard to be aware of your
automatic movements. One way to become aware of your
movements is to videotape yourself and carefully observe your
actions. By slowing down the tape, you can observe, frame by
frame, a very complex process.
When we are appraising an event, the thoughts occur incredibly

quickly and are sometimes referred to as automatic thoughts. Automatic re-
fers to a stage of a learning process. The more you repeat an action, the
more able you are to perform it and the faster you are able to do it.
Eventually, it is automatic.
For example, think about learning to drive. When you are just begin-
ning to learn and you see a traffic light, you talk to yourself about what
to do. Eventually, stopping when the light turns red becomes automatic,
like a reflex.
Because the appraisal process happens so quickly, it is not easy to
become aware of what we think about an event.
In the same way that we discussed videotaping your swimming the
previous example, we can try to find ways to “ videotape,” or record, our
thoughts. There is no easy way to record our thoughts, self-talk, or ap-
praisals. To identify more easily our appraisals, we have to start paying
close attention to our emotions. Emotions and physical reactions can be
clues to our thoughts.
Session 2 Homework
❚ Complete Stress and Sleep Monitoring Sheet.

❚ Complete Stress Monitoring Sheet.
Instructions These instructions are a guide to help you remember the de-
tails of the PMR exercise you learned in your session this week.
for 1. Right and left hands, forearm, and biceps: Hold your arm at a
45-degree angle, and make a fist as if making a muscle.
Progressive 2. Face and neck: Raise eyebrows, squint eyes, wrinkle nose,
Muscle bite down lightly, and pull back the corners of your mouth.
(If this feels strange, you are on the right track. What we
Relaxation: really want you to feel is the tightness around your face
and neck.) Pull head down until the chin almost rests on
Seven but is not touching the chest. Be sure not to pull too far in
because it may strain your neck.
Muscle 3. Chest, shoulders, upper back, and abdomen: Take a deep breath
and hold it, and pull your shoulders back together—all the
Groups while pushing your stomach out or pulling it in. Imagine
that you are trying to fit into a tight pair of pants.
4. Right and left thighs, calves, and feet: Lift feet off the floor or
mat, flex the foot slightly, and if you feel comfortable, turn
the toe inward. You will feel tension throughout your calf
and possibly in your thigh.
ID Number: ________ Week: _________

Stress and Relaxation Practice Stress Rating
Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________


1 2 3 4 5 6 7
Stressful Perceptions Automatic

Stress situation
or event
and
awareness
thoughts,
self-talk Emotions
Physical
symptoms
Monitoring Example: A “ That person “ That person Anger Muscle
Sheet person cut
in front of
just cut me
off!”
is a rude and
inconsiderate
tension;
flushed
you in driver.” face
traffic.
Session 3:
Automatic Thoughts and
Cognitive Distortions 3
Some Tips on Practicing
Your Stress Management
Techniques
Before learning more new techniques, it is important to reassess any

obstacles that may prevent you from practicing the stress management
exercises at home regularly. It is very important to find a special time and
place to practice these exercises daily. Check out your home environ-
ment to determine whether anything is preventing or delaying you from
initiating your exercises daily or nightly. Could anything (e.g., loud mu-
sic, regular house guests and visitors) be distracting you from focusing on
your exercises once you start them? Do you have any trouble monitor-
ing your stress levels or using the monitoring sheets? Begin to notice
which times and places are most convenient for you to practice your
relaxation and imagery exercises and which obstacles stand in your way.
If you experience a setback or have to deal with a crisis that prevents
you from practicing for several days in a row, do not give up—just pick
up where you left off. As we mentioned in the sessions, using stress man-
agement techniques is a skill that requires practice, so the more you can
practice regularly, the better. Research has shown that the key to regular
practice and skill building is dedicating a special time and place for doing
your exercises. Try to pay particular attention to this aspect of your train-
ing program this week.
21
Goal ❚ To introduce automatic thoughts and begin identifying cog-

nitive distortions.
This week you will be receiving an audiotape or CD made by your

group leaders. The tape contains numerous different relaxation instruc-
tion sets, which should help you structure your relaxation time each day.
You will need to find a place to store this tape or CD to build this experi-
ence into your daily routine.
Introduction to
Automatic Thoughts
Because events happen so quickly, it is not easy to become aware of what

we think about an event. To identify more easily our appraisals, we have
to start paying close attention to our emotions. When you feel an emo-
tion (e.g., sadness, anger, joy), you have organized thoughts or images,
and you also experience physical changes.
1. You have images or thoughts.
2. You feel the emotion.
3. You experience changes in your body.
4. You use certain coping mechanisms and behave in a certain way.
All of these components of emotion are important, and they interact
with each other. These indicators make you aware of your emotional
state. Your emotion indicates that you are appraising something. When
you feel the emotion, you can work backward to understand the event,
how you appraised the event, and how the appraisal made you feel.
Examples of
Emotion/Self-Talk
Each emotion is hypothesized to have its own core pattern of self-talk.

Emotions and their self-talk patterns can have important functions. If
our thoughts are accurate, then our emotions will probably be accurate
as well. Note how sadness, anger, guilt, and anxiety have different self-talk
patterns and specific functions. These patterns are helpful when thoughts
accurately match a situation.
Session 3: Automatic Thoughts and Cognitive Distortions 23
Feelings Thoughts and self-talk Function

Sadness “ Poor me!” Prepares and
“ I have lost something motivates you to
important.” grieve and reinvest
“ There is nothing I can do.” in something else
Anger “ This is not OK.” Prepares and
“ This is wrong!” motivates you to
“ This is someone else’s achieve a goal and
fault.” remove barriers or
“ It should not be like this.” to protect yourself
“ I’ll show them!”
Guilt “ I am not okay, I am Motivates you to
wrong.” adhere to personal
“ I should have done . . .” and social norms
“ Could I do something to
fix it?”
Anxiety “ I am in danger.” Prepares and
“ Something bad could motivates you to
happen to me.” meet a challenge
“ I had better go and or escape danger
prepare to fight or
escape fast.”
Take a moment and notice how your own recent experiences of sad-
ness, anger, guilt, and anxiety had different self-talk patterns and specific
functions. By becoming familiar with how these emotions feel, which
behavioral and bodily signals accompany them, and in which situations
they emerge, you will be more capable of understanding how thoughts
and feelings are linked in your own life.
❚ Are any of these thoughts particularly familiar to you?
❚ Do you understand the negative (self-defeating) and positive (func-
tional) aspects of these processes?
❚ Which emotional experience is a particularly common occurrence
in your life?
❚ When you are under stress or challenged in some way by other
people, are you more likely to experience sadness? Anger? Guilt?
Anxiety?
We must also recognize that because we have adopted regular pre-
conceived and perhaps mistaken response patterns to certain situations,
we often experience these emotional reactions unnecessarily.
You are going in for a follow-up mammogram and think about

Example the possibility of having a recurrence, consequently you “ feel”
more anxiety and your heart races. You notice your heart rac-
ing (awareness) and think you are unable to control it (appraisal),
which creates more anxiety. You think, “ I’m so anxious. I’m
sure they’ll find something wrong” (appraisal). This leads to
even more anxiety, and on the cycle goes. Pretty soon, you
feel like you cannot control your emotions.
Breaking the
Vicious Cycle
As we have shown, events can be interpreted in a way that creates un-

necessary emotional distress. The distress involves self-talk patterns that
help perpetuate the feelings.
As shown by the example scenario, one of the most difficult aspects
of stressful encounters is that the emotional and cognitive processes seem
to have a life of their own—they tend to feed off of and perpetuate one
another. These vicious cycles are the reason people have such a hard
time “ hanging up their hang-ups” and getting past their “ blind spot.” The
easiest way to begin to change the circular events comprising the way
you process stressors is at the level of appraisals, which are based on
thoughts and images. Remember, the way you interpret events deter-
mines how you feel about them. For instance, in the previous example,
you could break the anxious cycle by changing your negative thoughts
to something like, “ I’ve received excellent treatment for my breast can-
cer, and my prognosis is good. If they find something suspicious, I will
deal with it one step at a time.” A thought like this will lead to less anxi-
ety, so you may feel more comfortable during the procedure.
Now, although this technique is simple enough, it does take a lot of
practice to use it effectively. So how do we break the cycle? Several steps
are involved.
STEP 1: IDENTIFYING THE NEGATIVE THOUGHTS

Become aware of unrealistic or negative thoughts that are unnecessary
for your particular situation. Learn to recognize anxiety-producing
The doctor’s office left a message on your answering machine

Example asking you to call them back.
Old thought pattern: “ Something is wrong!”
New thought pattern: “ I don’t know whether something is
wrong. I am checked frequently, and all has been well. I will
reserve my conclusions until I talk with the doctor.”
thought patterns—the automatic thoughts that occur so quickly. Once

you learn to identify negative thoughts, you can work on changing them.
STEP 2: COGNITIVE RESTRUCTURING

Begin to change the maladaptive thought patterns so that they are more
accurate and balanced. With practice, your new thoughts can become
automatic.
SUMMARY
❚ Become aware of negative thinking patterns.
❚ Learn to recognize anxiety-producing appraisals. (Remember, you
can use physical signs as cues.)
❚ Begin to notice that these anxiety-producing thoughts are automatic.
❚ Take note that these thoughts are often negative or distorted.
❚ Begin to change so that you are using more balanced appraisals.
We will spend more time on this exercise in Session 4: Rational
Thought Replacement.
Negative Thinking or
Cognitive Distortions
As we mentioned, if your perceptions and cognitive appraisals about stres-

sors are accurate, then your emotions will probably be accurate as well.
However, if your appraisals are distorted or inaccurate, then your emo-
tions will probably be distorted or inaccurate. This is often how depres-
sion, anxiety, anger, guilt, and distress develop unnecessarily. This does
not mean that negative emotions always indicate that your appraisals
are distorted. Remember, negative emotions can be appropriate in cer-
tain situations and may indicate that you need to take action. Thoughts
are often a mixture of accurate and distorted appraisals.
EXAMPLES OF DISTORTED THINKING

Negative thinking often involves inaccurate appraisals, which are com-
monly used by most people at one time or another. We will introduce
some of the most common types of inaccurate appraisals and some famil-
iar corresponding negative thoughts. Although these appraisals are di-
vided into categories, they overlap significantly—a particular thought often
falls into more than one category of distorted thinking. The point of this
exercise is not for you to learn how to categorize every thought; it is to
familiarize you with the various types of maladaptive thoughts that may
accompany inaccurate appraisals. The following material is adapted from
Burns.1
All-or-Nothing Thinking (Black-and-White Thinking)

If you use all-or-nothing thinking, you appraise things in rigid catego-
ries; you see no in-between or gray areas. All-or-nothing, or black-and-
white, thinking forms the basis of perfectionism. It causes you to fear any
mistakes or imperfections because if your performance is less than per-
fect, you consider yourself a total failure; you may feel inadequate and
worthless. This type of thinking is unrealistic because life can rarely be
explained so definitively. A person using all-or-nothing thinking might
say, “ If I can’t perform 100% at work, I might as well not go to work at
all.”
Overgeneralization
If you are overgeneralizing, you assume that a single negative event will
develop into a never-ending pattern of defeat. In other words, you con-
clude that something that happened to you once will happen over and
over again. For example, you might say, “ Now that I have developed
breast cancer, all my children and grandchildren are doomed to have
cancer.”
Disqualifying the Positive

A person who disqualifies the positive dismisses positive experiences by
insisting that they are insignificant. Dismissing positive events allows you
1
D. Burns, Feeling Good: The New Mood Therapy, 1981. New York: New American Library.
to maintain a negative belief, even when it is contradicted by your every-

day experiences. For example, consider the way that some people re-
spond to compliments. When someone praises their work, clothing, or
appearance, they think, “ That person is just being nice.” Disqualifying
the positive is one of the most destructive examples of negative thinking
because you are telling yourself that you are second-rate and not worthy
of the positive aspects of your life.
Jumping to Conclusions
People who jump to conclusions negatively interpret various events even
though they have no definite facts that convincingly support their con-
clusions. Mind reading and fortune telling are two ways that you can jump
to conclusions.
❚ Mind readers arbitrarily conclude that someone is reacting nega-
tively to them, but they do not bother to verify whether it is true.
For example, you are walking around town, and you pass a friend
on the street. Your friend is so absorbed in her own thoughts that
she does not notice you or say “ hello.” You automatically con-
clude, “ She is ignoring me. She must be angry with me.”
❚ Fortune-tellers anticipate that things will turn out badly and feel
convinced that the prediction is an already established fact. For-
tune-telling is like having a crystal ball that foretells only misery
for you. You imagine that something bad is going to happen even
though it may be unrealistic. Someone who is fortune-telling would
think, “ I’m bound to have a recurrence, it’s just a matter of time”
rather than “ I may have a recurrence, but worrying won’t change
the future. I can make the most of each day and focus on leading a
healthy life.”
Magnification (Catastrophizing) or Minimization

People who magnify a situation (such as a mistake or someone else’s
achievement) exaggerates the situation’s importance. People who mini-
mize a situation inappropriately downplay the relevance of certain fac-
tors (such as their own positive qualities or another person’s imperfec-
tions).
❚ Magnification is another term for blowing a situation out of propor-
tion. For example, a woman who has had a mastectomy may as-
sume, “ Now that I’ve had surgery my husband won’t want me
any more. He will leave me. I will have no financial or emotional
support. I will be all alone and living in the streets.”
Exercise Which types of distortions do the following statements repre-

sent?
3.1: Label 1. You run into a friend who admires your shirt. You think,
“ She was looking at my breasts and wondering which one
Negative is a prosthesis. Everyone can tell I’ve had breast cancer.”
Thoughts 2. Recently, an additional person has been hired at your work-

place to perform duties that are similar to yours. You say to
yourself, “ I am being replaced. I need this job and the health
insurance! How will I ever find another job? No health
insurance company will take me.”
3. You feel particularly tired after a long day. You think, “ The
cancer must be back. I probably only have a week to live.”
❚ Minimization occurs when you play down the significance of your

strengths or the situation’s positive points (e.g., ignoring the fact
that having been diagnosed with cancer at a time when so many
effective treatments are available is better than being diagnosed at
a time when fewer options were available).
“Should” Statements
“ Should” and “ should not” statements, such as “ I should be able to do
this all by myself” and “ I should not ask for help,” simply make you feel
guilty. “ Must” and “ ought” statements have the same effect. Directing
“ should” statements (e.g., “ People should know what I need; if they don’t,
they just don’t care about me” ) toward others leaves you feeling angry,
frustrated, and resentful. Directing them toward yourself creates pres-
sure and additional resentment.
HOW CAN NEGATIVE THOUGHTS

INFLUENCE YOUR BEHAVIOR?
You may respond to your negative reactions by withdrawing or becom-
ing defensive. This self-defeating behavior pattern may act as a self-ful-
filling prophecy and create negative interactions in a relationship.
Possible situations in which negative thoughts can occur include
❚ family relationships
❚ oncologist appointments
❚ issues about your health care quality
❚ issues about your support network
ID Number: ________ Week: _________

Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________


1 2 3 4 5 6 7
Stress Emotional
and physical Automatic Type of
Monitoring Situation
Example: You
symptoms
Embarrassment
thought
“ No. I didn’t
distortion
Disqualifying
Sheet handle a difficult
situation, and
Feelings of
inadequacy
handle this
well. I was just
the positive
your supervisor Anxiety lucky that the

says to you, Flushed face person gave up
“ You handled and stopped
that situation arguing.”
well. That person
was difficult to
deal with.”
Example: You Guilt “ These Using

are undergoing Frustration treatments “ should”
daily radiation Even more fatigue aren’t such a statements.
treatment and when you push big deal. I should
are very fatigued. yourself too much. still be able to
You neglect some accomplish all my
of your usual daily activities.”
responsibilities.
POINTS TO THINK ABOUT

Which types of negative thoughts did you identify with the most? Think
about a specific situation in which you were recently anxious or depressed.
What were you thinking during that situation? Can you remember any
examples of negative thinking? Next week, we will discuss a method for
refuting irrational thoughts.
Session 3 Homework
❚ Complete the Stress and Sleep Monitoring Sheet.

❚ Complete the Stress Monitoring Sheet. You will notice that there
are four columns, asking you to list a recent stressful situation,
your emotional and physical reactions, any automatic thoughts
and the way you would label those thoughts. After reviewing the
two examples listed, enter a recent stressful situation that has oc-
curred in your life and complete the remaining columns.
Session 4:
Rational Thought
Replacement 4
Are you having any difficulties monitoring your tension levels or with
your relaxation practice? If you are having trouble understanding the
homework assignment from last week, we recommend that you reread
Session 3 before moving on to this week’s material. The relaxation tape
that you received in your group should be used each day.
Rational thought replacement can be thought of as the last step in cogni-
tive restructuring. You may recall from the last session that cognitive re-
structuring involves
❚ becoming more aware of the links between our thoughts and our
feelings
❚ increasing our awareness of our mind’s conversations, or apprais-
als
❚ learning to identify our emotional state and its associated apprais-
als
❚ identifying the cognitive distortions that we experience most of-
ten
❚ breaking the vicious cycle of distorted cognitions that feed extreme
emotional responses
Breaking the vicious cycle is the essence of rational thought replacement.
33
Goal ❚ To learn rational thought replacement as a stress manage-

ment technique.
Categories of Self-Talk
Stressful Situation
➤
➤
➤
Distorted?
➤Automatic Thought ➤
➤
➤
➤
➤ ➤
➤
So far, we have been focusing on identifying our distorted thoughts. Now

that we know how to become aware of, identify, and label these thoughts,
how do we go about changing them?
First, let’s discuss the three general categories of thoughts:
IRRATIONAL BALANCED IRRATIONAL

(Overly negative) (Overly positive)
Pessimistic Reasonable Denies concern
Negative Realistic Has distorted thoughts
Self-defeating Balanced perception Avoidant, falsely
of reality optimistic
OVERLY NEGATIVE IRRATIONAL SELF-TALK

Inaccurate, negative, or distorted thoughts tend to be catastrophic, abso-
lutist, illogical, self-defeating, and unrealistic. This type of self-talk in-
Session 4: Rational Thought Replacement 35
My back hurts. The cancer has

spread! The doctors won’t be
able to help me this time.
volves excessive concerns and often involves inaccurate perceptions of

reality. The thoughts tend to make us feel defeated and afraid. Because
these types of thoughts are irrational, we also refer to them as cognitive
distortions.
OVERLY POSITIVE IRRATIONAL SELF-TALK

Overly positive irrational thoughts are used to deny that we have con-
cerns or convince ourselves everything is ok. This type of self-talk in-
volves an inaccurate perception of reality; it is a “ Pollyanna,” or overly
optimistic, perspective.
My back hurts. It is nothing.

It will go away if I ignore it.
RATIONAL (BALANCED) SELF-TALK

Rational thoughts are reasonable, self-enhancing, accurate, and realistic.
A balanced inner dialogue is characterized by an appropriate level of con-
cern and an accurate, balanced perception of reality.
Overly negative and overly positive irrational thoughts are extreme
ways of thinking. We strive to have rational, balanced thoughts.
My back hurts. I may have

pulled a muscle. I’ll stop by the
doctor and check it out.
Example You find a lump in your breast (the one that was not cancer-
ous). What kinds of thoughts run through your mind? Iden-
tify examples of rational and irrational thoughts.
Coming Up With
Alternative Responses
Because inaccurate or negative self-talk leads to distress and negative

emotions, we need to learn to replace it with more rational thoughts.
One of the easiest ways to come up with alternative thought replace-
ments is to target a specific negative thought, identify the type of thought
involved, and then generate alternative thoughts. How do you come up
with an alternative response?
As we mentioned, the appraisal process is very fast (automatic), and
like when you are learning to swim or to drive, you must break down
the process into steps. By “ videotaping” our thought processes, we can
assess them frame by frame and become more aware of the steps involved.
Then we can use these same steps to challenge our automatic self-talk.
STEPS TO THOUGHT REPLACEMENT: A, B, C, D, E

Step 1: A wareness
Identify self-talk.
❚ Identify which self-statements are inaccurate, negative, or distorted.
❚ Identify feelings and behaviors that are related to self-talk; evalu-
ate the intensity of these feelings (low, moderate, high).
❚ Recognize and appraise automatic thoughts.
❚ Recognize emotional and physical reactions (e.g., tension).
Helpful tips include
1. Write down self-talk thoughts.
2. Separately identify thoughts about yourself, other people, and
situations.
3. Identify inaccurate or distorted self-talk thoughts.
4. Identify feelings and behaviors, and evaluate their intensity.
Exercise Identify whether each statement is overly negative, overly

positive, or balanced.
4.1: You have been home for a few days after your surgery, but
you are still feeling tired and weak. The house is a mess, the
Classifying dog needs to be walked, and the car needs an oil change. The
following thoughts go through your head:
Statements __ 1. My family and friends are worthless. They are never
there when I need them.
__ 2. It’s been 3 days. I should have enough energy by now!
I’m probably just using my surgery as an excuse to be
lazy.
__ 3. I’ll just ignore everything. The dog was walked 10 hours
ago. He’s fine.
__ 4. I will let my family and friends know how they can
help me. Jim can walk the dog, and Ann can take the
car in for an oil change. The house doesn’t always have
to be impeccable. The family members can pick up af-
ter themselves, and a thorough cleaning can wait for a
few more days.
Step 2: B eliefs
Rate the degree of belief in the cognitive appraisal (from 0% to 100%).
Step 3: C hallenge
Question the self-talk statement identified in Step 1.
❚ Do you have any rational support for this idea?
❚ What evidence suggests that this idea is false?
❚ What would you tell a friend in the same situation?
❚ What might be the consequences of this situation?
❚ What is the worst that could happen to you? What good things
might occur?
Step 4: D elete
Delete the inaccurate or negative self-talk statement, and replace it with
a more rational response. The following questions may help you identify
more rational responses:
❚ What can I say to myself that reduces excessive negative feelings?

❚ What can I say to myself that is self-enhancing instead of self-
deprecating?
❚ What can I say to myself that facilitates my ability to appropriately
cope with the situation?
❚ How can I restate this situation in new terms?
❚ How would I like to act and feel in this situation? What can I say to
myself to help me do this?
Step 5: E valuate
Evaluate how you feel after the change.
❚ Do you have (or do you anticipate) less stress?
❚ Is the situation more manageable?
❚ Do you feel better emotionally or physically?
HELPFUL GUIDELINES FOR GENERATING

RATIONAL RESPONSES
1. Pick specific thoughts to refute and replace.
2. Deal with specific problems—not with complicated situations or
philosophical stances.
3. If you get stuck and cannot think of a rational response, consider
the following:
❚ Think about the situation later.
❚ Think of how someone else would respond. Ask another per-
son how the person would respond.
❚ Think of how you would respond to someone else in the same
situation.
❚ Identify words in your response such as always, never, should,
or can’t.
❚ Learn to describe events in less extreme terms, such as inconve-
nient, disappointing, frustrating, or well-done rather than terrible,
horrible, catastrophic, or perfect.
EXAMPLES OF RATIONAL RESPONSES

If you are finding it difficult to think of rational responses, the following
examples can be used as an initial response to your inaccurate self-talk.
These examples can be expanded by additional rational thoughts appro-
priate for the situation.
Exercise Consider the following situation, and practice using rational

thought replacement.
4.2: You loaned a friend $100 2 months ago. She was sup-
posed to pay you a month ago and has not. You would
Classifying like the money back because you need it.
Situations
STEP 1. AWARENESS
Cognitions:
1. “ My friend lied and manipulated me!”
2. “ I can do without the money. She needs it more than I do.
I’ll just forget it.”
3. “ My friend may be having additional monetary difficulties
and is too embarrassed to call me. I will call her and try to
work out a payment agreement.”
Feelings: Annoyance
Intensity: Moderate
STEP 2. BELIEFS
❚ How much do I believe these cognitions to be true?
STEP 3. CHALLENGE
❚ Do I have rational support for these cognitions?
❚ What are the possible outcomes of the situation?
STEP 4. DELETE (AND REPLACE)

Reduce negative thoughts:
❚ “ It’s reasonable to ask my friend about the situation.”
❚ “ She may be angry, but I can live with that.”
Use self-enhancing statements:

❚ “ I’ll feel better if I know what’s going on.”
(Continued)
Facilitate coping:
❚ “ I’m taking care of myself when I check this out and try to
resolve it.”
Think about how you would like to act and feel:

❚ “ I’d like address this situation in a straightforward way so
that I know what to expect and believe that I’ve attempted
to resolve it.”
STEP 5. EVALUATE
❚ Do you feel less stress?
❚ Do you feel better or different emotionally?
❚ If you still feel distressed, has the intensity of the feeling
changed?
❚ “ I may be feeling negative emotions, but the situation itself is not

doing anything to me.”
❚ “ Nobody’s perfect.”
❚ “ Many symptoms are temporary.”
❚ “ I can influence how I feel by the way I think.”
❚ “ Open communication is the key to understanding each other.”
Session 4 Homework

❚ Keep your Session 4 Reminder Sheet in a conspicuous place.
❚ Identify a current stressful situation in your life, and take it through
the five steps of cognitive restructuring.
STEP 1. AWARENESS
❚ Cognitions: irrational, rationalized, or rational?
❚ Feelings: anger, worry, or annoyance?
❚ Intensity: low, moderate, or high?
STEP 2. BELIEFS
❚ How much do I believe this cognition to be true?
STEP 3. CHALLENGE
❚ Do I have rational support for these cognitions?
❚ What are possible outcomes of the situation?
STEP 4. DELETE (AND REPLACE)

❚ Reduce negative thoughts: “ It’s reasonable to ask my friend about the
situation” and “ She may be angry, but I can live with that.”
❚ Use self-enhancing statements: “ I’ll feel better if I know what’s going
on.”
❚ Facilitate coping: “ I’m taking care of myself when I check this out
and try to resolve it.”
❚ Think about how you would like to act and feel: “ I’d like to do this in a
straightforward way so that I know what to expect and feel I’ve
attempted to resolve the situation.”
STEP 5. EVALUATE
❚ Do you feel less stress?
❚ Do you feel better or different emotionally?
❚ If you still feel distressed, has the intensity of the feeling changed?
ID Number: ________ Week: _________

Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________


1 2 3 4 5 6 7
Emotional
Stress and physical
reactions
Monitoring (Rate intensity Automatic
of reaction: thoughts
Sheet Stressful low, medium, (Rate belief: Alternative
situation high 0% to 100%) thoughts Evaluation
1. Reactions:
Intensity:
2. Reactions:
Intensity:
Step 1. Awareness: Identify emotions and automatic thoughts.

Step 2. Beliefs: Rate degree of belief in cognitive appraisal.
Step 3. Challenge: Determine whether you have rational support for your cognitions. Think of the
possible consequences of the situation. Think about what you would tell a friend in the same situation.
Step 4. Delete (and Replace): Come up with alternative thoughts about or perspectives of the situation.
Step 5. Evaluate: Think about how you feel now.
Session 4: Rational Thought Replacement
43
Session 4 PROCEED SLOWLY!
Reminder COGNITIVE RESTRUCTURING IN PROGRESS.
Sheet What seems like an overwhelming situation . . .
➤
➤
Can be broken down into manageable pieces . . .

➤
➤
That can be handled individually, allowing you to prioritize

and deal with the most aspects.
Session 5:
Coping, Part I 5
Cognitive Restructuring
➤
Stressful Situation ➤
➤
YES
➤
➤
Distorted? NO
➤Automatic Thought ➤
➤
➤
➤
➤
➤
➤
Review
Look at your homework from Session 4. Review the ways you responded
to each of the following segments of the cognitive restructuring sequence:
❚ Describe a stressful situation: Was it a typical event for you?
❚ Describe one of your automatic thought scenarios: Were you surprised at
the number of appraisals involved?
45
46 STRESS MANAGEMENT: PARTICIPANT’S WORKBOOK
Goals ❚
❚
To introduce coping theory.
To increase your awareness of coping options.
❚ Describe types of cognitive distortions you used: Did they sound famil-
iar?
❚ Describe how you refuted the irrational thoughts: Were you able to do
something about your situation that changed the way you felt about
it?
Practice, Practice, Practice
By this point in the program, you have already learned about several
relaxation exercises, how to increase your awareness of stress appraisals,
and about cognitive restructuring. Together, these skills are an excellent
collection of stress management tools. However, you are probably aware
that becoming skilled in using these techniques requires regular practice
outside of the group meetings. We recommend that you practice the re-
laxation exercises at least once daily and complete the cognitive home-
work exercises at any time during the week when stressful events occur.
You may have noticed the techniques actually enhance one another.
For instance, it is possible that addressing cognitive appraisals about
a stressful encounter is easier when you are relaxed and open to the
stream of consciousness that is not clouded by daily demands. This is
precisely the reason we begin each group meeting with a relaxation ex-
ercise. Relaxation not only reduces the daily buildup of muscle tension
but also may help put you in a more open and aware state of mind—
ready to explore and learn new techniques and new ways of thinking
about stressors and concerns. Therefore, you should not consider relax-
ation exercises and cognitive restructuring as “either/or” techniques; you
can think of them as complementary. It is also important that you take
this time to reevaluate how successfully you have established a special
time and place for practicing these exercises at home. By doing this now,
you increase the likelihood that you will incorporate these skills into
your lifestyle on a long-term basis.
The next aspect of stress management we focus on examines the
ways in which you cope with stressful situations and demands. Like all of
the techniques you have learned so far, we begin this segment with ac-
tivities designed to increase your awareness of the different coping strate-
Session 5: Coping, Part I 47
Skills Self- 1. How do you find you are using these techniques?
2. Do breathing and relaxation give you more time to think
Check of more rational appraisals?
3. When do these techniques seem like they are not work-
ing?
4. In which situations could you be using the techniques but
are not?
gies you are currently using, evaluate the effectiveness of the strategies,
and demonstrate ways to broaden your coping options. The term coping
has different meanings for different people. Your definition is most likely
related to your past experiences with different stressful situations.
For example, you probably know people who use the word only in
reference to a negative experience (e.g., “ I just coped with it” ). This type
of attitude implies that you can do nothing about a situation but accept
it. Others have a more optimistic definition of coping (e.g., “ The situation
is bad, but fortunately I am able to cope with it” ). This attitude conveys a
sense of mastery over a difficult situation.
❚ How do you define coping?
❚ What are your coping resources?
❚ Do you feel that your coping resources are effective?
In this session, we focus on a definition of coping that refers to an
individual’s efforts to manage demands that are appraised as exceeding
their resources. People can cope by either changing the way they think
about a situation (cognitive restructuring) or changing their behavior in a
situation. This week, we focus on some of the behaviors that are collec-
tively referred to as coping strategies. Although this is the first time we
actually discuss coping using these terms, this is not the first time the
process of coping has been discussed in these sessions. In fact, increasing
your awareness of stress patterns, learning relaxation skills, and altering
inaccurate or distorted cognitions are all coping strategies. In this session,
we discuss coping itself in a slightly different way and break it down into
several aspects.
Various Aspects of Coping
We discuss the different dimensions of coping and then use a grid to

demonstrate how the dimensions relate to each other. Once we have
finished discussing the different aspects of coping, we help you identify

the coping strategies you commonly use and assign them to the correct
area of the grid.
CONTROLLABLE AND UNCONTROLLABLE

Remember that we defined coping as a person’s efforts to manage de-
mands that are appraised as exceeding resources. You have the coping
response after you appraise that a situation is stressful. Individual differ-
ences in coping actions and resources play a substantial role in how the
stress affects you. An important element of the appraisal process involves
determining which aspects of the immediate stressor are controllable and
which are uncontrollable.
PROBLEM-FOCUSED AND EMOTION-FOCUSED

APPROACHES
Coping mechanisms, or how a person copes with a stressful situation, can
be categorized as problem focused or emotion focused. Problem-focused coping
involves dealing with a problem or aspect of a problem that is causing
distress by using strategies such as cognitive problem solving, decision
making, conflict resolution, information seeking, advice seeking, and goal
setting. For example,
❚ Problem: A woman is not sure whether the medicine she is taking

to increase her blood counts is helping.
❚ Problem-focused coping: She talks to her doctor about her medica-
tion. She gets a second opinion about her chemotherapy regimen.
Emotion-focused coping involves regulating the emotional response to

a stressful situation by using coping strategies such as cognitive reap-
praisal and reframing, emotional expression, behavioral changes (e.g.,
engaging in pleasant activities), and physical stress reduction (e.g., exer-
cising, relaxation, deep breathing). For example,
❚ Problem: A woman is very upset because her doctor has recom-

mended that she cancel her weekend vacation plans and stay home
because of her low blood count. She feels very sad and depressed
about missing her trip.
❚ Emotion-focused coping: She talks to her husband, who reappraises
the situation by saying, “ If your blood counts are low, it means
that the chemotherapy is really working!”
Consider the immediate stressor, and decide which aspects of

Exercise the stressor are controllable and which are uncontrollable. Ini-
5.1: tially, try doing these without looking at the suggestions.
Controllable Example
A hurricane
1: Controllable
Protection of
❚
Uncontrollable
Where storm will
❚
and warning has

been issued.
your house and
valuables
strike
How much ❚
Uncontrollable Evacuation
❚
Stocking of
❚
warning you get
before the storm
Stressors supples (such as
food)
Example 2: Controllable Uncontrollable
You just found ❚ Which doctor ❚ The fact that you
out that you you use have cancer
have breast ❚ Whether you ❚ The fact that you
cancer. undergo a need medical
procedure (if treatment
it is an option)
and adjuvant
therapy
According to Folkman et al.,1 a key to adaptive coping involves mak-

ing sure that the type of coping behavior used is appropriate for the
stressor’s controllability.
As we have discussed, most situations have controllable and uncon-
trollable aspects. Thus, we often use both problem- and emotion-focused
strategies when coping with a stressful situation. In addition, the appro-
priate use of one strategy can facilitate the use of another. Changeable
aspects of a stressor are best addressed using problem-focused behaviors,
while unchangeable aspects of a stressor are best addressed using emotion-
focused coping strategies. A poor fit between the appraisal of a stressful
situation and the coping behaviors used may decrease your ability to
effectively manage your stress—and may increase it. For example,
1
S. Folkman, M. Chesney, L. McCusick, G. Ironson, D. Johnson, and T. Coates, “ Translating
Coping Theory Into Intervention,” in The Social Context of Coping, ed. J. Eckenrode (New York:
Plenum), 239–259.
Practicing relaxation exercises before a doctor’s appointment

Example can help decrease feelings of anxiety, which may help you fo-
cus better on the information provided by the doctor. Your
choice of coping strategies during periods of high stress can
contribute to your emotional and physical well-being. Most
importantly, the coping response is the part of the stress re-
sponse that is the most easily identified and changed.
❚ After learning that a hurricane is approaching (uncontrollable), some

people spend their time worrying and talking about the hurricane
(emotion-focused coping). Although this form of coping is likely to
alleviate some of their anxiety, it will not help them protect them-
selves or their property. On the other hand, coping with the con-
trollable aspects of the storm (e.g., how much it damages your
house) by putting up hurricane shutters and stocking up on food
(problem-focused coping) could have a real impact on how they get
through the storm.
❚ A woman who has just learned that she has breast cancer (uncon-
trollable) and has made a well-informed decision about her treat-
ment. She continues to gather information and advice (problem-
focused coping). This continued search for information is likely to
cause the woman to question her original treatment decision and
feel anxious. On the other hand, if the woman expresses her fears
and feelings about her medical condition (emotion-focused coping),
she is likely to feel less stress. Using problem-focused coping in an
uncontrollable situation keeps a person in a frustrating situation
and can create distress and fatigue. Exercise 5.1 (previous page)
elaborates these processes further.
ACTIVE AND PASSIVE APPROACHES

Another dimension of coping involves whether the coping strategy is
actively, or directly, addressing the problem or reaction to the problem or is
passively, or indirectly, dealing with the problem. This dimension is involved
in problem-focused and emotion-focused strategies.
We just provided some examples of active coping when we discussed
problem- and emotion-focused coping strategies. Active coping strate-
gies directly focus on resolving the problem (active problem-focused coping)
STRESSFUL EVENT
Coping
➤
Reminder AWARENESS
(Thoughts, feelings, physical sensations)
Sheet
➤
APPRAISAL
(Thoughts: inaccurate → rational thought replacement)
➤
APPRAISAL
(Situation: controllable or uncontrollable)
➤
COPING
(Choice: problem focused or emotion focused)
or the emotional consequences of the problem (active emotion-focused cop-

ing). In other words, active coping refers to coping that deals directly with
aspects of a situation. On the other hand, passive coping refers to behav-
iors used to avoid dealing directly with a situation. Passive problem-focused
strategies tend to involve strategies that we refer to as behavioral avoid-
ance and cognitive avoidance. These behaviors indirectly approach (or di-
rectly avoid) the problem.
BEHAVIORAL COGNITIVE
AVOIDANCE AVOIDANCE
The steps people take to avoid Distraction from or outright denial
an uncomfortable person, place, of the problem at hand, doing
or activity little to change the nature
of the burden
Passive emotion-focused strategies are other indirect actions that tend to
focus on decreasing the emotional consequences of stressful situations.
Passive strategies often feel good in the short term and may even be
helpful. However, in the long run, they are generally ineffective and in
extreme cases may be harmful. For example, after receiving a diagnosis
of breast cancer, a woman feels that “ this isn’t happening” to her and
tries to deny that she has a problem. In the short term, this strategy de-
creases her initial distress and gives time to come to adjust to her diagno-
sis. However, if she continues to use this type of coping long term, she
will not seek proper care and will endanger her life.
Examples of passive emotion-focused behaviors include
Exercise Draw and label the following grid on the board. Using
the list of coping strategies that was assembled earlier
5.2: in the session, ask participants to assign each re-

sponse to the correct area of the grid. Using examples
Controllable from this exercise, review and discuss aspects of cop-
ing.
and Problem focused Emotion focused
Uncontrollable (controllable) (uncontrollable)
Stressors Active
Passive
❚ denying or ignoring the problem

❚ giving up
❚ trapping feelings inside and not sharing feelings with others
❚ procrastinating
❚ increasing consumption (e.g., smoking, eating, drinking alcohol,
using recreational drugs) to distract or numb oneself from feelings
of anxiety
Exercise ❚
❚
What are your most common coping strategies?
Are you more problem focused or emotion focused? (People
5.3: ❚
tend to emphasize one or the other.)
When do you use active strategies?
Identifying ❚ Under what circumstances do you use passive strategies?
Your Own
Personal
Coping
Style
Exercise Think about your breast cancer experience and try to remem-
ber which coping strategies you have used.
5.4: Stressful event → Awareness → Appraisal → Coping
❚ Which strategies did you use?
Identifying ❚ Which were most helpful?
Your ❚
❚
Which were least helpful?
What changes would be beneficial at this point?
Coping
Responses
to
Situations
Related to
Breast
Cancer
Evidence shows that such indirect actions may actually increase de-
pressed feelings and impair physiological systems such as the immune
system. Research has found an association between an “ I give up” or
hopeless attitude and a poorer prognosis and shorter survival time for
people with some types of cancer.
Matching Your Coping

Responses to Your Situation
1. Identify the situation and its related cognitive, emotional, and

physical reactions.
2. Break the situation into problem-focused (controllable) and emo-
tion-focused (uncontrollable) aspects. (You may have several of
each, especially in more complex situations.)
3. Generate potential coping strategies for each aspect. Be sure they
are active strategies.
4. Set goals and priorities for each aspect of the situation.
Active Problem focused (for controllable aspects of stressors)

❚ Seeking information
Coping ❚ Making decisions

❚ Resolving conflict
Strategies ❚ Setting goals, prioritizing

❚ Requesting help (e.g., with activities)
Reminder ❚ Using focused activities (e.g., altering the situation when

possible)
Sheet Emotion focused (for uncontrollable aspects of stressors)
❚ Reappraising thoughts
❚ Reframing thoughts
❚ Recognizing and accepting negative emotions
❚ Seeking emotional support
❚ Exercising, getting massages
❚ Using relaxation exercises and meditation
Passive Coping Strategies

You should avoid these behaviors because they may have det-
rimental long-term consequences.
❚ Ignoring the problem
❚ Procrastinating
❚ Denying the problem exists
❚ Giving up
❚ Eating, drinking, or smoking to numb feelings
❚ Overmedicating
❚ Keeping feelings inside (not talking to others about what
you feel or need)
Use Exercises 5.2–5.4 to help you become more familiar with these
processes. Also make use of the Active Coping Strategies Reminder Sheet
to help you generate coping alternatives.
Session 5 Homework

❚ Complete Stress Monitoring Sheet. You will note that there are
four columns that describe aspects of a coping response, including
ID Number: ________ Week: _________

Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________


1 2 3 4 5 6 7
Stress Stressor Reactions

Control
aspects
Coping
strategies
Monitoring Problem
Sheet Example:
A hurricane
Cognitive:
“ It can’t
Controllable:
Being as
focused:
Prepare the
is hit the same prepared as house.
approaching. place twice.” possible Buy food and
“ I will lose Uncontrollable: water.
everything!” The fact that a Make
Emotional: hurricane is on arrangements for
Anxiety, fear, its way pets.
depression When and where Plan an
Physical: it will strike evacuation.
Muscle tension Emotion
Knots in focused:
stomach Talk to friends
and family.
Use relaxation
techniques.
Cognitive: Controllable: Problem

focused:
Emotion
Emotional: Uncontrollable: focused:
Physical:
describing the stressor; identifying your cognitive, emotional, and

physical reactions; separating out the controllable and uncontrol-
lable aspects of the stressor; and listing possible coping strategies
that can be used. The example of the hurricane warning has been
inserted on this sheet to help get you started. You will be entering
a recent stressor and then completing the additional columns.
Session 6:
Coping, Part II 6
Review
The process of understanding coping and its many facets can take some
time. Therefore, a large part of this session is spent reviewing last week’s
information and using homework examples to work through the process
of determining a situation’s demands and selecting appropriate coping
strategies.
❚ Coping is an individual’s efforts to manage demands that are ap-
praised as exceeding their resources.1
❚ Coping has three dimensions:
1. Controllable: We can change controllable aspects of stressors to
alter their effects.
Uncontrollable: Although some aspects are uncontrollable, we
can change our emotional and physiological reactions to them.
2. Problem-focused (for controllable aspects): We use problem-fo-
cused coping for dealing with concrete aspects we can change.
Emotion-focused (for uncontrollable aspects): We use emotion-
focused coping to decrease the intensity of or change our emo-
tional reactions to uncontrollable aspects.
1
S. Folkman, “Personal Control and Stress and Coping Processes: A Theoretical Analysis,” Jour-
nal of Personality and Social Psychology, 46, (1984), 839–852.
57
Goal ❚ To review the steps involved in executing coping responses.
3. Active approach: We deal with the situation directly.

Passive approach: We deal with the situation indirectly.
❚ The coping response occurs after you appraise a stressful situation.
Individual differences in coping behaviors and resources play a
substantial role in determining how stress affects you.
Stressful event → Awareness → Appraisal → Coping
Please review the following flow chart to see how coping fits in with
the stress management techniques we have learned so far. As you can
see, several steps and choices are involved in responding to stressful situ-
ations. First, we have automatic thoughts that determine our initial cog-
nitive, emotional, behavioral, physical, and social responses. When these
automatic thoughts are distorted, we can use cognitive restructuring to
make them more accurate or rational. Once we have made our thoughts
more rational, we can begin coping with the situation. The choice of
using an emotion-focused or problem-focused coping strategy is based
on a decision to focus on the uncontrollable or controllable aspects of the
situation.
Cognitive Restructuring
➤
Stressful Situation
➤
➤
YES
➤
➤
Distorted? NO
➤Automatic Thought
➤
➤
➤
➤
➤
➤
➤
➤
Cognitive Emotional Behavioral Physical Social Coping

➤
➤
UNCONTROLLABLE CONTROLLABLE
ASPECTS? ASPECTS?
➤
➤
➤
➤
Emotion-Focused Problem-Focused
Strategies Strategies
Session 6: Coping, Part II 59
Matching Controllable
aspects—
Uncontrollable
aspects—
Coping Stressor
type
problem-
focused response
emotion-
focused response
Strategies Active (direct) ❚ Information seeking ❚ Reappraisal of
Reminder ❚
❚
Goal setting
Decision making ❚
situation
Reframing of
Sheet ❚ Conflict
resolution ❚
thoughts
Exercise, massage,
walks
❚ Acceptance of
negative emotions
(e.g., self-soothing,
talks with friends)
Passive ❚ Behavioral ❚ Overconsumption

(indirect) avoidance (smoking, eating,
❚ Cognitive drinking alcohol)
avoidance (e.g., ❚ Not caring for self
denial, not thinking (e.g., not taking
about the medication,
situation) missing
chemotherapy
appointments)
❚ Keeping feelings
inside
To best deal with stress, it is important to choose the appropriate

coping strategies for particular stressors. The diagram on the previous
page illustrates how all of these processes work together.
Steps to Matching Stressors

With Strategies
1. Define the stressor.

2. Recognize whether cognitive distortions are associated with the
stressor. If they are, replace them with rational thoughts.
3. Break the problem into manageable pieces (progressing from gen-

eral to specific stressors).
4. Identify which aspects are controllable and which are not con-
trollable.
5. Pick a coping response that is appropriate for your situation. Re-
fer to the Matching Coping Strategies Reminder Sheet.
Patterns of Reactions
and Coping
❚ Which coping patterns do you tend to use?

❚ Are they appropriate for your situation?
❚ What active approaches do you tend to use?
❚ How can you change your passive approaches?
Acceptance/Softening1
Even after you have tried to cope and make your stressor more man-
ageable, your situation may feel so distressing or difficult that you still
feel uncomfortable. Physical pain is one such stressor, as are certain forms
of emotional pain, such as the pain caused by the loss of someone you
love. People often respond to physical pain, emotional distress, and other
discomfort by trying to build a wall around it and block off the feeling.
The more you resist pain, the more it hurts. Think of having an injec-
tion. If you tense your muscles, it always hurts more than if you keep
your muscles relaxed. The more it hurts, the more you will try to resist it.
This vicious cycle produces more pain and more resistance.
An alternative way to deal with pain is to learn to “ soften around it.”
First, acknowledge the presence of the physical pain or emotional dis-
tress. Allow yourself to experience physically and mentally whatever it is
that hurts you—like swimming with a riptide instead of against it.
When you “ soften around” a source of pain, you consciously relax
the muscles around the spot or the feeling that hurts. You focus on the
pain itself rather than all the tension you have generated. Softening also
means noticing but disregarding your thoughts about the intensity of the
discomfort or distress. When people experience fear or a physical pain in
1
Adapted from M. Davis, E. Eshelman, and M. McKay, The Relaxation and Stress Reduction Work-
book, 3rd ed. (Oakland, CA: New Harbinger, 1988).
ID Number: ________ Week: _________

Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________


1 2 3 4 5 6 7
Stress Coping: Matching Stressors With Strategies

Continue to monitor your cognitive, emotional, and physical
Monitoring reactions to stressors that you encounter during the week. List
the controllable and uncontrollable aspects of the stressful situ-
Sheet ation, and list the coping strategies that you used. Try to be
aware of when you are appropriately using problem-focused
strategies for controllable aspects or emotion-focused strate-
gies for uncontrollable aspects rather than the opposite. Did
you end up feeling differently in these different situations?
Useful
Control coping
Stressor Reactions aspects strategies
Cognitive: Controllable: Problem focused:
Emotional: Uncontrollable: Emotion focused:
Physical:
Cognitive: Controllable: Problem focused:
Emotional: Uncontrollable: Emotion focused:
Physical:
this way, they are often surprised that seemingly unmanageable feelings
become manageable.
Your attitude toward your feelings plays an important role in how
much stress you feel. By accepting your feelings and experiences, you
eliminate the stress created by resisting or running away from them and
allow yourself to use as much energy as possible to deal with the situa-
tion directly. Opening up your mind, without judgment, to the reality of
your situation can often bring a release and relief. This self-acceptance
allows you to accept what is rather than focus on what you would like
the situation to be. This kind of attitude allows you to take in as much
information as possible and maximize your options because you know
what you are dealing with. Keep in mind the “ softening” exercise you
learned in your group.
Session 6 Homework

❚ Complete Stress Monitoring Sheet to improve your skills in match-
ing coping strategies.
Session 7:
Social Support 7
The prior two weeks have focused on the ways in which internal re-
sources can be used to manage stress. We now move on to focus on an
important external resource, social support.
Definition of Social Support
Social support is the psychological and emotional, informational, and

tangible benefits we receive from our personal relationships.
Benefits of Social Support
Benefits of social support in nonstressful situations include warmth, inti-

macy, sharing accomplishments, self-esteem, and self-identity. Benefits
in stressful situations include emotional and psychological effects such as
consolation, comfort, and the alleviation of loneliness. In addition, we
often receive concrete and tangible help, such as information or access to
information, help with chores, and financial assistance.
Social support may intervene in the event → appraisal → emotion
equation by attenuating or buffering the appraisal. Therefore, by reduc-
65
To identify beneficial, plentiful, detrimental, and deficient

Goals ❚
sources of social support.
❚ To learn new strategies for improving and increasing sup-
portive ties.
ing the consequent emotional reaction, social support may help dampen
physiological processes or maladaptive behaviors.
Who are the typical members of a social support network?
❚ family members (spouse or partner, children, parents, siblings)
❚ close friends
❚ coworkers
❚ acquaintances (from church, school, or other activities)
❚ pets
Research has shown the quantity of people in your life is not as im-
portant as the quality of your social support. Why? Because even a single
source of social support can . . .
❚ serve as a stress buffer and coping resource
❚ increase feelings of well-being
❚ provide a sense of predictability and stability
Psychological
and emotional Informational Tangible
Encouragement, fun Personal knowledge, Medical care

activities, consolation, assistance in assistance, household
affiliation, love, researching material help, financial support,
spiritual guidance and needed for decision work schedule
prayer, someone to making, promotion of accommodation,
reduce feelings of healthier behavior child-care, job
helplessness, someone (often combined with sharing
to share the burden professional support)
Types of Social Support
Three major types of social support have been classified. Think of some
examples of social support you have received.
Session 7: Social Support 67
Exercise Write the first name or title (e.g., spouse, boss) of people who
7.1: have been helpful during your recent experience with breast
cancer. List the name in the area in which support was offered
Support and include a brief phrase describing the support offered. Try
to name at least 5 people total.
Systems
PSYCHOLOGICAL AND EMOTIONAL
SUPPORT
Name/title Support provided
INFORMATIONAL SUPPORT
TANGIBLE SUPPORT
Matching Type of Social

Support With Your Needs
Like coping, if the types of social support you receive are appropriate for
your needs, you will gain the maximum benefits. However, when the
type of support someone offers is not the type of support you need, you
could become more distressed.
Exercise EXAMPLE 1
A friend calls daily to find out if you need to talk. You are
7.2: Types feeling overwhelmed with work demands, radiation treatments,
and household chores.
of Support ❚ What type of support is your friend offering?
________________________________________
❚ What type of support do you need?
________________________________________
EXAMPLE 2
You have decided which surgical procedure to undergo and
which adjuvant therapy to use. Family members keep sending
loads of information on alternative treatments and new thera-
pies.
❚ What type of support are they offering?
________________________________________
❚ What type of support do you need?
________________________________________
It is important to remember that the various individuals in your so-

cial network are good at providing some types of support and not as good
at providing other forms. For example, if you were to ask your doctor for
money and your family members for drug prescriptions, you would end
up frustrated. Before reaching out for social support, focus on identifying
your needs and determining who can best address them. Complete Exer-
cise 7.1 to help identify these people in your network
Value and Quality

of Support
❚ How accessible is your support network? Considerations include

location and time or financial constraints.
❚ Do others initiate the offer of support and do so with enthusiasm?
Are they offering what you need?
❚ Prior relationship patterns may cause strain and stress within a

support group or among individuals in the group. Consider the
level of intimacy or involvement with your potential sources of
support.
❚ Are you able to ask for and receive help from others? Does doing
so make you feel overly dependent? Do you have a tendency to
withdraw when stressed? Are you concerned about frightening
others with your fears?
Spouse and Partner

Relationships
You may be worried about discussing mutual fears about loss and mak-
ing your spouse or partner feel even worse. Consequently, no one men-
tions the subject. You and your partner or spouse may avoid each other
or act cheerful in response to these fears. You may also both talk less and
be less physically intimate (at a time when physical closeness may be
especially desired). Changes in physical intimacy patterns, perhaps be-
cause of surgery and adjuvant treatment, changes in your physical sen-
sations, or concerns about altered appearance may affect both of you.
Frustration and exhaustion may result from the new strains that the ill-
ness introduces to your daily life.
Strategies for Enhancing

Quality of Support Network
1. Try cognitive reassessment and restructuring.

❚ Am I willing to receive help?
❚ Am I willing to ask for help?
❚ Am I afraid to ask for help?
❚ Are others willing to help me?
❚ Do I need to be strong and manage on my own?
2. Break down social support into individual components and make
decisions about each. Match your needs with the type of support
you elicit.
❚ Actively seek information (as needed).
❚ Request or arrange for tangible help (e.g., with chores, with
finances).
Introduction DEFINITION
Meditation is the practice of nonjudgmentally attempting to focus
to your attention on one “ thing” at a time. The nature of the “ thing”
is relatively unimportant and varies from one tradition to the
Meditation1 next. Often the focus of attention is a syllable, word, or group of
words that the meditator repeats aloud or silently. This is known
as mantra meditation. Gazing at a fixed object such as a flame or
flower can also anchor attention. Many meditators find that a
convenient and relaxing point of focus is the inhalation and
exhalation of their own breathing. Regardless, you can use any-
thing as the focus of your meditation.
QUALITY OF THOUGHT
It is important to understand that the heart of meditation
is not simply focusing on something to the exclusion of all other
thought but is also the process of trying to achieve this type of
focus. The mind does not want to stay concentrated on one
thought. Myriad thoughts will occur and seem to interfere with
your meditation. A typical meditation follows. (The meditator
has chosen the task of counting to three repeatedly as the fo-
cus of her attention.)
One . . . two . . . This isn’t so hard . . . one . . . two . . . three
. . . one . . . I’m not having many thoughts at all . . . Uh-
oh, I just had a thought. . . . That was another one . . .
two. . . . My nose itches . . . one. . . . I wonder if it’s okay
to scratch it. . . . Darn, there was another thought. I’ve
got to try harder . . . one … two . . . three . . . one . . . two
. . . I was judging myself pretty harshly. I’m not sup-
posed to do that . . . one . . . two . . . three . . . one. . . . I’m
hungry. Wonder what I’ll cook tonight . . . one . . . two
. . . three . . . I’m having way too many thoughts. . . . I’ll
never get this right . . . one . . . two. . . . Now don’t judge
. . . one . . . two . . . three . . . one.
1
Adapted from M. Davis, E. Eshelman, and M. McKay, The Relaxation and Stress
Reduction Workbook, 3rd ed. (Oakland, CA: New Harbinger, 1988); J. Mason, Guide
to Stress Reduction (Berkeley, CA: Celestial Arts, 2001).
(Continued)
Each time this meditator realizes that her mind has drifted
to other thoughts, she returns to the original object of her at-
tention. By continually refocusing her attention, numerous
surprising realizations will eventually become apparent.
PHYSIOLOGICAL EFFECTS
In 1968, Dr. Herbert Benson and his colleagues at Harvard
Medical School studied voluntary practitioners of transcenden-
tal meditation. Benson demonstrated that during meditation,
the following physical changes occur:
1. The heart and breathing rates slow down.
2. Oxygen consumption decreases by 20%.
3. Blood lactate levels decrease (levels that increase with stress
and fatigue).
4. Skin resistance to electrical current, a sign of relaxation,
increases fourfold.
5. Electroencephalogram ratings of brain wave patterns indi-
cate increased alpha activity, another sign of relaxation.
BASICS
Benson went on to show that any meditation practice can du-
plicate these physiological changes as long as four factors are
present:
1. a relatively quiet environment
2. a mental device that provides a constant stimulus
3. a comfortable position
4 a passive attitude (an aspect that will be discussed in depth
later)
EFFECT ON PHYSICAL SYMPTOMS

Meditation has been used successfully in the treatment and
prevention of high blood pressure, heart disease, strokes, mi-
graine headaches, and autoimmune diseases such as diabetes
and arthritis. It has also proved helpful in treating anxiety, de-
pression, and other disorders.
(Continued)
BENEFITS OF REGULAR PRACTICE

You can learn to meditate within a few minutes. While you
are meditating, your body will immediately use less oxygen (a
sign of deep relaxation). However, as with most new skills, the
benefits of meditation increase with practice. Levels of relax-
ation deepen, attention becomes more steady, and you become
more adept at living in the present moment. Therefore, it is
important to meditate regularly.
In general, any amount of time spent in meditation is more
relaxing than not meditating at all. When you first begin to
practice, maintain the meditation for only as long as is com-
fortable, even if it is only for 5 minutes a day. If you feel that
you are forcing yourself to participate, you may develop an
aversion to practicing meditation at all. As you progress in
your practice and meditation becomes easier, you will find
yourself wanting to extend your time. For relaxation, medi-
tating for 20 to 30 minutes once or twice a day is sufficient. If
you realize that you enjoy practicing meditation but not
enough to do it daily, you can alternate between meditation
and other relaxation techniques.
PREPARATION
Posture
1. Position: Sit in a chair with your knees comfortably apart
and your hands resting in your lap.
2. Back: Sit with your back straight, and let the weight of your
head fall directly down on your spinal column. This can be
accomplished by pulling your chin in slightly. Allow the
small of your back to arch.
3. Balance: Rock briefly from side to side, then from front to
back, and establish the point at which your upper torso
feels balanced on your hips.
4. Breathe: Close your mouth, and breathe through your nose.
Place your tongue on the roof of your mouth.
5. Hands: Your hands can either rest comfortably in your lap
or on your knees or can rest open on your knees with your
forefingers and thumbs touching.
(Continued)
MEDITATION PRACTICE
Mantra Meditation
Mantra meditation is the most common form of meditation
throughout the world. Before you begin, you should select a
word or syllable that you enjoy—preferably one that you think
has a healing or spiritual connotation. It is often easier to con-
centrate on a word with more than one syllable; each syllable
should have the same emphasis. Benson recommended using
the word one. Many meditators prefer the universal mantra,
OM or Shalom. Buddhist meditators often use the phrase hum
sa, which means “ I am that.”
When you are alone, it may be easier to repeat the word
out loud because it provides an additional means of focusing.
The biggest difference between relaxation and meditation is
that the goal of relaxation is to dissociate from your stressors,
whereas the goal of meditation is to relax your body so that
you can begin to focus. Alertness and awareness are key as-
pects of meditation, so even though you should be comfort-
able and well supported, you should not practice meditation
in bed or in a recliner because it is too easy to fall asleep.
The more adept you become at practicing meditation, the
more likely you are to develop insights while meditating, which
can then be applied to the various situations in your life. Re-
member, awareness should accompany meditation. You may
find that the repetition of a mantra, especially one that is re-
peated silently, can easily become mechanical. You may have
the sense that an inner voice is repeating your mantra while
you are lost in other thoughts or becoming sleepy. Try to be
aware of each repetition of each syllable.
Grounding and Centering Yourself in a

Meditative Position
Close your eyes, and focus on the point where your body is
touching the cushion or chair. What are the sensations there?
Next, notice the places where your body touches itself. Are
your hands crossed? Your legs? Pay attention to the physical
sensations at these points of contact. Finally, focus on the way
your body takes up space. Does it take up a lot of space? Little
(Continued)
space? Can you feel the boundary between your body and
the space surrounding it? Notice the feelings there.
Meditative Attitude
Maintaining a passive attitude during meditation is perhaps
the most important element in becoming relaxed. It is im-
portant to realize that especially as a beginner, you will have
many thoughts and relatively few moments of clear con-
centration. This is natural and expected. Realize that your
thoughts are not really interruptions but are an integral part
of meditation. If your thoughts did not interfere, you would
not be able to develop the ability to let them go.
A passive attitude means that you should not be con-
cerned about whether you are doing things correctly,
whether you are accomplishing any goals, or whether this
meditation is right for you. Try to have the attitude that you
are going to put in your time, just sitting, and whatever hap-
pens is exactly what should happen. Let your thoughts go
by. Imagine that you are watching your thoughts, just like
clouds, drifting by, but do not grab hold of them. If you find
that you are absorbed in thought, just let your thoughts go
and return to your meditation.
Breathing
With your eyes closed, take several deep breaths, and notice
the quality of your breathing. Is it fast or slow? Deep or shal-
low? Notice where your breath originates in your body. Is it
up high in your chest? In the midsection around your stom-
ach? Down low in your belly? During meditation, diaphrag-
matic breathing is the most relaxing.
How are you feeling now? Are you comfortable in your
position? Recall that you ended Session 7 with a meditation
exercise. Did it feel similar?
ID Number: ________ Week: _________

Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________


1 2 3 4 5 6 7
❚ Request time with family and friends for both illness-related

and pleasure-related activities.
❚ Attempt to communicate more directly your feelings and needs
with members of your current social support network. (This
step is discussed more in later sessions.)
❚ Try to find new avenues for sharing your feelings and receiv-
ing support (e.g., support groups, therapy or counseling, keep-
ing a journal, enjoying time with pets).
Session 7 Homework
❚ Read the “ Introduction to Meditation” section (pages 70–74).

❚ Complete the Stress and Sleep Monitoring Sheet.
Session 8:
Anger Management 8
Increasing Anger Awareness
Like most of the other stress management techniques you have learned
in this program, the first step in becoming aware of your anger is gaining
a better understanding of the subtleties of the situation; your appraisals
of the situation; and your emotional, physical, and behavioral responses
to the situation.
How do you know when you are angry?
❚ Physical signs: ____________________________________________
❚ Emotional signs: __________________________________________
❚ Behavioral signs: __________________________________________
❚ Cognitive signs: __________________________________________ .
Patterns of Anger Expression
It is important to increase our understanding of the role that anger plays

in our lives. For example, do you go to any extreme to avoid becoming
This module was initially developed by Dr. Gail Ironson, Dr. Nancy Costello, and Dr. Susan
Lutgendorf for men with HIV. It was subsequently adapted by our team for women with breast
cancer.
77
Goals ❚
❚
To identify characteristic patterns of anger.
To learn new strategies for anger assessment and manage-
ment.
angry or someone who is angry? The first step to understanding anger is

recognizing that our reactions to anger are learned. Like many of our
emotions, we learn by experience when, where, and how to express anger.
Much of this experience is gained from our families. Just as we learned
how to express our anger and respond to others’ anger, we can learn
new ways to handle angry feelings. Complete Exercise 8.1 to increase
your awareness of anger expression patterns.
What Makes You Angry?
During the last session, we thought of things that make us angry and
listed them on the board. Did any of these triggers stand out for you?
Some common triggers include frustration, harassment, disappointments,
pain, having cancer, deadlines, doctors’ lack of understanding, intoler-
ance, inconsiderate people, and not getting your way.
Expressing Anger
How do you express anger? Often people tend to behave in extremes,

either by “stuffing,” or internalizing, their anger, or by “exploding”—
verbally, emotionally, and perhaps physically.
EXPLODING ANGER VERSUS STUFFING ANGER

Following are some physical consequences of stuffing your anger or ex-
ploding:
❚ increased blood pressure
❚ increased blood flow (a flushed feeling, blushing)
❚ increased heart rate
❚ increased muscle tension
❚ knotted stomach
Session 8: Anger Management 79
Exercise Complete the following questionnaire. Connect past experi-

ences with present behavior patterns.
8.1: Self- 1. Do an anger inventory. Ask yourself the following ques-
tions: What messages did you receive as a child about ex-
Evaluation pressing anger?
Questionnaire: When ❚ my mother got angry she . . .

When my father got angry he . . .
❚
Developing When I got angry I . . .

❚
As a result of these experiences, what decisions have you
Anger made about anger, and what effect might it have on your
life?
Awareness 2. types
In relationship to your experience of anger now, which
of people, situations, and events tend to make you
angry?
3. Is it ever ok for you to feel angry?
❚ When I feel angry I . . .
4. How do you feel about expressing your angry feelings?
❚ When I get angry at someone, I . . .
5. How do you feel about other people expressing their an-
ger?
❚ When someone gets angry at me, I . . .
6. If you express anger, how do you go about it? Are you
aggressive? Assertive? Stubborn or resistant? Complain-
ing? Rebellious? Do you turn anger in on yourself?
❚ I’ve turned anger in on myself (been aggresive, been stubborn,
etc.) by . . .
7. What are you willing to do to increase your ability to rec-
ognize angry feelings? Express anger? Communicate an-
ger appropriately?
❚ I have used anger effectively when I . . .
8. In what ways has anger empowered you? List some of the
ways that anger has empowered you or ways you like to
use it to make changes in your life.
9. What do you like about the way you use anger? What do
you still want to change?
DISCUSSION
Consider the following additional issues that may have arisen
as you worked on the questionnaire.
(Continued)
❚ What did you learn about anger?

❚ Has what you learned been incorporated into your relation-
ships today?
❚ Is anger expression difficult for you?
❚ What happens when you express your anger?
❚ What happens when you do not express your feelings?
❚ Do you ever feel your anger is out of control?
❚ Do you think that expressing anger is good or bad?
ANGER APPRAISAL
You
Examine your appraisal of your situation. Apply the methods you learned
to form more balanced thoughts.
❚ What are you saying to yourself?
❚ Which part of your anger is valid?
❚ Do you have any distorted thoughts contributing to or exacerbat-
ing your anger (e.g., “ No one treats me with respect,” or “ I should
not be angry about this” ).
Them
Respect the other person’s point of view. People are more likely to listen
to you when you consider their vantage point.
❚ Try to consider where the other person is coming from.
❚ Is the other person being rational?
Discussion
❚ What happens when you suppress your anger?
REMEMBER
Black-and-White Thinking
Should Statements
Anger To review, those who stuff anger rarely express anger, or they
express it indirectly. Those who explode express anger often and
Review at times are loud and unfair.
Stuffers tend to Exploders tend to
Ruminate and stew Yell
Be cold Intimidate
Be “ extra nice” Nitpick
Stab you in the back Blame
Give you the silent treatment Throw things at people or
damange items
❚ Where does all that energy go?

❚ What might that mean for you physically?
Beginning the Anger

Awareness Process
The next time you are angry or involved in a frustrating situation, do the
following:
1. Notice physical symptoms.
2. Acknowledge your anger. (Do not invalidate your emotions.)
3. Recognize in which situations or with which people you tend to
deny that you are angry.
AWARENESS OF YOUR SITUATION’S DYNAMICS

❚ Recognize your position of power compared with others in the
situation (e.g., your boss, your dog). The degree to which you ex-
press angry feelings to another person must be determined in the
context of your relative power in the relationship. The conse-
quences of a confrontation with someone who is your superior,
such as your boss, may not be worth the potential benefits.
❚ Do you have a continuing relationship with the person involved
in the situation? Is it your spouse? A bank teller? You may be
more willing to reveal intense feelings to people with whom you
have a closer, more long-standing relationship than to people with

whom you have a casual relationship.
AWARENESS OF OTHER FACTORS

Recognize external factors:
❚ Are extenuating circumstances involved?
❚ Are you hungry? Have you had enough sleep?
Recognize internal factors: Know what your buttons are—
❚ What sets you off? Which issues are sensitive for you, based on
your personality and prior exercises?
Consequences of Anger
Does anger ever empower you or make good things happen to you?
Anger can help you stand up for yourself, protect others, and go after
things you want.
Does anger ever disempower you? Anger can make you too upset to
work things out, withdraw from the situation, or be embarrassed by your
reaction.
Changing Maladaptive
Anger Patterns
STRATEGY FOR CHANGING ANGER PATTERNS

Recognizing You Are Angry
❚ Note your physical symptoms.
❚ Acknowledge your feelings.
Deciding Whether to Act or Wait

❚ Are you too upset to be calm and straightforward?
❚ Do you need time to think about the situation?
❚ Does the other person need time to cool off or think?
Questions to ask yourself (remember the acronym ASAP):

Awareness: Who or what is really angering me?
Source: Why am I angry? What is the real source?
Alternatives: What do I want to do? Do I have alternatives for ac-
complishing it?
Plan: What is my plan of action?
Checking Out the Situation’s Dynamics

❚ Power differentials: Is the person involved in the situation your
boss? Your equal? Your employee? A service person? How does
this affect your reaction?
❚ Relationship factors: Do you have an ongoing or short-term
relationship with the person in the situation? How important is
this relationship to you? What type of relationship is it (i.e., inti-
mate, work, acquaintance)? Is the person a stranger?
❚ Extenuating factors: Are extenuating circumstances involved?
Are you or another person in a bad mood for an unrelated reason
(e.g., because you are hungry or have had a tough day)? Are out-
side pressures involved in the situation?
❚ Internal factors: Is one of your “ buttons” being pushed? (i.e.,
being late, being sloppy)? Are you overreacting?
Taking Action
❚ Reappraise the situation: What are you telling yourself? Do you
recognize any cognitive distortions or should statements? What is
your automatic reaction?
❚ Recognize your needs in the situation: What is it that is not
happening? What is a fair result for you?
❚ Recognize the other person’s needs in the situation.
❚ Determine the desired outcome: What would be fair for each
person in the situation? Consider the effect of your decision on
the future of your relationship.
❚ When the timing is right, take action: Speak your mind. Change
your behavior.
List your alternatives and pick the best one, even if it is not the most
comfortable one for you.
POSSIBLE RESPONSES TO CONSIDER IN

ACTION PLAN
Be aware that responses other than stuffing your anger or blowing up
are available. Start to learn which of them work for you.
❚ Assertive behavior: Tell the person how you feel; ask for what you
need
❚ Blowing up
❚ Cooling down
❚ Defusing: Find an unbiased, third-party negotiator
❚ Emotion-focused behavior: Exercise; relax; elicit support from friends
and family; express your emotions in a safe way
❚ Focus on incompatible behavior
❚ Let it Go when appropriate (which is different from stuffing)
❚ Humor: Joke and laugh
❚ Information seeking: Ask for advice; search for more information
Session 8 Homework

ID Number: ________ Week: _________

Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________


1 2 3 4 5 6 7
86
Briefly describe (column 1) each anger-arousing situation you experience this week, and state your
Stress immediate emotional and physical responses to them in column 2. Think about the self-talk, automatic
thoughts, and appraisals that you experienced during the situation, and list them in column 3.
Monitoring Finally, generate an alternative cognitive appraisal and list it in column 4. Be aware of how “ trying on
this appraisal for size” changes the way you feel emotionally or physically.
Sheet
Emotional Alternative
Anger-arousing and physical Appraisal, cognitive
situation response self-talk appraisal
STRESS MANAGEMENT: PARTICIPANT ’S WORKBOOK
Session 9:
Assertiveness Training 9
Assertiveness and
Stress Management
Assertiveness training provides you with a set of interpersonal stress

management tools. The techniques will help you to communicate more
effectively with others, express positive and negative feelings more freely,
and increase your sense of control over the give-and-take in your impor-
tant relationships. All of these steps are likely to reduce stress in your life
and may enhance the quality of some of your relationships. Assertiveness
techniques are based on the following premise: If people do not clearly
communicate their intentions, interpersonal conflict and stress may de-
velop.
Assertiveness generally decreases stress by facilitating the following
processes:
❚ allowing individuals to stand up for their rights without violating

rights of others
❚ allowing individuals to express their personal likes and dislikes more
easily
❚ providing an appropriate way for people to disagree openly
❚ allowing individuals to be less self-conscious when talking about
themselves
87
Goals ❚ To increase the number and variety of situations in which

assertive behavior is possible.
❚ To decrease occasions of passive or aggressive behaviors.
Learning to be assertive can be difficult, especially for people who

mistake aggression for assertiveness. It is best to begin by viewing
assertiveness as one of several interpersonal communication styles.
Four Interpersonal
Communication Styles
The four communication styles can have advantages and disadvantages.

Some of the advantages are relatively short term, whereas the disadvan-
tages can have longer term effects on relationships.
Basic Interpersonal Styles
➤
➤
AGGRESSIVE ASSERTIVE PASSIVE
Does not respect Stands up for Denies own
others’ rights own rights rights
without violating
others’ rights
➤ PASSIVE– ➤
AGGRESSIVE
Indirectly resists
influence of others
AGGRESSIVENESS
People who are aggressive stand up for their rights by ignoring the feel-
ings of other people.
❚ Advantages: People usually do not bully an aggressive person.
❚ Disadvantages: People avoid an aggressive person.
PASSIVENESS
Passive people indirectly violate their own rights by failing to express
their true feelings and beliefs.
Session 9: Assertiveness Training 89
❚ Advantages: They rarely experience direct rejection and avoid di-

rect conflict.
❚ Disadvantages: Because they are passive, other people make their
choices. Therefore, it is hard for them to achieve their personal
goals, leading to resentment and guilt.
PASSIVE–AGGRESSIVE
Passive–aggressive people are indirectly resistant.
❚ Advantages: They avoid direct conflict.
❚ Disadvantages: Their style often causes more interpersonal conflict
than if they directly handled the situation or approached the per-
son involved. They are prone to extreme resentment and may seek
ways to get even.
ASSERTIVENESS
Assertive individuals stand up for their rights and directly express their
true feelings and beliefs without violating the rights of others.
❚ Advantages: They choose their own goals, generally do not offend
people, and are self-reliant and have more self-esteem. Their style
decreases instances of interpersonal conflict.
❚ Disadvantages: People who are not comfortable or familiar with in-
dividuals who directly express their feelings and beliefs may with-
draw from or grow anxious or irritable during personal exchanges
with assertive people.
Assertiveness and
Stress Management
Try Exercise 9.1 to see how each of these communication styles might
affect your stress levels in a social situation. If a speaker’s intentions are
not clearly communicated, potentially stressful interpersonal conflict may
result. Previously, we noted how assertiveness might reduce stress over-
all. Being assertive also decreases stress in more specific ways:
❚ It allows people to more efficiently handle situations by permitting
them to stand up for their rights without violating the rights of
others.
❚ It allows individuals to express their personal likes and dislikes
more easily.
Exercise ROLE-PLAY
You are returning a defective microwave during busy store
9.1: hours. The clerk asks if you dropped it, if you placed metal
Identifying objects in it, or if your house has electrical problems. Try to

generate different examples of how individuals with each in-
the Four terpersonal style might respond to this situation. Imagine you
are these people, and act out the interchange between you
Different and the store clerk.
Interpersonal ❚ Aggressiveness: Complain in a loud voice, blaming the store

and using an accusatory attitude.
Styles ❚ Passiveness: You are intimidated by the sales person. You
question your rights and decide to keep the faulty merchan-
dise.
❚ Passive–aggressiveness: In the clerk’s presence, you seem to
accept his remarks quietly. When he leaves, you start com-
plaining to other customers about him and go to the man-
ager.
❚ Assertiveness: You calmly explain that you want to exchange
the merchandise. You explain your reasons and stand by
your decision.
DISCUSSION
❚ Which specific behavior helped you identify each interper-
sonal style?
❚ Can you think of descriptions for people who exhibit these
behaviors?
❚ How would you feel acting each of these ways?
❚ How would you feel dealing with a person acting each of
these ways?
❚ It promotes clearer communication, which leads to less emotional

ramifications.
❚ It makes negotiations and disagreements less personal and unpleas-
ant, which allows people to disagree openly.
Although assertive communication can be a useful stress manage-
ment technique, it is important to understand that the choice of whether
to use it depends on the individual situation. For example, assertiveness
may be less appropriate because of the culture of the people involved. In

addition, it is generally a good idea to make changes to your communica-
tion style gradually to avoid putting people “ on the defensive.”
Research Findings
on Assertiveness
❚ People often confuse assertiveness with pushiness or aggressive-

ness.
❚ People who are thinking “ irrationally” (e.g., who are overreact-
ing, avoiding issues, using black-and-white thinking) often have
trouble being assertive.
❚ Assertive people are calm, direct, and concerned about others and
usually have a gentle communication style.
Therefore, a number of the cognitive stress management techniques you
have already learned may facilitate your use of assertive communication.
Common Barriers to
Assertive Behavior
The most common barriers to activing assertively are our cognitive ap-
praisals. The following are samples of inaccurate or negative thinking
patterns that can be disputed and replaced:
❚ “ I may hurt someone.”
❚ “ I’ll be rejected.”
❚ “ My job is to make people happy.”
❚ “ There must be a winner and a loser.”
Three Common Reasons for

Not Being Assertive
FEAR OF REJECTION OR RETALIATION

Often, our reaction to the fear of rejection or retaliation is more immobi-
lizing than the fear itself. The possibility of rejection or retaliation makes
us feel vulnerable and unsafe, feelings that can be manifested as anger

and aggression. It is important to be aware of situations in which we may
feel vulnerable. To promote assertive behavior instead of aggressive be-
havior, it is important to monitor our thoughts for negative self-state-
ments and cognitive distortions and remember that we do not have to
passively accept inappropriate treatment.
MISTAKEN SENSE OF RESPONSIBILITY

When we hurt another person with our assertiveness, it is important to
discern whether we actually hurt the other person or whether the per-
son simply misinterpreted the behavior. If we internalize people’s hurt
feelings and incorrectly interpret their disapproval as a sign that we are
bad, we are more likely to become depressed and less likely to stand up
for our rights.
MISTAKEN VIEW OF HUMAN RIGHTS

Many people believe that they do not have the right to stand up for what
they want and need. It is very difficult to be assertive when you are
denying yourself these basic rights. Remember, you can accept and act
on your own human rights without violating the rights of others.
It may also be important to assess whether acting unassertively could
be beneficial. For example, by not standing up for your rights, someone
may defend you, and if you never disagree, you may appear to be easier
to get along with.
Discussion
❚ Did you identify with any of the common barriers to assertive be-
havior?
❚ What are some of the reasons you do not behave assertively?
❚ When do you behave unassertively?
❚ With whom do you act unassertive?
❚ What are some advantages of acting unassertive?
❚ In which types of situations or with which types of people is it
advisable to act unassertive?
Changing your style from passive to assertive may not be well re-
ceived by others because they are accustomed to you giving in to their
demands or opinions. In addition, you may not always get what you
want by being assertive. However, the point of being assertive is to allow
yourself to honestly express your feelings rather than stuffing or denying

them. Assertiveness allows you to communicate openly with others be-
cause you respect their point of view while still validating your own po-
sition.
Components of Assertive
Communication
Assertive communication can be facilitated by using the following three

components:
1. Sending an assertive message.
2. Listening effectively.
3. Understanding that there are situations with no immediate solu-
tions.
SENDING AN ASSERTIVE MESSAGE

“I Want” Statements
Clarify what you really want. Being clear allows the other person to un-
derstand how to help fulfill your wants (e.g., “ I want to eat dinner on
time tonight” ).
“I Feel” Statements
Clarify how you feel without blaming or attacking the other person. To
facilitate communication, do not use generalizations to describe how you
feel. Be specific and quantify your feelings (e.g., “ I feel slightly irritated
when you don’t call to let me know you’ll be late” ).
Empathic Assertion
An empathetic assertion message contains two statements. The first state-
ment (empathic) recognizes the other person’s situation, feelings, beliefs,
and wants; the second statement asserts your wants, feelings, and beliefs.
The message is sensitive to the other person but does not totally disre-
gard your rights (e.g., “ I know that you have a lot of work to get finished
and it is difficult to know when it will be done, but I want you to call if
you are going to be late so that I can organize my own schedule this
evening” ).
Exercise Read the following scenarios, and consider the style of com-
munication demonstrated in each. Answer the questions listed
9.2: after each scenario.
Scenario 1: “ I have difficulty saying ‘no’ to friends and family
Communication when they ask for favors. I don’t want to seem like I am incon-
Style siderate. I find myself overextended because I always place

others’ needs before my own.”
Examples How do you assertively and confidently deny a request from

❚
others?
❚ How do you respond when others deny your requests for
help?
Scenario 2: “ I was supposed to go out with a friend. At the last
minute, she called and canceled. This has been happening regu-
larly. I would really like to let her know that I am irritated with
this behavior.”
❚ How do you assertively criticize your friend’s behavior while
simultaneously letting her know that you value her friend-
ship?
“I” Language
Messages using the pronoun “ I” instead of “ you” are good for expressing
negative feelings in a way that does not blame the other person. These
statements help explain how others’ behaviors concretely affect you, but
they allow you to take ownership of your own feelings about the situa-
tion. For example, consider the following message in “ you” language,
“ When you are late from work, you make me feel insecure.” In “ I” lan-
guage, the same message reads, “ When you are late from work, I often
doubt myself and feel insecure about our relationship.”
Sarcastic Messages
Watch out! Assertiveness can transform into passive–aggressiveness and
sarcasm if you are not careful with the tone of your message.
EFFECTIVE LISTENING
Listening to others often encourages them to listen to you more atten-
tively. In addition, effective listening reduces the likelihood that you will
misinterpret the message. Effective listening is not a passive agreement

with the other person’s message. It is respecting the rights of others to
express their thoughts and feelings. Effective listening usually involves
paraphrasing the content of the message and using nonverbal communi-
cation to show that you are being attentive.
SITUATIONS WITH NO SOLUTIONS

In many situations, either no workable solution is available, or the risk of
being assertive is too great. Alternatives to direct assertive behavior in-
clude changing your environment and using problem-focused and espe-
cially emotion-focused coping techniques.
Steps to More
Assertive Behavior
❚ Identify situations in which you want to be effective.

❚ Decide how important each particular situation is to you.
❚ Plan for change.
1. Consider your rights, what you want, and what you need.
2. Consider other person’s rights, wants, and needs.
3. Arrange a time and place to discuss the situation.
4. Define your feelings using “ I” messages.
5. Express your request simply, firmly, and concisely.
6. Reinforce the possibility of getting what you want: (a) Describe
positive consequences and (b) describe negative consequences,
but avoid making threats.
❚ Learn to listen.
1. Prepare: Make sure you are ready to listen.
2. Listen and clarify.
3. Acknowledge: Tell the other person that you have heard the
person’s point of view.
Session 9 Homework

ID Number: ________ Week: _________

Sheet 1
No
2 3 4 5
Moderately
6 7
Extremely
Pre/Post Pre/Post
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
_____ ____/____ ____/____ Yes No
ID Number: ________ Week: _________


1 2 3 4 5 6 7
Choose a difficult or stressful situation involving an interpersonal exchange (i.e., an interaction
Stress with another person), and list it in column 1. Record the automatic thoughts, emotions and physical
responses, and interpersonal responses of which you were aware during this exchange. In other words,
Monitoring evaluate the interpersonal style you used in this situation (aggressiveness, passiveness, passive–
aggressiveness, assertiveness). For any situation in which you did not use an assertive interper-
Sheet sonal response, insert an assertive response you could have used. How does this exercise change the
way you feel about the exchange? The other person? Yourself?
Emotions Initial Possible

Automatic and physical interpersonal assertive
Situation thought response response response
Session 9: Assertiveness Training
97
Session 10:
Wrap-Up 10
SUMMARY OF B-SMART GOALS AND TOOLS
Goal Tools
Awareness Stress monitoring, body scan
Appraisals Cognitive restructuring
Coping Coping behavior change, assertion, anger
management, relaxation exercises
Resources Social network
Notice that we have discussed four major goals during the past 10 weeks:
❚ increasing awareness
❚ changing appraisals
❚ enhancing coping skills
❚ building up resources
Recall all of the tools, or techniques, that you have learned—tools
that can be used to achieve these goals now and in the future. Some of
these tools are listed in the previous chart. Which other tools do you
recall?
Think of these goals as interdependent. Increasing your awareness of
your thoughts during stressful encounters helps you change your ap-
praisals and vice versa. Better coping skills help you secure important
resources such as social support; in turn, feeling that you have support
helps you continue coping with difficult challenges.
99
To answer questions.
Goals ❚
❚ To wrap up loose ends.
❚ To quickly review the past 10 weeks.
Awareness ↔ Appraisals
Coping ↔ Resources
Personal Plan for

Implementation and
Maintenance
Remember, stress management fitness, like physical fitness, involves a

training and maintenance program. You just completed the training pro-
gram.
❚ How do you start a maintenance program?
❚ How do you plan to integrate stress management into your life?
❚ Do you think that you will be able to use some of these tools in the
future?
❚ Are you able to envision a regular program of home-based relax-
ation sessions using your audiotapes or CDs?
❚ How will you begin your maintenance program this week? Which
tools will you use?
1. When will you practice your exercises? In the morning? In the
evening?
2. Where will you practice?
3. Which signs of stress will you scan regularly?
Physical (bodily) ________________________
Emotional _____________________________
Cognitive ______________________________
Social _________________________________
Behavioral _____________________________
USING YOUR B-SMART TOOLS

How do you know when to use each of these tools? Use the flow chart
that follows to integrate all of the techniques you have learned in the B-
SMART program.
Session 10: Wrap-Up 101
As you have learned, stressful situations can be managed by seeking

out social support, an external resource that is maintained by practicing
anger management, and communicating assertively. During these stress-
ful situations, you also depend on internal resources: You have auto-
matic thoughts, which can have cognitive, emotional, behavioral, physi-
cal, and social consequences. Awareness of these changes allows you to
Anger
Management
➤
Social Cognitive Restructuring

Assertiveness
Support (challenging thoughts)
➤
➤
➤
➤
➤
Stressful Situation
➤
Black-and-white
➤
thinking, should
YES statements, mind-
reading
➤
➤
Distorted? NO
➤Automatic Thought
➤
➤
➤
➤
➤
➤
➤
➤

➤
Coping
UNCONTROLLABLE CONTROLLABLE
➤ ➤
Emotion Focused Problem Focused
❚ Reframing ❚ Making decision

❚ Venting ❚ Seeking information
❚ Making behavioral ❚ Seeking advice
changes ❚ Setting goals
❚ Practicing
relaxation
➤
➤
Softening
(If still distressed)
consider the nature of your automatic thoughts. Occasionally, these

thoughts are distorted (e.g., black-and-white thinking). You can use your
cognitive restructuring skills to challenge and replace these thoughts with
more accurate or rational ones.
However, not all of your automatic thoughts are distorted. When
you have accurate thoughts about a stressor, you need to cope with it in
some way. Your choice of coping response is guided by the aspects of the
stressor you want to address. You break down the general stressor into its
controllable and uncontrollable aspects and then use the appropriate
coping response—emotion focused or problem focused—for the issue at
hand. Although emotion-focused coping responses are most effective for
dealing with uncontrollable aspects of a stressor, problem-focused coping
can be used quite effectively to deal with controllable factors. You learned
which emotion-focused and problem-focused coping strategies are most
useful for you and are able to select the best ones for various situations.
Some stressful situations are not resolved immediately, even with
the most appropriate coping responses. You have additional skills (e.g.
softening, mediation, imagery) that you can use in these situations. Oc-
casionally, techniques such as softening may only address temporary
symptoms of distress. For persisting stressors and distress states, it may be
necessary to rethink the stressful situation, perhaps considering it in a
different way and going through the set of strategies again.
Finally, it is important to remember that we cannot always get through
every situation without the help of others, whether they are members of
our social network or professional resources. Following is a list of organi-
zations and their toll-free phone numbers that you can call for different
types of information that could be helpful for you during and after your
treatment. Good luck.
LIST OF COMMUNITY RESOURCES
Cancer Information Service 1-800-4-CANCER

American Cancer Society 1-800-ACS-2345
Y–ME National Organization for Breast
Cancer Information and Support 1-800-221-2142
Susan Komen Alliance Treatment and
Information Line 1-800-IM-AWARE
National Consumer Insurance Helpline 1-800-942-4242
National Lymphedema Network 1-800-541-3259
Session 10: Wrap-Up 103
About the Author
Michael H. Antoni is professor of psychology, psychiatry, and behavioral

sciences at the University of Miami, Coral Gables, Florida. He is director
of the Center for Psycho-Oncology Research and research director of the
Cancer Prevention and Control Program at the Sylvester Comprehensive
Cancer Center in the University of Miami School of Medicine. During
the past 20 years, he has conducted research testing the effects of stres-
sors and stress management interventions on psychosocial adjustment,
physiological functioning, and health outcomes among people with cer-
tain cancers and viral infections. He is currently the principal investiga-
tor of several National Institutes of Health clinical trials testing the effi-
cacy of cognitive–behavioral stress management interventions on quality
of life and immunity among individuals with conditions such as breast
cancer, prostate cancer, cervical neoplasia, HIV/AIDS, and chronic fa-
tigue syndrome. He has been a licensed clinical psychologist in Florida
since 1987 and is a member of the American Psychosomatic Society, the
Society of Behavioral Medicine, the American Psychological Association
(APA, Division 38), and the Psychoneuroimmunology Research Society.
Dr. Antoni was awarded the Early Investigator Award by the Society of
Behavioral Medicine and the APA in 1993. His writing has been pub-
lished in more than 200 publications, including journals, chapters, and
edited books in the area of health psychology. He is the associate editor
for the International Journal of Behavioral Medicine and Psychology and Health;
serves on the editorial boards of Health Psychology, Brain Behavior and Im-
munity, and Annals of Behavioral Medicine; and is a referee for more than
15 major medical and psychological journals.
103

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Contents

Goals ❚ To introduce the goals and expectations of the 10-week stress

which you experienced the event as stressful (e.g., “ I sensed my anger,”

Stress: What Is It?

Stress is the physical, mental, or emotional tension caused by an event.

Following is a list of several symptoms of stress. Check the symp-

of Stress for the degree of discomfort it causes you: 1 = little distress; 10 =

Hostility _____ Anger _____

3. Behavioral: avoidance of tasks; sleep problems; difficulty complet-

As we have discussed, stress affects us mentally, emotionally, behavior-

tion, various physiological responses occur. The first set of responses is

The portion of each session involving relaxation and imagery exercises

Activity If you have difficulty finding time to practice the relaxation

Stress and ID Number: ________ Week: _________

ID Number: ________ Week: _________

Total hours of sleep: _______

Cognitive Emotional Behavioral Physical Social

To introduce the concepts of stress management.

What Is Stress Management?

As we discussed last week, when an event is interpreted as stressful, it

2.1: Body neck. Ask yourselves the following questions:

tion, the body releases endogenous opiates, which act as analgesics to

AWARENESS OF PHYSICAL TENSION

stress and the associated automatic reactions and behaviors is an essen-

❚ What are your typical sources of tension?

THE APPRAISAL PROCESS

The Appraisal Process

World: The world comprises a series of EVENTS.

Thoughts and Appraisal: You interpret the events with a series of

of appraisals and are accompanied by behavioral and physical reactions.

DEMONSTRATION OF THE APPRAISAL PROCESS

It is important to become aware of the relationships among what you

Example Think about improving your swimming skills. To improve your

When we are appraising an event, the thoughts occur incredibly

❚ Complete Stress and Sleep Monitoring Sheet.

ID Number: ________ Week: _________

ID Number: ________ Week: _________

Total hours of sleep: _______

Stressful Perceptions Automatic

Before learning more new techniques, it is important to reassess any

Goal ❚ To introduce automatic thoughts and begin identifying cog-

This week you will be receiving an audiotape or CD made by your

Because events happen so quickly, it is not easy to become aware of what

Each emotion is hypothesized to have its own core pattern of self-talk.

Feelings Thoughts and self-talk Function

You are going in for a follow-up mammogram and think about

As we have shown, events can be interpreted in a way that creates un-

STEP 1: IDENTIFYING THE NEGATIVE THOUGHTS

The doctor’s office left a message on your answering machine

thought patterns—the automatic thoughts that occur so quickly. Once

STEP 2: COGNITIVE RESTRUCTURING

As we mentioned, if your perceptions and cognitive appraisals about stres-

EXAMPLES OF DISTORTED THINKING

All-or-Nothing Thinking (Black-and-White Thinking)

Disqualifying the Positive

to maintain a negative belief, even when it is contradicted by your every-

Magnification (Catastrophizing) or Minimization

Exercise Which types of distortions do the following statements repre-

Thoughts 2. Recently, an additional person has been hired at your work-

❚ Minimization occurs when you play down the significance of your

HOW CAN NEGATIVE THOUGHTS

ID Number: ________ Week: _________

ID Number: ________ Week: _________

Hostility _ Anger _

Stress and ID Number: Week: _

ID Number: Week: _

ID Number: Week: _

ID Number: Week: _

ID Number: Week: _

ID Number: Week: _

ID Number: Week: _

ID Number: Week: _

ID Number: Week: _

ID Number: Week: _