Stress Control was created by Dr Jim White in 1986 and is now, by far, the most widely-used stress management course within the NHS and HSE (Ireland).
In independent research, Stress Control performs at least as well as individual therapy (with continuing improvement at two year follow-up).
- Stress Control is a six session class (not a group therapy).
- As Stress Control operates as a class, there is no upper limit on the numbers who can attend (NHS classes routinely run with over 100 people).
- There is no discussion of personal problems in the class. This allows people who feel uncomfortable talking in front of others to attend without any concerns.
- ‘Stress’ usually involves a range of problems – anxiety, depression, panic, insomnia, poor self-esteem, low self-confidence, irritability and anger, drinking, using drugs to excess, burnout.
- It uses cognitive-behavioural techniques to reduce stress by teaching better coping strategies.
- Research shows that reducing stress does not necessarily result in better wellbeing. So Stress Control combines stress management with Mindfulness and Positive Psychology strategies to boost wellbeing.
- Classes are supported by slideshow presentations, hand-outs, video, audio and relaxation and mindfulness tracks (CD or on-line).
- Sessions (usually weekly) last for 90 minutes with a 10 minute break.
- The course does not use jargon and the 11 hand-outs are written for the average reader.
- It is used extensively in the British NHS and Irish HSE; in companies, e.g. Continental (worldwide); in Universities; in Local Authorities and in community settings.
- Over 1,000 teachers have delivered Stress Control classes to hundreds of thousands of people. The largest Stress Control, so far, was recently delivered, to great effect, to over 400 people in Malahide, Ireland.
- It is available in a wide range of countries including Britain, Ireland, Germany, Belgium, Holland, Norway, Sweden, Finland, Slovenia, Malaysia, Singapore, China, Korea, Mexico, Canada and USA.
Session 1: What Is Stress?
- INFORMATION: How Stress Control works. Detailed information about stress: anxiety, depression, insomnia, etc. Audio examples. How common is stress? The 14 most common signs. Anxiety and depression tests. What keeps stress going? The Vicious Circle. Important statements.
- SKILLS: Getting started: Stress Control in ten words: face your fears, be more active, watch what you drink.
Session 2: Controlling Your Body
- INFORMATION: The vicious circle: how the body feeds stressed feelings. Anxiety: fight/flight/faint/freeze. Depression: being overwhelmed and withdrawing. ‘I had a black dog’.
- SKILLS: Caffeine, breathing retraining, exercise, progressive relaxation. Relaxation CD or code to access relaxation section of website.
Session 3: Controlling Your Thoughts
- INFORMATION: The role of vigilance and threat; 'grasshopper thinking' and 'the Blinkers'.
- SKILLS: Thinking your way out of stress: 'Wait a minute', the Big 5 Challenges', Breaking stress up.
Session 4: Controlling Your Actions
- INFORMATION: The vicious circle: how actions feed stressed feelings, body symptoms and thoughts. Building the positive circle – seeing the big picture. Effects of avoidance and behaviour.
- SKILLS: Face your fears; getting out of the safety zone; problem solving.
Session 5a: Controlling Panic Feelings
- INFORMATION: Dealing with feeling overwhelmed with a focus on the role of breathing in causing stress and, by controlling it, in controlling stress.
- SKILLS: Breathing retraining, preventative CBT approaches.
Session 5b: Getting A Good Night’s Sleep
- INFORMATION: Looks at the importance in getting a good night’s sleep and the problems lack of sleep or poor quality sleep cause.
- SKILLS: Relaxation, ‘Sleeping tips’ and ‘Retraining your sleep’.
Session 6: Wellbeing
- INFORMATION: The importance of strengthening wellbeing in combination with removing stress
- SKILLS: ‘Five a day’: Connect, Be Active, Keep learning, Give, Take notice. The last of these leads into mindfulness. End by ‘controlling the future and ‘becoming your own therapist’.
Dr Jim White devised Stress Control in 1986, shortly after qualifying as a clinical psychologist, at a time when he worked for the NHS in Lanarkshire:
I noticed a few things quite quickly – the people I was seeing were not the same as the ‘perfect patients’ I read about in the books, journals and research studies. Secondly, GPs told me they could not persuade a lot of people to come to see me for individual therapy due to the stigma involved. Thirdly, I had a large number of people failing to attend or dropping out after a few sessions - fine if you enjoyed spending a lot of time in the tea-room, chatting to colleagues in the same situation (which I did) but not the best way to run a service. Fourthly, even with those who did complete therapy, many did not do well even those who clearly were working hard at putting what they learned in therapy into practice. Finally, for those who did do well at discharge, many returned to therapy just a few months later, unable to maintain their gains. One explanation was that I was simply an awful therapist but, happily for me, when I looked into the research literature, I found this was what many of my colleagues were also experiencing – that while the ‘perfect patients treated in perfect circumstances’ often did well (although not as well as you would imagine), NHS services were, for obvious reasons, unable to replicate these results.
The other major problem, one which still exists today, was that we were unable to get beneath the tip of the iceberg – the ‘common’ mental health problems of anxiety and depression were well named – they were incredibly common and no health care system would ever be able to cope if it relied on individual therapy (even if it worked) as its main intervention. Thus waiting lists became a huge issue for psychologists – it was not (and, sadly, is not) unusual to find people waiting more than a year to see a psychologist. Imagine going to your GP, having screwed up the courage to seek help only to be told that help is at hand, as long as you can wait for a year. A completely unacceptable situation. So, for both these reasons – inefficiency and ineffectiveness, we needed to experiment with different ways of helping people. But what?
As a young therapist, I came to believe that providing personally relevant, easily understood information to people was essential, combined with straightforward interventions that made sense in the context of peoples’ often difficult lives. Why not do that in a large group setting? In addition, it would let people see how many others were in the boat as themselves – that would, presumably, help reduce the stigma that is so often found with these problems. So, along with my colleague, Mary Keenan, I began to offer Stress Control classes on a Tuesday night in the Hunter Health Centre, East Kilbride (evenings also suited people as it meant they didn’t have to ask for time off work).
Although the omens were not good - the first class ran on the same day the US Space Shuttle Challenger blew-up - from the word go, it was obvious that Stress Control was going to meet the needs I had identified. People flocked to it, stayed the course, and, when we measured outcomes, it worked as well as individual therapy but, if anything, people maintained the progress they made at the class – possibly due to the important aim of the class to ‘turn you into your own therapist’. In 1997, I carried out a controlled trial of Stress Control for my Ph.D. that told us more about why it worked, allowing me to further calibrate the approach. Research and, through evidence-based practice, further improvements have continued to this day and will into the future as we learn more and more about this approach, greatly helped by data sent in from Stress Control teachers from across the world.
Studies & Findings
The published evidence we have strongly suggests that Stress Control works in a very flexible manner. Recent research in England looked at those with mild levels of stress, those with moderate levels and those with severe levels. All attended the same classes and so received the same programme. By the end of the six sessions, all three levels showed around a 50% reduction in anxiety and depression, i.e. stress levels. Thus Stress Control can be used for those with existing difficulties or as early intervention / prevention / relapse prevention with those at these different levels of stress able to attend the same sessions.
Working within the CBT tradition, since its earliest days, Stress Control has always been closely evaluated. Here is a summary of what we and others have discovered:
Pre - Post
A series of papers have shown that people who attend the class show highly significant change from Session 1 to Session 6, e.g. White and Keenan, 1990, White et al, 1992, Wood et al, 2005, Joice and Mercer, 2010, Kellett et al, 2004. An exception to this was Kitchener, 2009 which did not show change.
6 Months Follow-up
The studies that have looked at follow-up improvement have consistently shown that clients continued to improve 6 months after the class ended White et al, 1995, White and Keenan-Ross, 1997, Kellett et al, 2007, Van Daele, 2013.
2 Years Follow-up
Two studies have looked at long-term outcome with Stress Control. White, 1998 showed continued improvement at two years. A recent study, not yet published, by Professor Dirk Hermans and colleagues, University of Leuven, replicated this finding. Hermans also reported that a ‘no treatment’ control group got slightly worse. This suggests strongly that any change shown by those who received Stress Control was directly due to attending the class.
White et al, 1992 and White, 1993 showed that different versions of Stress Control: purely behavioural, purely cognitive and a cognitive behavioural versions produced the same level of positive outcome, suggesting the importance of non-specific factors. See also White et al, 1995.
This finding is strengthened by recent work in Edinburgh which came to the same conclusion Menzies et al, submitted. An earlier study Kellett et al, 2006 suggested that ‘normalisation’ was a critical component in Stress Control.
Kellett et al, 2007 compared individual CBT, individual psychotherapy and Stress Control. All three were equally effective with Stress Control much more efficient.
Several Improving Access to Psychological Services (IAPT) services in the NHS in England have looked at ‘recovery rates’. Individuals are said to ‘recover’ if their scores, at the end of the intervention, on two questionnaires - PHQ9 (depression) and GAD7 (anxiety) - drop into the ‘normal’ range. All show Stress Control to have better recovery rates than individual therapy, e.g. Sheffield IAPT, presenting at the British Association of Behavioural and Cognitive Psychotherapies Annual conference in Leeds, 2012, reported that ‘recovery’ for individual therapy was 50%; for Stress Control it was 59%.
- 96% of those attending would highly recommend the class to others
- 94% rated the class as ‘highly relevant ‘ to their needs
- 91% report the booklets to ‘excellent’
- 92% report the amount of information to be ‘just about right’
- 94% report the level of skills taught to be ‘just about right’
- 78% practiced the skills learned on the course either ‘most days’ or ‘every day’
Simply providing the booklets three weeks before the start of the class led to improvement White, 1997.
Asked to rate a range of different components in terms of how important they were, clients reported that the top 4 were:
- Learning ways to cope with the stress (97%)
- Getting information about stress (94%)
- Understanding why I was having problems with stress (88%)
- Finding hope that I could get better (88%)
Clients rated each session very highly: no session was rated clearly better or worse than the others Gray and White, 1998.
Demographic analysis shows that, unlike many services, Stress Control is good at attracting ‘hard to reach’ populations who, in general, do not use NHS mental health services in great number, e.g.
- Those from ethnic minority groups
- Those from the most deprived areas
- Men - 44% of those attending Stress control classes are men compared to only 31% in individual therapy
Publicised properly, class sizes are large. Typical south-east Glasgow NHS classes have around 140. Recent Irish classes have over 400.
A study on the role of empathy in Stress Control Joice and Mercer, 2010, reported that while the majority of clients reported that the teacher (Jim White) was highly empathic, this was not related to outcome.
Recent evaluation in England has looked at improvement across severity levels. Those with mild or moderate or severe anxiety and depression did equally well with clients reducing scores on commonly used questionnaires (PHQ9 and GAD7) by around 45-50%. These results suggest that Stress control is an appropriate intervention for any level of stress.
- White, J. and Keenan, M., 1990 ‘Stress Control’: A pilot study of large group therapy for Generalized Anxiety disorder. Behavioural Psychotherapy 18, 143-146.
- White, J., Keenan, M. and Brooks, N., 1992 ‘Stress Control’: A controlled comparative investigation of large group therapy for Generalized Anxiety Disorder. Behavioural Psychotherapy 20, 97-114.
- White, J., 1993 'Straight from the Horse's Mouth'. Clinical Psychology Forum 53, 20-22.
- White, J., 1993 'Subconscious Retraining': A placebo strategy for Generalized Anxiety Disorder. Behavioural Psychotherapy 21, 161-164.
- White, J., 1995 Stresspac: A self-help anxiety management package: A controlled outcome study. Behavioural and Cognitive Psychotherapy 23, 89-107.
- White, J., Brooks, N. and Keenan, M., 1995 Stress Control: A controlled comparative investigation of large group therapy for Generalized Anxiety Disorder: Process of change. Clinical Psychology and Psychotherapy 2, 86-97.
- White, J., 1995 An analysis of components in large group didactic therapy - 'Stress Control'. Clinical Psychology Forum 76, 11-13.
- White, J., 1995 ‘Stress Control’ large group therapy didactic therapy for the anxiety disorders: An introductory workshop. Clinical Psychology Forum 85, 24-25.
- White, J, 1997 ‘Stress Control’ large group therapy: Implications for managed care systems. Depression and Anxiety 5, 43-45.
- White, J. and Keenan-Ross, M., 1997 Stress Control large group didactic therapy for anxiety: an approach for managed care systems. The Behavior Therapist 20, 192-196.
- White, J., 1997 Stresspac. London: The Psychological Corporation
- Gray, A., and White, J., 1998 Can large scale anxiety management groups be regarded as true therapy? Clinical Psychology Forum 115, 30-33.
- White, J., 1998 ‘Stresspac’ - three year follow-up of a controlled trail of a self-help package for the anxiety disorders. Behavioural and Cognitive Psychotherapy 26, 133-141.
- White, J., 1998 ‘Stress Control’ large group therapy for Generalized Anxiety disorder: Two year follow-up. Behavioural and Cognitive Psychotherapy 26, 237-245.
- White, J., 2000 Treating anxiety and stress: A psycho-educational approach in groups using brief cognitive behavioural therapy (2000). Chichester: Wiley
- White, J., 2000 Clinical Psychology in Primary Care. Invited essay. Primary Care Psychiatry 6, 127-136.
- White, J., 2002 Designed in California, delivered in Castlemilk? Do we need more Clydebuilt therapies? The Bulletin of the Scottish Branch of the British Psychological Society, 29, 30-31.
- White, J., 2007 A View from Scotland: a response to IAPT. Clinical Psychology Forum, 155, 89-94
- Jones, R., Pearson, J., Cawsey, A., Bental, D, Barrett, D., White, J., White, C., and Gilmour, W., 2008 Effect of different forms of information produced for cancer patients on their use of the information, social support, and anxiety: randomised trial. British Medical Journal, 332, 942-948
- Jamieson, J. and White, J, 2008 Ethnic minority mental health: opening the doors of a primary care mental health service. Clinical Psychology Forum, 190, 33-38.
- Jamieson, J., Donnelly, R. and White, J, 2008 Laff Yer Heid Aff: The role of comedy in increasing public awareness of common mental health problems. Clinical Psychology Forum, 187, 55-58.
- White, J., 2008 Stepping up primary care. Invited essay, The Psychologist, 21 (10), 844-847
- White, J., 2008 CBT and the challenge of primary care: developing effective, efficient, equitable, acceptable and accessible services for common mental health problems. Journal of Public Mental Health, 7 (1), 32-41
- White, J. Joice, A., Petrie, S., Johnston, S., Gilroy, D., Hutton, P. and Hynes, N., 2008 STEPS: Going beyond the tip of the iceberg. A multi-level, multi-purpose approach to common mental health problems. Journal of Public Mental Health, 7 (1), 42 -50
- White, J, 2009 www.glasgowsteps.com: a low-intensity approach to common mental health problems. Clinical Psychology Forum, 204, 11-15
- Grant, K., McMeekin, L. and White, J., 2010 An evaluation of individuals’ experiences of attending a low-intensity advice clinic in primary care. Clinical Psychology Forum, 208, 20-24
- White, J., 2010 Everything you always wanted to know about stress (but were afraid to ask) or Trying to reach the Hard to Reach. Clinical Psychology Forum, 224, 13-16.
- White, J., 2010a The STEPS Model: a high volume, multi-level, multi-purpose approach to address common mental health problems. In The Oxford Guide to Low Intensity CBT Interventions (2010). Bennett-Levy, Christensen, Farrand, Griffiths, Kavanagh, Klein, Lau, Proudfoot, Richards, Ritterband, White, and Williams, (Eds.), 2010. Oxford: Oxford University Press.
- White, J., 2010b The Advice Clinic or What I did in my thirty minutes. In The Oxford Guide to Low Intensity CBT Interventions (2010). Bennett-Levy, Christensen, Farrand, Griffiths, Kavanagh, Klein, Lau, Proudfoot, Richards, Ritterband, White, and Williams, (Eds.), 2010. Oxford: Oxford University Press.
- White, J., 2010c Stress Control: Large group didactic CBT classes for common mental health problems. In The Oxford Guide to Low Intensity CBT Interventions (2010). Bennett-Levy, Christensen, Farrand, Griffiths, Kavanagh, Klein, Lau, Proudfoot, Richards, Ritterband, White, and Williams, (Eds.), 2010. Oxford: Oxford University Press.
- White, J., 2010d Bringing the public on board: Health promotion and social marketing in deprived communities. In The Oxford Guide to Low Intensity CBT Interventions (2010). Bennett-Levy, Christensen, Farrand, Griffiths, Kavanagh, Klein, Lau, Proudfoot, Richards, Ritterband, White, and Williams, (Eds.) (2010). Oxford: Oxford University Press.
- White, J., Ross, M., Richards, C., Johnston, S., and Manson, V., 2011 Call-back: Improving access to a multi-level, multi-purpose primary care mental health team. Division of Clinical Psychology Newsletter, 4, 29-34.
- Grant, K., McMeekin, E, Fairful, A., Jamieson, R., Miller, C. and White, J., 2012 Attrition rates in a low-intensity service: a comparison of CBT and PCT and the impact of deprivation. Behavioural and Cognitive Psychotherapy, 40, 245-249.
- White, J., Ross, M., Richards, C., Manson, V., and Johnston, S., 2012 ‘Call-back’: Increasing access to, and improving choice in, a multi-purpose, multi-level low-intensity service. The Cognitive Behaviour therapist, 5, 124-136.
- Palmer, M.L., Henderson, M., Sanders, M.R., Keown, L.J. and White, J., submitted Study protocol: Evaluation of a parenting and stress management programme: An exploratory randomised controlled trial of Triple P Discussion Groups and Stress Control.
- Lynch, K., Stuart, S. and White, J., in preparation Are we overlooking deprivation?
- Fairfull, A., and White, in preparation Qualitative analysis of the first fifty ‘Call-back’ users.
- White, J., Petrie, S and Campbell, R., in preparation ‘Healthy Reading’: a complimentary or alternative approach to Book Prescribing?
- Stuart, S., and White, J., in preparation Qualitative analysis of ‘Stress Control’ users.
- White, J. (in preparation) How do we really make a difference in population-level mental health?
- Joice, A., and Mercer, S., 2010 An evaluation of the impact of a large group psycho-educational programme (Stress Control) on patient outcome: does empathy make a difference? The Cognitive Behaviour Therapist, 3, 1-17.
- Breese, L., Maunder, L., Waddell, E., Gray, D. and White, J., 2012 Stress Control in Prison Health Care: an audit. British Journal of Forensic Practice, 14, 292-301.
- Kellett, S., Clarke, S., and Matthews, L., 2007 Delivering group psycho-educational CBT in Primary Care: Comparing outcomes with individual CBT and individual psychodynamic-interpersonal psychotherapy. British Journal of Clinical Psychology, 46, 211-222.
- Kellett, S., Clarke, S., and Matthews, L., 2006 Session impact and outcome in group psycho-educative cognitive behavioural therapy. Behavioural and Cognitive Psychotherapy, 35, 335-342.
- Kellett, S., Newman, D.W., Matthews, L., and Swift, A., 2004 Increasing the effectiveness of large group format CBT via the application of practise-based evidence. Behavioural and Cognitive Psychotherapy, 32, 231-234.
- Kitchener, N.J., Edwards, D., Wood, S., et al., 2009 A randomised controlled trial comparing an adult education class using cognitive behavioural therapy (‘Stress Control’), anxiety management group treatment and a waiting list for anxiety disorders. Journal of Mental Health, 18, 307-314
- Menzies, R., Drysdale, S., Karatzias, T., and Macdonald-Wooley, M., submitted The effectiveness of ‘Stress Control’ psycho-education classes for a self-referred population.
- Van Daele, T. et al, 2012 Empowerment implementation: Enhancing fidelity and adaptation in a psycho-educational intervention. Health Promotion International. Advance online publication. Doi: 10.1093/heapro/das070
- Van Daele, T. et al, 2012 Reduced memory specificity predicts the acquisition of problem-solving skills in psycho-education. Journal of Behavior Therapy and Experimental Psychiatry, 44, 135-140.
- Van Daele, T. et al, 2012 Stress reduction through psycho-education: a meta-analytic review. Health Education and Behavior, 39, 474-485.
- Van Daele, T. et al, 2013 A psycho-educational approach to stress management: an implementation and effectiveness study. Ph.D. University of Leuven
- Wood, S., Kitchener, N., and Bisson, J., 2005 Experiencing of implementing an adult educational approach to treating anxiety disorders. Journal of Psychiatric and Mental Health nursing, 12, 95-99
- Wood, S., Morgan, P. and Bowen, M., 2006 Managing stress and anxiety: Education for adults in primary care. Primary Health Care, 16, 34-40.