Stress - Association of Reflexologists

Stress
A reflexologist’s guide
Introduction
Welcome to the stress information pack for AoR members.
This is an information resource to allow you to be aware of how allencompassing stress can be and how many biological systems it affects.
Three of the articles enclosed will be appearing in the next edition of
Reflexions, but they are so good that we thought you should read them
twice! It was important too that they be included in this comprehensive
document.
Stress is particularly important because we are being restricted in what we
can say courtesy of the Advertising Standards Authority, but they do let us
say that reflexology ‘helps relax; improves mood; aids sleep; helps relieve
tension and improves a sense of well-being’. Once you have read this
booklet you will see just how important those effects are on the reduction
of stress and how reducing stress can itself benefit the individual greatly.
The physiological reactions of chronic stress do harm, so if reflexology can
in any way help reduce this, then it has to be positive!
Happy reading.
Regards
Tracey Smith BSc FMAR
Reflexology Support Manager
Contributors:
Laura Occleston
Nikke Ariff MAR
Nayna Kumari MAR
Dorthe Krogsgaard HMAR and Peter Lund Frandsen HMAR
Photographs from iStockphoto.com
© Copyright of the Association of Reflexologists 2011
Although the AoR takes all reasonable care to ensure that the information in this communication is accurate, we
cannot guarantee that it is free from inaccuracies, errors or omissions. No information given by the AoR should be
taken as legal advice, nor should it take the place of medical care or advice given by primary healthcare providers. As
such, the AoR shall not be liable for any loss or damage whatsoever arising from any information contained in this
communication.
What is stress?
Stress is a physiological reaction in the body which
results in physical and emotional changes in the
body.
Pressure is a variant on stress, the same physiological
processes take place but when it is labelled pressure it
is positive. Pressure is the surge of adrenalin you get
when a deadline is approaching it gives you clarity and
the ability to work longer hours, but this situation only
needs to last for a short time, when you get to the end
of your deadline you can then stop and relax.
Stress is where pressure becomes long term and
outside the realms of the individuals coping strategy.
This can be a slow yet incremental change from
constant positive pressure to intensely draining
negative stress and this can affect both short term and
long term health.
When you feel stress, it is the body’s first response to
fear or a perception of danger. We might feel stress
when confronted with a dangerous animal for example,
or when a speeding car is heading for us
However, in today’s relatively safe environment, we are
more likely to feel stress when a piece of work is late or
approaching its deadline, or when we’re about to enter
a meeting with a manager. Although these things will
not inherently risk our lives when they happen, our
primal sense of danger detects a risk to our food supply
or comfort, and initiates a fear response in our bodies
to help us to operate at our best in order to deal with it.
This response is known as the ‘fight or flight’ response.
It is an intricate combination of nervous impulses and
hormonal interactions with the body which prepare it
to meet and survive danger. This has wide-ranging
effects within the body. Later in this booklet, you can
find a diagram of the effects this has on all of the
different parts of the body.
Hans Selye, the endocrinologist whose work pioneered
the exploration of stress in a pathological sense, defined
the difference between good and bad stress. Good stress
or eustress is agreeable and healthy; it keeps us full of life
and excited. It not only helps to save our lives, it also
helps us to put on that extra spurt of energy that allows us
to produce our best work or achieve the gold medal in
sport. Without it, life is dull and depressing. Eustress is
intended as a short term response to an immediate
problem, and should quickly fade once the thing we are
afraid of goes away. Our bodies and minds are designed
to cope with this fast and short-lived reaction, so it causes
no long-term ill effects. Eustress allows us to see life as a
challenge rather than a threat. Too much eustress can still
be damaging though and downtime from eustress is still
required.
Distress is the opposite; it is bad for health and
disagreeable. There is a variable range between the two
poles and how you react as an individual to any stressor is
dependent upon conditioning. Conditioning relies on
factors that influence the body’s receptiveness to a
stressor (or a hormonal response to a stressor). Different
levels of stress can provoke different responses in
different individuals depending on internal (endogenous)
or external (exogenous) effects. Internal effects might be
genetic predisposition, age or sex while the external may
be added factors like environmental factors or drugs.
What is stress?
preparing the body to run away or fight; the body
starts to become exhausted with the effort of
maintaining a constant state of readiness – and with
that exhaustion comes susceptibility to opportunistic
illnesses. In addition to this, our ability to withstand
day-to-day stimuli erodes, and we might find ourselves
feeling overwhelmed at the slightest challenge.
What are the symptoms of
stress?
Stress is a complex, multifactorial condition, which
affects a person on several levels. You may start off
feeling only one or two symptoms – however, this
condition is progressive if left untreated, and so the
longer you are stressed, the more symptoms you may
experience, and the more prone you will be to other,
opportunistic illnesses. Even mild levels of stress have
been linked to long term disability, so it is better to
prevent stress from occurring than waiting for it to
become major issue2. The most common symptoms
are shown overleaf.
References
¹ Lazarus R.S. (1966), Psychological stress and the coping
process, New York: McGraw-Hill
2
http://www.bristol.ac.uk/news/2011/7554.html
Selye H, Collip JB. Fundamental factors in the
interpretation of stimuli infuencing endocrine glands.
The most widely used definition of stress says that stress
is a condition that occurs when a person perceives that
“demands exceed the personal and social resources the
individual is able to mobilize”¹. According to the Oxford
dictionary, stress is “a state of mental or emotional strain
or tension resulting from adverse or demanding
circumstances” – in other words, stress is what happens
to the body when the level of pressure it is feeling goes
beyond its natural ability to cope with it. When this
happens, the body’s response to pressure goes beyond
Endocrinology. 1936;20:667–672
Selye, H. (1976) Forty years of stress research: principal
remaining problems and misconceptions. Can. Med.
Assoc. J. 115, 53–56
Friedman, M. & Rosenman, R. H. (1960) Overt behavior
pattern in coronary artery disease: Detection of overt
pattern behavior A in patients with coronary artery
disease by a new psycho-physiological procedure. JAMA
173: 1320-1325.
Psychologically, you might notice...

Emotionally, you might notice...
You find it hard to
concentrate or make
simple decisions

You feel tearful


You become more irritable than
usual
Memory lapses


You experience mood swings
Your thoughts/ speech becoming vague


You become extra sensitive to criticism
You become easily distracted


You become more defensive
You become less intuitive & creative


You feel out of control
You worry a lot more than usual


You feel much less motivated than usual
You have more negative thoughts than usual

You feel angry
You feel ‘down’ frequently, or you feel over-anxious frequently

You feel frustrated

You feel much less confidence than usual

You feel less self-esteem than usual
Physically, you might notice...
Behaviourally, you might notice...

You feel more aches and pains,
more tension in your muscles,
and you may grind your teeth

You feel you have no time for
relaxation or pleasurable
activities

You succumb to colds/infections more frequently

You become forgetful and prone to accidents

You are affected by allergies, rashes or skin irritations
either more frequently or for the first time

You become more reliant on alcohol, smoking,
caffeine, recreational or illegal drugs

You experience constipation, diarrhoea or IBS

You become more of a ‘workaholic’

You lose weight or gain it with more than usual
rapidity

You become less effective at time management and
produce poorer standards of work

You feel indigestion, heartburn or stomach ulcers

You are absent from work more often

You hyperventilate, feel a lump in the throat or feel
pins & needles in your extremities

You neglect or change your appearance


You don’t want to participate in social activities
You feel dizzy, and may feel your heart beating harder
and faster than usual


You experience more problems with personal
relationships
You may experience panic attacks and nausea


You suffer from insomnia or wake up tired after sleep
You may feel physically tired, even after rest


You become more reckless
You may experience menstrual changes, loss of libido
or sexual problems


Your behaviour and speech become more aggressive
and you experience outbursts of anger
You may experience heart problems and high blood
pressure

You frequently feel nervous

You find yourself uncharacteristically lying
Information from International Stress Management Association UK - http://www.isma.org.uk/about-stress/how-to-identify-stress.html
The stages of stress
Hans Selye, an endocrinologist who undertook much of
the early work on stress, defined 3 stages of stress. He
called this phenomenon a general adaption to stress.
1) Alarm reaction – body shows changes
characteristic of the first exposure to a stressor.
In the first stage the body feels the initial alarm and
then starts to adapt ie the body adjusts to the
stressor.
2) Stage of Resistance- resistance follows if the
continued exposure to the stressor is compatible
with adaption.
During the second stage the stressor has been present
long enough to become ingrained physiologically,
there is a change in function
3) Stage of Exhaustion – following long term
exposure to the same stressor, to which the body has
become adjusted, eventually adaptive energy is
exhausted.
This results in changes in the function and structure of
the body.
References
Selye H. Syndrome produced by diverse nocuous agents.
He found that stress itself does not cause problems but
continuous stress does. He also discovered that the body
only has just so much adaptive energy, when that is
depleted then exhaustion results.
This is further complicated by the type A/ type B
personality separation. Type A’s are seen to be the go
getting aggressive type of people while the B’s are more
laid back and relaxed. Actually there again there are
gradations between the two types. Type A’s were thought
to be more likely to have heart disease from a piece of
work by Friedman and Rosenman although this research
has now been questioned. These type of personalities live
on distress and to help their health they need to turn
distress into eustress.
Nature. 1936;138:32.
Selye H, Collip JB. Fundamental factors in the
interpretation of stimuli infuencing endocrine glands.
Endocrinology. 1936;20:667–672
Selye, H. (1976) Forty years of stress research: principal
remaining problems and misconceptions. Can. Med.
Assoc. J. 115, 53–56
Friedman, M. & Rosenman, R. H. (1960) Overt behavior
pattern in coronary artery disease: Detection of overt
pattern behavior A in patients with coronary artery
disease by a new psycho-physiological procedure. JAMA
173: 1320-1325.
The biology of stress
When it comes to stress, the hypothalamic-pituitaryadrenal link is the most important axis in the human body,
this is the junction where the brain chemistry, or
neurotransmitters interact directly with the endocrine
tissue to produce heightened reactions throughout the
body. It’s the point where brain activity meets hormones
and can result in dramatic effects.
The hypothalamus is a small piece of neurological tissue
the size of a pearl buried deep within the brain at the
ventral end of the diencephalon. Its job is to communicate
between the autonomic nervous system, behavioural
functions and the endocrine system. In the stress reaction
the sympathetic nervous system takes control and
heightens reactions. The hypothalamus has a complicated
series of arteries, capillaries and veins forming a
vasculature that delivers the hypothalamic hormones in
minute quantities directly into the anterior pituitary gland.
The two main hormones involved in this process are:


Corticotrophic releasing factor (CRF)]
adrenocorticotrophic hormone (ACTH)
These in turn cause the production of


Adrenalin and Noradrenalin
Cortisol.
The hypothalamus releases CRF which acts on the anterior
of the pituitary gland to produce ACTH. Normally this
happens in a pulse like process throughout the day, with
diurnal variations (fluctuations that occur throughout the
day). During acute stress this release increases causing the
adrenal glands to produce the two hormones adrenalin
from the medulla of the adrenal gland and cortisol from
the cortex, at higher levels. Adrenalin provides short term
essential requirements, like increased heart rate, elevated
blood pressure and boosts the release of energy into the
system. These are all critical when there is a perceived
threat, if a runaway car is heading straight for you, you
need to be able to mobilise and run. Cortisol however
has an effect on long term non essential requirements –
it is decreasing and suppressing. It decreases the
immune system and the inflammatory response. It
suppresses the digestive and reproductive systems,
reduces thyroid function and heightens sugar uptake. In
the short term the body stops actions that are not
required during times of danger. Digestion is not
necessary in the midst of battle and reproduction is a
bad idea if you are fleeing for your life. When this action
happens over the short term it is right for the body,
there is a prevention of non essential systems but in the
long term these effects are all highly negative to health.
Elevated cortisol levels from prolonged or chronic stress
can cause side effects such as suppression of thyroid
function, cognitive impairment, increased blood pressure,
decreased bone density, and blood sugar imbalances. High
levels of cortisol can also lower your immunity and
inflammatory responses, as well as slow down the wound
healing process.
The control over the HPA axis is the negative feedback
loop. As the production of cortisol increases so does its
effects on the pituitary which in turn reduces the amount
of cortisol produced. This same feedback also reduces the
production of the CRF release form the hypothalamus.
When the feedback loop is working properly increased
cortisol results in lessened cortisol production. The
neurological effects of the parasympathetic nervous
system also come into play, this is the opposite (or
angonist) of the sympathetic nervous system, it calms the
systems down to baseline. However, constant
hyperactivation of the stress response can unbalance the
entire feedback loop.
Recent research on stressed rats showed that they quickly
learnt to become habit driven, often pressing a food bar to
release food even when they were not hungry. This was
underpinned by changes in the brain physiology, the
neural circuits became re-wired leading to a loss of goal
directed behaviours (decision making) while the areas
related to habit formation had increased. They became
stuck in a rut. On the plus side however, when the same
rats were removed from the torments of being stressed,
they reverted back to their original abilities. Also the
structural changes in the brain changed back to normal –
the stressed brain situation was reversible.
In human terms this is a lesson in remembering to take
holidays.
References
http://www.vivo.colostate.edu/hbooks/pathphy
s/endocrine/hypopit/anatomy.html
Cortisol and The Stress Connection. John R. Lee,
M.D. and Virginia Hopkins Virginia Hopkins
Health Watch, One-to-One Inc., 2009
Hypothalamic–pituitary–adrenal axis,
neuroendocrine factors and stress. Constantine
Tsigos, George P. Chrousos Journal of
Psychosomatic Research 53 (2002) 865– 871
Chronic stress causes frontostriatal
reorganization and affects decision-making.
Eduardo Dias-Ferreira, JoÃo C Sousa, Irene Melo,
Pedro Morgado, Ana R Mesquita, João J
Cerqueira, Rui M Costa and Nuno Sousa, Science
325(5940):621-5 (2009)
The Hypothalamicpituitary-adrenal axis
The sympathetic response
at the organ level
When the body reacts to a stressor, it brings into play
the sympathetic division of the autonomic nervous
system. This begins the cascade effect within the body
which prepares you to either fight the stressor or get
away from it. Much of the body’s response to stress
relies on the control the sympathetic nervous system
exerts over blood supply and the endocrine system.
When it appears that the stressor has gone away, the
body activates the parasympathetic division of the
autonomic nervous system, which stimulates the
various systems of the body to return to homeostasis.
Cognitive function
In order to facilitate a fast response from the body, blood
flows away from the parts of the brain associated with
rational thought and memory to enrich the supply of those
parts of the brain used to calculate whether to fight the
threat or run away, and those parts of the brain involved
with doing just that. This means that in a stress response,
the individual might not be able to concentrate on higher
order functions such as speech, reading, etc, and they
might have trouble remembering what was said to them
at the time they perceived the threat.
When the stress response becomes more prolonged,
those parts of the brain involved with higher-order
function may become starved of blood, and thus may lose
some function permanently, resulting in memory loss,
speech impediments and learning difficulties.
The cardio-pulmonary-vascular
systems
When preparing to fight or run away, the body knows it
needs to provide more oxygen and nutrients to the parts
of the body which will enable you to succeed at this. The
blood is the body’s carrier of both of these substances.
Therefore, the body must ensure that the blood supply to
the various organs involved with the fight or flight response
is swift, well oxygenated and plentiful.
To do this, the heart rate increases, thus increasing the
speed at which fresh blood reaches the fight or flight
organs, and the volume of blood that is pumped through
the arteries in any given minute. This raises blood pressure
(the pressure exerted on the walls of the arteries by the
blood due to the contractions of the heart). As a short term
response, the muscles of the heart and artery walls are built
to be able to cope with this increased workload; however,
should the stress response become more prolonged, these
muscles will become more fatigued and therefore more
susceptible to problems.
In order to fight or run away with maximum success, the
muscles will need to respire as efficiently as possible, in
order to provide the extra energy needed for more vigorous
muscle exercise. As you may know, the most efficient form
of respiration is aerobic respiration, which requires oxygen.
Therefore, the more vigorous the exercise, the more oxygen
will be needed. Whether you are fighting or running away,
you will need to exercise very vigorously indeed, for an
unspecified length of time. In order to prepare you for this,
part of the pressure response is that the body makes the
breaths you take more rapid and shallow, making sure that
the level of fresh oxygen in the lungs (and therefore passing
into the blood) is as high as possible.
The muscular system
When one thinks of fighting and running away, the
muscular system naturally takes centre stage. When the
body identifies a threat, the first thing it does is decide
which muscles are going to be useful to it in this situation
(i.e. peripheral skeletal muscle) and which aren’t (i.e. most
of the smooth muscle in the body).
In order to enable you to perform at your best, the body
ensures that there are sufficient supplies of oxygen and
nutrients available for aerobic respiration to take place in
the necessary muscles even under strenuous exercise. This
means that the body provides a path of least resistance for
the blood to rush to the muscles that require it most
through vasodilation (making the blood vessels supplying
these muscles wider so more blood can flow through
them), taking blood away from the organs that the body
deems irrelevant to the response via vasoconstriction
(making the blood vessels supplying irrelevant muscles
narrower so less blood can flow through them). In order to
provide sufficient nutrients for maximum supply of energy,
fat and glucose are released from storage into the blood
stream to be carried where they are needed most.
An interesting point to note is that the peripheral muscles
tense in anticipation of fighting or running away. This may
seem odd as on the surface, this seems to impede smooth
movement. However, if you have ever taken a blow with
your muscles tensed, you will know why the body does this
– the tense muscle provides an extra layer of protection
against the blow, meaning that it not only does less damage
to the delicate organs beneath, but it hurts less, too!
However, this can become a problem if the tension is
sustained for longer periods of time as would be the case in
sufferers of long term (chronic) stress. In the case of chronic
stress, the muscles remain tense for so long that they begin
to enter into a state of exhaustion and strain, which results
in aching pains within the muscles.
The senses
In order to see an object, the human eye must take in
different wavelengths of light reflecting off it; the brain
then processes this information to produce the image that
you see. As you may have noticed through personal
experience, it is much easier to see your surroundings when
there is a lot of light to reflect off them (e.g. in daylight/
electric light) than it is when there is less light (e.g. when it
is night time and there are no lights on). In In total darkness
we can see nothing at all.
Therefore, whenever we want or need to see more clearly,
we naturally seek to ‘switch the light on’ – and our bodies
act in much the same way: the pupils of our eyes dilate to
let in as much light as possible and therefore more
information about what we are seeing.
In the fight or flight response, the body knows that in order
to be able to fight or get away successfully, we need to be
able to see our adversary clearly and perceive their
movements in minute detail in order to work out what
they’re going to do next. To do this, the body will make the
pupils dilate to let in more light (and therefore more
information) even in broad daylight.
To help with this, the brain will automatically discard any
sensory input other than that relating to the threat in order,
which helps the body to avoid sensory overload. This means
that a person might develop what is known as ‘tunnel
vision’, where the only thing they can see is their adversary
as they focus in to gain the level of insight that might just
save their life. Their hearing may muffle so that the only
things they hear are the movements of their opposition.
Their sense of taste may be reduced or removed, as the
brain judges it irrelevant to the task at hand.
Pain perception is also reduced to help you carry on fighting
or running for as long as possible.
The digestive system
As you may know, the body does not have an unlimited
supply of blood, although it can make adjustments to
increase the available supplies of blood a little. In order to
compensate for this, the body constricts the blood supply to
any organs not directly involved with enabling the body to
fight or run away.
One of the places in which the blood supply constricts is the
digestive system. Have you ever had that sick feeling in your
stomach when you’re afraid? Or stomach cramps? These are
caused by the blood flow away from the smooth muscle of
the digestive tract, which causes less oxygen to be available
for these muscles to be able to respire aerobically. Instead,
the smooth muscle of the digestive tract begins to respire
anaerobically (without oxygen), producing a by-product
called lactic acid, which causes the muscles to become
irritated and thus feel cramped.
In order to reduce anaerobic respiration as much as possible,
the body slows down digestive processes (both mechanical
digestion and the secretion of digestive juices from saliva
to gastric juice) so that not as much energy is needed.
This means that food takes much longer to digest and
that the body is much less efficient at digesting food – if
digestion happens at all.
Normally, when the stressful situation is over, the
parasympathetic nervous system takes over and returns
the body to homeostasis, thus allowing digestion to
resume without impediments. However, with prolonged
stress, the muscles of the digestive tract become
malnourished and cease to function effectively. This
might lead to periods of spasm and cramps (such as in
IBS), periods of constipation, or reduced effectiveness
at extracting nutrients from the food for use in the
body.
The urinary system
Another further system the body considers irrelevant to
the fight or flight response is the urinary system. As with
the digestive system, this means that blood flows away
from the urinary system towards those organs more
associated with the fight or flight response (such as the
muscles on your arms and legs). The result of this is loss
of voluntary control over the muscles of the urinary
system, meaning that you lose the ability to retain the
urine until a convenient time. Over the short term, this
might mean a powerful and frequent desire to urinate;
over the long term, this can result in incontinence, as
the muscles become starved of nutrients and therefore
weaker.
The reproductive system
Again, the reproductive system is seen by the body as
irrelevant in the stress response. This means that blood
supply to the organs of the reproductive system becomes
restricted as the blood is directed to those organs directly
concerned with fight or flight, leading to malfunction of the
reproductive organs. A long term stress response can lead to
erectile dysfunction in men and an impaired lubrication
function in women, as well as a reduction in sexual desire
(through lack of blood supply to the higher order parts of the
brain which contribute to sexual desire).
The sympathetic nervous system in the body
Stress and the individual
Stress is a process that shows as very different symptoms in different people. It is variable and therefore it is up to
the individual to be aware of the changes and of how it affects them specifically. There is certainly an argument for
GP’s and workplaces to be aware of stress as it is estimated that:

Days lost to stress, depression, anxiety and other mental health issues cost UK employers around £28.3
billion per year
So employer awareness of the issue is not only important, but it is also a legal necessity.
However, it is equally important that individual accept personal responsibility as well, not perhaps for the fact that
they are stressed - the causes of this may be out of their control, but of the recognition that they are stressed. There
are recognised methods of self-help, some may come automatically to a person, other methods may need more
effort or even prompting from friends and family. Some methods of counteracting stress are constructive, others
destructive. It is of course important in taking personal responsibility that the individual choose carefully when
deciding the route to take.
Constructive self-help methods
1) Regular complementary therapy – we recommend reflexology here. An hour of manual therapy allowing
personal space may be very beneficial.
2) Regular exercise to suit the individual, for some this may be a team sport for others something more
individual like golf, dancing or yoga
3) Reduction in stimulants. This is not just coffee - tea and most cola based drinks contain high levels of
caffeine. Some energy boosting drinks are equal to multiple cups of coffee. Even chocolate contains
caffeine although at lower level. Alcohol, cigarettes and recreational drugs are also all stimulants. Adding
further stimulants to an already hyper stimulated system is not helpful.
4) Healthy eating, the increase in cortisol can make you crave unhealthy foods, high in fat sugar and salt.
Eating the right foods can help reduce the cravings and even replenish vitamins and minerals that are
being depleted by the stress.
5) Doing something creative, this can be anything from drawing to sewing to singing, what suits the
individual.
6) Increasing contact with your social relationships – visiting family and friends more
7) Meditation or at the very least deep breathing
8) More laughing! Smiling and laughing are thought to reduce stress levels and smiling uses fewer muscles
that frowning.
9) Taking on processes to learn how to cope – for example challenging unhelpful thoughts.
http://www.moodjuice.scot.nhs.uk/stress.asp
Destructive self-help methods
These are actually the opposites of the ones on the previous page. Particular ones to watch out for are…
1) Increased alcohol intake. The habit of one small glass of wine per night slowly increases to two large
glasses.
2) Increased use of stimulants especially recreational drugs
3) Changes in eating patterns – more or less
4) Increased release of anger / frustration
5) Lack of motivation in down time – zoning out with the TV or computer.
References:
http://www.medicinenet.com/script/main/art.asp?articlekey=55897&page=2
http://coffeetea.about.com/od/caffeinehealth/a/How-Much-Caffeine-Is-In-Coffee-Tea-Cola-And-Other-Drinks.htm
http://helpguide.org/mental/stress_management_relief_coping.htm
Stress at work
Definition of stress
HSE's formal definition of work related stress is:
"The adverse reaction people have to excessive pressures
or other types of demand placed on them at work."
Stress is not an illness – it is a state. However, if stress
becomes too excessive and prolonged, mental and
physical illness may develop.
Work is generally good for people if it is well designed, but
it can also be a great source of pressure. There is a
difference between pressure and stress. Pressure can be
positive and a motivating factor, and is often essential in a
job. It can help us achieve our goals and perform better.
Stress occurs when this pressure becomes excessive.
Stress is a natural reaction to too much pressure.
Balancing demands and
pressures with skills and
knowledge
A person experiences stress when they perceive that the
demands of their work are greater than their ability to
cope. Coping means balancing the demands and pressures
placed on you (i.e. the job requirements) with your skills
and knowledge (i.e. your capabilities). For example, if you
give a member of your team a tight deadline on a project
they feel they have neither the skills nor ability to do well,
they may begin to feel undue pressure which could result
in work related stress.
Stress can also result from having too few demands, as
people will become bored, feel undervalued and lack
recognition. If they feel they have little or no say over the
work they do or how they do it, this may cause them
stress
http://www.hse.gov.uk/stress/furtheradvice/whatisstress.
htm
Ethical considerations
Good employers would wish to do as much as they
reasonably can to reduce the risks of ill health caused by
work.
Legal considerations
The law requires an employer to tackle work related stress.
“Employers have a general duty to ensure, so far as is
reasonably practicable the health of their employees at
work”
(The Health and Safety at Work Act 1974)
“Must take account of the risk of stress related ill health
when meeting the legal obligations”
(Management of Health and Safety at Work Regulations
1999)
There are management standards for tackling work related
stress and these available through the Health and Safety
Executive. These standards expect organisations to carry
out suitable risk assessments for stress.
Tackling business stress brings business benefits in terms of







Employee work commitment
Staff turnover
Staff productivity and performance
Absenteeism levels
Recruitment and retention of staff
Organisational image and reputation
Last but not least reduces the chance of potential
litigation.
Loss of a member of a team through stress related illness
can have a serious effect on the rest of the team in terms of
work load and morale.
Tackling stress prevents ill health
days per worker.
http://www.hse.gov.uk/statistics/causdis/stress/dayslost.htm
In 2005/6 work related stress, depression and anxiety cost
Great Britain in excess of £530 million.
http://www.hse.gov.uk/press/2007/c07021.htm
There is also the problem of presenteeism – employees
attending work but not adding value while they are there,
due in part to the fear of being off sick. This is made worse
in times of recession where employees are also concerned
for their jobs. The Sainsbury Centre for Mental Health
(2007) estimated that presenteeism attributable to mental
health in the UK accounts for 1.5 times as many working
days lost as absenteeism.
Research has shown that prolonged periods of stress

can have physical effects such heart disease, pain,
headaches, reduced immunity and gastrointestinal
problems

can have psychological effects like anxiety and
depression. One study stated that in 1998 the
psychological conditions most likely to be seen by
occupational health doctors were anxiety and
depression (73%) and stress (56%).
References
Psychological Stress and the Human Immune System: A
Meta-Analytic Study of 30 Years of Inquiry Suzanne C.
Segerstrom and Gregory E. Miller Psychol Bull. 2004 July;
130(4): 601–630.
The scale of perceived occupational stress. A Smith.
2000, Occup Med. Vol 50, 294-298
Improving mental well-being in the workplace, D M
Miller. Occup Med, 47 (19980 PP 463 -467.
Economic considerations
In 2009/10, an estimated 9.8 million working days were lost
through work-related stress. On average, each person
suffering from work-related stress took an estimated 22.6
days off in 2009/10. This equates to an annual loss of 0.42
Promoting mental wellbeing at work, (NICE public health
guidance 2009) used the estimate made by the Sainsbury
Centre for Mental Health showing that positive steps in
line with the guidance recommendations to improve the
management of mental health in the workplace, including
prevention and early identification of problems, can result
in savings of 30%. They estimated that savings of £250,607
are possible for an organisation with 1000 employees.
Reflexology in the workplace
From small studies carried out in Denmark at the
beginning of the 90’s, there are indications that employing
a reflexologist can have a large effect in terms of sickness
and absenteeism. A study based in a health department in
Ishoj Denmark showed that not only was there a saving of
hundreds of thousands of Kroner over the period of time
the reflexologist was employed, through reduced sick
leave, but the fact that employees could get immediate
treatment meant there were no long term sick reports
filed during the same period. A similar study in Tastrup
Telecom quoted ‘There is a direct economical benefit as
well as increased wellbeing and productivity of the
employees’. Other Danish companies found that they
made savings because they all experienced significant
drops in absence due to illness after employing a company
reflexologist. They also found that because the employees
felt the companies were doing something for them there
was increased loyalty in return.
Forende Danske Zoneterapeuter
(Danish Reflexology Association) Reports 1993
Stress and women’s fertility
We already know that stress is a complex, multifactorial
condition which affects almost all parts of the body in
some way. However, did you know that there is also
some evidence to suggest that it may affect fertility?
It is suggested that the mechanical link between stress
and fertility is mainly an endocrine one.2 It all begins in
the brain’s ‘bridge’ between the nervous system and the
hormonal system: the hypothalamus. As well as fulfilling
a nervous function, the hypothalamus is also able to
secrete a small range of hormones. One of these
hormones is called gonadotrophic-releasing hormone
(GnRH). This has only one job: to pass into the anterior
(front) lobe of the pituitary gland and cause the release
of two further hormones associated with sexual
function: luteinising hormone (LH), which prepares the
lining of the uterus to receive an embryo, and follicle
stimulating hormone (FSH), which stimulates the ovaries
to release an ovum (egg) into the fallopian tube.
When a person is stressed, the hypothalamus secretes a
substance called corticotrophin releasing factor, which
is a neurotransmitter that passes from the
hypothalamus to the pituitary. This stimulates the
anterior part of the pituitary gland to produce
adrenocorticotrophic hormone (ACTH), which is a
message-carrying hormone which passes through the
blood stream to stimulate the adrenal glands. In
response to this hormone, the adrenal glands begin to
produce adrenalin, noradrenalin and cortisol.
It is suggested that glucocorticoids (a group of
hormones including cortisol, which are associated with
the stress response) stimulate the release of a hormone
known as gonadotrophin-inhibitory hormone (GnIH),
which suppresses the production of GnRH in the
hypothalamus. GnIH suppresses the production of FSH
and LH. In a woman, this would mean that there would
be less of a chance of her releasing an ovum to be
fertilised in the first place – and it may also mean that
even if the ovum is fertilised, the uterus may not be fully
prepared to receive the embryo. This may lessen the
likelihood of the pregnancy progressing beyond
fertilisation, as the embryo would not be able to embed
in the endometrium (uterine lining) and begin to grow.
References:
H. Selye (1950) The physiology and pathology of exposure
to stress: A Treatise Based on the concepts of the generaladaptation-syndrome and diseases of Adaptation, Acta,
Inc., Montreal
Moberg, G.P, (1987) Influence of the adrenal axis upon the
gonads. In Clarke, J.R, (ed), Oxford Reviews of
Reproductive Biology, Vol. 9. Clarendon Press, Oxford, pp
456 – 496.
S.L. Berga, T.L. Davies and D.E. Giles (1997) Women with
functional hypothalamic amenorrhea but not other forms
of anovulation display amplified cortisol concentrations. In
Fertility and Sterility Vol 67 No. 6, pp 1024 – 1030
M.D. Marcus, T.L. Loucks, S.L.Berga (2001) Psychological
correlates of functional hypothalamic amenorrhea. In
Fertility and Sterility Vol 76 No. 2, pp310 – 316
K.A. Sanders and N.W. Bruce (1997) A prospective study of
psychosocial stress and fertility. In Human Reproduction
Vol 12 No. 10, pp2324 – 2329
G.M. Buck Louis, K.J. Lum, M.S. Rajeshwari Sundaram, Z.
Chen, S. Kim, C.D. Lynch, E.F Schisterman, C. Pyper (2010)
Stress reduces conception probabilities across the fertile
window: evidence in support of relaxation. In Fertility and
Sterility Vol 95, No 7, pp 2184 – 2189
2
As above, and E.D. Kirby, A.C. Geraghty, T. Ubuka, G.E.
Bentley and D. Kaufer (2009) Stress increases putative
gonadotrophin inhibitory hormone and decreases
luteinizing hormone in male rats. In PNAS Vol 106 No. 27,
pp 11324 - 11329
Stress and the digestive system
Frequently stress is understood to be rooted in
psychological stress. This has meant that stress and the
biological changes seen in the digestive system have
been seen to be unrelated in the past. However, recent
understanding of the neurobiology of both acute and
chronic stress and its involvement through the braingut interaction is beginning to produce a different view
on chronic stress and its effects on the causes and
management of functional gastrointestinal disorders.
The onset of, or worsening of symptoms of some of the
most common gut related illnesses such as
inflammatory bowel disease(IBD), stomach acid reflux
and peptic ulcers have been associated with stressful
life events. Research has shown that life events from
early life, for example childhood abuse increases the
chance of contracting IBD in adult life or acute life
threatening instances for example linked to post
traumatic stress disorder have been shown to increase
the chance of functional gut disorders. These examples
are obviously the extreme end of stress, the link of any
stress to digestive illnesses may of course result in less
serious issues. This research also shows there can be a
short length of time between the stressor and the
affect or it that could be years from the point of stress
to the worsening of symptoms.
Stress can be caused by acute real or perceived threats
to the homeostasis of the body, these threats evoke an
adaptive response to retain the homeostasis and
protect the body’s survival. This ability to defend
homeostasis has been termed allostasis. The stressors
may be varied but the principles behind the response
stay remarkably similar. The pathway behind actual
physical stress, like a gut infection, involves the
hypothalamus and is a simple reflex response mediated
by neurones. Psychological stressors however, pass
through the brain including the cortex, hippocampus
and amygdala; these areas are involved in putting the
stressor ‘in context’ including memories of past stress
and personal beliefs.
In healthy individuals, the stressor causes a short term
activation of the response system, turned on and off in
relation to the duration and potential level of harm the
stressor could cause, thus limiting the harmful effects
of the stress response. However, in situations where
the stress remains chronic; is severe or where the
resulting physiological actions cause damage, this can
predispose an individual to acquire new diseases –
where the body becomes maladaptive. This is
particularly the case when the individual’s response to
stress and the ability to adapt has previously been
altered due to genetic or early life events, this can lead
to an increased susceptibility to the effects of stress
throughout life. Other factors can also affect this
susceptibility including cognitive factors and
environmental support.
Emotional biology of stress and
the digestive system.
In response to stressors, the brain has parallel outputs
of the brain’s central wiring (or emotional motor
system), these are responses from the autonomic
nervous system, the endocrine system and the pain
system via sensory modulation. Adrenalin has a positive
effect on the EMS heightening vigilance while the
endocrine response increased of cortisol has a negative
effect. The increase in any one of these three areas causes an increase in gastrointestinal symptoms. The autonomic
nervous system has a variability of action via different sympathetic neurones- some of the regulated pathways are
mucous production by the goblet cells of the large intestines, net water absorption by the gastrointestinal epithelial cells,
permeability of the mucosal layer and immune reactions in the gut. So it’s fairly easy to see how this can link stress to
many digestive disorders.
The emotional involvement of stress and
gastrointestinal disease
Increased
vigilance
Life events
Psychological
stress
Feelings
Physical
stress
Emotional motor
system
+ve effect
-ve effect
Adrenalin
Cortisol
Autonomic
nervous system
Pain via sensory
modulation
Endocrine
response
Gastrointestinal pathology resulting in
symptoms
From- Review: The neurobiology of stress and gastrointestinal disease, E A Mayer, Gut 2000;47:861–869
Stress and the immune system
The understanding of stress and the immune system has
been achieved by over 300 research studies since stress
was first described. Stressors can be categorised into types
depending on the duration and course of the stress – how
long it will be present and whether it is continuous or not.
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Acute stressors – lasting only minutes, for example
public speaking – can cause adaptive up regulation
of natural immunity and down regulation of
specific immunity. (Increased ability to fight
infection but reduced specific response)
Brief naturalistic stressors for example taking
exams presents a short term challenge –
suppresses cellular immunity while preserving
humoral immunity. (Preserved specific response but
less ability to fight infection)
Stressful single events- like the loss of a family
member or a natural disaster, these result in high
stress but there is a sense that the stress will
subside at some point in the future.
Chronic stressors- these pervade a person’s life
and there is no awareness of when it might end.
This form of stress suppresses both cellular and
humoral immunity. (Total reduction in immune
response)
Distant stressors – traumatic experiences that
occurred in the past yet are still causing long lasting
change in both emotional and cognitive behaviours
that result in modification of immune system
function. For example having been a prisoner of
war.
Other effects on the individual’s ability to cope with
stress may come from psychological challenges these
can further modify the immune response. The immune
system is actually very flexible to change and usually
keeps the body safe however this can also be
compromised by age and illness. Older adults are less able
to respond to vaccines and to mount cellular responses
which protect against malignancy. When disease is
present there is also the effect of loss of self regulation,
this is where the body recognises itself as self, as opposed
to foreign tissue which needs to be destroyed and this can
result in an increase in autoimmune diseases.
Immune responses
Natural immunity is not specific and is not protection
against specific pathogens but is an all purpose reaction.
This response has a short time frame (minutes to hours)
and is mainly produced by cells from the granulocyte
family such as macrophages and neutrophils. These cells
engulf and destroy invading microorganisms. They gather
at sites of infection and via cytokines produce
inflammation and fever, they are also important in wound
healing. There is also the natural killer cell which responds
to molecules on a cell surface that indicate it is not wholly
self, for example cancerous cells and virus infected cells
display these molecules. These cells are important in
limiting virus infections and controlling malignant cells. On
top of this is a family of proteins called complement, these
bind and enhance the engulfing properties of the
macrophages and neutrophils.
Specific immunity is specific but it is also slower, it can
take several days. This is about recognition of a particular
antigen (foreign molecule on the surface of an invader)
and the production of a cell that specifically recognises
only that antigen. This may come from having seen that
antigen before via a previous infection or by having
received it to promote immunity via a vaccination. This
prior knowledge allows for a quicker reaction than if the
antigen is previously unknown. A cell that recognises the
antigen becomes activated and then proliferates and
produces a population of cells to fight that infection.
However, natural immunity is relied upon to contain the
infection during the time the specific response takes to
react fully. The cells involved in the specific response are B
cells and T cells. B cells produce specific antibodies which
is the humoral response. T cells are responsible for the
cellular response. T cells are split into two groups - killer T
cells and helper T cells, helper T cells are in turn broken
down to T helper 1’s and T helper 2’s. The cytokines
produce by the Th1’s are involved in defence against
infection and malignant cells, but suppression of this
phase can lead to the production of more Th2 cytokines.
Th2 cytokines activate humoral immunity which in turn
increases the response to allergies and autoimmune
disease.
In summary, stress can affect all the levels of the immune
response. Depending on the type of stress, its duration
and course, different parts of the immune system are
affected at worst when stress is chronic all of the immune
response is suppressed. Managing stress therefore is
intrinsically linked to wellbeing and keeping well.
References:
Psychological Stress and the Human Immune System: A
Meta-Analytic Study of 30 Years of Inquiry Suzanne C.
Segerstrom and Gregory E. Miller.
Psychol Bull. 2004 July; 130(4): 601–630.
Stress Weakens the Immune System American
Psychological Association, February 23, 2006
Stress and the endocrine link
In 2010, the Health and Safety Executive reported that
“stress is the second most commonly reported type of workrelated illness” with 2009/10 figures estimating that
435,000 people were suffering from work-related stress.
Many of our clients will come to see us for reflexology,
reporting stress as one of their symptoms. An oft ‘bandied
about’ term, stress reflects an over stimulation of the
sympathetic nervous system, commonly known as the ‘fight
or flight’ response. It can manifest itself in many guises,
depending on the circumstances for each individual.
Hans Selye, a Canadian endocrinologist, was the first person
to officially coin the word stress as a pathological condition
in the 1930’s. He conducted research using mice into which
he injected various extracts and found that the mice all
displayed the same symptoms even though the irritating
substances were all different. Observing the human
response to illness, he noticed that different diseases would
manifest similar symptoms – in other words, the body had a
‘pattern’ to its response when ‘irritated’.
In 1976, Selye defined stress as “the nonspecific response of
the body to any demand”, where nonspecific indicates that
symptoms “can be elicited by numerous agents [in the body]
that make an intense demand upon the adaptability of the
organism”. He developed his theory of stress called General
Adaptation Syndrome (GAS), which suggested that the body
reacts to stress in three phases:
Phase 1: The Alarm Reaction
This involves the various degrees of stimulation of the
sympathetic nervous system known as the ‘fight or flight’
response – the overall effect of which is to generate an
emergency source of energy to confront or flee from real or
perceived danger.
Phase 2: The Stage of Resistance
If the stressful circumstances persist, the body’s coping
mechanisms become more drained and progressively less
efficient, as the short-term design of the ‘fight or flight’
response becomes chronic. The glands, nervous system and
organs become affected through prolonged stimulation to
maintain the body in ‘high defensive - offensive’ mode,
which doesn’t necessarily manifest in observable symptoms;
however, the organism as a whole is under strain.
Phase 3: The Stage of Exhaustion
This is where the body starts to manifest symptoms of wear
and tear from unrelieved and chronic stress. These signs
can reveal themselves in many guises: energy levels,
psychological, behavioural and emotional aspects.
Selye identified these three stages of stress in terms of
“glandular states” (he was an endocrinologist after all),
attributing GAS in terms of the hypothalamic-pituitaryadrenal (HPA) axis and its interface with the nervous
system. Today, this forms the basis of neuro-endocrinology
- the study of the electrical and chemical control systems of
the body.
When the brain perceives a stressful event, the
hypothalamus is the first to respond by stimulating the
pituitary to release adrenocorticotrophic hormone (ACTH)
into the blood stream, which activates the adrenals to
release cortisol. Simultaneously, the brain stem is also
activating the autonomic nervous system, together
ensuring that the chemical (hormonal) and electrical
(nervous) alarm systems of the body are fully responding.
When you consider the stress response in these terms, i.e.
not just the sympathetic nervous system acting in isolation
but in context of the hormonal impact, which actually
triggers the whole cascade effect – it is much easier to
understand why the symptoms of stress at the various GAS
stages devised by Selye can have such a generalised, nonspecific, ‘all body’ effect.
So how does the stress response manifest apart from the
physical symptoms we know so well: faster breathing
pattern, heart beat pounding, tense leg and arm muscles,
dry mouth, sweating, eyes focused and pupils dilated, to
name but a few –remember, Selye’s experiments revealed
there was a response pattern to the organism’s exposure to
irritation.
Stress can be a very ‘personal’ response - after all, it is a
perceived version of events measured against an
individual’s interpretation of reality. For example, the boss
might come into the office and one employee responds by
thinking “Wonderful, I’ve been waiting to see her all day! I
can now ask for some holiday time,” where another
employee may react nervously “Oh no, I had better look
busy or she will ask me how the report is getting on!” So
these personalised stress responses could include looking at
stress from the following perspectives: emotional,
cognitive, behavioural and psychological.
An emotional stress response will include fear,
terror, anger, helplessness, anxiety, panic and
feelings of vulnerability, to name a few.
Usually these symptoms will dissipate after the stressful
event has ended; however, there is the risk that the
emotional memory of the event will linger, and with time
and/or mental repetition becomes ‘embedded’ as the
reaction is replayed over and over again in the person’s
mind in the attempt to process and exorcise the memory of
it. If the individual has not been successful in processing
their experience of the event, their unconscious or
psychological ‘scar’ can manifest in psychoemotional based
symptoms including depression, panic attacks, feelings of
insecurity or unexplained anxiety, often without a direct
link to the original stressful event.
Cognitive stress responses can manifest as memory issues
(a type of ‘selective’ or total amnesia) surrounding the
event, lack of concentration, general poor memory, or
experiencing a ‘foggy’ brain. The person will usually utilise
negatively framed language when referring to the event or
incident including ‘catastrophising’ – a form of negative
over-exaggeration such as “I thought I was going to die” or
“I’ll never be able to look at that building ever again”. This
very real ‘dramatisation’ of the event turns up the volume
on all sensory levels and can even re-create the
physiological symptoms associated with the stress response
as they re-live the experience in full technicolour. The risk
here is that the person might fall into a vicious cycle by
replaying a ‘tainted’ version of the actual events and
thereby delaying, hampering and - to a degree suppressing their recovery.
Behavioural responses to stress are overt and perhaps
easier to identify. The client’s voice may start to falter as
they describe the event (even years after), their facial
expression may be tense or ‘pained’, they may fidget,
tremble, stutter or revert to substance abuse as a means
of coping (alcohol, ‘comfort’ eating, drugs and
medication).
Psychological stress can be described as the person’s
response in terms of how they emotionally and rationally
think and/or feel about their ‘safety’, post-event or as the
stressful situation continues. Their success in dealing with
the stress created by their personalised and perceived
version of events will be dictated by the coping skills they
have learnt and developed. Where the client’s personal
resources are lacking or limited, coping strategies can take
the form of denial or repression – both of which have the
potential to distort the facts of the event.
Other more positive and pro-active psychological stress
coping mechanisms include: taking control of the event or
how they are responding to it; predicting the stressful
event (e.g. anticipating a deadline and preparing in
advance for it); getting social support from family and
friends; and positive thinking, which can lead to problem
solving – the ‘glass is half full’ mindset. There is lots of
research available on the success of coping skills in
managing stress. So how effective are reflexology methods
in alleviating the multi dimensional aspects of the stress
response within an individual? The good news which many
of us therapists already know from anecdotal evidence in
our daily practices, is that any relaxation in an individual
means that the parasympathetic nervous system is being
engaged, and this immediately turns down or ‘switches
off’ the sympathetic nervous system. This means the mind
and the body are receiving a positive respite from the
repeating and ‘nagging’ onslaught of the biopsychosocial
response and that can only be a good thing!
Nikke Ariff MAR
References:
http://www.hse.gov.uk/statistics/causdis/stress/scale.htm
Selye, H (1936), A syndrome produced by nocuous agents.
Nature 138: 32
Selye, H (1976), Forty years of stress research: principal
remaining problems and misconceptions. CMA Journal 115:
53 - 56
Traumatic stress
Traumatic stress is much more common than was
previously understood and is associated with a substantial
level of debility. Traumatic Stress as a result of disasters,
accidents and shootings – the so called ‘one-off blow’ has been well documented by the media. But the effects
of prolonged trauma are less well known. Also known as
Complex Stress, this is where there has been an
accumulation of traumatic experiences such as in cases of
bullying or other emotional or physical abuse where each
incident is a trauma in itself. Or, the client may have
experienced multiple traumas of different types. People
each have a unique threshold for how much traumatic
stress they can contain without dealing with it. Once this
threshold is reached, the traumatic response begins to
spill into everyday life. Should you meet such a client, this
article may help you to recognise the signs and help them
to contain their feelings until you are able to direct them
to specialist help.
The confusing thing about responses to trauma is that
one model very definitely does not fit all. Clients present
with an assortment of physical and emotional adaptations
which could be attributed to a range of conditions, and
often both practitioner and client are baffled when
advances made during the course of the treatment begin
to slip away.
The Client
The physical signs of anxiety can be easily misunderstood
and are often misdiagnosed as symptoms of organic
illness. Most clients do not present complaining of
‘Traumatic Stress’. Instead they may list a catalogue of
symptoms for which there is no apparent medical
explanation. Clients may say that they have tried
everything, and are now desperate.
Individually, any of the indications seen on the right can
be explained by other means, but you need to be alert to
clients presenting with more than one.
Clients may present with:

Sleep disturbances

Nightmares

Waking up more tired than when they went
to bed

Exhaustion and listlessness throughout the
day – despite having slept all night

Feeling ‘spaced out’

Memory problems

An inability to concentrate

Problems with personal boundaries

Fluctuating symptoms

Inexplicable aches and pains

Feeling worse after relaxation

Feeling worse after exercise
The Nervous System
To deal with a stressful situation the body initially goes
into full alert to best meet the oncoming threat. This
response is designed to be short-lived and intense. Once
the crisis is over, the alarm response is halted and the
body returns to normal. However, if the fear continues, as
in instances of prolonged trauma, the body moves into
Resistance. The alarm response is maintained until the
body reaches Exhaustion (the stage where the body can
no longer function on overdrive). This can be experienced
as extreme fatigue and listlessness. Some people develop
an increased sensitivity and irritability to external stimuli,
such as noise, additional chores or tasks, other people,
food - in fact anything which the body regards as one
stressor too many. In essence the client has reached a
state of exhausted hyperarousal – also known as
‘overwhelm’ - where their mind and body are unable to
take in or process any further information or stimuli of
any kind.
Muscle Tension
General wisdom regards excessive muscle tension as
something which needs to be relieved. However, it can
play a role in helping a client to contain their experiences.
There is a small body of research which indicates that
relaxation can increase anxiety in some people¹. It seems
that the relaxation of muscles following calming activities
like reflexology can sometimes result in a lowering of
defences which have been suppressing the trauma. This
can then result in autonomic hyperarousal, sometimes
leading to overwhelm.
This may help to explain some forms of sleep
disturbances which are so often a part of traumatic stress.
The client feels tired and goes to bed, but upon relaxing,
they are almost immediately wide awake. In some cases,
the relaxation which sleep brings is enough to send the
client into overwhelm during the night and they may
wake up feeling ‘spaced out’, with tense muscles or
exhausted.
Bearing this in mind, you may
be able to detect some
additional signs:

Nervous stumbling speech

Temperature – Trauma clients often feel cold

Giving the appearance of some strong emotion (e.g.
anger) without seeming to be aware of it – voice,
facial expression, eyes and choice of words can all
be key indicators.

An inability to relax

Client may ‘pass out’ as soon as they lie on the
couch

Undue sensitivity

Signs of an exaggerated startle response (e.g. jittery
movements; awkwardness)
As you take their case history,
be alert for other clues:

Rapid weight gain or loss

Overreaction to problems

Immature Behaviour

Any suggestion that they may have been bullied or
suffered other traumatic experiences

Age – some people’s defences lessen as they get
older and experiences which they have been
successfully containing for years can suddenly spill
over into daily life.

Suddenly moving from being very functional to
being very dysfunctional
What you can do
‘And’ not ‘But’
Of course, you must refer clients who are traumatised to a
trauma specialist, but what do you do when they begin to
tell you about what has happened to them? Be aware that
the retelling of their story may be re-traumatizing. If the
client has not worked on the issues around the trauma, then
revisiting it might send them into hyperarousal or
overwhelm.
It is important that the client honours their own feelings.
For example “I am frightened but it happened twenty
years ago” suggests that the speaker feels that they
should no longer be feeling frightened. Encourage them
to honour the fear by slightly changing their sentence,
e.g. “I am frightened and it happened twenty years ago”.
Clients may find this enormously releasing as the internal
conflict between what they are feeling and what they
think they ought to be feeling begins to ease.
Remember: unless you are a trained counsellor or trauma
specialist it is in both yours and your client’s interests to
refer them to the correct specialist.
Bringing your client back into the
present
Verb tense
Paying attention to verb tense is a good indication of where
your client is. If it seems that your client is talking about the
past as if it is the present, do what you can to bring them
back. For example:
Client: I’m frightened
Therapist: Look around the room. Is there anything in here
which is frightening you?
Then encourage them to stay in the present by asking them
to describe things in the room.
Dual awareness
Within the Sensory Nervous System there are interoceptors
which gather information about what is going on inside the
body and there are exteroceptors which gather information
about the external environment. Traumatized clients often
use their interoceptors to evaluate their external
environment. For example, “My heart is beating and I am
feeling panicky, so it must be dangerous here and I need to
be alert.”
In this case, balance needs to be restored and equal weight
given to the exteroceptors.
Interoceptors
Exteroceptors
“My heart is racing”
Tell me three things you can see
as you look around the room
“I feel spaced out”
Could you describe that picture
on the wall?
Containment
Babette Rothschild (a psychotherapist and trauma
specialist) describes traumatised clients as being –
physically and psychologically – ‘thin-skinned’. Trauma is
often the result of an experience which was somehow
physically or emotionally intrusive and it is often the loss
of bodily integrity which accelerates the trauma process
out of control². The key word here is safety. Work on your
client’s feet with a slow, firm, reassuring touch. Try
holding the feet firmly with the intention of strengthening
the client’s ‘container’ and bringing them back into the
present. If it helps, think “I am supporting you and helping
you feel safe while you tell me this”.
Trauma response can be very debilitating for the client
and hard to contain once reawakened. To ensure that you
are prepared for this, you may find it useful to have the
contact details of a local trauma specialist to hand.
Nayna Kumari MAR
Reflexologist and Psychotherapist with a special interest
in how traumatic stress affects the body.
www.nk-bodypsychotherapy.com
References:
¹ Heide + Borkovec 1983, Jacobsen 1974, Lehrer + Woolfolk
1993. Cited in Babette Rothschild, Helping for the Healer.
Norton, New York, 2006. P.117
² Babette Rothschild: The Body Remembers, The
Psychophysiology of Trauma and Trauma Treatment.
Norton, New York, 2000. P.143
Can Stress be Painful?
That stress may cause various symptoms from the gut, as
well as headache, mood changes, etc is generally well
known. Much more overlooked is the fact that long term
stress may also produce pain in movement, most often in
the shoulders, neck or lower back.
Many stressed people waste a lot of time and money on
therapy, examinations and even operations for musculoskeletal symptoms with no or only temporary relief. Not
that their pains are not real - they most certainly are - and
medical tests do indeed show pathological tissue changes;
however the real cause is not found in the peripheral
tissues but instead involves reactions to prolonged
exposure to stress.
The shoulder as an example
Following exercise or use of the shoulder, minor tissue
damage might occur, which is then followed by a small
inflammation as part of normal healing/recovery. In the
long term presence of stress, a person’s healing capacity
can be dramatically reduced, potentially leading to chronic
shoulder inflammation and pain.
Many factors produce stress-pain
Under the chronic influence of high levels of stress
hormones:

Muscles have a tendency to tense up and cause
pain.

Circulation of blood and lymph is reduced, leading
to a poor nutritional state of some muscle tissue
and build up of acidic waste products. This
hardens the tissue, making it more prone to injury.

Neuroendocrine changes may directly stimulate
free nerve endings to send nociceptive (danger)
impulses to the brain, eventually producing a
painful sensation.

Brain functions are altered: one change is an
increased response to nociceptive signals, leading
to a lower pain threshold and therefore more
pain.
The physiological side of the stress response includes
raising the activity of the sympathetic branch of the
autonomic nervous system, leading to an imbalance
between sympathetic and parasympathetic. The
parasympathetic branch is responsible for healing and
tissue repair, but when the individual is stressed, the
sympathetic overdrive can effectively block or reduce
tissue repair, which means more pain. To contribute to this
vicious cycle, pain in itself acts as a stressor and adds to the
stress response.
An example from our practice
A 42 year old female, employed as a senior manager,
presented with shoulder pains. She was on long term sick
leave because of shoulder inflammation due to computer
work. She had received numerous therapies without effect,
but strongly emphasized that she was not stressed.
Initially, most of the applied techniques were therefore
related to the shoulder, neck and inflammation.
The therapeutic focus was consequently changed to
stress and after a few sessions with primarily stress
reducing techniques and less focus on the shoulder area,
the pains diminished and eventually went away.
This example illustrates how important and difficult it is
to find out whether stress is a key issue. This client could
probably have saved half of the treatments, had the
focus been right from the beginning.
Stress as treatment blocker
When working with a stressed reflexology client, the first
and most important thing to realize is the fact that severe
stress counteracts the effects of reflexology. You may
work session after session with the very best of
techniques, but as long as the client is in a chronic stage
of stress, nothing seems to get through.
Only when offering techniques that help reduce the
stress level and break the vicious cycle associated with
stress, will reflexology will be able to work.
6 tips for the reflexological
approach
Tip no. 1: To be invited inside
With a stressed person, the physiological response has
changed and it can be difficult to be “invited inside” with
any kind of treatment. Therefore, pay extra attention to
the initial phase of a reflexology session. Hold the feet,
palms against soles, and try intuitively to feel when the
connection is there. Ask the client to take 10 breaths,
very slow and quiet, breathing through the nose, while
you are still touching their feet.
Tip no. 2: No gain with pain
The “no pain, no gain” doctrine does not apply to
stressed out clients (if at all!).
Aim to keep the entire session pleasant and pain free, to
avoid increasing the sympathetic nervous system activity.
In the beginning of the session, try to find the right
amount of pressure. Your client will be able to help you
with this. An intense and at times painful treatment may
overload an already fully loaded system.
Tip no. 3: Stop thinking – but stay
awake
In our experience, it is a good idea to ask stressed clients
to “leave the head” and focus on the body - especially the
feet - during the treatment. Stressed people usually have
so many things going on in their minds and have often lost
contact with the rest of the body.
As you go along, inform your client which part of the body
you are giving impulses to. Ask them to focus on the area
and tell you about possible sensations or reactions in the
body or in the feet.
Stressed clients are often exhausted, but in our opinion the
session will be more effective if clients do not fall asleep.
The energy of their consciousness or concentration seems
to strengthen the healing response.
Tip no. 4: Work bilaterally, slow and
less
Work both feet symmetrically and simultaneously where
possible, as this helps the client to centre and focus on the
body instead of thinking in all different directions.
A stressed person needs more time for the reflexological
communication process. Try to offer slow and calm
impulses, and work with fewer reflexes but spend more
time on each. Make short breaks where you simply hold
the feet, to allow the person to absorb the impulses.
Tip no. 5: Work with the ANS
The autonomic nervous system is a key player in the stress
response. One way of working with the ANS is to use
reflexes for the spinal origin of these nerves. In figure 1,
the red area represents the origin of the sympathetic
branch of the ANS, which is found in the lateral horn of the
spinal cord in segments T1 to L2. The parasympathetic
branch originates in the brain stem, upper cervical spine
and sacral spine S2-S4 (blue on figure 1).
These reflexes can be worked on the plantar aspect of the
foot on the periosteum of the bones shown in the
illustration. Push the soft tissue aside while working, to
enable a direct contact with the bony surface.
Some reflexologists prefer to work with sedating
techniques on the sympathetic branch (which is too active
during chronic stress) and stimulating techniques on the
parasympathetic. We may also choose to simply work all
areas, letting the system adjust and find a new balance.
For the sympathetic nervous system, figure 1 also shows
connections from the spinal segments to areas in the
body. If this spinal origin is divided into three main parts,
we can see how sympathetic nerves innervate and
control blood supply to specific parts of the body
(vasomotor) and organs.
When a shoulder problem is present, the upper two
thirds of the lateral horn (T1-T9) are contributing to the
control of the blood supply to the shoulder. In terms of
organs, there are connections between the shoulder and
organs in the head, thorax and upper abdomen.
Tip no. 6: Linking with the sympathetic
reflex
As an additional technique, we can connect the
sympathetic origin reflex on the foot to symptom areas
either as foot reflexes or locally in the body.
Using the table in figure 1 as a guide, we might help a
shoulder problem by placing one thumb along the plantar
side of metatarsal 1 (T1-T9) and with the opposite hand
working the shoulder reflex. Try to experiment with
working both areas together, working one and just
touching the other or simply gently holding both areas, to
see which seems to be most effective in the given
situation. Inform your client what you are doing, and ask
for feedback on sensations, thoughts or reactions. This
principle can be applied in many situations where clients
experience any kind of pain.
Dorthe Krogsgaard HMAR and
Peter Lund Frandsen HMAR, Denmark
www.touchpoint.dk
References:
Nerve Reflexology Vol. I - III, Nico Pauly, Touchpoint, 2011
Association for Manual Neuro Therapy and Nerve
Reflexology: www.mnt-nr.com
Figure 1 - Segmental connections in the sympathetic nervous
system. Red indicates the origin of the sympathetic neurons in
the spinal cord and in the spinal cord foot reflex. Blue shows
the origin of the parasympathetic nervous system (Brain stem
+ C1-C3 and S2-S4). Shoulder connections are highlighted. ©
2011 Touchpoint Denmark
Touchpoint Workbooks: Round about: Stress and Round
about: Neck & Shoulder, 2010
Reflexology, stress and
research
Reflexology is a non intrusive complementary therapy
and while it does not and should not take the place of
medical advice it can comfortably work alongside medical
care especially with problems that affect the whole body.
Stress is a classic example of such a problem.
With ever increasing levels of stress in the world it is
important for individuals to take responsibility for their
own wellbeing. Reflexology can fit into a busy lifestyle and
can easily be part of an individual’s coping strategy
resulting in multi-system relaxation and increased
wellbeing. Stress is also thought to be responsible for
many other illnesses and problems, this is often quoted to
be around the 70% mark (we are unable to find originating
quote but believed to be from the Surgeon General of the
American Medical Association) and from the section about
the immune system it is easy to see why this could be the
case. Therefore in relieving stress, other future problems
may be prevented prophylactically.
When it comes to reflexology and research into stress,
while there is not a huge amount of research into
reflexology full stop, there are a few studies that are
starting to shed light on where reflexology may be of
benefit.
The most important study came from McVicar et al in 2007
where they were validating a measure of anxiety for use in
cancer patients receiving reflexology. It was initially used in
healthy individuals as a test of methodology and although
these individuals were not exhibiting clinical anxiety there
was still a statistically significant reduction in their anxiety
state after reflexology. (1)
This particular study had anxiety at its centre, other studies
have had stress, anxiety or coping mechanisms as
secondary or tertiary outcome measures. Some have used
more physiological outcomes such as blood pressure
parameters.
A small study of breast and lung cancer patients showed
a significant decrease in anxiety after reflexology. (2) A
larger randomised controlled trial of reflexology and the
psychological effects in early breast cancer patients,
showed that reflexology has a statistically significant and
clinically worthwhile effect on quality of life (QoL), which
includes anxiety and stress levels. (3)
Two audits of cancer patient’s perceptions of reflexology
(4) resulted in an ‘increased ability to cope with side
effects and ‘time out’ from their illness. In well yet
stressed individuals, this increased ability to cope and
time out could well be important with coping with the
day to day demands of life. A second result was again
improved quality of life and relief of symptoms and of
psychological and spiritual distress. (5).
A small study on patients with neurological illnesses
included 33 post treatment comments about feeling
calmer and less tense. There was also a statistical drop in
systolic blood pressure and heart rate. (6)
When it comes to stress in the workplace, in 1998, it was
estimated that the psychological conditions most
frequently seen by the doctors in occupational medicine
in the UK were: anxiety and depression 73% and stress
56%. It is probably fair to say that these estimates will
have increased in the last 14 years. A small study looked
at two NHS healthcare trusts that held stress awareness
days, these included ‘taster’ sessions of reflexology and
other therapies. 75% of attendees believed they had
benefitted from attending. (7) A further tiny study
about managing stress in the workplace suggested a
trend towards improvement in perceived health and
wellbeing following reflexology. (8)
Obviously this is a small amount of research and much
more is needed, but it does go some way to indicating
the effects of reflexology on stress.
UK stress survey
There is a great survey being run by the BBC at
https://www.bbc.co.uk/labuk/experiments/stress/,
where you can add to general data collection across the
UK by including your personal experience. It does take a
while to fill in though so don’t start it if you are in a hurry
or your stress levels may rise!
References:
(1) Evaluation of anxiety, salivary cortisol and
melatonin secretion following reflexology
treatment: A pilot study in healthy individuals, A.J.
Mc Vicar, C.R. Greenwood, F. Fewell, V. D’Arcy, S.
Chandrasekharan and L.C. Alldridge.
Complementary Therapies in Clinical Practice, 2007
VOL 13; NUMBER 3, page(s) 137-145
(2) The Effects of Foot Reflexology on Anxiety and Pain
in Patients With Breast and Lung Cancer
Stephenson, N. L. Weinrich, S. P. Tavakolil, A. S.
ONCOLOGY NURSING FORUM 2000 VOL 27; PART
1 , page(s) 67-76
(3) A randomised, controlled trial of the psychological
effects of reflexology in early breast cancer Donald
M. Sharp, Mary B. Walker, Amulya Chaturvedi,
Sunil Upadhyay, Abdel Hamid, Andrew A. Walker,
Julie S. Bateman, Fiona Braid, Karen Ellwood, Claire
Hebblewhite, Teresa Hope, Michael Lines, Leslie G.
Walker European Journal of cancer 2010 VOL 46;
NUMBER 2, page(s) 312-322
(4) Evaluation of a hospice based reflexology service: a
qualitative audit of patient perceptions Gambles,
M. Crooke, M. Wilkinson, S. EUROPEAN JOURNAL
OF ONCOLOGY NURSING 2002 VOL 6; NUMB 1,
page(s) 37-44
(5) Reflexology audit: patient satisfaction, impact on
quality of life and availability in Scottish hospices
Milligan, M. Fanning, M. Hunter, S. Tadjali, M.
Stevens, E. INTERNATIONAL JOURNAL OF
PALLIATIVE NURSING 2002 VOL 8; PART 10 ,
page(s) 489-496
(6) Just the ticket': integrating massage and
reflexology in practice (part 2) Dryden, S. L.
Holden, S. D. Mackereth, P. A. COMPLEMENTARY
THERAPIES IN NURSING AND MIDWIFERY
Complementary Therapies in Nursing and
Midwifery 1999 5, 19-21
(7) Would complementary and alternative medicine
be welcome in the workplace? R.Philipp, P. Thorne.
Public health 2008 Vol 122, issue 10, 1124 – 1127
(8) Using reflexology to manage stress in the
workplace: A preliminary study Rhian C. Atkins,
Philip Harris Complementary Therapies in Clinical
Practice VOL 14; NUMBER 4, page(s) 280-287
Facts and figures
The statistics below were taken from the Health and Safety
Executive website
(www.hse.gov.uk/statistics/causdis/stress/index.htm)

In 2009/2010 an estimated 435,000 working
people in Great Britain suffered from stress
caused or made worse by their current or past
work.

In 2009/10, an estimated 9.8 million working days
were lost through work-related stress
The statistics below were taken from a NICE (National
Institute of Clinical Excellence) news bulletin issued on 5th
November 2009, which can be found at
http://www.nice.org.uk/media/BFF/31/2009_063__Mental_wellbeing_in_the_workplace_APP_Upload.pdf.

Mental health conditions including stress,
depression and anxiety are currently estimated
to cost UK employers around £28.3 billion per
year at current pay levels.

Professor Mike Kelly, Public Health Excellence
Centre Director of The NHS National Institute of
Clinical Excellence estimates that employers
could save up to £250,000 a year due to
reduced absenteeism and increased
performance, through making “simple changes”
to improve conditions for employees.
The statistics below were taken from the ISMA website
(www.isma.org.uk/about-stress/facts-about-stress.html)

Employee absence levels in public sector at 9.6
days per annum per employee whilst private
sector absence at 6.6 days per annum per
employee.
- CIPD Absence Management survey 2010

Despite pressure to cut costs, 22% of
organisations have increased their spend on
employee wellbeing, with only 9% showing a
reduction. Those who have increased spending
in 2010 have indicated they are likely to increase
their wellbeing spend further in 2011
- CIPD Absence Management Survey 2010

According to self reports, consistently stress is
the second most commonly reported work
related illness
- Labour Force Survey.

In 2009/10, every person experiencing work
related stress was of work for an estimated 22.6
days which equates to 0.42 days per worker.
- HSE

Direct cost of sickness absence estimated as
£635 per person per year.
- CIPD 2008

Indirect costs of sickness absence have been
measured as twice the direct costs i.e. £1,270,
making a total of £1,905 per employee per year
– typically around 9% of payroll costs
- Norwich Union Healthcare

In 2008 - for every 80p spent on health
promotion and intervention programmes, £4
can be saved due to reduced absenteeism,
temporary staff, presenteeism and improved
motivation
- The European Network for Workplace Health
Promotion

The 2007 Psychosocial Working Conditions
(PWC) survey indicated that around 13.6% of all
working individuals thought their job was very
or extremely stressful.
- HSE

The annual incidence of work-related mental
health problems in Britain in 2007 was
approximately 5,750 new cases per year.
However, this almost certainly underestimates
the true incidence of these conditions in the
British workforce.
- HSE

According to self-reports, estimated 237 000
people, who worked in 2008, first became
aware of work-related stress, depression or
anxiety giving an annual incidence rate of 780
cases per 100 000 worker.
- Labour Force Survey
Photographs from iStockphoto.com
© Copyright of the Association of Reflexologists 2011
Although the AoR takes all reasonable care to ensure that the information in this
communication is accurate, we cannot guarantee that it is free from inaccuracies,
errors or omissions. No information given by the AoR should be taken as legal advice,
nor should it take the place of medical care or advice given by primary healthcare
providers. As such, the AoR shall not be liable for any loss or damage whatsoever
arising from any information contained in this communication.