Stress Inoculation Training: What It Is, How It Works, and Benefits

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Stress Inoculation Training: What It Is, How It Works, and Benefits

THC Editorial Team February 3, 2022
Photo by S Migaj on Unsplash (article on stress inoculation training)
Photo by S Migaj on Unsplash


Stress inoculation training (SIT) is a therapeutic intervention commonly used for treating clients with stress-related and/or trauma-related conditions such as posttraumatic stress disorder (PTSD) and anxiety. Therapists often use SIT to teach clients how to identify negative thinking patterns and triggers and develop coping skills to manage their symptoms and reduce their stress and anxiety.

What Is Stress Inoculation Training?

Stress inoculation training is a type of cognitive behavioral therapy (CBT).1 It is commonly used to help people who have high levels of anxiety and stress; it can also help people who have PTSD cope and manage stress when faced with triggering situations.1,2 Therapists who use SIT work with clients to identify and alter negative thinking patterns that influence their perceptions and behaviors and then to reconfigure those thoughts and beliefs to create a more positive perspective.1 They help clients develop resilience and learn how to manage stress before they experience it to protect themselves from anxiety and fear when exposed to triggers.

Rather than addressing cognitive events, the automatic self-statements and images a client is aware of and can report, SIT emphasizes modifying cognitive processes and cognitive structures. Cognitive processes encompass the search, inferential, storage, and retrieval processes that operate unconsciously to shape a person’s perceptions. Cognitive structures include the core beliefs, principles, assumptions, commitments, and meaning systems that influence a person’s worldview.1

What Is the History of Stress Inoculation Training?

Canadian psychologist Donald Meichenbaum developed SIT, in the early 1970s, as a training program for stress and anxiety reduction.1 As a contributor to the development of cognitive behavioral therapy, he believed that it was possible to inoculate people against stressful situations, thus preventing some of the adverse effects of stress.3,4 Meichenbaum identified three phases of SIT: conceptualization, skills acquisition, and follow-through.

Over time, SIT has become a relatively well-researched and well-supported tool for teaching coping skills to manage stress and anxiety.5

How Does Stress Inoculation Training Work?

During SIT, therapists teach clients to recognize triggering situations and develop coping skills that can help them when they encounter those triggers in the future. SIT is varied and depends on the individual client. The client’s treatment plan is developed according to their stressors, coping skills, and resources. The pace of treatment will depend on these factors so that the client is less likely to feel additional stress or become overwhelmed.

Three Phases of SIT

As noted above, SIT involves three phases. During the conceptualization phase of SIT, therapists conduct comprehensive interviews with the clients and educate them about how stress can negatively impact their life. One of the most important aspects of this phase is establishing a safe, warm, and caring therapeutic environment. This phase establishes the client as the so-called “expert” on their anxiety and assigns them considerable responsibility in the therapeutic relationship. In SIT, the client is an active agent, so the therapist encourages any self-monitored “homework” assignments to come from the client. This collaboration helps shift the client narrative from being a victim of anxiety to seeing problems as addressable.1 Clients learn how to identify negative thought patterns that cause or worsen stress.

Once clients complete the conceptualization phase, they move into the skills acquisition phase. During this phase of treatment, therapists help clients reduce anxiety and stress by teaching them appropriate coping skills for their situations and having them rehearse these skills. The therapist uses imagery recall, role-play, and graded assignments to instill how to use their maladaptive feelings, thoughts, behaviors, and reactions as cues to use their new coping strategies. The clients’ strengths, weaknesses, and stressors will all be considered during this phase.

There are four common types of coping skills that are generally part of the skills acquisition phase of an SIT treatment plan: applied relaxation, cognitive restructuring, problem-oriented self-instruction, and self-reward/self-efficacy self-instruction.1

Applied Relaxation.

These relaxation techniques are meant to help clients manage their anxious arousal. Therapists train clients in skills such as progressive relaxation procedures, relaxation without tension, pleasant imagery, breathing exercises, and cognitively cued relaxation. The therapist and client work on these coping strategies in the therapeutic environment. The client then applies them in nonstressful situations to work up to using them in stressful situations.1

Cognitive Restructuring.

Cognitive restructuring is commonly a five-step process that involves evaluating the validity of thoughts and beliefs, evaluating predictions, exploring alternative explanations, retraining in attribution, and altering catastrophic thinking styles. This poses clients’ automatic thoughts as hypotheses, not facts, that can be proven or disproven in experiments designed by the client and therapist. Cognitive restructuring helps clients view their anxiety as a problem that they have the tools to solve, as opposed to a personal threat.1

Problem-Oriented Self-Instruction.

This coping skill includes task-oriented, problem-solving, self-instructional training for clients who don’t have the cognitive skills to problem-solve effectively. This training is designed to fit the client’s cognitive and behavioral styles; it is aimed at addressing the specific anxiety-inducing demands in the client’s life, like preparing for an exam or making small talk in a social scenario.1

Self-Reward/Self-Efficacy Self-Instruction.

Self-reward/self-efficacy self-instruction consists of making believable self-statements. These statements can provide support for successful coping, rewards for trying to cope even when anxiety is not fully managed, realistic future expectations for anxiety control, and self-attributions to gain control over anxiety. Examples of these statements include, “Just stay cool. Getting all anxious and upset won’t help,” “Develop a plan. What would the first step be?” and “Don’t jump to conclusions. Check out the possibilities.”1

After learning these coping skills, clients enter the third phase of SIT: follow-through. During this phase, clients will test and strengthen their coping strategies in therapy before implementing them in real-life situations. The therapist might use various techniques to evoke real-world experiences, including visualization, role-play, simulations, and in vivo exposure, before the client brings the learned strategies to their day-to-day life.1 This third phase also encompasses relapse prevention. When clients fail to manage their anxiety outside of therapy, they may lapse into negative self-talk and forget the progress they’ve made and skills they’ve learned. Because of this, clients and therapists identify and rehearse situations that they deem high risk, or likely to cause relapse, so that the client has the skills to handle them. The therapist reminds the client that they will still experience anxiety; SIT does not eliminate stress from their life, but they are now equipped to handle it. They also encourage the client to credit themselves for their progress.1

The length of treatment during SIT varies greatly because it depends on the individual client’s needs.7 Sessions usually last 60 to 90 minutes. Clients might begin with up to 12 weekly sessions and then come back for additional follow-up sessions for a year or more. 6 SIT can be used in group therapy as well; practitioners recommend that group treatment span eight to 22 sessions lasting 75 to 90 minutes each, but length and quantity should still be based on the clients’ performance.1

When Is Stress Inoculation Training Used?

Stress inoculation training is commonly used in treating anxiety and anxiety-related disorders, trauma-related disorders, such as PTSD, stress management, and others, as one type of cognitive behavioral therapy in the therapist’s toolkit.1 Because it doesn’t require the client to revisit their trauma, it might be used when a client is too uncomfortable to actively confront triggers through exposure therapy.

The Potential Benefits and Effectiveness of Stress Inoculation Training

The adaptability of SIT means that it can offer numerous benefits for people dealing with a broad spectrum of issues. SIT can provide the following benefits:

  • reduced anxiety symptoms1
  • reduced panic attacks1
  • improved ability to deal with stress1
  • alleviated physical pain1
  • reduced symptoms of PTSD6
  • increased positive thoughts regarding self-esteem7
  • reduced work-related stress8
  • reduced performance anxiety1
  • increased ability to handle anxiety-inducing transitions1
  • increased ability to deal with stressful medical procedures1
  • reduced social anxiety1
  • increased assertiveness1

People working in high-stress fields, including healthcare workers, police officers, firefighters, military service members, and social workers, might benefit from SIT.

Researchers have conducted numerous studies evaluating the efficacy of SIT. In one 2015 randomized controlled study of 40 cancer patients, researchers from the Isfahan University of Medical Science in Iran assigned some participants to a case group and the other to a control group. Both groups had the same treatment plan, except the case group had additional SIT, which consisted of eight 90-minute sessions over eight weeks. Using the Depression, Anxiety, Stress Scales 42 (DASS-42) questionnaire and a demographic questionnaire, the researchers determined that the group that received SIT showed reduced anxiety, depression, and stress levels compared to the control group.9

Researchers from the University of California, Davis, conducted a study in 2019 regarding the effectiveness of SIT for veterans suffering from both PTSD and traumatic brain injuries (TBI). The researchers evaluated 65 veterans with PTSD and TBI who received 18 months of SIT. They found via self-report questionnaires that the veterans showed a reduction in PTSD symptoms, improvements in depression symptoms and performance, and an increased ability to tolerate stress across multiple life domains.2

A 2016 paper details the ways in which SIT shows promise as a pre-deployment intervention to help prevent the development of PTSD among Marines. Research Triangle Institute International’s researchers provided 351 Marines with educational materials on stress control, coping skills training that emphasized relaxation breathing exercises, and a multimedia stress environment to practice coping skills. The researchers found that those who received pre-deployment SIT were able to reduce their physiological arousal in stressful circumstances. Based on results of the Post-traumatic Stress Checklist they administered, they concluded that the Marines in the study were better protected from the development of PTSD.10

A 2012 article in the Journal of EMDR Practice and Research discussed how SIT might help to reduce test anxiety among college students who experience high levels of test-taking anxiety. Researchers compared 30 college students who received SIT with a group that received eye movement desensitization and reprocessing (EMDR) therapy and a no-treatment group. They found that the students who received either EMDR or SIT both showed significant reductions in test anxiety compared to the no-treatment group. However, those who received EMDR experienced greater improvements than those who received SIT.11 SIT is an effective treatment for many, but it may not be the optimal approach for everyone.

Summary/Key Takeaways

Stress inoculation training has improved the ability of people with anxiety and PTSD to manage their symptoms when encountering triggers. It also might help those who work in regularly stressful occupations. Those who want to try this therapeutic approach can search for a CBT therapist who regularly treats people with trauma and anxiety-related disorders.


  1. Deffenbacher, J. L., & Meichenbaum, D. H. (1988). Stress inoculation training. The Counseling Psychologist, 16(1), 69–90.
  2. Jackson, S., Baity, M. R., Bobb, K., Swick, D., & Giorgio, J. (2019). Stress inoculation training outcomes among veterans with PTSD and TBI. Psychological Trauma: Theory, Research, Practice, and Policy, 11(8), 842–850.
  3. Ruggiero, G. M., Spada, M. M., Caselli, G., & Sassaroli, S. (2018). A historical and theoretical review of cognitive-behavioral therapies: From structural self-knowledge to functional processes. Journal of Rational-Emotive Cognitive-Behavioral Therapy, 36, 378–403.
  4. Meichenbaum, D. (2007). Stress inoculation training: A preventative and treatment approach. In P. M. Lehrer, R. L. Woolfolk, & W. E. Sime (Eds.), Principles and practice of stress management (pp. 497–516). The Guilford Press.
  5. Society of Clinical Psychology Division 12 of the APA. (n.d.). Stress Inoculation Training for Post-Traumatic Stess Disorder. Retrieved February 4, 2022, from Society of Clinical Psychology Division 12 of the APA:
  6. National Center for PTSD. (n.d.). Stress inoculation training [Fact sheet]. United States Department of Veteran Affairs.
  7. Marian, M., & Szabo, Z. (2012). Stress inoculation training in adolescents: Classroom intervention benefits. Journal of Cognitive and Behavioral Psychotherapies, 12(2), 175–188.
  8. Flaxman, P. E., & Bond, F. W. (2010). A randomised worksite comparison of acceptance and commitment therapy and stress inoculation training. Behaviour research and therapy, 48(8), 816–820.
  9. Kashani, F., Kashani, P., Moghimian, M., & Shakour, M. (2015). Effect of stress inoculation training on the levels of stress, anxiety, and depression in cancer patients. Iranian Journal of Nursing and Midwifery Research, 20(3), 359.
  10. Hourani, L., Tueller, S., Kizakevich, P., Lewis, G., Strange, L., Weimer, B., Bryant, S., Bishop, E., Hubal, R., & Spira, J. (2016). Toward preventing post-traumatic stress disorder: Development and testing of a pilot predeployment stress inoculation training program. Military Medicine, 181(9), 1151–1160.
  11. Cook-Vienot, R., & Taylor, R. J. (2012). Comparison of eye movement desensitization and reprocessing and biofeedback/stress inoculation training in treating test anxiety. Journal of EMDR Practice and Research, 6(2), 62–72.

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