Worldwide Stress: Different Problems, Similar Solutions? Cultural Adaptation and Evaluation of a Standardized Stress Management Program in Hungary

  • Adrienne StauderEmail author
  • Barna Konkolÿ Thege
  • Mónika Erika Kovács
  • Piroska Balog
  • Virginia P. Williams
  • Redford B. Williams



Chronic stress is an important risk factor for morbidity and premature mortality at the individual and societal level.


Our aim was to describe the process of adapting and testing the effectiveness of a structured stress management skills training program in a culture different from the one in which it was first developed.


We translated an internationally used standardized behavioral intervention program into Hungarian and adapted it for use in a Hungarian cultural setting. We evaluated the changes in stress level and stress-related symptom scores among distressed voluntary participants on the basis of self-reported questionnaires completed before, immediately after, and 4 to 6 months after the 12-h intervention. The following measures were included: PSS-10, STAI-T, BDI-S, PHQ-15, and WBI-5. For statistical analyses, paired sample t test and Cohen’s d value for effect size were used.


In a sample of 107 distressed individuals, after the training, stress level, psychological and somatic symptoms decreased and well-being increased (p < 0.0001). These positive changes were maintained at follow-up in a subsample of 42 persons tested 4–6 months later.


These results confirm the long-term positive effects of this standardized behavioral intervention in a different cultural context and in real-world settings, which encourages further dissemination of the program in various community settings.


Behavioral intervention Stress management Cultural adaptation Effectiveness Translational research Life skills 



First of all, we thank Professor Maria S. Kopp who made it possible to get to know and adapt the Williams LifeSkills Program and continuously supports and encourages the work of our team. The authors also wish to thank all members of the LifeSkills workgroup who participated in the translation and adaptation process and/or the data collection, namely, András Beöthy-Molnár, Csilla Raduch, Anikó Hazag, Gabriella Seres, Kata Ress, Noémi Somorjai, Csilla Csoboth, Cecilia Bánki, Zoltán Cserháti, Edit Fenyák, Klára László, Noémi Tari-Keresztes, Tamás Martos, Magdolna Rohánszky, Gyöngyvér Salavecz, Melinda Sverteczki, Flóra Sztanó, and Krisztina Tóth. This study was supported by the Hungarian National Research Fund (OTKA) projects TS-40889 (2002) and TS-049785 (2004), Scientific School Grants and NKFP 1/002/2001 and NKFP 1b/020/2004, ETT 100/2006 and OTKA K73754 grants.

Financial disclosure

Dr. Redford Williams and Dr. Virginia Williams are founders and majority stock holders in Williams LifeSkills, INC.


  1. 1.
    Kopp MS, Réthelyi J. Where psychology meets physiology: chronic stress and premature mortality—the Central–Eastern European health paradox. Brain Res Bull. 2004;62:351–67.CrossRefPubMedGoogle Scholar
  2. 2.
    Kopp MS, Skrabski Á, Székely A, Stauder A, Williams R. Chronic stress and social changes, socioeconomic determination of chronic stress. Ann N Y Acad Sci. 2007;1113:325–38.CrossRefPubMedGoogle Scholar
  3. 3.
    Kopp MS, Stauder A, Purebl G, Janszky I. Work stress and mental health in a changing society. Eur J Public Health. 2008;18:238–44.CrossRefPubMedGoogle Scholar
  4. 4.
    Pikhart H, Bobak M, Pajak A, Malyutina S, Kubinova R, Topor R, et al. Psychosocial factors at work and depression in three countries of Central and Eastern Europe. Soc Sci Med. 2004;58:1475–82.CrossRefPubMedGoogle Scholar
  5. 5.
    Kopp MS, Skrabski Á, Szedmák S. Socioeconomic factors, severity of depressive symptomatology and sickness absence rate in the Hungarian population. J Psychosom Res. 1995;39:1019–29.CrossRefPubMedGoogle Scholar
  6. 6.
    Bishop GD, Kaur M, Tan VLM, Chua YL, Liew SM, Mak KH. Effects of a psychosocial skills training workshop on psychophysiological and psychosocial risk in patients undergoing coronary artery bypass grafting. Am Heart J. 2005;150:602–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Dusseldorp E, van Elderen T, Maes S, Meulman J, Kraaij V. A meta-analysis of psychoeducational programs for coronary heart disease patients. Health Psychol. 1999;18:506–19.CrossRefPubMedGoogle Scholar
  8. 8.
    Frasure-Smith N, Prince R. Long-term follow-up of the Ischemic Heart Disease Life Stress Monitoring Program. Psychosom Med. 1989;51:485–513.PubMedGoogle Scholar
  9. 9.
    Friedman M, Thoresen CE, Gill JJ, Ulmer D, Powell LH, Price VA, et al. Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project. Am Heart J. 1986;112:653–65.CrossRefPubMedGoogle Scholar
  10. 10.
    Gidron Y, Davidson K, Bata I. The short-term effects of a hostility-reduction intervention on CHD patients. Health Psychol. 1999;18:416–20.CrossRefPubMedGoogle Scholar
  11. 11.
    Schneiderman N, Saab PG, Catellier DJ, Powell LH, DeBusk RF, Williams RB, et al. Psychosocial treatment within sex by ethnicity subgroups in the Enhancing Recovery in Coronary Heart Disease Clinical Trial. Psychosom Med. 2004;66:475–83.CrossRefPubMedGoogle Scholar
  12. 12.
    Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet. 1990;336(8708):129–33.CrossRefPubMedGoogle Scholar
  13. 13.
    Ursin H, Eriksen HR. The cognitive activation theory of stress. Psychoneuroendocrinology. 2004;29:567–92.CrossRefPubMedGoogle Scholar
  14. 14.
    Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Support Care Cancer. 2001;9:112–23.CrossRefPubMedGoogle Scholar
  15. 15.
    Fawzy FI. Psychosocial interventions for patients with cancer: what works and what doesn’t. Eur J Cancer. 1999;35:1559–64.CrossRefPubMedGoogle Scholar
  16. 16.
    Fukui S, Koike M, Ooba A, Uchitomi Y. The effect of a psychosocial group intervention on loneliness and social support for Japanese women with primary breast cancer. Oncol Nurs Forum. 2003;30:823–30.CrossRefPubMedGoogle Scholar
  17. 17.
    Penedo FJ, Dahn JR, Molton I, Gonzalez JS, Kinsinger D, Roos BA, et al. Cognitive–behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma. Cancer. 2004;100:192–200.CrossRefPubMedGoogle Scholar
  18. 18.
    Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet. 1989;2:888–91.CrossRefPubMedGoogle Scholar
  19. 19.
    Trijsburg RW, van Knippenberg FCE, Rijpma SE. Effects of psychological treatment on cancer patients: a critical review. Psychosom Med. 1992;54:489–517.PubMedGoogle Scholar
  20. 20.
    Antoni MH, Cruess S, Cruess DG, Kumar M, Lutgendorf S, Ironson G, et al. Cognitive-behavioral stress management reduces distress and 24-hour urinary free cortisol output among symptomatic HIV-infected gay men. Ann Behav Med. 2000;22:29–37.CrossRefPubMedGoogle Scholar
  21. 21.
    Antoni MH, Cruess DG, Klimas N, Maher K, Cruess S, Kumar M, et al. Stress management and immune system reconstitution in symptomatic HIV-infected gay men over time: effects on transitional naive T cells (CD4(+)CD45RA(+)CD29(+)). Am J Psychiatry. 2002;159:143–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Lutgendorf SK, Antoni MH, Ironson G, Starr K, Costello N, Zuckerman M, et al. Changes in cognitive coping skills and social support during cognitive behavioral stress management intervention and distress outcomes in symptomatic human immunodeficiency virus (HIV)-seropositive gay men. Psychosom Med. 1998;60:204–14.PubMedGoogle Scholar
  23. 23.
    Kirby E, Williams VP, Hocking MC, Lane JD, Williams RB. Psychosocial benefits of three formats of a standardized behavioral stress management program. Psychosom Med. 2006;68:816–23.CrossRefPubMedGoogle Scholar
  24. 24.
    Woolf SH. The meaning of translational research and why it matters. JAMA. 2008;299:211–3.CrossRefPubMedGoogle Scholar
  25. 25.
    Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–96.CrossRefPubMedGoogle Scholar
  26. 26.
    Stauder A, Konkolÿ Thege B. Az Észlelt Stressz Kérdőív (PSS) magyar verziójának jellemzői [Characteristics of the Hungarian version of the perceived stress scale (PSS)]. Mentálhigiéné és Pszichoszomatika. 2006;7:203–16.CrossRefGoogle Scholar
  27. 27.
    Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press; 1970.Google Scholar
  28. 28.
    Sipos K, Sipos M. The development and validation of the Hungarian form of the state-trait anxiety inventory. In: Spilberger CD, Diaz-Guerrero R, editors. Cross-cultural anxiety, vol. 2. Washington: Hemisphere; 1983. p. 27–39.Google Scholar
  29. 29.
    Stauder A, Kovács M. Anxiety symptoms in allergic patients: identification and risk factors. Psychosom Med. 2003;65:816–23.CrossRefPubMedGoogle Scholar
  30. 30.
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71.PubMedGoogle Scholar
  31. 31.
    Rózsa S, Szádóczky E, Füredi J. A Beck depresszió kérdőív rövidített változatának jellemzői hazai mintán [Psychometric properties of the Hungarian version of the shortened Beck depression inventory]. Psychiatr Hung. 2001;16:384–402.Google Scholar
  32. 32.
    Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;68:258–66.Google Scholar
  33. 33.
    Bech P, Staehr-Johansen K, Gudex C. The WHO (ten) well-being index: validation in diabetes. Psychother Psychosom. 1996;65:183–90.CrossRefPubMedGoogle Scholar
  34. 34.
    Susánszky É, Konkolÿ Thege B, Stauder A, Kopp M. A WHO Jól-lét Kérdőív rövidített (WBI-5) magyar változatának validálása a Hungarostudy 2002 országos lakossági egészségfelmérés alapján [Validation of the short (5-item) version of the WHO well-being scale based on a Hungarian representative health survey (Hungarostudy 2002)]. Mentálhigiéné és Pszichoszomatika. 2006;7:247–55.CrossRefGoogle Scholar
  35. 35.
    Williams VP, Williams RB. LifeSkills: eight simple ways to build stronger relationships, communicate more clearly and improve your health. New York: Times Books; 1997.Google Scholar
  36. 36.
    Williams VP, Williams RB. In control: no more snapping at your family, sulking at work, steaming in the grocery line, seething at meetings, stuffing your frustration. New York: Rodale; 2006.Google Scholar
  37. 37.
    Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51:390–5.CrossRefPubMedGoogle Scholar
  38. 38.
    Yalom ID, Leszcz M. The theory and practice of group psychotherapy, 5th ed. New York: Basic Books; 2005.Google Scholar
  39. 39.
    D’Agostino RB Jr, D’Agostino RB Sr. Estimating treatment effects using observational data. JAMA. 2007;297:314–6.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2009

Authors and Affiliations

  • Adrienne Stauder
    • 1
    Email author
  • Barna Konkolÿ Thege
    • 1
  • Mónika Erika Kovács
    • 1
  • Piroska Balog
    • 1
  • Virginia P. Williams
    • 2
  • Redford B. Williams
    • 3
  1. 1.Institute of Behavioral SciencesSemmelweis UniversityBudapestHungary
  2. 2.Williams LifeSkills Inc.DurhamUSA
  3. 3.Department of Psychiatry and Behavioural SciencesDuke University Medical CenterDurhamUSA

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