The Psychological Problem Of Death And Dying - 1273 Words

During the all eras of human existence, doctors, thinkers, writers, artists, all of humanity as a whole and each individual thinks and reflects on the problem of death, trying to resolve the issues associated with its mysteries. Plato, Aristotle, Epicurus, and Schopenhauer, Nietzsche, Kà ¼bler-Ross, Freud, Jung, Adler, devoted the works to studying of a problem of the death. The problem of the man’s relation to death continues being the source of fair in modern society too, and people prefer not to speak about it. Therefore, in our world, most people die unprepared for this, of course, important events. In this regard, the actual problem of modern science, is the psychological problem of death and dying. The science of dying and death is called thanatology, thanatos – death, logos – science. However, besides of the keen interest of researchers to the problems of death, although the works of many leading foreign psychiatrists and therapists on this subject have b ecome classics as the Freud, Jung, and others. Psychological meaning that a person invests in the concept of death is various and caused. On the one hand, his involvement in the fatal events, and on the other, what does death is to him personally. Impersonal death, or death – as abstract concept. Daily the person faces it, listening, reading and seeing in mass media of the report on terrorism, accidents, and wars. Every day people face impersonal death. People face it by listening, reading and seeing in mass mediaShow MoreRelatedOn Death And Dying By Elisabeth Kubler Ross1445 Words   |  6 Pagesimpacting on an individual life, or reflecting as good and bad practice. For example, it may include underage pregnancy, coping with a staffing crisis, complaints or compliments received from workplace, breaches of confidentiality, a sudden unexpected death or hospitalisation. (Patient.co.uk, 2014) example of SLE: Childhood; such as loss of parent, going to Boarding School, divorce of parent, bullying etc. Adolescence; sexual experience, peer pressure, debt, education, new born baby etc. Adulthood; engagementRead MoreEnd of Life Essay1098 Words   |  5 Pagesand dying. Attention to the spiritual component of the illness experienced by the patient and family is not new within the context of nursing care, yet many nurses lack the comfort or skills to assess and intervene in this dimension. Spirituality contains features of religiosity, but the two concepts are not interchangeable (Puchalski, Lunsford, Harris, et al., 2006). Spirituality refers to â€Å"one’s relationship with the transcendent questions†. 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Many aspects of caregiving, treatment, and pain management are all part of the journey towards the end of one’s life. Many people are unclear about pain and symptom management during the end of life. Some believe that if you choose to medicate for pain then they are hastening or responsible for the death of their loved one. OthersRead MoreLate Adulthood: The Areas of Development in Psychological Aspects1323 Words   |  5 PagesLate adulthood begins after the age of 65 and it is characterized by the areas of development in psychological aspects, cognitive aspects as well as emotional aspects. Not only have the physical changes begun to demonstrate the deterioration of a person and its bodily functions but also the mental changes begin to occur as soon as the person proceeds towards his culmination of life span. The concept of death is deeply connected with late adulthood as it culminates the life span of an adult which is controlledRead MoreAbortion Essay750 Words   |  3 Pageschild, causes guilt for the mother’s decision to end her pregnancy and may cause problems to the mother’ s health; abortion is irreversible that child will not have life. Some women having an abortion can suffer from damage to the uterus, internal bleeding including having pieces of the baby left inside her body causing difficulties. By means of ending the pregnancy, the mother may experience regret and psychological problems after abortion. The pregnancy should not be terminated due to situations suchRead MoreAssisted Suicide : Rights And Responsibilities1570 Words   |  7 Pagesdose of drugs in March, 1998. The Oregon Death with Dignity Act passed a referendum in November, 1997, and it has been the United States only law legalizing assisted suicide since then. 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Coping and Health A Comparison of the Stress and Trauma Literatures Free Essays

Coping and Health: A Comparison of the Stress and Trauma Literatures Carolyn M. Aldwin and Loriena A. Yancura Dept. We will write a custom essay sample on Coping and Health: A Comparison of the Stress and Trauma Literatures or any similar topic only for you Order Now of Human and Community Development University of California, Davis Chapter prepared for P. P. Schnurr B. L. Green (Eds. ), Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association. COPING AND HEALTH Even a cursory review of PsychLit reveals that well over 20,000 articles on stress and coping processes have been published in the past two decades (Aldwin, 1999). A smaller proportion of these has specifically examined how individuals cope with trauma. Due to differences between researchers in how trauma is defined, a definitive number is difficult to 2 determine. However, a search for the key words trauma and coping yielded 1,000 articles. Given the magnitude of this literature, we will not attempt to provide a full review. However, we will briefly outline the different theoretical and methodological approaches to coping (for more complete reviews see Aldwin, 1999; Lazarus, 2000; Parker Endler, 1996; Schwarzer Schwarzer, 1996). Then we will examine the similarities and differences between coping with general problems and coping with trauma. Finally, we will provide whether a brief review of the relationship between coping and health outcomes, and focus on whether coping strategies can affect both the psychological and physical outcomes of trauma. THEORETICAL AND METHODOLOGICAL APPROACHES TO COPING There are four basic theoretical and methodological approaches to coping. Psychoanalytic approaches focus on the use of defense mechanisms, while personality approaches focus on coping styles. Both of these assume that adaptation is primarily a function of personal characteristics. In contrast, the coping process approach draws upon cognitive behavioral models, and is more likely to emphasize environmental demands and influences on coping. Coping process approaches tie the coping strategies to a particular stressful episode. Finally, COPING AND HEALTH daily coping processes use experience sampling techniques to examine how individuals cope throughout the course of the day with a wide variety of problems. Psychoanalytic Approaches Research on how individuals adapt grew out of early psychoanalytic studies of defense mechanisms, which are considered to be unconscious ways of warding off anxiety. DSM-IV (American Psychiatric Association, 1994) currently identifies seven major types of defense mechanisms, and orders them hierarchically from more to less severe. The most severe is defensive dysregulation, which refers to frankly psychotic processes involving projection, denial, and delusion. Action refers to acting out, passive aggression, or apathetic withdrawal, and major image-distorting mechanisms include autistic fantasy, projective identification, and splitting. The less severe or â€Å"immature† mechanisms include disavowal (denial, projection, and rationalization), minor image-distorting (devaluation, idealization, and omnipotence), and mental inhibitions (displacement, dissociation, intellectualization, repression, and the like). High adaptive or â€Å"mature@ defense mechanisms include altruism, humor, and sublimation, as well as suppression. Cramer (2000) compared the similarities and differences between defense mechanisms and coping processes. Defense mechanisms are unconscious, nonintentional, dispositional, hierarchical, and associated with pathology, while coping processes are conscious, used intentionally, situationally determined, nonhierarchical, and associated with normality. In other words, defense mechanisms are designated a priori as being more or less adaptive, and are not COPING AND HEALTH 4 consciously chosen. Individuals nonetheless can be characterized by primary defensive styles or defense mechanisms that they are most likely to exhibit under a wide variety of circumstances. In contrast, coping processes are thought to be consciously chosen and are responsive to environmental demands. Rather than hierarchically ordered, the effectiveness of coping processes is thought to vary as a function of appropriateness to environmental demands. Defense mechanisms are traditionally studied via the use of intensive interviews and case studies. However, a number of inventories have been developed to assess defense mechanisms via self-report, including Gleser Ihilevich (1969), Haan (1965) and Joffe Nadich (1977). However, the psychometric properties of these scales are questionable (Cramer, 1991; Davidson MacGregor, 1998). Of more recent vintage is a Defense Style Questionnaire (Bond, Gardiner, Sigel, 1983). However, as Cramer (2000) points out, there is a logical inconsistency in asking individuals to report on unconscious processes, and researchers are more likely to use observational methods and/or rely upon qualitative research coding interview or projective materials. In part because of the difficulty of systematically assessing defense mechanisms, there have been few large-scale studies of the adaptational outcomes of defensive strategies. Indeed, more research has been directed to identifying the developmental trajectory of defense mechanisms (Vaillant, 1977, 1993), as well as in identifying predictors of the use of immature defenses, including personality and affective disorders (see Cramer, 2000, for a review). Nonetheless, the study of defense mechanisms truly set the stage for understanding how people cope with both stress and trauma. COPING AND HEALTH Coping Styles. A major outgrowth of the psychoanalytic literature was the conception of coping styles, 5 which borrowed some of the language from psychoanalysis but was more focused on how people deal with information than how they deal with emotions per se. The earliest typology was repression-sensitization (Byrne, 1964). Repressors avoid or suppress information, while sensitizers seek or augment information. This dichotomy has reappeared in many different guises over the past 30 years, with blunting-monitoring (Miller, 1980) and approach-avoidance (Roth Cohen, 1986) being the current manifestation of dichotomy. In general, approachmonitoring-vigilant coping styles have been shown to be associated with better outcomes in a variety of situations, while repression-avoidant-blunting styles are associated with poorer outcomes (for reviews, see Aldwin, 1999; Roth Cohen, 1986). Dichotomizing coping strategies into two broad modalities can be psychometrically appealing. Certainly Endler and Parker (1990) have shown that the factor structure of coping style inventories, which currently focus more on problem- vs. emotion-focused coping, are more stable than process measures, and often correlate reasonably well with psychological symptom inventories. However, even early research by Lazarus and his colleagues showed that both types of coping were used in over 80% of episodes, and often individuals in highly stressful situations alternate between approaching and avoiding the problem (Folkman Lazarus, 1980; Lazarus, 1983). Nonetheless, the use of particular emotion-focused coping strategies may be more consistent across time and strategies, suggesting that individuals may have characteristic ways of dealing with and/or expressing emotion (see Aldwin, 1999). COPING AND HEALTH Coping Process As mentioned earlier, the coping process approach draws upon the cognitive behavioral perspective, and argues that coping is flexible and responsive to environmental demands, as well as personal preferences. In this model, how individuals cognitively appraise situations is the primary determinant of how they cope. The four primary appraisals are benign, threat, harm/loss, and challenge, and these are influenced both by environmental demands and individual beliefs, values, and commitments (Lazarus Folkman, 1984). Rather than examining general coping styles, coping process approaches examine how individuals cope with a particular stressor. Coping process approaches have recently come under attack from a variety of perspectives. Critics have charged that the factor structure for such inventories as the Ways of Coping is not stable, either across time or across samples (Endler Parker, 1990) although the factor structure for the COPE (Carver, Scheier, Weintraub, 1989), another widely-used coping measure, is also less than satisfactory (Schwarzer Schwarzer, 1996). However, the factor structure for coping process measures may not be stable precisely because they are responsive to environmental demands (Schwartz Daltroy, 1999). Coyne Racioppo (2000) also criticized coping inventories as being to o vague to generate clinically meaningful results, and argued for more situation-specific inventories (which, however, would also create problems of generalizability across situations). Nonetheless, there is broad agreement concerning the types of coping strategies that exist. There are five general types: problem-focused coping, emotion-focused coping, social support, COPING AND HEALTH 7 religious coping, and making meaning. Note that coping strategies are not mutually exclusive, and even strategies which may seem orthogonal, such as suppressing and expressing emotions, may be used sequentially in the same situation. Within each general type of coping strategy, there may be several subtypes. Problem-focused coping includes cognitions and behaviors that are directed at analyzing and solving the problem. It may include â€Å"chunking† or breaking a problem into more manageable pieces, seeking information, and considering alternatives, as well as direct action. Sometimes delaying or suppressing action is seen as a separate problem-focused strategy. Delaying action or decisions may be used in health circumstances in which people are waiting for the outcome of tests, and suppressing action may be useful in avoiding actions which may make a problem worse, such as acting in anger. Emotion-focused coping is often seen as a strategy in and of itself, but is best conceived as involving different sub-types. Avoidance and withdrawal may be different from expressing emotion, and suppression, setting one’s emotions aside in the service of a problem-solving effort, is clearly different from the use of substances to regulate emotion. Avoidance, withdrawal, and substance use are most generally associated with poor outcomes (Aldwin Revenson, 1987). Seeking social support and religious coping are strategies that involve elements of both problem-focused and emotion-focused coping. Support seeking may include asking for advice, concrete aid, emotional support, or justification for one’s perceptions and/or actions (Thoits, 1986). Similarly, religious coping, which includes prayer, is generally considered a form of emotion-focused coping, but may involve asking for advice or even concrete aid. The study of COPING AND HEALTH religious coping strategies is as yet in its infancy (Pargament, 1997), and the associations of to outcome measures by vary by religious denomination (Park, Cohen, Herb,1990). In general, religious coping may be most helpful with uncontrollable stressors (Aldwin, 1994) or for lower socioeconomic status groups (Cupertino, Aldwin, Schulz, 2000). Social support, conceptualized as social integration (Berkman Syme, 1994), and social disclosure (Smythe, 1998) are almost always associated with better mental and physical health outcomes, in coping studies. However, seeking social support is almost always associated with poorer outcomes (Monroe Steiner, 1986). The reasons for this are not well understood, but may devolve around negative reactions from others (Rook, 1998), or perhaps the act of seeking support may be indicative of poor networks or a catastrophizing coping style. Finally, making meaning is a strategy that is least well understood. It involves trying to make sense of the problem, and, in the general coping literature, may be called â€Å"cognitive reframing. † It involves such strategies as â€Å"looking for the silver lining† or trying to perceive 8 positive aspects of the current problem. Making meaning may be most often used in coping with extreme stressors, such as trauma or major losses (Mikulincer Florian, 1996), and thus will be discussed in greater detail in the trauma section. Daily Process Coping Daily process coping involves the assessment of coping strategies generally directed at specific problems once or more per day. Respondents may be asked to fill out questionnaires every evening, or they may be beeped and fill out mini inventories on the spot. To date, only a handful of coping studies have utilized this method (for a review, see Tennen, Affleck, Armeli, COPING AND HEALTH 9 Carney, 2000). The correlation between process and retrospective measures of coping is a matter of some controversy. While some claim that it is fairly low (Ptacek, Smith, Espe, Raffety, 1994), examination of the raw data reveals that, in at least one study (Stone et al. , 1998), the correlation is actually quite high, about . 7 (although only the r2 was reported). Further, Schwarzer and Schwarzer (1996) have criticized the psychometric properties of daily process measures, as they are of necessity quite short and often consist of single items. Nonetheless, the associations between momentary coping and process outcome measures tend to be encouraging, although there are within-subject and between-subject (aggregated) analyses may differ in some curious ways which merit further investigation. For example, Affleck et al. (2000) examined daily diary associates between coping and alcohol consumption in moderate- to heavy-drinking men and women. Aggregating the data, they found problem-focused coping had no effect average consumption, emotion-focused coping was negatively-related to consumption, but avoidant coping was positively related. However, a very different pattern of results emerged from the within subjects analyses. Instead of the aforementioned pattern, they found an inverse relationship between problem-focused coping and alcohol consumption. The reasons for this are unclear, but may relate to average differences in alcohol consumption. For similar reasons, it would make sense that within-subject analyses of pain patients should show a more protective effect of coping strategies on pain than between-subject analyses (Tennen Affleck, 1996). COPING WITH TRAUMA COPING AND HEALTH 10 It is one thing to describe individual differences in dealing with everyday stressors or even life events, but it is quite another thing to generalize this to traumatic situations. By definition, traumatic situations are generally outside of individuals’ usual experience, and most individuals have not developed the necessary repertoires to know how to deal with such events (although military personnel and some categories of civil servants such as police, firefighters, and emergency medical technicians do receive training). Indeed, at first glance, the initial reaction to major trauma seems stereotypical reports of emotional numbing, cognitive impairment, and aimless wandering have been reported for such disparate traumas as tornadoes (Wallace, 1956), concentration camps (Bettelheim, 1943), nuclear blasts (Lifton, 1968), and combat (Solomon, 1993). It would be tempting to argue that the environmental press of trauma is so great that there are few individual differences in reaction to it. However, closer examination of the trauma literature reveals marked individual differences in how people cope even with traumatic situations, although clearly environmental factors may constrain choices. Further, as we shall see, how coping strategies can influence the long-term psychological and perhaps physical responses to the trauma. Aldwin (1999) identified four ways in which the pattern of coping responses in traumatic situations differs from that from ordinary life events. First, individuals in traumatic situations may feel they have less control over their cognitions and behaviors. Solomon (1993, p. 3) quoted a crack paratrooper during the Yom Kippur war, who, despite his elite training, found himself frozen in the middle of action, unable to move to help his fellow soldiers. Such freezing reactions may also be common in rape (Burgess Holstrom, 1976). In naturalistic descriptions COPING AND HEALTH 11 of people in traumatic situations, the use of defense mechanisms such as di ssociation, repression, and denial may be much more widespread (Ward, 1988). Indeed, when being tortured, either by one’s political enemies or one’s parents, dissociation may be the only option available (Figley, 1983). Second, disclosure may be of particular importance in traumatic situations. While seeking social support may be associated with poorer outcomes with everyday stressors, in trauma situations, individuals who disclose to others typically do much better both in terms of short and long-term outcomes (Smythe, 1998; Lee, Vaillant, Torrey, Elder, 1995). However, the reaction of others in the social environment may moderate this relationship. In particular, individuals who experience negative reactions from others may have worse outcomes than individuals who did not disclose (Silver, Holman, Gil-Rivas, 2000). Third, the process of coping with trauma is usually much more extended than is coping with general hassles or even life events, especially if an individual develops post-traumatic stress disorder (Horowitz, 1986). Indeed, the sequellae of major trauma has been documented to last for decades (Aldwin, Levenson, Spiro, 1994; Kahana, 1992; Schnurr, Spiro, Aldwin, Stukel, 1998). Epstein (1991) has referred to trauma as the ‘atom-smasher’ of personality, and the process of reconstructing both lives and sense of identity may take years (Lomranz, 1990). Thus, it is not surprising that fourth difference, ‘making meaning’, is a strategy which has particular utility in traumatic situations (Mikulincer Florian, 1996). Making meaning may entail both reorganization of existing cognitive-motivational structures, as well as reappraisal or reinterpretation of not only the event but also the context of the event in a person’s life. Loss COPING AND HEALTH events may also entail a search for meaning, especially if those events are sudden or traumatic (Wortman, Battle, Lemkau, 1997). While this search for meaning may be painful in and of itself, and sometimes fruitless, as Wortman and her colleagues have often documented, it may 12 also set the stage of post-traumatic growth (Aldwin Sutton, 1998; Lieberman, 1992; Tedeschi, Park, Calhoun, 1998). Indeed, of the most intriguing aspects of the coping with trauma literature are the hints that trauma may constitute a major avenue for personality change in adulthood. For example, Schnurr, Rosenberg, Friedman (1993) examined change in MMPI scores from college to midlife as a function of combat exposure. They found that MMPI scores were most likely to improve in men who had moderate levels of combat exposure, compared to those who had heavy exposure — or none at all. Similarly, Park, Cohen, Murch (1996) found that students who perceived growth as a result of a major stressor increased in optimism over the course of a year. While some aspects of personality are widely believed to change as a function of trauma exposure (Epstein, 1991), more studies documenting this are needed. In particular, the possible mediating function of coping strategies merits further investigation (Aldwin, Lachman, Sutton, 1996). In addition to these four differences, another way in which studies of coping with trauma differ from general studies of coping with stress is that trauma studies sometimes focus on just one strategy. Examples of such studies include self-blame (Davis, Lehman, Silver, Wortman, Ellard, 1996; Delhanty et al. , 1997), â€Å"undoing† (Davis, Lehman, Wortman, Silver Thompson, 1995), and â€Å"temporal orientation† (Holman Silver, 1998). Surprisingly, while self-blame in everyday situations is generally associated with poor outcomes, in traumatic situations such as COPING AND HEALTH rape or automobile accidents, self-blame may be associated with positive outcomes in that it 13 provides at least an illusion of control in what are often uncontrollable situations. For example, if a rape victim blames herself for approaching a stranger in a car, she may feel that she would be able to avoid such circumstances in the future. Undoing is a particularly intriguing strategy, but may not be specific to trauma. Indeed, it would be very interesting to see how often and under what circumstances this strategy is used in everyday coping. Nonetheless, there have been a number of studies of trauma using standardized coping checklists, and, as we shall see, the process of coping with trauma may be more important for health outcomes than the exposure to trauma itself (Wolfe, Keane, Kaloupek, Mora, Winde, 1993). COPING AND HEALTH OUTCOMES There is a large literature on trauma and long-term health outcomes that will be reviewed by Baum and Dougall (this volume); instead, we will focus on the coping and health outcomes literature. The relationships detailed in this literature are highly complex, in large part because it is atheoretical, and thus difficult to organize effectively. Therefore, we will organize this review by type of outcomes, limiting it to physical health outcomes, with the exception of PTSD. The first section will focus on PTSD, as it is particularly germane to trauma, and the second to selfreported health outcomes. The third will focus on biomedical indicators such as cortisol, immune, cardiovascular reactivity, and lipids, while the fourth section summarizes research on coping and the progression of disease or disease outcomes. Finally, we will review the coping intervention COPING AND HEALTH literature, that is, studies which have actively sought to change how individuals cope with the particular stressor they are facing in an attempt to modify disease progression or outcomes. Coping and PTSD There is a growing recognition that how individuals cope with trauma may be more important in the development of post-traumatic stress disorder (PTSD) than the occurrence of 14 the trauma itself (Aldwin, 1999; Mikulincer Florian, 1996). For example, Fairbank, Hansen, Fitterling (1991) compared coping strategies of three groups of WWII male veterans, prisoners of war (POWs) ith PTSD, those without, and veterans who were not POWs. POWs with PTSD were more likely to use wishful thinking, self-blame, and self-isolation, whereas POWs without PTSD were more likely to use reappraisal coping. Aldwin, Levenson, Spiro (1994) also found that the perceived benefits of military service also resulted in lower PTSD symptoms in WWII veterans. Vietnam veterans who used more emot ion-focused coping were also more likely to report PTSD. The Israelis have also conducted a number of studies in this area. One prospective study of combat soldiers in the Lebanon War found that wishful thinking and denial were also predictive of PTSD over the course of a year (Solomon, Mikulincer, Benbenishty, 1989). Concurrent use of problem-focused coping was inversely related to PTSD two to three years after the war in the same population (Solomon, Mikulincer, Abitzur, 1988). Israeli civilians who used palliative coping during the SCUD missile bombing were more likely to experience negative stress reactions (Zeidner Hammer, 1992). COPING AND HEALTH 15 As mentioned earlier, the impact of emotional disclosure of trauma may be moderated by the reactions of others in the environment. Specifically, Stephens and Long (2000) found that New Zealand police officers who received positive peer communication and who could easily talk about trauma had lower PTSD scores and lower levels of physical symptoms. The effects of trauma on health may be mediated through the development of PTSD (Baum, Cohen, Hall, 1993; Davidson Baum, 1993; Schnurr, Spiro, Paris, 2000). Once again, coping strategies may have an indirect effect on health. If their use can prevent the development of PTSD, the adverse heath effects of trauma may be ameliorated. Coping and Self-Reported Health Outcomes While there is a fairly extensive literature on coping and mental health outcomes (for reviews see Aldwin, 1999; Lazarus Folkman, 1994; Zeidner Saklofske, 1996), there are surprisingly few studies of coping and self-reported physical health symptoms in general populations. Most occur in the context of clinical populations and disease progression, which usually include both biomedical and self-report outcomes, and are reviewed below. However, we did find a few studies which used either worker or student populations. . Eriksen, Hege Ursin (1999) examined the interaction between psychological demands, coping, and control in a large sample of Norwegian postal service workers. They found that individual coping styles were more important for subjective health complaints than were either control or organizational factors. Specifically, coping, as assessed by the Utrecht Coping List, moderated the effects of job stress such that individuals with low demands and high coping had the fewest health complaints, while those with high demands and low coping reported the COPING AND HEALTH 16 most. Interestingly, individuals with high demands and high coping had high perceptions of job stress but did not report high levels of symptoms. Pisarsi, Bohle, Callan (1998) examined coping and physical symptoms among shift workers. There were both direct and mediated effect of coping on health outcomes. Specifically, disengagement coping strategies were directly related to increased physical symptoms, but emotional expression was mediated through both conflicts and support. Thus, emotion expression appeared to increase physical symptoms via increased work conflicts and concomitant psychological symptoms, but to decrease physical symptoms through increased family support. Unfortunately, this study did not provide any test of the statistical significance of the indirect paths, and thus we cannot contrast the relative strengths of the indirect paths. However, it does make a certain amount of sense that complaining to coworkers may increase distress and result in more physical symptoms, while complaints to family may elicit more support and thus decrease symptoms. Finally, two studies found that the relationship between coping and physical symptoms disappeared once controlling for personality factors such as neuroticism (Costa McCrae, 1986) and anxiety (Hemenover Dienstbier, 1998). However, both of these studies used coping style measures with general outcomes, and thus it is not surprising that the personality traits would better predict a general outcome. More work is needed to determine if the relationship between coping processes and a time-specific measure of physical symptoms would be similarly overwhelmed by personality. Based on prior research with psychological symptom outcomes, (Bolger, 1990), we suspect that the effect of personality on health is at least partially mediated COPING AND HEALTH 17 through coping strategies, but that coping strategies will have independent effects on symptoms, but research is needed to confirm that. Coping and Biomedical Outcomes There are literally hundreds of studies in humans showing that stress affects both the neuroendocrine and immune systems, and there is a general agreement that there are individual differences in the effects of stress. Situational constraints such as controllability and personality factors such as Type A have been extensively studied (for reviews see Biondi Picardi, 1999; Cohen Herbert, 1996; Frankenhauser Johansson, 1986; Herbert Cohen, 1993; Olff, 1999). However, it is more difficult to actually demonstrate a relationship between coping strategies per se and Ahard@ biomedical outcomes, in part because there are surprisingly few published studies (although the number of studies examining disease outcomes is growing). Although Biondi and Picardi (1999), in their otherwise excellent review of stress and neuroendocrine factors, state that there is ‘a large body of evidence that coping strategies may significantly influence hormonal responses to both laboratory stressors and real life stress situations’ (p. 133), closer examination reveals that they based this conclusion on only four published studies. Further, most reviews focus on a particular biomedical outcome, and we felt that providing an overview of several outcomes might prove instructive. Our initial strategy was to divide the coping and biomedical outcomes literature into laboratory, field, disease outcomes, and intervention studies, separately by coping with stressors vs. coping with trauma in order to provide meaningful contrasts. However, the gaps in the literature made this strategy over-optimistic. While it is not surprising that there were no COPING AND HEALTH 18 laboratory studies on coping with trauma, it turns out that most of the field studies of coping and neuroendocrine outcomes involved traumatic situations. Thus, we will combine both stressor and trauma studies in the same categories, noting differences and similarities, where appropriate. Laboratory studies. Most laboratory studies examining the effect of coping on neuroendocrine outcomes rely on personality assessments of defenses or coping styles. In these often unpublished studies, defensiveness, avoidance, and repression are typically associated with higher cortisol levels (Biondi Picardi, 1999). Bossert et al. (1988) found no relationship between coping styles and cortisol, but their sample size was very small (12 men). Van Eck, Nicholson, Berkhof, Sulon (1996), using a larger sample, also found no relationship between coping style and salivary cortisol. Bohnen, Nicholson, Sulon, Jones (1991) found that ‘comforting cognitions’, a type of cognitive reframing, was negatively associated with cortisol response. A handful of studies have also examined specific coping strategies and cardiovascular outcomes. Tomaka, Blascovich, Kelsey (1992) found no association between repressive coping and psychophysiological reactivity to stress, once the effect of social desirability was controlled. However, Vitaliano, Russo, Paulsen, Bailey (1995) examined cardiovascular recovery from laboratory stressors in older adults, and found that avoidance coping was positively related to diastolic blood pressure and heart rate. The same laboratory also found similar findings among caregivers of Alzheimer patients (Vitaliano et al. , 1993). Controlling for standard risk factors such as smoking, avoidance coping was associated with higher levels of cardiovascular reactivity. COPING AND HEALTH Individuals who show the highest levels of cardiovascular reactivity also show the 19 reatest immune system disturbances to stress (Herbert, Coriell, Cohen, 1994). While there is a growing literature on stress and immune functioning (for reviews, see Cohen Herbert, 1996; Herbert Cohen, 1993; Kiecolt-Glaser Glaser, 1995), we located no laboratory studies which examined induced stressors, coping, and immune outcomes. This is surprising in view of the fact that the immune response to stressors occu rs in minutes (Eriksen, Olff, Murison, Ursin, 1999), even before cortisol responses, and thus the immediate impact of coping on immune function could be studied. However, most of the coping and neuroendocrine lab studies were done in the 1970’s and 1980’s, when the specificity of coping was not as yet well understood and most studies relied on defenses and coping styles. Thus, the absence of coping and immune studies in the laboratory may reflect a more mature understanding of coping. Nonetheless, carefully constructed laboratory studies could clear up some of the conflicting findings in the field studies. Field studies. Although animal studies have indicated that coping style is linked to neuroendocrine profiles in feral animals (Koolhaas et al. 1999), there are a limited number of field studies assessing the effects of coping on neuroendocrine outcomes in humans. Perhaps the most consistent finding is between urinary cortisol and the effectiveness of defenses. Vickers (1988) reviewed five field studies with stressors ranging from military basic training to having a fatally ill child, each of which found that individuals with e ffective defenses had lower levels of urinary cortisol. COPING AND HEALTH 20 Studies of coping strategies and neuroendocrine outcomes have yielded mixed results. For example, an early study by Schaeffer Baum (1984) showed that stress associated with the nuclear power plant disaster at Three Mile Island was related to urinary cortisol, as were psychological and physical symptoms, but coping styles were not. However, coping styles were related to lower levels of distress (Baum, Fleming, Singer, 1983), which presumably should have some effect, albeit indirect, on cortisol and catecholamines outcomes. Arnetz et al. (1991) conducted a prospective study of 354 employees of a telecommunications plant that was being downsized. Not surprisingly, long-term unemployment was associated with high levels of serum cortisol. However, coping was only indirectly related to cortisol via its effect on mastery. Emotion-focused coping was negatively related to mastery, which in turn was inversely associated with cortisol. Avoidance coping may be more directly related to cardiovascular outcomes. In a study of caregivers, avoidance coping was associated with higher levels of cholesterol fractions such as triglycerides, and low density lipoproteins (LDLs), but with lower levels of high density lipoproteins (HDLs) (Vitaliano, Russo, Niaura, 1995). Aldwin, Levenson, Spiro, Ward (1994) found that instrumental action was positively associated with HDLs and negatively with triglycerides, while self-blame showed the opposite pattern. Thus, the relations between coping and cholesterol may actually be more consistent that than between coping and cortisol, but many more studies are needed to show a consistent effect. A handful of studies have examined coping and immune system outcomes. Jamner, Schwartz, Leigh (1988), in a study of outpatients with stress-related disorders, found that COPING AND HEALTH repressive coping was negatively related to monocyte counts, but positively related to eosinophile counts. However, the repressors were also more likely to be taking antihistamines, so interpretation of this study is difficult. In a study of undergraduates, repressors had significantly higher antibody titers to Epstein-Barr, an indicator of a stressed immune system (Esterling, Antoni, Mahendra, Schneiderman, 1990). This pattern was not replicated by Solomon, Segerstrom, Grohr, Kemeny, and Fahey (1997) in their study of earthquake victims. 1 Repressive coping, as indicated by a Type C personality inventory, was unrelated to a variety of immune system outcomes, including lymphocyte subjects, lymphoid cell mitogenesis, and NK cell cytotoxity. However, there was an interaction between generalized distress and life disruption, such that individuals with high levels of disruption who did not report being distressed had impaired immune functioning (lower levels of CD3+ an d CD8+). The authors’ interpretation was that this was indirect support for the impact of repressive coping on immune function. With the exception of this last article, all of the studies reviewed in this section examined the main effects of coping on biomedical outcomes. However, coping is thought to be a moderator of the effects of stress, which would necessitate the examination of the interaction effects between stress and coping on outcomes. We located only two studies which did so, and thus merit some examination in depth. In a small sample of 11 seropositive males, Goodkin, Fuchs, Feaster, Leeka, Rishel (1992) found main effects of active coping on CD4+ cells; Active coping was associated with higher cell counts. While the interaction did not reach significance, contrast comparisons of COPING AND HEALTH 22 means within the high stressor group suggested that there were also significant differences in both total lymphocyte and T4 cells, with highly stressed active copers having higher cell counts than highly stressed passive copers. Goodkin and his colleagues (1992) repeated this study in a larger sample of 62 seropositive males. Carefully controlling for a variety of nutritional and lifestyle factors which affect immune function, there were main effects of coping on natural killer cell counts (NKCC), while venting emotions was associated with lower NKCCs. The interaction effect between stress and active coping was not significant. However, there was no indication that the authors centered the interaction terms to account for multicollinearity (cf. , Cohen Cohen, 1975). There was evidence of bouncing betas, as the beta for stress in the main effects model was . 72 but -25. 69 in the interaction effects model. Thus, the lack of significance of the interaction terms is difficult to interpret. Summary. Despite the hundreds of biomedical studies that have been done on stress and biomedical outcomes, relatively few studies have linked actual coping strategies with such indicators. The early laboratory studies relied primarily on trait measures of defenses, and various indices of what basically is emotional repression were related to higher cortisol levels. In addition, avoidant and repressive coping are related to greater cardiovascular reactivity and impaired immune function. However, there is some indication that positive coping is related to better outcomes. Problem-focused or active coping is related to higher natural killer and CD4+ cell counts and higher HDL levels. The results regarding coping and cholesterol are promising, but need more replication. COPING AND HEALTH 23 Besides its sparseness, a big limitation of this area is that most studies examine only main effects; given that coping is thought to be a moderator of stress, more studies should examine interaction effects. Barron Kenny (1986) caution, however, that valid examination of interaction effects often require very large sample sizes, which may be difficult to achieve in very small samples typical of psychoneuroendocrine and immune (PNI) studies (cf. , Mishra, Aldwin, Colby, Oseas, 1991). Another possible solution is for small sample studies to use jack-knife or boot-strap statistical techniques, which may provide more accurate assessments of the standard errors in small PNI samples (Aldwin, Spiro, Clark, Hall, 1991). Coping and Disease Outcomes There is a much more extensive literature on coping and disease outcomes. Several studies have examined pain and symptomology for individuals with chronic illnesses such as rheumatoid arthritis, the progression of serious illnesses such as AIDS and cancer, and even mortality (for reviews, see Garssen Goodkin, 1999; McCabe, Schneiderman, Field, Skylar, 1991; Tennen Affleck, 1996; Zautra Manne, 1992). These reviews often highlight the complex relationship between coping and outcomes. A variety of personal and contextual factors may moderate the effects of coping on health outcomes. For example, a review of studies on coping with rheumatoid arthritis (Zautra Manne, 1992) showed that there were some strategies that were associated with positive and negative outcomes such as pain. However, the results were often inconsistent, and depended upon coping efficacy, family environments, and personality dispositions. For example, the effect of relying on others has different effects depending upon the severity of illness. Relying on COPING AND HEALTH 24 thers led to increased psychological distress among women with rheumatoid arthritis who were in relatively good health, but lower levels of distress for women who were in poorer health (Reich Zautra, 1995). Helgeson, Cohen, Schulz, Yasko (2000) showed that social support groups had the most positive effect on physical functioning for those breast cancer patients who lacked natural support or had fewer personal resources, but were harmful for those women who had high levels of support. Further, the effects may vary by type of arthritis disease. Affleck et al. 1999) found that emotion-focused coping was positively associated with increased pain in rheumatoid arthritis patients, but decreased pain in osteoarthritis patients. The emotion-focused coping coded in this study involved seeking support and venting to others. Affleck et al. suggested that the differences between these two groups were due to the response of the caregivers. Osteoarthritis pain is specific to movement and thus may be more understandable to caregivers, whereas the pain involved in rheumatoid arthritis (swollen joints and fatigue) is more global and may evoke less sympathetic responses. This fits in very nicely with the trauma literature reviewed above, in which the effects of social disclosure were also moderate by the response of others in the social environment. There is also evidence that coping may have indirect or mediated effects on outcomes. Billings, Folkman, Acree, Moskowitz (2000) showed that coping affected positive and negative affect among men who were caregiving for AIDS patients. Social support coping predicted increases in positive affect, which in turn were related to fewer physical symptoms. COPING AND HEALTH 25 Avoidant coping, however, was related to increases in negative affect, which were related to more physical symptoms. Coping may also be related to the progression of AIDS. One prospective study of a sample of asymptomatic HIV+ men and women also reported that avoidance and passive coping was positively correlated with development of symptoms, while planful coping was negatively related to progression of HIV symptoms (Vassend, Eskild, Halvorsen, 1997). A crosssectional study also found that individuals diagnosed with AIDS were lower in planful problemsolving than HIV negative individuals (Krikorian, Kay Liang, 1995). A Dutch longitudinal study over one year also found that active confrontational coping predicted slower disease progression HIV+ men (Mulder et al. , 1995). A follow-up study also showed that individuals who used avoidant coping had a more rapid deterioration of CD4 cell counts over seven years (Mulder, de Vroome, van Griensven, Antoni, Sandfort, 1999). While there is at best weak evidence for the relationship between coping and the development of cancer (Garssen Goodkin, 1999), coping strategies may affect the response to cancer treatments. Women who used confrontive coping reported fewer side effects from chemotherapy than those who used avoidant strategies (Shapiro et al. , 1997). A few studies have directly looked at coping and the progression of cancer, primarily breast cancers. A series of British studies showed that women who used active coping styles lived longer, especially in those women with early, nonmetastatic cancer (Greer, 1991; Greer Morris, 1975; Morris et al. , 1981). In contrast, a study of women with breast cancer showed that repressors had elevated COPING AND HEALTH 26 evels of mortality, with a risk ratio of 3. 7 (Weihs, Enright, Simmens, Reiss, 2000). However, Buddeberg et al. (1996) found modest associates between coping and death from breast cancer. Individuals using problem tackling and self-encouragement were less likely to die, while individuals using distrust pessimism were more likely to die. COPING AND HEALTH 27 Summary. It is not at all surprising that coping skills and strategies shoul d affect disease progression, especially in those diseases such as AIDS and cancer that have very arduous treatment regimens. It makes perfect sense that individuals who are good planful problem solvers are more able to handle these regimens and have better outcomes, whereas avoidant copers have worse outcomes. More sobering, however, is the recognition that a variety of personal and contextual factors may moderate the relationship between coping and health outcomes such as pain. The effectiveness of coping strategies may vary by the stage of the illness, the type of illnesses, and the responsiveness of others in the environment. This suggests that interventions need to be very specifically tailored to individuals, which is often not the case. Intervention Studies One of the simplest and most dramatic coping interventions in the literature is a written emotional expression task. In this paradigm, individuals are encouraged to write about stressful episodes, especially traumatic ones. In a review of this literature, Smyth (1998) found that disclosure lead to significantly better health outcomes in a variety of biomedical outcomes, cardiovascular reactivity and risk factors, immune outcomes, physiological functioning, and health behaviors. No studies on neuroendocrine outcomes were included in this review. A drawback of these studies is that they utilize primarily undergraduate populations, and their utility varies as a function of duration of the writing task. While single intervention episodes can have significant effects, these tend to be weaker than interventions with multiple writing episodes, as narratives tend to become more focused and coherent over time. It is also unclear whether this is due to cognitive processing or the reversal of emotional repression. A review by COPING AND HEALTH Esterling, L’Abate, Murray, Pennebaker (1999) suggests that both mechanisms may be employed, but for different types of outcomes. Both cognitive processing and the reporting of positive emotions are predictive for emotional well-being, but the reversal of emotional repression may be important for neuroendocrine and immune system outcomes. A large number of ‘coping interventions’ in the behavioral medicine literature consist of psychoeducational interventions (for a review Compas et al. , 1998). The most dramatic and consistent results are seen with pain interventions. In a meta-analysis of 191 studies, Devine (1992) found that statically reliable, albeit modest, effects were found on recovery, postoperative pain, and psychological. Nearly all (79%) of these studies found a shorter length of 28 hospitalization. Interestingly, adding specific coping skills training to standard pain management treatment programs greatly improved pain control (Kole-Snijders et al. , 1999). Perhaps the most dramatic of interventions studies was conducted by Fawzy and his colleagues (Fawzy, Cousins et al. , 1990; Fawzy, Kemeny et al. 1990; Fawzy et al. , 1993; Fawzy Fawzy, 1994), who did specific coping skills interventions with melanoma patients. This was a six-week structured program with multiple components, including health education, psychological support, and training in both problem-solving and stress management. Short-term, the experimental subjects were more likely to use active behavior coping than the controls, and also had more positive affect. Differences in immune functioning were evident between the two groups at the six months assessment. Specifically, experimental subjects had a greater percentage of large granular lymphocytes, more NK cells, and better NK cytotoxicity. While coping strategies were not directly associated with immune cell changes, they were correlated with COPING AND HEALTH affect, which in turn was associated with immune functioning. This supports our supposition 29 that the effects of coping on biomedical outcomes may be mediated through affect. At a five-year follow-up, a third of the control group had died, compared to less than 10% of the experimental group. Longer survival was associated with more active coping at baseline. Towards a Theoretical Model As mentioned earlier, the literature on coping and health outcomes is difficult to disentangle, primarily because so little of it is guided by specific theories. In an early study, Aldwin and Revenson (1987) suggested that there are two possible models, direct effects and moderated effects. Escape/avoidant coping appeared to have primarily direct affects, that is, it tends to increase psychological symptoms, regardless of the stressfulness of the event. In contrast, problem-focused coping was more likely to have moderating or buffering effects. However, the current literature suggests that there are five possible models of the relationship between coping and health outcomes, which are illustrated in Figure 1. (1) Direct Effects. Most of the studies reviewed in this chapter examined only the direct effects of coping on outcome. That is, with notable exceptions, most used a simple correlational paradigm to examine whether coping strategies were related to outcomes. (2) Moderated Effects. Relatively few studies examined whether coping moderates or buffers the effects of stress; the few that did were hampered either by very small sample sizes or poorly constructed statistical analyses. COPING AND HEALTH (3) Mediated Effects. A number of studies suggested that the effects of coping were mediated 30 through other variables, especially affect. That is, coping related to outcome variables only to the extent that it modified affect. (4) Contextual Effects. A number of studies also suggested that the effects of coping, especially emotional expression, were moderated by the reaction of other individuals in the context. 5) Spurious Effects. A handful of studies suggested that the effect of coping on outcomes was spurious; that is, once controlling for personality, the relationship between coping and health outcomes disappeared. This was primarily true for studies with self-reported health outcomes which used coping styles measures. It appears from the literature reviewed here that different models apply to different types of outcome measures. Given the relatively few studies in each of these different areas, definitive conclusions cannot be drawn; rather, these hypotheses are offered as a useful heuristic that may guide future research. Table 1 represents our attempt to summarize this literature, and indicates which models were supported for different coping strategies by outcomes. Given the wide variety of coping measures used, we chose to roughly group strategies into instrumental action, avoidance (including escapism, wishful thinking, and self-isolation), meaning making, cognitive reframing, self-blame, and social support (which includes emotional expression and disclosure). We did try to differentiate between process and styles measures, although the distinction was not always clear from the studies. Unless otherwise noted, the direct effects of instrumental action, cognitive reframing, and meaning making are assumed to decrease or be associated with lower levels of health problems (indicated by a downward arrow), while avoidant and self-blame COPING AND HEALTH strategies are assumed to increase or be associated with higher levels of health problems 31 (indicated by an upward arrow). Tests for other types of models are indicated simply with an X. Question marks indicate contradictory or inconsistent findings. As indicated in Table 1, studies of coping with trauma consistently show that instrumental action and meaning making are associated with lower levels of PTSD, while avoidant coping strategies are associated with higher levels. The effects of social support, generally in the form of disclosure, depend upon the context: if the social network is supportive and responds positively, disclosure works well, but if the network is unsupportive, the individual may be worse off than if s/he had not disclosed their experience with trauma. Similarly, self-blame may be associated with oorer outcomes, but if self-blame allows an individual to maintain at least an illusion of controllability, than self-blame may be associated with positive effects. For example, if a rape victim blames herself for approaching strangers in a car, then theoretically at least she should be able to avoid such situations in the future and therefore decrease her risk of another attack. It is surprising that apparently no s tudies of coping with trauma examined any of the more complex models, such as moderated, mediated, or, for that matter, spurious. All of the self-reported symptoms studies reviewed here examined coping with ordinary stressors, not with trauma. Given the common findings of increased physical symptoms with trauma, is very surprising that none of the coping studies Nonetheless, the results are similar to those found with PTSD. Instrumental action is generally associated with fewer symptoms, and avoidant styles with higher symptoms. As with trauma, however, the effects of social support appear to be contextual. The one study that examined a mediated model found contradictory COPING AND HEALTH 32 athways: emotional expression increased coworker conflict, but also increased family support. Thus, it would appear that the effect is actually contextual — that is, emotional expression in the workplace may increase stress and therefore increase symptoms, but venting to family and friends may increase support and therefore decrease symptoms. It is not surprising that studies using coping styles find that the effect drops out once personality factors such as anxiety are controlled. Given the vast literature on stress and neuroendocrine function, it is surprising that the results were so inconsistent. While some early studies found that those with â€Å"effective defenses† had lower catecholamine levels, it was not clear exactly what this meant, and it was omitted from the table. More recent laboratory studies were just as likely to find no effects of coping styles in general or avoidant styles in particular as they were to find any effects, and none of the field studies found direct effects of coping on neuroendocrine function. However, both the trauma and job loss literatures suggest that the effects may be mediated through affect, although more direct tests are needed. Given the strength of the animal literature and the theoretical models, it is extremely surprising that stronger effects of coping on neuroendocrine function were not found. At first, our inclination was to attribute this to the problem of timing in field studies. Catecholamines have very rapid responses to stress, it is unlikely that the time periods of the coping behaviors and urine collection adequately overlapped. If the coping resulted in long-term changes in affect, then mediated effects might be seen. However, Stanford’s (1993) review of stress and catecholamines suggests an alternative hypothesis. She suggests that, in adapting to stress, COPING AND HEALTH 33 anxiety is associated with high levels of catecholamines, while depression is associated with low levels. Failure to differentiate between the reactions might well lead to the contradictory findings in the literature. In other words, avoidant coping may lead to depression or anxiety, that is, to lower or higher levels of catecholamines. Thus, we hypothesize that the relationship between coping is complex, and mediated not only by level of negative affect but by type as well. Only a handful of studies have examined coping and biomedical outcomes, and only one was in the context of coping with trauma. Avoidant strategies appear to be associated with higher levels of cardiovascular reactivity, while the effect of repressive style is spurious when controlling for anxiety. Similarly, instrumental action is associated with higher levels of HDL and lower levels of LDL and triglycerides, while avoidance and self-blame shows the opposite pattern. The very early studies on coping and immune outcomes are very difficult to interpret, given poor coping measures, specialized samples, and inconsistent results. Tentatively, instrumental action appears to be associated with higher levels of CD4+ and NKCC, while social support, in the form of emotional venting, was associated with lower levels of NKCC. Clearly there is a huge gap in the literature. More studies needed on the effects of coping on biomedical outcomes, especially in the context of trauma, and more sophisticated models need to be examined than simple direct effects. Finally, a more extensive literature exists on coping and disease outcomes. The results are much more consistent and give cause for optimism. Nearly every study has found that instrumental action is associated with slower disease progression, fewer side effects of treatment, and fewer symptoms, while avoidant coping shows the opposite pattern. Given the importance COPING AND HEALTH 34 of adherence to medical regimens and dietary restrictions in coping with chronic illnesses, it is not surprising that problem focus coping leads to better outcomes, and avoidant coping to poorer ones. Interestingly, though, Billings et al. (2000) suggests that all of the effects of coping (at least on physical symptoms in AIDS patients) are mediated through affect. Certainly more studies are needed which examine the mediators of coping on disease outcomes, especially vis-a-vis adherence and affect. The effect of social support on disease outcomes presents a more sobering picture. It is clear that the effects of support are primarily contextual, and have very different effects depending upon the type of illness, reactions to others, and needs of the individual. Clearly, if individuals are severely disabled or relatively socially isolated, provision of positive support may be very beneficial. However, if the primarily caretaker is unresponsive to genuine or creates dependency when support is no needed, then utilization of social support can have harmful effects. In summary, then, it is clear that much more research is needed in order to understand the effects of coping on physical outcomes, whether in the context of everyday stressors, chronic illness, or trauma. The trauma literature is especially deficient with regard to the effect of coping on biomedical outcomes. While most studies have simply examined direct effects, there are hints in the literature that reality is much more complicated. In particular, it is likely that nearly all of the effects of coping on biomedical and disease outcomes are mediated through affect, and, in the context of chronic illness, to adherence to medical regimes. The effects of social support, however, are highly contextual, and depend upon the needs of the individual and the COPING AND HEALTH 35 responsiveness of others in the environment. Given that nearly all of the theoretical models posit coping as a stress buffer, it is extremely surprising that almost no-one bothers to test this. Despite these gaps, however, the evidence does exist that how individuals cope with problems does have an effect on their physiology, and coping interventions can have sometimes dramatic effects on disease outcomes COPING AND HEALTH AUTHOR ACKNOWLEDGMENTS Preparation of this chapter was supported by Hatch Funds from the University of California Cooperative Extension Service. We would like to thank Dr. Crystal Park for her helpful comments on an earlier version of this chapter. 36 COPING AND HEALTH REFERENCES 37 Affleck, G. , Tennen, H. , Keefe, F. , Lefebvre, J. , Kashikar-Zuck, S. , Wright, K. , Starr, K. , Caldwell, D. (1999). Everyday life with osteoarthritis or rheumatoid arthritis: Independent effects of disease and gender on daily pain, mood, and coping. Pain, 83, 601-609. Aldwin, C. M. (August, 1994). 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My biggest concern before and during my speech was being within the time limits. I was able to learn many different methods of controlling stress while I was in the Army and there are two I use often: combat breathing and status recognition. Combat breathing is simply measuring your breathes and spacing them evenly. With practice your body will begin to breathe that way all the time. Status recognition is a little harder to explain. The easiest explanation is that humans operate at 4 different levels of stress: green, yellow, red, and black. The goal is to stay in the yellow zone and use your bodies natural stress reactions as a benefit. This method takes many years of practice to fully develop though. The new course knowledge I used was mostly related to using note cards. Ive never been a consistent user of note cards; I prefer having my hands free when I speak. 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Having more Information to talk about will also help to fill the time requirements. Self Evaluation free essay sample Each day I feel it is a struggle for me; however, I will not give up. I’ve come too far. Every day I am learning what is expected of me as a writer. I am learning what to do and what not to do. On my first day of English 102-06 I was kind of nervous. I really did not know what to expect. Especially once I meet my professor he seemed a bit intimidating. However, I still wanted to challenge myself. He gave all of his students the option to drop his class if we were not ready. He mentioned that the work would be intense. I still was interest in taking this class although the said all of this. I thought to myself this should be easy. Since I passed English 101, I thought it couldn’t be any worse. I was in such a surprise. In English 101 you’re doing more essay than anything, which isn’t that hard. We will write a custom essay sample on Self Evaluation or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page In English 102-06 it’s more of reading texts that you really don’t understand. It is intense but in a good way. Our first week of class we were assigned to write an essay about love and a literature journal. I said to myself, â€Å"What did I just get myself into? I still did the literature journal knowing t was a possibility that I had done it wrong. Of course I did it wrong, but at least I tried. In my first essay, I made many mistakes. One of my biggest mistakes was that I did not use the proper format, which is MLA format. My professor gave us resources to help us with the formatting however, I did not use them. Secondly I procrastinated which is the worst thing you can ever do. I am fully aware of my errors and I know what I need to do to fulfill the next task given to me. As a writer I am strong in some areas. I can come up with a great thesis statement. I try to organize and explain what I am going to write about, and try to make the reader want to read my writing. Although my first essay was a bit choppy and disorganized, I understand what I did wrong. I tried my hardest but it isn’t enough. I have many weaknesses as a writer. I need to use more transition swords so the reader can have a better understanding of what I am writing about. I also need to use the proper format that my professor tells me to use. If I can’t figure this out, I need to seek help. I need to learn how to brain storm more. Finally, I need to stop procrastinating and give myself more than enough time to complete my work to the best of my ability. Every day is a working progress that I am working on. On the other hand, I enjoy my English 102-06 course. My professor is amazing! When I leave class I say I actually learned something and he makes me want to learn. I learned how to express my own life experiences through stories that I am reading and new vocabulary words. My attendance to class is not an issue. I have only missed one of class day so far, and I make every effort to make it to class on time. However, as for my midterm grade I can never argue about any grade I earn. I feel as though I will pass this class with a good grade. I am learning as long as I do what is expected of me I will be fine I have come too far just to give up. I know what I need to work on and if that means seeking help at the tutorial center, then I will get all the help that is available to me. I never blame my life issues or what I signed up for on anyone. I knew what I was getting myself into. At time I do slack and it’s not easy, but I try not to allow that to discourage me. Each day I make a sacrifice that I am willing to make. At times I do want to give up but, I cannot because I have a daughter whose future depends on me. I know the rewards at the end will be great and things will get better. I just have to keep pushing forward. I do not want people to ever feel pity for me. Nor do I want people to doubt that I can do this. I know what I have to do to become a better writer. I have goals and I will accomplish them. Giving up is not an option. I will not fail my daughter.

The Revelation- Ernest Hemingways A Farewell To Arms Essays

The Revelation- Ernest Hemingway's A Farewell To Arms The Revelation Ernest Hemingways WWI classic, A Farewell to Arms is a story of initiation in which the growth of the protagonist, Frederic Henry, is recounted. Frederic is initially a na?ve and unreflective boy who cannot grasp the meaning of the war in which he is so dedicated, nor the significance of his lovers predictions about his future. He cannot place himself amidst the turmoil that surrounds him and therefore, is unable to fully justify a world of death and destruction. Ultimately, his distinction between his failed relationship with Catherine Barkley and the devastation of the war allows him to mature and arrive at the resolution that the only thing one can be sure of in the course of life is death and personal obliteration (Phelan 54). In order to chronicle Frederics maturation, it is first necessary to understand his character; he is what critics label a Hemingway Code Hero. Indigenous to nearly all of Ernest Hemingways novels, the Hemingway man lives by one simple rule: Man the player is born; life the game will kill him (Rovit and Brenner 90). This man looks to derive meaning and dignity from his stale, directionless being. In Frederic Henrys case, the search for a system of values and morals is difficult because he is caught between two very socially defined extremes, love and war. He only gains knowledge through his direct experience with these two elements and through the indirect teachings of various characters in the novel (Waldhorn 68). It is suggested that Frederic must commit to a comfortable medium between the selflessness of the young priest and the egocentricity of Rinaldi. In the introductory chapters, Frederic is torn between spending his holiday in the cold, clear mountains of Abruzzi with the priests family, and taking his leave in the city, where most of his time would be spent at the dispose of taverns and institutions of prostitution. Frederic chooses to spend his time in the city rather than Abruzzi, although that is where he had wanted to go (Hemingway 13). Frederic realizes that there is a moral and religious way of life, which the priest represents, and he respects these values of the priest. He acknowledges the fact that the priest has a code to live by. On the other shoulder sits Rinaldi, the satisfied, self-assured surgeon with whom Frederic also tries to identify. Rinaldi seems fulfilled, but as the war progresses he falls into a world of despair and disease. Although he cannot see it, Rinaldi too closely resembles Frederics dilemma and therefore is unable to tutor him (Waldhorn 69-70). Tremendously significant, Frederic Henrys exchanges with the priest and Rinaldi play a strong role in his development because he is unable to solely identify with either of them. Frederics education is enhanced by his relationship with the English nurse, Catherine Barkley, as well. Originally, Catherine is nothing more than an object of sensual desire, but as the novel progresses, Catherine becomes symbolic of Frederics final resolution. At first Frederic views Catherine as a replacement for the boring prostitutes that he is accustomed to visiting. He takes advantage of her situation; Catherines fianc? has been killed in the war. I thought she was probably a little crazy. It was alright if she was. I did not care what I was getting into. I knew I did not love Catherine Barkley nor had any idea of loving her. This was a game, like bridge, in which you said things instead of playing cards. Like bridge you had to pretend you were playing for money or playing for some stakes. Nobody had mentioned what the stakes were. It was alright with me (Hemingway 30-31). Typical of an immature youth, Frederic blatantly takes advantage of Catherine. He does not, however, realize the extent of Catherines shrewdness. She commits herself absolutely to the affair only because she had not given her innocence to her deceased fianc? (Donaldson 60). Catherine possesses the one major insight that Frederic does not: death is the end of all existence. Frederic attaches himself to Catherine because he yearns for a sort of order. Having discovered the value of his relationship with Catherine, Frederic returns to the front, only to find

How to Make Silver Polishing Dip

How to Make Silver Polishing Dip As silver oxidizes, it will tarnish. This layer of oxidation can be removed without polishing and scrubbing by simply dipping your silver in this non-toxic electrochemical dip. Another big advantage to using a dip is that the liquid can reach places a polishing cloth cannot. This is an easy experiment and takes mere minutes! Silver Polish Ingredients Sink or glass panHot waterBaking sodaSaltAluminum foilTarnished silver How to Remove Silver Tarnish Line the bottom of the sink or a glass baking dish with a sheet of aluminum foil.Fill the foil-lined container with steaming hot water.Add salt (sodium chloride) and baking soda (sodium bicarbonate) to the water. Some recipes call for 2 teaspoons of baking soda and 1 teaspoon of salt, whereas others call for 2 tablespoons each of baking soda and salt. No need to measure the amounts - just add a bit of each substance.Drop the silver items into the container so they are touching each other and resting on the foil. You will be able to watch the tarnish disappear.Leave heavily tarnished items in the solution for as long as 5 minutes. Otherwise, remove the silver when it appears clean.Rinse the silver with water and gently buff it dry with a soft towel.Ideally, you should store your silver in a low-humidity environment. You can place a container of activated charcoal or a piece of chalk in the storage area to minimize future tarnish. Tips for Success Use care when polishing or dipping silver plated items. It is easy to wear away the thin layer of silver and cause more harm than good through over-cleaning.Minimize exposing your silver to substances that contain sulfur (e.g., mayonnaise, eggs, mustard, onions, latex, wool) because the sulfur will cause corrosion.Using your silver flatware/holloware or wearing silver jewelry helps to keep it free from tarnish.

Proofread Essay

Proofread Essay Proofread Essay Proofread Essay: Essay which is Doomed to Success Only such essay is worth of the highest grade which content is interesting and informative one and which is free of different kinds of mistakes. Well, to write an essay is as important as to proofread it, that is why do not neglect the proofreading of the essay, obviously do it if you do not want to spoil the result. Proofread essay is any essay, which is domed to success with your professor. You can get a proofread essay with the help of different ways. First, you can reread your essay by yourself and edit it. However, they say that this very way is not a very effective one, as when the person proofreads his or her own essay, he or she is not able to see all the mistakes your essay contains and correct them. At this point, it is essential to ask someone to proofread your essay. You can appeal to your parents, relatives, friends, etc, to get your proofread essays. Of course, if the person sees an essay for the first time with, so to say, a fresh eye, he or she will be able to correct the majority of mistakes that is for sure. That is why better ask someone for help before you essay presenting. There exists one more way of how to get a proofread essay which is considered to be the best and most effective one. This way is called custom essay writing service. You see, within the servicing of our custom essay site, you may turn to such a service, which goes under the title of proofreading. If you make use of such an option, kindly offered by our site, your proofread essay will be worth of the highest grade, as it is going to be free of any kinds of mistakes. Our custom essay writing service will not only present you a proofread essay, but also will check your essay in terms of correspondence to the existing requirements from it. If it happens that some of the parts of your essay are not going to meet all the requirement from it or just will not be either cohesive or smooth, our custom essay writing service w ill correct these mistakes as well. After you have proofread essay with the help of our site, your professor will fail to find even a single mistake in it. We do not leave any chances to your professor to spoil your grade for your work, as proofread essay is always the essay, which gets A+ grade.

MGM D1 Health Care and The Law Essay Example | Topics and Well Written Essays - 250 words

MGM D1 Health Care and The Law - Essay Example Some of the things that cause suffering of the poor in healthcare services include racism and discrimination, denial of the minority groups in accessing healthcare services, and failure by the government to enroll the minority and the poor in the social healthcare programs (Kant & Rushefsky, 2006). In the US, according to the commissioner of civil rights, although there is existence of civil rights legislation that addresses the issues of healthcare discrimination of the minority and the poor, the reality is that these laws are not followed accordingly (Kant & Rushefsky, 2006). About 38 million Americans are not insured for healthcare services and have very limited financial means of accessing the healthcare services; a biggest proportion of this figure represents the poor (Kant & Rushefsky, 2006). In March 2010, president Obama signed legislation to refurbish the nation’s healthcare system which would guarantee access to medical insurance for all Americans (Shear, 2012). The law aims at extending insurance to over 30 million people, first and foremost by expanding Medicaid and availing federal subsidies to lower and middle-income earners. However, the bill is faced by enormous challenges after republicans appealed against it (Shear, 2012). Some of the challenges facing the law include tougher oversight of health insurers, protection of workers with pre existing conditions and expansion of coverage to one million young adults (Shear, 2012). However, the Obama administration retaliated that it would not unify essential health benefits and that each state should specify the benefits within broad categories. It can be argued that the legal challenges might be reasonable to some extent, although they seem to be politically instigated by republicans, something that would jeopardize its applications. All in all, these challenges are seen to be for the greater benefit of most Americans. All what needs to be done is for all the stakeholders to

International and Comparative HRM Essay Example | Topics and Well Written Essays - 3500 words

International and Comparative HRM - Essay Example Nevertheless, the management department of human resource faces some critical challenges in managing people of different cultural orientation, races, language, different educational backgrounds and system of believes. Moreover, the human resource department deals with intergenerational people with varying competencies as well as orientations. Human resource management adopts various frameworks for their operations depending in the country, prevailing factors such as government policies, and social cultural frameworks among other considerations. In particular, the human resource management within multinational corporations are the most hit by the dynamics that characterize the current world (Srivastava and Agarwa, 2012, 46-47). There is constant designing as well as implementation of policies geared to regulating the dynamics in this field within the different nations that the corporation operates. However, there are a whole range of potential strategic threats that the human manageme nt departments within Multinational Corporation are facing. Moreover, the practices within the department of human resource have some similarities, which this paper will as well discuss. Over and above this analysis, this paper aims at evaluating some potential problems faced by human resource management while managing people. These are the problems that the roots are traced back to the concerned people. They may include corruption, mismanagement of a corporation’s fund, age difference as well as the other ethical matters that govern a society. Decision making by the MNCs are influenced by the international as well as the national guiding frameworks in political, social, economic as well as the technological contexts. Multinational corporations consistently strive to unify the strategies adopted for dealing with the human resource within the different countries of operations. The major issues that are seen to adversely affect the efforts of the human resource management withi n the global perspective are the prevailing economic conditions and systems, political systems, legal systems, education systems as well as ethical (social-cultural) issues (Anyim, Ikemefuna and Mbah, 2011, 4) . A country’s economic system is seen to influence the human resource practices of multinationals in the way of training as well as hiring the personnel. For instance, within the socialist countries, multinational find it rather easy to training and manage own employees as the systems advocate for free educations systems. The costs that are incurred on the matters of training employees in their respective areas of specialization are low. However, the case in capitalistic countries is quite different as the costs of training are very high owing to the already fixed systems of education. Literature reveals that there exists a critical problem within the management of the employees from the different backgrounds especially as regards to the wages as well as the salary pack ages. Human resource management practices are also influenced by the legal systems that are in operation within the country of operation. Normally, the legal systems in existence within a country framework are derived from these cultures as well as the societal norms that do govern the people within the country. It is the responsibility

The effects of tourism on culture and the environment in asia and the pacific Essay Example for Free

The effects of tourism on culture and the environment in asia and the pacific Essay INTRODUCTION AsiaPacific or AsiaPacific is the part of the world in or near the Western Pacific Ocean. The region varies in size depending on context, but it typically includes at least much of East Asia, Southeast Asia, and Oceania. The Asia-Pacific region covers a wide geographical area, with diverse landscapes, climates, societies, cultures, religions, and economies. More than half of the world’s population lives in this region, of which close to half live on less than a dollar per day. Hence, the region contains the worlds largest number of people living in poverty. Asia-Pacific region generally includes: Australia, Brunei, Cambodia, Peoples Republic of China, Hong Kong, Macau, Fiji, Indonesia, Japan Kiribati, North Korea, South Korea, Laos, Malaysia, Marshall Islands, Federated States of Micronesia, Nauru, New Zealand, Palau, Papua New Guinea, Philippines, Samoa, Singapore, Solomon Islands, Thailand, Timor-Leste, Tonga Republic of China (Taiwan), Tuvalu, Vanuatu, Vietnam, United States Territories American Samoa, Guam, Northern Mariana Islands, Sometimes included India (member of the East Asia Summit), Mongolia (landlocked country in East Asia), Myanmar (Burma) (member of the ASEAN), Russia (the Russian Far East borders the Pacific Ocean). With its diversity as an asset, the region has enjoyed remarkable economic growth  in the last four decades. Several countries are experiencing rapid changes in economic development, population growth and urbanization, social transformation, and technological development, and these countries share common economic drivers. The expanding economy in Asia and the Pacific has brought about increased interdependence among the countries in terms of natural resources, finance, and trade. The economic expansion and population growth in Asia-Pacific over the last 40 years was underpinned by the region’s rich natural environment. The tourism sector in Asia and the Pacific is thriving, with the region accounting for 22% of inbound tourism arrivals in 2010. Noticeably, in 2010, China placed third in inbound tourism arrivals and fourth in inbound tourism expenditure in the world. In 2010, international tourism recovered more strongly than expected from the shock it had suffered in 2009 from economic recession and the global financial crisis. The estimated worldwide number of inbound tourism arrivals in 2010 was 940 million, up 6.6% over 2009 and 2.5% more than the pre-crisis peak in 2008. While some destinations are still struggling to come out of the crisis, the tourism sector in Asia and the Pacific has been buoyant. The Asia-Pacific region had an increase in inbound tourism arrivals of 13% between 2009 and 2010, making the region a leader in the global recovery of tourism. In comparison with other regions across the globe, Asia and the Pacific had the second highest growth in inbound tourism arrivals in 2010 over 2009. The Middle East was the fastest growing region (up 14.1%) in 2010, following a significant drop (of 4.3%) in 2009; As ia and the Pacific posted only a modest drop of 1.7% in 2009. Inbound tourism arrivals were up 7.3% in Africa, followed by Americas (up 6.6%) and Europe (up 3.3%). In 2009, Africa was the only region where inbound tourism arrivals increased (by 4%). In Asia and the Pacific, for the first time ever, inbound tourism arrivals surpassed 200 million in 2010. Overall, the Asia-Pacific regional share of world arrivals rose by 1.2 percentage points in 2010, for a 22% share among the world’s regions. The successful marketing stories of India and Malaysia, the massive rail expansion in China, the new resort developments in Singapore and Macao, China and the revitalized policy of Japan towards tourism, as well as the â€Å"visit year† campaigns in Bangladesh, Nepal and Sri Lanka, have helped buoy Asia-Pacific tourism. ASEAN has also adopted a long-term tourism strategy to help the development of the tourism  sector in the sub region. Tourism plays a very important role on a society because it is an aid to gain more income and to place many job opportunities to jobless individuals. Tourism therefore became the major income generator on the regions of Asia and the Pacific. STATEMENT OF THE PROBLEM The problems stated in this research paper are the following: 1. Why the tourism industry trends much on the Asia-Pacific region? 2. What is the role of tourism on the economy of the region? 3. What are the positive and negative effects of tourism on culture and environment? 4. How does tourism affect livelihood on the region? 5. What is the significance of tourism on a country? OBJECTIVES OF THE STUDY The main objective of the study is to gain an understanding of the nature of the effects of tourism on the local culture, environment and economy. The study purports: 1. To review the existing literature on tourism with an emphasis on the government policy and the present infrastructure of tourism; 2. To create a typology of tourism sites based on their similarities and difference; 3. To carry out in-depth case studies of two locations and to determine the impact of tourism on the people inhabiting those locations. 4. To come up with an answer and a solution regarding the problems that may arise in the particular event. 5. To increase the number of tourist arrivals. 6. To promote the environment, historical and cultural heritage and raise the quality of services and facilities related to tourism. 7. To develop the necessary infrastructure for the operation of efficient, safe, comfortable, and quality air services for the proper advancement of the tourism industry. 8. To gain more knowledge about the topic. SIGNIFICANCE OF THE STUDY This research is conducted for the researchers to gain more knowledge and to share to others what the ideas that they have gathered. The importance of this study is that we could gain more knowledge and understanding about the said topic. As citizens, it is our right to deeper our understanding on what is the connections of those things regarding on our daily life and activities. This is also intended to make everyone aware of the events that might go to happen regarding the subject, so that they will find also an easy way to go through it and synchronize them for a better environment adaptation. SCOPE AND DELIMITATIONS The Effects of Tourism on the Culture and Environment in Asia and the Pacific is a research paper project which deals about the major issues regarding how tourism will affect the culture and environment of a specific region which includes its significance and the solutions regarding the problem. This study only covers on how tourism affects the regions of Asia and the Pacific regarding in the means of culture, tradition and environment. The study is largely based on secondary information. Therefore it is difficult to quantify the impact of tourism on the culture and environment. Though there have been numerous studies related to tourism, these studies pertain to specific locations, which are not representative of the region as a whole. Since interviewing the respondents was not based on any scientific sample surveys, the results do not correlate directly to the inferences which are drawn from the sample surveys. The study is conducted by the research team at the College of Communication, Information Technology, Calamba, Misamis Occidental.