What email address or phone number would you like to use to sign in to Docs.com?
If you already have an account that you use with Office or other Microsoft services, enter it here.
Or sign in with:
Signing in allows you to download and like content, and it provides the authors analytical data about your interactions with their content.
Embed code for: HSBH PSYCHOLOGY Chapter 12
Select a size
9781488618826_T.indd 196 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. Yet research shows that even in the face of horrific circumstances, such as shootings and natural disasters, most of us are surprisingly resilient (Bonanno, 2004). Even most victims of child sexual abuse turn out to be psychologically healthy adults, although there are certainly exceptions (Rind, Tromovitch & Bauserman, 1998). Because practising psychologists tend to see only those people who react emotionally to stress— after all, the healthy people do not come for help—they probably overestimate most people’s fragility and underestimate their resilience, an error sometimes called the clini- cian’s illusion (Cohen & Cohen, 1984). Before we discuss why some people thrive and others nosedive when confronted with stressful life events, we will consider the fundamental question of what stress is. We then explore competing views of stress, the mind–body link responsible for stress- related disorders, how people cope with stressful situations, and the rapidly growing field of health psychology. What is stress? Before we proceed further, it is important to distinguish two terms—stress and trauma— that are commonly confused. Stress—a type of response—consists of the tension, discomfort or physical symptoms that arise when a situation, called a stressor—a type of stimulus—strains our ability to cope effectively. A traumatic event is a stressor that is so severe that it can produce long-term psychological or health consequences. The field’s thinking about stress has evolved over the years (Cooper & Drewe, 2004). Before the 1940s, scientists rarely used the term ‘stress’ outside of the engineering profession (Hayward, 1960, p. 185), where it referred to stresses on materials and building structures. A building was said to withstand stress if it did not collapse under intense pressure. It was not until 1944 that the term stress found its way into the psychological literature (Jones & Bright, 2001). This engineering analogy highlights the notion that ‘if the body were like a machine and machines are subject to wear and tear then so too would be the body’ (Doublet, 2000, p. 48). But, just as two buildings can withstand differing amounts of stress before weakening and collapsing, people differ widely in their personal resources, the meaning and significance they attach to stressful events, and their ability to grapple with them. Stress in the eye of the beholder: three approaches Researchers have approached the study of stress in three different, yet interrelated, ways (Kessler, Price & Wortman, 1985). Each approach has yielded valuable insights, illu- minating the big and small events that generate distress and the ways we perceive and respond to stressful situations. STRESSORS AS STIMULI. The stressors-as-stimuli approach focuses on identifying different types of stressful events. This approach has succeeded in pinpointing catego- ries of events that most people find dangerous and unpredictable, as well as the people who are most susceptible to stress following different events (Collins et al., 2003; Costa & McCrae, 1990). For example, first-year university students show a greater response to such negative life events as the break-up of a relationship than do older men or women (Jackson & Finney, 2002). When people are retired, the combination of low income and physical disability can make matters worse, suggesting that stressful situations can produce cumulative effects (Smith et al., 2005). Victims of natural disasters sometimes suffer from collective trauma that damages the bonds among them. In the aftermath of the Black Saturday bushfires in Victoria, survivors and state government officials argued over whether or not enough had been done to alert community members to the severity and threat of the fires. But disasters can also unify communities and bring out the best in us, exemplified in Victoria in the LO 12.1 Explain how stress is defined and approached in different ways. LO 12.2 Identify different approaches to measuring stress. LO 12.3 Identify different methods researchers have used to investigate the stress process, and the strengths and limitations of these. LO 12.4 Explain how experiencing a stressful event can change people’s behaviour for the better. The stress of unemployment includes not only the frustration and despair of looking for a new job, but the economic hardship of living on a sharply reduced income. (Source: Stephanie Swartz/Dreamstime.) What is stress? 503 M12_LILI6786_02_SE_C12.indd 503 13/08/14 2:35 PM 9781488618826_T.indd 197 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. corticosteroids stress hormones that activate the body and prepare us to respond to stressful circumstances primary appraisal initial decision regarding whether an event is harmful secondary appraisal perceptions regarding our ability to cope with an event that follow primary appraisal problem-focused coping coping strategy by which we tackle life’s challenges head-on emotion-focused coping coping strategy that features a positive outlook on feelings or situations accompanied by behaviours that reduce painful emotions numerous stories of people risking their lives to warn others of the approaching fires. Indeed, stressful circumstances that touch the lives of an entire community can increase social awareness, cement interpersonal bonds, and enhance a variety of positive personal characteristics (Peterson & Seligman, 2003). STRESS AS A RESPONSE. Stress researchers also study stress as a response—that is, they assess people’s psychological and physical reactions to stressful circumstances. Typically, scientists expose participants to independent variables such as stress-producing stimuli; in other cases, they study people who have encountered real-life stressors. Then they measure a host of dependent variables: stress-related feelings such as depression, hope- lessness and hostility; and physiological responses such as heart rate, blood pressure and the release of stress hormones called corticosteroids. These hormones activate the body and prepare us for stressful circumstances. But measuring the size and impact of stressors on mental and physical functioning can be challenging. STRESS AS A TRANSACTION. Stress is a subjective experience. Some people are devas- tated by the break-up of a meaningful relationship, whereas others are optimistic about the opportunity to start afresh. People’s varied reactions to the same event suggest that we can view stress as a transaction between people and their environments (Coyne & Holroyd, 1982; Lazarus, 1999; Lazarus & Folkman, 1984). Researchers who study stress as a transaction examine how people interpret and cope with stressful events. Richard Lazarus and his colleagues contended that a critical factor determining whether we expe- rience an event as stressful is our appraisal—that is, our evaluation—of the event. When we encounter a potentially threatening event, we initially engage in primary appraisal— that is, we first decide whether the event is harmful and then make a secondary appraisal about how well we can cope with it (Lazarus & Folkman, 1984). When we believe we cannot cope, we are more likely to experience a full-blown stress reaction than when we believe we can (Lazarus, 1999). When we are optimistic and think we can achieve our goals, we are more likely to engage in problem-focused coping, a coping strategy in which we tackle life’s challenges head-on (Carver & Scheier, 1999; Lazarus & Folkman, 1984). When situations arise that we cannot avoid or control, we are more likely to adopt emotion-focused coping, a coping strategy in which we try to place a positive spin on our feelings or predicaments and engage in behaviours to reduce painful emotions (Carver, Scheier & Weintraub, 1989; Lazarus & Folkman, 1984). After the break-up of a relationship, we may remind ourselves that we were unhappy months before it occurred and look forward to meeting someone new. No two stresses are created equal: measuring stress Measuring stress is a tricky business, largely because what is exceedingly stressful for one person, like an argument with a boss, may be a mere annoyance for another. Two scales—the Social Readjustment Rating Scale and the Hassles Scale—endeavour to gauge the nature and impact of differing stressful events. MAJOR LIFE EVENTS. Adopting the view that stressors are stimuli, David Holmes and his colleagues developed the Social Readjustment Rating Scale (SRRS), the first of many efforts to measure life events systematically. The SRRS is based on 43 life events such as ‘jail term’ and ‘personal injury or illness’, ranked in terms of their stressfulness as rated by participants (Holmes & Rahe, 1967; Miller & Rahe, 1997) (see Figure 12.1). Studies using the SRRS and related measures indicate that the number of stressful events people report over the previous year or so is associated with a variety of physical disorders (Dohren- wend & Dohrenwend, 1974; Holmes & Masuda, 1974) and psychological disorders like depression (Coyne, 1992; Holahan & Moos, 1991; Schmidt et al., 2004). Nevertheless, the sheer number of stressful life events is far from a perfect predictor of who will become physically or psychologically ill (Coyne & Racioppo, 2000). Emotion-focused coping may encourage people who have divorced to begin dating again. (Source: Luba V Nel/Dreamstime.) 504 ChaPtER 12 Stress, coping and health M12_LILI6786_02_SE_C12.indd 504 13/08/14 2:35 PM 9781488618826_T.indd 198 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. That is because this approach to measuring stressors doesn’t consider other crucial factors, including people’s interpretation of events, coping behaviours and resources, and diffi- culty recalling events accurately (Coyne & Racioppo, 2000; Lazarus, 1999). In addition, it neglects to take into account some of the more ‘chronic’, or ongoing, stressors that many individuals experience. Even subtle forms of discrimination or differential treatment based on race, gender, sexual orientation or religion, for example, can be a significant source of stress even though they rarely are prompted by or lead to a single stressful event we can check off a list. This approach also neglects the fact that some stressful life events, such as divorce and troubles with the boss, can be consequences rather than causes of people’s psychological problems (Depue & Monroe, 1986). That is because people’s psycholog- ical difficulties, such as severe depression and anxiety, can create a host of interpersonal problems, such as difficult interactions with loved ones and co-workers. HASSLES: DON’T SWEAT THE SMALL STUFF. We have all had days when just about everything goes wrong and everybody seems to get on our nerves. Our daily lives are ◀ CORRELatION VS CaUSatION Can we be sure that A causes B? 1. Death of a spouse 100 2. Divorce 73 3. Marital separation 65 4. Jail term 63 5 Death of a close family member 63 6. Personal injury or illness 53 7. Marriage 50 8. Fired at work 47 9. Marital reconciliation 45 10. Retirement 45 11. Change in health of family member 44 12. Pregnancy 40 13. Sex difficulties 39 14. Gain of a new family member 39 15. Business readjustments 39 16. Change in financial state 38 17. Death of a close friend 37 18. Change to different line of work 36 19. Change in number of arguments with spouse 35 20. Mortgage over $50 000 31 21. Foreclosure of mortgage 30 22. Change in responsibilities at work 29 23. Son or daughter leaving home 29 24. Trouble with in-laws 29 25. Outstanding personal achievements 28 30. Trouble with boss 23 31. Change in work hours or conditions 20 32. Change in residence 20 33. Change in university 20 34. Change in recreation 19 35. Change in religious activities 19 36. Change in social activities 18 37. Loan less than $50 000 17 38. Change in sleeping habits 16 39. Change in number of family get-togethers 15 40. Change in eating habits 15 41. Vacation 13 42. Holidays 12 43. Minor violation of laws 11 26. Spouse begins or stops work 26 27. Begin or end school 26 28. Change in living conditions 25 29. Revision of personal habits 24 SCORING Each event should be considered if it has taken place in the last 12 months. Add values to the right of each item to obtain the total score. Your susceptibility to illness and mental health problems: Low 149, Mild 150–200 Moderate 200–299 Major 300 FIGURE 12.1 Social Readjustment Rating Scale. (Source: Holmes & Rahe, 1967.) What is stress? 505 M12_LILI6786_02_SE_C12.indd 505 13/08/14 2:35 PM 9781488618826_T.indd 199 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. 9781488618826_T.indd 200 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. general adaptation syndrome (GAS) stress-response pattern proposed by Hans Selye that consists of three stages: alarm, resistance and exhaustion fight-or-flight response physical and psychological reaction that mobilises people and animals to either defend themselves (fight) or escape (flee) a threatening situation recognise a connection between his injections and symptoms of stress in the animals, including stomach ulcers and increases in the size of the adrenal gland, which produces stress hormones. Selye further connected this stress response in animals with his observa- tions of ill patients, who showed a consistent pattern of stress-related responses. Dovetailing with the engineering analogy we have already discussed, Selye believed that too much stress leads to breakdowns. He argued that we are equipped with a sensitive physiology that responds to stressful circumstances by kicking us into high gear. He called the pattern of responding to stress the general adaptation syndrome (GAS). According to Selye, all prolonged stressors take us through three stages of adapta- tion: alarm, resistance and exhaustion (see Figure 12.2). To illustrate key aspects of the GAS, and the extent to which our appraisals determine our reactions to stress, consider the experience of a participant in a treatment study for acrophobia (fear of heights) run by University of Queensland researchers (Coelho et al., 2008). We will call the participant Mark, and home in on what he expe- rienced during the third treatment session. As Mark stood on an eighth floor balcony of a downtown hotel, his cold, clammy hands clutched the railing. His mouth was dry. His heart pounded. His breathing was rapid and shallow. He felt light-headed and dizzy. Images of bodies falling from buildings that he had seen on television popped uncontrol- lably into his mind. On some level he knew he was safe, but that did not help. Mark knows he is safe because he is not actually on a hotel balcony; he is in a virtual environment, created by sophisticated, computer-controlled equipment that simulates the experience. The head-mounted display that Mark wears provides him with visual input specifying being up very high, and when he moves, the world below appears to shift as if he were looking at it from on high. Altogether, the effect is so convincing that much of the time he forgets he is in a laboratory. Over the course of three sessions, Mark successfully confronted and tamed his fear of heights. In treatment, he learned anxiety management techniques, including deep breathing, and learned to recognise that his uncomfortable physical reactions are responses to his negative thoughts about being up high. He was ‘virtually’ exposed to higher and higher balconies and encouraged to walk back and forth across them. Research shows that 70 per cent of participants who complete virtual exposure therapy like this become less afraid (Rothbaum et al, 2006). We can examine Mark’s experiences in terms of the GAS. THE ALARM REACTION. Selye’s first stage, the alarm reaction, involves excitation of the autonomic nervous system, the discharge of the stress hormone adrenaline, and physical symptoms of anxiety. Joseph LeDoux (1996) and others have identified the seat of anxiety within a region of the midbrain—dubbed the emotional brain—that consists of the amygdala, hypothalamus and hippocampus (see Chapter 3). Mark’s swift emotional reaction to his perception of falling is tripped largely by the amygdala, where vital emotional memories are stored (see Chapters 7 and 11) and create gut feelings of a possible fall. The hypothalamus sits atop a mind–body link known as the hypothalamus- pituitary-adrenal (HPA) axis, shown in Figure 12.3 (overleaf). When the hypothalamus (H) receives signals of fear, it hooks up with the pituitary gland (P), which releases hormones, including adrenaline, that trigger anxiety. Blood pressure rises as adrenaline (A) readies Mark for the fight-or-flight response, which Walter Cannon first described in 1915. This response is a set of physiological or psychological reactions that mobilise us to either confront or leave a threatening situation. Cannon noted that when people or animals face a threat, they have two options: fight (actively attack the threat or cope in the immediate situation) or flee (escape). Of course, Mark can take flight from the balcony and go inside the virtual hotel room, but given that he has agreed to complete the virtual reality (VR) treatment, he is ‘stuck’ confronting the source of his anxiety. So his fear escalates, with his hippocampus retrieving terrifying images in the news of people falling from great heights. FIGURE 12.2 Selye’s general adaptation syndrome. According to Selye’s general adaptation syndrome, our level of resistance to stress drops during the alarm phase, increases during the resistance phase, and drops again during the exhaustion phase. (Source: Adapted from Selye, 1956.) Shock Resistance to stress Stage 1 Alarm Stage 2 Resistance Stage 3 Exhaustion Normal level of resistance to stress How we adapt to stress: change and challenge 507 M12_LILI6786_02_SE_C12.indd 507 19/08/14 1:34 PM 9781488618826_T.indd 201 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. tend and befriend reaction that mobilises people to nurture (tend) or seek social support (befriend) under stress RESISTANCE. After the initial rush of adrenaline, Mark enters Selye’s second stage of the GAS: resistance. He adapts to the stressor and finds ways to cope with it. The instant Mark’s hippocampus detected danger from the first apparent view of the city below, it opened up a gateway to portions of his cerebral cortex, which LeDoux (1996) called the ‘thinking brain’. Confronted with a stressful situation, we examine each new devel- opment as it unfolds, consider alternative solutions and direct our efforts towards constructing a coping plan. At one point, Mark experienced a sudden impulse to tear off the VR headset, but his basal ganglia, linked to the frontal cortex of his thinking brain, wisely led him to think better of it. Mark slowly but surely got a handle on his fears. He reminded himself that people live in tall apartment buildings all over the world, without being injured or dying. He recalled that most people consider views of the city from on high to be desirable and attractive. Mark learned other coping behaviours. He reminded himself to breathe slowly, and with each breath his relaxation replaced tension. He no longer felt light-headed, and his tingling sensations disappeared. This exercise helps because when we are anxious our breathing is often rapid and shallow. When we do not exhale sufficiently, carbon dioxide accu- mulates at the bottom of our lungs, and even tiny increases in carbon dioxide level can cause numbness, tingling and light-headedness. Excess oxygen that accumulated with each of Mark’s shallow, rapid breaths made his heart beat strongly and rapidly. EXHAUSTION. Mark calmed down, and when he left the simulated balcony he felt more in control of his fear. But what happens when a stressor, such as wartime combat lasting months, is more prolonged and uncontrollable? This is when the third stage of Selye’s GAS—exhaustion—sets in. If our personal resources are limited and we lack good coping measures, our resistance may ultimately break down, causing our levels of activation to bottom out. The results can range from damage to an organ system, to depression and anxiety, to a breakdown in the immune system (which we discuss later in the chapter). The diversity of stress responses Not all of us react to stressors with a fight-or-flight response. Our reactions vary from one stressor to another, and these reactions may be shaped by gender. FIGHT OR FLIGHT, OR TEND AND BEFRIEND? Shelley Taylor and her colleagues coined the catchy phrase tend and befriend to describe a common pattern of reacting to stress among women (Taylor et al., 2000), although some men display it, too. Taylor observed that in times of stress, women generally rely on their social contacts and nurturing abilities—they tend to those around them and to themselves—more than men do. When stressed out, women typically befriend, or turn to others for support. That is not to say that women lack a self-preservation instinct. They do not shirk from defending themselves and their children or from attempting to escape when physically threatened. However, compared with men, women generally have more to lose—especially when they are pregnant, nursing or caring for children—if they are injured or killed fighting or fleeing. Therefore, over the course of evolutionary history, they have developed a tend-and-befriend rather than a fight-or-flight pattern of reacting to stressful circumstances to boost the odds of their and their offspring’s survival. The hormone oxytocin (see Chapter 3) further counters stress and promotes the tend-and- befriend response (Kosfeld et al., 2005; Taylor et al., 2000). Hypothalamus (H) (P) (A) Releasing factor Anterior pituitary ACTH (through blood) Adrenal cortex Cortisol FIGURE 12.3 The hypothalamus-pituitary- adrenal (HPA) axis. In stressful times, women often rely on friendships for support and comfort, a pattern that psychologist Shelley Taylor has called ‘tend and befriend’. (Source: Monkey Business Images/ Dreamstime.) 508 ChaPtER 12 Stress, coping and health M12_LILI6786_02_SE_C12.indd 508 13/08/14 2:35 PM 9781488618826_T.indd 202 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. Still, men and women are more alike than different in how they respond to stressors. Surely many men are invested in close relationships and caring for children, and many women react with a fight-or-flight response when endangered. Long-lasting stress reactions Bad things happen to all of us. For most of us, life goes on. But others experience long-lasting psychological repercussions, including posttraumatic stress disorder (Meichenbaum, 1994; Yehuda et al., 1993). On the morning of 26 December 2004, 20-year- old Sumithra was preparing to leave her village home on the west coast of Sri Lanka after a short holiday from university, to return to the city to prepare for final exams. After saying her temporary goodbyes, she set off for the bus station. On the way, she heard people shouting that the sea was approaching. She climbed onto the roof of a nearby building and watched as the first wave of the 2004 Boxing Day tsunami rushed by, taking people and debris with it. Afterwards, she ran home to find her house and family gone. She was taken to safety by neighbours before the second and third waves came. Over the next week, Sumithra found her siblings and parents in different camps around the area. She returned with them to rebuild their home, but she suffered constant fear of a new wave coming. She could not sleep and would not return to university for fear of being separated from those she loved (Hettiarachchi, 2007). Sumithra displays some of the hallmark symptoms of posttraumatic stress disorder (PTSD), a condition that sometimes follows extremely stressful life events. Its telltale symptoms include vivid memories, feelings and images of traumatic experiences, known commonly as flashbacks. Other symptoms of PTSD, which we consider in greater depth in Chapter 16, include efforts to avoid reminders of the trauma, feeling detached or estranged from others, and symptoms of increased arousal, such as difficulty sleeping and startling easily. The lifetime prevalence of PTSD varies between 9 and 37 per cent, depending on the severity, duration and nearness to the stressor (Ekblad & Jaranson, 2004). People who have experienced extreme and long-lasting stressors that result in displacement from their home, as is the case with many asylum seekers attempting to come to Australia, are at an especially high risk for PTSD (Steel & Silove, 2001). psychomythology ALMOST ALL PEOPLE ARE TRAUMATISED BY HIGHLY AVERSIVE EVENTS A widespread view in popular psychology is that most people exposed to trauma develop PTSD or other serious psychological disorders. Immediately following the Victorian bushfires, for example, many mental health professionals were concerned that there would be an epidemic of PTSD cases across Australia. But the data suggest otherwise. For instance, Parslow, Jorm and Christensen (2006) surveyed victims of the 2003 Canberra bushfires and found that three months after the tragedy, only 5 per cent of respondents met the criteria for PTSD. Although this rate is higher than the Australian PTSD prevalence of 1.5 per cent (Rosenman, 2002) and indicates that there are individuals who require psychological help following these sorts of traumatic events, it is striking that the vast majority of respondents were psycholog- ically healthy. So when it comes to responses to trauma, resilience is the rule rather than the exception. People who cope well in the aftermath of a serious stressor tend to display relatively high levels of functioning before the event (Bonanno et al., 2005). Yet resilience is not limited to a few particularly well-adjusted, brave or tough-minded people, or to a single type or class of events. Instead, it is actually the most common response to traumatic events. Most people who take care of a dying partner, suffer the death of a spouse, or survive a physical or sexual assault report few long-term psychological symptoms (Bonanno, 2004). Table 12.1 (overleaf) how we adapt to stress: change and challenge 509 M12_LILI6786_02_SE_C12.indd 509 13/08/14 2:35 PM 9781488618826_T.indd 203 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. 9781488618826_T.indd 204 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. immune system the body’s defence system against invading bacteria, viruses and other potentially illness- producing organisms and substances acquired immune deficiency syndrome (AIDS) a life-threatening, incurable, yet treatable condition in which the human immunodeficiency virus (HIV) attacks and damages the immune system poison ivy. In fact, he was touching them with leaves from a harmless plant. The reactions were remarkable. All of the boys—the hypnotic participants and the suggestion-alone participants—showed significant skin disturbance after believing they had been touched by the poison ivy–type leaves. As is so often the case in psychology, beliefs can create reality, in this case a nocebo effect (see Chapter 2). In the second phase of the study, the researchers reversed the conditions: They rubbed the boys’ arms with the poison ivy–type leaves, but told them the leaves were harmless. Four of the five hypnotic participants and seven of the eight suggestion-alone participants didn’t show any skin reactions to the leaves. Interestingly, all had developed skin reactions to the leaves prior to the study (Ikemi & Nakagawa, 1962). This study demonstrates how psychological factors, in this case the stressful idea of contracting an itchy rash, can influence physical processes. Indeed, much of what we call a ‘psychological’ response to events manifests itself in physiological reactions. In this chapter and others, you will see that stress can spill over into multiple domains of life, creating physical difficulties that disrupt our sleep (Chapter 5) and sexual functioning (Chapter 11). But can stress seep into our cells and weaken our body’s defences against infections? A number of fascinating studies tell us that the answer is yes. The immune system Ordinarily (and thankfully!), we never have to think about the billions of viruses, fungi, protozoa and bacteria that share our environment or inhabit our body. That is because our immune system neutralises or destroys them. The immune system is our body’s defence against invading bacteria, viruses and other potentially illness-producing organisms and substances. Our first shield from these foreign invaders, called antigens, is the skin, which blocks the entry of many disease-producing organisms, called pathogens. When we cough or sneeze, the lungs expel harmful bacteria and viruses. Saliva, urine, tears, perspiration and stomach acid also rid our body of pathogens. Some viruses or bacteria penetrate these defences, but the immune system is wily, and has other means of safeguarding us. Phagocytes and lymphocytes are two types of specialised white blood cells manufactured in the marrow of the bones. One type of phagocyte, called a neutrophil, is abundant and is first at the scene of an infection to engulf an invader. Longer-lived macrophages also wander through the body as scavengers, sticking to and destroying remaining antigens and dead tissue. Two types of lymphocytes, T cells and B cells, are also stalwart soldiers in the night-and-day battle to keep us healthy. Killer T cells, as they are called, move through the body and attach to proteins on the surface of virus- and cancer-infected cells, popping them like balloons. Memory T cells recognise the invading cells after an initial infection and promote an efficient response upon reinfection. B cells produce proteins called antibodies, which stick to the surface of the invader, slow its progress and attract other proteins that destroy the foreign organism. Under ordinary circumstances, the immune system is remarkably effective. But it is not a perfect barrier against infection. For example, some cancer cells can suppress an effective immune response, multiply and wreak havoc in the body. Serious disorders of the immune system, such as acquired immune deficiency syndrome (AIDS), are life-threatening. AIDS is an incurable yet often treatable condition in which the human immunodeficiency virus (HIV) attacks and damages the immune system. When the immune system is overactive, it can launch an attack on various organs of the body, causing autoimmune diseases such as arthritis, in which the immune system causes swelling and pain at the joints, and multiple sclerosis, in which the immune system attacks the protective myelin sheath surrounding neurons (see Chapter 3). Psychoneuroimmunology: our body, our environment and our health The study of the relationship between the immune system and the central nervous system—the seat of our emotions and reactions to the environment (Chapter 3)—goes how stress impacts our health 511 M12_LILI6786_02_SE_C12.indd 511 13/08/14 2:35 PM 9781488618826_T.indd 205 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. psychoneuroimmunology study of the relationship between the immune system and the central nervous system psychophysiological description of illnesses such as asthma and ulcers in which emotions and stress contribute to, maintain or aggravate the physical condition by the name psychoneuroimmunology (Cohen & Herbert, 1996). When evaluating psychoneuroimmunology, we must be careful not to fall prey to exaggerated claims. Illnesses are not the result of negative thinking, nor can positive thinking reverse serious illnesses. Nevertheless, researchers using rigorous designs have discovered at least some fascinating links between our life circumstances and our ability to fend off illnesses. STRESS AND COLDS. Many people believe they are more likely to get a cold when they are really stressed—and they are right. Sheldon Cohen and his associates placed cold viruses into volunteers’ nasal passages (Cohen, Tyrell & Smith, 1991). Other volunteers, in a placebo condition, did not receive the virus, but instead received nasal drops with a saline solution. Stressful life events in the year preceding the study predicted the number of colds people developed when exposed to the virus. Exposure to the virus was also important. People in the placebo condition did not develop as many colds, even when they experienced stressful events in the year before the study. The researchers (Cohen et al., 1998) later discovered that significant stressors, such as unemployment and inter- personal difficulties lasting at least a month, were the best predictors of who developed a cold. But a network of friends and relatives, and close ties to the community, afforded protection against colds (Cohen et al., 1997; Cohen et al., 2003). It is possible that stress affects health-related behaviours but has no direct impact on the immune system. For instance, our susceptibility to a cold may increase because when we are under stress we tend to sleep poorly, eat non-nutritious foods, and smoke and drink alcohol excessively, all of which depress the immune system. Yet Cohen and his colleagues found that even when they controlled for these influences, the relationship between stress and colds remained. STRESS AND IMMUNE FUNCTION: BEYOND THE COMMON COLD. Janice Kiecolt-Glaser and her associates are pioneers in the study of the connection between stressors and the immune system. Caring for a family member with Alzheimer’s disease, a severe form of dementia (see Chapter 3), can be exceedingly stressful and cause long-term deregulation of the immune system. Kiecolt-Glaser demonstrated that a small wound (standard- ised for size) took 24 per cent longer to heal in Alzheimer’s caregivers compared with a group of people who were not taking care of a relative with Alzheimer’s (Kiecolt-Glaser et al., 1995). All of the following stressors can lead to disruptions in the immune system (Kiecolt-Glaser et al., 2002): • taking an important test • the death of a spouse • unemployment • marital conflict • living near a damaged nuclear reactor • natural disasters. The good news is that positive emotions and social support, which we consider later in the chapter, can fortify our immune system (Esterling, Kiecolt-Glaser & Glaser, 1996; Kennedy, Kiecolt-Glaser & Glaser, 1990). Stress-related illnesses: a biopsychosocial view Not long ago a common myth of popular psychology was that beliefs and mental states were the root causes of many physical ailments. Certain illnesses or disorders were once called psychosomatic, because psychologists believed that psychological conflicts and emotional reactions were the culprits. Today, psychologists use the term psycho- physiological to describe illnesses like asthma and ulcers in which emotions and stress contribute to, maintain or aggravate physical conditions. RULING OUt RIVaL hYPOthESES ▶ Have important alternative explanations for the findings been excluded? Carers of people with Alzheimer’s disease experience high levels of stress, are at heightened risk of developing depression, and even show decreases in their blood’s ability to clot (associated with having a stroke) in response to stressful life events (von Känel et al., 2003). (Source: Lord and Leverett/ Pearson Education Ltd.) 512 ChaPtER 12 Stress, coping and health M12_LILI6786_02_SE_C12.indd 512 13/08/14 2:35 PM 9781488618826_T.indd 206 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. biopsychosocial perspective the view that an illness or a medical condition is the product of the interplay of biological, psychological and social factors coronary heart disease (CHD) damage to the heart from the complete or partial blockage of the arteries that provide oxygen to the heart Today, psychologists widely acknowledge that emotions and stress are associated with physical disorders, including coronary heart disease and AIDS. Most scientists have adopted a biopsychosocial perspective, which proposes that most medical conditions are neither all physical nor all psychological. Numerous physical illnesses depend on the interplay of genes, lifestyle, immunity, social support, everyday stressors and self- perceptions (Markus & Kitayama, 1991; Turk, 1996). from inquiry to understanding MORGELLONS DISEASE—HOW CAN HEALTHY PEOPLE BECOME CONVINCED THEY ARE SERIOUSLY ILL? Morgellons disease is one of the most mysterious afflictions to light up the internet in recent years. In 2001, the story goes, America mother Mary Leitao inspected several irritated areas under the lip of her two-year-old son, who complained that he felt itching and said the word ‘bugs’. In rubbing his lips with cream, she discovered what appeared to be fibres erupting from the boy’s skin sores, which she later examined under a microscope and described as white, red, black and blue. Puzzled and disturbed by her son’s strange condition, for which there appeared to be no medical explanation, she established a website and a foundation; she also coined the term Morgellons for his condition, after an account of similar symptoms published in 1674. News of this fascinating ailment spread quickly over the internet and became the darling disease of the media, after which people came forward in droves with reports of hairs embedded in their skin, accompanied by crawling, itching and stinging sensations, often with muscle and joint pain, fatigue and depression. In response to mounting concerns, the Centers For Disease Control and Prevention (CDC) in the USA conducted a rigorous scientific inquiry, finding no evidence for infection by foreign organisms such as bacteria, fungi or parasites, based on the examination of more than 100 Morgellons sufferers (Pearson et al., 2012). Researchers at the Mayo Clinic in Minnesota were quick to replicate the CDC findings (Hylwa et al., 2011). They studied all people treated at their clinic between 2001 and 2007 with Morgellons-like symptoms or beliefs that they were infested with parasites. Twenty-two percent of the patients reported fibres; 7 per cent, ‘specks’; and 4 per cent, either ‘triangles’ or gravel or grainlike materials in the skin. After a thorough evaluation, in only one case did the scientists identify a true parasite (lice) and in another case a tick, but neither could account for the stress-producing symptoms. Most of the patients, however, did suffer from dermatitis (skin irritation), a common condition that produces itching, and almost half had skin sores. A study of 148 patients drawn from four European countries replicated these findings and determined that the specimens people brought in as proof of infestation were mostly hair and skin particles (Freudenmann et al., 2012). The scientists at the Mayo Clinic and the European study group called the condition ‘delusional infestation’. Reviewing medical records, the Mayo Clinic researchers found that 81 per cent of the patients had prior psychiatric conditions (Foster et al., 2012) and many people were deeply troubled by their symptoms. Morgellons underscores the fact that regardless of whether physical symptoms have a medical basis or are the product of a fervent imagination, they can be stressful to the point that they interfere with everyday life. CORONARY HEART DISEASE. Scientists have learned that psychological factors, including stress and personality traits, are key risk factors for coronary heart disease (CHD). CHD is the complete or partial blockage of the arteries that provide oxygen to the heart. It kills more Australians than any other single disease, accounting for 17 per cent of all deaths annually (Australian Institute of Health & Welfare, 2008a). Before age 65, men are more likely than women to die from CHD. But after 65, the statistics even out: one in three men and women die of CHD. CHD develops when deposits of cholesterol—a waxy, fatty substance that travels in the bloodstream—collect in the walls of arteries, narrowing and how stress impacts our health 513 M12_LILI6786_02_SE_C12.indd 513 13/08/14 2:35 PM 9781488618826_T.indd 207 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. Type A personality personality type that describes people who are competitive, driven, hostile and ambitious blocking the coronary arteries, creating a condition called atherosclerosis. When athero- sclerosis worsens, it can lead to chest pain and the deterioration and death of heart tissue, otherwise known as a heart attack (see Figure 12.4). The role of stress in CHD. Many risk factors are associated with CHD, including a history of smoking, high cholesterol and high blood pressure (Clarke et al., 2009). A family history of CHD, diabetes and low levels of vitamin D—the ‘sunshine vitamin’— can also boost the risk of heart disease (Wang et al., 2008). Stress deserves a prominent place on the list of CHD risk factors. Stressful life events predict recurrences of heart attacks, high blood pressure, and enlargement of the heart (Repetti, Taylor & Seeman, 2002; Schnall et al., 1990; Troxel et al., 2003). Although only correlational, these data are consistent with this hypothesis that stressors may sometimes produce negative physiological effects. Moreover, high levels of stress hormones triggered by extreme stress can lead to disruptions in normal heart rhythm and even sudden death, as well as to atherosclerosis in people who are highly reactive to everyday stressors (Carney, Freedland & Veith, 2005; Sarafino, 2006). People with CHD also show signs of a hyped-up autonomic nervous system, with elevated heart rates and extreme responses to physical stressors (Carney, Freedland & Veith, 2005). Even though stress may exert a direct effect on CHD, stress is also associated with behavioural risk factors for CHD, including poor diet and inadequate exercise (Chandola et al., 2008). So at least some of the effects of stress on CHD may actually be due to the overlap between stress and these risk factors. The role of personality in CHD. In addition to stress, researchers have suggested that long-standing behaviour patterns contribute to risk for CHD. Two cardiologists, Meyer Friedman and Ray Rosenman (1959), coined the term Type A personality, now widely popularised in the media, to describe a curious behaviour pattern they observed among CHD patients. They noticed that the chairs in their hospital waiting room were rapidly becoming worn out around the edges. Many of their CHD patients were literally sitting and bouncing on the edge of their seats because of restlessness. Later, Friedman and Rosenman (1974) identified additional characteristics that clustered under the Type A description: perfectionistic, prone to hostility, stubborn, opinionated, cynical, controlling, and concerned with deadlines. Although early studies revealed high rates of CHD among extreme Type A individuals, later studies yielded many negative results (Gatchel & Oordt, 2003). Accord- ingly, scientists began to wonder whether certain Type A traits are more associated with heightened risk than other traits. Of all Type A traits researchers have studied, hostility turned out to be most predictive of heart disease (Matthews et al., 2004; Myrtek, 2001; Nabi et al., 2008; Smith & Gallo, 2001). In a study of healthy young-to-middle-aged Australian men, angry reactions to being criticised were linked to high levels of fat and cholesterol in the blood, the greatest physical risk factor for CHD (Richards, Hof & Alvarenga, 2000). Hostility is associated with other well- documented risk factors for CHD, such as alcohol consumption, smoking and weight gain (Bunde & Suls, 2006), so an alternative hypothesis is that its effects on CHD are indirect. Nevertheless, in a study of older white men, hostility surpassed these traditional risk factors in predicting CHD (Niaura et al., 2002). But there is a silver lining to this grey cloud: damping down anger and hostility helps. When researchers taught CHD patients techniques to curtail their anger, they found a 37 per cent decrease in deaths from heart attacks compared with other patients (Dusseldorp et al., 1999; Friedman et al., 1987). CHD, EVERYDAY EXPERIENCES AND SOCIOECONOMIC FACTORS. Hostility and other negative emotions do not always arise from enduring personality traits. These negative emotions can stem from the many pressures and demands we confront in our fast-paced, competitive society. Consider three sources of support for the claim that everyday expe- riences set the stage for many physical problems, including heart disease. First, people Plaque Blood flow Normal artery Artery narrowed by atherosclerosis FIGURE 12.4 Atherosclerosis. Cholesterol deposits in the large arteries form plaque, restricting the flow of blood. This condition, called atherosclerosis, can result in stroke, heart attack and serious chest pain. The classic Framingham Study, which began in 1948, continues to examine the health of more than 5000 American men and women in Framingham, Massachusetts. This longitudinal study has provided a treasure trove of data on risk factors for CHD. (Source: Nathan Benn/ Corbis.) 514 ChaPtER 12 Stress, coping and health M12_LILI6786_02_SE_C12.indd 514 13/08/14 2:35 PM 9781488618826_T.indd 208 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. who experience even one significant drop in their income over a five-year period face a 30 per cent increase in their risk of dying from any cause. Two such drops in income jack up the risk to a whopping 70 per cent (Duncan, 1996). Second, the INTERHEART study of more than 11 000 people from Europe, the Middle East, Australasia and the Americas showed that CHD was associated with psychosocial factors including work stress, financial stress and other major life events. Third, CHD is associated with substantial job stress and dissatisfaction (Quick et al., 1997). Although job stress is correlated with CHD, it may not cause it in all circumstances. An interesting possibility that has yet to be fully explored is that the causal arrow is reversed: perhaps CHD causes job stress in some people. Still, these findings, along with the others we have examined, point to another possibility that has been well supported by research: the burden of most health problems is shared disproportionately by the poor. Researchers have established a strong corre- lation between poverty and poor health (Antonovsky, 1967; Repetti, Taylor & Seeman, 2002), but we still need to ask: ‘What is responsible for this association?’ Linda Gallo and Karen Matthews (2003) addressed this question. They noted that life can prove immensely challenging for people who have little education, struggle in a bad job with a nasty supervisor and barely make enough money to pay the bills. People from low socioeconomic backgrounds who regularly encounter these circumstances experience a powerful drain on their personal and interpersonal resources. This state of affairs decreases their ability to cope with future stressors and with depression, hope- lessness and hostility, which, as we have seen, increase the risk of poor health and CHD. To make matters worse, negative thoughts and feelings can promote unhealthy habits like smoking, drinking and lack of exercise, which further increase the risk of physical problems (Gallo & Matthews, 2003). ILLNESS CAN CREATE STRESS. We have seen that stress can contribute to physical disorders, such as CHD. But, of course, physical disorders can also create stress. Not surprisingly, being diagnosed with a potentially fatal illness that has an uncertain outcome, like cancer, can be unimaginably stressful and pose innumerable challenges. The spectre of death and feelings of hopelessness, along with side-effects of treatment, including profound fatigue and embarrassing hair loss, frequently compound the distress of cancer. People who suffer from cancer often endure chronic pain and wonder whether even a slight increase in pain signals a downward, perhaps fatal, turn in the progression of their illness. Irritability, anger and frustration can also be by-products of prolonged periods of pain-related sleeplessness and the fatigue that results from it (Moffitt et al., 1991). Asthma: chronic illness and stress. Asthma provides another example of how an illness can contribute to stress and hamper people’s ability to cope with life’s challenges. The prevalence of asthma in Australia is among the highest in the world, with up to 12 per cent of adults suffering from the disease (Australian Institute of Health & Welfare, 2008c). Asthma sufferers find it difficult to breathe because the bronchial tubes in their lungs are inflamed, spasm and become clogged with mucus (see Figure 12.5, overleaf). People with asthma feel tightness in their chest, and cough and wheeze because of their lung condition. The narrowing of the bronchial tube can become so severe that it is life-threatening (Gatchel & Oordt, 2003). When asthmatics react to an attack with fear and agitation, their symptoms can intensify to the point of being disabling. Asthma sufferers often must deal with sleep loss, absences from school and work, loss of income and restriction of everyday activities (Labott, 2004; Mailick, Holden & Walther, 1994). Understandably, asthma is associated with anxiety (Vila et al., 2000) and depression (Chaney et al., 1999). Emotions by themselves do not cause most asthma attacks, but physical responses to stress or emotional responses (such as crying, laughter and coughing) can trigger attacks in some asthma patients (Purcell, 1963). Ulcers: changing views of psychophysiological disorders. In the case of some psycho physiological disorders, such as ulcers, psychologists are still sleuthing the role of stress. ◀ RULING OUt RIVaL hYPOthESES Have important alternative explanations for the findings been excluded? Can chronic anger be bad for our health? Research indicates that the anger component of the Type A personality can be deadly, increasing our risk for coronary heart disease. (Source: Kirk Johnson/Dreamstime.) asthma medical condition in which breathing becomes difficult when the bronchial tubes in the lungs become inflamed, spasm and are clogged with mucus how stress impacts our health 515 M12_LILI6786_02_SE_C12.indd 515 13/08/14 2:35 PM 9781488618826_T.indd 209 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. 9781488618826_T.indd 210 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. social support relationships with people and groups that can provide us with emotional comfort and personal and financial resources Social support Imagine that you survived the Boxing Day tsunami of 2004. What would be helpful? When we ask our students this question, many say the support of family, friends, neigh- bours, teachers, colleagues and clergy would be invaluable. Social support encompasses social relationships with people, groups and the larger community. Social support can provide us with emotional comfort, financial assistance and information to make decisions, solve problems and contend with stressful situations (Schaefer, Coyne & Lazarus, 1981; Stroebe, 2000; Wills & Fegan, 2001). Lisa Berkman and Leonard Syme (1979) conducted a landmark study of the hypothesis that social support buffers us against the adverse effects of stress on health. They analysed data from nearly 5000 men and women in Alameda County, California, over a nine-year period. They homed in on four kinds of social ties: marriage, contact with friends, church membership, and formal and informal group associations. They then created a social network index reflecting the number of social connections and social supports available to each person. Berkman and Syme found a strong relationship between the number of social connections, across every age group, and the probability of dying during the nine-year period. But do these findings mean that isolation increases our chances of dying? A rival hypothesis is that poor health results in few social bonds, rather than the other way around. To rule out this possibility, the researchers surveyed participants when they started the study. People with high and low levels of support reported a comparable illness history, suggesting that poor initial health cannot explain why people with the least social support are later more likely to die. Nevertheless, people are not necessarily accurate when they judge their health. To address this concern, James House, Cynthia Robbins and Helen Metzner (1982) ensured that their 2700 participants received a medical examination before their study got under way. This exam provided a more objective assessment of health status. The researchers replicated Berkman and Syme’s (1979) findings: even when they took initial health status into account, people with less social support had higher mortality rates. Fortunately, the positive influence of social support is not limited to health outcomes. Supportive and caring relationships can help us cope with short-term crises and life transitions. A happy marriage, for example, is protective against depression, even when people encounter major stressors (Alloway & Bebbington, 1987; Gotlib & Hammen, 1992). But the break-up of close relationships through separation, divorce, discrimina- tion or bereavement ranks among the most stressful events we can experience (Gardner, Gabriel & Diekman, 2000). Gaining control As mentioned earlier, we can also relieve stress by acquiring control of situations. Next, we discuss five types of control we can use in different situations (Bonanno, 2004; Cohen et al., 1986; Higgins & Endler, 1995; Lazarus & Folkman, 1984; Sarafino, 2006). BEHAVIOURAL CONTROL. Behavioural control is the ability to step up and do something to reduce the impact of a stressful situation. As you may recall, this type of active coping is called problem-focused and is generally more effective in relieving stress than avoidance- oriented coping—that is, avoiding action to solve our problems or giving up hope (Lazarus & Folkman, 1984; Roth & Cohen, 1986). Research shows that the more university students use problem-focused coping techniques, the less likely they are to use alcohol (Feil & Hasking, 2008). COGNITIVE CONTROL. Cognitive control is the ability to cognitively restructure or think differently about negative emotions that arise in response to stress-provoking events (Higgins & Endler, 1995; Lazarus & Folkman, 1984; Skinner et al., 2003). This type of control includes emotion-focused coping, which we introduced earlier, a strategy that ◀ RULING OUt RIVaL hYPOthESES Have important alternative explanations for the findings been excluded? ◀ REPLICaBILItY Can the results be duplicated in other studies? Support and comfort from others can buffer the effects of highly aversive situations. (Source: Yuri Arcurs/Dreamstime.) Coping with stress 517 M12_LILI6786_02_SE_C12.indd 517 13/08/14 2:35 PM 9781488618826_T.indd 211 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. proactive coping anticipation of problems and stressful situations that promotes effective coping comes in handy when we are adjusting to uncertain situations or aversive events we can not control or change. In one study (Strentz & Auerbach, 1988), experimenters exposed partic- ipants to a simulated abduction and four days of captivity. During captivity, participants who received instructions to use emotion-focused coping strategies reported less distress than did those who received instructions to use problem-focused coping. DECISIONAL CONTROL. Decisional control is the ability to choose among alternative courses of action (Sarafino, 2006). For instance, we can consult with trusted friends about which classes to take and which lecturers to avoid, and make decisions about which surgeon to consult to perform a high-stakes operation. INFORMATIONAL CONTROL. Informational control is the ability to acquire information about a stressful event. Knowing what types of questions are on the final exam can help us prepare for them, as can knowing something about the person we will be working for when we start a new job. We engage in proactive coping when we anticipate stressful situations and take steps to prevent or minimise difficulties before they arise (Greenglass, 2002; Karasek & Theorell, 1990; Schwarzer & Taubert, 2002). People who engage in proactive coping tend to perceive stressful circumstances as opportunities for growth (Greenglass, 2002). EMOTIONAL CONTROL. Emotional control is the ability to suppress and express emotions. Communication can strengthen social bonds, enhance problem-solving and regulate emotions (Bonanno, 2004; Ekman & Davidson, 1993). James Pennebaker and his colleagues (Pennebaker, Kiecolt-Glaser & Glaser, 1988) asked one group of uni students to write for 4 consecutive days for 20 minutes a day about their deepest thoughts and feelings about past traumas. They asked another group of students to write about superficial topics. Six weeks after the study, students who ‘opened up’ about their traumatic experiences made fewer visits to the health centre and showed signs of improved immune functioning compared with the students who wrote about trivial topics. Replications in laboratories around the world have confirmed that writing about traumatic events can influence a variety of academic, social and cognitive variables, and improve the health and well-being of people ranging from arthritis sufferers to maximum-security prisoners (Campbell & Pennebaker, 2003; Pennebaker & Graybeal, 2001; Smyth et al., 1999), although scientific debate regarding the size of these effects continues (Frisina, Borod & Lepore, 2004). Still, there are times when it is best to conceal our emotions, such as cloaking our fears when giving a speech and suppressing our anger when trying to resolve a problem with a colleague (Bonanno et al., 2004; Gross & Muñoz, 1995). As the old saying goes: ‘There’s a time and a place for everything.’ IS CATHARSIS A GOOD THING? Contrary to the popular notion that expressing what we feel is always beneficial, disclosing painful feelings, called catharsis, is a double-edged sword. When it involves problem-solving and constructive efforts to make troubling situ- ations ‘right’, it can be beneficial. But when catharsis reinforces a sense of helplessness, as when we stew endlessly about something we cannot or will not change, catharsis can actually be harmful (Littrell, 1998). This finding is worrisome, because a slew of popular psychotherapies rely on catharsis, encouraging clients to ‘get it out of your system’ or ‘get things off your chest’. Some of these therapies instruct clients to yell, punch pillows or throw balls against walls when they become upset (Lewis & Bucher, 1992; Lohr et al., 2007). Yet research shows that these activities rarely reduce our long-term stress, although they may make us feel slightly better for a few moments. In other cases, they actually seem to heighten our anger or anxiety in the long run (Tavris, 1989), perhaps because emotional upset often generates a vicious cycle: we can become distressed about the fact that we are distressed. DOES PSYCHOLOGICAL DEBRIEFING HELP? Around the world some therapists, often those employed by fire, police or other emergency services, administer a popular The work of James Pennebaker suggests that writing about our stressors can ward off physical illness, although this effect is only modest. (Source: Jonathan Ross/Dreamstime.) 518 ChaPtER 12 Stress, coping and health M12_LILI6786_02_SE_C12.indd 518 13/08/14 2:35 PM 9781488618826_T.indd 212 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. treatment called psychological debriefing, crisis debriefing or critical incidence stress debriefing, which is designed to ward off PTSD among people exposed to trauma. For instance, after the 2001 terrorist attacks on the World Trade Center in America, several thousand debriefers travelled to New York City in a well- meaning effort to help traumatised witnesses of the attacks. Crisis debriefing is a single-session procedure, typically conducted in groups, that usually lasts three to four hours. Most often, therapists conduct this procedure within a few days of a traumatic event, such as a terrible accident. It proceeds according to standardised steps, including strongly encouraging group members to discuss and ‘process’ their negative emotions, listing the posttraumatic symptoms that group members are likely to experience, and discouraging group members from discontinuing participation once the session has started. Recent studies indicate that psychological debriefing is not effective for trauma reactions. What is worse, several studies suggest that it may actually increase the risk of PTSD among people exposed to trauma, perhaps because it gets in the way of people’s natural coping strategies (Lilienfeld, 2007; Litz et al., 2002; McNally, Bryant & Ehlers, 2003). Based on these findings, in the aftermath of the Black Saturday bushfires, the Australian Centre for Posttraumatic Mental Health did not employ psychological debriefers, but instead developed a three-tiered approach for working with survivors that included a range of immediate and longer-term psychological treatments (Forbes et al., 2010). Indeed, there is not much evidence that merely talking about our problems when we are upset is helpful. A meta-analysis of 61 studies (Meads & Nouwen, 2005) revealed no overall benefits for emotional disclosure (compared with nondisclosure) on a variety of measures of physical and psychological health. None of this implies that we should never discuss our feelings with others when we are upset. But it does mean that doing so is most likely to be beneficial when it allows us to think about and work through our problems in a more constructive light. Individual differences in coping: attitudes, beliefs and personality Some people survive almost unimaginably horrific circumstances with few or no visible psychological scars, whereas others view the world through the dark lens of pessimism and crumble when the little things in life do not go their way. Our attitudes, personality and socialisation shape our reactions—for better and worse—to potential stressors. HARDINESS: CHALLENGE, COMMITMENT AND CONTROL. Over three decades ago, Salvatore Maddi and his colleagues (Kobasa, Hilker & Maddi, 1979) initiated a study of the qualities of stress-resistant people. They determined that resilient people possess a set of attitudes they called hardiness. Hardy people view change as a challenge rather than as a threat, are committed to their life and work, and believe they can control events. Hardy individuals have the courage and motivation to confront stressors and engage in problem-solving to contend with them (Maddi, 2004). Suzanne Kobasa and Salvatore Maddi asked 670 managers at a large company to report their stressful experiences on a checklist. Then they selected executives who scored high on both stress and illness, and another group who scored equally high on stress but reported below-average levels of illness. Managers who showed high stress but low levels of illness were more oriented to challenge and higher in their sense of control over events, and felt a deep sense of involvement in their work and social lives. When we are physically ill, we do not usually feel especially hardy. So we can appreciate the fact that another explanation for Kobasa and Maddi’s findings is that illness creates negative attitudes, rather than the other way around. To address the question of causal direction, Maddi and Kobasa (1984) conducted a longitudinal study (see Chapter 10) that examined changes in health and attitudes over time. At the end of two years, people whose attitudes towards life reflected high levels of control, commitment ◀ CORRELatION VS CaUSatION Can we be sure that A causes B? Psychological debriefing sessions, in which people discuss their reactions to a traumatic event in a group, may actually increase PTSD risk. hardiness set of attitudes marked by a sense of control over events, commitment to life and work, and courage and motivation to confront stressful events Coping with stress 519 M12_LILI6786_02_SE_C12.indd 519 13/08/14 2:35 PM 9781488618826_T.indd 213 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. spirituality search for the sacred, which may or may not extend to belief in God and challenge remained healthier than those whose attitudes did not. Hardiness also can boost stress resistance among nurses in hospice settings, immigrants adjusting to life in a new country, and military personnel who survive life-threatening stressors (Bartone, 1999; Maddi, 2002). In short, hardiness can transform stressors from potential disasters into valuable growth opportunities. OPTIMISM. We know them when we meet them. Optimistic people have a rosy outlook and do not dwell on the dark side of life. Even on a cloudy day, we can bask in their sunshine. As we discussed in Chapter 11, there are some distinct advantages to being optimistic. Optimistic people are more productive, focused, persistent and better at handling frus- tration than are pessimists (Peterson, 2000; Seligman, 1990). Optimism is also associated with a lower mortality rate (Stern, Dhanda & Hazuda, 2001), a more vigorous immune response (Segerstrom et al., 1998), lower distress in infertile women trying to have a child (Abbey, Halman & Andrews, 1992), better surgical outcomes (Scheier et al., 1989) and fewer physical complaints (Scheier & Carver, 1992). SPIRITUALITY AND RELIGIOUS INVOLVEMENT. Spirituality is a search for the sacred, which may or may not extend to belief in God. Spiritual and religious beliefs play vital roles in many of our lives. According to a Nielsen poll, 68 per cent of Australians believe in a God or Universal Spirit (Sydney Morning Herald, 19 December 2009). Compared with non-religious people, religious people have lower mortality rates, improved immune system functioning, lower blood pressure and a greater ability to recover from illnesses (Koenig, McCullough & Larson, 2001; Levin, 2001; Matthews, Larson & Barry, 1993). One explanation for these findings is that religious involvements activate a healing energy that scientists cannot measure (Ellison & Levin, 1998). This is an intriguing hypothesis. Nevertheless, explanations that depend on an undetectable force or energy cannot be empirically tested and therefore lie outside the boundaries of science. The correlation between religiosity and physical health is not easy to interpret. Some authors have measured religiosity by counting how often people attend church or other religious services, and found that such attendance is associated with better physical health. But this correlation is potentially attributable to a confound: people who are sick are less likely to attend religious services, so the causal arrow may be reversed (Sloan, Bagiella & Powell, 1999). Research on the links between spirituality and religious involvement, on the one hand, and health, on the other, is limited. But until more definitive evidence is available, we can consider several potential reasons why spirituality and religious involvements may be a boon to many people. 1. Many religions prohibit behaviours that are actually risky to health, including consuming alcohol, taking drugs and following unsafe sexual practices. 2. Religious engagement, such as attendance at services, often boosts social support. 3. A sense of meaning and purpose, control over life, positive emotions and positive appraisals of stressful situations associated with prayer and religious activities may enhance coping (Potts, 2004). Flexible coping The ability to adjust coping strategies as the situation demands is critical to contending with many stressful situations (Bonanno & Kaltman, 2001; Cheng, 2003; Westphal & Bonanno, 2004). George Bonanno and his colleagues (Bonanno et al., 2004) studied students who had just started university in New York City when terrorists destroyed the World Trade Center in 2001. The researchers predicted that students who had difficulties with managing their emotions would find the transition to university life particularly difficult. Participants completed a checklist of psychological symptoms at the start of the Optimists—who proverbially see the glass as ‘half full’ rather than ‘half empty’—are more likely than pessimists to view change as a challenge. (Source: Chad Heap/Dreamstime.) Research suggests that instructing someone not to think of something, like a white bear, often results in increases in the very thought the person is trying to suppress (Wegner, 1989). 520 ChaPtER 12 Stress, coping and health M12_LILI6786_02_SE_C12.indd 520 13/08/14 2:35 PM 9781488618826_T.indd 214 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. 9781488618826_T.indd 215 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. 1980). Health psychologists are employed in hospitals, rehabilitation centres, medical schools, industry, government agencies, and academic and research settings. Interven- tions developed within health psychology include teaching patients stress management skills and pain reduction techniques, and helping people to mobilise social support, comply with medical regimens and pursue healthy lifestyles. Towards a healthy lifestyle Health psychologists help patients to break the grip of unhealthy habits. Smoking, excessive drinking and overeating can be triggered by stress, and can be maintained when these activities reduce stress (Polivy, Schueneman & Carlson, 1976; Young, Oei & Knight, 1990). Among women who are survivors of sexual assault, drinking to reduce distress places them at risk for problem drinking (Ullman et al., 2005). Smokers are four times more likely to suffer from clinical depression as non-smokers, and may smoke in part to relieve distress (Breslau, Kilbey & Andreski, 1993). Moreover, people who report being concerned about stress are more likely to be smokers. Unfortunately, when we engage in unhealthy behaviours that reduce stress in the short run, we place ourselves at risk for health- and stress-related problems in the long run. In this section we examine five behaviours that can promote health. HEALTHY BEHAVIOUR #1: STOP SMOKING. Smoking ranks close to the top of the list of unhealthy habits. In Australia, about 21 per cent of men and 18 per cent of women smoke cigarettes daily (Scollo & Winstanley, 2008). Among Aboriginal Australians and Torres Strait Islanders aged 18–24, rates of smoking are alarmingly high, with nearly 50 per cent of both men and women smoking daily. These statistics are disturbing given that one in four regular smokers will die of a smoking-related disease (Woloshin, Schwartz & Welch, 2002). A 30- to 40-year-old male cigarette smoker with a two-pack-a-day habit loses about eight years of his life on average (Green, 2000). Smoking doubles the chance of dying from either CHD or stroke (McBride, 1992) and is responsible for more than 1 in 10 of all deaths in Australia annually (Scollo & Winstanley, 2008). Most smokers regret ever having started (Fong et al., 2004). Although about two-thirds of Australian smokers have attempted to quit at least once, only about 30 per cent of quitters are ultimately successful, usually over multiple attempts (Scollo & Winstanley, 2008). American author Mark Twain captured the challenges that smokers face in his famous quote: ‘Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times.’ Health psychologists make smoking treatment and prevention a high priority. Stop- smoking approaches typically educate people about the health consequences of smoking and teach smokers to manage stress. They also help smokers to pinpoint and avoid high-risk situations associated with past smoking, such as parties and bars (Marlatt & Gordon, 1985; Miller & Rollnick, 2002). These strategies are effective with 25 to 35 per cent of long-term smokers, and are also helpful for people who tend to eat or drink excessively. Each time people try to stop smoking, their chances of succeeding improve (Lynn & Kirsch, 2006). People who stop smoking live longer than those who do not, and women who stop smoking during the first few months of pregnancy reduce their risk of a problem pregnancy (such as a low-birth-weight baby) to that of women who have never smoked. After 10 to 15 years of non-smoking, an ex-smoker’s risk of premature death approaches that of someone who has never smoked (National Cancer Institute, 2000). So, if you are a smoker, do not quit your attempts to quit! HEALTHY BEHAVIOUR #2: CURB ALCOHOL CONSUMPTION. According to a recent survey, more than 80 per cent of Australian adults reported having drunk alcohol in the past year (Australian Institute of Health & Welfare, 2008b). Repeated bouts of heavy drinking, especially binge drinking—defined as drinking five or more drinks on one occasion for men and four or more drinks on one occasion for women—is asso- ciated with increases in many different types of cancer, serious and sometimes fatal 522 ChaPtER 12 Stress, coping and health M12_LILI6786_02_SE_C12.indd 522 13/08/14 2:35 PM 9781488618826_T.indd 216 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. liver problems, pregnancy complications, and brain shrinkage and other neurological problems (Bagnardi et al., 2001). Several controversial studies (Mukamal et al., 2003; Mukamal et al., 2005) suggest that light-to-moderate drinking—defined as two drinks per day for men and one drink per day for women—lessen the risk of heart disease and stroke. However, a rival explanation for these findings is that people who drink only moderate amounts of alcohol, such as wine, may have higher incomes and healthier lifestyles than people who either abstain from drinking or drink more than two drinks at a sitting (Lieber, 2003). Another hypothesis is that people who abstain are in poorer health to begin with than are light or moderate drinkers. Never- theless, meta-analyses comparing drinkers with non-drinkers who abstained because they chose to do so (not because of poor health, disability or weakness) found no health differ- ences between drinkers and abstainers (Fillmore et al., 2006). At this time, we cannot be sure that any amount of alcohol is safe, much less good for our health. One thing is reasonably certain, however: drinking heavily is associated with a greater risk of cardiovascular disease (Bagnardi et al., 2001). Fortunately, many of the negative effects of alcohol, including changes in the brain, can be reversed or minimised when we abstain from drinking (Tyas, 2001). HEALTHY BEHAVIOUR #3: ACHIEVE A HEALTHY WEIGHT. It is all over the news: Austral- ians are now among the most overweight people in the world. A recent national Australian Health Survey revealed that almost 60 per cent of Australian adults were classified as over- weight and more than 25 per cent of these were in the obese range (Australian Bureau of Statistics, 2012). The number of obese children and adolescents has tripled over the past decade or so, signalling an ominous trend. According to some researchers, our society faces an ‘obesity epidemic’ of enormous proportions, due in large measure to decreases in our physical activity (Australian Institute of Health & Welfare, 2004). People who are obese are at greater risk of heart disease, stroke, high blood pressure, arthritis, some types of cancer, respiratory problems and diabetes (Klein et al., 2004; Kurth et al., 2003). Those who carry their weight around the abdomen (so-called spare tyres) are at even greater risk for health problems, including CHD (Yusuf et al., 2004). Exercise is one of the best means of shedding that annoying fat around the tummy and losing weight over the long haul (Pronk & Wing, 1994). The more inactive we are, and the more time we spend watching television and using computers, the more likely we are to be obese (Ching et al., 1996; Gortmaker et al., 1996). Of course, these findings are only correlational; it is also possible that people who are obese are weaker and less energetic, and become couch potatoes as a result. Indeed, there is considerable controversy over how much of the negative association between obesity and physical health is due to obesity itself as opposed to the behaviours that often go along with it, such as inactivity ◀ RULING OUt RIVaL hYPOthESES Have important alternative explanations for the findings been excluded? TABLE 12.2 Reasons for obesity in Australia aside from diet and lack of exercise (1) Lack of adequate sleep, which directly causes weight gain (2) Endocrine disruptors in foods, which modify fats in the body (3) Comfortable temperatures as a result of heating/air conditioning that decrease kilojoules burned from sweating and shivering (4) Use of medicines that contribute to weight gain (5) Increasing numbers in certain segments of the population, such as middle-aged people, who have higher rates of obesity (6) Increase in mothers who give birth at older ages, which is associated with heavier children (7) Genetic influences during pregnancy (8) Moderately overweight people possibly having an evolutionary advantage over very thin people and being more likely to survive: Darwinian natural selection (9) People tending to marry people with a similar body type, a phenomenon called assortative mating—when heavy people reproduce, they are likely to give birth to relatively heavy children Promoting good health—and less stress! 523 M12_LILI6786_02_SE_C12.indd 523 13/08/14 2:35 PM 9781488618826_T.indd 217 1/11/17 11:38 AM Copyright © 2017 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488618826 – Lilienfeld/Health, Behaviour and Society HSBH1003 CB. amounts of alcohol, such as wine, may have higher incomes and healthier lifestyles than people who either abstain from drinking or drink more than two drinks at a sitting (Lieber, 2003). Another hypothesis is that people who abstain are in poorer health to begin with than are light or moderate drinkers. Never- theless, meta-analyses comparing drinkers with non-drinkers who abstained because they chose to do so (not because of poor health, disability or weakness) found no health differ- ences between drinkers and abstainers (Fillmore et al., 2006). At this time, we cannot be sure that any amount of alcohol is safe, much less good for our health. One thing is reasonably certain, however: drinking heavily is associated with a greater risk of cardiovascular disease (Bagnardi et al., 2001). Fortunately, many of the negative effects of alcohol, including changes in the brain, can be reversed or minimised when we abstain from drinking (Tyas, 2001). HEALTHY BEHAVIOUR #3: ACHIEVE A HEALTHY WEIGHT. It is all over the news: Austral- ians are now among the most overweight people in the world. A recent national Australian Health Survey revealed that almost 60 per cent of Australian adults were classified as over- weight and more than 25 per cen