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 Health Psychology & Stress Management

Introduction to Health Psychology & Stress Management Page 1

1. Psychodynamics of Behaviour Page 2

2. Stress Page 17

3. Physiology of Stress Page 38

4. Stress & Diseases Page 54

5. Personality as a Stress Variable Page 76

6. Sources of Stress Page 93

7. Health Damaging and Health Promoting Behaviour Page 130

8. Cognitive & Behavioural Coping Strategies Page 163

9. Relaxation & Meditation Systems Page 192

10. Behaviour Modification Page 230

Bibliography Page 250

 1

Introduction to Health Psychology & Stress

Management
This book deals with Health Psychology, Mental Health and Stress Management, and its
place in the overall perspective of health.
Stress has been the object of much speculation for several years now. It has existed from the
beginning but has now become an omnipresent phenomenon in the life of ‗Modern Man‘. It
has pervaded all layers of life. Yet, what has probably been neglected is the duality of its
nature. Often one correlates the term stress with strain and other negative terms. However, it
is necessary to clarify the fact that all stress is not bad.
This text aims at giving a comprehensive capsule of stress & its effects and of strategies to
manage stress. While putting the text together, we have tried to make sure that we have
touched all those aspects that are connected to stress.
Much of our source for this text has been books that have been written on stress as well as
articles from journals. The perspective, however, comes from years of working in this field.
This text begins with a chapter on the psychodynamics of behaviour. We have tried to
address both the concepts of normality and abnormality. The concept of normality becomes
very essential as it is most often ignored while discussing the dynamics of human behaviour.
This is particularly significant as it helps us to then understand the shift from health to ill
health, good stress to bad stress.
Stress is a Bio-Psycho-Social response and the next three chapters give an entire picture of
stress, the physiology behind it and the manifestation of diseases as a result of stress. Most
often we assume that stress has only a negative influence. We now understand that optimum
levels of stress are required for the successful completion of any task. These three chapters
focus on the issues of Eustress and Distress and how excess stress affects the human body.
When we try and locate the sources of stress we are often led to realize that there are both
internal and external stressors. The next two chapters address Source of Stress, Personality
types, Occupational stress and how certain professions cause more stress to an individual than
other.
Much of our behaviour is responsible for our state of health and we discuss health damaging
and health promoting behaviour next. Our daily health choices and their impact on health and
illness have been detailed. Health promoting behaviour has been discussed here as well as in
the next two chapters. Having discussed human behaviour, stress and its physiology, sources
and its effects we have then tried to give you a detailed account of the various strategies and
techniques (cognitive, behavioural, relaxation, meditation etc.) to cope with stress.
The last chapter deals with health correction requiring a therapist‘s intervention.
We hope this text will help you see the place of Human behaviour in the overall Illness
Wellness picture.
Savita Date Menon, MA(Cly.Psy.) PPHC. PhD.
 2

CHAPTER 1:
PSYCHODYNAMICS OF BEHAVIOUR
Introduction to Psychodynamics of Behaviour
In 1953, the World Health Organization (WHO) defined health as a complete state of
physical, mental, and social wellbeing and not merely the absence of disease and infirmity.
This marked a major shift in the emphasis and perspective of health. Health began to be
viewed more positively and emphasis was on wellbeing & positive health rather than absence
of disease.
Mental Health
It is the capacity in an individual to maintain balance and harmony amongst the important
facets of his personality; psychological, social, physical and spiritual

At around the same time, Psychiatrists made a concentrated effort to define mental health and
normality. Earlier, it was assumed that mental health was the opposite of mental illness. The
absence of gross psychopathology was often equated with normal behaviour. However, it has
become increasingly important for Psychiatrists to provide precise concepts and definitions of
mental health and normality
I. NORMAL BEHAVIOUR

The many theoretical and clinical concepts of normality seem to fall under four functional
perspectives. Although each perspective is unique, the perspectives complement each other
and together they represent the totality of the behavioural science and social science approach
to normality.
Normality as Health
The first perspective is the traditional medical approach to health and illness. Most physicians
equate normality with lack of illness and an individual is assumed to be within normal limit
 3

when no manifest psychopathology is present. In this context, health is a reasonable rather

than optimal state of functioning. Absence of illness is the marker of normality and not
necessarily the presence of Wellness. Unacceptable behaviour is clearly defined, acceptable
behaviour is not. The absence of undesirable behaviour is assumed to be normal. For example
absence of Hypertension, High blood Sugar and Hyperlipidemia makes the person a Normal,
Healthy person even if he is overweight, unfit and highly stressed.
Normality as Average
This perspective is commonly used in normative studies of behaviour and is based on the
statistical principle of the bell-shaped curve. According to this approach, the middle range of
the curve is seen as normal and both the extremes are considered deviant. Variability is
described only in the context of groups and not within the context of a single person.
Behaviour that is statistically most commonly seen is normal. Statistical rarity by extension
of logic therefore becomes uncommon and not normal. By this definition, a female with a
shoe size of 4 will fit into the ‗golden mean‘ – a sizes common to most of the adult female
population and sizes above and below will be less common and therefore less normal. Also,
people with an IQ of 140 will be as much of a statistical rarity as a mentally challenged
person with an IQ of 60. Both deviations will thereafter be considered abnormal. The major
weakness of this approach is that it doesn‘t differentiate between the more desirable or less
desirable rarity. While average behaviour is considered normal, no value is attributed to more
than average or less than average.
Normality as a Norm
Our society lives by a set of Norms – rules that tell us ‗right‘ from ‗wrong‘, ‗acceptable‘ from
‗unacceptable‘. These rules or ‗norms‘ address every aspect of behaviour from activities of
daily living to life changing situations. Vegetarianism is the norm in certain communities,
while animal sacrifice is a norm in others. Marriage amongst blood relatives is the rule in
certain communities while it is usually prohibited in several others. While formal attire is the
expected dress code in wedding ceremonies, jeans is a must for all teenage occasions. While
these norms may seem strange to an outsider, for people from that culture, it is a way of life.
Norms are not an absolute truth since they vary across time and culture. It makes conformity
the ideal form of behaviour, whereas change and progress come with nonconformity. Norms,
therefore, cannot be used as an absolute standard for judging normal behaviour.
Ullmann and Krasner (1969) maintain that normal behaviour is simply an adherence to social
expectations. Behaviour is considered abnormal if society labels it as such. However, serious
questions can be raised about the validity of this view. It rests on the assumption that
normality is nothing more than socially accepted behaviour and therefore socially accepted
behaviour cannot be abnormal
 4

This figure shows the bell – shaped normal curve identifying mean or average along with
standard deviations below and above the mean.

Normality as Process

This perspective stresses that normal behaviour is the end result of interacting systems.
According to this perspective, temporal changes are essential to complete the definition of
normality. In other words, it stresses changes or processes during the individual‘s life, rather
than a static definition of normality. Typical of the concept of this perspective is Erikson‘s
theory of personality development with its eight developmental stages essential to attain
mature adult functioning. It the process of mastering the periods of life and handling conflicts
and life changing events as a process of learning.

While all four perspectives are useful, each is not complete by itself. Together they represent
a sound understanding of normal behaviour.

II. PSYCHOANALYTICAL THEORY OF BEHAVIOUR

Sigmund Freud – One of the first theoretical systems to understand human behaviour is
Freud‘s psychoanalytic theory. This theoretical system is a model of personality development
and a philosophy of human nature.

 Some of the major contributions of Freud‘s theory are :

 Early childhood development has a profound effect on adult functioning.
 Human behaviour is most often governed by unconscious factors.
 An individual‘s mental life can be understood and insights into human nature can be
achieved

Table 1.1
Psychoanalytic Concepts of Normality
Theorist Concept
Sigmund Freud Normality is an ideal fiction
Kurt Eissler Absolute normality cannot be obtained because the normal person
must be totally aware of this or her thoughts and feelings
 5

Melanie Klein Normality is characterized by strength of character the capacity to deal

with conflicting emotions, the ability to experience pleasure without
conflict and the ability to love
Erik Erikson Normality is the ability to master the periods of life: trust vs. mistrust;
automony vs. shame and doubt; initiative vs. guilt; industry vs.
inferiority ; identity vs. role confusion ; intimacy vs. isolation ;
generativity vs. stagnation ; and ego integrity vs. despair
Laurence Kubie Normality is the ability to master the periods of life.
Hein Hatmann Conflict free ego functions represent the person‘s potential for
normality; the degree the ego can adapt to reality and be autonomous
is related to mental health
Karl Menninger Normality is the ability to adjust to the external world with
contentment and to master the task of acculturation
Alfred Adler The persons capacity to develop social feeling and to be productive is
relative to mental health; the ability to work, heightens self ‗esteem
and makes one capable of adaptions
R.E. Money- Normality is the ability to achieve insight into one‘s self, and ability
Kryle that is never fully accomplished
Otto Rank Normality is the capacity to live without fear, guilt or anxiety and to
take responsibility for one‘s own actions

a. Structure of personality

According to the Psychoanalytic view, an individual‘s personality structure consists of three

systems; the id, the ego, and the superego. These are psychological processes, which work
together and not as separate segments. These three systems are like three forces continually
interacting with one another, and when each has a different goal, the interaction often takes
the form of a conflict.

Freud and the psychoanalytical view also discussed the theory of consciousness and
unconsciousness

The Id: The Id is the biological component and the original system of personality. A person
is all id at birth. It lacks organization, and is blind, demanding and insistent. It is ruled by the
pleasure principle, which is aimed at reducing tension, avoiding pain and gaining pleasure. It
is illogical, amoral and driven by only one consideration that of satisfying instinctual needs.
The id is the unconscious part of personality.

The Ego: It is the contact with the external world of reality. The ego can be said to be the
executive of personality that governs, controls and regulates. Its principle job is to mediate
between the instincts and the surrounding environment. Ruled by the reality principle, the ego
does realistic and logical thinking and formulates plans of action for satisfying needs.

The Superego: This is the social and moral component of the personality. It reflects a
person‘s moral code, the main concern being whether the action is right or wrong, good or
bad. The superego represents the ideal rather than the real, and strives for perfection rather
than pleasure. It represents the traditional values and ideals of society as they are handed
 6

down from parents to children. The superego is the conscience of an individual, judging
acceptable from unacceptable and is not based merely on self-gratification.

The figure shows the three parts of the personality interacting with one another.

b. Consciousness and Unconsciousness: Perhaps Freud‘s greatest contributions are the

concepts of the unconscious and the levels of consciousness, which are the keys to
understanding behaviour and the problems of personality. The unconscious cannot be studied
directly and is inferred from behaviour – through dreams, slips of tongue, forgetting, post
hypnotic suggestions, free – association techniques, and projective techniques.

The Conscious – Consciousness is a thin slice of the total mind with the unconscious
forming the greater part. The mind is like an iceberg with the greater part existing below the
surface of awareness. Awareness is limited to the conscious mind.

The Unconscious – Unconscious stores up all experiences, memories, and repressed

material. Needs and motivations, which are out of awareness, are also a part of the
unconscious. The unconscious influences behaviour to a great extent and is at the root of all
neurotic behaviour and symptoms. Unconscious mind doesn‘t comprise of events as they
have happened but the way they have been perceived and interpreted to have happened.
Conscious memory that is traumatic and difficult to handle is suppressed and stored in the
unconscious mind with the conscious mind having no recall.

Subconscious – The subconscious is like a valve that allows memories from the unconscious
to emerge to the conscious mind via dreams, post hypnotic suggestions etc.

Modern psychology classifies mind into 3 different categories

 Conscious Mind
 Subconscious Mind
 Unconscious Mind
 7

Conscious Mind: The State of doing action… Running, Eating, Thinking of many things at a
time 10%

SubConscious Mind: Sleeping State : The process of dreaming happens in the realm of
subconscious mind.

Unconscious Mind: The most powerful part of the mind i.e. 90% All memories, habits, past
experience are stored in it. Thinking of one and only one thing at a time.

c. Development of personality

Freud‘s theory, which focused on the childhood period, was organised around his idea of
libidos. According to Freud, childhood phases of development correspond with successive
shifts in the investment of the libidos or sexual energy in the different areas. A significant
contribution of the psychoanalytic model is the delineation of the stages of psychosocial and
psychosexual development of the person from birth through adulthood.

The Oral stage (Birth to 1 year): During this stage, mouth is the area for experiencing
pleasure. While the mouth is used to satisfy hunger, infants also chew or bite any object that
arouses their curiosity. They suck or mouth anything available in search of oral stimulation.
Greediness and acquisitiveness may develop as a result of not getting enough food or love
during the early years of life. According to Freud, successful resolution of the oral phase
provides a basis for capabilities of giving and receiving from others without excessive
dependence or envy. It also helps to develop a sense of trust in others as well as sense of self
reliance and self – trust.

The Anal stage (1 to 3 years): Just as the oral stage demands that the person experience a
healthy sense of dependency, trust in the world and acceptance of love, so also the anal stage
which marks another step in the development of the person. The tasks to be mastered during
this stage are learning independence, personal power and autonomy, and learning how to
recognize and deal with negative feelings.

The anal zone becomes most significant in the formation of personality. Acquisition of
voluntary sphincter control is associated with an increasing shift from passivity to activity.
The conflicts over anal control during the process of toilet training give rise to ambivalence
along with struggle over separation, individuation and independence. Successful resolution of
the anal phase provides the basis for the development of personal autonomy, a capacity for
independence and personal initiative without guilt.
 8

The Phallic stage (3 to 5 years): By the age of three, the child discards infantile ways and
activity and proceeds to become an independent individual with a mind of his own. As
increased motor and perceptual abilities begin to develop, so also do interpersonal skills.
During the phallic stage, the child progresses from passive / receptive behaviour to active
mastery. Sexual activity becomes intense and the focus of attention is on the genitals.
Children become curious about their bodies and desire to explore, to discover the differences
between the two sexes.

The phallic stage provides the foundation for an emerging sense of sexual identity, a sense of
curiosity without embarrassment, initiative without guilt, as well as a sense of mastery not
only over objects and persons in the environment but also over internal processes and
impulses. One critical danger at this time is the parental indoctrination of rigid and unrealistic
moral standards, which can lead to the over control of the superego causing severe conflicts,
guilt, low self-esteem and self-condemnation.
Latency stage (5 to 11-13 years): This is the stage of relative inactivity of the sexual drive.
Latency is marked by a diminution of sexual interest, which is reactivated at puberty.
However, there is also important consolidation of the attainments during the previous
psychosexual stages and establishing decisive patterns of adaptive functioning. The child can
develop a sense of industry and a capacity for mastery of objects and concepts that allow
autonomous functioning. These important attainments need to be further integrated to form
the essential basis for a mature adult life of satisfaction in work and love.

The Genital stage (11-13 years to Young adulthood): The genital or adolescent phase of
psychosexual development is characterized by physiological maturation of genital (sexual)
functioning. The accompanying hormonal changes lead to an intensification of drives,
particularly libidinal drives. This causes a regression, which reopens conflicts of the previous
stages of development, and provides an opportunity for a resolution of these conflicts in order
to achieve a mature sexual and adult identity.

The successful resolution and reintegration of the previous stages set the stage for a fully
mature personality. Such a person has reached a satisfying capacity for self-realization and
meaningful participation in the areas of work and love, and the capacity to reach meaningful
goals.

Freud believed that the successful resolution of these phases were essential to normal adult
functioning

III. THE NEO – FREUDIAN CONCEPT OF BEHAVIOUR

The Neo-Freudians were against Freud‘s limited and deterministic concept of human nature.
They objected to his biological orientation and deterministic stand, and emphasized the
social-cultural and interpersonal dimensions of human behaviour. Some theories suggested
by other psychoanalysts are mentioned below

Carl Gustav Jung – Jung believed that external factors played an important role in people‘s
growth and adaptation. He emphasized the role of purpose in human development, and
 9

stressed the goal of self-actualization. According to Jung, a libido is every possible

manifestation of psychic energy. It is not limited to sexuality or aggression, but also includes
religious and spiritual urges and the desire to seek a clear and deep understanding of the
meaning of life.

The concepts contributed by Jung are:

The Personal unconscious – This consists of experiences that were once conscious but have
now been repressed and forgotten. It contains the person‘s painful ideas and thoughts.

The Collective unconscious – This is the storehouse of buried memories inherited from the
ancestral past. It is the ―racial‖ inheritance of significant memories passed from generation to
generation.

The Persona – It is the mask worn by a person in response to social situations and the
demands of social conventions. It is the public self, the side displayed to the world the social
façade.

Harry Stack Sullivan – He emphasized the role of personal relations and the study of people
in relationship with significant others. He conceived of human development as largely shaped
by external events, especially by social interaction. For him, the unit of study is the
interpersonal situation, and not the individual.

According to Sullivan, personality is not determined at an early age, and it may change at any
time as new interpersonal relations develop. He stresses that personality develops through
definite stages which include infancy, childhood, juvenile era, preadolescence, early
adolescence, late adolescence and maturity. Each phase is marked by a need for interaction
with certain significant people and the quality of these interactions influence the person‘s
personality

Erik Erikson – Although he accepted Freud‘s theory of infantile sexuality, he also thought
that a persons developmental potential occurred at all stages of life. He delineated eight
stages of development, each having a crucial need to be met and a crisis to be resolved. These
stages extend into adulthood and old age

Stage I Trust Vs Mistrust

Stage II Autonomy Vs Shame and Doubt
Stage III Initiative Vs Guilt
Stage IV Industry Vs Inferiority
Stage V Ego identity Vs Role confusion
Stage VI Intimacy Vs Isolation
Stage VII Generativist Vs Stagnation
Stage VIII Ego identity Vs Stagnation

The first five stages are ascribed to childhood, which correlates with Freud‘s psychosexual
stages. In addition, Erikson added three stages that extend beyond young adulthood and into
old age. These stages have both positive and negative aspects – each stage has its own crisis
 10

and is affected by the interaction with the person‘s biology, culture and society. Every stage
has two possible outcomes, one positive and healthy, and the other negative or unhealthy.
The crisis at each stage is resolved when the person achieves a higher level of functioning.
However, most people are unlikely to achieve the entire positive polarity, as each crisis must
be negotiated before a person can move to the next phase.

Other Neo-Freudians who have also contributed to the understanding of human nature are
Alfred Adler, Karen Horney, and Erich Fromm

IV. HUMANISTIC – EXISTENTIAL CONCEPT OF BEHAVIOUR

Abraham Maslow – Psychology has long been dominated by the empirical approach to the
study of individual behaviour. The existential –humanistic approach, however, emphasizes
the philosophical concerns of what it means to be fully human. Maslow, along with other
existentially oriented psychologists like Kurt Goldstein, S. Journal and others, argued for the
need for psychology to develop a broader perspective that would encompass the client‘s
subjective experiences of his or her private world. He believed in the self-actualization theory
– the need to understand the totality of a person.

Maslow described a hierarchical organization of needs present in everyone. As the primitive,

biological needs such as hunger and thirst, are satisfied, the advanced psychological needs
such as affection and self-esteem become the primary motivators. Self-actualization is the
highest need

The experience of self-actualization is an episodic, brief occurrence in which a person

suddenly experiences a powerful transcendental state of consciousness. During that state, a
person may experience a sense of heightened understanding and an altered perception of time
and space. Although a brief occurrence, it may produce long lasting beneficial effects.
 11

According to Maslow, this self – actualization is the ultimate goal of all human beings and
they strive toward it all the time.

Once we understand the normal development of individuals, we can understand behaviour

which is slightly deviant, but not to the extent where it can be termed as mental illness. One
such concept which is essential to understanding human nature is anxiety. Anxiety is a state
of tension that motivates us to do something. Its function is to warn of impending dangers.
However, this anxiety is not always experienced consciously. When the ego cannot deal with
anxiety by rational and direct methods, it gets suppressed in the unconscious and anxiety
handled by the use of Ego defense mechanisms

V. EGO DEFENCE MECHANISM

Ego defence mechanisms help the individual to cope with anxiety. They are not necessarily
pathological and they can have adjustive value if they do not become a way of life to avoid
facing reality. Defence mechanisms have two characteristics –

They deny or distort reality.

They operate at an unconscious level.

Some of the ego defence mechanisms are:

Denial: This is like ―closing one‘s eyes‖ to the existence of threatening reality. The person
refuses to accept reality, which evokes anxiety. This often occurs in tragic events or disasters
like wars, when the reality and loss becomes too painful to accept.

Projection: This is the process of attributing to another person those traits that are
unacceptable in self. For example, a person may condemn others and claim that they hate
him, when he himself is the one to possess that feeling. To avoid the pain involved in
recognizing in oneself impulses that are deemed evil, the person divorces himself from this
reality and attributes it to another.

Fixation: Fixation is getting ‗stuck‘ on one of the earlier stages of development because
taking the next step is extremely anxiety – provoking. Over dependence of a child is one such
example of fixation. The anxiety prevents the child from learning to become independent.

Regression: This means retreating to an earlier phase of development where the demands are
not so great. This is different from fixation where the child gets stuck in a particular stage. In
regression, the child reverts to an earlier phase of development when faced with anxiety –
provoking situations. This may be seen when a child indulges in infantile behaviour such as
weeping and thumb sucking when he is frightened in school.

Rationalization: This is the process of manufacturing a ―good‖ reason to explain away a hurt
ego. It is self-deception so that the reality of a disappointment does not hurt too much. This
may be seen when a person does not get the job he had applied for; and may find all sorts of
reasons why he is really glad he did not get the job.
 12

Sublimation: In sublimation, the person uses a higher or more socially acceptable outlet for
basic impulses. For example, aggressive impulses can be channelized into socially approved
competitive sports or corporate ambitions. The person finds a way of expressing his
aggressive feelings in a non-threatening way.

Displacement: The energy is directed toward another object or person when the original
object or person is inaccessible. The angry boy who would like to kick his parents kicks a
safer target – his younger sister, or even the pet dog.

Repression: This is the process of forgetting content that is traumatic or anxiety – provoking.
The individual pushes unacceptable reality into the unconscious. Repression is one of the
most important concepts since it forms the basis of many other ego defence mechanisms and
of neurotic disorders.

Reaction Formation: The person starts behaving in ways that are directly opposite to
unconscious wishes. When the deeper feelings are threatening, the person uses the cover-up
of opposite behaviour to deny these feelings. For example, a mother who feels she is rejecting
her child may go to the other extreme of over-protecting and ―overloving‖ her child.

These defense mechanisms are used at one time or another by everyone. They help the person
to deal with stressful situations. However, when these defence mechanisms become a way of
life and the individual uses it in every situation, these same defence mechanisms indicate an
abnormal behaviour. The excessive use of defence mechanisms can be seen in neurotic
disorders.

To be able to distinguish between normal and abnormal behaviour, it is important to

understand abnormal behaviour as well

VI. ABNORMAL BEHAVIOUR

Abnormal literally means ―away from the normal‖. It implies deviation from some clearly
defined norms. Another view maintains that behaviour is abnormal if it interferes with the
well-being of the individual and / or the group. Let us examine each of these perspectives.
Behaviour that is unacceptable to self or to society may also be considered abnormal
behaviour.

Abnormal as Maladaptive: Some degree of social conformity is essential for group life, and
some kinds of deviance are harmful to society and the individual. However, as we have seen
earlier, the best criterion for determining the normality of behaviour is not whether society
accepts it, but whether it helps in the wellbeing of the individual and the group.

The term ‗well-being‘ means not only survival but also growth and fulfilment – the
actualization of potentialities. According to this criterion, even conforming behaviour can be
abnormal if it is maladaptive and interferes with optimal functioning and growth. The
consequence of maladaptive behaviour is oftentimes personal discomfort. If a person is able
to meet most demands of life – occupational success, financial comfort, family peace and
 13

personal happiness, this behaviour is said to be adaptive. If a person is unable to meet

demands of life, this behaviour is maladaptive causing personal discomfort.

However, in certain life situation, adapting beyond a point may not be possible and yet
cannot be considered maladaptive e.g. tolerating repetitive physical abuse from spouse for the
sake of family peace. In this case adapting would probably be abnormal and harmful to self.

Personal Discomfort or Societal Discomfort: If a person is content with his life and there is
no norm violation, a mental health institution is not concerned with his lifestyle. However, if
the individual is unhappy and distressed over his thoughts and behaviour, they may be
considered abnormal and requiring treatment. Obsessive thoughts about God, prayer etc. may
cause great discomfort to the individual. Extra kilos on the weighing scale or extra fat even if
imaginary may cause great distress. However, when this behaviour results in anorexia, it may
cause distress to close family and require treatment.

Distressing behaviour, either reported by self or by society will be assessed by mental

institutions for abnormality.

VII. MENTAL ILLNESS

a. Mental Illness in America

24% of adults in the US (about 44 million people) experience a mental illness as substance
related diseases, during the course of any given year.

14 to 20% percent of individuals under 18 years suffer from a diagnosable mental disorder. In
the United States, an estimated 9 to 13 percent of children between the ages of 9 to 17 suffer
from a serious emotional disturbance – that is, a disorder that severely disrupts a child‘s daily
functioning in the family, school, or community.

2.6% of adults in the US (about 4.8 million people) suffer from a severe and persistent mental
illness – such as schizophrenia, bipolar disorder, or a severe form of depression or panic
disorder – in any given year.

2.8% of adults in the US (about 5.2 million people) experience a mental illness that seriously
interferes with one or more aspects of their daily life, such as their ability to work or relate to
other people.

International surveys have demonstrated that approximately 40% of people in a given

population experience a mental illness during their lives. These surveys also reveal that
anxiety disorders are usually even more common than depression
 14

b. Classification of Mental Disorders

Normal and abnormal behaviour lie on opposite sides of a spectrum with most of us falling in
between and some of us on either side. While we have understood normal behaviour, it is also
necessary to have a brief orientation of abnormal behaviour.

These abnormal behaviours are classified under various categories by the American
Psychiatric Association (APA) and the Diagnostic and Statistical manual of Mental Disorders
(DSM) and International Classification of Disorders (ICD).

The DSM (Diagnostic Statistical Manual of Psychiatry) gives us the current classification of
Mental Disorders. The purpose of DSM is to provide clear descriptions of diagnostic
categories in order to enable clinicians to diagnose, communicate about, study and treat
people with various mental disorders. Some of the more commonly seen mental disorders
have been here elaborated for your benefit. With a glimpse at these disorders the concept of
abnormality becomes much more clear.

Disorders first diagnosed in infancy, childhood or adolescence: This category includes

mental retardation, learning disorders, motor skills disorder, communication disorder,
attention deficit hyperactive disorder, pervasive developmental disorder etc.

Mental retardation is the significantly sub average intellectual functioning accompanied by

impairment in adaptive functioning. The onset for this disorder is anywhere between
conception and the end of development at 18 years.

Substance induced disorders: A maladaptive pattern of substance use leading to clinically

significant impairment or distress which later results in disorders related to the use of a
particular substance (e.g. Alcohol related disorder, Cannabis related disorders etc.). The
abuse of such substances also induces certain psychotic symptoms. While alcohol
intoxication and withdrawal have their own problems, they manifest in the form of disorders
mentioned here.

Specific to substance abuse are two alcohol induced persisting amnestic disorders. While
Wernicke‘s syndrome shows a set of acute symptoms, Korsakoff ‘s syndrome shows as a
chronic condition. The former is completely reversible with treatment, whereas only 20% of
the latter patients recover.

Organic Brain Disorders: Includes brain injuries, drug intoxication and a wide range of
other conditions based on brain pathology.

Mood disorders: This signifies the presence of some abnormality in the individual‘s mood
(excessively excited/very low), which is often accompanied by significant distress and
impairment in social, occupational and other areas of functioning. Mood disorders are often
classified into depressive disorder, bipolar disorder, mood disorder due to general medical
condition etc.
 15

The word depression signifies feelings of sadness, weight loss, diminished interest, social
withdrawal, loss of energy, worthlessness, loss of concentration, insomnia or hypersomnia
etc. Mania implies feelings of grandiosity, decreased sleep, unusually talkative, flight of
ideas, highly distractable etc. Bipolar disorder is usually a combination of manic and
depressive symptoms.

Schizophrenia: Schizophrenia is a psychotic disorder accompanied by characteristic

symptoms like delusions, hallucinations, disorganized speech and behaviour, negative
symptoms and followed by social and occupational dysfunction. Thought and perceptual
disturbances result in a breakdown of personality.

Some of the other psychotic disorders are schizoaffective disorders, delusional disorders,
shared psychotic disorder, psychotic disorder due to substance abuse and general medical
condition etc.

Anxiety disorders: This includes several other disorders like panic disorder, phobias (intense
fear), obsessive – compulsive disorder (OCD-obsessive thoughts and compulsive behaviour),
post-traumatic stress disorder (PTSD), generalized anxiety disorder etc. Anxiety disorders are
characterized by intense fear or discomfort accompanied by physiological symptoms
(palpitation, sweating, trembling, nausea, shortness of breath, fear of losing control etc.) and
of being in a situation where escape is impossible.

Somatoform disorders: Somatoform disorders are characterized by several physical

complaints, which have no physiological basis. Some of the disorders classified under this
category are pain disorder, conversion disorder, hypochondriasis, body dysmorphic disorder,
somatization disorder etc.

Somatization disorder traces a history of physical complaints before age 30 that recur over
the years accompanied often by pain or gastrointestinal or sexual symptoms which result in
social, occupational impairment.

Factitious disorders: It is the unconscious production of physical or psychological

symptoms with an expectation of external incentives for behaviour.

Some of the disorders under this category are dissociative amnesia, dissociative fugue,
dissociative identity disorder, depersonalization etc.

Sexual and gender identity disorders: This includes sexual dysfunctions, paraphilias
(exhibitionism, fetishism, pedophilia, sexual sadism, masochism, voyeurism) and gender
identity disorders. Each of these disorders differ in their symptoms, but are characterized by
persistent and marked distress about sexual orientation.

Eating disorders: Eating disorders like bulimia and anorexia often have the symptoms of
poor self-evaluation, which is unduly influenced by body shape and weight.

Patients of Anorexia nervosa show intense fear of gaining weight and refusal to maintain
body weight at the normal range with denial of seriousness of current low body state.
 16

Bulimia nervosa has recurrent episodes of binge eating followed by recurrent in appropriate
compensatory behaviour in order to prevent weight gain e.g. Vomiting, excessive exercise
etc.

Sleep disorders: These are disorders accompanied often by clinically significant distress or
impairment in social, occupational, or other areas of functioning. Some of the sleep disorders
are insomnia, hypersomnia, narcolepsy, sleep apnoea etc.

Personality disorders: The general criteria for a personality disorder is an enduring pattern
of inner experience and behaviour that deviates markedly from the expectations of the
individual‘s culture in the areas of cognition, affectivity, interpersonal functioning and
impulse control. This enduring pattern is inflexible and pervasive across a broad range of
personal and social situations, which lead to impairment in social, occupational, or other
important areas of functioning.

Some of the personality disorders are as follows: paranoid personality disorder, antisocial
personality disorder, histrionic personality disorder, schizoid personality disorder, borderline
personality disorder, narcissistic personality disorder etc.

The above classification of mental disorders gives you a brief glimpse of the nature of
abnormality. However, it is not essential for us to delve deeper into these issues since we are
concerned with understanding normal behaviour as well as the other end of the spectrum that
is abnormal behaviour. Our purpose here is not to diagnose and treat abnormality. As and
when there is a necessity to look closely at the links between stress and abnormal behaviour
we will do so.
 17

CHAPTER 2:
STRESS
I. INTRODUCTION TO STRESS

STRESS is an everyday fact of life. Even primitive man could not escape from its clutches.
Whenever confronted with overwhelming stress or an alarming situation – such as sudden
thunder, a wild animal, or fire, he usually responded in one of two ways, depending on his
perception of the situation. If he felt confident of overpowering the opponent, he would fight
and if he felt threatened, he would flee. Either way his body would prepare itself to handle,
the two situations. This alarm response is now understood as the ‗fight or flight‘ response.
This fight flight response was first discussed by Hans Selye.

Modern man, in spite of his current level of progress and advancement, is yet to conquer
stress. Threat-provoking situations have probably changed, but man‘s response in the face of
threats has not. In today‘s high-pressure world, stresses and strains of modern living can
become increasingly hard to bear. Stress is something, which cannot be avoided. It creeps in
stealthily and has the potential to make you or mar you.

Wouldn‘t you want to know more about this universal phenomenon/ experience what causes
it, what are its signs and symptoms and most importantly how best can you cope with it and
lead a healthy, productive and progressive life? Let us explore some of these issues and make
an attempt to understand them

Modern life, with its quick pace, occupational achievements, personal ambitions, social
pressures, environmental poisons and our orientation to sedentary mental work, presents
almost all of us with constantly stressful situations.
 18

Though we do differ in the extent to which we are stressed and the way in which we react to
it- the fact remains that all of us are affected by it in some way or the other, at some time or
the other.
In simple terms, stress is a reaction/response to any kind of change. It is the physical and
emotional response to situations, which are perceived as novel, frightening, confusing,
exciting or tiring. It not only gets precipitated by external demands, but can also be generated
from within by our hopes, fears, expectations and beliefs. It acts like a signal for the mind and
body to get prepared for any eventuality.
While stress places a demand on the human mind and body, with the right attitude, it can be
well managed. However, when stress becomes prolonged and chronic, long term stress can
then become too demanding and debilitating. Not only can it destroy your looks, but also
your vitality and eventually your health.
What makes long-term stress so damaging is the fact that it produces tension and a great
pressure on the bodily systems. The mind and body are in a perpetual state of high alert
without the much required periods of rest and recuperation.

UPTO DATE PICTURE TO BE SELECETED BY DR. SAVITA

II. STRESS CONTINUUM

Stress in other words is defined as ―our reaction to events, environmental or internal, that tax
or exceed our adaptive resources.‖ Each of us has a certain number of coping resources and
 19

when those coping resources are taxed or exceeded, it usually results in stress reactions
consist of both physical and emotional responses.

Stress is something that most people experience on a daily basis. When resources are not
overly taxed or depleted, the resulting stress can be healthy and rather challenging — this is
referred to as ―NORMAL STRESS‖ or by the more technical term, ―EUSTRESS.‖

However, when coping resources are not readily available, a more ―harmful stress‖ or
―distress‖ can occur. Distress can result from very traumatic incidents or from the
accumulation of stressors over long periods of time. Whether traumatic or cumulative,
burnout and subsequent impairment can result.

Normal Stress > Traumatic > Impairment

Normal Stress > Cumulative > Burnout, Impairment

III. OVERLOAD & STRESS

Take the following self-assessment exercise to assess your own personal stress level. (Girdin,
D.A., Everly, G.S. and Dusek, D.E., Controlling Stress and Tension, Allyn & Bacon,
Needham Heights, MA, 1996)

Choose the most appropriate answer for each of the following ten statements.

1. Almost always
2. often
3. seldom
4. almost never

How often do you …

1. Find yourself with insufficient time to do things you really enjoy?

2. Wish you had more support/assistance?
3. Lack sufficient time to complete your work most effectively?
4. Have difficulty falling asleep because you had too much on your mind?
5. Feel people simply expect too much from you?
6. Feel overwhelmed?
7. Find yourself becoming forgetful or indecisive because you have too much on
your mind?
8. Consider yourself to be in a high-pressure situation?
9. Feel you have too much responsibility for one person?
10. Feel exhausted at the end of the day?

Calculate Your total score as follows :a)=4 points; B)= 3 points; c)=2 points: d)=1 point:
Total = _____

This exercise was designed to assess your level of stress due to overload. Overload, or over-
stimulation, refers to the state in which the demands around you exceed your capacity to meet
 20

them. Some aspect(s) of your life may be placing excessive demands on you. When these
demands exceed your ability to comply with them, you experience distress.

The four major factors in overload are (1) time pressures (2) excessive responsibility or
accountability, (3) lack of support, and (4) excessive expectations from self and those around.
Any one or a combination of these factors can result in stress from overload.

Your total number of points on this exercise will help you assess how stressed you are by
overload. A total of 25-40 points indicates a high stress level, one that could be
psychologically and physiologically debilitating. What is the toll of unmanaged stress?

IV. BURNOUT

Burnout is defined as ―a state of mental and/or physical exhaustion caused by excessive and
prolonged stress.‖ Some research studies suggest that two of the major causes of burnout are
bureaucratic atmospheres and overwork! There are three stages of burnout:

Stage 1: Stress Arousal

Stage 2: Energy Conservation
Stage 3: Exhaustion

Stage 1: Stress Arousal

(Includes any two of the following symptoms)

1. Persistent irritability
2. Persistent anxiety
3. Periods of high blood pressure
4. Bruxism (grinding your teeth at night)
5. Insomnia
6. Forgetfulness
7. Heart palpitations
8. Unusual heart rhythms (skipped beats)
9. Inability to concentrate
10. Headaches

With the presence of any two of these symptoms, you may be experiencing Stage 1 of the
burnout cycle.

Stage 2: Energy Conservation

(Includes any two of the following)

1. Lateness for work

2. Procrastination
3. Need three-day weekends
4. Decreased sexual desire
5. Persistent tiredness in the mornings
 21

6. Turning work in late

7. Social withdrawal (from friends and/or family)
8. Cynical attitudes
9. Resentfulness
10. Increased coffee/tea/cola consumption
11. Increased alcohol consumption
12. Apathy

Again, any two of these symptoms may signal you‘re in Stage 2 of the burnout cycle.

Stage 3: Exhaustion

(Includes any two of the following)

Chronic sadness or depression

Chronic stomach or bowel problems

Chronic mental fatigue

Chronic physical fatigue

Chronic headaches

The desire to ―drop out‖ of society

The desire to move away from friends, work, and perhaps even family

Perhaps the desire to commit suicide

Again, any two of these symptoms may signal you‘re in Stage 3 of the burnout cycle.

These stages usually occur sequentially from Stage 1 to Stage 3, although the process can
be stopped at any point.

The exhaustion stage is where most people finally get a sense that something may be
wrong. Like the previous two stages, any two of these symptoms can indicate Stage 3
burnout. Remember, burnout is a process that usually occurs sequentially, it progresses
through stages thus giving the opportunity to recognize symptoms and take the necessary
steps to prevent it.

A model developed by Dr. Hans Selye describes the way people handle crisis situations,
prolonged and chronic crisis etc. Even the human cycle of Growth and Development
follows his model where Childhood is Stage I, Adulthood Stage II and Old age is stage III
i.e. exhaustion, decline of health and finally death.

In the alarm stage, the body gears itself to handle the stressful situation and goes into an
alert state. The autonomic nervous system is the first to react followed by the endocrine
system. As stress continues, the body also continues its response in the resistance stage.
 22

However, when stress continues further the body cannot face this onslaught without any
rest and recuperation and reaches the stage of exhaustion.

Unmanaged Stress
The Toll of Unmanaged Stress
Addictive Behaviour
Relationship Distress
Emotional/Behavioural Problems
Professional Consequences

Addictive Behaviours: Increased use of tobacco, alcohol, prescription medications and/or

illicit substances ―to help cope with stress‖ places the individual at great risk for physical
and psychological dependence.

Relationship Distress: Depersonalization, which refers to treating people like objects, may
arise as a protective mechanism especially in human services professionals to minimize
emotional involvement that could interfere with functioning in crisis situations. In
moderation, ―detached concern‖ toward patients by physicians may be appropriate and
necessary, but when excessive, it may lead to callousness and cynicism with subsequent
negative effects on the physician-patient relationship.

Emotional/Behavioural Consequences: Emotional exhaustion is caused by excessive

psychological and emotional demands made on people helping people that leave
individuals drained and depleted. Low morale, reduced effectiveness, burnout and health
problems are often the result.

Professional Consequences: Feelings of diminished personal accomplishment are

reflected in symptoms of stress, depression, and a sense of inefficiency and diminished
competence. With such feelings, the individual believes that his or her actions no longer
can or do make a difference. This adversely affects the physician-patient relationship,
patient satisfaction, and perhaps, ultimately, health outcomes.

According to Dr. Hans Selye, ―stress like relativity, is a scientific concept which has
suffered from the mixed blessing of being too well known and too little understood‖.
Different researchers have defined stress differently. It has been defined as an
environmental event, a physiological response or a cognitive – behavioural process. All
these definitions are of limited value since stress is now being understood as an inherently
multi-level concept. It consists of behavioural, cognitive, emotional and physiological
responses, related to transactions with the environment.

V. STRESS, A BIO – PSYCHO – SOCIAL RESPONSE

Stress is an organizing concept referring to many variables and processes occurring at

many levels of analysis: physiological, cognitive-affective, behavioural, and
environmental. Stress is therefore an integrated bio psychosocial response to events that
are perceived as harmful and that strain a person‘s coping
 23

skills. We will explore each of these levels in detail and demonstrate their reciprocal
influence.

Biological responses to stress: The concept of stress in relation to physical health

originated in the biological sciences. From the biological perspective, stress is defined as
―a specific syndrome which consists of all the changes within the biologic system‖
(Selye). Stress is a physiological response that is nonspecific in terms of both cause and
effect. Any event that requires adaptation can trigger the physiological responses that
characterize stress. These responses are also nonspecific; the changes observed are similar
across various types of stress inducing events.

While Selye first popularized the notion of stress, Cannon (1927) was the first researcher
to describe a physiological reaction to threat, which he called the ―fight or flight‖
response. Whenever a person is confronted with overwhelming stress, he usually reacts
with either ―fighting‖ or fleeing‖, depending upon his perception of the situation. The
activation of Selye‘s alarm stage is very similar to Cannon‘s ‗Fight or Flight‘ response. In
either case, there are certain physiological changes that occur – there is an increase in
heart rate, blood pressure and respiration and blood goes rushing to the large muscles.
These changes take place to prepare the person to either fight or flee. This arousal is a
built – in activation to enhance the chances of survival in a life threatening situation. All
of us experience this activation in the form of pounding heart, cold sweat, ‗butterflies‘ in
the stomach and dryness of throat.

However, these physiological changes do not necessarily take place only in life –
threatening situations. They may also occur in anticipating a difficult event like an
examination, thinking of a past event or even while watching films of gruesome events. A
number of laboratory experiments conducted by Selye and Cannon found the same
physiological changes when painful physical stimuli were used as stress.

The amount of stress experienced also depends on the ability to predict and control
stressful events. A series of studies conducted on rats by Weiss (1968- 1971)
demonstrated the importance of this predictability and control. He found that those rats
that had control over escaping the shock and could predict the occurrence of shock
showed fewer ulcers than those rats that had neither control nor could predict occurrence
of shock. The importance of predictability and control has been demonstrated in human
response to stress by Robin (1980). It has been seen that a threatening event has fewer
effects if we know when it is going to happen, and if we can do something about it
effectively.

Selye (1956) observed a related set of generalized physiological responses when

organisms were exposed to noxious stimuli like overcrowding, cold temperatures, or
toxins. He called these responses the general adaptation syndrome (GAS). The GAS
refers to neural and endocrine activities that permit organisms to withstand noxious
stimuli physiologically. The GAS is divided into three phases: alarm, resistance and
exhaustion. During alarm there is an initial activation response. During resistance, there is
 24

a sustained secretion of hormones from the adrenal gland, which is thought to protect the
organism from the noxious stimuli. If the stimuli continue unabated, these adrenal
hormones begin to have deleterious effects on the circulatory digestive and immune
systems. If the stressor continues long enough, the organism may die as its adaptive
resources are exhausted.

Environmental aspect of stress: The notion that stress is related to the environment came
from observations of physiological and behavioural breakdown in persons exposed to
extreme conditions like military combat (Cerinker and Spiegal 1945) and bereavement
(Lindermann, 1944). It was reasoned that if extreme situations caused stress in the
individual, an accumulation of less extreme events would also cause stress. From this
point of view, stress has been defined by Holroyed (1979) as ―any environmental event
that places a demand on the individual, taxing available resources, and requiring an
unusual response‖. Stress resides in the ‗demandingness‘ of the event rather than in the
person. So, it follows that the number and severity of stressful events experienced by a
person would affect the person‘s health status. To get an indication of the degree of stress
experienced, individuals are asked to indicate the events experienced by them in a given
time period (e.g. Last 6 months), from a list of events. The most well-known checklist is
the Schedule of Recent Events (SRE) by Holmes and Rahe, 1967. Both positive and
negative events are seen as life change events and stresses on adaptation. A number of
studies have been conducted using the SRE to establish a relationship between the
number and severity of stresses and the likelihood of diseases like cardiac arrests,
tuberculosis, ulcers etc.

Cognitive Aspects of stress: The cognitive approach defines stress as a transaction

between the individual and the environment in which the individual evaluates the
situation and decides whether it is threatening or not. (Lazarus, 1966). According to the
cognitive approach, stress is not present in either the event on the person‘s physiological
response alone, but in both factors as well as the cognitive evaluation of the situation. So,
the same situation may be viewed differently by different people and the level of stress
experienced would depend on the person‘s perception of the event. It is obvious that
people do not passively receive but actively appraise and evaluate the stimuli. This
approach and evaluation depends on personality variables, past experiences and other
persons in the environment.

However, events are not uniformly stressful for all individuals. The degree of stress
depends on the meaning of the event and the resources available to the individual. For
example, Lazarus, Opton, Nomikos, and Rankin (1965) had subjects view a film of
gruesome wood mill accidents in which one worker saws off a finger and another is killed
by a plank driven through his chest. Prior to observing the film, some subjects were told
the film was staged and other subjects were given no explanation. Those who were told
the film was staged experienced less arousal and distress, presumably because their
knowledge changed their appraisal of the degree to which an event was stressful.
 25

Psycho – Social Stress: Two processes are central to the psychological –behavioural
perspective: cognitive appraisal and coping. Cognitive appraisal refers to an evaluative
process by which a person determines whether and to what extent an event is threatening
or harmful. An event is stressful only if it is appraised as difficult. Coping refers to a
person‘s behavioural, cognitive and emotional responses to an event. An event is stressful
only in so far as a person lacks the means to cope. By integrating cognitive, affective,
behavioural and environmental aspects of stress, this perspective thus serves as a useful
starting point in building a systems approach to stress. The cognitive-behavioural
approach largely ignores biological aspects of stress and the mechanisms that connect the
cognitive, affective, and behavioural levels, with the biological level.

Table 2.1

Psychological – behavioural view

Cognitive Appraisal Coping

 Personal factors  Cognitive strategies
 Situational factors  Behavioural strategies
 Social support

a. Cognitive Appraisal

Aversive environmental, physiological, and mental stimuli do not automatically elicit a

stress response. Persons do not passively receive but rather actively appraise stimuli.
Appraisal is the process by which we make sense of events that occur within and around
us (Levine, Weinberg, & Ursin, 1978). We constantly evaluate the personal relevance and
hedonic connotations of stimuli to which we attend. Based on past experience and the
current situation, stimuli are evaluated as:

 Irrelevant, a state of no particular significance

 Benign, a positive state of affairs that enhances personal well-being; or
 Negative, a potential or actual negative state that threatens personal well-being
(Lazarus & Launier, 1978).

Personal Factors in Appraisal: The appraisal of stimuli and the coping responses to
those stimuli are strongly influenced by personal variables (Wrubel, Brenner, & Lazarus,
1981). A large number of personal variables have been studied in relation to stress.
Following Lazarus and Folkman (1984), we will examine only two personal variables:
commitments and control.

Commitments are what an individual values and considers important. This includes goals
and activities into which energy is invested and groups and organizations with whom an
individual identifies. Think about your commitments. What persons, activities and goals
are very important to you?
 26

Any threat, harm, or challenge to your commitments potentially poses intense stress. If
you love a person, threats to that person or to that relationship are particularly upsetting.

Commitments affect appraisal by influencing our sensitivity to certain stimuli. The more
we have invested in a particular person, goal or activity, the greater is the stress generated
when that person, goal or activity is threatened. Commitments increase our vulnerability.
Think of a person with whom you are deeply in love. A rejection by that person would
cause extreme hurt because of your strong attachment. On the other hand, your love for
that person can also generate moments of great excitement, fulfilment and pleasure.
Commitment is a two-edged sword.

A more health-relevant example is the ‗will to live‖. The loss of a life partner is
associated with increased mortality of the surviving partner (Jacobs & Ostfeld, 1977;
Parks, 1970). Conversely, finding meaning and having strong commitments can enhance
the chances of survival, even in the worst circumstances. Almost all survivors of Nazi
concentration camps reported finding some reason to survive: to bear witness to war
atrocities, for the sake of relatives or even for revenge (Frankl, 1959). Commitments
motivate in the face of adversity. When confronted with a threat to something we value,
we will work particularly hard to eliminate that threat.

A second personal variable affecting appraisal is our sense of control over events. A sense
of control decreases stress, whereas lack of control exacerbates stress. For example,
Ferrare (1962) found that aging persons who were relocated to a nursing home by their
own choice lived longer than those who were relocated without their choice while the first
group exercised choice and control, the second group was subjected to outside control.
Similarly, Langer & Robin (1976) examined the effects of enhancing the control of
elderly nursing home residents. Residents in a group given responsibility and choice over
daily activities and living arrangements were more alert, active and happy compared to a
group encouraged to feel the staff would take care of them. The residents with enhanced
control also demonstrated better physical health. Over an eighteen month period only,
15% of those with enhanced control had died versus 30% of the residents in the other
group.

The lack of control, perceived or real, is often called helplessness (Seligman, 1975).
Helplessness occurs when individuals feel that their behaviour has no effect on
consequences or that events are uncontrollable. It is characterized by behavioural
passivity, depressive effect, and thoughts centering on hopelessness. Helpless persons
stop trying, even in a new set of circumstances (Miller & Seligman, 1975). They have
negative expectations about themselves, the future, and the world; believing ―I‘m no
good, the world‘s no good, and it‘s not going to get any better.‖

Perceived control influences the impact of stress on a person. Stress is exacerbated when
persons feel behaviour and outcome are unrelated. The lack of control has negative
effects behaviourally, emotionally, and physiologically.
 27

Situational Factors in Appraisal: Properties of the stimulus event also affect appraisal.
We will focus on two such stimulus properties: predictability and timing. Predictability
refers to knowledge about when an event will occur. Generally, predictable event are less
stressful than unpredictable events. It is advantageous to know whether an aversive event
will occur and if so, when it will occur. Predictability reduces threat, harm or challenge
by allowing us to prepare for the event and to know when we are safe (Weinberg &
Levine, 1980).

The importance of predictability was demonstrated by Hunter (1979) in a study of wives

whose husbands were killed in action, missing in action, prisoners of war or returned
home from the Vietnam conflict. Predictability decreased for the wives in the following
order. Hunter found that the wives of men missing in action evidenced the worst
emotional and physical health. They were faced with the greatest uncertainty concerning
their marital status, roles and responsibilities. They were in limbo. The uncertainty of
their situation was more stressful that the bereavement on the death of a husband.

The imminence, duration, and frequency of stress also affects appraisal. As an event
becomes more imminent, it is appraised as increasingly threatening or challenging.
Mechanic (1962) found that students preparing for doctoral exams experienced more
anxiety and physical symptoms as the exams got nearer. Once the exams actually began,
there was considerable emotional relief and the symptoms diminished. One student said,
―Taking it was not as bad as anticipating it …. You don‘t have to worry while you are
doing it‖.

The duration of stressors ranges from time-limited events, such as exams and dental work
to on-going events, such as marital conflict, combat and cancer. The duration and
frequency of stressors are assumed to play a central role in determining the negative
effects of stress on health. The assumption is that chronic stress wears a person down
(Selye, 1956), but remarkably little research is available on the impact of stressors that
vary according to frequency or duration.

b. Coping

Coping refers to cognitive and behavioural actions taken to manage the demands of an
event appraised as stressful. When faced with a stressor, individuals try to remediate the
harm or prevent the threat. Limited data are available to identify how persons cope with
stressors in the natural environment. The variety of possible coping strategies is immense.

There are two major targets of coping: changing ourselves or changing our environment.
Persons can either make adjustments to fit in better with the environment (―go with the
flow‖) or change the environment to suit their own needs (―divide and conquer‖).
Imagine, for example, that your neighbours are having a noisy party that interrupts your
sleep. You could join the party (change yourself) or call the police (change the
environment).
 28

Coping efforts can be either emotion oriented or problem oriented. Emotion oriented
coping focuses on reducing the emotional arousal caused by stress. Problem –oriented
coping focuses on altering the event appraised as threatening or harmful. Problem and
emotion oriented coping may be implemented simultaneously or separately and may be
incompatible. In most stressful situations, coping efforts focus on both (Folkman &
Lazarus, 1980). Imagine you are very anxious about the midterm exams scheduled for
next week.

Problem-oriented coping would consist of intensive studying. Emotion-focused coping

could involve taking tranquilizers to reduce your anxiety. It may appear that problem-
oriented coping is preferable because it ―gets at the root of the problem,‖ but coping with
emotional responses to stress is also important. Emotions are often painful and distressing
and may consequently be a source of stress. Emotional arousal can also interfere with
skilled cognitive and behavioral efforts to deal with the problem. We have to get
ourselves under control before we can tackle the problem. In some cases (e.g., natural
disasters or enduring disabilities), there may be little we can do to deal with the problem.

The primary task is to cope with the emotional arousal elicited by those events. Our
coping strategies take three major forms: cognitive, behavioural, and social.

Cognitive Coping Strategies: We can cope with a stressor or our emotions by problem
solving, self-talk, and reappraisal. Problem solving involves analysing the situation to
generate possible courses of action, to evaluate the efficacy of those actions and to select
an effective plan of action (Janis & Mann, 1977). To continue with the midterm exams
example, problem solving could focus on how to reduce anxiety (emotion oriented, self as
target), or how to study to get good grades (problem oriented, self as target), or ― I‘m
really tense, need to take a couple of deep breaths to relax‖ (emotion oriented, self as
target); ―Maybe I can make this easier by distracting myself with pictures on the ceiling‖
(problem oriented, environment as target ); or ―I need to develop a plan to deal with this‖
(problem oriented, self as target).

Reappraisal involves reducing the impact of a stressful event by altering how that event is
interpreted. In other words, the event is given a different meaning. A student could deal
with an F on an exam by thinking, ―the test was unfair‖ (problem oriented, environment
as target), or ―I just had a bad day‖ (problem oriented, self as target). The anger
engendered by the F could be reappraised by thinking, ―the teacher is a real creep, I have
a right to be angry‖ (emotion oriented, environment as target), or ―No big deal, this
course isn‘t important anyway‖ (emotion oriented, self as target).

Behavioural Coping Strategies: Persons also respond to stress behaviourally. There are
four general classes of behavioural responses to stress: seeking information, direct action,
inhibiting action, and turning to others.
 29

Seeking information – Refers to gathering data on the nature of the stressor and on
possible coping strategies. An individual faced with a diagnosis of cancer, for example,
may seek information about prognosis from a healthcare provider. That individual may
use changes in sizes of a palpable tumor to assess the effectiveness of chemotherapy.
Information thus provides useful, instrumental coping strategies and enhances feelings of
control and predictability.

Direct action – Refers to overt verbal and motor responses that alter the stressor or stress-
related emotional arousal. An individual with a sprained ankle may rest, take painkillers,
or see a physician to find relief. An individual, who has recently experienced death of a
loved one, will find ways to deal with his grief.

Inhibiting action – Involves not doing something in order to reduce stress and emotional
arousal. A person with a persistent cough may stop smoking. Avoidance of anxiety
provoking situations would also fit in this category. For example, persons frequently
―miss‖ their appointments with health providers because of the pain and embarrassment
associated with those visits.

Social Support: The last class of behavioural coping, turning to others, has been
traditionally labelled social support. The phrase ―turning to others‖ is used here because it
emphasizes the active, interactional nature of this coping strategy. Our relationships with
other persons provide an important resource in dealing with stress. We can gain material,
emotional, and informational support from others. Material support includes money,
goods, and services available from significant others (Cohen & McKay, 1984). Emotional
support is the feeling of being loved and valued by others and the opportunity to
reciprocate those feelings (Cobb, 1976). Informational support is available when others
make suggestions about the meaning of stressful events or recommendations concerning
coping strategies, and provide feedback about the appropriateness of coping efforts
(Cohen & McKay, 1984). Lack of social support is related to poor health. Berkman and
Syme (1979), for example, found social support to be a modest but significant predictor
of mortality as well as health-impairing behaviours. Those persons with few social ties
had higher mortality rates.

Social support may also mitigate the negative effects of stress that have already occurred.
For example, social support is associated with longer survival time among those with
cancer (Weisman & Worden, 1975). A large proportion of the problems most frequently
reported by persons with the disease are interpersonal. These include difficulty
communicating with significant others about the cancer, speaking with family members
about the future, and gaining information from health providers (Wortman & Dunkel –
Schetter, 1979). Health providers, family, and friends can provide cancer victims with
clarification and reassurance about what is happening, show love and caring, and assists
in developing strategies to deal with the physical and emotional demands of cancer and its
treatment. Social support also promotes recovery by enhancing adherence to treatment
regimens (Suls, 1982).
 30

Caring relationships enhance physical and mental health. The timing and manner in
which social support is offered significantly influences its impact. Well-meaning but
unwanted assistance is not helpful. Social support is not a reservoir from which a person
passively borrows but rather an interpersonal exchange in which both parties are active
(Cohen & McKay, 1984). Social support may also have negative effects. For example,
significant others can interfere with adherence to treatment regimens, suggest ineffective
coping strategies, or create dependence by a person who is ill (Suls, 1982).

VI. DETERMINANTS OF COPING

A wide variety of coping strategies can be used to respond to stress. Person and
situational variables influence the selection of strategies. Such person variables as values
and beliefs that prescribe and proscribe certain types of action affect how a person copes
with a stressor. A response must also be in a person‘s repertoire before it can be used to
cope with a stressor. While divorce may seem to be the logical solution to marital conflict
or abuse, this alternative may be unacceptable to persons who hold religious beliefs that
divorce is sinful. An assertive response may seem the logical choice in dealing with
persons who are unreasonable or abrasive, but some people have not learned to express
their feelings and opinions in a direct, and firm manner. In sum, coping actions must be
available and acceptable to the person.

The situation in which a stressor occurs may also affect the means by which a person
copes. Obviously, the stressor itself can constrain the availability and effectiveness of
coping strategies. The loss of a loved one through death requires largely an emotion-
oriented form of coping; it is not possible to bring the person back. The context in which
the stressor occurs may also constrain coping. Slugging the boss in response to an
unreasonable job request is unlikely because of its consequences. Our coping efforts
usually fit with our environmental demands and constraints.

VII. GOOD & BAD STRESS

Stress is not only desirable but essential to life. A certain amount of stress is essential for
normal health. As Hans Selye has said ‗Complete freedom from stress is death!‘ Some
stress is definitely required to stimulate us to perform simple day-to-day tasks. In today‘s
competitive world, its presence is all the more important. Stress is not a pathological
symptom: it is an essential feature of the mechanism, which drives people. It is in danger
of turning into a pathological symptom if not well managed.
During the 2003 Cricket World cup played in South Africa, India‘s star batsman, Sachin
Tendulkar got caught twice after two consequent deliveries to the rope, with a very small
score. While this may have created conditions of challenge and positive stress in the
batsman that followed Sachin, ensuring success for India, a villager in Assam, (India)
could not take the idol‘s collapse. He went into a daze, collapsed and died before reaching
hospital.

Reaction to stress differs from one person to another. The same event may give positive
stress to one person and negative stress to another. Stress can be fatal and stress can be
 31

the driving force for great achievements. So, while it is important to understand the
dangers of stress, it is equally important to learn to harness its benefits.

Too much stress can be very harmful. After weeks of being criticized and picked at by the
teacher, a student may find it very difficult to put in a good performance on an exam.
Sometimes, even when the situation may be positive, like in the case of winning a large
sum in a lottery, the stress may prove to be too much for the person.

Too little stress can have an equally negative effect. At first glance, the absence of stress
may seem very desirable, but that is not the case. Those who suddenly lose their sense of
challenge, as in the case of retired managing directors of high profile firms, it has been
seen that they often enter a period of physical and mental decline. Complete absence of
stress makes life monotonous and dull. Infact, there are some people who are able to give
their best performance only when under stress.

Fig 2.3

As can be seen from the graph, too little stress and too much stress are both ―bad‖
stresses. Increase in stress helps in increasing the efficiency and performance of the
individual, upto a certain point. However, past the critical point, symptoms of burnout
such as impatience, irritability, headaches, sleeplessness, fatigue etc. begin to set in
ultimately affecting performance.

Efficiency decreases rapidly, sometimes going to below zero. In such a situation, stress
becomes counterproductive. It is important to have optimum level of stress for peak
performance.

Dr. Peter Hansan in his book ‗Joy of Stress‘, call this optimum level, the joy of stress.
While stress is high, efficiency is at its peak. The individual is highly motivated,
challenged and driven towards high achievement. However, he is also in a state of high
pressure, tight rope walking and balancing between pressure and performance. Each
 32

individual has to decide for himself, at what point is the pressure too much, finally
resulting in reduced efficiency and performance.

This graph applies to everyone; although the kind and the amount of stress required
reaching the maximum level of efficiency may differ for each individual. It is important
for each person to know his own capacity for withstanding stress and the limit beyond
which or below which, ―Good‖ stress becomes ―Bad‖ stress.

VIII. DIFFERENT KINDS OF STRESS

Management of stress can be complicated and confusing because there are different types
of stress – acute stress, episodic acute stress, and chronic stress – each with its own
characteristics, symptoms, duration, and treatment approaches. Let‘s look at each one.

Acute Stress: Acute stress is the most common form of stress. It comes from demands
and pressures of the recent past and anticipated demands and pressures of the near future.
Acute stress is thrilling and exciting in small doses, but too much is exhausting. A fast run
down a challenging ski slope, for example, is exhilarating early in the day. However, the
last ski run late in the day, is taxing and wearying. Skiing beyond your limits can lead to
falls and broken bones. By the same token, overdoing on short-term stress can lead to
psychological distress, tension headaches, upset stomach, and other symptoms.

Fortunately, acute stress symptoms are recognized by most people. It‘s a laundry list of
what has gone awry in their lives: the auto accident that crumpled the car fender, the loss
of an important contract, a deadline they‘re rushing to meet, their child‘s occasional
problems at school and so on.

Because it is short term, acute stress doesn‘t have enough time to do extensive damage
associated with long-term stress. The most common symptoms are:

 Emotional distress- a combination of anger or irritability, anxiety and depression,

the three stress emotions;
 Muscular problems including tension headache, back pain, jaw pain, and the
muscular tensions that lead to pulled muscles and tendon and ligament problems;
 Stomach, gut and bowel problems such as heartburn, acid stomach, flatulence,
diarrhoea, constipation, and irritable bowel syndrome;
 Transient over arousal leads to elevation in blood pressure, rapid heartbeat, sweaty
palms, heart palpitations, dizziness, migraine headaches, cold hands or feet,
shortness of breath, and chest pain.

Acute stress can crop up in anyone‘s life, and it is highly treatable and manageable.
 33

Episodic Acute Stress: There are those, however, who suffer acute stress frequently,
whose lives are so disordered that they are studies in chaos and crisis. They are always in
a rush, but always late. If something can go wrong, it does. They take on too much, have
too many irons in the fire, and can‘t organize the slew of self-inflicted demands and
pressures clamoring for their attention. They seem perpetually in the clutches of acute
stress.

It is common for people with acute stress reactions to be over aroused, short-tempered,
irritable, anxious, and tense. Often, they describe themselves as having ―a lot of nervous
energy.‖ Always in a hurry, they tend to be abrupt, and sometimes their irritability comes
across as hostility. Interpersonal relationships deteriorate rapidly when others respond
with real hostility. The Workplace becomes a very stressful place for them.

The cardiac prone, ―Type A‖ personality described first by cardiologists, Meyer Friedman
and Ray Rosenman, is similar to an extreme case of episodic acute stress. Type A‘s have
an excessive competitive drive, aggressiveness, impatience, and a harrying sense of time
urgency. In addition there is a free-floating, but well-rationalized form of hostility, and
almost always a deep-seated insecurity. Such personality characteristics would seem to
create frequent episodes of acute stress for the Type A individual. Friedman and
Rosenman found Type A‘s to be much more likely to develop coronary heart disease than
Type B‘s, who show an opposite pattern of behaviour.

Another form of episodic acute stress comes from ceaseless worry. ―Worry warts‖ see
disaster around every corner and pessimistically forecast catastrophe in every situation.
The world is a dangerous, unrewarding, punitive place where something awful is always
about to happen. These ―awfulizers‖ also tend to be over aroused and tense, but are more
anxious and depressed than angry and hostile.

The symptoms of episodic acute stress are the symptoms of extended over arousal:
persistent tension headaches, migraines, hypertension, chest pain, and heart disease.
Treating episodic acute stress requires intervention on a number of levels, generally
requiring professional help, which may take many months.

Often, lifestyle and personality issues are so ingrained and habitual with these individuals
that they see nothing wrong with the way they conduct their lives. They blame their woes
on other people and external events. Frequently, they see their lifestyle, their patterns of
interacting with others, and their ways of perceiving the world as part and parcel of who
and what they are.

Sufferers can be fiercely resistant to change. Only the promise of relief from pain and
discomfort of their symptoms can keep them in treatment and on track in their recovery
program.

Chronic Stress: While acute stress can be thrilling and exciting, chronic stress is not.
This is the grinding stress that wears people away day after day, year after year. Chronic
 34

stress destroys bodies, minds and lives. It wreaks havoc through long-term attrition. It‘s
the stress of poverty, of dysfunctional families, of being trapped in an unhappy marriage
or in a despised job or career. It‘s the stress that the never-ending ―troubles‖ have brought
to the people of Northern Ireland, the tensions of the Middle East have brought to the
Arab and Jew, and the endless ethnic rivalries that have been brought to the people of
Eastern Europe and the former Soviet Union. The common man in Kashmir, not part of
any political ideology also forces unending stress of survival.

Chronic stress comes when a person never sees a way out of a miserable situation. It‘s the
stress of unrelenting demands and pressures for seemingly interminable periods of time.
With no hope, the individual gives up searching for solutions.

Some chronic stresses stem from traumatic, early childhood experiences that become
internalized and remain forever painful and present. Some experiences profoundly affect
personality. A view of the world, or a belief system, is created that causes unending stress
for the individual (e.g., the world is a threatening place, people will find out you are a
pretender, you must be perfect at all times). When personality or deep-seated convictions
and beliefs must be reformulated, recovery requires active self-examination, often with
professional help.

The worst aspect of chronic stress is that people get used to it. They forget it‘s there.
People are immediately aware of acute stress because it is new; they ignore chronic stress
because it is old, familiar and sometimes, almost comfortable.

Chronic stress kills through suicide, violence, heart attack, stroke and perhaps even
cancer. People wear down to a final, fatal breakdown. Because physical and mental
resources are depleted through long-term attrition, the symptoms of chronic stress are
difficult to treat and may require extended medical as well as behavioural treatment and
stress management.

IX. BALANCING OF STRESS

Stress can be fatal, but it can also be fantastic. Not only do we need to respect its dangers,
we can also enjoy its benefits. The important thing is to learn to balance the amount to
stress, so that it is more beneficial than dangerous.

Stress comes from various sources such as work, home, personal and social factors. When
any one area, say, the level of stress at work is much greater than that of other areas, this
causes the Stress Tolerance Level to break up. This stress is greater than the tolerance
level of the individual and may be termed as bad stress. This can be seen in figure 2.4
 35

Fig 2.4

On the other hand, as shown in Figure 2.5 if the individual is able to balance the level of
stress coming from all areas, not only would he be able to cope with that stress
effectively, he would also be able to use that stress as a motivating factor. Here stress may
be coming from several areas but the individual‘s stress tolerance level is sufficiently
capable of coping with it. The result is a feeling of challenge and satisfaction.

Fig 2.5

If a balance of the stresses is maintained, it results in alertness, clarity, excitement and a

feeling of challenge.

A balance of stress on a job depends upon the levels of challenge and levels of individual
competence. A model display the positive outcome of a balance between Level of
challenge and Level of competence and also the negative outcome of a disbalance
between the two
 36

Fig 2.6

If the challenge is low and the competence the person is high, it would result in lethargy
and ultimately rust out of the individual. A high degree of challenge and low competence
results in feelings of panic and anxiety. Only where the level of challenge and level of
competence are optimum, the individual is most alert and creative.

X. CHRONICITY OF STRESS

According to WHO, 80% of bed occupancy in hospitals is the result of overstress.

Chronic stress is a causative factor in most illnesses. Some of the job related stress factors
are:

 Work overload.
 Time pressures.
 Poor quality of supervision.
 Insecure work climate.
 Role ambiguity.
 Differences in values of employee and company.
 Inability to achieve specific goals.

Most often, it takes a warning as severe as a heart attack for the individual to realize he
has been under prolonged stress. So it is important to recognize stress before it has drastic
effects. Some of the signals of stress are:

Nervous Reflexes: Nail biting, fist clenching, teeth grinding, drumming fingers,
clenching jaw, hunching shoulders, tapping feet and touching hair.
 37

Mood Changes: Feelings of anxiety, depression, frustration, habitual anger or hostility,

worthlessness, impatience, irritability and restlessness.

Behaviour: Aggression, disturbed sleep and appetite, emotional outbursts, over-reactions

and pressure of speech, doing several things at once and ending up leaving jobs
incomplete.

Stress Related Illnesses: Several chronic illnesses are also indicative of stress. Some of
these illnesses are asthma, back pain, digestive disorders, headaches, migraines, muscular
aches, sexual disorders and skin disorders.

Any behaviour or mood unusual for that person is a signal of stress. To ensure that you
are not under excess stress, certain steps can be taken:

 Develop optimum control of the situation by learning what you can control and
what you cannot.
 Make specific plans to change what you can control and accept what you cannot.
 Focus on what you can do and do it NOW.
 Anticipate situations and be proactive.
 Take positive action rather than brood.
 Use effective ways to handle anger.
 38

CHAPTER 3:
PHYSIOLOGY OF STRESS
Introduction to Physiology of Stress
An appraisal of threat triggers off various psychological changes. These changes are brought
about mainly through the Nervous system, the Endocrine system and Immune system. These
systems trigger physiological, affective as well as behavioural responses. While the
Automatic Nervous System (ANS) bring about all the immediate physiological changes, the
Intermediate changes are handled by the Endocrine system and more specifically by the
adrenal medulla. The endocrine system and immune system together handle the long term
physiological changes. While the starting point of this entire physiology is the Cerebral
Cortex, the outer part of the brain controlling higher level functions such as thinking,
reasoning and memory; the next part to get influenced is hypothalamus and the limbic
system.
The limbic system controls emotions and the hypothalamus controls basic body functions
such as eating, drinking, sexual activity etc. The next level of change happens at the nervous,
endocrine and immune systems, thereafter activating the end organs.
1.THE NERVOUS SYSTEM

The basic function of the nervous system is to integrate all the body‘s systems. In larger and
more complex organisms, the nervous system provides internal immunization and relays
information to and from the environment. The nervous system is organized hierarchically,
with major divisions and subdivisions.

The two major divisions of the nervous system are the central nervous system (CNS) and the
peripheral nervous system (PNS). The CNS is composed of the brain and the spinal cord, and
the PNS consists of all other nerves. We will discuss the PNS in detail because of its
relevance in the physiology of stress.

The Peripheral Nervous System: The peripheral nervous system is that part of the nervous
system lying outside the brain and spinal cord, is divided into two parts: the somatic nervous
system and the autonomic nervous system (ANS).

1. The Somatic Nervous System : The somatic division of the peripheral nervous system
serves muscles and skin. Sensory impulses begin with stimulation of the skin and muscles,
and these neural impulses travel toward the spinal cord by way of sensory nerves in the
somatic nervous system. Motor messages that originate in the brain travel down the spinal
cord, are relayed to muscles, and initiate muscle movement. The motor nerves that activate
muscles are part of the somatic nervous system.

2. The Autonomic Nervous System: The term autonomic means ―self-governing.‖ It has
been applied to this division of the peripheral nervous system because, traditionally, the
autonomic nervous system has been considered outside the realm of conscious or voluntary
control.
 39

The ANS allows for a variety of responses through its two divisions: the sympathetic nervous
system and the parasympathetic nervous system. These two subdivisions differ anatomically
as well as functionally.

The sympathetic division of the ANS mobilizes the body‘s resources in emergency, stressful,
and emotional situations. Walter Cannon (1932) termed this configuration of responses the
―Fight or Flight‖ reaction. Sympathetic activation prepares the body for intense motor
activity, the sort necessary for attack, defense, or escape. The reactions include an increase in
the rate and

The sympathetic division of the ANS mobilizes the body‘s resources in emergency, stressful,
and emotional situations. Walter Cannon (1932) termed this configuration of responses the
―Fight or Flight‖ reaction. Sympathetic activation prepares the body for intense motor
activity, the sort necessary for attack, defense, or escape. The reactions include an increase in
the rate and strength of cardiac contraction, constriction of blood vessels in the skin, a
decrease of gastrointestinal activity, an increase in respiration, stimulation of the sweat
glands, and dilation of the pupils in the eyes.

The parasympathetic division of the ANS, on the other hand, promotes relaxation and
functions under normal, non-stressful conditions. The parasympathetic and sympathetic
nervous systems serve the same target organs, but they tend to function reciprocally, with the
activation of one increasing as the other decreases.

Neurotransmission in the ANS is conducted mainly by two chemicals, acetylcholine and

norepinephrine, which have complex effects. Each of these neurotransmitters has different
effects in different neuro chemical receptors. In addition, the balance of these two main
neurotransmitters, as well as their absolute quantity, is important. Therefore, even though
there are only two major ANS neurotransmitters, they produce a wide variety of responses.

The table below depicts the reciprocal effect of the sympathetic and parasympathetic nervous
systems on various parts of the body when they change to alertness or relaxation.

Table 3.1
 40

II. THE NEUROENDOCRINE SYSTEM

The endocrine system consists of ductless glands distributed throughout the body. The
neuroendocrine system consists of those endocrine glands that are controlled by the nervous
system. Glands of the endocrine and neuroendocrine systems secrete chemicals known as
hormones, which move into the bloodstream to be carried to different parts of the body.
Specialized receptors on target tissues or organs allow hormones to have specific effects,
even though the hormones circulate throughout the body.

The endocrine and nervous systems can work closely together because they have several
similarities, but they also differ in important ways. Both systems share, synthesize, and
release chemicals. In the nervous system these chemicals are called neurotransmitters. In the
endocrine system they are called hormones. The activation of neurons is usually rapid and the
effect is short term; the endocrine system responds more slowly, and its action persists
longer. In the nervous system, neurotransmitters are released by stimulation of neural
impulse, flow across the synaptic cleft, and are immediately either reabsorbed or inactivated.
In the endocrine system hormones synthesized by the endocrine cells are released into the
blood, reach their targets in minutes or even hours and have prolonged effects. The endocrine
and nervous systems both work toward integrated, adaptive behaviours. The two systems are
related in function and interact in neuroendocrine responses.

The proper functioning of the Immune system depends upon hormones remaining at normal
levels. Stress triggers a change in the endocrine system followed by changes in the immune
system. The ANS also influences the thymus and other tissues triggering the immune
response results in both increasing and decreasing immune functioning. The four glands
involved in the stress response are Pituitary, Adrenal, Thyroid and Pancreas

III. PHYSIOLOGY OF THE STRESS RESPONSE

As mentioned earlier, the sympathetic division of the autonomic nervous system controls
mobilization of the body‘s resources in emotional, stressful and emergency situations.
Through the effects of various hormones, stress initiates a complex series of events within the
neuroendocrine system. The anterior pituitary (the part of the pituitary gland at the base of the
brain) secretes adrenocorticotropic hormone (ACTH), which stimulates the adrenal glands to
secrete glucocorticoids, including cortisol. Its secretion mobilizes the body‘s energy
resources, raising the level of blood sugar to provide energy for the cells. Cortisol also has an
anti-inflammatory effect, giving the body a natural defense against swelling from injuries that
might be sustained during a fight or a flight.

Activation of the adrenal medulla results in the secretion of catecholamines, the class of
chemicals that includes norepinephrine and epinephrine. Norepinephrine, however, is also
one of the neurotransmitters of the autonomic nervous system. Neurotransmitters work at the
synapse whereas hormones circulate through the blood. Norepinephrine has both actions and
is produced at many places in the body, not exclusively in the adrenal medulla.
 41

Epinephrine, on the other hand, is produced exclusively in the adrenal medulla. It is so

closely and uniquely associated with the adrenomedullary stress response that it is sometimes
used as an index of stress. The amount of epinephrine secreted can be determined by assaying
a person‘s urine, thus measuring stress by tapping into the physiology of the stress response.
Such an index can be helpful because it does not rely on personal perceptions of stress and its
use as a measure of stress can give an alternative perspective.

If an individual perceives that he is in a threatening situation or that he is unable to cope, then

messages are carried along neurons from the cerebral cortex (where the thought processes
occur) and the limbic system to the hypothalamus. This has a number of discrete parts. The
anterior hypothalamus produces sympathetic arousal of the autonomic nervous system
(ANS). The ANS is an automatic system that controls the heart, lungs, stomach, blood vessels
and glands. Due to its action we do not need to make any conscious effort to regulate our
breathing or heartbeat. The ANS consists of two different systems: the sympathetic nervous
system and the parasympathetic nervous system. Essentially, the parasympathetic nervous
system conserves energy levels. It increases bodily secretions such as tears, gastric acids,
mucus and saliva which help to defend the body and help digestion. Chemically, the
parasympathetic system sends its messages by a neurotransmitter called acetylcholine, which
is stored at nerve endings.

Unlike the parasympathetic nervous system which aids relaxation, the sympathetic nervous
system prepares the body for action. The main sympathetic neurotransmitter is called
Noradrenaline, which is released at the nerve endings. In a stressful situation, it quickly does
the following:

 Increases strength of skeletal muscles.

 Decreases blood clotting time.
 Increases heart rate.
 Increases sugar and fat levels in the blood.
 Reduces intestinal movement.
 Inhibits tears, digestive secretions.
 Relaxes the bladder.
 Dilates the pupils.
 Increases perspiration.
 Increases mental activity.
 Inhibits Penile erection/vaginal lubrication.
 Constricts most blood vessels but dilates those in heart/leg/arm muscles.
 The stress response also includes the activity of the Adrenal, Pituitary and Thyroid
glands.

The two adrenal glands are located one on top of each kidney. The middle part of the adrenal
gland is called the adrenal medulla and is connected to the sympathetic nervous system by
nerves. Once the latter system is in action it instructs the adrenal medulla to produce
adrenaline and noradrenaline (catecholamines) which are released into the blood supply. The
 42

adrenaline prepares the body for flight and the noradrenaline prepares the body for fight.
They increase both heart rate and pressure at which the blood leaves the heart; they dilate
bronchial passages and dilate coronary arteries; skin blood vessels constrict and there is an
increase in metabolic rate.

Also gastrointestinal system activity reduces which leads to a sensation of butterflies in the
stomach. Lying close to the hypothalamus in the brain is an endocrine gland called the
Pituitary. In a stressful situation, the anterior hypothalamus activates the Pituitary. The
Pituitary releases adrenocorticotropic hormone (ACTH) into the blood which then activates
the outer part of the adrenal gland, the adrenal cortex. This then synthesizes cortisol which
increases arterial blood pressure, mobilizes fats and glucose from the adipose (fat) tissues,
reduces allergic reactions, reduces inflammation and can decrease lymphocytes that are
involved in dealing with invading particles or bacteria. Consequently, increased cortisol
levels over a prolonged period of time lower the efficiency of the immune system.

The adrenal cortex releases aldosterone which increases blood volume and subsequently
blood pressure. Unfortunately, prolonged arousal over a period of time due to stress can lead
to essential hypertension. The pituitary also releases thyroid-stimulating hormone which
stimulates the thyroid gland, located in the neck, to secrete thyroxin. Thyroxin increases the
metabolic rate, raises blood sugar levels, increases respiration/heart rate/blood pressure/and
intestinal motility. Increased intestinal motility can lead to diarrhoea. (It is worth noting that
an overactive thyroid gland under normal circumstances can be a major contributory factor in
anxiety attacks. This would normally require medication).

The pituitary also releases Oxytocin and Vasopressin which contract smooth muscles such as
the blood vessels. Oxytocin causes contraction of the uterus. Vasopressin increases the
permeability of the vessels to water, thereby increasing blood pressure. It can lead to
contraction of the intestinal musculature.

If the individual perceives that the threatening situation has passed then the parasympathetic
nervous system helps to restore the person to a state of equilibrium. However, for many
clients whom we see for stress counselling every day of their life is perceived as stressful.
The prolonged effect of the stress response is that the body‘s immune system is lowered and
blood pressure is raised which may lead to hypertension and headaches. The adrenal gland
may malfunction which can result in tiredness with the muscles feeling weak; digestive
difficulties with a craving for sweet, starchy food; dizziness; and sleep disturbance.

IV. RESPONSES TO STRESS

It is useful to take a systematic approach to the responses that can be expected in a client
requesting stress counselling or stress management. The following list traces the responses to
stress under headings, which correspond to the multimodal model. This may help in the
assessment and subsequent treatment stages of therapy.
 43

Behaviour

 Alcohol/drug abuse
 Avoidance/phobias
 Sleep disturbances/insomnia
 Increased nicotine/caffeine intake
 Restlessness
 Loss of appetite/over-eating
 Anorexia, bulimia
 Aggression/irritability
 Poor driving
 Accident proneness
 Impaired speech/voice tremor
 Poor time management
 Compulsive behaviour
 Checking rituals
 Tics, spasms
 Nervous cough
 Low productivity
 Withdrawing from relationships
 Clenched fists
 Teeth grinding
 Type A behaviour, e.g. talking/walking/eating/faster; competitive; hostile
 Increased absenteeism
 Decreased/increased sexual activity
 Sulking behaviour
 Frequent crying
 Unkempt appearance
 Poor eye contact

Affect (emotions)

 Anxiety
 Depression
 Anger
 Guilt
 Hurt
 Morbid jealousy
 Shame/embarrassment
 Suicidal feelings
 44

Sensation

 Tension
 Headaches
 Palpitations
 Rapid heart beat
 Nausea
 Tremors/inner tremors
 Aches/pains
 Dizziness/feeling faint
 Indigestion
 Premature ejaculation/erectile dysfunction
 Vaginismus/psychogenic dyspareunia
 Limited sensual and sexual awareness
 Butterflies in stomach
 Spasms in stomach
 Numbness
 Dry mouth
 Cold sweat
 Clammy hands
 Abdominal cramps
 Sensory flashbacks
 Pain

Imaginary Images of:

 Helplessness
 Isolation/being alone
 Losing control o Accidents/injury
 Failure
 Humiliation/shame/embarrassment
 Self and/or others dying/suicide
 Physical/sexual abuse
 Nightmares/distressing recurring dreams
 Visual flashbacks
 Poor self-image

Interpersonal

 Passive/aggressive in relationships
 Timid/unassertive
 Loner
 No friends
 Competitive
 45

 Puts other‘s needs before own

 Sycophantic behaviour
 Withdrawn
 Makes friends easily/with difficulty
 Suspicious/secretive
 Manipulative tendencies
 Gossiping

Drugs/biology

 Use of drugs, stimulants, alcohol, tranquillizers, hallucinogens

 Diarrhoea/constipation/flatulence
 Frequent urination
 Allergies/skin rash
 High blood pressure/coronary heart disease (angina/heart attack)
 Dry skin
 Chronic fatigue/exhaustion/burn-out
 Cancer
 Diabetes
 Rheumatoid arthritis
 Asthma
 Flu/common cold
 Lowered immune system (reduction in lymphocytes and eosinophils)
 Poor nutrition, exercise and recreation

An individual may have been suffering from stress for a long time and this may lead to
problems of a physiological nature, such as diabetes, hypertension or ulcers. Stress
counseling and management can involve helping a person to deal with the stressors in life as
well as ailment. Unlike many other approaches to counseling, multimodal stress counseling
and therapy does not overlook the whole person and is concerned with much more than just
dealing with the emotional disturbances an individual may have

V. THEORIES OF STRESS

Stress has been defined in three different ways: as a stimulus, as a response, and as an
interaction. When some people talk about stress, they are referring to an environmental
stimulus, as in ―I have a high-stress job.‖ Others consider stress a physical response, as in
―My heart races when I feel a lot of stress.‖ Still others consider stress to result from the
interaction between environmental stimuli and the person, as in ―I feel stressed when I have
to make financial decisions at work, but other types of decisions do not stress me.‖

These three views of stress also appear in the different theories of stress. The view of stress as
an external event was the first approach taken by stress researchers, the most prominent of
whom was Hans Selye. During the course of his research, Selye changed to a more response-
 46

based view of stress, concentrating on the biological aspects of the stress response. The most
influential view of stress among psychologists has been the interactionist approach, proposed
by Richard Lazarus. The next two sections discuss the views of Selye and Lazarus.

Selye’s View: Beginning in the 1930s and continuing until his death in 1982, Hans Selye
(1956,1976, 1982) researched and popularized the concept of stress, making a strong case for
its relationship to physical illness and bringing the importance of stress to the attention of the
public. Although he did not originate the concept of stress, he researched the effects of stress
on physiological responses and tried to connect these reactions to the development of illness.

Over the course of his career, Selye first considered stress to be a stimulus and later saw it as
a response.

His original position was that stress was a stimulus, concentrating on the environmental
conditions that produced stress. In the 1950s, Selye started to use the term stress to refer to a
response that the organism makes. To distinguish the two, Selye started using the terms
stressor to refer to the stimulus and stress to mean the response.

Selye‘s contributions to stress research included a concept of stress and a model for how the
body defends itself in stressful situations. Selye conceptualized stress as a nonspecific
response, repeatedly insisting that stress is a general physical response caused by any of a
number of environmental stressors. He believed that a wide variety of different situations
could prompt the stress response, but that the response would always be the same.

The General Adaptation Syndrome: The body‘s generalized attempt to defend itself against
stress became known as the general adaptation syndrome (GAS). This syndrome is divided
into three stages, the first of which is the alarm reaction. During alarm, the body‘s defenses
against a stressor are mobilized through activation of the sympathetic nervous system. This
division activates body systems to maximize strength and prepares them for the ―fight or
flight‖ response. Adrenaline (epinephrine) is released, heart rate and blood pressure increase,
respiration becomes faster, blood is diverted away from the internal organs toward the
skeletal muscles, sweat glands are activated, and the gastrointestinal system decreases its
activity. As a short-term response to an emergency situation, these physical reactions are
adaptive. However, many modern stress situations involve prolonged exposure to stress, but
do not require physical action.

Selye called the second phase of the GAS, the resistance stage. In this stage, the organism
adapts to the stressor. How long this stage lasts depends on the severity of the stressor and the
adaptive capacity of the organism. If the organism can adapt, the resistance stage will
continue for a long time. During this stage, the person gives the outward appearance of
normality, but physiologically, the body‘s internal functioning is not normal

Continuing stress will cause continued neurological and hormonal changes. Selye believed
that these demands take a toll, setting the stage for what he described as diseases of
adaptation, those diseases related to continued, persistent stress. The Figure 3.1 illustrates
these stages and the point in the process at which diseases develop.
 47

Among the diseases Selye considered to be the result of prolonged resistance to stress are
peptic ulcers and ulcerative colitis, hypertension and cardiovascular disease, hyperthyroidism,
and bronchial asthma. In addition, Selye hypothesized that resistance to stress would cause
changes in the immune system, making infection more likely.

Fig 3.1

The capacity to resist stress is finite, and the final stage of the GAS is the exhaustion stage.
At the end, the organism‘s ability to resist is depleted, and a breakdown results. This stage is
characterized by activation of the parasympathetic division of the autonomic nervous system.
Under normal circumstances, parasympathetic activation keeps the body functioning in a
balanced state. In the exhaustion stage, however, functioning is at an abnormally low level to
compensate for the abnormally high level of sympathetic activation that has preceded it.
Selye believed that exhaustion frequently results in depression and sometimes even death.

Evaluation of Selye’s View: Selye‘s early concept of stress as a stimulus as well as his later
concentration on the physical aspects of stress have both been influential in researching and
measuring stress. The stimulus-based view of stress prompted researchers to investigate the
various environmental conditions that lead people to experience stress and also led to the
construction of stress inventories. Such inventories ask people to check or list the events they
have experienced in the recent past and measure the amount of stress by totalling these
events. We consider both the environmental sources of stress and the life event approach to
measuring stress later in this chapter.

In considering stress as a set of physical responses, Selye largely ignored psychological

factors, including the emotional component and the individual interpretation of stressful
events. John Mason (1971, 1975) criticized Selye for ignoring the element of emotion in
stress and hypothesized that the consistency in the stress response is due to this underlying
element of emotion.
 48

Selye emphasized the physiology of stress and conducted most of his research on nonhuman
animals. By downplaying the differences between humans and other animals, he neglected
the factors that are unique to humans, such as perception and interpretation of stressful
experiences. Selye‘s view has had a great influence on the popular conception of stress, but
an alternative model formulated by psychologist Richard Lazarus has had a greater impact
among psychologists.

Lazarus’s View: In Lazarus‘s view, the interpretation of stressful events is more important
than the events themselves. It is neither the environmental event nor the person‘s response
that defines stress, but rather the individual‘s perception of the psychological situation. This
perception includes potential harms, threats, and challenges as well as the individual‘s
perceived ability to cope with them.

For someone who has no money saved or no confidence in finding another job, loosing his
job can be a crisis. But to a person who has either another source of income or confidence in
finding a new job, loss of a job may be far less stressful. In Lazarus‘s view, a life event is not
what produces stress; rather, it is one‘s view of the situation that causes an event to become
stressful.

Lazarus and Susan Folkman defined psychological stress as ―a particular relationship

between the person and the environment that is appraised by the person as taxing or
exceeding his or her resources and endangering his or her well-being‖. You should note
several important points in this definition. First, Lazarus and Folkman take an interactional or
transactional position, holding that stress refers to a relationship between person and
environment. Second, they believe that the key to that transaction is the person‘s appraisal of
the psychological situation. Third, they believe the situation must be seen as threatening,
challenging, or harmful.

Appraisal: Lazarus and Folkman (1984) recognized that people use three kinds of appraisal to
assess situations: primary appraisal, secondary appraisal, and reappraisal. Primary appraisal is
not necessarily first in importance, but it is first in time. A person who first encounters an
event, such as an offer of a job promotion, appraises it in terms of its effect on his or her well-
being. An event may be viewed as irrelevant, benign-positive, or stressful. It is unlikely that
an offer of a job promotion would be seen as irrelevant, but many environmental events, such
as a snowstorm in another state, have no implications for a person‘s well-being. A benign-
positive appraisal means that the event is seen as having good implications. A stressful
appraisal can mean that the event is seen as harmful, threatening, or challenging. Each of
these three – harm, threat, and challenge, is likely to generate an emotion.

Lazarus (1993) defined harm as the psychological damage that has already been done, such
as an illness or injury; threat as the anticipation of harm; and challenge as a person‘s
confidence in overcoming difficult demands. An appraisal of harm may produce anger,
disgust, disappointment, or sadness. An appraisal of threat is likely to generate worry, anxiety
or fear. An appraisal of challenge may be followed by excitement or anticipation. It is
 49

important to remember that these emotions do not produce stress; instead, the individual‘s
generates them apprised of an event.

After a person‘s initial appraisal of an event, that person forms an impression of his or her
ability to control or cope with harm, threat, or challenge, an impression called secondary
appraisal. A person asks three questions in making secondary appraisal. The first is ―What
options are available to me?‖ The second is ―What is the likelihood that I can successfully
apply the necessary strategies to reduce this stress?‖ As an example, let‘s look at Anita, who
has just lost her job. Her secondary appraisal would begin with an assessment of her ability to
make a favorable impression that would lead to a job offer. The third question a person asks
is ―Will this procedure work? That is, will it alleviate my stress?‖ Even if Anita believes that
she makes a sufficiently good impression to get a job offer, she may not believe that a
favorable impression will lead to another job. When people believe they can do something
that will make a difference, when they believe they can successfully cope with a situation,
stress is reduced.

The third type of appraisal is reappraisal. Appraisals change constantly as new information
becomes available. Anita may recall some advice on writing an attractive letter of application
or relaxing during a job interview and gain more confidence in her ability to cope, thereby
reducing her stress. Or reappraisal may follow from an environmental source, as when Anita
reads a newspaper article about the strong demand for employees with her training and
experience. This new information may allow Anita to reappraise her employment situation
and to turn her previously stressful appraisal into a benign-positive one.

Reappraisal does not always result in less stress; sometimes it increases stress. A situation
previously assessed as benign or irrelevant can take on a threatening, harmful, or challenging
turn if the environment changes or the person begins to see the situation differently. For
example, a husband who has been satisfied with his marriage for years may begin seeing his
relationship with his wife as stressful when his wife begins college course work.

Vulnerability: Stress is most likely to be aroused when a person is vulnerable, when he or she
lacks resources in a situation of some personal importance. These resources may be either
physical or social, but their importance is determined by psychological factors, such as
perception and evaluation of the situation. An arthritic knee, for example, would produce
physical vulnerability in a professional athlete but would be a minor inconvenience to the
professional life of someone who works behind a desk.

Lazarus and Folkman (1984) insisted that physical or social deficits alone are not sufficient to
produce vulnerability. What matters is whether one considers the situation personally
important. Vulnerability differs from threat represents only the potential for threat. Threat
exists when one perceives that his or her self-esteem is in jeopardy; vulnerability exists when
the lack of resources creates a potentially threatening or harmful situation.

Coping: An important ingredient in Lazarus‘s theory of stress is the ability or inability to

cope with a stressful situation. Lazarus and Folkman defined coping as ―constantly changing
cognitive and behavioral efforts to manage specific external and/or internal demands that are
 50

appraised as taxing or exceeding the resources of the person‖. This definition spells out
several important features of coping. First, coping is a process, constantly changing as one‘s
efforts are evaluated as more or less successful. Second, coping is not automatic; it is a
learned pattern of responding to stressful situations. A response that is automatic (such as
closing one‘s eyes to block out intense light) or which becomes automatic through experience
(such as shifting one‘s weight while riding a bicycle) would not be considered coping. Third,
coping requires effort. A person need not be completely aware of his or her coping response,
and the outcome may or may not be successful, but effort must have been expended. Fourth,
coping is an effort to manage the situation; control and mastery are not necessary. For
example, most of us make an effort to manage our physical environment by striving for
comfortable air temperature. Thus we cope with our environment even though complete
mastery of the climate is impossible.

How well people are able to cope depends on several factors. Lazarus and Folkman listed
health and energy as one important coping resource. Healthy, robust individuals are better
able to manage external and internal demands than are frail, sick, tired people. A second
resource is a positive belief – the ability to cope with stress is enhanced when people believe
they can successfully bring about desired consequences. This ability is related to the third
resource: problem-solving skills. Knowledge of anatomy and physiology, for example, can be
an important source of coping when a person is receiving information about her or his own
health from a physician who is speaking in technical terms. A fourth coping resource is social
skills. Confidence in one‘s ability to get other people to cooperate can be an important source
of stress management. Closely allied to this resource is social support, or the feeling of being
accepted, loved, or prized by others. Finally, Lazarus and Folkman list material resources as
an important means of coping. Having the money to get one‘s car repaired decreases the
stress of having a transmission problem.

In Lazarus‘s transactional view, of course, material and social resources by themselves are
not so important as one‘s personal belief about these resources. Perceiving that you can
manage or alter a stressful environmental situation and feeling confident that you can regulate
your own emotional distress are two main ways to cope with stress. The ways people cope
with stressful life events, including daily annoyances, plays a leading role in stress-related
illness.

VI. STRESS: A WORKING MODEL

Multi modal transactional model of stress: The working model of stress we use in our
approach to stress counselling is known as ‗transactional‘. This model provides a simple but
realistic explanation of the complicated nature of stress as it addresses the inter-relationship
between the internal and external world of individuals. We have modified the transactional
models of stress proposed by Cox and Mackay (1981) to incorporate Lazarus‘ seven
modalities.
In the model, the psychological processes are of fundamental importance. How a person
reacts to an event is more due to his or her perceptions of it and his or her perceived abilities
to deal with it than the event or situation itself. Therefore, the event can be considered as a
 51

potential ‗trigger‘ to activate the stress response but not necessarily the main cause of its
activation. Once the event has passed, the person may remain disturbed about it due to the
action or interaction of the different modalities. For example, individuals suffering from a
chronic form of stress known as post-traumatic stress disorder may repeatedly see negative
images of the event, may have much negative cognition, may have physiological symptoms
of severe anxiety, and may avoid anything that reminds them of the event. This response can
still occur years after the stressful event. In other cases, clients who suffer an apparently
harmless life-event, such as the death of a pet, become overwhelmed by immense grief, as the
event takes on another personal meaning; for example, anxiety about their own death or
memories of the loss of a close family member.
To help understand the multi modal transactional model, it can be broken down into five
discrete stages.
In Stage 1, a pressure is usually perceived by the individual to be emanating from an external
source in the environment, for example, having to meet an important deadline. In fact, there
are also day-to-day physiological and psychological needs or demands an individual has in
order to survive, such as food and water.
Stage 2 reflects the individual‘s perception of the pressure or demand and her appraisal of her
ability to deal with it. If the individual perceives that she can cope, even if she is being
unrealistic, then she may stay in the situation; for example, working towards the deadline. If
it happens that the person perceives that she cannot cope, then at that moment she may
experience stress. However, added to this equation are social, family or cultural beliefs which
the individual may have absorbed into her belief system. Thus, if the individual believes that
she ‗must‘ always perform well at work , any innocuous deadline may assume great
importance. In reality, the ‗must‘ is an internal and not an external pressure as the individual
does not have to hold rigidly on to this belief. Many clients receiving stress counselling
cognitively appraise experience as ‗very stressful‘ as a result of their beliefs which distort the
importance of an actual or feared event. In this stage, then, the individual decides whether she
has the resources to cope with the external and internal pressures of a specific situation. If she
believes that she can deal with the situation then her stress response is less likely to be
activated. However, if she perceives that she does not have the coping strategies to deal with
the situation then she progresses on to Stage 3 of the model.
In Stage 3, psycho physiological changes occur. Taken together, these comprise what is
generally known as the ‗stress response‘. There is usually an emotion or combination of
emotions such as anxiety, anger or guilt. According to our multi modal model, these emotions
may have behavioural, sensory, imaginable, cognitive, interpersonal and
biological/physiological components. In addition, there will probably be behavioural and
cognitive attempts to change the environment or escape from the situation and thereby reduce
the pressure. However, like animals, some individuals have been known to freeze with fear,
which is not always helpful.
Stage 4 relates to the consequences of the application of the coping strategies or responses of
the individual. Once again, the individual‘s perception of the coping strategies applied is
important. Consequently, if an individual believes that his intervention is not helping, he may
picture himself as failing, which in itself, becomes an additional strain in the situation. Actual
failure to meet the demand is also detrimental if the individual truly believes that the demand
has to be met in a satisfactory manner.
Stage 5 is concerned with the feedback system. Interventions may be made by the individual,
which may either reduce or alter the external and internal pressures. If this occurs, then the
 52

organism may return to a neutral state of equilibrium. However, if the interventions are
ineffective, then the individual may experience prolonged stress. This has many psycho
physiological consequences, which may even lead to mental breakdown or death in extreme
cases. Death may be due to the prolonged effect of the stress hormones, adrenaline,
noradrenaline and cortisol, on the body.
Previous success in handling major stressful situations reinforces a person‘s belief in her
ability to deal with any stress in the future. Individuals who have managed to cope with
difficult life-events may view themselves as possessing coping skills which they can apply in
similar situations. This is known as ‗self-efficacy‘ and is a major cognitive component in the
appraisal of future events as non-threatening and therefore not stressful. They may hold
beliefs such as: ‗I‘m in control.‘ ‗I know I can do it.‘ ‗These will not be a problem.‘ ‗This will
be a challenge and not stressful.‘ These beliefs often prevent the person from going beyond
Stage 2 of our multimodal transactional model. Coping is considered by researchers as an
‗important part of the overall stress process‘ and, whenever possible, multimodal stress
counsellors attempt to help clients improve their coping strategies
 53

CHAPTER 4:
STRESS & DISEASES
Introduction to Stress & Disease

Disease is caused by many factors, and stress may be one of those factors. In any
consideration of the association between disease and major life events or daily hassles, it is
necessary to remember that most people at risk from stressful experiences do not always
develop a disease. In contrast to other risk factors such as having high cholesterol levels,
smoking cigarettes, or drinking alcohol the risks conferred by life events are usually
temporary. As one of the authors of the Social Readjustment Rating Scale expressed it, ―Most
individuals with high recent life-change totals do not remain at such levels for more than a
year or two before returning to baseline levels which connote far less risk‖(Rahe, 1984).

There are several possible pathways through which stress could produce disease. Direct
influence could occur through the effects of stress on the nervous and endocrine systems as
well as on the immune system, because any or all of these systems can create disease, there
are sufficient physiological foundations for a link between stress and disease. In addition,
 54

indirect effects could occur through changes in health practices that increase risks; that is,
stress tends to be related to increases in drinking, smoking, drug use, and sleep problems, all
of which can increase the risk for disease.

Psychosomatic medicine emphasizes the influence of the mind on the body (Psycho +
Somatic). The role of psychological factors could be in initiation, progression, aggravation of
a disease or it may even predispose the individual to a disease. Further, it may delay the
individual‘s recovery or prognosis, given a disease state. Psychosomatic medicine was
defined in 1978 by the National Academy of Science as ―the field concerned with the
development and integration of behavior and biomedical science, knowledge and techniques
relevant to health and illness and the application of this knowledge and these techniques to
prevention, diagnosis and rehabilitation.

Psychological factors affect a patients medical condition in various ways. The Diagnostic and
Statistical Manual of Psychiatry (DSM) identifies these psychological factors as :

 Mental disorders (e.g., major depressive disorders).

 Psychological symptoms (e.g., symptoms of anxiety or depression).

 Personality traits or coping style (e.g., passive personality).

 Maladaptive health behavior (e.g., over eating, smoking etc).

 Stress related psychological response affecting medical condition (e.g., stress related
exacerbation in ulcer, hypertension etc.,).

 Other unspecified psychological factors (e.g., interpersonal, cultural, religious).

Psychosomatic medicine emphasizes the unity of the mind and body as well as an interaction
between both and adopts a holistic approach to medicine, since it indicates that all diseases
are influenced in one way or another by psychological factors.

For atleast 100 years now Physicians and Psychiatrists have both agreed that some disorders
have an emotional overlay. It was Johann Christian Heinroth in 1818 who first used the term
Psychosomatic disorders for insomnia. This was later popularized by Maximilian Jacobi, a
German Psychiatrist. Later ulcerative colitis, peptic ulcer, migrane headache, bronchial
asthma, rheumotid arthritis were also included in the list. Mentioned below is a list of
psychosomatic disorders currently accepted by DSM.

Table 4.1

Some Psychosomatic Disorders

Acne Migraine
Allergic reactions Mucous colitis
 55

Angina pectoris Nausea

Arrhythmia Neurodermatitis
Asthmatic Wheezing Obesity
Irritable colon Painful menstruation
Angioneurotic edema Pruritus ani
Bronchial asthma Sacroiliac pain
Cardio spasm Pylorospasm
Chronic pain syndromes Regional enteritis
Coronary heart disease Rheumatoid arthritis
Diabetes mellitus Skin diseases, such as
Duodenal ulcer Psoriasis
Essential hypertension Spastic colitis
Gastric ulcer Tachycardia
Headache Tension headache
Herpes Tuberculosis
Hyperinsulinism Ulcerative colitis
Hyperthyroidism Urticaria
Hypoglycemia Vomiting
Immune diseases Warts

Chronic severe and perceived stress infact plays an influencing role in the development of
many somatic diseases. A stressful life event generates various changes within the organism.
Thomas Holmes and Richard Rahe in their Social adjustment rating scale listed 43 life events
associated with varying degrees of stress in the life of an average person. An accumulation of
200 or more life changes units in a single year increases the incidence of psychosomatic
ailments. The social readjustment rating scale below shows all the life events in the scale and
you may want to see how you figure in a single year.

The psychosomatic research study table below identifies the correlation of psychosomatic
medicine with various factors as researched by Physicians and Psychiatrists over several
years
56
 57

Table 4.2

Table 4.3 below identifies some common psychosomatic disorders listed in the Diagnostic
and Statistical Manual for Mental Disorders (DSM). Mentioned below are the body systems
& psychosomatic ailment connection

Table 4.3

Cardiovascular system

 Coronary Artery Disease

 Essential Hypertension
 Vasomotor syncope
 Cardiac Arrhythmias
 Raynaud‘s phenomenon
 Psychogenic cardiac nondisease

Respiratory System

 Hay fever
 Hyperventilation syndrome

Gastrointestinal systems

 Peptic ulcer
 Ulcerative collitis
 Obesity
 Annerextia nervosa

Muscular Skeletal system

 Rheumatiod Arthirtis
 Low back pain

Headaches

 Migraine (vascular) headaches

 Tension (muscle contraction) headaches

Endocrine system

 Hyperthyroidism
 Diabetes mellitus
 Female endocrine disorders
 Premenstrual disphoric disorder
 Menopausal distress]
 58

 Idiopathic amenorrhea
 Hyperlipidiemia

Chronic Pain Immune disorders

 Infectious diseases
 Allergic disorders
 Autoimmune diseases

Skin disorders

 Generalized pruritus
 Localized pruritus

Cancer

 Treatment related problems

 Patient related problems
 Pain, palliative care, psychotherapy
 Family problems

Some discussion on the relationship of stress with the various diseases mentioned below
follows.

1. Cardiovascular diseases
2. Hypertension
3. Asthma
4. Backache
5. Arthritis
6. Headache
7. Diabetes
8. Skin ailments
9. Obesity and stress
10. Peptic ulcer
11. Stress and Negative mood, Anxiety and Depression
12. Cancer
13. Insomnia

I. CARDIOVASCULAR DISEASE

Cardiovascular disease (CVD) has a number of behavioral risk factors, some of which are
related to stress. Studies from the 1970s seem to support the notion that stress leads to heart
disease; their findings indicate that people who died of a sudden heart attack had experienced
more stressful life events in the 6 months preceding the attack than did those who survived
(Rahe, Romo, Bennett, & Siltanen, 1974). In addition, specific stresses such as bereavement,
loss of prestige, and loss of employment have been found to be risks for heart attack.

More and more evidence suggests a relationship between the risk of cardiovascular disease
and environmental and psychosocial factors. These factors include job strain, social isolation
 59

and personality traits. But more research is needed on how stress contributes to heart disease
risk to know whether stress acts as an ―independent‖ risk factor for cardiovascular disease.
Acute and chronic stress may affect other coronary risk factors and behaviors, such as high
blood pressure and cholesterol levels, smoking, physical inactivity and overeating also.

Healthcare professionals have long been aware that certain behavioural features characterize
persons who develop coronary heart disease. In 1897, Sir Simon Osler noted, ― in the worry
and strain of modern life, arterial degeneration is not only very common but develops at a
relatively early age. For this, I believe that the high pressure at which men live, and the habit
of working the machine to its maximum capacity are responsible for coronary disease.‖ He
went on to suggest that a typical person with coronary heart disease was not ―the disease
neurotic‖ but the ―robust, the vigorous in mind and body, the keen and ambitious man, the
accelerator of whose machine is always at full speed ahead (Olser, 1910)

Friedman, Roseman and Roseman (1959) were the first cardiologists to systematically assess
those behaviours characterizing persons with coronary heart disease. They labeled those
behaviours Type A cardiac personalities

II. HYPERTENSION

Blood pressure is the force with which blood presses against artery walls. You need some
blood pressure to stay healthy. Without it, there‘s no way blood could make it around your
body – from your feet and legs back to your heart, or from your heart to your brain.
Throughout the day, your body adjusts your blood pressure. In some people, though, this
adjustment gets out of balance, and their blood pressure stays too high all the time. They have
the disease called Hypertension. High blood pressure (HBP) or hypertension is a major health
problem among Asians, African Americans and Latinos. High blood pressure is often called
the ―silent killer‖ with good reason — it doesn‘t make one look or feel sick, at least at first.
One can have it for years without any aches or pains. But all that time, high blood pressure is
doing damage and hurting health.

While BP is said to be normal when it ranges around 120 over 80 (upto 130/85), in general, it
is too high if it measures above 140/90 (140 over 90) most of the time. The higher your blood
pressure, the greater the chance of having a stroke as well.

The top number (systolic blood pressure) shows the force of the blood in the vessels when the
heart pumps. The bottom number (diastolic blood pressure) shows the force of the blood in
your vessels when your heart is between beats. Over 60 million men and women in the U.S.
have high blood pressure — about one-fourth of all adults. Of that 60 million, perhaps only
half — 30 million — know they have the disease. And of these, only about 15 million are
getting the treatment they need.

While people who are middle age or more, overweight, sedentary and smokers are at greater
risk, gender too plays a role. Men tend to get high blood pressure earlier. Once a woman
reaches menopause, however, her risk of getting high blood pressure rises to equal that of
 60

men. Its also very common for high blood pressure to run in families. If one or both of the
parents or grandparents have high blood pressure, the individual is more likely to have it, too.

While there is nothing you can do about your race, age of family history, there is plenty you
can do about stress & the other things that increase your risk.

Although a relationship between stress and high blood pressure appears to exist, the effects of
treatment for stress remain hazy. An analysis of 26 trails have reported promising effects.
They have used combinations of yoga, biofeedback, and/or meditation in order to manage
HBP. Some doctors recommend a variety of stress-reducing measures, sometimes tailoring
them to the needs and preferences of the person seeking help

III. ASTHMA

Sometimes, asthma can cause anxiety or a panic attack. At other times, anxiety or a panic
attack can trigger an asthma attack. Incidentally, ‗attack‘ is an alarming word; therefore, let
us just refer to it as asthma episode. Chronic stress, anxiety, or panic attacks have a direct
impact on breathing. Seeing an asthma episode coming, a person may experience anxiety or a
panic attack, which may lead to further aggravation of its symptoms. Breathing is
immediately affected when we sense even the slightest danger. Therefore, in an anxiety or a
panic attack, patients often experience severe problems with their breathing, described
as, shortness of breath, smothering, choking, ‗can‘t get enough air‘, along with complaints of
dizziness, lightheadedness, chest tightness or severe chest pains.
Significant consequences of asthma may include fatigue, loss of initiative, lack of self-
confidence, and various types of mental suffering.
Many adult asthma patients report that having had several weeks or months of absence of
symptoms, they begin to feel that their asthma is well under control, and then, suddenly, ‗out
of the blue‘, it‘s back! This leads to a renewed phase of worries and concerns. They get very
anxious and feel they‘ve lost control over it because it can come from behind and grab them
unawares.
But, was it really out of the blue or did something stressful happen just before asthma flare
up? The answer, most likely, is yes. Therefore, one shouldn‘t feel that one does not have any
control over one‘s asthma. Often stress has a role play or something to do with these ―out of
the blue‖ asthma episodes. When you understand the relationship between stress and asthma
and find ways to manage your stress, you are likely to have better control over your asthma.
Some people are predisposed to hyperactive airways. In some cases, anxious thoughts can
send a stream of nerve impulses to the airways causing bronchial constriction. At this point a
person may feel tightness in the chest and difficulty in breathing. Tension would further
constrict the airflow in and out and symptoms might get worse. The muscles lining the
airways further tighten. The lining of bronchial tubes swells and becomes inflamed. The
mucous that lubricates the airways becomes thick and sometimes may even plug them up.
So, it gets more and more difficult to exhale. The air that was not exhaled, that is, the
accumulated carbon dioxide, becomes trapped in the lungs, which leaves little room for fresh
air to enter. This is the point when people feel they can‘t breathe in because there is hardly
any room in the lungs for fresh air.
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Asthma is not generally caused by one‘s state of mind, but there is frequently a close
relationship between emotional upset and an asthmatic attack. It is evident that nervous and
emotional states may precipitate an attack of asthma, and sometimes the first attack will come
at the climax of an emotional crisis. Nervous pressure and anxiety make episodes worse, but
are only contributing factors to the allergic ailment; in many cases emotional responses are an
effect rather than a cause of asthma.
Asthma and Children: Children can worsen the stress of an attack by such normal
emotional expressions as laughing, crying, or yelling. Hyperventilation can exacerbate
asthma. Parents should point this out to their child, because he or she may be able to
moderate this behavior.
Of course, if there are serious ongoing emotional problems that seem to aggravate the asthma,
counseling for the family may be worthwhile. When a child is able to bring asthma under
control, resulting difficulties (i.e. feeing ―different‖ from his playmates) usually disappear. It
is important to remember that a parent‘s own fears can affect the child, while keeping calm
and proceeding with the treatment prescribed will reassure the child that he will soon feel
better.
Often, during the course of an asthmatic child‘s development, problems arise. The child may
be overly protected, miss school, and be prevented from participating in group activities. He
may suffer behavioral and personality disorders, becoming irritable and overly dependent.
The child may also go to other extremes, becoming aggressive, demanding, and oppressive
over parents and other children. Sometimes he or she becomes angry and frustrated and
refuses to take the medications that can prevent episodes. The uncontrolled emotions can
stimulate nerves that cause muscles in the airways to tighten. The fear during this episode can
cause him to hyperventilate, and trigger an attack.
An essential part of the total management of the child‘s asthma is recognition of the fact that
– as with any serious chronic condition – asthma will periodically affect the emotional health
of the child and the family. Children must learn to take control early, no matter where they
are, and not wait until things get out of hand. They can prevent a lot of trouble by taking their
medicine, drinking fluids, and relaxing at the first sign of an attack. A child feels far less
frightened and frustrated if he knows how to prevent and control asthma episodes. He has to
be taught that, when he feels excited, he should think about his breathing, and make an effort
to breathe slowly and deeply to relax the airways

IV. BACKACHE

Increased back pain may be associated with periods of stress. In response to stress muscles
become taut and ready for action and this frequent muscle tension can lead to pain. In one
study, healthy people who scored high on a distress questionnaire were more likely to
develop low back pain than those who scored low. All in all, the researchers believe
emotional factors may account for about 16% of low back pain cases.
Some facts

 60%-80% of people in the Western world are affected by backache.

 The incidence of back problems is highest between the ages of 30-50 years.
 Back pain is the third most common cause of loss of workdays (after headache and the
common cold).
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Studies show that people with acute back pain who go about their everyday activities as much
as possible do as well—and sometimes better—than those who rest in bed for a few days.
Also, those who resume normal activities despite their pain are less likely than those who rest
to experience chronic back pain in the future. The reason is that activity nourishes the spine.
Movement naturally causes the body to pump fluid into the spongy discs that separate and
cushion the vertebrae in the back. Prolonged inactivity also can cause back muscles to
weaken and become stiff, which may, in turn, worsen back problem.
The spine begins to show signs of wear and tear as early as age 35. As the back becomes less
strong and flexible, muscle strains and sprains are more likely.
However, people can strain their back at any age. It often occurs when people lift objects that
are too heavy or use improper form when lifting, twisting, bending or doing other activities.
Construction workers, nurses, and others with jobs that involve a lot of heavy work or
physical activity are more likely to develop back pain than those whose jobs are less
strenuous.
Various health problems also can cause back pain. These include osteoarthritis, osteoporosis,
sciatica, and kidney infections.
Experts admit that there‘s still a lot to be learned about what causes back pain. Up to 85% of
patients never find out the exact cause of their back pain. That‘s because X-rays and other
technology cannot always detect what is causing the pain.
A sedentary lifestyle, poor posture, being overweight, bad working practises and a high level
of stress all contribute to back problems.
Abnormal stress, either sudden or over time, can injure the muscles, ligaments or joints of the
spine. An acute back injury may result from an unexpected jolt or incorrect lift. Alternatively,
poor posture and weak muscles can lead to a chronic backache. Muscle and ligament strains
are the most common cause of back pain. Increased muscle tension will often stir up an
existing back problem. Prolonged muscle tension will result in muscle imbalances and
abnormal stress on the spine.
The Lower Back: Irritation to the spinal nerves of the lower back may result in back pain,
and this may be referred along the nerve pathways into the abdomen, groin, hips, legs or feet.
Often pain is felt along the large sciatic nerve which passes through the buttock and down the
back of the leg. There may also be sensations of numbness in any of these areas. Muscle
function may be affected, resulting in stiffness or weakness. The compression effect in the
lower back may be so severe that the back muscles lock up in a protective spasm, pulling the
spine sideways or forwards.
While body stress remains stored in the lower back, the irritation to the nerves may
undermine the normal function of the organs and areas they supply. Thus body stress may
lead to digestive problems, e.g. constipation/diarrhea, bladder complaints and may adversely
affect sexual function. The jarring effect of accidents and falls may cause body stress to
become locked into the lower back. Also, heavy or incorrect lifting or bending may strain
ligaments and muscles and result in stress becoming stored in the structures. The wrong kind
of exercise – those which involve twisting movements or repeated forward bending, may
stress the lower spine. Another cause is poor posture, especially sitting slumped in a position,
which reverses the normal lumbar curve.
Exercise your back: Improvement in general fitness helps to reduce and prevent back pain.
Regular back exercises will help to:
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1. Strengthen muscles supporting the back.

2. Stretch tight joints, muscles and ligaments.
3. Increase mobility.
4. Improve posture.
5. Maintain a good body posture while sitting, standing, bending, lifting, lying down etc.
6. Maintain the spine in its optimum position.

V. RHEUMATOID ARTHRITIS

A chronic inflammatory disease of the joints, may also be related to stress. Rheumatoid
arthritis is believed to be an autoimmune disorder in which a person‘s own immune system
attacks itself (Young, 1993). The attack produce inflammation and damages the tissue lining
of the joints, resulting in pain and loss of flexibility and mobility.

A growing body of evidence (Zautra, 1998) indicates that stress can make arthritis worse by
increasing pain sensitivity, reducing coping efforts, and possibly affecting the process of
inflammation itself. Direct effects of stress on inflammation could occur through neuro-
endocrine responses to stress. The disorder is not completely understood and therefore, the
role of stress in its development. Rheumatoid arthritis does bring about negative changes in
people‘s lives and requires extensive coping efforts

VI. Headaches

Headaches are a minor problem that may require no more than over-the-counter medication,
but headache is also one of the most frequent causes of visits to physicians (Hatch, 1993).
Headache can signal serious medical conditions, but most often the pain associated with the
headache is the problem. The majority of people who seek medical assistance for headaches
are plagued by the same sorts of headaches as those who do not; the difference stems from
the frequency and severity of the headaches or from personal factors involved in seeking
assistance.

Although over 100 types of headaches exist, distinguishing among them has become
controversial, and the underlying causes for the most common types remain unclear (Hatch,
1993). Nevertheless, diagnostic criteria have been devised for several types of headaches.
The most frequent type of headache is tension headache, usually associated with increased
muscle tension in the head and neck region. Tension is also a factor in vascular headache, and
many tension headaches have a vascular component. The most notorious of the vascular
headaches are migraine headaches, hypothesized to be caused by changes in constriction of
the vascular arteries and associated with throbbing pain localized in one side of the head.

Stress is recognized as a factor in both tension and vascular headaches (Rasmussen, 1993).
However, the type of stress associated with headaches tends not to be traumatic life events
but rather small daily hassles (Fernandez & Sheffield, 1996). People with tension and mixed
headaches are more likely than those with migraines to report more daily hassles as well as
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more intense daily hassles. In addition, stressful events precede periods of headache more
often than they precede times with no headache, and stress during a headache intensifies the
attack.

When a person has a headache, several areas of the head can hurt, including a network of
nerves that extends over the scalp and certain nerves in the face, mouth, and throat. The
muscles of the head and the blood vessels found along the surface and at the base of the brain
are also sensitive to pain because they contain delicate nerve fibers. The bones of the skull
and tissues of the brain itself never hurt because they lack pain-sensitive nerve fibers. The
ends of these pain-sensitive nerves, called nociceptors, can be stimulated by stress, muscular
tension, dilated blood vessels, and others triggers of headache. Vascular headaches are
thought to involve abnormal function of the brain‘s blood vessels or vascular system; muscle
contraction headaches appear to involve the tightening or tensing of facial and neck muscles;
and traction and inflammatory headaches are symptoms of other disorders, ranging from
brain tumor to stroke to sinus infection.

Some types of headache are signals of more serious disorders: sudden, severe headache;
headache associated with convulsions; headache accompanied by confusion or loss of
consciousness; headache following a blow on the head; headache associated with pain in the
eye or ear; persistent headache in a person who was previously headache free; recurring
headache in children; headache associated with fever; headache that interferes with normal
life. Physicians will obtain a full medical history, check blood pressure and may order a
blood test to screen for thyroid disease, anemia, or infections or x-rays to rule out a brain
tumor or blood clots. CTs, MRIs, and EEGs may also be recommended. An eye exam is
usually performed to check for weakness in the eye muscle or unequal pupil size. An ENT
exam may be preplanned to check for sinus infections as a cause for headaches. Some
scientists believe that fatigue, glaring or flickering lights, the weather, and certain foods may
trigger migraine headaches.

Is there any treatment?

Not all headaches require medical attention. Some result from missed meals or occasional
muscle tension and are easily remedied. If the problem is not relieved by standard treatments,
a headache sufferer may be referred to an internist, a neurologist, or a psychologist.
Specialists in Eye and ENT may also be called in to rule out any pathology in their areas.
Drug therapy, biofeedback training, stress reduction, and elimination of certain foods from
the diet are the most common methods of preventing and controlling migraine and other
vascular headaches. Regular exercise can also reduce the frequency and severity of migraine
headaches. Temporary relief can sometimes be obtained by a using cold pack or by pressing
on the bulging artery found in front of the ear on the painful side of the head.

Relaxation techniques and neck and shoulder exercise also help in loosening the tight
muscles of the neck and shoulders, reducing the intensity of the headache. Research has,
however, indicated that Biofeedback and Relaxation techniques succeed in the reducing the
pain and intensity of a headache. They may not result in removing the headache. Clients are
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also known to seek treatment from other schools such as Acupressure, Homeopathy etc. if
other measures don‘t bring relief.

VII. DIABETES MELLITUS

This is a chronic disease that may be related to stress. Two kinds of diabetes mellitus are
Type I or Insulin Dependent Diabetes Mellitus (IDDM) and Type II or Non Insulin
Dependent Diabetes Mellitus. IDDM is also called juvenile-onset diabetes, because it begins
in childhood and requires insulin injections for its control. NIDDM usually appears during
adulthood and can most often be controlled by dietary changes.
Diabetes dramatically increases a person‘s risk for heart disease and stroke and often is
associated with other cardiovascular risk factors, such as high blood pressure, high blood
sugar, cholesterol disorders, obesity and insulin resistance. Insulin resistance, a condition
where the body does not respond efficiently to the insulin it produces, seems to predispose a
person to both cardiovascular disease and diabetes.
Stress may contribute to the development of both types of diabetes through several routes
(Cox & Gonder-Frederick, 1992).
First, stress may contribute directly to the development of insulin-dependent diabetes
through the disruption of the immune system. In general, retrospective studies have found
that insulin-dependent diabetics had somewhat more stressful life events than non-diabetics.
However, prospective investigations of this issue are extremely difficult to conduct on
humans.
Second, stress may contribute directly to NIDDM through its effect on the sympathetic
nervous system; and,
Third, stress may contribute to NIDDM through its possible effects on obesity. Research on
stress and non insulin-dependent diabetics has shown that stress can be a triggering factor and
thus play a role in the age at which people develop adult-onset diabetes.
In addition, stress may affect the management of diabetes mellitus through its direct effects of
raising blood glucose (Wylie-Rosett, 1998) and through the indirect route of hindering
people‘s compliance with controlling glucose levels (Herschbach et al., 1997). Indeed,
compliance is a major problem for this disorder.

VIII. SKIN AILMENTS

Our skin is the largest and most visible of the five sense organ of the body. It reacts to stimuli
from inside and out. Goose pimples appear when we are chill or become frightened. We flush
when we have exercised or become angry.
The epidermis (outer skin) is durable yet sensitive, tough enough to walk on all day, yet
vulnerable to internal stresses. Our skin is the container for our bodies and a barrier to outside
invaders.
It is much easier to understand skin problems when we realize that both the skin and the
nervous system spring from a common ancestry in the embryo stage of human development.
While many skin problems have clearly physiological causes, it should also not be surprising,
that our skin can be the first place, a call for help is issued from our nervous system or our
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psyche. A rash, hives, itching and pimples can be the first signal that something inside is out
of balance. That ―something‖ may be physical, psychological, or often a combination of both.
Not every itch, pimple, and rash is an internal cry. Poison ivy, fleas and mosquito bites,
clogged pores, among other things, can be responsible, too. Many skin disorders are caused
by outside irritants, bacteria and viruses and aggravated by internal conditions. However
warts, psoriasis, eczema, herpes, and itching all are affected by emotional factors and stress.
It is not easy to catalogue skin disorders as being caused by either psychological conditions.,
there is no clear line between mind and body – the two systems are interwoven. Disease can
be brought on or allowed to develop because of a lowering of immune system.
If skin conditions are caused by emotional problems, the stress, conflict, feelings that have
ignored, will find another body part to aggravate. Usually, what is repressed becomes
stronger until it finds a way to be expressed, ventilated, or break out.
One needs to be sensitive to events, feelings, and situations in our lives that may need to be
released.
Anxiety is often related to skin problems. Self-hypnosis is an excellent prescription for the
desired improvements as well as for an understanding of the cause. With skin disorders,
people often get more anxious because they feel their body is out of control or because the
problem may be so easily seen by others.
Skin often responds to events in one‘s life. When an individual experience stress, the pressure
and anxiety felt often shows on the exterior. Any skin problem is frustrating – especially if
one is sure of the source. Here are some of the common reactions to stress that can surface on
the skin, and the possible reasons behind them.
Hives: Both stress and allergies can cause hives to appear. Facing a dreaded situation or
feeling extreme amounts of pressure can encourage them to show up in a matter of minutes.
Although hives sometimes occur as a reaction to food allergies, this is most often seen in
children. Antihistamines, behavioral therapy or assertiveness training are sometimes helpful.
Acne: This irritation can be anything from oiliness to inflammation to infection on the face,
chest and back.
Itching: One little known reaction to stress is itching. Histamines are released when a person
is feeling anxiety. Within seconds after these histamines are released into the skin, the overly-
stressed individual may find herself scratching any part of her body. Needless to say, this is
aggravating and uncomfortable. Some lotions may help to stop the itching as well as a little
mental relaxation.
Stress is increasing day by day thus disturbing every sphere of our life including our looks.
The skin is a reflection of inner physical and mental health.
Emotional stresses disturb the body homeostasis that results in hormonal malfunctioning,
impairment of body immunological functions and slows down the skin rejuvenation. Skin
constantly renews itself. At young age the cell renewal process completes within 28 days but
as we grow older the speed of this process slows down. In addition to age, that process is also
affected due to our state of mind. Mental disturbance slows down the process of cell renewal,
destroys collagen fibers in the skin, breaks down its elastin and increases the production of
sebum oils in oily skin people and dehydrate dry skin. In order to have healthy glowing
complexion, care of one‘s mental health is essential too, because that is the key to beautiful
skin.
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Following rules must be practiced to get rid of stress:

 First of all just leave the stressful situation and drink a glass of water.
 Don‘t make any decision during those phases.
 Don‘t make any negative judgement about yourself.
 Think about positive traits of your personality. Nobody is ideal and perfect in this world.
Every one has some weakness, if you too have some than there is nothing wrong with you.
 Don‘t try to seek the help of cigarette, alcohol or any drug.
 Get yourself involved in some easy to do work like cleaning your wardrobe, arranging
your bookshelf, do painting. But whatever work you start you have to complete it.
 Call your friend, talk to him/her about your problem. If you don‘t want to do so than just
take a paper and write down about every thing that is coming to your mind without
censoring anything.
 Do aerobics or yoga or just go out for a long walk

IX. OBESITY & STRESS

As much as 40 percent of the population in North America is obese and in India more than
50% of the urban population is overweight. Obesity is more than 10 percent above ideal body
weight.
Obese people often deny that they are big eaters, and insist on remembering details of only
the very modest lunches – the occasional half grapefruit and the few carrot slices that they
consume during their days. It is important to remember that ‗binge eating‘, even if it occurs
only once a month, must be added on to all the other calories that have been taken during the
rest of the time period. That is, there is no point in eating a diet that has only 800 calories per
day from Monday to Friday if, on the weekends, one gets into the nuts, chips, chocolates, or
other favorite fattening foods, and put away several calories in a few minutes. Denying these
extra calories does not make them disappear.
Obesity is never the problem. It is the result of one‘s problem. The real cause of obesity is
usually hidden beneath the surface. It is probably one of the following:
Boredom can lead to obesity: Boredom can certainly be experienced by both sexes, and by
all age groups. The solution to boredom in children and teens is usually quite obvious to
parents, namely, that some structure or discipline has to be provided each day to give the
child a sense of purpose. What we forget is that the same principles can apply to fighting
boredom in adults and the elderly.
Stress as a cause of over- eating: Obesity is an abnormal physiological response to stress,
the body tends to respond to stress by reducing its weight, burning up its stores of fat and
sugar with and increased metabolism triggered by increasing thyroid levels. However, some
people have an overwhelming oral urge retained from childhood. Whenever stress strikes,
they panic and shove something into their mouth. In many cases the oral urge involves
cigarettes or over-eating, and often both. Oral oriented people are frequently seen chewing
gum, sucking on mints, chewing their nails, and smoking – sometimes all at the same time.
Under stress, the obese tend to eat beyond the point of satiety, to gratify the mouth even at the
expense of straining the stomach.
Lifestyle and peer pressure as reasons for over-eating: Lifestyle can be one of the most
damaging reasons for overeating, as it usually begins in early childhood. The pressure
actually starts with well-meaning parents who feel that a fat baby is healthy one; that all the
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food on your plate must be finished; and that a reward for doing something well should be
food, often a sweet. In most cultures, whenever company is invited, food must be made and
served – usually food that is fattening. Peer pressure is see in the form of a good Host who
must feed a lot and good Guests who must finish all that is cooked. The association of food
with all of these various activities and emotions is instilled at an early age and can cause a
lifetime of bad eating habits.
Poor self-image as a reason for over-eating: Poor self-image is possibly the most
significant and important reason for obesity. It is often immediately obvious from the way
people dress and carry themselves – the non-verbal clues they give. Soon this becomes a
cycle with poor self image leading and overeating in turn adding to the poor self – image.

X. PEPTIC ULCER

The stomach as we know pours out acid as well as pepsin as needed. Even before the meal
reaches the stomach, the specialized cells in the lining of the stomach wall have begun to
secrete digestive juices. With such a well-developed machine, we may sometimes wonder
how come the stomach does not digest itself. Since there is a lot of acid and pepsin around,
the stomach must take no chances. It has quite an effective defensive squad to handle the
equally powerful offensive squad. First, the surface lining cells pour forth a thick layer of
mucous that coats the stomach wall like a layer of protective Vaseline to keep the acid and
liquid away. Secondly, the lining cells pour forth their own antacid bicarbonate of soda which
can neutralize the acidity. Thirdly when acid approaches the surface lining, the surface cells
seem to tighten themselves up to repel the acid. Finally if injury takes place, neighbour
surface cells rush in to fill the gaps and replace the damaged cells. The stomach is a good
machine to defend itself against auto digestion.
At times thing do go wrong. The old slogan ‗no acid no ulcer‘ still holds true since pepsin can
only do damage in the presence of acid. The underlying cause of ulcer is still unknown. In a
healthy person there is a balance between the amount of acid and pepsin the stomach secretes,
and the ability of the stomach lining to resist their erosive action. High acidity combined with
small amounts of pepsin makes pure gastric juice one of the most corrosive of the body
secretions. We must conclude at present that ulcer develops when there is a breakdown in the
balance between the offensive squad – the acid pepsin attack and the defensive squad – the
normal protective machinery in the stomach wall. A number of factors can play their part in
undermining the local defences. Heredity is a factor. Your risk of getting an ulcer is increased
three fold if one of your blood relatives have ulcer, but how the genes allows this is unknown.
Cigarette smoking has been repeatedly shown to impair ulcer healing and increase ulcer
recurrence. Many reasons have been proposed, including stimulation of acid formation,
reduction in blood flow, increased reflux of bile from the duodenum into the stomach.
Whatever be the reason, cigarette smoking does its damage.
Psychological stress also causes ulcer: Caffeine a very strong starter of acid secretion.
Alcohol is not a strong stimulant of acid secretion, but can interfere with the healing of
stomach lining. The potential side effects of non-steroidal anti-inflammatory drugs are ulcers.
Researchers are now debating whether peptic ulcers are associated with the infectious agent
Helicobacter pylori, which is existent in human stomachs. It has been found in all human
population and increases as we get older. It is found that many of the people with ulcers had
Helicobacter pylori.
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The striking feature in the pain of the stomach and duodenal peptic ulceration is the timing.
The pain seems to come on after meals. Eating again temporarily relieves it. Quite typically it
lets us know it is there because we are awakened with pain in the middle of the night. This is
clearly due to the fact that the stomach has emptied its last meal and is full of acid.
If the ulcer is left untreated three main serious complications are obstruction, perforation and
bleeding. When an ulcer occurs in the duodenum or in the narrow sector where the stomach
connects to the duodenum, this can cause spasms in the adjacent muscle and swelling of
surrounding tissues. This swelling can be an obstruction that can narrow the intestinal
opening or close it off completely preventing chyme from leaving the stomach. In such cases
the victim can vomit the stomach contents and nutritional needs will not be met and may
develop more problems.
Psychological stress can either aggravate or cause ulcers. Or due to the neuro-endocrine
response to stress several changes take place. In times of stress, all the body‘s system are
geared up into a state of arousal. The systems responsible for action all the energy and other
systems like digestion, bowel mobility shut down. Normal functioning of the digestive
system once again resumes after stress in over and the parasympathetic system takes over.
The stress-arousal response interferes with normal digestion and the relaxation response
restores normalcy in digestion. When stress becomes chronic state of flux. Periods of rest and
relaxation are very limited giving in sufficient time to the digestive process. This entire
process triggers or aggravates a whole range of Gastro-Intestinal disorders including acidity,
flatulence, irritable bowel syndrome and peptic ulcers.
Peptic ulcer either gastric or duodenal is a serious illness but not life threatening. It has a
tendency to recur and a tendency to be a lifetime one. The diagnosis must inevitably involve
rearrangement of many aspects of life habits and diets involving taking medication for a long
time. Duodenal ulcers are never malignant. On the other hand gastric ulcers may appear to be
benign but may become cancerous. But most of the time ulcers are benign or malignant from
the start and several biopsies must be performed to be certain of the ulcer status

XI. STRESS AND NEGATIVE MOOD, DEPRESSION AND ANXIETY

The relationship between stress and negative mood seems obvious – stress puts people in a
bad mood. Being in a bad mood can change immune function. One group of researchers
(Futterman, Kemeny, Shapiro, & Fahey, 1994) investigated the effect of mood change on
immune function by inducing positive and negative mood states in a group of actors and
measuring their immune function afterward. They found that mood changes of both types
affected immune function. Thus, even daily normal mood swings can influence the function
of the immune system.

Negative affectivity is a general tendency to experience distress and dissatisfaction in a

variety of situations. Individuals high in negative affectivity focus on the negative aspects of
self, others, and situations; the result is a pessimistic view of life. They complain about their
health even when they are not sick.

Depression: The evidence that stressful life events cause depression is less than
overwhelming. In general, research suggests a slight tendency for stressful life events to be a
factor in depressive symptoms (Kessler, 1997). The ability to cope and coping resources,
however, are more closely associated with depression: people who can cope effectively are
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able to avoid depression. Again, the factor of negative affectivity may exacerbate stress,
making people complain of health problems more prone to poor coping and to increased
depression.

Depressed people are more likely than non depressed individuals to have experienced major
stressful life events preceding the onset of depression (Rabkin, 1993). Although the
correlations between life events and depression are typically quite small, some life events
have been shown to relate to depression. One such life event is the experience of chronic
disease, either as a person with the disease or as a caregiver. Heart disease (Holahan, Moos,
Holahan, & Brennan, 1995), cancer (Telch & Telch, 1985), AIDS (Fleishman & fogel, 1994),
and Alzheimer‘s disease (Rabins, 1989) have all been related to increased incidence of
depression. In addition, some research (Bodnar & Kiecolt-Glaser, 1994) indicates that the
depression of caring for an Alzheimer‘s patient persists even after the care giving has ended
with the patient‘s death. In general, caregivers are prone to become depressed (Wright, 1997).
Also, the incidence of depression seems to be directly proportional to amount of care giving;
that is, wives have the greatest burden for care giving, and care giving wives have the highest
rates for depression, followed by care giving daughters, sons, and husbands in that order
(Wright, 1997).

Anxiety Disorders: Anxiety disorders include a variety of fears and phobias, often leading to
avoidance behaviors. Included in this definition are such conditions as panic attack,
agoraphobia, generalized anxiety, obsessive-compulsive disorders, and posttraumatic stress
(American psychiatric Association, 1994). This section looks at stress as a possible
contributor to anxiety states.

One anxiety disorder that, by definition, is related to stress is posttraumatic stress disorder
(PTSD). The Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (American
Psychiatric Association, 1994) defines PTSD as ―the development of characteristic symptoms
following exposure to an extreme traumatic stressor involving direct personal experience of
an event that involving actual or threatened death or serious injury‖. PTSD can also stem
from experiencing threats to one‘s physical integrity; witnessing another person‘s serious
injury, death, or threatened physical integrity; and learning about death or injury to family
members or friends. The traumatic events often include military combat, but sexual assault,
physical attack, robbery, mugging, and other personal violent assaults can trigger
posttraumatic stress disorder.

Symptoms of PTSD include recurrent and intrusive memories of the traumatic event,
recurrent distressing dreams that replay the event, and extreme psychological and
physiological distress. Events that resemble or symbolize the original traumatic event as well
as anniversaries of that event may also trigger symptoms. People with posttraumatic stress
disorder attempt to avoid thoughts, feelings, or conversations about the event and to avoid
any person or place that might trigger acute distress
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XII. CANCER

The complex relationship between physical and psychological health is not well understood.
Scientists know that many types of stress activate the body‘s endocrine (hormone) system,
which in turn can cause changes in the immune system, the body‘s defense against infection
and disease including cancer. However, the immune system is a highly specialized network
whose activity is affected not only by stress but by a number of other factors. It has not been
clearly shown that stress-induced changes in the immune system directly cause cancer.

Some studies have indicated an increased incidence of early death, including cancer death,
among people who have experienced the recent loss of a spouse or other loved one. However,
most cancers have been developing for many years and are diagnosed only after they have
been growing in the body for a long time (from 2 to 3 years). This fact argues against an
association between the death of a loved one and the triggering of cancer.

The relationship between breast cancer and stress has received particular attention. Some
studies of women with breast cancer have shown significantly higher rates of this disease
among those women who experienced traumatic life events and losses within several years
before their diagnosis. Although studies have shown that stress factors (such as death of a
spouse, social isolation, and school examinations) alter the way the immune system
functions, they have not provided scientific evidence of a direct cause-and-effect relationship
between these immune system changes and the development of cancer. Studies suggest that
there is an important association between stressful life events, such as the death of a loved
one or divorce, and breast cancer risk. However, more research to find if there is a
relationship between psychological stress and the transformation of normal cells into
cancerous cells is needed.

One area that is currently being studied is the effect of stress on women already diagnosed
with breast cancer. These studies are looking at whether stress reduction can improve the
immune response and possibly slow cancer progression.

Studies that have looked at all kinds of cancer, not just breast cancer, have found no direct
evidence for a link with stress. If there is a link, different cancers are probably affected more
than others. And because breast cancer is affected by hormones – which are affected by stress
– stress may play more of a role in breast cancer than other types of cancer.

To find out if stress does have anything to do with the risk of cancer it is important to look at
the experiences of a lot of people – that is, whether people who have had severe stress in their
lives are more likely to get cancer.

Stress could also have indirect effects because people who are under stress may do things that
increase their risk of cancer – such as smoking and drinking too much alcohol. Good health
habits that might prevent cancer, like eating plenty of fresh fruit and vegetables and getting
enough exercise, may also fall by the wayside if one is stressed.
 72

Breast cancer: Breast cancer patients who feel high levels of stress concerning their
diagnosis and treatment show evidence of a weakened immune system compared to patients
experiencing less stress, a new preliminary study shows.

Researchers found that highly stressed women had lower levels of natural killer cells than
women who reported less stress. Natural killer cells are one vital weapon making up the
immune system.

―Natural killer cells have an extremely important function with regard to cancer because they
are capable of detecting and killing cancer cells,‖ said Barbara Andersen, leader of the
research team and Professor at Ohio State University. ―These results, although preliminary,
suggest that psychological stress may play a role in how the immune system responds to
cancer.‖ Andersen presented the results at the annual meeting of the American Psychological
Association. These results so far are the initial findings of an ongoing study that will examine
the relationship between stress, immunity and breast cancer. The study will involve more
than 200 women with breast cancer who are being treated at the Arthur G. James Cancer
Hospital and Research Institute at Ohio State or by collaborating physicians in the Columbus
area.

Women entered the study within one to two weeks of surgical treatment and before they
began any additional therapy. The women completed questionnaires that examined signs of
stress such as intrusive thoughts about the disease and attempts to avoid thinking or talking
about it.

The results are consistent with other studies that have found links between stress and immune
function in relatively healthy individuals.

For a cancer patient the process of dealing with cancer begins at the moment of the diagnosis.
The diagnosis of cancer is equal to a death warrant as society is conditioned to believe.
Cancer brings to mind several fears and preconceived notions/beliefs. While fear of
disfigurement and other fears of cancer may revolve around loss of function in activities of
daily living, in Breast cancer it strips the patient off her femininity. Her breasts give her
feminine shape and form symbolically as well as fulfilling the role of a mother. Breast cancer
can also lead to a loss of self-confidence about sexual attractiveness. Relearning to be
intimate is a challenge for the woman as well as her sexual partner owing to feeling of
awkwardness and good communication between partners and with medical professionals can
help resolve sexual concerns, as well as help her come to terms with her changed Body
image. The use of Prostheses can help a woman restore her outward appearances as well as
feel better balanced. With a warm supportive attitude of family and friends, there may still be
moments when a patient, even expatient feels isolated and alone. Healthcare professionals,
family and friends not having gone through the experience themselves may be seen to offer
limited comfort. At such moments, contact with other cancer patients who have succeeded in
returning to normal life can be invaluable. Support groups can provide a bridge back to
normal life and help the patient adhere to life enhancing regimens.
 73

While factors mentioned above don‘t cause cancer, they certainly aid in the prognosis as well
as quality of life, thereby reducing stress. Stress may not play a causative role, but certainly
acts as an exacerbating factor, even influencing prognosis from the disease

XIII. INSOMNIA

Insomnia is best considered a symptom & not a disease. It includes difficulty in falling
asleep, repeated or lengthy awakenings, waking up early, inadequate total sleep time, or poor
quality of sleep. Individual differences in sleep requirements and in the consequences of not
sleeping well (such as tiredness, lack of energy, difficulty concentrating, irritability, or
daytime sleepiness), as well as conflicts between subjective and objective measures of
nighttime sleep, all contribute to the challenge of assessing insomnia.

Approximately one-third of adult Americans have reported being affected by insomnia during
the course of a year. About 9% to 15% of patients with insomnia regard the problem as
severe. Insomnia is more common in females (1.3 times more frequent than in males ) and
older patients (frequency at age 65 and older is 1.5 times the frequency before age 65).
However, studies indicate significant problems with insomnia in 12% of adolescents.

Acute Insomnia: One classification system for insomnia is based on how long the patient has
had a problem sleeping. These categories include transient (lasting one to three nights), acute
(lasting from three nights to three weeks), and chronic (lasting more than three weeks, even
months or years). The duration of the insomnia will often influence the treatment plan, which
is why the question ―When did this problem begin?‖ is usually the most important one to ask
to focus the history taking.

Acute insomnia is extremely common. Typically, it is triggered by a physical or

psychological cause. Pain, excess caffeine intake, a noisy sleeping environment, and stressful
events during the day (good or bad ) are common examples (see box below). Acute insomnia
usually does not result in physician visits, either because the patient can easily identify the
cause or simply because the problem resolves soon enough.

The problem is not to be taken lightly, however, because acute insomnia can develop into a
chronic condition. Acute insomnia generally responds well to hypnotics, especially the
benzodiazepines or benzodiazepine receptor agonists, taken infrequently and judiciously. The
shorter-acting hypnotics include triazolam, zolpidem, and zaleplon. Their advantage is that
they are less likely to result in daytime drowsiness. Intermediate-acting hypnotics include
temazepam and estazolam.

When patients stop taking short-or intermediate-acting hypnotics after a period of nightly use,
they may experience several nights of insomnia that is worse than their original complaint, a
condition known as rebound insomnia. This problem can be avoided by tapering the dose of
the hypnotic over several days.

Possible Causes of Acute Insomnia:

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 Acute pain.
 Late eating, with gastroesophageal reflux.
 Use of caffeine or nicotine close to bedtime.
 Psychological stressors and anxiety provoking thoughts (usually negative, such as
work related problems or problems in a relationship; however, it can sometimes be
positive stressors, such as planning a wedding or preparing for an exciting vacation).
 Uncomfortable or unusual sleeping environment.
 New medications.
 Acute withdrawal of alcohol or some medications to produce daytime drowsiness.

Chronic insomnia: Some patients suffering from acute insomnia may take over-the –counter
sleeping aids oralcohol for weeks or even months before seeking help, by which time their
insomnia has become a chronic problem. Others may have taken hypnotics for a long time,
without benefit, before finally seeing a physician. In such cases, the patient may no longer be
able to identify the factors that contributed to the onset of the insomnia.

To manage chronic insomnia appropriately, it is important to find the underlying cause of the
problem before initiating therapy. These causes includes:

Medical disorders

 Asthma and chronic obstructive lung disease.

 Congestive heart failure.
 Gastroesophageal reflux.
 Rheumatic diseases.
 Obstructive sleep apnea.
 Side effect of medications.


Neurologic disorders

 Restless legs syndrome.

 Periodic limb movement disorder.
 Chronic headache.
 Parkinson‘s disease.
 Stroke.
 Epilepsy.

Psychiatric disorders

 Major depression.
 Mania.
 Generalized anxiety disorder.
 Panic attacks.
 Obsessive-compulsive disorder.
 75

 Drug-or alcohol-dependent sleep disorder.

 Circadian disorders.
 Shift work disorder.
 Time zone change disorder.
 Delayed sleep phase syndrome.
 Excessive daytime sleep.

Behavioral disorder

Psychophysiologic insomnia

Insomnia caused by circadian disorders: Shift workers may develop sleep-onset insomnia
as they rotate shifts, especially if they are starting an earlier shift. Some research indicates
that frequent rotation interferes with sleep more than shift work itself. If night shift is
maintained for a period of time, it gives individuals time to settle into a new sleep wake
cycle. Business travelers who cross time zones are at risk for chronic insomnia if they
develop maladaptive sleep behaviors. Some adolescents regularly stay up well past midnight
and sleep late in the mornings. This pattern, known as delayed sleep phase syndrome, will
usually result in sleep-onset insomnia when they try to go to sleep at an earlier time.

Insomnia caused by psychiatric disorders: Approximately 30% to 40% of people who

suffer from chronic insomnia have a coexisting psychiatric disorder. Both insomnia and
fatigue are important criteria in the diagnosis of depression and generalized anxiety disorder.
It is important to keep in mind that the patient who presents with chronic insomnia may have
an undiagnosed psychiatric disorder.

Psychophysiologic insomnia: Psychophysiologic insomnia is the second most common

cause of chronic insomnia after psychiatric disorders. If a stressful event, such as an acute
medical illness, divorce, or loss of a family member or job, occurs, it can precipitate
insomnia. Most people will develop appropriate coping mechanisms and the insomnia will
resolve. However, in some people, perpetuating factors develop that promote chronic
insomnia. These factors are learned behaviors: they include anxiety about the lack of sleep,
spending too much time in bed to compensate for the insomnia, spending time in bed engaged
in non-sleeping activities (for example, working or worrying), napping, increased day time
sleep to compensate for might sleep loss and dependence on alcohol or hypnotics.

Affected individuals become extremely concerned about the inability to sleep and the fatigue
they feel the next day. They fall into a pattern of actively trying to sleep instead of allowing
sleep to happen naturally. The resultant anxiety leads to a conditioned arousal response
towards the bedroom.

Extrinsic factors: It is important to inquire about extrinsic factors that may exacerbate
insomnia, such as excessive caffeine, nicotine, or a alcohol use. Although these factors are
not the primary cause of insomnia, their modification may be important in the overall
treatment plan. The patient may use alcohol, for example, as an aid in inducing sleep.
However, as alcohol is metabolized, the patient may experience sleep maintenance insomnia
 76

during the night. Unfortunately, withdrawal from alcohol can also result in insomnia.
Medications Including beta agonists, theophylline, beta blockers, and stimulating
antidepressants, can induce insomnia. A bedroom that is noisy, too cold or too hot, or not
dark enough may exacerbate insomnia in the predisposed patient.

Evaluating and Treating Chronic insomnia: A comprehensive sleep history is the most
important element in the evaluation of chronic insomnia. It is equally important to obtain
information from the bed partner, if there is one, as well as the patient.

When history suggests an underlying psychiatric disorder, appropriate screening tests may be
indicated. If dementia is suspected, mental status exams should be performed. It is helpful to
have patients keep a sleep diary for several weeks to determine certain patterns, such as what
time they go to bed, how long it takes them to fall asleep, non-sleep activities during the
night, and other behaviors that are not conducive to sleep.

Therapy should be directed to correct specific sleep disorders that may be producing or
exacerbating the insomnia
 77

CHAPTER 5:
PERSONALITY AS A STRESS
VARIABLE
Introduction to Personality as a Stress variable

Stress is matter of perception. Each individual responds differently to stress. Some people are
able to take great amount of stress in their stride, Infact; there are some people who do their
best when under stress. There are others who tend to break down with even the minimal
amount of stress. These differences indicate that the outside or environmental stressors alone
are not responsible for the person feeling stressed. Our own response to the situation is
equally important. Two people may go on a roller-coaster ride for the first time. For one, it
may be the most exciting time of his life because of the thrill involved, whereas for the other
person, it may be the longest two minutes he has ever spent. The personality of the individual
causes the person to react in a particular way.

Each personality is distinctly different and unique. All of us look different. Even the most
similar looking twins have some subtle differences in their appearance. Similarly, we all
think differently, feel differently and act differently. Personality is shaped as a result of
family influences, socio-cultural factors, birth order, gender, education, early life experiences,
exposure and several other factors. While some of these factors give each one of us our
uniqueness and individuality, other factors are common and shared with other people.

This specific personality make-up determines our feelings, thinking and behaviour and our
way of dealing with people and handling situations. It also determines how people and
situations, in turn, affect us, and the extent to which they affect us. Some personalities are
more prone to stress while others are relatively easy-going.

In spite of our differences there are some commonalties, on the basis of which all of us can be
grouped into several broad categories.

I. TYPES OF PERSONALITY

Let us consider some personality types and their stress proneness.

Suspicious Personality: A person with a suspicious personality is usually extra vigilant,
guarded and uneasy in social interactions. He appears to be cold and unemotional in social
situations. For such people, social interactions can be a source of tremendous stress as they
are unable to relate to others comfortably. Due to his suspicious nature, he finds it difficult to
take others into confidence and this propounds his stress levels.
As result of these personality traits this person is on guard and watchful most of the time. A
person with these traits not only creates problems for himself, also becomes a source of stress
 78

for others in his environment. His suspicious nature causes uneasiness, fear and conflict in
others as well as within himself. He is not able to be calm and relaxed.
Asocial Personality: There are some people who show social withdrawal. This type of
person often appears to be lonely and isolated, aloof and uninvolved. He loves to daydream
and any situation demanding involvement or active participation is extremely stressful.
Expression of appropriate anger or mature sexual functioning is characteristically lacking.
Due to the distant, introvert, and unsociable self, he may have remarkably little need or
longing for emotional ties with others. This could lead to a great deal of stress and stain in
interpersonal relations with those around him. So, he is unable to work in situations requiring
team effort. This becomes another source of stress for him since his employability and
capacity to hold on a job is poor. As he is unable to have ties with others, he is unable to
share his problems and seek advice in situations of distress. This further aggravates his
stressful situation.
Volatile Personality: The other extreme of asocial personality is the excitable, volatile
personality. These people are usually dramatic and flamboyant. However, these individuals
constantly need assurance from those around them and can be extremely dependent and
helpless without it. They are very demanding and manipulative in their interpersonal
behaviour. They are greatly stressed if they are unable to get the attention they want. They
also become a source of stress for the other person because of their clinging behaviour and
manipulations and also hinder the development of a relationship. Reciprocity and mutual give
and take, the features essential to sustain any relationship, are generally absent. Such people
often display irrational behavior, angry outbursts or tantrums whenever under stress, and this
stress in not being noticed, results, in their feeling left out/less important.
Antisocial Personality: There are certain people who are constantly in conflict with the
accepted social norms and rules. They are constantly aggressive and anti-social. They remain
misfits in all social situations. Poor occupational performances, inappropriate behaviour with
boss and subordinates, marital tensions, wife or child abuse are a regular feature. Although
their indifference, lack of concern and self-centeredness may make them appear stress-free,
there is an underlying frustration and stress, which takes on the form of unexplained
aggression and other antisocial behaviours. A deep emotional deprivation is usually
responsible for such behaviour.
Hypersensitive personality: On one hand, there is the antisocial personality who are
extremely unconcerned, and on the other hand, there is the hypersensitive personality who are
extremely touchy about everything. Due to their extreme sensitivity, these persons may lead
socially withdrawn lives. They have very low self-esteem and are overly touchy about their
short-comings. They need to have strong guarantees of uncritical acceptance. They show a
lack of self-confidence and appear shy in their interpersonal relationships. This lack of
assertiveness and self-confidence makes them prone to stress, especially in day-to-day
experiences.
Inadequate Personality: The people who belong to this category are lacking in self-
confidence, are passive and pessimistic. They find it difficult to express their own feelings.
They avoid positions of responsibility since they consider themselves to be incapable of
fulfilling responsibility adequately. A position of responsibility makes them anxious and
stressed as it leads to feelings of indecisiveness, further aggravating their sense of self-doubt
and lack of self-confidence.
Obsessive Personality: People with an obsessive personality may be too stubborn and insist
that things be done according to the ways suggested by them. They are often preoccupied by
 79

order and detail. They are extremely conventional, serious, and formal, stubborn, inflexible
and self-opinionated. They must have things done their way. The individual himself is under
plenty of stress because different options bother him greatly. He is afraid of making mistakes,
which further discourages his making choices. Lack of order and systems puts them under a
great deal of stress.
Passive Personality: Another category of people who postpone making choices and
completing tasks are those with a passive personality. They lack assertiveness in most
situations and are unable to state their needs clearly. At the same time, they can be quite
critical of others. As a result, they often get caught between passivity and aggression. This
confusion can be a great source of stress. Their inability to express their needs also causes a
lot of stress.

Most of us have some amount of all these traits. However, it becomes maladaptive if these
traits are found in extremes. To understand how stress will manifest itself in different people,
it becomes important to understand personality and its traits. Our personality types determine
how life-events are perceived and how we behave in response to stress. Certain personality
types are prone to specific illness. The understanding of personality types and their
manifestations help us to not only modify our behaviours, but also prevent the onset of
related illness

II. ILLNESS – PRONE PERSONALITY

Now let us consider some stress prone personality types and their illness proneness as well.
Table 5.1
Psychosomatic Ailments
Body Systems Personality Traits
Cardio-Vascular System Type A, Aggressive Compulsive Emotional Stress Phobia
Respiratory System Dependent, Submissive Over Protected
Gastrointestinal System Obsessive, Compulsive Passive – Aggressive Suppressed Anger
Musculoskeletal System All Types
 80

Headaches Emotional Stress Obsessive Type A Passive – Aggressive

Endocrine System Dependent, Submissive Timid

Type –A Personality

Type – A personality is characterized by high amount of ambition, feeling of competition and

impatience. These people are constantly hyperactive, preoccupied with deadlines and trying
to achieve a number of things in the shortest amount of time. Research has shown that people
with Type-A personality are prone to heart attacks and other heart-related problems. Type –A
behaviour has been understood as a coping response toward threat or possible loss of control.
In case of loss of control, the Type-A personality falls into a state of collapse.

Specific types of personalities seem to be more susceptible to the effects of stress than others.
In 1959, two cardiologists, Drs. Meyer Friedman and Ray Rosenman, summarized decades of
research to come up with the much publicized

Type A personality. The person with a Type A personality:

 Has a chronic sense of time urgency. Rushed and hurried, this person is always ―on
edge.‖
 Has quick and abrupt speech, often interrupting others.
 Is very competitive – even in noncompetitive situations.
 Is a hard-driving, achievement-oriented, and status-conscious person.
 Frequently becomes hostile and aggressive.

The relationship between type A personality and heart disease has become a common
knowledge, at least, among Cardiologists and their afflicted patients. There are two cardinal
features of type A that we must remember, namely, ―time urgency or time- impatience‖ and
―free-floating (all pervasive and ever-present) hostility.‖

Healthcare professionals have long been aware that certain behavioral features characterize
persons who develop coronary heart disease. In 1897, Sir William Osler noted that ―in the
worry and strain of modern life, arterial degeneration is not only very common but develops
at a relatively early age. For this, I believe that the high pressure at which men live, and the
habit of working the machine to its maximum capacity are responsible for coronary disease.‖
He went on to suggest that the typical person with coronary heart was not ―the delicate
neurotic‖ but the ―robust, the vigorous in mind and body, the keen and ambitious man, the
indicator of whose machine is always at full speed ahead‖.

Type A behavior can be considered a particular style of evaluating and coping with the
environment. Jenkins (1971) describes Type A personality as an overt behavioral syndrome
or style of living characterized by extremes of competitiveness, aggressiveness (sometimes
stringently repressed), haste, impatience, restlessness, hyperalertness, explosiveness of
speech, tenseness of facial musculature and feelings of being under the pressure of time and
 81

under the challenge of responsibility. Persons having this pattern are often so deeply
committed to their vocation that other aspects of their lives are relatively neglected.

Type A behavior has both cognitive and behavioral components. Cognitively, Type A
persons create much of their own stress by perceiving challenges and threats where others do
not (Glass, 1977). Type A persons emphasize competition and achievement and thus
consistently view tasks as challenges to their competency. Behaviorally, they work to exert
and maintain control when under stress. They work long hours, complete tasks in a rapid
fashion, and often engage in several tasks simultaneously. There appear to be three basic
components to coronary-prone behavior: time urgency, achievement striving
(competitiveness), and hostility (aggressiveness). Let us look at each of these.

Time Urgency. Type A persons always seem to be in a hurry. They typically do several
things at a time. They underestimate the amount of time that has passed (Glass, 1977). They
show frustration and impatience when they have to wait, and do more poorly on tasks that
require slow, careful responding (Glass, Snyder & Hollis, 1974). They walk, talk and eat very
quickly (Friedman & Rosenman, 1974).

Achievement Striving. Type A persons have an intense need to succeed. They perceive
situations as competitive. They have to win, even when playing games. Type A students
expect higher grades (Glass, 1977) and will work harder without a deadline. They self-
impose deadlines and view tasks as personal challenges, thereby creating stress. Type A
students are involved in more sports in high school and more extracurricular activities in
college. They are more likely to achieve academic honors. They ignore or suppress fatigue in
order to continue working on a task (Glass, 1977). They frequently feel guilty about ―doing
nothing‖ in the evening or on weekends.

Hostility. The third major facet of Type A behavior is hostility and aggressiveness. Type A
persons compete with and challenge others. Their speech is judged to carry more rancor and
contentiousness (Friedman & Rosenman, 1974). They respond to threat with aggressiveness
(Glass, 1977). There is a strong correlation between Type A behavior and hostility as
measured by personality tests (Williams, Haney & Blumenthal, 1981).

Type A Behaviour Pattern

1. Work long hours constantly under deadlines and conditions of overload.

2. Take work home on evenings and at weekends; they are unable to relax.
3. Often cut holidays short to get back to work, or may not even take a holiday.
4. Constantly compete with themselves and others; also drive themselves to meet high,
often unrealistic standards.
5. Feel frustrated in the work efforts of their subordinates.
6. Often irritable with work efforts of their subordinates.
7. Feel misunderstood by their superiors.
8. A general expression of vigor and energy, alertness and confidence.
9. A firm handshake and brisk walking pace.
10. Loud and/or vigorous voice .
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11. Terse speech, abbreviated responses.

12. Rapid speech and the acceleration of speech at the end of a longer sentence.
13. Explosive speech (speech punctuated with certain words spoken emphatically and this
is established as the speaker‘s general pattern) that may contain swear words.
14. Interruption by frequent rapid responses given before another speaker has completed
his question or statement.
15. Speech hurrying in the form of saying ―yes, yes‖ or ―mm, mm‖ or ― right, right‖ or by
nodding his head in assent while another person speaks.
16. Vehement reactions to questions relating to impedance of time progress (i.e., driving
slowly, waiting in lines).
17. Use of clenched fists or pointing his finger at you to emphasize his verbalization.
18. Frequent sighing especially related to questions about his work. It is important to
differentiate this from sighs of a depressed person.
19. Hostility directed at the interviewer or at the topics of the interview.
20. Frequent, abrupt and emphatic one word responses to your questions (i.e., Yes!
Never! Definitely! Absolutely!).

Association of Type A Behavior and Coronary Artery Disease.

Over forty studies have found an association between Type A behavior and atherosclerotic
coronary heart disease (Jenkins, 1981). Rather than providing an exhaustive review, two such
studies will be considered in detail. The Western Collaborative Group Study (Rosenman,
Brand, Jenkins, Friedman, Strauss & Wurm, 1975) is a classic. It began in 1960 as a
prospective study of the incidence of coronary heart disease in 3,524 men aged thirty-nine to
fifty-nine. At the beginning of the study, subjects were given an extensive medical exam and
were administered the structured Type A interview. Initially, 113 men had coronary heart
disease, 71% of whom displayed Type A behavior. The remaining subjects were followed of
the 257 men that developed coronary heart disease during this interval, 178 were classified as
Type A. Type A persons were over twice as likely to develop coronary artery disease. When
controlling for age, smoking, blood pressure, and blood cholesterol, Type A persons were
still twice as likely to develop coronary artery disease. Recurring heart attacks were observed
in 41 subjects, 34 of whom were Type A. Type A were five times as likely to have multiple
heart attacks. The relationship between Type A behavior and coronary artery disease was
linear; the higher the person‘s Type A score, the greater the risk.
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Table 5.2

Type A behavior has also been associated with coronary atherosclerosis (Williams, Haney,
Lee Kang, Blumenthal & Whalen, 1980). Subjects in this study were persons referred for
coronary angiography (filming the inside of the coronary arteries). Their angiograms were
interpreted by three cardiologists who had no knowledge of the Type A status of the subjects.
Any subject who had an obstruction of 75% or more in any of the coronary arteries was
considered to have a significant disease. In a sample of 307 men and 117 women, 71% of
those judged to be Type A had significant atherosclerosis compared to 56% of those judged
to be Type B. The findings were as strong for women as men.

A study of offshore rig workers showed that 36% of individuals identified as Type A reported
accident – involvement leading to injury. It was also observed that Type As were
significantly more dissatisfied with their job, demonstrated a greatly reduced level of mental
well- being and were often anxious and depressed.

The Development of Type A Behavior : (Glass, 1977) proposed that these patterns are
acquired during socialization via direct reinforcement and modeling. Butensky, Farelli,
Heebnere, and Waldron (1976) found the children from middle class homes displayed more
Type A behavior than their age- and sexmatched counterparts from rural working class
homes.

Suinn (1977) suggested that Type A behavior is maintained by both positive and negative
reinforcement. Type A actions are positively reinforced by the products achieved and
recognition of these accomplishments by others. An advertising executive, for example, who
is very aggressive and works long hours to have the highest accounts in the firm, is likely to
receive a raise and to be esteemed by coworkers and the boss. However, Type A persons also
create a lot of stress for themselves because they perceive their work as a challenge and
demand high quantities of work from themselves.

Cancer-Prone Personality: The occurrence of cancer is on the increase in recent years.

Plenty of research has gone into understanding the cancer personality, but no conclusive
results can be seen. It is difficult to say whether there is actually a cancer-prone personality or
 84

not. However, it has been established that people suffering from cancer have experience a
great loss or deprivation before the age of 15 years, leading to a sense of loneliness, anxiety
and depression. Once these feelings are entrenched in the person, this emotional stress can
cause a malignant growth. It is believed that psychological, emotional, and personal attitudes
play a very important role in the onset and course of cancer.

Personality is an important factor in coping with cancer. For many patients the best weapon
in the battle is a simple determination to go on living. For others it is ―fighting the enemy
from the first moment of contact‖ (Mountainn) it is this attitude that may decide the success
or failure of treatment.

For many years it has been suggested that certain personality traits may predispose people to
the development of cancer. Dating back to 2nd century A.D, Physician Galen suggested that
women with melancholic disposition were more likely to develop breast cancer than women
who were more sanguine. In 1701 Gendron and in more recent times, Lawrence Le Shan
suggest a strong personal component. Le Shan also suggest that a cancer patient is an end
product of a neurotic mechanism that goes back to childhood. While several other studies
have been done on a Cancer prone personality, many scholars are skeptical and believe that
variables such as age, age at menarche, age of first sexual intercourse, number of sexual
partners at an early age, age at first child birth, family history, exposure to carcinogens, diet,
substance abuse etc, all risks in themselves, were not controlled in studying the personality
correlation.

The Diagnostic and Statistical Manual of Psychiatry indicates that at least 50% of cancer
patients undergo some psychiatric disorder. While 68% experience adjustment disorder, only
13% actually suffer from Major Depressive disorder. Adjustment disorders are frequently
associated with major crisis situations and respond well to psychological intervention.

Another theory suggests that the way people cope with the news of cancer depends in part on
how they are used to coping with other crisis of life a (Time Life Books). A study by Bernie
S. Siegel, Surgeon & Professor at Yale University suggests that every person has a ‗healing
potential‘. The ability of a person to develop this potential is the difference between one
patient surviving and another succumbing.

David Spiegel‘s rigorous study with 86 women with Metastatic breast cancer followed over
ten years, indicated longer survival time for women who went through psychological
intervention. Deepak Chopra in ―Unconditional life‖ and ―Quantum Healing‖ writes about
many Breast Cancer patients who had miraculous remissions when Transcendental
Meditation and Ayurvedic treatment was added to conservative medical treatment.

While personality may or may not cause cancer it certainly influences the prognosis. Women
who internalize and suppress the trauma, which adopt a passive approach reduce their coping
skills.

Justice Bird never had a serious illness in life. The first reaction after a diagnosis of cancer
was a denial to learn anything about the disease. After surgery, Justice Bird got busy with
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work and any thoughts about cancer were suppressed. Until a relapse forced an attitude of
facing up to, seeking information, support and counseling.

The best weapon in this battle is a simple determination to go on living – to live a normal life.
When Nick Tannis, a 27 year old University Teacher was diagnosed with cancer, his first
statement was ―Damnit, I am going to live.‖ Nick missed only 2 classes during his treatment.

While it makes sense to have faith in Medical practitioners and their treatment plan, it also
makes sense to have faith in oneself and one‘s ability to bounce back. With a patient being
assertive and involved in her treatment an important link in the chain is complete.

Cancer Prone Personality – Some Research Findings

2nd century AD, Galen – Women with melancholic dispositions were more likely to
develop Breast Cancer than women who were sanguine.

1701, Gordon depressed and anxious women were more prone to develop Cancer.

Lawrance Le Shan – A highly regarded psychologist, more than 30 years ago pioneered the
startling theory that cancer has a personal component. He argued that becoming a Cancer
patient is the end product of neurotic mechanism that goes back to childhood. He used
psychotherapy to revive the patient‘s instinct to heal.

Schmale & Ikee, 1981, gave the MMPI and an interview to women who had suspicious
looking cells in their cervix. Then, before the tests could determine whether or not the cells
were cancerous, they tried to predict who did and did not have cancer. Based on their
hypothesis that high levels of hopelessness would predispose patients to cancer they correctly
predicted the occurrence of cancer in 36 of the 51 cases.

Shekelle & colleagues, 1981, using MMPI, found that depression in a group of more than
2000 healthy males was associated with a in cancer during the 17 years he followed these
patients after the initial testing.

Professional Interventions and support groups to Teach Coping Skills

Carl Simonton, (Physician & Radiologist), & Stephanie Mathews. Simonton approach – the
well known & controversial program – involved relaxation therapy, physical exercise and
dietary changes along with limited medical treatment for cancer patients. The program also
prescribed imagery, that is imagining the demise of cancer cells at the hands of the body‘s
natural defense system. They suggested that this would promote disease repression and even
lead to cure e.g.- White knights & armadillos -where no trace of tumor was found in the
pancreases. But no scientifically acceptable paper was ever published to establish this
program as a practice.

Bernie S Siegel – Surgeon & Professor at Yale University in his 1986 Best selling book –
Love, Medicine and Miracles, suggested a correlation between illness and attitude or belief
system. Every person has a ―healing potential‖ can be facilitated by love, therapeutic
confrontation and one‘s attitude. Ability to develop this healing power would result in some
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patients showing relatively few side effects and others becoming very ill, some patients
surviving and others succumbing. He created the ―Exceptional Cancer

Patient” approach – a specialized form of individual & group therapy to facilitate healing
within each individual.

David Spiegel & Colleagues – (1989) studied 86 women with Metastatic advanced Breast
Cancer were split into a group that received weekly supportive group therapy for a year or to
a control group that did not receive psychological intervention. Each group therapy session
lasted approx 90 minutes and was led by a psychiatrist along with a co-therapist who had
breast cancer in remission. The focus was to identify strategies for coping & increase social
support. Patients were not told about the different interventions and effect on the course of
Cancer. A follow up for 10 years showed 3 survivors at the end of 10 years, all form the
treatment group. Results showed a survival time for patients in treatment group was longer by
18 months or more. Psychological intervention can up survival time of Metastatic breast
cancer.

M.R. Jensen (1978) – Yale University suggested that Breast Cancer spreads faster in women
with repressed personality, helplessness, inability to express anger and negative emotions.

A Study of 400 cases of spontaneous remission of cancer, interpreted by Elmer & Alyce
Green of Menninger clinic, found one common factor in all patients: a change of attitude after
cancer occurred. They became more hopeful, courageous and positive remission happened
thereafter.

Heinrich and Schag, 1985, randomly assigned 51 cancer patients to usual medical care and
usual medical care + stress management program. Prior to, immediately after, and 4 months
after treatment, clients were assessed on – knowledge of cancer, coping activity, activities of
daily living, adjustment specific to cancer related problems, quality of life and general
psychological problems. The Stress management program comprised of Cognitive,
Behavioral, Problem Solving, Relaxation techniques and Education on cancer and treatment.
The stress management group reported increased quality of coping & more satisfaction with
medical care.

Telch and Telch, 1985, studied 41 Cancer patients and randomly assigned patients to one or
three groups:

1. Coping skills training.

2. Support group therapy.
3. No psychological treatment.

All patients were assessed before & after treatment. The coping skills program comprised of
Relaxation, Problem solving, Communication skills, Assertiveness, Affect management and
Activity planning. The study showed that the Coping skills groups had most improvement on
all measures. The second best was Group therapy.
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Pethingale & colleagues (1977) in their study showed that Breast Cancer patients who
reacted to their cancer with a ‗fighting spirit‘ were more likely to be disease free 10 years
after their treatment than women characterized by stoic acceptance of their disease or by
feelings of helplessness & hopelessness.

Spiegal, Bloom and Yalom (1981) compared women with breast cancer who did and did not
participate in a social support group. One year later, support group participants reported less
anxiety, confusion and fatigue, fewer phobias and maladaptive coping responses and more
vigor relative to the non-participants.

Dr. Deepak Chopra ‘Mind Body Medicine’ – Endocrinologist and founder President of
American Association of Ayurvedic Medicine, administers Transcendental Meditation,
Visualization, Ayurvedic remedies and more balanced lifestyle along with Medical Therapy
with the patient‘s Oncologist. Practice of Relaxation techniques changes the Brain waves
from Beta to Alpha (and later to Theta & Delta states). It also reduces the arousal response of
the endocrine system. Several records of cancer patients in his IP facility in Lancaster, USA
show a remission and recovery that looks more like a miracle.Being positive does not mean
that you don‘t experience negative emotions & thoughts. When it is natural and unavoidable
you do experience them, but are not at their mercy. A positive attitude towards illness is, to
emerge above the negative, not to not experience it.

Whortman & Dunkel and Schelter in 1979 found support groups were important. They
were defined as a group of peers who share the same disease and who experience similar
problems. Sharing similar experiences may serve as a particularly potent coping model and
consequently enhance prognosis and quality of life.

Migraine – Prone Personality: Migraine and tension headaches are becoming increasingly
common today. Obsessive personalities who feel overly controlled and suppress their anger
are often the ones who suffer from migraines. These people often feel a sense of
unworthiness and have a tendency to accept a greater burden of work than they can cope
with. They are also easily given to frustrations and sudden outbursts of anger.

Migraine has assumed alarming proportions under modern conditions of living and is now
believed to afflict about 10 percent of the world‘s population. Migraine can be defined as a
paroxysmal affliction, accompanied by severe headache, generally on one side of the head
and associated with disorders of digestion, liver and vision. It usually occurs when the person
is under great mental tension or has suddenly got over that state.

Migraine is one of the most common disorders in office practice. It affects more than eleven
million Americans. Migraine may possibly be considered an exaggeration of normal
phenomena. For example, an important part of migraine is vasospasm, the squeezing down of
arteries. Arterial muscle tone regulates blood flow and is always precisely controlled. Almost
everyone experiences some dysregulation of their arterial tone (state of spasm) from time to
time.
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Phases of Migraine Attack

Aura (vasospasm) – At this time, arteries squeeze down or constrict (vasoconstriction).

Some of the brain may not get a sufficient supply of blood There will be a neurological
deficit of some kind. In some instances and especially in the visual area in the back of the
brain, brain tissue that is not getting enough blood reacts by being more active electrically.
That is probably why some people have visions or distortions. This is what is meant by
positive visual phenomena. Most persons just have negative visual phenomena areas in their
field of vision of relative blindness. For all intents and purposes aura is equal to vasospasm.

Headache (Compensatory Vasodilatation) – The second phase of a migraine headache is

the pain phase. At this time arteries overly dilate. Cranial arteries are pain sensitive structures
whose walls contain tiny nerve endings that go into the trigeminal nerve. As the pulse beat
goes through a dilated sensitive artery, you may feel a pounding severe headache. Recall that
arteries constrict in the earlier aura phase and that in this second phase they now dilate. That
is why, classically, the aura ceases as you get into the pain phase. Not always, but most often
this does often. This pain is often accompanied by nausea and vomiting defining migraine as
a so-called, sick headache.

Inflammatory-muscle contraction – In the third phase, pain becomes more diffuse. There
are inflammatory chemicals and cells, (white blood cells) that come into the nervous system
and covering of the brain, the meninges. There is photophobia, fear or avoidance of light. The
person wants to be in a dark room. There can be a clouding of thought or mental functioning
and prolonged persistent misery.

Post-headache symptoms – Interestingly enough, some persons have a fourth phase as well,
a post-headache phase during which there are temporary psychological changes. Some feel a
sort of release, some fatigue, some people even a kind of elation. Connected with a full-
blown migraine attack is a whole host of chemicals that scientists have only recently started
to detect and define.

Migraine has more than just a physical side. Clinicians have noticed that certain kinds of
people tend to have migraines. They are often intelligent, compulsive and perfectionistic. A
lot times they may be fine while they are working hard or during an argument, but when they
try to relax on the weekend or during a vacation, they get nailed with a headache attack. It is
sometimes possible to find a relationship between headache frequency and life stresses. There
is a great debate in medical circles as to personality types and migraine. Migraine is
statistically related to both depressive and compulsive personalities. That‘s not to say that
every migraneur is compulsive or depressed, but many are.

Persons who suffer from this disease have a migrainous personality. They are intelligent,
sensitive, rigid, methodical and tend to be perfectionists. For them, everything has to be done
right away and when they finish, they come down suddenly from a state of utmost mental
tension to a feeling of great relief. Then all of a sudden, comes the migraine which is a purely
psychological process. The head and neck muscles, reacting from continuous stress become
overworked. The tight muscles squeeze the arteries and reduce blood flow. Then, when the
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person relaxes suddenly, the constricted muscles expand, stretching the blood-vessel wall.
With each heartbeat, the blood pushes through these vessels and expands them further,
causing intense pain.

Sleep is a big factor. Often sleep may vary as when someone is on a swing shift at work or
there may be a sleep disorder with significant insomnia nocturnal sleep that varies with
interspersed daytime sleeping patterns. This is important for several reasons. The brainstem,
involved in migraine, also affects sleep. Depression and many emotional disorders are almost
always tied to disturbed sleep. In fact all other things being equal doctors use sleep health and
regularity as the most important single index of a person‘s mental health.

Migraine may result from a lot of causes such as low blood sugar, allergy, infection,
excessive intake of certain drugs like vitamin A, weak constitution, low energy, nutritional
deficiency, overwork, improper sleep and rest, excessive smoking, drinking and sex.
Menstruation in women may also be one of the important causes of migraine due to the effect
of chemical hormone changes occurring during this period. This form of migraine is usually
eliminated with menopause.

There are various factors which trigger off migraine. The most important is consuming food
which the patient may be allergic to. Such foods include certain chocolates, cheese and other
dairy products, fried foods in general, onions, tomatoes, citrus fruits as well as coffee, tea,
nicotine and alcoholic drinks which stimulate or depress the nerves and alter the size of blood
vessels. Other triggers include excessive bright light, eye-strain, excitement, fright, hurry,
anger, resentment and depression after hard work.

Whatever be the cause of the migraine, it is essential to remember that dealing with the stress
causing factor itself gives relief from the migraine.

Besides these specific disorders, there are certain other illnesses, which are a result of the
personality of the individual. The inhibited personality, who is shy, nervous, and has
difficulty expressing anger, may develop rheumatoid arthritis. If exposed to severe and long
duration of stress, ulcerative colitis is another stress related problem, which may be seen in
persons with obsessive personality. People who are greatly preoccupied with neatness,
morality and conformity, and who find it difficult to express hostility directly is very likely to
develop ulcerative colitis. Diabetes, peptic ulcers and asthma are also some of the diseases
caused by stress and influenced by the personality type of the person.

III. PERSONALITY CHARACTERISTICS AS MODERATORS OF STRESS

RESPONSE

Response to stress is the product of the situation and the individual personality, taking into
account all the factors which influence resistance and /or increase vulnerability.

This approach to the understanding of stress is termed the interactive model; researchers
assess how the characteristics of the individual and those of the situation work
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simultaneously and in interaction to produce stress with physiological, psychological and

organizational consequences.

Attempts have been made to understand certain dimensions of personality as moderators of

the response to stress. These include:

Extroversion – Introversion: Neuroticism, Type A behaviour, Locus of Control, and the

‗Hardy‘ personality. Extroversion – Introversion: Eysenck (1967) described personality in
terms of ‗type‘ where type is defined as a group of correlated traits. Traits are simply
described as groups of correlated behavioral acts or action tendencies. The extrovert is seen
as sociable, cheerful, talkative, lively and outgoing, whereas the introvert is quieter, shy,
more withdrawn and unsociable. The majority of the population is at the midpoint of the E-I
dimension.

Physiologically, differences are also related to the level of activity in the corticoreticular
loop. Higher levels of cortical activity are observed in introverts, so they are in a significantly
higher state of arousal than extroverts. This observation has implications in the prediction of
performance. Physiological arousal progressively increases during the daytime, so extroverts
are sub optimally aroused in the afternoon (Eysenck, 1982). Research indicates that the body
temperature of introverts is higher than that of extroverts early in the day, but is lower in the
evening. The arousal theory explains the differences in preference for social contact between
introverts and extroverts. Social interaction and interpersonal intimacy increases arousal
level, thus, the stimulus-seeking extrovert will be positively influenced by social contact.
Extroverts, with low arousal levels or high arousal threshold will require and seek more
stimulation and be less tolerant to monotonous, routine conditions.

The degree of extroversion is also suggested as a modifier of response to stress (Eysenck,

1967; Brebner and Cooper, 1979). The extrovert is seen as geared to respond and will attempt
a response when given the opportunity. Kahn et al (1964) found that reaction to role conflict
was mediated by personality.

Introverts reacted more negatively and suffered greater tension than extroverts. However,
extroverts are more likely to participate in behaviour that may both exacerbate the response to
stress and constitute an additional source of stress; extroverts drink more alcohol than
introverts, are more likely to seek the stimulation afforded by cigarette smoking and consume
spicy foods.

Stability–Neuroticism and Behaviour: Eysenck (1967) identifies the factor of neuroticism

in the structure of personality, which predisposes a person to respond to stress with neurotic
symptoms.

Furnham (1981) found that neurotic individuals tend to avoid stimulating, active and unusual
situations more than stable individuals. In intimate, interpersonal situations, attempts are
made to reduce the level of intimacy by gaze avoidance.

Although shyness is associated with anxious behaviour, Eysenck and Eysenck (1969)
postulate two distinct forms of social shyness. Introverted shyness stems from the preference
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to be alone, although the introvert is capable of functioning effectively in company. However,

the neurotic individual may desire the company of others but is also fearful of it because of
worries of inadequacy. In the work environment, neurotics and neurotic – introverts are the
most susceptible to stressful situations. High emotionality is likely to affect performance, but
can both hinder or facilitate performance.

Locus of Control: Another personality characteristic which might be an important moderator

of response to a stressful situation is described as locus of control. This construct, attributed
to Rotter (1966) is based on an interactionistic view of the person. The individual learns from
the environment through modeling and past experience and reinforcement of certain
behaviours has an effect on expectancy. Eventually expectancy leads to behaviour. Locus of
control refers to the extent to which the individual perceives that he/she has control over a
given situation. Someone with an internal locus of control believes that she plays a role in
determining the events that impinge upon her. Thus, she suffers less threat and fewer adverse
consequences than the externally oriented individual who tends to believe in luck or fate. The
person with external control believes that she has little influence upon situations and
outcomes.

Internality is associated with academic success and motivation to achieve (Rotter, 1966). The
external appears to be less able to deal with frustration, tends to be more anxious and is less
concerned with achievement; thus, psychological adjustment and coping ability are poorer.
Externals are likely to be compliant and conforming individuals, prone to persuasion and
ready to accept information, whereas internals prefer to be in control and resist efforts aimed
at manipulating their behaviour (McKenna, 1987). Phares (1984) suggests that the most basic
difference between internals and externals is in the way that they seek knowledge about their
environment. Internals put more effort into obtaining information because they feel in control
of the reinforcement or reward that results from their subsequent behaviour. For example,
Arndt et al (1983) found that secretarial staff, classified as externals, were more reluctant to
use word processing equipment than internals, who displayed a natural curiosity about the
potential of the equipment. Thus, the internal- external dimension of locus control may be an
important moderator in the stress associated with the introduction of new technology.

Rotter (1966) also suggests that both extreme externals and internals are more maladjusted
psychologically than individuals scoring in the mid-range of the dimension.

The ‘Hardy’ Personality: Hardiness is considered to keep a person healthy despite the
experience of stressful life events. Stress resistance is expressed as commitment vs alienation,
control vs powerlessness and challenge vs threat. Commitment means the tendency to fully
involve oneself in whatever one is doing rather than disengaging. Challenge involves the
expectation that it is normal for life to change and that change stimulates personal growth.
Thus, the individual tends to look for stimulation and opportunities with an openness of mind
and willingness to experiment. Control is defined as the tendency to believe and act, as if one
can influence the course of events (the same description as applied to the internal oriented
person in locus of control theory). As Kobasa (1982) suggests, hardiness facilitates a form of
coping that includes the ability
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to keep specific stressors in perspective, knowing that one has the resources with which to
respond, and seeing stressful situations as potential opportunities for change (even
undesirable events are viewed in terms of possibility rather than threat).

Being hardy is important for one‘s health especially when one is undergoing an intensely
stressful time (Kobasa, 1982) but application of the theory to other occupational and social
groups has yet to be demonstrated

IV. PERSONAL VARIABLES AS MODERATORS OF THE STRESS RESPONSE

 Gender: The changing role of women in contemporary society has produced a significant
amount of research interest and this extends into the area of the stress-strain relationship
as well. In terms of risk for stress-related illness, women have been at less risk than men
but increasingly it is acknowledged that if women work like men, they die like men. For
example, Davidson and Cooper (1983) found that certain stressors in society have a more
adverse impact on women than men; these include male attitudes towards working
women, lack of resource support for working mothers and expectations in child rearing
practices etc. Behavioral response to stress includes a substantial increase in the
proportion of women alcoholics in the early 1960s and late 1970s (Cooper and Davidson,
1982); female managers tend to smoke more than women in other occupational groups and
more than their male counterparts (Jacobson, 1981); and female executives take
significantly more tranquillizers, sleeping pills and antidepressants than male
executives.For full-time working women, the associations are stronger with work than
with the family. As Karasek et al suggest, this shows that it is mainly job- related
problems and not family ones that are the cause of employees‘ psychological trouble.
Studies of women in the blue-collar environment are more rare and sex-difference
comparisons are usually impossible because the nature of the work varies as a function of
gender.

 Education, Ability and Experience: These variables are viewed as important moderators
in the response to stress, because they influence the perception of demand and threat, and
affect the neds and value systems of the individual. Coping mechanisms are dependent on
experience and these in turn are related to one‘s level of educational attainment.For
example, an understanding of role or work overload as a source of stress must include the
concepts of ability for the job. Qualitative work overload also relates to ability, in that,
some employees may not complete the work successfully, regardless of time allowed
because they do not have the skill required to perform the task. Experience as a moderator
is the essence of training, especially in coping with crises situations, where rote behaviour
is necessary to override fear and panic.

 Ethnicity: Membership of a particular racial or minority group can also affect an

individual‘s response to stress. Racial prejudice may promote feelings of inadequacy,
inferiority or low self-esteem and these will indirectly act as modifiers of the stress
response. Low morale and poor motivation will also reduce tolerance to other stressors.
Lack of role models in life in general or more specifically in the workplace can create a
stress situation, and exacerbate response to other stressors, which leads to role conflict and
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role ambiguity for the racially different or distinct individuals, for example, occupying a
job for the first time, without the support of a sympathetic peer group.

 Age, Life stage and Physical condition: Age is a significant moderator of response to
stress and is considered here with the physical condition of the individual. Each life stage
has its own particular vulnerability and coping mechanism (McLean, 1979) and so
response to stress is an ever changing, dynamic process. The response of older individuals
to experimental stressors indicates a stronger activation of the sympathetic nervous
system, but in real – life working conditions, individual coping strategies may
counterbalance this effect.The impact of stress may be influenced by the age of an
individual in two ways. First, the biological condition of the person will mediate the
response. For example, complaints about the physical strain of work, such as difficulties in
adapting to shift work increases with age. Age in relation to past experiences, will affect
the way stress is perceived. Second, one‘s physical condition is likely to be related to the
age of the individual. Intuitively it seems that an unfit or ill (physically or mentally)
employee may be less tolerant and more vulnerable to other stressors at work.

 Diet: Overeating and the resulting obesity may be the response to a stressful situation but
ultimately obesity will become the stressor, which increases the likelihood of cardiac and
respiratory illnesses or diabetes. An individual under pressure may respond by eating
spicy foods, high in salt content and therefore will exacerbate a hypertension condition. As
Quick and Quick indicate, use of certain palliatives such as caffeine, alcohol and tobacco
will result in the development of arrhythmias (heartbeat irregularities), ulcers and gastritis
among individuals predisposed to these responses.

 Social support: The value of supportive relationship in one‘s social network, as a

protection against adverse environmental forces or negative life events, has intuitive
common-sense appeal. Conceptually, social support theory owes its origins to the
discipline of sociology. Social identity and evaluation of self-esteem are based on social
interaction (Mead, 1934) and ‗anomie‘ theory (Durkheim, 1951) which states that
psychological well-being is associated with social integration. In an attempt to understand
why some individuals suffer adverse consequences from exposure to stressful situations
and others remain apparently unaffected, the concept of social support is cited as an
intervening or conditioning variable in the stress perception process. Knowledge that
social support is available affects the way a stressor is perceived and the coping strategy
adopted; it is, therefore, a socially learned response with a predisposition to respond in a
certain way.

Social support consists entirely of information, leading the individual to believe, that she:

1. Is cared for and loved;

2. Is esteemed and valued;
3. Belongs to a network of communication and mutual obligation in which others can be
counted on, should the need arise.

Studies have consistently shown that individuals who lack social support from family, friends
and the community have more symptoms of physical and psychological ill-health than those
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with support. Gore (1978) reports higher serum cholesterol levels, depression and illness
among the unemployed who lack social support compared to those with supportive
relationships. Lack of support from a spouse or partner was also related to poor mental well-
being, anxiety and depression
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CHAPTER 6:
SOURCES OF STRESS
Introduction to Sources of Stress

Searching for sources of stress in the environment is consistent with the concept of stress as a
stimulus (Kasl, 1996). This view leads us to investigate factors that produce stress, to
quantify those sources of stress, and to relate them to health outcomes.

We face some challenge every day of our life. The challenge may come at home, at work or
in a social situation. Sometimes, some out-of-the-ordinary demands are placed on us. Stress
creates a state of arousal with which the body responds. We have all used the statement ―I am
under great stress‖ at one point or another. It is an undeniable fact that all of us face some
degree of stress almost everyday. The stress situation may vary from a specific incident to the
culmination of many small irritants.

Stress in a person is caused by external factors as well as internal factors. The same situation
may affect different people differently. So stress, to a great extent, is what we perceive it to
be. In the last chapter, we had talked about internal factors like personality, which influence
the perception of stress. In this chapter, we will study several external factors which cause
stress in a person as well as a few internal factors

1.ENVIRONMENT

Many people associate environmental sources of stress with urban life. They think of noise,
pollution, crowding, fear of crime, and personal alienation as being associated with city
living. However, adverse environmental factors are not limited to large metropolitan
communities alone, although they are frequently more concentrated there. Rural life can also
be noisy, polluted, hot, cold, humid, or even crowded, with many people living in a one-or
two-room dwelling. The noise from farm machinery is often louder than any experienced by
urban dwellers. And although air and water pollution usually originate in urban or industrial
settings, they may then disperse to other parts of the world.

While environmental sources of stress effect both rural and urban settings, factors such as
crowding, noise, pollution, fear of crime, and personal alienation combine to produce an
urban environment that is stressful to many city dwellers. Each source of stress needs to be
considered separately, as well as a combination of these stressors as they occur in a natural
context

Crowding: Experiments with animals have revealed a variety of adverse effects from high-
density living conditions (Calhoun, 1956,1962), but research on human health is not as clear.
When rats live in ideal conditions, they breed rapidly, and overcrowding occurs but does not
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progress to ―standing room only.‖ Rat behavior changes with population density. Male rats
form dominance hierarchies, and the dominant rats become more territorial and aggressive.
Infant mortality increases, and sexual behavior changes, resulting in a stable, high population
level but with higher levels of violence and poorer social integration. Crowding causes social,
emotional, and health changes in rats, but experiments to demonstrate similar effects in
humans are not ethically acceptable. Therefore, many of the studies with humans have been
short-term laboratory studies or naturalistic studies in crowded environments.

A distinction between the concepts of population density and crowding helps in

understanding the effects of crowding on humans. In 1972, Daniel Stokolsdefined population
density as a physical condition in which a large population occupies a limited space.
Crowding, however, is a psychological condition that arises from a person‘s perception of the
high-density environment in which that person is confined. Thus, density is necessary for
crowding but does not automatically produce the feeling of being crowded. The crush of
people in the lobby of a theater during intermission of a popular play may not be experienced
as crowding, despite the extremely high population density. Conversely, however, a reclusive
early American pioneer who migrated westward when a new resident came into his country
would also not be crowded. He may have felt uncomfortable living within 10 miles of another
person, but because the population was not dense, his experience would not meet Stokols‘s
definition of being crowded. The distinction between density and crowding means that
personal perceptions are critical in the definition of crowding.

Both density and crowding affect human behavior in negative ways, but the effect on mental
well-being is clearer than the effect on health. One study that weighs directly on the issue of
health and crowding was conducted within a prison environment (Paulus, McCain, & Cox,
1978). In addition to being crowded, prison inmates might find crowding particularly
unpleasant because they have no control over the type and duration of their housing

Pollution: Pollution is a second environmental condition that may produce stress, and
pollution affects health directly as well as through increased stress. Although pollution of the
environment has become an important concern , it is not a recent phenomenon. Both air and
water pollution predate history (Eckholm, 1977). Modern technology has given us more
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pollutants and speeded their dispersion, but it did not originate the practice of adding harmful
substances to air, water and soil.
Modern technology has increased not only the amount of pollution but also the potential for
accidents in the storing or handling of dangerous nuclear or chemical pollutants. An accident
with toxic chemicals could create extreme feelings of helplessness because such accidents are
beyond the control of many of the affected people. Indeed, these accidents may occur quite
randomly, as in a train derailment or a tanker accident, and thus are quite unpredictable.
Furthermore, the fear of accidents may pervade the entire neighborhoods near industries
where dangerous chemicals are used or manufactured, providing long-lasting stress for
residents (Baum, Gatchel, & Schaeffer, 1983; Moffatt, Phillimore, Bhopal, & Foy, 1995).
Studies on the psychological effects of pollution have implications for stress and health, and
several of these studies deal with feelings of personal control and perceived severity of the
pollution. According to an early study (Rankin, 1969), people who are concerned about air
pollution in their community frequently do not complain because they believe their protests
will do no good; that is, they feel helpless. Another study (Rotton, Yoshikawa, & Kaplan,
1979) investigated the effect of control over air quality and tolerance for frustration and
found that the perception of control is more crucial than the level of pollution in making the
experience stressful. In summary, pollution is a source of stress and its health effects are a
direct result of their toxic effects as well as indirect effects through increasing stress levels.
Noise: In addition to crowding and pollution, exposure to noise may produce stress. Noise is
considered a type of pollution because it is a disturbing unwanted stimulus that intrudes into a
person‘s environment. Evidence also shows a relationship between noise and health
problems, but again, the health effects of noise might be direct influences of noise rather than
indirect effects produced by increased stress. In addition, noise is quite difficult to define in
any objective way. Definitions are invariably subjective, because noise is a sound that a
person does not want to hear. Noise can be loud, soft, or somewhere between. One person‘s
music is another person‘s noise.
Defined by the objective criterion of volume, noise can produce detrimental health effects.
For example, workers exposed to high levels of noise reported more nausea, headaches,
impotence, argumentativeness, and moodiness than workers exposed to less noise (Cohen,
Glass, & Phillips, 1977). In a naturalistic study of the effects of noise on cognitive, physical,
and emotional factors in children (Evans, Hygge, & Bullinger, 1995), results indicated that
living in a high-noise area produced an elevation of physiological responses associated with
chronic stress. In addition, children living with high noise were less persistent in performing a
challenging cognitive task and reported more annoyance with the noise in their community.
Urban press: Crowding, pollution and noise can occur in any social context, but these
factors are a commonplace combination in the urban environment.Eric Graig (1993) used the
term urban press to refer to the many environmental stressors that affect city living.
Commuting hassles and fear of crime add to the urban dwellers‘ experience with crowding,
pollution, and noise. Graig pointed out that the laboratory studies on crowding, noise and
pollution fall far short of capturing the experience of actually living with these stressors.
Graig also noted that not only are all these sources of stress combined in city life, but that
they tend to be beyond personal control. Laboratory studies on noise and pollution indicate
that lack of control tends to make people feel more stressed, which may apply to these factors
in the urban environment.
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Crime is not unique to urban life, but fear of crime has become part of the urban environment
(Riger, 1985) and these fears can affect behavior, such as installing locks on the doors and
bars on the windows and avoiding locations perceived as high – crime areas.
Other research (Liska & Baccaglini, 1990) has shown more complex relationships between
newspaper reports and people‘s fear of crime, but these researches found that the information
in official crime statistics was mediated through newspaper coverage. Such studies
demonstrate the power of the press to increase or decrease the fear of crime.
When people fear victimization, their behavior changes and some changes can lead people to
withdraw from their communities (Taylor, Repetti, & Seeman, 1997). When people restrict
activities that might take them into areas considered dangerous, they restrict their social
interactions. For example, people who are concerned with increasing crime avoid walking
alone at night (Forde, 1993).

II. PERSONAL STRESSORS

Personal Relationships: Personal relationships are another potential source of stress, but
they can also buffer against stress; that is, people who have fewer personal relationships are
at increased health risk compared to those with more relationships (Berkman & Syme, 1979;
Hobfoll &Vaux, 1993). Relationships do not automatically provide benefits. As the research
on social support at work suggests, problems in personal relationships can create stress, but
supportive relationships can protect against stress. These effects are not unique to the work-
place but apply to other relationships as well.
In a survey of college students (Ptacek, Smith, & Zanas, 1992), one third of the stress events
involved relationships. The frequency of this source of stress should not be surprising
considering the number of potential relationships – coworkers, supervisors, friends, and
romantic partners as well as family relationships that include parents, children, spouses,
aunts, uncles and cousins. For the college students, nonfamily relationships were a more
frequent source of stress than family relationships, but perhaps the social circumstances of
college students tend to create more nonfamily interactions and stresses. College students
also give more importance to peer group than family relationships, hence increased stress.
Multiple commitments of employment and family can produce stress for both men and
women and this stress is increased by feelings of lack of support from the spouse.
Sleep problems: Sleep and stress interact: Stress is a common cause of sleep problems, and
difficulties in sleeping are a source of stress for many people (Rosch, 1996).
The most common sleep-related problem is insomnia, the inability either to fall asleep or to
stay asleep, but some people intentionally receive very little sleep in order to have more time
to do other things. Whether voluntary or involuntary, sleep deprivation is associated with a
variety of behavioral and health problems.
People who do not get sufficient sleep often feel tired, anxious, drowsy, weary, and fatigued;
the number of people affected has been estimated at between 30% – 50% of the population.
Adolescents often skip sleep to have more time to work, study or socialize; and adults
sometimes decrease their sleep time to do more work or to spend time with family.
Additionally, many jobs require shift work and changes in worker‘s sleep schedules.
Deprived of sleep, adolescents may fall asleep in class and adults may be too fatigued to
work efficiently. Sleep-deprived people have an increased risk for accidents resulting from
fatigue, impaired coordination and altered judgment.
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Life events: Any new event in your life can cause stress as you try to adjust to the demands
made by that event. Some events are more stressful than others as these events, themselves
can be positive or negative.
Research suggests that experiencing an excessive number of ‗life events‘ in a particular
period of time can lead to increased ill-health. The work of two American
researchers, Holmes and Rahe has indicated the relation of life events to our health. These
events range from day to day events to crisis situations that occur in everyone‘s life over a
lifetime—birth, death, marriage, divorce, new job, retirement, moving house or going for a
holiday. The important factor is how often you experience these changes, whether they occur
together at the same time or in a short period time and whether they are positive or negative.
It may be wise to avoid unnecessary additional changes when you have had a major life
event. Changing jobs soon after the death of your spouse, or moving to new house when you
have just had a child can add dramatically to the amount of stress you are already
experiencing and make coping with the situation extremely taxing.
Daily Events: Major life events are rare occurrences for most of us. You do not generally get
married more than once or have more than two or three children, or change jobs frequently.
Usually most of us are able to cope with these events quite effectively without being under
too much pressure
Table 6.1
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Holmes and Rahe Life Events Schedule

Events Stress Points
Death of a spouse 100
Divorce 73
Marital separation 65
Jail term 63
Death of a close family member 63
Personal injury or illness 3
Marriage 50
Fired at work 47
Marital reconciliation 45
Retirement 45
Change in a family member‘s health 44
Pregnancy 40
Sexual difficulties 39
Addition in the family 39
Business readjustment 39
Change in financial state 38
Death of a close friend 37
Change to a different line of work 36
Change in the number of arguments with spouse 35
Taking out of a large mortgage or loan 31
Foreclosure on mortgage or loan 30
Change in work responsibilities 29
Son or daughter leaving home 29
Trouble with in –laws 29
Outstanding personal achievement 28
Spouse begins or stops work 26
Starting or finishing school 26
Change in living conditions 25
Revision of personal habits 24
Trouble with boss 23
Change in work hours or conditions 20
Change in residence 20
Change in school 20
Change in recreational habits 19
Change in religious activities 19
Change in social activities 18
Taking out a small mortgage or loan 17
Change in sleeping habits 16
Change in the number of family gatherings 15
Change in eating habits 15
Holiday 13
Minor violation of the law 11

Total Score
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What does the score mean?

30 percent probability of developing an
Less than 150
illness, i.e., No more than average risk.
50 percent probability of developing an
Between 150 and 299
illness.
80 percent probability of developing an
Over 300
illness.

What could actually be more stressful are the small daily events which appear trivial, like
standing in long busqueues, getting stuck in a traffic jam, arguments and fights with an
uncooperative colleague at work, tension etween family members or a very sick, aging
parent. These daily tensions can produce a cumulative effect and like the proverbial last
straw, may result in your having a breakdown one day!

It might just be easier to muster up all available resources and support and deal with a major
crisis that happens in life. However, trivial but daily stressors have a way of sapping your
resources and reducing your stress tolerance threshold. Cumulative daily stress can do as
much if not more damage as a single major crisis event.

Chronic stress from such daily hassles or stressors can cause physiological damage and also
lead to the development of psychosomatic illnesses such as arthritis, irritable bowel
syndrome, bronchial asthma, hypertension, migraine and other chronic illnesses

Beliefs and Attitudes: All of us respond to potentially stressful situations in different ways.
It is not only the outside stressor that is important but also how you interact with that stressor.
How you perceive or adapt to a particular stressor depends upon your belief systems, your
expectations of yourself, of others and of life in general.

Your attitude to an event matters more than the event itself. If your beliefs and attitudes are
irrational they affect the way you think and perceive yourself and the world in general. It is
irrational to think that you must be right all the time, be loved by all people, be accepted by
everyone around you, that everybody should do things your way or that life must always be
pleasant, painless and smooth-sailing. It is not surprising, then, that certain assumptions,
beliefs and expectations bring with them certain negative consequences.

Most of our beliefs and values are formed and shaped by our family, friends, the group we
belong to, the sort of books we read, programs we watch on television and our social and
cultural background. These may not embody the absolute truth or reality although we often
think they do to the extent that they are accepted unquestioningly and this can result in
emotional distress or internal conflicts within us.

More than the stressful situation itself, it is our belief and attitude towards the situation that
makes it stressful. This belief gives it a negative or positive colour. Our beliefs are shaped by
past experiences. Past experiences of success increase confidence and the ability to cope with
a situation. Frequent failure undermines this ability and makes one respond with negativity.
 102

Unrealistic Expectations: McKay and Fanning, authors, of Self-Esteem, talk about the
power of ‗should‘ and ‗musts‘ reflecting our unrealistic beliefs and rigid attitudes.

 I should be in a higher position than I am in.

 I should never quarrel with my spouse.
 I must never raise my voice at my children.
 I should be generous and unselfish.
 I should be a perfect lover, friend, parent and student.
 I should be a super executive, super mom and super wife.
 I should be able to find a solution to every problem.
 I should have foreseen the problem.
 I must never be jealous.
 I should endure hardship with equanimity.
 I must not make mistakes.
 I will never be able to forgive myself if I fail.
 I should be completely self-reliant.
 I must not indulge.
 I must not cry since I am a man.
 I must take care of everyone who cares for me.

It is impossible to live up to all ‗Shoulds‘ and ‗Musts‘ that are forced upon us by the society
and culture in which we live. This absolute and rigid framework, demands super human
capability and therefore creates conditions of chronic stress.

‗Shoulds‘ and ‗Musts‘ should not be followed blindly without proper evaluation and self-
assessment. You need to have healthy values which are flexible, and realistic rather than
holding them as absolute, universal unchanging truths.

Negative Self-talk: Many a times you will be surprised to observe that you are holding silent
conversations with yourself. Psychologists call this self-talk. You may notice that often this
self-talk is negative in content, especially if you are a person who has a low self-image. This
self-talk can come with highly self-condemnatory statements, in which you may allude to
yourself as an ‗idiot‘, as ‗incompetent‘, ‗lazy‘, ‗a failure‘, or ‗no-gooder‘ even for the
slightest mistake. You may exaggerate your weaknesses, blow trivialities out of proportion
with statements like ‗I am fat and ugly. How can anyone like me?‘ or ‗I am so clumsy. How
can I do anything right?‘ You may not realize that you are being your own severest critic,
blaming yourself, judging yourself too harshly and undermining your self-worth all the time.

Such chronic negative thinking can lead to chronic stress, depression and physical ill-health.
Negative thoughts generate helplessness and a sense of lack of control over your body and
behavior and make you feel pessimistic. On the other hand, being optimistic and positive in
your thinking will create a belief in oneself and one‘s capabilities -improving self-esteem.
This state of well-being may actually protect your body and mind from stress and its ill-
effects and lead to a longer, happier life.
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Meaning in Life: There are those who may be in relative control of their lives, knowing
exactly what they want of it and go about living life purposefully and meaningfully; while
there may be some who are mere drifters, not sure what exactly they expect from themselves
or their lives. It is important to have an idea about what your goals and values are, whether
these are couched in religion, philosophy or morality. It provides a framework to plan your
life, lend meaning to your existence and giving a direction for the future. A clear goal and
vision for the future has the ability to pull us out of day to day stress and make goal
attainment the focus. This vision gives meaning to life and improves stress coping.

III. DOMESTIC STRESSORS

One of the most significant aspects of our lives is the home and family. In times of crisis, it is
the family that we turn to, for support and care. However, these finely tuned relationship can
also be a great source of stress. Demands and expectations of family members, daily routine
chores and tremendous pressure to perform can lead to high levels of stress.

Marriage: Of all the domestic relationships that are likely to become stressful, marriage is
the most complicated one. When two people from different backgrounds decide to live
together, there are bound to be differences. Each person has to make certain commitments
and some adjustments. The expectations from each other are also very high. If both persons
are able to look at the situation rationally, most of these differences are resolved over time. In
the event of adjustment problems, marital friction may be caused which can lead to excessive
stress for both the partners and in extreme situations, may also lead to a break-up.

The changing role of women in today‘s society also contributes towards domestic stress.
With the woman going out of the house, some household chores have to be taken up by the
man. The support system available has also reduced due to the break-up of joint families.
Couples are under greater pressure due to a fast paced life and changing lifestyles. Some men
feel unhappy and even threatened by their wives‘ success in their area of work. The woman
may feel trapped by her biological role and social expectations in bringing up a family on the
one hand and her own role to have a satisfying career on the other.

Studies have found that outside employment has helped women. Employment seems to have
a positive effect on the mental health of women. Employment improves their economic status
and self-esteem. It also alleviates boredom in women. However, it often creates a feeling of
independence that may not be acceptable in a traditional marriage.

The demanding roles of a wife, a mother caregiver and career woman makes the married
woman particularly susceptible to stress as she tries to balance the expectations of her
different roles to the best of her ability. The changing face of society and family, redefining
of roles, expectations of adjustment that one has not learned through childhood, all place a
great demand on the role of a man as well. He has to learn to share the status of head of the
family and bread winner, requiring some adjustment on his part.
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Some common problems affecting marriage and creating stress in the relationship are
mentioned here.

 Lack of communication with spouse.

 Difference in mutual interests.
 Recurrent financial problems.
 Sexual difficulties leading to frustration.
 Different values and priorities leading to conflict.
 Irrational jealousy.
 Unfaithfulness.
 Sharing of domestic chores.
 Spouse away from home too much.
 Conflicting careers.
 Illness of spouse.
 Prolonged separation.

Children : Although children can be a source of great joy, they can also be a source of stress.
The coming of a baby is stressful, physically and emotionally, even if the baby is planned and
desired. However, the looking after of the baby can also cause a lot of physical strain, loss of
sleep and loss of freedom. A newborn demands time and both parents need to readjust their
time schedules to meet this new need.

There is also an increase in financial responsibility and anxiety, which comes along with
rearing children. A newborn demands time and both parents need to readjust their own time
schedules to meet this new need.

Children are a source of excessive stress for the working women. Leaving children
unattended when going for work causes a great amount of anxiety and guilt in working
women. Sickness in children also leads to stress in women. Having a permanently
handicapped child further compounds the problem, as it may lead to the conflict of whether to
work or not.

Some common conditions created by children, both young and grownup, leading to increased
stress are as follows :

• Sick child left with permanent impairment.

• Disobedient children.
• Temper tantrums.
• Handicapped child.
• Lack of respect for parents or teachers.
• Conflict between own and children‘s interests.
• Child who plays truant.
• Poor academic performance.
• Bad behavior at school.
• Youngsters monopolizing the phone.
• Children with drug problems.
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• Generation gap.

Divorce : In spite of efforts on the part of both partners, the marriage may not work out. In
some cases, the stressful martial situation may end in a separation or a divorce. In the Holmes
– Rahe Life Events Schedule (LSE) divorce ranks as the second most stressful event. Life is
totally disrupted and a great amount of readjustment is required. The effect of divorce on the
children further complicates the situation and increases the stress on the divorcing couple.
While everything was shared so far, now two of everything needs to be created: two homes,
two sets of furniture, cars, even two sets of friends.

Readjusting after the divorce is also a greatly stressful situation. Being a single parent to the
children further increases stress. It has been said that it takes up to 5 years to readjust and
make a new beginning after a divorce. Social, financial, occupational, domestic and other
pressures increase and much adjustment is needed.

Death of a Spouse : Death of a spouse is the most stressful event. The severity of this stress is
seen to be the highest according to the Holmes and Rahe (LES). It totally devastates the life
of the family. Companionship and sharing that was available from the partner are suddenly
gone leaving the surviving partner very lonely and lost. In some cases the role of both parents
has to be played by one. The stress of loss is compounded by social and financial stresses.

Other Domestic Stressors:

1. In today‘s changing scenario, one of the sources of stress is also the decision to marry
or not. Although social and family expectations have not changed, younger people are
fast becoming career-oriented and consider marrying a hindrance. This conflict is
greater in the case of women.
2. Aging parents who are physically and / or financially dependent are also a source of
some stress. Sons and daughters living away from parents with the responsibility of
taking care of their needs places further stress on already busy day to day schedules.
3. Demanding in-laws and sharing house with other relatives has also been seen as a
domestic stress.
4. Other domestic and social Stressors :

 Single-parent family.
 Demanding pregnancy.
 Difficult neighbours.

IV. STRESS AT WORK

What‘s different about work that you find satisfying and challenging and work that you
dread? What makes some work healthy and some work a risk to your mental and physical
health? Read on to find out what makes work stressful and potentially harmful to your health
and what you can do about it.
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Contrary to what you might think, it is not just a matter of how demanding you find work that
can lead to ill health. Stressful work is more than ―demanding‖ work. Equally important
features of stressful work are when you have limited control over how you meet job demands
and the negative results of being unable to meet job demands. Job demands come in many
forms such as:

 Meeting a production quota.

 Solving a problem for a client or customer.
 Keeping up with the pace of a machine.
 The amount of time you are given to complete a task.
 The tools you are given to do a job.
 The workplace rules that govern your actions.

Job stressors are conditions or events at work that cause stress.

Three main sources of job stressors are :

 The physical work environment.

 The way jobs are organized or designed.
 General, social and economic conditions.

Sometimes the conditions that produce stress are short lived. You can usually gather
resources to cope with the situation. On the other hand, stressful working conditions may
persist with no end in sight. Your ability to cope dwindles over time. Often the strain spills
over into other parts of your life. In time the strain can threaten your health. The effects of
stressful work can be seen in your

 Mental and emotional well-being.

 Behaviour.
 Physical health.

In the short term you may feel frustrated, hostile, or anxious. The strain may be apparent in
your behaviour – excess use of alcohol, increased smoking, being absent from work, or poor
performance of our social roles, for example, as a parent or as a friend. In the long term,
stress can contribute to mental illness such as depression. Chronic stress can also contribute
to the onset or worsening of serious physical ailments such as :

 Heart disease.
 Diabetes.
 Stomach and bowel problems.
 Asthma.
 Rheumatoid arthritis.
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It is important to remember that stressful work does not affect all individuals in the same way
or at the same time. Also there are many other risk factors for these health problems,
especially the long-term physical problems. Nevertheless long-term stress is now a well-
recognized contributor to these disorders.

Most of our waking hours are spent at our place of work. Infact, work is an important part of
our self-identity. Work and workplace are a valuable source of satisfaction for us, and plays
an important role in the well-being of a person.

If the job is not to our satisfaction, or if we are unable to cope with the job, it becomes a
source of stress. A job can be a source of stress if there is dissatisfaction, work overload, too
many dead lines, conflicting demands, uncertainty, inadequate pay, noise, overcrowding etc.
Physical environment, nature of the job, and interpersonal relationships all go to make an
occupational environment stressful.

Fig 6.1

Job Characteristics: Some jobs are more stressful than the others by nature. There is a
tendency to think that occupational stress applies mainly to the busy executive. Studies have
shown that the executives experience less stress than the people immediately below them.
Part of the reason for this is attributed to their freedom to make choice and decisions. They
have a control over their working life, which is better than being unable to exert any control
over what has to be done.

There are various factors, which cause the job to be perceived as stressful:

Occupation, Control and Stress – Do business executives who must make many decisions
every day suffer more from a higher level of stress than do their employees who merely carry
out those decisions? Most executives have jobs in which the demands are high but so is their
level of control and research indicates that lack of control is more stressful than the burden of
decision making.

In most workplaces the employer decides how much control you have over decisions related
to your work. This element of control is very important. It involves the freedom or authority
to make decisions about how the work is done and the ability to use a range of skills on the
job. It is commonly thought that most stressful occupations have a great deal of responsibility
or many demands associated with them, corporate executives and doctors, for instance. But
over the last two decades, research has painted a very different picture. It has been found that
 108

the most demanding jobs place heavy stress on the worker when combined with little control
over how or when to meet the demands.

Assembly line workers, data entry operators, or retail service clerks are examples of high
demand-low control jobs. The negative results of not meeting job demands can range from
mild to severe. Examples are:

 Loss of self esteem for letting down coworkers or your supervisor.

 Reduced quality of service to clients.
 Receiving a reprimand, being fired.

High pressure and low control, the deadliest twin stressors – Unremitting job demands,
coupled with little or no control, can grind people into the ground. The combination is a
deadly duo that produces not only mental strain, but can also elevate blood pressure and
increase heart disease risks. Authoritarian practices that allow employees little or no
influence over the pace and execution of tasks produce great distress.

It‘s a fallacy to think that high-level positions carry the most stress. Although executives,
bureau chiefs and medical officers bear heavy responsibilities, they also possess the authority
to carry through their plans. Bosses who run the ship tend to be less stressed than
subordinates who have to simply follow instructions. Assistants, secretaries and nurses, who
often take the brunt of making things run smoothly but without authority to make decisions,
are highly prone to job distress.

Employees who feel more in command of their work are more likely to gain mastery over
other aspects of life, including their health. Jobs that give workers at least a modicum of
control over the work method and pace generally increase self-esteem and, while demanding,
produce efficacious employees who are energetic, assertive and self- reliant.

Employees who take part in decision-making are generally more cooperative, less prone to
sabotage, errors and illness. Supportive relationships can help to mute the ill effects of job
distress. Sharing and discussing problems may lessen the strain.

Learned helplessness can carry over into everyday life – While some react to stress by
trying to alter circumstances, many adopt a helpless, passive attitude, withdraw, stop trying
and take sick leave. Lack of decision-making influence induces a depressed attitude aptly
called learned helplessness. Learned helplessness may be the cumulative end-point of master-
servant relationships and being endlessly treated as a subordinate. This learned helplessness
may spill over into everyday life, undermining the will to make decisions, causing apathy and
lack of interest in community affairs. Feeling helpless at work, people come to believe they
cannot alter any aspect of their lives.

If the distress is not recognized and alleviated, the sense of helplessness may become
entrenched and lead to ill health. Instead of facing and dealing with mental health problems,
 109

explains one therapist, ailing workers who feel helpless may become disabled, dependent
persons, unable to work. Anxiety, depression or other stress- related disorders often express
themselves or somatize as physical ailments, such as muscular pain, headaches, digestive
upsets, sleeplessness and cardiovascular (heart) symptoms. People may unconsciously deny
the underlying reasons for distress, labelling mental and emotional problems as physical
ailments that call for medical treatment, thus avoiding the stigma of mental illness. Taking on
the sick role because of organic ailments, they seek medical instead of the needed
psychological therapy. Many studies now link job stress to elevated blood pressure and
cardiovascular risks.

Workers who describe their jobs as overly demanding, especially with a low levels of
decision-latitude (little say in what they do) are more likely than others to develop
cardiovascular disease.

A Swedish study showed that young men working in non- learning occupations that under-
utilized their abilities were more susceptible than others to physical signs of stress, high
levels of blood adrenaline and elevated blood pressure. Other investigators found that men
who had heart attacks before age 45 identified less influence over their tasks than men
without heart problems. Job monotony was a significant discriminator between cases (men
with heart attack) and controls (those without heart attack).

The renowned British Whitehall study, which tracked 10,000 civil servants for nearly 20
years, found a striking difference in heart disease rates between those at the top and bottom of
the job ladder. Lower-rank civil servants (mainly unskilled manual workers) had coronary
disease rates almost four times greater than those in top (administrative) grades. The higher
illness rates of lowerrank employees cannot simply be attributed to poverty, as those studied
were far from impoverished or deprived and included people with substantial incomes. One
explanation is that because low job status is also associated with poor workplace support,
those in lower- rank jobs might be short on all three stress-reducing factors: a sense of
control, decision-making influence and social interaction.

Lower-level occupations are actually more stressful than executive jobs (Smith, Colligan,
Horning, & Hurrel, 1978). Using stress-related illness as a criterion, the jobs of construction
worker, secretary, laboratory technician, waiter or waitress, machine operator, farm worker,
and painter were among the most stressful. These jobs all share a high level of demand
combined with a low level of control. Another highly stressful job is that of the middle-level
manager, such as a Foreman or Supervisor. Middle managers must meet demands from two
directions: their bosses and their workers. Thus, they have more than their share of stress and
stress-related illnesses.

Repetitive Jobs : There is nothing more stressful in an occupation than a repetitive,

monotonous task like that of an assembly-line worker. The shorter the cycle of work, the
greater is the stress experienced. The ―turning off ‖mechanisms that the workers of repetitive
 110

jobs employ to cope with boredom often leads to a feeling of alienation. This mindless
repetition leads to errors, which increase the stress of the person.

Shift work : High demands and low control also combine with other workplace conditions to
increase on-the – job stress.

Neither noise nor danger of chemical exposure is sufficient to produce stressful work
conditions (Cottington & House, 1987), but the combination of a noisy workplace and
rotating shift work can produce a higher level of epinephrine excretion, a physiological index
of stress. In addition, shift work can lead to a variety of physical complaints, including sleep
and gas-trointestinal problems, and rotating shifts can interfere with family life (Holt, 1993).
The stresses of shift work are of a very different kind. The body‘s daily rhythms are disturbed
caus-ing a lot of stress. Another source of stress due to shift work is the limited social circle.
Working very early or very late limit the social interactions of the individual. Some shift
workers like night watch men, feel isolated not only in social circles, but also from the rest of
the work force since they have limited opportunity of interacting with both.

Excessive Travel : Jobs requiring excessive traveling can be very stressful for the person.
The discomfort of being in trains and planes is compounded by the inability to see their
families for long periods. Salesmen are the ones who are most affected by this factor of
stress. A busy executive may find the traveling equally stressful. Living out of a suitcase
leaves one feeling very unsettled. There is less time available at home, increasing stress on
home relationships, job demand increase as a result of the work sphere increasing and
traveling alone leads to increased loneliness. This sometimes lead to negative coping
techniques such as alcoholism etc.

Commuting : Driving to and from the place of work in this steadily increasing traffic is
another area of stress. Those commuting to work by public transport such as metros, local
trains, buses and taxis donot experience the stress of driving. However, being on time, not
being in control of external condition etc all add up to cause stress. Long hours spent
commuting certainty add to stress.

This stress is further compounded for people for whom driving is a job, like lorry drivers,
taxi, drivers, and chauffeurs. Although some people claim that driving is not a stressful
activity, physical signs of stress are shown by drivers even when they do not report feeling
stress. Heart rate increases and there are increased levels of catecholamines in the urine.
Stress in driving can be caused by a number of factors like traffic, weather, road conditions,
trouble with the car, general noise, fatigue, and passengers. Passengers contribute to stress by
distracting the driver. Children in particular can be a great source of tension.

Physical Environment: When we consider physical environment as a source of stress, we

often think of obvious reasons like a person working in heavy industry, mining and other
jobs, which put the person in a dangerous situations. However, there are other physical
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stressors in the work environment which are so simple that they escape notice, such as,
closed, congested offices, unclear environment, noise and air pollution, poor lighting etc.
These factors are now called hygiene factors, which means that, they are now a must at the
workplace. While the presence of Hygiene factors may not improve motivation and work
output, their absence will certainty increase stress levels and reduce work output.

Stressors in the physical work environment :

 Noise
 Lighting
 Ventilation
 Vibration
 Temperature extremes
 Toxic chemicals
 Poor workstation or tool design
 Safety hazards

a) Noise – Advances in engineering and technology have brought with them an increase in
noise levels. The sound of typewriters, word processors and printers, photocopying machines
and telephones can be very distracting and stressful, particularly when a muffled sound of
outside traffic is also added to it. Noise not only causes generalized stress responses like
mood changes, it also causes specific physical damage of hearing so that the person‘s
sensitivity to certain sound frequencies is reduced. The effect of noise on performance varies.
Tasks requiring skill and speed, and high level of perceptual capacity will beaffected the
most. Anxious people are also more affected by the ambient noise as compared to others.

b) Poor Lighting – Lighting needs to be appropriate to the task at hand especially where
precision is called for. It has also been seen that poor lighting leads to people feeling gloomy
and lethargic. Headaches occur frequently, which are caused by frowning and screwing up
eyes to see well. Working in an environment that has no natural light often leads to low
energy and morale.

c) Air Pollution – This may be caused by poor ventilation, no circulation of fresh air and no
filtration of stale air. An increasingly common reason for air pollution is smoking and a
smoke-filled atmosphere. Headaches, watery eyes, and sore throat are the physical effects of
working in a polluted atmosphere, which also leads to an accumulation of stressful situations.

Socio cultural – Environmental factors: The work atmosphere and social milieu are also
factors that contribute to stress. Some occupations and environments encourage type A
behaviour in their employee. Type A environment is a job that expects permanent long hours,
total involvement, and little time for outside interests, including the family. Working with
tight deadlines with more work than the person can handle also contribute to stress. This
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environment also demands that the person think quickly and make important decisions. All
this contributes to tension.

Besides this, office politics, hostile atmosphere, and passive – aggressive persons and rude
people also add to stress in environmental and social aspects of a job environment.

Unemployment – When you are unemployed it is but natural to feel a sense of inadequacy.
Prolonged unemployment can cause bitterness and cynicism, further leading to feelings of
helplessness, hopelessness and severe depression. Financial hardship and negative criticism
by others can further heighten stress.

It is one of the major achievements of recent research to have demonstrated beyond

reasonable doubt that unemployment causes, rather than merely results from, poor mental
health. Anxiety, depression, dissatisfaction with one‘s present life, experienced strain,
negative self-esteem, hopelessness regarding the future and other negative emotional states
have each been demonstrated in cross sectional studies to be higher in unemployed people
than in matched groups of employed people.

There is also an emerging consensus that the physical, as well as mental health of
unemployed people is also generally lower than that of employed people.

Marie Jahoda in 1980 said that employment is a social institution with objective
consequences that occur for all effected by it, overriding individual differences in feelings,
thoughts, motivation and purpose. Some of these, like earning a living, are intended or
manifest. Others are unintended or latent.

According to Jahoda : ―Employment makes the following categories of experience inevitable

: it imposes a time structure on the waking day; it compels contacts and shared experiences
with others outside the nuclear family; it demonstrates that there are goals and purposes
which are beyond the scope of an individual but require a collectivity; it imposes status and
social identity through the division of labour in modern employment; it enforces activity…‖

Crucially, unemployment is said by Jahoda to damage mental health because of the

psychological deprivation of these unintended consequences of employment which normally
function as psychological supports.

Dr. David Fryer, visiting psychologist from Stirling University in Scotland, has studied the
psychological effects of unemployment for 14 years. His studies showed that up to 40% of
unemployed people suffered psychological distress.

The initial news of being unemployed often brings the following reactions –

Shock and Denial : Can‘t believe it happened to you. Some think it‘s just a holiday and start
spending severance pay on a trip or luxuries.
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Anger: People get mad at their former employer, the government, partners, kids, themselves
and the world in general. This anger must be released without hurting oneself or others
around.

Guilt : Often people take undeserved responsibility for the situation.

Depression and Isolation : Many will withdraw from friends or won‘t have contact with
former work associates. Self-esteem will decline. Some won‘t appear to want to change the
situation they are in.

The loss of a job affects everyone in the family, not just the family member whose job has
disappeared. The effects of job loss are:

 Economic (there is less money).

 Emotional (grief or anger are common reactions).
 Social (more disagreements among family members about coping with the situation).

Although no single activity (short of getting another job that is equal to or better than the old
one) can make the stress magically disappear, taking positive steps can help ease the pain and
get the unemployed on the road to recovery. Taking Care of Oneself Include All Family
Members in Open Discussions of the Situation A few steps to as follows :

 Match Spending with Income.

 Look for Additional Money.
 Talk to Your Creditors.
 Make Plans for the Future.

Unemployment creates stress for everyone. It is essential that all involved can express how
they feel about the situation. Men are raised to be ―strong‖ to keep their feeling inside and
women are more likely to show their emotions. Children will recognize the change and the
associated stress. It is essential that children learn from the experience too. However, they
should not be over burdened.

Working women : A working woman is particularly susceptible to stress. The image of a

harassed woman caught in a frenzy of activity during the morning hours getting the family
organized before departing for work herself, is sure to come to mind. There always seems to
be so much to do and never enough time to do it in. A married workingwoman on a two-shift
work schedule has to strike a delicate balance in her roles as mother, housewife and career
woman.

Tension is further heightened when there is gender bias and prejudice at the workplace. In
spite of the achievements of the modern woman, she is still discriminated against; often earns
a lower income compared to that of a man of her own status, has to face prejudices about her
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capabilities or efficiency and is even denied promotions to higher posts. Sexual harassment is
also a potential stressor for a workingwoman.

Working women often complain of fatigue, exhaustion, guilt feelings about not giving
enough time to the family or doing justice to their job. This leads to anxiety, depression and
psychosomatic illness – all related to the enormous stress their peculiar role places them
under.

The conflict between work demand and family obligations affects both men and women, but
the increase in employment for women has sparked more research on their potential sources
of job stress. Contrary to what many people might assume, women who pursue careers are
not at increased risk for coronary heart disease (Haynes, Feinleib, & Kannel, 1980).
However, factors in their careers and home may increase their stress, and women who have
employment and child care obligations experience more stress than women without children
(Luecken et al., 1997). However, employed women also experience more satisfaction and
better health (Betz, 1993). A good income, control, and support in family work are important
in decreasing the stress of fulfilling multiple roles.

Work Stressors

 Change in work practice requiring new skills.

 Numerous deadlines.
 Unclear goals.
 Boss with abrasive communication style.
 Lack of leadership in times of crises.
 Poor design of work process.
 Inadequate rewards.
 Low salary.
 Job without meaning.
 Insufficient time to do job properly.
 Insubordinate juniors.
 Degree of decision making authority.
 Degree of decision making authority.

Poor prospects

 Lack of clarity about the scope and responsibilities of the job.

 Hostile customers.
 Trapped in an unsatisfying job.
 Incompetent co-workers.
 Transfer involving geographic relocation.
 New management style.
 Technological change.
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 Boredom and monotony.

 Equipment breakdowns.
 Frequent night-shifts.
 Conflicting demands.

Psychological Stressors

 Office politics.
 Hostile atmosphere.
 Isolated environment.
 Over crowded environment.
 Sexual harassment.
 Indecisive stallers.

Bullies

 Silent, unresponsive types.

 Loudmouths.
 Rude people.
 Moaners and groaners.
 Know-it-alls.

V. CAREGIVER STRESS

A caregiver gives basic care to a person who has a chronic medical condition. A chronic
condition is an illness that doesn‘t go away.

Some types of basic care are helping with activities of daily living such as, bathing, dressing
and feeding, household chores like cleaning, cooking and shopping. Many people with
chronic medical conditions like cancer, stroke, multiple sclerosis, dementia or Alzheimer‘s
disease need extra help.

A caregiver does the following things for another person:

 Lifting, Turning in bed.

 Cleaning, Bathing, Dressing.
 Cooking, Feeding, Giving medicine.
 Shopping, Paying bills.
 Running errands.
 Keeping him or her company.
 Providing emotional support.

The caregiver could be a spouse or a close family member like son/daughter/ sibling etc. The
caregiver could also be professional staff such as a home nurse or an ancillary nurse who are
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trained as care givers. The symptoms experienced due to caregiver stress may after be in
terms of feelings of sadness or moodiness. The caregiver may not have any time for his/her
self as a result of the demanding patient. Most often the caregiver has no time to see/meet
friends or relatives too. The stress is often so high that it can result in loss of appetite,
sleeplessness or excessive urge to sleep, loss of interest in recreational activities, tendency to
lose temper etc.

These feelings may also lead to a general sense of anger towards the cause of stress, which is
the person that oneself is caring you. This further adds to one‘s sense of guilt and frustration.

These feelings are not wrong or strange. Caregiving can be very stressful. Because being a
caregiver is so hard, some doctors think of caregivers as ―hidden patients.‖ If one does not
take care of oneself and stay well, one can‘t help anyone else.

Talking with family doctor about feelings, staying in touch with friends and family members,
asking them for help in giving care, are some of the ways of dealing with stress in the
caregiver.

Stress in the Medical Profession: While each profession has stress associated with it the
Medical and health professions are even more so since they cater to an area that is personal,
confidential and immediate – individual health or illness. Delegation is possible in a limited
way making the physician feel that the buck stops with him.

Some of the occupational stressors that may impact physician well-being are as follows :

 Excessively high client – care giver ratio.

 Lack of time-outs for a temporary emotional breather.
 Excessive, continuous direct contact with patients.
 No systems for care givers to ―cover‖ for each other.
 No access to a social-professional support system
 No time and place to share personal feelings with colleagues.
 Inadequate training for working with people.• Tendency in the work setting to blame
people rather than the situation when care or service deteriorates.
 Repetitive single tasks.
 Problems without solutions.
 Time pressures and demands.
 Indispensable syndrome.

Prolonged exposure to these stressors naturally affects Medical and Health care professionals
adversely. Constant pressure of time, long years spent in training, working in emotionally
charged environment, all take their toll. Some of the more adverse stressors faced are :

 Inherent uncertainty involved in patient care.

 Chronic fatigue.
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 Dealing with life and death or difficult issues.

 Difficult, demanding, chronically or terminally ill patients.
 Maintaining clinical competence

Unanticipated Stressors Unique to the Medical and Health Profession – while the above
emotional stressors are anticipated some unanticipated stressors unique to the Medical
Profession need to be mentioned.

 Government regulation.
 Third party intrusions.
 Increase in malpractice litigation.
 Pressure to practice defensive medicine.
 Diminished public image of physicians.
 Increased paperwork.
 Inadequate support personnel.
 Fears of violent patients.

Patient expectations also place a great deal of stress on the Medical professional. On the other
hand members of the profession subject themselves to an unwritten code of expectations
further aggravating the situation.

Myths in Medicine Contributing to Burnout

 Physicians should be all knowing.

 Uncertainty is a sign of weakness.
 Patients should always come first.
 Technical excellence will provide solutions to illness.
 Physicians are immune from illness.

Physicians’ Expectations of Themselves that Increase Risk for Burnout

 Emphasis on High Achievement.

 Be Strong — don‘t Show Feelings.
 Know Everything.
 Don‘t Make Mistakes.
 Please Everyone (Home, Work, Play).
 Make Lots of Money.
 No focus on leisure time and vacations.
 Poor lifestyle as a result of time pressure

VI. CORPORATE STRESS

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Just as stress is known to obstruct the natural flow of intelligence in the individual
physiology, so stress in the collective system also obstructs the flow of the group creative
process.

―Collective‖ stress will give rise to a wide range of unproductive behaviours including
unnecessary conflicts, attachments to the current ways of doing things, reluctant to change
chaotic activity, lethargy, resentments, disloyalty, secrecy, hidden agendas and even hostility
to the organization.

Group stress can be as damaging as floodwaters during monsoons. The cumulative effect
carries all in its wake and reversing these changes becomes even more difficult. One + One =
Eleven, can take a positive direction of increased performance with team energy but as a
group can be a very negative one as well. A management team can set itself the role of
facilitator or empower helping to deliver a positive stress environment within which the
workforce can perform and develop to the optimum extent. Sixteen major causes of stress at
work have been identified and all are fully capable of being alleviated if tackled in the
appropriate way.

Sixteen major corporate stressors

 No clear objectives to work for.

 Unrealistic objectives impossible to achieve.
 Loss of a natural routine due to overwork, unsympathetic work schedules or chaotic
management.
 Environmental factors such as constant background noise, artificial lighting,
electromagnetic fields, stale air, poor surroundings, inadequate equipment.
 Isolated working conditions, very prevalent today with executives tied to computer
terminals and missing out on social mixing and peer group support.
 Over competitive internal environment.
 New functions being allotted without adequate training or guidance.
 Unclear boundaries of functions.
 Disharmonious Relationships including personality conflicts, incompatibilities,
serious personality disorders and authoritarian management.
 Onerous externally imposed dead lines, insufficient time to do tasks.
 Disagreement with organizational values or philosophy.
 Responsibility with out genuine control of events.
 Career uncertainty.
 Insufficient support from senior management or colleagues in the form of emotional
criticism, and lack of appreciation for a job well done.
 Loss of a natural routine where work is carried out across different time zones.

Stressed organizations are unhappy places to work – Just remember that stressed
organizations are unhappy places to work and so tend to lose good people. At the same time
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such organizations tend to attract people with high levels of personal stress, which only
makes the situation worse.

Stress as a result of ones occupation is a common theme in the modern times. With
technological advancements, the stressors have increased in many field. Often it is the nature
of the job (the demands at work) which is the cause of severe stress.

Tracking organizational stressors across organizations – A hierarchical, nonparticipatory,

authoritarian organization that gives employees little decisionmakinginfluence over the
execution of their work increases job distress.

Arbitrary changes made without consulting employees can engender great anxiety.

Conflicts or disagreement with a boss or workmates, and uncertainty about responsibilities

are also powerful stressors. Some stressors are an inescapable part of the job. For example,
call center and telephone operators feel stressed by being monitored for their voice and client
approach; while also being bombarded with consumer questions beyond their authority levels
or difficult answers such as weather conditions, road reports, restaurants or movies. Teachers
experience high stress when, in addition to uninterested pupils, they face extra administrative
chores and meal duties. The latest trend to total quality management, emphasizing customer
satisfaction and zero defects, can exert enormous pressure on employees.

Worldwide, bus drivers are particularly stressed by the simultaneous need to meet schedules,
be polite to passengers and deal with traffic. Scandinavian studies show they are plagued by
gastrointestinal disorders, hypertension (high blood pressure) and heart problems. Bus
schedules are often arranged without considering road conditions. No sooner do drivers sit in
the bus than they are already behind schedule. Social isolation can add to the strain. Most
drivers work long shifts and some stay at the bus depot to wind down. By the time they get
home, many have little time to socialize with spouse, children or friends.

Besides improving posture and seat design, overcoming the tyranny of the schedule might do
wonders for driver stress-reduction. But changes should involve the drivers themselves. One
expert describes how a transit company allowed bus drivers input into new seat designs,
bringing more comfort and greater satisfaction

VII. COMPUTER STRESS

Anyone who uses a computer regularly knows how valuable these 20th century machines can
be. And anyone who has ever waited for their on-line service to respond, received a mailbox
full message, had their hard disk crash, been flamed on the internet, upgraded to Win 2000, or
tried to set up their own home based computer network knows that there is also a dark side to
this modern wonder of technology.
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Yes, working with computers can sometimes be stressful. And dealing with computer stress
is really no different from dealing with any other type of stress in life. A report by Morton C
Orman, MD, identifies some common causes of Computer Related Stress (CRS)

Failing to Anticipate Problems : Many stressful problems computer users experience can be
prevented. Yes, power outages do occur, but equipment and software controls are available to
keep you from losing data. Theft or damage from children, natural disasters, viruses,
intruders, and hard disk failures may not always be avoidable. But adopting a regular backup
schedule and keeping a recent backup in a second location can make such losses easier to
bear.

Trying to Get By Cheap : Sometimes we invite disasters by trying to do things on the cheap.
That less expensive computer or modem you could pick up at a computer shop may save you,
but are the potential headaches worth the risk? Failing to Ask for Help : Many novice
computer users (and some veterans too), are reluctant to ask other people for help. This can
lead to an incredible amount of stress, most of which is totally unnecessary. There is a
tremendous amount of free (and not so free) technical support available by phone, fax, and
on-line that is provided by most product manufacturers.

Failing to Relate to Stress as Feedback : Whether you get angry, frustrated, or impatient
with your computer from time to time, or whether you worry about some computer disaster
befalling you, the very best way to deal with any type of stress in your life is to view it as
personal feedback.

Instead of blaming your computer, blaming software developers and manufacturing

companies, or blaming life itself, take the viewpoint that any type of stress in your life may
have something to do with your own thinking and behavior.

Whatever type of computer stress you might be experiencing, look for your own hidden
thought patterns and behavior patterns lurking in the background.

If you‘re not familiar with how to do this, there are several excellent self-help references
available.

Trying to Cut Corners : In addition to cutting financial corners, there are many other ways
computer users get themselves into trouble by trying to skip important or critical steps.
Trying to use hardware or software without reading the manuals or doing the basic tutorials is
one very common cause.

Unfortunately, the new ―Plug and Play‖ mentality fosters this behavior. Many Plug and Play
users, on the other hand, have found out that they still need to understand how their new
equipment works (and installs) to get it up and running smoothly.
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The usual excuse for skipping these steps is time. Many people feel that they just don‘t have
the time to sit down and study their manuals, read an additional book, attend a class, or hire a
professional trainer. Unfortunately, when you don‘t put in the time to learn what you are
doing on the front end, you usually end up spending much more time (and sometimes money)
in the long run.

Unrealistic Expectations : Much of our stress in life is caused by our own unrealistic
expectations. Many of these expectations are quite silly when examined in the open. But they
often lurk in the background of our thinking, causing mischief and stress in ways that we may
not always be consciously aware of.

Take the common experience of frustration associated with computers. Much of this
frustration comes from expecting ourselves or our computers to function perfectly all the
time. While this is a laudable goal, it is not very realistic. From time to time, computer
problems will occur. The file we are working on may have appeared to disappear! (Don‘t
worry, it‘s usually still there—somewhere.) Heavy traffic on our on-line service may
preclude us from being able to connect when we want or may cause a system slow down just
at the moment we need things to be fast.

Another area where expectations play an important role is how we respond to the behavior of
others. In the computer world, there are many opportunities to become upset with other
people. Some people may not respond in a timely manner (or at all) to your e-mail messages.
Others will send you unsolicited email or will flame you repeatedly for making a beginner‘s
mistake. And then there are all the vendors, sales people, repair technicians, receptionists,
tech support people and many others who repeatedly fail to live up to our personal standards
for how people should behave.

This common source of stress is not just limited to the world of computer usage. If you look
at other instances of stress in your life, you will almost always find unrealistic expectations,
of one type or another, lurking somewhere.

Beating Up On Yourself Unnecessarily: Along with the expectations of perfectionism and

universally faultless performance comes the very common behavior pattern of beating
yourself whenever you do something wrong or make a ―dumb‖ mistake.

Mistakes in the computer world are very common. All it takes is entering one incorrect letter,
number, or symbol and your whole operation can grind to a halt. Deleting the wrong file (or a
whole directory of important files!) happens to the very best of us. And when it comes to
operating complex software applications or coordinating the installation of complex hardware
or networking systems, errors are common, and you should not feel too bad or demean
yourself when they occur.

Conflicts With Other People: Much of our stress in life comes from conflicts and
interpersonal difficulties we encounter with other people. While the computer world may
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give you the illusion of working alone and isolating yourself from others, this is not really the
case. Both at home and at work may different types of computer related conflicts and
resultant stress can arise. At home, there may be issues of sharing usage between family
members, exposure of children to outside influence, increased financial burdens, conflicts
over the amount of time spent at the terminal (or not being spent elsewhere) and many others.
These types of conflicts require strong communication, relationship building, and negotiation
skills.

Limiting the outside world: After spending much time with the computer as well as on the
web, this takes on the role of a companion limiting other social relationships. People seek
companions on the web and chatting becomes a time consumer often with make believe
games. The more time a person spends, the more isolated he gets. Another issue causing
stress could be the quality of browsing being done, the chat friends being developed by
children and also partner. Children may fail to complete homework as a result of the time
spent on the computer.

Repetitive Stress Injury (RSI): Carpal tunnel syndrome and repetitive stress disorders are
common in computer users but are preventable. The best possible scenario is never to
develop symptoms, to work intelligently and to respect your body‘s needs. But if trouble does
begin it is extremely important to act immediately, before the symptoms become a big
problem. Pain and burning are the #1 indicators that something is wrong. The discomfort and
pain can be in your fingers, hand, wrist, forearm, elbow, shoulder, neck, upper back or lower
back. It is much better to take these preventative steps while you are pain-free, instead of
waiting for major dysfunction. And if you are experiencing symptoms, you should see a
healthcare professional immediately.

VIII. STRESS IN THE SOCIAL ENVIRONMENT

The economic and political climate of a country places subtle tensions on the quality of life
we lead. Political unrest, recession and inflation are conditions that often sensitize you to
succumb to other direct stressors.

The Social environment is equally important in determining the kind of lives we lead.
Changing social structures and family systems like the disintegrating of joint family and
increasing number of nuclear families as well as singleparent families, all contribute toward
increasing the stress levels among individuals.

Industrialization, over-crowded cities, inadequate urban development, deficient water supply,

frequent electricity failures are some of the factors that cause chronic, imperceptible stress in
our daily lives. These stresses build up tension in a cumulative manner.
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Some specific social stressors that have the ability of influencing our personal lives have been
mentioned in the Table 6.2

Table 6.2

Social

 Class discrimination
 Permissiveness
 Overpopulation
 Human rights violations
 Social isolation
 Housing shortage
 Social outcasts
 Violence and hooliganism
 Communal tensions
 Unsafe living conditions

Economic

 Slow economic growth

 Energy crisis
 Recession
 Increased imports
 Consumer boom causing expenditure
 Devaluation of currency
 Rich-poor divide
 Unemployment
 Exorbitant property prices.

Political

 Income tax
 Bureaucracy
 Lack of leadership
 Urban disintegration
 Corrupt government officials
 Strikes
 Welfare benefits
 Immigration laws
 Insurgency or terrorism
 Law and order break down
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IX. AGE & GENDER RELATED STRESS

Children and Stress : Stress shows itself in children in complaints about stomachaches,
nervousness, trouble sleeping, anger and infections.
One of the many challenging things about working with children is that they often do not
exhibit stress in the same way that adults do. The younger the child is, the less likely he or
she is to be able to communicate their troubles in words. They therefore are more likely to
show their stress in their actions. Examples of such behaviors can range from as mild as
becoming irritable, moody, erratic in communication, erratic in appetite etc., to as severe as
physically fighting with peers and/or adults, abusing alcohol or drugs, or trying to kill him- or
herself.
Reactions to stress vary with the child‘s stage of development, ability to cope, the length of
time the stress continues, intensity of the stress, and the degree of support from family and
friends. The two most frequent indicators that children are stressed are change in
behaviors and regression of behaviors. Children under stress change their behavior and react
by doing things that are not in keeping with their usual style.
In order to figure out if a child is stressed, the adults in the child‘s life should think in the
context of what is ―normal‖ for that child‘s age. For example, questioning adult authority is
something that normal teenagers often engage in. For a seven year old, such behavior should
be looked at more closely for signs of stress since this is something that normal seven year
olds rarely do.
Understanding normal behaviors based on age is also important from the standpoint of
knowing when a child is reverting back to younger behaviors. Such regression is also a
common sign of stress. An example of this is a fully toilet-trained four year old suddenly
beginning to wet the bed again. To assess what may be normal or abnormal behavior for a
child, parents and teachers may consider comparing that child to other children of similar age,
ethnic background and socioeconomic status. A disaster is frightening to everyone.
Several factors play an important part in a child‘s reaction to the event. Children will be
affected by the amount of direct exposure they have had to the disaster. If a friend or family
member has been killed or seriously injured and/or the child‘s school, home or neighborhood
has been destroyed or severely damaged, there is a greater chance that the child will
experience difficulties. Adults can help children grieve by patiently listening and being able
to tolerate feelings.
This is a major factor in a child‘s perception of adults‘ reactions to the disaster. Children are
very aware of adults‘ worries most of the time but they are particularly sensitive during the
period of a disaster. Acknowledging your concerns to the children is important, as is your
ability to cope with stress.Another factor that affects a child‘s response is his/her
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developmental age. Talking about the disaster together using words children can understand
is important, as is being sensitive to their different responses.
Preschool children will cling to parents and teachers and will worry about their parents‘
whereabouts. School-age children whose homes have been damaged by a fire may express
the fear that life isn‘t safe or fair, whereas adolescents may minimize their concerns but fight
more with parents and spend more time with their friends. It is important to listen to
children‘s individual concerns and to be alert to signs of difficulty. Children are the most
vulnerable population. Times of disaster and trauma increase their vulnerability. Recognizing
children‘s symptoms of stress is not easy. Some stress reactions may include the following:
Disaster related stress reactions Children and Adolescents.

 Sleep disorders
 Persistent thoughts of trauma
 Belief that another bad event will occur
 Conduct disturbances
 Hyperalertness
 Avoidance of stimulus or similar events, i.e., boating, swimming, baths, traveling
 Moping
 Regression, thumb sucking
 Dependent behaviors
 Time distortion
 Obsession about the event
 Feeling vulnerable
 Excessive attachment behaviors

Expected Reactions of Children and Adolescents to disasters

 Refusal to return to school or child care. This may emerge up to several months after the
disaster.
 Fears related to the disaster (i.e. the sound of wind, rain, thunder, sirens, etc.)
 Sleep disturbances persisting several months after the disaster, manifested by nightmares
and bed wetting.
 Misconduct and disobedience related to the disaster reflecting anxieties and losses that the
child may not be talking about may appear weeks or months later.
 Increased susceptibility to infection and physical complaints (stomach aches, fevers,
headaches, dizziness) for which no immediate physical cause is apparent.
 Withdrawal from family and friends, listlessness, decreased activity, preoccupations with
the events of the disaster. Many children may be confused or upset by their normal grief
reaction. Children have reported that they do not feel enough support from adults during a
disaster.
 Loss of concentration, irritability.

While children may express stress in ways that are vastly different than the way adults do,
they may also show stress in very similar ways as adults. Children can become irritable,
increase or decrease their appetite, increase or decrease their sleep, experience trouble
sleeping or a tendency to sleep excessively, and engage in dangerous behaviors, just as may
happen with adults.
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Preschoolers under stress react by exhibiting irritability, anxiety, uncontrollable crying,

trembling with fright and eating or sleep problems. Toddlers may regress to infant behaviors,
feel angry and not understand their feelings, fear being alone or without their parent,
withdraw, bite, or be sensitive to sudden or loud noises. They may become sad, angry or
aggressive, have nightmares, or be accident prone.
Elementary-age children react to stress by whining, withdrawing, feeling unloved, being
distrustful, not attending to school or friendships, and having difficulty naming their feelings.
Under stress, they may worry about the future, complain of head or stomach aches, have
trouble sleeping, have a loss of appetite, or need to urinate frequently.
Preteens and adolescents under stress may feel angry longer, feel disillusioned, lack self-
esteem, and generally distrust everything. Sometimes they will show extreme behaviors
ranging from doing everything they are asked, to rebelling and breaking all of the rules, and
taking part in high-risk behaviors (drugs, alcohol, shoplifting, skipping school). Depression
and suicidal tendencies are concerns.
Child’s perceptions of family reactions: Sometimes, anxiety in children can be attributed to
anxiety in parents. Children who realize that their parents are powerless (the inevitability of
flood waters for example) are fearful. Erikson suggests a loss in the belief of adults‘ power
results in the questioning of adult authority in other instances and may manifest itself in
juvenile misconduct.
Building safety nets for stress : Just as children‘s reactions are each different, so are their
coping strategies. Children can cope with stress through tears or tantrums or by retreating
from unpleasant situations. They could be masterful at considering options, finding
compromise solutions, or finding substitute comfort. Usually a child‘s thinking is not fully
developed enough to think of options or think about the results of possible actions. Children
who live in supportive environments and develop a range of coping strategies become more
resilient. Resiliency is the ability to bounce back from stress and crisis. Many children do not
have a supportive environment and do not learn to cope with stress.
The consequences of stress in childhood can be as varied in presentation and severity as the
children who experience them. Children who experience mild, short term stress have the best
chance of having no long term problems as a result. Examples of such stress and the reactions
children present include sweaty palms because of anticipation of a challenging test at school,
or feeling tired because of catching a cold. Causes of, and reactions to, stress on the very
severe end include lack of motivation to get a job from being used to poverty, or hearing
voices as the result of suffering physical or sexual abuse. Also important is that the greater
the number of stressors a child has to endure, the less control the child has over the stressor,
and the higher the involvement of a loved one in inflicting the stress, the more severe the long
term consequences often are.
Points That Cause Stress in Students:

 Stress is created by parental pressure to perform and to stand out among other children.
When they can‘t rise up to that expectation, or during the process of meeting it, children
may suffer from frustration, physical stress, aggression, undesirable complexes, and
depression.
 Students who are under-performers, develop negative traits such as shyness,
unfriendliness, jealousy, and may retreat into their own world to become loners.
 Another major student stressor is perhaps the middle school malaise, which refers to the
physio-psychological transition of students from elementary to junior high school.
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 Researchers at the University of Michigan have studied this transition from elementary to
middle school and have found that: On average, children‘s grades drop dramatically
during the first year of middle school compared to their grades in elementary school.
 After moving to junior high school, children become less interested in school and less self-
assured about their abilities.
 Compared to elementary schools, middle schools are more controlling, less cognitively
challenging and focus more on competition and comparing students‘ abilities.

Women and stress : Stress in women is caused by what researchers call ―role conflicts.‖
This is a predicament in which women can‘t abandon a role to adopt another one. Stuck
between their careers and their families, they must therefore solve several affective dilemmas,
such as staying at the bedside of a sick child when they just signed a big contract or writing a
report after shopping for groceries.
Aside from managing role conflicts, women are also in charge of domestic duties that can be
quite stressful. Indeed, many women play the role of the boss at home—though the job
doesn‘t come with any special bonuses or a higher salary. In comparison, men often do only
the chores that have been thought out (and planned) by their wives.‖ Studies indicate that
women are definitely meant to be more sensitive and detail oriented. It appears that women
are born with stress response systems that are exquisitely ensitive, to enhance their ability to
caregive throughout life. But its a double-edged sword. It also makes a woman more
vulnerable to giving to others with disregard to her own needs. Without that daily attention to
their own self care, women can potentially self destruct in the end.
In 1999, a global survey was published detailing how men and women throughout the world
perceived the stress of daily living. This study found that the majority of women, across
cultures, perceived more stress in their lives than men. Not surprisingly, the stress was greater
for women with children, and greatest for single working mothers with childcare
responsibilities. Other researchers have discovered similar findings.
A study published in Psychosomatic Medicine by Canadian researchers found that women
with large family responsibilities and job strain had greater increases in blood pressure than
women with either large family responsibilities or job strain.
Researchers from North Carolina found in a study of 109 women that working women with
children at home excreted higher levels of the stress hormone cortisol, regardless of their
marital situation.
Redford Williams PhD, a stress physiologist, has published numerous studies emonstrating
that most women in the workplace perceive and react to stress differently than men. Under
the typical pressures of a workday, a woman will be less likely to face off in a confrontation
with a fellow worker, and will often personalize the experience, seeing fault first in herself,
and finding difficulty in objectively assessing the situation. Williams found that women will
frequently try to avoid conflict, internalizing the tension and stress, and then will go home
with increasing feelings of anxiety, frustration and helplessness. This will often manifest
itself in self destructive behavior, such as overeating, smoking and social withdrawal. Of
special note as his studies of heart disease in those women who typically internalize their
feelings of stress. Williams and his colleagues found that over time, these women were more
likely to develop high blood pressure, develop plaque in their coronary arteries, and
eventually succumb to heart disease.
Female Hormones : Thus it can be seen that in a woman‘s life it is often multiple factors
which are increasing the stress. However the same factors may cause stress for men too. The
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point to be noted here is that women due to the stereotypical roles that they have played in
their lives or those roles which are often expected of them just by the virtue of them being
women are the ones which cause greater stress so women are often juggling several things at
one time which causes them to react with greater stress.
At the time of puberty, the Pituitary, a small pea sized Endocrine gland inside the skull on the
under-surface of the brain, starts secreting a hormonal secretion called gonadotrophin which
activates the two ovaries, the female sex glands in the abdomen. The ovaries, in turn, secrete
a hormone called oestrogen. This sets in motion the process of adulthood. In one of the
ovaries is produced a follicle, from which emerges a female egg or ovum. This process is
called ovulation. The empty follicle now starts secreting another hormone called progesterone
whose function is to prepare the uterus for pregnancy. In case the menarche and menopause
pregnancy does not occur, these preparations go waste and the temporary lining of the uterus
is shed off in the form of menstruation. This cycle is repeated usually every 28 or 29 days till
the ovaries become inactive again, produce no oestrogen or eggs, and menstruation stops.
Menpause happens in most of the women between the ages of forty and fifty.
Pre-menstrual Syndrome : Once a woman passes through puberty, her body is designed to
function best in the presence of female hormones. For women past puberty, a lack of female
hormones is a major stress on the body. Once a month,
just prior to menstruation, a woman‘s hormone levels drop sharply. In many women, the
stress of sharply falling hormones is enough to create a temporary overstress. This temporary
overstress is popularly known as PMS or Pre Menstrual Syndrome. While dipping hormonal
levels cause stress, stress also influences hormonal levels and behaviour making PMS a
vicious cycle.
Post–Partum : Following pregnancy, hormone levels change dramatically. After a normal
childbirth, or even a miscarriage, some women may be thrown into overstress by loss of the
hormones of pregnancy.
Menopause : Another time in a woman‘s life when hormone levels decline is during
Menopause. The decline in hormones during menopause is slow and steady. Nevertheless,
this menopausal decline causes enough stress on the body to produce overstress in many
women. Anxiety, fatigue, tension, emotional liability, irritability, depression and insomnia are
some of the more common psychological symptoms experienced by women.
When the ovaries stop secreting oestrogens, a lot of changes occur in the body. A new
balance is to be setup among different hormonal secretions of the glands. When the ovaries
stop secreting oestrogens, a lot of changes occur in the body. A new balance is to be setup
among different hormonal secretions of the glands. It is in this period when the old balance
gives place to a new one that is different Peculiar symptoms are produced in majority of
women. It is only a small percentage who escape it entirely. This, however, is a temporary
phase. When the new balance gets set up, the symptoms disappear.
Menopause is usually said to have occurred after an absence of menstrual periods for one
year. Usually, menses taper off during a 2-5 year span occurring between 45 – 55 years of
age as well as following surgical removal of ovaries.
Psychological symptoms associated with menopause are anxiety, fatigue, tension, emotional
liability, irritability, depression, disease, insomnia.
Physical signs and symptoms include night sweats, flushed and hot flushes. Hot flash is a
sudden perception of heat within or on the body, accompanied with sweating and color
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change. The physical change may being 4-8 years before the last menstrual period. The
severiety of symptoms may be related to the rate of hormone withdrawal, hormone depletion,
the women constitution ability to withstand the overall aging process, her overall health and
level of activity and psychological meaning of aging to her.
Exercise, diet and symptomatic treatment are all helpful in reducing physical discomfort.
Psychological therapy should also be made available.
If a woman has rather severe symptoms she could be helped by taking, under the advice of
her doctor, a hormonal preparation called (Hormone replacement therapy – HRT). They can
help her by suppressing the symptoms.
Midlife stress in men : In youth one starts with grandiose ideas: amassing wealth, becoming
the senior most officer in the department, creating a lasting image in the world, winning a
Nobel prize, etc. But as the years slip by and one enters the forties, at moments, Men assess
what they have achieved so far. At this stage, one can, with some reasonable degree of
certainty, foresee also what more he can possibly achieve. He sees a huge gap between what
he started with to achieve and what he could achieve. This gap could be for the better or
worse. He may have done rather well for himself, even better than he expected. Or their
assessment could be a disappointing moment with opportunities and achievements missed.
Along with that come the tell tale signs of advancing years: gray hair, expanding middle, a
feeling of tiredness. On top of that, appears a new generation throwing up challenges to the
competence of the older generation and threatening to throw them out or waiting the time
when they would be thrown over.
This is a difficult situation for many. They feel depressed, out of sorts, irritable and toss about
in the bed at night. Some of them become extroverts. They start growing their sideburns and
beards, wear fancy trousers and flashy shirts. They even start using perfumes. It is at this
stage, that they may even start smoking and drinking if they were not doing before. Worse
still, they might go after young girls. This all is to assure themselves that still have the
qualities of youth left.
Others, at this stage, may become introverts. They withdraw into themselves like a tortoise,
withdrawing itself inside its shell when it senses danger. They think of maintaining the status
quo. Their only sphere of interest or emotions becomes the job, the wife and their children.
Both these groups aggravate their difficulties, anxieties and tensions. None can escape from
this stage or period of life. One has to realize and understand that the capabilities of youth are
a thing of the post. One has to reconcile oneself to what one has achieved or what one can
possibly achieve. Men who adjust well learn to value their achievements of money, status,
position, social capability, experience and exposure against what is lost vigour and vitality of
youth. The solution is neither fight nor flight, but just a realization of the situation and
adjusting oneself accordingly. Ageing is a reality that has to be reconciled with gracefully.
One of the best ways of getting out of a feeling of depression at this age is to focus on good
health, fitness of body and mind. It is now even more necessary to maintain good health.
Physical exercise is a must at this period of life. Also use discretion in diet. Less food and a
well-balanced diet can keep one healthy and trim.
Statistics gathered from insurance companies show that between the ages of forty and forty-
five, over-weight begins to tell upon health. An excess of 12.5 kgs. for instance, lessens the
expectation of life by 2.5 percent and a further increase is even worse.
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Stress in Old Age : Advanced age is a period of time when the body suffers a tremendous
amount of breakdown because of a natural ageing process and also because of the onslaught
of Lifestyle itself.
The period of conception till 18-20 years of age is a period of all around development –
physical, mental and social. The period of 20 – 40 years is a period of peak performance if
good care and maintenance is taken. The period post 40 yrs is the time when ageing beings
and breakdown happens at the rate of 1 % per year. A person at 40 yrs is functionally less
capable than at the age of 20 years.
Natural degeneration is further loaded by inappropriate diet, a sedentary life, pressures and
tension of work and family life. Growing family needs, older and more demanding children
may add to the financial burden.
With approaching retirement, a person may experience a lot of stress. Finance, loss of
important position in society, loss of status in the homefront, all indicate the shifting of
importance to the next generation. One has to adjust to an advisory, grandparent role from a
more active and hands on parent role.
This manifests in the form of various ailments such as High Blood Pressure, Diabetes,
Obesity, Arthritis, Back pain, Osteoporosis, Cardiac ailments, Cancer, Spondiolosis,
Digestive disorders, to name a few.
While Health and Well-being is usually taken for granted during the development period as
well as the maintenance period, it needs special attention beyond 40 years of age. Those
individuals who are aware of this or have learned their lesson early, take good care of
themselves. With informed and appropriate care an individual at age 45 can be as fit as he
was at age 35 or even younger.
Aging Phenomena
Biological

 Increase in collagen and calcium in the tissues.

 Decreased elasticity of blood vessels and lungs.
 Decrease in cells, especially neural (brain) cells.
 Increase in fat deposits.
 Decrease in metabolism.
 Decreased waste removal.
 Decreased oxygen intake.
 Decreased muscular strength.
 Decreased activity of hormones.
 Decreased function of immune system.
 Thicker and less efficient heart, slower pulse rate.
 Higher blood pressure.
 Poorer circulation.
 Decreased function of brain and nervous system.
 Decreased function of kidneys and genital organs.
 Decline in vision, hearing, taste, smell, touch.

Psychological

 Memory loss for recent events; better recall for past events.
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 A self-assertive attitude.
 Anxiety about death, disease, body changes, security, etc.
 A turning inward.
 Loneliness and isolation.
 Conservatism.
 Lack of energy.
 Feeling of loss of attractiveness.
 Trying to revert to younger behaviour.
 Depression
 Emotional instability.
 Carelessness in appearance.

Sociological

 Loss of job.
 Loss of family ties.
 Loss of friends.
 Economic instability.
 Loss of power and status.
 Loss of respect by others.

Planned retirement in the form of financial comfort and companionship of spouse, support of
relatives and friends for social needs, the love and affection and respect of children and grand
children, peaceful and comfortable living space all go a long way towards making old age
comfortable, secure and stress free. Good health habits of age appropriate exercise and health
appropriate diet, a relaxed attitude towards life, and financial planning or medical insurance
to take care of increasing medical needs adds greatly to security about health and improves
quality of life. These steps make it possible for old age to be lived like the golden age, happy,
healthy and stress free

CHAPTER 7:
HEALTH DAMAGING & HEALTH
PROMOTING BEHAVIOUR
Introduction to Health Damaging and Health Promoting Behaviour

Behavior plays a central role in health and illness. Health damaging habits and lifestyle are
important risk factors for chronic disease and death, whereas health promoting habits enhance
biological and psychological functioning. Maladaptive and adaptive health behaviors are
acquired and maintained by the same processes. Their acquisition and shaping are a function
of maturation and learning. Once established, their performance is evoked and maintained by
the biological, cognitive, social, environmental and behavioral cues and consequences that
exist in an individual‘s daily experience.
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The modification of health behavior is a primary task in clinical and preventive medicine.
Health behaviors are influenced by multiple factors and functionally involve the client and
the environment.
Stress as we already know is an all-pervasive fact of life. It is unavoidable and inescapable.
The only thing to do about it is to maintain stress at a manageable level and cope with it.
Each of us uses certain strategies to handle stress.
Coping strategies would include three areas of change, self, others, and environment.
Unfortunately, it is not easy to bring about changes in others and in the environment unless
one is in a position of authority. If one is not in control of the situation, it is more likely to
cause stress. So, the only aspect one can bring changes in is in oneself and our perception of
stressful situations.
Managing stress is not merely coping with stress, but learning to cope adaptively and
effectively. Some coping behaviors are positive and health enhancing. Others appear to help
one cope with stress, but they have a short term benefit leading to more stress in the long run.
They also affect health adversely, sometimes causing illness and sometimes coming in the
way of prognosis or recovery from illness. Coping behaviors like smoking and drinking
alcohol are negative ways of coping. These must be avoided at all costs

Fig 7.1

As shown in figure, all behavior is learned and acquired. Exposure, environment,

acceptability and availability are some of the factors that shape this learning. If Health
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damaging behavior is learned, it is often as a consequence of these factors. The chances of a

smoker‘s son being a smoker are greater than in a family where there is no acceptance of this
habit. Once behavior is learned, it becomes a part of daily lifestyle. Good habits naturally
lead to a positive lifestyle and this in turn leads to optimum health and prevention of disease.
poor habits lead to a negative lifestyle, ultimately leading to poor health and ailments.

While Health Damaging Habits and lifestyle can be corrected by preventive means, the end
result that is illness requires medical treatment

HEALTH DAMAGING BEHAVIOUR

In order to understand why certain behaviors are damaging to health, it is also necessary to
understand the nature and composition of the substance used or rather abused, how the habit
develops, what factors trigger it again and again, some strategies for quitting and also relapse
prevention. While daily indulgence in these substances is a dependence and leads to many
medical ailments, over a period of time it leads to risk of cancer. It brings out the question
that, is quitting an option and a choice, or a compulsory responsibility? Smoking, Alcohol
and Drugs are the substance abuses discussed in detail here. Other health damaging behaviors
touched upon are eating and overwork, however in lesser detail since these factors have been
discussed in other chapters and they are not quite as destructive as the other three.

A discussion of some common Health damaging habits follows:

I. SMOKING

―Cigarette smoking is a major world wide public health problem, associated with a growing
number of illnesses and responsible for over 4 million deaths annually, reports a study
recorded in the journal CHEST, 2002. This is alarming, as smoking tendencies among high
school students appears to be increasing. The mainstream of public health efforts to curb the
smoking epidemic therefore focuses both on encouraging addicted smokers to quit and on
preventing adolescent nonsmokers from starting. In order to decrease the overall prevalence
of smoking and its concomitant morbidity and mortality, it is essential to prevent the onset of
smoking. This is particularly important in adolescents because smoking initiation at an early
age is associated with greater daily cigarette consumption, and a lower cumulative probability
of quitting.

It has been reported that a significant number of Adolescents start smoking at about 17 years
of age. In the United States, 90% of adult smokers begin by the age of 18 years.

The tobacco industry targets Adolescents and Women, particularly in lower socioeconomic
groups and developing countries, as they represent a major untapped market. This group is
being targeted with aggressive advertising, marketing, and promotional campaigns and
sponsorships. The result is in terms of increase in consumers for such goods owing primarily
to the marketing strategies. In the past, cigarette advertisements directly alluded to physical
traits, such as rugged virile men at work, such as in the advertisements for ‗Marlboro
cigarettes‘.
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While the message in the advertisement may not be evident at first view, it registers in the
subconscious mind, where it influences perception and hence preference. The overall effect is
that the consumer entertains and indulges in such habits in spite of knowing the health risks.

Although smoking is decreasing among men, it is increasing in women and children. The age
of onset for smoking is getting younger every year. This is mostly due to the social
acceptability of smoking.

Smoking induces a superficial sense of relief and calmness. It also brings along its own stress
reaction by introducing nicotine into the blood stream. As stress increases, so does the
smoking of the individual. This, in turn, increases the stress levels within the body, pushing
the person to pick up one more cigarette. Smoking then becomes a habit and an addiction.
The only sensible thing is to quit smoking, but it is not as easy as it seems. However, since
stress is the root cause of smoking, dealing with stress in more adaptive ways may help in
dealing with the problem of smoking.

Some people also smoke when the stress levels are so low that they are bored. It is a way of
introducing something stimulating into the situation. It is important that the root cause of
boredom be dealt with, rather than depending on a habit which is self-defeating and
endangering to the individual‘s health.

Identifying the reason for smoking is the first step to quit the habit.

Smoking is a behaviour that develops in a series of stages – preparation, initiation, and

habitual smoking. After this, most people try to stop smoking. Some are able to quit
successfully and abstain from smoking, whereas others may resume after a period of time.

The developmental stages by which smoking becomes an acquired habit is illustrated in table
7.1

Table 7.1

Developmental Stages

Preparation (Psychological factors before smoking)

Modelling by significant others
Stage1
Attitudes concerning the function and desirability of smoking

Initiation (Psychological factors leading to experimentation)

Peer pressure and reinforcement
Availability
Stage2
Curiosity, rebelliousness, and impulsivity
Viewing smoking as a sign of adulthood and independence

Habitual (psychological and physiological factors leading to continued

smoking)
Nicotine regulation
Stage3 Emotional regulation
Cues in the environment
Peer pressure and reinforcement
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Urges to smoke

Stopping (Psychological cues leading to attempts to stop)

Health Concerns
Expense , Aesthetic concerns
Stage4 Bad Example to others (e.g. children)
Availability of social support for stopping
Notions of self-mastery

Resuming (Psychological and Physiological factors leading to restarting)

Withdrawal symptoms
Stage5 Increased stress and other negative effects
Social and work pressures

Preparation for smoking comes early, when the child observes people in his environment and
significant people in society smoking. This establishes for him the acceptability of smoking.
Peer pressure is one of the prime initiators into experimentation with smoking. Those
children who are impulsive, less successful at school, rebellious, and tough are more likely to
experiment and continue smoking.

After a period of 2-3 years, the person becomes a habitual smoker. The need for cigarettes
becomes regular and there is an increase in the number of cigarettes smoked in a day. At a
physiological level, nicotine is addictive and the body begins to expect a certain level of
nicotine in the blood. There can be withdrawal symptoms, which serve as a negative
reinforcement to quit smoking. Its stimulating and alerting effects may further reinforce
smoking.

Smoking may also play a central role in emotional regulation. The experience of unpleasant
emotions like anxiety, anger, boredom, and depression may cue smoking. A consequent
relaxation or reduction in negative effect then reinforces the smoking response. Smokers also
report cravings for cigarettes or other tobacco products. These cravings for cigarettes or other
tobacco products may be cognitive correlates of low nicotine levels, of affective arousal, or of
the positive consequences associated with smoking, including taste, relaxation, or
stimulation. Cravings may also be triggered by external stimuli (e.g. seeing others smoke) or
by other behavior (e.g., a cup of coffee). Finally, a smoker may engage in self reinforcement
(e.g., seeing oneself as mature, adult or a ‗Marlboro man‘)

The table below illustrates the Antecedent Cues and Consequences of Smoking.

Table 7.2……
Antecedent Cues and Consequences of smoking

VARIABLE ANTECEDENT CUES CONSEQUENCES

Stimulation, relaxation
Nicotine dependence
Nicotine regulation
Physiological Withdrawal symptoms
Decreased withdrawal symptoms
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Anxiety, Tension Relaxation

Psychological Craving Excuses and Satisfaction
Rationalizations Positive self-image

Peer and adult models Peer approval

Social and Cultural Invitations and peer pressure Group affiliation

Commercials
Situations that evoke smoking Visual cues
Environmental
Situational stressors Social cues
Automatic behavior

Multiple behavioural cues (e.g.

Habitual behaviour
Behavioural with coffee after meals)

The smoking habit often becomes a vicious cycle wherein an individual responds to a
stressor, by smoking. Owing to its sense of immediate relief as ‗stimulation‘. This response to
the stressor turns into a habit very soon with several health problems. This smoking in turn
becomes another stress, which is too difficult to get rid of.
The journal CHEST recommends several strategies to quit smoking, which are noted in the
table (Table). However, it must be remembered that quitting such a habit requires essentially
willingness and motivation on the part of the dependent.

Table 7.3
Brief strategies: helping the patient willing to quit

Action Strategies for implementation

Implement an office wide system
that ensures that, for every patient at Advise-strongly urge all tobacco users to
every clinic visit, tobacco use status quit
is queried and documented.
Advice should be: Clear ―I think it is important for
you to quit smoking now and I can help you‖.
―Cutting down while
you are ill is not enough‖. Strong – ―As your
In a clear, strong, and personalized
clinician, I need you to know that quitting smoking is
manner, urge every tobacco user to
the most important thing you can do to protect
quit
your health now an in the future. The clinic staff and I
will help you. ―Encourage all clinical staff to
reinforce the cessation message and support the
patient‘s quit attempt
Assess-determine willingness to make a quit
attempt
Ask every tobacco user if he or she Assess patient‘s willingness to quit:
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willing to make a quit attempt at this If the patient is willing to make an attempt to quit at
time (e.g. within the next 30days) this time, provide assistance.
If the patient clearly states he/she is unwilling to
make an attempt to quit at this time, provide a
motivational intervention.
If the patient is a member of a special population (e.g.
adolescent, pregnant smoker, racial/ethnic minority),
consider providing additional information.
Assist-aid the patient in quitting
A patient‘s preparation for quitting:
Set a quit date, ideally, the quit date should be within
2 weeks. Tell family, friends, and co-workers about
quitting and request understanding support.
Anticipate challenges to planned quit attempt,
Help the patient with a plan to quit
particularly during the critical first few weeks: these
include nicotine withdrawal symptoms. Remove
tobacco products from your environment; prior to
quitting, avoid smoking in places where your spend a
lot of time (eg. work, home, car)
Abstinence – total abstinence is essential; not even a
single puff after the quit date Past quit experience-
review past quit attempts including identification of
what helped during the quit attempt and what factors
contributed to relapse.
Anticipate triggers or challenges in upcoming
attempt-discuss challenges / triggers and how patient
will successfully overcome them.
Provide practical Counselling
Alcohol – drinking alcohol is highly associated with
(problem solving/skills training)
relapse: the patient should consider
limiting/abstaining from alcohol during the quit
process.
Quit smokers in the house hold-The presence of other
smokers in the house hold, particularly a spouse or
partner, is associated with lower abstinence rates.
Patients should be asked to smoke outdoors and not in
the quitters presence.

Provide a supportive clinical environment while

encouraging the patient in his or her quit attempt;
Provide intratreatment social
―my other staff and I are available to assist you.‖
support. Help patient obtain extra
treatment social support. Help patient develop social support for his or her
Recommend the use of approved attempt to quit in his or her environments outside of
pharmacotherapy except in special treatment: ―ask
circumstances Provide your spouse/partner, friends and co-workers to
supplementary materials. support you in quit attempt.‖ Recommend the use of
pharmacotherapies found to be effective in the
guideline explain how these medications increase
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smoking cessation success and reduce withdrawal

symptoms; the first-line pharmacotherapy
medications include the following: Nicotine gum,
Nicotine inhaler, Nicotine nasal spray, and nicotine
patch. Sources-federal agencies, non-profit agencies,
or local/state health department.
Arrange – schedule follow-up contact
Timing-follow-up contact should occur soon after the
quit date, preferably during the first week; a second
follow-up contact is recommended within the first
month; schedule further follow-up contacts indicated.
Actions during follow-up contact-congratulate
Schedule follow-up contact, success; if tobacco use has occurred, review
either in person or via circumstances and elicit recommitment to total
telephone abstinence; remind patient that a lapse can be used as
a learning experience; identify problems already
encountered and anticipate challenges in the
immediate future; assess pharmacotherapy use an
problems; consider use or referral to more intensive
treatment.

Motivating to Quit
The Clinician / Therapist should have a detailed discussion with the client to understand
reasons for quitting elicit sufficient information to check patients awareness of Risks in
smoking, rewards in quitting and danger of relapse. This discussion will enhance client
motivation to quit. The greatest motivator of all is of course, the desire to quit.

Relevance : Encourage the patient to indicate why quitting is personally relevant, being as
specific as possible. Motivational information has the greatest impact if it is
relevant to a patient‘s disease status or risk, family or social situation (e.g.
having children in the home), health concerns, age, gender, and other important
patient characteristics (e.g. prior quitting experience, personal barriers to
cessation)
The Clinician should ask the patient to identify potential negative
consequences of tobacco use; the clinician may suggest and highlight those
that seem to be the most relevant to the patient; the clinician should emphasize
Risks : that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco
(e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks.
Examples of risks are: Acute risks: shortness of breath, exacerbation of asthma,
harm to pregnancy, impotence, infertility, increased serum carbon monoxide.
Long-term risks: heart attacks and strokes, lung and other cancers (larynx, oral
cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive
pulmonary diseases (chronic bronchitis and emphysema), long-term disability
and need for extended care: increased risk of lung cancer and heart disease in
spouses; higher rates of smoking by children of tobacco users; increased risk
for low birth weight, asthma, middle ear disease, and respiratory infections in
 139

children of smokers.
The clinician should ask the patient to identify potential benefits of stopping
Rewards : tobacco use; the clinician may suggest and highlight those that seem to be the
most relevant to the patient. Examples of rewards follow :

 Improved sense of smell.

 Save money.
 Feel better about yourself.
 Home, car, clothing, breath will smell better.
 Can stop worrying about quitting.
 Set a good example for kids.
 Have healthier babies and children.
 No worry about exposing others to smoke.
 Feel better physically.
 Perform better in physical activities.
 Reduced wrinkling/aging of skin.

Road blocks : The clinician should ask the patient to identify barriers or impediments to
quitting and note elements of treatment (i.e., Problem-solving, pharmacotherapy) that could
address barriers. Typical barriers might include:

 Withdrawal symptoms.
 Fear of failure.
 Weight gain.
 Lack of support.
 Depression.

Repetition: The motivational intervention should be repeated every time an unmotivated

patient visits the clinic setting: tobacco users who have failed in previous quit attempts should
be told that some people make repeated quit attempts before they are successful.
Positive Reinforcement should be a part of every encounter with a patient who has quit
recently. Every ex-tobacco user undergoing relapse prevention should receive congratulations
on any success and strong encouragement to remain abstinent. When encountering a recent
quitter, use open-ended questions designed to initiate patient problem-solving (e.g., ―How has
stopping tobacco use helped you?‖).The clinician should encourage the patients‘ active
discussion of the benefits the patient may derive from cessation, success the patient has had
in quitting, problems encountered or anticipated threats to maintaining abstinence.

Table 7.4
 140

Components of Relapse Prevention.

Schedule follows – up visits or phone calls with the

patient. Help the patient identify sources of support
Lack of support for cessation within his/her environment. Refer the patient to an
appropriate organization that offers cessation
counselling or support.
If significant, provide counselling, prescribe
Negative mood or depression appropriate medications, or refer the patient to a
specialist.
If the patient reports prolonged craving or other
withdrawal symptoms, consider extending the use of
Strong or prolonged
an approved pharmacotherapy or adding/combining
withdrawal symptoms
pharmacology medications to reduce strong
withdrawal symptoms.
Recommend starting or increasing physical activity:
discourage strict dieting. Reassure the patient that
some weight gain after quitting is common and
appears to be self-limiting. Emphasize the
Weight gain importance of a healthy diet with plenty of fruits and
vegetables. Maintain the patient on pharmacotherapy
known to delay weight gain (eg SR, NRTs,
particularly nicotine gum). Refer the patient to a
specialist or program.
Recommend rewarding activities. Probe to insure that
the patient is not engaged in periodic tobacco use.
Flagging motivation/ feeling deprived Emphasize that beginning to smoke (even a puff) will
increase urges and make quitting more
difficult.
Source – [CHEST June 2002]

II. ALCOHOLISM

Yet another health damaging behavior is the abuse of Alcohol. Let us first have a look at
what the term Alcohol implies and whether it is an acceptable form of behavior and how it is
linked to stress.

The word alcohol is derived from the Arabian term, ‗al-kuhul‘, which means ‗finely divided
spirit‘. There are many types of alcohol – amyl, butyl, isopropyl, isobutyl, methyl, ethyl
alcohol, etc. and different types of alcohol have various industrial and chemical use. Ethyl
alcohol (Ethanol) is what is commonly consumed. Alcohol is a clear, thin, highly volatile
liquid, with a harsh burning taste.

Addiction to alcohol (Alcoholism) The common man sees ‗alcoholism‘ as a weakness of

character. The moralist looks at it as a vice. Law finds the consequential acts of alcoholism as
a crime. The clergyman considers it a sin.

Who is a ‘social drinker’? A social drinker is one who drinks the way his social group
permits. He never oversteps their unwritten, unspoken, but clearly understood boundaries. He
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either drinks occasionally, or drinks regularly in moderate quantities. His intake of alcohol
does not cause any problem whatsoever in his life.

Who is an ‘alcoholic’? ―An alcoholic is one, whose drinking causes continuing problems in
one or more areas of his life (family-relationship, financial position, occupation, etc)‖. In
spite of these problems, he will keep on drinking. Here, ‗continuing‘ is the key word. This is
what differentiates him from a social drinker.

An ‗alcoholic‘ will not be able to take note of his problems and stop drinking totally. He tries,
but never succeeds on a long-term basis. He develops a physical and psychological
dependence on alcohol. He will have no control over his drinking, and even if he stops
drinking for a short duration, he will definitely go back to obsessive drinking.

Out of ten people who start drinking for the pleasure associated with it, two become
alcoholics.

What is alcoholism ?

It is characterized by the repeated drinking of alcoholic beverages, to an extent that exceeds

customary compliance with the social customs of the community and that interferes with the
drinker‘s health or the social or economic functioning.

Alcohol dependence can be both physical and psychological. Physical dependence is a state
wherein the body has adapted itself to the presence of alcohol. If it is suddenly stopped,
withdrawal symptoms occur. These symptoms range from sleep disturbances, nervousness,
tremors, convulsions, hallucinations, disorientation, delirium tremens, (DTs) and possibly
death.

Psychological dependence exists when alcohol becomes so central to a person‘s thoughts,

emotions and activities, that it becomes practically impossible to stop taking it. The ethos of
this condition is a compelling need or craving for alcohol.

Alcohol Alert explains that, the association between drinking and stress is very complicated,
because both drinking behavior and an individual‘s response to stress are determined by
multiple genetic and environmental factors. Studying the link between alcohol consumption
and stress may further our understanding of drinking behavior.

In many studies, individuals report that they drink in response to stress and do so for a variety
of reasons. Studies indicate that people drink as a means of coping with economic stress, job
stress, and marital problems, often in the absence of social support, and that the more severe
and chronic the stressor, the greater the alcohol consumption. However, whether an
individual will drink in response to stress appears to depend on many factors, including
possible genetic determinants of drinking in response to stress, an individual‘s usual drinking
behavior, one‘s expectations regarding the effect of alcohol on stress, the intensity and type
of stressor, the individual‘s sense of control over the stressor, the range of one‘s responses to
cope with the perceived stress, and the availability of social support to buffer the effects of
stress. Some researchers have found that high levels of stress may influence drinking when
alternative resources are lacking, when alcohol is accessible, and when the individual
believes that alcohol will help to reduce the stress, one‘s responses to cope with the perceived
stress, and the availability of social support to buffer the effects of stress. Some researchers
 142

have found that high levels of stress may influence drinking when alternative resources are
lacking, when alcohol is accessible, and when the individual believes that alcohol will help to
reduce the stress.

Stress may be linked to social drinking, and the physiological response to stress is different in
actively drinking alcoholics compared with nonalcoholic. Researchers have found that
animals preferring alcohol over water have a different physiological response to stress than
animals that do not prefer alcohol. Nonetheless, a clear association between stress and the
development of alcoholism in humans has yet to be established.

Stress is commonly believed to be a factor in the development of alcoholism (alcohol

dependence). However, current science is more informative about the relationship between
drinking and stress than about the relationship between stress and alcohol dependence.

Drinking alcohol produces physiological stress, that is, some of the body‘s responses to
alcohol are similar to its responses to other stressors. Yet, individuals also drink to relieve
stress. Why people should engage in an activity that produces effects similar to those they are
trying to relieve is a paradox that we do not yet understand. One hypothesis is that stress
responses are not exclusively unpleasant; the arousal associated with stress itself may be
rewarding. This might explain, for example, compulsive gambling or repeated participation in
―thrill-seeking‖ activities. Current studies may illuminate genetic variations in the
physiological response to stress that are important in drinking or other activities with the
potential to become addictive.

Whether alcohol addiction is a cause of ‗Psychological stress‘ or ‗the physiological stress

induced by intake of alcohol itself‘ leads to addiction, the damage is detrimental to health.

Three distinct stages of alcoholism

Whatever be the cause for consuming Alcoholic beverages, the general means by which the
intake of alcoholic beverages turns into an addiction proceeds in broadly three stages which
have been illustrated in the table given below.

The three stages namely Early stage, Middle stage and Chronic stage have been illustrated in
terms of general physical and behavioral signs and have been accompanied by the respective
responses felt by the patient as well as by others.

Table 7.5 Three distinct stages of alcoholism

Warning sings As felt by the patient As perceived by others

Early stage

Remains ‗steady‘ even after many

Increased tolerance Increased amounts of alcohol
drinks

Blackout People say ―I did this; said that! Has become a liar. Refuses to
Can it be true? Am I forgetting believe others when they tell him
 143

totally?‖ how he behaved

―I want to drink… yes right Gives lame excuses for going out;
Preoccupation
away!‖ always returns drunk

―They have again started Even at the mention of alcohol, he

Avoiding references to talking about alcohol. They are flares up, gets angry, walks away,
alcohol sure to pounce on me finally. I or
have to stop this conversation‖ changes the topic.

―Drinking helps me to
Drinks at the slightest provocation
Relief drinking overcome negative emotions
(criticism, conflict or stress)
like stress, anger or anxiety.‖

Middle stage

‗I‘ m not able to stop with one

or two drinks; I am unable to Drinks continuously anywhere;
Loss of control
exercise control over the time anytime of the day.
or occasion of drinking‖.

―I do drink; but is does not

Finds reasons, excuses for his
Denial cause any problems.
behavior
Everybody is exaggerating‖.

―I have got a lot. Let me give Talks ‗big‘ about himself; spends
Grandiosity
away something to others also.‖ far beyond his means.

―Others are too unreasonable.

Physical, verbal abuse; breaks
Aggression They
articles.
make me angry.‖

He can give up drinking if only he

wants to. He did it when he went
Abstaining for short ―If I want to stop, I can do it, I
on a
periods have proved it before.‖
pilgrimage. He only has to make
up his mind.

Solitary drinking ―I prefer to drink alone.‖ Drinks at home all alone

Problems, social
relationships, family ―I need a drink to face my
Is always drinking
problems, problems‖
Morning drinks,
 144

Chronic Stage

Is not able to avoid continuous Drinks day in and day out from
Binge drinking
drinking morning to evening

Unable to drink as much as Even with a very small quantity he

Decreased tolerance
before gets intoxicated.

―I must have alcohol right now. Steals money; tells lies about
Ethical breakdown
I do not care how I get it.‖ money matters; has lots of debts.

Refuses to open the door when

someone rings the bell; hides
Feeling of fear Indefinable fear
himself when people come to his
house.

―Everybody is after me. They

are going to harm or kill me!
Paranoia Suspects his wife, believes she is
My wife is also having affairs
having an affair with someone else
with other
men.‖

Hears voices, sees visions, feels

Hallucinations Afraid he is getting crazy.
something is crawling on his
skin.

Lack of motor Unable to control body Is not able to button his shirt, tie
coordination movements his shoelaces or hold a glass.

The effects of alcohol are directly related to its concentration in the blood (Blood alcohol
level). Alcohol acts directly on the brain and changes its working ability. The effects depend
on the speed at which the person drinks, his weight, presence of food in the stomach, and the
type of the beverage taken. The effects of alcohol on an individual also depend on a variety of
other factors like situation, one‘s attitude to drinking and one‘s drinking experience.
Path of alcohol in the body
 Alcohol is taken into the body through the mouth and travels to the stomach via the
esophagus. Alcohol, in its initial state, is in a form which can be immediately used by
the body.
 145

 In the stomach, chemicals are added to the alcohol. These chemicals have little effect
on the alcohol. Much of the alcohol is absorbed into the bloodstream directly from the
stomach. Unlike food, alcohol does not need digestion
 The remaining alcohol travels to the small intestine where it is absorbed in to the
blood.
 Once in the bloodstream, the alcohol travels to all part of the body. It affects heart
rate, blood pressure, appetite, gastric secretion, urine output, etc.
 Alcohol also effects the brain causing a variety of reactions ranging from relaxation to
unconsciousness and death.
 In the liver, alcohol undergoes a process of oxidation, where it is eventually changed
to carbon dioxide, water and a release of energy. These chemicals re-enter the
bloodstream and move on to the kidneys.
 The kidneys filter out the end products of the oxidation process, which are finally
excreted out of the body.
 About 95-98% of the alcohol undergoes steps 1-7; however , the remaining 2-5%
escapes unchanged via sweat, breath and urine.
Alcohol is one of the few things that is absorbed as soon as it enters the stomach. It molecules
are small and its chemical pattern simple enough to be used for fuel almost immediately after
swallowing. The rate of absorption is not constant, but dependent on various factors like the
speed of drinking, concentration of alcohol taken, the amount of foodstuff in the stomach, etc.
Table 7.6 The alcohol content and the source of some alcoholic beverages:

Name of the Source Percentage of Approximate 1 Drink or 10

beverage Alcohol Alcohol grams of
Brandy Distilled wine 40-50% 30 ml (1 oz)
Rum Sugar Cane (Molasses) 40-55% ‖
Grapes (Port, sherry,
Wines 10-22% 60 ml (2oz)
Champagne, Etc.)
Beer Barley 6- 8% 285 ml (10 oz)
Toddy Palm juice 5-10% ‖
Whisky Cereals 40-55% ‖

Long-term effects of Alcohol Addiction

When alcohol is repeatedly taken in large doses over a long period of time, it proves
disastrous, impairing both the length and quality of life. An excessive intake of alcohol over a
long period of time leads to several physical damages like gastritis, ulcers, cardiomyopathy,
polyneuritis, cirrhosis, pancreatitis, etc. This is because the important organs of the body like
the heart, liver and brain are affected.
As a person continues to drink excessively, his tolerance for alcohol increases. He is required
to take more and more of it, to experience the same effect.
Table 7.7 Percentage of Blood Alcohol and How it Effects Behavior
 146

Blood Alcohol in Percentage Behavioural Effects

Lowered alertness, ―feeling fine‖, no inhibitions, lack of
(5%)
―good judgment‖.
Slowed reaction time, impaired motor functions,
(10%)
recklessness and ―dare devil‖ behavior.
Large lapses in reaction time and judgement, some short
(15%)
term memory loss.
Marked depression, ―coming down‖, decreasing sensory and
(20%)
motor ability, slurring words.
Severe motor disturbance (stumbling, staggering, falling
(25%) down), little to no sensory input (can‘t smell or taste, blurred
vision)
Stuporous (totally unaware of what is going on around you)
(30%)
but still conscious, no awareness of pain, no pain reflexes.
Unconscious and in some cases in distress, vomiting occurs,
no motor skills (can‘t roll over when vomiting), similar to
(35%)
being under surgical anaesthesia. Occasionally, coma can
occur at this level

Alcohol and disease

Alcoholism, per se, is a disease that leads to physical, emotional, psychological and social
problems. It is a progressive and permanent disease. Apart from this, an excessive use of
alcohol affects the functioning of various systems in the body and lead to several
complications.
Alcohol and the Gastrointestinal tract : It is clear that alcohol damages the esophagus by
direct chemical irritation to its mucosa (interior lining). It also causes disturbances in the
stomach and small intestine. Gastro-intestinal bleeding, pain, difficulty swallowing, bleeding
lesions, diarrhoea are all common problems faced by alcoholics.
Pancreas : Alcoholism is associated with a significant increase in the incidence of
pancreatitis – a chronic inflammation of the pancreases. Acute pancreatitis produces severe
abdominal pain, fever, and the patient may go into a shock. Vomiting occurs and abdominal
tenderness is noticeable.
Alcohol and the liver : Alcohol causes three major pathological problems in the liver. These
problems are – fatty liver, alcoholic hepatitis and cirrhosis.
Alcohol causes an alteration in fat metabolism resulting in a gradual accumulation of fat in
the liver, and this in turn causes a fatty liver. The liver is enlarged and non-tender. Treatment
is possible and the patient recovers within six weeks.
Alcoholic Hepatitis is a very serious condition which may lead to hepatic failure or cirrhosis.
This often follows severe or prolonged bouts of drinking. This problem may persist even
when patients give up alcohol. The most important problem experienced is jaundice. Other
symptoms of alcoholic hepatitis include weakness, fatigue, loss of appetite, nausea and
vomiting, low grade fever and loss of weight.
 147

On the other hand, if he continues to drink excessively, it will result in Alcoholic Cirrhosis.
Cirrhosis can also occur without prior occurrence of alcoholic hepatitis. The word, ‗cirrhosis‘
means ‗scarring‘. In a cirrhotic liver, there is a widespread destruction of liver cells. These
cells are replaced by fibrous tissue scars. This condition is irreversible and is associated with
metabolic and physiological abnormalities. The liver is unable to perform its function.
Hepatic coma can occur as a result of this.
Alcohol and the vascular system: Alcohol in moderate amounts causes dilation of blood
vessels–especially blood vessels in the skin. This causes a sensation of warmth and flushing.
Due to the dilation of blood vessels, a lot of body heat is lost and internal temperature also
drops. Alcohol dependent persons become deficient in folic acid, since alcohol decreases the
absorption of folic acid from the small intestine. This leads to folic acid deficiency anemia.
Chronic alcohol ingestion decreases white blood cell production, and this leads to a number
of infections since the white blood corpuscles are an important part of our body defense
system. Chronic alcohol intake also decreases platelet function in the body by interfering with
the ability of platelets to stick together. Platelets control the blood clotting mechanism, and
the adverse effect of alcohol makes the person bleed profusely.
Alcoholic Cardiomyopathy : Alcohol cardiomyopathy is believed to be caused by the toxic
effects of alcohol or its metabolic products on the myocardium. Its symptoms are chronic
shortness of breath and signs of congestive heart failure. It causes enlargement of the heart,
abnormal heart signs, oedema, enlargement of the spleen or the liver and disturbances in the
cardiac rhythm.
Alcohol and the respiratory system : Alcohol affects the rate of respiration. Low to
moderate doses of alcohol increases the respiratory rate. In larger doses, the rate of
respiration is decreased. The lungs are not directly damaged by alcohol.
Alcohol and the nervous system : Brain nerve cells generate and conduct electricity,
transmitting information to the adjacent nerve cell by the release of specific chemicals called
neurotransmitters. The receiving cell provides feedback to the transmitting cell regarding the
message sent. Each cell can receive and integrate information from many others. This is a
function which alcohol can, and does alter.
Wernicke-Korsakoff syndrome – (alcohol induced persistent amnestic disorder) A person
with Wernicke‘s syndrome is apt to be confused, apprehensive and delirious. There is a
characteristic dysfunction of the eyes (Nystagmus) – paralysis of the eye muscles that control
eye movements.
The patients complain of double vision and their gait becomes unsteady. Difficulty in
walking is due to the peripheral and /or cerebella nerve damage. When first seen, the patient
may display signs and symptoms of alcohol withdrawal—delirium, tremulousness, confusion,
hallucinations, altered sense of perception etc. He is apathetic, listless, and disoriented.
Wernicke‘s syndrome shows a set of acute symptoms and is completely reversible with
treatment.
Korsakoff‘s psychosis is characterized by distorted memory function. Because of the severe
brain damage, the patient cannot process or store information. In order to fill these memory
gaps, he makes up stories. The ability to learn is severely impaired. He will require long-term
medical attention. Korsakoff‘s syndrome is a chromic condition where only about 20% of
patient‘s recover.
 148

Alcohol and the muscles: Alcohol is known to cause damage to muscle tissue. In binge
drinkers, acute muscle damage occurs as a result of which they experience pain and weakness
especially in the limbs. The affected muscles may later become swollen and bruised. This
indicates a certain degree of muscle tissue death. The dead muscle tissue floating in the
bloodstream can clog up the kidney‘s filtration system. If this problem is severe, it may result
in death due to kidney failure.
Alcohol and the excretory system: Alcohol inhibits the release of an anti-diuretic hormone,
which leads to excessive urination (diuresis). This results in increased fluid loss and it occurs
only when the level of blood alcohol is rising. This leads to the loss of some important body
chemicals such as potassium, magnesium and phosphorus. This can lead to serious muscle,
nerve and other damages.
Alcohol, Sexuality and the reproductive system : There is a popular misconception that
alcohol improves sexual functioning. There is a common misunderstanding that alcohol acts
as an aphrodisiac, and apparently increases sexual functioning. This is totally wrong. Alcohol
depresses that part of the brain that controls inhibitions, and therefore the person becomes
less inhibited. The problem lies, however, in the fact that although desire exists, sexual
performance and capability are diminished. Not much clinical research has been done in this
area; but there does seem to be a direct correlation between increasing alcohol blood levels
and decreasing sexual performance. It is proved however, that male alcohol dependents suffer
from sexual dysfunction.
Alcohol affects the sexual functioning of women also. This mechanism is only poorly
understood; however in alcoholic women there is failure to ovulate. Fetal alcohol syndrome is
a disorder found in children born of mothers who used alcohol excessively during pregnancy.
Alcohol and the skin : The skin disorders in alcoholics are a result of vitamin deficiencies,
inability to fight infections or neglect to take care of cuts and bruises.
If an excessive alcohol user has a liver disease, spider angiomas can be seen especially in the
upper chest area. Acne rosacea, the red nose of alcoholics, may result from chronic dilation of
blood vessels. Rhinophyma or ‗Brandy nose‘ is a result of increase in nasal sweat glands
which causes an increase in the size of the lower part of the nose.
Treatment:
In most of the treatment, the goal is complete abstinence from drugs, in any form and under
any condition, for the rest of the patient‘s life. This is coupled with a change in lifestyle.
Currently, research is being conducted to determine if a return to social drinking might be
possible for some individuals. However, this is a highly debated and controversial issue and
no definite conclusions have been drawn so far.
Methods:
Various methods, in different fields, have been implemented by various professionals. These
are discussed below:
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Medical management becomes necessary to handle problems associated with drug abuse.
Medical help is given in the following ways:
 Handling problems associated with overdose of drugs.
 Dealing with withdrawal symptoms.
 Administering medicines like antabuse or narcotic antagonists.
Psychosocial management consists of different methods of psychological treatment
procedures. These include :
 Individual couselling.
 Group therapy.
 Family therapy.
 Behavioural therapy.
 Other techniques
a) Acupuncture
Acupuncture technique can alleviate the agitation and pain of withdrawal and produce rapid
sedative and even euphoric effects on the patient.
b) Comprehensive multi-disciplinary approach
A comprehensive treatment programme, implemented by a multi-disciplinary team has been
found to be most beneficial.
There are four broadly described phases in the treatment of addiction:
 Identification/intervention
 Detoxification
 Rehabilitation
 After-care
A dynamic approach to treatment of Alcoholism ought to combine all the above given
methods i.e., Medical management, Psychosocial management and other techniques. The
problems faced by an alcoholic are several and therefore, the treatment has to be holistic in
order to deal with all the problem areas. The methods employed to deal with a specific
problem would depend upon the problem itself and also the goal of treatment.
The treatment goals are divided into smaller goals, which employ specific methods to deal
with the problem. The table given below (Table) illustrates the goals of treatment, the
methods used and the clinical setting involved.
Table 7.8

Phase Goals Methods Settings

Employee assistance
Braking of denial through Programme, School
Problem identification empathetic, non- welfare agency,
Phase I Patients entering judgemental, supportive, physician‘s office,
treatment confrontation Individual Criminal Justice system,
therapy Referral agency, In-patient or out-patient
medical
 150

and psychiatric services

Helping the patient to
Outpatient emergency
become drug free
Ingestion of medicines care services, inpatient
Phase II Motivation counselling
Nursing care hospital or detox
towards treatment and
services
rehabilitation
For the patient and his
family Change in self-
Individual counselling
concept Change in In-patient, Outpatient,
Phase Reeducative lectures Group
personality traits Change Day
III therapy Relaxation therapy
in lifestyle Restoration of programme
Spiritual counselling
physical health with
proper nutrition.
Prevention of relapses Same as Phase III Self-help
Phase Outpatient clinics half
Reinforcement of new groups After care sessions
IV way homes.
patterns of sober living Vocational rehabilitation

As mentioned earlier, Alcohol is another commonly used negative coping mechanism. It is a

powerful drug and mostly used because of its effect on mood. In small quantities it quickly
produces a feeling of well being, and in larger doses it produces euphoria and a release of
social inhibitions. For many people, this makes social interaction easier. These people usually
take alcohol in small quantities and may remain ‗social drinkers‘. But, for some, these small
amounts soon begin to seem insufficient and they need larger amounts to experience the same
―Kick‖. This increased tolerance is an early warning sign of the person moving toward
alcoholism.
Dependence on alcohol can be both physical and psychological. If the person believes that he
has to have a drink when he returns home from work, and only that can help him to unwind,
there is a definite psychological dependence. Psychological dependence exists when alcohol
becomes so central to a person‘s thoughts, emotions, and activities, that it becomes
practically impossible to stop taking it. There is a compelling need or craving for alcohol.

The chronic stage of alcoholism is characterized by binge drinking, decreased tolerance,

feeling of paranoia, hallucinations, and a lack of motor co-ordination. At this stage, there is a
physical as well as a psychological dependence. If the person has a serious drinking problem,
then he will need professional help to deal with it. As with smoking, dealing with the root
cause of stress and learning more effective ways of coping may make dealing with the
drinking problem easier.
Top ten facts on Alcohol
1. Alcohol is the most socially accepted addictive substance and is a contributing factor
in over 75% of all Date Rapes.
2. Alcohol dehydrates you: it does not quench thirst, it makes thirst worst. Alcohol is
also extremely high in empty calories.
3. Drinking alcohol while pregnant can cause permanent brain damage and often causes
physical deformations in babies. These devastating disorders often render their
victims unable to function in society or to care for themselves in socially acceptable
ways; many of these children grow up to commit suicide or end up ―living‖ in the
criminal justice system.
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4. Alcohol causes varying degrees of the following side effects in every one who uses it;
dullness of sensation, lowered sensory motor skills, lowered reactive or reflexive
motor responses, impaired thought processes, impaired memory, impaired judgment,
sleep or sleeplessness, and in extreme cases can cause coma and death.
5. When an alcoholic beverage is ingested, a full 20% of the alcohol immediately enters
the bloodstream by penetrating the wall of your stomach; drinking on a full stomach
can slow this process.
6. Many people mistakenly believe that alcohol is a stimulant, like coffee, when in fact it
is a depressant.
7. One of the first things to go with drinking alcohol is the sense of ―good judgment‖
and ―inhibitions‖.
8. Alcohol can cause the following behaviour; aggression, sexual openness, excessive
talking, spilling secrets, lying, phony friendliness and quick tempers.
9. A ‗hang over‘ is what happens when the body experiences alcohol withdrawal and the
headaches are caused by extreme dehydration of the brain – the brain is literally being
pulled away from skull, leading to throbbing aches and sharp pains at attachment
points like the temples and base of the neck.
10. 70% of alcoholics and alcohol abusers suffer the following irreversible physical side
effects; cirrhosis of the liver (fatal in over 60% of cases), ―cauliflowering‖ of the nose
and ears (where your ears and nose become cauliflower shaped), permanent
restructuring of the brain including loss of long term memory, heart problems,
obesity, premature dementia (partial and full), loss of bladder control and slurred
speech even when sober
III. DRUGS

The use of drugs has increased dramatically in our society, over the last 20 years. Taking
medication under doctor‘s supervision to deal with stress is also not the best way to deal with
the situation since the problem continues to remain. While symptoms are managed with
drugs, the cause of the symptoms still lies untreated. It has become quite common to take a
tranquilizer whenever there is a problem, but this offers only temporary relief. Infact, this
could become habit forming due to both physical and psychological dependence. The person
becomes psychologically dependent because taking of these tranquilizers gives temporary
relief from a stressful situation. This further decreases the individual‘s abilities to cope since
the person does not make any efforts to bring about any changes in himself or the situation. In
addition, some of the tranquilizers also cause physical dependence.
The habitual use of illegal drugs like marijuana and heroin, causes rapid deterioration in the
taker‘s physical health and social interactions. The addict accepts these effects on his physical
and mental health for his escape from stress and tension.
Any chemical that alters the physical or mental functioning of an individual is a drug. When
drugs are used to cure an illness, or improve the medical condition it is termed ‗drug use‘.
When drugs are taken for reasons other than medical, in strength, frequency or manner that
damages the physical or mental functioning of an individual, it becomes ‗drug abuse‘. Any
type of drug can be abused. Drugs with medical uses can also be abused in the following
ways :
Too much : Taking increased dosages without medical advice. E.g. Taking 10 mg of valium
when only 2 mg has been prescribed.
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Too often : Taking small doses frequently, taking the drug during daytime when a bedtime
dosage alone has been prescribed.
Too long : Taking the drug for an extended period of time – longer than the prescribed
period; continued use of the drug for months when the physician has advised usage only for a
fortnight.
Wrong use : Taking a drug for reasons other than medical, for which it is intended, or taking
a drug without medical advice. Taking Gardinal (an anti-epileptic drug) for the sedative side
– effect it products.
Wrong combination : Taking a drug in combination with certain other drugs. E.g. taking
barbiturates (a depressant drug) with alcohol to enhance the effect.
Illegal drugs like brown sugar and ganja have no medical use at all. To use these drugs is to
abuse them. From the very outset, this is drug abuse.
Drug abuse leads to drug addiction with the development of tolerance and dependence.
Tolerance refers to a condition where the user needs more and more of the drug to experience
the same effect. Smaller quantities, which were sufficient earlier, are no longer effective and
the user is forced to increase the amount of drug intake.
Psychological dependence is a state characterized by emotional and mental preoccupation
with the effects of the drugs and by a persistent craving for it. When psychological
dependence develops, the user gets mentally ‗hooked on‘ to the drug.
When physical dependence develops, the user‘s body becomes totally dependant on the drug.
With prolonged use, the body becomes so used to functioning under the influence of the drug,
that is able to function normally only if the drug is present.
After the user becomes dependent, if the intake of drugs is abruptly stopped, withdrawal
symptoms occur. In a sense, the body becomes ‗confused‘ and protests against the absence of
the drug. The withdrawal symptoms may range from mild discomfort to convulsions,
depending on the type of drug abused. The intensity of withdrawal symptoms depends on the
type of drug abused, the amount of drug intake and the duration of abuse.
These withdrawal symptoms make it difficult to give up drugs. The user is seemingly caught
in a web of his own making. He wants to avoid the unpleasant withdrawal symptoms; to
avoid them he needs the drugs. The addict is thus forced to continue drug use even when he
knows that drugs are hurting him.
Classification of addictive drugs
Addictive drugs are classified in various ways based on their origin, chemical structure,
mechanism of action etc. When classified according to their effects on the user, addictive
drugs can be classified into five major categories:

 Narcotic analgesics
 Stimulants
 Depressants
 Hallucinogens
 Cannabis

1. Narcotic Analgesics
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In Greek the prefix ‗narco‘ means to deaden or ‗benumb‘. Analgesic means pain-killing or
pain relieving. The term ‗narcotic‘ medically refers to opium and opium derivatives or
synthetic substitutes that produce opium-like effects. As a class, they are painkillers with a
high addictive potential.
Drugs belonging to this category can be studied under three broad categories: narcotics of
natural origin, semi synthetic narcotics and synthetic narcotics.
Fig 7.2

a. Narcotics of natural origin: The poppy plant ‘Papavaer Somniferum’, is the source of
naturally occurring narcotic drugs. For thousands of years this plant has been widely
cultivated for its pleasurable effects. Today, its cultivation has been restricted by law.
Opium is made from a milky fluid that is collected from the unripe pod of the poppy plant.
Opium is a dark greyish or brownish tar like substance.
Routes of Administration: Opium is smoked, chewed and absorbed through the mucuous
membranes of the mouth. It is also boiled with water and drunk.

 Morphine is the principal alkaloid that is extracted from opium. About 10-15% of the
opium exudates contains morphine. Morphine is one of the most effective drugs for relief
of pain. It is still used medically.Routes of administration: Injected – subcutaneously,
intramuscularly or intravenously. Most morphine addicts use the intravenous route.
 Codeine is another alkaloid found in opium though in a smaller percentage than in
morphine (one to two percent). Codeine is used in cough suppressant drugs and anti –
diarrhoel preparations.Routes of administration: Injected – substaneously or
intramuscularly. Oral – medical preparations of codeine are usually made in combination
with other chemicals and are available in the form of tables and syrups.Codeine is very
rarely abused as its analgesic effects are mild and severe side effects (e.g. convulsions) are
often experienced.

b. Semi-synthetic narcotics : Heroin/Brown sugar (di-acetyl morphine) is a semi – synthetic

derivative of the drug morphine. Brown sugar is the adulterated form of heroin.
Routes of Administration: Brown sugar is smoked or ‗chased‘.
c. Synthetic : Meperidine (Pethedine) is probably the most widely used drug for the relief or
moderate to severe pain.
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Routes of Administration: Meperidine can be administered orally in the form of tablets or

Injected – subcutaneously, intrasmuscularly or intravenously. Pethidine addicts almost
always inject the drug intravenously.
From the 1960‘s Methadone received wide recognition in the area of narcotic addiction
treatment in the USA. It later became a part of heroin addiction treatment. Ironically, later on,
many got addicted to methadone and it became the major cause of overdose deaths. Since
then, it‘s use has declined.
Routes of administration: Methadone is almost as effective when administered orally as it is
by injection. So methadone is usually taken in the form of tablets.
Adverse effects of Narcotic analgesics
With large doses, pupils constrict to pin point size and respiratory depression becomes more
pronounced. With an overdose, cyanosis develops in which skin becomes cold, moist and
bluish. Convulsions occur which may be followed by respiratory arrest and death.
Long-tem effects: Severe constipation, contracted pupils and moodiness are some the long-
term effects. Chronic users may develop lung problems due to its effects on the respiratory
system. Unsterile needles can cause infection. Abscesses (pus formation), cellulites
(inflammation of connective tissues), liver damage, tetanus and brain damage are the other
problems which may develop.
Tolerance and dependence : Tolerance develops fairly rapidly making higher doses
necessary to maintain the intensity of its effects. The narcotic analgesic class of drugs is
highly addictive, and regular use results in severe physical and psychological dependence.
Withdrawal symptoms : The withdrawal symptoms of narcotic analgesic are more painful
and severe, compared to the withdrawal symptoms of other categories of drugs. The severity
of withdrawal symptoms will depend on the type of narcotic used, the amount, the duration of
use and the general health condition of the person.
2. Stimulants
Stimulants are drugs which excite or speed up the central nervous system. The two most
prevalent stimulants are nicotine, found in tobacco products, and caffeine, the active
ingredient in coffee and tea. Among the potent ones are amphetamines and cocaine, which we
will discuss here.
a. Amphetamines are synthetic drugs produced entirely within the laboratory. Amphetamine,
dextroamphetamine and meth-amphetamine collectively come under the term amphetamines.
The effects produced by these three are the same and can be differentiated only by clinical
analysis.
Amphetamines are sometimes used in weight control programmes, in the treatment of mild
depression and to provide relief from fatigue. Amaphetamines, however, are now recognized
as a poor choice for treating these disorders.
Amphetamines are white, odourless, crystalline powders with a bitter taste. Illicit varieties
include fine or coarse powders and crystals that are off-white to yellow in color. They are
supplied loose or in the form of capsules and tablets. Amphetamines are usually abused by:

 Students, to ward off sleep, enabling them to study through the night prior to the
examination.
 Athletes, to mask feelings of fatigue and increase their endurance.
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 Busy Executives often abuse both stimulants (‗uppers‘) and depressants (‗downers‘) – the
stimulant to increase their activity during the day and the depressant to calm down and
sleep during the night.

Routes of Administration: Amphetamines are absorbed orally and are taken in the form of
tablets or capsules.
b. Cocaine, a potent stimulant of natural origin, is extracted from the leaves of the coca plant
(Erythroxylon coca). Cocaine was formerly used in eye, nose and throat surgery because of
its ability to anaesthetize tissues and simultaneously constrict blood vessels and limit
bleeding. It is no longer employed medically. It is an odorless, white crystalline powder, with
a bitter numbing taste. Street cocaine is often adulterated with other chemicals.
Routes of Administration: The leaves of coca plant are sometimes chewed and cocaine, the
chief psychomotor chemical present, is absorbed through mucuous membranes of the mouth.
Cocaine is usually ‘snorted‘ or taken in through the nasal passage (like snuff). Very rarely is
cocaine injected for a heightened effect.
Short-term effects of stimulants: Amphetamines and cocaine have different mechanisms of
action but the overall impact is the same and their effects parallel each other very closely.
The effects include :

 A heightened feeling of well being, euphoria (elation).

 A sense of super-abundant energy, increased self – confidence.
 An increased motor and speech activity.
 A suppression of appetite (which is why it is used in diet pills).
 An increased wakefulness that masks feeling of fatigue (the reason why amphetamines are
abused by students during examinations).
 Pupilary dilation, dryness of mouth, increased respiration, heart rate and blood pressure,
reduced gastrointestinal activity and urinary retention.
 Unpleasant effects such as temporary impotence, anxiety or even panic.

With large doses, very rapid heartbeat, hypertension, headache, profuse sweating, severe
agitation and tremors may occur. Very high doses cause rapid, irregular and shallow
respiration, convulsions and coma.
Long-term effects : Chronic sleep problems, poor appetite, high blood pressure, rapid and
irregular heart beat, impotence, mood swings, anxiety and tension states are the long-term
effects of stimulant use. Acts of violence, homicide and suicide among stimulant abusers are
high. Chronic use may produce ‗amphetamine psychosis‘. Paranoid ideations, hallucinations
and purposeless stereotype behaviour may develop. A full blown amphetamine psychotic
state closely resembles paranoid schizophrenia.
Tolerance and dependence : Tolerance does develop to a certain extent. As the intensity of
the pleasurable effects are high, strong psychological dependence also develops.
Withdrawal symptoms : When chronic use is abruptly discontinued, withdrawal symptoms
occur. However, the clinical picture does not include major grossly observable physiological
disruptions. Extreme fatigue, prolonged but disturbed sleep, voracious appetite, irritability
and moderate to severe depression are the commonly reported withdrawal symptoms.
3. Depressants
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Depressant are drugs which depress or slow down the functions of the central nervous
system. The drugs which come under this category include:
a)Sedative-hypnotics
b) Alcohol
a. Sedative-hypnotics are non-narcotic depressant drugs whose primary effects are calming,
sedation or inducing of sleep. Barbiturates and benzodiazipines are two main drugs that fall
into this category.

 Barbiturates– More than 2500 barbiturates have been synthesized and about 50
compounds marketed. These compounds have been researched and developed for their
tranquilizing and sleep inducing effects. Some of the more commonly used barbiturates
are listed in the table below (Table 7.9).

Table 7.9
Generic Name Trade Name
Thiopental Sodium pentothal
Pentobarbital Nembutal
Secobarbital Seconal
Phenobarbital Luminal
Secobarbital & Amylobarbital Gardinal
Vesparax

Barbiturates are medically prescribed for sedation and to induce sleep. They are also used for
narcoanalysis (truth–serum) and as anti-convulsants (anti–seizure, eg. Phenobarbital) Salts of
barbiturates are white bitter powders.
Routes of Administration: Barbiturates are administered orally in the form of tablets or
capsules. Barbiturates can also be injected – subcutaneously, intravenously or
intramuscularly.

 Benzodiazepines– Over 2000 types of benzodiazepines have been synthesized but only
twelve of them are marketed. Benzodiazepines as a class are the most frequently
prescribed drugs. The following table (Table7.10 ) lists some of the most commonly
prescribed benzodiazepines.

Table 7.10
Generic Name Trade Name
Diazepam Valium, Calmpose
Chlordiazepoxide Librium
Flurazepam Dalmane
Alprazolam Alprax
Iorazepam Ativan

Benzodiazepines are clinically used to reduce anxiety, induce sleep and for muscle relaxation.
These are also used as pre-anaesthetic medications and to control seizures. Of late, however,
physicians have been discouraged from prescribing these drugs for anxiety arising out of
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everyday living. The use of tranquilisers on a daily basis for more than three months is
becoming less acceptable. Benzodiazepines are white or pale yellow crystalline powders.
Routes of Administration : Benzodiazepines are taken in the form of tables or capsules.
Diazepam and chlordiazepoxide are also injected intravenously.
b. Alcohol : The second category of Depressants has been discussed in great detail in the
previous pages of this chapter.
Short-term effects of depressants : Sedative hypnotics produce effects that are similar to
that of alcohol. The main effects include :

 Relief from anxiety and tension.

 Euphoria (usually with barbiturates).
 Mild release from inhibitions.
 Sedation, sleep with larger doses.
 Poor motor coordination (especially for fine motor tasks).
 Impaired concentration and judgement.
 Slurred speech and blurred vision.

Nausea, abdominal pain, excitation which may lead to hostile behaviour can also occur.
With large doses, barbiturates can cause irregular breathing, weak pulse, coma and death.
Death due to overdosage rarely occurs with sedative hypnotics, but may occur with a
combination of sedative hypnotics and alcohol.
Long term effects : Long term use can produce depression, chronic fatigue, respiratory
impairments, impaired sexual function, decreased attention span, poor memory and judgment.
Chronic sleep problems may develop. Reduced REM sleep due to drug use makes the quality
of sleep so poor that the user does not feel rested on waking up.
Tolerance and dependence : Tolerance does not develop uniformly in all the depressants.
With barbiturates, tolerance to the sleep inducing effects develops very rapidly often within a
week or two of regular use. In the case of benzodiazepines, with chronic use, tolerance
develops to the anxiety and tension releaving effects.
Tolerance diminishes following a short period of abstinence. Physical dependence can
develop with regular use. However, the psychological dependence produced is significant.
Anxiety or even panic is evident if the user is temporarily unable to obtain a supply of the
drug. The user experiences a persistent craving for the drug even when significant
psychoactive effects are not felt.
Withdrawal symptoms : Withdrawal symptoms after abrupt abstinence are often not as
severe as withdrawal from other classes of drugs.Mild withdrawal symptoms like anxiety,
insomnia, weakness and nausea are usually noticed. With very high chronic use of the drug,
agitation, high body temperature, delirium, hallucinations and convulsions develop.
4. Hallucinogens
Hallucinogens are drugs which dramatically affect perception, emotions and mental
processes. As they distort the perception of objective reality and produce hallucinations, these
are known as ‗hallucinogens‘. Hallucinogens are also referred to as psychedelic (mind
altering) drugs.
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Hallucinogens include a wide variety of substances ranging from wholly synthetic products to
naturally occurring substances. Hallucinogenic drugs are very rarely available in India,
making it the least abused class of drugs. The most common hallucinogenic drugs are listed
below:
a. LSD (Lysergic acid diethlamide) is a semi-synthetic drug and the most powerful
hallucinogen. It is produced from lysergic acid, a substance derived from the ergot fungus
which grows on rye, or from lysergic acid amide, a chemical found in morning glory seeds.
LSD was used only as a research tool to study the mechanism of mental illness. It has no
medical use and is a white odorless crystalline material which is soluble in water.
Routes of Administration : It is easily absorbed orally and is usually taken in the form of
tablets. LSD blotter papers are also common. LSD is dissolved in water and is absorbed in
blotting paper. A piece of this paper is torn off, placed under the tongue and sucked.
b. PCP (Phencyclidine) was synthesized and tested as a human anesthetic in the 1950‘s. Its
use was later discontinued due to its side effects that included confusion and delirium. It later
came to be used in veterinary medicine. PCP is now produced only in clandestine
laboratories.
PCP is commonly called ‗angel-dust‘. PCP in its pure form is a white crystalline powder that
readily dissolves in water.
Routes of Administration : It is snorted, smoked, eaten and rarely taken intravenously.
c. Mescaline is derived from the Mexican peyote cactus‘ and the ‗San Perdo cactus‘. For
centuries consumption of mescaline was part of religious ceremonies in parts of North
America. It is still used in these areas. Mescaline can also be produced synthetically.
Mescaline appears as a white or colored powder.
Routes of Administration : The oral route of administration is most common
d. Psilocybin is chiefly derived from the ‗psilocybe‘ mushoroom. The drug can be
synthetically produced only with great difficulty. Crude mushroom preparations containing
psilocybin are usually sold as dried brown mushrooms.
Routes of Administration : This drug is well absorbed orally. The mushroom itself may be
eaten or dried, powered and smoked.
Short term effects of hallucinogens: The physical effects produced and perceptual effects
created differ from one drug to another and wide chemical differences also exist. The main
effects include:

 Alterations of mood – usually euphoric but sometimes severely depressive.

 Distortions of the sense of direction, distance and time (eg. passage of a few minutes may
seem like hours).
 Intensification of sense of vision. Colour and texture of items become more vivid and
perception of detail is increased.
 ‗Pseudo‘ hallucinations (‗pseudo‘ because the user knows that the experience is not true.
E.g. seeing a myriad of colours or bizarre images).
 Synsthesia or a melting of two sensory modalities (user may feel he can see music, hear
colours etc.).
 Feelings of depersonalization, loss of body image and a loss of sense of reality (the user
may feel that his body is shrinking or becoming weightless).
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 Sense of past, present and future may be jumbled. Concentration becomes difficult and
attention fluctuates rapidly.
 Vague ideas and extreme preoccupation with philosophical issues are common. The great
truths and insights he believes that he discovers are unintelligible or nonsensical to those
not under the influence of LSD.

Hallucinogens are, however, unpredictable in their effects each time they are used. Acute
panic reactions can also be produced resulting in a ‗bad trip‘. Acute anxiety, restlessness and
sleeplessness are common until the effect of the drug wears off. Self-destructive behavior and
rash decisions and accidents springing from impaired judgment are common.
Long-term effects : ‘Flashbacks or spontaneous recurrences of an LSD experience can occur
without warning for up to a year after LSD use. The exact mechanism of the effect is not
known. The user may experience effects such as intensification of colour, apparent movement
of a fixed object or other hallucinogenic effects even after abstinence for a few months. The
user becomes very apathetic, is very passive and shows no interest in life.
Acute panic reaction which can occur may lead the user into a stage of drug-induced
psychosis. It may resemble paranoid schizophrenia in many respects with hallucinations
(mainly visual), delusional thinking and bizarre behaviour. The psychotic episode normally
lasts for several hours but in some cases it may last for years.
Tolerance and dependence : Tolerance develops very quickly and disappears rapidly after
discontinuation. Due to rapid development of tolerance, most of the users discontinue use of
the drug at least for a while, to regain original sensitivity. Psychological dependence develops
though the user does not become physically dependant. Particular withdrawal symptoms are
not reported
IV. EATING
There are two ways in which eating may be affected by stress. The patient could either go on
an eating binge or not eat at all. The more common practice is to eat under stress, reaching
out for ‗comfort food‘, which usually tends to be rich in carbohydrates and fats, to enhance
satiety & satisfaction.
However, both groups need to be aware of their problem to take steps to overcome it. An
occasional missed meal may not make much difference but missing meals over a period of
time may result in hypoglycemia, irritability and poor judgement. Similarly, over-indulgence
occasionally may not matter much, but could result in obesity and its related problems of
hypertension, diabetes etc. if carried on over a period of time.
Obesity is a major health problem in the United States. Depending on the definition of
obesity, it has been estimated that between 30 to 50% of American adults are overweight.
Obesity is associated with high blood pressure, diabetes, heart disease, kidney problems,
psychological problems and stroke. Approximately 50% of Indian urban population is
overweight.
Why are people obese ? Simply put, it is the result of consuming more calories than are
expended by exercise or metabolism. The balance between consumption and expenditure of
calories is a delicate one. The average, non obese adult male consumes about 1 million
calories of food per year. If he increases his caloric intake by 10% without simultaneously
increasing exercise by a comparable amount, he will gain 15 kgs. in that year. Two behaviors
are thus critically involved in weight control: eating and exercise. We are over weight
because we eat too much, exercise too little, or both.
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The opposite of over eating would be not eating at all, for reason of beauty, of obsession
about themselves, and primarily for dealing with a very poor self-concept. Today many
youngsters chose not to eat at all. This behavior results in extreme stress to one‘s physical
status and also can cause disorders like Anorexia, which endangers the health of the
individual
V. OVERWORK
Another health damaging behavior is over work. Over work is more likely to be understood
as a cause of stress, rather than a way of coping with stress. However, it is true that many
people try to cope with stress through overwork. A person may try to cover up his
inefficiency through overwork, not realizing that in an effort to cope, he is infact increasing
his amount of stress. Working extra hours leaves the person tired thereby causing him to
make mistakes and increase his workload.
Some people may also use over work as a way of coping with family problems, and social
problems. A person who is having problems at home, or is not comfortable in social
situations may prefer to stay at work rather than face those situations. Either way, dealing
with the basic problem will stop the need for overwork. It is important to find out the real
cause for overwork and overcome it

HEALTH PROMOTING BEHAVIOUR

If there are health damaging behaviors, we also have coping behaviors which are health
promoting. There is no doubt about the role of Exercise and the importance of a Balanced
Healthy Diet, in helping the individual to overcome stress. If stress is the problem, then
relaxation is certainly one solution. There are a number of factors, which contribute to staying
healthy and combating stress.
I. EXERCISE
Exercise brings with it many benefits for the individual. The person feels fitter and healthier,
and more able to cope with the daily stresses of life. Exercise also improves body shape and
muscles tone, both of which are great morale boosters. The ability to have the self-discipline
to keep to a regular exercise regime is also important. Another aspect of exercise is that it
distracts the individual from mundane worries and in general, contributes to the
psychological well being of an individual.
It is, however, necessary to be careful while exercising. It is always best to take the doctor‘s
advice before beginning any exercise programme. It is also important(to exercise in
moderation and at a comfortable pace.) Do not keep on exercising if there is chest pain, or if
you fell dizzy, light-headed or fatigued. Several other details regarding exercise are discussed
in other chapters in this book.
II. BALANCED DIET
Eating a well balanced diet is an effective way of combating stress. If you have the tendency
to overeat under stress, it would not be a problem if you reached for fresh fruit and
vegetables. Replace the need for coffee with fruit juice and plain water. Not only does this
make the person feel more physically fit and capable of taking on stressful situations, but it
also makes the person feel good about himself since he looks physically fit and not obese.
If the problem is one of being unable to eat under stress, it helps to eat light, easily digested
food in small servings. It is better to eat a little less and more often, than to force oneself to
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eat big, heavy meals, which one does not want. Eating plenty of fresh fruits and vegetables is
also helpful.
‗Your nutrition can determine how you look, act and feel‘. Proper nutrition and healthy eating
habits can increase resistance to stress as well as disease and also promote wellness.
III. SLEEP HYGIENE
Sleeping well and getting a good night‘s rest is one the most effective coping mechanisms for
stress. It brings the body into a state of rest and recuperation and restores the body‘s
equilibrium. If however, the problem is with sleeping, i.e. being unable to sleep because of
worry, keeping certain points in mind may help you to fall asleep.

 Sleep for 6 – 8 hours daily.

 Have set rigid time for going to bed and getting up.
 Do not eat full meals before going to bed.
 Exercise moderately daily.
 Do not take stimulants like alcohol, tea or coffee before going to bed.
 Do not sit up and work in bed.
 Take a warm bath before going to bed.
 Make sure you are comfortable in your bed and bedroom.

IV. RELAXATION
Relaxing is a skill which may not solve the stress problem on its own, but puts the person in a
state where he may be able to think about the problem calmly and deal with it. It may also
deal with the aches and pains caused by tension.
Relaxation does not mean lying around and doing nothing. Nor does it mean reading a book
or watching T.V. Rather, it is a process of systematically relaxing groups of muscles, until the
whole body is relaxed. Progressive relaxation is one of the most commonly used techniques,
which was developed by Edmund Jacobson. At the heart of the theory is the fact that the body
tenses under stress. This bodily tension increases the subjective experience of anxiety. This
bodily tension is reduced by muscular relaxation which thereby reduces anxiety. The
sequence for relaxation involves tensing and then letting go.
CONCLUSION
Table 7.11 Categories various Health Promoting behavior. These habits help in reducing
stress, as well as in preventing illness. Practiced regularly they take the individual towards a
state of Positive and Total Health. These factors have been discussed in greater detail in
Chapters 8 and 9
Table 7.11
 Cardio – Vascular- respiratory exercises or Aerobic exercise or simply
stamina exercises
 Walking, jogging, Dance Aerobics, swimming, cycling, Games
Exercise
 Strength building exercises for muscles
 Flexibility exercises for Back pain, Repetitive stress injury etc.

Balanced  Therapeutic Nutrition for medical ailments such as Hypertension,

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Diet Diabetics, Hyperlipideama, Anemia etc.

 Balanced diet for good health
 Weight Management through diet & exercise

 Sleep of 6-8 hours daily on an average

 Relaxation techniques such as progressive muscular relaxation,
visualization, Autogenic training, Self Hypnosis
Relaxation
 Meditation techniques such as yogic breathing Meditation, Yoganidra,
 Massage

 Appropriate time for health promoting behavior on a daily basis- sleep,

Routine work, exercise, meals, family time.

 Assertive Personality
 Conflict Management
Positive
 Positive thinking
coping
Behavior  Positive stress
 Thought stopping

 Music, Painting, Hobbies, Friends etc.

Others

The first step towards Good Physical and Mental Health is to instill healthy habits in yourself
and your family. This step will help you Prevent Illness and Promote Wellness. If you
imagine that health is a God given gift that doesn‘t need your inputs, you will neglect health
and take a step towards illness. Symptoms will be followed by medical ailments. This will
now require Secondary Prevention. If you still don‘t see the writing on the wall or behave
like the Ostrich, dig your head in sand and imagine that since you can‘t see illness, illness
also can‘t spot you and nail you, you are in danger. Ailments will become chronic and you
will now need Tertiary Prevention.
Take the first step towards health by adopting Health Promoting Behaviour. Thereafter, keep
taking this step everyday. The benefits are huge – a fit body and a sound mind
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CHAPTER 8:
COGNITIVE & BEHAVIOURAL COPING
STRATEGIES
Introduction to Cognitive & Behavioural Coping Strategies
It is a paradox of modern civilization that when mankind is able to find a cure for all diseases
it should be making Stress into an all pervading phenomenon, affecting all professions, age
groups, gender and strata of society and taking a heavy toll on the its well being.
Stress is a powerful force which can do much good or much harm. It is like a flowing river.
When tamed and directed it can spread much goodness along its path; when managed, stress
can provide a sense of challenge, excitement, efficiency and productivity.

However, like the havoc caused by an untamed river, stress can also become a devastating
way of life, chronic enough to disturb balance and aggravate all diseases.
Managers and Corporates are getting overpowered by a stress prone work ethic and there is a
need to stop and learn new as well as age old coping techniques. There is a need to find a
balance between peak performance, high energy and excitement on the one hand and rest,
rejuvenation, harmony and tranquility on the other.
Each of us needs a certain amount of stress to be alert and capable of functioning. Good
Stress is the much required driving force, the movement from Plan to Action, the extra stretch
to success.
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Like everything else too much is bad. It challenges our Tolerance limits and threatens the
organ or system that is the weakest link in our Physiological chain.
At no time are you being advised to do away with stress and lead a passive, laid back life.
Stress results when your capabilities fall short of life‘s demands. While stress and challenge
are exciting, they need to be balanced with Rest, Sleep, Relaxation, Exercise and a Calm
Personality.
This balance will take you away from disease and towards Personal growth and Good Health.
Fig 8.1

One of the most important aspects of stress management is awareness of what causes the
stress and preparation to combat its effects in anticipation. Management techniques prepare
the person to face a problem situation more effectively. A negative frame of mind makes a
person feel nervous and upset in stressful situation, he will be unable to deal with it. On the
other hand, if he takes a positive attitude, the mind and body are more relaxed and better
equipped to handle the crisis.
Before talking about specific ways of dealing with stress, there are some general rules and
guidelines for promoting change and coping.
Basically two responses can be made to deal with situations that create stressful conditions
within us. One can either reduce stress or improve coping skills. While the former may not be
in our control, the latter certainly is. Stress usually elicits two types of responses. (Table 8.1)
An individual may decide to approach the situation and confront it. He decides to move
towards clarity. His is an active, positive approach.
Another copes with the situation by avoiding making any response, by denial of the problem,
and using various escape methods such as anger, withdrawal, smoking, alcohol and other
addictions. This is a passive, self-destructive approach.
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Table 8.1
Coping Mechanism
Approach Avoidance
Confront Denial
Clarity Anger or withdrawal
Activity Abuses/Addictions
Positive approach Negative/Escaping approach
Growth of person Increased stress in person

While both cope with stress, one leads towards growth of the individual and the other is self-
destructive. Following are some techniques to show us how to move towards the approach
mode of behaviour.
In the previous chapter we had discussed health enhancing and health endangering
behaviours in a general way. In this chapter we will discuss specific cognitive and
behavioural coping strategies which help you to cope with stress in positive ways
.
I. ASSERTIVENESS TRAINING

Communicating is one of man‘s great accomplishments. But it is stress producing. The act of
talking raises Blood pressure and Heart rate. These changes occur even in sign language of
the hearing impaired. Psychologists have identified 4 styles of communicating: Passive,
Aggressive, Passive-Aggressive (manipulative) and Assertive.
Assertiveness is a high improvement of the fight / flight response of our ancestors, the cave
dwellers. It is better than a disruptive fight or an inward flight of modern life. It allows the
individual clear, direct, honest and firm communication of what she wants and feels. While
we feel compelled to behave in a way we feel is expected of us we also feel cheated when
others are not guided by these same principles. This behaviour takes time to learn since you
need to stop other stress prone behaviour out of old habit. It is the use of personal power in a
pleasant and positive way. It adds to our self confidence, earns us respect and while it may
not always result in personal success, certainly increases the odds in our favour. While it may
or may not ensure a Win, it certainly ensures that one doesn‘t walk away from the situation
with more stress than one started with.
Being assertive means being able to stand up for your own rights and being able to say ―No‖
without violating the sensitivity of others and without being aggressive. The person who is
non – assertive is reluctant to express his feelings and thoughts, finds it difficult to refuse
requests from others even if they affect adversely his own time and resources, gives in to
views of others, frequently makes compromises and is submissive in the presence of
aggressive behaviour. This behaviour of being unable to stand for himself makes the situation
extremely stressful for him. This stress becomes compounded since this non-assertive
behaviour arises out of a fear of rejection.
Being assertive, on the other hand, means being able to express thoughts and feelings in a
way, which is not offensive to others. It means being able to stand for your own rights and
needs without violating the rights of others.
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Assertiveness helps to reduce interpersonal tensions. It increases a sense of well being by

increasing self-confidence and self-esteem. It helps in reducing anxiety and promotes a sense
of satisfaction with life.
Being assertive and standing for your rights does not mean being aggressive. In aggressive
behaviour, the person demands his rights without considering the rights of others and without
being aware that he is violating others rights. An assertive person balances her rights along
the rights of other people.

Aspects of assertive behaviour

 You are able to put limits on your own behaviour and that of others.
 You have a realistic outlook about your abilities and limitations.
 You are not affected adversely by rude or impolite people
 You can rejoice in your successes and also accept your failures.
 You are in control of your behaviour and do not get pushed into either rage or submission
by other people.
 You are able to say ―No‖ when you are not in a position to do something.
 You are able to express your thoughts and feelings without upsetting others.

General behaviour : The assertive person tries to avoid I win/You lose situations. She takes
appropriate action towards getting what she wants, but ensuring that getting what she wants
does not deny the rights of others. She tries not to play games with others: she negotiates,
using compromise (i.e. she doesn‘t always win, but she doesn‘t lose). She evaluates
impartially, trying to accept others and their idea on their own merit. She is relaxed and
competent enough to be able to trust others, and thus delegates much of her work. She is not
naïve about political processes. She deals with power and politics openly, unlike the crafty
manipulative, the pushy aggressive and the anxious and gullible passive.
The other three styles are often reactive, reacting to crises with recriminations, second-
guessing and blaming etc. The assertive tends to be more proactive, seeing crises as
symptoms rather than causes and concentrating on solutions- ―what we are going to do rather
than on what we should have done.‖
The assertive person is not ethereal and saint-like, without feelings and fallibility –quite the
reverse. She acknowledges and respect others‘ feelings, including their fears and their anger.
She also takes risks with expressing her own feelings, and tries to act as a model of behaviour
for others. She claims the right, not the privilege, to make mistakes. She thus avoids the
massive stress that aggressives, who must always appear infallible and thus never delegate,
are under. Because she anticipate mistakes, and will not be crushed when they happen, she
can take risks with change and innovation, like all good evolutionary successes do.
Interestingly, she also claims the right to be non-assertive . In a world infested with
manipulatives, passives and aggressives, it can be wearing being an assertive, because
assertion is such a violation of the status quo. Consequently, even the assertive person needs
to lapse every now and then into another behavioural style.
The assertive person tends to be consistent in her behaviour, and does not experience guilt
feelings about things she has said and done, or has not said and done – unlike the aggressive,
passive, and manipulative. Of all the four behaviour types, the assertive alone has non-verbal
and verbal behaviour which is congruent: in other words, there is no contradiction between
her words and her actions.
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Becoming assertive: Most people (not all) would say that the assertive style is superior to,
and preferable to, the aggressive, passive and manipulative styles. We can learn to adopt the
general behaviour and the specific verbal and non-verbal behaviour of the assertive style.
There are other tools of control and counter-control that assertive people and would-be
assertive people can learn such as the following verbal skills:
Broken record is the skill of calmly repeating what you want, over and over again. Just like
a broken record. If you know you can depend upon Broken Record, you do not have to psych
yourself up for a dialogue with someone else, and you can also calmly sidestep irrelevant
logic and baiting from the other person.
Fogging is the skill of calmly acknowledging that criticism of you may well be justified.
Your antagonist, instead of lashing out and hitting something solid, thus lashes out but finds
no resistance, as if they were trying to punch fog. Fogging helps to separate personalities
from problems.
Free information is the skill of giving and recognizing basic factual information that can
help conversation beyond the basic ―what do you think of the weather‖ type lines.
Self disclosure is the skill of revealing positive and negative aspects of yourself to others.
This is the next step to free information.
Negative enquiry is the skill of actively seeking constructive criticism from others. This will
provide you with useful information and/or exhaust the manipulative/aggressive ploys of
others.
Positive enquiry is the skill of actively seeking information from others about what solutions
they see to their problems.
Workable compromise is the skill of proposing a negotiated solution to a conflict that will
satisfy both parties, without sacrificing the self respect of either party.
These specific tools can be of great help in coping assertively with a wide variety of
situations.
Table 8.2 gives details of the 4 styles of behaviour, their verbal cues, facial expressions eye
contact, posture and gestures. This should help you identify traits in your own personality and
also recognize the behaviour style of others and therefore handle them better.
Table 8.2
Style-Aggressive Style-passive
Wishes to dominate Has decisions hijacked by others-plays
Wishes to win at all cost doomed martyr
Believes in her own perfection, Helplessness-feels a victim of life‘s cruel
indispensability, superiority, to others game
Self-righteous, patronizing, Brood, stews on other‘s aggression
Critical Complains, does not act
Talks loud, fast Gets ‗nerves‘ in meetings, public situations
Interrupts others, completes their Avoids conflict at all costs
sentences Shyness
I statements Stumbles over words- ―um….ah….‖
You must/should/ought Over polite
Impatient explanations Avoids saying ‗no‘
Arms crossed, unapproachable Silence
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Invades others personal space Evasive eye contact, often downcast,

Points finger Tears
Shakes head as if other person isn‘t to be Nods continually
believed Wrings hands
Impatient tapping of feet, drumming of Covers mouth with hands-oral insecurity
fingers Fidgets with objects
Hands behind head
Feet on desk
Style Passive-Aggressive (manipulative) Style assertive
Wants power without responsibility Negotiates, evaluates
Over politicized-always tries to get her Trusts, delegates
own way through connections, Proactive, solution – oriented
namedropping, Acknowledges and respects others‘ feelings,
mutual back-scratching including fear, anger
Flattering, while undermining Claims right to make mistakes
Feigned stupidity-slow learner ―I choose to‖
Plays on guilt ―Let‘s look at what alternatives we have…‖
Emotional blackmail ―Tell me the good new and the bad news‖
‗I will wrap him/her around my little finger‘ Distinction drawn between fact and opinion
Sarcasm Appropriately firm, warm tone
Tears Direct-not staring gaze
Conspiratorial expression Attentive and open minded
Body oriented away from Relaxed
‗uninteresting‘ ‗uninfluential‘ people – Open hand movements (showing honesty;
even when speaking to them inviting others to speak)
Drumming fingers, tapping feet-impatience

The aggressive personality is also called a Type A personality. This personality is very
focused on her own interests, very ambitious and is compulsive about winning. A Type A
personality is a very competitive personality. Since this competitiveness is with all around
her, the target keeps shifting. Pressure of work and pressure of time are seen together in this
personality. Impatience often gives way to irritation and irritation to quick anger. This is an
achievement oriented but also cardiac prone personality and has been discussed in detail in
earlier chapters.
A passive personality on the other hand is submissive and internalizes problems and conflicts.
While she may complain about unhappy situations, by not acting, she continues to subject
herself to that unhappiness. In her need to avoid conflicts at all costs, she often gives her own
needs a backseat, putting others in front. While problems get suppressed and not discussed
openly, they are never forgotten either. Even trivial problems are remembered and recalled
years after they occurred.
A passive-aggressive personality is actually an aggressive personality without the strength
and courage to be open. While needs, ambition and behaviour are all the same, what is seen
on the surface is quite different.
A passive personality on the other hand is submissive and internalizes problems and conflicts.
While she may complain about unhappy situations, by not acting, she continues to subject
herself to that unhappiness. In her need to avoid conflicts at all costs, she often gives her own
needs a backseat, putting others in front. While problems get suppressed and not discussed
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openly, they are never forgotten either. Even trivial problems are remembered and recalled
years after they occurred.
A passive-aggressive personality is actually an aggressive personality without the strength
and courage to be open. While needs, ambition and behaviour are all the same, what is seen
on the surface is quite different.

Assertion also partakes of qualities of aggression and passivity, although the synthesis is a
more positive, constructive and ―other-regarding‖ one. Because of this, the assertive upper
hemisphere of the figure is given a positive sign.
We need to keep in mind that people (including ourselves) often combine styles, and that
people (including ourselves) may display a style in one situation but not in another.
Steps in Assertiveness Training
Step 1 – Identify you own present style of interpersonal behaviour, i.e. whether your
behaviour is passive or aggressive.
Step 2 – Identify situations in which you have been non-assertive and situations in which you
would like to behave more effectively. You can also define when, with whom and in what
situation you would like to be more assertive.
Step 3 – Identify the situations in which you feel uncomfortable and awkward. Select a mild
or moderately uncomfortable situation and write down its description, write in detail the
persons involved.
Step 4 – Write down that situation and change the script making it more assertive. This
should include changes you need to bring in your talk and behaviour in order to be assertive.
Step 5 – Use assertive body language, which include maintaining eye contact, erect posture,
gestures and facial expressions for emphasis. Speak firmly and clearly.
Step 6 – Listen actively to other peoples‘ opinions and feelings. Clarify wherever there is a
doubt and acknowledge the other person‘s point of veiw.
Step 7 – Wherever interests clash, make a fair compromise that satisfies both parties
involved.
Step 8 – Avoid trying to manipulate or control others, and learn to avoid being manipulated.
Assertiveness means learning to communicate effectively. It means having and exercising
choices. This greatly reduces stress and promotes a positive state of mind.
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Limitations of assertiveness: It is likely that Assertiveness does not work with extreme
passive, aggressive and manipulatives. Schwimmer (1979)suggests that there is only one
assertive technique that works on a true tyrant is to walk away for good (if that option is open
to you). McNeilage and Adams (1982) argue that the true manipulative is totally bad news;
there is nothing you can do with the extreme type, because such a person has simply
forgotten what it is like to conduct open communication with anyone else. Similarity, with
the extreme passive, it is difficult to wean them away from their deep-seated behaviour.
II. A POSITIVE ATTITUDE

Another strategy to cope with stress is to encourage positive thinking and develop a positive
attitude. An attitude is the way you look at things mentally. This attitude can be seen in the
way you communicate your mood to others. When you are optimistic and anticipate
successful encounters, you transmit a positive attitude and people usually respond favorably
to you. When you are pessimistic, your mood is often negative.
Attitude is your mental focus on the outside world which is based on your perceptions.
Perception – the complicated process of viewing and interpreting your environment – is a
mental phenomenon. It is within your power to concentrate on selected aspects of the
environment and ignore the others. How you perceive a situation influences your attitude.
Attitude is highly personal and individual. It is also never static. It is an ongoing dynamic,
sensitive, perceptual process. Unless you are on constant guard, negative aspects can slip into
your perception. This will result in your spending greater amount of time and thought on
negative aspects rather than on the positive aspects of the situation. If negative aspects stay in
your mind for too long, they will get reflected in your disposition.
A situation is never wholly negative or positive. If it is acceptable to us we see it as positive,
if unacceptable negative. If we feel capable of handling it, we respond to the situation as a
positive challenge. When one feels incapable and not in control of, then pessimism and
negativity take over. Our past experiences, self confidence, sense of self worth, all help us to
interpret a situation as being positive or negative. The challenge of positive thinking is to
push the negative aspects to the outer perimeter of your thinking process. Not everybody is
basically a positive thinking person. But a person wanting to achieve a positive attitude
continually searches for ways to maintain and improve this attitude. Infact, a positive attitude
is the most priceless possession any person can have.
It is also not possible to be positive all the time. Excessive positive thinking is not realistic.
Positive thinking should not be an act – it must be genuine. Sometimes when things get really
tough, it may be impossible to have a positive attitude. One might then go into a pessimistic,
negative state of mind, feeling beaten, low and helpless. However, those individuals who are
able to bounce back, cope with stress better than those who dwell excessively upon their
misfortunes.
A positive attitude provides the courage to address a problem and take action to resolve it
before it goes out of hand. While all of us get angry from time to time, refusal to stay angry
or distraught can motivate you to assemble the facts, talk to others, determine options, and
then come up with the best option. Even if there is no ideal solution, a positive attitude can
help you live with the problem more gracefully.
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Some of the advantages of positive thinking and attitude are:

 It triggers enthusiasm.
 It enhances creativity.
 It optimizes your personality.

Give your positive attitude to others. When you are frustrated by the behaviour of others, you
may be tempted to give them a piece of your mind. This is understandable. It is a better
policy, however, to give them a piece of your positive mind. When you do this, it allows
others to adjust your attitude for you.
When you give a part of your positive attitude to others, you create a symbiotic relationship.
The recipient feels better, but so do you. It is interesting but true that you keep your positive
attitude by giving it to others.
When it comes to giving your positive attitude to others, you can be generous and selfish at
the same time.
Flipside exercise: Most problems have a flip or humorous side. List in the circles below in
Figure 8.3 one or two negative situations to which you are currently adjusting. Examples
might be a job change, new boss, or a different work schedule. Once accomplished, use the
circles on the right side to identify any humour you might generate on the flipside. Keep in
mind that if the technique was easy to employ, more people would do it.

Just as every coin has two sides, every situation has at least two or more facets. Most of the
time, one sees only one side of the coin, or half the picture. By broadening your perception, it
is possible to see a larger picture. Attitude is like a self fulfilling prophecy. You achieve what
you will yourself to achieve. A positive attitude influences events in a positive manner,
ultimately leading to a positive outcome. A negative attitude will only make matters worse.
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A few techniques for leaders to keep the team positive:

The rotten apple principle – Given enough time, one rotten apple in a barrel will spoil the
rest. Given enough time, one negative team member will destroy the positive attitudes of the
others. To resolve this means that the negative person should be counseled by the leader until
he or she makes an attitude adjustment or other action is taken. In professional sports, for a
highly talented player this can mean a transfer. In all cases, waiting too long can destroy
productivity and the ‗game is lost‘.
The policy of sound Human relations – Sound human principles, such as treating each
person as an individual using the mutual reward principle, and being sensitive to the needs of
others, should be honoured. Any leader who uses dehumanizing techniques, such as bullying
an individual in front of the team, can destroy morale.
Attitudes are caught, not taught – This principle means that the attitudes of followers
reflect the attitudes of their leader. The first responsibility of any leader is to maintain her or
his own positive attitude. It might be a good idea to use adjustment steps.
The attitude/confidence connection – This basic principle states that team members with
positive outlooks enjoy greater personal confidence. Golfers without confidence never make
the cut. Sales representatives without confidence might as well stay at home. Nurses without
confidence do their patients a disservice. Supervisors without confidence are seldom
successful. The foundation for personal confidence is a positive outlook.
The instant replay principle – The process of attitude renewal (positive approach) should
start whenever a problem is encountered.
In some roles (team building, selling, costumer relations etc) attitude is more important than
talent. Leaders who follow certain attitude –building principles (e.g. attitudes are caught – not
taught) are measurably more successful. While it is natural to feel down and low after failure
or defeat, the process of attitude renewal should start soon thereafter.
Strategies for Positive Management: Now we will talk about strategies to deal with specific
events, making a realistic analysis and attempting a positive outcome. The steps involved are:

 Imagine the forthcoming event. Concentrate on the event, all the aspects of the event,
people associated with the event, and your feelings related to the event and its aspects.
 Prepare adequately, Specify your goals. If you anticipate an unpleasant situation, work out
how you are going to react to it.
 Practice before the event. Imagine the situation in your mind and rehearse fully how you
are going to face the situation. Visualize yourself as going through the situation in a
controlled, confident, and relaxed manner.
 Take a break. If the anticipation period becomes too tense, give yourself a break and
indulge in some enjoyable activities. This will help you to deal with the nervous energy
building up inside you and prevent you from becoming tense.
 Prepare for the worst. Imaging the worst and visualize yourself dealing with it effectively.
 Expect some stress to occur in the situation. Inspite of all preparation, some amount of
stress is still likely to be present. Infact, small amounts of stress enhance performance.
 Give yourself positive strokes. It may not be possible to deal with every situation
successfully. Whatever the degree of success, it deserves some kind of self-reward.
 Reassess the situation. After going through the situation, re-evaluate the situation to see
what you did well and where you went wrong. This reassessment helps in thinking of
better strategies to deal with the situation in future.
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Positive attitude works when it becomes a way of life, and to become part of our thought,
plan and action, it must be practiced continuously. Each one of us has several attitudes that
need readjustment. List them down in the left column and how you plan to readjust them in
the right column of Table 8.3 give below

III. THOUGHT STOPPING

Bain in 1928, was the first to introduce thought stopping in his book ―Thought control in
every day Life‖. Later, it was adapted by other behavioral therapists for treatment of
obsessive and phobic behaviours.
As the term implies, thought stopping involves stopping a specific thought or idea. Initially,
the person is asked to concentrate on the unwanted thought for a brief period of time and then
suddenly stop and empty the mind. A verbal command such as ‗stop‘ or a loud noise is often
used as an indication to stop the unpleasant or unwanted thought. Although this method
seems simplistic, this technique is very effective.
This method of thought stopping works in three different ways:

 When the command to stop is given sharply and sternly, it acts as a punishment and results
in inhibiting the negative thought process.
 he command acts as a distractor and interrupts the chain of unpleasant thoughts.
 All thoughts have an effect on the person‘s emotional reactions, with negative thoughts
having negative impact on the emotional reactions. So, by learning to control our
thoughts, we can greatly reduce our over all stress levels.

This technique has been very successful with persons having obsessive or phobic thoughts.
Obsessive thoughts like thoughts of failure, death, accidents, and sexual inadequacy, and
phobias like fear of snakes, driving in the dark, fear of diseases etc have been effectively
dealt with by thought stopping. This technique can be applied to treat conditions in which
highly disturbing thoughts are the primary stress-causing elements.
For the technique to be effective, it must be practiced throughout the day for atleast a week.
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Method
Step 1 – List out the stressful thoughts, and find out their level of interference in daily
functioning. Analyze the thoughts to see which thought is unrealistic, unproductive, or self-
defeating. Then select the thoughts, which are most disturbing and work on them.
Step 2 – Sit comfortably in a chair and imagine the thoughts. Visualize situations for stressful
thoughts. Allow stressful thoughts to flow through your mind for a while.
Step 3 –Stop the negative thoughts. This can be done with the help of external aids like an
alarm clock. Shout stop when the alarm rings. This acts as an interruption in the negative
chain of thoughts. Empty your mind of all negative thoughts and replace them with normal
and positive thoughts. If this is done consistently for half-an-hour, the mind will remain
relatively free of stressful thoughts.
Step 4 – After getting used to thought interruption with the help of an external aid, now move
on to practicing it without any external aid. Progress step by step from using an alarm clock
to saying ‗stop‘ softly, to hearing ‗stop‘ as a subvocal command. This will help you to carry
out the procedure even in public, without drawing attention to yourself.
Step 5 – The last step includes substitution of positive thoughts in place of the unwanted
stressful thoughts.
However, the verbal command of ‗stop‘ may not be sufficient for thought interruption in
certain cases. In situations where the thoughts are very repetitive or resistant to interruption, a
verbal command of ‗stop‘ may not prove to be effective. In such cases, the ‗stop‘ command is
reinforced with aversive or unpleasant aids like a mild shock, a rubber-band around the wrist,
or a rap with a ruler to inflict a small degree of symbolic pain.
Points to Remember

1. At the initial stage, create a checklist of negative thoughts and then select a thought which
is not too stressful, so that you can master the technique and then move on to handling the
more stressful thoughts.
2. If you are embarrassed to say ‗stop‘ aloud in public, use other techniques as a substitute.
You may use a rubber-band around the wrist, pinch yourself, or dig your fingernails into
the palm.
3. Thought stopping requires a lot of time and patience. The idea is to stop the thought each
time it surfaces. The thoughts will gradually decrease and eventually go away.

Table 8.4
A checklist of unwanted thoughts YES No
Do you worry about leaving the lights or gas on? Y N
Do you worry whether the doors are locked? Y N
Do you worry about your personal belongings? Y N
Do you worry about your physical health? Y N
Do frightening thoughts keep coming to your mind over and over again? Y N
Have you been troubled by thoughts of harming others or yourself? Y N
Do you have difficulty in deciding all matters? Y N
Do you have doubts about the things you do? Y N
Do you worry a lot about money? Y N
Do you frequently think that things are not likely to get better and may, infact, Y N
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get worse?
Are you excessively worried about what people will think Y N
Do you usually worry about looking silly? Y N
Are you frequently afraid of performing badly? Y N
Do you feel nervous of heights? Y N
Do you worry about accidents? Y N
Do you worry about getting trapped in crowds, elevators etc? Y N
Do you keep thinking about your failures? Y N
Are you preoccupied with thoughts of sex and sexual adequacy? Y N

Total your Yes and No answers in Table 8.4. If your Yes‘s are more than No‘s it means you
are plagued with unwarranted thoughts that ultimately take you into a spiral of negative
thinking and unsolvable worries and anxieties. You are not in control of your thinking. Your
negative thoughts control you. If you have more No‘s you are better than the previous
category. However, you do have a few Yes‘s. Please use techniques discussed to stop your
unwarranted thoughts. If you have very few Yes answers, well all of us have some unwanted
worries. Your life is not unduly affected by these thoughts. Working on these thoughts will
help you to feel more a master of your own life.
IV. TIME MANAGEMENT

Manage your time before some body else does it for you. Make your plans and schedules
bearing in mind your unique personality. You may need a half hour to come fully awake or
you may need a half hour to unwind when you get back from work. Another person may need
10 minutes only, so plan according to your unique needs.
Plan for idleness and leisure in your schedule. Don‘t structure your plan so rigidly that it is
not flexible enough to incorporate changes. An ideal plan may look good on paper and may
even work for a few days. But maybe its ‗No Fun‘ and it doesn‘t suit your needs. It will prove
too tough for you to follow and will be ultimately discarded.
Don‘t structure your leisure time – plan a little idleness in each day. If you are the type of
person who might meander in preparing any task then keep time for the meandering in your
plan. Make your plans keeping your personality in mind. If you structure your vacations like
the movie, if it Tuesday, it must be Belguim, (13 countries in 12 days) you may never reach
home safely and need another holiday to relax on your return. More importantly, you may not
have any fun. Plan a little idle time in your holiday time. Remember a vacation should have
sightseeing but also give time for relaxation.
Live by your calendar not your watch. Your need for relaxation may not always coincide with
coffee break time. Make your schedule flexible enough to accommodate your office
schedules.
For many people, learning to manage time more effectively would solve most of their stress
problems. Managing time effectively would mean being better organized, working more
efficiently, and wasting less time. This takes discipline and organization. The only way of
saving time is to make the best use of it.
A few ways to help you are mentioned here:

1. The best way to manage time is to keep a time dairy to see what you do with your time.
You could either keep a record of the time, i.e. record what you did every one hour, or you
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could keep a record of time taken over every task. At the end of the day, you would know
exactly what you did with your time, and whether you have been effective about managing
your time or not.
2. Prioritize your list of things to be done. Sort out the jobs, which are urgent and important,
from your list of tasks. Urgent tasks may not always be important, so they must be
disposed off immediately and in the minimum time. The amount of time spent on a
particular task depends on its importance.
3. The secret of time management is that once the plan for time management is decided, it
must be carried out. Concentrate on one thing at a time and complete it before proceeding
on to the next task.
4. Avoid procrastination at all costs. Procrastination is something that affects all people.
Usually it is when we are faced with something we don‘t want to do. But putting off
something endlessly also has serious consequences. To manage procrastination, take the
first step immediately and do not expect too much too quickly. Do not make excuses for
not doing something.
5. Another aspect of effective time management is to delegate. It is not possible to do
everything yourself. Delegation means giving a task to someone, making sure that the
person has the requisite skills for doing that job, making the person responsible for it, and
giving the person enough authority to carry out the task.

Many people find it difficult to delegate thinking that it is easier and faster to do it
themselves. But, if that was the case, you would not feel the stress of overwork. However,
when delegating, it is important that you know what you are asking the other person to do.
Then, ensure that the other person also clearly understands what you want. Give the person
enough background material to ensure that he is able to do the job well.

Table 8.5

V. CONFLICT RESOLUTION

Man is a social animal living and working in groups and communication is what brings
people together into groups. Groups exist because individuals communicate with one another
and share motives and goals. Managers make more extensive use of the group to improve
performance. On the homefront too, family members live together as a nuclear family group
or a joint family group. Being social animals, we tend to participate in social group activity as
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well. Sometimes these are loosely structured friend circles and at other times, more formal
social organizations like the Rotary, Round table, Free Masons, etc. Social interest groups are
on the rise today, with Peace, Legal aid, Medical aid, Humanitarian laws, Environment etc
being the interests shared by members.

There is more effort to make the workplace more democratic. We, therefore, have groups like
committees, task forces and project teams. Along with decision-making, responsibility also
shifts from the Manager to the employees. Also, fewer employees work in highly structured
firms. More employees are in entertainment, advertising, government and other such
organizations with goals and problems that are far from routine and where greater group work
is required.

Two or more persons engaged in any kind of functional relationship, with proximity to one
another, interacting and influencing one another, will certainly have both positive and
negative features. Group dynamics, a term introduced by Kurt Lewin, or group processes can
be explained in terms of the rewards they receive and the costs that are incurred. In effect,
there is a quid pro quo. Something is exchanged for something.

When individuals work together, it is only natural to have disagreements, disputes, dislikes
and dissent. Conflicts are an inevitable part of daily life. With all the love and affection
shared, family members have intense conflicts too. Conflicts and rivalry are part of the
relationship between growing siblings. When the relationship is less personal, conflicts may
take a while to emerge but are a reality nevertheless.

There as several reasons due to which conflicts occur and some of the more common factors
are discussed here:

Groups are made up of people with unique needs. People have a diverse background. If the
similarities are few and dissimilarities more amongst members, the group will lack
cohesiveness, creating grounds for conflict.

Members in a group may not be acceptable to each other and harmonious relationships cannot
be built. If shared attraction is less, compatibilityis less, giving rise to frequent conflicts.

Conformity is a good thing. It generates trust and faith. Non-conformity or deviance evokes a
feeling of discomfort and disrupts a set balance. Conformity gives a common goal and
direction. Energy is channellised towards a common goal.

While non conformity may challenge a set order, sometimes this gives way to a better order
as well. The age old ways sometimes need to give way to current day needs. Changes often
leads to increased growth in the future. Willingness of the group to work together, to set aside
individual opinions and to resolve disputes keeps the group together. Lack of willingness and
inability to handle dissent results in the group breaking up with the slightest non-conformity.

One thing is certain. Conflict gives rise to pressure, tension and stress and if not managed,
results in a breakdown. People have to learn to live and work together. Individuals cannot
live in isolation. Independence is not the reality, inter-dependence is. Unresolved conflicts at
the family level may result in separation and divorce, children running away from home. At
the Organizational level, Union Management conflicts result in a strike, lockout and if not
resolved, a shut down. At the national level unresolved conflicts lead to pandemonium and
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bad governance and at the religious level, to riots. At the international level, the end result of
unresolved conflicts is often War.

Following are the basic styles of reaction to conflict and conflict resolution

Table 8.6

Competition is concerned with personal goals. The individual is committed to personal

rewards and benefits. There is a need to achieve more than others and competition is often at
the expense of the others rewards.

Cooperation on the other hand is working together for mutually acceptable goals. It involves
supporting each other and contributing time and effort towards common rewards.

Avoiding is an unassertive style. Belief in self worth is low and evading and avoiding a
conflict is seen as the best means of resolving that conflict.

Accommodating on the other hand is to make room for another person‘s thoughts, opinions
and ideas even if they are different from ones own. There is an interest for the other party‘s
welfare too.

Compromise is to give up some personal goals for the sake of the other and for the benefit of
the relationship. It involves both people taking a step towards each other, each shedding some
conflict areas.

Collaboration is a setting down of common needs and goals and also a common path to work
towards their attainment. Since the goal is shared, commitment towards the goal is also
shared.

You may have observed that the left corner of the table 8.6 shows behaviour ranging from
Aggressive to Passive and the right corner indicates Assertive behaviour. Cooperation and
collaboration result in individual goals being accommodated into the group goal. Each
individual is encouraged to compete, but against a personal standard, ultimately benefiting
the group. Each member of the group has an equal status with equal respect and equal power.
Unequal power amounts to obedience and compliance.

However, a group can jointly agree to vest greater power in a leader for clarity in critical
times, such as competitive team sports, a battleship or a growing corporate. A world cup
sports team is a perfect example. Each member needs to compete for better performance.
However, for the team to win, members have to cooperate with each other, accommodate
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individual strengths and also weaknesses and collaborate towards a common goal – the world
cup itself.

Conflict managed increases performance and reduces individual and group stress.
Achievement become possible when people work together. Alone, it utilizes more effort and
time and also generate more stress.

Deal with conflicts, especially when they are important. Don‘t deny them. They wont
disappear on their own. Make sure your rights don‘t interfere with the rights of another. This
is the breeding ground of conflicts

VI. STRESS & PRODUCTIVITY CURVE

Every achievement in our lives, every milestone covered, whether developmental or

academic, has stress associated with it. Stress is that force which drives us towards greater
performance, pushes us towards achieving our potential. Stress makes full use of our
capability and converts this into peak performance.
When stress levels are low, performance it low. Capability is present but not utilized. This
leads to a wasting of capability and a state of Rustout. (Figure 8.4) As stress increase,
productivity also increases. The individual has a feeling of alertness, challenge and thrill.
When a perfect match is reached between stress and productivity, the individual is filled with
a sense of achievement and satisfaction. While he is pushing his capabilities, he only
experiences joy. When stress increases beyond this peak, performance deteriorates.
Capability is sorely challenged and the pressure is no more joyful. This is a time of fatigue
and if it persists, ill health and breakdown follows. This state of overburden is called Burnout.

Fig 8.4

Low levels of stress leads to low levels of involvement. This can only lead to low
productivity. As pressure and productivity rise up, individuals can reach a point of peak
performance. Any further pressure results in overload and productivity dips. There is a need
to identify our stress tolerance limits. We need to optimize productivity & pleasure by
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learning how much stress is too much. You need to ask yourself if the added responsibility is
increasing or decreasing your efficiency. Once you find out this secret formula your will
make stress work for you.
You will discover the Joy of Stress e.g. A sportsman working for an event cannot perform at
his peak without stress. He uses this stress to stimulate and charge himself to higher levels of
performance. This is his joyful state. However, beyond a point, this stress challenges his
capability and takes him toward mental and physical fatigue.
By WHO standards a hospital works at its best at 80% bed occupancy. From 80-100% it is
stretched to its maximum capability – yet efficiency stays up. Beyond 100% occupancy the
hospital is stressed the facilities diluted and efficiency is in danger.
In a heightened state of tension, individuals and organizations cannot be continually
functioning at their optimum. Some strategy has to be designed to manage it.

VII. CRISIS & CHANGE

Perhaps the only constant factor in life is change. Situations change, people change, jobs
change and so do our lives. While it may be easy to accept this theoretically, human beings
are set in their ways and any change disturbs and destabilizes their set routine. It gives rise to
new situations that require adjustment. Any situation, whether positive or negative, creates
change and therefore disturbs the set equilibrium. As shown in Holmes- Rahe – Life change
events scale, grief, loss of job, marriage, child birth all create change and stress. Major
change disrupts the equilibrium more and may take upto 6 months to a year to adjust to.
Some emotions commonly seen in Major change, grief and crisis situations are:
Denial/Shock: Disbelief that the situation could happen. The person is in a dazed, shocked
state, unable to comprehended the reality of the situation. Sometimes the event is denied and
blocked out and the person behaves as if no crisis has occurred and life is the same.
Anger: The next emotion often seen is one of anger. The person is angry at having this crisis
happen in his life. The goodness of life, mankind and God is doubted. This anger is expressed
against anyone in the immediate environment e.g. Hospital, Nurses and Doctors when a
family member is critically ill.
Bargaining: In trying to grapple with the crisis, the person tries to negotiate with the crisis,
hoping that the situation will go away. Doctor shopping i.e. shifting from doctor to doctor is
practiced in the hope that the diagnosis will change to a more pleasant one. Prayers, fasts and
visits to different religious places are all attempts at bargaining with Life/Superpower/God
for the crisis to be reduced or go away.
Depression: When the realization finally sets in that the crisis is here to stay, people often
experience feelings of sadness, helplessness and depression. There appears to be no road
ahead making the situation look completely hopeless. Sorrow, despair and tears replace any
anger present. This final realization and the expression of all difficult emotions, helps the
person to come to the next and final stage.
Acceptance and Rehabilitation: The crisis is finally accepted as a reality and methods of
dealing with it are planned. The person is now open to look for ways to cope with this
difficult situation. Coping leads to rehabilitation and setting into a new pattern of balance and
equilibrium.
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Knowledge of these emotional states will help Clinicians and Health Professionals to
understand the patient and lend greater support.
Research by Charles F Shoeshell, M.D., Phd. suggests that it takes approximately 6 months
of practice and use for a new stress management skill to replace an old habit completely.
E.g. During the Presidency of Lyndon Johnson, the Federal Government decided it would
start a new program called Revenue sharing under which it would share money with local
governments. One day a small town in one of the states in New England, got a large sum of
money from Washington. The citizens didn‘t know quite what to do with the money. So they
called a town meeting. There they decided to build a new fire station. To preserve the beauty
of the town square they resolved to turn the original structure into a fire fighting museum
with fire fighters continuing to sleep in the same area of the museum. Another pole was
installed some feet away from the old pole to allow quick access to the new stations. The fist
time the bell went, the men found themselves sliding down the old pole and into the museum.
When an emergency hit they automatically followed their old pattern of reacting.
In most of our lives when an alarm goes off we continue to react in the old automatic or
reflexive way. If you want to change to a new mode of behaviour you will have to start
catching yourself when you respond in the old, unhealthy way. Initially you will catch
yourself too late. But as you practice applying new behaviour, in about 6 months your will
find yourself automatically reacting in the better way.
While change creates a disruption it also brings growth. Understanding change and planning
for it will help us to cope with the inevitable even better.

VIII. GOAL SETTING

Appropriate goal setting helps in attaining your desired aim easier. The goals need to be both
short term and long term i.e. they could either be plans about what you want to achieve in
your life or they may be about what you plan to finish in the next one hour.
How you phrase your aim is equally important. It is better to phrase them in a positive rather
than a negative way. It is better to say ―I want to complete my work more often‖ than
saying,‖ I want to procrastinate less‖.
Problem-solving skills – This means adopting procedures which will result in solving a
problem you are facing. The solution may not always be what you want, however, accepting
such a situation is also a part of problem – solving.
The procedure to solve problems involves certain steps –

1. Identify problems that you want to deal with and make a list. State the problem in different
ways to get different points of view and also try to identify if there are issues below the
surface.
2. Put the list into an order of priority and see what is urgent and important.
3. Identify solutions to the problem by writing down as many ways of dealing with the
problem as possible. Try and find alternatives for solving the problem.
4. Consider all the possible solutions and decide on the solution which best suits your
priorities and goals.
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Put your plan into operation and take a feedback on whether your solution has been
successful or not
.

IX. COPING IN THE FAMILY

It is not necessary to be a therapist to help children cope with stress. One key element in
reducing stress is a low-stress environment, which is based on social support, having the
ability to find hope by thinking through solutions, and being able to anticipate stress and learn
new ways to avoid it.
Social support means having people to lean on during difficult times. Parents who listen,
friends to talk to, hugs, and help in thinking through solutions are ways children feel support.
Specifically:

 Notice them – Well-developed observation skills are essential. Observe for more quarrels
with playmates, poor concentration, or bed-wetting.
 Praise them – Encourage children and show you care. Be positive.
 Acknowledge feelings – Let children know it is OK to feel angry, alone, scared, or lonely.
Give children names for their feelings and words to express how they are feeling.
 Have children view the situation more positively – Some stressors make the child feel
ashamed. Shaming affects self-esteem.
 Structure activities for cooperation, not competition – This allows individuals to go at
their own pace and increases the learning of social skills.
 Be involved – Read books together, eat meals together, plan weekend family outings,
encouraging togetherness, openness and listening.
 Host regular, safe talks – Members of the family and others who feel comfortable can
share experiences, fears, and feelings, Adults can recognize the steps a child uses to cope
and help others learn from these experiences. Hold regular meetings (family, classroom,
religious), to plan activities or to suggest solutions.

Thinking It Through Clearly: Children must learn to think through a problem. Some
specific strategies include self-talk, writing about the problem and making a plan. Thinking
positively and thinking up real solutions is important. Adults can:

 Show how they can cope in a healthy way – Keep calm, control anger, think through a
plan, and share the plan with the family.
 Be proactive – Plan plenty of playtime, inform children about changes, and plan activities
where children can play out their feelings, Books, art, puppetry, play and writing help
children think through and name their feelings.
 Develop thinking skills – Help children think through the consequences of actions. Pose
situations (friendship, stealing, emergencies) and think through actions. Ask open-ended
questions about what the solutions to problems could include, such as ―What could we do
about this?‖
 Help children tell reality from fantasy – A child‘s behavior, for example, did not cause his
or her parents‘ divorce. Give information about reality relevant to the child‘s age.
 As an adult, focus on the stressor – Model how thinking through options for dealing with
difficult people, situations or problems helps you find solutions.
 Find individual talking time – Talk about stressful events and everyday events.
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 Use stories and books – Stories can help the child identify with the feelings of the
character and tap their own feelings to ease them out for discussion and to discuss coping
strategies. Stories can also be used to give the child a message about her own situations
and improve coping.
 Use art for expressing feelings – Paint, clay, sand and water all allow for active
expression.
 Encourage children to act out coping skills – Playing with dolls, boxes, toy telephones,
puppets, blocks, cars and similar items provides another avenue to bring feelings out for
discussion.
 Give the child some degree of control – Children should be allowed to choose within the
framework of what is expected. Allow them to make some manageable decisions, such as
how to arrange their room, to voice their opinion in some family decisions, which activity
to complete.
 Identify what could cause stress and plan ways to avoid it or deal with it.
 Encourage children to be proud of themselves in some way. Developing a special interest
or skill can serve as a source of pride and self-esteem.
 Use gentle humor or read a silly book to create laughter and to reframe negative thoughts
into opportunities.
 Offer personal space – Modify the environment. Quiet space and alone time should be
allowed. (Adjust noise levels and check the traffic pattern.)
 Teach relaxation and deep breathing techniques -Ask children to close their eyes and
imagine a quiet and or happy place (the beach with waves, a birthday party, a cup of hot
chocolate).
 Teach conflict resolution strategies – Teach children to think through alternative ways to
solve problems. Who else can help solve given problems? What additional information do
they need?

As adults, we can make sure we don‘t add to children‘s stress by expecting them to act in
adult ways. We can praise, be positive, seek positive solutions, help children name their
feelings, teach fairness, help children learn to like themselves, be patient, teach honesty and
give lots of love and encouragement, particularly during difficult times.
Student-life coincides with adolescence, and stress can manifest in children as a reaction to
the changes in life in addition to academic pressures. Children become more self-aware and
self-conscious, and their thinking becomes more critical and complex. At the same time,
children often lack in academic motivation and performance, as their attention is divided
among a lot many things, especially creating an identity for themselves.
How Teen Stress Can Be Relieved
Hormonal Factors: The vast hormonal changes of puberty are severe stressors. A person‘s
body actually changes shape, sexual organs begin to function, new hormones are released in
large quantities. Puberty, as we all know, is very stressful. It is a period of storm and stress
with a child changing from an asexual to a sexual being. This bring about changes in
behaviour, dress, peer group etc. Likes and dislike change drastically in this period. Not only
is the child under stress but parents and family members are also victims.

 The first step for parents is to be aware of possible stressors and to recognize signs of
stress.
 Be sensitive to changes in your children‘s behavior and respond to them.
 Provide opportunities for them to learn stress management techniques.
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 Have reasonable expectations and set manageable goals in academic and extra curricular
fields.
 When you are under extra stress, be sure that you are not passing it along to your child.
 Physical exercise and sports are good stress reducers, provided there is not a debilitating
level of competition, pressure to perform or fear of failure.
 Encourage relationships with extended family members, friends and helpful neighbors.
Just knowing there is someone else to turn, to share their feelings can be relieving for
children.
 Spending time together or having a few good laughs together goes a long way in reducing
stress and in building solid family relationships.
 Encourage students to try new things, learn new skills.
 Tell them that it is OK to fail.
 Teach them that learning takes effort, time and practice.

Many psychologists, who research on childhood and education, believe that an important
cause of stress is how children think about their own intelligence and abilities. If a child
thinks of his or her intelligence as fixed—‖I‘m either this dumb or this smart‖—he or she will
avoid tasks that challenge their ability or risk failure. Instead, they choose to work on
problems that they already know how to solve
Suggestions for Parents: Stress is a life event or situation that causes imbalance in a child‘s
life. An unhealthy response to stress occurs when the demands of the stressor exceed the
child‘s coping ability. In the fast-moving world of today, the norms and values of the older
generation do not find favour with the younger one. In the home, when children behave in a
way different from what their parents expect them to do, it creates conflict and mental
tension.
Set an example yourself of what you want your child to do. When discussing school activities
with children, the parents must see that they speak respectfully about their teachers. The
teacher should never be ridiculed before the child, otherwise, the latter would lose respect for
her and also for her authority and authority figures in general.
If a child does something wrong, he needs to be explained and not punished. Older children
sometimes do need punishing , but it should never be delivered in anger or rage. The idea of
punishment is not to take revenge, but to make the child understand acceptable and
unacceptable behaviour.
Both the parents should present one joint team before the children for the sake of the children
and the well being of the family. Parents must try to examine objectively other‘s view and
review their own methods of upbringing. Parents should avoid comparing their children
among themselves. Let the child decide what he want to do in life based on his special
inclination and capabilities.
Factors That Support Children and Create a Safety Net:

 A healthy relationship with at least one parent or close adult.

 Well-developed social skills.
 Well-developed problem-solving skills.
 Ability to act independently.
 sense of positive self-esteem and personal responsibility.
 Religious commitment.
 Ability to focus attention.
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 Special interests and hobbies.

Families Can Provide Protection by:

 Developing trust, particularly during the first year of life.

 Being supportive.
 Showing caring and warmth.
 Having high, clear expectations without being overly rigid.
 Providing ways for children to contribute to the family in meaningful ways (involvement
in family decisions, chores, etc.).
 Being sensitive to family cultural beliefs.
 Building on family strengths.

X. DEALING WITH WORK STRESS

Combating the stressful job: You have seen how job stressors can be hazardous to your
health. This makes stressful work a serious workplace health concern. Ultimately, the best
way to reduce stressful work is to eliminate its causes. If an organization or company wanted
to design a workplace, which would enhance employee health, psychological well-being and
productivity of its workers, what would it need to do? It is not possible to list all the features
of healthy work, but here are a few. Design jobs to :

 Enable workers to vary their tasks and move around at various times during the workday.
 Fit tasks and work flow together to make a complete job.
 Enable workers to understand how their jobs fit into the larger goal of the organization and
to feel they have achieved something meaningful at the end of the shift.
 Allow workers input in deciding how their jobs are done, speed of work, and how they
will respond to other job demands.
 Offer workers the possibility to make the maximum use of their skills and provide
opportunities to learn new skills.
 Develop clarity in tasks, jobs, and roles and minimize conflicting expectations.
 Make work ergonomics (workstation, posture, seating etc.) as stress free as possible.

Buffering stress: The role of social support Adequate social support can cushion you from
the effects of chronic job stressors. One researcher describes social support at work as ―… the
overall levels of helpful social interaction available on the job from coworkers and
supervisors: (Karasek, 1990) there are a number of sources of social support in the workplace
— coworkers, management and union. Social support can range from informal interactions
between individuals to more formal ways of providing social support to workers. The
employer is very influential in creating a climate for positive social interaction and support in
the workplace. Some of the means of providing social support include :

 Allowing social interaction on the job.

 Providing employee assistance programs which are planned jointly by workers and
management such as confidential advice and counseling to individuals for a range of
personal and work related problems.
 Creating ‗family-friendly‘ programs such as on-site childcare facilities, flexible working.
Arrangements, and use of sick time for family illness.
 Developing ways of effectively resolving workplace conflict.
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Some unions offer special programs such as union counseling, a program designed to help
union activists refer their members to appropriate resources in the community in times of
need.
Dealing with stress as an individual: personal anti-stress tactics: Here‘s a list of ideas you
have probably read or heard for how you might personally deal with stress. Try them. Test
different methods in a variety of situations. Rely on the ones best suited to you. Remember to
see the suggestions for what they are — a bandaid.

 Exercise regularly, eat a healthy diet, get sufficient rest.

 Limit caffeine and alcohol intake.
 Make a habit of relaxation: try techniques such as meditation, yoga or deep breathing and
visualization.
 Enjoy your social relationships.
 Recognize you limits by prioritizing important matters in life and learning to say ―no‖ to
the extras.
 Talk you feelings out with someone you can trust.
 Go easy on yourself — don‘t expect perfection.
 Build some fun into your life every day.

Identifying the stressors on your job is a good first step. Once you have compiled a list, try to
evaluate each item and prioritize them. Consider the mechanisms available to you for solving
these problems. You can turn to your joint workplace health and safety committee. If there is
a contract violation, use the grievance procedure. Maybe a labour-management meeting
would help.
XI. LIFESTYLE CHANGES

Lifestyle can be a major source of stress. Stress is not always what influences us from the
outside. It can also be generated from within ourselves.
Critical and crisis events or trivial day-to-day events are a part of life. These events cannot be
stopped. The only way to deal with all the daily life events is to bring changes in our lifestyle
so that our body becomes more healthy and thereby capable of taking on stress without
giving way and our mind remains calm and effective. A good lifestyle improves stamina and
coping in the face of a stressful situation. Age appropriate exercise and a healthy diet both
improve health and reduce psychosomatic ailments.
1) Physical management – Exercise
While modern science has taken many forwards steps, and human beings may have shed their
tailbone, the stress arousal response remains the same as our ancestors, the cave –dwellers.
When Stress is perceived by the mind, our body system automatically dives into to action
similar to the cave dweller‘s flight / fight response. In doing so various chemical and
hormonal changes take place activated by the autonomic nervous system and the Endocrine
system. As stress of the modern man is no more physical, the response to it is also therefore
not physical in nature.
Exercise burns the biochemical byproducts of the stress response. It reduces the risk of heart
attack by acclimatizing it to a heightened activity of an arousal state similar to stress.
Research shows that regular exercise reduces hostility by approximately 60% & depression
by 30% among healthy adults. Excise improves Physical stamina, which then helps in
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sustaining energy levels and reducing fatigue in stress. While exercise raises the body to an
arousal state similar to stress, the end benefit is similar to relaxation techniques. Heart rate
come down, Breathing is calmer and Brainwaves move from alert Beta brain waves to
relaxed Alpha waves. The Benefit of exercise to psychosomatic ailments is tremendous.
Hypertension, Diabetes, Respiratory Disorders, Insomnia, PMS and many more – all improve
with exercise.
However an exercise regimen must be fun, convenient and sustainable and in keeping with
age and physical condition. It has been seen that walking continues even one year after
starting, usually not so with jogging. While swimming is very beneficial for all age groups,
games can be beneficial and fun for the more fit. The benefits of exercise cannot be stored for
future use. It therefore needs to be regularly practiced.
Stress, associated with modern lifestyle and sedentary work also affects certain joints in our
body. Stress reduction exercises stretch and mobilize the joints, keeping them flexible. This
in turn prevents various psychosomatic ailments such as Backache and Tension headaches,
Hand and wrist pain and so on.
Repetitive Stress Injury – Prevention and Exercises: Modern day urban life is mostly
sedentary. Physical activity is limited, while mental activity is hectic. Most work is done
sitting, placing most stress on the back and spine. Practice these RSI exercise to prevent
injury to your joints. These exercises are very relevant for all those who work long hours on
the computer or for that matter also sitting at a table and chair and also for those with very
sedentary work and a lot of stress.
RSI Prevention: Get up from your desk and move around every 1/2 – 1 hour. Stay aware of
your posture while you are sitting at your desk. Don‘t slouch or recline too much. Sit back
such that the major part of your back is supported by your seat back. Do not eat your lunch at
your desk. During your lunch break do some physical activity. Include full body stretches in
your daily activity, emphasizing the upper body. Observe your sleeping position. Don‘t curl
up too much. The neck should be supported, with pillows in line with the rest of the spine
when you sleep. Check that your workstation is set up correctly. Your monitor screen should
be at eye level or below eye level. New keyboards and mouse designs that support the wrist
can help prevent strain.
RSI Stretch Exercises: Here are some yoga-based exercises which you can do in the office
during the course of the day to help prevent carpal tunnel and repetitive stress injuries. Hold
the positions for a few breaths and let the stretch increase but do not force it.
Eye exercise – Keep your arm extended and thumb out. Let your eyes follow your thumb.
Rotate left to right, right to left, then diagonally left bottom to right top and vice versa, move
eyes around in circles or diagonal.
Silent scream – Without making any sound pretend that you are screaming out loud by
opening your mouth as wide as you possibly can.
Neck exercise – Point Chin to the sky then tuck chin into your chest. Head tilt to left
shoulder then right. Chin point to left shoulder then right. Neck rotation left to right and vice
a versa. There are four different neck movements.
Shoulder rotation – Forward rotation and backwards. Arms up clasp hands together and
stretch skywards. Repeat same with arms stretching to left side then to right.
Chest release – Hold hands behind your back and raise up as much as possible.
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Hug yourself –Tightly cross arms across your chest with hands touching your upperback.
Then reverse with the opposite arm up. This releases your upperback.
Side stretch – Sitting straight in chair twist body to left side as much as possible. Repeat on
right side. Same thing can be done standing.
Toe touch – Keeping legs close together stretch arms up and then bend forward to toes or as
close as possible without bending knees.
Knees up – Standing straight bring one knee up to chest and hug close to chest. Repeat with
other leg.
Knees back – Standing straight bend knee back with foot heel touching buttocks. Repeat
with other leg.
Ankle rotation – Sitting or standing stretch leg out and rotate ankle in both directions. Then
repeat with other leg.
Namaste – Bring arms across chest with hands touching in namaste. Then make sure that
fingers and palm above wrist are flat and touching and lower this right up to elbow level if
possible.
Finger stretch – Clench fists tight then open and stretch your fingers out and stretch thumbs
up.
Standing up – Place both hands flat on the table and press palms down.
Wrist rotation – Rotate wrist in one direction and then opposite.
Thumbs up – Place both fists on the table with thumbs side up. Move both fists outwards
and then inwards keeping wrist in the same place.
Palms up – Stretch arms out, palm facing down. Now move hands up and down to stretch
wrist.
Deep breathing – Breathe in from the nose and out from mouth, 5 – 10 times.
Finally shake arms out, shake legs out one at a time and do the skeletal dance (dance as if
you are completely loose).
Physical exercise is indispensable for a healthy body and mind. Stress can manifest itself in
many ways like knots in the shoulders, tension in the neck and butterflies in the stomach. It
may also be seen as fatigue and irritability. The most effective way of dealing with this stress
is to participate in physical activity. Any suitable exercise done consistently and with some
degree of commitment is sure to be effective.
Some of the advantages of exercising are:

 It increases physical health and stamina.

 It tones up muscles, makes the joints supple and encourages good posture.
 It reduces Hypertension and other psychosomatic ailments.
 It makes you more alert.
 It regularizes sleep and appetite.
 It generates self-confidence.
 It increases concentration.
 It helps you to relax.
 It balances the body and mind.
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However, certain aspects need to be kept in mind when following an exercise routine.
a) Safety – Choose an activity suitable to your age and physical ability. Build up your
exercises gradually till you reach your target level. If you have any health problems, consult
the doctor before embarking on an exercise routine.
b) Suppleness– Develop a wide range of movements without causing strain. Stretching
exercises increase flexibility.
c) Stamina – Stamina means endurance or ability to keep going without gasping for breath.
With regular exercise, stamina can be slowly increased. So, include stamina building exercise
like jogging, cycling, running and walking.
d) Strength – Strengthening exercises like weight-lifting help in maintaining a well-
proportioned body and prepare you for any sudden physical demands. So some strength
building exercises also need to be a part of your routine.
e) Enjoyment – You need to enjoy the exercises you are doing because if you find them
boring, you will not continue them. Benefits can be expected only if you follow the exercise
routine regularly. Which exercise you choose depends upon your inclination, abilities and
disabilities, physical health, time, and facilities available. Choose what will work best for
your and do it regularly.
3) Nutrition
Nutrition can greatly influence the way you look and feel. It affects the person
physiologically and psychologically. According to Davis in ―Lets Eat right to Keep Fit‖,
nutrition can either help you to think clearly or feel dull, make you enjoy your work or make
it a drudgery. The message of all doctors, dieticians, parents and family is that good nutrition
promotes good health.
Proper nutrition and healthy eating habits can increase the resistance to stress by increasing
the health of the body. When energy level is high and the body is strong and resistant, the
effect of the environment and its stress is less. Poor nutrition makes the body vulnerable to
illness which itself can be a cause of stress, and make the body more stress-prone. The person
also feels fatigued, anxious, and irritable.
While some foods are good for you and give you long lasting energy, other foods lead to
various problems if indulged in excess. The advice given below foods to avoid – foods to eat
is good for all adults in general. In addition, you will know what foods make you feel good
and what foods cause you discomfort. Especially in stressful moments, ensure that your
digestive system works in your favour and not against you.
Foods to avoid

Sugar : Puddings, cakes, sugar in beverages, ice creams, milk shakes, ‗mithai‘, etc.
Fats : Butter, margarine, ghee, dalda, fat, meats(mutton, beef, pork), eggs, cream,
etc.
Drinks : Alcohol, aerated drinks.
Additives Salt, sauces, pickles, excess (more than 4 cups) tea/coffee, commercially
: prepared foods.
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Foods to eat (in the following ratio)

Grain & Cereal- 40% of daily diet (preferably unmilled)
Vegetables & 35% of daily diet (cooked & uncooked)
Fruits –
Dairy Products/Oil 10% of daily diet (skim milk products & unsaturated vegetable oils)
–
Meat/Pulses/Beans 10% of daily diet (lean white meat, fish, assorted pulses, beans)
–
Other Foods – Mineral/Vitamins if prescribed
Water – 8 glasses daily (besides other fluids)

Although individual requirements may vary, it is important to keep in mind the desirable
aspects of a proper diet. A more detailed description follows:

1. Eat different types of food, so that the likelihood of deficiency or excess of any nutrient is
avoided.
2. Try to maintain a healthy body weight. Being over-weight increases the stress on the
body, interferes with the ability to cope with environmental stress, and threatens self-
esteem. Excess body-weight is also associated with a number of illnesses.
3. Avoid fats, as high levels of fats are associated with heart disease. It also makes your feel
lethargic and tired soon.
4. Eat more raw or lightly steamed foods.
5. Avoid sugar, especially when you are under stress. The body secretes more sugar at this
time anyway. And you need long lasting energy from complex carbohydrates, not quick
energy from sugar that is quickly exhausted too.
6. Do not take more than 5 mgs of salt everyday.
7. Avoid alcohol and cigarettes and do not use them as ways of dealing with stress.
8. Avoid caffeine. Caffeine is present in black tea, coffee, chocolates and colas. Caffeine
chemically induces a ―fight or flight‖ response and makes it difficult to cope with stress.
9. Vitamins and mineral supplements need to be taken on advice as more vitamins and
minerals are required in stressful situations.
10. A well-balanced diet needs to include plenty of seeds, grains, nuts, sprouts, fresh
vegetables and fruit.
11. Eat frequently and calmly. Frequent small meals are better than three large meals,
especially when under stress

XII. Laughter

―If you can‘t laugh at yourself, you will find plenty of volunteers to do it for you!‖ Dr. Peter
Hanson – Joy of stress.
Laughter is like ‗Internal Jogging‘ for your heart rate, breathing activity, blood pressure body
temperature, and it also releases natural pain reducing chemicals called endorphins. Muscles
tense as we wait for the punch line and contract as we laugh and relax profoundly – this
relaxed state lasts for up to 45 minutes as we recover from the excitement of laughing. Heart
rate and Blood pressure then drops below pre-laugh levels.
One study found that laughter reduced stress about as much as biofeedback training. Yet how
much time do we spend each day on Laughter? William Fray, a professor in an American
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university and a pioneer in Laughter Research found that 100 belly laughs is the aerobic
equivalent of 10 minutes on the Rowing machine.
A 1997 study covered 48 Heart attack patients. Along with medical treatment, half the group
watched comedy films for 30 minutes daily. The other half received medical treatment only.
After a year, both groups were reviewed to find that in the second group, 10 patients had
repeat heart attacks. Only 2 patients in the first group had heart attacks. As Dr. Lee Berk of
university of California (UCLA) said, laughter can do the job of Beta Blockers prescribed for
heart disease patients.
Laughter or a sense of Humour, i.e., the ability to find humour in real life, even in ourselves
gives a good perspective towards life events. It makes us look at the situation in totality, seek
humour, thereby reducing the stress immediately. Any situation where one can laugh will
definitely appear as a more manageable situation. Endorphins released lend a positive energy
to cope with the problem.
Seek humor in life. Laughter is an inbuilt tranquilizer. Humour and fun frees the mind. In a
crisis situation for instance, a little laughter tends to calm the emotions and helps find new
and creative solutions. Laugh with the problem and at oneself. Laughter must not, however,
be directed at the other. This will only worsen the situation.
Conclusion
Many behavioral coping techniques have been discussed in this chapter. An attempt has been
made to present them in a light, easy manner so they look more implementable. The only
thing to do now is to try it. Attempt any one technique first and benefit from its stress
reducing rewards. Of course, it‘s not easy. It may be easier to send man to the moon than get
man to change his behaviour, his attitude and his personality.
But then, as the saying goes, ―If you only do what you always did, you will only get what you
always got!‖
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CHAPTER 9:
RELAXATION & MEDITATION
SYSTEMS
Introduction to Relaxation & Meditation Systems

Everyone seeks peace and harmony, because these are what we require in our lives. From
time to time we all experience agitation, irritation, disharmony and suffering, and when one
suffers from agitation, one does not keep this discomfort limited to oneself. This gets
distributed to others as well. The agitation permeates the atmosphere around the miserable
person. Everyone who comes into contact with him is in danger of becoming irritated and
agitated. Certainly this is not a comfortable proper way to live.
Agitation can be caused by a particular situation or by ones perception and attitude towards
the situation. Management of this situation needs a two-pronged approach. A positive attitude
will help understand the problem and plan strategies for stress reduction. On the other hand, a
calm, rested and relaxed mind will have a calmer perspective of life situations. The same
situation will not appear as stressful because of this relaxed overview.
We have defined Mental Health as a balance and harmony between four forces in our
personality; the psychological, social, physical and spiritual. This is in keeping with the
WHO definition of ‗Health‘. Unless each force is perfectly balanced with the other, we
cannot have internal harmony. And we can only give harmony if we have it. Creating this
harmony will require the following focus.
Physical Well-being: The physical body represents the outer structure of head, face, limbs
etc, to some, but also all the internal organs, body systems and their physiology to medical
and health professional. This perfectly tuned machine provided by nature and genetics works
almost automatically. We only realize its value, when something goes wrong. Keeping this
body well maintained with the help of regular exercise, physical activity and a healthy diet
will prevent any medical break down and take us towards physical well-being.
Social well-being: The isolated and introverted person is an island within an ocean. Social
comfort depends on the balance between the several wheels in each persons life. Each
individual has several roles to play and in doing so interacts with several people around him.
Those close to him come into the innermost wheel. Extended family, office colleagues,
neighbors, acquaintances etc, occupy the outer wheels and exert a lesser degree of influence.
At the core of all these wheels, is the person himself. If all these wheels are well adjusted
with each other, there is harmony in his inter personal relationships. The core and each of the
wheels, need to coexist to mutual comfort and growth for there to be social well-being.
Mental and Emotional Well-being: The mind also needs appropriate activity to keep it well.
Stretching your capabilities, taking on new challenges, adding to your academic repertoire
and planning for success will stretch the mind and keep it fit. Developing a resilient and
hardy personality that can take failure but stand up again with confidence to face new
challenges and succeed will create emotional comfort. Working on anger, negativity and
other emotional baggage that we all carry, will take us towards assertiveness, positivity and
emotional well-being. An alert and aroused mind needs sufficient periods of rest and
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relaxation. This relaxation brings the body to a state of equilibrium and centers the mind into
a calm, creative state & accordingly, one achieves body mind wellness.
Spiritual Well-being: Spiritual Well-being is promoted through study, prayer, inner
reflection and times of silence. Getting in touch with ones spiritual side is essential. It is there
that one finds inner peace, joy, beauty and strength that he/she never knew existed.
Meditation, was once associated only with saints and mystics, but is now sweeping the globe.
Never before have so many felt the need to search for personal fulfillment within themselves.
This growing trend embraces all faiths and traditions. People everywhere are turning inward
to enhance their spiritual lives and to find a greater degree of peace. Spiritual growth is a state
of total awareness with the reactive environment common to man. There is no separation then
between the individual consciousness and the larger consciousness. A state of oneness and
peacefulness with all around is a state of spiritual well-being.
This chapter focuses on various relaxation techniques that calm the body mind complex.
Meditation as practiced by various schools and their relevance to modern man have also been
discussed in this chapter. We have also created an audio tape with guided relaxation
techniques, while this chapter will give good knowledge about these techniques, the tape will
help to practice them.

I. THE RELAXATION – MEDITATION RESPONSE

Stress is an aroused response. This arousal prepares the body for physical activity and mental
challenge.
However, most of today‘s challenges require a calm perspective for creative problem solving.
Most of the times a ‗fight‘ stance is not acceptable and probably worsens the stressful
situation. ‗Flight‘ is not an available option since most situations have to be lived with. If the
only option is to ‗stay and deal‘ then a calm body mind complex is required, not arousal.
Relaxation is useful when we want the right balance between energy & skill. We prefer to use
stress in the working of a new project, but in the final presentation we prefer to use
Relaxation.
Progressive Muscular Relaxation was designed by physician Edward Jacobson who found
that people could relax a muscle to a significantly greater degree after tensing it. The tension
relaxation technique makes you more aware of the difference between tension and relaxation.
Unlike sleep, conscious relaxation consists of learning to systematically empty the mind &
muscles of stress & external stimuli through a series of deliberately disciplined progressive
exercises.
If stress is a learned and conditioned response, coming on automatically, the relaxation
response can be learned to counter the automatic reaction of stress. The arousal response can
be replaced with the relaxation response.
These Management techniques are being used more & more by doctors in the treatments of
various physiological & psychosomatic disorders such as chronic pain disorder, headache,
hypertension, peptic ulcer cardiac conditions, sexual dysfunction, skin disorders, gastritis,
gastro-entities, arthritis, sleep disorders and even cancers. They are used either with
Pharmacotherapy or some times by themselves. They are also used along with various
psychological techniques.
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In simple terms, Meditation can be defined as total relaxation of the bodymind complex. The
word, ―bodymind‖, may look strange because ordinarily we think that the body and mind are
separate things. In fact, they are not. The mind is the subtle part of the body and body is
the gross part of mind. That is why, when the body is sick, the mind also becomes sick and
when the mind is sick, the body also suffers.
Meditation can also be defined as the art of living in the present moment. We rarely if
ever, live in the present moment. Our mind almost always dwells in the past or future. Isn‘t it
strange that the reason of all our so called stress is rooted either in the past or in future. The
present is rarely the source of stress. Relaxation could be achieved by living in the present
moment. The experience of deep relaxation or the art of living in the present moment creates
the required situation i.e. (a deep silent mind) to know our real self.
Healing effects of meditation: Health is a result of harmony and natural flow or pulsation of
life energies through every part of our body. Disease occurs when this joyful flow is
interrupted. Poor lifestyle, emotional conflict, mental tension with consequent energy
depletion or inherited pre-dispositions are the main causes of poor health. A number of
physical diseases are often related to these subtle problems. Meditation is very helpful in
overcoming these problems.
Stress triggers the Autonomic nervous system and the Endocrine system, ultimately
influencing all other systems including the Immune system. Relaxation and Meditation
triggers the parasympathetic nervous system. bringing the body to make relaxation response.
All psychosomatic ailments are greatly benefited by relaxation, which is now widely used
alone or in combination with medical treatment. It is sometimes referred to as Behavioral
aspirin or Tranquilizers.
During stress, stress chemicals such as Adrenalin and Nor-adrenaline are released into the
blood stream. In the same way, during meditation there is an increase in certain mood altering
chemicals of the body known as Neurotransmitters like Serotonin. Recent research also
shows that during meditation, Endorphin is also released, which is associated with happiness
and well being. Meditation reduces oxygen consumption and carbon-dioxide production by
20%, and lowers the blood pressure and level of blood lactate (associated with anxiety and
high blood pressure), by 33%
II. TECHNIQUES OF RELAXATION

Relaxation techniques, when used consistently, can prove effective in controlling stress by
helping reach a state of mental calm, even when in the middle of a stressful situation. There
are several relaxation techniques which can be done almost anywhere at any time to help
control stress. Any relaxation technique should preferably be practiced in a quiet and peaceful
room. Curtains can be drawn and lights reduced. Room temperature, light and sound must be
controlled to create a soothing environment. Remove distractions from visitors, TV etc.
Light, instrumental music may aid the process. Avoid vocal music, symphonies etc.
The position used could be sitting or lying down. If sitting, the back should be supported and
if lying down, a soft but firm mattresses should be used to support the body. Twenty minutes
is a good time for a session and regularity is important for sustained benefit. Learning from a
guide makes it easier to practice. Preferably a fixed time should be set aside for this practice
as per individual convenience. This will help in making it a daily habit and part of a healthy
lifestyle.
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Relaxation is a learned, systematic and conscious technique. As far as possible, sleep must be
avoided. Sleep is not a conscious process and relaxation does not always happen if sleep is
disturbed. Some relaxation techniques are discussed here:
a. Breathing
Abdominal breathing is a simple technique that can relax tense muscles, focus energy and
help one be more productive. To use the technique, you may adopt a sitting or lying down
posture. Ensure that your back is well supported and your neck and shoulders are
comfortable. Now breathe in deeply through the nose, letting your stomach expand as much
as possible. It may be helpful to place your hands lightly and comfortably on your stomach
during the exercise. Once you‘ve breathed in as much as possible, hold your breath for a few
seconds and then exhale slowly through your mouth pressing your hands into your abdomen
this is called Abdominal or Diaphragmatic breathing. Do not move your shoulders. Inhale
and push your abdomen out. By doing this, the diaphragm is pulled down and more room is
created for the lungs to expand. Also, the breath is pulled down to the lower part of the lungs
where most of the blood circulates. Chest and shoulder breathing increases shallow breathing.
With diaphragmatic breathing, oxygen absorption is optimized slowing breathing down.
You will now have moved from rapid, shallow breathing to slow, calm and deep breathing.
Continue this breathing and now focus on counting your breathing, inhaling one count and
exhaling to the second and so on. When you focus on counting, the mind moves away from
any anxiety providing thoughts, further reducing the rate of breathing.
This technique can be used at any time or place and within a few minutes will help you to
feel more calm and relaxed. Performance will benefit greatly from this calmness.
b. Biofeedback
Biofeedback refers to a set of procedures used to teach a person to control body and nervous
system activities by electronically recording and processing information about those activities
and displaying it to the person. It makes available information about body processes that are
usually unavailable. On the basis of this information, the person can learn physiological
processes. Feedback is integral to biological homeostasis & relaxation.
Biofeedback simply involves the addition of special monitoring equipment to pick up and
provide feedback about body functions. This information is then used by the individual to
alter those body functions systematically and in a manner consistent with instructions given.
Although many different physiological processes may be monitored in biofeedback, the
equipment has to carry out five basic functions:

 Detecting some electrical or mechanical signal of the body;

 Amplifying it;
 Filtering it;
 Converting; and
 Displaying the signal to the individual.

Two important aspects of biofeedback should be noted. First, the information is fed back
quickly and precisely.
Second, the biofeedback apparatus does not cause a change in the person‘s physiology. The
person must do that himself. The biofeedback equipment only provides the person with
quick, accurate information about the physiological process being monitored.
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In addition to muscle tension, Electromyography or EMG biofeedback, many other types of

feedback are used. These include blood pressure, heart rate (electrocardiogram or EKG),
brain activity (electroencephalogram (ECG) or EEG), skin temperature, skin conductance
(galvanic skin response or GSR), and blood flow through body tissues.
Biofeedback can be used as a primary treatment in many disorders thought to be responsive
only to medical treatment. Biofeedback cannot restore damaged tissue, but it can make
persons become more aware of physiological processes and to gain control over those
processes. Conditions and symptoms that can be benefited by Biofeedback are given below.
Table 9.1
Symptoms/Disorders
Hypertension
Heart rate
Respiration
Migraine headaches
Tension headaches
Skin temperature
Anxiety related disorders
Pain disorders
Anger
Addiction
Stress response

Control with Feedback – Initially, treatment focuses on teaching new skills. Using
biofeedback, the client is trained via shaping to control the physiological process being
monitored. The client is given a series of trials with feedback and asked to alter the
physiological process based on the feedback. Very small changes in the desired direction are
reinforced via success and verbal praise. Over time, as the client can reliably demonstrate
these small changes, larger changes in the desired direction are used as the criteria for
reinforcement until the client can consistently bring about the desired amount of change.
Specific strategies like relaxation, pleasant imagery, and the like may be used to assist the
client or the client may be asked to experiment with her own strategies to see what works.
Following each biofeedback session, the therapist also helps the client learn cognitive and
behavioral skills to cope more effectively with stress-producing situations.
When the client has learned to decrease heart rate with feedback reliably, the next step is to
teach her to generate that response without feedback so that it can be used in the natural
environment. This is facilitated by trying to control the response on some trials when there is
no feedback. When the client can reliably control the response without feedback, additional
steps may be taken to ensure that he/she can exert this control in actual stressful situations.
c. Jacobson’s Progressive Muscular Relaxation
Physiological processes can also be altered without electronically monitoring and feeding
back information concerning a specific physiological function. Clients can learn to alter
physiological activity when given specific instructions to do so. Cognitive or somatic
strategies help to produce the desired changes.
Progressive Muscle Relaxation : Progressive relaxation, pioneered in the 1930‘s by
physiologist and psychologist Edmund Jacobson, is an effective way to relax and reduce
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anxiety. Jacobson believed that, if people could learn to relax their muscles through a precise
method, mental relaxation would follow. Jacobson‘s technique involves tensing and relaxing
various voluntary muscle groups throughout the body in an orderly sequence. According to
psychologists Robert Woolfolk and Frank Richardson in their book ―Stress, Sanity, and
Survival‖, ―Despite the relative obscurity of this method, progressive relaxation is perhaps
the most reliable and effective procedure of all the different means of achieving relaxation.‖
Progressive relaxation works because of the relationship between muscle tension and
emotional tension. When emotionally distraught, automatically muscles get tensed. Muscle
tension is a cause of the headaches and backaches.
Progressive muscular relaxation training consists of a series of instructions that direct a client
to relax his voluntary musculature. After a thorough assessment to determine the potential
usefulness of relaxation, the client is provided with a conceptualization of the problem as one
of excess tension or arousal. Relaxation training is suggested as an effective mode of
reducing that arousal, thus having a beneficial impact on the presenting problem.
Active relaxation is a process that can help you actually feel the difference between tension
and relaxation. It is accomplished by first tensing and then relaxing each muscle in the body.
Start with the muscles in the head and move down to the muscles in the feet. This is also
called progressive or systemic relaxation.
Procedure: The client is seated comfortably in a quiet room. He is directed first to tense and
then to relax sixteen muscle groups, one at a time, in the sequence given in Table 9.2. The
client‘s attention is focused on the target muscle group, and at the predetermined signal from
the clinician, the client tenses the muscle group for 5 to 7 seconds and then relaxes the muscle
group for 20 to 30 seconds. During the relaxation phase, the therapist makes statements to
keep the client‘s focus on the feelings of relaxation in that muscle group. While the goal of
progressive relaxation training is to help the client achieve a deeply relaxed state, the initial
use of tensing prior to relaxing is to help the client feel the arousal similar to stress and then
feel the benefit of the relaxation that replaces it.
As the client is able to achieve deep relaxation with the tension and release of the sixteen
muscle groups, a series of procedures are used to decrease the time and effort needed to
achieve relaxation. First, the sixteen muscle groups are combined into seven, and the client
practices tensing and relaxing these combined groups as before. Later with practice this can
be consolidated to four groups.
Patients with a specific ailment need to be careful while tensing the relevant muscle group.
e.g. spondilosis and arthritis.
Table 9.2
Summary of Progressive Relaxation Training

Initial sessions Combined Session Combined Combined

Tensing and Relaxing Set of 7 Session Session
Tensing and Set of 4 Set of 4
Relaxing Tensing and Only Relaxing
Relaxing
Dominant hand forearm Dominantarm Arms Arms
dominant biceps
Non dominant arm forearm, Nondominant arm Arms Arms
biceps
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Forehead Face/Neck Face/Neck Face/Neck

Upper cheeks
Nose
Lower cheeks
Neck Jaws
Neck and throat
Shoulders Torso Torso Torso
Chest
Upper back
Abdominal region
Dominant calf Dominant leg legs legs
Dominant foot
Non-dominant thigh
Non-dominant calf
Non-dominant foot Nondominant leg ( 2 sessions ) (1 sessions )
( 7 sessions ) ( 2 sessions )

The benefits of JPMR are tremendous. It conditions the client to learn to replace the stress
arousal response with a relaxation response. Psychosomatic ailments are more controlled with
the practice of JPMR. It is also used as part of behaviour modification and also to correct
health damaging behaviour. Various psychological disorders are treated with the help of
JPMR such as phobias, obsessive compulsive disorder etc.
d. Autogenic Relaxation Technique
This is essentially an exercise involving self-directed talk. Its benefit is to normalize the
functioning of bodily processes.
The process is one of passive concentration. Lie prone on the floor on a firm mattress or
couch. The floor is preferred since it is beneficial for the back. If necessary, place a pillow
under your knees. Lying on your back, place your feet about eighteen inches apart and your
hands about ten inches from the side of your body, palms facing up or face down as
comfortable to you.
Next, instruct yourself to spend twenty minutes in a state of conditioned relaxation. You do
not have to think about this again. In exactly twenty minutes you will feel inclined to open
your eyes and sit up. At first when you are practicing this exercise you may be a little under
or over the twenty-minute mark. With practice you will find that you are remarkably accurate
to the second. Occasionally, you may spend thirty or forty-five minutes in this relaxing state.
This is normal since you probably needed it.
With your eyes closed, mentally bring your attention to the toes of one of your feet. Instruct
your toes to relax and then let your attention move to the toes of the other foot. say to
yourself mentally or sub vocally, ―Toes, relax.‖ Do the same for your other foot.
After you have relaxed the toes of both feet, again attend to one of your feet and say, ―Ball of
the (right or left) foot, relax.‖ Then move to the other foot. Slowly and rhythmically do every
part of the anatomy of your body that you can recall from the bottom of your feet to the top of
your head: arches, insteps, heels, ankles, calves, knees, hips, thighs, genitals, kidneys,
bladder, pancreas, liver, spleen, stomach, large intestine, small intestine, bowels, buttocks,
abdomen, lungs, chest, heart, solar plexus, breathing, circulation, spinal column, nervous
system, lower back, upper back, shoulders, arms neck, face, and so on.
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During the exercise you may find yourself drifting off before covering every part of your
body. This is to be desired and is considered very beneficial. Sometimes you may get only as
far as your knees and suddenly open your eyes twenty minutes later without realizing you
have drifted off for twenty minutes. Again, this is very beneficial. Relaxing aids in sleep and
you may have been sleep deprived, consider the exercise completed.
At other times you may complete this relaxation process and find your attention is drawn
back to certain parts of your body because you may be experiencing some discomfort in that
part. Even if you may not be feeling any discomfort in your body, for some inexplicable
reason your attention may simply wander to some body part and want to stay there for a few
seconds. Just keep the attention there and keep telling that part of your body to relax and
function normally.
From time to time, other experiences may occur to you in this state of conditioned relaxation,
such as a lightness or tingling sensation. These experiences are also to be considered
beneficial and normal. Do not pay attention to them. Continue with the practice. The more
faithfully you do this exercise the more benefits you will derive from it. You may want to do
this more than once a day. Do it as often as you wish, but do it at least once each day.
Useful times are at the end of the day‘s work just before dinner, or any time you feel
particularly tense and in need of relaxation and more energy. If you have difficulty falling
asleep, you might try this exercise to put yourself to sleep.
e. Guided Imagery or Visualization
Thoughts have a direct influence on the way we feel and behave. If one tends to dwell on sad
or negative thoughts, he/she is most likely not a very happy person. Likewise, if one thinks
that their job is enough to give them a headache, it probably will. This is just another clear
example of the power the mind exerts over the body.
Imagination can be a powerful tool to help combat stress, tension, and anxiety. Visualization
can be used to harness the energy of imagination, and it does not take long (probably just a
few weeks) to master the technique. Try to visualize two or three times a day. Most people
find it easiest to practice this in bed in the morning and at night before falling asleep, though
with practice you‘ll be able to visualize whenever and wherever the need arises.
Technique : To begin visualization, sit or be in a comfortable position and close your eyes.
Scan your body for any muscle tension and relax the areas that need it. Once you feel relaxed,
begin to visualize a scene, object, or place that is soothing and pleasing to you. Imagine every
aspect of the scene, involving all of your senses.
For example, if you like to visualize a waterfall on a mountain, imagine first what this looks
like: the rushing water, the stream flowing from it, the size and thickness of the trees all
around, the sky above and the sun filtering through the branches, and so on. You have now
soothed the sense of sight. Then imagine how this place would smell-damp and musty or of
fragrant pine. Perhaps you can get the smell of wet earth, and the fragrance of flowers. You
have relaxed the sense of smell. Next listen for the sounds you would hear if you were there:
the water rushing over rocks, the hush of the wind rising and then quieting down, birds
singing and crickets chirping. You have now calmed your sense of hearing. How does the
ground feel beneath your feet? Is it rocky and rough, or soft and smooth from pine needles or
moss? How does the breeze feel against your skin and the lapping of water around your
body? You have soother the sense of touch. Imagine chewing on a blade of grass, or taking a
long, cool drink from the water- fall. How do these taste? You have calmed the sense of taste.
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As you become more involved in your visual image, your body will relax and you will be
able to let go of the problems or worries that you‘d felt before. To encourage this relaxation
to occur, you can punctuate the images with positive statements, such as ―I am letting go of
tension‖ or ―I feel calm and relaxed.‖
Sample Session: Using the subject of your favorite place, here is an example of a
visualization exercise that you can tape record. If you do record it, or something similar to
this, be sure to speak slowly and allow generous pauses so your visualizations can form.
Sit or lie down, close your eyes, and take deep breaths. Scan your body for tension and try to
relax those muscles. (long pause) Once your body feels relaxed, go to your favorite place . . .
it is calm and safe, a place where your worries disappear. Look around at this place and take
in all the sights. How does it feel to be here? You are safe and at peace. Notice what you hear
in this special place. What do you smell? Walk a bit farther into your favorite place. Look up,
and down, and all around. Notice what you see and how it makes you feel. Say to yourself, ―I
am relaxed . . . my worries are gone . . . tension has flowed out of my body.‖ Take in all of
the sights, sounds, smells, and feelings of this special place. You can return here whenever
your want to. Repeat to yourself, ―I am relaxed here . . . this is my favorite place.‖
When you have thoroughly visualized this place, open your eyes but stay in the same
comfortable position. Continue to breathe smoothly and rhythmically, and take a few
moments to experience and enjoy your relaxation. Rest assured that your special place is
available to you whenever you need to go there.
One can visualize emotions in this state of relaxation. Negative emotions can be allowed to
come, observed for a while and then allowed to pass. Positive emotions can be allowed to
come and replace negative emotions and conflicts.
Another type of visualization involves an image that you associate with tension which you
can replace with an image for relaxation. For example, you might visualize tension as a taut
rope, the sound of thunder, the color red, pitch darkness, persistent hammering, or blinding
white light. These images of tension can soften and fade into images of relaxation. For
instance, the taut rope loosens, the thunder subsides and is replaced by light rain, red turns to
orchid, the darkness begins to lighten, the pounding hammer is replaced by the murmur of
cicadas and crickets, the blinding white light softens to a sunrise or sunset.
When you feel a muscle becoming tense, imagine that it is one of these tension images. Then
let it transform into a relaxation image as you repeat to yourself, ―I can relax . . . the tension
is slipping away.‖
III. METHODS OF MEDITATION

While there are different types of meditation any method that creates awareness with
relaxation is the right method. The methods may vary from person to person. One has to find
out which method suits one the best. While all methods overlap, they can be classified under
three broad heads.

Active Methods (Body Oriented): Hatha Yoga.

Passive Methods (Mind Oriented): Raja Yoga.
Heart Methods (Emotion Oriented): Bhakti Yoga.
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Active Methods – In the active meditation techniques, the body is used a lot. These methods
are primarily to activate body energy between the opposite poles and in turn generate a deep
cleansing effect. Many blocks created in the body by mental repression are removed.
Passive Methods – These are basically mind oriented techniques and minimum body activity
is involved.
Heart Methods – In these methods the emotions are situations. Deeply emotionally and
devotionally inclined people can be benefited through this methods.

Fig 9.1

Meditation in other words is the process by which a person learns to shut off the thinking
mind and to begin feeling. Feelings are more at an intuitive level. The process of meditation
teaches one to activate that sense of feeling and to use it deliberately.
The goal of meditation is to feel everything around one self and to do it without comparisons,
evaluation or judgment; to turn off the thinking mind and just feel. In this state of feeling
your awareness will gradually expand to include more of from the environment. Ultimately,
when a person‘s awareness has expanded to include all of creation, they will achieve
―Cosmic Consciousness‖. Cosmic consciousness is the state where awareness includes all
space (and everything in it), all time (past, present, future), and all knowledge. In this state of
cosmic consciousness, there is no separation between the individual and anything else. All is
one … just as you feel you and your body are all one, but at a much higher scale.
There are many schools for learning meditation (such as Transcendental Meditation,
Vipasana), but meditation itself is very simple. It‘s simply a process where you focus you
attention on something constant like your breathing or a candle flame. By focusing the mind
on something constant, there is nothing to stimulate ones thinking mind, and it in effect goes
to sleep.
Meditation can be very useful because it enables an individual to feel the cause of a disease.
Once an individual fully feels and experiences what‘s causing an illness his/her inner wisdom
will guide him back towards health.
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Whatever the method of meditation, it is important to remember that the practice is just the
means by which one discovers ones inner self. Sometimes people get distracted by focusing
their attention on the means rather than on feeling. If this happens then the meditation
practice becomes a ritual and the seeker gets side tracked on his path.
Since meditation and feeling is experiential rather than intellectual, it is recommended that
people initially learn meditation from someone in person…ideally someone (a guide) who
teaches meditation without any religious trappings, but uses it as a means toward the goal of
feeling
A Few Myths of Meditation
While meditation is a much talked about technique, it is not always completely understood.
Myths and misconceptions have to be analysed and put aside for more people to learn and
benefit from the practice of meditation.
Meditation and concentration: While concentration is certainly a part of meditation, there
is much more to meditation. There are two kinds of differences between concentration and
meditation, both in technique as well as in their ultimate goal. In meditation, the ideation or
meaning which comes with the technique is very important. There is an ancient saying in the
yogic tradition: ―As you think, so you become.‖ Concentrating on the word ‗one‘, focusing
on a candle flame or becoming immersed in jogging or some other activity can not lead us to
our true self. Concentration is a mental activity that results in alertness. Meditation on the
other hand is a state of calm awareness. Certainly these techniques are useful for mental
development, but meditation leads to spiritual development as well. In meditation we seek to
continue our self development until we become fully aware of our highest human potential.
True meditation accepts no limited conception of our Self. It leads us toward the infinite
which is ultimately beyond technique.
Meditation relaxation and peace of mind: While relaxation exercises are very beneficial
for the practice of meditation, they are only a starting point. Similarly, peace of mind is only
one of the many benefits of meditation. Meditation leads us to deeper self-awareness, in the
broadest sense of the word. Sometimes self-awareness is painful and disturbing. Sometimes
meditation will lead us into troubled portions of our mind. We may feel, at those times, that
we are no longer on the path of meditation; but actually these troubles, if properly
understood, can be helpful for our self development. Whatever is within us, we must
eventually come to accept. This self- acceptance is the first step towards self-transformation.
Then we can continue to delve into the deeper layers of our mind. It is true that one of the
ultimate goals of meditation is to attain that blissful state of true inner peace. It is also true
that the process of meditation will lead us slowly but steadily toward this inner peace of
mind. But we must remember that meditation, because it makes us more aware, also opens us
to the pain which exists inside and around us. That is why meditation also helps us to develop
our compassion.
Meditation is esoteric and unscientific: Actually meditation is a universal practice which
has been used worldwide for thousands of years. While some cultures are more attuned to the
practice and philosophy of meditation, it still has roots in all of the world‘s spiritual
traditions. And despite the mystique in which meditation is sometimes cloaked, the reality is
that anyone can learn to meditate. Proper instruction and regular practice are important, but
they are important in learning to play a musical instrument, too. Meditation techniques have
been systematically developed for at least 7000 years. Countless meditators have
experimented with a myriad of techniques in the laboratory of their minds. There is nothing
haphazard about a proper meditation technique. Meditation is unique because it is a science
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of our inner realms – an intuitive science. This intuitive science is so astute that western
physics is only now coming to understand aspects of the ultimate nature of reality in the
universe which were grasped and described by meditators thousands of years ago. Instead of
calling meditation unscientific we need to expand our notion of what science is.
Meditation is escapist: Actually, when meditation is properly taught and practiced, it will
often lead toward greater involvement in the world. One of the goals of meditation is the
experience of the oneness of all creation. As we delve deeper and deeper into our true selves,
we become more aware of how we are all linked. From this realization comes compassion,
love for others and a stronger desire to bring justice into the world. Meditation also gives us a
broader perspective from which to view our daily lives and more mental balance to guide our
actions. Meditation may change our feelings about what is important in the world, but it does
so by giving us more food for thought, not less.
Meditation is purely a mental exercise: Certainly meditation begins in the mind. Its
culmination, though, is found in our emotion, in the innermost core of our being where we
feel love for all creation. Meditation has been called the practice of universal kinship, for as
we delve into the deepest layers of our mind we discover that our external differences melt
away. So, it is no surprise that many meditative paths also make use of devotional practices
like chanting, spiritual dance and music, and sharing with others. On the spiritual path, an
open mind and an open heart go hand in hand.
Meditation is too complex to learn: Actually beginning a meditation technique is amazingly
simple. It is the establishing of a regular practice of meditation that takes time and effort. The
paradox of meditation is that one can receive the basic teaching in minutes and then spend the
rest of life uncovering all the wisdom that is hidden in that teaching. Guidance and
companionship on the path are freely available and practice is easier with guidance.
Meditation is contemplation: Contemplation triggers thought processes. As long as the
mind contemplates these thoughts, the body and mind are not relaxed. Relaxation is the first
step to Meditation.
Meditation conflicts with my religious beliefs and practices: One of the goals of
meditation is to give every individual an experience of the spiritual reality that all religions
speak of indeed meditation will bring you closer to the essence of any religious creed.
Meditation will give me bliss easily: Many new meditators become discouraged if they
don‘t have some sort of dramatic or blissful experience in a short time. While it is true that
some people have wonderful experiences early on, the vast majority of us have to diligently
practice for months or years before we begin to attain these higher states of consciousness.
What happens usually is that we change in small and subtle ways which we may not fully
notice or acknowledge to ourselves. Meditation is a slow but steady process of inner growth
and expanded awareness. It‘s slow because it‘s real. The changes often occur deep inside
where we don‘t usually see ourselves. How quickly and how noticeably these changes appear
is a wholly personal matter. Just like you can‘t judge a book by its cover, you can‘t judge
spiritual attainment and self-realization by external changes. It‘s important to remember that
most of us have spent long, long periods of time looking outside of ourselves. If you‘ve been
looking mostly outside for 20, 30, 40 or more years, can you really expect to turn inside and
see clearly in a few weeks? In Sanskrit, meditation is called sadhana. Sadhana means the
effort to complete ourselves, the effort to become whole. So, what‘s most important in the
practice of meditation is sincerity and effort bliss will come, sooner or later.
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IV. SCHOOLS OF MEDITATION

a. Transcendental Meditation:
―Transcendental Meditation is that one simple procedure to enliven the most basic level of
life and thereby raise every individual and every society to its full dignity‖.- Maharshi
Mahesh Yogi
Transcendental Meditation is a simple technique which gives a unique quality of rest to mind
and body. It allows stress and tiredness to be released in a natural way, resulting in greater
energy, clarity and enjoyment of life. It is unique and fundamentally different from any other
systems of meditation and relaxation.Over 5 million people around the world – and almost
200,000 in the UK – have learned the technique since it was founded by Maharishi Mahesh
Yogi in 1957. Transcendental Meditation is very simple to learn and practise, yet it brings
great practical benefit to all areas of life.
People learn Transcendental Meditation for many reasons:

 Reducing stress and bringing balance to life.

 Improving health – especially with stress-related problems.
 Personal effectiveness – clarity of thought, creativity, getting more done.
 Improving relationships.
 Self Knowledge – fulfilling life‘s deepest need.

The first scientific research on Transcendental Meditation was published in 1970. By now
there are many hundreds of published studies, which document the benefits for mind, body,
relationships, and the environment. It is neither mind-control nor mental discipline; it is not
concentration, eastern philosophy, or a way of life.
Origins: The knowledge of Transcendental Meditation has been kept alive and pure in the
Vedic tradition of India, the world‘s oldest tradition of knowledge.
In modern times the knowledge of Transcendental Meditation (TM) has been spread by
Maharishi Mahesh Yogi. Maharishi received the technique from his Teacher with whom he
studied for many years, before inaugurating a world-wide movement to spread the knowledge
of TM around the world in 1957.
Transcendental Meditation is a technique. It does not involve or require any faith or belief. It
simply utilizes the natural tendency of the mind to settle down and experience the least
excited state of consciousness, a state of restful alertness.
Transcendental Meditation doesn‘t fall into either of the two categories: concentration and
contemplation. Concentration involves effort – and effort will inevitably keep the mind lively
and active. Contemplation, on the other hand, involves thinking about something. One
thought leads onto another, and again the mind remains active.
An analogy will perhaps make this clear. The mind is like the ocean, with the busy, active
everyday level of thinking on the surface, and quieter, more comprehensive more holistic and
intuitive thoughts, feeling and wisdom towards the depths. In this analogy, concentration
would be akin to treading water (expending energy staying up on the surface), while
contemplation would be swimming around on the surface (drifting from one active thought to
another). Transcendental Meditation, in contrast, involves diving deep to the bottom of the
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ocean, experiencing the mind in its silent, wide-awake state. This is the source of all
creativity, intelligence and happiness in the mind.
Transcendental Meditation is not mind-control or mental discipline; it is not concentration or
eastern philosophy. One does not have to control breathing or muscles. One does not even
have to try to relax. In this, people are learning a technique which facilitates a completely
natural process: an ability which is ingrained in the nature of the mind.
Additionally, Transcendental Meditation had been found to:

 Increase physiological relaxation.

 Decrease cigarette use.
 Increase self actualization.
 Decrease alcohol use.
 Decrease drug use.
 Improve psychological factors.
 Reduce blood pressure.

Benefits of Transcendental Meditation: Because Transcendental Meditation enlivens the

most profound level of the mind, it brings wide-ranging benefit to many areas of life.

 Unfolding the potential of the mind – personal effectiveness.

 Reducing stress.
 Improving health.
 Reducing the negative effects of ageing.
 Improving relationships.

b. Sahaja Yoga
Sahaja Yoga is a unique method of meditation based on an experience called Self Realization
(Kundalini awakening) that can occur within each human being. Through this process an
inner transformation takes place by which one becomes moral, united, integrated and
balanced. One can actually feel the all pervading divine power as a cool breeze, as described
in all religions and spiritual traditions of the world.
What is Sahaja Yoga ?
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Sahaja Yoga is a method of meditation which brings a breakthrough in the evolution of

human awareness. It was created by Shri Mataji Nirmala Devi in 1970 and has since spread
all around the world.
In Shri Mataji‘s own words: ―Global unity of mankind can be achieved through this
awakening that can occur within each human being, so that transformation takes place within
us. By this process a person becomes moral, united, integrated and balanced. One actually
gets the experience of the feeling of the all-pervading divine power as cool breeze. ―Know
thyself‖ is the main theme of all the scriptures – it becomes evident and one reaches the
absolute understanding of oneself. Thus one becomes peaceful and joyous in life. One
becomes collective as a drop falling into the ocean of compassion. This method works for the
multitudes and not individually. Of course one cannot pay for the experience of Divine Love.
Moreover, it is the last breakthrough of our evolution. This is the actualization of such
transformation, which is taking place now, worldwide, and has been proved and experienced
by hundreds of thousands in over 85 countries.‖
This inner awakening is called by many names: Self Realization, Second Birth,
Enlightenment, Liberation, Moksha, Satori and it is the goal of all religions and spiritual
traditions of the world. This knowledge is ancient, but for a long time it was available only to
a few souls, being kept secret and transmitted from guru to disciple, since Self Realization
was extremely difficult to achieve. In these modern times, through Sahaja (―spontaneous‖)
Yoga (―union with one‘s Self‖), this experience has become effortless and available to
everyone, for the first time in the history of human spirituality.
Through the practice of Sahaja Yoga, awareness gains a new dimension where absolute truth
can be felt tangibly – on the central nervous system. As a result of this happening, spiritual
ascent takes place effortlessly and physical, mental and emotional balance are achieved as a
byproduct of this growth of ones awareness.
How does this happen? In Shri Mataji Nirmala Devi’s own words, ―Everyday we see seeds
sprouting, flowers blooming, fruits ripening, but we do not want to think how it happens.
There is a power that does this work, it is the all pervading power of Divine Love. Now the
time has come to feel this power through the instrument within us. This instrument has no use
unless it is connected to the mains. We do not know our potential, our beauty, but once this
connection with the mains is established, we will be surprised at the dynamic results.‖
At the outset we have to understand that this connection is not mental. Through religion this
connection cannot be made because religion also is mental. However, human awareness can
be developed to a higher dimension through Sahaja Yoga which is not a mental projection. It
is a becoming. This is the last step in evolution. Whatever we have achieved in our evolution
has to manifest through our central nervous system.
When the foetus is about 2 to 3 months old in the mother‘s womb, columns of rays of
consciousness emitted through the all pervading power of Divine Love, pass through the
brain to enlighten it. The shape of the brain being prism-like, the column of rays falling on it
gets refracted into four diverse channels corresponding to the four aspects of the nervous
system.

 Sympathetic nervous system – right side.

 Sympathetic nervous system – left side.
 Parasympathetic nervous system.
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 Central nervous system.

The subtle energy enters through the centers in the brain and precipitates on its way to six
more centers called chakras. The residual energy then settles down in three and a half coils in
the triangular bone placed at the end of the spinal cord (sacrum bone), known as Kundalini.
The fundamental of this living force is self-organization, self-regeneration and ascent.
Through self-organization it sustains and protects. Self-regeneration is its innate ability to
renew, heal, balance and recycle. Ascent is its capacity to transcend the mind and myth and
attain collective consciousness.‖
How is Sahaja Yoga different from other types of Yoga? Sahaja Yoga is different from the
other types of Yoga because it begins with Self Realization instead of this being the
unobtainable dream of a distant goal.
Kundalini is the power of pure desire within every individual, a motherly and soothing
spiritual energy which lies dormant at the base of the spine in the sacrum bone (the ancient
civilizations knew that in this bone resides a sacred energy).
Self Realization is the awakening of the Kundalini through the central channel, piercing
through the six chakras above the sacrum bone and emerging at the top of the head
(fontanelle bone area) as a gentle ―fountain‖ of coolness. The word fontanelle itself means
―little fountain‖ which shows again the ancient knowledge about this phenomenon of Self
Realization.
Vibrations: In Shri Mataji‘s words, ―Chaitanya (vibrations) is the integrated force of your
physiological, mental, emotional and religious selves.‖
c. Zen Buddhism and Meditation
Although students of Zen Buddhism aim to be enlightened by practicing its teachings and
techniques, the main goal behind Zen Buddhism and its practices is for students to wipe out
everything from their mind, including the whole Buddhist organization and literature. This
idea of clearing one‘s mind of everything, including the ideals that one is studying, may
sound hypocritical and irrational, but it is actually the main focus of Zen Buddhism.
Despite the fact that Zen Buddhism, or traditionally the Ch‘an movement in China,
concentrates on the ―oneness‖ of all things, there two major schools of Zen Buddhism since it
came on the scene in China during the early 7th century. Shen-hsiu was the Zen Master in the
Northern Chinese School, and Hui-neng represented Southern China‘s School of Zen
Buddhism. Both of these Masters were also students of Hung-jen, who taught his pupils Zen
Buddhism from the ―Diamond Scripture,‖ one of the most popular Buddhist scriptures in
China with its emphasis strictly on the mind. The principle difference between the Northern
and Southern schools is that the former teaches its students to focus on attaining
enlightenment gradually, while the latter focuses on sudden enlightenment.
While the Northern Zen School believes that for one‘s mind to be pure and enlightened, there
needs to be complete quietude and every irrelevant thought must be eliminated, the Zen
School in the South maintains that one‘s mind cannot be split into separate parts, and that all
thoughts are important. An additional divergence of the two school‘s ideologies is found
where the Northern School makes a distinction between the undisturbed mind in a state of
calmness, called ―samadhi,‖ and the senses in their undisturbed state of wisdom, ―prajna.‖
The Southern School, however, does not accept the distinction between the two. Rather, it
argues that the two states are one and that the mind is interlaced with its various components
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and with every other aspect of the world as well. It is these views of the Southern school that
are more widely known commonly and accepted as Zen Buddhism.
Even though the teachings of Zen Buddhism concentrate on one‘s mind as the resource for all
necessities, the views of the Southern Zen School are based on much more liberal and open-
minded ideals that they appear to be. ―The Buddha-mind is everywhere so that anything can
be an occasion for its realization at any moment and this realization can take place in any way
(Chan, 428).‖ This notion is the key idea behind the Zen belief in relaxing the mind and
rather than concentrating on getting rid of all outside distractions, simply having the ―absence
of thought‖ and ―letting the mind take its own course‖ in order to gain understanding.
One of the main ideas behind Zen Buddhism is to have undistracted, pure thought. However,
if one tries to rid the mind of thoughts believed to be unnecessary, then the basic concept of
Zen Buddhism is lost. One of the Southern School‘s most basic concepts is that by accepting
all thoughts, relevant or not, one can only then rid themselves of all thought. If you were to
try and block out certain thoughts, the actual process of ―blocking out‖ will only distract the
mind and work against you. To free one‘s mind, one must and not think about what not to
think about. Although this idea definitely sounds confusing, the teachings of Zen Buddhism
argue that this ability unquestionably lies in every person‘s mind.
While Zen Buddhism maintains that all which one needs may be found directly in the mind,
students have often found themselves confused about many aspects of thought and
meditation. Even more confusing, however, are the answers that such curious students
receive when questions have been brought to their Zen Masters throughout history. In one
ancient account, a senior monk asks the head monk what ―the basic idea of the Law preached
by the Buddha clearly is.‖ Each of the three times he asks this question, the senior monk
received only a beating from the head monk. Confused, the senior monk sought out advice
from a friend and then discovered the answer to be that the main goal of Zen Buddhism is to
rid the mind of all thought so when a Zen Master is asked about basic ideas of ―the Law‖ of
Zen Buddhism, there is really nothing there to explain.
In the beliefs of Zen Buddhism, when one is first born, the mind is pure, unbiased, and has
endless paths which may be followed. The number of possible paths decreases as time goes
on, and the mind and body develop biases and judgments. However, in Zen Buddhism, the
key concept is to eternally maintain one‘s beginning state of mind in order to constantly be
ready and open to anything and everything.
Instead of separating right from wrong, good from bad, or relevant thoughts from irrelevant
thoughts, one must accept and understand the fact that everything is wrong and right, good
and bad, and relevant and irrelevant at the same time. This seemingly confusing and
contradicting idea is central to Zen Buddhism, and is referred to as ―the oneness of duality.‖
It is key for a student to comprehend that the body and mind are both two and one at the same
time. Zazen posture, the term for the mediation posture in Zen Buddhism, expresses the
concept of ―the oneness of duality‖ through a meditation position, the ―Full Lotus.‖ In the
―Full Lotus,‖ the left foot is on the right thigh, and the right foot is on the left thigh. By
having your two feet crossed together in one form, the idea of ―the oneness of duality‖ is
conveyed through the posture.
Although much of Zen Buddhism‘s focus is on the mind, the modern Zen Master, Shunryu
Suzuki, explains in his book, ―Zen Mind, Beginner’s Mind,‖ ―these forms (the meditation
positions) are not a means of obtaining the right state of mind. To take this posture itself is
the purpose of our practice. When you have this posture, you have the right state of mind, so
there is no need to try to attain some special state ‖
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While breathing is something that is usually simply seen as the way of sustaining life, in the
practice of Zazen, meaning practicing Zen Buddhism, breathing is what links the world inside
our body, the ―inner world,‖ with the world outside our body, the ―outer world.‖ The concept
is that when one inhales, the mind follows the breathing into the inner world, and while
exhaling, the mind follows the breathing into the outer world. The throat then acts as a
―swinging door‖ between the two worlds. One‘s body and the outer world are actually
considered one world in Zen Buddhism, and your throat, acting as a swinging door, is what
connects you to the world.
Having control over the mind while practicing Zen Buddhism is necessary, but when you try
to gain control over the mind, you increasingly go out of control. Suzuki uses an excellent
analogy that demonstrates this concept again in his book. ―The best way to control people is
to encourage them to be mischievous. Then they will be in control in its wilder sense (Suzuki,
28).‖ He further explains that if one ignores people, or actually makes an effort to control
people, neither path will yield control. However, if one would just watch them, without trying
to control them, then control is ultimately obtained.
From this clear example of how to acquire control with people, one can apply the same
concept and principles to gaining control over one‘s mind. When practicing Zazen
meditation, irrelevant thoughts are bound to come into the mind. If you try to ignore these
kinds of thoughts, or you become agitated by them, the control and calmness that is necessary
for meditation will be lost. However, if you can apply the same method to the mind that was
used toward the people in the previous example, then you can ―let the irrelevant thoughts
come, and let them go, then they will be under control ‖
Another major aspect of Zen Buddhism is the idea that every action and each individual task
that we perform is an expression of our own true nature. No matter how insignificant a
specific routine action may be, it is seen as a practice and an expression of one‘s self. This
outlook leads to the idea of being completely involved in whatever one is doing. One should
have a true, unobstructed appreciation for the action being performed at that specific time.
This is referred to in Zen Buddhism as ―the single minded way (Suzuki, 50).‖ Whether you
are cooking, exercising, or reading a book, the single minded way explains that there should
be absolutely nothing bothering or going through your mind while you are performing that
specific task. This concept really focuses on enjoying the moment and living for the moment
that you are experiencing. But you must not try to be single-minded on purpose because then
the mind will be concentrating and will begin to wander. It is taught in Zen Buddhism that it
is already in each of our nature to have this single-minded way, so just by relaxing it will
come.
The true way of Zen Buddhism is not a well-kept secret that is only revealed when one is
enlightened. It is actually the way of our every-day lives. It is central to Zen Buddhism that
you must not become excited or overanxious when practicing. Throughout a normal day in
your life, a calm and happy attitude is necessary so that you do not get caught up and lost in
the busy world. When many people begin to practice Zazen techniques, they get too excited
and involved in the whole process and end up forgetting to focus on their own mind. This
only leads to the person forsaking the basic meaning of Zen Buddhism‘s concentration on the
individual mind.
Despite the fact that Zen Buddhism appears to be confusing and very philosophical,
understanding in Zen Buddhism only comes when one realizes that its practices and ways are
extremely simple in their nature. In reality, Zen students and Masters are not very concerned
with a vast understanding of Buddhism. As Suzuki so perfectly explains, ―Instead of having a
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deep understanding of the teaching, we need a strong confidence in our teaching, which says
that originally we have a Buddha nature…and only through practice, actual practice, can we
understand what Buddhism is (Suzuki, 95,98).‖ The schools and meditation practices of Zen
Buddhism are simple ways in a very confusing world to find all the answers to our questions
directly in our own minds.
d. Sufi Meditation
Every school of meditation offers a way to still the mind, because spiritual experiences take
place beyond the level of the mind. The mind is known as ―the slayer of the real‖; its
thoughts keep us isolated in a world of illusion. The mind keeps us identified with the ego,
and the mind‘s continual chatter separates us from the deeper levels of our being. Watching
our thoughts, we can see how often the mind thinks us, and not the other way around. We are
prisoners of our mind and ego, but meditation can help set us free.
Different spiritual traditions use different techniques to still the mind. Sufism is a path with
love. Love is the greatest power in creation and in Sufism‘s deep prayers and meditations, it
takes us beyond the mind and beyond the self: the lover is taken into the presence of the
Beloved.
In these states we may experience the intimacies of divine love: a tender caress, words
whispered into our heart. We may feel the wonder of being loved, or taste the peace of our
soul. But for the mystic, the journey goes even deeper, into the infinite emptiness that lies
beyond the mind: ―The dark silence in which all lovers lose themselves.‖
For the Sufi, the mystical journey is from form to formlessness, from the presence of our own
self to the presence of the Beloved for whom our heart longs. On this journey, love leads us
back to love. God, our Beloved, comes into our heart and calls us, seducing us with the
sweetness of touch, with an intoxicating taste of union. The work of the lover is to surrender
to this mystery of loving, to allow the heart to be opened. And although most of this work
happens secretly within us, in the very core of our being, there are ancient techniques to open
us to the beyond, to the wonder that is within our own heart.
The Sufi meditation of the heart is a method of lifting the veils of separation and awakening
us to what is real. It is a simple but effective way to use the energy of love to still the mind
and go beyond the ego. It is best practiced for at least half an hour every morning.
In This Meditation Three Things are imagined:

1. We must suppose that we go, deeper and deeper into our most hidden self. There in our
inmost being, in the very core of ourselves, we will find a place where there is peace,
stillness, and above all, love.
2. After having found this place, we must imagine that we are seated there, immersed into,
surrounded by, the Love of God. We are in deepest peace. We are loved; we are sheltered;
we are secure. Each part of us is there, physical body and all; nothing is outside, not even
a fingertip, not even the tinniest hair. Our whole being is contained within the Love of
God.
3. As we sit there, happy, serene in God‘s presence, thoughts will intrude into our mind-
what we did the day before, what we have to do tomorrow. Memories float by, images
appear before the mind‘s eye.

We have to imagine that we are getting hold of every thought, every image and feeling, and
drowning it, merging it into the feeling of love.
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Every feeling, especially the feeling of love, is much more dynamic than the thinking
process, so if one does this practice well, with the utmost involvement, all thoughts will
disappear. Nothing will remain, The mind will be empty.
When we become familiar with this meditation, we no longer use the imagination. We just
fill the heart with the feeling of love and then drown any thoughts in the heart. Emptying the
mind, we create an inner space where we can become aware of the presence of our Beloved.
God is always with us, but our mind, emotions, and the outer world are veils which separate
us. God is silent emptiness, and in order to experience God we need to become silent. In
meditation we give ourselves back to God, our Beloved, returning from the world of forms to
the formless Truth within the heart.
e. Tai Chi
Tai chi is a Chinese martial art that is primarily practiced for its health benefits, including a
means for dealing with tension and stress. Among the martial arts, there are two basic types:
the hard martial arts and the soft martial arts. The latter are also called internal arts. Examples
of the hard martial arts are karate and kung fu (or wushu). Examples of the soft martial arts
are ba gua and tai chi.
Tai chi emphasizes complete relaxation, and is essentially a form of meditation, or what has
been called ―meditation in motion.‖ Unlike the hard martial arts, tai chi is characterized by
soft, slow, flowing movements that emphasize force, rather than brute strength. Though it is
soft, slow and flowing, the movements are executed precisely.
A brief history of Tai chi: The history of Tai Chi is a difficult one, since it is often difficult
to sort out fact from legend. But we can say loosely, at least, that Tai chi traces its roots back
to approximately the 2nd millennium BC, with the practice of yoga in ancient India. In China,
yoga came to be developed into what is called Saolin chuan (―chuan,‖ briefly, means boxing).
In the 13th century AD, a Taoist monk by the name of Chang Sang Feng developed what has
come to be known as Tai Chi. Subsequently Tai Chi came to be associated with different
families in China. These family names came to designate the different styles of tai chi. The
tai chi family or style from which all other current styles or families of Tai Chi developed
was the Chen family. A man by the name of Yang, studied with the Chen family and later
modified the Chen style, into the Yang style of Tai Chi Chuan. Which is the most common
traditional style of Tai Chi Chuan practiced today. The Yang style has three different forms
that are practiced: the simplified form, the short form, and the long form.
Tai chi Philosophy: Tai Chi arises out of two important philosophical texts in China: the Tao
Te Ching and the I Ching. Though the title, Tao Te Ching, is translated in different ways, one
translation of the title is ―the classic way of integrity.‖ Both of these texts stress what the
Chinese call ―chi.‖ Chi is an ancient Chinese notion designating a form of energy. The term
literally means something like ―breath,‖ as does the ancient Greek word from which we get
the word ―spirit.‖ According to the philosophy of tai chi, this energy or chi flows throughout
the body, but can become blocked. According to tai chi philosophy, one becomes ill when the
flow of the chi through the body becomes blocked. The Chinese recognize several means for
freeing up the flow of chi. Two of the more commonly known forms in this country are
acupuncture and tai chi.
In addition to its physical benefits, tai chi is said, to have certain psychological effects as
well. Tai Chi, as a form of meditation, is intended to help one understand oneself and to
enable one to deal with others more effectively. This latter function is rooted in one‘s
learning to control oneself. This self-control can come about through two principal notions
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found in the Tao Te Ching and I Ching. These two notions are the fundamental Taoist notions
of yin and yang. The philosophy of Taoism understands everything in terms of these two
opposing principles. Though these two principles are seen as opposites, the one necessarily
merges into the other, creating the natural balance of self and world, hence the classic symbol
of tai chi. The tai chi form is meant to enable one to bring the principles of yin and yang back
into their fundamental, natural harmony. The ultimate effect of this harmony is physical and
spiritual well being.
Tai Chi and health: Tai Chi has a stabilizing effect on the heart cycle and harmonizes the
nervous system by the fact that it serves as balance of the stress of the everyday life. The
upright practice has positive effects on the attitude and the spinal column. It promotes
digestion, adjusts the respiration strengthens joints and muscles.
Developing Chi consists of three major stages

1. Feel ones own energy (awareness),

2. Move the energy at will and use it to move the body (circulation),
3. Transmit energy, for healing or self-defense (application).

To enjoy the benefits of the practice, one must first train the mind and body to be responsive
to the will.Gathering Chi through the breath requires that we regulate our breathing.
Storing the chi requires the body to be relaxed. Issuing chi requires we have a root.
All Tai Chi Chuan postures derive their essence from the foundation of the Postures. The
Essential Postures are rooted in the Five Elements of Chinese Medicine and the Eight
Trigrams of the I Ching.
f. Osho: His Philosophy and Meditation
Osho was a mystic who brought the timeless wisdom of the East to bear on the urgent
questions facing men and women today. He spoke of the search for harmony and wholeness
that lies at the core of all religious and spiritual traditions, illuminating the essence of
Christianity, Judaism, Buddhism, Sufism, Tantra, Tao, Yoga and Zen.
Osho‘s envisioned a new man. After his enlightenment in 1953, the evolution of that new
man became his whole work. In 1963, he left the academic world where he had taught
philosophy at the University of Jabalpur
to focus intensely on developing practical tools for man‘s transformation. Modern man, he
said, is so burdened with traditions of the past and anxieties of modern-day living, that he
must go through a deep cleansing process before he can begin to discover the thought-free
relaxed state of meditation.
Osho, who was born in India in 1931 and left his body in 1990, belonged to no tradition.
Describing meditation, Osho has said, ―The word ‗meditation‘ and the word ‗medicine‘ come
from the same root. What medicine is for the body, meditation is for the soul. It is medicinal,
it is a cure.‖
Osho on Meditation: ―(There are 112 basic techniques of meditation.) I have developed my
own techniques other than the 112, because I saw that for the modern man there are a few
problems which are not covered in those 112 techniques. They were written perhaps ten
thousand years ago for a totally different kind of mankind, a different kind of culture,
different kind of people. The modern man, the contemporary man, has some differences–over
ten thousand years it is absolutely unavoidable.‖
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Some of the Osho Meditation Techniques are discussed here:

Osho devised a number of meditations to start ones journey for inner growth. These
meditations last for about an hour and are accompanied with special music composed for
each one of them. All of Osho‘s active meditations involve a beginning stage of activity —
sometimes intense and physical — followed by a period of silence. All are accompanied by
music that has been specially composed to guide the meditator through the different stages.
Osho has also recommended different meditations for different times of the day.
Dynamic Meditation is also called ‗active‘ meditation, is the basic of all Osho‘s meditations
aimed at catharsis before attaining silence. In our stressful, crowded lives catharsis helps in
creating enough space in our cluttered lives and overloaded senses to make room for a bit of
silence. It is best when practiced first thing in the morning for a great start to the day. ―This is
a meditation in which you have to be continuously alert, conscious, aware. Whatsoever you
do, remain a witness.‖ – Osho
It is a very effective method for releasing emotions such as anger, fear, violence, sadness,
repressed thoughts etc. It has five stages:
First,Stage:10,Minutes:
Breath rapidly in and out through the nose…….giving importance on the exhalation ….. the
body will take care of the inhalation…. Use the natural body movements to build up
energy…….
SecondStage:10minutes
Explode! Let go of every thing that needs to be thrown out ….. scream, shout, cry, jump,
dance….,sing,…..laugh,…..throw yourself around…….
Do not stand still……
Third Stage: 10 Minutes:
With raised arms, jump up and down shouting the mantra Hoo! Hoo! Hoo! as deeply as
possible….. Each time you land on the flats of your feet, let the Hoo! sound hammer deep
within you.
Fourth Stage: 15 minutes:
Stop! Freeze where you are in whatever position you find yourself. Simply be a witness of
the inside…..
Fifth stage: 15 minutes:
Celebrate! With music and dance, expressing your gratitude towards the whole……
Nadabrahma Meditation
This is an old Tibetan technique of humming, which creates a healing vibration throughout
the body, and a hand movement which centers the energy at the navel. Nadabrahma
meditation lasts for one hour and has three stages. It can be done at any time of day, alone or
with others, but on an empty stomach and one hs to remain inactive for at least 15 minutes
afterwards.
First stage:
Sit in a relaxed position with eyes closed and lips together. Start humming loudly and create a
vibration throughout the body…. There is no special breathing and one can alter the pitch or
move the body smoothly…
Second stage:
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This stage is divided into two parts: First , keep the hands at the navel, palms up. Move the
hands forward and make large circles and feel that you are giving energy to the universe.
For the second part, hands at the navel, palms down, and move them in opposite direction.
Feel that you are taking energy in from the universe.
The movements of the hands should be so slow that at times there will appear to be no
movement at all
Third stage:
Lie down, be silent and still.
Nataraj Meditation is dance meditation suitable for the early evening.‖Let the dance flow in
its own way; don‘t force it. Rather, follow it; allow it to happen. It is not a doing but a
happening. Remain in the mood of festivity. You are not doing something serious; you are
just playing, playing with your life energy, playing with your bio-energy, allowing it to move
in its own way. Just like the wind blows and the river flows, you are flowing and blowing.
Feel it. And be playful…‖-Osho
Kundalini Meditation is a shaking meditation – a great way to ―unwind‖ from a stressful
day. Kundalini meditation, although easier, is based on the same basic principles as Dynamic
and is best attempted in the afternoon.‖…Allow the shaking, don‘t do it. Stand silently, feel it
coming, and when your body starts a little trembling help it – but don‘t do it. Enjoy it, feel
blissful about it, allow it, receive it, welcome it – but don‘t will it. If you force it, it will
become an exercise, a bodily physical exercise. Then the shaking will be there but just on the
surface, it will not penetrate you. You will remain solid, stone like, rock like within; you will
be the manipulator, the doer, and the body will just be following. The body is not the question
– you are the question.‖ – Osho
Laughing Meditation ―when you laugh, laugh through your whole body — that‘s the point
to be understood. You can laugh only with the lips, you can laugh with the throat; that is not
going to be very deep. So sit on the floor in the middle of the room and feel as if laughter is
coming from the very soles of your feet. First close your eyes and then feel that ripples of
laughter are coming from your feet. ? They are very subtle‖. Osho
Whirling Meditation Going round and round at a single spot, the eyes de-focus and one
become stationery within by performing this Sufi meditation that has been revived by Osho.
In the night, just the opposite of the morning — be completely unconscious; don‘t bother at
all. The night has come, the sun has set, now everything is moving into unconsciousness.
Move into unconsciousness. This whirling, Sufi whirling, is one of the most ancient
techniques, one of the most forceful.
g. Vipassana
This is the meditation that has made more people in the world enlightened than any other,
because it is the very essence. All other meditations have the same essence, but in different
forms; something nonessential is also joined with them. But vipassana is pure essence. You
cannot drop anything out of it and you cannot add anything to improve it.
Vipassana Meditation: Twenty-five centuries ago Gautham Buddha gave this method of
innerwitnessing to his disciples. It is a method of watching- the mind, emotions, body
movements- without reacting to what we observe.
A comfortable sitting posture with the back and head straight, Eyes closed and normal
breathing is advised. A chair could be used and sleep must be avoided.
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The primary object of the attention is the rise and fall of the belly caused by normal in and
out breathing. It is not a concentration technique so when other things come into the field of
watching the breath, these too are part of meditation. Nothing is a distraction in Vipasana.
When something takes the attention, place the whole attention on it, whatever it is. Any
disturbance is not seen as a distraction. Because of the change and when the attention is free
then again the process of breathing should be watched. It is the process of watching which is
important, not what is being watched. Don‘t try to control it. Only watch it. Watching will
automatically regulate breathing. Emotions will become stable. Vipasana is also called
Vipaschana or Watching of breath.
Positions for Vipasana meditation while one may sit on a chair or on the ground, knees
folded or legs stretched or even slowly, the posture must be upright with the back straight like
the Bodhi tree.
Table 9.3
Sitting in a chair Cross-Legged position Sitting against a wall
Use a hard chair lower Sit on a mat placed on the Sit on the floor, legs
and mid back supported, floor, keeping the body outstretched knees and feet
feet together and hands upright and arms together, back straight against a
resting gently on the lap. relaxed on the knees wall, hands

The benefits of meditation are many, each has its own special significance but, as an overall
effect one can see a definite sense of relaxation in the individual. Meditation calms the nerves
and has a holistic impact on the entire human system. The figure below is a perfect
representation of the positive effects of meditation on the various body systems
V. YOGA

Yoga from the Sanskrit word ‗Yug‘ meaning union {with the Divine}. It is the oldest and
most holistic system of mind – body fitness. It means a vision of Physical, Mental Spiritual
health. Yoga stretches all parts of the body, massages the internal organs, stimulates
circulation and supplies oxygen to all parts. By doing this, Yoga creates a body-mind
harmony.
In recent times, yoga is mainly looked upon as a set of techniques useful for achieving fitness
in daily life and prevention and cure of some specific diseases or disorders.
Fig 9.4
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Unfortunately, yoga in the west has come to mean ―hatha‖ yoga which is mainly physical
exercise and postures (asanas). In fact, asanas is only a single step in the eight-step path
(Asthanga yoga of patanjali). Patanjali is quick to point out that asanas are to be used as a
stepping stone for the higher paths, since just working on the beauty and welfare of an
impermanent object (the body) is a waste of time and effort. Asthanga yoga is sometimes
referred to as Raja yoga. However, Asthanga yoga is more of a philosophy like basic
research, while raja yoga usually refers to specific techniques which are based on not only
Asthanga yoga but also on various [minor] upanishhads.
The goal of yoga was different when yoga practices came into existence more than three
thousands years ago. Throughout its history, yoga seems to have undergone changes
regarding the purpose for which it was practiced. Many different varieties of yoga came to be
practiced.
The final goal or general purpose of all the above varieties of yoga was the same. The goal
was to know oneself as the manifestation of the divine and live life in its totality with divine
inspiration. The methods and contents of each variety of yoga was different from the others.
Bhakti yoga: Includes prayer, bhajan, kirtna, worship, observing austerities and abstinence,
and practice of virtue and total surrender to God. In the middle ages in India, many saints
cultivated the way of devotion as a mass-movement.
Karma yoga: The main principles of karmayoga include never giving up in one‘s duty,
whether as student, house holder or worker and without worrying about reward to look
equally upon opposites such as success and failure, pleasure and pain, without being affected
or swayed by them. Surrendering the fruits of work to God.
Gyana yoga includes outer and inner aspects of disciplining and training the body and mind.
It has three important techniques: postures, breath control, and meditation.
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Asthanga or the eight step path was developed by Patanjali. The eight steps would lead a
seeker from ignorance to enlightenment
Theses include
Yama – Abstinence or self control.

Niyama – Strict Observances of character.

Asana – Postures of body.

Pranayama – Control of ‗Prana‘ through Breathing.

Pratyahara – Retrieving the mind from objects of enjoyment and pleasure.

Dharana – Concentration on an object.

Dhyana – Meditation on the divine.

Sandhi – Union with the divine.

Different types of yoga: Before we examine them, we should remember that all of them
lead to the same goal, unification with the Divine. The yoga paths can be broadly classified
into
Bhakti yoga : Path of Devotion.

Karma yoga : Path of Selfless Action.

Gyana yoga : Path of Transcendental Knowledge.

Asthanga yoga : Path of Patanjali.

The present day practitioners of yoga can be divided into two groups. The smallest group
comprises of those who take it very seriously as a way of life and as a philosophy of
renunciation and emancipation. Such persons live in monasteries and ashrams. The second
and the larger group consists of people who are not very keen on the deep philosophical or
esoteric implications of yoga or in a new way of life. Instead, they want to keep fit, lose
weight and overcome some specific health problems that are largely due to stress and
psychosomatic imbalances to lead a happier and more productive life. This group is mainly
interested in quick, easy cures to their problems.
Yoga for this large group consists of five main categories of techniques. Each one of them
has its special importance and utility. These include :

1. Postures of asanas.
2. Control of ‗Prana‘ through Breathing – Pranayama.
3. Cleansing techniques or shuddhikriyas.
4. Relaxation.
5. Meditation.

All these five categories together form an integrated system, which takes care of all the
organs and functions of the body, including the mind.
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 Asanas: Asanas are a wide range of postures that improve flexibility of muscles and
suppleness of joints. People who are not sufficiently well informed about various aspects
of yoga believe that yoga practice mainly comprises of practice of asanas. This is perhaps
because a large number of yoga teachers are experts of asanas, many books on yoga
discuss only the techniques of various asanas, and many common discussions, exhibitions
and performances of yoga deal only with the asanas.
 Pranayama: Pranayama is a technique of controlling breathing. It involves sitting in a
comfortable, steady, relaxed position, and taking deep, full breaths with prolonged,
uniform and complete inspirations and expirations. After practising deep breathing for
some time, retention of breath inside and outside may also be practiced. Pranayama yields
benefits for all functions like respiration, blood circulation, digestion, excretion, secretion,
removing congestion of blood, and release of tension etc. It helps considerably to calm
down an irritated and excited mind and make it steady.
 Sudhikriya: Suddhikriya are cleansing techniques that cleanse various internal organs of
the body. Neti is used for cleansing the nasal passage with water, and /or linen thread.
Dhauti is used for cleansing the stomach with water or with a twenty-two feet long strip of
cloth. Basti is a technique of cleansing the colon. Trantka which is a technique to cleanse
the eyes and the mind. Nauli (abdominal massaging) which is the foremost among the
cleansing techniques, is used to tone up all the organs and glands inside the abdomen and
make them strong. Kapalbhati is an exercise of continuous abdominal breathing, is said to
cleanse lungs, blood and mind.
 Relaxation: In the dead pose, called shavasana is a special technique of yoga for deep
relaxation in order to lessen the ill effects of stress. Meditational postures and pranayama
are also effective in reducing the adverse effects of stress.
 Yoganidra: A relaxation technique which systematically relaxes the body and internal
organs, step by step. Starting from the toe and finishing at the temple, yoganidra visualizes
every organ and focuses on repair and healing.
 Meditation: It is an effective method for improving the stability of the mind. When
meditation is combined with other techniques of yoga, its effect is greatly enhanced for
treatment of a wide range of health problems or disorders.

As mentioned above, yoga includes a variety of techniques and you need to choose those that
are most suited for your individual needs.
While strictly advised in the morning. Yoga can be done at any time during the day. It will
benefit you irrespective of whether you are young or old, lean or heavily built, highly
educated or unlettered, rich or poor, busy, over busy, or retired or worker in the factory or in
the office. Yoga has something very valuable, and useful to offer to everyone. It is often
described as the best form of health insurance for all from the age of seven to seventy one.
The two main advantages of Yoga are prevention of disorders and ailments and maintenance
of health and fitness in daily life. Other advantages include flexible muscles, supple joints,
relaxed and tension-free mind and efficient working vital organs such as the heart, lungs,
endocrine glands, liver, pancreas and the brain etc. With a regular routine of yoga, you can
enjoy good vital capacity, appetite, digestion, cheerfulness, and good balance between
various functions, such as neuromuscular coordination, etc. However, yoga should not be
practiced unless you have learned the correct technique from an expert.
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VI. SPIRITUALITY

The word ‗Spirituality‘ comes from the word ‗Spirit‘ which means the essence, the subtle, the
subtlest aspect possible of anything. It also means a rational, intelligent being without a
material body. (Oxford Dictionary).
Everything at its deepest core is a very subtle phenomenon. This subtle phenomenon
manifests very differently at the gross & the peripheral level but at the deepest core all
diversities merge and mingle and become one unified energy. It is from here that we can
locate the emergence of perfect orderliness, unfathomable energy unlimited creativity and
supreme intelligence. If we look around we will find these in nature.
A Scientific Perspective:
Physics investigates the mysteries of nature. It tries to uncover the deeper levels of nature and
the common ground where all are rooted, (the plants, the animals, the rocks, the people, the
galaxies etc.) the very source of everything. Science has found that nature is structured in
layers. Within the molecules are atoms, and within atoms are subatomic particles. All the
force and matter fields in the universe have been glimpsed by modern science in the unified
quantum field of natural law. It is a field of pure energy and intelligence which underlies
everything in creation and which is responsible for all forms and events in the universe. The
entire universe emerges from the ―self-interacting dynamics‖ of the great source, the unified
field which gives rise to all the laws of nature that govern the entire universe.
For example, the source, the unified field is like a seed which contains the big tree. The seed
permeates the entire tree, manifesting itself as flower, leaf etc. In the same way, the unified
field underlies and pervades the universe. It is the source of the infinite energy, creativity, and
intelligence displayed in nature.
What modern science has come to know now has been well known to the ancient sages. They
have described the unified field as a complete science of consciousness, as a field of pure
consciousness, the field of unlimited energy, creativity, and intelligence underlying man and
nature. They had called it God. Through meditation or yogic approach to life, the unified
field, the supreme intelligence – can be enlivened by all human beings, and we can display
the infinite creativity, intelligence and dynamism in the practical day to day life. There is a
deep rooted link between the unified field and the most fundamental state of consciousness in
us, the mind, the thinking process, which is the basis of any activity.
Thought is the basis of any activity. The painting of a painter begins with the thought of the
painter, the poetry of a poet also begins with the thoughts of a poet and same is the case with
an architect. What can make thought more powerful and intelligent? It is through contact with
the source, the intelligence deep within the mind. This contact with the source will make
human awareness open to its full potential of intelligence. Meditative awareness is the simple
procedure, which can raise life to its full dignity in which perfect health; happiness and peace
will be a natural feature of daily life.
Such a person who is in tune with the supreme intelligence of the source is called a ‗spiritual
person‘. Spirituality is the essence of the underlying pure consciousness, which manifests on
the surface as creativity, compassion, love, intelligence, non-violence etc.
Meditation allows the mind to cease (No mind state/thoughtless state) and in turn helps the
field of pure intelligence, pure consciousness to surface, which is a self-referral state of the
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source or the unified filed of natural law. The practice of meditation will lead us to
spirituality which in turn will help us to achieve total health.
―Health is a state of Equilibrium between humans and the physical, biological and social
environment. We can never be described as healthy so long as our actions whether deliberate
or unwitting, continue to damage other humans or ecosystems with which we are
interdependent.‖ John Last – 1987
―Health includes positive, peaceful, caring attitudes expressed towards ourselves and towards
the people and circumstances around us.‖ Richard Hetzel, President Whole Health Institute,
Australia
On the path of evolution man has criss crossed many hurdles. Darwin‘s theory of evolution
mentions that man has evolved from animal. The Eastern mystics have dived very deep into
human psyche and have found that man has a very very long past and that the evolutionary
process has started from stones, plants-trees, animals and after a long long journey the present
status has been achieved. The whole evolutionary phenomenon is the process of development
of consciousness. Plants are more conscious than stones; animals are more conscious than
trees and plants; human being is more conscious than animals; an enlightened person is more
conscious than man. There are two extreme points, at one point is matter and the other
extreme point is enlightenment. Matter is totally unconscious whereas an enlightened one is
totally conscious. Man is exactly in the middle, pulled from both the ends. On the one hand is
existence and on the other hand spirituality. Man is constantly torn between material
existence and spirituality and the enlightened path. And that is what is the real misery of man.
Below man all evolution is collective, but with man, the evolution becomes individual.
Rocks, trees, animals etc. are evolving mechanically and naturally. No rock or tree or animal
is trying anything on their part for evolution. Human is the last product of this natural,
mechanical and unconscious evolution. With man conscious evolution begins and from this
point man has to put his own effort for evolution. The choice is entirely with each individual.
The dignity, the beauty and the glory of man is consciousness and with consciousness comes
a tremendous responsibility. Only man is responsible for his growth and evolution.
A spiritual person is one who has come to realize that his evolution is his choice, and with
choice also comes responsibility. He cannot make any body responsible for his life. He takes
this responsibility as a great opportunity for evolution.
With the quantum leap from collective to individual dimension the human is blessed with
many qualities; one of them is freedom; the freedom to choose. Evolution is also a choice to
man. He can decide not to evolve. There are three avenues open and available to man:

1. Going back to the collective unconscious : This is possible only temporarily by taking
drugs, alcohol etc., one becomes a part of the collective unconscious for a while but the
moment the effect of the drug is over one is again thrown back to the old level. It creates a
vicious circle, the person again goes back to drugs, as it gives some temporary relief and
makes the person not responsible for anything. It is the basic tendency of man to run away
from responsibilities.
2. Staying at the same level of consciousness: Many people have chosen this, i.e., to stay at
the same level. It has its own miseries & happiness. Stress, tension and many other kinds
of dualities are a constant companion. Persons at this level of consciousness are pulled
from both the ends. The pull of the animal instincts and the pull of the super
consciousness.
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3. To evolve and become fully conscious: This is the third option which is an arduous one
and very few people dare to undertake the journey. The whole function of a master is to
help individuals to take up this challenge. They devise ways and means to push people or
create a desire in them to reach to the highest peak of consciousness and fulfill their
destiny. A person who has reached to the peak of consciousness or flowered totally has
evolved fully.

All the meditation techniques developed down the ages by great masters make us conscious,
alert, aware and recognize our true nature to fulfill our destiny.
From the above, it can be realized that spirituality is a term which has been described
differently by different people. If one is to equate this concept with Maslow‘s theory of self
actualization which was discussed in chapter one, it is seen that self actualization is also a
form of spirituality, because man has ascended beyond his basic needs.
Sprituality is frequently combined with Religion and understood to be the same. Since
Meditation originated in the East, it is understood to be part of eastern religion such as
Hinduism, Buddhism etc. Let us try and see if there exists any relation between religion &
spirituality
The word ‗Religion‘ comes from the Greek word ―Religere‖ meaning to rejoin, to reunite
with the eternal source from where everything has emerged. The source of all, mankind
animals, trees, rocks, sun, moon, stars, the galaxies etc. is one. Everything has been created
from this source and every thing goes back to this source. The ancients have called it God. In
reality all are already rooted, in the source. Below man all are rooted unconsciously with the
source. They have no remembrance of the unification, however it is the privilege of man to
know the unification consciously and be blissful. A religious person is one who remembers
this unification with the eternal source. He has become a member of the whole. An
enlightened person is one who has remembered this unification and lives in accordance, in
tune, in harmony with the source.
The entire universe emerges from the ―self-interacting dynamics‖ of the unified field and it is
this field that gives rise to all the laws of nature and governs the entire universe. Some
traditions have called it ―Dhamma‖. It has come from the Sanskrit word ‗Dharma‘ which
means the supreme law. This supreme law governs our existence.
The words spiritual and religious are synonymous. It means the same. A spiritual person is
one who knows the essence of the underlying supreme phenomena and lives according to its
law. Spirituality or Religion is the essence of the underlying pure consciousness. Love,
compassion, creativity, peace, non-violence, intelligence are its byproduct.
On a very general and mundane level religion is associated with different sects and belief
systems. In fact all the great sects were born around great masters who had experienced the
ultimate reality. For example, Hinduism, Judaism, Buddhism, Jainism, Islam, Christianity,
Sikhism and Zoroastrianism all happened around great visionaries. They had attained the
peak of consciousness by arduous inner exploration and then shared their experience and
created ways and means to help those who showed inclination to grow and know the truth.
The masters presence was a great benediction and motivating force for the seekers to
undertake the arduous inner journey. But as the master left the body gradually ―experiment
and experience‖ gave way to ‗belief system‘ and since believing does not require any arduous
effort on an individual‘s part, majority of people chose the easy path which is being followed
even today. But belief systems cannot transform a person from the roots, at the most there
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will be a little change superficially but this change is not going to help a person to unearth the
divine qualities hidden within.
Our world is an ideal example of this phenomena. Here everybody seems to be religious or
spiritual since they belong to some sects or religion by birth or tradition but very few people
radiate love, peace or compassion. Anger, hatered etc. have become the predominant qualities
in our life. In 3000 years we have fought 5000 wars, mainly in the name of religion. This is a
great tragedy, a great calamity that has been tormenting man on this earth. It is very clear that
religion has been deeply misunderstood.
Mankind has come to a point where we have to take a decision; whether to continue through
the old habits which have divided man or go to the original meaning of religion-‗Religere‘ to
rejoin and reunite with the eternal source and live according to its law and bring peace, love,
compassion etc in life. Meditation is a process through which the individual experiences
unification with the almighty source.

VII. SLEEP

A newborn spends over 16 hours a day in sleep. An adult requires 6 –8 hours of sleep a day
to be rested, but may not have the time to afford this luxury. An old man has more time but is
unable to sleep long as he grows older. One third of our lives is spent in sleep. People
generally believe that sleep is merely a matter of physical and mental rest and that there is
virtue in not wasting so much valuable lifetime on something so mundane-that this time could
be more productively used. We are now beginning to understand that sleep is more complex
and that it is vitally necessary for life, since it is during periods of sleep that the body release
endorphins and hormones that repair and heal the body and rejuvenate it to meet the
onslaught of the next day. Sleep is a great healer, clearing emotional unconscious conflicts,
bringing repair and regeneration with it.
Sleep patterns
As persons fall asleep, their brain waves go through certain characteristic changes. The
waking electroencephalogram (EEG) is characterized by alpha waves of 8 to 12 cycles a
second and low-voltage activity of mixed frequency. As the person falls asleep, alpha activity
begins to disappear. Stage 1, considered the lightest stage of sleep, is characterized by low-
voltage, regular activity at 3 to 7 cycles a second. After a few seconds or minutes that stage
gives way to stage 2, a pattern showing frequent spindle-shaped tracings at 12 to 14 cycles a
second (sleep spindles). Soon thereafter, delta waves- high voltage activity at 0.5 to 2.5
cycles a second-make their appearance and occupy more than 50 percentage of tracing (stage
3) Eventually, in stage 4, delta waves occupy more than 50 percentage of record. It is
common practice to describe stages 3 and 4 as delta sleep or slow-wave sleep (SWS) because
or their characteristic appearance on the EEG record.
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Fig 9.5

Sleep is made up of two physiological states: nonrapid eve movement (NREM) sleep and
rapid eye movement (REM) sleep. NREM sleep is composed of stages 1 through 4. As
compared with wakefulness, most physiological functions are markedly reduced during
NREM sleep. REM sleep is qualitatively different kind of sleep characterized by a highly
active brain and physiological activity levels similar to those in wakefulness. About 90
minutes after sleep onset, NREM yields to the first REM episode of the night . That REM
latency of 90 minutes is a consistent finding in normal adults. The EEG records the rapid
conjugate eye movements that are the identifying feature of that sleep state (there are no or
few rapid eye movements in NREM sleep); the electromyography (EMG) shows a marked
reduction in muscle tone.
In a normal person, NREM sleep is a peaceful state relative to waking. The pulse rate is
typically slowed 5 or 10 beats a minute below the level of restful waking and is very regular.
Respiration behaves in the same way. Blood pressure also tends to be low, with few minute-
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to-minute variations. The resting muscle potential of the body musculature is lower in REM
sleep than in a waking state. Episodic, involuntary body movements are present in NREM
sleep. There are few rapid eye movements, if any and seldom any penile erections. The blood
flow through most tissues, including cerebral blood flow, is slightly reduced.
Fig 9.6

If one was not aware of the behavioral stage of the person and one happened to be recording a
variety of physiological measures (but not muscle tone) during REM periods, one would
undoubtedly conclude that the person or animal was in an active waking state. Because of
that observation, REM sleep has also been termed ‗paradoxical sleep‘. Pulse, respiration, and
blood pressure in humans are all high during REM sleep- much higher than during NREM
and often higher than during waking. Even more striking than the level or the rate is the
variability from minute to minute. Brain‘s oxygen use increases during REM sleep. Almost
every REM period is accompanied by a partial or full penile erection. That finding is of
significant clinical value in evaluating the cause of impotence. The nocturnal penile
tumescence study is one of the most commonly requested sleep laboratory tests. Another
physiological change that occurs during REM sleep is the near total paralysis of the skeletal
(postural) muscles. Because of that motor inhibition, body movement is absent during REM
sleep. Probably the most distinctive feature of REM sleep is dreaming. Dreams during REM
sleep are typically abstract and surreal. Dreaming does occur during NREM sleep, but it is
typically lucid and purposeful.
The cyclical nature of sleep is regular and reliable; a REM period occurs about every 90 and
100 minutes during the night. The first REM period tends to be the shortest, usually lasting
less than 10 minutes; the later REM periods may last 15 to 40 minutes each. Most REM
periods occur in the last third of the night, whereas most stage 4 sleep, occurs in the first third
of the night.
The functions of sleep have been examined in a variety of ways. Most investigators conclude
that sleep serves a restorative, homeostatic function and appears to be crucial for normal
thermoregulation and energy conservation. Prolonged periods of sleep deprivation sometimes
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lead to ego disorganization, hallucinations, and delusions. Depriving persons of REM sleep
by awakening them at the beginning of REM cycles produces an increase in the number of
REM periods and in the amount of REM sleep (rebound increase) when they are allowed to
sleep without interruption. REM deprived patients may exhibit irritability and lethargy.
Some persons are normally short sleepers who require fewer than six hours of sleep each
night and who function adequately. Long sleepers are those who sleep more than nine hours
each night in order to function adequately. Short sleepers are generally efficient, ambitious,
socially adept, and content. Long sleepers tend to be mildly depressed, anxious and socially
withdrawn. Increased sleep needs occur with physical work, exercise, illness, pregnancy,
general mental stress and increased mental activity.
Sleep is also influenced by biological rhythms. Within a 24-hour period, adults sleep once,
sometimes twice. That rhythm is not present at birth but develops over the first two years of
life. In some women, sleep pattern change during the phases of the menstrual cycle. Sleep
pattern are not physiologically the same when one sleeps in the daytime or during the time
when one‘s body is accustomed to being awake; the psychological and behavioral effects of
sleep differ as well. In a world of industry and communication that often functions on a 24
hour-a-day basis, those interactions are becoming increasingly significant. Even in persons
who do not work at night, interference with the various rhythms can produces problems. The
best known example is jet lag, in which after flying east to west, one tries to convince one‘s
body to go to sleep at a time that is out phase with some body cycles. Most bodies adapt
within a few days, but some require more time.
How much sleep do we need?
Eight hours is the universally mentioned figure, but the amount of sleep each person needs
varies tremendously from person to person. Some can do with four hours others are
comfortable with ten. The average is six to eight hours. However, the amount of sleep that
each individual requires is fairly constant, meaning that in case your sleep period stabilizes at
five hours, on a day to day basis, and if you get up in the mornings feeling rested and bright,
five hours is probably correct for you. The issue really is not how long or little you sleep, but
whether you get up refreshed. If you do, then the sleep period is correct for you. Mahatma
Gandhi and Napoleon were short sleeper. Einstein, on the other hand was a long sleeper as
most scientists and artists are.
While newborn babies sleep over 16 hours daily, by age two years the average sleep
requirement is about 12 hours. 10 year olds usually sleep 10 hours, and teenagers sleep eight
hours. (While these hours may vary from day to day, they are usually constant over a week)
On reaching adulthood the sleep requirement varies according to individual needs; and
averages between 6-8 hours. There is a misconception that older adults above 60 years
require less sleep. Usually the sleep requirement remains constant throughout adulthood,
however as gets older and with the onset of various sleep disorders the sleep period is usually
reduced. This infact accelerates the aging process.
What are dreams?
Over the centuries, the answer to this question has varied. In biblical times, dreams were
considered prophesies, that predicated war, famine and prosperity. In the year 1900, Freud
published his revolutionary book on the interpretation of dreams, indicating that dreams were
a way of processing wishes that could not be safely acted out in the waking world, and that a
dream was only a disguised from of a repressed wish. Freud saw dreams as a means of
fulfilling wishes that are unacceptable to the conscious mind. The current theory is, that the
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sleeping brain process the random thoughts and events of the previous working period,
comprising conversation, activities etc and stores it in the unconscious level in a coherent
form. The conscious mind occupies 10% of the brain information and the deeper unconscious
mind occupied 90% of the brain function. According to this theory dreaming is merely an
elaborate memory store in the unconscious mind, thereby making for space in the conscious
mind for waking information relevant to the next day. However, researcher Francis Crick,
one of the discoverers of the DNA molecule, claims that those dreams that are not
remembered on awakening are simply dumped by the brain so as to rid itself of garbage.
Effects of poor sleep
Missing one night‘s sleep is not unusual and this has no effect on the next day‘s activities,
whether it is making a speech or sitting for an examination. It is fairly common to have
difficulty sleeping the night before a momentous event. The effect of loss of sleep for two or
three nights in a row is that you feel very drowsy throughout the day; you lose motivation to
do anything. You are unable to pay attention or concentrate and you reaction time, both
mental and physical are somewhat slowed down. This inability to concentrate has its impact
on boring repetitive jobs as in a factory assembly line and delayed reaction time will have
frightening consequences in relationship to use of machinery and in automobile driving.
Sleep researchers are also now beginning to understand the effects of sleep debt. Many adults
frequently obtain less than optimum sleep and small sleep losses build up day after day and a
sizeable sleep deficit in created. Such sleep deprivation causes the same effects as sleep loss,
resulting in lapses of attention, irritability, erratic behaviour, decline of mental function,
delayed physical response and so on. Imagine the consequences of these impediments on
your day-to-day life, and imagine the impact of these on individuals associated with crucial
jobs such as on surgeons, airline pilots, automobile drivers and so on. Sleep deprivation is
also known to impact the immune system, increasing susceptibility to infections, including
flu, colds asthma, hay fever and allergies. It is also known to impact hypertension.
Virtually everyone has bad nights sleep occasionally. Currently 33% individuals have longer
periods of poor sleep lasting for about a week or two (Transient Insomnia) and 17% have
major sleep problems that requires professional help (Chronic insomnia).
Medical causes for poor sleep range from allergies, infection, arthritis, headache, indigestion,
cough and cold, and pain, to more serious causes including kidney and thyroid problems
cancer and even brain tumours. Another cause of poor sleep is medication and several
antidepressants, stimulants, bronchodilators, steroids, medication for high blood pressure,
asthma etc., all cause insomnia. If you are on medication and unable to sleep. Consult your
physician for change of medication, dosage or timing.
Mental disorders such as Bipolar disorders, Schizophrenia and other Anxiety and Psychotic
disorders also have sleep problems. Smoking and alcohol interfere with sleep cycles. Factors
that affect Light-Dark cycle such as shift work, jet lag etc. also cause sleep problems.
Irregular, late and large meals and lack of fixed sleep timing also causes problems.
Therapeutic interventions for Insomnia
While several factors cause insomnia, lack of sleep inturn leads to various problems. It
therefore necessary to look at various steps to improve sleep. Several forms of behavioral
therapy that have proved beneficial in the treatment of insomnia are as follows:
Stimulus control therapy: Evidence has demonstrated that stimulus control therapy is the
most important form of behavioral therapy. Its goal is to eliminate the patient‘s learned
maladaptive sleep behaviors and to re associate the bedroom with behaviors that are
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conducive to sleep. The patient is given specific instructions to facilitate this transition-
follow-up visits to clarify questions and reinforce the learning process are essential. Sleep
deprivation, which is often induced by stimulus control therapy, may be a benefit of this
treatment, but care should be taken that it doesn‘t reach a level that would impair the patient‘s
safety.
Relaxation therapy: Various forms of relaxation therapy may be useful in treating the
anxious patient with chronic insomnia. With progressive muscle relaxation, for example, the
patient is trained to tense and relax different muscle groups in sequence. As the patient
progresses through the exercise, following either printed instructions or a videotape, tension
should begin to dissipate. Biofeedback is another form of relaxation therapy that uses visual
or auditory feedback to relieve stress and muscle tension. Meditation and hypnosis, on the
other hand, have not proved helpful in treating chronic insomnia.
Paradoxical Intention: With this therapy, which is designed to combat the anxiety that
accompanies the inability to fall sleep, the patient is instructed to stay awake. If the anxiety
can be diminished in this way, the patient is instructed to stay awake. If the anxiety can be
diminished in this way, the patient may fall asleep more easily.
Sleep restriction: This therapy is often used in combination with stimulus control therapy.
The goal is to restrict the time the patient spends in bed to the act of sleeping only. Initially,
the patient restricts the time he or she spends in bed as much as possible. Usually, this would
not be less than five hours; care must be taken to avoid impairing safety. Sleep restriction
produces a state of mild sleep deprivation, which should make it easier for the patient to fall
asleep. On a weekly basis, the patient can increase the time spent in bed by 30 minutes until
an optimal sleep period is attained.
Cognitive behavioral therapy: With this form of therapy, the goal of the cognitive
component is to help the patient understand and alter his or her dysfunctional beliefs and
unrealistic expectations about sleep. The patient is then instructed on ways to replace these
thoughts with more positive ones. The behavioral component utilizes stimulus control
therapy, progressive muscle relaxation, and sleep restriction, as described above.
Sleep hygiene:

 Go to bed and wakeup at the same time daily and observe regular bedtimes. Certainly
there will be the occasional night outs, and disruption, but by and large try and maintain a
regular bedtime. Going to bed at different times each day in known to and confuse the
circadian sleep cycle.
 There are advocates for and against the afternoon siesta. A middle path is the best
solution. If you have had a bad night and are feeling particularly tired, then by all means
have a quick nap. This nap, should ideally be for not more than 20-30 minutes. Enough to
pep you up and relieve your tiredness. But not enough to disrupt you night time sleep
cycle. However, if your sleep problems are frequent, avoid daytime sleep.
 Avoid stimulating activities in bed. (Sex is the exception) Use your bedroom and
especially your bed as a place of relaxation. Working, reading, talking on the phone,
discussing the days problems, watching T.V, eating snacks in bed, should all be avoided.
You must associate your bed with relaxation and peace. It has been found by researcher
Dr.Karacan that making love, has been used for centuries as a way to go to sleep and that
for most people, an orgasm results in deep physical relaxation.
 For most people going to bed is a nightly ritual. Some watch the late news on TV, some
read a bit, some brush their teeth, cream their face, and brush their hair ritually, some walk
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the dog or cat, some say their night prayers. These rituals allows time to unwind. Most
often these routines are sleep inducing, especially for children. Children love taking their
cuddly toys to bed, they look forward to the bed time to story and the good night hug. And
don‘t forget, that most children prefer a night lamp and the door to their rooms just
slightly ajar so that they feel connected to adults in case they have bad dreams.
 A warm beverage, such as milk, a warm bath, create a feeling of relaxation and aid in
sleep. Coffee and Alcohol disturb sleep and must be avoided. Cigarettes are also
stimulants and should be avoided before bedtime. A light dinner aids in sleep and a heavy
dinner creates discomfort and interferes with sleep.
 The bedroom and bed must be comforting and relaxing in color schemes, room
temperature, aesthetics, privacy, lights etc. Pillows and mattresses must be firm but not
hard, not very soft either.
 Regular exercise improves sleep. However, vigorous exercise around bedtime is not a
good idea since it stimulates the body system, even increasing body temperature and
delaying sleep onset till relaxation happens.
 If after all attempts, sleep doesn‘t come – Quit trying. Get up from your bed, change to
some other activity such as reading for a half hour before trying to sleep again. Trying,
tossing and turning and not succeeding creates conditions of panic further affecting sleep.

Combination pharmacologic and nonpharmacologic therapy: As noted earlier, many

patients with chronic insomnia have been taking hypnotics for a long time. Recent studies
have examined the effect of combining these drugs with various forms of behavioral therapy.
Mc Cluskey compared triazolam plus stimulus control and relaxation therapy to these two
forms of behavioral therapy alone. The combination of triazolam and behavioral therapy
produced a better early response; however, patients who received behavioral therapy alone
had better long-term benefits.
A second study by Hauri compared relaxation therapy and sleep hygiene education to these
forms of behavioral therapy plus triazolam as needed. Immediate improvement was noted in
both groups. After ten months of follow-up, however, the patients who received behavioral
therapy alone reported greater improvement than those in the combination group.
Lastly, Morin and colleagues compared cognitive behavioral therapy (specifically, stimulus
control therapy, sleep restriction, and sleep hygiene education) alone, temazepam alone, and
both cognitive behavioral therapy and temazepam to placebo. In the short term, all three
forms of therapy were more effective than placebo. However, at 12-and 24-month follow-up,
patients receiving cognitive behavioral therapy alone continued to demonstrate greater
improvement than those in the temazepam alone and combination groups.
These studies suggest that a hypnotic may be beneficial in the short-term treatment of patients
with behavioral therapy. However, as the dose of the drug is tapered, many patients do not
sustain the benefit of the behavioral therapy alone. This suggests that the hypnotic may
interfere with proper learning during behavioral therapy. Therefore, if a hypnotic is used with
behavioral therapy, it may be necessary to provide longer follow-up after the drug is
discontinued to ensure that patients continue to benefit from the behavioral therapy.
In summary, acute and chronic insomnia require different treatment plans. Acute insomnia
may be best managed with benzodiazepines or benzodiazepine receptor agonists. Chronic
insomnia often has an underlying cause that should be diagnosed and treated if the problem is
to be resolved. Behavioral therapy has proved to be the most effective treatment plan in the
management of psychophysiologic insomnia.
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CONCLUSION
That stress is arousal and chronic arousal will result in psychosomatic ailments has been
firmly established. While medication may be a solution, a holistic approach will make this a
complete solution. A holistic, early approach will help even further by avoiding this state. If a
stress prone work ethic is the rule, if family needs and social engagements are aplenty and if
personal needs and ambitions are on the rise, then ways of balancing this high pressured,
ailment prone lifestyle have to be found.
If neither, ‗flight‘ nor ‗fight‘ can be used, the approach must then change to ‗stay‘ and ‗cope‘.
Regular practice of behavioral coping, relaxation techniques and meditation will help you
stay and cope more productively with modern day stressors. Children will be less irritable
and concentrate better in studies. Grand parents will sleep better and have a better quality of
life with reduced disease state. Adults will be able to cope with challenges of life with a calm
and stress free perspective.
Table 9.4

Breathing and respiration will be calm, hypertension will reduce, endocrine disorders will be
more balanced. Headaches will reduce, muscle tension and Back pain will come down, Skin
ailments will improve, PMS and menopause will be more manageable. Respiratory- allergic
problems will be better controlled and you will sleep more peacefully.
You will then be ready to take the next step – towards Self-actualization and Spirituality.
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CHAPTER 10
BEHAVIOUR MODIFICATION
Introduction to behaviour Modification

In the previous chapters, we have talked about stress and its various causes. We also
discussed some of the ways of dealing with stress. However, there may be some situations of
stress, which may not respond to the previously discussed methods. There are certain
psychological procedures, which alter the behavioural process relevant to health and illness.
Preventive medicine and epidemiology have long recognized the importance of behavioral
and environmental factors in understanding health and altering health actions. However,
because health providers in these fields have been trained from a biological perspective, there
is need for more emphasis and clearer involvement of psychological and behavioral process
in their work. Behavior change principles, based on classic modes of learning: operant and
respondent conditioning and observational learning, can aid tremendously in stress
management. Using these principles, behavior change strategies relevant to health and illness
have been discussed.
I. OPERANT CONDITIONING

The principles of operant conditioning describe the relationship between behaviour and
consequent environmental events that influence the occurrence of that behaviour. In other
words, operant theory states that the performance of a particular behaviour is influenced by
the consequences its produces. We work for a salary, study to get good grades and interact
with people who are pleasant. We desist from actions that lead to pain or that have no payoff.
This may sound very simplistic, but much of our behavior is influenced by its consequences.
Health-promoting and health-impairing behaviors, and illness-related decisions and actions
are strongly influenced by their consequences. Thus operant principles are relevant to the
direct effects of behavior on health and illness. Coping responses to stress are also operants.
We have learned that the availability of effective coping responses in an individual influences
the impact of stress on health status, and that the short- and long-term consequences of
coping responses in reducing or exacerbating stress, influences the kinds of responses made
to stress. Thus, operant principles are relevant to understanding both the direct and indirect
effects of the environment and behavior on health and illness. The actions having positive
consequences are reinforced. We avoid situations that have a negative consequence or no pay
off at all. The relationship between response and reward is the essence of operant
conditioning. Operant conditioning is also called ‘instrumental conditioning‘ because the
organism‘s response is instrumental in gaining some rewards. Coping responses to stress are
also operant in nature. The long-term and short-term consequences of the coping responses
influence the kind of responses made to stress.
Operant conditioning, as we have seen, is learning via consequences. Under certain stimulus
conditions, we produce a certain response, and the fact that this response is followed by
positive or negative consequences provides an incentive for us to repeat or avoid that same
response when next we are faced with those same stimulus conditions.
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Operant behavior then, involves three components: (1) the stimulus or cue for a certain
response, (2) the response, and (3) the consequences. Behavior therapists have found that by
altering any of these components, they can change maladaptive patterns of behavior that
cause much stress.
Contingency Management: The manipulation of the consequences of a response in order to
change the frequency of that response is called contingency management. Retarded children
can be taught to tie their shoes, feed themselves, speak and master many other skills through
the administration of rewards. Reinforcement for achieving academic goals has produced
large gains in classrooms programs (Kelley and Stokes, 1982). Children are persuaded to
clean up their rooms, employees to arrive at work on time, and spouses to take out the
garbage through this time honored method of influencing other people‘s behavior. Several
types of relationships exist between behaviour and the consequence. The major operant
principles are: reinforcement, punishment and extinction.
1. Reinforcement
Reinforcement refers to an increase in desirable behaviour due to a positive consequence of
that behaviour. Any event that increases the frequency of the behaviour is called a reinforcer.
A reinforcer may be positive or negative in nature. Positive reinforcers are the events that are
presented after a response, to increase the frequency of that response. These are also called
rewards. Primary positive reinforcers are food, water and sex. Secondary positive reinforcers
are those that acquire reinforcement value through learning. These include money, grades and
praise. When selecting reinforcers for particular behavior, two aspects need to be kept in
mind:

1. An event may be a reinforcer for one person but not for another.
2. An event may be a reinforcer for a person in one situation, but not in another.

Negative reinforcers are events that increase the frequency of behaviour by reducing or
removing an aversive event. One of the most common examples of negative reinforcement is
switching on the fan when feeling hot or taking an aspirin to reduce headache.
While the operations employed are different in both positive and negative reinforcement, the
objective is to increase the frequency of behaviour.
2. Punishment
Punishment refers to the presentation of an aversive event or the removal of a positive event
as a result of some response that causes a decrease in the frequency of that response.
Punishment may be of two types:

1. An aversive event is presented after the response is performed, which discourages the
person from presenting that response. Eg. A child being scolded for a behaviour would not
continue with that behaviour.
2. Removal of a positive reinforcer after the response is performed. Being grounded and not
allowed to go out because of bad behaviour is an example of such punishment. In such a
case, privileges are withdrawn to correct bad behaviour.

Punishment suppresses behaviour. It tells the person what not to do.

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3. Extinction
Extinction refers to the reduction in the frequency of behaviour by not reinforcing it in any
way. No event is presented or taken away. Punishment too leads to reduction in frequency of
behaviour, which is done through an aversive reinforcement. In extinction, however, quite
simply no consequence is provided for a response – no event is taken away or presented. The
rate of response decreases when reinforcement is consistently absent. Complete absence of
reinforcement eventually results in extinction of that response.
In this case, there are chances of spontaneous recovery if the person is removed from the
conditioning situation for some time and then returned to it. This can be seen in a situation in
which a baby‘s consistent crying at bedtime is dealt with, by not paying any attention.
However, if the child is taken to another room for some time and then brought back to the
earlier room, he may resume his crying at bedtime.
Operant conditioning is achieved most efficiently when reinforcement – primary or
secondary – follows immediately after the desired response. The smaller the interval between
response and reinforcement, the faster the conditioning. In the acquisition of a conditioned
response, even a delay of a few seconds may retard the conditioning process. Once the
response is established, immediacy becomes less important.
The influence of operant conditioning is quite wide spread. It is used in a number of
situations to reinforce positive and desirable behavior. It has been seen to be very effective in
reinforcing effective coping behaviours and reducing negative coping behaviours like use of
alcohol and smoking.
Stimulus Control: Behaviorists have found that operant behavior is controlled not only by
the rewards or punishments that follow it, but also by the stimuli that precede it. Our
environment is filled with ―cues for reinforcement,‖ which, without thinking about it, we are
constantly obeying. For many people, finishing a meal is a cue for smoking. For others,
sitting down in front of the television is a cue for snacking. And just as behavior can be
changed by controlling its consequences, it can also be changed by controlling its cues, a
procedure known as stimulus control. In stimulus control one establishes a highly predictable
relationship between a given stimulus and a given response by eliminating all other stimuli
associated with that response and all other responses associated with that stimulus. The object
is to create a situation in which that stimulus, and no other, will automatically illicit that
response, and no other. If this object is attained, then the frequency of the response can be
controlled by controlling the frequency of exposure to the stimulus.
Imagine a woman who is overweight and wants to decrease the frequency of her eating
behavior. She would be told to confine all eating behavior to one location and not to combine
it with any other activities, such as television watching, reading, or socializing (Ferster et al.,
1962). This program, if carefully followed, would eventually eliminate all other cues for
eating and thereby eliminate impulsive and random eating behavior.
To decrease a behaviour, as we just saw, one must confine the behavior to one cue. To
increase behavior, on the other hand, one must confine the cue to one behavior, in other
words, to banish all other activities from stimulus condition in which the target behavior is
supposed to take place.
Insomniacs, for example, often use their beds at night for a number of activities besides
sleeping–reading, television watching, telephone conversations, and so forth. To reestablish
the bed as cue for sleeping, insomniacs are told to confine bed to sleeping only.
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Implementing Operant Programmes:

Implementing a behavior change through operant conditioning requires us to keep certain
aspects in mind. These are: identifying, selecting and measuring target behaviours, deciding
on the process for change and assessing the effectiveness of the programme. Therefore, the
steps involved are:
1) Targeting Behaviours – The behaviours that need to be changed are targeted. These
behaviours may either be excesses (i.e. inappropriate behaviours occurring frequently) or
deficits (i.e. desirable behaviour not occurring at the right time). In either case, the behaviour
requiring change needs to be defined clearly and explicitly.
2) Assessing Behaviors – The extent to which the target behaviour is being performed prior
to the treatment needs to be assessed. The frequency, strength or duration of the target
behaviour needs to be assessed. This provides the baseline to assess the effectiveness of the
treatment programme.
The antecedents and the consequences of the target behaviour as it occurs in the natural
environment also needs to be observed. It is these events that need to be systematically
altered in order to implement an effective treatment programme.
Implementing Operant Programme: Positive Reinforcement – Consequences of the target
behaviour are systematically manipulated in order to bring about the desired results. For
behaviour deficits, the objective is to increase the frequency of the desired behaviour. For this
purpose, it is important to use positive reinforcement. For excesses, where the aim is to
reduce or eliminate undesirable behaviour, it is important to reinforce the desirable behaviour
required in place of the undesirable behaviour. Punishment only teaches what not to do. It
does not teach the person what to do.
Certain guidelines for reinforcement need to be followed. Firstly, there should be minimal
delay between performance of the target behaviour and the positive reinforcement. Secondly,
the amount and strength of the reinforcer should be sufficient to motivate the person but not
so great as to satisfy the person so that he loses interest in the reinforcer for future use. When
initially reinforcing a behaviour, each occurrence of the behaviour should be reinforced. Once
the behaviour is well established, it needs to be reinforced intermittently. This shift from
continuous to intermittent reinforcement is made because intermittently reinforced responses
are harder to extinguish, client is less likely to lose interest in the reinforcer, and it is less time
consuming.
A slightly different but useful application of reinforcement principles is the development of
contracts between individuals. Contracts are written statements that specify the relationship
between behaviours and consequences. Such contracts are negotiated between two
consequences on that behaviour. A good contract has five characteristics:

 Contract should detail the reinforcement for each party.

 Contract should concretely specify the behaviour to be reinforced in terms of its frequency
and timing.
 Contract should define the punishment for not meeting the terms of contract.
 Contract should include bonus for consistent compliance.
 Contract should specify the means of keeping track of behaviours and its reinforcers.

Implementing Operant Programme: Punishment and Extinction – Undesirable

behaviours can be reduced or stopped with the help of punishment. However, it is important
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to very carefully consider the situation before deciding on punishment as an operant option.
Firstly, it does not teach the person what to do; it only teaches what not to do. Secondly, it is
difficult to implement. And thirdly, punishment may result in negative side effects. However,
it is an important aspect of behaviour change particularly where the behaviour may be life
threatening. Punishment is also effectively used when dealing with alcoholism.
Punishment can be used in several ways. Verbal reprimands, warnings or expressing
disapproval is one way of punishing the individual. However, this does not always have the
desired effect. Infact, in certain situations, it may also act as a reinforcer for negative
behaviour. For example, a child with oppositional behaviour may specifically act in an
undesirable behaviour to get negative attention from his mother.
Withdrawal or removal of privileges for a certain period of time is another form of
punishment. This could also take the form of giving the child time-out from fun activities,
where the person is physically isolated from activities.
Another aspect of punishment is ‗over correction‘, where the person not only unlearns the
negative undesirable behaviour, but also learns desirable behaviour to replace it.
All these procedures have been found to be effective in different situations and with different
individuals. The procedure to be selected depends upon its effect on the person concerned,
ease of implementation, and the degree acceptable to the client. The punishment should be
delivered immediately after the occurrence of the target behaviour, in order to be effective.
The punishment should be of the intensity required to bring about change. It is also important
to positively reinforce the desirable behaviour.
Extinction refers to withholding any kind of reinforcement to suppress inappropriate
behaviours. This leads to gradual reduction of the undesirable behaviours. Extinction as a
mode of dealing with target behaviour is not usually possible because there are rein forcers,
which occur naturally in the environment. These may unwittingly act as intermittent
reinforcers thereby making the behaviour even more difficult to change.
Implementing Operant Programme: Response Maintenance and Transfer
After the principles of operant conditioning have resulted in observable changes in required
behaviours, it is important to ensure that these changes transfer to new situations and are
maintained over a period of time. This can be done by a number of strategies. The response
can be maintained by changing the procedure of reinforcement from consistent to
intermittent. The schedule may be changed by selecting the number of occurrences of the
desired behaviour to be reinforced. Or, the time delay between the behaviour and the
reinforcement may be gradually increased. This would reduce the chances of extinction.
To promote transfer, it is important to select behaviours that have a high likelihood of being
reinforced in the natural environment. This would encourage continuous reinforcement and
greater occurrence of the behaviour in different situations.
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Fig 10.1 General Procedure For Implementing an Operant Programme.

Operant Procedures: A clinical example

The following example is an abbreviated description of a study that utilizes operant
procedures to deal with a serious medical problem (Snyder, 1987). A male adolescent was
referred for treatment because of his unwillingness to engage in appropriate self-care for
diabetes. The client had Type I, insulin-dependent diabetes since age six. Although he was
quite knowledgeable and capable of caring for his diabetes by self administering insulin,
doing urine glucose tests, and eating appropriate foods as scheduled, his self-care had become
increasingly erratic during the nine months previous to referral such that he had been
frequently hospitalized for both hypoglycemia (low blood sugar resulting from the failure to
eat sufficient calories or the use of too much insulin) and hyperglycemia (high blood sugar
resulting from the ingestion of too much sugar or the failure to take enough insulin).
Four target behaviors were clearly defined and systematically assessed: (1) the child‘s
diabetes self-care practices; (2) the child‘s aggressive, noncompliant behavior; (3) the child‘s
school attendance; and (4) the verbal conflict between mother and child.
A functional analysis of these target behaviors indicated that the child and his mother were
engaged in a temporal cycle of aversive control. At the beginning of a cycle, the child would
engage in relatively good self-care but frequent aggression and noncompliance. In response
to his aggression and noncompliance, the mother would increase her nagging and threats. Her
nagging and threats reduced his aggression and noncompliance, thus negatively reinforcing
her behavior. However, he also deliberately reduced his self-care in an attempt to turn off her
nagging and threats. Poor self-care would continue until a diabetic crisis occurred, resulting
in a termination of the nagging and threats (negative reinforcement of his poor self-care) and
in maternal expressions of caring and concern (positive reinforcement). After his diabetes
restabilized, the cycle would begin anew.
Treatment entailed the development of a behavioral contract
Table 10.1 Behavioral Contract for Diabetic Self-Care and General Behavior
Responsibilities of Son Consequences From Mother
Will make appropriate foods of son‘s choice
Will eat specified foods for morning meal
available, will remind son only once for each
(by 8 A.M), morning snack (by 10 A.M), meal or snack, will pay 25 cents per episode
noon meal (by noon), afternoon snack (by 4 of eating proper amount and type on time.
P.M), evening meal (by 6 P.M), and evening
snack (by 10 P.M)
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Will take insulin twice daily, at 7 A.M and 5 Will make insulin available, will remind only
P.M. once, will pay 50 cents per on- time injection.
Will be in bed by midnight with Will remind only once at 11:55 P.M Son will
lights and TV off Sunday through be able to keep his own TV in his room the
Thursday nights. following day.
Will be at school at 9 A.M each For each day, will earn 1 chip; chips are
weekday morning, will stay in school exchangeable for backup rewards (eg., dirt
until 3.30 P.M. bike or time at video arcade).
Will engage in no aggression or Will earn 1 chip for each day; chips are
noncompliance exchangeable as in number 4.

Bonus: – Perfect week on numbers 1 and 2 will result in a $. 2.50 bonus

If son fails to maintain eating and insulin injection such that a hyperglycemic or
hypoglycemic episode occurs resulting in the loss of consciousness, he will be taken to the
hospital and admitted for 2 days with no TV, visitors, magazines etc.

Penalty:
-If son fails to attend school regularly (less then 4 days per week), juvenile authorities
will be contacted and adjudication proceedings will be initiated.
-If son engages in any antisocial behavior (e.g. aggression or stealing), he will work at
a task defined by his mother as commensurate with his action‘s seriousness.
-James J. Snyder

Source of Clinical Study: Health Psychology and Behavioral Medicine

The contract was implemented and led to reduction in hyperglycemic and hypoglycemic
episodes, improved self-care, improved school attendance, and a reduction in aggression and
noncompliance. The son was attending school daily, and diabetic episode did not occur for
over three months (compared to a monthly occurrence prior to treatment

II. CLASSICAL CONDITIONING

Another type of stimulus – response conditioning is called classical conditioning

or Respondent conditioning. It is constantly influencing almost all aspects of our lives. It
may be described as a process of having our behaviour modified, more or less permanently,
by what we do and the consequences of our action.
The sight of food causes salivation, sharp light causes pupil restriction, and pain elicits a
reflex action of avoidance. These stimuli, which have an automatic or unlearned response, are
called unconditioned stimuli. In classical conditioning, a stimulus that does not automatically
elicit a response (called conditioned stimulus) is made to elicit the response. Unlike operant
conditioning, the respondent does not freely emit the response, rather the response is elicited.
The classic example of this form of conditioning is Pavlov‘s experiment with dogs. In the
Pavlovian method, the subject is conditioned or trained to salivate in response to the sound of
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a bell or a flash of light, after associating it with food. First, the sound of bell is presented,
followed by the food, which evokes the inborn salivary response. After repeated presentations
of the sound followed by the food, the sound itself is adequate to elicit the salivary response.
The bell is then referred to the conditioned stimulus (CS) and the salivation is the conditioned
response (CR).

There have been many demonstrations of conditioned responses in humans. In a study

conducted in the USA, it was seen that asthmatic patients experienced relief with just the
inhaler alone after associating the inhaler with relief over a period of time. A classically
conditioned response can be extinguished by presenting the conditioned stimulus (CS)
repeatedly in the absence of unconditioned stimulus (US). If the asthmatic continues to use
the inhaler that contains no medication, the use of the inhaler will cease to be effective after a
period of time.
Fig 10.2

1. Conditioning Principles:
Extinction – Once a conditioned response is established it can also be eliminated. This can
be done by presenting the conditioned stimulus repeatedly without following it with the
unconditioned stimulus. This is, the bell, which had been eliciting a salivary response, is rung
repeatedly without following it with food. The saliva recreated in response to the bell
gradually decreases till it stops altogether.
Spontaneous Recovery – An extinguished response usually returns, though lower in
strength, after an interval of time. For example, an extinguished salivary response may
reappear if one or two days elapse without further trials and then the bell is rung again.
Continued extinguishing of a conditioned response produces less and less spontaneous
recovery until the response fails to appear at all.
Stimulus Generalization – Stimuli similar to the conditioned stimulus would also elicit the
same response. In the Pavlovian experiment, a buzzer or a horn would also cause the dog to
salivate. Similarly, a person who feels anxious about meeting new people would feel anxious
in all situations regardless of whether the situation is threatening or not.
Differential conditioning – It is possible to condition an organism to differentiate between
the conditioned stimulus and other stimuli. When the sound of the bell is followed by food
and the sound of buzzer or horn is not followed by food, the subject learns to distinguish
between stimuli and will salivate only at the sound of the bell and not at hearing the other
sounds.
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It is important to understand these basic conditioning principles in order to understand the

role it plays in stress. A large number of responses such as heart-rate, galvanic skin response,
brain activity, respiration and stomach contractions can be classically conditioned. Classical
or respondent conditioning is particularly helpful in dealing with emotional responses like
fear, anger, anxiety, and guilt. Painful stimuli automatically produce ―emotional‖ behaviour
(fight or flight response), physiological response (increase in heart-rate, stomach cramps,
blood pressure, sweating etc), and subjective feelings of distress. Through inadvertent
classical conditioning in the environment, subjective, behavioural and physiological aspects
of emotional responses may be elicited by formerly innocuous stimuli, even when no threat
exists. For example, if a person has had a painful dental experience, he will experience
increased heart-beat, sweating and nausea even when he is accompanying someone else to the
dentist. Although the situation is not threatening to him personally, he does experience the
anxiety and its accompanying physiological responses. An autocratic authority figure in
childhood may condition a child to fear any authority figure in adulthood as well. Classical
conditioning is also thought to be responsible for the anticipatory nausea and vomiting
experienced by persons receiving chemotherapy for Cancer.
Two procedures for extinguishing conditioned emotional response are: flooding and
systematic desensitization. Extinction is the process by which a conditioned emotional
response is eliminated by repeatedly presenting the conditioned stimulus in the absence of the
unconditioned stimulus. Flooding entails extended exposure to the most threatening situation
without escape until heightened behavioural and physiological responses are no longer
evident. Systematic desensitization is done in steps. It is often preferable since it is less
threatening and less likely to result in premature termination.
2. Systematic Desensitization:
Perhaps the earliest example of the therapeutic use of respondent conditioning was the
famous experiment in which Mary Cover Jones cured the furry-animal phobia of a little boy
named Peter by giving him candy and then bringing a rabbit closer and closer to him.
Systematic desensitization is a similar technique, in which patients are exposed to an anxiety-
producing stimulus while in a relaxed state. This gives the patient the chance to confront the
stimulus without feeling anxiety. As a result, the anxiety is allowed to extinguish.
Systematic desensitization is one of the most widely used techniques in behaviour
modification. It is used to extinguish negatively conditioned behavior. It aims at teaching the
client to emit a response that is inconsistent with energy.
Systematic desensitization also involves relaxation techniques. The client is taught to relax
and to associate a state of relaxation with imagined or visualized anxiety provoking
experiences. Situations are presented in a series that moves from the least to the most
threatening. This hierarchy of anxiety producing stimuli firmly established, is repeatedly
paired with relaxing stimuli until the connection between those stimuli is firmly established
and the response of anxiety is eliminated. The process is ended when the client is able to
remain in a relaxed state while imagining the scene that was formerly disturbing and anxiety
– provoking.

Fig 10.3
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First named and developed as a formal treatment procedure by Joseph Wolpe (1958),
systematic desensitization is based on the premise that if a response antagonistic to anxiety
(such as relaxation) can be made to occur in the presence of anxiety-provoking stimuli, the
bond between these stimuli and anxiety will be weakened. Systematic desensitization
involves three steps as shown in Table 10.2. In the first step, the therapist trains the client in
muscle relaxation, usually Jacobson‘s progressive relaxation. In the second step, therapist and
client construct a hierarchy of fears – that is, a list of anxiety-producing situations in the order
of their increasing horror to the client.
The following Tables below, for example, are the hierarchy of fears established for patients
who were plagued by fears of Dogs and Animal Toys.
Table 10.3
Fear of Dog – Increasing Hierarchy
 Looking At Picture of Dog
 Cuddling Toy Dog
 Seeing Poodle on leash 10 yards away
 Seeing Poodle Pass by
 Touching Neighbors Spaniel in Arms
 Touching Spaniel
 Watching Alsatian
 Feeding Spaniel
 Spaniel Running Around
 Spaniel Barking
 Alsatian Barking
 Dogs Fighting

Table 10.4
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Fear of Animal Toys – Increasing Hierarchy

 Looking at Picture of Toys
 Watching Other Children Play with the Toys
 Seeing Toys in Toy Shop
 Seeing Toys 4 Yards Away
 Seeing Toys Close By
 Contact with Doll/Cat/Stuffed toy
 Contact with Elephant (Toy)
 Close Contact with Animal Toys
 Holding Animal Toy in arms / lap

Systematic desensitization can be effectively applied to a wide variety of anxiety –

provoking situations like interpersonal situations, examination fears, generalized fears,
phobias and sexual dysfunctions.
3. Flooding
Flooding might be described as a cold turkey extinction therapy. Unlike the gradual exposure
paired with relaxation that constitutes systematic desensitization, flooding involves prolonged
exposure to the feared stimulusor, if that is not possible, then to vivid representations of the
stimulus – in a situation that does not permit avoidance (Aronson, 1979). Like systematic
desensitization, the technique depends on the therapist‘s first finding out exactly what it is
that the client most fears.
Flooding has proved to be particularly useful in the elimination of obsessivecompulsive
rituals.
Contamination and checking: When the fear is contamination, flooding involves having
clients actually ―contaminate‖ themselves by touching and handling dirt or whatever
substance they are trying to avoid, all the while preventing them from carrying out their
anxiety-alleviating rituals (in this case, usually hand washing). The hoped-for result is that
they will realize that the thing they fear actually poses no real threat.
Flooding technique consists of the repeated presentation of the conditioned stimulus without
reinforcement. That is, in a non-threatening environment, the person is asked to imagine the
most anxiety provoking situation and to continue to imagine or visualize it till it is no longer
anxiety provoking. It is different from systematic desensitization in that no counter-
conditioning agent (relaxation) is used, nor is a hierarchy of anxieties constructed. The
therapist presents the anxiety – producing stimuli, the client imagines the situation, and the
therapist attempts to maintain the clients anxiety. The attempt is to elicit a massive flood of
anxiety. The rationale of the technique is that if a person is repeatedly exposed to some
anxiety ridden situation and if no dire consequences occur, the anxiety is reduced or
eliminated.
The effectiveness of systematic desensitization and flooding is well established. Not only do
they help in dealing with the emotional responses to anxiety – provoking situations, they also
help in dealing with physiological repercussions of these emotional responses. The psycho
physiological arousal accompanying frequent and prolonged elicitation of emotional response
may contribute to psychosomatic illnesses like Ulcers, Hypertension, Asthma, Skin diseases,
Cancer etc. Interventions using behavioural principles to alter the person‘s behaviour, help in
promoting resistance to these diseases by dealing with basic stress.
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4. Aversion Therapy
Aversion therapy, whereby a maladaptive response is paired with an aversive stimulus such
as electric shock or nausea-producing drug, has been used extensively in the treatment of
sexual deviations, homosexuality, and alcoholism.
Such therapy, particularly when it involves electric shock, seems extremely harsh to many
people, including many clinicians. Nevertheless, a number of clients consider it far preferable
to the behavior they are trying to eradicate. Furthermore, the mere fact that it seems to work
in cases where other therapies do not is a strong argument for its use

III. COGNITIVE RESTRUCTURING

Several of the techniques we have just described depend on cognitive processes. Systematic
desensitization uses mental imagery; modeling procedures, depends on mental variables-
memory, admiration of the model, and so forth. Thus, while not the main focus, cognitive
processes do play a part in traditional behavior therapy.
The central tenet of cognitive behaviorism is that, cognition or thoughts are the most
important causes of behavior; it is our thoughts, more than any external stimuli, that elicit,
reward and punish our actions and thereby control them. Hence, if we wish to change a
pattern of behavior, we must change the pattern of thoughts underlying it. To this end, the
cognitive behaviorists have developed a variety of techniques to increase coping skills, to
develop problem solving, and to change the way clients perceive and interpret their worlds
(eg. Kendall and Hollon, 1979). One important set of techniques, calledcognitive
restructuring, has developed from procedures suggested by cognitive therapists such
as Albert Ellis and Aaron T. Beck as shown in Table below.
Table 10.5

Cognitive Restructuring

Rational Emotive Therapy – Albert Ellis (1962)

Cognitive Therapy – Aaron Beck (1976)
Self-instructional training – Donald Meichenbaum (1977)

Several individual treatments fall under the heading of cognitive restructuring. Perhaps the
oldest is rational-emotive therapy, developed by Albert Ellis(1962). Ellis‘basic contention
is that emotional disturbances are the result not of objective events in people‘s lives but of the
irrational beliefs that guide their interpretations of those events. For example, it is not failure
that causes depression but rather failure filtered through the belief that one should be
thoroughly competent, adequate, intelligent, and achieving in all possible respects. Likewise,
it is not threatening situations that generate anxiety but rather threatening situations
interpreted according to the irrational belief that if something is or may be dangerous or
frightening, one should be very upset about it.
To combat such beliefs, Ellis and his followers point out in blunt terms the irrationality of the
client‘s thinking, model more realistic, evaluations of the client‘s situation (eg., ― So what if
your mother didn‘t love you. That‘s her problem!‖), instruct the client to monitor and correct
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his or her thoughts, rehearse the client in appraising situations realistically and give
homework assignments so that new ways of interpreting experience can be strengthened.
Similar in theory if not in tone is Aaron Beck’s (1976) Cognitive Therapy. Like Ellis, Beck
holds that emotional disorders are caused primarily by irrational thoughts. In his view, this
disturbance is the result of a ―cognitive triad‖ of self-devaluation, a negative view of life
experiences, and a pessimistic view of the future.
Table 10.6 Cognitive-Triad

– Self devaluation
– A negative view of life‘s experiences
– A pessimistic view of future

To change such cognitions, Beck adopts a less didactic and more Socratic approach than
Ellis, questioning patients in such a way that they themselves gradually discover the
inappropriateness of their thoughts.
A more recent variant of cognitive restructuring is self-instructional training, developed
by Donald Meichenbaum and his colleagues. Instead of focusing on general beliefs or
attitudes, like Beck and Ellis, these investigators concentrate on ―Self-talk,‖ the things that
people say to themselves before, during and after their actions. And instead of assessing this
self-talk in terms of its rationality or irrationality, they simply try to change it in such a way
that instead of defeating the person, it helps him or her to cope with threatening situations. In
self-instructional training, therapists will typically model ―cognitive coping exercises.‖ First,
they will voice defeating self-sentences, so as to alert clients to kinds of thoughts that trigger
and reinforce maladaptive behavior. Then they will ―answer back‖ with more constructive
self-talk, thus showing patients how they can combat defeating thoughts.
Though differing in tone and emphasis, these three therapies share the same basic goals: to
change behavior by changing the thoughts that produce the behavior. They do not seek the
deep-seated causes of the patient‘s cognition and then to change them, using well-tried
behavioral techniques such as modeling, behavioral rehearsal, and reinforcement.

IV. STRESS INOCULATION TRAINING

Stress Inoculation Training (SIT) is a cognitive behavioral treatment method, which

combines physiological arousal management with cognitive coping strategies and behavioral
rehearsal. It was the pioneering work of Meichanbaum and his colleagues in the early and
middle 1970‘s that paved the way for the development of this treatment method.
Initially, SIT was applied to schizophrenic adults and then to impulsive children. Although
SIT, has now been found to be affective with numerous other client groups such as pain
patients, individuals with anger control problems and victim groups, it has been applied most
frequently to various anxiety or stress problems.
1. Education
In the education phase, the therapist and the client conceptualise the client‘s maladaptive
emotional pattern as a reaction to stress. The therapist also instructs the client to view the
stress problem as a series of manageable phases rather than a single overpowering gestalt
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which include, preparation for the stressor confirmation with the stressor coping in the
possibility of being overwhelmed by the stressor, and self reinforcement after coping with the
stressor
2. Skill Acquisition
In this phase, the therapist trains the client in coping techniques involving direct action or
cognitive techniques. Direct actions include becoming knowledgeable about the stressful
situation planning alternative escape routes, and relaxation induction. Cognitive coping
techniques involve learning self statements that help adaptively to assess the stressful
situation, control negative thoughts and images to recognize and relabel physiological
arousal.
3. Application
In the phase, the coping skills are applied in actual stress situations. The therapist exposes the
client to ego threatening stressors such as imagined stress sequences, stress inducing films or
even electric shock. As the coping skills are mastered, attention is turned to transferring them
to the external environment.
An important element of the application phase is that of relapse prevention. Relapse
prevention emphasizes the important role of preparing the clients to cognitively reframe their
setbacks, failures and back sliding as learning trials.
SIT is also concerned with follow-through into the future. Some form of follow-up or booster
session in built-in.
SIT can be implemented on an individual or group basis. It is a comprehensive and flexible
system. As with many therapeutic approaches, it may not work for clients who cannot form
collaborative relationships, resist completely taking responsibility for change activities, or
have expectations that differ dramatically from the stress inoculation model.

V. OBSERVATIONAL LEARNING

Observational learning (or Modelling) refers to a process by which a person‘s behaviour

changes as a function of observing, hearing, or reading about the behaviour of another
person. The person extracts information about how to engage in certain behaviours and deal
with specific situations and the consequences likely to occur as a result of those behaviours.
This way it is possible to learn new behaviours quickly, without having to perform them or
shape them through conditioning principles. Already existing behaviours can also be altered
through observation.
Observational learning or modelling is an innate behaviour. Young children learn by
observing and then readily imitating the behaviour of their parents and other significant
persons in their environment. In contrast to operant and classical conditioning, a person can
learn through observation without engaging in any overt behaviour or experiencing any
environmental stimuli. Bandura (1977) suggests four basic processes that are involved in
observational learning.

 Attention – not everything observed is learned. To learn something the person must pay
attention to and absorb the target behaviour.
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 Retention – once attention to and comprehension of the target behaviour occurs, the
observer must remember the material by actively processing the information.
 Reproduction – the person must reproduce and practice those behaviours and become
skilled in them.
 Motivation – the actual performance of the behaviour depends on anticipated and actual
consequence of those behaviours.

Observational learning is an effective tool to learn appropriate behaviours and deal with
stressful situations. Certain social skills can be acquired by observing and imitating the
behaviour of appropriate models. Also, disturbing emotional reactions can be extinguished by
observing others approach feared objects or situations without experiencing dire
consequences for their behaviour. Self – control can be learned through the observation of
others who get punished
VI. PSYCHODRAMA

Another behavior modification technique is Psychodrama or Drama Therapy. Muller –

Thalheim has spoken of healing, life-affirming aspects of creativity, ―we know the fantasies
and artistic daydreams which help to conquer the painful limits of existence and lead through
play to art. They also help us to manage our basic conflicts.‖
The term ‗drama therapy‘ refers to drama as a form of therapy. There are two perspectives to
drama therapy. The first is that drama is a way of actively participating in the world. The
second, is that within drama there is a powerful potential for healing.
The premise of Drama therapy is that, not all art is therapy. It does not preclude art made
primarily for creative, political or financial purposes. It does not seek to pathologise the artist
or artistic creativity. It does, however, recognize that artistic processes and products have
healing potentials and that, if worked with in particular ways in specific contexts, drama can
be a therapy.
Definition of Drama therapy
Drama therapy is involvement in drama with a healing intention. It facilitates change through
drama processes. It uses potential of drama to reflect and transform life experiences to enable
clients to express and work through problems they are encountering or to maintain a clients
well-being and health.
A connection is created between the client‘s inner world, problematic situation or life
experience, and the activity in the drama therapy session. The client seeks to achieve a new
relationship towards the problems or life experiences they bring to therapy. The aim, is to
find in this new relationship-resolution, relief, a new understanding, or changed ways of
functioning.

Basic Processes of Drama therapy

A number of key processes lie at the heart of drama therapy and they are the main ways in
which therapeutic change occurs. These are core processes:
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 Dramatic Projection is the process by which clients project aspects of themselves or their
experience into theatrical or dramatic materials or into enactment and thereby externalize
inner conflicts. Dramatic Projection enables access to dramatic processes as a means to
explore the issues, which the client has brought to therapy. The dramatic expression
creates a new representation of the client‘s material, and new relationships to the material
can be achieved.
 Therapeutic Performance Process – involves the process of identifying a need to
express a particular problematic issue. The structure of needs identifying, rehearsal, and
showing is a vehicle for exploration and re-exploration of a problem. The performance
process may be therapeutic in itself, no matter what the content or subject matter brought
by the client. The client may hold one or many roles or become the director of the script or
even become the audience. These different roles can offer the opportunity for change in
perspectives concerning the expressed material.
 Drama therapeutic Empathy and Distancing – Empathy encourages emotional
identification and high emotional involvement within any work. For those clients who
have problems in developing relationships or dealing with others due to lack of
understanding or ability to empathize, development of an empathic relationship during
dramatic work can help to encourage empathy toward others in life outside the Drama
therapy.Distancing encourages an involvement, which is more oriented toward thought,
reflection and perspective. In some situations, use of the distancing approach can help a
client create a perspective on themselves or an issue.Within any one reaction, the client is
likely to experience aspects of both processes and this can be used to fuel development
and movement within that drama therapy session.
 Personification and Impersonation – A client represents a feeling, issue, or person,
themselves or aspect of themselves within a dramatic framework. They do it usually by
impersonation (depicting something or playing a part themselves) or by personification
using objects like toys or puppets to represent the material. Impersonation and
personification provides a particular focus for the client‘s expression and exploration of
problems and issues.
 Interactive Audience and Witnessing – Witnessing is the act of being the audience to
others or to oneself. Both acts are equally important. The audience is interactive and can
be used in a number of ways – as support, as confronter, as guide, as a companion or as a
pool of individuals to take part in the enactment. The nature of the audience can be
significant in the dynamics of the group.
 Embodiment: Dramatising the Body – For most forms of theatre and drama, the body is
the main means of communication. The actor discovers and expresses roles, ideas and
relationships through face, hands, movements, voice. Embodiment in drama therapy
involves the way the self is realised by and through the body. Attention is given to the
ways in which the body communicates on an unconscious as well as conscious level.
 Playing – A state of playfulness is created whereby the client enters into a special playing
state. The Drama therapy session is a space, which has a playful relationship with reality.
The relationship is characterized by a more creative, flexible attitude toward events,
consequences, and ideas held. This enables the client to adopt a playful, experimenting
attitude toward themselves and their life experience.Play content of drama therapy, usually
includes play with objects and symbolic toys, projective work with toys in the creation of
small worlds, rough-and-tumble play, make–believe play involving taking on characters
and games. For some clients, playing might be a way of returning to a developmental
stage in childhood where a problem or block occurred. The playing process would aim to
revisit that aspect of themselves and their life and to assist the client in renegotiating the
developmental stages.
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 Life – drama connection – At times the work within dramatherapy involves a direct
dramatic representation of reality. At other times, the actual dramatic work will have an
apparently indirect relationship with specific life events. Many activities make a number
of different kinds of connections simultaneously. A realistic role play of an interaction
between the client and her mother, exploring an unresolved problem might have a number
of significances. To the client presenting the material to other actors and to the audience,
the interaction might symbolise a struggle between two aspects of the self, personified by
the mother and daughter.

At times the life-drama contact will be conscious and overt for the client. They might decide
on an issue from their life and proceed to create a dramatic expression deliberately linked to
it. However, the client might proceed into a piece of work without knowing what the contact
with themselves or their life might become.
Only during the enactment might the connections with themselves be made. A client might
also be working in someone else‘s drama when he makes the connection.
The fact that the drama therapy space is connected to, but not part of everyday life is
important to some clients. In others, the life-drama connection will need to be constantly
acknowledged. This would be important for clients whose relationship with reality might be
confused or tenacious.
• Transformation –

1. Life events are transformed into enacted representations of those events.

2. People encountered in everyday life are transformed into roles or characters.
3. Objects are transformed into representation of something.
4. Everyday experiences are transformed into dramatic reality.
5. The process of being involved in making drama, the potential creative satisfaction of
enactment, can be transformative.
6. The relationships, which the client forms with the Dramatherapy or with other group
members, can be experienced as Transformative. Past relationships, past events, and past
ways of responding can be brought into the present of the Dramatherapy group. Here, they
can be reworked within the drama and the relationship within the group.

Table 10.7 below refers to the steps followed in Drama therapy

Table 10.7 Basic Shape of Drama Therapy
• Warm Up.
• Focussing.
• Main Activity.
• Closure and de-rolling.
• Completion.

CONCLUSION:
A commonly voiced criticism of behaviour therapy is that it is superficial. Because it does not
dwell on the patient‘s past, does not have insight as a primary goal, and does not concern
itself with philosophical issues, it seems shallow to those who feel that therapy should lead to
greater self-acceptance and self-understanding. This is criticism that cannot really be
answered. Though many behaviour therapists believe in the value of self-understanding, they
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also feel that it is too vague and grandiose an ideal to serve as a treatment goal. The goal of
behaviour therapy is simply to provide with skills they need in order to deal more effectively
with life.
Critics of behaviour therapy argue that it denies individual freedom, that behaviour therapists
move in and take control of the patient‘s behaviour, manipulating it according to their own
values. Actually, all psychotherapies involve some control on the part of the therapist,
whether that control is directed toward insight or self-actualization or reconditioning.
Likewise, in all therapies, the therapist‘s values play an important part.
How well does behaviour therapy do in achieving its goal of behaviour change? According to
the evidence, quite well.
Aside from the fact that it often works, behaviour therapy has other advantages as well. It
tends to be faster and less expensive than other therapies. Its techniques can be taught to
paraprofessionals and non-professional, so that therapy can be extended beyond the
consulting room to hospital wards, classrooms, and homes. Finally, because behaviour
therapy is precise in its goals and techniques, it can be reported, discussed, and evaluated
with precision.
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Websites

www.americanheart.org
www.healthinfo.org
www.psychology.org
www.mindtools.com
www.naspepatient.org
www.oshoworld.com
www.stresscure.com
www.transendentalmeditation.org.uk

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