CONCEPT I: Life-Style and Health

According to the biomedical model, sickness is the result of biological malfunction, and is best treated by medical professionals. The biopsychosocial model holds that social, psychological, and biological factors interact to affect our health. The biomedical model focuses on containing illness; the biopsychosocial model seeks to promote health and it forms the basis of health psychology, a growing subfield of psychology.

Before this century, the major causes of death in the United States were acute infectious diseases. Now, our major health problems are life-style disorders like cardiovascular disease, cancer, and automobile accidents. These problems can often be linked to patterns of behavior, like smoking and overeating.

Although Americans appear to be health conscious, many of us do not take simple steps to reduce our risks of developing serious diseases, such as self-examination for breast cancer, and taking necessary precautions in dealing with AIDS.

The cognitive-behavioral approach is based on the idea that both attitudes and behaviors must change in order for life-style adjustment to be successful. It also requires that the client accept responsibility for change, rather than leaving that responsibility entirely with the therapist. The most successful programs use a multimodal approach which involves several kinds of learning techniques such as self-observation and self-monitoring (paying attention and keeping track of one's own behavior), stimulus control (removing cues that initiate the unwanted behavior), and self-reinforcement (rewarding oneself for appropriate behavior) which might include shaping, or gradual reduction in the pattern of rewards. In contingency contracting, a person makes a contract with another which details the rewards or punishments that will result from the behavior being controlled. Cognitive restructuring is used to help clients change the way they think about their behaviors. Finally, skills training, in which the therapist helps the client develop better social skills, can help the client become better able to control his or her life.

Alcohol consumption generally peaks in the U.S. between the ages of 18 and 25. In itself, it is a health risk, and it is also associated with automobile accidents, the leading cause of death among young Americans, and other unsafe behaviors. College students can learn to control their drinking behavior by engaging in placebo drinking, where they substitute a non-alcoholic beverage for alcohol at least part of the time when they are drinking. Also stress management, relaxation techniques, and life-style rebalancing (finding healthy alternatives such as exercise instead of drinking) can help people control their use of alcohol.

Relapse rates after treatment for most addictive disorders run from 50 to 90 percent. Furthermore, neither "booster sessions," contingency management, nor life-long treatment seems to help. The most promising results seem to come from building relapse protection into the initial therapy sessions so clients can work out strategies in advance for how to respond when temptation occurs.

CONCEPT II: Stress

Stress has both physiological and psychological components. An early model of stress reactions, the fight-or-flight response, held that, when threatened, the sympathetic nervous system and endocrine system are aroused and enable the organism to fight or flee. According to Selye's general adaptation syndrome theory, all types of stress evoke a similar pattern of physiological responses. The general adaptation syndrome postulates three stages in a stress reaction: alarm, in which the sympathetic nervous system supplies additional energy; resistance, in which the body appears normal but is being gradually weakened; and exhaustion, in which the body's ability to combat stress begins to break down. Other researchers suggest that cognitive and emotional factors also play a role in stress, and that stress responses vary with the individual and with the type of stress.

The psychological view defines stress as that which we appraise as harmful, threatening, or challenging. It emphasizes that differences exist among people in how, when, and to what they react, and focuses its attention on how we appraise, or evaluate, a situation. Appraisal is important in the interpretation of stressful events. For example, one research study showed that subjects who focused on the pain and trauma experienced by people in a film were much more stressed than those who focused on the religious significance of the film's subjects. Appraisal involves two steps: whether we judge a situation as a threat (primary appraisal), and whether we believe we can cope with it (secondary appraisal).

Psychoimmunology is a new field which examines how psychological factors alter the immune system and alter the risk of immune system-related diseases like AIDS, cancer, arthritis, infections, and allergies. The immune system guards the body against foreign invaders (called antigens). B-lymphocytes, which are made in the lymph organs and bone marrow, coat or neutralize the antigens. Then macrophages ingest and destroy them. T-lymphocytes attack invader cells directly, breaking down their cell membranes. Natural killer (NK) cells attack cells already infected and secrete interferon, which inhibits virus reproduction. Immunocompetence refers to how well the immune system is operating. Even the academic stress during exams can lower students' immunocompetence, as can problems with interpersonal relationships. And both acute and long-term stress can lower one's resistance.

Holmes and Rahe developed the Social Readjustment Rating Scale (SRRS) to measure the amount of stress in a person's life. It consists of a scale of points associated with stressful life events. People who have experienced more stressful life events have higher scores, and are at greater risk for illness and injury. Critics of this approach argue that the scale items are too ambiguous, that people experience the items in different ways, that the scale does not consider the context of the events, and that the scale focuses on past, rather than present, events and situations.

Early studies in the 1950s and 1960s of abortion led to the conclusion that abortion, which was still illegal, was a devastating experience for women who went through it. The conclusions of these studies were accepted because they fit the prevailing psychoanalytic views of women at the time, even though they were based on a biased sample of women who sought psychotherapy. In 1988, the Surgeon General concluded that, 15 years after abortion had become legal, its psychological effects, although potentially overwhelming for an individual, were minuscule from a public health perspective. The American Psychological Association assembled a panel of experts to review the literature on this subject and concluded that legal abortion in the first trimester did not pose a psychological hazard for most women. In fact, most studies found more stress before than after an abortion, and 76 percent of the women who had abortions felt relieved. Studies comparing women who have abortions and women who have their babies have found the groups to be similar, although one study found the women who had chosen abortion to have a more positive psychological profile.

However, the amount of negative emotion felt is linked to how difficult the abortion decision was. Women who terminated pregnancies that were wanted, who lacked support for the abortion, or who were less sure of their decision seemed to be at greater risk for negative consequences.

Research on the question of the effects of abortion has tended to focus on the time just before and after the abortion, has treated the abortion as a single event, and has not fully attended to the differences in situations experienced by different women. We also know little about the long-term effects of abortion, and we have had difficulty in comparing women who have abortions to an appropriate control group. We also know very little about the impact of social and political climate on women's responses, and additional research in all these areas is warranted.

Although some research supports the view that chronic stress is worse than acute stress, it is difficult to separate the two. Many studies suggest that uncontrollable situations are more stressful than controllable ones. In a study of nursing home residents, the group who were encouraged to take control of their lives were happier, more active, more assertive, healthier, and lived longer than members of the group who were encouraged to let others care for them.

Posttraumatic stress disorder (PTSD) is a delayed reaction to stress seen among combat veterans and other victims of traumatic experiences. Symptoms may last for months or years, and can include hyperalertness, sleep disturbances, guilt, memory loss, and emotional distance. As many as 50 percent of combat veterans experience PTSD. Thus, both major traumas and minor irritations can affect health.

Personality traits also can affect health. For example, the hostility trait in the Type A personality is linked to coronary heart disease (CHD). Optimism seems to be linked to better health than pessimism, perhaps because pessimists tend to blame themselves for bad events and to see negative events as stable and global. Too much optimism may, however, lead to a maladaptive denial of real problems, just as excessive pessimism may lead to the engagement of maladaptive behavior. Thus, the controversy remains. Other things being equal, an optimistic but reality-based view may be related to a healthier state.

Stress may be linked to illness in a variety of ways. The direct route suggests that stress may produce physiological and psychological changes that contribute to the development of illness. However, preexisting variables, such as personality, may influence the link between stress and illness. Stress may also act by altering health behaviors, and stress may actually promote "illness behaviors" for which people seek treatment. Finally, all these factors may interact, with no one factor being enough to cause illness, but with a combination of them being powerful enough to have an effect on health.

CONCEPT III: Coping with Stress

Coping is the process of managing the internal and external demands that one appraises as taxing or overwhelming. Coping takes two main forms: problem-directed coping (trying to do something about the stressful situation) and emotion-focused coping (trying to regulate the emotional consequences of a stressful situation), and oftentimes these two forms work together.

The Ways of Coping Questionnaire asks subjects to list and then rate the major events of their lives, and then indicate how they have dealt with them. Eight coping strategies have been identified: confrontational coping (fighting for what you want), social support (turning to others for comfort and advice), planful problem solving (devising a plan of action), self-control (not letting your feelings show), distancing (keeping your mind off the problem), positive reappraisal (looking for the best in a situation), accept responsibility (accept the situation as yours and try to learn from it), and escape/avoidance (denying the situation or escaping through drugs). Generally, research shows that confrontation is a better coping strategy than avoidance, although both have their appropriate uses. In many cases, a combination of strategies is the most successful.

Catharsis is the process of venting emotions, often by talking about stressful events. Generally, catharsis increases short-term stress but provides long-term benefits in coping. One exception is that sometimes talking about stressful events intensifies the negative emotions associated with them. Talking about stressful situations can be helpful if we can rely on a social support system composed of others who will listen and care about our well being. Social support can include tangible assistance (money or food, for example), information (especially on what actions are appropriate), and emotional support (reassurance that others care). Effective social support can reduce stress, lower the likelihood of illness, speed recovery from illness, reduce the risk of death from disease, and lead to better health habits. Sometimes, however, social support can be unhelpful. These unhelpful tactics most often include giving advice, encouraging too quick a recovery, minimizing the loss, and trying to identify with the bereaved's loss ("I know just how you feel.") Helpful tactics include "just being there," being available to discuss feelings, and expressing concern. Subjects in a smoking study found it easier to quit when the proportion of positive to negative behaviors in their social support network was high.

Stress management techniques can also help people reduce stress. One cognitive-behavioral technique involves first education about stress, its relationship to health and performance, its symptoms, and some coping strategies. Next, subjects receive some training about how they can develop better work habits and social skills. The third stage is practice, where subjects try out their strategies in real-life situations and report back to the group on their experiences.

Biofeedback is a specialized procedure for monitoring and controlling the physiological aspects of stress and pain. In early trials, biofeedback was thought to be very effective in reducing stress-related physical problems such as migraine headaches.

Relaxation techniques, however, are easier to use and seem to be equally effective. Since relaxation is the counterpoint to stress, if we can teach ourselves to relax, we can reduce our stress levels. Progressive relaxation requires that the subject progressively tense and relax muscle groups in the body. Controlled breathing also reduces stress. Subjects who undertake relaxation programs have been shown to experience less stress and have better immune functioning than those who don't.

Exercise, especially if it is aerobic (demands oxygen intake), helps increase tolerance for stress, improves cardiovascular fitness, and improves general health, mood, and well-being. Exercise should consist of brisk workouts for at least 15 minutes at least 3 times a week. Even though exercise is touted in society as desirable, American children are becoming physically unfit in greater percentages than even 10 years ago. Health is an active achievement toward which we need to work.