Transcript Lecture 2: Stress and Coping - Centre on Behavioral Health

Lecture 2
Stress and Its Management
Dr. Antoinette Lee
The University of Hong Kong
Lecture Outline
 What is Stress?
 Sources of Stress
 Models/Theories of Stress
 Stress Response
 Assessing Stress
 Adverse Effects of Stress
– On psychological Functioning
– On physical health
 Moderators of the Stress-Illness Relationship
 Coping
 Stress Management
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress
“Stress” may mean different
things:
1. Stressor
2. Stress
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
I. Stress: What Are We Referring
To?
1. Stressors:
 external environmental events
that cause a person to feel
stressful
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress
2. Stress:
 Response to the stressor
(physiological, psychological,
and behavioral changes)
 Person-environment fit : role of
appraisal
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Definition of Stress
 “Stress is a negative emotional experience
accompanied by predictable biochemical,
physiological, cognitive, and behavioral changes that
are directed either toward altering the stressful event or
accommodating to its effects” (Baum, 1990)
 Consequence of a person’s appraisal processes
 the assessment of whether personal resources are
sufficient to meet the demands of the environment”.
 Stress is determined by the person-environment fit:
the Transactional Model of Stress (Lazarus & Folkman,
1984)
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
II. Sources of Stress
1.) Life events/changes (Holmes & Rahe, 1967)
 any noticeable alterations in one’s living
circumstances that require readjustment
 changes, both positive and negative, can be
stressful
 Social Readjustment Rating Scale (SRRS): 43
major life events
 Events which force people to make greater
changes in their lives cause more stressful
 Modest prediction of both onset of acute illness
and exacerbation of chronic illness
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sources of Stress
2.) Daily hassles(Lazarus et al., 1981)
 minor everyday hassles / irritants can
also be very stressful
 cumulative effect
 examples:
• noise
• misplacing or losing things
• troublesome neighbours
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sources of Stress
• social obligations
• traffic jam
• concerns about owing money
 hassles related to psychological
symptoms especially depression and
anxiety
 hassles versus uplifts
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sources of Stress
 5 most commonly reported hassles
• concern about weight, health of family
member, rising price of common good,
home maintenance, too many things to do
 5 most commonly reported uplifts
• relating well with spouse or lover, relating
well with friends, completing a task, feeling
health, getting enough sleep
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Survey on Common Hassles of
University Students Graduating
in 1996
• In decreasing order of intensity (frequency X
severity):



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





Too many things to do
Not getting enough rest
Academic workload too heavy
Not getting enough sleep
Troubling thoughts about the future
Too many responsibilities
Concern about future career prospects
Concern about future career decision
Meeting deadlines
Feeling down
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sources of Stress
3.) Frustration
• occurs when the pursuit of some goal is
hindered
• e.g. traffic jams, failures, losses
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sources of Stress
4.) Conflict
 should I or shouldn’t I
 conflict occurs when 2 or more
incompatible motivations or behavioral
impulses compete
 King and Emmons (1990): related to
anxiety, depression ,and physical
symptoms
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sources of Stress
• Types of conflict:
 (1) approach-approach
• less stressful
 (2) avoidance-avoidance
• most unpleasant and stressful
 (3) approach-avoidance
• vacillation
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sources of Stress
5.) Pressure
 expectations or demands that one behave in
a certain way
 Expectations from self
 Expectations from others
 Weiten, 1988: strong relationship found
between level of pressure and psychological
symptoms; level of pressure was even more
strongly related to mental health than SRRS
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sources of Stress
6.) Poverty and powerlessness
• those who are at the lower end of the
socioeconomic ladder have worse health
• many stressors: high crime rates, poor housing,
less recreation
7.) Environmental stressors
• e.g. noise, crowding,
natural disasters, air pollution
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
What Makes Events
Stressful?
 Characteristics of potential stressors
that make them more likely to be
appraised as stressful
•
•
•
•
•
1.) Negative events
2.) Unpredictability and uncontrollability
3.) Ambiguity
4.) Salient events
5.) Overload
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
III. Models/Theories of Stress
1.)
Cannon (1932)
 stress as physiological responses to
stressors
 Physiological arousal via the sympathetic
division of the autonomic nervous system
 e.g. increased heart beat, blood pressure,
perspiration, respiration rate
 fight-or-flight response
 Supposed to be adaptive and protective,
evolutionary value
 But what about in face of modern day stresses?
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Models / Theories of Stress
2.)
Selye (1956)
 General Adaptation Syndrome (GAS)
 Nonspecific; responses are the same across different
stressors
 Physiological pattern of reaction
 Lays the foundation for understanding the stressdisease link
 3 stages
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
General Adaptation
Syndrome
• Alarm Stage: initial physiological responses to
stressors; the fight-or-flight response
• Resistance stage: attempts to cope with the
threats and restore equilibrium; ability to resist
new stressors impaired
• Exhaustion stage: depletion of resources as the
individual fails to overcome the threat; symptoms
and health problems occur - “diseases of
adaptation”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Models/ Theories of Stress
3.) Tend-and-Befriend (Taylor et al.
2000)
 affiliative response to stress
 In addition to fight or flight
 Embracing, finding support from family and
friends, community cohesion in response to
natural disasters…….
 Normal sympathetic arousal associated with the
fight-or-flight response downregulated in
females, leading to social and nurturant
behaviors
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Models/ Theories of Stress
 Especially characteristic of females
 Males and females faced different adaptive
challenges during the evolvement of responses
to stress
 Female responses to stress evolved to protect
not only the self but also offspring
 Affiliating with others enhances female’s selfpreservation and off-spring protection ability
 Biological basis: oxytocin
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Models / Theories of Stress
4.) Transactional Model of Stress
(Lazarus, 1968)
 complex physiological and psychological reactions
 “stress as a transaction between people and
environment” (Lazarus and Launier, 1978)
 Cognitive appraisal
 consequence of a person’s appraisal
(assessment) of whether personal resources are
sufficient to meet the demands of the
environment
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Transactional Model of
Stress
Primary appraisal:
 To determine the meaning of the event
 positive, neutral / irrelavant, or negative
 how harmful, threatening or challenging?
 Harm: assessment of damage that has already been done
by the stressor
 Threat: assessment of possible future damage
 Challenge: assessment of potential to overcome and even
profit from the event
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Transactional Model of
Stress
Secondary appraisal:
 Initiated at the same time as primary
appraisal is occurring
 assessing if one’s coping abilities and
resources are sufficient to deal with
the stressor
 e.g. “I can’t do it”, “I’ll try but my chances of
success are slim”, “If this method doesn’t
work, I can try a few others”, “I can do it if I
work hard”, “No problem, I’ll make it”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Experience of Stress
Primary Appraisal:
Positive, neutral, or negative?
If negative, harmful, threatening, or
potentially challenging?
Stress:
Physiological,
cognitive,
emotional, and
behavioral
responses
Primary Stressor
Secondary Appraisal:
Are coping abilities and resources
sufficient to overcome the harm,
threat, or challenge?
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Transactional Model of
Stress
Stress
 subjective experience as a result of the
balance between primary and secondary
appraisal
 physiological, emotional, cognitive and
behavioral responses
 Some are involuntary, some are intentional as
conscious efforts to cope
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
IV. Stress Response
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Response
A) Physiological Responses
 through two systems:
 Sympathetic adrenomedullary (SAM) system
• Hypothalamus activates the sympathetic division of
the autonomic nervous system; adrenal glands
stimulated to release the hormone catecholamines
• Fight-or-flight response: Increased heart rate,
increased breathing, sweating, increased blood flow,
pupils dilate, digestive processes slow down,
increased muscle strength, increased mental activity
etc
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Response
 Hypothalmic-pituitary-adrenocortical (HPA) system
 Hypothalamus signals pituitary gland to secrete the
hormone ACTH which in turn stimulate the adrenal
cortex to secrete the hormone corticosteroids
 release of more protein and fat, increase of energy,
inhibit tissue inflammation in case of injury
 Increased level of opioids beta endorphins and
enkaphalin
 Immune function
 Psychiatric problems
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Physiological Changes and Their Functions
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Response
B) Emotional Responses
 Lazarus (1993): stress tends to elicit unpleasant rather then
pleasant emotions
 Study of relationship between stress and mood among 96
women over a 28-day period
 emotions commonly elicited:
 anxiety and fear
 sadness and grief
 Anger, annoyance, rage
 depression
 guilt
 shame
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Response
 Emotional arousal
• mild emotional arousal is useful
• strong emotional arousal can interfere with efforts
to cope with stress
• impairs attention, memory retrieval, judgment, and
decision making
• the inverted-U hypothesis (Anderson, 1990;
Mandler, 1993)
• relationship between emotional arousal and
task performance
• optimal level of arousal
• depends on task complexity
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Response
C) Behavioral Responses
 Coping efforts
• active efforts to master, reduce, or tolerate
the demands created by stress
• can be healthy (adaptive) or maladaptive
• positive: e.g. improving yourself, seeking
help from others
• negative: e.g. striking out at others, giving
up, social withdrawal, indulging oneself,
substance abuse
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
V. Assessing Stress
1.) Physiological measures
 acute stress paradigm
 Polygraph to measure and record heart
rate, blood pressure, respiration rate, and
GSR (galvanic skin response)
 Biochemical analyses:
 Blood, urine or saliva samples to measure
levels and changes in levels of catecholamines
and cortisol
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Polygraph
Calm
Tense
Assessing Stress
2.) Self-Report Measures
a.) Life Events: The Social Readjustment Rating
Scale
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
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43 major life events
Life events in the past year
Numerical value for each type of life event
SRRS total score: An index of the amount of
change-related stress the person has recently
experienced
 people with higher SRRS scores tend to be more
vulnerable to many kinds of physical and
psychological problems
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
SRRS
• 150 to 199: 33% chance of illness
• 200 to 299: 50% chance of illness
• 300+: 80% chance of illness
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
SRRS
 criticisms:
• some items are vague
• subjective experience
• context
• personal values and priorities
• whether the event has been
resolved
• measuring change or negative
experience?
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Assessing Stress
b.) Hassles Scale (Kanner, Coyne,
Schaeffer, & Lazarus, 1981)
 Measure of daily hassles
 Circle the hassles that have happened to you in
the past month, then indicate the severity of each
hassle using a scale of 1 (somewhat severe), 2
(moderately severe), or 3 (extremely severe)
 Samples of items: misplacing or losing things,
troublesome neighbors, social obligations, health
of a family member, inconsiderate smokers,
concerns about owing money
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Assessing Stress
c.) Perceived Stress Scale (Cohen, Kamarck, &
Mermelstein, 1983)
 Measure of level of subjectively perceived stress
 E.g.
 “In the last month, how often have you been upset
because of something that happened unexpectedly”
 “In the past month, how often have you felt nervous and
stressed”
 “In the past month, how often have you found that you
could not cope with all the things that you had to do?”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
VI. Adverse Effects of Stress
 On Psychological Functioning
 On Physical Health
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Adverse Effects of Stress on
Psychological Functioning
1.) Psychological Problems and Disorders
 stress related to insomnia, nightmares,
sexual difficulties, substance abuse, and
unhappiness
 anxiety disorders, depression,
schizophrenia, eating disorders etc
 Learned helplessness and depression
• When repeated efforts to exert control over
situations fail to achieve desired effects, learned
helplessness occurs
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Adverse Effects of Stress on
Psychological Functioning
2.) Cognitive Impairment and Impaired Task
Performance
 Cognitive costs:
 Less cognitive resources to deal with other
aspects of life
 Difficulty concentrating
• Distraction: focuses on body response and
worries instead of problems that need to be
solved
 Memory problems
 Impaired judgment
 Impaired problem-solving ability
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Adverse Effects of Stress on
Psychological Functioning
3.) Burnout
 physical, mental, and emotional exhaustion
that is attributable to long-term involvement
in emotionally demanding situations
Physical exhaustion
weakness
chronic fatigue
weariness
low energy
poor sleep
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Emotional exhaustion
depression
helpless
hopeless
reduced life satisfaction
feeling trapped
Mental exhaustion
negative attitude
impersonal
self doubt
impaired performance
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Adverse Effects of Stress on
Psychological Functioning
4.) Posttraumatic Stress Disorder
 Disturbance that occur after experiencing a
traumatic stressful event e.g. war, rape,
natural disasters, being held as hostage,
serious accident
 Symptoms of the stress experience persist
long after the event is over
 flashbacks, nightmares, anxiety, fear,
startle reaction, physiological arousal,
numbing, avoidance
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Adverse Effects of Stress on
Physical Health
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Adverse Effects of Stress on
Physical Health
 Three pathways (Baum, 1994):
• (1) Physiological
• (2) Health habits
• (3) Health behaviors
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
How stress may produce disease?
(Baum, 1994)
Stress
Direct Physiological effects
Health habit efforts
Health behavior effects
•elevated lipids
•elevated blood pressure
•decreased immunity
•increased hormonal
activity
•increased smoking, alcohol
use
•decreased nutrition
•decreased sleep
•increased drug use
•decreased compliance
•delayed in help-seeking
•obscured symptom profile
•decreased likelihood of
seeking care
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress and Illness
(1) Physiological
 Psychoneuroimmunology
 relationship between psychological factors and
nervous, endocrine, and immunological
changes
 stress results in increased blood pressure
and lipids level, and decreased immunity
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress and Illness
The role of SAM and HPA activation (Ogden,
2004):
 SAM activation
 Prolonged production of catecholamines can
result in:
 Increased blood pressure
 Increased heart rate
 Irregular heart beats
 Blood clot formation
 Fat deposits
 Immunosuppression
 Increase chances of heart disease, kidney disease, and
infection
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress and Illness
 HPA activation
 Prolonged production of cortisol can result
in:
 Decreased immune function
 Increase of fat stores in central visceral area
 Damage to neurons in the hippocampus
Increase chances of infection, psychiatric
problems, and deterioration of memory and
concentration
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress and Illness
 Meta-analysis (Herbert & Cohen, 1993)
• relation between stress and decreases in
immune measures
• objective stressful events related to larger
immune system decline than subjective
evaluations of stress
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress and Illness
 stress and infectious diseases e.g.
upper respiratory infections, herpes
 Kiecolt-Glaser et al. (1984) study of
immune response of medical students
one month before final exam, on the
first of the final exam, as well as
relationship with SRRS
 Cohen & Williamson’s (1991) study on
stress and common cold
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Cohen’s study on stress and
common cold
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress and Illness
(2) Health habits
 Stress leads to behavioral changes which
in turn put the individual at greater risk of
developing illnesses
 e.g. smoking, alcohol consumption,
carelessness
 (3) Health behaviors effects
 delay in help seeking
 decreased compliance
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
VII. Moderators of the
Stress-Illness Link
Not everyone who’s exposed to stressors
develop illness. Why?
 Coping
 Stress moderators
 Role in reducing:
 Stress experienced
 impact of stress on psychological response and
illness
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
The Coping Process
Tangible resource
such as money, time
The stressful
life events, its
stage, and
anticipated
future course
Appraisal and
interpretation
of the stressor
• primary appraisal
• secondary appraisal
Coping Responses
and strategies
for problem solving
and emotional
regulation
Usual
Coping
Style(s)
Antoinette M. Lee
Other life stressors such
as major life events
and daily hassles
Social Support
Coping tasks
• reduce harm
•tolerate or adjust
•maintain positive
self-image
•maintain emotion
equilibrium
•continue relationship
Other personality factors
that influence selection
of coping responses and
strategies
Master of Behavioral Health
Health Psychology Module, Spring 2005
Coping outcome
•psychological
functioning
•resumption of
usual activities
•physiological
changes, illness
Moderators of the Stress-Illness
Link
Stress moderators:
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






Personality
Tangible external resources
Other life stressors
Cognitive style
Humor
Social support
Physical fitness
Autonomic reactivity
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of the Stress-Illness
Link
1.) Personality
a. Hardiness (Kobasa, 1990; Kobasa et al.,
1994)
 Kobasa’s study of middle-and upper-level
business executives
 a collection of traits that buffer stress and is
related to both good physical health and good
mental health
 three characteristics of “hardy” people:
• (1) commitment
• (2) challenge
• (3) control
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of the Stress-Illness
Link
 Why?
 Hardy people may appraise potentially stressful
events more favorably
 Take more direct action to find out more about
the events and to learn from them what may be
of value for the future
 Use more active and constructive coping
strategies e.g. seeking social support, problemfocused coping
 More adaptive illness behaviors
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of the Stress-Illness
Link
1.) Personality
b. Negative affectivity
 a pervasive negative mood marked by anxiety,
depression, and hostility: “disease-prone
personality”
 Associated with elevated cortisol secretion
 More prone to have asthma, arthritis, ulcers,
headaches, and coronary artery disease
 Also associated to poorer adjustment to treatment
(e.g. coronary artery bypass surgery)
 However, negative affectivity may be associated
with reporting of higher levels of distressing
symptoms, thereby creating a false impression of
poor health
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of the Stress-Illness
Link
1.) Personality
b. Optimism
 general tendency to expect good outcomes
 surgical patients
• optimism related to faster recovery after coronary bypass
surgery
 optimists cope with stress in more adaptive ways than
pessimists
•
•
•
•
action-oriented
problem-focused
seek information and find social support
emphasizing the positive aspects of stressful events
 Versus pessimistic explanatory style
 Pessimism associated with suppressed immune function
 “defensive pessimism”: especially useful for Asians
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of the Stress-Illness
Link
1.) Personality
d. Perceived control and Self-efficacy
 Self-efficacy: beliefs that one can handle a task,
manage a stressor, and is in charge of one’s life
and well-being
 Psychological and biological (lower levels of
adrenaline) outcomes
 Role of health behaviors
 feeling in control reduces pain, improves
adjustment, and speed up recovery from some
diseases
 sense of control affects neuroendocrine and
immune system: study of old people in nursing
homes
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of Stress-Illness
Link
 Related issue: predictability
 ability to predict the onset of a stressor moderates its
impact
 sense of control
 prepare coping strategies, planning
 Locus of control (Rotter, 1990)
 internal locus of control versus external locus of control
 Cultural influences
• western cultures: primary control (changing others and
situation)
• eastern cultures: secondary control (changing one’s
goals and desires; accepting reality)
• a balance of the two!
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of Stress-Illness
Link
2.) Tangible external resources






time
money
education
decent job
children
standard of living
3.) Presence of other stressors in life
 Depletes resources
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of Stress-Illness
Link
4.) Coping Styles
 General propensity to deal with stressful
events in a particular way
 Avoidance versus Confrontative coping
 Effectiveness of each depends on the
situation, how long-term the stressor is
 Disclosure of emotional experiences:
inhibition leads to greater physiological
arousal
 Reduced physiological arousal
 More social support, more information, cognitive
effects
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of Stress-Illness
Link
5.) Sense of Humor
 Redefines the stressful situation in a less
threatening way
 Martin and Lefcourt (1983)’s study:
students who were able to produce humor
in difficult situations were less affected by
negative life events
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of Stress-Illness
Link
6.) Social support
 people with high social support are less
distressed by stress
 Forms of support:
 emotional concern / support
 instrumental support
 informational support
 appraisal (feedback)
 socializing
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Role of Social Support
High
Low High
social
support
Low
social
support
High
Social
Support
High
Social
Support
Low
Low
Low
High
Buffering
Hypothesis
Antoinette M. Lee
Low
High
Direct Effects
Hypothesis
Master of Behavioral Health
Health Psychology Module, Spring 2005
Role of Social Support
 Buffering Hypothesis
 social support can buffer stress at 2 points:
• (1) affects appraisal of stressors (perceive
stressors as less threatening)
• (2) intervene between the experience of stress
and the onset of illness
 Direct Effects Hypothesis
 Sense of belonging and feelings of selfesteem  positive outlook
 Healthy lifestyles
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of Stress-Illness
Link
7.) physical fitness (Brown, 1991)
- stress-buffering effects of subjective
and objective fitness
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Moderators of Stress-Illness Link
8.) Autonomic Reactivity
 Those with a more placid ANS (especially
cardiovascular reactivity) tends to be less affected
by stress
 Subjects exposed to stressful tasks in laboratory
settings show fairly consistent inter-individual
differences in cardiovascular reactivity over time
and across a variety of tasks
 Some people are more prone to cardiovascular diseases
because of their cardiovascular reactivity
 Genetic basis
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
VIII. Coping with Stress
 Definition of coping:
• the process of managing demands (external or
internal) that are appraised as taxing or exceeding
the resources of the person (Lazarus & Folkman,
1984)
• One’s constantly changing cognitive and
behavioral efforts to manage specific external
and/or internal demands that are appraised as
taxing or exceeding one’s resources (Lazarus &
Folkman, 1984)
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Functions of coping
 Alter the problem causing the stress
 Regulate the emotional response to the
problem
Two general types of coping strategies
 Problem-focused coping
 Emotion-focused coping
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Problem-focused coping
 Aims at constructively reducing the
demands of the stressful situation or
expanding the resources to deal with it
 E.g. quitting a stressful job, improving
one’s abilities, seeking medical or
psychological treatment
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Emotion-focused coping
 Aims at controlling the emotional
response to the stressful situation
 Two approaches:
 Behavioral, e.g. using alcohol, seeking
emotional support from friends or relatives
 Cognitive, e.g. denying unpleasant facts
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Ways of Coping
(Problem-focused)
1.) Planful problem-solving
• Deliberate, problem-focused efforts to solve
the situation
• E.g. “I’ve been trying to come up with a
strategy about what to do”
2.) Confrontive coping
• Taking assertive action (often involving anger
or risk-taking) to change the situation
• E.g. I stood my ground and fought for what I
wanted”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Ways of Coping
(Problem-focused)
3.) Seeking social support
• Efforts to acquire information support from
others
• E.g. I talked to someone to find out more
about the situation”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Ways of Coping
(Emotion-focused)
4.) Distancing
• Detaching oneself from the stressful
situation or create a positive outlook
• E.g. “I didn’t let it get to me. I refused to
think about it too much”
5.) Escape/avoidance
• Wishful thinking or efforts to escape or
avoid the situation
• E.g. “I wished that the situation would go
away”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Ways of Coping
(Emotion-focused)
6.) Self-control
• Efforts to regulate one’s own feelings or
action
• E.g. “I tried to keep my feelings to myself”
7.) Accepting responsibility
• Acknowledging one’s role in the problem
• E.g. “I criticized or lectured myself”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Ways of Coping
(Emotion-focused)
8.) Positive reappraisal
• Efforts to find positive meaning in the experience
• E.g. “I’ve been looking for something good in what
is happening”
9.) Seeking social support
• Trying to acquire emotional support
• E.g. “I’ve been getting emotional support from
others”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Ways of Coping
(Emotion-focused)
10.) Emotional discharge
• Expressing or releasing feelings about a
stressful situation
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Ways of Coping
Problem-focused
Emotion-focused
Increase attention to stressful
situation
Tend to promote avoidance of
the problem
More effective in the long run
Benefit coping in the short run
(the first couple of weeks)
Emerge during childhood
Develop in late childhood or
early adolescence
More popular with men or
people with higher incomes
and educational levels
More popular with women or
people with less income and
education
Used when people believe
Used when people believe they
their resources or the
can do nothing to change the
demands of the situation are
stressful conditions
changeable
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Ways of Coping
 Patterns in using different coping methods
• Consistent in the way people cope with a
particular type of stressor (Stone & Neale, 1984)
• People seldom use just one method to cope
(Holahan & Moos, 1985)
• Different methods are used in coping with shortterm and long-term stressors (Aldwin & Brustrom,
1997)
• Twin studies suggested genetic influence on
choice of coping styles (Busjahn, Faulhaber,
Freier, & Luft, 1999)
• But not for denial
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Putting it All Together
Dynamics of a Stressful Encounter: Cognitive Appraisal,
Coping, and Encounter Outcomes (Folkman et al., 1985)
• A lack of information about:
– Contextual variables that influence coping
processes
– the relation among appraisal, coping, and
the outcomes of specific stressful
encounters
• Folkman and colleagues (1985)
conducted an intraindividual approach
to the problem
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Methods
• Participants:
– 75 married couples
– Mean age of women: 39.6
– Mean age of men: 41.4
• Procedures:
– Interviewed once a month for 6 months
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Instruments
• Primary appraisal:
– What was at stake in a stressful encounter
– 13 items on a 5-point Likert scale on various stakes:
• Self-esteem, concern for loved one’s well-being, loss of respect
for someone else, goal at work, strain on finances, and harm to
own physical health
• Secondary appraisal:
– Assessed with 4 items on a 5-point Likert scale that
described coping options:
• Could change, had to accept, need more information, and hand
to hold back
• Coping:
– Revised Ways of Coping Questionnaire
– 67 items on a 4-point Likert scale that described 8 ways of
coping
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Relation between Primary Appraisal and Coping
Self-esteem
stakes
Confrontive
coping

Concern for
loved one’s
well being

Loss of
respect for
someone else
Goal at work

Strain on
finances
Harm to own
physical
health

Distancing
Selfcontrolling




Seeking social
support
Accepting
responsibility

Escapeavoidance

Planful
problemsolving




Positive
reappraisal
Note: All coping methods were used in each encounter.
“ “ indicates that more of that was used when the particular stake was high than when the stake was low.
Antoinette M. Lee
Master of Behavioral Health
Health Psychology
Spring 2005
Folkman Module,
et al., Journal
of Personality and Social Psychology. 1986; 50(5): 992-1003.
Relation between Secondary Appraisal and Coping
Could change
Confrontive coping
Had to accept
Need more
information

Distancing


Self-controling

Seeking social
support

Accepting
responsibility
Positive reappraisal


Escape-avoidance
Planful problemsolving
Had to hold back





Note: All coping methods were used in each encounter.
“ “ indicates that more of that was used the coping option was more used.
Antoinette M. Lee
Master of Behavioral Health
Health Psychology
Spring 2005
Folkman Module,
et al., Journal
of Personality and Social Psychology. 1986; 50(5): 992-1003.
Results
• Primary Appraisal and Coping:
– Threats to self-esteem:
• used more confrontive coping, self-control coping,
accepted more responsibility and used more escapeavoidance
• less social support
– When “loved one’s well being” was at stake:
• Used more confrontive and escape-avoidance coping
• less planful problem-solving and distancing
– When “loss of respect for someone else” was
threatened:
• More confrontive coping and self-control
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Results
• Primary Appraisal and Coping:
– Threats to “goal at work”:
• More self-control and planful problem-solving coping
– Strain on “financial resources”:
• More confrontive coping and seeking social support
– Threats to “one’s own physical health”:
• More seeking of social support and escape-avoidance
– Self-control, escape-avoidance and seeking social
support were used more in high-stake conditions
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Results
• Secondary Appraisal and Coping:
– “Could change” encounters:
• More accepting responsibility, confrontive coping, planful
problem-solving, and positive reappraisal
– “Had to accept” encounters:
• More distancing and escape-avoidance
– “Need more information” encounters:
• More social support, self-control and planful problemsolving
– “Had to hold back” encounters:
• More confrontive coping, self-control and escapeavoidance
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Results
• Coping and Outcomes:
– Significant difference in coping between
unsatisfactory and satisfactory outcomes,
F(8, 76) = 4.64, p<.001
– Satisfactory outcomes:
• higher levels of planful problem-solving and
positive reappraisal
– Unsatisfactory outcomes:
• Higher levels of confrontive coping
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Results
• Primary Appraisal and Outcomes:
– Significant difference in stakes in
encounters with unsatisfactory and
satisfactory outcomes, F(6,77) = 2.74, p
= .018
– Encounters with unsatisfactory outcomes
were associated with more loss of respect
than with satisfactory outcomes
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Results
• Secondary Appraisal and Outcomes:
– Significant difference in the appraisal of
coping options in encounters with
satisfactory and unsatisfactory outcomes,
F(4, 80) = 5.65, p<.001
– Encounters with satisfactory outcomes
were associated with higher levels of
changeability and lower levels of the need
to hold back from doing what one wanted
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Implications
• Variability in coping is partially a
function of:
– people’s judgment about what is at stake
(primary appraisal) in specific stressful
encounters, and
– what they view as the options for coping
(secondary appraisal)
• Bidirectional relations rather than causal
ones exist among appraisal, coping and
outcomes
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
IX. Stress Management
• Pharmacological approach
• Psychological approach
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management:
Pharmacological Approach
• Reduce physiological arousal, feelings of
stress, and stress response
• Benzodiazepines, eg. Valium and Librium
– Activate a neurotransmitter that decreases neural
transmission in the central nervous system
• Beta-blockers, eg Inderal
– Block the activity of sympathetic neurons in the
peripheral nervous system that are stimulated by
epinephrine and norepineephrine
• Analgesic to reduce pain from headache,
muscle tension
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management:
Psychological Approach
Basic principle
 aims at manipulating the environment to
remove stressors, or to change our
response patterns to cushion their
harmful effects
 Tailored to individual needs
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management
1.
2.
3.
4.
5.
6.
Understanding stress
Reducing stressors
Changing appraisal
Reducing response to stress
Improve coping
Strengthening buffers
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management:
Psychological Approach
1. Understanding Stress
 Sources of stress, stress response, transactional model of
stress
 Monitoring one’s stress
 Identify stressors
 Stress response
 Coping
2. Reducing stressors
 Clarify goals
• Long-term goals and short-term goals
• Realistic goal-setting
 Minimize non-essentials
 Avoid certain stressors
 Preparation
 Time management
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Time management
 Causes of wasted time:
•
•
•
•
inability to set priorities
inability to say no
inability to delegate responsibility
inability to accept anything less than perfect
 Myths
• Being busy and active I the best way to get the most done
• The best way to deal with my time problems is to work
harder
• I am the only person who can do the job (well).
• If I do things well, I am using my time wisely
• The is no need to plan for day-to-day activities
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Time Management
 Time management:
• monitor use of time: use daily log
• clarify goals
– Realistic
– Set long term goals and prioritise
– Make short-term goals based on long-term goals
• plan activity using a schedule
– Make sure you set aside time for yourself to relax
and think, and for pleasurable activities
– Do not schedule activity every minute of the day
• find out your prime time and protect it
• increase efficiency
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management
3. Changing Appraisal
 Cognitive restructuring
 Ellis’ Rational-Emotive Therapy
 Challenging and changing irrational beliefs
 Changing self-talk
 Beck’s Cognitive Therapy
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management
• Rational-emotive therapy (RET) (Ellis, 1962,
1977, 1987)
 A-B-C-D-E paradigm:
• A – activating event
• B – beliefs and thoughts that go through the person’s
mind in response to A
• C – emotional and behavioral consequences
• D – disputing of irrational beliefs
• E – therapy’s effect, a restructured belief system and
philosophy
 Irrational beliefs
• “mustabatory thoughts”
• catastrophizing
• Global evaluations
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management
 Beck’s cognitive therapy
• Negative cognitive triad
• Automatic negative thoughts
• Collaborative empiricism
• Hypothesis-testing approach
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management
4. Reducing response to stress





Relaxation
Meditation
Biofeedback
Taking time-off, vacation
Exercise
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management:
Psychological Approach
 Relaxation
• Breathing exercise
• Progressive muscle relaxation
• People focus attention on specific muscle groups while
alternately tightening and relaxing these muscles
(Sarafino, 2001)
• Guided imagery
• Things to note
• Meditation
• People who receive training show less
cardiovascular reactivity to stressors and stronger
immune function (Lucini et al., 1997; Sherman,
Carlson, McCubbin, & Wilson, 1997)
• Idiosyncratic forms of relaxation
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Benson’s Relaxation Response

Herbert Benson and colleague at the
Harvard Medical School

As opposed to the fight-or-flight response

Quieting the body’s response to stress

Not automatic, needs to be learned and
practiced
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Benson’s Relaxation Response
 2 main techniques to bring about the relaxation
response:
1. Focusing one’s mind on a repetitive phrase, word, breath or
action
2. Adopting a passive attitude
 + comfortable posture, quiet/stable environment
 Brings about both immediate and long-term effects
(when regularly practiced)
– Immediate: lowering of BP, heart rate, breathing rate, and
oxygen consumption (measure of metabolic rate)
– Long-term: alter body’s response to adrenalin, decrease in
anxiety
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Benson’s Relaxation Procedure
1. Sit quietly in a comfortable position
2. Close your eyes
3. Deeply relax all your muscles,
beginning at your feet and progressing
up to your face
4. Breathe through your nose; become
aware of your breathing. As you
breathe out, say the word “one”
silently to yourself
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Benson’s Relaxation Procedure
5. Continue for 10 to 20 minutes. You
may open your eyes to check the time
but do not use alarm. When you finish,
sit quietly for severa
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management:
Behavioral Methods
 Biofeedback
 An electromechanical device monitors the status
of a person’s physiological processes, such as
heart rate or muscle tension
 Immediately reports that information back to the
individual
 Enables the person to gain voluntary control over
these processes through operant conditioning
 Reinforces whatever efforts the individual made to
accomplish the decrease in tension
 Successful in treating stress-related health
problems
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management:
Behavioral Methods
• Exercise
 Detoxification of stress-related compounds
 As an outlet for negative emotions
 Reducing muscle tension and counteracting the
physiological response to stress
 Moving meditation (e.g. jogging)
 Enhance feelings of self efficacy and improves
self-esteem
 Doing something that is beneficial to oneself
 Sense of mastery
 Social support
 Improves sleep
 Enhances physical fitness (a stress moderator)
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress-Inoculation Training
(Meichenbaum & Cameron, 1983)
•
•
•
•
Learn coping skills and then practice using
the skills while being exposed to one or
more stressors
Analogous to immunization
Coping skills as “psychological antibodies”
Three phases:
1. Conceptualization
2. Coping Skills Acquisition and Rehearsal
3. Application and Follow Through
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress-Inoculation Training
1. Conceptualization
 Educational:
• Emphasize the role of appraisal
– Past stressful experiences may be used as
illustration
• Coping skills can be learned
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management:
Psychological Approach
5. Improve coping



Seeking help
Releasing pent-up emotions
Problem-solving skills




Antoinette M. Lee
Define the problem
Generate alternative courses of action
Evaluate the pros and cons of each course
and deciding on a course of action
Implementation and evaluation
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress Management
6. Strengthening Buffers




Social support
Enhance commitment, control and challenge
Enhance self-efficacy and self-esteem
Cultivate a sense of humour
 Redefining the stressful situation in a less threatening
manner
 Physical fitness
 Sleep
 Diet
 Exercise
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress-Inoculation Training
2. Skills Acquisition and Rehearsal
 Learning of general and specific coping skills
 General:
 (i) cognitive restructuring
 Changing negative thoughts
 Coping self-statements, e.g.:
 “Just think about what I can do about it. It’s
better then getting anxious.”
 “One step at a time. I can handle the situation.”
 “Relax, I’m in control. Take a deep breath.”
 “Don’t assume the worst or jump to conclusions”
 “The tension I’m feeling is a signal for me to start
using my coping strategies”
 “Keep the focus on the present; what do I have
to do?”
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress-Inoculation Training
 (ii) problem-solving self-instructions
 Examples:
 Viewing the stressful situation as a problem
(“This is not the end of the world, just a problem
to be solved”)
 Breaking the stressful situation into smaller units
(“How can I break this thing down so I can
tackle one piece at a time?”)
 Problem-solving (“What’s my goal? What would
I like to happen?”, “Set up a plan of action. What
is the first thing to do?”)
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress-Inoculation Training
 (iii) self-reinforcement / self-efficacy self-instructions
 Self-reinforcement / self-efficacy self-instructions to
reinforce oneself to continue to use coping skills, e.g.:
 “Keep it up. You’re doing great!”
 “I’m getting better and better at this.”
 “Hang in there. You’re coping well.”
 “I’m not doing as well as I would like but I do feel good
that I’m continuing to try. Next time it will be better.”
 (iv) relaxation
 Specific: depends on the situation, e.g.
communication skills, assertiveness skills,
parenting skills, study skills
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stress-Inoculation Training
3. Application and Follow-Through
• Applying the coping skills to stressful
situations
– Initially, in therapy sessions:
» Visualization of stressful situations
» Role-plays
– When coping skills are adequately mastered,
homework assignments to gradually expose
the person to real-life stress
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Insomnia
• Primary Insomnia
• Chief complaint is nonrestorative sleep, difficulty in initiating
sleep, or difficulty in maintaining sleep
• Continues for at least one month (For ICD-10, the
disturbance must occur at least 3 times a week for a month)
• Independent of any known physical or mental condition
• Patients with primary insomnia often preoccupied with
getting enough sleep
• Secondary Insomnia
• Secondary to / symptom of an underlying medical or
psychological condition
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Treatment of Primary Insomnia
• Medication
• Effectiveness?
• Side effects
• Problem of dependence
• Sleep hygiene
• Stimulus control
• Reassurance that health is not at risk
even if one does not get 6-8 hours of
sleep
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Sleep Hygiene
• Arise at the same time daily
• Limit daily in-bed time to the usual amount before the
sleep disturbance
• Avoid compensation sleep and daytime nap
• Avoid caffeine-including coke, nicotine, alcohol, and
stimulants
• Establish physical fitness by means of a graded
program of vigorous exercise early in the day
• Avoid evening stimulation
• Hot 20-minute bath soak near bedtime
• Eat at regular times daily; avoid large meals near
bedtime
• Practice evening relaxation routines
• Maintain comfortable sleeping conditions
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Stimulus Control
• Get into bed only when you are sleepy
• Bed used only for sleeping (and
perhaps, sex)
• Get out of bed and go to another room if
you cannot sleep within 15 minutes and
return to bed only when you feel sleepy
• Go to bed the same time every night
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005
Multiple Roles
Impact of:
 Number of Roles
 Scarcity hypothesis
 Enhancement hypothesis
 Specific Role Combinations
 Mainly focus on paid worker, wife, and
mother roles
 Role quality
Antoinette M. Lee
Master of Behavioral Health
Health Psychology Module, Spring 2005