mes asses. exam 1 (1-4)

marriage

MARRIAGE The majority of Americans marry at some time in their lives. Marriage continues to remain popular because it satisfies several basic needs. There are many important social, moral, economic, and political aspects of marriage, all of which have changed over the years. In the past people married mainly for practical reasons, such as raising children or forming an economic unit. Today people marry more for personal, emotional reasons. The Benefits of Marriage The primary functions and benefits of marriage are those of any intimate relationship: affection, personal affirmation, companionship, sexual fulfillment, and emotional growth. Marriage also provides a setting in which to raise children, although an increasing number of couples choose to remain childless, and people can also choose to raise children without being married. Marriage is also important for providing for the future. By committing themselves to the relationship, people hope to establish themselves with lifelong companions as well as some insurance for their later years. Research shows that good marriages have myriad positive effects on individuals' health. Issues and Trends in Marriage Marital roles and responsibilities have undergone profound changes over time. Many couples no longer accept traditional role assumptions, such as that the husband is solely responsible for supporting the family and the wife is solely responsible for domestic work. Many husbands share domestic tasks, and many wives work outside the home. About 60% of married women are in the labor force, including women with babies under one year of age. Although women still take most of the responsibility for home and children even when they work and although men still suffer more job-related stress and health problems than women do, the trend is toward an equalization of responsibilities in the home. Other recent trends include couples choosing not to marry, couples marrying later—after a lengthy cohabitation, and couples marrying without a formal marriage certificate. A second, later-life union (cohabitation or marriage) is also common. A recent study reports that both women and men experienced health benefits from second unions; from first unions, men in particular had reduced emotional distress from getting married without first living together. What about love? Although we might like to believe otherwise, love is not enough to make a successful marriage. Relationship problems can become magnified rather than solved by marriage. The following relationship characteristics appear to be the best predictors of a happy marriage: The partners have realistic expectations about their relationship. Each feels good about the personality of the other. Partners develop friendships with other couples. They communicate well. They have effective ways of resolving conflicts. They agree on religious/ethical values. They have an egalitarian role relationship. They have a good balance of individual versus joint interests and leisure activities. Once married, couples must provide each other with emotional support, negotiate and establish marital roles, establish domestic and career priorities, handle their finances, make sexual adjustments, manage boundaries and relationships with their extended family, and participate in the larger community. The Role of Commitment Studies show that commitment not only brings stability to a relationship but also is essential to overcoming the inevitable ups and downs experienced in relationships. Commitment is based on conscious choice rather than on feelings, which, by their very nature, are transitory. Commitment is a promise of a shared future—a promise to be together, come what may. No matter how they feel, committed partners put effort and energy into the relationship. They take time to attend to their partners, give compliments, and deal with conflict when necessary. Commitment has become an important concept in recent years. To many people, commitment is the most important part of a relationship. Separation and Divorce Although the rates have dropped since the year 2000 (Figure 4.3), divorce is still fairly common in the United States. Those who have never experienced divorce personally—either Page 105their own or that of their parents—almost certainly have friends or relatives who have. The high rate of divorce in the United States may reflect our extremely high expectations for emotional fulfillment and satisfaction in marriage. It may also indicate that our culture no longer embraces the concept of marriage as permanent. Bar chart with divorce and annulment rates by year, showing a decline from 4.0 in 2000 to 3.2 in 2014. [D] FIGURE 4.3 Divorces and annulments: United States, 2000-2014. source: CDC/NCHS National Vital Statistics System (http://www.cdc.gov/nchs/nvss/marriage_divorce_tables.htm). The process of divorce usually begins with an emotional separation. Often one partner is unhappy and looks for a more satisfying relationship. Dissatisfaction increases until the unhappy partner decides he or she can no longer stay. Physical separation follows, although it may take some time for the relationship to be over emotionally. Except for the death of a spouse or family member, divorce may be the greatest stress-producing event in life. Studies show that divorced women are more likely to develop heart disease than married, remarried, or widowed women. Both men and women experience turmoil, depression, and lowered self-esteem during and after divorce. People experience separation distress and loneliness for about a year and then begin a recovery period of one to three years. During this time they gradually construct a postdivorce identity, along with a new pattern of life. Most people are surprised how long it takes to recover from divorce. Children are especially vulnerable to the trauma of divorce, and sometimes counseling is appropriate to help them adjust to the change. However, recent research has found that children who spend substantial time with both parents are usually better adjusted than those in sole custody and are as well-adjusted as their peers from intact families. Coping with divorce has been found to be difficult for children at any age, including adult children. Despite the distress of separation and divorce, the negative effects are usually balanced sooner or later by the possibility of finding a more suitable partner, constructing a new life, and developing new aspects of the self. About 75% of all people who divorce remarry, often within five years. One result of the high divorce and remarriage rate is a growing number of stepfamilies. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION How do you define "commitment" in a relationship? Is it simply a matter of staying faithful to a partner, or is there more? In your own relationships, what signs of commitment do you look for from your partner? What signs of commitment does your partner see in you?

managing stress

MANAGING STRESS You can control the stress in your life by taking the following steps: Shore up your support system. Improve your communication skills. Develop healthy exercise and eating habits. Learn to identify and moderate individual stressors. Learn mindfulness skills. Adequate sleep is another key strategy for managing stress and for improving your overall wellness. Sleep is described in detail in the next section. The effort required for stress management is well worth the time. People who manage stress effectively not only are healthier but also have more time to enjoy life and accomplish goals. Social Support Having the support of friends and family members contributes to the well-being of body and mind. Research supports this conclusion and demonstrates the value of affiliation or connectedness, as the following examples demonstrate: A study of college students living in overcrowded apartments revealed that those with a strong social support Page 42system were less distressed by their cramped quarters than were the loners who navigated life's challenges on their own. Young adults who have strong relationships with their parents tend to cope with stress better than peers with poor parental relationships. Many studies show that married people live longer than single people (including those who are divorced, widowed, or never married) and have lower death rates from practically all causes. Social support can provide a critical counterbalance to the stress in our lives. Give yourself time to develop and maintain a network of people you can count on for emotional support, feedback, and nurturing. If you believe you don't have enough social support, consider becoming a volunteer to help build your network of friends and to enhance your spiritual wellness. QUICK STATS 53% of adults say they feel good about themselves after exercising, 35% say it puts them in a good mood, and 30% say they feel less stressed. —American Psychological Association, 2014 Volunteering Studies show that not all giving is the same—for example, donating money does not have the same beneficial health effects as volunteering that involves personal contact. A few simple guidelines can help you get the most out of giving: Choose a volunteer activity that puts you in contact with people. Volunteer with a group. Sharing your interests with other volunteers increases social support. Volunteering seems to have the most benefits for people who also have other close relationships and social interests. Know your limits. Helping that goes beyond what you can handle depletes your own resources and is detrimental to your health. Communication Communicating in an assertive way that respects the rights of others—while protecting your own rights—can prevent stressful situations from getting out of control. Some people have trouble either telling others what they need or saying no to the needs of others. They may suppress their feelings of anger, frustration, and resentment, and they may end up feeling taken advantage of or suffering in unhealthy relationships. At the other extreme are people who express anger openly and directly by being verbally or physically aggressive or indirectly by making critical, hurtful comments to others. Because their abusive behavior pushes away other people, they also have problems with relationships. Better communication skills can help everyone form and maintain healthy relationships. Chapter 3 includes a discussion of anger and its impact on health and relationships. Chapter 4 discusses communication techniques for building healthy relationships. Exercise Exercise helps maintain a healthy body and mind and even stimulates the birth of new brain cells. Regular physical activity can also reduce many of the negative effects of stress. Consider the following examples: Taking a long walk can decrease anxiety and blood pressure. A brisk 10-minute walk can leave you feeling more relaxed and energetic for up to two hours. People who exercise regularly react with milder physical stress responses before, during, and after exposure to stressors. In one study, people who took three brisk 45-minute walks each week for three months reported fewer daily hassles and an increased sense of wellness. These findings should not be surprising because the stress response mobilizes energy resources and readies the body for physical emergencies. If you experience stress and do not physically exert yourself, you are not completing the energy cycle. You may not be able to exercise while your daily Page 43stressors occur—during class, for example, or while sitting in a traffic jam—but you can be active at other times of the day. Physical activity allows you to expend the nervous energy you have built up and trains your body to more readily achieve homeostasis following stressful situations. Couple is raking leaves. Exercise—even light activity—can be an antidote to stress. © Nick Daly/Getty Images Nutrition A healthful diet gives you an energy bank to draw from whenever you experience stress. Eating wisely also can enhance your feelings of self-control and self-esteem. Learning the principles of sound nutrition is easy, and sensible eating habits rapidly become second nature when practiced regularly. (For information about nutrition and healthy eating habits, see Chapter 12.) For managing stress, limit or avoid caffeine. Although one or two cups of coffee a day probably won't hurt you, caffeine is a mildly addictive stimulant that leaves some people jittery, irritable, and unable to sleep. Consuming caffeine during stressful situations can raise blood pressure and increase levels of cortisol. Although your diet affects the way your body handles stress, the reverse is also true. Excess stress can negatively affect the way you eat. Many people, for example, respond to stress by overeating; other people skip meals or stop eating altogether during stressful periods. Not only are both responses ineffective (they don't address the causes of stress), but they are also potentially unhealthy. Time Management Learning to manage your time can be crucial to coping with everyday stressors. Overcommitment, procrastination, and even boredom are significant stressors for many people. Try these strategies for improving your time management skills: Set priorities. Divide your tasks into three groups: essential, important, and trivial. Focus on the first two, and ignore the third. Schedule tasks for peak efficiency. You've probably noticed you're most productive at certain times of the day (or night). Schedule as many of your tasks for those hours as you can, and stick to your schedule. Set realistic goals and write them down. Attainable goals spur you on. Impossible goals, by definition, cause frustration and failure. Fully commit yourself to achieving your goals by putting them in writing. Budget enough time. For each project you undertake, calculate how long it will take to complete. Then tack on another 10-15%, or even 25%, as a buffer. Break up long-term goals into short-term ones. Instead of waiting for large blocks of time, use short amounts of time to start a project or keep it moving. Visualize the achievement of your goals. By mentally rehearsing your performance of a task, you will be able to reach your goal more smoothly. Keep track of the tasks you put off. Analyze why you procrastinate. If the task is difficult or unpleasant, look for ways to make it easier or more fun. Consider doing your least favorite tasks first. Once you have the most unpleasant ones out of the way, you can work on the tasks you enjoy more. Consolidate tasks when possible. For example, try walking to the store so that you run your errands and exercise in the same block of time. Identify quick transitional tasks. Keep a list of 5- to 10-minute tasks you can do while waiting or between other tasks, such as watering your plants, doing the dishes, or checking a homework assignment. Delegate responsibility. Asking for help when you have too much to do is no cop-out; it's good time management. Just don't delegate the jobs you know you should do yourself. Say no when necessary. If the demands made on you don't seem reasonable, say no—tactfully, but without guilt or apology. Give yourself a break. Allow time for play—free, unstructured time when you can ignore the clock. Don't consider this a waste of time. Play renews you and enables you to work more efficiently. Avoid your personal "time sinks." You can probably identify your own time sinks—activities that consistently use up more time than you anticipate and put you behind schedule, like watching television, surfing the Internet, or talking on the phone. On particularly busy days, avoid these problematic activities altogether. For example, if you have a Page 44big paper due, don't sit down for a five-minute TV break if that's likely to turn into a two-hour break. Try a five-minute walk instead. Stop thinking or talking about what you're going to do, and just do it! Sometimes the best solution for procrastination is to stop waiting for the right moment and just get started. You will probably find that things are not as bad as you feared, and your momentum will keep you going. Managing the many commitments of adult life—including work, school, and parenthood—can produce a great deal of stress. Time management skills, including careful scheduling with a date book, smartphone, or tablet, can help people cope with busy days. © Cathy Yeulet/123RF Cultivating Spiritual Wellness Spiritual wellness is associated with more effective coping skills and higher levels of overall wellness. It is a very personal wellness component, and there are many ways to develop it. Researchers have linked spiritual wellness to longer life expectancy, reduced risk of disease, faster recovery, and improved emotional health. Although spirituality is difficult to study, and researchers aren't sure how or why spirituality seems to improve health, several explanations have been offered: Social support. Attending religious services or joining a weekly meditation group as well as investing time participating in volunteer organizations helps people feel that they are part of a community with similar values and promotes social connectedness and caring. Healthy habits. Some paths to spiritual wellness encourage healthy behaviors, such as eating a vegetarian diet or consuming less meat and alcohol, while discouraging harmful habits like smoking. Positive attitude. Spirituality can give a person a sense of meaning and purpose, and these qualities create a more positive attitude, which in turn helps her or him cope with life's challenges. Moments of relaxation. When invested in practices like meditation and prayer, people can feel profound states of relaxation and are no longer caught up in thoughts and habits of mind that create distress. Spiritual wellness does not require participation in organized religion. Many people find meaning and purpose in other ways. Spending time appreciating the marvels in nature or working to care for the environment are powerful ways to feel continuity with the natural world. Spiritual wellness may also come through helping others in your community or by promoting human rights, peace, and harmony among people globally through art, the written word, or personal relationships. Spiritual wellness can make you more aware of your personal values and can help clarify them. Living according to values means considering your options carefully before making a choice, choosing between options without succumbing to outside pressures that oppose your values, and making a choice and acting on it rather than doing nothing. Confiding in Yourself through Writing Keeping a diary is analogous to confiding in others, except that you are confiding in and becoming more attuned to yourself. This form of coping with severe stress may be especially helpful for those who find it difficult to open up to others. Although writing about traumatic and stressful events may have a short-term negative effect on mood, over the long term, stress is reduced and positive changes in health occur. A key to promoting health and well-being through journaling is to write about your emotional responses to stressful events. Set aside a special time each day or week to write down your feelings about stressful events in your life. Cognitive Techniques Some stressors arise in your own mind. Ideas, beliefs, perceptions, and patterns of thinking can add to your stress level. Each of the following techniques can help you change unhealthy thought patterns to ones that will help you cope with stress (also see the box "Mindfulness Meditation"). As with any skill, mastering these techniques takes practice and patience. TAKE CHARGE: Mindfulness Meditation Mindfulness meditation is a powerful way to manage stress and has been the topic of an enormous body of medical research since 1979. At the center of this research is mindfulness-based stress reduction (MBSR), which as a program continues to be the mindfulness intervention most intensively researched to this day. This research demonstrates that when it comes to stress and its influence on health, you can do far more for yourself than anyone else can. MBSR was founded by Jon Kabat-Zinn in 1979 at the University of Massachusetts Medical Center and is now offered in over 800 medical centers, hospitals, and clinics around the United States and many more hospitals and medical centers around the world, such as the Scripps Center for Integrative Medicine, Duke Integrative Medicine, and the Myrna Brind Center for Integrative Medicine at Jefferson. MBSR classes are taught by physicians, nurses, social workers, counselors, and psychologists as well as other non-health professionals who have invested themselves in becoming MBSR teachers. At the core of this model is a philosophy of health based on the inherent wholeness and interconnectedness of everyone and an understanding that in a very real way, no matter what health condition you are coping with, "there is more right with you than there is wrong with you." In practice, this program facilitates an active partnership in which patients or clients seeking help with stress take on significant responsibility for doing interior work to tap into their own deepest inner resources for learning, growing, and healing. Mindfulness is both a mental state and the practices that cultivate this mental state. We cultivate this mental state by paying attention in a kind way to our mental, physical, and behavioral activities as they happen. By investing this kind of attention in ourselves and our lives, we soon discover that we all create most of our own stress, and that we can each do more than anyone else can to reduce that stress and take better care of ourselves. Here are two practices to use for stress reduction. Mindful Breathing You are always breathing, so this is a powerful and convenient way to become present wherever you go and in whatever you do. After you read these instructions, please close your eyes and invest 5-15 minutes in being present with your breath. Sitting comfortably where you are right now, bring your body into a posture that is upright and supported, with a sense of balance and dignity. See if you can align your head, neck, and body in a way that is neither too rigid nor too relaxed, but somewhere in between. The intention is to be wakeful and alert, yet not tense; at ease, but not sleeping. Bring attention to your breathing, wherever you feel it most prominently and notice the sensations of your breath coming and going as it will, in its own way and with its own pace. If your mind wanders from your breath, return to it by feeling the sensations of the breath as they come and go. Use these sensations as your way to be present, here and now, in each successive moment for the time you have set aside. Research has repeatedly demonstrated that extending this practice to 30 or 45 minutes on a regular basis significantly reduces stress and stress-related illnesses and conditions. Walking Meditation Find a place where you can walk and be uninterrupted by other people or traffic—if possible, in natural surroundings, like in a park. You can adapt this practice to fit yourself, whatever your circumstances are with mobility—for example, it can become a mindful-rolling practice if you rely on a wheelchair. Once you're ready, begin walking—slowly at first (as slowly as possible for about 10 minutes)—paying close attention to each step and using the sensations of each foot touching the ground as your way to be present. When you are ready, accelerate your pace, broadening your attention to take in more of your experience as you walk. In this mindful-movement practice, you may walk any distance, anywhere, at any speed that feels right for you. In the beginning, however, give yourself about 30 minutes. The principal instruction is to be fully present in each moment you are walking rather than consumed with mind chatter or destination. Be open to the experience of your environment and notice, for example, the way clouds move or how the sunlight glistens in the trees and foliage around you. Turn toward whatever calls your attention and be with it as long as you like, stopping if you want to take a close look at a bug or flowers or to listen to the rustling of leaves. Remember, the overarching intention is to be mindful, to be in this experience of the now. In other words, shift to experiential presence and away from the usual conceptual and discursive activities of mind. As you become more skilled in mindful awareness practice, you will be able to do this anywhere, even on a bustling college campus. If you want to pick up the speed or duration of your walk, you can make this walking practice part of a regular exercise program, and you will grow in strength and cardiovascular health as well as mindfulness. Mindfulness is a lifetime engagement—not to get somewhere else, but to be where and as you are in this very moment, whether the experience is pleasant, unpleasant, or neutral. The more you invest in the practice, the more you draw forth and nourish the mental state of mindfulness with which you were born. Think and Act Constructively Think back to the worries you had last week. How many of them were needless? By growing more aware of the ways you habitually think and feel, you can learn to recognize habits of mind that create distress and divest from them before they overwhelm you. Think about things you can control, particularly your way of looking at things. Try to stand aside from the problem, consider more effective steps you can take to solve it, and then carry them out. Remember that between a stimulus and a response there is a space, and in that space lies your freedom and power. In other words, if you can successfully recognize that a stressor is occurring, you can better control your response to it. In the evening, invest energy in considering how you may better promote the things you want individually or socially. This may mean reflecting on how you may better deal with an unpleasant person or stay focused in a class you find boring. By taking a constructive approach, you can prevent stressors from becoming negative events and perhaps even turn them into positive experiences. Take Control A situation often feels more stressful if you feel you're not in control of it. Time may seem to be slipping away before a big exam, for example. Unexpected obstacles may appear in your path, throwing you off course. When you feel your environment is controlling you instead of the other way around, take charge! Concentrate on what you can control rather than what you cannot, and set realistic goals. Be confident of your ability to succeed. Problem-Solve Students with greater problem-solving abilities report easier adjustment to university life, higher motivation levels, lower stress levels, and higher grades.Page 46 When you find yourself stewing over a problem, sit down with a piece of paper and try this approach: Define the problem in one or two sentences. Identify the causes of the problem. Consider alternative solutions. Don't just stop with the most obvious one. Weigh positive and negative consequences for each alternative. Make a decision—choose a solution. Make a list of tasks you must perform to act on your decision. Carry out the tasks on your list. Evaluate the outcome and revise your approach if necessary. Modify Your Expectations Expectations are exhausting and restricting. The fewer expectations you have, the more you can live spontaneously and joyfully. The more you expect from others, the more often you will feel let down. And trying to meet the expectations others have of you is often futile. Stay Positive If you tend to beat up on yourself—"Late for class again! You can't even cope with college! How do you expect to ever hold down a real job?"—try being kind to yourself instead. Talk to yourself as you would to a child you love: "You're a smart, capable person. You've solved other problems; you'll handle this one. Tomorrow you'll simply schedule things so you get to class with a few minutes to spare." Practice Affirmations One way of cultivating the positive is to systematically repeat positive thoughts, or affirmations, to yourself. For example, if you react to stress with low self-esteem, you might repeat sentences such as "I accept myself completely" and "It doesn't matter what others say, but what I believe." Say kinder and more loving things to yourself every day to promote more responding and less reacting. Cultivate Your Sense of Humor When it comes to stress, laughter may be the best medicine. It is said, "He who can laugh at himself will never cease to be amused!" Even a fleeting smile produces changes in your autonomic nervous system that can lift your spirits. A few minutes of belly laughing can be as invigorating as brisk exercise. Hearty laughter elevates your heart rate, aids digestion, eases pain, and triggers the release of endorphins and other pleasurable and stimulating chemicals in the brain. After a good laugh, your muscles go slack; your pulse and blood pressure dip below normal. You are relaxed. Cultivate the ability to laugh at yourself, and you'll have a handy and instantly effective stress reliever. Focus on What's Important A major source of stress is trying to store too much data. Forget unimportant details (they will usually be self-evident) and organize important information. One technique you can try is to "chunk" important material into categories. If your next exam covers three chapters from your textbook, consider each chapter a chunk of information. Then break down each chunk into its three or four most important features. Create a mental outline that allows you to trace your way from the most general category down to the most specific details. This technique can be applied to managing daily responsibilities as well. Body Awareness Techniques Research conducted by neuroscientist Richard Davidson suggests that practicing mindfulness promotes stronger connections between the prefrontal cortex and the amygdala areas of the brain. This connection has been demonstrated to facilitate greater problem-solving skills, emotional self-regulation, and resilience. In a recent University of California study, researchers reported that schoolteachers who took an eight-week mindfulness-based stress-reduction course were less anxious and depressed and had a greater ability to face a stressor than those in a control group. Similarly, a 2009 Massachusetts General Hospital study involving before-and-after magnetic resonance imaging (MRI) brain scans showed the program reduced the gray matter density in the amygdala, which correlated with participants feeling less stressed. Practicing mindfulness has been shown to be particularly effective in devaluing bothersome thoughts and enabling presence and emotional balance to occur at their own pace. Yoga Hatha yoga, the most common yoga style practiced in the United States, emphasizes physical balance and breath control. It integrates components of flexibility, muscular strength and endurance, and muscle relaxation; it also sometimes serves as a preliminary to meditation. A session of yoga typically involves a series of postures, each held for a few seconds to several minutes, which involve stretching and balance and coordinated breathing. Yoga can be a powerful way to cultivate body awareness, ease, and flexibility. If you are interested in trying yoga, take a class with an experienced instructor. Tai Chi This martial art (in Chinese, taijiquan) is a system of self-defense that incorporates philosophical concepts from Taoism and Confucianism. In addition to self-defense, tai chi aims to bring the body into balance and harmony to promote health and spiritual growth. It teaches practitioners to remain calm and centered, to conserve and concentrate energy, and to manipulate force by becoming part of it—by "going with the flow." Tai chi is considered the gentlest of the martial arts. Instead of quick and powerful movements, tai chi consists of a series of slow, fluid, elegant movements, which reinforce the idea of moving with rather than against the stressors of everyday life. As with yoga, it's best to start tai chi with a class led by an experienced instructor.Page 47 Qigong Qigong (pronounced "chee-gung") originates in China and has as its goal the restoration of energy and balance to the body. It is used to relieve stress and chronic pain through various exercises of flowing movements, visualization, and breathing while assuming postures. Although its popularity is rising, there is no scientific evidence so far that it helps relieve stress or pain. Counterproductive Coping Strategies College is a time when you'll learn to adapt to new and challenging situations and gain skills that will last a lifetime. It is also a time when many people develop counterproductive and unhealthy habits in response to stress. Such habits can last well beyond graduation. Tobacco Use Many young adults who never smoked in high school smoke their first cigarette in college, usually at a party or in a dorm with friends. Many smokers report that smoking helps them cope with stress by providing a feeling of relaxation, giving them something to do with their hands in social situations, or breaking up monotony and routine. Cigarettes and other tobacco products contain nicotine, a chemical that enhances the actions of neurotransmitters. Nicotine can make you feel relaxed and even increase your ability to concentrate, but it is highly addictive. In fact, nicotine dependence itself is considered a psychological disorder. Cigarette smoke also contains substances that cause heart disease, stroke, lung cancer, and emphysema. These negative consequences far outweigh any beneficial effects, and tobacco use should be avoided. The easiest way to avoid the habit is to not start. See Chapter 11 for more about the health effects of tobacco use and for tips on how to quit. QUICK STATS 37.7% of college-age Americans binge-drink. —Substance Abuse and Mental Health Services Administration, 2015 Use of Alcohol and Other Drugs Like nicotine, alcohol is addictive, and many alcoholics find it hard to relax without a drink. Having a few drinks might make you feel temporarily at ease, and drinking until you're intoxicated may help you forget your current stressors. However, using alcohol to deal with stress places you at risk for all the short- and long-term problems associated with alcohol abuse. It also does nothing to address the causes of stress in your life. Although limited alcohol consumption may have potential health benefits for some people, many college students have patterns of drinking that detract from wellness. For more about the responsible use of alcohol, refer to Chapter 10. Using other psychoactive drugs to cope with stress is also usually counterproductive: Stimulants, such as amphetamines, can activate the stress response. They also affect the same areas of the brain that are involved in regulating the stress response. Use of marijuana causes a brief period of euphoria and decreased short-term memory and attentional abilities. Physiological effects clearly show that marijuana use doesn't cause relaxation; in fact, some neurochemicals in marijuana act to enhance the stress response, and getting high on a regular basis can elicit panic attacks. To compound this, withdrawal from marijuana may also be associated with an increase in circulating stress hormones. Opioids such as morphine and heroin can mimic the effects of your body's natural painkillers and act to reduce anxiety. However, tolerance to opioids develops quickly, and many users become dependent. Tranquilizers such as Valium and Xanax mimic some of the functions of your body's parasympathetic nervous system, and as with opioids, tolerance develops quickly, causing increased dependency and toxicity. For more information about the health effects of using psychoactive drugs, see Chapter 9. Unhealthy Eating Habits The nutrients in the food you eat provide energy and substances needed to maintain your body. Eating is also psychologically rewarding. The feelings of satiation and sedation that follow eating produce a relaxed state. However, regular use of eating as a means of coping with stress may lead to unhealthy eating habits. In fact, a survey by the American Psychological Association revealed that about 25% of Americans use food as a means of coping with stress or anxiety. These "comfort eaters" are twice as likely to be obese as average Americans. Certain foods and supplements are sometimes thought to fight stress. Carbohydrates may reduce the stress response by promoting activity of the parasympathetic nervous system; however, a high-carbohydrate diet can lead to weight gain in sedentary people and is not recommended as a strategy for coping with stressors. In addition, some evidence suggests that greater ingestion of carbohydrates, simple sugars, and fatty foods may be a predisposing factor for psychological distress. Many dietary supplements are marketed for stress reduction, but supplements are not required to meet the same standards as medications in terms of safety, effectiveness, and manufacturing (see Chapters 12 and 20). Getting Help What are the most important sources of stress in your life? Are you coping successfully with them? No single strategy or program for managing stress will work for everyone. The most important starting point for a successful stress management plan is to learn to listen to your body. When you Page 48recognize the stress response and the emotions and thoughts that accompany it, you'll be in a position to take charge of that crucial moment and handle it in a healthy way. If the techniques discussed so far don't provide you with enough relief, you might need to look further. Excellent self-help guides can be found in bookstores or the library. Additional resources are listed in the "For More Information" section at the end of the chapter. Your student health center or student affairs office can tell you whether your campus has a mindfulness-based stress-reduction program. If you are seeking social support, see if your campus offers a peer counseling program. Such programs are usually staffed by volunteer students with special training that emphasizes maintaining confidentiality. Peer counselors can guide you to other campus or community resources or can simply provide understanding. Support groups are typically organized around a particular issue or problem. In your area, you might find a support group for first-year students; for reentering students; for single parents; for students of your race or ethnicity, religion, or national origin; for people with eating disorders; or for rape survivors. The number of such groups has increased in recent years as more and more people discover how therapeutic it can be to talk with others who share the same situation. Short-term psychotherapy can also be tremendously helpful in dealing with stress-related problems. Your student health center may offer psychotherapy on a sliding-fee scale; the county mental health center in your area may do the same. If you belong to any type of religious organization, check to see whether pastoral counseling is available. Your physician can refer you to psychotherapists in your community. Not all therapists are right for all people, so be prepared to have initial sessions with several. Choose the one with whom you feel most comfortable.

meeting life's challenges with a positive self concept

Page 62 MEETING LIFE'S CHALLENGES WITH A POSITIVE SELF-CONCEPT Life is full of challenges—large and small. Everyone, regardless of heredity and family influences, must learn to cope successfully with new situations and new people. For emotional and mental wellness, each of us must continue to cultivate an adult identity that enhances our self-esteem and autonomy. We must also learn to communicate honestly, handle anger and loneliness appropriately, and avoid being defensive. Growing Up Psychologically Our responses to life's challenges influence the development of our personality and identity. Psychologist Erik Erikson proposed that development proceeds through a series of eight stages that extend throughout life. Each stage is characterized by a conflict or turning point—a time of increased vulnerability as well as increased potential for psychological growth (Table 3.1). Table 3.1 Erikson's Stages of Development AGE CONFLICT IMPORTANT PEOPLE TASK Birth-1 year Trust vs. mistrust Mother, father, or other primary caregiver In being fed and comforted, developing the trust that others will respond to your needs 1-3 years Autonomy vs. shame and self-doubt Parents In toilet training, locomotion, and exploration, learning self-control without losing the capacity for assertiveness 3-6 years Initiative vs. guilt Family In playful talking and locomotion, developing a conscience based on parental prohibitions that are not too inhibiting 6-12 years Industry vs. inferiority Neighborhood and school In school and playing with peers, learning the value of accomplishment and perseverance without feeling inadequate Adolescence Identity vs. identity confusion Peers Developing a stable sense of who you are—your needs, abilities, interpersonal style, and values Young adulthood Intimacy vs. isolation Close friends, sex partners Learning to live and share intimately with others, often in sexual relationships Middle adulthood Generativity vs. self-absorption Work associates, children, community Doing things for others, including parenting and civic activities Older adulthood Integrity vs. despair Humankind Affirming the value of life and its ideals source: Erikson, E. 1963. Childhood and Society. New York: Norton. The successful mastery of one stage is a basis for mastering the next, so early failures can have repercussions in later life. Fortunately, life provides ongoing opportunities for mastering these tasks. For example, although the development of trust begins in infancy, it is refined as we grow older. We learn to trust some people outside our immediate family and to identify others as untrustworthy. Developing an Adult Identity A primary task beginning in adolescence is the development of an adult identity: a unified sense of self, characterized by attitudes, beliefs, and ways of acting that are genuinely our own. People with adult identities know who they are, what they are capable of, what roles they play, and their place among their peers. They have a sense of their own uniqueness but also appreciate what they have in common with others. They view themselves realistically and can assess their strengths and weaknesses without relying on the opinions of others. Achieving an identity also means that we can form intimate relationships with others while maintaining a strong sense of self. Our identities evolve as we interact with the world and make choices about what we'd like to do and whom we'd like to model ourselves after. Developing an adult identity is particularly challenging in a heterogeneous, secular, and relatively affluent society like ours, in which many roles are possible, many choices are tolerated, and ample time is allowed for experimenting and making up your mind. This idea of a core self may seem contradictory to the idea that we are always changing. We show different sides of ourselves, not just as we pass through different ages, but also from one day to the next, depending on whom we're with or the environment we're in. Early identities are often modeled after parents and adult caregivers—or the opposite of parents, in rebellion against what they represent. Over time, peers, rock stars, sports heroes, and religious figures are added to the list of possible role models. In high school and college, people often join cliques that assert a certain identity, such as "jocks," "nerds," or "slackers." Although much of our identity is internal—a way of viewing ourselves and the world—certain aspects of it can be external, such as styles of talking and dressing, ornaments like earrings, and hairstyles. Early identities are rarely permanent. A hardworking student seeking approval one year can turn into a dropout Page 63devoted to sleeping all day and partying all night the next year. At some point, however, most of us adopt a more stable, individual identity that ties together the experiences of childhood and the expectations and aspirations of adulthood. Erikson's theory does not suggest that one day we suddenly assume our final identity and never change after that. Life is more interesting for people who continue evolving into more distinct individuals, rather than being rigidly controlled by their pasts. Identity reflects a lifelong process, and it changes as a person develops new relationships and roles. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Write down times when you felt Free Aloof Angry Generous Happy Talkative For each moment you recall, who were you with when you felt those ways? What had recently happened in your life? Where were you? Did you feel most "yourself" in any of those moments? Which? Developing an adult identity is an important part of psychological wellness. Without a personal identity, we begin to feel confused about who we are. Erikson called this situation an identity crisis. Until we have "found ourselves," we cannot have much self-esteem because a self is not firmly in place. Developing Intimacy People with established identities can form intimate relationships and sexual unions characterized by sharing, open communication, long-term commitment, and love. Those who lack a firm sense of self may have difficulty establishing relationships because they feel overwhelmed by closeness and the needs of another person. As a result, they experience only short-term, superficial relationships with others and may remain isolated. Developing Values and Purpose in Your Life Erikson assigned his last two stages, generativity versus self-absorption and integrity versus despair, to middle adulthood and older adulthood, respectively. But these stages concern values that need to be addressed by young people and reexamined throughout life. Values are criteria for judging what is good and bad, and they underlie our moral decisions and behavior. The first morality of the young child is to consider "good" to mean what brings immediate and tangible rewards, and "bad" to mean whatever results in punishment. An older child will explain right and wrong in terms of authority figures and rules. But the final stage of moral development, one that not everyone attains, is being able to conceive of right and wrong in more abstract terms such as justice and virtue. As adults we need to assess how far we have evolved morally and what values we have adopted. Without an awareness of our personal values, our lives may be hurriedly driven forward by immediate desires and the passing demands of others. Living according to values means Considering your options carefully before making a choice Choosing among options without succumbing to outside pressures that conflict with your values Making a choice and acting on it rather than doing nothing Your actions and how you justify them proclaim to others what you stand for. Achieving Healthy Self-Esteem Having a healthy level of self-esteem means regarding your self—which includes all aspects of your identity—as good, competent, and worthy of love. It is a critical component of wellness. Developing a Positive Self-Concept Ideally a positive self-concept begins in childhood, based on experiences both within the family and outside it. Children need to develop a sense of being loved and being able to give love and to accomplish their goals. If they feel rejected or neglected by their parents, they may fail to develop feelings of self-worth. They may grow to have a negative concept of themselves. Another component of self-concept is integration. An integrated self-concept is one that you have made for yourself—not someone else's image of you or a mask that doesn't quite fit. Important building blocks of self-concept are the personality characteristics and mannerisms of parents, which children may adopt without realizing it. Later they may be surprised to find themselves acting like one of their parents. Eventually such building blocks may be reshaped and integrated into a new, individual personality. Another aspect of self-concept is stability. Stability depends on the integration of the self and its freedom from contradictions. People who have gotten mixed messages about themselves from parents and friends may have contradictory self-images, which defy integration and make them vulnerable to shifting levels of self-esteem. At times they regard themselves as entirely good, capable, and lovable—an ideal self—and at other times they see themselves as entirely Page 64bad, incompetent, and unworthy of love. Neither of these extreme self-concepts allows people to see themselves or others realistically, and their relationships with other people are filled with misunderstandings and ultimately with conflict. A positive self-concept begins in infancy. The knowledge that he's loved and valued by his parents gives this baby a solid basis for lifelong psychological health. © Purestock/PunchStock RF The concepts we have about ourselves and others are an important part of our personalities. And all the components of our self-concepts profoundly influence our interpersonal relationships. Meeting Challenges to Self-Esteem As an adult, you sometimes run into situations that challenge your self-concept. People you care about may tell you they don't love you or feel loved by you, for example, or your attempts to accomplish a goal may end in failure. You can react to such challenges in several ways. The best approach is to acknowledge that something has gone wrong and try again, adjusting your goals to your abilities without radically revising your self-concept. Less productive responses are denying that anything went wrong and blaming someone else. These attitudes may preserve your self-concept temporarily, but in the long run they keep you from meeting the challenge. The worst reaction is to develop a lasting negative self-concept in which you feel bad, unloved, and ineffective—in other words, to become demoralized. Instead of coping, the demoralized person gives up (at least temporarily), reinforcing the negative self-concept and setting in motion a cycle of bad self-concept and failure. In people who are genetically predisposed to depression, demoralization can progress to additional symptoms, which are discussed later in the chapter. Notice Your Patterns of Thinking One method for fighting demoralization is to recognize and test the negative thoughts and assumptions you may have about yourself and others. Note exactly when an unpleasant emotion—feeling worthless, wanting to give up, feeling depressed—occurs or gets worse, to identify the events or daydreams that trigger that emotion, and to observe whatever thoughts come into your head just before or during the emotional experience. Keep a daily journal about such events. Avoid Focusing on the Negative Imagine that you are waiting for a friend to meet you for dinner, but he's 30 minutes late. What kinds of thoughts go through your head? You might wonder what caused the delay: Perhaps he is stuck in traffic, you think, or needs to help a roommate who has the flu. This kind of reaction is healthy for several reasons: You aren't jumping to a conclusion or blaming your friend for a failure. After all, he probably hasn't forgotten about you or decided to ditch you. You are being reasonable by giving your friend the benefit of the doubt. Things happen. Your friend probably has a good reason for not being there. He deserves a chance to explain and may need your help dealing with the situation that made him late. You avoid personalizing the situation in such a way that you feel hurt or betrayed. Jumping to a negative conclusion (such as "He isn't coming because he doesn't really like me") can make you feel bad unnecessarily. The same thing happens if you place blame—either on your friend or yourself—without knowing all the facts. By contrast, people who are demoralized tend to use all-or-nothing thinking. They overgeneralize from negative events. They overlook the positive and jump to negative conclusions, minimizing their own successes and magnifying the successes of others. They take responsibility for unfortunate situations that are not their fault, then jump to more negative conclusions and more unfounded overgeneralizations. Patterns of thinking that make events seem worse than they are in reality are called cognitive distortions. Develop Realistic Self-Talk When you react to a situation, an important piece of that reaction is your self-talk—the statements you make to yourself inside your own mind. To Page 65pick up on our earlier example, suppose your friend is late for a dinner date. As you wait for your friend to arrive, your self-talk has a profound effect on your reaction to his lateness. Someone who is demoralized or wrestling with a poor self-concept might immediately react with negative self-talk: "He isn't coming. It's my fault; he probably doesn't like me because I'm boring. I bet he's with someone else." In your own fight against demoralization, you may find it hard to think of a rational response until hours or days after the event that upset you. Responding rationally can be especially hard when you are having an argument with someone else, which is why people often say things they don't mean in the heat of the moment or develop hurt feelings even when the other person had no intention of hurting them. Once you get used to noticing the way your mind works, however, you may be able to catch yourself thinking negatively and change the process before it goes too far. This approach to controlling your reactions is not the same as positive thinking—which means substituting a positive thought for a negative one. Instead you simply try to make your thoughts as logical and accurate as possible, based on the facts of the situation as you know them, and not on snap judgments or conclusions that may turn out to be false. Demoralized people can be tenacious about their negative beliefs—so tenacious that they make their beliefs come true in a self-fulfilling prophecy. For example, if you conclude that you are so boring that no one will like you anyway, you may decide not to bother socializing. This behavior could make the negative belief become a reality because you limit your opportunities to meet people and develop new relationships. For additional tips on changing distorted, negative ways of thinking, see the box "Realistic Self-Talk." TAKE CHARGE: Realistic Self-Talk Do your patterns of thinking make events seem worse than they truly are? Do negative beliefs you have about yourself become self-fulfilling prophecies? Substituting realistic self-talk for negative self-talk can help you build and maintain self-esteem and cope better with the challenges in your life. Here are some examples of common types of distorted, negative self-talk, along with suggestions for more accurate and rational responses: COGNITIVE DISTORTION NEGATIVE SELF-TALK REALISTIC SELF-TALK Focusing on negatives Babysitting is such a pain in the neck; I wish I didn't need the extra money so bad. This is a tough job, but at least the money's decent and I can study once the kids go to bed. Expecting the worst I know I'm going to get an F in this course. I should just drop out of school now. I'm not doing too well in this course. I should talk to my professor to see what kind of help I can get. Overgeneralizing My hair is a mess and I'm gaining weight. I'm so ugly. No one would ever want to date me. I could use a haircut and should try to exercise more. This way I'll start feeling better about myself and will be more confident when I meet people. Minimizing It was nice of everyone to eat the dinner I cooked, even though I ruined it. I'm such a rotten cook. Well, the roast was a little dry, but they ate every bite. The veggies and rolls made up for it. I'm finally getting the hang of cooking! Blaming others Everyone I meet is such a jerk. Why aren't people friendlier? I am going to make more of an effort to meet people who share my interests. Expecting perfection I cannot believe I flubbed that solo. They probably won't even let me audition for the orchestra next year. It's a good thing I didn't stop playing when I hit that sour note. It didn't seem like anyone noticed it as much as I did. Believing you're the cause of everything Tom and Sara broke up, and it's my fault. I shouldn't have insisted that Tom spend so much time with me and the guys. It's a shame Tom and Sara broke up. I wish I knew what happened between them. Maybe Tom will tell me at soccer practice. At any rate, it isn't my fault; I've been a good friend to both of them. Thinking in black and white I thought that Mike was really cool, but after what he said today, I realize we have nothing in common. I was really surprised that Mike disagreed with me today. I guess there are still things I don't know about him. Magnifying events I stuttered when I was giving my speech today in class. I must have sounded like a complete idiot. I'm sure everyone is talking about it. My speech went really well, except for that one stutter. I bet most people didn't even notice it, though. Page 66 Psychological Defense Mechanisms—Healthy and Unhealthy We are always trying to manage our feelings, even if we aren't aware we are doing it. We try to manage uncomfortable feelings through what are called psychological defenses. By using defense mechanisms, we change unacceptable feelings (like shame or anger or anxiety) into ones with which we are more comfortable. Table 3.2 lists some standard defense mechanisms. Defense mechanisms can be healthy and adaptive—such as humor and altruism—but sometimes they are what are called maladaptive. For example, it would be maladaptive to displace your anger at your teacher by yelling at your roommates because doing so doesn't help your relationship with your teacher or your roommates. The drawback of many defenses is that they make feelings better temporarily but don't address underlying causes. Table 3.2 Defense and Coping Mechanisms MECHANISM DESCRIPTION EXAMPLE Projection Reacting to unacceptable impulses by denying their existence in yourself and attributing them to others A student who dislikes his roommate feels that the roommate dislikes him. Repression Keeping an unpleasant feeling, idea, or memory out of awareness The child of an alcoholic, neglectful father remembers only when her father showed consideration and love. Denial Refusing to acknowledge to yourself what you really know to be true A person believes that smoking cigarettes won't harm her because she's young and healthy. Displacement Shifting your feelings about a person to another person A student who is angry with one of his professors returns home and yells at one of his housemates. Dissociation Detaching from a current experience to avoid emotional distress Rather than listen to his angry father, Beethoven composes a piece in his mind. Rationalization Giving a false, acceptable reason when the real reason is unacceptable A shy young man decides not to attend a dorm party, telling himself he'd be bored. Reaction formation Concealing emotions or impulses by exaggerating the opposite ones A person who dislikes children frequently buys expensive gifts for, and speaks with enthusiasm about, the children of her friends. Substitution Replacing an unacceptable or unobtainable goal with an acceptable one A man in love with an unavailable partner throws himself into training for a marathon. Acting out Engaging in an action that makes an unacceptable feeling go away A person who feels disrespected and devalued gets into a fight at a bar with a stranger. Humor Finding something funny in unpleasant situations A student whose bicycle has been stolen thinks how surprised the thief will be when he or she starts downhill and discovers the brakes don't work. Altruism Serving others without expecting anything in return A person who grew up in an upper-class neighborhood volunteers at a foundation that helps people get out of poverty. Recognizing our own defense mechanisms can be difficult because we are not aware of them, as they occur unconsciously. But we all have some inkling about how our minds operate. By remembering the details of conflict situations, a person may be able to figure out which defense mechanisms she or he used in successful or unsuccessful attempts to cope. Recall a psychologically stressful situation and view yourself as an objective outside observer would; now analyze your thoughts and behavior in that situation. Having insight into what strategies you typically use can lead to new, more rewarding and effective ways of coping. Being Optimistic Most of us have a predisposition toward optimism or pessimism. Pessimism is a tendency to focus on the negative and expect an unfavorable outcome; optimism is a tendency to emphasize the hopeful and expect a favorable outcome. Pessimists not only expect repeated failure and rejection but also accept it as deserved. They do not see themselves as capable of success and irrationally dismiss any evidence of their own accomplishments. This negative point of view is learned, typically at a young age from parents and other authority figures. Optimists, by contrast, consider bad events to be temporary and consider failure to be limited and look forward to new pursuits. You can learn to be optimistic by recording adverse events in a diary, along with the reactions and beliefs with which you met those events. By doing so, you learn to recognize and dispute the false, negative predictions you generate about yourself, like "The problem is going to last forever and ruin everything, and it's all my fault." Refuting such negative self-talk frees energy for realistic coping.Page 67 Maintaining Honest Communication Another important area of psychological functioning is communicating honestly with others. It can be very frustrating for us and for people around us if we cannot express what we want and feel. Others can hardly respond to our needs if they don't know what those needs are. We must recognize what we want to communicate and then express it clearly. Some people know what they want others to do but don't state it clearly because they fear denial of the request, which they interpret as personal rejection. Such people might benefit from assertiveness training: learning to insist on their rights and to bargain for what they want. Assertiveness includes being able to say no or yes depending on the situation. Communicating your feelings appropriately and clearly is important. For example, if you tell people you feel sad, they may have various reactions. If they feel close to you, they may express an intimate thought of their own. Or they may feel guilty because they think you're implying they have caused your sadness. They may even be angry because they feel you expect them to cheer you up. Depending on your intention and your prediction of how a statement will be taken, you may or may not wish to make it. For example, if you say, "I feel like staying home tonight," you may also be implying something different. You could really mean "Don't bother me." Or you mean that you're open to a negotiation: "I would be willing to do something else if the conditions are right." Although keeping your real thoughts and feelings to yourself may help you avoid a confrontation (or even a discussion) with someone, it is unfair because you are not really being clear about what you want. Good communication means expressing yourself clearly. You don't need any special psychological jargon to communicate effectively. Dealing with Loneliness It can be hard to strike the right balance between being alone and being with others. Some people are motivated to socialize from fear of being alone. If you discover how to enjoy being by yourself, you'll be better able to cope with periods when you're forced to be alone—for example, when you are no longer in a romantic relationship or when your usual friends are away on vacation. Unhappiness with being alone may come from interpreting it as a sign of rejection—that others are not interested in spending time with you. Before you reach such a conclusion, be sure that you give others a real chance to get to know you. Examine your patterns of thinking: You may harbor unrealistic expectations about other people—for example, that everyone you meet must like you and, if they don't, you must be flawed. You might also consider the possibility that you expect too much from new acquaintances, and, sensing this, they start to draw back, triggering feelings of rejection. Not everyone you meet is suitable and willing to have a close or intimate relationship. Feeling pressure to have such a relationship may lead you to connect with someone whose interests and needs are remote from yours or whose need to be cared for leaves you with little time of your own. You may have traded loneliness for potentially worse problems. College offers many antidotes to loneliness in the forms of clubs, organized activities, sports, and just hanging out with friends. © Hero Images/Getty Images Loneliness is a passive feeling state. If you decide that you're not spending enough time with people, change the situation. College life provides many opportunities to meet people. If you're shy or introverted, you may have to push yourself to join a group. Look for something you've enjoyed in the past or in which you have a genuine interest. Dealing with Anger Anger is a part of the array of normal emotions, yet it is often confusing and difficult to deal with. Some people feel that expressing anger is beneficial for psychological and physical health. However, if angry words or actions damage relationships or produce feelings of guilt or loss of control, they do not contribute to psychological wellness. It is important to distinguish between a destructive expression of anger and a reasonable level of self-assertiveness. At one extreme are people who never express anger or any opinion that might offend others, even when their own Page 68rights and needs are being jeopardized. They may be trapped in unhealthy relationships or chronically deprived of satisfaction at work and at home. If you have trouble expressing your anger, consider training in assertiveness and appropriate expressions of anger to help you learn to express yourself constructively. At the other extreme are people whose anger is explosive or misdirected—such expression of anger can signal a condition called intermittent explosive disorder (IED). It may also be a symptom of a more serious problem—angry outbursts, for instance, are associated with posttraumatic stress disorder. Explosive anger may also happen during periods of intoxication with alcohol or drugs such as amphetamines or cocaine. Explosive anger or rage, like a child's tantrum, renders an individual temporarily unable to think straight or to act in his or her own best interest. During an IED episode, a person may lash out uncontrollably, hurting someone else physically or verbally, or destroying property. Anyone who expresses anger this way should seek professional help. Some studies have suggested that overtly hostile people seem to be at higher risk for heart attacks. Managing Your Anger If you feel explosive anger coming on, consider the following two strategies to head it off. First, try to reframe what you're thinking at that moment. You'll be less angry at another person if there is a possibility that his or her behavior was not intentionally directed against you. Imagine that another driver suddenly cuts in front of you. You would certainly be angry if you knew the other driver did it on purpose, but you probably would be less angry if you knew he simply did not see you. If you're angry because you've just been criticized, avoid mentally replaying scenes from the past when you received other unjust criticisms. Think about what is happening now, and try to act differently than you would have in the past—less defensively and more analytically. Second, until you're able to change your thinking, try to distract yourself. Use the old trick of counting to 10 before you respond, or start concentrating on your breathing. If necessary, cool off by leaving the situation until your anger has subsided. This does not mean that you should permanently avoid the sensitive topics. Return to the matter after you've had a chance to think clearly about it. QUICK STATS In 2014, an estimated 43.6 million adults age 18 and older in the United States had a mental illness. This number represented 18.1% of all U.S. adults. —National Institute of Mental Health, 2015 Dealing with Anger in Other People Anger can be infectious, and it disrupts cooperation and communication. If someone you're with becomes very angry, respond "asymmetrically" by reacting not with anger but with calm. Try to validate the other person by acknowledging that he or she has some reason to be angry: "I totally get that this is making you mad," or "If I were you, I'd be upset, too." This does not mean apologizing if you don't think you're to blame, or accepting verbal abuse. It means that you have considered the other's perspective and that you understand why she might be angry. Finally, if the person cannot be calmed, it may be best to disengage, at least temporarily. After a time-out, you may have better luck trying to solve the problem rationally. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Think about the last time you were truly angry. What triggered your anger? How did you express it? Do you typically handle your anger in the same manner? How appropriate does your anger-management technique seem?y

communication

COMMUNICATION The key to developing and maintaining any type of intimate relationship is good communication. Most of the time we don't think about communicating; we simply talk and behave naturally. But when problems arise—when we feel others don't understand us or when someone accuses us of not listening—we become aware of our limitations or, more commonly, what we think are other people's limitations. Miscommunication creates frustration and distances us from our friends and partners. Nonverbal Communication Even when we're silent, we're communicating. We send messages when we look at someone or look away, lean forward or sit back, smile or frown. Especially important forms of nonverbal communication are touch, eye contact, and proximity. If someone we're talking to touches our hand or arm, looks into our eyes, and leans toward us when we talk, we get the message that the person is interested in us and cares about what we're saying. If a person keeps looking around the room while we're Page 96talking or takes a step backward, we get the impression the person is uninterested or wants to end the conversation. The ability to interpret nonverbal messages correctly is important to the success of relationships. It's also important, when sending messages, to make sure our body language agrees with our words. When our verbal and nonverbal messages don't correspond, we send a mixed message. Attunement, or tuning in to each other's tone of voice, is important. More than any other cue, tone of voice conveys most accurately a person's emotional state. Our effectiveness at connecting or reconnecting emotionally with another depends on the accuracy of our attunement. Effective attunement recreates a healthy child-caregiver connection, or it provides a connection that was lacking during childhood. How we feel when communicating with another can give the listener important data about the speaker. If "out of nowhere" we begin to feel sad, anxious, or angry, these may be emotional states the other person is communicating. An example would be feeling sad when communicating with a grieving friend. Digital Communication and Our Social Networks Social media enable us to communicate more rapidly, but some experts question whether this capability is undermining interpersonal relations generally and, specifically, our ability to relate to others in person. Some evidence suggests just the opposite is true: Surveys by the Pew Internet and American Life Project found that technology users had larger and more diverse discussion networks and were just as involved in their communities as people who communicate face-to-face. Many young adults (aged 18-29 years) who were in a serious relationship reported feeling closer to their spouse or partner due to online or text-message conversations. Some said they were able to resolve arguments that they couldn't face-to-face. Social media tools afford wide-ranging types of communication. For example, the brief immediacy of a tweet is very different from an extended conversation over Skype. However, people often overlook these distinctions, and some observers worry about the effect of the technologies because they change the nature of the social environment and the size and makeup of social networks. Facebook, for example, facilitates relationships with people we have shared interests with but may never meet in person. These relationships are achieved, rather than ascribed to us, like the relationships with relatives and neighbors. Some people view these achieved relationships as weaker or less valuable than the ascribed ones, but these relationships do not necessarily take away from stronger ones. The bottom line is that social media can be an advantage or a disadvantage, depending on how one uses them. For instance, social media allow for instant and easy communication with others across the globe. This can offer a tremendous advantage: It permits friends and partners to stay connected over long distances; it allows people to find and reconnect with important people from their pasts; and it allows people to connect with others who share similar (sometimes rare) identities, interests, and experiences. But such ease of communication also makes it easier to communicate impulsively, such as sending drunk or angry texts or messages, "Facebook-stalking" one's ex when feeling lonely, or sending flirtatious messages to someone new despite being in a monogamous relationship. Using social media while avoiding their pitfalls means being mindful of how these technologies can influence communication and relationships. In addition to the capacity for impulsive communication, here are some other problem areas online: Missing nonverbal cues such as body language and tone of voice. A comment or joke intended as playful may instead come off as critical or harsh. Promoting an idealized version of oneself. Since we have control of our online image (to a degree), many of us promote a version that involves only the most flattering photos and happiest moments. Doing so can have a serious downside if the gap between one's "real" and online lives becomes too large, or the pull to maintain this image becomes too consuming, as in the case of the Instagram star Essena O'Neill, who deleted over 2000 Instagram photos, stating that she had become addicted to social media and social approval. Spying. In the past, people who suspected their partners of cheating had to follow them or hire detectives to see what they were doing. These days, it is as easy as checking statuses and messages, which makes it more tempting to invade a partner's privacy when feeling suspicious or insecure. Checking one's phone rather than staying present. How often have you seen a couple out at a nice restaurant, and both of them are checking their phones rather than engaging in conversation? Social media can be a great tool, but only when it doesn't replace experiencing life in the moment. Publicizing more areas of one's life. Messages, photos, and status updates are often accessible to large numbers of people, making it important to think carefully about what information to share on social media. Sometimes people in a relationship differ dramatically in their ideas about what should be public versus private, so this is an important topic for discussion. Communication Skills Three skills essential to good communication in relationships are self-disclosure, listening, and feedback: Self-disclosure involves revealing personal information that we ordinarily wouldn't reveal due to the risk involved. It usually increases feelings of closeness and moves the relationship to a deeper level of intimacy. Friends often disclose the most to each other, sharing feelings, experiences, hopes, and disappointments. Married couples sometimes share less Page 97and may make unwarranted assumptions because they think they already know everything about each other. Listening requires that we spend more time and energy trying to fully understand another person's "story" and less time judging, evaluating, blaming, advising, analyzing, or trying to control. Empathy, warmth, respect, and genuineness are qualities of skillful listeners. Attentive listening encourages friends or partners to share more and, in turn, to be attentive listeners. To connect with other people and develop real emotional intimacy, listening is essential. Feedback, a constructive response to another's self-disclosure, is the third key to good communication. Giving positive feedback means acknowledging that the friend's or partner's feelings are valid—no matter how upsetting or troubling—and offering self-disclosure in response. If, for example, your partner discloses unhappiness about your relationship, it is more constructive to say that you're concerned or saddened by that and want to hear more about it than to get angry, blame, try to inflict pain, or withdraw. Self-disclosure and feedback can open the door to change, whereas other responses block communication and change. (For tips on improving your skills, see the box "Guidelines for Effective Communication.") TAKE CHARGE: Guidelines for Effective Communication Getting Started When you want to have a serious discussion with your partner, choose a private place and a time when you won't be interrupted or rushed. Avoid having important conversations via text or other media. Face your partner and maintain eye contact. Use nonverbal feedback to show that you are interested and involved. Being an Effective Speaker State your concern or issue as clearly as you can. Use "I" statements rather than statements beginning with "you." When you use "I" statements, you take responsibility for your feelings. "You" statements are often blaming or accusatory and will probably get a defensive or resentful response. The statement "I feel unloved," for example, sends a clearer, less blaming message than the statement "You don't love me." Focus on a behavior, not the whole person. Be specific about the behavior you like or don't like. Avoid generalizations beginning with "you always" or "you never." Such statements make people feel defensive. Make constructive requests. Opening your request with "I would like" keeps the focus on your needs rather than your partner's supposed deficiencies. Avoid blaming, accusing, and belittling. Even if you are right, you have little to gain by putting your partner down. When people feel criticized or attacked, they are less able to think rationally or solve problems constructively. Set up your partner for success. Tell your partner what you would like to have happen in the future; don't wait for him or her to blow it and then express anger or disappointment. Being an Effective Listener Provide appropriate nonverbal feedback (nodding, smiling, making eye contact, and so on). Don't interrupt. Listen reflectively. Don't judge, evaluate, analyze, or offer solutions (unless asked to do so). Your partner may just need to sort out his or her feelings. By jumping in to "fix" the problem, you may cut off communication. Don't offer unsolicited advice. Giving advice implies that you know more about what a person needs to do than she or he does; therefore, it often evokes anger or resentment. Clarify your understanding of what your partner is saying by restating it in your own words and asking if your understanding is correct. "I think you're saying that you would feel uncomfortable having dinner with my parents and that you'd prefer to meet them in a more casual setting. Is that right?" This type of specific feedback prevents misunderstandings and helps validate the speaker's feelings and message. Be sure you are really listening, not off somewhere in your mind rehearsing your reply. Try to tune in to your partner's feelings and needs as well as the words. Accurately reflecting the other person's feelings and needs is often a more powerful way of connecting than just reframing his or her thoughts. Let your partner know that you value what he or she is saying and want to understand. Respect for the other person is the cornerstone of effective communication. QUICK STATS 30.9% of college students say their intimate relationships have been traumatic or hard to handle at least once in the past year. —American College Health Association, 2015 Conflict and Conflict Resolution Conflict is natural in intimate relationships. No matter how close two people become, they still remain separate individuals with their own needs, desires, past experiences, Page 98and ways of seeing the world. In fact, the closer the relationship, the more differences and the more opportunities for conflict. Conflict is an inevitable part of any intimate relationship. How can we resolve our conflicts in constructive ways? © Photodisc/Getty Images RF Conflict itself isn't dangerous to a relationship. In fact, it may indicate that the relationship is growing. But if it isn't handled constructively, conflict can damage—and ultimately destroy—the relationship. Consider the guidelines discussed here, but remember that different couples communicate in different ways around conflict. Conflict is often accompanied by anger—a natural emotion—but one that can be difficult to handle. If we express anger aggressively, we risk creating distrust, fear, and distance. If we act out our anger without thinking things through, we can cause the conflict to escalate. If we suppress anger, it turns into resentment and hostility. The best way to handle anger in a relationship is to recognize it as a symptom of something that requires attention and needs to be addressed. When angry, partners should exercise restraint so as not to become abusive. It is important to express anger skillfully and not in a way that is out of proportion to the issue at hand. The best time to express yourself is almost certainly when you are not boiling over with strong emotions. The sources of conflict for couples change over time but revolve primarily around these issues: finances, sex, children, in-laws, and housework. Although there are numerous theories on and approaches to conflict resolution, the following strategies can be helpful: Clarify the issue. Take responsibility for thinking through your feelings and discovering what's really bothering you. Agree that one partner will speak first and have the chance to speak fully while the other listens. Then reverse the roles. Try to understand your partner's position fully by repeating what you've heard and asking questions to clarify or elicit more information. Agree to talk only about the topic at hand and not get distracted by other issues. Sum up what your partner has said. Find out what each person wants. Ask your partner to express his or her desires. Don't assume you know what your partner wants, and don't speak for him or her. Determine how you both can get what you want. Brainstorm to come up with a variety of options. Decide how to negotiate. Work out a plan for change. For example, one partner will do one task and the other will do another task. Be willing to compromise, and avoid trying to "win." Solidify the agreements. If necessary, go over the plan and write it down, to ensure that you both understand and agree to it. Review and renegotiate. Decide on a time frame for trying out your plan, and set a time to discuss how it's working. Make adjustments as needed. To resolve conflicts, partners have to feel safe in voicing disagreements. They have to trust that the discussion won't get out of control, that they won't be abandoned, and that the partner won't take advantage of their vulnerability. Partners should follow some basic ground rules when they argue, such as avoiding ultimatums, resisting the urge to give the silent treatment, refusing to "hit below the belt," and not using sex to smooth over disagreements. When you argue, maintain a spirit of goodwill and avoid being harshly critical or contemptuous. Remember—you care about your partner and want things to work out. See the disagreement as a difficulty that the two of you have together rather than as something your partner does to you. Finish serious discussions on a positive note by expressing your respect and affection for your partner and your appreciation for having been listened to. If you and your partner find that you argue again and again over the same issue, it may be better to stop trying to resolve that problem and instead come to accept the differences between you. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever ended an intimate relationship? If so, how did you handle it? How did you feel after the breakup? How do you think the breakup affected your former partner? Did the experience help you in other relationships?

defining psychological health

DEFINING PSYCHOLOGICAL HEALTH Psychological health (or mental health) can be defined either negatively, as the absence of sickness, or positively, as the presence of wellness. The vast majority of people do not Page 60suffer from mental illness, yet all of us have to deal with stress, interpersonal conflicts, and difficult emotions. Psychological health refers to the extent to which we are able to function optimally in the face of these challenges, whether or not we have a mental illness. Positive Psychology In his book Toward a Psychology of Being, psychologist Abraham Maslow adopted a perspective that he called "positive psychology." Maslow developed a hierarchy of needs (Figure 3.1): The most important kind is the satisfaction of physiological needs; following this is a feeling of safety, a state of being loved, maintenance of self-esteem, and finally, self-actualization. FIGURE 3.1 Maslow's hierarchy of needs. source: Maslow, A. 1970. Motivation and Personality, 2nd ed. New York: Harper & Row. When urgent (life-sustaining) needs—such as the need for food and water—are satisfied, less basic needs take priority. Maslow's conclusions were based on his study of a group of visibly successful people who seemed to have lived, or to be living, at their fullest. He suggested that these people had fulfilled a good measure of their human potential and achieved self-actualization. Self-actualized people all share certain qualities: Realism. Self-actualized people know the difference between what is real and what they want. As a result, they can cope with the world as it exists without demanding that it be different; they know what they can and cannot change. Just as important, realistic people accept evidence that contradicts what they want to believe. Acceptance. Self-accepting people have a positive but realistic self-concept, or self-image. They typically feel satisfaction and confidence in themselves, and thus they have healthy self-esteem. Self-acceptance also means being tolerant of your own imperfections—an ability that makes it easier to accept the imperfections of others. Autonomy.Autonomous people can direct themselves, acting independently of their social environment. Autonomy is more than physical independence. It is social, emotional, and intellectual independence, as well. Authenticity. Self-actualized people are not afraid to be themselves. Sometimes, in fact, their capacity for being "real" may give them a certain childlike quality. They respond in a genuine, or authentic, spontaneous way to whatever happens, without pretense or self-consciousness. Capacity for intimacy. People capable of intimacy can share their feelings and thoughts without fear of rejection. They are open to the pleasure of physical contact and the satisfaction of being close to others—but without being afraid of the risks involved in intimacy, such as the possibility of rejection. (Chapters 4 and 5 discuss intimacy in more detail.) Creativity. Creative people continually look at the world with renewed appreciation and curiosity. Such buoyancy can enhance creativity. Self-actualization is an ideal to strive for rather than something most people can reasonably hope to achieve. Maslow himself believed it was achieved quite rarely. Still, fulfilling your own potential is a goal that everyone can work toward. Influenced by the work of Abraham Maslow, psychologist Martin Seligman suggests that the goal of positive psychology is "to find and nurture genius and talent" and "to make normal life more fulfilling" rather than just to identify and treat illness. In other words, it means being able to define positive goals and identify concrete, measurable ways of achieving them. You can develop happiness in any number of ways. The keys are to focus on work and activities you enjoy and to develop a supportive network of friends and family. © Ciaran Griffin/Getty Images RF According to Seligman, happiness can come to us through three equally valid dimensions: The pleasant life. This life is dedicated to maximizing positive emotions about the past, present, and future, and to minimizing pain and negative emotions. The engaged life. This life involves cultivating positive personality traits (such as courage, leadership, kindness, and Page 61integrity) and actively using your talents. "Engagement" also involves cultivating a capacity to "live in the moment" and immerse yourself fully in your activities. A key to being engaged and successful in life is the positive personality trait of emotional intelligence. An emotionally intelligent person can identify and manage his or her own emotions and respond to the emotions of others. People with higher emotional intelligence can perceive their own emotions and can also channel them to reach their intended goals. Psychologists and educators believe that emotional intelligence is not as rooted as abstract intelligence and that it can be learned. The meaningful life. Another road to happiness entails working with others toward a meaningful end. Many people find meaning in their connections with and service to families, friends, religious institutions, social causes, and/or work. The happiness to be found by following this path is strongest when meaning comes from more than one source. Seligman and his colleagues are developing methods of assessing these ways of life and of teaching people how to become happier by adopting one or more of them. They need not be mutually exclusive. Not everyone accepts the ideas of positive psychology—or even the concept of psychological health—because they involve value judgments that are inconsistent with psychology's scientific status. Defining psychological health requires making assumptions and value judgments about what human goals are desirable, and some people think these are matters for religion or philosophy. Positive psychology has also been criticized as promoting a shortsighted denial of reality and unwarranted optimism. In particular, therapists guided by existential philosophy believe that psychological health comes from acknowledging and accepting the painful realities of life. QUICK STATS 48.4% of college students report having sought counseling in their lives. —Penn State Center for Collegiate Mental Health Annual Report on Student Counseling Centers, 2015 What Psychological Health Is Not We can define normal body temperature because a few degrees above or below this temperature means physical sickness, but we cannot measure psychological health this way. Your ideas and attitudes can vary tremendously without impeding your ability to function well or causing you to feel emotional distress. Moreover, psychological diversity—the understanding, acceptance, and respect for how much individuals differ in psychological terms—is actually a valuable asset; encountering a wide range of ideas, lifestyles, and attitudes broadens our perspectives and helps us solve problems of the social world. Psychological health does not mean being "normal": What is considered healthy for one person may be quite different for someone else. Not seeking help for personal problems does not prove you are psychologically healthy, any more than seeking help proves you are mentally ill or unhealthy. Unhappy people may avoid seeking help for many reasons, and severely disturbed people may not even realize they need help. Further, we can't say people are "mentally ill" or "mentally healthy" based solely on the presence or absence of symptoms. Consider the symptom of anxiety, for example. Anxiety can help you face a problem and solve it before it becomes too big. Someone who shows no anxiety may be refusing to recognize problems or to do anything about them. A person who is anxious for good reason is likely to be judged more psychologically healthy in the long run than someone who is inappropriately calm. Finally, we cannot judge psychological health from the way people look. All too often, a person who seems to be okay and even happy suddenly takes his or her own life. At an early age, we learn to conceal our feelings and even to lie about them. We may believe that our complaints put unfair demands on others. Although maintaining privacy about emotional pain may seem to be a virtue, it can also be an impediment to getting help. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever had a reason to feel concerned about your own psychological health? If so, what was the reason? Did your concern lead you to talk to someone about the issue, or to seek professional help? If you did, what was the outcome, and how do you feel about it now?

Being Healthy for life

BEING HEALTHY FOR LIFE Your first few behavior change projects may never go beyond the planning stage. Those that do may not all succeed. But as you begin to see progress and changes, you'll start to experience new and surprising positive feelings about yourself. You'll probably find that you're less likely to buckle under stress. You may accomplish things you never thought possible—running a marathon, traveling abroad, or finding a rewarding relationship. Being healthy takes extra effort, but the paybacks in energy and vitality are priceless. Once you've started, don't stop. Remember that maintaining good health is an ongoing process. Tackle one area at a time, but make a careful inventory of your health strengths and weaknesses and lay out a long-range plan. Page 25Take on the easier problems first, and then use what you have learned to attack more difficult areas. Keep informed about the latest health news and trends; research is continually providing new information that directly affects daily choices and habits. You can't completely control every aspect of your health. At least three other factors—heredity, health care, and environment—play important roles in your well-being. After you quit smoking, for example, you may still be inhaling smoke from other people's cigarettes. Your resolve to eat better foods may suffer a setback when you have trouble finding healthy choices on campus. But you can make a difference—you can help create an environment around you that supports wellness for everyone. You can support nonsmoking areas in public places. You can speak up in favor of more nutritious foods and better physical fitness facilities. You can provide nonalcoholic drinks at your parties. You can also work on larger environmental challenges: air and water pollution, traffic congestion, overcrowding and overpopulation, global warming and climate change, toxic and nuclear waste, and many others. These difficult issues need the attention and energy of people who are informed and who care about good health. On every level, from personal to planetary, we can all take an active role in shaping our environment.

common sources or stress

COMMON SOURCES OF STRESS Recognizing potential sources of stress is an important step in successfully managing the stress in your life.Page 39 Major Life Changes Any major change in your life that requires adjustment and accommodation can be a source of stress. Early adulthood and the college years are associated with many significant changes, such as moving out of the family home. Even changes typically thought of as positive—graduation, job promotion, marriage—can be stressful. Clusters of life changes, particularly those that are perceived negatively, may be linked to health problems in some people. Personality and coping skills, however, are important moderating influences. People with strong support networks and stress-resistant personalities are less likely to become ill in response to life changes than are people with fewer resources. Daily Hassles Although major life changes are stressful, they seldom occur regularly. Researchers have proposed that minor problems—life's daily hassles, such as losing your keys or wallet—can be an even greater source of stress because they occur much more often. People who perceive hassles negatively are likely to experience a moderate stress response every time they face one. Over time, this can take a significant toll on health. Studies indicate that, for some people, daily hassles contribute to a general decrease in overall wellness. College Stressors College is a time of major changes and minor hassles. For many students, college means being away from home and family for the first time. Nearly all students share stresses like the following: Academic stress. Exams, grades, and an endless workload await every college student but can be especially troublesome for students just out of high school. Interpersonal stress. Most students are more than just students; they are also friends, children, employees, spouses, parents, and so on. Managing relationships while juggling the rigors of college life can be daunting, especially if some friends or family members are less than supportive. Time pressures. Class schedules, assignments, and deadlines are an inescapable part of college life. But these time pressures can be compounded drastically for students who also have job or family responsibilities. Financial concerns. The majority of college students need financial aid not just to cover the cost of tuition but also to survive from day to day while in school. For many, college life isn't possible without a job, and the pressure to stay afloat financially competes with academic and other stressors. Worries about anything but especially about the future. As college comes to an end, students face the next set of decisions. This decision making means thinking about a career, choosing a place to live, and leaving the friends and routines of school behind. Students may find it helpful to go to the campus career center, where they can talk to counselors and read guides for job seekers such as What Color Is My Parachute? by Richard N. Bolles, first published in 1970 and updated every year. Job-Related Stressors Americans rate their jobs as a key source of stress in their lives. Various surveys indicate that 40-50% of working Americans say they typically feel tense or stressed out while at work. Tight schedules and overtime leave less time to exercise, socialize, and engage in other stress-proofing activities. Although daily work activities can be stressful enough on their own, stress can be even worse for people who are left out of important decisions relating to their jobs. When workers are given the opportunity to shape how their jobs are performed, job satisfaction goes up and stress levels go down. Social Stressors Social networks can be real or virtual. Both types can help improve your ability to deal with stress, but any social network can also become a stressor in itself. Real Social Networks Although social support is a key buffer against stress, your interactions with others can themselves be a source of stress. The college years, in particular, can be a time of great change in interpersonal relationships. The larger community where you live can also act as a stressor. Social stressors include prejudice and discrimination. You may feel stress as you try to relate to people of other ethnic, racial, or socioeconomic groups. You may feel pressure to assimilate into mainstream society, or to spend as much time as possible with others who share your background. If English is not your first language, you may face the added burden of conducting daily activities in a language with which you are not comfortable. All these pressures can become significant sources of stress. (See the box "Diverse Populations, Discrimination, and Stress.") DIVERSITY MATTERS: Diverse Populations, Discrimination, and Stress Stress is universal, but an individual's response to stress can vary depending on gender, cultural background, prior experience, and genetic factors. In diverse multiethnic and multicultural nations such as the United States, some groups face special stressors and have higher-than-average rates of stress-related physical and emotional problems. These groups include racial and ethnic minorities, the poor, those with physical or mental disabilities, and those who don't express mainstream gender roles. Discrimination occurs when people speak or act according to their prejudices—biased, negative beliefs or attitudes toward some group. A blatant example, rising to the level of hate speech and criminal activity, is painting a swastika on a Jewish studies house or vandalizing a mosque. A more subtle example is when Middle Eastern American or African American students notice that residents in a mostly white college town tend to keep a close eye on them. Immigrants to the United States have to learn to live in a new society. Doing so requires a balance between assimilating and changing to be like the majority, and maintaining a connection to their own culture, language, and religion. The process of acculturation is generally stressful, especially when the person's background is radically different from that of the people he or she is now living among, or when people in the new community are suspicious or unwelcoming, as has recently been the case with immigrants from war-torn regions of the Middle East. © Boston Globe/Getty Images Both immigrants and minorities who have lived for generations in the United States can face job- and school-related stressors because of stereotypes and discrimination. They may make less money in comparable jobs with comparable levels of education and may find it more difficult to achieve leadership positions. On a positive note, however, many who experience hardship, disability, or prejudice develop effective goal-directed coping skills and are successful at overcoming obstacles and managing the stress they face. Virtual Social Networks Technology can help you save time, but it can also increase stress. Being electronically connected to work, family, and friends all the time can impinge on your personal space, waste time, and distract you from your current real situation. If you are "always on"—that is, always available by voice or text messaging—some friends or colleagues may think it's all right to contact you anytime, even if you're in class or trying to work, and they may expect an immediate response. The convenience of staying electronically connected comes at a price.Page 40 Environmental Stressors Have you tried to eat at a restaurant where the food was great, but the atmosphere was so noisy that it put you on edge? This is an example of a minor environmental stressor—a condition or event in the physical environment that causes stress. Examples of more disturbing and disruptive, even catastrophic, environmental stressors include the following: Natural disasters Acts of violence Industrial accidents Intrusive noises or smells Like the noisy atmosphere of some restaurants, many environmental stressors are mere inconveniences that are easy to avoid. Others, such as pollen or construction noise, may be unavoidable daily sources of stress. For those who live in poor or violent neighborhoods, the environment can contain major stressors, and in every corner of the country today, people are exposed to disturbing news and images via the media (see the box "Coping with News of Traumatic Events"). WELLNESS ON CAMPUS: Coping with News of Traumatic Events We are continually exposed to news of tragic events: natural disasters, war, terrorism, and poverty. Both experiencing trauma and observing it can result in extreme stress, requiring time and effort to recover. Such events can weaken your sense of security and create uncertainty about how the future may unfold. People react to such news in different ways, depending on their proximity to the event and how recent it was. People far from the site may suffer emotional reactions simply from watching endless coverage on television. Responses to trauma include disbelief, shock, fear, anger, resentment, anxiety, mood swings, irritability, sadness, depression, panic, guilt, apathy, feelings of isolation or powerlessness, and many of the symptoms of excess stress. Some people affected by such violence develop posttraumatic stress disorder (PTSD), a more serious condition. In the case of the shooting rampages in 2015 at a workplace in San Bernardino, California, and in 2016 at a nightclub in Orlando, Florida, both of which left multiple people dead and injured, communities mobilized quickly to respond to the expected surge in behavioral health needs generated by the attacks. Information sources and support groups were established for people grieving the loss of friends, family, neighbors, or colleagues. Unfortunately these kinds of horrific events have been repeated numerous times in recent years. If you are becoming preoccupied with some recent disastrous event, such as a school shooting or terrorist attack, take these steps: Be sure you have the best information about what happened and whether a continuing risk is present. That information may be available through websites or on local radio or TV stations. Don't expose yourself to so much media coverage that it overwhelms you. Take care of yourself. Use the stress-relief techniques discussed in this chapter. Share your feelings and concerns with others. Be a supportive listener. If you feel able, help others in any way you can, such as by volunteering to work with victims. If you feel emotionally distressed days or weeks after the event, consider asking for professional help. © Scott Olsen/Getty Images Internal Stressors Many stressors are found not in our environment but within ourselves, and often are created by the ways we think and look at things. Here is one useful way to think about this: Stress is 10% what's happening and 90% how you look at it. For example, we pressure ourselves to reach goals and continually judge our progress and performance. Striving to reach goals can enhance self-esteem if the goals are reasonable. Unrealistic expectations, however, can be a significant source of stress and can damage self-esteem. Other internal stressors are emotional states such as despair or hostility, and physical states, such as chronic illness and exhaustion; each can be both a cause and an effect of unmanaged stress.Page 41 Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION What are the top two or three stressors in your life right now? Are they new to your life—as part of your college experience—or have you experienced them in the past? Do they include both positive and negative experiences (eustress and distress)?

models of human nature and therapeutic change CH2

MODELS OF HUMAN NATURE AND THERAPEUTIC CHANGE Human problems such as the psychological disorders discussed in this chapter can be evaluated from at least four perspectives: biological, behavioral, cognitive, and psychodynamic. Each perspective has a distinct view of human nature, and from those views of human nature come distinct therapeutic approaches. The Biological Model The biological model emphasizes that the mind's activity depends entirely on an organic structure, the brain, whose composition is genetically determined. The activity of neurons, mediated by complex chemical reactions, gives rise to our most complex thoughts, our most ardent desires, and our most pathological behaviors. As an organ, the brain responds well to healthy lifestyle behaviors such as maintaining a nutritious diet and exercising. (See the box "Does Exercise Improve Mental Health?") When true mental health issues arise, however, drug therapies can help. TAKE CHARGE: Does Exercise Improve Mental Health? Since 1995, more than 30 major population-based studies (involving 175,000 Americans) have been published on the association between physical activity and mental health. The overall conclusion is that exercise—even modest activity such as taking a daily walk—can help combat a variety of mental health problems and contribute to psychological health. For example, studies found that regular physical activity protects against depression and the onset of major depressive disorder; it can also reduce symptoms of depression in otherwise healthy people. Other studies found that physical activity protects against anxiety and the onset of anxiety disorders (such as specific phobia, social phobia, generalized anxiety, and panic disorder); it also helps reduce symptoms in people affected with an anxiety disorder. Physical activity can enhance feelings of well-being in some people, which may provide some protection against psychological distress. Overall, physically active people are about 25-30% less likely to feel distressed than inactive people. Regardless of the number, age, or health status of the people being studied, those who were active managed stress better than their inactive counterparts. Researchers have also looked at specific aspects of the association between activity and stress. For example, one study found that taking a long walk can be effective at reducing anxiety and blood pressure. Another showed that a brisk walk as short as 10 minutes can leave people feeling more relaxed and energetic for up to two hours. People who took three brisk 45-minute walks a week for three months reported that they perceived fewer daily hassles and had a greater sense of general wellness. Physical activity also helps you sleep better, and consistently sound sleep is critical to stress management and mental health. According to the National Sleep Foundation, about two-thirds of Americans have trouble sleeping at least a few nights a week, and 41% say they have difficulty sleeping virtually every night. There are about 70 known sleep disorders, and disordered sleep is associated with a variety of physical and neurological problems, including health problems related to stress. Although only a few small-scale studies have examined the relationship between physical activity and sleep, most experts have concluded that regular activity promotes better sleep and provides some protection against sleep interruptions such as insomnia and sleep apnea. Consistent, restful sleep is now regarded as a protective factor in disorders such as depression, anxiety, obesity, and heart disease. sources: Physical Activity Guidelines Advisory Committee. 2008. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services (http://www.health.gov/paguidelines/); Loprinzi, P. D., & Loenneke, J. P. (2015). Engagement in muscular strengthening activities is associated with better sleep. Preventive Medicine Reports, 2, 927-929. Pharmacological Therapy The most important kind of therapy inspired by the biological model is pharmacological, or medication treatment. A list of some of the popular medications currently used for treating psychological disorders follows. All require a prescription from a psychiatrist or other medical doctor. All have received U.S. Food and Drug Administration approval as being safe and more effective than a placebo. However, as with all pharmacological therapies, these drugs may cause side effects. For example, the side effects of widely used antidepressants range from diminished appetite to loss of sexual pleasure. In addition, a patient may have to try several drugs before finding one that is effective and has acceptable side effects. Antidepressants. One group is called selective serotonin reuptake inhibitors (SSRIs) because of one of their actions; this group includes Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram), and Lexapro (escitalopram). Another group is Page 78called serotonin and norepinephrine reuptake inhibitors (SNRIs) and includes Effexor (venlafaxine), Pristiq (desvenlafaxine), and Cymbalta (duloxetine). Antidepressants that do not fit into these groups include Wellbutrin (bupropion), Remeron (mirtazapine), Brintellix (vortioxetine), Viibryd (vilazodone), and Fetzima (levomilnacipran). Another group is called the tricyclics after their chemical structure; it includes Aventyl (nortriptyline) and Elavil (amitriptyline), although these medications are used only infrequently as they may have more side effects than newer antidepressants and can be fatal in overdose due to their effects on heart rhythms. No one antidepressant is known to be better than another, and they are often chosen based on their side effects (or lack thereof). Surprisingly, these antidepressants are as effective in treating panic disorder and certain kinds of chronic anxiety as they are in treating depression. Some also alleviate the symptoms of OCD. For more information, see the National Institute of Mental Health's "Mental Health Medications" website at http://www.nimh.nih.gov/health/publications/mental-health-medications/index.shtml. Mood stabilizers. Lithium carbonate, Depakote (valproic acid), and Lamictal (lamotrigine) are prescribed as mood stabilizers. They are taken to prevent mood swings that occur in bipolar disorder and schizoaffective disorder. Lamictal is used primarily to prevent depression, Depakote to prevent mania, and lithium to prevent both. Antipsychotics. Older antipsychotics include Haldol (haloperidol) and Prolixin (fluphenazine); newer antipsychotics (sometimes called "atypical antipsychotics") are Clozaril (clozapine), Zyprexa (olanzapine), Risperdal (risperidone), Seroquel (quetiapine), Abilify (aripiprazole), Geodon (zisprasidone), Latuda (lurasidone), and Saphris (asenapine). The drugs reduce hallucinations and disordered thinking in people with schizophrenia, bipolar disorder, and delirium, and they have a calming effect on agitated patients. Anxiolytics(antianxiety agents)and hypnotics(sleeping pills). One of the largest and most prescribed classes of anxiolytics is the benzodiazepines, a group of drugs that includes Valium (diazepam), Librium (chlordiazepoxide), Xanax (alprazolam), and Ativan (lorazepam). Dalmane (flurazepam), Restoril (temazepam), and Halcion (triazolam) are benzodiazepines that have been prescribed as sleeping aids, but newer non-benzodiazepine hypnotics such as Sonata (zaleplon), Ambien (zolpidem), and Lunesta (eszopiclone) are more commonly prescribed. Stimulants. Ritalin (methylphenidate) and Adderall (dextroamphetamine and amphetamine) are most commonly used to treat ADHD in children and less often in adults. Drugs of this type are also marketed under the names Dexedrine, Concerta, Focalin, Vyvanse, Daytrana, and Metadate. They are also used against daytime sleepiness in adults, as are purified caffeine (e.g., NoDoz), Provigil (modafinil), and Nuvigil (armodafinil). An antidepressant-like drug called Strattera (atomoxetine) is used to treat ADHD, and two antihypertensive medications (medications that lower blood pressure)—Kapvay (clonidine) and Intuniv (guanfacine)—also work to treat ADHD. Pharmacological therapy (medication) is a common form of treatment for many psychological disorders. Medications can be very effective, but they have risks and side effects, and they do not work for all patients. © Comstock Images/PictureQuest Issues in Drug Therapy The discovery that many psychological disorders have a biological basis in disordered brain chemistry has led to a revolution in the treatment of many disorders, particularly depression. The new view of depression as based in brain chemistry has also lessened the stigma attached to the condition, leading more people to seek treatment. Antidepressants are now among the most widely prescribed drugs in the United States. The development of effective drugs has provided relief for many people, but the wide use of antidepressants has also raised many questions. Critics of drug therapy ask whether the new drugs are really better than the old ones or are just being marketed Page 79by drug companies because their patents on old drugs have run out. Critics also say that the efficacy of antidepressants has been exaggerated by drug company-sponsored research and that psychological treatments of depression are usually just as good. Research indicates that, for mild cases of depression, psychotherapy and antidepressants are about equally effective. For major depression, combined therapy is significantly more effective than either type of treatment alone. Therapy can help provide insight into factors that precipitated the depression, such as high levels of stress or a history of abuse. A therapist can also provide guidance in changing patterns of thinking and behavior that contribute to the problem. The Behavioral Model The behavioral model focuses on what people do—their overt behavior—rather than on brain structures and chemistry or on thoughts and consciousness. This model regards psychological problems as "maladaptive behavior" or bad habits. When and how a person learned maladaptive behavior is less important than what makes it continue in the present. Behaviorists analyze behavior in terms of stimulus,response, and reinforcement. The essence of behavior therapy is to discover what reinforcements keep an undesirable behavior going and then to try to alter those reinforcements. For example, if people who fear speaking in class (the stimulus) remove themselves from that situation (the response), they experience immediate relief, which acts as reinforcement for future avoidance and escape. To change their behavior, fearful people are taught to practice exposure—to deliberately and repeatedly enter the feared situation and remain in it until their fear begins to abate. A student who is afraid to speak in class might begin his behavioral therapy program by keeping a diary listing each time he makes a contribution to a classroom discussion, how long he speaks, and his anxiety levels before, during, and after speaking. He would then develop concrete but realistic Page 80goals for increasing his speaking frequency and contract with himself to reward his successes by spending more time in activities he finds enjoyable. Behavioral therapy can help people overcome many kinds of fears, including that of public speaking. © Yuri Arcurs/Getty Images Although exposure to the real situation works best, exposure in your imagination or through the virtual reality of computer simulation can also be effective. For example, in the case of someone who is afraid of flying, a simulated scenario would likely be vivid enough to elicit the fear necessary to practice exposure techniques. The Cognitive Model The cognitive model emphasizes the effect of ideas on behavior and feeling. According to this model, behavior results from complicated attitudes, expectations, and motives rather than from simple, immediate reinforcements. Cognitive therapy tries to expose and identify false ideas that produce feelings such as anxiety and depression. For example, a student afraid of speaking in class may harbor thoughts such as "If I begin to speak, I'll say something stupid; if I say something stupid, the teacher and my classmates will lose respect for me; then I'll get a low grade, my classmates will avoid me, and life will be hell." In cognitive therapy, these ideas will be examined critically. If the student prepares, will he or she really sound stupid? Does every sentence said have to be exactly correct and beautifully delivered, or is that an unrealistic expectation? Will classmates' opinions be completely transformed by one presentation? Do classmates even care that much? And why does the student care so much about what they think? People in cognitive therapy are taught to notice their unrealistic thoughts and to substitute more realistic ones, and they are advised to repeatedly test their assumptions. The Psychodynamic Model The psychodynamic model also emphasizes thoughts. Proponents of this model, however, do not believe thoughts can be changed directly because they are fed by other unconscious ideas and impulses. Symptoms are not isolated pieces of behavior but the result of a complex set of wishes and emotions hidden by active defenses (see Table 3.2). In psychodynamic therapy, patients speak as freely as possible in front of the therapist and try to gain an understanding of the basis of their feelings toward the therapist and others. Through this process, patients gain insights that help them overcome their maladaptive patterns. Current therapies of this type tend to focus more on the present (the here and now) than on the past, and the therapist tries to facilitate self-exploration rather than providing explanations. Evaluating the Models Ignoring theoretical conflicts among psychological models, therapists have recently developed pragmatic cognitive-behavioral therapies (CBTs) that combine effective elements of both models in a single package. For example, the package for treating social anxiety emphasizes exposure as well as changing problematic patterns of thinking (see the Behavior Change Strategy "Dealing with Social Anxiety" at the end of the chapter). Combined therapies have also been developed for panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, and depression. These packages, involving 10 or more individual or group sessions with a therapist and homework between sessions, have been shown to produce significant improvement. Drug therapy and CBTs are also sometimes combined, especially in the case of depression. For anxiety disorders, both kinds of therapy are equally effective, but the effects of drug therapy last only as long as the drug is being taken, whereas CBTs produce longer-term improvement. For schizophrenia, drug therapy is a must, but a continuing relationship with therapists who give support and advice is also indispensable. Psychodynamic therapies have been attacked as ineffective and endless. Of course, effectiveness is hard to demonstrate for therapies that do not focus on specific symptoms. But common sense tells us that being able to open yourself up and discuss your problems with a supportive but objective person who focuses on you and lets you speak freely can enhance your sense of self and reduce feelings of confusion and despair.Page 81 Other Psychotherapies In addition to existing forms of treatment, newer psychotherapies such as dialectical behavior therapy (DBT) have become available. Developed by Marsha Linehan, DBT is used to treat borderline personality disorder and chronic suicidal behavior, but it has since been expanded to treat other disorders, such as drug addiction and eating disorders. This therapy uses the principles of standard CBT by encouraging distress tolerance and acceptance of painful feelings and emotions through mindfulness (mindful awareness, discussed in Chapter 2), originally derived from Buddhist meditation and other Eastern practices. Mindfulness aims to allow a person to be aware of feelings rather than react to them, and to learn techniques to regulate emotions, by decreasing the intensity of emotional reactions. Mindfulness is practiced in group and individual therapy, often involving the use of workbooks and homework between sessions. Another newer therapy called acceptance and commitment therapy (ACT) is a scientifically studied psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility. Psychological flexibility is the process of embracing the present moment fully as a conscious human being, and then changing or continuing your behavior in the service of your own chosen values. It was developed in the 1980s by psychologists Steven C. Hayes, Kelly G. Wilson, and Kirk D. Strosahl. QUICK STATS 28,200 psychiatrists and 173,900 psychologists were practicing in the United States in 2014. —Bureau of Labor Statistics, 2015 getting help GETTING HELP Knowing when you need help dealing with a mental health problem is usually not as difficult as deciding which self-help method or which mental health professional to choose. Self-Help A smart way to begin helping yourself is by finding out what you can do on your own. For example, certain behavioral and cognitive approaches can be effective because they all involve becoming more aware of self-defeating actions and ideas and combating them in some way: being more assertive; communicating honestly; raising your self-esteem by counteracting the negative thoughts, people, and actions that undermine it; and confronting, rather than avoiding, the things you fear. Although information from books in the psychology or self-help sections of libraries and bookstores can be helpful, you should avoid any that make fantastic claims or deviate from mainstream approaches. Some people find it helpful to express their feelings in a journal. Grappling with a painful experience in this way provides an emotional release and can help you develop more constructive ways of dealing with similar situations in the future. Research indicates that using a journal in this way can improve physical as well as emotional wellness. For some people, religious belief and practice may promote psychological health. Religious organizations provide a social network and a supportive community, and religious practices, such as prayer and meditation, offer a path for personal change and transformation. Peer Counseling and Support Groups Sharing your concerns with others is another helpful way of dealing with psychological health challenges. Just being able to Page 82share what's troubling you with an accepting, empathetic person can bring relief. Comparing notes with people who have problems similar to yours can give you new ideas about coping. Individual therapy is just one of many approaches to psychological counseling. © Tom M Johnson/Getty Images Many colleges offer peer counseling through a health center or through the psychology or education department. Volunteer students specially trained in maintaining confidentiality are usually those who offer counsel. They may steer you toward an appropriate campus or community resource or simply offer a sympathetic ear. Many self-help groups work on the principle of bringing together people with similar problems to share their experiences and support one another. Support groups are typically organized around a specific problem, such as eating disorders or substance abuse. Self-help groups may be listed online or in the campus newspaper. Professional Help Sometimes trying self-help or talking to nonprofessionals is not enough, especially if you might have a mental illness. Overcoming the stigma about seeking help is a first step. In many communities and cultures, great shame and stigma are associated with talking to a mental health professional; in others, there is much less. You may someday find yourself having to overcome your own reluctance, or that of a friend, about seeking help.Page 83 A person has many options when seeking professional help (see the box "Choosing and Evaluating Mental Health Professionals"). For students, the student health center is a great start. The professionals there have extensive experience evaluating and working with people who have all sorts of needs, from the stress of adjusting to college life and dealing with relationships, to severe mental illnesses. Pediatricians and primary care providers can also make referrals. CRITICAL CONSUMER: Choosing and Evaluating Mental Health Professionals Mental health workers belong to various professions and have different roles. Psychiatrists are medical doctors. They are experts in deciding whether a medical disease lies behind psychological symptoms, and they are usually involved in treatment if medication or hospitalization is required. Clinical psychologists typically hold a doctoral degree (PhD); they are often experts in behavioral and cognitive therapies. Other mental health workers include social workers, licensed counselors, and clergy with special training in pastoral counseling. In hospitals and clinics, various mental health professionals may join together in treatment teams. In choosing a mental health professional, financial considerations are important. Research the costs and what your health insurance will cover. City, county, and state governments may support mental health clinics for those with few financial resources. Some on-campus services may be free or offered at very little cost. The cost of treatment is linked to how many therapy sessions will be needed, which in turn depends on the type of therapy and the nature of the problem. Getting this information before you start treatment is important. Many mental health professionals do not accept health insurance payments and only accept direct payments from patients. Psychological therapies focusing on specific problems may require weekly visits for a period of 8-24 sessions, depending on the type of therapy. Therapies based on CBT, DBT, and ACT are often time limited, and your therapist can tell you how many sessions to expect. Therapies aiming for psychological awareness and personality change, such as psychodynamic therapies, can last months or years. Deciding whether a therapist is right for you will require meeting the therapist in person. Before or during your first meeting, find out about the therapist's background and training: Does she or he have a degree from an appropriate professional school and a state license to practice? Has she or he had experience treating problems similar to yours? How much will therapy cost? You have a right to know the answers to these questions and should not hesitate to ask them. After your initial meeting, evaluate your impressions: Does the therapist seem like a warm, intelligent person who would be able to help you and seems interested in doing so? Are you comfortable with the therapist's personality, values, and beliefs? Is he or she willing to talk about the techniques in use? Do these techniques make sense to you? If you answer yes to these questions, this therapist may be satisfactory for you. If you feel uncomfortable—and you're not in need of emergency care—it's worthwhile to set up one-time consultations with one or two others before you make up your mind. Take the time to find someone who feels right for you. Later in your treatment, evaluate your progress: Are you being helped by the treatment? If you are displeased, is it because you aren't making progress, or because therapy is raising difficult, painful issues you don't want to deal with? Can you express dissatisfaction to your therapist? Such feedback can improve your treatment. The most important predictor of whether your therapy will be helpful is how much rapport you feel with your therapist at the first session. This has been shown to be true no matter what model of psychotherapy the therapist is practicing. You have to like your therapist and feel that she or he will be able to help you—if you do, there's a good chance that it will be helpful. If you sense that your therapy isn't working or is actually harmful, thank your therapist for her or his efforts, and find another. It's extra work for you, but it's important for your health. Many kinds of professionals are trained to evaluate people's psychological and psychiatric needs and to provide treatment. Psychotherapists, for example, come from a variety of backgrounds and include licensed social workers or family and marital therapists (with master's degrees); specially trained nurses with advanced degrees; psychologists (with doctorates); and psychiatrists, who have medical degrees and thus can prescribe medication. Many national organizations have websites that may be useful in finding help. Here are some examples: Anxiety and Depression Association of America—adaa.org Depression and Bipolar Support Alliance—dbsalliance.org National Alliance on Mental Illness—nami.org National Association of Social Workers—socialworkers.org American Psychological Association—apa.org American Psychiatric Association—psychiatry.org Professional help is appropriate in any of the following situations: Depression, anxiety, or other emotional problems interfere seriously with school or work performance or in getting along with others. Suicide is attempted or is seriously considered (see the warning signs listed earlier in the chapter). Symptoms such as hallucinations, delusions, incoherent speech, or loss of memory occur. Alcohol or drugs are used to the extent that they impair normal functioning during much of the week, that finding or taking drugs occupies much of the week, or that reducing their dosage leads to psychological or physiological withdrawal symptoms. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Are you open to discussing the intimate details of your life, your emotions, your fears, your deepest thoughts? Have you ever truly opened up to another person in this manner? Would you be open to this kind of sharing if it meant getting help for a psychological disorder?

promoting national health

PROMOTING NATIONAL HEALTH Wellness is a personal concern, but the U.S. government has financial and humanitarian interests in it, too. A healthy population is the nation's source of vitality, creativity, and wealth. Poor health drains the nation's resources and raises health care costs for all. The primary health promotion strategies at the government and community levels are public health policies and agencies that identify and discourage unhealthy and high-risk behaviors and that encourage and provide incentives for positive health behaviors. At the federal level in the United States, the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) are charged with promoting the public's health. These and other agencies translate research results into interventions and communicate research findings to health care providers and the public. There are also health promotion agencies and programs at the state, community, workplace, and college levels. Take advantage of health promotion resources at all levels that are available to you. The Affordable Care Act The Affordable Care Act (ACA), also called "Obamacare," was signed into law on March 23, 2010, and upheld by the Supreme Court in 2012 and 2015. The new law requires most people to obtain health insurance or pay a federal penalty. Here is a brief summary of the new law: Coverage Health plans can no longer deny or limit benefits due to a preexisting condition. If you are under 26, you may be eligible to be covered under your parent's health plan. Insurers can no longer cancel your coverage because of honest mistakes in your application. If your plan denies payment, you are guaranteed the right to appeal. Costs Lifetime dollar limits are not permitted on most benefits you receive. Insurance companies must now publicly justify rate hikes. Your premium dollars must be spent primarily on health care—not administrative costs. Care Recommended preventive health services are covered with no copayment. From your plan's network, you can choose the primary care doctor you want. You can seek emergency care at a hospital outside your health plan's network. Finding a Plan Under the ACA, health insurance marketplaces, also called health exchanges, facilitate the purchase of health insurance in every state. The health exchanges provide a selection of government-regulated health care plans that students and others may choose from. Those who are below income requirements are eligible for federal help with the premiums.Page 10 Benefits to College Students The ACA permits students to stay on their parents' health insurance plans until age 26—even if they are married or have coverage through an employer. Students not on their parents' plans who do not want to purchase insurance through their schools can do so through a health insurance marketplace. If you're under 30, you have the option of buying a "catastrophic" health plan. Such plans tend to have low premiums but require you to pay all medical costs up to a certain amount, usually several thousand dollars. The insurance company would pay for essential health benefits over that amount. Students whose income is below a certain level may qualify for Medicaid. Check with your state. Individuals with nonimmigrant status, which includes worker visas and student visas, qualify for insurance coverage through the exchanges. You can browse plans and apply for coverage at HealthCare.gov. The Healthy People Initiative The national Healthy People initiative aims to prevent disease and improve Americans' quality of life. Healthy People reports, published each decade since 1980, set national health goals based on 10-year agendas. The initiative's most recent iteration, Healthy People 2020, was released to the public in 2010 and envisions "a society in which all people live long, healthy lives" and proposes the eventual achievement of the following broad national health objectives: Eliminate preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote healthy development and healthy behaviors across every stage of life. In a shift from the past, Healthy People 2020 emphasizes the importance of health determinants—factors that affect the health of individuals, demographic groups, or entire populations. Health determinants are social (including factors such as ethnicity, education level, or economic status) and environmental (including natural and human-made environments). Thus one goal is to improve living conditions in ways that reduce the impact of negative health determinants. Examples of individual health-promotion goals from Healthy People 2020, along with estimates of how well Americans are tracking toward achieving those goals, appear in Table 1.4. Table 1.4 Progress toward Healthy People 2020 Targets BASELINE (% IN 2008) MOST RECENT (% IN 2013-2014) TARGET (% BY 2020) PROGRESS TOWARD GOAL Increase proportion of people with health insurance 83.2 86.7 100.0 Significant progress Help adults with hypertension get blood pressure under control 43.7 48.9 61.2 Significant progress Reduce proportion of obese adults 33.9 37.7 30.5 Getting worse Reduce proportion of adults who drank excessively in past 30 days 27.1 26.9 24.4 Insignificant progress Increase proportion of adults who meet federal guidelines for exercise 18.2 21.3 20.1 Target met Reduce proportion of adults who use cigarettes 20.6 17.0 12.0 Significant progress source: U.S. Department of Health and Human Services. Healthy People 2020 data search (https://www.healthypeople.gov/2020/data-search/Search-the-Data). Health Issues for Diverse Populations We all need to exercise, eat well, manage stress, and cultivate positive relationships. We also need to protect ourselves from disease and injuries. But some of our differences—both as individuals and as members of groups—have important implications for wellness. These differences can be biological (determined genetically) or cultural (acquired as patterns of behavior through daily interactions with family, community, and society); many health conditions are a function of biology and culture combined. As described in the previous section, eliminating health disparities is a major focus of Healthy People 2020. But not all health differences between groups are considered health disparities, which are those differences linked with social, economic, and/or environmental disadvantage. They affect groups who have systematically experienced greater obstacles to health based on characteristics that are historically linked to exclusion or discrimination. For example, the fact that women have a higher rate of breast cancer than men is a health difference but is not considered a disparity. In contrast, the higher death rates from breast cancer for black women compared with non-Hispanic white women is considered a health disparity. You share patterns of influences with certain others, and information about those groups can help you identify areas that may be of concern to you and your family. Healthy People 2020 tracks health status and behaviors in relation to a number of demographic dimensions, including sex and gender, race and ethnicity, income and educational attainment, Page 11disability status, geographic location (rural and urban), and sexual orientation and gender identity. These are broad categories, and you should consider whether and to what degree issues associated with a particular group are relevant for you. Sex and Gender Sex refers to the biological and physiological characteristics that define men, women, and intersex people. In contrast, gender encompasses how people identify themselves and also the roles, behaviors, activities, and attributes that a given society considers appropriate for them. A person's gender is rooted in biology and physiology, but it is also shaped by how society responds to individuals based on their sex. (See Chapters 4 and 5 for more on sex, gender, and gender roles.) Examples of gender-related characteristics that affect wellness include the higher rates of smoking and drinking found among men and the lower earnings found among women (compared with men doing similar work). Although men are more biologically likely than women to suffer from certain diseases (a sex issue), men are less likely to visit their physicians for regular exams (a gender issue). Men have higher rates of death from injuries, suicide, and homicide, whereas women are at greater risk for Alzheimer's disease and depression. On average, men and women also differ in body composition and certain aspects of physical performance. Race and Ethnicity Among America's racial and ethnic groups, striking disparities exist in health status, access to and quality of health care, and life expectancy. However, measuring the relationships between ethnic or racial backgrounds and health issues is complicated for several reasons. First, separating the effects of race and ethnicity from socioeconomic status is difficult. In some studies, controlling for social conditions reduces health disparities. For example, a study from the Exploring Health Disparities in Integrated Communities project found that in a racially integrated community where blacks and whites had the same earnings, disparities were eliminated or reduced in the areas of hypertension, female obesity, and diabetes. In other studies, even when patients shared equal status in terms of education and income, insurance coverage, and clinical need, disparities in care persisted. For example, compared with non-Hispanic whites, blacks and Hispanics are less likely to get appropriate medication for heart conditions or to have coronary artery bypass surgery; they are also less likely to receive kidney transplants or dialysis. Second, the classification of race (a social construct) itself is complex. How are participants in medical studies classified? Sometimes participants choose their own identities; sometimes the physician/researcher assigns identities; sometimes both parties are involved in the classification; and sometimes participants and researchers may disagree. Despite these limitations, it is still useful to identify and track health risks among population groups. Some diseases are concentrated in certain gene pools, the result of each ethnic group's relatively distinct history. Sickle-cell disease, for example, is most common among people of African ancestry. Tay-Sachs disease tends to afflict people of Eastern European Jewish heritage and French Canadian heritage. Cystic fibrosis is more common among Northern Europeans. In addition to biological differences, many cultural differences occur along ethnic lines. Ethnic groups vary in their traditional diets; the fabric of their family and interpersonal relationships; their attitudes toward tobacco, alcohol, and other drugs; and their health beliefs and practices. All these factors have implications for wellness. In tracking health status, the federal government collects data on what they define as five race groups (African American/black, American Indian or Alaska Native, Asian American, Native Hawaiian or Other Pacific Islander, and white) as well as two categories of ethnicity (Hispanic or Latino; not Hispanic or Latino); Hispanics may identify as being of any race group. Other researchers may use these or similar designations. Health concerns have been identified for each of the broad ethnic or racial minority groups. African Americans have the same leading causes of death as the general population, but they have a higher infant mortality rate and lower rates of suicide and osteoporosis. Health issues of special concern for African Americans include high blood pressure, stroke, diabetes, asthma, and obesity. African American men are at significantly higher risk of prostate cancer than men in other groups. American Indians and Alaska Natives typically embrace a tribal identity, such as Sioux, Navaho, or Hopi. American Indians and Alaska Natives have lower death rates from heart disease, stroke, and cancer than the general population, but they have higher rates of early death from causes linked to smoking and alcohol use, including injuries and cirrhosis. Diabetes is a special concern for many groups. Asian Americans include people who trace their ancestry to countries in the Far East, Southeast Asia, or the Indian subcontinent, including Japan, China, Vietnam, Laos, Cambodia, Korea, the Philippines, India, and Pakistan. Asian Americans have lower rates of coronary heart disease and obesity. However, health differences exist among these groups. For example, Southeast Asian American men have higher rates of smoking and lung cancer, and Vietnamese American women have higher rates of cervical cancer. Native Hawaiian and other Pacific IslanderAmericans trace their ancestry to the original peoples of Hawaii, Guam, Samoa, and other Pacific Islands. Pacific Islander Americans have a higher overall death rate than the general population and higher rates of diabetes and asthma. Smoking and obesity are special concerns for this group. Latinos are a diverse group, with roots in Mexico, Puerto Rico, Cuba, and South and Central America. Many Latinos are of mixed Spanish and American Indian descent or of mixed Spanish, Indian, and African American descent. Latinos on average have lower rates of heart disease, cancer, and suicide than the general population; areas of concern include gallbladder disease, obesity, diabetes, and lack of health insurance. Page 12 Why do these disparities exist? Poverty and low educational attainment are key factors underlying ethnic health disparities, but they do not fully account for the differences. Access to appropriate health care can be a challenge, even as the Affordable Care Act has reduced the number of uninsured Americans. Non-white racial and ethnic groups, regardless of income, may live in areas that are medically underserved, with fewer sources of high-quality or specialist care. Language and cultural barriers, along with racism and discrimination, can also prevent people from receiving appropriate health services. Not all the news is bad, however. Progress is being made on reducing health disparities and in developing effective strategies to tackle health issues that disproportionately affect specific population groups. See the box "Moving toward Health Equity." DIVERSITY MATTERS: Moving toward Health Equity In 2016, the National Center for Health Statistics released a special review of progress on racial and ethnic health disparities over a 15-year period. Although disparities persist, the gaps have shrunk in many key measures of health conditions, health behaviors, and access to and use of health care. Examples include the following: The life expectancy gap between whites and blacks dropped from 5.9 years to 3.4 years. The percentage of adults without health insurance declined among all groups following the passage of the Affordable Care Act, with the greatest improvement seen among Latinos. Infant mortality rates dropped among all groups; the largest declines were for the two groups with the highest rates—African Americans and American Indian or Alaska Natives. One key goal for collecting data by demographic characteristics is to better identify the population groups at risk and to target those groups with tailored strategies specifically designed to reduce health disparities. A 2016 report from the CDC highlighted a variety of successful interventions (see table). Public health professionals hope to identify and implement more such programs that promote health equity and help ensure that all Americans live long and healthy lives. You can help by supporting health promotion programs in your community. TARGETED POPULATION INTERVENTION AND RESULTS Black and Hispanic children Case management and home visits by community health workers decreased asthma-related hospitalizations. Non-white racial/ethnic groups Expanded vaccination recommendations eliminated some disparities in hepatitis A disease. People living with disabilities Curriculum for living well with a disability improved quality of life. Men who have sex with men Personalized counseling reduced HIV risk behaviors. American Indian and Alaska Native populations Tribally driven efforts to reclaim traditional food systems facilitated dialogue about health. Low-income populations and Alaska Natives Client and provider reminders and patient navigators increased colorectal cancer screening rates. Youth in high-risk communities Programs and policies supporting better neighborhood conditions reduced violence. Hispanic and Latino immigrant men Lay health advisors reduced HIV risk behaviors. sources: National Center for Health Statistics. 2016. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD: National Center for Health Statistics; Centers for Disease Control and Prevention. 2016. Selected CDC-Sponsored Interventions, United States, 2016 (http://www.cdc.gov/minorityhealth/strategies2016/index.html). Income and Education Income and education are closely related. Groups with the highest poverty rates and least education have the worst health status. They have higher rates of infant mortality, traumatic injury, violent death, and many diseases, including heart disease, diabetes, tuberculosis, HIV infection, and some cancers. They are also more likely to eat poorly, be overweight, smoke, drink, and use drugs. And to complicate and magnify all these factors, they are also exposed to more day-to-day stressors and have less access to health care services. Researchers estimate that about 250,000 deaths per year can be attributed to low educational attainment, 175,000 to individual and community poverty, and 120,000 to income inequality. Disability People with disabilities have activity limitations or need assistance due to a physical or mental impairment. About one in five people in the United States has some level of disability, and the rate is rising, especially among younger segments of the population. People with disabilities are more likely to be inactive and overweight. They report more days of depression than people without disabilities. Many also lack access to health care services.Page 13 Geographic Location About one in four Americans currently lives in a rural area—a place with fewer than 10,000 residents. People living in rural areas are less likely to be physically active, use seat belts, or obtain screening tests for preventive health care. They have less access to timely emergency services and much higher rates of some diseases and injury-related deaths than people living in urban areas. They are also more likely to lack health insurance. Children living in dangerous neighborhoods—rural or urban—are less likely to play outside and are four times more likely to be overweight than children living in safer areas. Sexual Orientation and Gender Identity Lesbian, gay, bisexual, and transgender (LGBT) health was added as a new topic area in Healthy People 2020. Questions about sexual orientation and gender identity have not been included in many health surveys, making it difficult to estimate the number of LGBT people and to identify their special health needs. However, research suggests that LGBT individuals may face health disparities due to discrimination and denial of their civil and human rights. LGBT youth have high rates of tobacco, alcohol, and other drug use as well as an elevated risk of suicide; they are more likely to be homeless and are less likely to have health insurance and access to appropriate health care providers and services.

sleep

SLEEP Don't underestimate the value of a good night's sleep as a means of managing stress. Getting enough sleep isn't just good for you physically. Adequate sleep also improves mood, fosters feelings of competence and self-worth, enhances mental functioning, and supports emotional functioning. How Sleep Works: The Physiology of Sleep Sleep occurs in two phases: rapid eye movement (REM) sleep and non-rapid eye movement (NREM) sleep. A sleeper goes through several cycles of NREM and REM sleep each night. NREM Sleep NREM sleep includes four stages of successively deeper sleep (I, II, III, IV). As you move through these stages, a variety of physiological changes occur: Blood pressure drops. Respiration and heart rates slow. Body temperature declines. Growth hormone is released. Brain wave patterns become slow and even. Each stage is characterized by a different pattern of electrical brain activity, measured by the electroencephalogram (EEG). When a person is awake but resting with eyes closed, the EEG shows the resting wakefulness pattern, which is called the alpha rhythm. Stage I of sleep occurs when the alpha rhythm disappears and a slower rhythm, called the theta rhythm, emerges. In Stage II, there are bursts of highly synchronized activity called K complexes and spindles that mark a brain state in which most sensory stimuli from the environment no longer can reach the higher-level brain centers. In Stages III and IV of sleep, there are large synchronized slow waves, creating a pattern that has similarities to large waves in the ocean. In slow wave sleep, it is difficult to arouse people quickly, and they may be confused when awakened. REM Sleep The last stage is REM sleep. During REM sleep, dreams occur. REM sleep is characterized by rapid movement of the eyes under closed eyelids, similar to when people move their eyes while awake. Blood pressure and respiration and heart rates rise, and brain activity increases to levels equal to or greater than those during waking hours. Muscles in the limbs relax completely, because the body is prevented from moving during dreaming, like a form of paralysis. Sleep Cycles When people fall asleep, they cycle through the four stages of NREM and then REM sleep (Figure 2.5). The sequence lasts about 90 minutes, and then the cycle repeats. During one night of sleep, a person is likely to go through four to five cycles, but the cycles differ somewhat over the course of the night: The slow-wave periods are longer in the first part of the night, and the REM periods are longer in the last part of the night. Because people have more slow wave sleep in the first part of the night, confusional awakening and sleep walking are more likely to occur then. Because people have more REM sleep in the last part of the night, that is when dreaming more often occurs. FIGURE 2.5 Sleep stages and cycles. During one night of sleep, the sleeper typically goes through four or five cycles of NREM sleep (four stages) followed by REM sleep. source: Adapted from Krejcar, O., J Jirka, and D. Janckulik. 2011. Use of mobile phones as intelligent sensors for sound input analysis and sleep state detection. Sensors 11(6): 6037-6055. Natural Sleep Drives Two main natural forces drive us toward sleep—the homeostatic sleep drive and the circadian rhythm. Understanding Page 49how these work and learning how to strengthen them can have a big impact on sleep. Homeostatic Sleep Drive A force called the homeostatic sleep drive gets stronger the longer you are awake. When people are awake during the day, a neurochemical called adenosine accumulates in the brain. This is a by-product of energy used by the brain, and it promotes sleep onset. The homeostatic drive is strengthened if you get up at a reasonably early time in the morning and then remain awake until your intended bedtime at night. Naps or dozing in the afternoon will strongly reduce this sleep drive at night, as will sleeping late in the morning. People who have problems falling asleep or staying asleep can strengthen the sleep drive by avoiding naps and setting a reasonably early wake time goal every day. This allows for enough wake time during the day for the sleep drive to accumulate. Caffeine blocks the homeostatic sleep drive by blocking adenosine receptors in the brain, and if a person has problems falling asleep, reduction of caffeine can be very important. Circadian Rhythm The circadian rhythm is the sleep and wake pattern coordinated by the brain's master internal clock, the suprachiasmatic nucleus (SCN). The SCN controls the sleep-wake cycle of the brain as well as the entire body: Every cell in every organ has a sleep-wake cycle, and the SCN sends signals not only to the rest of the brain, but also to organs such as the liver, gastrointestinal tract, pancreas, heart, muscles, and even the cells in the blood and skin. Each cell has DNA machinery that produces an internal clock, but the SCN has to synchronize this clock with all the other clocks. Anyone who has traveled to another time zone is probably familiar with jet lag, which occurs when the internal body clock is set to a different time from that of a new environment. People with jet lag commonly experience nausea and loss of appetite, which is related to the gastrointestinal system's being out of sync with the new time zone. It can also be difficult to fall asleep and wake up at the appropriate times in the new location. But jet lag is not the only disrupter of circadian rhythms. Some people have habits that cause their internal body clocks to be set at a time that is different from the time zone where they live. An example is a person who stays up regularly until four in the morning, and then sleeps until noon, a pattern called delayed sleep phase. If this person occasionally has to wake up earlier—say, to attend a morning lecture or go to a morning appointment—the switch can be difficult, and the person will feel poorly, just like a person with jet lag. The master clock can be reset by "time-givers," or zeitgebers. Although there are many zeitgebers, including activity, exercise, and eating, the strongest is light. Light has a direct connection to the SCN master clock via specific cells in the eye that instead of processing vision send impulses directly to the SCN to allow measurement of outside light. If the person is exposed to light in the morning at a certain time on a regular basis, it will indicate to the SCN that it should set the internal clock to wake around that time. Through another pathway, when light is reduced at night, as when natural dusk occurs, the SCN conveys impulses to a gland in the brain to produce melatonin, which signals systems involved in preparation for sleep. People who are blind often have problems with sleep because they do not have the usual light signals to help synchronize their circadian rhythms. To strengthen the circadian rhythm, get good light exposure in the morning and daytime and reduce exposure to light at night. The challenge in the modern age is that we live with abundant sources of artificial light to which we can be exposed at all times of the day, allowing us to be insulated from the natural 24-hour rhythm of the sun. Our non-natural rhythms of light exposure are also compounded by electronics. We commonly use backlit electronic devices and other hand-held devices right before bed. However, as these devices evolve, the light emission might be engineered to reduce light in the evenings. For more on electronic devices and sleep, see the box "Digital Devices: Help or Harm for a Good Night's Sleep?"Page 50 TAKE CHARGE: Digital Devices: Help or Harm for a Good Night's Sleep? Many apps are promoted as sleep aids and trackers. Can they really improve sleep? Or can using digital devices hurt the body's natural sleep cycles? Digital Devices and Sleep Before we look at sleep apps, let's consider how use of your digital devices can negatively affect your sleep. Tablets, smartphones, and computers emit blue light, which impedes the release of melatonin, a hormone that affects sleep and wake cycles. In one study, researchers compared the sleep of people who read an e-book on a digital device in the hours before bedtime with people who did so with a print book. Those who read the digital book took longer to fall asleep, had reduced melatonin release, and were less alert the next morning. Does heavy texting affect sleep? Psychologist Karla Murdock reported that texting was a direct predictor of sleep problems among first-year students in a study that examined links among interpersonal stress, text-messaging behavior, and three indicators of college students' health: burnout, sleep problems, and emotional well-being. Murdock and other sleep experts suggest turning off your screens. Use them less during the day and also when preparing to sleep at night. If you have trouble relaxing and transitioning to sleep in the evenings, shut down all your devices an hour or more before you intend to sleep. Now that you are resting in the dark, why would you consider using a sleep app or digital tracker? Ironically, a smartphone may help you get to sleep—if you tuck it into the corner of your bed. Digital Aids for Relaxation Many free and low-cost apps provide aids for relaxation and to improve sleep. Some include music, white noise, or sounds of nature (e.g., wind, rain, waves, or songbirds). Others offer specific techniques, such as guided meditation or breathing exercises, to promote relaxation to aid in falling asleep. Experiment to find the aids that work best for you. Digital Sleep Trackers More complicated technologies attempt to track and analyze sleep. Many are based on movement detectors in smartphones. These apps estimate the amount and type of sleep you get based on your movements during the night; they may generate detailed graphs of your sleep quality and then time your wake-up alarm to a specific sleep cycle. Some apps also include a sound recorder, which detects sleep talking, snoring, and other night noises, providing further information. In addition to smartphone apps, specialized fitness wristbands such as those by Fitbit and Garmin include sleep trackers. Many of these are also based on movement detectors, but some incorporate heart rate data as well; preliminary research indicates that adding heart rate data to movement tracking may improve the accuracy of the results. Fitbit and other wearables, along with some apps, may combine sleep and fitness data into an overall picture of an individual's activity over the course of a day. Apps and devices may be popular, but no consumer technology yet developed can equal the capability of a sleep lab at detecting sleep stages or diagnosing specific sleep disorders. If you enjoy the features of an app or wearable tracker, go ahead and use them, but don't rely on an app to diagnose the presence or absence of a serious sleep problem. One good effect of using a sleep tracker is simply the greater focus it places on sleep. source: Chang, A. M., et al. 2015. Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proceedings of the National Academy of Sciences 112(4): 1232-1237; Bhat, S., et al. 2015. Is there a clinical role for smartphone sleep apps? Comparison of sleep cycle detection by a smartphone application to polysomnography. Journal of Clinical Sleep Medicine, February 3; Gradisar, M., et al. 2013. The sleep and technology use of Americans. Journal of Clinical Sleep Medicine 9(12): 1291-1299; Behar, J., et al. 2013. A review of current sleep screening applications for smartphones. Physiological Measurement 34(7): R29-R46; Lewis, J. G. 2013. Sleep cycle app: Precise, or placebo? Mind Read: Connecting Brain and Behavior (http://www.nature.com/scitable/blog/mind-read/sleep_cycle_app_precise_or); Murdock, K. K. 2013. Texting while stressed: Implications for students' burnout, sleep, and well-being. Psychology of Popular Media Culture, DOI: 10.1037/ppm0000012. Adequate Sleep and Your Health Poor-quality or insufficient sleep has been associated with a number of health problems and impairments, including heart disease, high blood pressure, depression, earlier death, increased risk for dementia, weight gain, poorer glucose control, increased risk for accidents, reduced motivation and attention, and increased irritability or hyperactivity. With such a profound potential impact, ensuring good sleep can be extremely important. But as you will see, sleep interacts with health and well-being in many ways. The good news is that with more knowledge about sleep, and the factors that affect it, people can improve their sleep and, in turn, their health. Along with exercise and good nutrition, good sleep is a critical pillar of good health. Sleep and Stress Stress hormone levels in the bloodstream vary throughout the day and are related to sleep patterns. Peak concentrations occur in the early morning, followed by a slow decline during the day and evening. Concentrations return to peak levels during the final stages of sleep and in the early morning hours. Stress hormone levels are low during NREM sleep and increase during REM sleep. Page 51With each successive sleep cycle during the night, REM sleep lasts a little longer. This increase in REM sleep duration with each sleep cycle may underlie the progressive increase in circulating stress hormones during the final stages of sleep. Even though stress hormones are released during sleep, it is the lack of sleep that has the greatest impact on stress. In someone who is suffering from sleep deprivation (not getting enough sleep over time), mental and physical processes deteriorate steadily. A sleep-deprived person experiences headaches, feels irritable, cannot concentrate, and is prone to forgetfulness. Poor-quality sleep has long been associated with stress and depression. Acute sleep deprivation slows the daytime decline in stress hormones, so evening levels are higher than normal. A decrease in total sleep time also causes an increase in the level of stress hormones. Together these changes may increase stress hormone levels throughout the day and contribute to physical and mental exhaustion. Extreme sleep deprivation can lead to hallucinations and other psychotic symptoms, as well as to a significant increase in heart attack risk. Sleep and Driving Researchers estimate that drowsy driving is responsible for more than 70,000 crashes, 40,000 injuries, and as many as 7500 deaths per year. In surveys, about 4% of adult drivers (1 in 25) report having fallen asleep at the wheel in the previous 30 days. Even if you don't fall completely asleep, drowsiness slows your reaction time and lessens your ability to pay attention and make good decisions. Going 24 hours without sleep can impair a driver to the same extent as a blood alcohol level of 0.10%, which is above the legal limit. Some states have laws against drowsy driving; for example, New Jersey defines driving after being awake for 24 or more hours as reckless driving, in the same class as intoxicated driving. People who are most at risk for falling asleep while driving include young adults—aged 18-29, with men at slightly greater risk than women; parents with small children; shift workers; people who have accumulated sleep debt; and those who have other untreated sleep disorders such as sleep apnea or insomnia. The peak period for drowsiness-related accidents is between 4 a.m. and 6 a.m., though they can occur at any time. Sleepiness is worsened when people take substances such as muscle relaxants, antihistamines, cold medicines, or alcohol. The good news is that accidents due to sleepiness are preventable. First and foremost, if you find yourself drowsy while driving, pull over. Taking a nap or short rest can help, but if drowsiness persists, let someone else do the driving. Caffeine can provide a short-term burst of alertness, but you shouldn't use it excessively because it can promote sleep deprivation. You can also open the windows and turn on the radio for stimulation. However, take any drowsiness extremely seriously. Only a few seconds of inattention can lead to tragedy, so the best course of action is to stop driving when you're drowsy. Sleep Disorders Although many of us can attribute the lack of sleep to long workdays and family responsibilities, as many as 70 million Americans suffer from chronic sleep disorders—medical conditions that prevent them from sleeping well. Some of the most common ones are described in the sections that follow. Chronic Insomnia Many people have trouble falling asleep or staying asleep—a condition called insomnia. For most people, insomnia is brief and is due to life circumstances, such as worrying about an upcoming deadline or consuming too much caffeine or alcohol on a particular day. A person is considered to have chronic insomnia if sleep disruption occurs at least three nights per week and lasts at least three months. If you experience insomnia, try the strategies described in this chapter for promoting healthy sleep patterns and in the box "Overcoming Insomnia"; see also the Behavior Change Strategy "Taking Control of Your Sleep" at the end of the chapter. TAKE CHARGE: Overcoming Insomnia Most people can overcome insomnia by discovering the cause of poor sleep and taking steps to remedy it. If your insomnia lasts more than six months and interferes with daytime functioning, you should probably talk to a sleep specialist in a medical center. Sleeping pills are not recommended for chronic insomnia because they can be habit-forming; they also lose their effectiveness over time. If you're bothered by insomnia, try the following: Determine how much sleep you need to feel refreshed the next day, and don't sleep longer than that. Go to bed at the same time every night and, more important, get up at the same time every morning, seven days a week, regardless of how much sleep you got. Don't nap during the day if you can help it. If you fall asleep in the afternoon, make the nap short—less than 30 minutes. Exercise every day, but not too close to bedtime. Your metabolism takes up to six hours to slow down after exercise. Avoid caffeine late in the day and alcohol before bedtime (it causes disturbed, fragmented sleep). If you take any medications (prescription or not), ask your doctor or pharmacist if they are known to interfere with sleep. Do what you can to make your sleeping environment quiet, dark, and a comfortable temperature. Overhearing music or talking can make it hard to sleep. Have a light snack before bedtime; you'll sleep better if you're not hungry. Use your bed only for sleep. Don't eat, read, study, or watch television in bed. Relax before bedtime with a bath, a book, music, or relaxation exercises. If you don't fall asleep in 15-20 minutes, or if you wake up and can't fall asleep again, turn on your back and engage in a mindful breathing exercise (see guided practices, p. 45). If sleep problems persist, ask your physician for a referral to a sleep specialist. You may be a candidate for a sleep study—an overnight evaluation of your sleep pattern that can uncover many sleep-related disorders. Restless Leg Syndrome Restless leg syndrome (RLS) affects about 5% of the adult population and as many as 25% of pregnant women. RLS is characterized by muscle throbbing or creeping or other uncomfortable sensations in the legs, which in turn cause an uncontrollable urge to move them. Symptoms occur primarily at night or while resting. RLS can be associated with small kicking movements during the night, can interfere with falling asleep, and can make falling back to sleep more difficult. Simple measures that help RLS include getting more exercise during the day; avoiding all caffeine, tobacco, and alcohol; massaging the legs or using heating pads or a warm bath; maintaining a regular sleep pattern; and correcting any deficiencies in iron, folate, or magnesium. Medications are also available, but certain substances should be avoided: Diphenhydramine (Benadryl), which is a common ingredient in over-the-counter sleeping pills, paradoxically worsens RLS symptoms and can worsen sleep. Sleep Apnea Sleep apnea occurs when a person repeatedly stops breathing for short periods while asleep. Apnea can be caused by a number of factors, but it typically results when the soft tissue at the back of the mouth (such as the tongue or soft palate) "collapses" during sleep, blocking the Page 52airway (Figure 2.6). When breathing is interrupted, so is sleep, because the sleeper awakens throughout the night to begin breathing again. In most cases, this occurs without the sleeper's even being aware of it. However, the disruption to sleep can be significant, and over time, acute sleep deprivation can result. Sleep apnea is most common among people who are overweight, but it can occur in people classified as at normal weight; children with enlarged tonsils may also develop the condition. Risk increases with age, and up to 50% of adults over age 65 may have some degree of sleep apnea. Untreated, sleep apnea increases the risk of high blood pressure, heart attack, stroke, obesity, and diabetes. It also increases the risk of work-related or driving accidents. FIGURE 2.6 Sleep apnea. Sleep apnea occurs when soft tissues surrounding the airway relax, "collapsing" the airway and restricting airflow. Despite loss of sleep, not all people with sleep apnea are sleepy during the day, nor do all people realize that their sleep is disrupted, because they have become accustomed to it. But moderate to loud snoring and a family history of sleep apnea should make one consider checking for this possibility even in the absence of symptoms. Interestingly, many people with sleep apnea are mainly aware of having insomnia and do not complain of breathing problems or snoring. Sleep apnea is treatable, and treatment improves quality of life and daytime function, as well as reducing associated risks. Treatments include the following: Lifestyle changes, including weight loss, sleeping on your side, quitting smoking, and using nasal sprays or allergy medicines to keep nasal passages open at night. Mouthpieces (oral appliances) that are worn at night and adjust the position of the lower jaw to help keep airways open. Breathing devices such as the continuous positive airway pressure (CPAP) machine, which has a mask that fits over the mouth and/or nose and gently blows air into the throat. Improving Sleep If you're like the average American, you get less than the recommended amount of sleep each night. The Centers for Disease Control and Prevention calls sleep deprivation a national public epidemic.Page 53 In adults, between seven and nine hours of sleep is generally sufficient, but sleep needs vary from person to person; some people need only six hours, while others need more than nine. Learning how much sleep you need for optimal function is important. In childhood and adolescence, sleep needs are greater, and parents should reinforce reasonable bedtimes. Although popular literature offers many recommendations about how much sleep people need, the target amount of regular sleep time has to be tailored to the individual. Getting into bed too early can paradoxically worsen sleep, so each of us must find the appropriate sleep time goal for our individual needs. Support Natural Sleep Rhythms and Drives Sleep is a natural physiological process, so you can't "will" yourself to sleep—meaning, don't get frustrated if you don't fall asleep. As noted, to strengthen physiological sleep drives, keep a consistent sleep schedule throughout the week. To support circadian rhythm, set a goal wake time with good light exposure, and avoid bright lights and electronic devices at night. To enhance the homeostatic drive, make your wake time sufficiently early, avoid naps, and minimize caffeine. Create a Good Sleep Environment Your bedroom should be cool, dark, and quiet, ideally without pets. Although you'll want to be warm when you get into bed, sleep comes more easily in cool temperatures. Therefore, you may want to take a warm shower or bath before bed, to warm the body, and wear socks if you tend to have cold extremities at night. But after that, fewer blankets and a cooler temperature setting are beneficial. Generally if you tend to awaken at night, avoid activities in the bedroom that might be stimulating, such as watching television or using electronic devices. Some sleep experts also recommend removing clocks or turning them around to avoid the tendency to focus on the time. As long as you are relaxed and in bed during the appropriate sleep period, you have no need to check the clock. Doing so can interfere with feeling relaxed and dozing. You can still set your alarm to ensure you'll awaken when you want to in the morning. Avoid Substances That Disrupt Sleep People vary greatly in how they are affected by caffeine, but those with poor-quality sleep, difficulty falling asleep, or nighttime awakenings need to be especially careful. Caffeine can have physiological effects for over 24 hours in susceptible people, and even caffeine consumed in the morning can affect sleep throughout the night. Keep in mind that caffeine comes from many sources, including sodas, diet sodas, hot or iced teas, sweet teas, energy drinks, chocolate, and decaffeinated coffee. Some medications, such as Excedrin, also contain caffeine. Alcohol is another substance that can affect sleep. Some people think that alcohol improves sleep, but it can cause poorer sleep in the second part of the night when the effects wear off and leading to increased activation and arousal. For people with poor sleep, reducing alcohol consumption can be beneficial. Treat Conditions That Interfere with Sleep A number of readily treated medical conditions, including nasal congestion and acid reflux, can disrupt sleep. Simple interventions, such as using medications or saline spray to treat allergies or limiting foods and fluids for several hours before bedtime, can help in some cases. If symptoms are severe and continue to interfere with sleep, consult a health care provider. Don't Equate Sleeplessness with Job or School Performance We live in a society where people work long hours, and our culture can seem to reward people who sleep less and work more. But establishing balance between sleep and life activities is important. "Cramming" all night before an exam, or staying up all night to write a paper, is something most college students have been tempted to do, but all-nighters can interfere with learning and memory. Having a full night's sleep after studying promotes long-term memory formation. Similarly, some job environments encourage longer working hours. But equating work ethic with long work hours and less sleep can lead to burnout and lower productivity. In the new age of constant connectivity, we all face "telepressure" from e-mail, texting, and other direct lines of communication that occur at all hours of the day and night. Setting limits on when you will answer e-mails or check electronic platforms can protect personal time and help you disengage from work to allow for relaxation and better sleep. People who work the night shift must try especially hard to protect downtime and sleep periods and refrain from adding other daytime commitments that interfere with sleep. It can be tempting in the short term to cut back on sleep, but in the longer term this is likely to backfire, resulting in increased mood problems and the health-related issues associated with sleep loss. Avoid Sleep Pitfalls Have realistic expectations. Don't compare yourself to others: "I want to sleep like my friend Joe, who hits the pillow, falls asleep immediately, and sleeps all night." As it turns out, people like "Joe" are rare. When thinking about your own sleep, remember that everyone is different and have realistic expectations. Focusing on step-by-step sleep-health goals that are tailored to your own situation will be more productive. Try not to worry about a bout of sleeplessness. Worry can worsen sleep, and when you are having trouble sleeping, it can be easy to start worrying about the consequences for the next day. Most of the time, even if you sleep poorly, the next day's activities will be fine. The ups and down of mental and physical performance are not always correlated to the prior night's sleep. Remember the value of relaxation. Quiet relaxation has restorative value. You don't have to be sound asleep to benefit from quiet time; resting, relaxing, and dozing can also be beneficial. Consider the relaxation techniques presented earlier in this chapter. If you find that, despite everything, you feel anxious or frustrated during the night when awake, you may benefit from leaving the bedroom and engaging in a quiet activity like reading until you feel more relaxed and sleepy again.

stress and health

STRESS AND HEALTH According to the American Psychological Association, 76% of the general population report suffering physical symptoms related to stress (such as tense muscles or headaches), and 71% report nonphysical symptoms (emotional or behavioral problems). The role of stress in health is complex, but evidence suggests that stress can increase vulnerability to many ailments. Several theories have been proposed to explain the relationship between stress and disease. The General Adaptation Syndrome Biologist Hans Selye was one of the first scientists to develop a comprehensive theory of stress and disease in the 1930s and 1940s. His theory became the foundation for subsequent research into how stress affects the human body. Selye described what he called the general adaptation syndrome (GAS), a universal and predictable response pattern to all stressors. This research identified an automatic self-regulation system of the mind and body that attempts to return the body to a state of homeostasis (inner balance) after being subjected to stress. As mentioned earlier, stressors can be either pleasant (attending a party) or unpleasant (getting a bad grade). According to the GAS theory, the stress resulting from a stressor perceived to be pleasant although perhaps a challenge is called eustress; stress brought on by a stressor perceived to be unpleasant and a hindrance is called distress. The sequence of physical responses associated with GAS is the same for eustress and distress and occurs in the same three stages: alarm, resistance, and exhaustion (see Figure 2.3). FIGURE 2.3 The general adaptation syndrome. During the alarm phase, the body's resistance to injury lowers. With continued stress, resistance to injury is enhanced. With prolonged exposure to repeated stressors, exhaustion sets in. Alarm. The body initially experiences a stressor in a shock phase. This is followed by an antishock phase, which includes the complex sequence of events brought on by the fight-or-flight response. In these two phases, the body is more susceptible to disease or injury because it is using resources and energy to deal with a crisis. Someone in this stage may experience headaches, indigestion, anxiety, and disrupted eating or sleep patterns. Resistance. Under continued stress, the body develops a new level of homeostasis in which it is more resistant to disease and injury than usual. In this stage, a person can cope with normal life and added stress. However, at some point, the body's resources will become depleted. Exhaustion. The first two stages of GAS require a great deal of energy. If a stressor persists, or if several stressors occur in succession, general exhaustion sets in. This is not the sort of exhaustion you feel after a long, busy day. Rather, it's a life-threatening physiological exhaustion. The body's resources are depleted, and the body is unable to maintain normal function. If this stage is extended, long-term damage may result, manifesting itself in ulcers, digestive system trouble, depression, diabetes, cardiovascular problems, and/or mental illnesses. Selye's GAS theory compelled further research into just how stress and health are connected, but at the time, scientists did not have the technology needed to study that relationship Page 36effectively. Another step in stress research was taken in the 1970s and 1980s with the advent of "biofeedback" techniques, through which researchers could use instruments to measure brain waves, skin conduction, heart rates, and muscle tone. One of these researchers was Gary Schwartz, at Yale University. Connectedness and Health Schwartz proposed a model that used biofeedback techniques to enable people to become more aware of their own physiological functions and to moderate these functions to better manage stress. His model was based on systems theory, an approach that recognizes that the whole of a system is more than its component parts and that it self-regulates in ways that to this day scientists can only characterize as amazing. His research employed the premise that bodies maintain inner balance through self-regulating feedback loops among systems related to mental states, respiration, and heart rate. Furthermore, he established that self-regulation is the means through which bodies maintain stability as they adapt to life circumstances. Schwartz used the term disregulation to describe what happens when a physiological system becomes imbalanced. He further proposed that disregulation is one of the consequences of inattention and disconnection between feedback loops of mind and body that progressively lead to disorder and disease. For example, finding yourself stuck in a traffic jam while already late for a midterm exam, you notice that you are clenching your teeth so tightly that your jaw aches, and you realize that your dentist was right! The ache you have been suffering in your jaw is because you have been clenching your teeth, and you now know you clench when you feel anxious! You now focus on an important connection between your mind and body, and you are in a better position to find relief. Schwartz's model was further developed and modified by his student, Shauna Shapiro, a mindfulness researcher at Santa Clara University. The model she and her colleagues created from Schwartz's early research is called IAA (intention, attention, attitude), and it demonstrates the real value of intentional attention to the mind and body to restore connectedness, balance, and health in a mind-body system that has become disregulated and diseased. Shapiro's model emphasizes the cultivation of mindfulness—intentional cultivation of attention in a way that is nonjudging and nonstriving and therefore an ideal means of restoring natural self-regulation and health. Her research demonstrates that by mindfully attending to what is happening even in the midst of a serious disorder or disease, you can once again develop connectedness and self-regulation and gradually reverse the progression of disorder and disease. Here is a useful way to remember this resource for self-regulation and health: Inattention leads to disconnection, disconnection leads to disregulation, disregulation leads to disorder, and disorder may lead to illness. Mindfulness practices (discussed in more detail later in this chapter) can reverse this deadly progression and promote wellness (see Figure 2.4): Attention leads to connection, which leads to regulation, which leads to order, which leads to ease. We may call this responding to stressors rather than reacting to them, and continued research repeatedly demonstrates the health benefits. Inattention leads to disconnection, disregulation, disorder, disease. Attention leads to connection, regulation, order, ease. FIGURE 2.4 The consequences of inattention; the benefits of attention. Allostatic Load Long-term overexposure to stress hormones such as cortisol has been linked to health problems. Further, although physical stress reactions promote homeostasis, they may also have negative effects. The "wear and tear" on the body that results from long-term exposure to repeated or chronic stress is known as allostatic load. The concept of allostatic load explains how frequent activation of the body's stress response, although essential for managing acute threats, can in fact damage the body in the long run if stress reactions are occurring when they are not really called for. For example, a person may be so afraid of snakes that just seeing a coiled up rope in the grass can trigger the fight-or-flight reaction of the autonomic nervous system. Allostatic load is generally measured through indicators of cumulative strain on several organs and tissues, especially on the cardiovascular system. Psychoneuroimmunology One of the most fruitful areas of current research into the relationship between stress and disease is psychoneuroimmunology (PNI). PNI is the study of the interactions among Page 37the nervous system, the endocrine system, and the immune system. The underlying premise of PNI is that stress, through the actions of the nervous and endocrine systems, impairs the immune system and thereby affects health. A complex network of nerve and chemical connections exists among the nervous and the endocrine systems. In general, increased levels of cortisol are linked to a decreased number of immune system cells, or lymphocytes. Epinephrine appears to promote the release of lymphocytes but at the same time reduces their efficiency. Scientists have identified hormone-like substances called neuropeptides that appear to translate stressful emotions into biochemical events, some of which affect the immune system, providing a physical link between emotions and immune function. Different types of stress may affect immunity in different ways. For instance, during acute stress (typically lasting between 5 and 100 minutes), white blood cells move into the skin, where they enhance the immune response. During a stressful event sequence, such as a personal trauma and the events that follow, however, there are typically no overall significant immune changes. Chronic (ongoing) stressors such as unemployment have negative effects on almost all functional measures of immunity. Chronic stress may cause prolonged secretion of cortisol (sometimes called the "antistress hormone" because it seeks to return the nervous system to homeostasis after a stress reaction) and may accelerate the course of diseases that involve inflammation, including multiple sclerosis, heart disease, type 2 diabetes, and clinical depression. In other words, this is one way that too many stress reactions over a prolonged length of time can have a negative impact on health. Mood, personality, behavior, and immune functioning are intertwined. For example, people who are generally pessimistic may neglect the basics of health care, become passive when ill, and fail to engage in health-promoting behaviors. People who are depressed may reduce physical activity and social interaction, which may in turn affect the immune system and the cognitive appraisal of a stressor. Optimism, successful coping, and positive problem solving, by contrast, may positively influence immunity. Although much remains to be learned, it is clear that people who have unresolved chronic stress in their lives or who handle stressors poorly are at risk for a wide range of health problems. In the short term, the problem might be just a cold, a stiff neck, or a stomachache. Over the long term, the problems can be more severe—cardiovascular disease (CVD), high blood pressure, impaired immune function, or a host of other problems. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Think of the last time you faced a significant stressor. How did you react? List the physical, emotional, and behavioral reactions you experienced. Were the reactions appropriate to the circumstances? Did these reactions help you better deal with the stress, or did they interfere with your efforts to handle it? Cardiovascular Disease During the stress response, heart rate increases and blood vessels constrict, causing blood pressure to rise. Chronic high blood pressure is a major cause of atherosclerosis, a disease in which blood vessels become damaged and caked with fatty deposits. These deposits can block arteries, causing heart attacks and strokes. The stress response can precipitate a heart attack in someone with atherosclerosis. The stress response can also cause stress cardiomyopathy ("broken heart syndrome"), a condition that mimics a heart attack but doesn't block the blood vessels supplying the heart. Certain emotional responses may increase a person's risk of CVD. As described earlier, people who tend to react to situations with anger and hostility are more likely to have heart attacks than are people with less explosive, more trusting personalities. Inflammation has been linked to stress and is a key component of the damage to blood vessels that leads to heart attacks (see Chapter 15 for more about CVD.) QUICK STATS Half of American adults have at least one chronic illness. —Centers for Disease Control and Prevention, 2016 Psychological Problems Many stressors are inherently anxiety-producing, depressing, or both. Stress has been found to contribute to psychological problems such as depression, panic attacks, anxiety, eating disorders, and posttraumatic stress disorder (PTSD). PTSD, which afflicts war veterans, rape and child abuse survivors, and others who have suffered or witnessed severe trauma, is characterized by nightmares, flashbacks, and a diminished capacity to experience or express emotion. (For information about psychological health, see Chapter 3.) Altered Immune Function PNI research helps explain how stress affects the immune system. Some of the health problems linked to stress-related changes in immune function include vulnerability to colds and other infections, asthma and allergy attacks, and flare-ups of chronic sexually transmitted infections such as genital herpes and HIV infection. Headaches More than 45 million Americans suffer from chronic, recurrent headaches. Headaches come in various types but are often grouped into the following three categories: Tension headaches. Approximately 90% of all headaches are tension headaches, characterized by a dull, steady pain, usually on both sides of the head. It may feel as though a band of pressure is tightening around the head, and the pain may extend to the neck and shoulders. Acute tension headaches may last from hours to days, whereas chronic tension headaches may occur almost every day for months or even years. Ineffective stress management Page 38skills, poor posture, and immobility are the leading causes of tension headaches. There is no cure, but the pain can sometimes be avoided and relieved with mindfulness skills, over-the-counter painkillers, and therapies such as massage, acupuncture, relaxation, hot or cold showers, and rest. Migraine headaches. Migraines typically progress through a series of stages lasting from several minutes to several days. They may produce a variety of symptoms, including throbbing pain that starts on one side of the head and may spread; heightened sensitivity to light; visual disturbances such as flashing lights or temporary blindness; nausea; dizziness; and fatigue. Women are more than twice as likely as men to suffer from migraines. Potential triggers include menstruation, stress, fatigue, atmospheric changes, bright light, specific sounds or odors, and certain foods. The frequency of attacks varies from a few in a lifetime to several per week. Treatment can help reduce the frequency, severity, and duration of migraines. Aerobic exercise is frequently recommended as a treatment for migraine headaches. However, the evidence for the efficacy of exercise to reduce the frequency and severity of migraine headaches is mixed. There is mild evidence that exercise may reduce stress levels, a known trigger for migraine headaches. Researchers have not been able to replicate these findings consistently, however. Several studies have failed to show exercise as an effective treatment for migraine headaches. And for some people, exercise itself can trigger migraines. Cluster headaches. Cluster headaches are extremely severe headaches that cause intense pain in and around one eye. They usually occur in clusters of one to three headaches each day over a period of weeks or months, alternating with periods of remission in which no headaches occur. More than twice as many men than women suffer from cluster headaches. There is no known cause or cure for cluster headaches, but a number of treatments are available. During cluster periods, it is important to refrain from smoking cigarettes and drinking alcohol, because these activities can trigger attacks. For more information on treating headaches and when a headache may signal a serious illness, see Appendix B. Ongoing stress has been shown to make people more vulnerable to everyday ailments, such as colds and allergies. © Somos/Veer/Getty Images Other Health Problems Many other health problems may be caused or worsened by excessive stress, including the following: Digestive problems such as stomachaches, diarrhea, constipation, irritable bowel syndrome, and ulcers Asthma Cancer Skin disorders Fibromyalgia Insomnia and fatigue Injuries, including on-the-job injuries caused by repetitive strain Menstrual irregularities, impotence, and pregnancy complications Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever been so stressed that you felt ill? If so, what were your symptoms? How did you handle them? Did the experience affect the way you reacted to other stressful events?

suicide

SUICIDE In the United States, suicide is the second leading cause of death for young people aged 15-24 and the 10th leading cause for people of all ages. In 2013, among adults age 18 and over, 1.1% made suicide plans, and 0.6% went ahead and attempted it. (see Figure 3.3 for data on suicidal thoughts). Suicide rates vary by race or ethnicity: Among adolescents and young adults, the suicide rate is highest among American Indians or Alaska Natives; among adults, non-Hispanic whites have the highest suicide rate. The suicide rate among men is still more than three times higher than that among women, but the gap has narrowed in recent years. Overall, non-Hispanic white men aged 45-54 have the highest suicide rate. Suicidal thoughts are highest among adults reporting two or more races, followed by American Indians/Alaskan Natives. [D] FIGURE 3.3 Percentages of Americans age 18 and over having suicidal thoughts in the past year. source: Centers for Disease Control and Prevention. 2015. Suicide. Facts at a Glance. National Center for Injury Prevention and Control. Atlanta, GA (http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf). Suicide rarely occurs without warning signs (see Table 3.4). About 60% of people who kill themselves are depressed. The more symptoms of depression a person has, the greater the risk. A threat of suicide should not be taken as only a cry for help but also as a possible future occurrence. Here are specific warning signs: Any mention of dying, disappearing, jumping, shooting oneself, or other types of self-harm. Changes in personality, including sadness, withdrawal, irritability, anxiety, fatigue, indecisiveness, or apathy. A sudden, inexplicable brightening of mood (which can mean the person has decided to attempt suicide). A sudden move to give away important possessions, accompanied by statements such as, "I won't be needing these anymore." An increase in reckless behaviors. Table 3.4 Myths about Suicide: Don't Be Misled MYTH FACT People who really intend to kill themselves do not let anyone know about it. This belief can be an excuse for doing nothing when someone says he or she might attempt suicide. In fact, most people who eventually follow through with suicide have talked about doing it. People who made a suicide attempt but survived did not really intend to die. This belief may be true for certain people, but people who seriously want to end their lives may fail because they misjudge what it takes. Even a pharmacist may misjudge the lethal dose of a drug. People who succeed in suicide really wanted to die. We cannot be sure of that either. Some people are only trying to make a dramatic gesture or plea for help but miscalculate. People who really want to kill themselves will do it regardless of any attempts to prevent them. Few people are single-minded about suicide even at the moment of attempting it. People who are quite determined to take their lives today may completely change their minds tomorrow. Suicide is proof of mental illness. Many suicides are carried out by people who do not meet ordinary criteria for mental illness, although people with depression, schizophrenia, and other psychological disorders have a much higher than average suicide rate. People inherit suicidal tendencies. Certain kinds of depression that lead to suicide do have a genetic component. But many examples of suicide running in a family can be explained by factors such as psychologically identifying with a family member who kill themselves, often a parent. All suicides are irrational. By some standards, all suicides may seem "irrational." But many people find it at least understandable that someone might want to attempt suicide—for example, when approaching the end of a terminal illness or when facing a long prison term. Page 76In addition to warning signs, certain risk factors increase the likelihood that someone will attempt suicide (see the box "Deliberate Self-Harm"). Protective factors decrease the likelihood. Risk factors and protective factors can be intrapersonal,social/situational, or cultural. WELLNESS ON CAMPUS: Deliberate Self-Harm In general, people want to be well and healthy and to protect themselves from harm. But many individuals—predominantly in their teens and adolescence—do deliberately harm themselves, although in a nonfatal way. A common method of self-harm involves people cutting or burning their own skin, leaving scars that they hide beneath their clothes. Self-cutting and other self-injurious behaviors are not aesthetically motivated. Many people who engage in these behaviors report seeking the physical sensations (including pain) produced by a self-inflected injury, which may temporarily relieve feelings of tension, perhaps through a release of endorphins. In 2011, a research group led by Alicia Meuret, an associate professor of psychology at Southern Methodist University, conducted surveys on more than 550 college students and found that over 20% had engaged in self-injury at some point, which is consistent with prevalence estimates in other studies on college populations. In examining differences between self-injurers and noninjurers, individuals who had recently engaged in self-harm were significantly more depressed, anxious, and disgusted with themselves. Compared to noninjurers, self-injurers were roughly 4 times more likely to report a history of physical abuse and 11 times more likely to report a history of sexual abuse. Self-injury is not the same as a suicide attempt, but individuals who repeatedly hurt themselves are more likely than the general population to kill themselves. In any case, self-injury should be taken seriously. Treatment usually includes group therapy, individual therapy, medication (e.g., antidepressants), or stress reduction and management skills. The following are key risk factors: A history of previous attempts A sense of hopelessness, helplessness, guilt, or worthlessness Alcohol or other substance use disorders Serious medical problems Mental disorders, particularly mood disorders such as depression and bipolar disorder Availability of a weapon Family history of suicide Social isolation A history of having been abused or neglected A current or past experience of being a victim of bullying, in person or online The following are key protective factors: Strong religious faith or other cultural prohibition on suicide Connection to other people, including family that is supportive Engagement in treatment in which the person is getting help Connection with one's own children (or even pets) Lack of access to lethal means (guns, pills, railroad tracks) Page 77If you are severely depressed or know someone who is, expert help from a mental health professional is essential. Don't be afraid to discuss the possibility of suicide with someone you fear is suicidal. You won't give them an idea they haven't already thought of. Ask direct questions to determine whether someone seriously intends to kill themselves. Encourage your friend to talk and to take positive steps to improve his or her situation. You can call the National Suicide Prevention Lifeline at 800-273-TALK (8255). Trained crisis workers are available to talk 24 hours a day, 7 days a week. If you think someone is in immediate danger, do not leave him or her alone. Call for help or take him or her to an emergency room. Most communities have emergency help available, often in the form of a hotline telephone counseling service run by a suicide prevention agency. Firearms are used in more suicides than homicides. Among gun-related deaths in the home, 83% are the result of suicide, often by someone other than the gun owner. If you learn someone at high risk for suicide has access to a gun, try to convince him or her to put it in safekeeping.

Wellness as a heath goal

WELLNESS AS A HEALTH GOAL Generations of people have viewed good health simply as the absence of disease, and that view largely prevails today. The word health typically refers to the overall condition of a person's body or mind and to the presence or absence of illness or injury. Wellness expands this idea of good health to include living a rich, meaningful, and energetic life. Beyond the simple presence or absence of disease, wellness can refer to optimal health and vitality—to living life to its fullest. Although we use the words health and wellness interchangeably, they differ in two important ways: Health—or some aspects of it—can be determined or influenced by factors beyond your control, such as your genes, age, and family history. Consider, for example, a 50-year-old man with a strong family history of early heart disease. This factor increases this man's risk of having a heart attack at an earlier age than might be expected. Wellness is determined largely by the decisions you make about how you live. That same 50-year-old man can reduce his risk of an early heart attack by eating sensibly, exercising, and having regular screening tests. Even if he develops heart disease, he may still live a long, rich, meaningful life. These factors suggest he should choose not only to care for himself physically but also to maintain a positive outlook, enjoy his relationships with others, challenge himself intellectually, and nurture other aspects of his life. Page 3 Wellness, therefore, involves conscious decisions that affect risk factors that contribute to disease or injury. We cannot control risk factors such as age and family history, but we can control lifestyle behaviors. Dimensions of Wellness The process of achieving wellness is continuing and dynamic (Figure 1.1), involving change and growth. Wellness is not static. The encouraging aspect of wellness is that you can actively pursue it. Here are nine dimensions of wellness: Physical Emotional Intellectual Interpersonal Cultural Spiritual Environmental Financial Occupational FIGURE 1.1 The wellness continuum. The concept of wellness includes vitality in a number of interrelated dimensions, all of which contribute to wellness. These dimensions are interrelated and may affect each other, as the following sections explain. Figure 1.2 lists specific qualities and behaviors associated with each dimension. PHYSICAL WELLNESS EMOTIONAL WELLNESS INTELLECTUAL WELLNESS Eating well Exercising Avoiding harmful habits Practicing safer sex Recognizing symptoms of disease Getting regular checkups Avoiding injuries Optimism Trust Self-esteem Self-acceptance Self-confidence Ability to understand and accept one's feelings Ability to share feelings with others Openness to new ideas Capacity to question Ability to think critically Motivation to master new skills Sense of humor Creativity Curiosity Lifelong learning INTERPERSONAL WELLNESS CULTURAL WELLNESS SPIRITUAL WELLNESS Communication skills Capacity for intimacy Ability to establish and maintain satisfying relationships Ability to cultivate a support system of friends and family Creating relationships with those who are different from you Maintaining and valuing your own cultural identity Avoiding stereotyping based on race, ethnicity, gender, religion, or sexual orientation Capacity for love Compassion Forgiveness Altruism Joy and fulfillment Caring for others Sense of meaning and purpose Sense of belonging to something greater than oneself ENVIRONMENTAL WELLNESS FINANCIAL WELLNESS OCCUPATIONAL WELLNESS Having abundant, clean natural resources Maintaining sustainable development Recycling whenever possible Reducing pollution and waste Having a basic understanding of how money works Living within one's means Avoiding debt, especially for unnecessary items Saving for the future and for emergencies Enjoying what you do Feeling valued by your manager Building satisfying relationships with coworkers Taking advantage of opportunities to learn and be challenged FIGURE 1.2 Qualities and behaviors associated with the dimensions of wellness. Carefully review each dimension and consider your personal wellness strengths and weaknesses. Physical Wellness Your physical wellness includes not just your body's overall condition and the absence of disease but also your fitness level and your ability to care for yourself. The higher your fitness level, the higher your level of physical wellness. Similarly, as you develop the ability to take care of your own physical needs, you ensure greater physical wellness. The decisions you make now, and the habits you develop over your lifetime, will determine the length and quality of your life. Emotional Wellness Trust, self-confidence, optimism, satisfying relationships, and self-esteem are some of the qualities of emotional wellness. Emotional wellness is dynamic and involves the ups and downs of living. No one can achieve an emotional "high" all the time. Emotional wellness fluctuates with your intellectual, physical, spiritual, cultural, and interpersonal health. Maintaining emotional wellness requires exploring thoughts and feelings. Self-acceptance is your personal satisfaction with yourself—it might exclude society's expectations—whereas self-esteem relates to the way you think others perceive you; self-confidence can be a part of both acceptance and esteem. Achieving emotional wellness means finding solutions to emotional problems, with professional help if necessary. Intellectual Wellness Those who enjoy intellectual wellness continually challenge their minds. An active mind is essential to wellness because it detects problems, finds solutions, and directs behavior. Throughout their lifetimes people who enjoy intellectual wellness never stop learning. Often they discover new things about themselves. Interpersonal Wellness Satisfying and supportive relationships are important to physical and emotional wellness. Learning good communication skills, developing the capacity for intimacy, and cultivating a supportive network are all important to interpersonal (or social) wellness. Social wellness requires participating in and contributing to your community and to society. Cultural Wellness Cultural wellness refers to the way you interact with others who are different from you in terms of ethnicity, religion, gender, sexual orientation, age, and customs (practices). It involves creating relationships with others and suspending judgment on others' behavior until you have lived with them or "walked in their shoes." It also includes accepting, valuing, and even celebrating the different cultural ways people interact in the world. The extent to which you maintain and value cultural identities is one measure of cultural wellness. Spiritual Wellness To enjoy spiritual wellness is to possess a set of guiding beliefs, principles, or values that give meaning and purpose to your life, especially in difficult times. The spiritually well person focuses on the positive Page 4aspects of life and finds spirituality to be an antidote for negative feelings such as cynicism, anger, and pessimism. Organized religions help many people develop spiritual health. Religion, however, is not the only source or form of spiritual wellness. Many people find meaning and purpose in their lives through their loved ones or on their own—through nature, art, meditation, or good works. Environmental Wellness Your environmental wellness is defined by the livability of your surroundings. Personal health depends on the health of the planet—from the safety of the food supply to the degree of violence in society. Your physical environment can support your wellness or diminish it. To improve your environmental wellness, you can learn about and protect yourself against hazards in your surroundings and work to make your world a cleaner and safer place. Financial Wellness Financial wellness refers to your ability to live within your means and manage your money in a way that gives you peace of mind. It includes balancing your income and expenses, staying out of debt, saving for the future, and understanding your emotions about money. See the "Financial Wellness" box. TAKE CHARGE: Financial Wellness Researchers surveyed nearly 90,000 college students about their financial behaviors and attitudes. According to results released in 2016, a large percentage of students feel less prepared to manage their money than to handle almost any other aspect of college life. They also express distress over their current and future financial decisions. Front and center in their minds is how to manage student loan debt. Financial wellness means having a healthy relationship with money. Here are strategies for establishing that relationship: Follow a Budget A budget is a way of tracking where your money goes and making sure you're spending it on the things that are most important to you. To start one, list your monthly income and expenditures. If you aren't sure where you spend your money, track your expenses for a few weeks or a month. Then organize them into categories, such as housing, food, transportation, entertainment, services, personal care, clothes, books and school supplies, health care, credit card and loan payments, and miscellaneous. Knowing where your money goes is the first step in gaining control of it. Now total your income and expenditures and examine your spending patterns. Use this information to set guidelines and goals for yourself. If your expenses exceed your income, identify ways to make some cuts. For example, if you spend money going out at night, consider less expensive options like having a weekly game night with friends or organizing an occasional potluck. Be Wary of Credit Cards Students have easy access to credit but little training in finances. The percentage of students who have access to credit cards has increased from 28% in 2012 to 41% in 2015. This increase in credit card use has also correlated with an increase in paying credit card bills late, paying only the minimum amount, and having larger total outstanding credit balances. Shifting away from using credit cards and toward using debit cards is a good strategy for staying out of debt. Familiarity with financial terminology helps as well. Basic financial literacy with regard to credit cards involves understanding terms like APR (annual percentage rate—the interest you're charged on your balance), credit limit (the maximum amount you can borrow), minimum monthly payment (the smallest payment your creditor will accept each month), grace period (the number of days you have to pay your bill before interest or penalties are charged), and over-the-limit and late fees (the amounts you'll be charged if you go over your credit limit or your payment is late). Manage Your Debt A 2015 study indicated that graduating college students often had debts of $35,000—and this amount is expected to rise. When it comes to student loans, having a direct, personal plan for repayment can save time and money, reduce stress, and help you prepare for the future. However, only about 10% of students surveyed feel they have all the information needed to pay off their loans. Work with your lender and make sure you know how to access your balance, when to start repayment, how to make payments, what your repayment plan options are, and what to do if you have trouble making payments. Information on managing federal student loans is available from https://studentaid.ed.gov/sa/. If you have credit card debt, stop using your cards and start paying them off. If you can't pay the whole balance, try to pay more than the minimum payment each month. It can take a very long time to pay off a loan by making only the minimum payments. For example, paying off a credit card balance of $2000 at 10% interest with monthly payments of $20 would take 203 months—nearly 17 years. Check out an online credit card calculator like http://money.cnn.com/calculator/pf/debt-free/. If you carry a balance and incur finance charges, you are paying back much more than your initial loan. Start Saving If you start saving early, the same miracle of compound interest that locks you into years of credit card debt can work to your benefit (for an online compound interest calculator, visit http://www.interestcalc.org). Experts recommend "paying yourself first" every month—that is, putting some money into savings before you pay your bills. You may want to save for a large purchase, or you may even be looking ahead to retirement. If you work for a company with a 401(k) retirement plan, contribute as much as you can every pay period. Become Financially Literate Most Americans have not received any basic financial training. For this reason, the U.S. government has established the Financial Literacy and Education Commission (MyMoney.gov) to help Americans learn how to save, invest, and manage money better. Developing lifelong financial skills should begin in early adulthood, during the college years, if not earlier, as money-management experience appears to have a more direct effect on financial knowledge than does education. For example, when tested on their basic financial literacy, students who had checking accounts had higher scores than those who did not. sources: Smith, C., and G. A. Barboza. 2013. The role of trans-generational financial knowledge and self-reported financial literacy on borrowing practices and debt accumulation of college students. Social Science Research Network (http://ssrn.com/abstract=2342168); Plymouth State University. 2013. Student Monetary Awareness and Responsibility Today! (http://www.plymouth.edu/office/financial-aid/smart/); U.S. Financial Literacy and Education Commission. 2013. MyMoney.gov (http://www.mymoney.gov); Sparshott, J. 2015. Congratulations, Class of 2015. You're the most indebted ever (for now). Wall Street Journal, May 8, 2015 (http://blogs.wsj.com/economics/2015/05/08/congratulations-class-of-2015-youre-the-most-indebted-ever-for-now/); EverFi. 2016. Money Matters on Campus: Examining Financial Attitudes and Behaviors of Two-Year and Four-Year College Students (www.moneymattersoncampus.org). Occupational Wellness Occupational wellness refers to the level of happiness and fulfillment you gain through your work. Although high salaries and prestigious titles are gratifying, they alone may not bring about occupational wellness. An occupationally well person enjoys his or her work, feels a connection with others in the workplace, and takes advantage of the opportunities to learn and be challenged. Another important aspect of occupational wellness is recognition from managers and colleagues. An ideal job draws on your interests and passions, as well as your vocational skills, and allows you to feel that you are making a contribution in your everyday work. New Opportunities for Taking Charge Wellness is a fairly new concept. One hundred and fifty years ago, Americans considered themselves lucky just to survive to adulthood. A boy born in 1850, for example, could expect to live only about 38 years and a girl, 40 years. Morbidity and mortality rates (rates of illness and death, respectively) from common infectious diseases (such as pneumonia, tuberculosis, and diarrhea) were much higher than Americans experience today. By 1980, life expectancy Page 6nearly doubled, due largely to the development of vaccines and antibiotics to fight infections, and to public health measures such as water purification and sewage treatment to improve living conditions (Figure 1.3). But even though life expectancy has increased, poor health will limit most Americans' activities during the last 15% of their lives, resulting in some sort of impaired life (Figure 1.4). Today a different set of diseases has emerged as our major health threat: Heart disease, cancer, and chronic lower respiratory diseases are now the three leading causes of death for Americans (Table 1.1). An obesity epidemic, beginning in the late 1970s, has also spurred predictions that American life expectancy will decline within the next several decades (see box "Life Expectancy and the Obesity Epidemic" on p. 8). Obesity and poor eating habits can lead to all of the major chronic diseases. FIGURE 1.3 Public health, life expectancy, and quality of life. Public health achievements during the 20th century are credited with adding more than 25 years to life expectancy for Americans, greatly improving quality of life, and dramatically reducing deaths from infectious diseases. Public health improvements continue into the 21st century, including greater roadway safety and a steep decline in childhood lead poisoning. In 2013, the government mandated that all Americans be covered by health insurance, a protection already long established in most other industrialized countries. sources: Kochanek, K.D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4); Centers for Disease Control and Prevention. 2011. Ten great public health achievements—United States, 2001-2010. MMWR 60(19): 619-623; Centers for Disease Control and Prevention. 1999. Ten great public health achievements—United States, 1900-1999. MMWR 48(50): 1141. FIGURE 1.4 Quantity of life versus quality of life. Years of healthy life as a proportion of life expectancy in the U.S. population. source: Kochanek, K. D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4). National Center for Health Statistics. 2012. Healthy People 2010 Final Review. Hyattsville, MD: National Center for Health Statistics. VITAL STATISTICS Table 1.1 Leading Causes of Death in the United States, 2013 RANK CAUSE OF DEATH NUMBER OF DEATHS PERCENTAGE OF TOTAL DEATHS LIFESTYLE FACTORS 1 Heart disease 614,348 23.4 2 Cancer 591,699 22.5 3 Chronic lower respiratory diseases 147,101 5.6 4 Unintentional injuries (accidents) 136,053 5.2 5 Stroke 133,103 5.1 6 Alzheimer's disease 93,541 3.6 7 Diabetes mellitus 76,488 2.9 8 Influenza and pneumonia 55,227 2.1 9 Kidney disease 48,146 1.8 10 Intentional self-harm (suicide) 42,773 1.6 11 Septicemia (systemic blood infection) 38,940 1.5 12 Chronic liver disease and cirrhosis 38,170 1.5 13 Hypertension (high blood pressure) 30,221 1.2 14 Parkinson's disease 26,150 1.0 15 Lung inflammation due to solids and liquids 18,792 0.7 All other causes 535,666 All causes 2,626,418 100.0 note: Although not among the overall top 15 causes of death, HIV/AIDS (6,721 deaths in 2014) is a major killer. In 2014, HIV/AIDS was the 13th leading cause of death for Americans aged 15-24 years and the 8th leading cause of death for those aged 25-34 years. source: Kochanek, K. D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4). TAKE CHARGE: Life Expectancy and the Obesity Epidemic Life expectancy consistently increased each decade in the United States since 1900 (see Figure 1.3). But is this trend continuing? Will children today live longer and healthier lives than their parents? The upward trend has slowed, and some researchers point to the significant increase in obesity among Americans as a potential cause. According to estimates released in 2016, 35% of American men and 40% of American women are obese. The problem isn't confined to the United States: The World Health Organization estimates that 2 billion adults worldwide are overweight or obese. Along with increases in obesity come increased rates of diabetes, chronic liver disease, heart disease, stroke, and other chronic diseases that are leading causes of death. Of course, medical interventions for these conditions have improved over time, lessening the impact of obesity to date. Still, medical treatments may be reaching their limits in preventing early deaths related to obesity. Moreover, people are becoming obese at earlier ages, exposing them to the adverse effects of excess body fat over a longer period of time. The magnitude of the obesity problem has brought predictions that an overall decline in life expectancy will take place in the United States by the mid-21st century. What can be done? For an individual, body composition is influenced by a complex interplay of personal factors, including heredity, metabolic rate, hormones, age, and dietary and activity habits. But many outside forces—social, cultural, and economic—shape our behavior, and some experts recommend viewing obesity as a public health problem that requires an urgent and coordinated public health response. A response in health care technology such as gastric bypass surgery, medications, and early screening for obesity-related diseases has helped in the past, but if obesity trends persist, especially among children, average life spans may begin to decrease. What actions might be taken? Suggestions from health promotion advocates include the following: Change food pricing to promote healthful options; for example, tax sugary beverages and offer incentives to farmers and food manufacturers to produce and market affordable healthy choices and smaller portion sizes. Limit advertising of unhealthy foods targeting children. Require daily physical education classes in schools. Fund strategies to promote physical activity by creating more walkable communities, parks, and recreational facilities. Train health professionals to provide nutrition and exercise counseling, and mandate health insurance coverage for treatment of obesity as a chronic condition. Promote expansion of worksite programs for improving diet and physical activity habits. Encourage increased public investment in obesity-related research. In addition to indirectly supporting these actions, you can directly do the following: Analyze your own food choices, and make appropriate changes. Nutrition is discussed in detail in Chapter 12, but you can start by shifting away from consuming foods high in sugar and refined grains. Be more physically active. Take the stairs rather than the elevator, ride a bike instead of driving a car, and reduce your overall sedentary time. Educate yourself about current recommendations and areas of debate in nutrition. Speak out, vote, and become an advocate for healthy changes in your community. See Chapters 12-14 for more on nutrition, exercise, and weight management. sources: Flegal, K. M., et al. 2016. Trends in obesity among adults in the United States, 2005-2014. JAMA 315(21): 2284-2291. Ludwig, D. S. 2016. Lifespan weighed down by diet. JAMA (published online April 4, 2016, DOI: 10.1001/jama.2016.3829); Olshansky, S. J., et al. 2005. A potential decline in life expectancy in the United States in the 21st century. New England Journal of Medicine 352(11): 1138-1145; National Center for Health Statistics. 2016. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD: National Center for Health Statistics; International Food Policy Research Institute. 2016. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Washington, DC: International Food Policy Research Institute; U.S. Department of Agriculture. 2015. Scientific Report of the 2015 Dietary Guidelines Advisory Committee (http://www.health.gov/dietaryguidelines/2015-scientific-report). The good news is that people have some control over whether they develop chronic diseases. People make choices every day that increase or decrease their risks for such diseases. For example, each of us can take personal responsibility for lifestyle choices regarding smoking, diet, exercise, and alcohol use. Table 1.2 shows the estimated number of annual deaths tied to selected underlying causes. For example, the estimated 90,000 deaths tied to alcohol includes deaths due directly to alcohol poisoning as well as a proportion of deaths from causes such as liver cancer and injuries. Similarly, sexual behavior is linked to a proportion of all Page 8deaths from HIV/AIDS and cervical cancer. As Table 1.2 makes clear, lifestyle factors contribute to many deaths in the United States. VITAL STATISTICS Table 1.2 Key Contributors to Deaths among Americans ESTIMATED NUMBER OF DEATHS PER YEAR PERCENTAGE OF TOTAL DEATHS PER YEAR Tobacco 480,000 18.3 Diet/activity patterns (obesity)* 400,000 15.2 Alcohol consumption 90,000 3.4 Microbial agents** 80,000 3.0 Firearms 30,000 1.1 Illicit drug use*** 25,000+ 1.0 Motor vehicles 20,000 0.8 Sexual behavior**** 15,000 0.6 *The number of deaths due to obesity is an area of ongoing controversy and research. Recent estimates have ranged from 112,000 to 400,000. **Microbial agents include bacterial and viral infections, such as influenza, pneumonia, and hepatitis. Infections transmitted sexually are counted in the "sexual behavior" category, including a proportion of deaths related to hepatitis, which can be transmitted both sexually and nonsexually. ***Drug overdose deaths have increased rapidly in recent years, making it likely that this estimate will rise. ****Estimated deaths linked to sexual behavior includes deaths from cervical cancer and sexually acquired HIV, hepatitis B, and hepatitis C. sources: Kochanek, K. D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4), National Research Council, Institute of Medicine. 2015. Measuring the Risks and Causes of Premature Death: Summary of Workshops. Washington, DC: National Academies Press; Stahre, M., et al. 2014. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Preventing Chronic Disease: Research, Practice, and Policy 11: 130293; U.S. Department of Health and Human Services. 2014. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. The need to make good choices is especially true for teens and young adults. For Americans aged 15-24, for example, the leading cause of death is unintentional injuries (accidents), with the greatest number of deaths linked to car crashes (Table 1.3). Factors that influence wellness, including the choices we can all make to promote it, are discussed later in this chapter. VITAL STATISTICS Table 1.3 Leading Causes of Death among Americans Aged 15-24, 2014 RANK CAUSE OF DEATH NUMBER OF DEATHS PERCENTAGE OF TOTAL DEATHS 1 Unintentional injuries (accidents): Motor vehicle All other unintentional injuries 11,836 6,959 4,877 41.1 24.2 16.9 2 Suicide 5,079 17.6 3 Homicide 4,144 14.4 4 Cancer 1,569 5.4 5 Heart disease 1,199 4.2 All causes 28,791 100.0 source: Kochanek, K. D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4). Page 9 Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION How often do you feel exuberant? Vital? Joyful? What makes you feel that way? Conversely, how often do you feel downhearted, de-energized, or depressed? What makes you feel that way? Have you ever thought about how you might increase experiences of vitality and decrease experiences of discouragement?

Developing intimate relationships

DEVELOPING INTIMATE RELATIONSHIPS Successful intimate relationships depend on a belief in ourselves and the people around us. We must be willing to share our ideas, feelings, time, and needs and to accept what others want to give us in return. Just as important is the relationship we develop with ourselves—that is, how we generally feel about ourselves, which is the principal element that we bring to all our relationships. What does it mean to have a healthy relationship with oneself? Self-Concept, Self-Esteem, and Self-Acceptance To have successful relationships, we must first accept and feel good about ourselves. Having a healthy relationship with yourself means being able to self-soothe, regulate your emotions, and feel comfortable with your own company. The factors that contribute to a healthy sense of self include a positive self-concept (how you perceive your self), a healthy level of self-esteem (how you feel about your self), and an affirmative self-acceptance (how you value your self). Each of these factors allows us to love and respect others. As discussed in Chapter 3, the roots of our identity and sense of self can be found in childhood, in the relationships Page 89we had with our caregivers. As adults, we are more likely to have a sense that we are basically lovable, and to view ourselves as worthwhile people who can trust others, if we had the following experiences as babies and children: We felt loved, valued, accepted, and respected. Adults responded to our needs in appropriate ways. Adults gave us the freedom to play, explore, and develop a sense of being separate individuals. These conditions not only encourage us to develop a positive self-concept and healthy self-acceptance, but they also contribute to a basic self-confidence that helps us navigate life's inevitable challenges. Gender Role and Communication We also learn in early childhood how to take on a gender role—the activities, abilities, and characteristics deemed culturally appropriate for us based on our sex. From almost day one of our lives, we receive messages about how a boy versus a girl, or a man versus a woman, should act. As will be discussed in detail in Chapter 5, sex and gender are not the same thing, and the gender and gender role assigned by one's culture may not match one's own internal sense of being male or female—that is, one's gender identity. Cultural expectations associated with traditional gender roles for men prescribed that they provide for their families; assume aggressive, competitive, and power-oriented behaviors; and solve problems logically. Women were expected to take care of home and children; be cooperative, supportive, and nurturing; and approach life emotionally and intuitively. As transgender and feminist movements have progressed, and women have entered more positions of power, expectations have also changed. It is now common for women to work outside the home and for men to participate more actively in parenting. Studies have shown that girls do not necessarily play cooperatively, and that gender behaviors that previously seemed so ingrained can be changed depending on the messages children receive from caregivers, mass media, and other institutions. You may have heard that men and women speak different languages, and that this difference lies behind many conflicts. But do men speak in a more logical way and women in a more emotional way? Although we can find differing patterns in the language of some men and some women, this observation does not fit the data of many studies on gendered communication. There is no gene for gendered language. We learn how to speak just as we learn how to become men and women, and we can decide how we want to communicate based on any particular situation. Still, don't we observe differences in the way men and women communicate? Yes, there are some patterns among certain groups of women, men, girls, and boys, and not because of hardwiring but because we (sometimes unconsciously) follow cultural norms. For example, sociolinguist Penny Eckert finds that in early adolescence, girls start using their voices so that in one moment they speak in a very low pitch and in the next a very high one. Boys, by contrast, decrease their range in pitch, sounding relatively monotone. These changes represent ways that girls and boys differentiate themselves, preparing to participate in what Eckert calls a heterosexual market. They speak differently so as to fit in socially and to anticipate finding a mate. Attachment Another thing we learn in childhood is how to relate to others. Psychologists have suggested that our adult styles of loving may be based on the type of attachment we established in infancy with our mother, father, siblings, or other primary caregivers. According to this view, people who are secure in their intimate relationships as adults probably had a secure, trusting, mutually satisfying attachment to their mother, father, or other parenting figure. Securely attached people find it relatively easy to get close to others, and don't worry excessively about being abandoned or having someone get too close to them. They feel that other people accept them and are generally well intentioned. People who run from relationships may have experienced an "anxious/avoidant" attachment as children. In this type of attachment, a parent's responses were either engulfing or abandoning. Anxious/avoidant adults feel uncomfortable being close to others and seek escape from another's control. They're distrustful and fearful of becoming dependent on and intimate with their partners. Individuals who endured distant and aloof attachments as children can still establish satisfying relationships later in life. In fact, relationships established during adolescence and adulthood give us the opportunity to work through unresolved issues and conflicts. Human beings can be resilient and flexible. We have the capacity to change our ideas, beliefs, and behaviors. We can learn ways to raise our self-esteem and become more trusting, accepting, and appreciative of others and ourselves. We can acquire the communication and conflict resolution skills needed to maintain successful relationships. Although it helps to have a good start in life, it may be even more important to begin again, right from where you are. Friendship Friendships are the first relationships we form outside the family. The friendships we form in childhood are an important part of our growth. Through them, we learn about Page 90tolerance, sharing, and trust. Friendships usually include the following characteristics: Companionship is the good feeling you have when you're with someone else. Friends are usually relaxed and happy when they're together. They typically share common values and interests and plan to spend time together. Real friends can also be tense and unhappy with each other. Even on bad days, we support our friends as we would want them to support us. Respect. Friends have a basic respect for each other's individuality. Good friends respect each other's feelings and opinions and work to resolve their differences without demeaning or insulting each other. They also show their respect by expressing honest feelings. Acceptance. Friends accept each other "warts and all." They feel free to be themselves and express their feelings without fear of ridicule or criticism. Help. Friends know they can rely on each other in times of need. Help may include sharing time, energy, and even material goods. Trust. Friends are secure in the knowledge that they will not intentionally hurt each other. They feel safe confiding in one another. Loyalty. Friends can count on one another. In moments of challenge, a friend will stand up for his or her partner rather than join the opposition. Mutuality. Friends retain their individual identities, but close friendships are characterized by a sense of mutuality—"what affects you affects me." Friends share the ups and downs in each other's lives. Reciprocity. Friendships are reciprocal. There is give-and-take between friends and the feeling that both share joys and burdens more or less equally. The type and strength of our attachment to our caregivers can affect other relationships throughout our lives. © Ariel Skelley/Blend Images LLC RF Intimate partnerships are like friendships in many ways, but they have additional characteristics. These relationships usually include sexual desire and expression, a greater demand for exclusiveness, and deeper levels of caring. Friendships may be more stable and longer lasting than intimate partnerships. Friends are often more accepting and less critical than lovers, perhaps because their expectations differ. Like love relationships, friendships bind society together, providing people with emotional support and buffering them from stress. Love, Sex, and Intimacy Love is one of the most basic and profound human emotions. It is a powerful force in all our intimate relationships. Love encompasses opposites: affection and anger, excitement and boredom, stability and change, bonds and freedom. Love does not give us perfect happiness, but it can give us more meaning in our lives. In many kinds of adult relationships, love is closely affected by sexuality. In the past, marriage was considered the only acceptable context for sexual activities, but for many people today, sex is legitimized by love. According to Gallup and other surveys, the proportion of adults who view sex between an unmarried man and woman as morally acceptable increased from 29% in 1972 to 67% in 2016. Many couples, gay and straight, live together in committed relationships, and many Americans now use personal standards rather than social norms to make decisions about sex. Shifts in cultural attitudes related to sex and marriage can happen slowly or quickly. The most rapid recent change, according to Gallup surveys, has been in Americans' attitudes toward same-sex marriage: between 2005 and 2016, acceptance rose from 37% to 61%. Many people, however, worry about this trend and the bypassing of traditional Page 91norms and values. They fear that the prevailing attitude about sexuality has resulted in a greater emphasis on sex over love and a permissiveness that has undermined the commitment needed to make a loving relationship work. For most people, love, sex, and commitment are closely linked. Love reflects the positive factors that draw people together and sustain their relationship. It includes trust, caring, respect, loyalty, interest in the other, and concern for the other's well-being. Sex brings excitement and passion to the relationship. It intensifies the relationship and adds fascination and pleasure. Commitment contributes stability, which helps maintain a relationship. Responsibility, reliability, and faithfulness are characteristics of commitment. Although love, sex, and commitment are related, they are not necessarily connected. One can exist without the others. Despite the various "faces" of love, sex, and commitment, many of us long for a special relationship that contains them all. Other elements can be identified as features of love, such as euphoria, preoccupation with the loved one, idealization or devaluation of the loved one, and so on, but these elements tend to be temporary. These characteristics may include infatuation, which will fade or deepen into something more substantial. As relationships progress, the central aspects of love and commitment take on more importance. Psychologist Robert Sternberg proposed that love has three dimensions: intimacy, passion, and a commitment component (Figure 4.1). Intimacy refers to feelings of attachment, closeness, connectedness, and bondedness. Passion encompasses motivational drives and sexual attraction. Commitment relates to the decision to remain together with the ultimate goal of making long-term plans with that person. The amount of love one experiences depends on the absolute strength of each of the three components and on the strengths relative to each other. FIGURE 4.1 The triangular theory of love. Different stages and types of love can be understood as different combinations of the three dimensions. Ultimately a relationship based on a single element is less likely to survive than is one based on two or three dimensions. Researchers suggest that gender plays a role in the relationship between love (intimacy) and sex (passion). Although many men report that their most erotic sexual experiences occur in the context of a love relationship, many studies have found that men separate love from sex more easily than women do. Women more often view sex from the point of view of a relationship. Some people believe you can have satisfying sex without love—with friends, acquaintances, or strangers. Although sex with love is an important norm in our culture, the two are often pursued separately in practice. QUICK STATS The number of people aged 18-29 who are single and not living with a partner rose from 52% in 2004 to 64% in 2014. —Gallup surveys, 2015 The Pleasure and Pain of Love The experience of intense love has confused and tormented lovers throughout history. They live in a tumultuous state of excitement, subject to wildly fluctuating feelings of joy and despair. They lose their appetite, can't sleep, and can think of nothing but the loved one. Is this happiness? Misery? Both? The contradictory nature of passionate love can be understood by recognizing that human emotions have two components: physiological arousal and an emotional explanation for the arousal. Love is just one of many emotions accompanied by physiological arousal. Many unpleasant emotions can also generate arousal, such as fear, rejection, and frustration. Although experiences like attraction and sexual desire are pleasant, extreme excitement is physiologically similar to fear and can be unpleasant. For this reason, passionate love may be too intense for some people to enjoy. Over time, the physical intensity and excitement tend to diminish. When this happens, pleasure may actually increase. The Transformation of Love Human relationships change over time, and love relationships are no exception. At first, love is likely to be characterized by high levels of passion and rapidly increasing intimacy. After a while, passion decreases as we become habituated to it and to the person. The diminishing of romance or passionate love can be experienced as a crisis in a relationship. If a more lasting love fails to emerge, the relationship will likely break up. Unlike passion, however, commitment does not necessarily diminish over time. When intensity diminishes, partners often discover a more enduring love. They can now move from absorption in each other to a relationship that includes external goals and projects, friends, and family. In this kind of intimate, more secure love, satisfaction comes not just from the relationship itself but also from achieving other creative goals, such as work or child rearing. The key to successful relationships is in transforming passion into an intimate love based on closeness, caring, and the promise of a shared future.Page 92 Although passion and physical intimacy often decline with time, other aspects of a relationship—such as commitment—tend to grow as the relationship matures. © Lane Oatey/Blue Jean Images/Getty Images Challenges in Relationships Many people believe that love naturally makes an intimate relationship easy to begin and maintain, but in fact obstacles arise and challenges occur. Even in the best of circumstances, a loving relationship will be tested. Partners enter a relationship with diverse needs and desires, some of which emerge only at times of change or stress. Common relationship challenges relate to self-disclosure, commitment, expectations, competitiveness, and jealousy. What Opportunities Do Our Relationships Offer? Obviously we have relationships for fun, companionship, children, and support. But is there more to it? Are we fully conscious of the reasons behind our choices of intimate partners? Do these relationships repeat issues and conflicts from our past—or offer a way to heal and grow beyond these early-life problems? Some experts suggest that, as adults, we unconsciously recreate relationships with others that replay the dramas of childhood. In doing so, we attempt to work through problems from the past. At various points in our lives, we may unconsciously play the part of our younger selves—or the part of another person (such as a parent or a sibling)—with the new emotional figure in our lives. We often play these roles in the hope of getting emotionally what we failed to get as children. But we also have the potential to use the positive models of the past to provide nurturing behaviors in current relationships. Problems in relationships don't always signal incompatibility. Sometimes they may arise from issues that are emotionally difficult because of past hurtful experiences. The good news is that problems in relationships are a potential path to growth, as individuals and as a couple. A man who feels he doesn't receive enough love from his partner (and didn't from his parents) may benefit from cultivating additional platonic relationships rather than hoping for complete satisfaction from one person. A woman who feels the need for more independence in a relationship (which she didn't have growing up) may grow from learning to stay with her discomfort around intimacy and gradually experience closeness without becoming fearful. Ultimately it seems that the healthiest relationships are those that allow us to feel secure even when we are apart. Developmental psychologists suggest that the healthiest infants can be comforted by their caregivers without feeling overwhelmed and can be apart from their caregivers without feeling abandoned. Knowing when to comfort and when to let go can be a critical part of any relationship. Psychologist Carl Rogers suggests that relationships in which we can be open, nonjudgmental, expressive, and understood offer us the greatest chance to grow, develop our potential, and awaken to as much of life as possible. Perhaps the larger, masked meaning of relationships may need to be clarified to help us cultivate the intimacy or freedom that may have been in short supply while we were growing up. We can help ourselves and others to grow by offering and asking for love and compassion. We can free ourselves from the limits imposed on us from the past by challenging ourselves to see where we are afraid to go in our relationships, and then going there with our partners. Honesty and Openness At the beginning of a relationship most of us prefer to present ourselves in the most favorable light. Although sharing thoughts and feelings can be emotionally risky, honesty is necessary to achieve the freedom for the next step of the relationship. Over time, you and your partner will learn more about each other and feel more comfortable sharing. In fact, intimate familiarity with your partner's life is a key characteristic of successful long-term relationships. Emotional Intelligence In his book Emotional Intelligence—Why It Can Matter More Than IQ, Daniel Goleman argues that classical IQ is not destiny and that our traditional view of intelligence is too narrow. He asserts that the traditional view ignores a range of abilities vital to how well we function in life. Goleman illuminates the factors at work when people with high IQs flounder and those with Page 93modest IQs do remarkably well. These factors include self-awareness, self-discipline, and empathy, and they add up to a different way of being intelligent, known as "emotionally intelligent." Psychologists Peter Salovey and John D. Mayer define emotional intelligence as "the subset of social intelligence that involves the ability to monitor one's own and others' feelings and emotions, to discriminate among them and to use this information to guide one's thinking and actions." The key to developing emotional intelligence lies in cultivating the overarching skill of mindfulness—the ability to dispassionately observe thoughts and feelings as they occur (see Chapter 2). When we are able to note and observe emotions without judging them or immediately acting on them, we can make more measured, wise, and skillful responses. These skills can be particularly helpful when we are involved in an argument or a conflict with someone with whom we have a close relationship. Mindfulness can be cultivated by paying more attention to the operation of our minds, slowing down our lives enough to make more detailed observations, and staying in the moment as we go about our day-to-day activities. Although we often have limited control over external events, we have a great deal of ability to discipline, focus, and train our minds. Practicing mindfulness and developing emotional intelligence will improve your sense of self and the quality of your relationships, and may even result in the peace of mind that many people find so elusive. (To rate your current level of emotional intelligence, see the box "Are You Emotionally Intelligent?") ASSESS YOURSELF: Are You Emotionally Intelligent? Below are the behavioral habits of emotional intelligence. As you read these, rate yourself on each habit. Is this a habit you practice Always? Usually? Sometimes? Seldom? Almost Never? 5 points 4 points 3 points 2 points 1 point Behavioral Habit Score 1. I respect other people and their feelings 2. I can easily identify my feelings 3. I take responsibility for own emotions 4. I can maintain control of my emotions 5. I find it easy to validate others' feelings and values 6. I do not rush to judge or label other people and situations 7. I do not try to manipulate, criticize, blame, or overpower others 8. I challenge my habitual responses and am willing to try considered alternatives 9. I live in the present, learn from experiences, and do not carry negative feelings forward Scoring: 40-45 = You have a high level of emotional maturity, awareness, and control. You have a positive and inspiring impact on others. 35-39 = You have a higher than average level of emotional intelligence. Concentrate on self-awareness and control, and developing increased empathy for others. 27-34 = You have a baseline awareness of what emotional intelligence is. Be alert for opportunities to increase levels of self-awareness and empathy toward others, and to refine responses. 9-26 = Now that you're of aware of emotional intelligence, monitor your emotions and their impact on you and others. Notice how your behavior affects others and get feedback on how to modify behavior that provokes a defensive response. source: © Donna Earl, 2003 www.DonnaEarlTraining.com. Donna Earl is a business educator who provides workshops on Emotional Intelligence. Unequal or Premature Commitment When one person in an intimate partnership becomes more serious about the relationship than the other, it can be difficult to maintain it without someone feeling hurt. Sometimes a Page 94couple makes a premature commitment, and then one of the partners has second thoughts and wants to break off the relationship. Eventually both partners recognize that something is wrong, but each is afraid to tell the other. It may be painful but necessary to resolve this conflict by stepping up and saying, "We have a problem. Can we have an honest talk about it?" Such problems usually can be resolved only by honest and sensitive communication. Unrealistic Expectations Each partner brings hopes and expectations to a relationship, some of which may be unrealistic, unfair, and ultimately damaging to the relationship. These include the following: Expecting your partner to change. Your partner may have certain behaviors that you like, and others that annoy you. It's okay to discuss them with your partner, but it's unfair to demand that your partner change to meet all of your expectations. Accept the differences between your ideal and reality. Assuming that your partner has all the same opinions, priorities, interests, and goals as you. Don't assume that you think or feel the same way about everything—or that you must if the relationship is to succeed. Agreement on key issues (such as whether to have children) is important, but differences can enhance a relationship as long as partners understand and respect each other's points of view. Believing that a relationship will fulfill all of your personal, financial, intellectual, and social needs. Expecting a relationship to fulfill all your needs places too much pressure on your partner and on your relationship, and it will inevitably lead to disappointment. For your own well-being, it's important to maintain some degree of autonomy and self-sufficiency. Competitiveness Games and competitive sports add flavor to the bonding process—as long as the focus is on fun. If one partner always feels compelled to compete and win, it can detract from the sense of connectedness, interdependence, equality, and mutuality between partners. The same can be said for a perfectionistic need to be right in every instance—to "win" every argument. If competitiveness is a problem for you, ask yourself if your need to win is more important than your partner's feelings or the future of your relationship. Try noncompetitive activities or an activity where you are a beginner and your partner excels. Accept that your partner's views may be just as valid and important to your partner as your own views are to you. Balancing Time Together and Apart You may enjoy time together with your partner, but you may also want to spend time alone or with other friends. If you or your partner interpret time apart as rejection or lack of commitment, it can damage the relationship. Talk with your partner about what time apart means and share your feelings about what you expect from the relationship in terms of time together. Consider your partner's feelings carefully, and try to reach a compromise that satisfies both of you. Supportiveness is a sign of commitment and compassion and is an important part of any healthy relationship. © Justin Horrocks/Getty Images Differences in expectations about time spent together can mirror differences in ideas about emotional closeness. Any romantic relationship involves giving up some degree of autonomy in order to develop an identity as a couple. But remember that every person is unique and has different needs for distance and closeness in a relationship. Jealousy Jealousy is the angry, painful response to a partner's real, imagined, or possible involvement with a third person. Some people think that the existence of jealousy proves the existence of love, but jealousy is actually a sign of insecurity or possessiveness. In its irrational and extreme forms, jealousy can destroy a relationship by its insistent demands and attempts at control. Jealousy is a factor in precipitating violence in dating relationships among both high school and college students, and abusive spouses often use jealousy to justify their violence. (Problems with control and violence in relationships are discussed in Chapter 21.) People with a healthy level of self-esteem are less likely to feel jealous. When jealousy occurs in a relationship, it's important for the partners to communicate clearly with each other about their feelings. In this sense, jealousy can offer partners the chance to look closely at issues like possessiveness, insecurity, and low self-esteem and thereby strengthen the relationship by working through jealousy. Supportiveness Another key to successful relationships is the ability to ask for and give support. Partners need to know that they can count on each other during difficult times. Unhealthy Relationships Everyone should be able to recognize when a relationship is unhealthy. Relatively extreme examples of unhealthy relationships are those that are physically or emotionally abusive or that involve codependency.Page 95 Even relationships that are not abusive or codependent can still be unhealthy. If your relationship lacks love and respect and places little value on the time you and your partner have spent together, it may be time to get professional help or to end the partnership. Further, if your relationship is characterized by communication styles that include criticism, contempt, defensiveness, and withdrawal—despite real efforts to repair these destructive patterns—the relationship may not be salvageable. Consider these questions: Do you and your partner have more negative than positive experiences and interactions? Are there old hurts that you or your partner cannot forgive? Do you feel disrespected or unloved? Do you find it hard to feel positive feelings of affection for your partner? Does it feel as if your relationship has been a waste of time? Spiritual leaders suggest that relationships are unhealthy when you feel that your sense of spontaneity, your potential for inner growth and joy, and your connection to your spiritual life are deadened. There are negative physical and mental consequences of being in an unhappy relationship. Although breaking up is painful and difficult, it is ultimately better than living in a toxic relationship. Ending a Relationship Even when a couple starts out with the best of intentions, an intimate relationship may not last. Some breakups occur quickly following direct action by one or both partners, but many occur over an extended period as the couple goes through a cycle of separating and reconciling. Ending an intimate relationship is usually difficult and painful. Both partners may feel attacked and abandoned, but feelings of distress are likely to be more acute for the rejected partner. If you are involved in a breakup, the following suggestions may help make the ending easier: Give the relationship a fair chance before breaking up. If it's still not working, you'll know you did everything you could. Be fair and honest. If you're initiating the breakup, don't try to make your partner feel responsible. Be tactful and compassionate. You can leave the relationship without deliberately damaging your partner's self-esteem. Emphasize your mutual incompatibility, and admit your own contributions to the problem. If you are the rejected person, give yourself time to resolve your anger and pain. Mobilize your coping resources, including social support and other stress management techniques. You may go through a process of mourning the relationship, experiencing disbelief, anger, sadness, and finally acceptance. Remember that there are actually many people with whom you can potentially have an intimate relationship. Recognize the value in the experience. You honor the feelings that you shared with your partner by validating the relationship as a worthwhile experience. Ending a close relationship can teach you valuable lessons about your needs, preferences, strengths, and weaknesses. Use your insights to increase your chance of success in your next relationship. Use the recovery period following a breakup for self-renewal. Redirect more of your attention to yourself, and reconnect with people and areas of your life that may have been neglected as a result of the relationship. Time will help heal the pain of the loss of the relationship. Finally, be aware of the tendency or impulse to "rebound" quickly into another relationship. Although a new relationship may mute the pain of a breakup, forming a relationship in order to avoid feeling pain is not a good strategy. Too often, rebound relationships fail because they were designed to be "lifeboats" or because one or both of the partners is not truly ready to be close to someone else again.

factors that influence wellness

FACTORS THAT INFLUENCE WELLNESS Optimal health and wellness come mostly from a healthy lifestyle—patterns of behavior that promote and support your health and promote wellness now and as you get older. In the pages that follow, you'll find current information and suggestions you can use to build a healthier lifestyle; also, see the "Wellness Matters for College Students" box. WELLNESS ON CAMPUS: Wellness Matters for College Students Most college students, in their late teens and early twenties, appear to be healthy. But appearances can be deceiving. Each year, thousands of students lose productive academic time to physical and emotional health problems—some of which can continue to plague them for life. The following table shows the top 10 health issues affecting students' academic performance, according to the fall 2015 American College Health Association-National College Health Assessment II. HEALTH ISSUE STUDENTS AFFECTED (%) Stress 30.3 Anxiety 23.7 Sleep difficulties 20.4 Depression 14.6 Cold/flu/sore throat 13.5 Concern for a friend/family member 10.0 Relationship difficulties 8.6 Attention deficit/hyperactivity disorder 6.0 Death of a friend/family member 5.5 Sinus or ear infection, strep throat, bronchitis 4.7 Each of these issues is related to one or more of the dimensions of wellness, and most can be influenced by choices students make daily. Although some troubles—such as the death of a friend or family member—cannot be controlled, students can moderate their physical and emotional impact by choosing healthy behaviors. For example, there are many ways to manage stress, the top health issue affecting students (see Chapter 2). By reducing unhealthy choices (such as using alcohol to relax) and by increasing healthy choices (such as using time management and relaxation techniques), students can reduce the impact of stress on their lives. The survey also estimated that, based on students' reporting of their height and weight, nearly 23.3% of college students are overweight and 16.3% are obese. Although heredity plays a role in determining your weight, lifestyle is also a factor in weight management. In many studies over the past few decades, a large percentage of students have reported behaviors such as the following: Overeating Frequently eating high-fat foods Using alcohol and binge drinking Clearly, eating behaviors are often a matter of choice. Although students may not see (or feel) the effects of their dietary habits today, the long-term health risks are significant. Overweight and obese persons run a higher-than-normal risk of developing diabetes, heart disease, and cancer later in life. We now know with certainty that improving one's eating habits, even a little, can lead to weight loss and improved overall health. Other Choices, Other Problems Students commonly make other unhealthy choices. Here are some examples from the 2015 National College Health Assessment II: Only 47.8% of students reported that they used a condom during vaginal intercourse in the past 30 days. About 18.7% of students had seven or more drinks the last time they partied. About 9.6% of students had smoked cigarettes at least once during the past month. What choices do you make in these situations? Remember: It's never too late to change. The sooner you trade an unhealthy behavior for a healthy one, the longer you'll be around to enjoy the benefits. source: American College Health Association. 2015. American College Health Association-National College Health Assessment IIc: Reference Group Executive Summary Fall 2015. Hanover, MD: American College Health Association. Reprinted by permission of the American College Health Association (http://www.acha-ncha.org/reports_ACHA-NCHAIIc.html). QUICK STATS More than 29 million American adults have diabetes, and 25% of them don't know it. —Centers for Disease Control and Prevention, 2016 Our behavior, family health history, environment, and access to health care are all important influences on wellness. These factors, which vary for both individuals and groups, can interact in ways that produce either health or disease. Health Habits Research continually reveals new connections between our habits and health. For example, heart disease is associated with smoking, stress, a hostile attitude, a poor diet, and being sedentary. Poor health habits take hold before many Americans reach adulthood. Other habits, however, are beneficial. Regular exercise can help prevent heart disease, high blood pressure, diabetes, osteoporosis, and depression. Exercise can also reduce the risk of colon cancer, stroke, and back injury. A balanced and varied diet helps prevent many chronic diseases. As we learn more about how our actions affect our bodies and minds, we can make informed choices for a healthier life. Heredity/Family History Your genome consists of the complete set of genetic material in your cells—about 25,000 genes, half from each of your parents. Genes control the production of proteins that serve both as the structural material for your body and as the regulators of all your body's chemical reactions and metabolic processes. The human genome varies only slightly from person to person, and many of these differences do not affect health. However, some differences have important implications for health, and knowing your family's health history can help you determine which conditions may be of special concern for you. Errors in our genes are responsible for about 3500 clearly hereditary conditions, including sickle-cell disease and cystic fibrosis. Altered genes also play a part in heart disease, cancer, stroke, diabetes, and many other common conditions. However, in these more common and complex disorders, genetic alterations serve only to increase an individual's risk, and the disease itself results from the interaction of many genes with other factors. An example of the power of behavior and environment can be seen in the more than 60% increase in the incidence of diabetes that has occurred among Americans since 1990. This huge increase is not due to any sudden change in our genes; it is the result of increasing rates of obesity caused by poor dietary choices and lack of physical activity. Environment Your environment includes substances and conditions in your home, workplace, and community. Are you frequently exposed to environmental tobacco smoke or the radiation in sunlight? Do you live in an area with high rates of crime and violence? Do you have access to nature? Today environmental influences on wellness also include conditions in other countries and around the globe, particularly weather and climate changes occurring as a result of global warming. In the past few years, climate change has attracted much attention worldwide. Most climate scientists agree that human activity—specifically, the burning of fossil fuels for energy and the release of greenhouse gases into the atmosphere—has caused changes that are raising Earth's Page 14temperature and threatening the health of the planet and its living systems. The evidence includes melting ice caps, shifting weather patterns, and the threatened extinction of species. Scientists are trying to determine how high Earth's temperature can climb before damage becomes irreversible. Access to Health Care Adequate health care helps improve both quality and quantity of life through preventive care and the treatment of disease. For example, vaccinations prevent many dangerous infections, and screening tests help identify key risk factors and diseases in their early treatable stages. As described earlier, inadequate access to health care is tied to factors such as low income, lack of health insurance, and geographic location. Cost is one of many issues surrounding the development of advanced health-related technologies. Personal Health Behaviors In many cases, behavior can tip the balance toward good health, even when heredity or environment is a negative factor. For example, breast cancer can run in families, but it also may be associated with being overweight and inactive. A Page 15woman with a family history of breast cancer is less likely to develop the disease if she controls her weight, exercises regularly, and has regular mammograms to help detect the disease in its early, most treatable stage. Similarly, a young man with a family history of obesity can maintain a normal weight by balancing calorie intake against activities that burn calories. If your life is highly stressful, you can lessen the chances of heart disease and stroke by managing and coping with stress (see Chapter 2). If you live in an area with severe air pollution, you can reduce the risk of lung disease by not smoking. You can also take an active role in improving your environment. Behaviors like these can make a difference in how great an impact heredity and environment will have on your health. QUICK STATS More than two-thirds of American adults are overweight. —National Center for Health Statistics, 2016

Family Life

FAMILY LIFE American families are very different today than they were even a few decades ago. In 1960, 73% of children under the age of 18 lived with both parents in their first marriage; in 2014, it was 46%. Over the same time period, the proportion of children living with a single parent grew from 9% to 26%. Becoming a Parent Few new parents are prepared for the job of parenting, yet they literally must assume the role overnight. They must quickly learn how to hold and feed a baby, change diapers, and differentiate a cry of hunger from a cry of pain or fear. No wonder the birth of the first child is one of the most stressful transitions for any couple. Even couples with an egalitarian relationship before their first child is born find that their marital roles become more traditional with the arrival of the new baby. In heterosexual couples, the father typically becomes the primary provider and protector, and the mother typically becomes the primary nurturer. Most research indicates that mothers have to make greater changes in their lives than fathers do. Although men today spend more time caring for their infants than ever before, women still take the ultimate responsibility for the baby. Women are usually the ones who make job changes, either quitting work or reducing work hours in order to stay home with the baby for several months or more. Many mothers juggle the multiple roles of mother, homemaker, and employer/employee and feel guilty that they never have enough time to do justice to any of these roles. Not surprisingly, marital satisfaction often declines after the birth of the first child. The wife who has stopped working may feel she is cut off from the world; the wife who is trying to fulfill duties both at home and on the job may feel overburdened and resentful. The husband may have a hard time adjusting to having to share his wife's love and attention with the baby, as well as the stress of trying to provide for a growing family. But marital dissatisfaction after the baby is born is not inevitable. Couples who successfully weather the stresses of a new baby are reported to have these three characteristics in common: They had developed a strong relationship before the baby was born. They had planned to have the child. They communicate well about their feelings and expectations. Page 106 Parenting Parents may wonder about the long-term impact of each decision they make on their child's well-being and personality. According to parenting experts, no one action or decision (within limits) will determine a child's personality or development. Instead the parenting style, or overall approach to parenting, is most important. Parenting styles vary according to the levels of two characteristics of the parents: Demandingness encompasses the use of discipline and supervision, the expectation that children act responsibly and maturely, and the direct reaction to disobedience. Responsiveness refers to a parent's warmth and intent to facilitate independence and self-confidence in a child by being supportive, connected, and understanding of the child's needs. Several parenting styles have been identified. Each style emerges according to the parents' balance of demandingness and responsiveness. Here are some examples: Authoritarian parents are high in demandingness and low in responsiveness. They give orders and expect obedience, giving very little warmth or consideration to their children's special needs. Authoritative parents are high in both demandingness and responsiveness. They set clear boundaries and expectations, but they are also loving, supportive, and attuned to their children's needs. Permissive parents are high in responsiveness and low in demandingness. They do not expect their children to act maturely but instead allow them to follow their own impulses. They are very warm, patient, and accepting, and they are focused on not stifling their child's innate creativity. Uninvolved parents are low in both demandingness and responsiveness. They require little from their children and respond with little attention, frequency, or effort. In extreme cases, this style of parenting might reach the level of child neglect. Children's Temperaments Every child has a tendency toward certain moods and a style of reacting—a temperament—that is apparent from infancy and often lasts into adulthood. Research has identified three basic temperament types. Most children show aspects of different temperaments but tend toward one. Easy children are happy and content, and have regular sleeping and eating habits. They are adaptable and not easily upset. Difficult children are fussy, are fearful in new situations or with strangers, and have irregular sleeping and feeding habits. They are easily upset and often hard to soothe. Slow-to-warm-up children are somewhat fussy and tend to react negatively or fearfully to new people or situations; however, they slowly warm up and adapt positively. Setting clear boundaries, holding children to high expectations, and responding with warmth to children's needs are all positive parenting strategies. © Rosemarie Gearhart/Getty Images Parenting is a skill that often must be learned. Conflicts arise when there is a mismatch in temperaments and styles between parent and child. For example, a parent who expects quick action in response to a command may not be a good match for a child who is naturally slow to respond. Parents should be attuned to their child's distinct style and do their best to support the child. According to psychologists, "optimal attunement" of the parent to the child involves allowing the child to feel close and connected without feeling engulfed or impinged upon, and also allowing for separation and aloneness without the child feeling abandoned or rejected. Attachment parenting advocates believe that if children are consistently held, attended to, and not allowed to be unhappy for any length of time, they will internalize the parents' consistent care and support and grow up to be more independent adults. Parenting and the Family Life Cycle At each stage of the family life cycle, the relationship between parents and children changes. And with those changes come new challenges. The parents' primary responsibility to a baby is to ensure its physical well-being around the clock. As babies grow into toddlers and begin to walk and talk, they begin to be able to take care of some of their own physical needs. For parents, the challenge at this stage is to strike a balance between giving children the freedom to explore and setting limits that will keep the children safe and secure. As children grow toward adolescence, parents need to give them increasing independence and gradually be willing to let them risk success or failure on their own. Marital satisfaction for most couples tends to decline while the children are in school. Reasons include the financial and emotional pressures of a growing family and the increased job and community responsibilities of parents in their thirties, forties, and fifties. Once the last child has left home, marital satisfaction can increase because the parents have more time to focus on each other.Page 107 Single Parents Today the family life cycle for many adults is marriage, parenthood, divorce, single parenthood, remarriage, and potentially widow- or widower-hood. According to Pew Research Institute, about 26% of children today are living with a single parent (Figure 4.4). In some single-parent families, the traditional family life cycle is reversed and the baby comes before the marriage. In these families, the single parent is often (but not always) a teenage mother. Bar graph showing data on family living arrangements in 1960, 1980, and 2014. [D] FIGURE 4.4 Family living arrangements for American families with children under age 18. note: Data regarding cohabitation are not available for 1960 and 1980; in those years, children with cohabiting parents are included in "single parent." For 2014, the total share of children living with two married parents is 62% after rounding. "Married parents" refer to those in a heterosexual marriage only. Figures do not add up to 100% due to rounding. source: Pew Research Center. 2015. Parenting in America: Outlook, Worries, Aspirations Are Strongly Linked to Financial Situation (http://www.pewsocialtrends.org/2015/12/17/parenting-in-america) Even if both parents work after a divorce, their combined incomes must support two households, straining finances. Economic difficulties are the primary problem for single mothers, especially for unmarried mothers who have not finished high school and have difficulty finding work. Divorced mothers usually experience a sharp drop in income the first few years on their own, but if they have job skills or education they usually can eventually support themselves and their children. Other problems for single mothers are the often-conflicting demands of being both father and mother and the difficulty of satisfying their own needs for adult companionship and affection. Financial pressures are also a complaint of single fathers, but due to higher incomes among men, they do not experience them to the extent that single mothers do. Because they are likely to have less practice than mothers in juggling parental and professional roles, they may worry that they do not spend enough time with their children. Research about the effect on children of growing up in a single-parent family is inconclusive. Evidence seems to indicate that these children tend to have less success in school and in their careers than children from two-parent families, but these effects may be associated more strongly with lower educational attainment and fewer financial resources of the single parent than with the absence of the second parent. Two-parent families are not necessarily better if one of the parents spends little time relating to the children or is physically or emotionally abusive. QUICK STATS 5% of American children live in a home where neither parent is present. —Pew Research Center, 2014 Stepfamilies Single parenthood is usually a transitional stage: About three out of four divorced women and about four out of five divorced men will ultimately remarry. Rates are lower for widowed men and women, but overall almost half the marriages in the United States are remarriages for the husband, the wife, or both. If either partner brings children from a previous marriage into the new family unit, a stepfamily (or "blended family") is formed. Stepfamilies are significantly different from primary families and should not be expected to duplicate the emotions and relationships of a primary family. Research has shown that healthy stepfamilies are less cohesive and more adaptable than healthy primary families; they have a greater capacity to allow for individual differences and accept that biologically related family members will have emotionally closer relationships. Stepfamilies gradually gain more of a sense of being a family as they build a history of shared daily experiences and major life events. Successful Families Family life can be extremely challenging. A strong family is not a family without problems; it's a family that copes successfully with stress and crisis (see the box "Strategies of Strong Families"). Successful families are intentionally connected—members share experiences and meanings. TAKE CHARGE: Strategies of Strong Families Life is full of challenges, but strong families work together to meet those challenges. Strong families use the following strategies to deal with life's difficulties: Look for something positive in difficult situations. No matter how difficult, most problems teach us lessons that we can draw on in future situations. Pull together. Think of the problem not as one family member's difficulty but as a challenge for the family as a whole. Gethelp outside the family. Call on extended family members, supportive friends, neighbors, colleagues, church or synagogue members, and community professionals. Listenand empathize. Offer each other nonjudgmental support. Userituals for bonding and healing. A ritual could include a memorial event, a tradition that the family repeats each year on a significant date or for a holiday, or a shared daily meal or time for conversation. Beflexible. Crises often force family members to learn new approaches to life or take on different responsibilities. Each person needs time to heal from challenges at her or his own pace. Give each other space. Respect family members' need for privacy and alone time. Focuson the big picture and set priorities. Getting caught up in details rather than the essentials can make people edgy, even hysterical. Takecare of each other. We often forget that we are biological beings. Like kindergartners, we need a good lunch and time to play. We need to have our hair stroked, a hug, or a nap. Validate each other. Offer appreciation and praise. Createa life full of meaning and purpose. We all face severe crises in life; they're unavoidable. Sometimes it helps to focus on others, to offer service to the community. Giving of ourselves brings richness and dignity to our lives despite the troubles we endure. Activelymeet challenges head-on. Life's disasters do not go away when we look in another direction. Gowith the flow to some degree. Sometimes we are relatively powerless in the face of a crisis. Simply saying to ourselves that things will get better with time can be useful. Beprepared in advance for life's challenges. Healthy family relationships are like an ample bank balance: If our relational accounts are in order, we will be able to weather life's most difficult storms—together. sources: Binghamton University Counseling Center. n.d. Dealing with crisis and trauma events. American Academy of Experts in Traumatic Stress (http://www.aaets.org/article164.htm); Olson, D. H., and J. DeFrain. 2007. Marriages and Families: Intimacy, Diversity, and Strengths, 6th ed. New York: McGraw-Hill. Copyright © 2007 The McGraw-Hill Companies, Inc. Reprinted by permission of The McGraw-Hill Companies, Inc. An excellent way to build strong family ties is to develop family rituals and routines—organized, repeated activities that have meaning for family members. Families with regular routines and rituals have healthier children, more satisfyingPage 108 marriages, and stronger family relationships. Some of the most common routines identified in research studies are dinnertime, a regular bedtime, and household chores; common rituals include birthdays, holidays, and weekend activities. Family routines may even serve as protective factors, balancing out potential risk factors associated with single-parent families and families with divorce and remarriage. Incorporating a regular family mealtime into a family's routine allows parents and children to develop closer relationships and leads to better parenting, healthier children, and better school performance. Although you can find tremendous variation among American families, experts have proposed that seven major qualities or themes appear in strong families: Commitment. The family is very important to its members, and members take their responsibilities seriously. Everyone knows they are loved, valued, and special to each other. Appreciation. Family members care about one another and express their appreciation. They don't wait for special occasions to celebrate each other. Communication. Family members spend time listening to one another and enjoying one another's company. They talk through disagreements and attempt to solve problems. Time together. Family members do things together—often simple activities that don't cost money. They put down their devices and their work, and they focus on each other. Spiritual wellness. The family promotes sharing, love, and compassion for other human beings. Stress and crisis management. When faced with illness, death, marital conflict, or other crises, family members pull together, seek help, and use other coping strategies to meet the challenge. Affectionate physical contact. People of all ages need hugs, cuddles, and caresses for their emotional health and to demonstrate caring and love for one another. It may surprise some people that members of strong families are often seen at counseling centers. They know that the smartest thing to do in some situations is to get help.Page 109 Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Do you think of your own family as successful? Why or why not? Either way, what could you do to make your relationships in your family more successful? Are you comfortable talking to your family about these issues?

what is stress

WHAT IS STRESS? In common usage, the term stress refers to two things: the mental states or events that trigger physical and psychological reactions (e.g., "That relationship is way too much stress"), and the reactions themselves (e.g., "I feel a lot of stress every time I walk into that classroom"). This text uses the more precise term stressor for a physical or psychological event that triggers physical and emotional reactions and Page 30the term stress response for the reactions themselves. Thoughts or feelings about an approaching event can be just as stressful as the event itself, such as a first date or a final exam; sweaty palms and a pounding heart are symptoms of the stress response. We'll use the term stress to describe the general physical and emotional state that accompanies the stress response. Each individual's experience of stress depends on many factors, including the nature of the stressor and how it is perceived. Stressors take many different forms. Like a fire in your home, some occur suddenly and neither last long nor repeat. Others, like air pollution or quarreling parents, can continue for a long time. The memory of a stressful occurrence can itself be a stressor years after the event, such as the memory of the loss of a loved one. Responses to stressors can include a wide variety of physical, emotional, and behavioral changes. A short-term response might be an upset stomach or insomnia, whereas a long-term response might be a change in your personality or social relations. Physical Responses to Stressors Imagine a close call: As you step off the curb, a car careens toward you. With just a fraction of a second to spare, you leap safely out of harm's way. In that split second of danger and in the moments following it, you experience a predictable series of physical reactions. Your body goes from a relaxed state to one prepared for physical action to cope with a threat to your life. Two systems in your body are responsible for your physical response to stressors: the nervous system and the endocrine system. Through rapid chemical reactions affecting almost every part of your body, you are primed to act quickly and appropriately in time of danger. The Nervous System The nervous system consists of the brain, spinal cord, and nerves. Part of the nervous Page 31system is under voluntary control, as when you tell your arm to reach for a chocolate. The part that is not under conscious supervision—for example, the part that controls the digestion of the chocolate—is the autonomic nervous system. In addition to digestion, it controls your heart rate, breathing, blood pressure, and hundreds of other involuntary functions. The autonomic nervous system consists of two divisions: The parasympathetic division is in control when you are relaxed. It aids in digesting food, storing energy, and promoting growth. The sympathetic division is activated when your body is stimulated, for example, by exercise, and when there is an emergency, such as severe pain, anger, or fear. Sympathetic nerves affect nearly every organ, sweat gland, blood vessel, and muscle in order to enable your body to best handle an emergency. Actions of the Nervous and Endocrine Systems Together During stress, the sympathetic nervous system triggers the endocrine system. This system of glands, tissues, and cells helps control body functions by releasing hormones and other chemical messengers into the bloodstream to influence metabolism and other body processes. The nervous system handles very short-term stress, whereas the endocrine system deals with both short-term (acute) and long-term (chronic) stress. How do both systems work together in an emergency? Higher cognitive areas in your brain decide that you are facing a threat. The nervous and endocrine systems activate adrenal glands, which are located near the top of the kidneys. These glands release the hormones cortisol and epinephrine (also called adrenaline). These hormones then trigger the physiological changes shown in Figure 2.1, including the following: Heart and respiration rates accelerate to speed oxygen through the body. Hearing and vision become more acute. The liver releases extra sugar into the bloodstream to boost energy. Perspiration increases to cool the skin. The brain releases endorphins—chemicals that can inhibit or block sensations of pain—in case you are injured. Detailed list by body system of the effects of the fight-or-flight reaction. [D] FIGURE 2.1 The fight-or-flight reaction. In response to a stressor, the autonomic nervous system and the endocrine system prepare the body to deal with an emergency. As a group, these nearly instantaneous physiological changes are called the fight-or-flight reaction. These changes give you the heightened reflexes and strength you need to dodge a car or deal with other stressors. Although these physiological changes may vary in intensity, the same basic set of physiological reactions occurs in response to any type of stressor—positive or negative, physiological or psychological. The Return to Homeostasis Once a stressful situation ends, the parasympathetic division of your autonomic nervous system takes command and halts the stress response. It restores homeostasis, a state in which blood pressure, heart rate, hormone levels, and other vital functions are maintained within a narrow range of normal. Your parasympathetic nervous system calms your body down, slowing a rapid heartbeat, drying sweaty palms, and returning breathing to normal. Gradually your body resumes its normal "housekeeping" functions, such as digestion and temperature regulation. Damage that may have been sustained during the fight-or-flight reaction is repaired. The day after you narrowly dodge the car, you wake up feeling fine. In this way, your body can grow, repair itself, and acquire new reserves of energy. When the next crisis comes, you'll be ready to respond again instantly. The Fight-or-Flight Reaction in Modern Life The fight-or-flight reaction is part of our biological heritage, and it's a survival mechanism that has served humans well. In modern life, however, it is often absurdly inappropriate. Many of the stressors we face in everyday life do not require a physical response—for example, an exam, a mess left by a roommate, or a stoplight. The fight-or-flight reaction prepares the body for physical action regardless of whether a particular stressor necessitates such a response.Page 32 Psychological and Behavioral Responses to Stressors We all experience a similar set of physical responses to stressors, which makes up the fight-or-flight reaction. These responses, however, vary from person to person and from one situation to another. People's perceptions of potential stressors—and of their reactions to such stressors—also vary greatly. For example, you may feel confident about taking exams but be nervous about talking to people you don't know, whereas your roommate may love challenging social situations but may be nervous about taking tests. Our individual ways of perceiving things play a huge role in the stress equation. Your cognitive (mental) appraisal of a potential stressor strongly influences how you view it. Two factors that can reduce the magnitude of the stress response are successful prediction and the perception of control. For instance, receiving a course syllabus at the beginning of the term allows you to predict the timing of major deadlines and exams. Having this predictive knowledge also allows you to exert some control over your study plans and can help reduce the stress caused by exams. Cognitive appraisal is highly individual and strongly related to emotions. The facts of a situation—Who? What? Where? When?—typically are evaluated fairly consistently from person to person. But evaluation with respect to personal outcome Page 33varies: What does this mean for me? Can I do anything about it? Will it improve or worsen? If a person perceives a situation as exceeding her or his ability to cope, the result can be negative emotions and an inappropriate stress response. If, by contrast, a person perceives a situation as a challenge that is within her or his ability to manage, more positive and appropriate responses are likely. A certain amount of stress, if coped with appropriately, can help promote optimal performance (Figure 2.2). FIGURE 2.2 Stress level, performance, and well-being. A moderate level of stress challenges individuals in a way that promotes optimal performance and well-being. Too little stress, and people are not challenged enough to improve; too much stress, and the challenges become stressors that can impair physical and emotional health. © Image Source/Getty Images; © John Fedele/Getty Images; © John Lund/Drew Kelly/Blend Images LLC QUICK STATS 86.7% of college students reported feeling overwhelmed by their workload at least once in the past year. —American College Health Association-National College Health Assessment II, 2015 Effective and Ineffective Responses Common psychological responses to stressors include anxiety, depression, and fear. Although emotional responses are determined in part by inborn personality or temperament, we often can moderate or learn to control them. Coping techniques are discussed later in the chapter. Unlike behavioral reactions, our behavioral responses to stressors are controlled by the somatic nervous system, which manages our conscious actions. Effective behavioral responses such as talking, laughing, exercising, meditating, learning time management skills, and becoming more assertive can promote wellness and enable us to function at our best. Ineffective behavioral responses to stressors include overeating; expressing hostility; and using tobacco, alcohol, or other drugs. Personality and Stress Some people seem to be nervous, irritable, and easily upset by minor annoyances. Others are calm and composed even in difficult situations. Scientists remain unsure just why this is or how the brain's complex emotional mechanisms work. But personality—the sum of cognitive, behavioral, and emotional tendencies—clearly affects how people perceive and react to stressors. To investigate the links among personality, stress, and wellness, researchers examine characteristic "personality types" and "personality traits." Personality Types Depending on the situation, most of us display some of the behaviors characteristic of one or more of the following types. Type A. People with Type A personality are overly competitive, controlling, impatient, and aggressive. Type A people have a higher perceived stress level and more problems coping with stress. They react explosively to stressors and are upset by events that others would consider only annoyances. Studies indicate that certain characteristics of the Type A pattern—anger, cynicism, and hostility—increase the risk of heart disease, cancer, and other life-threatening conditions. Type B. The Type B personality is relaxed and contemplative. Type B people are less frustrated by daily events and more tolerant of the behavior of others. These persons are "here and now," more at ease in the world, and less driven by time urgency. Type C. The Type C personality is characterized by anger suppression, difficulty expressing emotions, feelings of hopelessness and despair, and an exaggerated response to minor stressors. This type has been associated with elevated risk for cancer. Type D. The Type D personality tends toward negative emotional states such as anxiety, depression, and irritability. Type D people also avoid social interactions, worrying that others will react negatively toward them. Having this kind of personality predicts a number of poor health outcomes, including cardiovascular disease. Personality Traits Researchers have also looked for personality traits that enable people to deal more effectively with stress. One such trait is hardiness, a particular form of optimism. People with a hardy personality view potential stressors as challenges and opportunities for growth and learning, rather than as burdens. They see fewer situations as stressful and react less intensely to stress than nonhardy people might. Hardy people are committed to their activities, have a sense of inner purpose and an inner locus of control, and feel at least partly in control of their lives. Another psychological characteristic that prompts you to behave in a certain way is motivation. Two types of motivation have been studied that relate to stress and health. Stressed power motivation is associated with people who are aggressive and argumentative, and who need to have power over others. One study of college students found that persons Page 34with this personality trait tend to get sick when their need for power is blocked or threatened. In contrast, people with unstressed affiliation motivation are drawn to others and want to be liked as friends. The same study of college students found that students with this trait reported the least illness. Another important personality trait—resilience—is especially associated with social and academic success in groups at risk for stress, such as people from low-income families and those with mental or physical disabilities. Resilient people tend to face adversity effectively and recover quickly after facing challenges. There are three basic types of resilience, and each one can determine how a person responds to stress: Nonreactive resilience, in which a person does not react to a stressor Homeostatic resilience, in which a person may react strongly but returns to baseline functioning quickly Positive growth resilience, in which a person learns and grows from the stress experience A person's emotional and behavioral responses to stressors depend on many factors, including personality, gender, and cultural background. © Fancy/Alamy Resilience is associated with emotional intelligence and violence prevention and is also a trait demonstrated to improve with mindfulness-based stress reduction. Contemporary research repeatedly demonstrates that you can change some basic elements of your personality as well as your typical behaviors and patterns of thinking using positive stress-management techniques like those described later in the chapter. Cultural Background Young adults from around the world come to the United States for a higher education; most students finish college with a greater appreciation for other cultures and worldviews. The clash of cultures, however, can be a big source of stress for many students—especially when it leads to disrespectful treatment, harassment, or violence. It is important to consider that our reactions to stressful events are influenced by family and cultural background. Learning to appreciate the cultural backgrounds of other people can be both a mind-opening experience and a way to avoid stress over cultural differences. Gender Your gender role—the activities, abilities, and behaviors your culture expects of you based on your sex—can affect your experience of stress. Some behavioral responses to stressors, such as crying or openly expressing anger, may be deemed more appropriate for one gender than another. Strict adherence to gender roles, however, can limit one's response to stress and can itself become a source of stress. Gender roles can also affect one's perception of a stressor. If a man derives most of his self-worth from his work, for example, retirement may be more stressful for him than for a woman whose self-image is based on several different roles. Since the American Psychological Association began its yearly "Stress in America" survey in 2007, women have reported a higher level of stress than men. In 2015, 11.2% of female college students reported "tremendous stress," as compared to 8.1% of male college students. The survey also shows that women are more likely than men to try to reduce their stress, although a lower percentage say they were successful than the percentage of men who tried to reduce theirs. Women coped with stress through behaviors such as reading, spending time with friends, or meditating, in contrast to men, who preferred playing sports. Experience Past experiences can profoundly influence the evaluation of a potential stressor. Consider someone who has had a bad experience giving a speech in the past. He or she is much more likely to perceive an upcoming speech as stressful than someone who has had positive public speaking experiences. The Stress Experience as a Whole As Table 2.1 shows, the physical, emotional, and behavioral symptoms of excess negative stress are distinct. But they are also intimately interrelated. The more intense the emotional response, the stronger is the physical response. Effective behavioral responses can lessen stress; ineffective ones only worsen it. Sometimes people have such intense responses to stressors or such ineffective coping techniques that they need professional help. More often, however, people can learn to handle stressors on their own.Page 35 Table 2.1 Physical, Emotional, and Behavioral Symptoms of Excess Stress PHYSICAL SYMPTOMS EMOTIONAL SYMPTOMS BEHAVIORAL SYMPTOMS Dry mouth Anxiety Crying Frequent illnesses Depression Disrupted eating habits Gastrointestinal problems Edginess Disrupted sleeping habits Headaches Hypervigilance Irritability High blood pressure Impulsiveness Problems communicating Pounding heart Fatigue Increased use of tobacco, alcohol, or other drugs Stiff neck or aching lower back Inability to concentrate Sexual problems Sweating Irritability Social isolation Teeth grinding Trouble remembering things

Reaching wellness through lifestyle management

REACHING WELLNESS THROUGH LIFESTYLE MANAGEMENT As you consider the behaviors that contribute to wellness—being physically active, choosing a healthful diet, and so on—you may be doing a mental comparison with your own behaviors. If you are like most young adults, you probably have some healthy habits and some habits that place your health at risk. For example, you may be physically active and have a healthful diet but spend excessive hours playing video games. You may be careful to wear your seat belt in your car but skip meals. Moving in the direction of wellness means cultivating healthy behaviors and working to overcome unhealthy ones. This approach to lifestyle management is called behavior change. As you may already know, changing an unhealthy habit (such as giving up cigarettes) can be harder than it sounds. When you embark on a behavior change plan, it may seem like too much work at first. But as you make progress, you will gain confidence in your ability to take charge of your life. You will also experience the benefits of wellness—more energy, greater vitality, deeper feelings of appreciation and curiosity, and a higher quality of life. Getting Serious about Your Health Before you can start changing a wellness-related behavior, you have to know that the behavior is problematic and that you can change it. To make good decisions, you need information about relevant topics and issues, including what resources are available to help you change. Examine Your Current Health Habits How is your current lifestyle affecting your health today and in the future? Think about which of your current habits enhance your health and which detract from it? Begin your journey toward wellness with self-assessment: Talk with friends and family members about what they have noticed about your lifestyle and your health, and take the quiz in the box titled "Wellness: Evaluate Your Lifestyle." Challenge any unrealistically optimistic attitudes or ideas you may hold—for example, "To protect my health, I don't need to worry about quitting smoking until I'm 40 years old" or "Being overweight won't put me at risk for diabetes." Health risks are very real and can become significant while you're young; health habits are important throughout life. ASSESS YOURSELF: Wellness: Evaluate Your Lifestyle All of us want optimal health, but many of us do not know how to achieve it. Taking this quiz, adapted from one created by the U.S. Public Health Service, is a good place to start. The behaviors covered in the quiz are recommended for most Americans. (Some of them may not apply to people with certain diseases or disabilities or to pregnant women, who may require special advice from their physician.) After you take the quiz, add up your score for each section. Tobacco Use If you never use tobacco, enter a score of 10 for this section and go to the next section. almost always sometimes never I avoid smoking tobacco. 4 1 0 I avoid using a pipe or cigars. 2 1 0 I avoid spit tobacco. 2 1 0 I limit my exposure to environmental tobacco smoke. 2 1 0 Tobacco Score: _______________________ Alcohol and Other Drugs almost always sometimes never I avoid alcohol or I drink no more than one drink (women) or two drinks (men) a day. 4 1 0 I avoid using alcohol or other drugs as a way of handling stressful situations or problems in my life. 2 1 0 I am careful not to drink alcohol when taking medications, such as for colds or allergies, or when pregnant. 2 1 0 I read and follow the label directions when using prescribed and over-the-counter drugs. 2 1 0 Alcohol and other drugs score: _______________________ Nutrition almost always sometimes never I eat a variety of foods each day, including seven or more servings of fruits and vegetables. 3 1 0 I limit the amount of saturated and trans fat in my diet. 3 1 0 I avoid skipping meals. 2 1 0 I limit the amount of salt and added sugar I eat. 2 1 0 Nutrition score: _______________________ Exercise/Fitness almost always sometimes never I engage in moderate-intensity exercise for 150 minutes per week. 4 1 0 I maintain a healthy weight, avoiding overweight and underweight. 2 1 0 I exercise to develop muscular strength and endurance at least twice a week. 2 1 0 I spend some of my leisure time participating in physical activities such as gardening, bowling, golf, or baseball. 2 1 0 Exercise/fitness score: _______________________ Emotional Health almost always sometimes never I enjoy being a student, and I have a job or do other work that I like. 2 1 0 I find it easy to relax and express my feelings freely. 2 1 0 I manage stress well. 2 1 0 I get along well with other people. 2 1 0 I participate in group activities (such as church and community organizations) or hobbies that I enjoy. 2 1 0 Emotional health score: _______________________ Support almost always sometimes never I volunteer one or more times each year. 2 1 0 I enjoy helping other people. 2 1 0 I feel free to ask others for help. 2 1 0 I have close friends with whom I can talk about personal matters. 2 1 0 I acknowledge the success and achievements of others. 2 1 0 Support score: _______________________ Safety almost always sometimes never I wear a seat belt while riding in a car. 2 1 0 I avoid driving while under the influence of alcohol or other drugs. 2 1 0 I obey traffic rules and speed limits when driving. 2 1 0 I read and follow instructions on the labels of potentially harmful products or substances, such as household cleaners, poisons, and electrical appliances. 2 1 0 I avoid using a cell phone while driving. 2 1 0 Safety score: _______________________ Disease Prevention almost always sometimes never I know the warning signs of cancer, diabetes, heart attack, and stroke. 2 1 0 I avoid overexposure to the sun and use sunscreen. 2 1 0 I get recommended medical screening tests (such as blood pressure checks and Pap tests), immunizations, and booster shots. 2 1 0 I do not share needles to inject drugs. 2 1 0 I am not sexually active, or I have sex with only one mutually faithful, uninfected partner, or I always engage in safer sex (using condoms). 2 1 0 Disease prevention score: _______________________ What Your Scores Mean Scores of 9 and 10 Excellent! Your answers show that you are aware of the importance of this area to your health. More important, you are putting your knowledge to work for you by practicing good health habits. As long as you continue to do so, this area should not pose a serious health risk. Scores of 6 to 8 Your health practices in this area are good, but there is room for improvement. Scores of 3 to 5 Your health risks are showing. Scores of 0 to 2 You may be taking serious and unnecessary risks with your health. Many people consider changing a behavior when friends or family members express concern, when a landmark event occurs (such as turning 30), or when new information raises their awareness of risk. If you find yourself reevaluating some of your behaviors as you read this text, take advantage of the opportunity to make a change in a structured way. Choose a Target Behavior Changing any behavior can be demanding. Start small by choosing one behavior you want to change—called a target behavior—and working on it until you succeed. Your chances of success will be greater if your first goal is simple, such as resisting the urge to snack between classes. As you change one behavior, make your next goal a little more significant, and build on your success. Learn about Your Target Behavior Once you've chosen a target behavior, you need to learn its risks and benefits—both now and in the future. Ask these questions: How is your target behavior affecting your level of wellness today? Which diseases or conditions does this behavior place you at risk for? What effect would changing your behavior have on your health? As a starting point, use this text and the resources listed in the "For More Information" section at the end of each chapter. See the "Evaluating Sources of Health Information" box for additional guidelines. CRITICAL CONSUMER: Evaluating Sources of Health Information Surveys indicate that college students are smart about evaluating health information. They trust the health information they receive from health professionals and educators and are skeptical about popular information sources, such as magazine articles and websites. How good are you at evaluating health information? Here are some tips. General Strategies Whenever you encounter health-related information, take the following steps to make sure it is credible: Go to the original source. Media reports often simplify the results of medical research. Find out for yourself what a study really reported, and determine whether it was based on good science. What type of study was it? Was it published in a recognized medical journal? Was it an animal study, or did it involve people? Did the study include a large number of people? What did the authors of the study actually report? Watch for misleading language. Reports that tout "breakthroughs" or "dramatic proof" are probably hype. A study may state that a behavior "contributes to" or is "associated with" an outcome; this does not prove a cause-and-effect relationship. Distinguish between research reports and public health advice. Do not change your behavior based on the results of a single report or study. If an agency such as the National Cancer Institute urges a behavior change, however, follow its advice. Large, publicly funded organizations issue such advice based on many studies, not a single report. Remember that anecdotes are not facts. A friend may tell you he lost weight on some new diet, but individual success stories do not mean the plan is truly safe or effective. Check with your doctor before making any serious lifestyle changes. Be skeptical. If a report seems too good to be true, it probably is. Be wary of information contained in advertisements. An ad's goal is to sell a product, even if there is no need for it. Make choices that are right for you. Friends and family members can be a great source of ideas and inspiration, but you need to make health-related choices that work best for you. Internet Resources Online sources pose special challenges; when reviewing a health-related website, ask these questions: What is the source of the information? Websites maintained by government agencies, professional associations, or established academic or medical institutions are likely to present trustworthy information. Many other groups and individuals post accurate information, but it is important to look at the qualifications of the people who are behind the site. (Check the home page or click the "About Us" link.) How often is the site updated? Look for sites that are updated frequently. Check the "last modified" date of any web page. Is the site promotional? Be wary of information from sites that sell specific products, use testimonials as evidence, appear to have a social or political agenda, or ask for money. What do other sources say about a topic? Be cautious of claims or information that appear at only one site or come from a chat room, bulletin board, newsgroup, or blog. Does the site conform to any set of guidelines or criteria for quality and accuracy? Look for sites that identify themselves as conforming to some code or set of principles, such as those established by the Health on the Net Foundation or the American Medical Association. These codes include criteria such as use of information from respected sources and disclosure of the site's sponsors. Find Help Have you identified a particularly challenging target behavior or condition—something like overuse of alcohol, binge eating, or depression—that interferes with your ability to function or places you at a serious health risk? If so, you may need help to change a behavior or address a disorder that is deeply rooted or too serious for self-management. Don't let the problem's seriousness stop you; many resources are available to help you solve it. On campus, the student health center or campus counseling center can provide assistance. To locate community resources, consult the yellow pages, your physician, or the Internet. Page 18 Building Motivation to Change Knowledge is necessary for behavior change, but it isn't usually enough to make people act. Millions of people have sedentary lifestyles, for example, even though they know it's bad for their health. This is particularly true of young adults, who feel healthy despite their unhealthy behaviors. To succeed at behavior change, you need strong motivation. The sections that follow address some considerations. Examine the Pros and Cons of Change Health behaviors have short-term and long-term benefits and costs. Consider the benefits and costs of an inactive lifestyle: Short-term. Such a lifestyle allows you more time to watch TV, use social media, do your homework, and hang out with friends, but it leaves you less physically fit and less able to participate in recreational activities. Long-term. It increases the risk of heart disease, cancer, stroke, and premature death. To successfully change your behavior, you must believe that the benefits of change outweigh the costs. Carefully examine the pros and cons of continuing your current behavior and of changing to a healthier one. Focus on the effects that are most meaningful to you, including Page 19those that are tied to your personal identity and values. For example, engaging in regular physical activity and getting adequate sleep can support an image of yourself as an active person who is a good role model for others. To complete your analysis, ask friends and family members about the effects of your behavior on them. A younger sister may say that your smoking habit influenced her decision to start smoking. The short-term benefits of behavior change can be an important motivating force. Although some people are motivated by long-term goals, such as avoiding a disease that may hit them in 30 years, most are more likely to be moved to action by shorter-term, more personal goals. Feeling better, doing better in school, improving at a sport, reducing stress, and increasing self-esteem are common short-term benefits of health behavior change. Many wellness behaviors are associated with immediate improvements in quality of life. For example, surveys of Americans have found that nonsmokers feel healthy and full of energy more days each month than do smokers, and they report fewer days of sadness and troubled sleep; the same is true when physically active people are compared with sedentary people. Over time, these types of differences add up to a substantially higher quality of life for people who engage in healthy behaviors. QUICK STATS Nearly 70% of U.S. adult smokers want to quit. —Centers for Disease Control and Prevention, 2015 Boost Self-Efficacy A big factor in your eventual success is whether you feel confident in your ability to change. Self-efficacy refers to your belief in your ability to successfully take action and perform a specific task. Strategies for boosting self-efficacy include developing an internal locus of control, using visualization and self-talk, and getting encouragement from supportive people. Locus of Control Who do you believe is controlling your life? Is it your parents, friends, or school? Is it "fate"? Or is it you? Locus of control refers to the extent to which a person believes he or she has control over the events in his or her life. People who believe they are in control of their lives are said to have an internal locus of control. Those who believe that factors beyond their control determine the course of their lives are said to have an external locus of control. For lifestyle management, an internal locus of control is an advantage because it reinforces motivation and commitment. An external locus of control can sabotage efforts to change behavior. For example, if you believe that you are destined to die of breast cancer because your mother died from the disease, you may view regular screening mammograms as a waste of time. In contrast, if you believe that you can take action to reduce your risk of breast cancer despite hereditary factors, you will be motivated to follow guidelines for early detection of the disease. If you find yourself attributing too much influence to outside forces, gather more information about your wellness-related behaviors. List all the ways that making lifestyle changes will improve your health. If you believe you'll succeed, and if you recognize that you are in charge of your life, you're on your way to wellness. Visualization and Self-Talk One of the best ways to boost your confidence and self-efficacy is to visualize yourself successfully engaging in a new, healthier behavior. Imagine yourself going for an afternoon run three days a week or no longer smoking cigarettes. Also visualize yourself enjoying all the short-term and long-term benefits that your lifestyle change will bring. Create a new self-image: What will you and your life be like when you become a regular exerciser or a nonsmoker? You can also use self-talk, the internal dialogue you carry on with yourself, to increase your confidence in your ability to change. Counter any self-defeating patterns of thought with more positive or realistic thoughts: "I am a strong, capable person, and I can maintain my commitment to change." (See Chapter 3 for more about self-talk.) Role Models and Supportive People Social support can make a big difference in your level of motivation and your chances of success. Perhaps you know people who have reached the goal you are striving for. They could be role models or mentors for you, providing information and support for your efforts. Gain strength from their experiences, and tell yourself, "If they can do it, so can I." Find a partner who wants to make the same changes you do and who can take an active role in your behavior change program. For example, an exercise partner can provide companionship and encouragement when you might be tempted to skip your workout. Identify and Overcome Barriers to Change Don't let past failures at behavior change discourage you. They can be a great source of information you can use to boost your chances of future success. Make a list of the problems and challenges you faced in any previous behavior change attempts. To this, add the short-term costs of behavior change that you identified in your analysis of the pros and cons of change. Once you've listed these key barriers to change, develop a practical plan for overcoming each one. For example, if you are not getting enough sleep when you're with certain friends, decide in advance how you will turn down their next late-night invitation.Page 20 Enhancing Your Readiness to Change The transtheoretical, or "stages of change," model has been shown to be an effective approach to lifestyle self-management. To understand this model, what should you know? You should know your target behavior, which is the ideal place you want to end up. According to this model, you move through distinct stages of action as you achieve your target behavior. First, determine what stage you are in now so that you can choose appropriate strategies to progress through the cycle of change. This will help you enhance your readiness and intention to change. Read the following sections to determine what stage you are in. Let's use exercise as an example of changing unhealthy behavior to active, engaging behavior. Precontemplation At this stage, you think you have no problem and don't intend to change your behavior. Here's an example. Your friends have commented that you should exercise more, but you are resistant. You have tried to exercise in the past and now think your situation is hopeless. You are unaware of risks associated with being sedentary; and you also blame external factors like other people for your condition. You believe that there are more important reasons not to change than there are reasons to change. To move forward in this stage, try raising your awareness. Research the importance of exercise, for example. Look up references that address the issue. How does exercise affect the body and mind? Look also at the mechanisms you use to resist change, such as denial or rationalization. Find ways to counteract these mechanisms of resistance. Seek social support. Friends and family members can help you identify target behaviors (e.g., fitting in exercise into your time schedule or encouraging you while you work out). Other resources might include exercise classes or stress management workshops offered by your school. Contemplation You now know you have a problem and within six months intend to do something about it, such as invite a friend to work out with you. You realize that getting more exercise will help decrease your stress level. You acknowledge the benefits of behavior change but are also aware that the barriers to change may be difficult to overcome. You consider possible courses of action but don't know how to proceed. To take charge, start by keeping a journal. Record what you have done so far and include your plan of action. Do a cost-benefit analysis: Identify the costs (e.g., it will cost money to take an exercise class) and benefits (e.g., I will probably stick to my goal if someone else is guiding me through the exercise). Identify barriers to change (e.g., I hate getting sweaty when I have no opportunity to shower). Knowing these obstacles can help you overcome them. Next, engage your emotions. Watch movies or read books about people with your target behavior. Imagine what your life will be like if you don't change. Other ways to move forward in the contemplation stage include creating a new self-image and thinking before you act. Imagine what you'll be like after changing your unhealthy behavior. Try to think of yourself in those new terms right now. Learn why you engage in the unhealthy behavior. Determine what "sets you off" and train yourself not to act reflexively. Preparation You plan to take action within a month or may already have begun to make small changes in your behavior. You may have discovered a place to go jogging but have not yet gone regularly or consistently. You may have created a plan for change but are worried about failing. Work on creating a plan. Include a start date, goals, rewards, and specific steps you will take to change your behavior. Make change a priority. Create and sign a contract with yourself. Practice visualization and self-talk. Say, "I see myself jogging three times a week and going to yoga on Fridays." "I know I can do it because I've met challenging goals before." Take small steps. Successfully practicing your new behavior for a short time—even a single day—can boost your confidence and motivation. Action You outwardly modify your behavior and your environment. Maybe you start riding your bike to school or work. You put your stationary bicycle in front of the TV, and you leave your yoga mat out on your bedroom floor. The action stage requires the greatest commitment of time and energy, and people in this stage are at risk of relapsing into old, unhealthy patterns of behavior. Monitor your progress. Keep up with your journal entries. Make changes that will discourage the unwanted behavior—for example, park your car farther from your house or closer to the stairs. Find alternatives to your old behavior. Make a list of things you can do to replace the behavior. Reward yourself. Rewards should be identified in your change plan. Praise yourself and focus on your success. Involve your friends. Tell them you want to change, and ask for their help. Don't get discouraged. Real change is difficult. Maintenance You have maintained your new, healthier lifestyle for at least six months by working out and riding your bike. Lapses have occurred, but you have been successful in quickly reestablishing the desired behavior. The maintenance stage can last months or years. Keep going. Continue using the positive strategies that worked in earlier stages. And be prepared for lapses. If you find yourself skipping exercise class, don't give up on the whole project. Try inviting a friend to join you and then keep the date. Be a role model. Once you successfully change your behavior, you may be able to help someone do the same thing. Termination For some behaviors, you may reach the sixth and final stage of termination. At this stage, you have exited the cycle of change and are no longer tempted to lapse back into your old behavior. You have a new self-image and total control with regard to your target behavior.Page 21 Dealing with Relapse People seldom progress through the stages of change in a straightforward, linear way. Rather, they tend to move to a certain stage and then slip back to a previous stage before resuming their forward progress. Research suggests that most people make several attempts before they successfully change a behavior, and four out of five people experience some degree of backsliding. For this reason, the stages of change are best conceptualized as a spiral in which people cycle back through previous stages but are farther along in the process each time they renew their commitment (Figure 1.5). FIGURE 1.5 The stages of change: A spiral model. source: Adapted from Centers for Disease Control and Prevention. n.d. PEP Guide: Personal Empowerment Plan for Improving Eating and Increasing Physical Activity. Dallas, TX: The Cooper Institute. If you experience a lapse (a single slip) or a relapse (a return to old habits), don't give up. Relapse can be demoralizing, but it is not the same as failure; failure means stopping before you reach your goal and never changing your target behavior. During the early stages of the change process, it's a good idea to plan for relapse so that you can avoid guilt and self-blame and get back on track quickly. Follow these steps: Forgive yourself. A single setback isn't the end of the world, but abandoning your efforts to change could have negative effects on your life. Give yourself credit for the progress you have already made. You can use that success as motivation to continue. Move on. You can learn from a relapse and use that knowledge to deal with potential future setbacks. If relapses keep occurring or you can't seem to control them, you may need to return to a previous stage of the behavior change process. If this is necessary, reevaluate your goals and strategy. A different or less stressful approach may help you avoid setbacks when you try again. Developing Skills for Change: Creating a Personalized Plan Once you are committed to making a change, put together a plan of action. Your key to success is a well-thought-out plan that sets goals, anticipates problems, and includes rewards. 1. Monitor Your Behavior and Gather Data Keep a record of your target behavior and the circumstances surrounding it. Record this information for at least a week or two. Keep your notes in a health journal or notebook or on your computer (see the sample journal entries in Figure 1.6). Record each occurrence of your behavior, noting the following: What the activity was When and where it happened What you were doing How you felt at that time For example, if your goal is to start an exercise program, track your activities to determine how to make time for workouts. For example, if you wanted to change your eating habits, you would track not only what you eat, but when, where, and with whom you ate, what else you were doing, what made you want to eat, and how you felt after. FIGURE 1.6 Sample health journal entries. 2. Analyze the Data and Identify Patterns After you have collected data on the behavior, analyze the data to identify patterns. When are you most likely to overeat? To skip a meal? What events trigger your appetite? Perhaps you are especially hungry at midmorning or when you put off eating dinner until 9:00. Perhaps you overindulge in food and drink when you go to a particular restaurant or when you're with certain friends. Note the connections between your feelings and such external cues as time of day, location, situation, and the actions of others around you. 3. Be "SMART" about Setting Goals If your goals are too challenging, you will have trouble making steady progress and will be more likely to give up altogether. If, for example, you are in poor physical condition, it will not make sense to set a goal of being ready to run a marathon within two months. If you set goals you can live with, it will be easier to stick with your behavior change plan and be successful. Experts suggest that your goals meet the "SMART" criteria; that is, your behavior change goals should be Specific. Avoid vague goals like "eat more fruits and vegetables." Instead state your objectives in specific terms, such as "eat two cups of fruit and three cups of vegetables every day." Measurable. Recognize that your progress will be easier to track if your goals are quantifiable, so give your goal a number. You might measure your goal in terms of time (such as "walk briskly for 20 minutes a day"), distance ("run two miles, three days per week"), or some other amount ("drink eight glasses of water every day"). Attainable. Set goals that are within your physical limits. For example, if you are a poor swimmer, you might not Page 22be able to meet a short-term fitness goal by swimming laps. Walking or biking might be better options. Realistic. Manage your expectations when you set goals. For example, a long-time smoker may not be able to quit cold turkey. A more realistic approach might be to use nicotine replacement patches or gum for several weeks while getting help from a support group. Time frame-specific. Give yourself a reasonable amount of time to reach your goal, state the time frame in your behavior change plan, and set your agenda to meet the goal within the given time frame. Using these criteria, sedentary people who want to improve their health and build fitness might set a goal of being able to run three miles in 30 minutes, to be achieved within a time frame of six months. To work toward that goal, they might set a number of smaller, intermediate goals that are easier to achieve. For example, their list of goals might look like this: WEEK FREQUENCY (DAYS/WEEK) ACTIVITY DURATION (MINUTES) 1 3 Walk < 1 mile 10-15 2 3 Walk 1 mile 15-20 3 4 Walk 1-2 miles 20-25 4 4 Walk 2-3 miles 25-30 5-7 3-4 Walk/run 1 mile 15-20 ⋮ 21-24 4-5 Run 2-3 miles 25-30 Of course you may not be able to meet these goals, but you never know until you try. As you work toward meeting your long-term goal, you may need to adjust your short-term goals. For example, you may find that you can start running sooner than you thought, or you may be able to run farther than you originally estimated. In such cases, you may want to make your goals more challenging. In contrast, if your goals are too difficult, you may want to make them easier in order to stay motivated. For some goals and situations, it may make more sense to focus on something other than your outcome goal. If you are in an early stage of change, for example, your goal may be to learn more about the risks associated with your target behavior or to complete a cost-benefit analysis. If your goal involves a long-term lifestyle change, such as reaching a healthy weight, focus on developing healthy habits rather than targeting a specific weight loss. Your goal in this case might be exercising for 30 minutes every day, reducing portion sizes, or eliminating late-night snacks. 4. Devise a Plan of Action Develop a strategy that will support your efforts to change. Your plan of action should include the following steps: Get what you need. Identify resources that can help you. For example, you can join a community walking club or sign up for a smoking cessation program. You may also need to buy some new running shoes or nicotine replacement patches. Get the items you need right away; waiting can delay your progress. Modify your environment. If you have cues in your environment that trigger your target behavior, control them. For example, if you typically have alcohol at home, getting rid of it can help prevent you from indulging. If you usually study with a group of friends in an environment that allows smoking, move to a nonsmoking area. If you always buy a snack at a certain vending machine, change your route so that you don't pass by it. Control related habits. You may have habits that contribute to your target behavior. Modifying these habits can Page 23help change the behavior. For example, if you usually plop down on the sofa while watching TV, try putting an exercise bike in front of the set so that you can burn calories while watching your favorite programs. Reward yourself. Giving yourself instant, real rewards for good behavior will reinforce your efforts. Plan your rewards; decide in advance what each one will be and how you will earn it. Tie rewards to achieving specific goals or subgoals. For example, you might treat yourself to a movie after a week of avoiding snacks. Make a list of items or events to use as rewards. They should be special to you and preferably unrelated to food or alcohol. Involve the people around you. Tell family and friends about your plan and ask them to help. To help them respond appropriately to your needs, create a specific list of dos and don'ts. For example, ask them to support you when you set aside time to exercise or avoid second helpings at dinner. Plan for challenges. Think about situations and people that might derail your program and develop ways to cope with them. For example, if you think it will be hard to stick to your usual exercise program during exams, schedule short bouts of physical activity (such as a brisk walk) as stress-reducing study breaks. An empty staircase sits next to a crowded escalator. Your environment contains powerful cues for both positive and negative lifestyle choices. Identifying and using the healthier options available to you throughout the day is a key part of a successful behavior change program. © Cindy Charles/PhotoEdit—All rights reserved Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Think about the last time you made an unhealthy choice instead of a healthy one. How could you have changed the situation, the people in the situation, or your own thoughts, feelings, or intentions to avoid making that choice? What can you do in similar situations in the future to produce a different outcome? 5. Make a Personal Contract A serious personal contract—one that commits you to your word—can result in a better chance of follow-through than a casual, offhand promise. Your contract can help prevent procrastination by specifying important dates and can also serve as a reminder of your personal commitment to change. Your contract should include a statement of your goal and your commitment to reaching it. The contract should also include details such as the following: The date you will start The steps you will take to measure your progress The strategies you plan to use to promote change The date you expect to reach your final goal Have someone—preferably someone who will be actively helping you with your program—sign your contract as a witness. Figure 1.7 shows a sample behavior change contract for someone who is committing to eating more fruit every day. In this sample, someone has identified strategies to increase her fruit consumption. She has also included a list of mini-goals and rewards for reaching them. FIGURE 1.7 A sample behavior change contract. You can apply the general behavior change planning framework presented in this chapter to any target behavior. Additional examples of behavior change plans appear in the Behavior Change Strategy sections at the end of many chapters in this text. In these sections, you will find specific plans for quitting smoking, starting an exercise program, and making other positive lifestyle changes. Page 24 Putting Your Plan into Action When you're ready to put your plan into action, you need commitment—the resolve to stick with the plan no matter what temptations you encounter. Remember all the reasons you have to make the change—and remember that you are the boss. Use all your strategies to make your plan work. Make sure your environment is change-friendly, and get as much support and encouragement from others as possible. Keep track of your progress in your health journal and give yourself regular rewards. And don't forget to give yourself a pat on the back—congratulate yourself, notice how much better you look or feel, and feel good about how far you've come and how you've gained control of your behavior. Staying with It As you continue with your program, don't be surprised when you run up against obstacles; they're inevitable. In fact, it's a good idea to expect problems and give yourself time to step back, see how you're doing, regroup, and make some changes before going on. If your program is grinding to a halt, identify what is blocking your progress. It may come from one of the sources described in the following sections. Social Influences Take a hard look at the reactions of the people you're counting on, and see if they're really supporting you. If they come up short, connect with others who will be more supportive. Finding a dedicated workout partner, for example, can renew your desire to work toward your goal. A related trap is trying to get your friends or family members to change their behaviors. The decision to make a major behavior change is something people come to only after intensive self-examination. The fact that you have seen a light doesn't mean that anyone else has. You may be able to influence someone by tactfully providing facts or support, but you cannot demand more. Focus on yourself. When you succeed, you may become a role model for others. Levels of Motivation and Commitment You won't make real progress until an inner drive leads you to the stage of change at which you are ready to make a personal commitment to the goal. If commitment is your problem, you may need to wait until the behavior you're dealing with makes you unhappier or unhealthier; then your desire to change it will be stronger. Or you may find that changing your goal will inspire you to keep going. Choice of Techniques and Level of Effort If your plan is not working as well as you thought it would, make changes where you're having the most trouble. If you've lagged on your running schedule, for example, maybe it's because you don't like running. An aerobics class might suit you better. There are many ways to move toward your goal. Or you may not be trying hard enough. Regardless, continue to push toward your goal. If it were easy, you wouldn't need a plan. Stress If you hit a wall in your program, look at the sources of stress in your life. If the stress is temporary, such as catching a cold or having a term paper due, you may want to wait until it passes before strengthening your efforts. If the stress is ongoing, find healthy ways to manage it (see Chapter 2). You may even want to make stress management your highest priority for behavior change. Procrastinating, Rationalizing, and Blaming Be alert to games you might be playing with yourself, so that you can stop them. Such games include the following: Procrastinating. If you tell yourself, "It's Friday already; I might as well wait until Monday to start," you're procrastinating. Break your plan into smaller steps that you can accomplish one day at a time. Figure out how to enjoy the activity, whether that involves doing it with music, going outdoors, adding meditation to your program, or visualizing the desired end result. Rationalizing. If you tell yourself, "I wanted to go swimming today but wouldn't have had time to wash my hair afterward," you're making excuses. When you "win" by deceiving yourself, it isn't much of a victory. Blaming. If you tell yourself, "I couldn't exercise because Dave was hogging the elliptical trainer," you're blaming others for your own failure to follow through. Blaming is a way of taking your focus off the real problem and denying responsibility for your own actions. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you tried to change a behavior in the past, such as exercising more or quitting smoking? How successful were you? Do you feel the need to try again? If so, what would you do differently to improve your chances of success?

psychological disorders

PSYCHOLOGICAL DISORDERS All of us feel anxious at times. In dealing with anxiety, we may avoid doing something we want to do or should do. Most of us have periods of feeling down when we become pessimistic, less energetic, and less able to enjoy life. Many of us are bothered at times by irrational thoughts or odd feelings. Such feelings and thoughts can be normal responses to the ordinary challenges of life, but when emotions or irrational thoughts interfere with daily activities and rob us of peace of mind, they can be considered symptoms of a psychological disorder. Psychological disorders are generally the result of many factors. Genetic differences, which underlie differences in how the brain processes information and experiences, are known to play an important role, especially in certain disorders such as autism, schizophrenia, and bipolar disorder. However, exactly which genes are involved, and how they alter the structure and chemistry of the brain, is still under study. A dysfunctional interaction between neurotransmitters and their receptors is associated with some psychiatric disorders (Figure 3.2). The trouble begins when neurotransmitters (chemicals that transmit messages between nerve cells) misfire and the nerve cells do not communicate properly. FIGURE 3.2 Nerve cell communication. Nerve cells (neurons) communicate through a combination of electrical impulses and chemical messages. Neurotransmitters such as serotonin and norepinephrine alter the overall responsiveness of the brain and are responsible for mood, levels of attentiveness, and other psychological states. Many psychological issues are related to problems with neurotransmitters and their receptors, and drug treatments frequently target them. For example, some antidepressant drugs increase levels of serotonin by slowing the resorption (reuptake) of serotonin. Learning and life events are important, too: Although one identical twin is often at higher risk of having a disorder if the other has it, the two don't necessarily have the same psychological disorders despite having identical genes. Some people have been exposed to more traumatic events than others, leading either to greater vulnerability to future traumas or, conversely, to the development of better coping skills. Further, what your parents, peers, and others have taught you Page 69strongly influences your level of self-esteem and how you deal with frightening or depressing life events (see the box "Ethnicity, Culture, and Psychological Health"). DIVERSITY MATTERS: Ethnicity, Culture, and Psychological Health Cultures develop unique ideas about mental health—about what is normal and what is problematic, how symptoms should be interpreted and communicated, whether treatment should be sought, and whether a social stigma is attached to a particular symptom or disorder. Based on their various environmental, cultural, and socioeconomic backgrounds, cultures perceive—categorize and interpret—psychological disorders differently. Climate and geography, as well as other environmental factors, such as diet, contribute to a group's health. These culturally distinct ideas change as the group comes into contact with other groups. For example, Asian immigrants to the United States have often come from collectivist cultures that anticipate and care for the needs of each other, so that individuals don't need to request support. In U.S. cultures, usually no group is expected to look after the needs of an individual; rather, individuals or their close families are responsible for seeking help for themselves. For this reason Asian immigrants appear to have more trouble than European Americans asking for explicit social support. The process by which individuals and groups adapt to each other's cultures, called acculturation, is an important influence on health. This adaptation ideally represents an exchange between both cultures, so that they learn how to do things a new way. Acculturation, however, often applies only to immigrants' adopting influences from a dominant culture. When a dominant group takes over the resources of a minority group—for example, a government enforces an English-only policy on bilingual speakers, thereby increasing the difficulties of the immigrants seeking help—then the socioeconomic status of the adapting group often decreases. As the following examples show, this status change may then further affect the psychological health of the group. Arctic Native Populations Studies of native populations around the Arctic (e.g., in northern Canada, Greenland, and Scandinavia) reveal many cases of elevated and chronic stress, accompanied by high blood pressure and cardiovascular risk. This chronic stress is linked to 50 years of rapid socioeconomic change: The population has experienced long-term unemployment, contamination of food, and a multitude of other acculturation problems. As they have acculturated, indigenous people have suffered discrimination, loss of traditional values, and lack of control over their resources. Because they live in climates with less light during winter months, they also experience seasonal affective disorder, a form of depression. Cultural expressions of their high levels of anxiety and depression include increased incidence of suicide and violence. Adolescents, in particular, among Alaska Natives and Greenland Inuit, have recently had a high number of suicides. In these populations, levels of injury and violence reach two to four times as high as national averages. Latinos in the United States Latinos in the United States generally are healthier than other U.S. racial and ethnic groups, for example, in mortality rates for adults and newborn babies. Still, mortality rates, incidence of chronic illness, and some mental health conditions such as depression vary within the U.S. Latino population, depending on Latino origin or cultural heritage (e.g., Mexican, Puerto Rican, or Cuban). One of the largest immigrant groups in the United States is from Mexico. Surprisingly, surveys show that these immigrants are psychologically healthier than their own children born in the United States. The children, who have acculturated into the dominant society—or acquired some knowledge of its language, food choice, dress, music, sports, etc.—are more likely to suffer from problems with depression, substance abuse, poor diet, and birth outcomes (e.g., prematurity, low birthweight, and teen pregnancy). Reasons for the negative effects of acculturation may be the stresses of cultural conflicts around ideas of individuality, interpersonal relationships, and what it means to succeed. Access to processed American foods high in simple sugars and excess fat may also prevail over the diets of their parents, which tend to be higher in fiber, protein, and vegetables and fruits. Despite these problems, second-generation Americans nevertheless tend to have higher rates of insurance coverage and access to health care. Their greater facility with English is correlated with higher frequencies of general physical, vision, and dental check-ups. Regardless of one's generation, other factors affect immigrants' health outcomes living in the U.S.: education, wealth, occupational and language skills all influence their lifestyles, as well as the policies of the government and attitudes of Americans already here. sources: Fisher, E. B. 2014. Peer support in health care and prevention: Cultural, organizational, and dissemination issues. Annual Review of Public Health 35: 363-383; Leyse-Wallace, R. 2013. Nutrition and Mental Health. Boca Raton, FL: CRC Press; Snodgrass, J. J. 2013. Health of indigenous circumpolar populations. Annual Review of Anthropology 42: 69-87; Brick, K., et al. 2011. Mexican and Central American immigrants in the United States. Washington, D.C: Migration Policy Institute; Lara, M., et al. 2005. Acculturation and Latino health in the United States: A review of the literature and its sociopolitical context. Annual Review of Public Health 26: 367-397. This section examines some of the more common psychological disorders, including anxiety disorders, mood disorders, and schizophrenia. Table 3.3 shows the likelihood of these disorders occurring during a lifetime. VITAL STATISTICS Table 3.3 Prevalence of Selected Psychological Disorders among Americans MEN WOMEN DISORDER LIFETIME PREVALENCE (%) LIFETIME PREVALENCE (%) Anxiety Disorders Specific Phobia 6.7 15.7 Social phobia 11.1 15.5 Panic disorder 2.0 5.0 Generalized anxiety disorder 3.6 6.6 Obsessive-compulsive disorder 1.7 2.8 Posttraumatic stress disorder 5.0 10.4 Mood disorders Major depressive episode 11.2 20.7 Manic episode 1.4 1.9 Schizophrenia and related disorders 0.8 0.4 sources: Centers for Disease Control and Prevention. 2011. Mental illness surveillance among adults in the United States. MMWR 60 (Suppl.): 1-29; Kessler, R. C., et al. 2005. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCSR). Archives of General Psychiatry 62(6): 617-627; Kessler, R. C., et al. 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry 51(1): 8-19; Kessler, R. C., et al. 1995. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52(12): 1048-1060; Plassman, B. L., et al. 2007. Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology 29: 125-132; Kukull, W. A., et al. 2002. Dementia and Alzheimer's disease incidence. Archives of Neurology 59 (Nov.): 1737-1776. Anxiety Disorders Fear is a basic and useful emotion. Its value for our ancestors' survival cannot be overestimated. For modern humans, fear motivates us to protect ourselves and to learn how to cope with new or potentially dangerous situations. We consider fear to be a problem only when it is out of proportion to real danger. Anxiety is another word for fear, in particular, fear that is not in response to any definite threat. It becomes a disorder when it occurs almost daily or in life situations that recur and cannot be avoided, interfering with your relationships and the ability to function in social and professional situations. Specific Phobia The most common and understandable anxiety disorder, called specific phobia, is a fear of something definite like lightning, a particular type of animal, or a place. Snakes, spiders, and dogs are commonly feared animals; high or enclosed spaces are often frightening places. Sometimes, but not always, these fears originate in bad experiences, such as being bitten by a snake. Social Phobia The 15 million Americans with social phobia fear humiliation or embarrassment. Fear of speaking in public is perhaps the most common phobia of this kind. Extremely shy people can have social fears in almost all social situations. People with these kinds of fears may not continue in school as far as they could and may restrict themselves to lower-paying jobs in which they do not have to come into contact with new people. Panic Disorder People with panic disorder experience sudden unexpected surges in anxiety, accompanied by symptoms such as rapid and strong heartbeat, shortness of breath, loss of physical equilibrium, and a feeling of losing mental control. Such attacks usually begin in a person's early twenties and can lead to a fear of being in crowds or closed places or of driving or flying. Sufferers fear that a panic attack will occur in a situation from which escape is difficult (in an elevator), where the attack could be incapacitating and result in a dangerous or embarrassing loss of control (driving a car or shopping), or where no medical help would be available if needed (alone away from home). Fears such as these lead to avoidance of situations that might cause trouble. The fears Page 70and avoidance may spread to a large variety of situations until a person is virtually housebound, a condition called agoraphobia. People with panic disorder can often function normally in feared situations if with someone they trust. Panic disorder is different from an occasional panic attack, which affects about 40 million American adults age 18 and older every year. This occasional attack of overwhelming Page 71anxiety may have no obvious antecedent and usually resolves in an hour or less. Generalized Anxiety Disorder A basic reaction to future threats is to worry about them. Generalized anxiety disorder (GAD) is a diagnosis given to people whose worries about multiple issues linger more than six months. Worries may involve family, other relationships, work, school, money, and health. The GAD sufferer's worrying is not completely unjustified—after all, thinking about problems can result in solving them. But this kind of thinking seems to just go around in circles, and the more you try to stop it, the more you feel at its mercy. The end result is a persistent feeling of nervousness, often accompanied by depression. QUICK STATS 8 million American adults suffer from posttraumatic stress disorder. —U.S. Department of Veterans Affairs, 2015 Obsessive-Compulsive Disorder Someone diagnosed with obsessive-compulsive disorder (OCD) struggles with obsessions, compulsions, or both. Obsessions are recurrent, unwanted thoughts or impulses. Unlike the worries of GAD, they are not ordinary concerns but improbable fears such as of suddenly committing an antisocial act or of having been contaminated by germs. Compulsions are repetitive, difficult-to-resist actions usually associated with obsessions. A common compulsion is hand washing, associated with an obsessive fear of contamination by dirt. Other compulsions are counting and repeatedly checking whether something has been done—for example, whether a door has been locked or a stove turned off. People with OCD feel anxious, out of control, and embarrassed. Their rituals can occupy much of their time and make them inefficient at work and difficult to live with. Posttraumatic Stress Disorder (PTSD) People who suffer from posttraumatic stress disorder are reacting to severely traumatic events (events that produce a sense of terror and helplessness) such as physical violence to themselves or their loved ones. Trauma occurs in personal Page 72assaults (rape, military combat), natural disasters (floods, hurricanes), and tragedies (fires, airplane or car crashes). Symptoms include reexperiencing the trauma in dreams and in intrusive memories, trying to avoid anything associated with the trauma, and numbing of feelings. Hyperarousal (being on edge or easily startled), sleep disturbances, and other symptoms of anxiety and depression also commonly occur. Such symptoms can last months or even years. The symptoms of PTSD must last at least a month for the diagnosis to be made. Those whose symptoms have lasted only a month before resolving are considered to have acute stress disorder. PTSD symptoms often decrease over time, but up to one-third of PTSD sufferers do not fully recover. Recovery may be slower in those who have previously experienced trauma or who suffer from ongoing psychological problems. A study by the U.S. Department of Veterans Affairs National Center for PTSD found that, as a result of the Boston Marathon bombing in April 2013, many Boston-area military veterans diagnosed with PTSD experienced flashbacks, unwanted memories, and other psychological effects. The study raised awareness of the effects that tragic events such as terror attacks and mass shootings have on people directly involved but also on those with PTSD and other preexisting psychological conditions. The researchers urged health care systems to be prepared in the future to provide treatment for individuals either directly or indirectly affected by such tragedies. Treating Anxiety Disorders Therapies for anxiety disorders range from medication to psychological interventions concentrating on a person's thoughts and behavior. Both drug treatments and cognitive-behavioral therapies are effective in panic disorder, OCD, and GAD. Specific phobias are best treated without drugs. Attention-Deficit/Hyperactivity Disorder Attention-deficit/hyperactivity disorder (ADHD) is one of the most common disorders of childhood and adolescence. The main features of ADHD are inattention, hyperactivity, and/or impulsivity. Because these behaviors are normally found in children, attention must be paid to the persistence and severity of the symptoms. They may go misdiagnosed for a time: The impulsive child may be labeled a "discipline problem." An inattentive child may be described as "unmotivated" or "unintelligent." A diagnosis of ADHD is made only if the individual exhibits a persistent pattern of these behaviors; the behaviors must also interfere with the individual's functioning or development, as well as negatively affect school performance, peer relationships, or behavior at home. Inattention includes failure to pay close attention to details; tendency to make careless mistakes; trouble holding attention; failure to listen when spoken to directly; inability to follow through on or complete a task; avoidance of activities that require sustained effort; and tendency to get easily distracted. Hyperactivity and impulsivity include a tendency to fidget or squirm; inability to stay seated when expected; inability to play quietly; tendency to be high energy, to talk excessively, and to interrupt others; and inability to wait his or her turn. To be diagnosed, a person must have symptoms of ADHD before age 12 (even if an adult at first diagnosis). There must also be evidence that the ADHD behaviors are present in two or more settings—for example, at home, school or work; with friends and family; and in other activities. Someone who can pay attention at work but is inattentive only at home usually wouldn't qualify for a diagnosis of ADHD. ADHD has no cure, and scientists are still working on treatments. They are using tools such as brain imaging to find ways to prevent it. The use of medications is controversial. At best it can relieve some symptoms of the disorder. Other treatments include psychotherapy, education and training, and a combination of treatments. Mood Disorders We've all experienced sadness and feeling "down" or elated or irritable, but sometimes these feelings can be persistent or severe and interfere with life functioning. The two main types of mood disorder, major depressive disorder and bipolar disorder (what used to be called manic-depression) are together the most common mental disorders in the United States. Depression Depression differs from person to person but includes the following symptoms that persist most of the day and last more than two consecutive weeks: A feeling of sadness and hopelessness or loss of pleasure in doing usual activities (anhedonia) Poor appetite and weight loss or, alternatively, increased eating compared to usual Insomnia or disturbed sleep, including waking up and being unable to fall back to sleep or sleeping more than normal Decreased energy Restlessness or, alternatively, slowed thinking or activity Thoughts of worthlessness and guilt Trouble concentrating or making decisions Thoughts of death or suicide A person experiencing depression may not have all of these symptoms but must have depressed mood or anhedonia and at least four other symptoms. Sometimes instead of poor Page 73appetite and insomnia, the opposite occurs—eating too much and sleeping too long. Thus depression may contribute to weight gain in young women. People can have multiple symptoms of depression without feeling depressed, although they usually experience a loss of interest or pleasure. (See the box "Are You Suffering from a Mood Disorder?") ASSESS YOURSELF: Are You Suffering from a Mood Disorder? You should be evaluated by a professional if you've had five or more of the following symptoms for more than two weeks or if any of these symptoms causes such a big change that you can't keep up your usual routine. When You're Depressed ______ You feel sad or cry a lot, and it doesn't go away. ______ You feel guilty for no reason; you feel you're no good; you've lost your confidence. ______ Life seems meaningless, or you think nothing good is ever going to happen again. ______ You have a negative attitude a lot of the time, or it seems as if you have no feelings. ______ You don't feel like doing a lot of the things you used to like—music, sports, being with friends, going out, and so on—and you want to be left alone most of the time. ______ It's hard to make up your mind. You forget lots of things, and it's hard to concentrate. ______ You get irritated often. Little things make you lose your temper; you overreact. ______ Your sleep pattern changes: You start sleeping a lot more or you have trouble falling asleep at night; or you wake up really early most mornings and can't get back to sleep. ______ Your eating patterns change: You've lost your appetite or you eat a lot more. ______ You feel restless and tired most of the time. ______ You think about death or feel as if you're dying or have thoughts about suicide. When You're Manic or Hypomanic ______ You feel abnormally good or confident, like you're "on top of the world." ______ You get unrealistic ideas about the great things you can do—things that you really can't do. ______ Thoughts go racing through your head, you jump from one subject to another, and you talk a lot. ______ You're starting multiple projects at the same time—doing too many things at once. ______ You do risky things that may be out of character—spending much more money than usual, having more sex with more partners, driving recklessly, and so on. ______ You're so energized that you don't need much sleep. ______ You're so abnormally irritable that you can't get along at home or school or with your friends. If you are concerned about depression or manic behavior in yourself or a friend, or if you are thinking about hurting or killing yourself, talk to someone about it and get help immediately. In some cases, depression is a clear-cut reaction to a specific event, such as the loss of a loved one or a failure in school or work, whereas in other cases no trigger event is obvious. Regardless of the reason, severe symptoms should be taken seriously. Someone who has symptoms of major depression for more than two weeks, even if it is in reaction to a specific event, should consider treatment. One danger of severe depression is suicide, which is discussed later in this chapter, but the overall impact of depression on general health and ability to function, with or without suicidal thoughts, can be devastating. The National Institutes of Health estimates that depression strikes nearly 6.7% of Americans annually—20% of people have it in their lifetime—making depression the most common mood disorder. Depression affects the young as well as adults; about 3% of adolescents aged 13-18 suffer a major depressive episode each year, and nearly 50% of college students report depression severe enough to hinder their daily functioning. Depression tends to be more severe and persistent in blacks than in people of other races. Despite this, only about 60% of blacks affected by depression receive treatment for it. Almost twice as many women as men have serious depression. Overall, about three times as many women as men attempt suicide, but women's attempts are less likely to be lethal. Why women have more depression than do men is a matter of debate. Some experts think much of the difference is Page 74the result of reporting bias: Women are more willing to admit experiencing negative emotions, being stressed, or having difficulty coping. Women may also be more likely to seek treatment. Other experts point to biologically based sex differences, particularly in the level and action of hormones. It may also be that men are more likely than women to have symptoms such as anger or irritability when they are depressed, leading them to be misdiagnosed or for the diagnosis to be missed. In addition, women's social roles and expectations often differ from those of men. Women may put more emphasis on relationships in determining self-esteem, so the deterioration of a relationship is a cause of depression that can hit women harder than men. Culturally determined gender roles are more likely to place women in situations where they have less control over key life decisions, and lack of autonomy is associated with depression. Although treatments are highly effective, only about 35% of people who suffer from depression currently seek treatment. Treatment for depression depends on its severity and on whether the depressed person is suicidal. The best initial treatment for moderate to severe depression is probably a combination of drug therapy and psychotherapy. Newer prescription antidepressants work well, although they may need several weeks to take effect, and patients may need to try multiple medications before finding one that works well. If someone is severely depressed and at risk of suicide, hospitalization for more intensive treatment to ensure the patient's safety is sometimes necessary. Antidepressants work by targeting key neurotransmitters in the brain, including serotonin. When you take an antidepressant, your levels of serotonin increase. This increase has been revealed to help depression and other bodily conditions that serotonin influences, including mood, sexual desire and function, appetite, sleep, memory and learning, temperature regulation, and some social behavior. When women take antidepressants, they may need a lower dose than men; at the same dosage, blood levels of medication tend to be higher in women. An issue for women who may become pregnant is whether antidepressants can harm a fetus or newborn. The best evidence indicates that the most frequently prescribed types of antidepressants do not cause birth defects, although some studies have reported withdrawal symptoms in some newborns whose mothers used certain antidepressants. Electroconvulsive therapy (ECT) is effective for severe depression when other approaches have failed, including medications and other electronic therapies. In ECT, an epileptic-like seizure is induced by an electrical impulse transmitted through electrodes placed on the head. Patients are given an anesthetic and a muscle relaxant to reduce anxiety and prevent injuries associated with seizures. ECT usually includes three treatments per week for two to four weeks. For patients with seasonal affective disorder (SAD)—a type of depression—the treatment involves sitting with eyes open in front of a bright light source every morning. For patients with SAD, depression worsens during winter months as daylight hours diminish. Light therapy may work by extending the perceived length of the day and thus convincing the brain that it is summertime even during the winter months. The American Psychiatric Association estimates that 10-20% of Americans suffer symptoms that may be linked to SAD. SAD is more common among people who live at higher latitudes, where there are fewer hours of light in winter. QUICK STATS 51% of all suicides in the United States are committed with a firearm—more than 21,000 per year. —National Center for Health Statistics, 2016 Bipolar Disorder People who experience mania, characteristic of a severe mood disorder called bipolar disorder, undergo discrete periods of time when they may be restless, have excess energy or activity, feel rested with less sleep than usual, and speak rapidly. They may feel elevated (that is, much better than normal) or abnormally irritable. These feelings are often accompanied by impulsive behavior without regard for the consequences—for example, spending too much money or engaging in risky sexual activity. When such episodes are severe (requiring hospitalization, for example, or producing severe consequences), they are known as manic episodes, and the person who experiences them has what is known as bipolar I disorder. If such episodes of elevation or irritability are not so severe as to significantly impair functioning, they are known as hypomanic episodes. If hypomania alternates with periods of depression, that person is diagnosed with what is known as bipolar II disorder. People with bipolar disorder typically have periods of both mania or hypomania and depression, and the periods of depression can be persistent and severe. Bipolar disorder typically begins in the late teens through the twenties. Many people with bipolar disorder also struggle with substance and alcohol use disorders and anxiety. Suicide rates are high in bipolar disorders, especially early in life. This syndrome affects men and women equally. Antimanic drugs include lithium (a salt that calms manic episodes), mood stabilizers, and antipsychotic medications. For people who have recurrent episodes of mania or depression, continued, lifelong medication treatment is recommended. Specific medications to treat bipolar depression may also be prescribed.Page 75 Schizophrenia Schizophrenia is a devastating mental disorder that affects a person's thinking and perceptions of reality. People with schizophrenia frequently develop paranoid ideas and false beliefs (delusions), or may have auditory hallucinations (hearing "voices"). People with schizophrenia are often convinced that the voices they hear are "real." The disease can be severe and debilitating or so mild that it's hardly noticeable. Although people are capable of diagnosing their own depression, they usually don't diagnose their own schizophrenia because they often can't see that anything is wrong. This disorder is not rare; in fact, 1 in every 100 people has schizophrenia, most commonly starting in adolescence, which is perhaps what is most tragic and disturbing about the disease—that it starts to affect people in the prime of their lives. Scientists are uncertain about the exact causes of schizophrenia. Researchers have identified possible chemical and structural differences in the brains of people with the disorder as well as several genes that appear to increase risk. Schizophrenia is likely caused by a combination of genes and environmental factors that occur during pregnancy and development. For example, children born to older fathers have higher rates of schizophrenia, as do children with prenatal exposure to certain infections or medications. Some general characteristics of schizophrenia include the following: Disorganized thoughts. Thoughts may be expressed in a vague or confusing way. Inappropriate emotions. Emotions may be either absent or strong but inappropriate. Delusions. People with delusions—firmly held false beliefs—may think that their minds are controlled by outside forces, that people can read their minds, that they are great personages like Jesus Christ or the president of the United States, or that they are being persecuted by a group such as the CIA. Paranoid delusions can give people the feeling that they are in grave danger of being harmed. Auditory hallucinations. People with schizophrenia may hear voices when no one is present. Sometimes these voices tell them to do things (like harm themselves or others), belittle and criticize them, or give individuals a running commentary on someone's thoughts and behaviors. These voices can seem very real to the person hearing them and therefore are quite terrifying. Deteriorating social and work functioning. Social withdrawal and increasingly poor performance at school or work may be so gradual that they are hardly noticed at first, but over time people suffering from the disease fall far behind their peers—and far behind others' earlier expectations. None of these characteristics is invariably present. Some schizophrenic people are quite logical except on the subject of their delusions. Others show disorganized thoughts but no delusions or hallucinations. A schizophrenic person needs help from a mental health professional. Suicide is a risk in schizophrenia, and expert treatment can reduce that risk and minimize the social consequences of the illness by shortening the period when symptoms are active. The key element in treatment is regular medication. At times medication is like insulin for diabetes—it makes the difference between being able to function or not. Sometimes hospitalization is required temporarily to relieve family and friends. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever wondered if you were depressed? Try to recall your situation at the time. How did you feel, and what do you think brought about those feelings? What, if anything, did you do to bring about change and to feel better?

pairing and singlehood

PAIRING AND SINGLEHOOD Although most people eventually marry or commit to a partner, everyone spends some time as a single person, and nearly all people make some attempt, consciously or unconsciously, to find a partner. Intimate relationships are as important for singles as for couples. Choosing a Partner Most people select partners for long-term relationships through a fairly predictable process, although they may not be consciously aware of it. First attraction is based on easily observable characteristics: looks, dress, social status, and reciprocated interest. Studies have shown that most people pair with someone who Lives in the same geographic area Comes from a similar racial, ethnic, and socioeconomic background Has a similar educational status Page 99 Leads a lifestyle like theirs Has (what they think is) the same level of physical attractiveness as themselves Physical attraction plays a strong role in the initial choosing of a partner. People tend to gravitate toward others who share similar characteristics, such as appearance, race, ethnicity, education, and socioeconomic background. © Image Source/Getty Images RF Once the euphoria of romantic love winds down, personality traits and behaviors become more significant factors in how partners view each other. The emphasis shifts to basic values and future aspirations regarding career, family, and children. At some point, they decide whether the relationship feels viable and is worthy of their continued commitment. Perhaps the most important question for potential mates to ask is, "How much do we have in common?" Although differences add interest to a relationship, similarities increase the chances of a relationship's success. Differences can affect a relationship in the areas of values, religion, race, ethnicity, attitudes toward sexuality and gender roles, socioeconomic status, familiarity with each other's culture, and interactions with the extended family. But acceptance and communication skills go a long way toward making a relationship work, no matter how different the partners. Dating Every culture has certain rituals for pairing and finding mates. Parent-arranged marriages, still the norm in many cultures, are often stable and permanent. Although the American cultural norm is personal choice in courtship and mate selection, the popularity of dating services and online matchmaking suggests that many people want help finding a suitable partner. Many people find romantic partners through some form of dating. They narrow the field through a process of getting to know each other. Dating often revolves around a mutually enjoyable activity, such as seeing a movie or having dinner. Casual dating may then evolve into steady or exclusive dating, then engagement, and finally marriage. For many college students today, group activities have replaced dating as a way to meet and get to know potential partners. © Brook Slezak/Stone/Getty Images In recent years, traditional dating has given way to a more casual form of getting together in groups. Two people may begin to spend more time together, but often with other couples or groups. If sexual involvement develops, it is more likely to be based on friendship, respect, and common interests than on expectations related to gender roles. In this model, mate selection may progress from getting together to living together to marriage. Among some teenagers and young adults, dating has been supplanted by hooking up—casual sexual activity without any relationship commitment. For more about this trend, see the box "Hooking Up." WELLNESS ON CAMPUS: Hooking Up Hooking up—having casual sexual encounters with acquaintances or strangers with no commitment or investment in an emotionally intimate relationship—is said to be a current trend among teenagers and young adults. Although casual sex is not new, the difference today is that hooking up is said to be the main form of sexual activity for many people, as opposed to sexual activity within a relationship. Some data indicate that more than 80% of college students have had at least one hookup experience. If dating occurs at all, it happens after people have had sex and become a couple. Hooking up is said to have its roots in the changing social and sexual patterns of the 1960s. Since then, changes in college policies have contributed to the shift, such as the move away from colleges acting in loco parentis (in the place of parents), the trend toward coed dorms, a trend toward getting married at a later age, and the availability of dating apps such as Tinder. Hooking up addresses the desire for "instant intimacy" but also protects the participants from the risk or responsibility of emotional involvement. Because hooking up is often fueled by alcohol, it is associated with sexual risk taking and negative health effects, including the risk of acquiring a sexually transmitted infection. According to the Centers for Disease Control and Prevention (CDC), in 2014, young adults aged 15-24 had rates of chlamydia that were almost five times the overall incidence rate for the general population. Hooking up can also have adverse emotional and mental health consequences, including sexual regret and psychological distress. Due to these and other concerns, a backlash against hooking up has taken place on some college campuses. In some cases, individuals are deciding they don't want to be part of the hookup culture. In other cases, groups and organizations have formed to call for a return to traditional dating or at least some middle ground between dating and hooking up. However, recent studies question whether hookup culture is actually anything new. Results from the General Social Survey, which explores attitudes and behaviors around a wide variety of issues, suggest that millennials are actually less promiscuous than previous generations. If that's true, then how did the idea of hookup culture become so widespread? First, we tend to look at the past with rose-colored glasses and thus imagine the "good old days" when people had sex only in the context of committed relationships. Second, young people have a tendency to assume (incorrectly) that all their peers are having sex—that everyone around them is hooking up, except for them. Third, people who aren't the norm (that is, outliers who are having outrageous amounts of sex) are the ones who tend to get media attention, since they provide a more titillating story. sources: Carpenter, L., and J. DeLamater, eds. 2012. Sex for Life: From Virginity to Viagra, How Sexuality Changes Throughout Our Lives. New York: New York University Press, pp. 128-144; Garcia, J. R., et al. 2013. Sexual hook-up culture. Monitor on Psychology 44(2): 60. Online Dating and Relationships Connecting with people online has advantages and drawbacks. It allows people to communicate in a relaxed way, try out different personas, and share things they might Page 100not share when face-to-face with family or friends. It's easier to put yourself out there without too much investment; you can get to know someone from the comfort of your own home, set your own pace, and start and end relationships at any time. With millions of singles using dating sites that let them describe exactly what they are seeking, the Internet can increase a person's chance of finding a good match. However, participants sometimes misrepresent themselves, pretending to be very different—older or younger or even of a different sex—than they really are. Investing time and emotional resources in such relationships can be painful. In rare cases, online romances become dangerous or even deadly (see Chapter 21 for information on cyberstalking). Because people have greater freedom to reveal only what they want to, users should also be aware of a greater tendency to idealize online partners. If your online friend seems perfect, take that as a warning sign. You may search for perfection, find fault quickly, and not give people a chance; conversely, you may act on impulse with insufficient information. Relationship sites also remove an important and powerful source of information from the process: chemistry and in-person intuition. Much of our communication is transmitted through body language and tone, which aren't obvious in text messages and can't be captured fully even by web cams and microphones. Consider these questions. Are you comfortable in disclosing personal information about yourself? Is there a balance in the amount of time spent talking by each of you? Is the other person respecting your boundaries? Just as in face-to-face dating, online relationships require you to use common sense and to trust your instincts. If you pursue an online relationship, the following guidelines may help you have a positive experience and stay safe: Choose a site that fits with your own relationship goals. Some sites are primarily geared for hookups—that is, arranging meetings for casual sex—whereas others aim to facilitate classic dating relationships. Inspect each site thoroughly before registering or providing any information about yourself. If you aren't comfortable with a site's content or purpose, close your web browser and clear out its cache and its store of cookies. (If you don't know how to do this, check your browser's help section for instructions.) Know what you are looking for as well as what you can offer someone else. If you are looking for a relationship, Page 101make that fact clear. Find out the other person's intentions. Don't post photos unless you are completely comfortable with potential consequences (e.g., they might be downloaded by others). Don't give out personal information, including your real full name, school, or place of employment, until you feel sure that you are giving the information to someone who is trustworthy. Set up a second e-mail account for sending and receiving dating-related e-mails. If someone does not respond to a message, don't take it personally. There are many reasons why a person may not pursue the connection. Don't continue to send messages to an unresponsive person; doing so could lead to an accusation of stalking. Before deciding whether to meet an online contact in person, consider talking over the phone. Don't agree to meet someone face-to-face unless you feel comfortable about it. Always meet initially in a public place—a museum, a coffee shop, or a restaurant. Consider bringing along a friend to increase your safety, and let others know where you will be. If you pursue online relationships, don't let them interfere with your other personal relationships and social activities. To support your emotional and personal wellness, use the Internet to widen your circle of friends, not shrink it. QUICK STATS About 15% of all American adults, and 27% of those age 18-24, have used an online dating site or mobile dating app. —Pew Research Center, 2016 Living Together According to the U.S. Census Bureau, about 5.4 million opposite-sex couples and 700,000 same-sex couples live together in the United States. The Human Rights Campaign, however, estimates that the number of same-sex couples in the United States is closer to 1.6 million. Living together, or cohabitation, is one of the most rapid and dramatic social changes that has occurred in our society. By age 30, about half of all adults will have cohabited. Several factors are involved in this change, including greater acceptance of sex outside of marriage, increased availability of contraceptives, the tendency for people to wait longer before getting married, and a larger pool of single and divorced individuals. Cohabitation is more popular among younger people than older, although a significant number of older couples live together without marrying. Cohabitation provides many of the benefits of marriage: companionship; a setting for an enjoyable and meaningful relationship; a chance to develop greater intimacy through learning, compromising, and sharing; a satisfying sex life; and a way to save on living costs. Are there advantages to living together over marriage? For one thing, it may give the partners a greater sense of autonomy. Not bound by the social rules and expectations that are part of marriage, partners may find it easier to keep their identities and more of their independence. Cohabitation doesn't incur the same obligations as marriage. If things don't work out, the partners may find it easier to leave a relationship that hasn't been legally sanctioned. Researchers previously believed that cohabiting before marriage led to higher divorce rates, but a 2014 study by the Council on Contemporary Families found that the age at which couples first cohabit or marry has a greater impact on relationship longevity. Those who wait until at least age 23 have the best relationship outcomes. Of course, living together has drawbacks as well. In many cases, the legal protections of marriage are absent, such as health insurance benefits and property and inheritance rights. These considerations can be particularly serious if the couple has children. Couples may feel social or family pressure to marry or otherwise change their living arrangements, especially if they have young children. The general trend, however, is toward legitimizing nonmarital partnerships; for example, some employers, communities, and states now extend benefits to unmarried domestic partners. QUICK STATS Two-thirds of new marriages take place between couples who have already lived together for an average of 31 months. —Council on Contemporary Families, 2014 Sexual Orientation and Gender Identity in Relationships People demonstrate great diversity in their emotional and sexual attractions (see Chapter 5). Sexual orientation refers to a consistent pattern of emotional and sexual attraction to persons of the same sex or gender, a different sex or gender, or more than one sex or gender. A word that has come into use to describe sexual orientations other than heterosexual/straight is queer. People who prefer to self-identify as queer do so because it is an umbrella term, meaning it does not require one to specify between categories such as gay and bisexual. Rejecting categorization can feel like a relief to those who are still exploring their sexual orientation, or who experience it as fluid. Since queer is a pejorative term that has been reclaimed, never use it to label other people without their permission. Page 102In other words, respect the identity people choose for themselves rather than applying your own label to them. Although they constitute a minority of the population, same-sex partnerships are more visible than they used to be. © Pekic/iStock/360/Getty Images RF Regardless of sexual orientation, most people look for love in a committed relationship. In this sense, queer couples have more similarities than differences from straight couples. Like any intimate relationship, queer partnerships provide intimacy, passion, and security. However, there are also some significant differences between these partnerships. Same-sex partnerships tend to be more egalitarian (equal) and less organized around traditional gender roles. Same-sex couples put greater emphasis on partnership than on role assignment. Domestic tasks are shared or split, and both partners usually support themselves financially. Although many challenges for queer partnerships are common to all relationships, some issues are unique. Sexual minorities often have to deal with societal hostility or ambivalence toward their relationships, in contrast to the societal approval and rights given to heterosexual couples (see the box "Marriage Equality"). Homophobia, which is fear or hatred of homosexuals, can be obvious, as in the case of violence or discrimination. Or it can be subtler—for example, if same-sex couples are portrayed in a stereotypical way in the media. Additional stress can arise if a sexual minority individual belongs to a family, cultural group, or religion that doesn't accept her or his sexual orientation. Because of the rejection these individuals experience by society at large, community resources and support are often more important for queer-identified individuals than for heterosexuals. Many communities offer support groups for same-sex partners and families to help them build social networks. DIVERSITY MATTERS: Marriage Equality In its legal definitions, marriage is an institution in which couples derive legal and economic rights and responsibilities from state and federal statutes. The U.S. Government Accountability Office says more than 1000 federal laws make distinctions based on marriage. Marital status affects many aspects of life, such as Social Security benefits, federal tax status, inheritance, and medical decision making. The push for legal recognition of same-sex partnerships has gone on for decades. Supporters of same-sex marriage rights have met opposition at the local, state, and federal levels, in both the public and private sectors. However, support for marriage equality has increased rapidly in the past several years. In 2001, Americans opposed marriage equality by a 57% to 35% margin, but in 2016, a majority of Americans (61%) supported marriage equality, compared with 37% who opposed it. In 2013, the U.S. Supreme Court ruled that the federal government must recognize same-sex marriages performed by states that allow them, and in 2015, it declared all state bans on same-sex marriage unconstitutional. Couples in which one or both partners are transgender are affected by this ruling as well, but only if their legal gender classifies them as a same-sex couple at the time of their marriage. Heterosexual transgender couples were generally able to marry previous to this ruling, so long as they were legally man-and-woman at the time of the marriage. © Eric Risberg/AP Images What are benefits of marriage for same-sex couples? Health insurance and retirement benefits for employees' spouses Social Security benefits for spouses, widows, and widowers Support and benefits for military spouses, widows, and widowers Joint income tax filing and exemption from federal estate taxes Immigration protections for binational couples Rights to creative and intellectual property Protection from some types of employment discrimination (e.g., getting fired for marrying a same-sex spouse) Marriage also matters in terms of child rearing. Children who grow up with married parents benefit because their parents' relationship is recognized by law and receives legal protections. Additionally, spouses are generally entitled to joint child custody and visitation should the marriage end in divorce. They also bear an obligation to pay child support. Finally, marriage can have an impact on emotional well-being. Research shows that married people tend to live longer, have higher incomes, engage less frequently in risky behaviors, have a healthier diet, and have fewer psychological problems than unmarried people. Overall, unmarried couples have lower levels of happiness and well-being than married couples. Finally, studies show that denying same-sex couples the right to marry has a negative impact on their mental health. The long-term impact of marriage equality is not yet known, but it is likely to benefit the legal, economic, and emotional well-being of millions of Americans. sources: Shah, Dayna K. 2004. Letter to Senator Bill Frist. (http://www.gao.gov/new.items/d04353r.pdf); Marriage Equality FAQ: Frequently Asked Questions about the Supreme Court's Marriage Ruling (https://marriageequalityfacts.org/); Gonzales, G. 2014. Same-sex marriage—A prescription for better health. New England Journal of Medicine 370: 1373-1376; Wight, R. G. 2013. Same-sex legal marriage and psychological well-being: Findings from the California Health Interview Survey. American Journal of Public Health 103(2): 339-346. See Chapter 5 for more information about sexual orientation, gender identity, and sexual behavior. Singlehood Despite the popularity of marriage, a significant and growing number of adults in our society never marry. Currently more than 116 million single individuals—the largest group of unmarried adults—have never been married (Figure 4.2). Pie charts showing marital status by gender. [D] FIGURE 4.2 Marital status of the U.S. population, 2015. source: U.S. Census Bureau. 2016. Families and Living Arrangements: 2015 (https://www.census.gov/hhes/families/data/marital.html). Several factors contribute to the growing number of single people. One is the changing view of singlehood, which is increasingly being viewed as a legitimate alternative to marriage. Education and careers are delaying the age at which young people are marrying. The median age for marriage is now 29 years for men and 27 years for women. More young people are living with their parents as they complete their education, seek jobs, or strive for financial independence. Page 103Many other single people live together without being married. High divorce rates mean more singles, and people who have experienced divorce may have more negative attitudes about marriage and more positive attitudes about singlehood. Being single, however, does not mean living without the benefit of close relationships. Single people date, enjoy active and fulfilling social lives, and have a variety of sexual experiences and relationships. Other advantages of being single include more opportunities for personal and career development without concern for family obligations and more freedom and control in making life choices. Disadvantages include loneliness and a lack of companionship, as well as economic hardships (particularly for single women, who on average earn less than men). Single men and women alike experience some discrimination and often are pressured to get married. Nearly every adult has at least one episode of being single, whether prior to marriage, between marriages, following divorce or the death of a spouse, or for his or her Page 104entire life. How enjoyable and valuable this single time is depends on several factors, including how deliberately the person has chosen it; how satisfied the person is with his or her social relationships, standard of living, and job; how comfortable the person feels when alone; and how resourceful and energetic the person is about creating an interesting and fulfilling life. QUICK STATS Just over 2 million marriages took place in the United States in 2014. —National Center for Health Statistics (CDC), 2014