DOING SKILLS REQUIRED DURING TIMES OF SI: SELF MANAGEMENT UNDER TIMES OF SEVERE STRESS UNIVERSITY OF SOUTH AFRICA – SCHOOL OF BUSINESS LEADERSHIP PRESENTED BY CORNEL BROWN MA Clinical Psychology – PU for CHE Health Worx Medical Centre, Randridge Mall, Randpark Ridge, Randburg Cell: 082 471 4746 Tel: (011) 801 – 4300 Fax: 801 – 4327 E-mail: cb_za@yahoo.com 1 INDEX 1. INTRODUCTION 3 2. THE PROCESS OF STRESS 4 2.1. An integrated model of stress 4 2.2. The event 4 2.3. The appraisal process 5 2.4. The psycho-emotional and physiological stress response 6 2.5. Adaptation 7 3. SELF-MANAGEMENT DURING THE STRESS RESPONSE 8 3.1. Behavioural coping 8 3.2. Emotional coping 9 3.3. Problem-focused coping 10 4. FACTORS THAT INFLUENCE THE PROCESS OF STRESS 4.1. Personality 11 12 4.4.1. Personality factors 12 4.4.2. The Type-A Personality 12 4.2. Culture 13 4.3. Skills and experience 14 4.4. Positive aspects 14 4.4.1. Character strengths 14 4.4.2. Resilience and psychological well-being 16 4.4.3. Healthy living 19 4.5. Negative aspects 20 4.5.1. Adrenalin addiction 20 4.5.2. Depression 20 4.5.3. Psychological disorders 21 5. PATHOLOGICAL STRESS 22 6. CONCLUSION 24 REFERENCES 25 2 1. INTRODUCTION Stress can be seen as a person’s psycho-emotional and physiological response to something in the environment that challenges the person (called a stressor or stressful event) (Sternberg, 2001). The aim of this paper is to discuss positive self-management or coping when exposed to severe stressors. Firstly, the process of stress will be discussed; secondly how stress can be managed during this process; and thirdly how different factors that may influence the process of stress can be managed to decrease the frequency and intensity of the stress response. Lastly, some attention will be paid to signs of pathological stress. The process of stress will be discussed according to the steps of an integrated model of stress. These steps are the event; the appraisal process; the psycho-emotional and psychological stress response; and adaptation. The discussion on management during the stress response will focus on behavioural coping, emotional coping and problem-focussed coping. The factors that influences the process of stress that will be discussed are Personality; Culture; Skills and experience; Positive aspects: character strengths, resilience and psychological well-being, and healthy living; and Negative aspects: adrenalin addiction, depression, and psychological disorders. The examples of pathological stress that will be discussed are Acute Stress Disorder, Posttraumatic Stress Disorder and Panic Attack. 3 2. THE PROCESS OF STRESS 2.1. An integrated model of stress (adapted from Sternberg, 2001) Environmental Event Appraisal process - Any event, challenge or situation that could be appraised as a harm/loss or threat - Does the challenge constitute a harm/loss or threat? - Do I have sufficient coping resources to deal with the challenge? - If so, the challenge is managed without distress - If not the psycho-emotional and physiological stress response is experienced. Psycho-emotional and physiological stress response Psycho-emotionally - Cognitions are limited to “fight or flight” reactions. - Feelings of automatic behaviour, depersonalisation or derealisation may occur. - Aggressiveness, irritability and hostility might be experienced. - Strong emotions like anger, fear or sadness might be experienced. Physiologically - The body gets ready for “fight or flight” - The autonomic nervous system triggers the sympathetic response, which increases heart rate, respiration and blood pressure and decreases digestion. - Nerve impulses and the endocrine system triggers the adrenal system, which releases adrenalin (arousing the body for action), nor-adrenalin (prolongs sympathetic response) and corticosteroids (increases metabolism, provides energy, decreases immune inflammatory response). - The body is in a state of alarm and the body’s resources are used at a high rate Adaptation - Physically, the body can not maintain the state of alarm indefinitely, and goes into a state of resistance where it imposes a counterbalance through the parasympathetic nervous system, declining for example the demands on the heart and lungs. - Ideally, the stressor would have been resolved and the body can slow down completely and start to restore its resources. - If the stressor is not resolved, the body does not return to a state of rest, and persistent stress is experienced, alternating the body between sates of alarm and resistance. - This ultimately leads to the body’s resources being depleted completely, moving the body into a state of exhaustion. This leads to a weakened immune system and other health problems. 2.2. The event As said before, stress can be seen as a person’s psycho-emotional and physiological response to something in the environment that challenges the person. Such challenges are called stressors. Examples of stressors are time pressure, work pressure, family pressure, financial pressure, divorce, being disciplined at work and moving house. The severity of stressors are determined by the perceived intensity of the challenge and by the time exposed to the stressor. A less intense stressor can therefore become severe when a person is continuously exposed to the stressor (Sternberg, 2001). When a stressor’s 4 intensity reaches the extent of actual or threatened death or serious injury, or a threat to the physical integrity of self or others, the event is seen as a traumatic event (APA, 1994). 2.3. The appraisal process Though the stress response is experienced as an immediate and direct reaction to the event, it is apparently more one’s appraisal of the event that causes the stress response (Sternberg, 2001). When a person appraises an event to be a harm, loss or threat, and they appraise their coping resources to be insufficient to deal with this challenge, they experience the stress response. If a person would for example walk around a corner and see a green snake, and perceive this snake to be a green mamba and consequently appraise the situation as physically dangerous, the person would probably have a stress response. If the person perceives the snake to be a rubber snake and appraise the situation as safe, the person would probably not have a stress response and rather respond with something like curiosity. A person who perceives the snake to be a green mamba, but works with snakes on a daily basis, might also appraise the situation as safe and not react with a stress response. From this example the following becomes clear about the appraisal process: The appraisal of the situation is really what determines whether a stress response will be experienced or not. The stress response is experienced when: - The event is appraised as harm, a threat or a loss, and - The coping resources are appraised to be insufficient to deal with the challenge. The process functions quickly, automatically and subconsciously. There can be different individual factors that influence the appraisal process (of which some will be discussed under Factors that influence the process of stress). This means that two people could appraise the same situation differently, resulting in one having a stress response to the situation, and the other not. 5 2.4. The psycho-emotional and physiological stress response The psycho-emotional stress response is when the event was appraised as a threat and the person is ready for the “fight or flight” response. This means that the person will either aggressively confront the challenge, or flee from the challenge. In the past, when people were in more physical danger, this was an important protective reaction to the perceived threat, built in for survival. If a person for example walked in a field and saw a lion, the person would have to react immediately by running away or if it was too late for that defend him/herself. The person did not have time to sit around calmly and consider different options. Because of this, the stress response leads to a narrowing of cognition to two options: fight or flee. A stressed person will also probably feel strong emotions of fear, anger, irritability or hostility and would seem to others to be aggressive and attacking or emotional and evasive. While acting the person might feel as if things happen automatically and that they are almost not in control of themselves. They might even feel that they are detached or outside of themselves (depersonalisation) or time and space (derealisation). Though this stress reaction might sometimes be positive (people have been reported to do miraculous things like lifting heavy objects off trapped victims), it is often excessive to the situation and the narrowing of options lead to the person being less able to resolve the challenge constructively. This then leads to a continuance of stress. The physical stress response is when the body is ready to “fight or flee”. This means that the body’s resources are used at the most vital organs and muscles. The heart rate needs to increase, the muscles need to tense, the arteries need to constrict (to not bleed to much when injured), less important functions need to be suspended (like the digestive system and blood flow to the face), and the body’s immune inflammatory response needs to be suspended (to not feel pain and be able to run away or act). All this is done through the autonomic nervous system and the adrenal glands (Sternberg, 2001). The autonomic nervous system triggers the sympathetic response, which increases the person’s heart rate, respiration and blood pressure, and decreases digestion. 6 The adrenal medulla (the inner part of the adrenal gland) is an agent of the sympathetic response and is triggered by nerve impulses. When activated it secretes catecholamines: epinephrine (adrenalin) and norepinephrine (noradrenalin). This stimulates the heart, raises the blood pressure, widens the pupils, and sends the blood to the most vital organs and muscles (The Learning Company, 1997). The adrenal cortex (the outer part of the adrenal gland) is triggered by the endocrine gland, which in turn is activated by the hormone ACTH, which is sent from the pituitary gland. When activated, the adrenal cortex secretes corticosteroids: cortisol and aldosterone. Aldosterone regulates the mineral and water balance of the body, prevents excessive loss of water, and influences the contractibility of muscles. Cortisol generates energy by turning carbohydrates into glucose, sends reserves to the liver, and suppresses inflammation (decreasing the body’s immune inflammatory response) (The Learning Company, 1997). When the psycho-emotional and physiological stress response is at its height, the person is ready to “fight or flee” and the person is in a state of alarm. 2.5. Adaptation Physically, the body cannot maintain the state of alarm indefinitely, and goes into a state of resistance where it imposes a counterbalance through the parasympathetic nervous system, declining for example the demands on the heart and lungs (Sternberg, 2001). The intensity of the person’s emotions could also decline and the person might gain more control over thoughts and actions. At this time, the person returns to the appraisal process to determine whether the stressor is resolved. Ideally, the stressor would have been resolved and the body can slow down completely and start to restore its resources. The person would also be able to regain some psychoemotional balance and might feel a sense of relieve and other positive emotions. Cognitively, they would regain their ability to see different options and behaviourly they would seem more relaxed and less aggressive and attacking. 7 If the stressor is not resolved, the person does not return to a state of complete rest, but has another stress response. This can continue so that persistent stress is experienced, alternating the body and mind between states of alarm and resistance. This is a condition of chronic stress (Sternberg, 2001). This ultimately leads to the body’s resources being depleted completely, moving the body into a state of exhaustion. On the short term the person’s ability to restore damaged or worn-out tissues is diminished and the immune system is weakened, resulting in a diminished resistance against opportunistic infections and latent viruses. On the long term, the repeated secretion of adrenalin and cortisol, the weakened immune system, and the continuous taxing of the heart and arteries and the digestive system (which is to frequently suspended) leads to a gradual increase in the alostatic load. Heightened allostatic load has been associated with a number of health problems, where under diabetes, stomach ulcer, heart attack, and stroke (Ryff & Singer, 1998). Psycho-emotionally prolonged stress might negatively influence the person’s interpersonal relationships and self-esteem and might even lead to depression or an anxiety disorder. 3. SELF-MANAGEMENT DURING THE STRESS RESPONSE Self-management involves the implementation of techniques that suspend the continuation of the stress response and promote recovery of resources. Self-management should be done on three levels: a behavioural level, an emotional level and a problemfocused level. 3.1. Behavioural coping On a behavioural level, the person needs to stop the physical stress response by relaxing the body and thereby assisting the parasympathetic response of the body. There are several relaxation techniques, but they can generally be grouped into two categories: Progressive Muscle Relaxation Techniques (of which one is included in Appendix A) and 8 Imagery Relaxation Techniques. Progressive Muscle Relaxation Techniques work by physically tensing and relaxing the muscles in the body. The contrast created between tensing and relaxing the muscles allows the person to experience the feeling of relaxation. The person then purposefully focuses on the relaxed feeling and allows that feeling to become stronger. Imagery Relaxation Techniques work by imagining either a relaxed environment or visualizing how your breath goes to and loosens the stress that is stuck in your body and how that loosened stress is breathed out again. An important aspect of both approaches is breathing. When people become stressed, they tend to breathe very fast and/or very shallow. This results in a too low amount of oxygen in their body, which intensifies and prolongs the stress response. Slow deep breathing is thus a good intervention on its own when stress is experienced, but is also used as part of a relaxation technique. Any other method that is personally relaxing to the person, for example listing to music or going for a quick jog may also be used to assist the body to relax. If the person is caught in chronic stress, the person needs to realize that they would have to break the cycle by taking time out to allow their body to recover. This implies lifestyle changes and changing ones approach to challenges. 3.2. Emotional coping Emotional self-management involves dealing with the emotions that accompany the stress response. As long as uncontrollable emotions are experienced, the stress response will continue. Managing emotions does however not mean to simply ventilate ones feeling. This means that if the feeling is anger for example, simply ventilating this by screaming at people or throwing things; or if the feeling is sadness simply sitting and crying all day is not necessarily dealing with the emotion. In fact, some researchers warn that the mere ventilation of feelings is destructive and argues that it increases the stress response (Stanton, Parsa & Austenfeld, 2002). Some even suggest that emotions should be temporarily suppressed during the stressful event and that the person should rather 9 take a problem-focused approach to the problem (Sternberger, 2001). This will however be difficult, as negative emotions limits cognitive options to either fight or flight. Stanto, Parsa and Austenfield (2002) argue that there is a place for emotional selfmanagement if it is done constructively. The first step in managing emotions would be to identify the emotion. The second step would be to acknowledge the emotion and to attribute the emotion to its specific source. Thereafter expression of emotion to another person or in a journal may occur. Emotional self-management is especially valuable when the person has little control of the stressful situation, for example when somebody discovers that they have cancer. Studies show that people with cancer who acknowledge and constructively deal with their emotions, experience less stress and a better response to treatment than people who suppress their emotions (Stanto, Parsa & Austenfield, 2002). 3.3. Problem-focused coping Problem-focused management usually works best when somebody has more control over the challenge. Once the person stopped the physical stress response and constructively dealt with the associated emotions, their options seem to open up and they are ready to face the challenge constructively. This is best done with a problem-focused approach. Again, there are many models of problem-focused coping. One such a model is that of Egan (1994), who proposes a three-step model of problemfocused coping. The steps are as follows: Step I: Identifying and clarifying the problem situation. The person should at this stage review the facts of the problem, identify the aspects of the problem which causes the most distress and attempt to reframe those aspects or describe it from another perspective, and prioritize which aspects of the problem are the most important and would be most beneficial if resolved. 10 Step II: Developing the preferred scenario During this stage, the person focuses on the preferred outcome of the challenge, which implies looking at the bigger picture. If the challenge is for example to complete a specific task before a specified deadline, the person might take a step back and ask what he/she wants to accomplish by doing the task. If the person wanted to build a reputation for the outstanding quality of his/her work, he/she might explore the possibility of finishing the task later, but producing a better product. If the person wanted to prove his/her own time-efficacy, completing the task with less detail would be more beneficial. After the preferred outcome has been identified, the question is asked which of those outcomes can realistically be obtained, and turning those realistic possibilities into viable goals. Thereafter the person makes the commitment to pursue the chosen goals. Stage III: Determining how to get there Now that the person has identified goals, the process of pursuing the goals is started. Firstly, the person brainstorms strategies for accomplishing the goals, trying to uncover as many strategies as possible. Secondly, the best strategies are chosen within context of the person’s environment and resources. Lastly, a plan is formulated whereby the person identifies a step-by-step procedure for accomplishing each goal of the preferred scenario. The person is now ready to apply the problem-focused solution to the challenge. 4. FACTORS THAT INFLUENCE THE PROCESS OF STRESS Different factors may influence the process of stress. Some factors could influence the process at the appraisal stage and others at the adaptation stage. These factors also influence the ability of the person to cope with the specified challenge. The factors therefore become an important point of intervention in self-management under times of high challenges. If a person could manipulate the factors that influence the process of stress, it is likely that the person could reduce the frequency and intensity of stress experienced. Consequently, a few of the factors that may influence the process of stress and possible interventions of those factors will be discussed. The factors that will be discussed here are personality; culture; skills and experience; positive factors: character 11 strengths, resilience and psychological well-being and healthy living; and negative factors: adrenalin addiction, depression, and psychological disorders. 4.1. Personality 4.1.1. Personality factors Personality plays an important part in whether somebody would find a situation stressful or not. An extrovert could for example find an environment or challenge stressful that requires him/her to work in isolation and resolve the challenge using only internal resources, whereas an introvert might find a situation stressful that requires a high level of interpersonal interaction. Similarly, many personality traits, which are beyond the scope of this paper to discuss, may influence whether a particular person experiences a particular situation as stressful or not. The ideal would however be to find an appropriate fit between a person’s personality and the environment they need to function in and in the type of challenges presented to them. Personality tests such as the 16 Personality Factor Inventory (Cattell, Eber & Tatsuoka, 1980) provide an assessment of a wide variety of personality factors, which could be used as a guide in finding an appropriate fit between the person and the environment. Furthermore, it could be beneficial to at least realise when something in the environment is experienced as stressful as a result of a personality factor. A person can then learn to adapt or compromise with regard to that personality factor. If the person however is unwilling or unable to adapt in this regard, an attempt should be made to modify that specific aspect of the challenge or environment. 4.1.2. The Type-A Personality The next aspect of personality that will be discussed is when a person has a combination of personality factors and characteristics that cumulate in a specific personality style, called the Type-A Personality. A person with a Type-A Personality usually demonstrates: a competitive orientation toward achievement, a sense of urgency about time, and a strong tendency to feel anger and hostility toward other people. 12 People with a Type-A Personality experience the stress response more frequently than other members of the population. Possible reasons for this are that they respond more forcefully to challenges, that they are more likely to view challenges as threats to their personal self-control and that they act in ways that would increase their likelihood to encounter stressful situations. In other words, they create some of their own stress by seeking out demanding, competitive situations or by creating artificial deadlines for themselves (Sternberg, 2001). Intervention of Type-A Personality related stress is difficult, as this would require a change in the person’s approach to life. People with a Type-A Personality often believe that if they don’t stress about something, nobody will, and if nobody stresses, nothing will get done. They therefore seek and thrive on stress, believing that this is the only recipe for successful living. This is however a myth, as the stress response limits the person’s reaction to “fight or flight”, while a non-stressed response to a challenge enables the person to have a broad range of options for action available. The probability is therefore higher that a non-stressed person would find and apply an appropriate and efficient solution to the challenge. If the person with the Type-A Personality would however change their approach to life on a cognitive level, they could also use relaxation techniques to decrease the stress response and make behavioural changes to their stressful lifestyle. 4.2. Culture Culture can often determine whether a person would experience a situation as stressful or not. A person from a culture that places high emphasis on individuality would for example probably experience more stress when marrying into a hierarchical enmeshed family than somebody from a culture that places high emphasis on interpersonal involvement. Stress resulting from a discrepancy between a person’s culture and an aspect of a challenge could be reduced by improving tolerance for the person’s culture and by an approach that differences between cultures does not necessarily mean that the one is absolutely right and the other absolutely wrong. 13 4.3. Skills and Experience The stress response can be experienced when a person is faced with a challenge that they do not have the necessary skills to do. A person who, for example does not know how to swim, would probably find canoeing to be a severely stressful rather than a relaxing experience. The only way to intervene in this stress response is either to develop the needed skill or to modify the challenge. When a person is however put into such a situation unexpectedly, the amount of stress experienced would be determined by other factors, such as the person’s adaptability and confidence in their own ability to learn. Even when a person has the necessary skills to perform a task, some stress might still be experienced if the person lacks experience of the specific challenge. A doctor might for example have all the academic knowledge on how to perform an operation, but experience severe stress when doing it for the first time. Again, the only way to intervene would be to gain the needed experience. Less stress could be experienced if the experience was gained in a safer and supported environment, if the person had confidence in his/her ability and if the person had a realistic expectation of his/her performance. 4.4. Positive aspects 4.4.1. Character strengths Character strengths could be another aspect of personality that influences whether a situation is experienced as stressful or not. Character strengths are personality traits that can be acquired and promoted and is voluntarily acted upon. Examples of character strengths are creativity, perspective, persistence, integrity, kindness, fairness, leadership, prudence, self-control, gratitude, hope and humour (Seligman, 2002). All of these could, under different conditions, contribute to a person experiencing less or no stress where a stress response would be expected. A person might for example use humour to defuse an emotionally volatile situation and thereby avoid the stress response. Another person might come up with a creative solution to a challenge, before the challenge reaches the required intensity to cause a stress response. The theory of character strengths predicts that a person who is in touch with his character strengths and who consciously applies those strengths would be less prone to experience his/her environment or challenges as 14 stressful. Building and broadening character strengths can therefore be seen as a preventative form of self-management when functioning in a challenging environment. Though character strengths are positive characteristics, they can also lead to the stress response being experienced. Three ways in which character strengths can contribute to experiencing a situation or environment as stressful will be discussed. First, a situation or task could be experienced as stressful when it requires a character strength in which the person is less strong. If a person for example has less persistence, but is faced with long-term tasks and objectives that seem enormous with irregular opportunities for feedback, that challenge could be experienced as severely stressful. Character strengths can however be promoted to a certain extend. A possible intervention could thus be to work on increasing specific strengths if they are frequently required in the environment one functions in. A second scenario is when character strengths are frustrated by the environment. A person could find a challenge or environment severely stressful if the behaviour required was the opposite from what they feel strongly about. A person who has a high sense of integrity and honesty would for example find a challenge severely stressful if the challenge required them to pretend that things are as they are not. Similarly, a person who places high value on forgiveness, mercy and kindness might find it extremely stressful to have to fire an employee. The only intervention that can be proposed in this regard is that a person exercises and develops their ability to judge whether they should apply a strength in the particular situation or not, remembering that not all strengths are applicable to all situations (though it is still a positive characteristic). Another technique to prevent future stress is to prioritise beforehand which strengths or believes can be compromised under which circumstances and which strengths, believes or values may not be compromised, even if that meant failure in the challenge. Thirdly, a person might find a challenge or environment to be stressful if there are no opportunities to exercise their strongest character strengths. If a person is for example 15 very creative and curious, they would experience an environment as severely stressful if they were given no opportunity to act autonomously or to develop new and productive ways to conceptualise and do things. A possible intervention in this regard is to identify one’s most prominent strengths and to find ways to incorporate their use in one’s environment or in the challenges one faces. An example of this can be seen in the following story: A man woke up in hospital after an operation and saw a man standing at the opposite wall meticulously placing and replacing paintings on the wall. When the man who had the operation asked the person who he was, he learned that this person was the cleaner whose main job it was to wash the floors and clean out bedpans, but that he interpreted his job as being responsible for the patient’s well-being to the extent that they would wake up in a clean environment and that the first thing they would see would be beautiful, therefore his particular attention to the paintings. The cleaner in this story therefore took his relatively mundane environment and applied his character strengths of love for people and his appreciation of beauty to transform his environment and challenges into a personally fulfilling experience. All of the above interventions regarding character strengths involve the identification, enhancement or application of character strengths. More information on assessing and applying character strengths can be found in Martin Seligman’s book on Authentic Happiness (Seligman, 2002) (see references) and on his website: www.authentichappiness.org. A questionnaire for the assessment of character strengths is also available on the website. 4.4.2. Resilience and Psychological well-being Resilience refers to “a class of phenomena characterized by patterns of positive adaptation in the context of significant adversity or risk” (Masten & Reed, 2002). Resilient people have also been labelled as “stress resistant”, implying that the resilient person is less likely to appraise a challenge in such a way that would elicit the stress response. The overall resilience of a person is therefore an important factor in the process of stress. A person who is frequently exposed to challenging situations would thus benefit greatly from developing higher overall resilience. 16 Seligman (2003) believes that higher psychological well-being serve to buffer against misfortune and stress during high challenges and that they may be the key to building resilience. Developing higher overall resilience therefore becomes a matter of improving general psychological well-being. General psychological well-being refers to the degree of psychological health of a person and not merely to the absence of disease and infirmity. The theory is that the more psychologically healthy the person is, the bigger the buffer and therefore resilience against stress. Many models of psychological well-being and the enhancement thereof exist, but the core questions are: what makes life worth living?, and what is the good life? Unfortunately all the models and aspects of psychological well-being can not be discussed here, but readers are welcome to contact the author of this paper, should they require more information. Only one model of psychological well-being will be discussed here, and one other aspect of psychological well-being will be discussed. Ryff and Keyes (1995) developed a model of psychological well-being wherein they identified six aspects of psychological well-being that may be improved to increase general psychological well-being. The six aspects are as follows: AUTONOMY Low High Is concerned about the expectations and evaluations of others; Is self-determining and independent; able to resist social conforms to social pressures to think and act in certain ways; pressures to think and act in certain ways; regulates behaviour relies on judgements of others to make important decisions. from within; evaluates self by personal standards. ENVIRONMENTAL MASTERY Low High Has difficulty managing everyday affairs; feels unable to change Has a sense of mastery and competence in managing the or improve surrounding context; is unaware of surrounding environment; controls complex array of external activities; makes opportunities; lacks sense of control over external world effective use of surrounding opportunities; able to choose or create contexts suitable to personal needs and values. 17 PERSONAL GROWTH Low High Has a sense of personal stagnation; lacks sense of improvement Has a feeling of continued development; sees self as growing and or expansion over time; feels bored and uninterested with life; expanding; is open to new experiences; has sense of realising feels unable to develop new attitudes or behaviours one’s potential; sees improvement in self and behaviour over time; is changing in ways that reflect more self knowledge and effectiveness. POSITIVE RELATIONS WITH OTHERS Low High Has few close, trusting relationships with others; finds it difficult Has warm, satisfying, trusting relationships with others; is to be warm, open, and concerned about others; is isolated and concerned about the welfare of others; capable of strong frustrated in interpersonal relationships; not willing to make empathy, affection, and intimacy; understands give and take of compromise to sustain important ties with others. human relationships. SELF-ACCEPTANCE Low High Feels dissatisfied with self; is disappointed with what has Possesses a positive attitude toward the self; acknowledges and occurred in past life; is troubled about certain personal qualities; accepts multiple aspects of self, including good and bad qualities; wishes to be different than one is. feels positive about past life. PURPOSE IN LIFE Low High Lacks a sense of meaning in life; has few goals or aims; lacks Has goals in life and a sense of directedness; feels there is sense of direction; does not see purpose of past life; has no meaning to present and past life; holds believes that give life outlook or believe that give life meaning. purpose; has aims and objectives for living. These six aspects of psychological well-being may be improved by purposefully paying attention to aspects that the person wants to improve. Purpose in life can often be improved within religious or spiritual contexts. People who want to improve their sense of purpose in life can therefore benefit from discussions with their spiritual or religious leaders. A psychologist can also do well-being psychotherapy. Assessment of these aspects can be done with the well-being scales developed by Ryff and Keys (1995). Another aspect of psychological well-being that may influence the frequency and intensity of the stress response is hope. Hope has been associated with many indices of constructive coping, especially problem-focused coping. Snyder et al. (1991) argues that hope is a cognitive set that is based on reciprocally derived sense of successful “agency” 18 (goal-directed determination) and “pathways” (planning of ways to meet goals). A person with hope would therefore expect positive outcomes in new challenges (resulting in less stress about the challenge) based on their previous experience of themselves as being goal-directed and determined and being able to find ways in which to reach their goals. People who function in a challenging environment could therefore aim to improve their level of hope to reduce their levels of stress. One’s current level of hope can be assessed with the Hope Scale (Snyder et al., 1991) (Appendix B). Hope can be further developed by increasing one’s experience of “agency” and “pathways”. This is managed by following a problem-focused approach to dealing with challenges as described above (see 3.3. problem-focussed coping). Lopez et al. (2000) suggests that hope can be increased through goal development and developed a questionnaire to assist with goal development. This questionnaire may be used to improve goal development to increase hope (Appendix C). 4.4.3. Healthy Living The last positive aspect that will be discussed is healthy living. A person who lives a healthy lifestyle is less likely to experience the stress response, and will be physically and mentally more able to cope with the stress response. There are five aspects of a healthy lifestyle that a person can pay attention to in order to improve their resistance against stress. They are as follows: 1) Sleep: Establish a routine of going to bed at the same time every night and waking up at the same time every morning. Get at least 8 hours of sleep per night. Do not use the bed and bedroom for to many other activities like reading or watching television. An association between going to bed and sleeping should be established. 2) Eating: Following a healthy diet helps the body produce the energy to face challenges and to cope better with the stress response. Again, developing a routine of taking at least three meals a day would be beneficial. 19 3) Exercise: Moderate exercise helps to build the immune system, improve blood flow, provides energy and helps the body to restore more easily from the stress response. 4) Exposure to the sun: Limited exposure to sunlight (about ten minutes a day) promotes the production of serotonin in the body, which helps to regulate mood, anxiety and stress. 5) Lifestyle: Paying attention to living a less stress seeking lifestyle, is as said before, an important part of stress management. 4.5. Negative aspects 4.5.1. Adrenalin addiction The body secretes adrenalin as part of the stress response to ready the person to fight or flee (see 2.4. the psycho-emotional and physiological stress response). Adrenalin however also stimulates the “reward centre” (also known as the pleasure centre) in the brain. This is the same pathway used by other stimulants such as cocaine. It is therefore not surprising that a person could become addicted to the high that adrenalin gives. This leads people to seek out stress, or to create unnecessary stress about minor challenges to establish a surge of adrenalin. It is therefore a good sign that this process might be at work if somebody runs from the one “crisis” to the next. Intervention of this process would almost be the same as with other addictions. The person needs to identify that this is happening and needs to commit to change the pattern. Then they would have to make behavioural changes, remembering that they might feel irritated due to withdrawal and be tempted frequently to restart with the same pattern. The relaxation techniques discussed above can also be used positively in this regard (Hart, 2001). 4.5.2. Depression Depression can influence the process of stress in two ways. Firstly, a person who suffers from depression may use stress to self-medicate their depression. As discussed above, adrenalin also influences the pleasure centre of the brain, which means that a person might feel better when they have a surge of adrenalin (Hart, 2001). Nor-adrenalin, 20 adrenalin and serotonin (which is converted from nor-adrenalin) are also important biochemicals in the process of depression. Too low levels of serotonin and nor-adrenalin are often associated with depression. The person thus attempts to raise their levels of serotonin by seeking stress. The second way that depression influences the stress response is at the appraisal phase. Depression influences the way people think about themselves and the world, leading to more frequent appraisals of challenges as threatening and therefore stressful. Low selfworth, for example is one of the symptoms of depression. If someone has low-self worth, they could become severely stressed because they believe that they or their actions or their performance is not good enough and that they have failed (even when they did not) and will be rejected. Intervention of depression should ideally be done through working with a professional psychologist or psychiatrist. Treatment usually includes a combination of medicinal treatment and psychotherapeutic treatment. Some signs of depression that may assist the reader in recognising depression are given hereunder. These symptoms may be especially prevalent after a period of high stress or while the person is not concealing or selfmedicating the symptoms with stress. - Depressed mood - Loss of interest in usual activities - Lack of pleasure - Suicidal ideation - Diminished libido - Anticipating the worst - Worry - Poor concentration - Irritability - Hypervigilance (overly cautious and aware) - Crying - Unsatisfying sleep, insomnia or hypersomnia - Guilt - Fatigue - Poor memory - Sense of worthlessness - Hopelessness - Poor appetite or overeating - Loss of energy - Psychomotor agitation or retardation - Anxiety - Somatic complaints (Barlow & Durand, 1995) 21 4.5.3. Psychological disorders Other psychological disorders may also contribute to somebody experiencing high levels of stress. In personality disorders, for example the Paranoid Personality Disorder, neuroticism is one of the most prominent symptoms. This means that a person with this disorder experiences almost constant stress as all people they come into contact with are perceived as potentially threatening. A person with obsessive-compulsive disorder experiences constant and obsessive stress with regard to a specific issue, for example bacteria and germs. Usually the biggest indication of pathology is when a person’s reactions are grossly inappropriate or excessive to the situation. Psychological disorders however have to be diagnosed and treated by a medical professional. 5. PATHOLOGICAL STRESS Stress becomes pathological when the stress is chronic and severe to the extent that it causes significant functional impairment in an important area of the person’s life (e.g. work or interpersonal relationships); or when clinically significant distress is experienced. This usually happens when the person has been exposed to an event that is so severe that it is classified as a trauma, or when the person had been exposed to stressors for a prolonged period of time. At this stage self management has also become insufficient to deal with the stress response. Treatment of pathological stress usually involves a combination of pharmacological and psychotherapeutic treatment and is done by medical professionals. The symptoms of three examples of pathological stress will be listed hereunder to assist the reader in recognizing when stress becomes pathological. They are panic attack, acute stress disorder and posttraumatic stress disorder. Panic attack - A discrete period of intense fear or discomfort - Symptoms developed abruptly and reached a peak within 10 minutes - Four or more of the following symptoms were experienced: * Palpitations, pounding heart, or accelerated heart rate * Sweating * Trembling or shaking 22 * Sensations of shortness of breath or smothering * Feeling of choking * Chest pain or discomfort * Nausea or abdominal distress * Feeling dizzy, unsteady, light-headed, or faint * Derealisation (feelings of unreality) or depersonalisation (being detached from oneself). * Fear of losing control or going crazy * Fear of dying * Paresthesias (numbness or tingling sensations) * Chills or hot flushes (APA, 1994) Acute stress disorder and posttraumatic stress disorder - Exposure to a traumatic event in which the person experienced, witnessed, or was confronted with actual or threatened death or serious injury, or a threat to the physical integrity of self or others. - The person’s response involved intense fear, helplessness or horror. - With Acute stress disorder the person experienced three or more dissociative symptoms during or after the distressing event. Dissociative symptoms are a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of his or her surroundings (being in a daze); derealisation; depersonalisation; and dissociative amnesia (an inability to recall an important aspect of the trauma). - The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes or a sense of reliving the experience, or distress on exposure to reminders of the traumatic event. - Avoidance of stimuli that arouse recollections of the trauma for example thoughts, feelings or conversations associated with the trauma; and activities, places or people associated with the trauma. With Posttraumatic stress disorder other 23 symptoms of avoidance that may also be experienced are markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; restricted range of affect; and a sense of a foreshortened future. - Anxiety or increased arousal as evident in difficulty sleeping; irritability; poor concentration; hypervigilance; exaggerated startle response; and motor restlessness. - In Acute stress disorder symptoms last for a minimum of 2 days and a maximum of 4 weeks. In Posttraumatic stress disorder symptoms last for a minimum of 1 month. Symptoms may appear immediately after or long after the actual traumatic event. (APA, 1994) 6. CONCLUSION The aim of this paper was to discuss self-management under times of severe stress, or times of high challenges. This was done by first looking at the process of stress according to the steps of an integrated model of stress. Therein it was seen that stress is a psychoemotional and physiological response to an event that is appraised as a harm, threat or loss. Adaptation as final stage of the stress response was also discussed. Secondly, selfmanagement during the stress response was discussed from behavioural, emotional and problem-focused perspective. Therein it was seen that all three of these approaches play an important role in self-management during times of stress. Thirdly, factors that influence the process of stress were discussed where it became apparent how many different factors do influence the process of stress and how these factors can be used to reduce stress. Lastly, the signs of stress that has become pathological was discussed to enable the reader to recognise pathological stress. 24 REFERENCES American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders. 4th ed. (DSM-IV). Washington, DC: APA. Barlow, D.H. & Durand, M.V. (1995). 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