STRESS AND ILLNESS:

Every day we are confronted with problems. When we are confronted with a problem we must determine the seriousness of the problem and determine whether or not we have the resources (e.g., emotional resources) necessary in order to cope with it. If we believe that the problem is serious and we also believe that we do not have the resources necessary to cope with it, we will perceive ourselves as being under stress (Cohen et. al., 1995).

Defining Stress:
Stress can be defined as appraising environmental events as harmful, threatening, or challenging and responding to that appraisal with physiological, emotional, cognitive, and behavioral changes. (Taylor, Peplau, & Sears, 2006) Stress is any physical or psychological event perceived as potentially constituting physical harm or emotional distress. (Baron & Byrne, 2004) Stress can be defined as a process in which environmental demands strain an organisms adaptive capacity, resulting in both psychological as well as biological changes that could place a person at risk for illness. (Cohen et. al., 1995) Stress is a negative emotional experience accompanied by predictable physiological, biochemical, and behavioral changes that are designed to reduce or adapt to the stressor either by manipulating the situation to alter the stressor or by accommodating its effects (Baum, 1990).

What Is A Stressor?
Stimuli that cause us stress are called stressors (Rubin, Paplau, & Salovey, 1993). Many events can be thought of as stressors. These include disasters, life crises, life changes, and daily hassles (Rubin, Paplau, & Salovey, 1993). Examples of stressors include hurricanes, earthquakes, disease, divorce, unemployment, marriage, and traffic jams. Stressors are

things that interfere with an important personal goal (Rubin, Paplau & Salovey, 1993). The more important the goal is, the more stress a person will feel when that goal is threatened (Rubin, Paplau & Salovey, 1993).

Three Theories of Stress:

Stress affects everyone, young and old, rich and poor. Life is full of stress. There is work stress, school stress, financial stress, and emotional stress, to name a few. There are three theories or perspectives regarding stress. 1. The environmental stress perspective emphasizes assessment of environmental situations or experiences that are objectively related to substantial adaptive demands (Cohen et. al., 1995). 2. The psychological stress perspective emphasizes peoples subjective evaluations of their ability to cope with the demands presented to them by certain situations and experiences (Cohen et. al., 1995). 3. Finally, the biological stress perspective emphasizes the activation of certain physiological systems in the body that have been shown time and time again to be regulated by both psychologically and physically demanding conditions (Cohen et. al., 1995).

Individual Differences:
Despite some commonalities in the experience of stress, not everyone perceives the events as stressful. For example, one person may experience a job interview as threatening, whereas another may welcome it as a challenge. The fact that stress is, to some degree, in the eye of the beholder makes it clearly a psychological process. That is, events are stressful when they are regarded as stressful, and not otherwise (Lazarus & Folkman, 1984).

Given the same amount and intensity of stress, some people react more negatively than others and are thus more likely to become ill. Each of us falls somewhere along a dispositional continuum that ranges from disease-prone personality to self-healing personality. Disease-prone personality is characterized by negative emotional reactions to stress, ineffective coping strategies, and unhealthy behavior patterns. Among the correlates are a higher incidence of illness and a shorter life span. (Baron & Byrne, 2004) Self-healing personality is characterized by effective coping with stress. Self-healing individuals are energetic, responsive to others, and positive about life. For them, stress is unpleasant but it is perceived as something to be managed. (Baron & Byrne, 2004)

What Makes Events Stressful?

Some types of events are more likely than are others to be appraised as stressful. Any event (usually negative) that requires a person to adjust, make changes, or expend resources has the potential to be stressful. (Taylor, Peplau, & Sears, 2006) For example, although the December holidays are usually viewed as a positive event, they may also be highly stressful, because they can involve last-minute shopping, extensive travel, social occasions with relatives, excessive consumption of rich food, and little sleep. Following are some characteristics of events that can be more stressful: Unpleasant or negative events cause people more psychological distress and produce more physical symptoms than do more positive stressful events (e.g., Sarason, Johnson, & Siegel, 1978). Uncontrollable or unpredictable events are more likely to be stressful than controllable or predictable ones (Bandura, Cioffi, Taylor, & Brouillard, 1988). An uncontrollable

event that is unpredictable does not allow the person experiencing the stress to develop ways to cope with the problem. Ambiguous events are often perceived as more stressful than clear-cut events. Clear stressors enable people to find solutions and do not leave them stuck at the problemsolving stage (Billings & Moos, 1984). Unresolvable events are more stressful than those that can be resolved. The relationship between stressful experiences and adverse psychological responses, such as stress, physiological changes, and even illness, may be accounted for largely by stressful events that an individual has been unable to resolve (Holman & Silver, 1998).

Stress and Illness:

If the stress prolongs and the body is unable to cope with it, there is likely to be breakdown of bodily resources (Rubin, Paplau, & Salovey, 1993). Stressful life events are related to the risk of infected individuals developing an illness (Cohen et. al., 1998). Traumatic stressful events may trigger either behavioral or biological processes that contribute to the onset of disease. Long-term exposure to chronic stress may facilitate the development of illness during exposure to stress (Cohen et. al., 1995). Exposure to chronic stress may results in permanent or at the very least long-term psychological, biological, or behavioral responses that alter the progression of illness (Cohen et. al., 1995).

How Stress Can Cause Illness:

Stressful life experiences and the way people cope with those stressful events have an impact on health (Taylor, 2003). Stress is not necessarily a bad thing. A certain amount of stress is natural. However, chronic negative stress may be harmful to our health. The experience of stress is both physiological and psychological. Your body moves into a state of heightened arousal, your mouth goes dry, your heart beats faster, your hands may shake a little, and you may perspire more heavily. You have trouble concentrating on anything but the stressful event, which you replay in your mind over and over again (Holman & Silver, 1998). The experience of stress is a problem for people not only because it produces emotional distress and physiological strain, but also because over time it may lay the groundwork for illness (Taylor, 2003). Researchers now believe that over time, stress can wear down the body, making it more vulnerable to illness. Moreover, the effects of stress are longlasting, often continuing long after the stressor is over. Repeated exposure to stressful events and repeated subjection to the physiological changes that accompany stress (e.g., increase in blood pressure, blood sugar level, and respiration) exert wear-and-tear on physiological systems. This damage, in turn, may lay the groundwork for a variety of health problems, including heart disease, hypertension, and even cancer (e.g., Friedman & Rosenman, 1974; Jemmott & Locke, 1984). Baums View Baum (1994) proposes that direct and indirect effects of stress each lead to an increase in illness. The indirect effects occur when the negative emotional effects of stress interfere with health-related behaviors, such as eating a balanced diet or scheduling a physical examination.

The direct physical effects are somewhat more surprising in that stress delays the healing process in wounds, has a negative effect on the endocrine system, and interferes with the functioning of the immune system. As stress increases, anxiety and anger also increase (Martin et al., 1999), and these negative emotions bring about increased risk of illness, the malfunctioning of the immune system, pain, and even a greater possibility of dying (Suinn, 2001). Thomas Holmes View Thomas Holmes asserted that any and all change is stressful because it forces individuals to adapt to new, unfamiliar circumstances (Brehm & Kassin, 1993). Holmes acknowledged that some changes require more of an adjustment than other changes (Brehm & Kassin, 1993). Holmes believes that the change resulting from both positive (e.g., marriage, promotion, graduation) and negative (e.g., divorce, unemployment) life events are stressful and may possibly harm an individuals health (Brehm & Kassin, 1993).

How Have The Effects Of Stress Been Studied On Behavior And Health? 1. Major Stressful Life Events
The earliest research to demonstrate the relation of stress to health examined the role of major stressful life events in the onset of illness through the use of questionnaires that list a variety of potentially stressful events that require people to make changes in their lives, such as getting married or having ones spouse die. 2. Daily Hassles More recently, psychologists have begun to suspect that the more minor stressful events or the daily hassles of life may also have a cumulative and negative impact on health. Such

hassles include being stuck in a traffic jam, doing household chores, or having difficulty making a small decision. Interpersonal conflicts are by far the most distressing daily hassles (Bolger, DeLongis, Kessler, & Schilling, 1989). Although the research is not yet conclusive, it is possible that the cumulative effect of the small irritations of daily life as well as major, less common stressful events predict illness and psychological stress (Kohn, Lafreniere, & Gurevich, 1991). 3. Chronic Stress Increasingly, researchers are recognizing the importance of chronic stress in health. Living in a noisy, crowded, crime-filled environment not only is stressful day to day but also, over time, can have cumulative adverse effects on health. The well-known relationship between social class and mortality has been explained with reference to chronic stress (Taylor et al., 1997). The environments in which we live, and the resources we bring to them substantially influence our vulnerability to disease and even our life expectancy (Adler, Marmot, & McEwen, 1999).

Coping With Stressful Events:

Once we experience an event as stressful, we usually begin to make efforts to cope with that event. Coping refers to the process of managing internal or environmental demands that are appraised as taxing or exceeding ones resources. (Taylor, Peplau, & Sears, 2006) Coping refers to responding to stress in a way that reduces the threat and its effects; includes what a person does, feels, or thinks in order to master, tolerate, or decrease the negative effects of a stressful situation. (Baron & Byrne, 2004)

 Coping has been defined as the behavioral and cognitive efforts a person uses to manage the demands of a stressful situation. (Chang & Strunk, 1999) Coping As A Dynamic Process Coping with a stressful event is a dynamic process (Aspinwall & Taylor, 1997). It begins with the appraisals people make of the situations with which they must cope (Major, Richards, Cooper, Cozzarelli, & Zubeck, 1998). These appraisals are central to subsequent efforts to manage the stressful situation. Appraising a potentially stressful event as a challenge can lead to a confident coping, little sense of threat, and positive emotions, whereas assessing a potential stressor as threatening can lower confidence in ones coping abilities and increase negative emotions (Skinner & Brewer, 2002). Types Of Coping Efforts Generally researchers distinguish between two types of coping efforts (Lazarus & Folkman, 1984; Pearlin & Schooler, 1978): 1. Problem-solving efforts: are attempts to do something constructive to change the stressful circumstances; and 2. Efforts at emotional regulation: emotion-focused coping involves efforts to regulate or work through ones emotional reactions to the stressful event. These two types of coping can occur simultaneously. For example, when romantic partners break up, both people may try to cope by cheering themselves up and by taking steps to meet new people. Generally speaking, the ability to be flexible in the use of ones coping strategies is associated with more successful coping (Cheng, 2001).

Some further and more specific coping strategies have also been studied by psychologists including: Active coping methods; such as seeking information, planning, or attempting to get help from others. Active coping is used more often and is more adaptive to situations that are changeable. Emotion-focused coping methods; which include positive reinterpretation, acceptance, or turning to religion. These coping techniques may be more appropriate in situations that cannot be changed. Avoidant coping methods involve disengaging behaviorally or mentally from a stressful event, as through substance abuse or distancing. These coping strategies are maladaptive for health and mental health. Criterion For Successful Coping Coping efforts are judged to be successful by researchers based on the following criteria (Lazarus & Folkman, 1984): i. If they reduce psychological arousal and its indicators, such as heart rate, pulse, and skin conductivity; ii. Whether and how quickly people can return to their previous life activities which may be disrupted by stressful events; and iii. How effective coping strategies are in reducing psychological distress, such as anxiety and depression Sources Of Successful Coping Successful coping depends on a variety of coping resources. 1. Internal resources consist of coping styles and personality attributes.

2. External resources include money, time, social support, and other life events that may be occurring at the same time. All these factors interact with each other to determine coping processes (Taylor, 2003). A model of the coping process in presented below. 1. Internal Coping Resources I. Coping Style

Coping style is one internal coping resource. It consists of a general tendency for a person to deal with a stressful event in a particular way. However, in addition to stress, coping style is also related to the development of illness. i. Avoidance versus Confrontation Some people meet stressful events head-on and tackle problems directly, whereas other people avoid stressful events by minimizing their significance or withdrawing from them through alcohol, drugs, or television. People who cope by minimizing or avoiding stress appear to cope effectively with shortterm threats. However, if the threat is repeated or persist over time, avoidance may not be a successful strategy. Avoiders may be unable to deal with the possibility of future threat and may not make enough effort to anticipate and manage future problems (Taylor & Clark, 1986). They may also pay a price in the form of physiological activation and poor health (Smith, Ruiz, & Uchino, 2000). Approach coping or confrontation is when the person focuses on both the sources of the stress as well as the reactions to it (Chang & Strunk, 1999). Individuals who cope with threatening events through confrontation may deal effectively with long-term threats. In the short-run, however, they may be more anxious as they deal with the stressor directly (e.g., Miller

& Mangan, 1983). Generally speaking active coping is more effective than avoidant coping, which actually seems to make stressful situations worse. ii. Hostility Some coping styles used to deal with stressful events have an adverse effect on health. A pattern of hostile responses to stressful circumstances seems to be associated with the development of coronary artery disease. A particular type of hostility is especially implicated, namely, cynical hostility, characterized by suspiciousness, resentment, frequent anger, antagonism, and distrust of others (Williams & Barefoot, 1988). Individuals who have these negative beliefs about others are often highly verbally aggressive and exhibit controlling and subtly antagonistic behavior toward others. Interpersonal hostility may contribute to the development in coronary heart disease in several ways (Helmers et al., 1995). a) First, people who show this hostile response are more likely to have high levels of cardiovascular responses to stressful events, such as increased blood pressure and rapid heart rate. b) Second, such people may also take longer to recover from stressful episodes physiologically. c) Third, people who exhibit this pattern seem to derive fewer benefits from social support (Lepore, 1995). Consequently, they may be unable to extract the health benefit of social support that would otherwise be available. iii. Feeling in Control as a Way of Coping People cope better with a painful or threatening situation when they can exercise some sort of control over the situation (Rubin, Paplau, & Salovey, 1993). For example, suppose you

are overweight and your doctor tells you that it is because you have a genetic disorder. You have no control over your situation. This may be very stressful for you. However, suppose now that you are overweight but your doctor tells you that with diet and exercise you can lose the weight. This situation may be less stressful for you because you know that you can do something about your weight. Just knowing that you can control your weight makes the situation less stressful than if you were unable to control your weight. Even when you cannot control unpleasant events, they tend to be less stressful if they are predictable, that is if you know they are coming (Rubin, Peplau, & Salovey, 1993). So, knowing that traffic will be heavy on the freeway at 8:00 am is less stressful than when traffic is heavy at 3:00 am because you expect traffic to be heavy at 8:00 am but not at 3:00 am. iv. Optimism and Pessimism Coping Style Some people seem to believe that they can maintain control over stressful situations. These people are said to have an optimistic coping style (Rubin, Paplau, & Salovey, 1993). Other people have a pessimistic coping style, they view the world as an uncontrollable, unpredictable place in which they will never be able to gain control over things that bother them (Rubin, Paplau, & Salovey, 1993). v. Appraisal and Coping A key component to peoples reactions to stress is how they appraise or think about a potentially stressful situation (Rubin, Paplau, & Salovey, 1993). What may be stressful for one person may not be stressful for another person. For example, one person may see going to college as a stressful experience. He may be anxious about living away from home for the first time. He may be worried about making new friends and doing well in school. Another person

may see going to college as the beginning of a new, fun adventure. He may be excited about living away from home for the first time and making new friends. He may confident that he can do very well in school. Both of these people experience the same event (going to college), but for one person the event was stressful, while for the other it was not stressful. When faced with potential stressors (like going to college) we appraise the situation to determine if it is threatening to our well-being (Rubin, Paplau, & Salovey, 1993). If there is a threat, we need to evaluate the personal resources at our command in order to meet the demands of the situations (Rubin, Paplau, & Salovey, 1993). In other words, when faced with a stressful situation, we need to determine if we have the ability to cope or not.
Primary and Secondary Appraisals

There are two types of appraisals, primary and secondary: a) Primary appraisals refer to a set of cognitions regarding the importance of a stressful situation for a person (Chang & Strunk, 1999). b) Secondary appraisals are a set of cognitions concerning an individual's resources for dealing effectively with situation (Chang & Strunk, 1999). Both appraisals affect a person's ability to cope and adjust to stressful situations.
Reappraisal as a Way of Coping

In order to cope effectively, it usually helps to reappraise a situation as a challenge or an opportunity rather than as a threat (Rubin, Paplau, & Salovey, 1993). For example, suppose you are on your way to a very important interview and you get stuck in traffic. You might think to yourself that this is terrible, this is a very important interview. If you miss it you won't get the job and your life will be over. You should have left earlier. You should have checked the traffic report before you left. These types of appraisals are going to lead to stress.

On the other hand, suppose that instead of thinking the worst, you had a more positive attitude. You might decide that this interview really isn't that important. Its only one interview, if you miss it, there will be others. So what if you don't get this job, life will go on. You're going to be fine. If you appraise the situation this way, you're likely to feel a lot less stressed. vi. Repressive Coping Having a repressive coping style is also related to the development of illness. Events only influence people who appraise the events as stressful (Chang & Strunk, 1999). People with a repressive coping style neither experience nor express stressful events. They are less likely to report chronic stress and inadequacy of family and social support than those who do not have a repressive coping style (Jensen, 1987). Those with a repressive coping style consistently report good psychological reactivity to stress and greater health problems in some studies. Jensen (1987) examined the relationship between psychological factors and the course of breast cancer. The study found that repressive coping style was more likely to be seen among those who had a history of cancer and was most likely to be seen among those whose cancer was advanced. Repressive copers reported little distress or emotional complications. Yet, they have the worst outcomes for cancer among the groups studied. Eleven participants died from breast cancer, eight of which were repressive copers. II. Personality Attributes As Internal Coping Resources

Psychologists have identified several personality resources that people may bring to bear on a stressful event to improve psychological adjustment. i. Dispositional Optimism Dispositional optimism is a generalized positive belief that positive outcomes will occur in ones life. (Taylor, Peplau, & Sears, 2006)

Such optimism may enable people to appraise stressful events more positively and to mobilize their resources to take direct action in response to a stressor (Chang, 1998). Optimists may also show fewer adverse immune changes in response to stress than those who are less optimistic, as well as lower blood pressure. Optimism may buffer people against illness itself. ii. Conscientiousness Conscientious, socially dependable children are more likely to live longer into adulthood (Friedman et al., 1993, 1995a), whereas people with impulsive, under-controlled personalities are more likely to die young (Friedman et al., 1995b). Specifically, conscientious individuals are less likely to have accidents and to use unhealthful substances such as alcohol, tobacco, and drugs. Conscientious people may also take a more active, self-conscious approach to their health than those who lack these personal qualities. iii. Hardiness Hardiness is a set of attitudes that makes people stress-resistant. (Taylor, Peplau, & Sears, 2006) These attitudes include a sense of commitment, a positive response to challenge, and an internal sense of control. These beliefs are believed to buffer hardy people from the negative effects of coping with stress or change. People with a sense of personal control typically cope more successfully with stressful events, even stressful events that are largely uncontrollable (e.g., Helgeson, 1992). iv. Catharsis Pennebaker and his colleagues (e.g., Pennebaker, Colder, & Sharp, 1990) have suggested that catharsis, the process of disclosing emotional traumas, may have psychological benefits. In studies, where people are instructed to write or talk about the traumatic events that they have

gone through, beneficial long-term changes in psychological adjustment and immune functioning and fewer visits to health services have been found (King & Miner, 2000). v. Religion Religion also provides many people with strength and solace in dealing with stressful events (Blaine & Crocker, 1995). III. Problematic Internal Resources

Personality problems such as neuroticism lead people to appraise events as more stressful, to become more distressed by problems, and to react more strongly to them (Gunthert, Armeli, & Cohen, 1999; Suls, Green, & Hillis, 1998). In addition, neurotics report more physical symptoms, although, in some cases, they are not actually more ill (e.g., Feldman, Cohen, Doyle, Skoner, & Gwaltney, 1999). Neurotics also seem to experience more social conflict and react more strongly to it, a finding suggesting that they create gaps in social support that might otherwise have been available to help them combat effects of stressful events. 2. External Coping Resources: i. Social support

Recent work by health psychologists suggests that socially supportive relationships may mute the effects of stress, help people cope with stress, and enhance health. Social support can be defined as information from others that one is cared and valued. (Taylor, Peplau, & Sears, 2006) Social support may be provided in one of the several ways. a) First, emotional concern expressed through liking, love or empathy can be supportive.

For example, if you are going through an awkward breakup with a romantic partner, expressions of caring from friends can be very welcome. b) Second, instrumental aid, such as the provision of goods or services during stressful times, can be an act of social support. For example, if you are having difficulty getting to your classes on time because your car is unreliable, a friends offer to fix your car or to drive you to car would be supportive. c) Third, providing information about a stressful situation can be helpful. For example, if you feel poorly prepared for an exam and someone who took the course last year gives you information about the types of questions on the midterm and final, this information may be useful in helping you study. d) Finally, information may be supportive when it is relevant to self-appraisal, i.e., selfevaluation. For example, if you are uncertain whether you have made the right decision in breaking up with your romantic partner, information from your friends telling you that you did the right thing for the right reasons can be very comforting. Sources Of Social Support Social support can come from a spouse or partner, family members, friends, social or community contacts, fellow club members, from religious fellows, and coworkers or supervisors on the job (Buunk, Doosje, Jans, & Hopstaken, 1993). Effectiveness Of Social Support Social support effectively reduces psychological distress during stressful times (Broman, 1993). For example, it helps students cope with the stressors of college life (Lepore, 1995).

 Social support also appears to lower the likelihood of illness and to speed recovery from illness (House, Landis, & Umberson, 1988), ranging from common cold to heart disease. Social support from marriage reduces the likelihood that a person will engage in a risky lifestyle and increases the practice of good health behaviors, which are, in turn, associated with better health (Wickrama, Conger, & Lorenz, 1995). Social support has also been tied to: better immune functioning; reduced physiological responses to stress; more effective functioning in response to a variety of chronic disease Social support influences health habits and health behaviors. Social support may be most effective when it is invisible. When we are aware that other people are going out of their way to help us, we experience emotional costs, which mute the effectiveness of the social support we receive. But when social support occurs quietly, almost automatically, as a result of the relationships we have, it can reduce stress and promote health. Empirical Support Fukunishi et al. (1999) examined coping with stress, including social support, dealing with illness, and mood states among people not yet diagnosed as having glucose tolerance abnormality. They found that that poor utilization of social support was related to the onset of glucose tolerance abnormality. It seems that patients with glucose tolerance abnormality are unable to adequately utilize social support to cope with stress, even though they receive and perceive social support. Glynn, Christenfeld, and Gerin (1999) examined gender, social support, and cardiovascular responses to stress. Male and female participants gave a speech and received

either supportive or nonsupportive feedback form a male or female confederate. They found that social support from a female was more effective at lowering blood pressure responses to stress in both males and females than support from a male. Cohen et. al. (1997) conducted a study examining the relationship between diversity of social ties (having more than one type of social tie) and susceptibility to colds. They found that the rate of colds decreased with increased social diversity. In other words, the more diverse a person's social network was, the less likely that the person was to get a cold. Why might social networks protect people from the harmful effects of stress? One possible explanation lies in a person's ability to perceive stress. A person may not see a potentially harmful event as stressful if he believe that his social network will help him to cope (Cohen et. al., 1995). It is possible that having social ties reduces the amount of stress a person experiences and therefore, reduces his risk of infectious illness.

Stress Management:
Some individuals have difficulty coping with stressful events on their own. Stress management programs have been developed to help people deal with these events more effectively. Such programs train people in techniques that can be used to cope with a variety of stressful events, or they may focus on coping with a particular stressful event (Taylor, 2003). Most stress management programs include a wide array of techniques that an individual can use to combat stress. Some techniques will work better for some individuals while others will work better for other individuals. Some colleges and universities have instituted programs that involve teaching students stress management techniques to help them cope with the stressful events they may face in college, such as being away from home alone for the first time, high noise levels, difficult

academic schedules, etc. these programs consist of several phases. Generally the process is as follows: Phase 1: In the first phase, students learn what stress is and how it creates wear-and-tear on ones system. Students learn that stress is in the eye of the beholder and that college life is not inherently stressful but can become stressful depending on how a student perceives it. Phase 2: In the second phase, students are taught to observe their own behavior closely, and to record the circumstances that they find most stressful. They also typically record their physiological, emotional, and behavioral reactions to stressful events. They may also write down any efforts they make to cope with the stressful events, such as sleeping, eating, watching television, or using drugs or alcohol. Phase 3: Once they learn to chart these stressful responses, students in the third phase are then encouraged to examine what triggers those reactions. For example, a student may feel overwhelmed by academic life only when he must deal with speaking out in class or only when he thinks about having to use the computer in a particularly demanding course. By pinpointing the circumstances that initiate their feelings of stress, students can more clearly identify their own particular trouble spots. Phase 4: In the fourth phase, students are trained to recognize the negative self-talk they engage in while facing stressful events. For example, the student who fears speaking out in class may come to recognize how her self-statements contribute to the stress she feels (I hate asking questions and I always get tongue-tied). Such negative self-talk undermines feelings of self-efficacy and will become a target for modification later in the intervention.

Phase 5: Typically, in the fifth phase, students set specific goals for reducing the stress of college life. For example, the student mentioned above may set the goal as to learn to speak in class without experiencing overwhelming anxiety. Phase 6: Once the goals have been set, the students, in the sixth phase, identify some behaviors that can help them meet those goals. For example, the student who fears speaking out in class may decide that she will begin to raise her hand whenever she knows the answer to factual questions that require only a one- or two-word response. By beginning with relatively little speaking in class, she can train herself to give longer answers and ultimately to speak more effectively. Phase 7: With realistic goals set and target behaviors identified, the students will now learn in the seventh phase how to engage in positive self-talk. For example, the student desiring to overcome the fear of oral presentations might remind himself of the occasions when he has spoken successfully in public. Once he has achieved some success in speaking publicly, the same student might encourage himself by highlighting the positive aspects of the experience (e.g., holding the attention of audience or making some good points). As he becomes more effective, he might try to create opportunities to speak publicly and reward himself each time he does so by engaging in some desirable activity by, e.g., going to a movie. Typically, students also learn some ways of modifying the physiological reactions associated with stress. Usually these methods involve relaxation-training techniques and may include deep breathing, muscle relaxation, guided imagery, or meditation (English & Baker, 1983). Such methods can help reduce heart rate, muscle tension, and blood pressure.

If a student finds a task overwhelming, he or she might take a 5- to 10-minute break, breathe deeply and relax completely, and then return to the task freer of previous tension (Scheufele, 2000; Speca, Carlson, Goodey, & Angen, 2000).

SOCIAL PROBLEMS LINKED TO MENTAL ILLNESS IN PAKISTAN:

Mental health problems in Pakistan, a developing country, have in the last few decades reached an appalling level linked to both the current violence in Pakistani society and disruption in its social structure. Many researchers are agreed that the psychological outcome of the communities as a whole will be that of resilience rather than psychopathology. Nevertheless, a greater magnitude of exposure to traumatic events is known to be associated with the greater prevalence of severe mental health problems. This continuous violence and threat to life has had a damaging effect to the psychological health of many people in general and particularly in Pakistani society. Current Mental Health Issues In Pakistan Mental health in Pakistan has remained a subject of debate since the last few years. The incidence and prevalence have both increased tremendously in the background of growing insecurity, terrorism, economical problems, political uncertainty, unemployment and disruption of the social fabric. Common mental health problems have been identified in both the rural and urban population which seems to have a positive association with socio-economic adversities, relationship problems and lack of social support. Depressive and anxiety disorders appear to be highest followed by bipolar, schizophrenia, psychosomatic disorders, obsessive compulsive disorder and post-traumatic stress disorder. In addition, there is a serious problem of substance misuse and drug addiction. In Pakistan, relationship problems and financial difficulties are linked to anxiety and depression whereas the support of family and friends may protect against the development of these disorders. According to some researchers, Pakistans population has been exposed to

sociopolitical instability, economic uncertainty, violence and conflict for at least past three decades. These are the risk factors for developing psychiatric disorders and may help to explain the findings. Mental Health Care Services in Pakistan Mental health care needs to be incorporated as a core service in primary care and supported by specialist services. There is a strong need to provide adequate training for general practitioners and postgraduate training for mental health professionals to meet the current demands. A collaborative network between stakeholders in the public and private sector, as well as non-governmental organizations are required that promotes mental health care and advocates for changes in mental health policy of Pakistan.