SELYE'S CONCEPT OF A GENERAL ADAPTATION SYNDROME

Hans Selye (1907-1982) started the modern era of research into something called stress. In 1950, Selye addressed the American Psychological Association convention. He described a theory of stress-induced responses that become the standard model of stress, the one people usually refer to (or criticize) in academic journal articles about stress.
How did Selye discover the stress response?

Selye's discovery of the stress response was an accident. He was doing research on the effect of hormone injections in rats. Initially he thought he detected a harmful effect from the hormones, because many of the rats became sick after receiving the injections. But when Selye used a control group of rats, injected only with a neutral solution containing no hormones, he observed that they became sick, too. As it turned out, the rats responded more profoundly to the trauma of being injected than they did to the hormones. The experience of being handled and injected led to high levels of sympathetic nervous system arousal and eventually to health problems such as ulcers. Selye coined the term "stressor" to label a stimulus that had this effect.
What is a stressor for rats? For lab assistants?

The immediate response to stress is the release of adrenaline into the blood plasma (the liquid part of the bloodstream). "Mild stressors such as opening a cage door or handling a rat produces an eightfold increase in plasma epinephrine [adrenaline] concentrations" (Axelrod and Reisine, 1984). The sentence is ambiguous; does the rat or the human experience the eightfold increase in adrenaline? In this case, it is the rat which is having its adrenaline (plasma epinephrine) measured. However, many lab assistants probably experience a burst of adrenaline, too, when handling a rat for the first time.

What were the three stages of Selye's General Adaptation Syndrome?

Selye proposed a three-stage pattern of response to stress that he called the General Adaptation Syndrome (GAS) . He proposed that when the organism first encountered stress, in the form of novelty or threat, it responded with an alarm reaction. This is followed by a recovery or resistance stage during which the organism repairs itself and stores energy. If the stress-causing events continue, exhaustion sets in. This third stage is what became known popularly as burn-out. Classic symptoms of burn-out include loss of drive, emotional flatness, and (in humans) dulling of responsiveness to the needs of others.

COMMON STRESSORS
Each phase of life has its special stressors (stimuli which cause stress). In the college population, typical stressors are cramming for tests, worrying about friends or love relationships, or trying to work at a job while going to school. Pre-college adolescents rate events such as "divorce of parents" or "wrecking the family car" most stressful.
What are major stressors for college students? What is evidence that moving can be stressful? What did a psychologist recommend, to minimize this effect?

A common stressor for people of all ages is moving to a new location. Clinical psychologist Ronald Raymond, who worked for a relocation counseling firm, found evidence for great stress associated with moves. Of 2,000 people studied, only 30% did it without "anguish." Fear and a sense of isolation take over upon arrival at a new town, and this can paralyze people right when they should be making new friends. Fearing rejection, many rationalize that the new community is unfriendly (Brooks, 1983) Raymond found that the worst time, for people who move, is about two months after arriving at the new community. At that point the honeymoon period of excitement over new opportunities is over. Culture shock may set in. Unfamiliar streets, foods, and social rituals become disturbing. The best medicine,

Raymond says, is preventative. One should become involved with others in the new community immediately upon arrival, during the honeymoon period, when it is easiest.
What are some occupations have a reputation for being stressful?

Getting fired is notoriously stressful. (In Chapter 9 it was described as one of the few things, along with death of a spouse, that can put a lasting dip in a person's normal happiness level.) However, being employed is no guarantee against stress. Certain occupations are traditionally regarded as high-stress jobs. These include being an air-traffic controller, member of the police force, or an executive. The helping professions like social work, counseling, and clinical psychology are quite stressful and are associated with a high rate of burn-out. Professions where workers must constantly face deadlines, such as printing and publishing, are notorious for high alcoholism rates that presumably reflect stress. MacLennan and Maier (1983) emphasize that stress is increased by lack of control.
What factor increases stress, in laboratory studies?

We found that rats exposed to footshock became sensitized to both amphetamine and cocaine only if they cannot cope with or control the shock. (MacLennan and Maier, 1983, p.1091) This shows it is not the stressful stimulus (stressor) itself that causes stress: it is the inability to cope with the stressor that causes stress. Rats who were allowed to cope with footshock by running from one compartment to another, thus escaping it, suffered fewer negative effects than rats who were hooked to the same shock apparatus (receiving shocks at the same time) but could not control it through an escape response. Animal studies show the effects of stress on immune competence : the disease-fighting capability of the body.
How might stress increase chances of illness?

...Stress-induced increases in corticoid hormones produce secondary effects

involving T cells, B cells (bursa equivalent), NK (natural killer) cells, and thymic components, all vital elements of the immunological apparatus. (Riley, 1981, p.1101) In one study, Visintainer, Volpicelli and Seligman (1982) showed that rats given inescapable shock were less likely to reject tumors. Rats who were able to control the shock showed no such effect, even though they received as many jolts as the helpless group. So stress could even affect cancer risk. These were the types of studies that led to the discipline of psychoneuroimmunology, discussed earlier. However, as noted in that section, the exact nature of the interaction between experience and immune system functioning has been hard to pin down.

COGNITIVE EFFECTS OF STRESS

The excitation caused by stress makes complex and subtle thought processes more difficult. There is too much noise in the nervous system. This leads to phenomena such as "freezing" (being unable to think straight or remember important information) on an exam. Under stress, a person becomes more reactive and impulsive and more likely to do something that looks maladaptive (harmful, not constructive) to others. A psychologist gave the example of a friend who, after being fired, spent 10 hours a day playing pinball for two weeks.
What are negative effects of stress? What activities are performed well under stress?

One type of cognitive and motor activity can be performed well under stress: this is the type of activity psychologists call overlearned. Overlearned activities are things you have repeated so many times you could probably do them in your sleep. Most academic material is not overlearned...at least, not until you are a teacher and you have given the same lecture many times. The more superficially something is learned, the more likely it is to become unavailable to your memory in an emergency.
Why is it important to keep emergency procedures simple?

The tendency of people to perform simple activities better than complex activities, under stress, underlines the importance of keeping emergency procedures simple. In an emergency, people are under unusual degrees of stress. If they have to remember a complex procedure, they may fail entirely. The 911 system for getting emergency help over the phone, used in American cities, works well because people can remember to dial 911 even if they are panic-stricken. Stories of people freezing at the telephone because they cannot find "eleven" on the dial are untrue (Brunvand, 1974).
How does mild stress benefit students?

As mentioned in Chapter 6 (Memory) and Chapter 9 (Motivation) mild stress is a different matter altogether. A small amount of adrenaline-perhaps the amount stimulated by a caffeine drink or an impending testincreases the brain's ability to form new memories. Mild stress also makes actions of all kinds more likely. An impending deadline may suddenly unleash a student's ability to write a term paper, after weeks of procrastination. Severe stress can immobilize people, but mild stress usually has an activating effect. Prev page

EUSTRESS
What was Selye's concept of eustress?

What type of stressors produced harmful stress reactions?

Hans Selye originally defined stress as the body's response to challenges. He was dismayed by the implication that all challenging events in life were unhealthy and undesirable. Stress was not always bad, he pointed out. Sometimes a challenge is a good thing. Indeed, one could argue that nothing useful in life can be accomplished without some degree of stress. "Good stress," Selye pointed out, is "the spice of life." To

combat the notion that all stress was bad, Selye developed the idea of eustress, which is a person's ideal stress level. Selye proposed that different people needed different levels of challenge or stimulation (stress) in their lives. Some people ("turtles") need low levels of stress. Others ("racehorses") thrive on challenges. In the long run, the popular conception of stress as something bad proved to be more durable and accurate than Selye's notion of stress as a challenge to the system. In other words, the word stress continues to mean something bad (not something challenging) to most people. That seems to make the most sense, because psychologists found that only unpleasant stressors produced the harmful stress reaction identified by Selye (corticosteroid secretion). Challenges were not harmful in themselves. A person could be a busy executive or engage in strenuous exercise without experiencing negative stress-related symptoms, as long as the person enjoyed the challenge.

THE ROLE OF EMOTION IN STRESS

In Chapter 9 we described a conceptual leap advocated by Arnold Lazarus (1993) that greatly simplifies the interpretation of stress research. As a rule, challenging events are stressful only when accompanied by negative emotions. For example, when untamed rats are handled or injected, they no doubt experience the terror of being captured by a dangerous predator (a human) and their health suffers, as Selye documented. But a tame rat seeks handling by its owner and appears to enjoy it and it suffers no ill effects. In fact, handling tame animals appears to make them more healthy, not less (Nerem, Levesque, and Cornhill, 1980).
As a rule, what challenging events are stressful?

In Chapter 2 we discussed how situations that are painful can lead to the release of endorphins, opiate-like substances, into the bloodstream. However, not every painful event stimulates endorphins. A common laboratory procedure for creating pain under controlled conditionsdunking a volunteer's arm into a tub of ice waterdoes not stimulate the release of endorphins. This unexpected finding suggests that pain by itself is

not necessarily stressful. Subjects who dunk their arms into ice water know they are in a laboratory test that will be over soon. They may be intrigued by the test, and they are unlikely to feel negative emotions about it. So they do not experience stress. (A second implication of this finding is that stress, not pain, stimulates endorphins.) Similarly, in the MacLennan and Maier (1983) research described earlier, a footshock that the rat can turn off with an escape behavior does not produce the ill effects of stress. It just produces a rat successfully coping with a painful event. That is why rats who have control over their stressors do not suffer adverse health effects. However, a rat who is hooked to the same apparatus (a condition researchers call a yoked control) feels shocks that come at random times and cannot be controlled. That is no doubt distressing, and these rats experience ill health effects from the same number of shocks.
What did Lazarus argue, about stress and emotion?

It is because negative emotions are so important in defining stress that Lazarus wrote, "Stress should be a sub-topic of emotion." This has important implications for stress-reduction as well. Often the easiest way to reduce stress is to change one's interpretation or appraisal of an event, so negative emotions are replaced by neutral or positive emotions. The importance of appraisal was shown by a classic study, described by Lazarus (1993), in which subjects watching stress-inducing films. One film was about woodworking shop accidents and contained a scene in which a worker died after being impaled by a board kicked out of a large circular saw. Another scene showed a man getting his finger cut off. Subjects listened to recorded passages before viewing the film. One recording was an attempt to stimulate denial of the events in the film. The subjects were told, "The people in the film are not hurt or distressed by what is happening," or "These accidents didn't really happen but were staged for their effect."
How did researchers manipulate people's response to a potentially distressing film?

Another condition was intended to trigger a different defense mechanism, "intellectualization or distancing," in which events were not denied but they were interpreted in a rational, non-emotional way. In this condition, subjects heard a narrator say, "The accidents portrayed in this film provide the basis for instructions about how to avoid injuries in a woodworking shop." A third condition was intended to heighten the psychological stress. Subjects were told subjects in the film suffered pain or injury. A fourth group did not listen to any recording before viewing the film and served as a control group.
What was the "important point"?

As the researchers expected, the first two conditions lowered stress reactions, compared to the control group that viewed the film. The third condition raised levels of stress reactions. This simple demonstration made an important point. Stress is not an inevitable consequence of a particular stressful event. It depends to a great extent on how the event is interpreted or appraised.
How does this relate to the therapy ideas of Ellis?

Does this technique of changing appraisal merely advocate "happy talk" in place of realistic but sad emotions? Not if you examine the research example from Lazarus. The movie of shop accidents probably was created to train shop workers to avoid injuries. It is like seeing a wrecked car and being told, "This is what can happen if you drink and drive." It is also like admitting a mistake but vowing to learn from it, so you can get something good out of it. This is not happy talk; it is a realistic way to get something valuable out of a negative event. It is the opposite of catastrophizing and awfulizing in Albert Ellis's terms. As Ellis pointed out, those forms of self-talk or appraisal merely inflame negative emotions and make people stressed out and sick about what is happening to them. A more constructive (and less stressful) response to a bad situation is to appraise it realistically and try to learn from it.

STRESS REDUCTION
Stress management techniques fall into two categories. Category #1 is a set of techniques that promote relaxed or calm feelings, addressing the biological state of overarousal or exhaustion caused by stress. Category #2 is a set of techniques that treats stress by attempting to change a person's appraisal of the stress-causing situation.
What are two categories of stress reduction technique? How can sleep influence stress?

Category #1 includes the lowest-tech remedy: sleep. Stage 4 sleepthe type of deep sleep during which there is deep breathing, a slow steady heart rate, and little body movementincreases after stressful events and helps people recover from stress. Conversely, lack of sleep due to a sleep disorder such as apnea (periods of breathlessness) can mimic the effects of stress. Meditation is enthusiastically endorsed by some people as a stress-reducer. Relaxation training can have similar effects. Herbert Benson of the Harvard Medical School made a career out of promoting the relaxation response which is simply the ability to let go of muscle tension and stressful thoughts in a "physiological state of deep rest." People who learn to relax have reduced adrenaline levels when stressed, although their heart rate and blood pressure responses are similar to other people (Hoffman and colleagues, 1981). The reduction in adrenaline should reduce the health risk for people who learn to relax, because it is the adrenal response to an emergency that affects the immune and cardiac systems in negative ways, not the temporary changes in heart rate and blood pressure.
What are techniques for producing calm feelings?

Exercise can reduce stress. For many people, the aftereffect of exercise is a satisfied feeling, followed by a good sleep at night. Different forms of exercise can have this effect. Weightlifting, although it activates anaerobic muscle fibers different from those activated by jogging, has much the same stress-reducing effects as jogging.
How can loving interactions benefit people? Rabbits?

Loving interactions reduce stress. Relaxed, friendly conversations, hugs, or patting a puppy or kitten can reduce stress. When humans stroke animals, the humans may experience a drop in blood pressure. Animals also seem to benefit from this type of interaction. In one study, rabbits fed a high-cholesterol diet did not develop atherosclerosis (fat in the arteries, which can lead to heart disease) if they were petted and handled every day by the same person (Nerem, Levesque, and Cornhill, 1980). A control group given the same diet developed serious heart disease.

COGNITIVE RESTRUCTURING
The second major category of stress reducing techniques is more cognitive in nature. We have already encountered it a few pages back in the research of Lazarus (1993). This approach involves changing the negative emotions that produce a stressful event. Reinterpreting an event is called cognitive restructuring or reframing.
What useful insight is cited, erroneously, over a million times on the web?

For example, almost any unexpected set-back can be construed as an opportunity rather than a catastrophe. (This is like the often cited "fact" that the Chinese character for crisis contains the character for opportunity. This turns out to be an error, based on a misunderstanding of the Chinese characters. However, the insight is so useful that it is cited over a million times on the web.) Reframing a set-back as an opportunity may open the door to constructive decision-making while simultaneously reducing negative emotions and stress. As Albert Ellis might say, we are not kings and queens of the universe, and we cannot automatically change every negative situation to be neutral or positive. "Reality often stinks." But often a re-appraisal is simultaneously more realistic (most teachers are not, in fact, intentionally trying to do students harm) and stress-reducing (once a student realizes the teacher is not out to do harm, a difficult class may seem challenging but not so stressful). Ideally, changing an emotional script means coming up with a more accurate version of reality that also does not trigger harmful stress reactions.

How can the "anger script" be changed?

Suggesting ways in which a script might be re-written does not take long, so this type of counseling can be accomplished in brief therapy. Consider Bloom's recommendations concerning brief therapies in Chapter 13. He said the goal is to identify a focal problem quickly and offer an interpretation that expands a patient's awareness with the goal of starting a problem-solving sequence. This was done in a two-hour session.
What is the "anxiety script"?

Suppose a student is anxious about doing poorly in school. In a two-hour session, one might essentially re-write the anxiety script. The script for anxiety involves (1) an event in the future (such as being expelled from school) and (2) a threat to one's wellbeing (such as "my parents are going to kill me"). We might borrow Ellis's technique of disputing irrational ideas and challenge that statement, because the parents are not really going to kill the student, one would hope. Then one might attempt to re-write the "anxiety" script into a "hope" script by giving a different scenario of future events.
How might this technique be used with a student in danger of flunking out?

How is an anxiety script converted into a hope script? To stay faithful to the principles outlined above, the re-appraisal must be accurate but also a new, less negative perspective. One might point out, for example, that all those older, so-called nontraditional students on campus (who are usually excellent students and a delight to professors) must come from somewhere. Obviously they are people who never completed college at an earlier age. So it is not a life-ending tragedy if one is expelled for low grades. It is a chance to re-assess one's plans, maybe enter a different type of school such as a technical school instead of a university, or perhaps just to do a little growing up before coming back to complete a degree as a slightly older person. In truth, if you are performing at a marginal level, leaving school may be one of the best things that could happen to you. It may prevent you from wasting your one opportunity in life to get an undergraduate education (because nobody does it twice). Instead of sliding through with Cs and Ds as

an 18 or 19 year old, you can come back and get As and Bs as an older, more mature person.
What is the hoped-for effect of rewriting an anxiety script into a hope script?

As a form of therapy with a student who is distressed about flunking out, this is more than just wishful thinking (although it might be for some people, if they never return to school). It is a plan for the future that offers hope of a positive outcome. It is also more accurate than thinking, "If I flunk out, my parents will kill me." So it is an attempt to do what Bloom recommended: offer a new perspective to a person in distress and help the person start thinking about future goals and problem solving. That, in turn, might relieve some anxiety at the end of a disastrous school term.

HOW THERAPY MIGHT CHANGE THE BRAIN

As researcher Richard Davidson said in 1999, there are two main circuits involved in emotional response. One is the anxiety and avoidance circuit, centered in the amygdalar region of the right hemisphere. The other is the optimistic, future-planning circuit, centered in the prefrontal cortex of the left hemisphere.
What changes in the brain might result from therapy?

If we take this literally, then Bloom's brief therapy strategyor Lazarus's tactic of re-writing the scripts of negative emotions (previous page)could be construed as an attempt to switch a troubled person's type of processing from one type to another: from worried, anxious processing to optimistic, planning processing. Such a change might even be visible on a brain scan. It would show up as a shift of activity from the right amygdalar region to the left frontal region or, judging from research in the 2000s (summarized below) it could show up in the synchronization of activity between the two areas, as the left frontal area regains control over the amygdala.
What is area 25 in the brain?

Within a few years of Davidson's hopeful speculations, neuroimaging research confirmed this

basic idea. Patients with depressive disorders showed abnormalities in the anterior cingulate gyrus of the left frontal lobe, a brain area the experts call area 25. This happens to be the same area Posner pointed out as crucial to comprehensive forward planning and executive control in Chapter 2. Area 25 is dependent upon serotonin, the same neurotransmitter boosted by anti-depressant drugs called serotonin-reuptake inhibitors (SRIs) such as Prozac, Luvox, Paxil, and their relatives. The obvious implication is that, if you boost activity in area 25, a depressed person may regain some executive control and ability to make rational plans. This may be the main mechanism of action for antidepressants. Adding to the big picture, people who inherit an allele (genetic locus) that reduces the volume of area 25 have increased risk of major depression, and their brains show reduced coupling of this area to the amygdala. So they have less executive control over the anxiety and avoidance-producing brain center, the amygdala. The plot thickens! The next logical step, taken in 2005 research, was to stimulate area 25 electrically. This relieved the symptoms of depression in people with a major depressive disorder. Apparently, boosting the activity in area 25 re-establishes some executive control over the worry center in the amygdala.
How does neuroimaging research support cognitive restructuring therapy?

This flurry of related, convergent research (reported in Insel, 2007) shows that the "tractability of emotion to neuroscience" anticipated by Davidson is coming true. The results of complex neuroimaging research are dovetailing with the results of therapy experience. A boost to rational thinking and executive planning (whether achieved by antidepressants, brain stimulation, or cognitive restructuring therapy) can establish control over worries and anxieties that might otherwise govern behavior and emotions.

ADDICTION
The concept of addictive behavior covers much more than drug addiction. Psychologists now realize there is a common pattern underlying alcoholism, gambling,

compulsive overeating, drug addiction, sexual promiscuity, and many other problems. Each involves a repeated behavior that is ultimately damaging to the individual but pleasurable in the short run. Such behaviors can easily derail important long-term plans. Addictions can become the dominant focus of an individual's life, leading to neglect or sacrifice of other important concerns.
What is the common pattern of harmful addictive behavior?

In modern psychology, the concept of addictive behavior is also being applied to positive, constructive behaviors. Love, exercise, parachute jumping, sauna bathing, giving blood, fire fighting, providing emergency medical aid, important executive decision-makingall have been portrayed as addictions. All could be part of a happy, well-adjusted life.
How have conceptions of addiction changed?

In the old days, negative moral judgments were mingled with scientific description. Only negative or harmful addictions were recognized. Addicts were portrayed as running away from something, not toward something. In more modern conceptions, addicts are portrayed as seeking pleasure, not avoiding pain. Such an approach leads to moral ambiguity, in some cases. However, that may actually be beneficial to critical thinking (and it certainly corresponds to William James's advice to "consider the alternative" when confronting controversial issues). Two examples involve computers and the internet.
What was an early warning about internet addiction? What happened instead?

In the late 1990s, when the internet was still fairly new, some psychologists published a study showing that increased internet use led to increased social isolation. Many articles in popular magazines warned against "internet addiction," which was defined as spending hours every day on the weba strange-seeming behavior at the time. Wellintentioned pundits warned of a generation of social outcasts, lost in the dim glow of computer monitors, cut off from social contact.

If you are a properly educated critical thinker, this should immediately raise your suspicion, because it is a correlation being reported as a cause-effect link. Perhaps people using the internet a lot, in those days, were fleeing from bad social situations, or perhaps they were immersed in cutting-edge technologies to the point where they had litle time for social contacts. Or perhaps the correlation was spurious, a temporary statistical association that could disappear. As it happened, the correlation did disappear. By the mid-2000s (around the same time instant messaging became popular and social networking sites like facebook.com and myspace.com became widely known) the correlation between increased internet use and feelings of social isolation was no longer found. To the contrary, internet users started to report a feeling of increased social connection due in part to their discovery of online communities of individuals with similar interests.
What does research show about video gaming in children?

Another false alarm, apparently, is the worry over video game addiction in children. Yes, there was a student in Korea who died after days of uninterrupted gaming, but research in the mid 2000s suggests video gaming can actually have positive effects on motor coordination, mental quickness, and academic achievement (not to mention computer literacy) of school-age children. The terrible long-term effects of video game addiction have not appeared. In the meantime, the horror of a previous generationtelevision addictionhas became mysteriously less problematic. The moral of the story, perhaps, is that any new social trend will inspire alarmist reporting. Any upward trend in the frequency of a questionable (or simply unfamiliar) behavior will be projected into the future, the word addiction will be applied to it, and pundits will suggest that it might lead to disaster. But with the exception of a few drug addictions and perhaps gambling addiction, the warnings often prove to be exaggerated.

SOLOMON'S "OPPONENT PROCESS" THEORY

Common patterns underlie all addiction, indeed all hedonic or pleasure-seeking behavior. These patterns are described in Richard Solomon's opponent process theory of acquired motives. (Note that "acquired motives" could be a polite euphemism for "addictions.") We discussed Solomon's theory initially in Chapter 9, in the context of pleasure and pain as motivating forces. Here we elaborate on its relevance to addiction.
How are the A and B components different, in Solomon's theory?

Solomon discovered two components in every reaction to an emotional situation. The first component he called the A reaction. It is short-lived and intense. For example, while receiving an award, you may feel great joy at the moment when you are handed your medal or certificate. This response probably correlates with neural activity in the brain; it is quick and almost simultaneous with experience of the emotion-causing stimulus. The B reaction is opposite from the A component in hedonic value. In other words, if the A reaction is a happy emotion, the B reaction is sad, and vice versa. The B response is slower to build and slower to decay. An hour after getting an award, you may feel a bit let down, but the feeling gradually disappears toward the end of the day. Sometimes a B reaction can be rapid. Solomon points out that a small child who is in a good mood can be put into a bad mood by giving the child a lollipop then taking it away. Instead of returning to a neutral emotional state, the child reacts to sudden reinforcement, then removal of the reinforcer, by crying. That reaction is immediate. However, most of the time, a B reaction is slower. The slower B reaction is probably hormonal, involving chemical messengers that move in the bloodstream. An hour after a moment of great excitement, the body's response might be, "You've been under a lot of stress; time to get away from it all, rest, and recuperate."

The B response occurs with both pleasure and pain. Both lead to rebound reactions which Solomon called hedonic contrast. Feelings of joy are often followed by a let-down or irritability, a few hours later. Feelings of tension and anger may be followed by a more happy or mellow period. (See the examples in Chapter 9.)
What happens as an event is repeated?

They key to Solomon's theory of addiction is that as an event is repeated the B component becomes larger while the A component becomes smaller. The result, sometimes, is a complete reversal of emotion. An event that was initially fun becomes boring, or an event that was initially terrifying becomes fun. Solomon uses the example of parachute jumping. A beginning parachutist feels a primary emotional response of fear at the prospect of jumping out of a plane. This is the A response: the quick, intense response to a situation. After making the jump, landing on the ground, and returning to the clubhouse, the beginner is typically talkative and excited, as if very happy. This is the B response, a rebound reaction to the earlier fear and a feeling of exhilaration at having conquered it. During their first free-fall, before the parachute opens, military parachutists may experience terror: They may yell, pupils dilated, eyes bulging, bodies curled forward and stiff, heart racing and breathing irregular. After they land safely, they may walk around with a stunned and stony-faced expression for a few minutes, and then usually they smile, chatter, and gesticulate, being very socially active and appearing to be elated. (Solomon, 1980, p.693) The A process (anxiety) diminishes as the jump is repeated and is increasingly regarded as a normal event. Meanwhile, the B response grows bigger. In the case of parachute jumping, the pleasant aftereffects grow more pronounced. An experienced jumper may experience a high lasting eight hours after a jump.

What is tolerance?

Eventually the body adjusts and no longer reacts strongly to the formerly emotional experience. A person requires a bigger dose or more extreme stimulus to get the same effect. For example, a gambler requires a bigger bet to get the same high feeling he once got with a small bet. A heroin addict requires larger doses of the drug. The parachute jumper gets bored with ordinary jumping. This is called tolerance. When tolerance builds up, the excitement of the addiction starts to disappear. It becomes routine. The addict may still enjoy the addicting event, yet at the same time it is no longer such a big deal. The thrill is gone.
How does Solomon's theory explain common phenomena of drug addiction?

Drug addiction phenomena can be explained with the opponent process theory. First an addictive event causes a large A reaction, for example, great feelings of joy, with possibly a mild depression as an aftereffect. (This is sometimes called the honeymoon period in an addiction.) But after repeated experiences, the joy is greatly reduced. Tolerance occurs; the body adjusts to the drug. The B reaction becomes stronger. In this case, that means the negative aftereffects of taking the drug, such as bad moods or craving, become stronger. Soon the addictive stimulus is badly needed, because the withdrawal period is intensely unpleasant, yet the drug experience itself is nothing special. That is the end of the honeymoon. This does not always happen, so when does it not happen? When does the fun not go out of an activity? The short answer appears to be: When the "A reaction" (the immediate reaction to something) is not strong enough, or repeated often enough, to cause tolerance. Moderate drinking (defined as the equivalent of a glass or wine, a beer, or a shot of liquor per day) does not cause tolerance. A person does not cease to feel it because of the body's adaptation. It also does not "get old." People who are in the habit of drinking a glass of wine for dinner do not get bored with it or find that it no long produces a kick. In a sense, there is no "kick" in the first place, if that word is defined as pushing the hedonic control system to an extreme. There is no

strong B reaction, either. A person who has a glass of wine for dinner does not get a hangover or feel sluggish the next day because of it. Similarly, a couple with an established frequency of sex that is satisfactory to both parties does not become bored with that activity. They recover their appetite between encounters, and (research shows) sexual frequency stays about the same in happy couples from middle age to old age. However, a young and infatuated couple may indeed tire of each other. Pam, Plutchik and Conte (1975) found a negative correlation between intensity of love feelings and the likelihood a young couple would still be together, six months later. Maybe the ancient Greeks had the right idea with the famous allpurpose advice: moderation in all things.
What important paradox is explained by Solomon's theory?

Solomon's theory explains an important paradox about addictions. Greatest dependence (need for the drug) occurs after tolerance becomes strong, because the B reaction (which causes craving) increases in size at the same time the A reaction (which produces the thrill) is disappearing. Consequently, an addiction may be most powerful when the addictive behavior is no longer thrilling. Hardcore heroin addicts testify that they need the drug just to feel normal. Yet it is they who have the hardest time quitting. Stanton Peele wrote Love and Addiction (1976) to explain why people stay in bad relationships despite misery. He described a combination of tolerance and dependence much like drug addiction. The analog to tolerance is the mutual boredom and lack of excitement that occurs in so many relationships, after the initial thrill of love wears off. In an effort to recapture the intense pleasures of the early honeymoon phase, dosages of the relationship may be increased. The couple may spend all their time together. They may find each other's company increasingly unsatisfying, but they cannot quit. They may start fighting all the time, but if they try to break up, they experience craving, miss each other, and get back together.
What pattern did Peele point out in Love and Addiction?

Luckily this destructive cycle is not inevitable. Better alternatives for love relationships are discussed in Chapter 16. The opponent-process theory also helps explain why people can learn to enjoy some peculiar things. The appeal of monster movies and horror movies is an example. Horror movies are shocking at first, but after a while the shock is not so unpleasant and the aftereffect becomes more pleasant. Emergency Medical Service technicians can become addicted to the excitement of emergency runs, and some firemen admit to enjoying big fires. In each case, an event which is initially horrifying or traumatic comes to produce a B reaction which is enjoyable, even addictive.
How does the opponent process theory explain enjoyment of horror movies? Giving blood? Fighting fires?

The act of giving blood can be addicting. It is a classic example of opponent processes at work. Before giving blood, first-time donors described their feelings as "uptight, skeptical, suspicious, angry, and jittery." After the donation, they felt "relaxed, playful, carefree, kindly, and warmhearted." The more times a person gives blood, the less pronounced are the negative effects and the more pronounced are the positive aftereffects. "They unconsciously acquire a positive response to blood donation" (Brittain, 1983). http://www.psywww.com/intropsych/ch14_frontiers/helpful_addictions.html A Pragmatic View of Jean Watsons Caring Theory Chantal Cara, Ph.D., RN Universit de Montral Faculty of Nursing Goals Provide an overview of Dr. Jean Watsons caring theory to the nursing community. Facilitate the understanding of her work allowing nurses to readily apply this knowledge within their practice. Objectives Describe the general aspects of Watsons caring theory. Describe how Watsons caring theory can be applied to clinical practice. Describe the person through Watsons caring lens. Describe the persons health through Watsons caring lens. Describe nursing through Watsons caring lens.

Key Words: Watsons caring theory, clinical caritas processes, transpersonal caring relationships, caring occasion, clinical application of Watsons theory Abstract As most health care systems around the world are undergoing major administrative restructuring, we expose ourselves to the risk of dehumanizing patient care. If we are to consider caring as the core of nursing, nurses will have to make a conscious effort to preserve human caring within their clinical, administrative, educational, and/or research practice. Caring must not be allowed to simply wither away from our heritage. To help preserve this heritage, caring theories such as those from Jean Watson, Madeleine Leininger, Simone Roach, and Anne Boykin are vital. Through this continuing education paper we will learn the essential elements of Watsons caring theory and explore an example of a clinical application of her work. Introduction The changes in the health care delivery systems around the world have intensified nurses responsibilities and workloads. Nurses must now deal with patients increased acuity and complexity in regard to their health care situation. Despite such hardships, nurses must find ways to preserve their caring practice and Jean Watsons caring theory can be seen as indispensable to this goal. Through this pragmatic continuing education paper, we will explore the essential elements of Watsons caring theory and, in a clinical application, illustrate how it can be applied in a practice setting. Being informed by Watsons caring theory allows us to return to our deep professional roots and values; it represents the archetype of an ideal nurse. Caring endorses our professional identity within a context where humanistic values are constantly questioned and challenged (Duquette & Cara, 2000). Upholding these caring values in our daily practice helps transcend the nurse from a state where nursing is perceived as just a job, to that of a gratifying profession. Upholding Watsons caring theory not only allows the nurse to practice the art of caring, to provide compassion to ease patients and families suffering, and to promote their healing and dignity but it can also contribute to expand the nurses own actualization. In fact, Watson is one of the few nursing theorists who consider not only the cared-for but also the caregiver. Promoting and applying these caring values in our practice is not only essential to our own health, as nurses, but its significance is also fundamentally tributary to finding meaning in our work. For a more comprehensive, philosophical, or conceptual perspective pertaining to Watsons Caring Theory, the readers can refer to the original work (Watson, 1979, 1988a, 1988b, 1989, 1990a, 1990b, 1990c, 1990d, 1994, 1997a, 1997b, 1999, 2000, 2001, 2002a, 2002b, 2002c; Watson & Smith, 2002d), as well other sources, such as McGraw (2002). Overview of Watsons Caring Theory First, we begin with an introduction of Dr. Jean Watson. Dr. Watson is an American nursing scholar born in West Virginia and now living in Boulder, Colorado since 1962. From the University of Colorado, she earned her undergraduate degree in nursing and

psychology, her masters degree in psychiatric-mental health nursing, and continued to earn her Ph.D. in educational psychology and counseling. She is currently a Distinguished Professor of Nursing and the Murchinson-Scoville Chair in Caring Science at the University of Colorado, School of Nursing and is the founder of the Center for Human Caring in Colorado. Dr. Watson is a Fellow in the American Academy of Nursing and has received several national and international honors, and honorary doctoral degrees. She has published numerous works describing her philosophy and theory of human caring, which are studied by nurses in various parts of the world. The following is a summary of the fundamentals of the caring theory. According to Watson (2001), the major elements of her theory are (a) the carative factors, (b) the transpersonal caring relationship, and (c) the caring occasion/caring moment. These elements are described below, and will be exemplified in the clinical application that follows. Additionally, the reader may consult Table 1 and Table 2 for the theoretical values and assumptions. Carative Factors Developed in 1979, and revised in 1985 and 1988b, Watson views the carative factors as a guide for the core of nursing. She uses the term carative to contrast with conventional medicines curative factors. Her carative factors attempt to honor the human dimensions of nursings work and the inner life world and subjective experiences of the people we serve (Watson, 1997b, p. 50). In all, the carative factors are comprised of 10 elements: Humanistic-altruistic system of value. Faith-Hope. Sensitivity to self and others. Helping-trusting, human care relationship. Expressing positive and negative feelings. Creative problem-solving caring process. Transpersonal teaching-learning. Supportive, protective, and/or corrective mental, physical, societal, and spiritual environment. Human needs assistance. Existential-phenomenological-spiritual forces. (Watson, 1988b, p. 75) As she continued to evolve her theory, Watson introduced the concept of clinical caritas processes, which have now replaced her carative factors. The reader will be able to observe a greater spiritual dimension in these new processes. Watson (2001) explained that the word caritas originates from the Greek vocabulary, meaning to cherish and to give special loving attention. The following are Watsons (2001) translation of the carative factors into clinical caritas processes: Practice of loving kindness and equanimity within context of caring consciousness. Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and the one-being-cared-for. Cultivation of ones own spiritual practices and transpersonal self, going beyond ego self, opening to others with sensitivity and compassion. Developing and sustaining a helping-trusting, authentic caring relationship.

Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for. Creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices. Engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within others frames of reference. Creating healing environment at all levels (physical as well as non-physical), subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated. Assisting with basic needs, with an intentional caring consciousness, administering human care essentials, which potentiate alignment of mindbodyspirit, wholeness, and unity of being in all aspects of care; tending to both the embodied spirit and evolving spiritual emergence. Opening and attending to spiritual-mysterious and existential dimensions of ones own life-death; soul care for self and the one-being-cared-for. (Watson, 2001, p. 347) Transpersonal Caring Relationship For Watson (1999), the transpersonal caring relationship characterizes a special kind of human care relationship that depends on: The nurses moral commitment in protecting and enhancing human dignity as well as the deeper/higher self. The nurses caring consciousness communicated to preserve and honor the embodied spirit, therefore, not reducing the person to the moral status of an object. The nurses caring consciousness and connection having the potential to heal since experience, perception, and intentional connection are taking place. This relationship describes how the nurse goes beyond an objective assessment, showing concerns toward the persons subjective and deeper meaning regarding their own health care situation. The nurses caring consciousness becomes essential for the connection and understanding of the other persons perspective. This approach highlights the uniqueness of both the person and the nurse, and also the mutuality between the two individuals, which is fundamental to the relationship. As such, the one caring and the one cared-for, both connect in mutual search for meaning and wholeness, and perhaps for the spiritual transcendence of suffering (Watson, 2001). The term transpersonal means to go beyond ones own ego and the here and now, as it allows one to reach deeper spiritual connections in promoting the patients comfort and healing. Finally, the goal of a transpersonal caring relationship corresponds to protecting, enhancing, and preserving the persons dignity, humanity, wholeness, and inner harmony. Caring Occasion/Caring Moment According to Watson (1988b, 1999), a caring occasion is the moment (focal point in space and time) when the nurse and another person come together in such a way that an occasion for human caring is created. Both persons, with their unique phenomenal fields, have the possibility to come together in a human-to-human transaction. For Watson (1988b, 1999), a phenomenal field corresponds to the persons frame of reference or the totality of human experience consisting of feelings, bodily sensations, thoughts, spiritual beliefs, goals, expectations, environmental considerations, and meanings of ones

perceptionsall of which are based upon ones past life history, ones present moment, and ones imagined future. Not simply a goal for the cared-for, Watson (1999) insists that the nurse, i.e., the caregiver, also needs to be aware of her own consciousness and authentic presence of being in a caring moment with her patient. Moreover, both the one cared-for and the one caring can be influenced by the caring moment through the choices and actions decided within the relationship, thereby, influencing and becoming part of their own life history. The caring occasion becomes transpersonal when it allows for the presence of the spirit of boththen the event of the moment expands the limits of openness and has the ability to expand human capabilities (Watson, 1999, pp. 116-117). Clinical Application The intent of this section is to create a better understanding of Watsons theory through a clinical story. For this reason, whenever a single or several clinical caritas process(es) (CCP) are encountered, their appropriate numbers are identified within parentheses. The reader shall also notice that this story deviates from the traditional format as it includes reflection and analysis, the purpose of which is to provide an expeditious grasp related to these abstract concepts. Additionally, the reader can also refer to Table 3 for an example of a caring process using Watsons caring theory (adapted from Cara, 1999; Cara & Gagnon, 2000). It is December 5th, I am assigned to take care of Mr. Smith, a 55-year-old Caucasian man who will undergo his 5th amputation. Gangrene has ravaged both feet and legs. He is scheduled for an above knee amputation of his right leg, because the last amputation did not heal properly. I know him quite well, since I took care of him during his past hospitalizations (CCP#4). Ive always liked this patient (CCP#1), it seems that we connected right away after our first meeting (CCP#4). He shared with me his life story [referred to as phenomenal field by Watson], which allowed me to know him as a person not just a case going for surgery on our unit. I welcome him as he is admitted onto the unit. As we glance to each other, he returns a faint smile. [At this moment, a caring occasion takes place.] I ask him how he is doing and tell him that since our last meeting I thought of some creative ways of how he could remember to take his medicine (CCP#6, CCP#7). [According to Watson, the nurses creativity contributes to making nursing an art.] He responds that he will be happy to discuss it and also asks how I have been doing. Mr. Smith knows me as a person, he does not consider me as just another nurse, I am his nurse. He knows that I care for him and that I am committed to helping him through his ordeal (CCP#4). [This is an example of what Watson means by our relationship becoming part of both our life history.] From his faint smile I can sense that he is depressed. Probably since part of his leg has to be amputated some more. However, I cannot make this assumption and will have to discuss his perceptions and feelings pertaining to his lived experience (CCP#3, CCP#5, CCP#10). While I help him settle in his room, I arrange his environment so that he can feel at ease (CCP#8). Right away, I use the time we have together to ask about himself, his feelings, and his priorities for his care plan and hospitalization (CCP#5, CCP#10). He explains that he wants to be home for Christmas because his son and grandson are coming to visit. Consequently, we will have to plan everything according to his priority.

[Although caring takes too much time according to some people, I have found, through experience, that focusing on the patients priorities and meaning will often help them participate more actively in their healing process. Therefore, even though more time was taken initially, I noticed that, eventually, more time is saved in caring for patients. As Watson (2000) emphasizes, the outcomes that may arise, develop from the process and are characterized and guided by the inner journey of the one being cared-for, not the one caring (or attempting to cure).] While I help him settle in his bed, he asks for the bedpan (CCP#9). As I install the bedpan delicately underneath him, he says to me, Look at me, I cant even manage by myself anymore! I feel like a piece of meat in this bed! Will this surgery work this time or is it a waste of time and money? I am troubled by his comment and ask him to clarify (CCP#5). He says that people used to respect him but losing his legs also made him lose this respect. I am speechless! [My patient makes me realize the importance of Watsons caring values based on respecting and preserving human dignity. Yet, hearing how other peoples reaction affects him, I understand more than ever that Mr. Smith and his environment are interrelated (CCP#8, CCP#10)]. He continues to say, If only you knew me back then, when I was walking and working. Without my legs, I am no longer the same guy! I ask how losing his legs made him different (CCP#5, CCP#9, CCP#10). He says that he no longer has social recognition and usefulness. [I find it difficult to consider how people can disrespect a human being for being different! Yet, one has to look beyond the body, and look at the mind and the soul.] Sensing that he wants to be alone, I tell him that I will return in a few minutes and I gently pull the curtains to provide privacy and comfort (CCP#8). Trusting that I will return, he thanks me for my help (CCP#4). As I leave the room, I feel powerless towards my patient, not knowing what to say or what to do. [Watson (2000) reminds us that being caring is being vulnerable. If we are not able to be vulnerable with ourselves and others, we become robotic, mechanical, detached and de-personal in our lives and work and relationships (p. 6). I want to help him reach some harmony (mindbodyspirit) in his life again (CCP#9). Promoting hope to patients when their situation is somber can be quite overwhelming (CCP#2). But since I believe that giving hope is essential to his harmony, I will have to be somewhat creative (CCP#6). Caring for him is important to me, it is my motivation that contributes to the way I actualize myself professionally. Caring allows me to work with passion! It becomes clear that my most important goal is establishing a transpersonal caring relationship that will, as Watson states, protect, enhance, and preserve my patients dignity, humanity, wholeness, and inner harmony. Caring, for me, is what nursing is all about!] (C.C., RN) Viewing the Person Through Watsons Caring Lens Watson (1988b) defines the person as a being-in-the-world who holds three spheres of beingmind, body, and spiritthat are influenced by the concept of self and who is unique and free to make choices. Referring to Mr. Smith (see story above) as a being-inthe-world entails that I cannot consider him without his context or environment (family, culture, community, society, etc.). In fact, using such definition accentuates the interconnectedness between the person and the environment. Therefore, in my data collection, I inquire about his family, friends, resources within his community, etc. In essence, I am concerned on how he relates with his environment.

In Watsons later work, she revisits Nightingales concept of environment and discusses how the healing space or environment can expand the persons awareness and consciousness and promote mindbodyspirit wholeness and healing (1999, p. 254). This is why Watson recognizes the importance of making the patients room a soothing, healing, and sacred place. It is not uncommon in this day and age to enter in a patients room only to find it disorganized and unsanitary. One wonders how patients can heal their mindbodyspirit in such an environment. Watson (1979, 1988b, 1999) acknowledges also the unity of the persons mindbodyspirit. Therefore, while collecting the data, I do not consider his body alone but will inquire about his mind and spirit as well. The mind corresponds in our example, to Mr. Smiths emotions, intelligence, and memories. For Watson, the mind is the point of access to the body and the spirit. The spirit relates to Mr. Smiths soul, the inner self, the essence of the person, the spiritual self. It is the spirit that allows Mr. Smith to transcend the here and now coexisting with past, present, and future, all at once through, for example, creative imagination and visualization. In other words, your spirit allows you to read this article in the present time, while thinking about patients you had in the past, along with visioning how you can utilize this knowledge in the future. Watson believes that spirituality upholds a foremost importance in our profession. In fact, she ascertains that the care of the soul remains the most powerful aspect of the art of caring in nursing (Watson, 1997a). The following questions are examples of how one could enter in a patients phenomenal field: Tell me about yourself? Tell me about your life experiences? Tell me about your bodily sensations? Tell me about your spiritual and cultural beliefs? Tell me about your goals and expectations? Such questions generally assist people to share their life story. Another important aspect of Watsons perspective corresponds to the respect for the other persons choices and decisions. Essentially, respect is easily acquired until the person disagrees with your recommendations, at which point, respecting the other persons choices can become more complex. Of course, it does not mean that you cannot share your point of view, especially if the patient asks for your perspective. Viewing the Persons Health Through Watsons Caring Lens Watsons definition of health does not correspond to the simple absence of disease. In her earlier work, she defines the persons health as a subjective experience. Health also corresponds to the persons harmony, or balance, within the mindbodyspirit, related to the degree of congruence between the self as perceived (for example, Mr. Smith is perceiving his condition as deteriorating) and the self as experienced (for example, Mr. Smith is being informed by the health care professionals that his situation is deteriorating and that another amputation will be required). Watson (1988b) believes as one is able to experience ones real self, the more harmony there will be within the mindbodyspirit, so that a higher degree of health will be present. The following are example questions that can help assess the patients perspective about health: Tell me about your health?

What is it like to be in your situation? Tell me how you perceive yourself in this situation? What meaning are you giving to this situation? Tell me about your health priorities? Tell me about the harmony you wish to reach? Such questions usually contribute to helping people find meaning to the crisis in their life. Viewing Nursing Through Watsons Caring Lens Watson defines nursing as a human science of persons and human healthillness experiences that are mediated by professional, personal, scientific, esthetic, and ethical human care transactions (1988b, p. 54). In addition, she also views nursing as both a science and an art. Unfortunately, artistry, along with creativity, is often seen as incongruent with an institutions policies and procedures. However, according to Watson, being an artist is part of our role and certainly part of caring for patients and their families. In 1999, she exemplifies the artistic domain of nursing as emerging transpersonal caring-healing modalities. Such transpersonal caring-healing modalities correspond to providing comfort measures, helping the cared-for to alleviate pain, stress, and suffering, as well as to promote well-being and healing. Congruent with other nursing scholars, Watson (1988b) acknowledges caring as the essence of nursing. She also adds that caring can be viewed as the nurses moral ideal of preserving human dignity by assisting a person to find meaning in illness and suffering in order to restore or promote the persons harmony. You may be inclined to view such moral ideal as being extremely intangible and inaccessible. However, as one usually aspires to be the best nurse possible, one tends to evaluate oneself to such ideal. Consequently, the nurse can experience frustrations if he/she feels incongruent with his/her own moral ideal. Instead, an ideal is a guide for shaping practice. Watsons (1999) present definition includes caring as a special way of being-in-relation with ones self, with others, and the broader environment. Such relationship requires both an intention and a commitment to care for the individual. In other words, the nurse has to be conscious and engaged to care in order to connect and establish a relationship with the cared-for to promote health/healing. The following self-reflective questions are examples that you may ask yourself in regard to your role as a nurse: What is the meaning of caring for the persons and their families? For myself? How do I express my caring consciousness and commitment to the persons and their families? To working colleagues? To other health care professionals? To my superiors? To the institution? How do I define the person, environment, health/healing, and nursing? How do I make a difference in peoples life and suffering? How can I be informed by the clinical caritas processes in my practice? How can I be inspired by Watsons caring theory in my practice? Such questions can help the nurse reflect upon his/her caring practice and contribute to the meaningfulness of professional life. Conclusion

Through this continuing education paper, we were able to learn the essential elements of Watsons caring theory and explore an example of a clinical application of her work through a clinical story. Aiming to preserve our human caring heritage, this paper offered some suggestions and ideas in order to help nurses grasp and utilize Watsons caring theory in their work environment. Nursing can expand its existing role, continuing to make contributions to health care within the modern model by developing its foundational caring-healing and health strengths that have always been present on the margin. (Watson, 1999, p. 45) Author Note Chantal Cara, Ph.D., RN is an associate professor at the Universit de Montral, Faculty of Nursing. She completed her doctoral studies in nursing at the University of Colorado under the supervision of Dr. Jean Watson. Her main areas of interest are caring philosophy, managerial and staff nurses caring practices, and qualitative research methodology. She is also involved in the implementation of caring approaches in nursing practice. She is currently a board member of the International Association of Human Caring. The author would like to thank Dr. Jean Watson for her review and critique of this paper. Correspondence concerning this article should be addressed to Chantal Cara, Faculty of Nursing, Universit de Montral, C.P. 6128, Succursale Centre-ville, Montral, Qubec, Canada, H3C 3J7. Electronic mail may be sent via Internet to [email protected] References Cara, C. (1999). Caring philosophy and theory for the advancement of the nursing discipline. Closing key note conference. XVI Jornades Catalanes dinfermeria Intensiva, Barcelone, Espagne. Cara, C., & Gagnon, L. (2000). Une approche base sur le caring: Un nouveau regard sur la radaptation. Recueil dabrgs du 4me colloque Alice-Girard (p. 12). Montral, Qubec: Facult des sciences infirmires, Universit de Montral. Duquette, A., & Cara, C. (2000). Le caring et la sant de linfirmire. Linfirmire Canadienne, 1(2), 10-11. McGraw, M.J. (2002). Watsons philosophy in nursing practice. In M.R. Alligood, & A. Marriner Tomey (Eds.), Nursing theory: Utilization and application (pp. 97-122). Toronto, Canada: Mosby. Watson, J. (1979). Nursing: The philosophy and science of caring. Boston: Little Brown. Watson, J. (1988a). New dimensions of human caring theory. Nursing Science Quarterly, 1(4), 175-181. Watson, J. (1988b). Nursing: Human science and human care. A theory of nursing (2nd printing). New York: National League for Nursing. (Original work published in 1985.) Watson, J. (1989). Human caring and suffering: A subjective model for health sciences. In R. Taylor & J. Watson (Eds.), They shall not hurt: Human suffering and human caring (pp. 125-135). Boulder, CO: Colorado Associated University Press. Watson, J. (1990a). Caring knowledge and informed moral passion. Advances in Nursing Science, 13(1), 15-24.

Watson, J. (1990b). Human caring: A public agenda. In J.S. Stevenson & T. TrippReimer (Eds.), Knowledge about care and caring (pp. 41-48). Kansas, MO: American Academy of Nursing. Watson, J. (1990c). The moral failure of the patriarchy. Nursing Outlook, 28(2), 62-66. Watson, J. (1990d). Transpersonal caring: A transcendent view of person, health, and healing. In M.E. Parker (Ed.), Nursing theories in practice (pp. 277-288). New York: National League for Nursing. Watson, J. (1997a). Artistry of caring: Heart and soul of nursing. In D. Marks-Maran & P. Rose (Eds.), Nursing: Beyond art and sciences (pp. 54-62). Boulder, CO: Colorado Associated University Press. Watson, J. (1997b). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10(1), 49-52. Watson, J. (1999). Postmodern nursing and beyond. Toronto, Canada: Churchill Livingstone. Watson, J. (2000). Via negativa: Considering caring by way of non-caring. The Australian Journal of Holistic Nursing, 7(1), 4-8. Watson, J. (2001). Jean Watson: Theory of human caring. In M.E. Parker (Ed.), Nursing theories and nursing practice (pp. 343-354). Philadelphia: Davis. Watson, J. (2002a). Guest editorial: Nursing: Seeking its source and survival. ICUs and Nursing Web Journal Issue, 9th(Spring), 1-7. Available: www.nursing.gr/J.W.editorial.pdf Watson, J. (2002b). Instruments for assessing and measuring caring in nursing and health sciences. New York: Springer. Watson, J. (2002c, in press). Intentionality and caring-healing consciousness: A theory of transpersonal nursing. Holistic Nursing Journal, July. Watson, J. (Ed.) (1994). Applying the art and science of human caring. New York: National League for Nursing. Watson, J., & Smith, M. (2002). Transpersonal caring science and the science of unitary human beings: A transtheoretical discourse for nursing knowledge development. International Journal of Advanced Nursing, 37(5), 452-461.

Table 1 Premises and Values Watson, 1988b, pp. 34-35 Deep respect for the wonders and mysteries of life. Acknowledgement of a spiritual dimension to life and internal power of the human care process, growth, and change. A high regard and reverence for a person and human life. Nonpaternalistic values that are related to human autonomy and freedom of choice. A high value on the subjective-internal world of the experiencing person and how the person (both patient and nurse) is perceiving and experiencing health-illness conditions. An emphasis is placed upon helping a person gain more self-knowledge, self-control, and readiness for self-healing, regardless of the external health condition. The nurse is viewed as a co-participant in the human care process. A high value is placed on the relationship between the nurse and the person. Watson, 1999, p. 129 There is an expanded view of the person and what it means to be humanfully embodied, but more than body physical; an embodied spirit; a transpersonal, transcendent, evolving consciousness; unity of mindbodyspirit; person-nature-universe as oneness, connected. Acknowledgement of the human-environment energy fieldlife energy field and universal field of consciousness; universal mind (in Teilhard de Chardin and Bohms sense of mind). Positing of consciousness as energy; caring-healing consciousness becomes primary for the caring-healing practitioner. Caring potentiates healing, wholeness. Caring-healing modalities (sacred feminine archetype of nursing) have been excluded from nursing and health systems; their development and reintroduction are essential for postmodern, transpersonal, caring-healing models, and transformation. Caring-healing processes and relationships are considered sacred. Unitary consciousness as the worldview and cosmology, i.e., viewing the connectedness of all. Caring as a moral imperative to human and planetary survival. Caring as a converging global agenda for nursing and society alike.

Table 2 Assumptions Watson, 1999, pp. 102-103 Caring is based on an ontology and ethic of relationship and connectedness, and of relationship and consciousness. Caring consciousness, in-relation, becomes primary. Caring can be most effectively demonstrated and practiced interpersonally and transpersonally. Caring consists of caritas consciousness, values, and motives. It is guided by carative components [carative factors]. A caring relationship and a caring environment attend to soul care: the spiritual growth of both the one-caring and the one-being-cared-for. A caring relationship and a caring environment preserve human dignity, wholeness, and integrity; they offer an authentic presencing and choice. Caring promotes self-growth, self-knowledge, self-control, and self-healing processes and possibilities. Caring accepts and holds safe space (sacred space) for people to seek their own wholeness of being and becoming, not only now but in the future, evolving toward wholeness, greater complexity and connectedness with the deep self, the soul and the higher self. Each caring act seeks to hold an intentional consciousness of caring. This energetic, focused consciousness of caring and authentic presencing has the potential to change the field of caring, thereby potentiating healing and wholeness. Caring, as ontology and consciousness, calls for ontological authenticity and advanced ontological competencies and skills. These, in turn, can be translated into professional ontologically based caring-healing modalities. The practice of transpersonal caring-healing requires an expanding epistemology and transformative science and art model for further advancement. This practice integrates all ways of knowing. The art and science of a postmodern model of transpersonal caringhealing is complementary to the science of medical curing, modern nursing, and medical practices.

Table 3 Section of Mr. Smiths Caring Process Adapted from Cara (1999) and Cara & Gagnon (2000) Meaning of the Priorities and health Clinical caritas processes persons health care decisions of the experience person Mr. Smith describes Mr. Smith wants to go Sustaining a helping-trusting and authentic himself as a different home for Christmas. caring relationship with Mr. Smith and his person since the Mr. Smith would like family (CCP#4). amputations to have his amputation Facilitating the expression of positive and (disharmony). heal properly. negative feelings in regard to the Mr. Smith does not Mr. Smith would like amputations (CCP#5). have a meaning to his to find meaning in his Being authentically present as well as life. life. enabling and sustaining the deep belief system of Mr. Smiths future (CCP#2). Being open and present to Mr. Smiths spiritual and existential dimensions in terms of his own life/death in order to help find meaning to his life (CCP#10). Creating a healing environment at all levels, (physical as well as non-physical) whereby healing, comfort, and dignity are potentiated (CCP#8). Engaging in genuine teaching-learning experience with Mr. Smith that attends to his healing, meaning, and harmony (CCP#7). Assisting Mr. Smith with basic needs with an intentional caring consciousness, administering human care essentials, which potentiate alignment of mindbodyspirit and unity of being in all aspects of care (CCP#9). Validation Did Mr. Smiths amputation heal properly? Did Mr. Smith perceive himself as being in harmony? Has Mr. Smith found meaning to his life?

Post-Test for Continuing Education Credits A Pragmatic View of Jean Watsons Caring Theory By Chantal Cara, Ph.D., RN Please circle the correct answer for each question below. 1. What is the meaning of the Watsons concept of caring? A. The essence of medicine. B. The nurses moral standards. C. Being nice to the patients and families. D. A human intersubjective process between the nurse and the cared-for. 2. What does Jean Watson mean by caring occasion? A. The time needed for the nurse to set up a helping relationship with her patient. B. A focal point in time and space where a caring transaction between the nurse and the person can be created. C. The time that the nurse has available to be caring with the person. D. The essence of nursing. 3. What is the meaning of the term phenomenal field for Watson? A. The persons frame of reference corresponding to the totality of his/her human experience. B. An energetic field. C. The results of a phenomenological research useful to the nurses working within a specific clinical arena. D. The persons environment. 4. Which of the following statements is consistent with Watsons caring theory? A. A caring relationship and environment attend only to soul care. B. Being caring does not imply that you have to be vulnerable in front of patients and families. C. The clinical caritas processes serve as guide for the nurse in her caring practice. D. The persons harmony within the mindbodyspirit is related to the degree of congruence among the health care professionals. 5. Choose the best statement corresponding to Jean Watson: A. Jean Watson is among the few nursing theorists to consider the caregiver along with the cared-for. B. Jean Watson is a nursing theorist only known within the United States. C. Jean Watson gives emphasis to the physical aspect of the cared-for. 6. The transpersonal caring relationship characterizes a special kind of human care relationship, which depends on: A. The nurses moral commitment in protecting and enhancing her own career.

B. The nurses caring consciousness and connection having the potential to heal since experience, perception and intentional connection are taking place. C. The nurses caring consciousness communicated to preserve and honor the embodied spirit, therefore, reducing the person to the moral status of an object. 7. Which of the following statements corresponds to Jean Watsons work? A. Caring-healing processes and relationships are considered sacred. B. The outcome are defined and guided by the inner journey of the one caring. C. A high regard and reverence for the spiritual-objective center of the person. 8. Which of the following statements highlights the goal of Watsons transpersonal perspective? The end is the actualization of the one caring. The end is the persons adaptation to the environment. The end is the cure of the one cared-for. The end is the preservation of dignity, humanity, and inner harmony. 9. Choose the appropriate statement pertaining to Watsons caring moment: A. Only the one caring is influenced by the caring moment through the choices and actions decided within the relationship. B. Both, the one cared-for and the one caring are influenced by the caring moment, through the choices and actions decided within the relationship. C. Only the one cared-for is influenced by the caring moment through the choices and actions decided within the relationship. 10. According to Jean Watson, when does the caring occasion become transpersonal? A. When it allows for the presence of the spirit of both persons. B. When it expands the limits of openness. C. When it has the ability to expand human capabilities. D. All the statements are correct. 11. Which of the following statements corresponds to Watsons definition of human being? A. A bio-psycho-social being-in-the-world. B. A cultural being who survived to both time and space. C. A being-in-the-world who possesses three spheres of beingmind, body, and spirit, and who is free to make choices. D. An irreducible, indivisible and pandimensional energy field. 12. Identify the appropriate statement consistent with Jean Watsons definition of health: A. The harmony within the mindbodyspirit. B. The absence of disease. C. The independence to satisfy ones basic needs. D. The quality of life. 13. Which of the following statements is related to Watsons definition of nursing?

A. To enhance the adaptation of the person in order to respond to environmental stimuli. B. A human science of persons and human healthillness experiences that are mediated by human care transactions. C. To preserve the patients behavior by means of imposing regulatory mechanisms or by providing resources. D. A significant, therapeutic, interpersonal process where the nurse-patient relationship has four overlapping phases. 14. Jean Watsons transpersonal caringhealing modalities correspond to the following statement: A. Comfort measures associated with therapeutic touch. B. Nursing standards developed in interaction with the nursing diagnosis. C. Nursing policies and procedures related to basic techniques. D. Comfort measures to alleviate stress and suffering and promote healing. 15. Within the following statements, identify the one that does correspond to Watsons concept of spirit? A. The persons intelligence. B. The persons phenomenal field. C. The inner self. D. The emotional self. The following questions are based on Mrs. Davis situation. Mrs. Davis is a 65-year-old patient admitted on your unit for bacterial peritonitis. You mention to her that she needs an intravenous catheter in order to start the antibiotic therapy. She then says that she doesnt need any antibiotics to heal but requires only prayers. Inspired by Jean Watsons theory, answer the following questions. 16. Why would you use the 10th clinical caritas process, opening and attending to spiritual-mysterious, and existential dimensions of ones own life-death; soul care for self and the one-being-cared-for with Mrs. Davis? A. Because the meaning Mrs. Davis will give to her health care situation is influenced by her lived experience and spirituality. B. Because Mrs. Davis is a religious person. C. Because the physician ordered antibiotic therapy for Mrs. Davis. D. Because Mrs. Davis is entitled to a caring relationship. 17. Inspired by Watsons work, why would you use the 7th clinical caritas process Engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within the others frame of reference? A. It will assist in providing the information related to her nursing diagnosis. B. It will help in considering Mrs. Davis meaning pertaining to her health situation. C. It will assist in demanding that Mrs. Davis complies with her physicians orders.

18. Inspired by Jean Watsons theory, what question would help Mrs. Davis share her life story? A. Tell me about your spiritual and cultural beliefs? B. Tell me about your health priorities? C. Do you suffer from any allergies? D. Just consulting Mrs. Davis chart would be sufficient. 19. Based on Watsons caring theory, what would be one of your nursing care interventions with Mrs. Davis? A. Convince Mrs. Davis to receive her antibiotics or to be discharged at her own risk. B. Demand that Mrs. Davis behaviors follow hospitals policies. C. Establish a transpersonal caring relationship so she can express her positive and negative feelings towards the situation. D. Have the physician talk to her. 20. Identify the clinical caritas process you would find useful with Mrs. Davis while trying to make her feel comfortable in her room? A. Creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices. B. Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and the one-being-cared-for. C. Developing and sustaining a helping-trusting, authentic caring relationship. D. Creating healing environment at all levels, (physical as well as non-physical, subtle environment of energy and consciousness) whereby wholeness, beauty, comfort, dignity, and peace are potentiated. Please note: No more than 4 answers can be incorrect in order to receive continuing education credit.

Registration Form Please complete this form and return with the Evaluation and Post-Test Forms to the address below. Name_________________________________________ Affiliation_____________________________________ Address_______________________________________ City__________________________________________ State__________Country_______________ Postal Code__________ License #_____________ (if applicable) Certification Statement I hereby certify that I have read the materials entitled A Pragmatic View of Jean Watsons Caring Theory by affixing my signature to this certification. Signature__________________________ Date____________ State_____________

Mail this form, the Evaluation and Post-Test Forms, and a check for $15.00 US made out to IAHC to the following address: IAHC Continuing Education2090 Linglestown RD Suite 107 Harrisburg, PA 17110

Evaluation Form Title: A Pragmatic View of Jean Watsons Caring Theory Presenter: Chantal Cara, Ph.D., RN Please fill in your response in the box provided 1 = Excellent 2 = Good 3 = Fair 4 = Poor Rating

A. How well did the presenter meet the identified objectives? Describe the general aspects of Watsons caring theory Describe how Watsons caring theory can be applied to clinical practice Describe the person through Watsons caring lens Describe the persons health through Watsons caring lens Describe Nursing Through Watsons Caring Lens B. How would you rate your overall satisfaction with the program? C. Rate the relevance of the content presented to stated objectives. D. How well prepared did the presenter seem to be? E. Rate the presenters ability to communicate information effectively. F. How long did it take you to complete this CEU activity? Comments:

What would you like to see for future topics?

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Theories of Stress
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Have a Question ! Thursday, Jan 10 2008

There are several theoretical positions devised for examining and understanding stress and stress-related disorders. Brantley and Thomason (1995) categorized them into three groups: response theories, stimulus theories, and interaction (or transaction) theories. Given the distinction made earlier between stress as a stimulus and as a response, this system serves as a useful way to present the various theories and associated research.

Response Theories and Research

Because chronic stress responses involve actual physiological changes to body systems and organs, a good bit of attention has been paid to acute physiological stress responses and how they might possibly lead to subsequent chronic stress responses (McEwen and Stellar, 1993). Historically, both Walter Cannon (1929) and Hans Selye (1956) provided the foundation for the current interest in this physiological process. The Work of Walter Cannon Cannon was a physiologist at Harvard University who was the first to use the term homeostasis. According to Cannon (1929), the body possesses an internal mechanism to maintain stable bodily functioning or equilibrium. As the environment presents the organism with various challenges, the body must respond to each new situation by adjusting various physiological systems to compensate for the resources being taxed. A classic example of this type of compensation involves fluid regulation. When an organism ingests a large amount of water, the kidney releases more waste fluid into the bladder for eventual disposal in an effort to maintain bodily equilibrium. Many of the feedback mechanisms that regulate blood pressure presented in Chapter 1 share similar characteristics with bodily systems that maintain homeostasis. According to Cannon (1935), failure of the body to respond to environmental challenges by maintaining bodily homeostasis results in damage to target organs and eventually death.

Translating his work with physical challenges associated with eating, drinking, and physical activity into those of a psychological nature, Cannon hypothesized that common homeostatic mechanisms were involved. Accordingly, if an organisms response to threat involves significant sympathetic nervous system arousal so that respiration and heart rate increase significantly, the bodys compensatory response should involve either reducing sympathetic nervous system activity or increasing parasympathetic nervous system counter-activity. If the compensatory response is inadequate, tissue damage can result, placing the organism at a greater risk for subsequent medical problems associated with the damaged tissue. In brief, the concept of homeostasis introduced by Cannon has proved to be very valuable in explaining how acute physiological stress responses to threats of survival lead toward chronic stress responses. The Work of Hans Selye Selye (1956) was the first investigator to use the term stress to describe the problems associated with homeostasis identified by Cannon decades earlier. Although he borrowed the term from physics, he used it to describe the effects on the organism rather than the environmental stressors he examined in his empirical work. According to Selye, the stress response of the organism represented a common set of generalized physiological responses that were experienced by all organisms exposed to a variety of environmental challenges like temperature change or exposure to noise. From his perspective, the stress response was nonspecific; that is, the type of stressor experienced did not affect the pattern of response. In other words, a wide variety of stressors elicited an identical or general stress response. He termed this nonspecific response the General Adaptation Syndrome, which consisted of three stages: Alarm Reaction, Resistance, and Exhaustion. Selye reasoned that the first stage, Alarm Reaction, involved the classic fight-flight response described above. As a result, the bodys physiological system dropped below optimal functioning. As the body attempted to compensate for the physiological reactions observed in the Alarm Reaction stage, the organism entered the Resistance stage. Physiological compensatory systems began working at peak capacity to resist the challenges the entire system was confronting, and according to Selye, actually raised the bodys resistance to stress above homeostatic levels. However, because this response consumed so much energy, a body could not sustain it forever. Once energy had been depleted, the organism entered the stage of Exhaustion. In this stage, resistance to environmental stressors broke down and the body became susceptible to tissue damage and perhaps even death. In Selyes terminology, the Alarm Reaction Stage was comparable to the acute stress response described above and the Exhaustion Stage was comparable to a chronic stress response. The Work of Bruce McEwen More recently, the historic works of Cannon and Selye that have attempted to explain how acute physiological stress responses evolved into chronic stress responses have been revisited by Bruce McEwen and colleagues (McEwen and Stellar, 1993; McEwen, 1998) at Rockefeller University. In contrast to the state of physiological equilibrium of homeostasis essential for survival that Cannon discussed, McEwen used the term allostasis, referring to the bodys ability to adapt to a changing environment in situations that did not challenge survival. From his perspective, an organism that maintained a perfectly stable physiological equilibrium during a stressful encounter (a nonresponse) might be just as problematic as an organism that exhibited an exaggerated physiological response. Allostasis referred to the bodys ability to adjust to a new steady state in response to the environmental challenge (McEwen and Stellar, 1993). To clarify the distinction between homeostasis and allostasis, consider two physiological parameters: body temperature and heart rate. For an organism to survive in a changing environment, there exists a very narrow window of acceptable body temperatures. Even though the temperature of the environment can change 50 degrees over the course of a single day, body temperature remains constant. Deviations from a normal temperature are met with a range of symptoms (sweating, chills) that occur as part of our bodys attempt to regain homeostasis. For body temperature, homeostasis is a very important mechanism of survival. Now, lets consider heart rate. In contrast to body temperature, our body can tolerate a wide range of heart rates. When we are asleep, our heart rate drops to basal levels. When we are

awake, heart rates increase substantially, and when we are engaged in aerobic exercise, heart rates climb even higher. Rather than maintaining stability in the face of a changing environment, as body temperature does, heart rate adjusts to a changing environment to optimize functioning. In this case, the ability of the body to adjust to aerobic exercise by resetting heart rate at a higher level is called allostasis, not homeostasis. McEwen argues that most acute stress responses represent challenges to the bodys allostasis, not challenges to its homeostasis. According to the work of McEwen and colleagues, allostatic load is a term that refers to the price the body pays for being challenged repeatedly by a variety of environmental stressors. Increased allostatic load, or what McEwen and Wingfield (2003) called allostatic overload, occurs with increased frequency of exposure to stressors, increased intensities of these stressors, or decreased efficiency in coordinating the onset and termination of the physiological response. McEwen (1998) outlined four distinct types of allostatic overload (see Figure 3.1). In the first type, the organism is exposed to multiple environmental stressors during a short period of time. Figure 3.1. The various types of allostatic overload. Reprinted from B. S. McEwen (1998), Protective and damaging effects of stress mediators, The New England Journal of Medicine, 338, 171???179. For example, imagine chasing a pesky salesperson off your front porch, running to get the phone only to realize it is a telemarketer, then finding your three-year-old coloring on the kitchen wall with permanent markers, and the family dog urinating on the floor. In a case like this, the physiological response associated with the first stressor was just starting to lessen when the second stressor hit, and likewise, recovery from the second stressor was interrupted by the onset of the third stressor. In this type of allostatic overload, the problem is associated with the frequency of the stressors encountered. In the second form of allostatic overload, repeated stressors elicit responses that fail to habituate. Consider an example in which you are dealing with five consecutive irate customers who are demanding their money back for a defective product that you sold them. Normally, ones physiological response to this series of encounters would decrease, or habituate, with each subsequent encounter. When the body fails to exhibit the normal habituation response, this type of allostatic overload occurs. A third form of allostatic overload involves delayed physiological recovery from a given environmental stressor. In this case, the frequency or magnitude of the physiological response may be entirely normal; however, it is the length of time that the response is sustained that leads to allostatic overload. For example, imagine having an argument with a family member and experiencing some physiological arousal associated with the argument. Rather than the arousal gradually declining after the argument, in this type of allostatic overload the physiological recovery is delayed and the arousal is still apparent hours or days later. The final form of allostatic overload involves an inadequate physiological response. In this case, the organism encounters a stressful circumstance or environmental change, but the physiological response is either very weak or entirely absent. Imagine walking through the woods and encountering a black bear, only to find that your bodys fight-flight response failed to occur and therefore did not provide the necessary energy and altered blood flow to run away from the threat. According to McEwen and Stellar (1993), allostatic overload, whatever its source, is the mechanism through which acute physiological responses result in permanent tissue damage. Research using animals documents not only changes in peripheral tissues associated with increased allostatic load, but also altered functioning in the cerebral cortex (McEwen, 1998). This altered brain functioning has included atrophy of dendrites on neurons, suppression of neurogenesis (creation and proliferation of new neurons), and permanent loss of pyramidal neurons. Obviously, McEwen and other contemporary stress researchers have extended the theories and empirical work of Cannon and Selye to further our understanding of how stress results in actual tissue damage in the brain and peripheral body systems.

Selyes (1956) General Adaptation Syndrome described above is a classic representation of a theoretical perspective that focuses upon stress as a response. In fact, Selye went so far as to state that the nature of the stimulus was irrelevant to the stress response. To support his view, he subjected animals to a wide variety of experimental conditions that elicited very similar physiologic stress responses including temperature change, pain stimulation, and exposure to infection. Likewise, although acknowledging the importance of the stress stimulus in their theoretical models, McEwen and colleagues have also focused on the physiological stress response, paying less attention to the type or nature of the eliciting stimulus (McEwen and Stellar, 1993; McEwen, 1998). Although response theories have contributed greatly to our understanding of the physiological response systems that mediate the relation between environmental stressors and chronic stress responses, they have typically neglected a detailed exploration of types of environmental stressors and how they might influence the disease process.

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