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Health-Psychology - Health psychology notes 5th sem

Bsc psychology (University of Calicut)

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HEALTH PSYCHOLOGY
MODULE 1: INTRODUCTION TO HEALTH PSYCHOLOGY
Definition of Health Psychology, Mind Body Relationship, Need and Significance of Health
Psychology, Biopsychosocial Model V/S Biomedical Model

MODULE 2: HEALTH BEHAVIOUR AND PRIMARY PREVENTION

Health Behaviours, Changing Health Habits-Attitude Change, Cognitive Behavioural
Approach- Health Belief Model, Theory of Planned Behaviour, Trans Theoretical Model,
Protection Motivation Theory, Social Cognitive Theory and Attribution Theory, Models of
Prevention

MODULE 3: STRESS AND COPING

Stress, Theoretical Contributions to Stress-Fight-Flight, Selye’s General Adaptation
Syndrome, tend –Befriend, Psychological Appraisal & Stress, Coping: Moderators of
Coping-Personality, Social Support, Other Life Stressors, Stress Management Programmes

MODULE 4: PSYCHOSOCIAL ISSUES AND MANAGEMENT OF ADVANCING AND

TERMINAL ILLNESS
Emotional Responses to Chronic Illness, Psychosocial Issues —Continued Treatment, Issue
of Non – Traditional Treatment, Stages to Adjustment to Dying, Psychological
Management of Terminal Illness, Medical Staff and Terminal Ill Patient, Individual
Counselling, Family Therapy, Management of Terminal Illness in Children

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MODULE 1: INTRODUCTION TO HEALTH PSYCHOLOGY

“Health Psychology is a branch of psychology that focuses on how mental, emotional and
social factors affect a person’s physical wellbeing”
“It is the study of psychological and behavioral processes in health, illness and health
care.it concerned with understanding how psychological, behavioral and cultural factors
contribute to physical health and illness”

NEED AND SIGNIFICANCE OF HEALTH PSYCHOLOGY

→ Changing patterns of illness
→ Advances in technology and research
→ Role epidemiology in health psychology
→ Expanded health care services
→ Increased medical acceptance
→ Demonstrated contributions to health
→ Methodological contributions to health

ROLE OF HEALTH PSYCHOLOGIST/5 MAIN GOALS OF HEALTH PSYCHOLOGY

→ Health promotion and maintenance
→ Prevention and treatment of illness
→ Etiology and correlates of health, illness and dysfunction
→ Improve the health care system and the formulation of health policy

MIND BODY RELATIONSHIP

During prehumen history, disease was thought to arise when evil spirit entered the body.
Treatment is to make a hole in a patient’s skull and to allow the evil spirit to leave the body.
Ancient Greeks developed a humoral theory. They believe that disease resulted when the four
humors or circulating fluids on the body. Treatment was to restore the balance among the
humors.
They described personality types associated with each humors:
• Blood – passionate temperament
• Black bile –sadness
• Yellow bile – angry disposition
• Phlegm –laid back approach to life (relaxed and easygoing)

During the Middle age, disease was regarded as god’s punishment for evil doing and cure often
consisted of driving out the evil forces by torturing the body. Later this form of therapy was
replaced by penance (punishment) through prayed and good work. During this time church was
the guardian of medical knowledge and priest is considered as physician.

In advanced period, science of cellular pathology progressed, the humoral theory of illness was
finally put into rest.

Psychoanalytic contribution- According to Freud specific unconscious conflicts can produce

particular physical disturbances that produce psychological conflicts.

Psychosomatic medicine - Freud believed that conversion reactions occur without any necessary
physiological changes. Dunbar and alexander argued that conflict produce anxiety which
becomes unconscious and takes a physiological role on the body via the autonomic nervous
system. Continuous physiological changes eventually produce an actual organic disturbance.

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BIOPSYCHOSOCIAL MODEL V/S BIOMEDICAL MODEL

BIOMEDICAL MODEL
• Illness can be explained on the basis of aberrant somatic bodily process such as biochemical
imbalances or neurophysiological abnormalities.
• They assume that psychological and social factors largely irrelevant to the disease process.
• It’s a reductionist model-reduce the illness to low level processes (only in biological level not in
psycho social level).
• Single factor model- explains illness in terms of biological malfunction.
• Assumes a mind body dualism- both are different entities.

BIO PSYCHOSOCIAL MODEL

It maintains that biological, psychological and social factors are all important determinants of
health and illness. Health and illness caused by multiple factors and multiple effects.
- SYSTEM THEORY
All levels of organization in any entity are linked to each other hierarchically and that changes in
any one level will effect change in all other levels.

Clinical implications:
→ Maintains that the process of diagnosis
→ Treatment must involve three sets of factors
→ Makes explicit the significance of the relationship between patient and practitioner.

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MODULE 2: HEALTH BEHAVIOUR & PRIMARY PREVENTION

HEALTH BEHAVIOURS
Health behaviors are behaviors undertaken by people to enhance or maintain their health. A
health habit is a health behavior that is firmly established and often performed automatically,
without awareness. These habits usually develop in childhood and begin to stabilize around age
11 or 12. Wearing a seat belt, brushing one’s teeth, and eating a healthy diet are examples of
these behaviors.
Although a health habit may develop initially because it is reinforced by positive outcomes, such
as parental approval, it eventually becomes independent of the reinforcement process. For
example, you may brush your teeth automatically before going to bed. It is important
to establish good health behaviors and to eliminate poor ones early in life. Important healthy
habits include:
• Sleeping 7 to 8 hours a night
• Not smoking
• Eating breakfast each day
• Having no more than one or two alcoholic drinks each day
• Getting egular exercise
• Not eating between meals
• Being no more than 10% overweight
PRIMARY PREVENTION
Instilling good health habits and changing poor ones is the task of primary
prevention. This means taking measures to combat risk factors for illness before an illness has a
chance to develop. There are two general strategies of primary prevention.
✓ The first and most common strategy is to get people to alter their problematic health
behaviors, such as helping people lose weight through an intervention.
✓ The second, more recent approach is to keep people from developing poor health habits
in the first place. Smoking prevention programs with young adolescents are an example.
FACTORS INFLUENCING HEALTH BEHAVIOUR
• Demographic Factors Younger, more affluent, better-educated people with low levels of
stress and high levels of social support typically practice better health habits than people
under higher levels of stress with fewer resources.
• Age Health habits are typically good in childhood, deteriorate in adolescence and young
adulthood, but improve again among older people.
• Values affect the practice of health habits. For example, exercise for women may be
considered desirable in one culture but undesirable in another
• Personal Control People who regard their health as under their personal control practice
better health habits than people who regard their health as due to chance.
• Social Influence Family, friends, and workplace companions influence health-related
behaviors, sometimes in a beneficial direction, other times in an adverse direction. For
example, peer pressure often leads to smoking in adolescence but may influence people to
stop smoking in adulthood.
• Personal Goals and Values Health habits are tied to personal goals. If personal fitness is an
important goal, a person is more likely to exercise.
• Perceived Symptoms Some health habits are controlled by perceived symptoms. For
example, a smoker who wakes up with a smoker’s cough and raspy throat may cut back in
the belief that he or she is vulnerable to health problems at that time.
• Access to the Health Care Delivery System Access to the health care The health locus of
delivery system affects health behaviors. control scale measures
• Knowledge and Intelligence The practice of health behaviors is tied the degree to which
to cognitive factors, such as knowledge and intelligence. More people perceive their
knowledgeable and smarter people typically take better care of health to be under
themselves. People who are identified as intelligent in childhood have personal control, control
better health-related biological profiles in adulthood.
by the health
practitioner, or chance.

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CHANGING HEALTH HABITS

ATTITUDE CHANGE AND HEALTH BEHAVIOR
• Educational Appeals Educational appeals make the assumption that people will change
their health habits if they have good information about their habits. More recently, though,
a fact that attitude change may not lead to behavior.
• Fear Appeals Attitudinal approaches to changing health habits often make use of fear
appeals. This approach assumes that if people are afraid that a particular habit is hurting
their health, they will change their behavior to reduce their fear. However, this relationship
does not always hold. Persuasive messages that elicit too much fear may actually
undermine health behavior change. Moreover, fear alone may not be sufficient to change
behavior.
• Message Framing A health message can be phrased in positive or negative terms. For
example, a reminder card to get a flu immunization can stress the benefits of being
immunized or stress the discomfort of the flu itself.
Messages that emphasize problems seem to work better for behaviors that have uncertain
outcomes, for health behaviors that need to be practiced only once, such as vaccinations,
and for issues about which people are fearful. Which kind of message framing will most affect
behavior also depends on people’s personal characteristics.
SOCIAL ENGINEERING
Much health behavior change occurs not through programs such as CBT interventions, but
through social engineering. Social engineering modifies the environment in ways that affect
people’s abilities to practice a particular health behavior. Often, social engineering solutions are
legally mandated. Some examples include requiring vaccinations for school entry.

COGNITIVE BEHVAIOURAL APPROACH

COGNITIVE-BEHAVIOR THERAPY (CBT)
Cognitive-behavior approaches to health habit modification focus on the target behavior itself,
the conditions that elicit and maintain it, and the factors that reinforce it. The most effective
approach to health habit modification often comes from cognitive-behavior therapy (CBT).
CLASSICAL CONDITIONING
First described by Ivan Pavlov, a Russian physiologist. It is a process that involves pairing of an
unconditioned reflex with a new stimulus, producing a conditioned reflex.
OPERANT CONDITIONING
First described by B. F. Skinner, an American psychologist. It focusses on using either reinforcement
or punishment in order to increase or decrease a behaviour.
SELF MONITORING
Many programs of cognitive-behavioural modification use self-monitoring as the first step toward
behavior change. The rationale is that a person must understand the dimensions a target
behaviour before change can be inflicted.
Two steps are involved:
1. Learn to discriminate the target behaviour. e.g. A smoker should be able to tell whether
he/she is smoking.
2. Charting the behaviour. e.g. A smoker may be trained to keep a detailed behaviour
record of all the smoking events.
SELF REINFORCEMENT
Self-reinforcement involves systematically rewarding oneself to increase or decrease the
occurrence of a target behaviour.
• Positive self-reward involves rewarding oneself with something desirable after successful
modification of a target behaviour. e.g. going to a movie following successful weight loss
• Negative self-reward involves removing an aversive factor in the environment after
successful modification of target behaviour. e.g. taking the Miss Piggy poster off the
refrigerator once regular controlled eating has been achieved
• Positive self-punishment involves the administration of an unpleasant stimulus to punish an
undesirable behaviour. e.g. electric shock each time he or she experiences a desire

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• Negative self-punishment involves withdrawing a positive reinforce in the environment

each time an undesirable behaviour is performed. e.g. rip up money each time he or she
has a cigarette that exceeds a quota.
These reinforcements and punishments are effective only if they perform the activities. One form
of self-punishment that is effective in behavior modification is contingency contracting.
Contingency Contracting is when an individual forms a contract with another person such as a
therapist, detailing what rewards/punishments are contingent on the performance or non-
performance of a behaviour.

HEALTH BELIEF MODEL

An early influential attitude theory of why people practice health behaviors is the health belief
model. According to this model, whether a person practices a health behavior depends on two
factors: whether the person perceives a personal health threat, and whether the person
believes that a particular health practice will be effective in reducing that threat.
1. PERCEIEVED HEALTH THREAT
The perception of a personal health threat is influenced by at least three factors:
• General health values, which include interest in and concern about health
• Specific beliefs about personal vulnerability to a particular disorder
• Beliefs about the consequences of the disorder, such as whether they are serious.
Thus, for example, people may change their diet to include low cholesterol foods if they value
health, feel threatened by the possibility of heart disease, and perceive that the personal threat of
heart disease is severe.
2. PERCEIVED THREAT REDUCTION
Whether a person believes a health measure will reduce threat has two subcomponents:
• Whether the person thinks the health practice will be effective
• Whether the cost of undertaking that measure exceeds its benefits.
For example, the man who is considering changing his diet to avoid a heart attack may
believe that dietary change alone would not reduce his risk of a heart attack and that
changing his diet would interfere with his enjoyment of life too much to justify taking the
action. So, even if his perceived vulnerability to heart disease is great, he would probably not
make any changes.

Many studies have used the health belief model to modify a large variety of health habits. The
health belief model does, however, leave out an important component of health behavior
change, and that is a sense of self efficacy: the belief that one can control one’s practice of a
particular behavior.
For example, smokers who believe they cannot stop smoking are unlikely to make the effort.

THEORY OF PLANNED BEHAVIOUR

A theory that attempts to link health beliefs directly to behavior is Ajzen’s theory of planned
behavior. According to this theory, a health behavior is the direct result of a behavioural intention.
Behavioral intentions are themselves made up of three components:
• Attitudes toward the specific action: Attitudes toward the action center on the likely
outcomes of the action and evaluations of those outcomes.

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• Subjective norms regarding the action: what a person believes others think that person
should do (normative beliefs) and the motivation to comply with those normative beliefs.
• Perceived behavioural control: It is the perception that one can perform the action and
that the action will have the intended effect; this component of the model is similar to self-
efficacy.
These factors combine to produce a behavioural intention and, ultimately, behavior change.
For example, smokers who believe that smoking causes serious health outcomes, who believe
that other people think they should stop smoking, who are motivated to comply with those
normative beliefs, who believe that they are capable of stopping smoking, and who form a
specific intention to do so will be more likely to stop smoking than people who do not hold these
beliefs.

TRANS THEORETICAL MODEL

Changing a bad health habit does not take place all at once. People go through stages while
they are trying to change their health behaviors.
The trans theoretical model of behavior change is a model that analyses the stages and
processes people go through in bringing about a change in behavior and suggested treatment
goals and interventions for each stage. Originally developed to treat addictive disorders, such as
substance abuse, the stage model has now been applied to a broad
range of health habits, including exercising and sun protection behaviors.
STAGES
1. Precontemplation: The precontemplation stage occurs when a person has no intention of
changing his or her behavior.
2. Contemplation: It is the stage in which people are aware that they have a problem and
are thinking about it but have not yet made a commitment to take action. Many people
remain in the contemplation stage for years. Interventions aimed at increasing receptivity
to behavior change can be helpful at this stage.
3. Preparation: In this stage, people intend to change their behavior but have not yet done so
successfully. In some cases, they have modified the target behavior somewhat, such as
smoking fewer cigarettes than usual, but have not yet made the commitment to eliminate
the behavior altogether.
4. Action: This stage occurs when people modify their behavior to overcome the problem.
Action requires the commitment of time and energy to making real behavior change. It
includes stopping the behavior and modifying one’s lifestyle and environment to rid one’s
life of cues associated with the behavior.
5. Maintenance: In the stage of maintenance, people work to prevent relapse and to
consolidate the gains they have made. For example, if a person is able to remain free of an
addictive behavior for more than 6 months, he or she is assumed to be in the maintenance
stage.
A person may take action, attempt maintenance, relapse, return to the precontemplation phase,
cycle through the subsequent stages to action, repeat the cycle again,
and do so several times until they have eliminated the behavior

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PROTECTION MOTIVATION THEORY

The decision on whether or not to engage in health
related behaviors is governed by two distinct
cognitive processes – threat appraisal and coping
appraisal. Both these processes deal with the
consequences that can be expected as a result of
engaging or not engaging in specific health
behavior. Perceptions of what others will expect or
react are aspects of both types of appraisal.
THREAT APPRAISAL
It deals with how threatened one feels by the
threat. In threat appraisal, the mind evaluates the various factors that are likely to influence one
to get involved in a potentially unhealthy behavior like smoking or using drugs.
Perceived vulnerability and perceived severity are the two sets of beliefs from which threat
appraisals are derived.
• Perceived vulnerability is the individual’s belief that he is susceptible to an illness that is a
potential health threat.
• Perceived Severity-Feeling that the health threat will have severe consequences in one’s
life is called as perceived severity.
COPING APPRAISAL
Here one evaluates the various factors that are likely to ensure that one engages in a
recommended response that is preventive in nature. For example, taking a daily walk or using a
condom.
There are three sets of beliefs involved here.
• Response efficacy is the belief that engaging in a certain behavior will result in the health
threat getting reduced. For example, here there is a feeling that ‘If I exercise more, I will
lose weight and lessen the threat of heart disease.’
• self-efficacy deals with the belief that one has the required capabilities to engage in a
health behavior.
• The perceived response-cost deals with the costs that one attaches to the performance of
a health behavior. For example, a lady should feel comfortable getting a mammogram.

SOCIAL COGNITIVE THEORY

Social Cognitive Theory (SCT) started as the Social Learning
Theory (SLT) in the 1960s by Albert Bandura. It developed into
the SCT in 1986 and posits that learning occurs in a social
context with a dynamic and reciprocal interaction of the
person, environment, and behavior.
Reciprocal determinism
Bandura’s theory says that a person’s behavior is influenced
by the environment and vice versa. In simpler terms, this
means that the environment tends to make changes in the
behavior of the individual, and, on the other hand, the
behavior of the person is also responsible for changing the
environment. Therefore, it means that not only the
environment influences the person, but the person also
influences the environment OR Bandura’s theory says that a person’s behavior is influenced by the
environment and vice versa.
TYPES OF LEARNING
• Enactive learning: Learning by doing and is reinforced by the consequences of
actions/outcomes.
• Vicarious learning: Learning through observation not performance.

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LEARNING PROCESS REQUIREMENTS

• Attention: Learning by being attentive. Anything that distracts the attention will be going to
have a negative effect on learning. If the situation is far likely to the interest, the more the
learner dedicate his full attention to learn.
• Retention: The ability to store information is also an important part of the learning process.
This can be affected by a number of factors, but the ability to pull up information later and
act on its vital observation.
• Reproduction: Once a person pays attention and be able to retain the information, it is
time to actually perform the behaviour you observed. Further practice of the learned
behaviour leads to improvement and skill advancement.
• Motivation: In order to be successful, you have to be motivated to learn being aware of its
outcome. Reinforcement and punishment play an important role in motivation.
Weakness of theory
→ The theory is loosely structure.
→ Doesn’t take emotional responses into account.
→ Ignores biological differences between individuals – genetic factors.
→ Assumes that all behaviour is a result of modeling, not genetics, illness, or other influences.

MODELS OF PREVENTION
A model is a theoretical way of understanding a concept or idea. A prevention is a set of actions
aimed at eradicating, eliminating or minimizing the impact of disease and disability.
LEVELS OF PREVENTION
• PRIMORDIAL PREVENTION: Primordial prevention consists of actions and measure that inhibit
the emergence of risk factors in the form of environmental, economic, social, and
behavioural conditions and cultural patterns of living etc.
It is the prevention of the emergence or development of risk factors in countries or
population groups in which they have not yet appeared.
For example, many adult health problems (e.g. obesity, hypertension) have their early
origins in childhood, because this is the time when lifestyles are formed (for example,
smoking, eating patterns, physical exercise)
• PRIMARY PREVENTION: Primary prevention can be defined as the action taken prior to the
onset of disease, which removes the possibility that the disease will ever occur.
It signifies intervention in the pre pathogenesis phase of a disease or health problem.
Primary prevention may be accomplished by measure of Health promotion and specific
protection.
• SECONDARY PREVENTION: It is defined as “action which halts the progress of a disease at its
incipient stage and prevents complications.” The specific interventions are: early diagnosis
(e.g. screening tests, and case finding programs) and adequate treatment.
Secondary prevention attempts to arrest the disease process, restore health by seeking out
unrecognized disease and treating it before irreversible pathological changes take place,
and reverse communicability of infectious diseases. It thus protects others from in the
community from acquiring the infection and thus provide at once secondary prevention
for the infected ones and primary prevention for their potential contacts.
• TERTIARY PREVENTION: It is used when the disease process has advanced beyond its early
stages. It is defined as “all the measure available to reduce or limit impairments and
disabilities, and to promote the patients’ adjustment to irremediable conditions”
Intervention that should be accomplished in the stage of tertiary prevention are disability
limitation and rehabilitation.

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MODULE 3: STRESS AND COPING

“Stress is a pattern of negative physiological responses occurring in situations where people perceive threats
to their wellbeing which they may be unable to meet” -Lazarus and Folkman (1984)

Stress is a negative emotional experience accompanied by predictable biochemical,

physiological, cognitive, and behavioral changes that are directed either toward altering the
stressful event or accommodating to its effects.

Stress is a key survival mechanism that developed in response to real or imagined threats. It is the
body’s way of reacting to both the good and the bad. Stress can stem from an event, thought, or
experience that makes you feel frustrated, angry, nervous, or overwhelmed. It often manifests as a
feeling of physical or emotional tension in the body.

When your body detects stress, the brain responds by flooding your system with hormones, such as
adrenaline and cortisol. It is these hormones that prompt the “fight-or-flight” response, or cause
people to freeze up in certain situations.

PHYSIOLOGICAL STRESS
It can be defined as any internal or external condition that challenges the homeostasis of a cell or
an organism. The body’s response to stress is its natural automatic response to a perceived
danger or to an upsetting situation. It activates a chain reaction of events in the body known as
the body’s physiological responses to stress as it rises to the occasion to meet the stressful situation.
Two interrelated systems are involved in the stress response. They are: sympathetic-
adrenomedullary (SAM) system and hypothalamic-pituitary-adrenocortical (HPA).

• Sympathetic Activation: When events are perceived as harmful or threatening, they are
identified as by the cerebral cortex in the brain, which in turn sets off a chain of reactions
mediated by these appraisals. Parasympathetic nervous system returns the body to
homeostasis. Therefore, parasympathetic modulation is an important restorative aspect of
sleep, and so changes in heart rate variability may both represent a pathway to disturbed
sleep and help to explain the relation of stress to illness and increased risk for mortality.
• HPA Activation: Hypothalamic-pituitary-adrenal (HPA) axis is the second major
physiological stress –response center. The SAM and HPA axes are regulated by several brain
regions, including the limbic system, prefrontal cortex, amygdala hypothalamus and stria
terminalis. Through these mechanisms stress can alter memory functions reward immune
function metabolism and susceptibility to diseases.

THEORETICAL CONTRIBUTIONS TO STRESS

FIGHT OR FLIGHT RESPONSE
The fight or flight response was the very earliest contribution to stress research by Walter Cannon.
Cannon proposed that it is a reaction a stressful or frightening event. The perception of the event
activates the sympathetic nervous system and triggers an acute stress response. This concerted
physiological response mobilizes the organism to attack the threat or to flee; hence, it is called the
fight-or-flight response.
These responses occur when we feel strong emotion such as fear. Fight refers to aggressive
response to stress, such as getting angry or taking action whereas flight is reflected in social
withdrawal or withdrawal through substance use or distracting activities. The fight-or-flight
response is adaptive because it enables the organism to respond quickly to threat. It can also be
harmful because stress disrupts emotional and physiological functioning, and when stress
continues unabated, it lays the groundwork for health problem

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SELYE’S GENERAL ADAPTATION SYNDROME

Hans Selye, a medical doctor and researcher, came up with theory of GAS. GAS is the three stage
process that describes the physiological changes the body goes through when under stress Selye
observed a series of physiological changes in the rats that resulted from exposure to stressful
events during an experiment with lab rats.

THE RAT EXPERIMENT

Selye repeatedly injected the rats with ovarian extracts. He then exposed rats to a variety of
stressors, such as extreme cold and fatigue, and observed their physiological responses. To his
surprise all stressors produced essentially the same pattern of physiological changes. They all led to
an enlarged adrenal cortex, shrinking of the thymus and lymph glands, and ulceration of the
stomach and duodenum. Selye discovered that it was not the effect of the extracts that gave
such reaction, but the stress of receiving these painful injections and the chronic stressors was
responsible for such results. From these findings, Selye proposed the General Adaptation
Syndrome.

THE GAS THEORY

The general adaptation syndrome consists of three phases:
• Alarm Reaction Stage: The person becomes mobilized to meet the threat. The presence of
a noxious stimulus or stressor leads to activation of the adrenal-pituitary-cortex system. This
triggers the release of hormones producing the stress response. Now the individual is ready
to fight or flight. The body reacts to a stressor with diminished resistance.
• Resistance Stage: If stress is prolonged, the resistance stage begins. The person makes
efforts to cope with the threat, as through confrontation. The para sympathetic nervous
system calls for more cautious use of the body's resources. The organism makes efforts to
cope with the threat, as through confrontation. Stress responses rise above normal. Signs of
the resistance stage include irritability, frustration, and poor concentration.
• Exhaustion Stage: Continued exposure to the same stressor or additional stressors drains the
body of its resources and leads to third stage of exhaustion. The physiological systems
involved in alarm reaction and resistance become ineffective and susceptibility to stress-
related diseases such as high blood pressure becomes more likely. From prolonged
exposure to the stressor, resistance will fall below the normal. Signs include fatigue, burnout,
depression, anxiety, and decreased stress tolerance.

TEND AND BEFRIEND THEORY

S. E. Taylor and colleagues developed a theory of responses to stress termed tend and-befriend.
The theory maintains that, in addition to fight or flight, people and animals respond to stress with
social affiliation and nurturant behavior toward offspring. Tend-and-befriend has an underlying
biological mechanism, in particular, the hormone oxytocin. Oxytocin is a stress hormone, rapidly
released in response to some stressful events, and its effects are especially influenced by estrogen.
In addition, animals and humans with high levels of oxytocin are calmer and more relaxed, which
may contribute to their social and nurturant behavior. Women are more likely than men to
respond to stress by turning to others. Mothers’ responses to offspring during times of stress also
appear to be different from those of fathers in ways encompassed by the tend-and-befriend
theory.

PSYCHOLOGICAL APPRAISALS AND STRESS

Stress is the consequence of a person’s appraisal processes. There are two appraisals:
1. PRIMARY APPRAISALS
Occurs as a person is trying to understand what the event is and what it will mean. Events may be
appraised for their harm, threat, or challenge. Harm is the assessment of the damage that has
already been done, as for example being fired from a job. Threat is the assessment of possible
future damage, as a person anticipates the problems that loss of income will create for him and

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his family. But events may also be appraised in terms of their challenge, that is, the potential to
overcome or even profit from the event. For example, a man who lost his job may regard his
unemployment as an opportunity to try something new.
2. SECONDARY APPRAISALS
Assess whether personal resources are sufficient to meet the demands of the environment. When
a person’s resources are more than adequate to deal with a difficult situation, he or she may feel
little stress and experience a sense of challenge instead. When the person perceives that his or her
resources will probably not be sufficient to overcome the stressor, he or she may experience a
great deal of stress.

COPING
Coping is often defined as efforts to prevent or diminish threat, harm, and loss, or to reduce
associated distress. Some prefer to limit the concept of coping to voluntary responses; others
include automatic and involuntary responses within the coping construct.

COPING DISTINCTIONS AND GROUPINGS

Coping style is a method to deal with stressful events in a particular way. Coping is a very broad
concept. Several distinctions have been made within the broad domain. Some of them are:

1. PROBLEM VS EMOTION FOCUSED:

Problem focused coping is directed at the stressor itself; taking steps to remove or to evade it, or
to diminish its impact if it cannot be evaded. For example, if layoffs are expected, an employee’s
problem-focused coping might include saving money, applying for other jobs, obtaining training
to enhance hiring prospects, or working harder at the current job to reduce the likelihood of being
let go.
Emotion-focused coping is aimed at minimizing distress triggered by stressors. Because there are
many ways to reduce distress, emotion-focused coping includes a wide range of responses,
ranging from self-soothing (e.g. relaxation, seeking emotional support), to expression of negative
emotion (e.g. yelling, crying), to a focus on negative thoughts (e.g., rumination), to attempts to
escape stressful situations (e.g. avoidance, denial, wishful thinking).
Some behaviours can serve either function, depending on the goal behind. Problem and emotion
focused coping can also facilitate one another.
2. ENGAGEMENT VS DISENGAGEMENT:
Engagement coping (approach) is aimed at dealing with the stressor or the resulting distress
emotions (related emotions). It includes problem-focused coping and some forms of emotion-
focused coping: support seeking, acceptance, emotion regulation and cognitive restructuring.
Disengagement coping (avoidance) is aimed at escaping from dealing with the stressor or the
resulting distress emotions. Disengagement coping includes responses such as avoidance, denial,
and wishful thinking. Disengagement coping is often emotion focused, because it involves an
attempt to escape feelings of distress. It is generally ineffective in reducing distress over the long
term, as it does nothing about the threat’s existence and its eventual impact.
3. ACCOMMODATIVE COPING AND MEANING-FOCUSED COPING:
Within engagement coping, distinctions have been made between attempts to control the
stressor itself, called primary control coping, and attempts to adapt or adjust to the stressor,
termed accommodative or secondary-control coping. It refers to adjustments within the self that
are made in response to constraints. Accommodation applies to responses such as self-
distraction, acceptance, cognitive restructuring, and scaling back one’s goals in the face of
insurmountable interference.
A related concept is what Folkman (1997) called “meaning-focused coping”, in which people
draw on their beliefs and values to find, or remind themselves of, benefits in stressful expert. It
includes reordering life priorities and infusing ordinary events with positive meaning. It involves
reappraisal, and appears to be most likely when stressful experiences are uncontrollable or are
going badly.

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4. PROACTIVE COPING:
Some coping occurs proactively before the occurrence of any stressor. It is intended to prevent
threatening or harmful situations from arising. Proactive coping is problem-focused. It requires first,
the ability to anticipate or detect potential stressors; second, coping skills for managing them; and
third, self-regulatory skills.

CHARACTERISTICS OF COPING:
→ The relationship between coping and a stressful event is a dynamic process: It is a series of
transactions between a person who has a set of resources, values, and commitments and
a particular environment with its own resources, demands, and constraints.
→ The breadth of coping: Emotional reactions, including anger or depression, are part of the
coping process, as are actions that are voluntarily undertaken to confront the event.

COPING OUTCOMES:
When coping, health psychologists typically assess whether the following outcomes have been
achieved:
✓ Reducing or eliminating stressors
✓ Tolerating/adjusting to negative events or realities
✓ Maintaining a positive self-image
✓ Maintaining emotional equilibrium
✓ Continuing satisfying relationships with others
✓ Enhancing the prospects of recovery, if one is ill
✓ Keeping physiological, neuroendocrine, and immune reactivity relatively low or restoring
these systems to pre-stress levels.

COPING INTERVENTIONS:
Not everyone is able to cope with stress successfully on their own, and so interventions for coping
with stress have been developed. Some of them are:
─ Mindfulness Meditation and Acceptance/Commitment Therapy
─ Expressive writing
─ Self-affirmation
─ Relaxation training and Coping skills training
─ Managing the stress of college
─ Stress Management Program
─ Identifying stressors and monitoring stress
─ Identifying stress antecedents
─ Avoiding negative self-talk. Engaging in positive self-talks and self-instruction
─ Completing take-home assignments
─ Acquiring skills and setting new goals
─ Using other cognitive-behavioral techniques.

MODERATORS OF COPING – PERSONALITY

Coping can function as a moderator when the relationship between stressors and stress reaction is
dependent on whether a person is a “good” or a “bad” coper. Our target question is how
personality relates to coping. Personality and coping play both independent and interactive roles
in influencing physical and mental health. On the personality side, information on that question
provides an elaborated view of how traits influence behavior. On the coping side, it provides a
clearer view of who can be expected to engage in which type of coping in response to different
kinds of adversities. Associations between personality and coping, inventories for the assessment
of coping, and the dimensions of coping behaviour, are then considered.

Several moderators: age, stressor type and severity, situational vs dispositional coping and time
lag emerge between the coping activity and the coping report. The role of individual differences

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in work stress processes, with particular reference to personality and coping act as moderator
variables.

• AGE: Many relations between personality and coping were stronger in younger than in
older samples, particularly those for problem solving and cognitive restructuring. There are a few
reasons for this. Temperament may affect coping responses more strongly in children than in
adults, who are likely more skilled at matching coping strategies to situational demands. Age
related declines in neuroticism and increases in agreeableness and conscientiousness may lead
older adults to experience less distress and thus more consistent in coping. The fact that much of
the moderation occurred for problem solving and cognitive restructuring suggests the possibility
that most people acquire more skill as they age, tending to wash out individual differences.

• STRESSOR TYPE AND SEVERITY: Relations between personality and coping were generally
stronger in samples facing a high degree of stress (e.g., cancer, chronic pain, divorce) than in
samples with little stress. Low-grade stressors promote less coping variability than chronic stressors
do. Stressors that require clear, specific responses, such as changing a flat tire or meeting a work
deadline, also provide little room for individual differences to operate. Thus, chronic or high
intensity stressors may best reveal relations between personality and coping.
The domain of stress also moderates relations between optimism and coping. Optimism was more
strongly linked to problem-focused engagement for academic and health stressors than for the
less controllable trauma-related stressors. In contrast, optimism related more strongly to emotion-
focused engagement for traumatic and health stressors, which are more severe and less
controllable than academic stressors. This suggests that optimism is associated with flexible coping
and the capacity to match coping to the demands of the stressor. Daily-report studies also
suggest the importance of context.

• SITUATIONAL VERSUS DISPOSITIONAL COPING: Situational coping is a transactional process in

which individuals change their coping response to meet the demands of specific life stressors.
Dispositional coping is conceptualized as habitual tendencies that shape the way individuals
handle stress. Dispositional coping measures demonstrate greater stability over time than
situational assessments. Furthermore, dispositional coping predicts similar situational coping
reliably, but the magnitude of the relations is often low. This shows that the two constructs are
related but not redundant.
• TIME LAG: Another potentially important moderator is the time lag between the coping
activity and the coping report. Retrospective coping reports are weakly related to daily reports,
with longer recall periods and higher stress levels promoting greater discrepancies. There are
several likely reasons. Accuracy of reports is influenced by difficulty aggregating responses over
time, memory errors, self-presentation biases, and the extent to which stresses were resolved.
Indeed, personality may influence the nature of recall biases: People may be more likely to
remember and report strategies that work well for them or are consistent with their traits.

SOCIAL SUPPORT
“Social support is defined as information from others that one is loved and cared for, esteemed
and valued, and part of a network of communication and mutual obligations.”

Social support refers to the psychological and material resources provided by a social network to
help individuals cope with stress. Social support can come from parents, a spouse or partner, other
relatives, friends social and community contacts or even a developed pet. People with social
support experience less stress when they confront a stressful experience, cope with it more
successfully, and even experience positive life events more positively. Not having social support in
times of need is stressful and social isolation and loneliness are powerful predictors of health and
longevity. People who have difficulty with social relationships such as the chronically shy or those
who anticipate rejection by others are at risk for isolating themselves socially. Just as a social

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support has health benefits, loneliness and social isolation have risk for physical, cognitive and
emotional functioning.

TYPES OF SOCIAL SUPPORT

Social support can take any of several forms.
• Tangible assistance involves the provision of material support, such as services, financial
assistance or goods. For example: the gifts of food that often arrive after a death in a family
mean that the bereaved family members will not have to cook for themselves and visiting
friends and family.
• Family and friends provide informational support about stressful events. For example, if an
individual is facing an uncomfortable medical procedure, a friend who went through the
same thing could provide information about the exact steps involved.
• Supportive friends and family can provide emotional support by reassuring the person that he
or she is a valuable individual who is therefore the warmed and nurture and provided by other
people can enable a person under stress to approach the stressful event with greater
assurance.

EFFECT OF SOCIAL SUPPORT ON ILLNESS

Social support can lower the likelihood of illness, speed recovery from illness or treatment and
reduce the risk of mortality due to serious disease. Social support also typically benefits health
behaviours as well. People with high levels of social support are more adherent to their medical
regiments and they are more likely to use health services. Lonely and socially isolated people
have poor health and experience more adverse symptoms on a daily basis. They also practice
poorer health habits which may contribute to risk for poor health.

MODERATION OF STRESS BY SOCIAL SUPPORT

The two possibilities explored to study moderation of stress by social support are:
(i) DIRECT EFFECTS HYPOTHESIS - The direct effects hypothesis maintains the social support is
generally beneficial during non-stressful as well as stressful times.
(ii) BUFFERING HYPOTHESIS – The buffering hypothesis maintains that the physical and
mental health benefits of social support are chiefly evident during periods of high stress;
when there is little stress, social support may offer few such benefits.
According to this view point, social support acts as a reserve and resource that blunts the effects
of stress when it is at high levels.

WHAT KIND OF SUPPORT ARE MORE EFFECTIVE?

• FAMILY SUPPORT
Support from family is important. Receiving social support from one's parents in early life and living
in a stable and supportive environment as a child have long-term effects on cropping abilities and
on health. Marriage, especially a satisfying marriage, is one of the best protectors against stress.
• COMMUNITY SUPPORT
Support from one's community beneficially affects health. For example: an investigation in
Indonesia found that mothers who were active in the community were more likely to get resources
and information about healthcare for their children.

GIVING SOCIAL SUPPORT

Giving support can promote health. Most research on social support has focused on getting
support from others which has benefits. But giving social support others has beneficial effects on
mental and Physical health as well. For example: one study examined the effects of giving and
receiving social support among older married people. People who provided instrumental support
to friends’ relatives and neighbours or who provide emotional support to their spouses were less
likely to die over the next five years.

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ENHANCING SOCIAL SUPPORT

Health psychologists view social support as an important resource in primary prevention.
Increasingly, people are living alone for long periods during their lives, either because they have
never married or divorced or have lost a spouse due to death. Clearly, patterns of social support
are shifting, but whether they are shifting in ways that continue to provide support remains to be
seen. Finding ways to increase the effectiveness of existing or potential support from family,
friends, and Internet buddies should be a high research priority. A number of interventions have
been undertaken to try to reduce loneliness. Some of these focus on improving social skills,
whereas others attempt to enhance existing social support.

THREATS TO SOCIAL SUPPORT

Stressful events can interfere with obtaining social support. People who are in stress may express
distress to others and drive those others away, thus making a bad situation even worse. Sometimes
would – be support providers do not provide the support that is needed and instead react in an
unsupportive manner that aggravates the negative events.

LIFE STRESSORS
A stressor is a chemical or biological agent, environmental condition, external stimulus or an event
seen as causing stress to an organism. Psychologically speaking, a stressor can be events or
environments that individuals might consider demanding, challenging, and/or threatening
individual safety. Stressors occur when an individual is unable to cope with the demands of their
environment. Stressors are of two types:
• External stressors are events or situations that happen to you. Some examples include
major life changes, environment, unpredictable events, workplace.
• Internal Stressors are self-induced. The feelings and thoughts that pop into your head and
cause you unrest are known as internal stressors. Examples of internal stressors include fears,
uncertainty, beliefs, unrealistic expectations, and change.

STRESS MANAGEMENT PROGRAMMES

Stress management is a wide spectrum of techniques and psychotherapies aimed at controlling a
person's level of stress, especially chronic stress, usually for the purpose of and for the motive of
improving everyday functioning. Managing stress, therefore, can involve learning tips to change
the external factors which confront you or the internal factors which strengthen your ability to deal
with what comes your way.
1. IDENTIFYING STRESSORS: Effective stress management starts with identifying your sources of
stress and developing strategies to manage them. One way to do this is to make a list of
the situations, concerns or challenges that trigger stress response. These can be divided into
external stressors and internal stressors.
2. MONITORING STRESS: Individuals are trained to observe their own behaviour closely and to
record the circumstances that they notice that are most nerve-racking. In addition, they
record their physical, emotional, and behavioural reactions to those stresses as they
experience them They also record any maladaptive efforts they undertook to cope with
these stressful events, including excessive sleeping or eating, online activity, and alcohol
consumption.
3. NEGATIVE SELF-TALK: Negative self-talk is any inner dialogue you have with yourself that
may be limiting your ability to believe in yourself and your own abilities, and to reach your
potential. So, avoiding negative self-talk would be hard. It is often far easier to change the
intensity of your language. "I can't stand this" becomes, "This is challenging." "I hate..."
becomes, "I don't like..." and even, "I don't prefer..." When your self-talk uses more gentle
language, much of its negative power is muted as well.
4. KEEP A STRESS DIARY: This is one of the stress coping strategies which clarifies the causes of
any stress you might be feeling and helping you managing the stress. You may be able to

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see patterns in the stress you go through. This will help you to be able to concentrate on
areas you need to improve your ability to cope. And even help you to see how much you
can cope with.
5. ACQUIRING SKILLS: These skills embrace cognitive-behavioural management techniques,
time management skills, and other stress reducing interventions, such as exercise. Some of
these techniques are designed to eliminate the stressful event; others are geared toward
reducing the experience of stress while not essentially modifying the event itself.
6. SETTING NEW GOALS: Goal setting can be an effective stress reliever. It can help you
reduce the vagueness often bogging down otherwise specific goals. Due to this
specification, they’re also measurable, which means you can pass certain milestones
which help to motivate and excite you moving forward.

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MODULE 4: PSYCHOSOCIAL ISSUES & MANAGEMENT OF

ADVANCING AND TERMINAL ILLNESS
Terminal illness is used to describe patients with advanced disease and a drastically reduced
lifespan, with perhaps months or weeks to live. Inevitably the range and severity of physical
symptoms will have increased, and will be having a profound effect on how the patient lives his
life. General symptoms such as fatigue, pain and sleeplessness will all be taking their toll. How well
a patient will cope is dependent on a number of variables, age of patient, level of education,
religion, previous experience of illness, social support, personality and medical factors such as pain
to name but a few. An optimal adjustment also depends on how bad news is delivered, and how
the various reactions to this are manage.
In many cases, but not all, the patient will only have reached the terminal phase of the illness after
a period of declining health and failed treatment. Both the patient and his family may well be
aware of the possibility that the prognosis is grave, but this is different to being told that death is
certain in so many months. There are also cases where the patient may present with metastatic
disease, and the diagnosis and prognosis may come as an enormous shock to patient and family
alike.
EMOTIONAL RESPONSES TO CHRONIC ILLNESS
Immediately after a chronic health disorder is a diagnosed, a patient can be in a state of crisis
marked by physical, social, and psychological disequilibrium. If the patient’s usual coping efforts
fail to resolve these problems, the results can be an exaggeration of symptoms and their meaning,
indiscriminate efforts to cope, an increasingly negative attitude, and worsening health. People
with chronic health disorders are more likely to suffer from depression, anxiety and generalized
distress. These psychological changes are important because they compromise quality of life,
predict adherence to treatment and increase the risk of dying early.
DENIAL
Denial is a defense mechanism by which people avoid the implications of a disorder, especially
one that may be life-threatening. It is a common early reaction to chronic health disorders.
Immediately after the diagnosis of the health disorder, denial can serve a protective function by
keeping the patient from having to come to terms with problems posed by the health disorder
when he or she is learnt able to do so. It can interfere with taking in necessary treatment
information and compromise health. Many people use denial in their everyday lives to avoid
dealing with painful feelings or areas of their life they don't wish to admit.
Simple denial occurs when someone denies that something unpleasant is happening.
Minimization occurs when a person admits an unpleasant fact while denying its seriousness.
Projection occurs when a person admits both the seriousness and reality of an unpleasant fact but
blames someone else.
ANXIETY
Anxiety is also common and occurs when the patients are overwhelmed by the potential
changes in their lives and, in some cases, by the prospect of dying. Anxiety is especially high when
people are waiting for test results, receiving diagnoses, awaiting invasive medical procedures,
and anticipating or experiencing adverse side effects of treatment.
Anxiety is a problem not only because it is intrinsically distressing but also because it interferes with
treatment. Symptoms of anxiety may also be mistaken for symptoms of the underlying disease and
thus interfere with assessments of the disease and its treatment.
DEPRESSION
Depression is a common reaction to chronic health disorders. Up to one third of all medical in
patients with chronic disease report symptoms of depression, and up to one-quarter suffer from
severe depression. Depression especially common among stroke patients, cancer patients and
heart disease patients as well as among people with more than one chronic disorder. Depression

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predicts death from all causes. Depression complicates treatment adherence and medical
decision making. Depression is sometimes a delayed reaction to chronic health disorders,
because it takes time for patient to understand the full implications of their condition. Depression
increases with severity of the health disorder and with pain and disability.

ASSESSING DEPRESSION: Depression is so prevalent among chronically ill patients that experts
recommended routine screening for depressive symptoms during medical visits. Many symptoms
of depression such as fatigue, sleeplessness, and weight loss can also be symptoms of disease or
side effect of a treatment.

PSYCHOSOCIAL ISSUES
Psychosocial care of the patient with terminal illness begins with delivery of the diagnosis. There
are so many possible reactions a patient may have when informed of the diagnosis, it is helpful to
have some plan of action in mind that will permit the greatest range and freedom of response by
the patient. Guidelines have been developed for communicating bad news.
When the diagnosis is made and it is time to inform the patient, the physician should meet with the
patient in a private place. If possible, the patient should be informed ahead of time that after all
the tests are completed the physician will review the results and discuss treatment plans in detail. If
the patient is tested as an outpatient and returns home before the results are known, he or she
should be told that the diagnostic information is too important to convey by phone, and a
meeting to discuss the results should be arranged. Relaying bad news by phone may be
perceived by patients as thoughtless, even though they may have asked for information. A
physician must also be prepared to respond to a patient who wishes no or minimal information
about the diagnosis.

CONTINUED TREATMENT
Advancing and terminal illness frequently bring the need for continued treatments with
debilitating and unpleasant side effects. For example, chemotherapy for cancer may produce
chronic diarrhea, hair loss, and fatigue. The patient with advancing cancer may require removal
of an organ to which the illness has now spread, such as a lung or part of the liver. There may,
consequently, come a time when the question of whether to continue treatments becomes an
issue. In some cases, refusal of treatment may indicate depression and feelings of hopelessness,
but in many cases, the patient’s decision may be supported by thoughtful choice.

ISSUE OF NON TRADITIONAL TREATMENT

In general, it is used to describe practices outside the bounds of conventional medicine. As both
health and communication deteriorate, some terminally ill patients turn away from traditional
medical care. Frantic family members, friends who are trying to be helpful, and patients
themselves may scour fringe publications for seemingly effective remedies or cures. Some patients
are so frantic at the prospect of death that they will use up both their own savings and those of
the family in the hope of a miracle cure. People seek out these alternatives because
i. they are dissatisfied in some way with conventional treatment.
ii. they see alternative treatments as offering more personal autonomy and control over
health care decisions.
iii. the alternatives are seen as more compatible with the patients’ values, worldview, or
beliefs regarding the nature and meaning of health and illness.

STAGES TO ADJUSTMENT TO DYING

The five stages of the Kübler-Ross stage model are the best-known description of the emotional
and psychological responses that many people experience when faced with a life-threatening
illness or life-changing situation.
STAGE 1: DENIAL-The main characteristic is thinking the new never happened. The person would
continue life as if nothing happened. One treatment option is to force the person into angle
deliberately (not the smartest thing, but it works apparently).

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STAGE 2: ANGER- A second reaction to the prospect of

dying is anger. Anger is one of the hardest responses for
family and friends to deal with. The family may need to
work together with a therapist to understand that the
patient is not really angry with them but at fate. The
angry patient may show resentment to anyone who is
healthy, such as hospital staff, family or friends. Angry
patients who cannot express their anger directly by
being irritable may do so indirectly by becoming
embittered.

STAGE 3: BARGAINING- At this point, the patients

abandons anger in favor of different strategy, trading
good behaviour for good health. Bargaining may take
the form of a pact in which the patient agrees to
engage in good works or atleast to abandon selfish ways in exchange for better health or more
time. A sudden rush of charitable activity or uncharacteristically pleasant behaviour may be a
sign that the patient is trying to strike such a bargain.

STAGE 4: DEPRESSION- It may be viewed as coming to terms with lack of control. The patient
acknowledges that little can now be done to stay the course of illness. This realization may be
coincident with a worsening of symptoms, tangible evidence that the illness is not going to be
cured. At this stage, patients may feel nauseated, breathless, and tired. They may find it hard to
eat, to control elimination, to focus attention, and to escape pain or discomfort.
This grieving process may occur in two stages, as the patient first comes to terms with the loss of
past valued activities and friends and then begins to anticipate the future loss of activities and
relationships. Depression, though far from pleasant, can be functional in that patients begin to
prepare for the future. Depression can nonetheless require treatment, so that symptoms of
depression can be distinguished from symptoms of physical deterioration.

STAGE 5: ACCEPTANCE- At this point, the patient may be too weak, to be angry and too
accustomed to the idea of dying to be depressed. Instead, a tired, a peaceful though not
necessarily pleasant calm may descend. Some patients use this time to make preparations,
deciding how to divide up their remaining possessions and saying goodbye to old friends and
family members.

PSYCHOLOGICAL MANAGEMENT OF TERMINAL ILLNESS

BREAKING BAD NEWS
There are various essentials to the delivery of bad news, which although they sound obvious are
not always adhered to. A senior doctor who knows the patient and family well should arrange to
see the patient, and if at all possible with a relative or family friend. Sufficient time and privacy are
important, an open ward not being the best place to impart bad news. How much do the patient
and family already know, in some cases there may be a discrepancy between the two, the family
withholding information from the patient or vice versa. Unfortunately, this latter scenario is very
common which then creates communication barriers and undermines effective support; it also
puts the doctor in a difficult ethical situation. Resolving this situation can be difficult and requires a
lot of time and effort talking to all parties involved. When the prognosis is actually given to the
patient it is best to avoid giving a specific time limit as the patient views this as a death sentence,
and will be counting off the days. It is far better to talk in terms of months whilst giving them some
hope in the future in terms of new treatments that may come out, or other patients who have
beaten the odds and survived far longer. In other words, they should prepare for the worst, but
hope for the best.

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ADJUSTMENT TO LIFE THREATENING ILLNESS

The patient may react in a number of ways when faced with a life-threatening situation. Elizabeth
Kubler Ross described five stages in coping with loss, a period of denial followed by anger,
bargaining, depression and finally acceptance. This is still a very useful framework although these
stages may not always occur in the order given above. Greer and Watson described five
adjustment styles that a patient may exhibit when confronted with a life threatening illness:
1. Fighting Spirit: A patient who exhibits fighting spirit sees the illness and ensuing difficulties as a
challenge.
2. Avoidance or Denial: Some degree of avoidance or denial can be beneficial in that it can
allow the patient to carry on with their lives but this may interfere with treatment compliance.
3. Fatalism: These patients are unduly passive and feel they have little influence over the course
of the disease.
4. Hopelessness and Helplessness: The patient is unduly hopeless and feels powerless in the face
of such an overwhelming threat. The patient becomes death centered rather than life
centered.
5. Anxious preoccupation: Living with the uncertainty of the future causes them untold distress
and they seek constant reassurance from the Doctor or relatives
PREVALENCE
The commonest psychiatric disorders seen in the terminally ill are adjustment disorders, depression,
anxiety and delirium.
PHYSICAL REHABILITATION
It involves several goals such as learning to use one’s body as much as possible, how to make the
appropriate physical accommodations, learn new physical management skills, learn a necessary
treatment regimen, and to learn how to control energy expenditure.
THE IMPACT ON SEXUALITY
The ability to continue physically intimate relations can improve relationship satisfaction among
people with chronic and terminal health disorders and improve emotional functioning.
THE FINANCIAL IMPACT OF CHRONIC HEALTH DISORDERS
Chronic and terminal health disorders can have a substantial financial impact on the patient and
the family. Many people are not covered by insurance sufficient to meet their needs.
SOCIAL INTERACTION PROBLEMS
After diagnosis, some people with chronic health disorders have trouble re-establishing normal
social relations.

MEDICAL STAFF AND TERMINAL ILL PATIENT

Death in an institution can be a long, lonely, mechanized, painful, and dehumanizing experience.
Problems such as wards being understaffed, staff unable to provide any emotional support to the
patient, hospital regulations, or terminal patients being under medicated arises.
THE SIGNIFICANCE OF HOSPITAL STAFF TO THE PATIENT
Patients are entirely dependent on medical staff for improvement of their pain and staff may be
the only people to see a dying patient on a regular basis if he or she has no friends or family who
visit regularly. Moreover, staff may be the only people who know the patient’s actual physical
state; hence, they are the patient’s only source of realistic information. Finally, staff are important
because they are private to one of the patient’s most personal and private acts, the act of
death.
RISKS OF TERMINAL CARE FOR STAFF
Terminal care is hard on hospital staff. It involves a lot of unpleasant custodial work, such as
feeding, changing, and bathing the patient, and sometimes symptoms go undertreated. The staff
may burn out from watching patient after patient die, despite their best efforts.
Physicians, in particular, want to reserve their time for patients who can most profit from it and,
consequently, may spend little time with a terminally ill patient. Unfortunately, terminally ill patients
may interpret such behavior as abandonment and take it very hard.
Useful set of goals for medical staff in their work with the dying:
• Informed Consent—Patients should be told the nature of their condition and treatment and, to
some extent, be involved in their own treatment.

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• Safe Conduct—The physician and other staff should act as helpful guides for the patient
through this new and frightening stage of life.
• Significant Survival—The physician and other medical staff should help the patient use his or
her remaining time as well as possible.
• Anticipatory Grief—Both the patient and his or her family members should be aided in working
through their anticipatory sense of loss and depression.
• Timely and Appropriate Death—The patient should be allowed to die when and how he or she
wants to, as much as possible. The patient should be allowed to achieve death with dignity.
These guidelines, established many years ago, still provide the goals and means for terminal
care.

INDIVIDUAL THERAPY
Individual counseling is a one-on-one counseling between a client and a trained therapist, in a
safe, caring, and confidential environment. The client expresses whatever comes in his mind. After
counseling they know what is bothering them, and what they actually want from life. Therapy with
the dying is different from typical psychotherapy in several respects. First, for obvious reasons, it is
likely to be short term. The format of therapy with the dying also varies from that of traditional
psychotherapy.
The nature and timing of visits must depend on the inclination and energy level of the patient,
rather than a fixed schedule of appointments. Terminally ill patients may also need help in
resolving unfinished business. Through careful counselling, a therapist may help the patient come
to terms with the need for these arrangements, as well as with the need to recognize that some
things will remain undone. Positive self-talk, such as focusing on one’s life achievements, can
undermine the depression that often accompanies dying. It can be emotionally exhausting to
become intimately involved with people who have only a short time to live. Nonetheless, such
efforts can help dying people place their lives into perspective prior to death. Many people find
meaning in symbolic immortality, a sense that one is leaving behind a legacy through one’s
children or that one is joining afterlife and becoming one with god. Thus the last weeks of life can
crystallize the meaning of a lifetime.

FAMILY THERAPY
Sometimes, the preferable therapeutic route with dying patients is through the family. Dying does
not happen in a vacuum but is often a family experience. As a consequence, family therapy can
be an appropriate way to deal with the most common issues raised by terminal illness:
communication, death- related plans and decisions, and the need to find meaning in life while
making a loving and appropriate separation. Sometimes the therapist will need to meet
separately with the family members as with the patient.
Family and patient may be mismatched in their adjustment to the illness, and the need of the
living and the dying can be in conflict, with the living needing to maintain their resources and
performs their daily activities at the same time that the patient needs a great deal of support. A
therapist can help family members find a balance between their own needs and those of the
patient. Other conflicts may arise that require intervention. If a patient withdraws from some family
members but not others, a therapist can anticipate the issues that may arise so that the patient’s
withdrawal is not misunderstood, becoming a basis for conflict. Both patients and family members
are trying to express. For many families, terminal illness can be a time of great closeness and
sharing. It may be the only time when the family sets aside time to say what their lives within the
family have meant.

THE MANAGEMENT OF TERMINAL ILLNESS IN CHILDREN

A disease that cannot be cured and that is reasonably expected to result in the death of the
child within a short period of time is termed as terminal illness.
Working with terminally ill children is perhaps the most stressful of all terminal care. As a result,
family members, friends, and even medical staff may be reluctant to talk openly with a dying
child about his or her situation. Nonetheless, terminally ill children often know more about their

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situation than they are given credit for. Children use cues from their treatments and from the
people around them to infer what their condition must be. As their own physical condition
worsens, they develop an idea of their own death and realization that it may not be far off.
Counselling with a terminally ill child may be required and typically follows some of the same
guidelines as is true with dying adults, but therapists can take cues about what to discuss from the
child. Parents of dying children experience an enormous stress burden to the degree that they
sometimes have the symptoms of post-traumatic stress disorder. Parents too may need counselling
to help them cope with the impending death. They may blame themselves for the child’s illness or
feel that there is more they could have done. Counsellor working with the family can help restore
balance.
TREATMENT OPTIONS FOR TERMINALLY ILL CHILDREN
• Hospital
Family may choose to remain in the hospital to receive care if the Child’s illness or condition is
unstable and home care is not an option or the family is uncomfortable with providing care at
home. Hospital care for the terminally ill is comforting, emotionally wrenching, and demanding of
personalized attention in ways that often go beyond the resources of the hospital. Consequently,
hospice care in one’s own home or in a hospice facility is increasingly an option for dying people.
• Home Care
Home care is often the option chosen by physicians and families because of the traditional view
that a child must be considered to have a life expectancy of less than six months to be referred to
hospice care. Home care appears to be the choice for most terminally ill patients, and for many
patients, it may be the only economically feasible care. The psychological advantages of home
care are that the patient is surrounded by personal items and by the family rather than medial
staff. Although home care is often easier on the patient psychology, it can be very stressful for the
family.
• Hospice Care
Hospice is a community health care organization that specializes in the care of dying patients by
combining the Hospice philosophy with the principles of Palliative Care. The idea behind hospice
care is the acceptance of death, emphasizing the relief of suffering rather than the cure of illness.
Hospice care is designed to provide Palliative Care and emotional support to dying patients and
family members.

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