The Lathe of Heaven by Ursula K. LeGuin Essay - 568 Words

Sometimes your dreams seem better than reality; sometimes they can be worse than your nightmares. In Ursula K. LeGuin’s The Lathe of Heaven, we follow the character George Orr as his dreams alter the reality of his dystopian world. Sometimes for the better, sometimes for the worse. After an attempt to control his subconscious with drugs, George Orr is forced to attend sessions of psychotherapy with a man named Dr. Haber, the antagonist of the story. He discovers Orr’s ability to dream a new reality and tries to use the power for the greater good of Earth by manipulating Orr’s dreams with an â€Å"Augmentor†. As the new reality begins taking shape throughout the story, the dreams rapidly become more destructive. George also hires an†¦show more content†¦Ã¢â‚¬ËœI suppose that you suggested that there be no more color problems. No question of race.’ † In trying to abolish racism, everyone’s skin is turned gray. No African Americans, no white people. This complicates things when the dream creates a reality where Heather Lelache no longer exists. George cannot let this new normal stand, as the love of his life is now non-existent. Without an issue like this getting in the way, ridding the world of racism is quite a brilliant idea. After previous failed experiments, Haber decides to shoot for all-around world peace. â€Å"Presently he felt a heavy hand on his shoulder. ‘Bad time again? Damn, I thought I’d let you off easy. Told you to dream about peace.’,† Haber says to George. This also proves to be a problem as dreams can never be exactly as we wish they could be. In dreaming about world peace, it is accomplished. However, there is only peace on Earth because there is distress beyond the planet. Aliens are invading the moon, which results in a war between mankind and the extraterrestrials. This unites Earth in peace to fight another species. Seen in all the exa mples, Haber wishes to fix big problems. They just never went right. If Haber had not lost this mind within the power and chaos, he could have been seen as a noble, unsung hero. HisShow MoreRelated Ursula K. LeGuins The Lathe of Heaven and Science Fiction and the Future1234 Words   |  5 PagesUrsula K. LeGuins The Lathe of Heaven and Science Fiction and the Future What will happen in a couple of days? a month ? a year? or twenty years from now? The answer is not known. Author Ursula K. LeGuin gives us the answers about the future from her point of view which can be seen through her article Science Fiction and the Future and her novel, The Lathe of Heaven. Ursula K. LeGuin believes people try to control the future they may have when in reality they have no control over the futureRead MoreThe Dystopian Novel Of Literature2214 Words   |  9 Pagesacross Other Dystopian Texts Along with Fahrenheit 451 another book that continues to bend the minds of readers is The Lathe of Heaven. The Lathe of Heaven is a dystopian/science fiction novel written by Ursula K. LeGuin. In the novel, LeGuin created a character named George Orr who has a supernatural power. The power to turn his dreams into a reality. In the beginning of the book LeGuin lets the reader know that George has been taking pills that would keep him from falling asleep. George was avoidingRead More Perfection in Ursula LeGuins The Lathe of Heaven Essay1933 Words   |  8 PagesPerfection in Ursula LeGuins The Lathe of Heaven Is there such a place where ideal perfection exists? Can our views on social, political, and moral issues ever concur with one another? The answer to these questions is simple - no. The world we live in today is full of social, political, and moral imperfections that hinder our ability to live a life free of evil. In Ursula LeGuins The Lathe of Heaven, this imperfect lifestyle is the foundation on which the desire for a utopian society sits

Is Hamlet Insane or Is He Not - 745 Words

Is Hamlet insane or is he not? There is no right answer to that question because some argue that he is and others argue that he is not. I however do not consider Hamlet insane. I believe that he is depressed because of the death of his father and the hasty marriage of his mother to his uncle not too long after his father’s death. Hamlet does not understand why his mother is still not grieving the death of his father like he is. I feel that he is upset with his mother because he see her new marriage to his uncle as her being unfaithful to the marriage that she had with his father. Hamlet expresses his disappointment of his mother for disregarding the death of husband. When he expressed his disappointment of her he called her â€Å"frailty, thy name is woman† (1.2.148). In the beginning of play we find out that Hamlet fathers ghost has been seen by Horatio, Marcellus and Bernardo. Horatio advises them that they should tell Hamlet about seeing the ghost of his father. Since he was not able to get the ghost to speak to him. He does not think that the ghost will refuse to speak to his son Hamlet. When they tell Hamlet that they saw the ghost, he insisted on going back with them to speak with the ghost. The ghost made Hamlet follow him so that he could inform him of how he was murdered by Claudius hands and orders Hamlet to avenge his death. Hamlet decides that he needed to find more evidence to support the claim the ghost made. However, the Devil can adopt a pleasing form that canShow MoreRelatedSanity in William Shakespeares Hamlet Essay1037 Words   |  5 PagesShakespeares Hamlet Hamlet is a play about a man who has had a father killed by his uncle, after this act of treachery the uncle then marries Hamlet’s mother. Hamlet is sane in this play because prior to going â€Å"insane† he informs us he is going to. If Hamlet were truly insane he would not be able to tell others that he is going to act insane as of a certain point in time. Hamlet would try to deny insanity, not pride himself in the fact that he is insane. Hamlet uses insanityRead MoreAll that Hamlet has Gone Through887 Words   |  4 PagesHamlet is a character which has gone through a lot.Throughout the play it is not sure if he has gone insane or if he is just truly pretending to be. Needless to say he went through some things that could make anyone go insane. In such a short amount of time his life turned upside down. His dad died, which by itself can make anyone go crazy. To make matters worse shortly after his dad dies, his mom decides to marry his uncle. His uncle who becomes king after he murders Hamlets dad. Although HamletRead MoreWas Hamlet Faking His Insanity? Essay572 Words   |  3 PagesIn Hamlet, he seems to be mad, but there is a question that everyone asks when reading or watching this play â€Å"was it, or was it not true that Hamlet was faking his insanity, really suffering, or maybe even both.† First, this is what insanity is: insanity is acting crazy, but not knowing that they ’re acting crazy. Also, it’s going through a lot of stress at the same time causing you to act stranger then a normal person. Hamlet was not totally insane. It doesn’t fit. I’m not saying that Hamlet wasRead MoreHamlet, By William Shakespeare866 Words   |  4 PagesHamlet, the son of the former King of Denmark is in a state of depression due to his father’s murder which was committed by his uncle. This is followed by the marriage of his mother and the same uncle who killed his father; this forces Hamlet into a state of misery. Upon learning that his father was murdered, Hamlet is also told by his father’s ghost to get revenge. Throughout the play, Hamlet often pretends to be insane or in a state of madness. This is all apart of how he will plan to kill is murdererRead MoreThe Complexity Of Vessity Insanity In William Shakespeares Hamlet1016 Words   |  5 PagesOne of his famous tragedies play is Hamlet, which based on Prince Hamlet’s revengeful plan against his uncle, King Claudius. However, some critics question Hamlet’s insanity and they believe Hamlet is actually pretending to be insane. The purpose of this essa y is to examine the extent to which the character, Hamlet, is insane. Despite different critics’ opinions regarding Hamlet’s insanity, it seems Hamlet is not insane at the beginning but becomes insane when he confronts his mother. The followingRead MoreHamlet by William Shakespeare788 Words   |  3 PagesInsane or Not Insane? In the tragedy, Hamlet by William Shakespeare, the audience is presented with a character who suffers inner and external conflicts. Hamlet, the young prince, continues to mourn his father’s death from the beginning of the play until the end. Hamlet’s inner conflict is that he discovers Claudius, his uncle, has committed the murder of his father. Hamlet does not analyze how he will seek revenge and murder his Uncle Claudius without his conscience interfering. The external conflictRead MoreMadness And Madness In Hamlet1455 Words   |  6 Pagesâ€Å"Hamlet, a revenge tragedy, is about Hamlet, the prince of Denmark, trying to figure out the mist behind his father’s death. By talking to his father’s ghost, Hamlet realizes that his father, King Hamlet, was killed by his own uncle, Claudius† (Kara 2). Throughout the play, the theme of madness often occurs from multiple characters. Madness can be defined as a mental disability or a pathological condition of the mind eliminating all rational thoughts caused by an unthinkable injury. These injuriesRead More Use of Insanity and Madness in Hamlet Essay1141 Words   |  5 Pages It is or is it not true that Hamlet was faking his insanity? I’m not saying Hamlet was faking the whole thing. The meaning for insanity on Dictionary.com is â€Å"a permanent disorder of the mind.† I dont think Hamlet had a permanent disorder of the mind he knew what he was doing and even planned the majority of the events that happened. Most of the time anyway. Having your father die is bad enough, but to have your mother marry your uncle, within a few weeks of your father’s death? Then to seeRead MoreHamlets Personality Faults1306 Words   |  6 PagesThroughout Hamlet, written by Shakespeare, Hamlet’s emotions, actions, and thoughts cause much trouble during the play. Hamlet encounters stages of sarcasm, inanity, suicidal tendencies/self-deprecation, and procreation/indecision which develop not only his personality but the play itself. Hamlet uses sarcasm to express his emotions, pretends to be insane (ultimately leading him to become truly insane), self-deprecates throughout the play due to family events, and procrastinates because he is indecisiveRead MoreInsanity In Hamlet Essay975 Words   |  4 PagesQuestioning the Sanity of Hamlet In Hamlet by William Shakespeare, Hamlet’s sanity is questionable throughout the play. Insanity is defined as the â€Å"unsoundness of mind or lack of the ability to understand† (Merriam-Webster). In the play, Hamlet’s father, King Hamlet, is murdered by Claudius, Hamlet’s uncle, in secrecy. To make matter’s worse, Claudius then continues on to get married in an inscetuous relationship with Hamlet’s mother, the queen. Emotions are heightened when Hamlet then see’s a ghost that

Jane Addams And Gloria Steinem - 1903 Words

Feminism has been a controversial topic since as early as the 19th century. Feminism has had a profound effect on women’s roles in society as well as their everyday life. There are countless feminists whose achievements are still recognized and remembered today. Jane Addams is a historical feminist who changed the lives for the women of her time, and is still talked about to this day. While feminism was huge in the earlier years of America, there are contemporary feminists who fight for the rights and equality of women that are still not met. In recent years, Gloria Steinem has spoken up for the equality of women and pushed for social reform. Jane Addams and Gloria Steinem are more than feminists, they are activists with many accomplishments that changed the lives for every woman of their time. Jane Addams is a well-known historical feminist, activist, social worker, and leader in women’s suffrage whose legacy still lives on today. Although she was considered radical fo r her time, she thought of ways to push for social and political reforms in socially acceptable ways. Her achievements created an abundance of opportunities for women that would change their roles in society. September 6, 1860 Addams was born in Cedarville, Illinois to a family with a great amount of money. Since her teens, Addams had big dreams to do something useful in the world. Addams was full of ambition that stemmed from her childhood experiences. Her mother passed away when Addams was only two years

Compare And Contrast John Smith And William Bradford

Compare/Contrast Essay In the early 1580-1590 two Englishman named John Smith and William Bradford establish colonies, but they were two different leaders in that time. They both wrote journals to explain what happens in those months one in first person and the other in third person. â€Å" Such actions have ever since the worlds beginnings and been subject to such accidents, and everything of what is found full of difficulties, and but nothing so difficulties†Ã¢â‚¬ ¦. I think what John means that you cant get everything life easily you need to work for it and earn it like you should and everyone does when it comes to hard working. Also, that life has obstacles, but you can overcome them with a positive attitude. â€Å" They were good people†¦show more content†¦His journal was about himself and everyone else, especially about his crew and what happens during those months. He wrote his book in first person, but he never braggart no he was very humble. â€Å" They were good people, in ot her words, Christians they all got along with each other out when they were unhealthy and when it comes to surviving.†(Willam) What he meant that they were religious and they brought women and children to their colonies, not just men. The difference between Jamestown and Plymouth they were opposites from each other, Especially how they care themselves during the difficult times. Jamestown they only care about themselves, no one else besides them they didnt care if they were sick or dying, they just left them alone and did their only thing. But Plymouth was more caring they were good people who want to help a person out if they throw up or were very sick. Some things they had in common were they both wrote journals, but John in 3rd person and William in the first person. Also, both English men had starvation times and good times as well. But the most was probably deaths they had so many people but only half them survives. Finally, they both got attacked by native American because they wanted to protect the land that the white man is trying to take over and native American .had no spare it was more like dangerous. The two men, both wanted something they both wanted to know how the New World is gonnaShow MoreRelatedC omparison Between John Smith and William Bradford737 Words   |  3 PagesEngland by John Smith The author John Smith, a pilgrim who arrived to the Americas, wrote a description of the new land in his book â€Å" A Description of New England †. In this book Smith shows a wonderful world of vast food and pleasure. Also, William Bradford another pilgrim who arrived to Plymouth on the coast of Massachusetts, wrote a book called â€Å" Of Plymouth Plantation † in which he describes what really happened, how the pilgrims actually lived. The purpose of this essay is to compare and contrastRead More Analysis of A Description of New England by John Smith Essay646 Words   |  3 PagesEngland by John Smith The author John Smith, a pilgrim who arrived to the Americas, wrote a description of the new land in his book â€Å" A Description of New England †. In this book Smith shows a wonderful world of vast food and pleasure. Also, William Bradford another pilgrim who arrived to Plymouth on the coast of Massachusetts, wrote a book called â€Å" Of Plymouth Plantation † in which he describes what really happened, how the pilgrims actually lived. The purpose of this essay is to compare and contrastRead MoreCompare And Contrast Of Smith And Bradford935 Words   |  4 Pages Rust 1 Mrs. Myers September 20, 2016 Compare and Contrast of Smith and Bradford On April 10, 1606, John Smith (an adventurer) explorer and author, and his crew were sent by King James I to start a colony in Jamestown. In December 1606 the company sent out three ships carrying 106 settlers to start the new colony. On May 13, 1607 John Smith named the colony Jamestown in honor of the King. Years later on September 6, 1620 William Bradford (an English Separatist) went to Cape Cod, MassachusettsRead MoreSimilarities And Differences Between Plymouth And Jamestown1185 Words   |  5 PagesLeaders of Plymouth and Jamestown are both compare because they both came from England, Native Americans aided the newly incorporated groups by supplying them for food, and both empires resulted in the starvation and death. However, in Jamestown, John Smith set a goal to make money and get rich, developed the idea of everyone for themselves, men were the dominant gender, and Smith abandoned the colony and never decided to return. As for Plymouth, William Bradford s’ goal was to have religious freedomRead MoreInterpreting Bias Within Historical Accounts1501 Words   |  7 Pagestreat an author’s bias as an opportunity to uncover â€Å"truths† that can be even more meaningful than the unattainable accurate representation of facts. A primary example of how history can be obscured by writers is the way in which two Englishmen, William Bradford (1590-1657) and Thomas Morton (1579-1647), provide two very different accounts of the same events in Of Plymouth Plantation and in New English Canaan respectively. Both men are affected by the desire to promote their beliefs and to make theirRead MoreAmerican Revolution and Study Guide Essay example5377 Words   |  22 PagesIndians. What specific developments illustrate that the English living in the plantation colonies tried to apply these lessons? (25 pts) 2. Compare and contrast the ways in which tobacco and sugar affected the social and economic development of colonial America (10pts) Chapter 3 Study Guide â€Å"Settling the Northern Colonies† 1. Compare and contrast the motives of the their founders, religious and social orientation, economic pursuits, and political developments of TWO of the early colonialRead MoreRethinking Mercantalism Essay15042 Words   |  61 PagesRethinking Mercantilism: Political Economy, the British Empire, and the Atlantic World in the Seventeenth and Eighteenth Centuries Author(s): Steve Pincus Reviewed work(s): Source: The William and Mary Quarterly, Vol. 69, No. 1 (January 2012), pp. 3-34 Published by: Omohundro Institute of Early American History and Culture Stable URL: http://www.jstor.org/stable/10.5309/willmaryquar.69.1.0003 . Accessed: 06/09/2012 12:18 Your use of the JSTOR archive indicates your acceptance of the TermsRead MoreHistory of Management Thought Revision17812 Words   |  72 Pagesthat management is not a science in an academic sense, but Taylor intended to use a scientific fact-finding method to determine a better way): a. Time study -- this was prescriptive in that Taylor sought to identify the time a job should take (contrast this with Charles Babbage who measured only the length of a work cycle). b. Time study was analytical, breaking the job into its components and eliminating useless movements; and constructive, building a file of movements that were common to otherRead MoreDebt vs. Equity and Asymmetric Information: a Review16933 Words   |  68 Pagesequilibrium is generally used in models in which the uninformed agent moves first by offering a menu of incentive compatible choices (contracts) from which the informed self-select, revealing their private information through their choice. 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Coping and Health A Comparison of the Stress and Trauma Literatures Free Essays

Coping and Health: A Comparison of the Stress and Trauma Literatures Carolyn M. Aldwin and Loriena A. Yancura Dept. We will write a custom essay sample on Coping and Health: A Comparison of the Stress and Trauma Literatures or any similar topic only for you Order Now of Human and Community Development University of California, Davis Chapter prepared for P. P. Schnurr B. L. Green (Eds. ), Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association. COPING AND HEALTH Even a cursory review of PsychLit reveals that well over 20,000 articles on stress and coping processes have been published in the past two decades (Aldwin, 1999). A smaller proportion of these has specifically examined how individuals cope with trauma. Due to differences between researchers in how trauma is defined, a definitive number is difficult to 2 determine. However, a search for the key words trauma and coping yielded 1,000 articles. Given the magnitude of this literature, we will not attempt to provide a full review. However, we will briefly outline the different theoretical and methodological approaches to coping (for more complete reviews see Aldwin, 1999; Lazarus, 2000; Parker Endler, 1996; Schwarzer Schwarzer, 1996). Then we will examine the similarities and differences between coping with general problems and coping with trauma. Finally, we will provide whether a brief review of the relationship between coping and health outcomes, and focus on whether coping strategies can affect both the psychological and physical outcomes of trauma. THEORETICAL AND METHODOLOGICAL APPROACHES TO COPING There are four basic theoretical and methodological approaches to coping. Psychoanalytic approaches focus on the use of defense mechanisms, while personality approaches focus on coping styles. Both of these assume that adaptation is primarily a function of personal characteristics. In contrast, the coping process approach draws upon cognitive behavioral models, and is more likely to emphasize environmental demands and influences on coping. Coping process approaches tie the coping strategies to a particular stressful episode. Finally, COPING AND HEALTH daily coping processes use experience sampling techniques to examine how individuals cope throughout the course of the day with a wide variety of problems. Psychoanalytic Approaches Research on how individuals adapt grew out of early psychoanalytic studies of defense mechanisms, which are considered to be unconscious ways of warding off anxiety. DSM-IV (American Psychiatric Association, 1994) currently identifies seven major types of defense mechanisms, and orders them hierarchically from more to less severe. The most severe is defensive dysregulation, which refers to frankly psychotic processes involving projection, denial, and delusion. Action refers to acting out, passive aggression, or apathetic withdrawal, and major image-distorting mechanisms include autistic fantasy, projective identification, and splitting. The less severe or â€Å"immature† mechanisms include disavowal (denial, projection, and rationalization), minor image-distorting (devaluation, idealization, and omnipotence), and mental inhibitions (displacement, dissociation, intellectualization, repression, and the like). High adaptive or â€Å"mature@ defense mechanisms include altruism, humor, and sublimation, as well as suppression. Cramer (2000) compared the similarities and differences between defense mechanisms and coping processes. Defense mechanisms are unconscious, nonintentional, dispositional, hierarchical, and associated with pathology, while coping processes are conscious, used intentionally, situationally determined, nonhierarchical, and associated with normality. In other words, defense mechanisms are designated a priori as being more or less adaptive, and are not COPING AND HEALTH 4 consciously chosen. Individuals nonetheless can be characterized by primary defensive styles or defense mechanisms that they are most likely to exhibit under a wide variety of circumstances. In contrast, coping processes are thought to be consciously chosen and are responsive to environmental demands. Rather than hierarchically ordered, the effectiveness of coping processes is thought to vary as a function of appropriateness to environmental demands. Defense mechanisms are traditionally studied via the use of intensive interviews and case studies. However, a number of inventories have been developed to assess defense mechanisms via self-report, including Gleser Ihilevich (1969), Haan (1965) and Joffe Nadich (1977). However, the psychometric properties of these scales are questionable (Cramer, 1991; Davidson MacGregor, 1998). Of more recent vintage is a Defense Style Questionnaire (Bond, Gardiner, Sigel, 1983). However, as Cramer (2000) points out, there is a logical inconsistency in asking individuals to report on unconscious processes, and researchers are more likely to use observational methods and/or rely upon qualitative research coding interview or projective materials. In part because of the difficulty of systematically assessing defense mechanisms, there have been few large-scale studies of the adaptational outcomes of defensive strategies. Indeed, more research has been directed to identifying the developmental trajectory of defense mechanisms (Vaillant, 1977, 1993), as well as in identifying predictors of the use of immature defenses, including personality and affective disorders (see Cramer, 2000, for a review). Nonetheless, the study of defense mechanisms truly set the stage for understanding how people cope with both stress and trauma. COPING AND HEALTH Coping Styles. A major outgrowth of the psychoanalytic literature was the conception of coping styles, 5 which borrowed some of the language from psychoanalysis but was more focused on how people deal with information than how they deal with emotions per se. The earliest typology was repression-sensitization (Byrne, 1964). Repressors avoid or suppress information, while sensitizers seek or augment information. This dichotomy has reappeared in many different guises over the past 30 years, with blunting-monitoring (Miller, 1980) and approach-avoidance (Roth Cohen, 1986) being the current manifestation of dichotomy. In general, approachmonitoring-vigilant coping styles have been shown to be associated with better outcomes in a variety of situations, while repression-avoidant-blunting styles are associated with poorer outcomes (for reviews, see Aldwin, 1999; Roth Cohen, 1986). Dichotomizing coping strategies into two broad modalities can be psychometrically appealing. Certainly Endler and Parker (1990) have shown that the factor structure of coping style inventories, which currently focus more on problem- vs. emotion-focused coping, are more stable than process measures, and often correlate reasonably well with psychological symptom inventories. However, even early research by Lazarus and his colleagues showed that both types of coping were used in over 80% of episodes, and often individuals in highly stressful situations alternate between approaching and avoiding the problem (Folkman Lazarus, 1980; Lazarus, 1983). Nonetheless, the use of particular emotion-focused coping strategies may be more consistent across time and strategies, suggesting that individuals may have characteristic ways of dealing with and/or expressing emotion (see Aldwin, 1999). COPING AND HEALTH Coping Process As mentioned earlier, the coping process approach draws upon the cognitive behavioral perspective, and argues that coping is flexible and responsive to environmental demands, as well as personal preferences. In this model, how individuals cognitively appraise situations is the primary determinant of how they cope. The four primary appraisals are benign, threat, harm/loss, and challenge, and these are influenced both by environmental demands and individual beliefs, values, and commitments (Lazarus Folkman, 1984). Rather than examining general coping styles, coping process approaches examine how individuals cope with a particular stressor. Coping process approaches have recently come under attack from a variety of perspectives. Critics have charged that the factor structure for such inventories as the Ways of Coping is not stable, either across time or across samples (Endler Parker, 1990) although the factor structure for the COPE (Carver, Scheier, Weintraub, 1989), another widely-used coping measure, is also less than satisfactory (Schwarzer Schwarzer, 1996). However, the factor structure for coping process measures may not be stable precisely because they are responsive to environmental demands (Schwartz Daltroy, 1999). Coyne Racioppo (2000) also criticized coping inventories as being to o vague to generate clinically meaningful results, and argued for more situation-specific inventories (which, however, would also create problems of generalizability across situations). Nonetheless, there is broad agreement concerning the types of coping strategies that exist. There are five general types: problem-focused coping, emotion-focused coping, social support, COPING AND HEALTH 7 religious coping, and making meaning. Note that coping strategies are not mutually exclusive, and even strategies which may seem orthogonal, such as suppressing and expressing emotions, may be used sequentially in the same situation. Within each general type of coping strategy, there may be several subtypes. Problem-focused coping includes cognitions and behaviors that are directed at analyzing and solving the problem. It may include â€Å"chunking† or breaking a problem into more manageable pieces, seeking information, and considering alternatives, as well as direct action. Sometimes delaying or suppressing action is seen as a separate problem-focused strategy. Delaying action or decisions may be used in health circumstances in which people are waiting for the outcome of tests, and suppressing action may be useful in avoiding actions which may make a problem worse, such as acting in anger. Emotion-focused coping is often seen as a strategy in and of itself, but is best conceived as involving different sub-types. Avoidance and withdrawal may be different from expressing emotion, and suppression, setting one’s emotions aside in the service of a problem-solving effort, is clearly different from the use of substances to regulate emotion. Avoidance, withdrawal, and substance use are most generally associated with poor outcomes (Aldwin Revenson, 1987). Seeking social support and religious coping are strategies that involve elements of both problem-focused and emotion-focused coping. Support seeking may include asking for advice, concrete aid, emotional support, or justification for one’s perceptions and/or actions (Thoits, 1986). Similarly, religious coping, which includes prayer, is generally considered a form of emotion-focused coping, but may involve asking for advice or even concrete aid. The study of COPING AND HEALTH religious coping strategies is as yet in its infancy (Pargament, 1997), and the associations of to outcome measures by vary by religious denomination (Park, Cohen, Herb,1990). In general, religious coping may be most helpful with uncontrollable stressors (Aldwin, 1994) or for lower socioeconomic status groups (Cupertino, Aldwin, Schulz, 2000). Social support, conceptualized as social integration (Berkman Syme, 1994), and social disclosure (Smythe, 1998) are almost always associated with better mental and physical health outcomes, in coping studies. However, seeking social support is almost always associated with poorer outcomes (Monroe Steiner, 1986). The reasons for this are not well understood, but may devolve around negative reactions from others (Rook, 1998), or perhaps the act of seeking support may be indicative of poor networks or a catastrophizing coping style. Finally, making meaning is a strategy that is least well understood. It involves trying to make sense of the problem, and, in the general coping literature, may be called â€Å"cognitive reframing. † It involves such strategies as â€Å"looking for the silver lining† or trying to perceive 8 positive aspects of the current problem. Making meaning may be most often used in coping with extreme stressors, such as trauma or major losses (Mikulincer Florian, 1996), and thus will be discussed in greater detail in the trauma section. Daily Process Coping Daily process coping involves the assessment of coping strategies generally directed at specific problems once or more per day. Respondents may be asked to fill out questionnaires every evening, or they may be beeped and fill out mini inventories on the spot. To date, only a handful of coping studies have utilized this method (for a review, see Tennen, Affleck, Armeli, COPING AND HEALTH 9 Carney, 2000). The correlation between process and retrospective measures of coping is a matter of some controversy. While some claim that it is fairly low (Ptacek, Smith, Espe, Raffety, 1994), examination of the raw data reveals that, in at least one study (Stone et al. , 1998), the correlation is actually quite high, about . 7 (although only the r2 was reported). Further, Schwarzer and Schwarzer (1996) have criticized the psychometric properties of daily process measures, as they are of necessity quite short and often consist of single items. Nonetheless, the associations between momentary coping and process outcome measures tend to be encouraging, although there are within-subject and between-subject (aggregated) analyses may differ in some curious ways which merit further investigation. For example, Affleck et al. (2000) examined daily diary associates between coping and alcohol consumption in moderate- to heavy-drinking men and women. Aggregating the data, they found problem-focused coping had no effect average consumption, emotion-focused coping was negatively-related to consumption, but avoidant coping was positively related. However, a very different pattern of results emerged from the within subjects analyses. Instead of the aforementioned pattern, they found an inverse relationship between problem-focused coping and alcohol consumption. The reasons for this are unclear, but may relate to average differences in alcohol consumption. For similar reasons, it would make sense that within-subject analyses of pain patients should show a more protective effect of coping strategies on pain than between-subject analyses (Tennen Affleck, 1996). COPING WITH TRAUMA COPING AND HEALTH 10 It is one thing to describe individual differences in dealing with everyday stressors or even life events, but it is quite another thing to generalize this to traumatic situations. By definition, traumatic situations are generally outside of individuals’ usual experience, and most individuals have not developed the necessary repertoires to know how to deal with such events (although military personnel and some categories of civil servants such as police, firefighters, and emergency medical technicians do receive training). Indeed, at first glance, the initial reaction to major trauma seems stereotypical reports of emotional numbing, cognitive impairment, and aimless wandering have been reported for such disparate traumas as tornadoes (Wallace, 1956), concentration camps (Bettelheim, 1943), nuclear blasts (Lifton, 1968), and combat (Solomon, 1993). It would be tempting to argue that the environmental press of trauma is so great that there are few individual differences in reaction to it. However, closer examination of the trauma literature reveals marked individual differences in how people cope even with traumatic situations, although clearly environmental factors may constrain choices. Further, as we shall see, how coping strategies can influence the long-term psychological and perhaps physical responses to the trauma. Aldwin (1999) identified four ways in which the pattern of coping responses in traumatic situations differs from that from ordinary life events. First, individuals in traumatic situations may feel they have less control over their cognitions and behaviors. Solomon (1993, p. 3) quoted a crack paratrooper during the Yom Kippur war, who, despite his elite training, found himself frozen in the middle of action, unable to move to help his fellow soldiers. Such freezing reactions may also be common in rape (Burgess Holstrom, 1976). In naturalistic descriptions COPING AND HEALTH 11 of people in traumatic situations, the use of defense mechanisms such as di ssociation, repression, and denial may be much more widespread (Ward, 1988). Indeed, when being tortured, either by one’s political enemies or one’s parents, dissociation may be the only option available (Figley, 1983). Second, disclosure may be of particular importance in traumatic situations. While seeking social support may be associated with poorer outcomes with everyday stressors, in trauma situations, individuals who disclose to others typically do much better both in terms of short and long-term outcomes (Smythe, 1998; Lee, Vaillant, Torrey, Elder, 1995). However, the reaction of others in the social environment may moderate this relationship. In particular, individuals who experience negative reactions from others may have worse outcomes than individuals who did not disclose (Silver, Holman, Gil-Rivas, 2000). Third, the process of coping with trauma is usually much more extended than is coping with general hassles or even life events, especially if an individual develops post-traumatic stress disorder (Horowitz, 1986). Indeed, the sequellae of major trauma has been documented to last for decades (Aldwin, Levenson, Spiro, 1994; Kahana, 1992; Schnurr, Spiro, Aldwin, Stukel, 1998). Epstein (1991) has referred to trauma as the ‘atom-smasher’ of personality, and the process of reconstructing both lives and sense of identity may take years (Lomranz, 1990). Thus, it is not surprising that fourth difference, ‘making meaning’, is a strategy which has particular utility in traumatic situations (Mikulincer Florian, 1996). Making meaning may entail both reorganization of existing cognitive-motivational structures, as well as reappraisal or reinterpretation of not only the event but also the context of the event in a person’s life. Loss COPING AND HEALTH events may also entail a search for meaning, especially if those events are sudden or traumatic (Wortman, Battle, Lemkau, 1997). While this search for meaning may be painful in and of itself, and sometimes fruitless, as Wortman and her colleagues have often documented, it may 12 also set the stage of post-traumatic growth (Aldwin Sutton, 1998; Lieberman, 1992; Tedeschi, Park, Calhoun, 1998). Indeed, of the most intriguing aspects of the coping with trauma literature are the hints that trauma may constitute a major avenue for personality change in adulthood. For example, Schnurr, Rosenberg, Friedman (1993) examined change in MMPI scores from college to midlife as a function of combat exposure. They found that MMPI scores were most likely to improve in men who had moderate levels of combat exposure, compared to those who had heavy exposure — or none at all. Similarly, Park, Cohen, Murch (1996) found that students who perceived growth as a result of a major stressor increased in optimism over the course of a year. While some aspects of personality are widely believed to change as a function of trauma exposure (Epstein, 1991), more studies documenting this are needed. In particular, the possible mediating function of coping strategies merits further investigation (Aldwin, Lachman, Sutton, 1996). In addition to these four differences, another way in which studies of coping with trauma differ from general studies of coping with stress is that trauma studies sometimes focus on just one strategy. Examples of such studies include self-blame (Davis, Lehman, Silver, Wortman, Ellard, 1996; Delhanty et al. , 1997), â€Å"undoing† (Davis, Lehman, Wortman, Silver Thompson, 1995), and â€Å"temporal orientation† (Holman Silver, 1998). Surprisingly, while self-blame in everyday situations is generally associated with poor outcomes, in traumatic situations such as COPING AND HEALTH rape or automobile accidents, self-blame may be associated with positive outcomes in that it 13 provides at least an illusion of control in what are often uncontrollable situations. For example, if a rape victim blames herself for approaching a stranger in a car, she may feel that she would be able to avoid such circumstances in the future. Undoing is a particularly intriguing strategy, but may not be specific to trauma. Indeed, it would be very interesting to see how often and under what circumstances this strategy is used in everyday coping. Nonetheless, there have been a number of studies of trauma using standardized coping checklists, and, as we shall see, the process of coping with trauma may be more important for health outcomes than the exposure to trauma itself (Wolfe, Keane, Kaloupek, Mora, Winde, 1993). COPING AND HEALTH OUTCOMES There is a large literature on trauma and long-term health outcomes that will be reviewed by Baum and Dougall (this volume); instead, we will focus on the coping and health outcomes literature. The relationships detailed in this literature are highly complex, in large part because it is atheoretical, and thus difficult to organize effectively. Therefore, we will organize this review by type of outcomes, limiting it to physical health outcomes, with the exception of PTSD. The first section will focus on PTSD, as it is particularly germane to trauma, and the second to selfreported health outcomes. The third will focus on biomedical indicators such as cortisol, immune, cardiovascular reactivity, and lipids, while the fourth section summarizes research on coping and the progression of disease or disease outcomes. Finally, we will review the coping intervention COPING AND HEALTH literature, that is, studies which have actively sought to change how individuals cope with the particular stressor they are facing in an attempt to modify disease progression or outcomes. Coping and PTSD There is a growing recognition that how individuals cope with trauma may be more important in the development of post-traumatic stress disorder (PTSD) than the occurrence of 14 the trauma itself (Aldwin, 1999; Mikulincer Florian, 1996). For example, Fairbank, Hansen, Fitterling (1991) compared coping strategies of three groups of WWII male veterans, prisoners of war (POWs) ith PTSD, those without, and veterans who were not POWs. POWs with PTSD were more likely to use wishful thinking, self-blame, and self-isolation, whereas POWs without PTSD were more likely to use reappraisal coping. Aldwin, Levenson, Spiro (1994) also found that the perceived benefits of military service also resulted in lower PTSD symptoms in WWII veterans. Vietnam veterans who used more emot ion-focused coping were also more likely to report PTSD. The Israelis have also conducted a number of studies in this area. One prospective study of combat soldiers in the Lebanon War found that wishful thinking and denial were also predictive of PTSD over the course of a year (Solomon, Mikulincer, Benbenishty, 1989). Concurrent use of problem-focused coping was inversely related to PTSD two to three years after the war in the same population (Solomon, Mikulincer, Abitzur, 1988). Israeli civilians who used palliative coping during the SCUD missile bombing were more likely to experience negative stress reactions (Zeidner Hammer, 1992). COPING AND HEALTH 15 As mentioned earlier, the impact of emotional disclosure of trauma may be moderated by the reactions of others in the environment. Specifically, Stephens and Long (2000) found that New Zealand police officers who received positive peer communication and who could easily talk about trauma had lower PTSD scores and lower levels of physical symptoms. The effects of trauma on health may be mediated through the development of PTSD (Baum, Cohen, Hall, 1993; Davidson Baum, 1993; Schnurr, Spiro, Paris, 2000). Once again, coping strategies may have an indirect effect on health. If their use can prevent the development of PTSD, the adverse heath effects of trauma may be ameliorated. Coping and Self-Reported Health Outcomes While there is a fairly extensive literature on coping and mental health outcomes (for reviews see Aldwin, 1999; Lazarus Folkman, 1994; Zeidner Saklofske, 1996), there are surprisingly few studies of coping and self-reported physical health symptoms in general populations. Most occur in the context of clinical populations and disease progression, which usually include both biomedical and self-report outcomes, and are reviewed below. However, we did find a few studies which used either worker or student populations. . Eriksen, Hege Ursin (1999) examined the interaction between psychological demands, coping, and control in a large sample of Norwegian postal service workers. They found that individual coping styles were more important for subjective health complaints than were either control or organizational factors. Specifically, coping, as assessed by the Utrecht Coping List, moderated the effects of job stress such that individuals with low demands and high coping had the fewest health complaints, while those with high demands and low coping reported the COPING AND HEALTH 16 most. Interestingly, individuals with high demands and high coping had high perceptions of job stress but did not report high levels of symptoms. Pisarsi, Bohle, Callan (1998) examined coping and physical symptoms among shift workers. There were both direct and mediated effect of coping on health outcomes. Specifically, disengagement coping strategies were directly related to increased physical symptoms, but emotional expression was mediated through both conflicts and support. Thus, emotion expression appeared to increase physical symptoms via increased work conflicts and concomitant psychological symptoms, but to decrease physical symptoms through increased family support. Unfortunately, this study did not provide any test of the statistical significance of the indirect paths, and thus we cannot contrast the relative strengths of the indirect paths. However, it does make a certain amount of sense that complaining to coworkers may increase distress and result in more physical symptoms, while complaints to family may elicit more support and thus decrease symptoms. Finally, two studies found that the relationship between coping and physical symptoms disappeared once controlling for personality factors such as neuroticism (Costa McCrae, 1986) and anxiety (Hemenover Dienstbier, 1998). However, both of these studies used coping style measures with general outcomes, and thus it is not surprising that the personality traits would better predict a general outcome. More work is needed to determine if the relationship between coping processes and a time-specific measure of physical symptoms would be similarly overwhelmed by personality. Based on prior research with psychological symptom outcomes, (Bolger, 1990), we suspect that the effect of personality on health is at least partially mediated COPING AND HEALTH 17 through coping strategies, but that coping strategies will have independent effects on symptoms, but research is needed to confirm that. Coping and Biomedical Outcomes There are literally hundreds of studies in humans showing that stress affects both the neuroendocrine and immune systems, and there is a general agreement that there are individual differences in the effects of stress. Situational constraints such as controllability and personality factors such as Type A have been extensively studied (for reviews see Biondi Picardi, 1999; Cohen Herbert, 1996; Frankenhauser Johansson, 1986; Herbert Cohen, 1993; Olff, 1999). However, it is more difficult to actually demonstrate a relationship between coping strategies per se and Ahard@ biomedical outcomes, in part because there are surprisingly few published studies (although the number of studies examining disease outcomes is growing). Although Biondi and Picardi (1999), in their otherwise excellent review of stress and neuroendocrine factors, state that there is ‘a large body of evidence that coping strategies may significantly influence hormonal responses to both laboratory stressors and real life stress situations’ (p. 133), closer examination reveals that they based this conclusion on only four published studies. Further, most reviews focus on a particular biomedical outcome, and we felt that providing an overview of several outcomes might prove instructive. Our initial strategy was to divide the coping and biomedical outcomes literature into laboratory, field, disease outcomes, and intervention studies, separately by coping with stressors vs. coping with trauma in order to provide meaningful contrasts. However, the gaps in the literature made this strategy over-optimistic. While it is not surprising that there were no COPING AND HEALTH 18 laboratory studies on coping with trauma, it turns out that most of the field studies of coping and neuroendocrine outcomes involved traumatic situations. Thus, we will combine both stressor and trauma studies in the same categories, noting differences and similarities, where appropriate. Laboratory studies. Most laboratory studies examining the effect of coping on neuroendocrine outcomes rely on personality assessments of defenses or coping styles. In these often unpublished studies, defensiveness, avoidance, and repression are typically associated with higher cortisol levels (Biondi Picardi, 1999). Bossert et al. (1988) found no relationship between coping styles and cortisol, but their sample size was very small (12 men). Van Eck, Nicholson, Berkhof, Sulon (1996), using a larger sample, also found no relationship between coping style and salivary cortisol. Bohnen, Nicholson, Sulon, Jones (1991) found that ‘comforting cognitions’, a type of cognitive reframing, was negatively associated with cortisol response. A handful of studies have also examined specific coping strategies and cardiovascular outcomes. Tomaka, Blascovich, Kelsey (1992) found no association between repressive coping and psychophysiological reactivity to stress, once the effect of social desirability was controlled. However, Vitaliano, Russo, Paulsen, Bailey (1995) examined cardiovascular recovery from laboratory stressors in older adults, and found that avoidance coping was positively related to diastolic blood pressure and heart rate. The same laboratory also found similar findings among caregivers of Alzheimer patients (Vitaliano et al. , 1993). Controlling for standard risk factors such as smoking, avoidance coping was associated with higher levels of cardiovascular reactivity. COPING AND HEALTH Individuals who show the highest levels of cardiovascular reactivity also show the 19 reatest immune system disturbances to stress (Herbert, Coriell, Cohen, 1994). While there is a growing literature on stress and immune functioning (for reviews, see Cohen Herbert, 1996; Herbert Cohen, 1993; Kiecolt-Glaser Glaser, 1995), we located no laboratory studies which examined induced stressors, coping, and immune outcomes. This is surprising in view of the fact that the immune response to stressors occu rs in minutes (Eriksen, Olff, Murison, Ursin, 1999), even before cortisol responses, and thus the immediate impact of coping on immune function could be studied. However, most of the coping and neuroendocrine lab studies were done in the 1970’s and 1980’s, when the specificity of coping was not as yet well understood and most studies relied on defenses and coping styles. Thus, the absence of coping and immune studies in the laboratory may reflect a more mature understanding of coping. Nonetheless, carefully constructed laboratory studies could clear up some of the conflicting findings in the field studies. Field studies. Although animal studies have indicated that coping style is linked to neuroendocrine profiles in feral animals (Koolhaas et al. 1999), there are a limited number of field studies assessing the effects of coping on neuroendocrine outcomes in humans. Perhaps the most consistent finding is between urinary cortisol and the effectiveness of defenses. Vickers (1988) reviewed five field studies with stressors ranging from military basic training to having a fatally ill child, each of which found that individuals with e ffective defenses had lower levels of urinary cortisol. COPING AND HEALTH 20 Studies of coping strategies and neuroendocrine outcomes have yielded mixed results. For example, an early study by Schaeffer Baum (1984) showed that stress associated with the nuclear power plant disaster at Three Mile Island was related to urinary cortisol, as were psychological and physical symptoms, but coping styles were not. However, coping styles were related to lower levels of distress (Baum, Fleming, Singer, 1983), which presumably should have some effect, albeit indirect, on cortisol and catecholamines outcomes. Arnetz et al. (1991) conducted a prospective study of 354 employees of a telecommunications plant that was being downsized. Not surprisingly, long-term unemployment was associated with high levels of serum cortisol. However, coping was only indirectly related to cortisol via its effect on mastery. Emotion-focused coping was negatively related to mastery, which in turn was inversely associated with cortisol. Avoidance coping may be more directly related to cardiovascular outcomes. In a study of caregivers, avoidance coping was associated with higher levels of cholesterol fractions such as triglycerides, and low density lipoproteins (LDLs), but with lower levels of high density lipoproteins (HDLs) (Vitaliano, Russo, Niaura, 1995). Aldwin, Levenson, Spiro, Ward (1994) found that instrumental action was positively associated with HDLs and negatively with triglycerides, while self-blame showed the opposite pattern. Thus, the relations between coping and cholesterol may actually be more consistent that than between coping and cortisol, but many more studies are needed to show a consistent effect. A handful of studies have examined coping and immune system outcomes. Jamner, Schwartz, Leigh (1988), in a study of outpatients with stress-related disorders, found that COPING AND HEALTH repressive coping was negatively related to monocyte counts, but positively related to eosinophile counts. However, the repressors were also more likely to be taking antihistamines, so interpretation of this study is difficult. In a study of undergraduates, repressors had significantly higher antibody titers to Epstein-Barr, an indicator of a stressed immune system (Esterling, Antoni, Mahendra, Schneiderman, 1990). This pattern was not replicated by Solomon, Segerstrom, Grohr, Kemeny, and Fahey (1997) in their study of earthquake victims. 1 Repressive coping, as indicated by a Type C personality inventory, was unrelated to a variety of immune system outcomes, including lymphocyte subjects, lymphoid cell mitogenesis, and NK cell cytotoxity. However, there was an interaction between generalized distress and life disruption, such that individuals with high levels of disruption who did not report being distressed had impaired immune functioning (lower levels of CD3+ an d CD8+). The authors’ interpretation was that this was indirect support for the impact of repressive coping on immune function. With the exception of this last article, all of the studies reviewed in this section examined the main effects of coping on biomedical outcomes. However, coping is thought to be a moderator of the effects of stress, which would necessitate the examination of the interaction effects between stress and coping on outcomes. We located only two studies which did so, and thus merit some examination in depth. In a small sample of 11 seropositive males, Goodkin, Fuchs, Feaster, Leeka, Rishel (1992) found main effects of active coping on CD4+ cells; Active coping was associated with higher cell counts. While the interaction did not reach significance, contrast comparisons of COPING AND HEALTH 22 means within the high stressor group suggested that there were also significant differences in both total lymphocyte and T4 cells, with highly stressed active copers having higher cell counts than highly stressed passive copers. Goodkin and his colleagues (1992) repeated this study in a larger sample of 62 seropositive males. Carefully controlling for a variety of nutritional and lifestyle factors which affect immune function, there were main effects of coping on natural killer cell counts (NKCC), while venting emotions was associated with lower NKCCs. The interaction effect between stress and active coping was not significant. However, there was no indication that the authors centered the interaction terms to account for multicollinearity (cf. , Cohen Cohen, 1975). There was evidence of bouncing betas, as the beta for stress in the main effects model was . 72 but -25. 69 in the interaction effects model. Thus, the lack of significance of the interaction terms is difficult to interpret. Summary. Despite the hundreds of biomedical studies that have been done on stress and biomedical outcomes, relatively few studies have linked actual coping strategies with such indicators. The early laboratory studies relied primarily on trait measures of defenses, and various indices of what basically is emotional repression were related to higher cortisol levels. In addition, avoidant and repressive coping are related to greater cardiovascular reactivity and impaired immune function. However, there is some indication that positive coping is related to better outcomes. Problem-focused or active coping is related to higher natural killer and CD4+ cell counts and higher HDL levels. The results regarding coping and cholesterol are promising, but need more replication. COPING AND HEALTH 23 Besides its sparseness, a big limitation of this area is that most studies examine only main effects; given that coping is thought to be a moderator of stress, more studies should examine interaction effects. Barron Kenny (1986) caution, however, that valid examination of interaction effects often require very large sample sizes, which may be difficult to achieve in very small samples typical of psychoneuroendocrine and immune (PNI) studies (cf. , Mishra, Aldwin, Colby, Oseas, 1991). Another possible solution is for small sample studies to use jack-knife or boot-strap statistical techniques, which may provide more accurate assessments of the standard errors in small PNI samples (Aldwin, Spiro, Clark, Hall, 1991). Coping and Disease Outcomes There is a much more extensive literature on coping and disease outcomes. Several studies have examined pain and symptomology for individuals with chronic illnesses such as rheumatoid arthritis, the progression of serious illnesses such as AIDS and cancer, and even mortality (for reviews, see Garssen Goodkin, 1999; McCabe, Schneiderman, Field, Skylar, 1991; Tennen Affleck, 1996; Zautra Manne, 1992). These reviews often highlight the complex relationship between coping and outcomes. A variety of personal and contextual factors may moderate the effects of coping on health outcomes. For example, a review of studies on coping with rheumatoid arthritis (Zautra Manne, 1992) showed that there were some strategies that were associated with positive and negative outcomes such as pain. However, the results were often inconsistent, and depended upon coping efficacy, family environments, and personality dispositions. For example, the effect of relying on others has different effects depending upon the severity of illness. Relying on COPING AND HEALTH 24 thers led to increased psychological distress among women with rheumatoid arthritis who were in relatively good health, but lower levels of distress for women who were in poorer health (Reich Zautra, 1995). Helgeson, Cohen, Schulz, Yasko (2000) showed that social support groups had the most positive effect on physical functioning for those breast cancer patients who lacked natural support or had fewer personal resources, but were harmful for those women who had high levels of support. Further, the effects may vary by type of arthritis disease. Affleck et al. 1999) found that emotion-focused coping was positively associated with increased pain in rheumatoid arthritis patients, but decreased pain in osteoarthritis patients. The emotion-focused coping coded in this study involved seeking support and venting to others. Affleck et al. suggested that the differences between these two groups were due to the response of the caregivers. Osteoarthritis pain is specific to movement and thus may be more understandable to caregivers, whereas the pain involved in rheumatoid arthritis (swollen joints and fatigue) is more global and may evoke less sympathetic responses. This fits in very nicely with the trauma literature reviewed above, in which the effects of social disclosure were also moderate by the response of others in the social environment. There is also evidence that coping may have indirect or mediated effects on outcomes. Billings, Folkman, Acree, Moskowitz (2000) showed that coping affected positive and negative affect among men who were caregiving for AIDS patients. Social support coping predicted increases in positive affect, which in turn were related to fewer physical symptoms. COPING AND HEALTH 25 Avoidant coping, however, was related to increases in negative affect, which were related to more physical symptoms. Coping may also be related to the progression of AIDS. One prospective study of a sample of asymptomatic HIV+ men and women also reported that avoidance and passive coping was positively correlated with development of symptoms, while planful coping was negatively related to progression of HIV symptoms (Vassend, Eskild, Halvorsen, 1997). A crosssectional study also found that individuals diagnosed with AIDS were lower in planful problemsolving than HIV negative individuals (Krikorian, Kay Liang, 1995). A Dutch longitudinal study over one year also found that active confrontational coping predicted slower disease progression HIV+ men (Mulder et al. , 1995). A follow-up study also showed that individuals who used avoidant coping had a more rapid deterioration of CD4 cell counts over seven years (Mulder, de Vroome, van Griensven, Antoni, Sandfort, 1999). While there is at best weak evidence for the relationship between coping and the development of cancer (Garssen Goodkin, 1999), coping strategies may affect the response to cancer treatments. Women who used confrontive coping reported fewer side effects from chemotherapy than those who used avoidant strategies (Shapiro et al. , 1997). A few studies have directly looked at coping and the progression of cancer, primarily breast cancers. A series of British studies showed that women who used active coping styles lived longer, especially in those women with early, nonmetastatic cancer (Greer, 1991; Greer Morris, 1975; Morris et al. , 1981). In contrast, a study of women with breast cancer showed that repressors had elevated COPING AND HEALTH 26 evels of mortality, with a risk ratio of 3. 7 (Weihs, Enright, Simmens, Reiss, 2000). However, Buddeberg et al. (1996) found modest associates between coping and death from breast cancer. Individuals using problem tackling and self-encouragement were less likely to die, while individuals using distrust pessimism were more likely to die. COPING AND HEALTH 27 Summary. It is not at all surprising that coping skills and strategies shoul d affect disease progression, especially in those diseases such as AIDS and cancer that have very arduous treatment regimens. It makes perfect sense that individuals who are good planful problem solvers are more able to handle these regimens and have better outcomes, whereas avoidant copers have worse outcomes. More sobering, however, is the recognition that a variety of personal and contextual factors may moderate the relationship between coping and health outcomes such as pain. The effectiveness of coping strategies may vary by the stage of the illness, the type of illnesses, and the responsiveness of others in the environment. This suggests that interventions need to be very specifically tailored to individuals, which is often not the case. Intervention Studies One of the simplest and most dramatic coping interventions in the literature is a written emotional expression task. In this paradigm, individuals are encouraged to write about stressful episodes, especially traumatic ones. In a review of this literature, Smyth (1998) found that disclosure lead to significantly better health outcomes in a variety of biomedical outcomes, cardiovascular reactivity and risk factors, immune outcomes, physiological functioning, and health behaviors. No studies on neuroendocrine outcomes were included in this review. A drawback of these studies is that they utilize primarily undergraduate populations, and their utility varies as a function of duration of the writing task. While single intervention episodes can have significant effects, these tend to be weaker than interventions with multiple writing episodes, as narratives tend to become more focused and coherent over time. It is also unclear whether this is due to cognitive processing or the reversal of emotional repression. A review by COPING AND HEALTH Esterling, L’Abate, Murray, Pennebaker (1999) suggests that both mechanisms may be employed, but for different types of outcomes. Both cognitive processing and the reporting of positive emotions are predictive for emotional well-being, but the reversal of emotional repression may be important for neuroendocrine and immune system outcomes. A large number of ‘coping interventions’ in the behavioral medicine literature consist of psychoeducational interventions (for a review Compas et al. , 1998). The most dramatic and consistent results are seen with pain interventions. In a meta-analysis of 191 studies, Devine (1992) found that statically reliable, albeit modest, effects were found on recovery, postoperative pain, and psychological. Nearly all (79%) of these studies found a shorter length of 28 hospitalization. Interestingly, adding specific coping skills training to standard pain management treatment programs greatly improved pain control (Kole-Snijders et al. , 1999). Perhaps the most dramatic of interventions studies was conducted by Fawzy and his colleagues (Fawzy, Cousins et al. , 1990; Fawzy, Kemeny et al. 1990; Fawzy et al. , 1993; Fawzy Fawzy, 1994), who did specific coping skills interventions with melanoma patients. This was a six-week structured program with multiple components, including health education, psychological support, and training in both problem-solving and stress management. Short-term, the experimental subjects were more likely to use active behavior coping than the controls, and also had more positive affect. Differences in immune functioning were evident between the two groups at the six months assessment. Specifically, experimental subjects had a greater percentage of large granular lymphocytes, more NK cells, and better NK cytotoxicity. While coping strategies were not directly associated with immune cell changes, they were correlated with COPING AND HEALTH affect, which in turn was associated with immune functioning. This supports our supposition 29 that the effects of coping on biomedical outcomes may be mediated through affect. At a five-year follow-up, a third of the control group had died, compared to less than 10% of the experimental group. Longer survival was associated with more active coping at baseline. Towards a Theoretical Model As mentioned earlier, the literature on coping and health outcomes is difficult to disentangle, primarily because so little of it is guided by specific theories. In an early study, Aldwin and Revenson (1987) suggested that there are two possible models, direct effects and moderated effects. Escape/avoidant coping appeared to have primarily direct affects, that is, it tends to increase psychological symptoms, regardless of the stressfulness of the event. In contrast, problem-focused coping was more likely to have moderating or buffering effects. However, the current literature suggests that there are five possible models of the relationship between coping and health outcomes, which are illustrated in Figure 1. (1) Direct Effects. Most of the studies reviewed in this chapter examined only the direct effects of coping on outcome. That is, with notable exceptions, most used a simple correlational paradigm to examine whether coping strategies were related to outcomes. (2) Moderated Effects. Relatively few studies examined whether coping moderates or buffers the effects of stress; the few that did were hampered either by very small sample sizes or poorly constructed statistical analyses. COPING AND HEALTH (3) Mediated Effects. A number of studies suggested that the effects of coping were mediated 30 through other variables, especially affect. That is, coping related to outcome variables only to the extent that it modified affect. (4) Contextual Effects. A number of studies also suggested that the effects of coping, especially emotional expression, were moderated by the reaction of other individuals in the context. 5) Spurious Effects. A handful of studies suggested that the effect of coping on outcomes was spurious; that is, once controlling for personality, the relationship between coping and health outcomes disappeared. This was primarily true for studies with self-reported health outcomes which used coping styles measures. It appears from the literature reviewed here that different models apply to different types of outcome measures. Given the relatively few studies in each of these different areas, definitive conclusions cannot be drawn; rather, these hypotheses are offered as a useful heuristic that may guide future research. Table 1 represents our attempt to summarize this literature, and indicates which models were supported for different coping strategies by outcomes. Given the wide variety of coping measures used, we chose to roughly group strategies into instrumental action, avoidance (including escapism, wishful thinking, and self-isolation), meaning making, cognitive reframing, self-blame, and social support (which includes emotional expression and disclosure). We did try to differentiate between process and styles measures, although the distinction was not always clear from the studies. Unless otherwise noted, the direct effects of instrumental action, cognitive reframing, and meaning making are assumed to decrease or be associated with lower levels of health problems (indicated by a downward arrow), while avoidant and self-blame COPING AND HEALTH strategies are assumed to increase or be associated with higher levels of health problems 31 (indicated by an upward arrow). Tests for other types of models are indicated simply with an X. Question marks indicate contradictory or inconsistent findings. As indicated in Table 1, studies of coping with trauma consistently show that instrumental action and meaning making are associated with lower levels of PTSD, while avoidant coping strategies are associated with higher levels. The effects of social support, generally in the form of disclosure, depend upon the context: if the social network is supportive and responds positively, disclosure works well, but if the network is unsupportive, the individual may be worse off than if s/he had not disclosed their experience with trauma. Similarly, self-blame may be associated with oorer outcomes, but if self-blame allows an individual to maintain at least an illusion of controllability, than self-blame may be associated with positive effects. For example, if a rape victim blames herself for approaching strangers in a car, then theoretically at least she should be able to avoid such situations in the future and therefore decrease her risk of another attack. It is surprising that apparently no s tudies of coping with trauma examined any of the more complex models, such as moderated, mediated, or, for that matter, spurious. All of the self-reported symptoms studies reviewed here examined coping with ordinary stressors, not with trauma. Given the common findings of increased physical symptoms with trauma, is very surprising that none of the coping studies Nonetheless, the results are similar to those found with PTSD. Instrumental action is generally associated with fewer symptoms, and avoidant styles with higher symptoms. As with trauma, however, the effects of social support appear to be contextual. The one study that examined a mediated model found contradictory COPING AND HEALTH 32 athways: emotional expression increased coworker conflict, but also increased family support. Thus, it would appear that the effect is actually contextual — that is, emotional expression in the workplace may increase stress and therefore increase symptoms, but venting to family and friends may increase support and therefore decrease symptoms. It is not surprising that studies using coping styles find that the effect drops out once personality factors such as anxiety are controlled. Given the vast literature on stress and neuroendocrine function, it is surprising that the results were so inconsistent. While some early studies found that those with â€Å"effective defenses† had lower catecholamine levels, it was not clear exactly what this meant, and it was omitted from the table. More recent laboratory studies were just as likely to find no effects of coping styles in general or avoidant styles in particular as they were to find any effects, and none of the field studies found direct effects of coping on neuroendocrine function. However, both the trauma and job loss literatures suggest that the effects may be mediated through affect, although more direct tests are needed. Given the strength of the animal literature and the theoretical models, it is extremely surprising that stronger effects of coping on neuroendocrine function were not found. At first, our inclination was to attribute this to the problem of timing in field studies. Catecholamines have very rapid responses to stress, it is unlikely that the time periods of the coping behaviors and urine collection adequately overlapped. If the coping resulted in long-term changes in affect, then mediated effects might be seen. However, Stanford’s (1993) review of stress and catecholamines suggests an alternative hypothesis. She suggests that, in adapting to stress, COPING AND HEALTH 33 anxiety is associated with high levels of catecholamines, while depression is associated with low levels. Failure to differentiate between the reactions might well lead to the contradictory findings in the literature. In other words, avoidant coping may lead to depression or anxiety, that is, to lower or higher levels of catecholamines. Thus, we hypothesize that the relationship between coping is complex, and mediated not only by level of negative affect but by type as well. Only a handful of studies have examined coping and biomedical outcomes, and only one was in the context of coping with trauma. Avoidant strategies appear to be associated with higher levels of cardiovascular reactivity, while the effect of repressive style is spurious when controlling for anxiety. Similarly, instrumental action is associated with higher levels of HDL and lower levels of LDL and triglycerides, while avoidance and self-blame shows the opposite pattern. The very early studies on coping and immune outcomes are very difficult to interpret, given poor coping measures, specialized samples, and inconsistent results. Tentatively, instrumental action appears to be associated with higher levels of CD4+ and NKCC, while social support, in the form of emotional venting, was associated with lower levels of NKCC. Clearly there is a huge gap in the literature. More studies needed on the effects of coping on biomedical outcomes, especially in the context of trauma, and more sophisticated models need to be examined than simple direct effects. Finally, a more extensive literature exists on coping and disease outcomes. The results are much more consistent and give cause for optimism. Nearly every study has found that instrumental action is associated with slower disease progression, fewer side effects of treatment, and fewer symptoms, while avoidant coping shows the opposite pattern. Given the importance COPING AND HEALTH 34 of adherence to medical regimens and dietary restrictions in coping with chronic illnesses, it is not surprising that problem focus coping leads to better outcomes, and avoidant coping to poorer ones. Interestingly, though, Billings et al. (2000) suggests that all of the effects of coping (at least on physical symptoms in AIDS patients) are mediated through affect. Certainly more studies are needed which examine the mediators of coping on disease outcomes, especially vis-a-vis adherence and affect. The effect of social support on disease outcomes presents a more sobering picture. It is clear that the effects of support are primarily contextual, and have very different effects depending upon the type of illness, reactions to others, and needs of the individual. Clearly, if individuals are severely disabled or relatively socially isolated, provision of positive support may be very beneficial. However, if the primarily caretaker is unresponsive to genuine or creates dependency when support is no needed, then utilization of social support can have harmful effects. In summary, then, it is clear that much more research is needed in order to understand the effects of coping on physical outcomes, whether in the context of everyday stressors, chronic illness, or trauma. The trauma literature is especially deficient with regard to the effect of coping on biomedical outcomes. While most studies have simply examined direct effects, there are hints in the literature that reality is much more complicated. In particular, it is likely that nearly all of the effects of coping on biomedical and disease outcomes are mediated through affect, and, in the context of chronic illness, to adherence to medical regimes. The effects of social support, however, are highly contextual, and depend upon the needs of the individual and the COPING AND HEALTH 35 responsiveness of others in the environment. Given that nearly all of the theoretical models posit coping as a stress buffer, it is extremely surprising that almost no-one bothers to test this. Despite these gaps, however, the evidence does exist that how individuals cope with problems does have an effect on their physiology, and coping interventions can have sometimes dramatic effects on disease outcomes COPING AND HEALTH AUTHOR ACKNOWLEDGMENTS Preparation of this chapter was supported by Hatch Funds from the University of California Cooperative Extension Service. We would like to thank Dr. Crystal Park for her helpful comments on an earlier version of this chapter. 36 COPING AND HEALTH REFERENCES 37 Affleck, G. , Tennen, H. , Keefe, F. , Lefebvre, J. , Kashikar-Zuck, S. , Wright, K. , Starr, K. , Caldwell, D. (1999). Everyday life with osteoarthritis or rheumatoid arthritis: Independent effects of disease and gender on daily pain, mood, and coping. Pain, 83, 601-609. Aldwin, C. M. (August, 1994). 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Audit and Assurance Business Investment Portfolio

Question: Describe about the Audit and Assurance for Business Investment Portfolio. Answer: Insurance as a business is intrinsically risky and has plenty of risks that the company needs to prudently manage in order to run the business in a profitable and sustainable manner. Some of the key risks in this regard are outlined as follows. (Gay Simnett, 2012). The investment portfolio that the company invest is exposed to continued market risk. Besides, due to human errors in the business processes and operations, there are operational risks. However, the greatest risk that the insurance business is exposed to is perhaps underwriting risk when the claims tend to exceed the premiums collected The above risks clearly indicate that the business risks are significant but these can be mitigated if managed well using appropriate risk management, One of the key strategies to manage the underwriting risk is to apply the prudential regulation norms but HIH does not follow these and instead practices a strategy that worsens the underlying risk which is reinsurance. On top of it, the company had expanded business into segments where the losses could be potentially huge such as aviation and money could be made only if sound risk framework is in place. However, HIHs internal working is extremely lousy and reckless. The group has embarked on acquisition without enough due diligence and thereby ended up acquiring a company which it should not and in the process inflated the pressure on the already deteriorating balance sheet. The company lacked sound risk management based on planning of adverse events and the nexus of the management with the auditor further prolonged these practices an d pushed HIH towards the brink of failure. Apparently, the business risk associated with HIH can be termed as high in wake of the arguments presented above. The various inherent risk factors that impact the HIH at the financial level are summarised below based on the information provided in the case. Lack of application of prudential norms It is known that the company did not apply the prudential norms despite having exposure to high risk sectors and instead opted for reinsurance which is widely believed to further increase the risk for insurance companies. Thus, this approach enhanced the inherent risk of the business and played a key role in the groups failure. Acquisition of FAI Insurance The acquisition of the above company was completed by HIH without even undergoing adequate due diligence and having enough consultations at the level of the board which is not acceptable. The end result was that the HIH group ended up paying a premium for a company they should have not even acquired as it did not make business sense for them. However, this deteriorated the financial position of the company and therefore increased the inherent risk. Management Auditor Nexus It is apparent from the information presented that there was nexus operation between the management and auditor where each party was serving each other interest so as to serve their selfish interest and in the process the investors and clients ended up as the loser. This nexus prolonged the reckless policies usage at HIH and thereby enhanced the inherent risk of the company (Gay Simnett, 2012). Independence of the Board of Directors compromised The company appointed three of the previous audit partners on the board which clearly had an adverse impact on the boards neutrality and prudence and ensured that the reckless policies and imprudent risk management policies continued unabated in the company without these coming to the notice of the external stakeholders. This evidently led to the rise in the inherent risk associated with the business (Arens et. al., 2013). 2. 1) The concerned case which the auditors counsel can quote to hint at liability of the directors of the partnership firm is Equitable Life Assurance Society v Hyman [2000] case. As per the case facts, the society sold an insurance policy with two variants i.e. a guaranteed annual return rate as against the market return. The premium associated with both these was the same so that investors can choose as per their risk profile. However, it so happened that whenever it was found that the guaranteed returns exceeded the market rate of returns, then the directors deployed their discretion to cause reduction in the terminal bonuses of the guaranteed returns policyholders. This resulted in lesser returns than promised and hence the court ruled the matter in favour of aggrieved policyholders holding the directors of the firm responsible for the losses borne by clients (Swarb, 2015). 2) For avoiding the liability from the creditors, the auditors counsel can bring to notice the Therapy Partners of America Inc v. Health Providers, Inc[1998] case. In case of a declaratory judgement, it is imperative for the court to ensure, if there is any existence of controversy between the parties and if the same is justifiable or not. From this case, it can be highlighted that it is possible for the partnership frim to defend a declaratory decision and take a stance in such cases which implies that liability of creditors is to be borne by the partnership firm (Findlaw, nd). For establishing negligence beyond any doubt, it is of utmost importance that the following three conditions need to be satisfied, Duty of Care It needs to be established that the defendant had a duty to care towards the plaintiff owing to the proximate relation to be tested through the neighbour test where it is seen whether the plaintiff would be impacted by the choices made by the defendant with regards to engaging or refraining from a particular activity. However, the contour of this duty to care is limited to only that danger or harm which is foreseeable by any reasonable third party in the given situation (Harvey, 2009). Breach of Duty The defendant owing to the duty to care is obliged to take relevant and reasonable measures to ensure that no damage is caused to the plaintiff and precautions should be taken. The level of care extended towards the plaintiff has direct relationship with the possibility of risk and the extent of damage to result from the same. However, if the defendant acts in a reckless manner and hence do not extend adequate care towards plaintiff so as to recharge his/her duty,, then breach of duty has taken place (Lindgren, 2011). Damage The breach of duty could cause damage to the plaintiff and this is wide in its meaning and includes not only physical or financial harm but extends in the domain of mental and emotional suffering as well. However, it is imperative to develop a causal link between the breach of duty by the defendant and the damage being suffered by the plaintiff. The recommended manner to establish the same is to prove that damage could have been prevented if the duty had not been breached (Pathinayake, 2014). The fulfilment of all the above conditions leads to negligence being conclusively established. 3. It is apparent from the information provided that the previous audit partners have been appointed to the board. The appointment of not one but three partners from one audit firm seems extremely dubious and by any stretch of imagination no justifiable reason emerges except the strong possibility of a quid pro quo relationship between the management of HIH and Arthur Anderson audit partners. The company rewarded the auditors with hefty fees through the consulting contracts where the auditors performed their jobs by being :cooperative and assuring by ensuring that the glaring discrepancies tend to continue without being reported in any report for the external shareholders. The current move to appoint the auditors at the board positions seems a symbolic gesture and a continued ploy of management auditor nexus where the mutual interests are served (Heeler, 2009). Even though there are issues with the concept of auditors also being involved in consulting on account of conflict of interests, however there are some obvious advantages due to which the idea is still muted in academic and professional circles. These are summed below. Audit Services Quality Enhancement The involving of the audit company in providing consulting services to the same client results in enhanced understanding of the companys business model coupled with potential risks. For an auditor, this information is highly valuable as the auditor also needs to critically determine the inherent risk of the business which requires a sound understanding of the underlying business. Also, the key risks and critical functions also become apparent which facilitates the process of audit planning and related formation of strategy to implement the audit work. Also, this enhanced understanding of the business is critical for the audit team with regards to application of requisite controls and procedures. Hence, the net impact of this is that there is material drop in the misrepresentation of financial statements as the audit quality witnesses an improvement (Gay Simnett, 2012). Consulting Services Quality Enhancement Further, the audit services experience and information aids in the consulting process which can provide solutions that are more pragmatic and take into consideration the clients needs. In this context, a pivotal role is granted by due consideration to the tax structures and the implications of the business decisions in this regard and ensuring tax effective solutions are proposed (Arens et. al., 2013). c) Currently, there is a trend where the audit providers are also venturing into consulting services and engaging in cross selling to the same client. While this may be permissible by law but clearly in the wake of the recent incidents, this is an extremely unethical approach. This is because acting in a dual capacity of auditor and consultant could result in conflict of interest. This risk is even compounded when the client associate lucrative consulting contracts with the auditing flexibility displayed by the auditor in provided an unqualified audit opinion (Clout, Chappelle Gandhi, 2013). With the investor confidence in audit services at the nadir after incidents such as Enron and HIH where the explicit involvement of auditors cannot be denied, it is imperative that the auditors should refrain from engaging in any activity that leads to suspicion in the mind of investors and other users. The practices adopted by HIH in the given case are testimony to how the dual provision of con sulting and auditing can be detrimental to the investors interest. This could potentially enhance the agency costs and pose doom for the profession of audit in the long run as investor confidence gradually erodes (Livne, 2015). d) The emergence of various reforms like Ramsay Report and CLERP assume importance in the wake of incidents such as HIH where it was clearly highlighted that lack of disclosures from HIH coupled with compromised independence of external auditor proved to be a nemesis for the investors (Arens et. al., 2013). The aim of CLERP 9 was to ensure that sound corporate governance policies be framed and implemented by the companies that would lead to greater transparency. Prominent recommendations are outlined below (Clout, Chappelle Gandhi, 2013). Increase the amount of disclosures in the annual report of the company. In this regard, particular emphasis was given on adding incremental sections such as Directors report and Remuneration Section which would enhance the overall information received at the end of investors. External auditors to be rotated on a periodic basis so as to avoid collusion of the management and auditor. On the other hand, the core focus of the Ramsay Report was to ensure external auditor independence for which the following measures were suggested (Parker, 2002). The internal audit committee to be strengthened with greater powers and scope of functioning. Proactive measures need to be taken to ensure that the relationship between auditor and client remains constrained. The annual report should contain declaration with regards to auditor independence and also board independence to be issued by the board and auditor respectively. It was suggested that a committee named as Auditor Independence Supervisory Board be put in place to ensure that independence of the auditor is not compromised. The steps taken above if implemented with full intent could potentially prove to a game changer and enhance the overall corporate governance standards thereby lowering the agency costs and also provide a new lifeline to the auditor profession which currently is facing a looming crisis (Gay Simnett, 2012). References Arens, A., Best, P., Shailer, G. Fiedler,I. 2013. Auditing, Assurance Services and Ethics in Australia, 2nd eds., Pearson Australia, Sydney Findlaw nd, THERAPY PARTNERS OF AMERICA INC v. HEALTH PROVIDERS INC, Findlaw Website, Available online from https://caselaw.findlaw.com/oh-court-of-appeals/1097866.html (Accessed on September 4, 2016) Clout, V, Chappelle, E Gandhi, N 2013, The impact of auditor independence regulations on established and emerging firms,Accounting Research JournalVol. 26, No. 2, pp. 88-108 Gay, G. Simnett, R. 2012, Auditing and Assurance Services in Australia, 5th eds., McGraw-Hill Education, Sydney Harvey, C. 2009, Foundations of Australian law. 3rd eds., Tilde University Press, Prahran, Victoria Heeler, D 2009, Audit Principles, Risk Assessment Effective Reporting. 4th ed., Pearson Press, Sydney Lindgren, KE 2011, Vermeesch and Lindgren's Business Law of Australia, 12th eds., LexisNexis Publications, Sydney Livne, G 2015, Threats to Auditor Independence and Possible Remedies, Finance Practitioner Website, Available online from https://www.financepractitioner.com/auditing-best-practice/threats-to-auditor-independence-and-possible-remedies?full. (Accessed on September 4, 2016) Parker, C 2002. Auditing at arms length, CACharter, February, pp. 38-40 Pathinayake, A 2014, Commercial and Corporations Law, 2nd eds., Thomson-Reuters, Sydney Swarb 2015, EQUITABLE LIFE ASSURANCE SOCIETY V HYMAN; HL 20 JUL 2000, Available online from https://swarb.co.uk/equitable-life-assurance-society-v-hyman-hl-20-jul-2000/ (Accessed on September 4. 2016)