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Coping With Stress: Cognitive-Behavioral Stress Reduction

Coping With Stress: Cognitive-Behavioral Stress Reduction
this ucsd-tv program is presented by university of california television like what you learn visit our website or follow us on Facebook and Twitter to keep up with the latest programs also make sure to check out and subscribe to our YouTube original channel you see TV prime available only on YouTube my great pleasure to introduce dr. Jason Satterfield who's we've worked together now for at least 10 years 15 oh thank you for my mental status alertness dr. Satterfield is an associate professor and medicine and director of the

behavioral

medicine program in my division of general internal medicine and I just found out from the bibliography that he's also an author of a book that's about to be published next February so I've already a commitment to get a signed copy he's really really really a gifted teacher and more importantly an expert in the area that he's going to be discussing tonight and I already shared with him that after all of your questions two weeks ago after dr. Kennedy's presentation on the effect of

stress

on the immune system that you were all very anxious to hear about concrete tools and how that manifests itself in what's called

cognitive

behavioral

therapies my pleasure to introduce dr. Satterfield well good evening everyone it's my pleasure to be here tonight and I think you might see that the talk tonight is a slight change of pace I believe you guys have learned a lot about the basic science the basic research behind...
coping with stress cognitive behavioral stress reduction

stress

and behind

coping

you've also learned from dr. Kemeny two weeks ago about the physiology of

stress

of course important for disease and it's one of the reasons probably the main reason we want to learn about

stress

management tonight I decided that I would take a very practical and very clinical approach so we're going to be talking about a lot of very practical hands-on hopefully useful interventions that you can try for yourself or for your loved ones in order to order in terms of reducing the magnitude of your

stress

response where we're going to focus there's really a long long menu of different types of

stress

management ideas that we could talk about but we're going to focus really on how to use our minds to change the way our bodies feel the broad category of mind-body medicine but more specifically we're going to look at

cognitive

behavioral

interventions and how they influence our experience of

stress

sometimes the negative ways but hopefully we'll learn to use them in positive ways in order to do that there are sort of several road marks we need to pass through along the way today we want to talk first about some of the

stress

basics and I want to calibrate our language to make sure that the words in terms I'm using are sort of matching what you guys have learned already I want to share some basic

cognitive

behavioral

foundations so really give you a little bit of the history and sort of the theoretical underpinnings of why...
coping with stress cognitive behavioral stress reduction
we think changing the way we think might change the way your body feels let me say from the outset that this is not the don't worry be happy' seminar this is not about wordplay it's not about mind games or sophistry it's about understanding the interconnectedness between how we think and how we feel in that the

behavioral

choices that we make we're going to go through some specific examples of how to work with appraisals the way we think about

stress

ors in the way we think about

coping

we'll talk about a specific example of explanatory style we'll then move to some present moment

coping

strategies to change the way that we feel both emotionally and also physically but from there we'll go to much deeper ways of

coping

something I've called depth

coping

it's not necessarily about the present moment but it helps us to lay a more solid foundation in facing the

stress

ors that might be ahead of us in the future and there we'll talk about connections we'll talk about social support and we'll end by talking about meaning so this is just a quick review from you guys Susan Folkman the very first lecture of this series talked about some of her research with dick Lazarus she talked about the

stress

process and these are some of the major players or stages in this process first on the left we have the occurrence of a potential

stress

or this could be real or it could be imagined this could be an exam you have to take this could be...
coping with stress cognitive behavioral stress reduction
deadlines at work this could be a conflict a recurrent conflict that you have with a spouse we think about that

stress

or in a couple of different ways we have our primary appraisals thoughts that you have about the

stress

or does it matter is it a big deal what are the implications should I really be worried about this or not secondary appraisals this is think about your

coping

resources am i able to face this do I know what to do do I have social supports do I have money time energy to do whatever needs to be done to face this potential

stress

or so potential

stress

or happens you think about the

stress

or you do an appraisal of the

stress

or you do an appraisal of your

coping

resources and depending on your type of appraisal it helps us to understand the type and the magnitude of your

stress

response the praise Allah stew understand why two people can experience the exact same event one will feel incredibly

stress

ed the other might not feel that

stress

ed at all it's because they probably thought differently about the importance of the

stress

or the primary appraisal or maybe they thought differently about their capacity to cope with that

stress

or if we're looking at opportunities for

stress

management you should already see that there's a couple of different places we could target those interventions we could change the likelihood you'll be exposed to a

stress

or or we could change the way you think about the

stress

or or change the way you think about your

coping

...
resources that's not all we also want to think about the nature of the

stress

or itself are really the frame that we put on the

stress

or and in general we divide

stress

ors into two categories

stress

isn't bad

stress

is important we need

stress

it helps to activate us it gives us energy it sometimes gives us a focus that we need in order to fix or to change a particular problem but there's this split that occurs fairly early on and whether or not we see a

stress

or is something that's a challenge or something that's a threat if we see something that's a challenge yes it may be difficult it may require a lot of time and energy but I feel a little jazzed up about it it's a project at work that I really like and it's going to take a lot of time but I believe I'm up to it I believe I'm going to learn something from it I believe I can get help it's a challenge but I don't see it as a threat for a threat in general people see it is something that the outcome is somewhat unknown a positive outcome might be unlikely your capacity to cope with it or even if you know what it will take to cope is much lower you see it as a threat you have low control and much more anxiety as a consequence of your approximation or your evaluation of that

stress

or the other thing we want to look at is not just is it a challenge or is it a threat is it chronic or is it a cube so is it a one-time-only

stress

or is it something that's going to recur or be...
present over a period of time worst case scenario and times up in terms of the magnitude of our

stress

response is something that's chronic so it's going to be there for quite some time and it's something that's seen as a threat now we care about these but we care about

stress

and we care about our ways of

coping

because it is related to our well-being it's related to our mental well-being but also to our physical well-being as well we are mostly going to be talking about

stress

management as a way to buffer the physiologic effects of

stress

but it's important to remember that there are a number of different pathways that

stress

can contribute to illness these are the three primary pathways it's important to remember that when most of us get

stress

ed we do the exact opposite of what we need to do to stay healthy so when most people are

stress

ed they sleep less they drink more alcohol they may smoke more cigarettes they pull away from their social supports they eat less food they don't have time to go out and cook or to prepare healthy meals so what they're doing as they get more

stress

ed is actually engaging in more health damaging behaviors so that's one pathway just on a

behavioral

level another pathway is that we see changes in medical compliance or medical adherence we often see folks who have had an exacerbation or relapse of their disease their diabetes suddenly gets worse because they've gotten

stress

ed and they stop taking...
their medication they stopped exercising they stop doing the things that they need to do to manage their disease and stay healthy and the last pathway is the physiologic pathway and this is what dr. Timoney was talking about in talking about how the

stress

affects the immune system all three are important so we want to help to decrease the magnitude of the

stress

response this box here we might also want to help people in choosing more appropriate more helpful more constructive ways to cope with the

stress

or this was also in dr. Folkman's top the very first talk of the series she talked about as we experienced a

stress

or we think about the

stress

or our

coping

resources we have our

stress

response remember that can be physical emotional

behavioral

cognitive

we decide what it is that we're going to do and our responses to that

stress

or generally fit into two categories problem focused meaning you roll up your sleeves and you do whatever it takes to change or directly address the

stress

or so if the

stress

or is you have say a relicensing exam that's coming up at some point a problem focused

coping

mechanism would be to study for that exam it directly affects the outcome of that

stress

or the other categories emotion-focused

coping

and it's equally important but really has a different focus here it's not necessarily about doing something constructive to change the

stress

or it's doing something to change the way that you feel if you're in a situation...
where the

stress

or is unchangeable or you've already studied for that that exam as much as you possibly can but you're still feeling anxious distraction might be helpful calling a friend might be helpful doing something that you find pleasurable that pulls your mind that pulls your emotions to a more productive into a more positive state might be helpful the best copers are individuals who know when to use what type of

coping

most

stress

ors require a mixture of both types of

coping

so you need to know when do I use problem focus when do I use emotion focus and we'll talk about that a little bit later as I mentioned

stress

management might include interventions at any point on this pathway it may include

behavioral

interventions to prevent you from being exposed to a

stress

or let's say that many of your

stress

ors come from your workplace they come from your boss they come from your co-workers they come from the job cast itself a perhaps very effective strategy in terms of managing your

stress

would be to quit your job and to move to the different job you're exchanging one group of

stress

ors for a different group of

stress

ors but again you've done something very concrete and

behavioral

that pulls you away from those things which are causing you

stress

that would be here on the level of

stress

ors another intervention would be to look at the primary and secondary appraisals you have made and whether or not those appraisals are helpful whether or not those...
appraisals are accurate we'll talk about that more another intervention might be to directly affect the

stress

response that you're having and here is really the category of medications so things such as benzodiazepines pills for anxiety that help individuals to turn down the Mack two of the

stress

response that they're having other interventions may teach you better ways of

coping

either in terms of problem-solving rolling up your sleeves and learning how to address a problem more effectively or in terms of building or eliciting your social supports or mood management strategies more effectively all right so let's talk a little bit about some of the basics behind

cognitive

therapy we're really not talking about

cognitive

therapy per se tonight but we're talking about

cognitive

behavior interventions that have been pulled from sort of a full package of therapy now this full package of therapy was first developed for the treatment of depression and the person who developed them or at least is given a primary credit is Aaron Beck he's in the upper left hand or right hand corner of the slide it was late 1960s he had been trained in probably one of the premier psychoanalytic training institutes his primary interest was in the treatment of depression incredibly common and at that time also very difficult and challenging to treat treatment sometimes requiring three to four psychoanalytic sessions per week up to two to three years and not a whole whole...
lot of evidence to suggest that the if a person did get better it was the therapy that was helping them well despite his frustration with the length of treatment that was required he also began to notice that there were a lot of similar patterns in the depressed patients that he was seeing they all tended to have a very negative self-image they had very negative mostly hyper critical thoughts about themselves they had a very pessimistic view of the world and of their future and they also had very negative thoughts about other people and other relationships and what other people might do to them or not to do for them in terms of supporting them or loving them he found that in all of his depressed patients they had this

cognitive

triad this constellation of a way of thinking that team seemed to deepen and worse than their depressive symptoms the light bulb went on for Beck and he started to think about what if I was to directly address the way a person's thinking but if I started at the top how they're thinking in the present moment got them to reflect on the way they're thinking change the way they're thinking would that change the way they're feeling where that eventually change their relationships would that eventually change them in a biological sense and that they no longer would meet criteria for this biological disease that we call depression as you can guess as the story goes he found that this was actually quite effective in now about 40 years or so...
later they're probably been over 10,000 or so studies looking at CBT not just for depression it's really expanded to anxiety to

stress

to eating disorders to a lot of different disorders and have found that there's really a collection of both

cognitive

and

behavioral

strategies that can be effective either for psychopathology or just generally for mental health some of the general ideas that are important to understand before thinking about

cognitive

interventions is first we're not particularly rational that's not a bad thing but we are not computers we are not perfect information processors our memory is very fluid the way we think about our relationships the way we see the world the kinds of things we remember the kinds of things we pay attention to are very much a subjective they're very very much influenced by your personalities they're very much influenced by our environment they're even influenced by our current mood stays at the time so it's first of all important that that you realize it's not a matter of intelligence it's not how quick you are that's just the way that people think that what's that's what makes us so fantastic and so interesting but when things don't go so well that can cause a great deal of unnecessary suffering that suffering or what Beck calls dysfunctional thinking is common to all psychological disturbances there's sort of a different flavor or a different variety to the types of...
distortions that tend to occur based on the type of disorder we're thinking about so for an individual who has an eating disorder say anorexia a lot of the distortions are thoughts about the way they look or about their body image about the importance of control over what they're eating for depression it's thoughts about the self it's thoughts about others and it's the pessimism about the future and about the world the last idea is to remember the interdependence of thoughts feelings and behaviors as represented in this classic triangle that most CBT therapists draw for their patients this is the idea that the way we feel is intimately related to how we're thinking which is also intimately related to our behaviors so an example of that would be say an individual is feeling depressed so that's the mood that they happen to be in they're feeling depressed so they're thinking things very negatively they have they're remembering everything bad that's happened they're making negative predictions about the future they're evaluating themselves very negatively which makes them more depressed which makes them think more negatively which makes them more depressed and so on and so on it's not just about thoughts and mood though it's also about behaviors here in this bottom right hand corner a person's feeling depressed they're thinking very negative thoughts what they tend to do is to shut down and withdraw if things are...
bad they aren't going to go well they aren't going to be enjoyable you're not going to be very good at it anyway why would you get out of bed why would you bother to try a person's depressed causes them to think negatively which causes them to withdraw and shut down which makes them more depress which makes them think more negatively and so on and so on the good news about this interdependence is it provides us a couple of different opportunities of where we can intervene to change how a person's feeling now again you could directly intervene with medication say antidepressants anti-anxiety agents have change the way a person is feeling you can also however look at the level of thoughts how's a person thinking are there ways that we can reassess or change or reshape the ways they're thinking to change how they're feeling we can also intervene on a level of behavior could we build new social supports could we change their job could we get them to engage in a different mix of activities that would have a more positive or constructive impact on their mood and I'll give you some examples of that but important to remember we have lots of opportunities but our two main pathways are entering through the avenue of thoughts entering through the avenue of behaviors so we're going to run through several different examples and I thought it would be a lot more interesting rather than me just sort of talking about these actually having you do some of...
these exercises and we could debrief them a little bit you don't have to do them if you don't want to but I would just recommend you do have someplace some space for notes so we'll do a couple of different exercises as we work through this list I'll ask for a few volunteers and just so you get a feel of what it's like to do some of these strategies we're going to look at a few

cognitive

interventions we're going to do something called an ABCD we're going to jump into explanatory style I'll describe activity scheduling it's probably a little too complex to do it in a group that's this large but then move to talk about somatic quieting and then I hope we have time to do a social support exercise towards the end so to understand the ABCD we have to understand to the

cognitive

model that explains why we we feel and we do the things that we do since it's a

cognitive

model you can imagine they're going to talk about the predominance or the importance of cognition or of thoughts of the ways we think about situations the non

cognitive

model or the typical model is that there's an activating event something happens around you and it makes you feel do say a particular thing however the

cognitive

therapist would say no that's naturally not quite true there's a middle step that's quite important that most of us don't think about because it happens so quickly it's automatic it's an automatic thought that pops...
to mind it's your subjective interpretation of what just happened so the ABC here is the activating event something happened you had some beliefs thoughts about it and those thoughts help us to understand why you felt or did what you did as a result of that situation so here's an example and this is just from my clinic a couple of weeks ago I do see patients here at UCSF in the

behavioral

medicine unit and I try to stay on time I've been on the other side of the desk before and have waited very very long time for for my doctors and so I try to stay on time and I try to end on time just so people can plan their days and leave their jobs and all that around around their appointment times so first patient comes in on time and said to me you know I really appreciate the fact that you always start on time you always remember what we did before we always sort of pick up where we left off it really feels efficient and respectful and I'm really glad that that happens and I just wanted to tell you that that felt good and that's kind of what I hoped would be the result we have the next patient that come in it was actually just the next day after that we started on time the patient came din came in it seemed a little bit unhappy and I said well what's going on he's like you know you're on time to the dot I don't like this place it's just like a factory same activating event we're starting our appointment on time very different reaction and the...
reason there was a different reaction there was a very different interpretation of why we're on time first patient thinks it's a sign of respect second patient thinks it's a sign of being dehumanize dehumanized it's just a factory that they're in not that one is necessarily better or worse but they have different consequences and when I encourage people to look at the beliefs part the B part of the ABC it's not to find the truth it's not to find what's right or wrong it's to think about what thoughts are helpful what thoughts are hurtful if those thoughts are pushing you towards reactions that are helpful no need to analyze them if those thoughts are poor pushing you to reactions that aren't so helpful then maybe it's time to take a step back and to think about your thinking I guess the other point I want to make are as far as just to remember that thoughts aren't facts thoughts are opinions they're our best guests our subjective reading of a particular situation and if we're able to put our ego aside we'll see that I think for all of us our opinions have at times been wrong our opinions are changeable in fact hopefully they change oftentimes as we're presented with new information so all beliefs are changeable they're not facts just because you feel it strongly doesn't necessarily make it true we've also found in the work of

cognitive

therapy that people not only have these subjective interpretations...
of these ideas these opinions people tend to develop habits and the kinds of ideas that come up we all take thinking shortcuts that's the way the human brain works but we tend to find habits probably based on disposition maybe based on early family history of the types of shortcuts we tend to make these are some examples of some habits of mind some of them may look familiar for you or they may look familiar for some of your family members or for friends some people have a habit of over personalizing so sometimes when bad things happen they assume that it was done to them they take it very personally and get angry or hurt as a consequence there may be a tendency to magnify of things that happen or to minimize positive things that happen you may know individuals who have a very hard time acknowledging their successes who have a very hard time accepting a compliment they tend to minimize the positive that happens and they tend not to remember it selective attention there's just too much going on in our worlds to pay attention to everything at the same time we tend to focus sometimes on the glass that's half-full and other people focus on the glass that's half-empty again not necessarily right or wrong or good or bad but we just want to look at the consequences of that particular habit I won't go through all of these but I think other common ones all Arnon thinking so I'm all a success or I'm all the failure it's all black or it's all white...
mind reading probably an 8 at least that's what social neuroscience is telling us mind-reading is when we're in a social situation and we're picking up those subtle nonverbal clues from people and we're imagining what they might be thinking some of us are really good at that some of us not so good at all of us make errors when we're trying to imagine what another person might be thinking some people because they've been hurt a lot in the past because they have a sensitivity to rejection they may always assume that the other person's thinking negative things about the and of course that has its its own set of negative consequences so here's our ABCD exercise and I just want to walk through an example first and then I'm going to ask you if you're willing to do your own ABCD exercise a b c d stands for the activating event that's the a the B of the beliefs C are the consequences and those can be emotional those can also be

behavioral

and the d box in the bottom right hand corner is a dispute box this is where you roll up your sleeves and you start wrestling with your thoughts so you take a step back you ask yourself are these thoughts fair are they balanced am I making shortcuts is there another side to the story if my friend were to think or to say this what would I say to him or her is there a more constructive way to think about this situation okay so here the example the activating event is I'm sitting at work and I get an...
email from the boss moving up an important deadline just the facts just the situation beliefs this is terrible I'll never be able to finish this is a setup for failure I'm doomed what a selfish creep consequences I feel anxious worried and angry I complain to coworkers that's the behavior the dispute this is going to be tough but I can go over the calendar with the boss and see what we can figure out maybe his hands are tied to I can share my worries with him it shows he trusts me with an important and challenging project so same situation a very different spin and how you think about that situation hopefully with different emotional and maybe with different

behavioral

consequences as well so what I'll ask you to do is to do your own ABCD and the good thing about this is you don't need a special form you just need a blank square of paper you put an X right down the middle divide it into four boxes activating event beliefs consequences and dispute so I'll ask you to do one of those and I would recommend if this is your very first one ever that you pick an activating event that's relatively small so an example of an activating event that small would be you pulled into the parking garage and you saw how much it costs to park on Parnassus so you might have certain beliefs about that there might be certain emotional or

behavioral

consequences then we can work on the disputes you of course can do this with a much bigger event but in a group setting and...
we'll be talking about it as a group it's a lot harder to talk about the divorce bereavement sort of those big emotionally charged events those are very hard to work up some disputes so why don't you go ahead and just take a minute write down an activating event write down some beliefs write down any emotional or

behavioral

consequences and I'm going to ask for a volunteer or two so I will warn you that nearly everyone gets stuck on the dispute box the first few times they do this it's difficult even for sort of a small low investment activating event it can still be difficult when you do it as a group it's a lot easier to do someone else's dispute box because you're not emotionally attached to it so how about a volunteer and I know you guys aren't quite done yet we can work through this together we'll just take one volunteer I'll ask you to share the activating event we'll pull out some of the beliefs talk about consequences and as a group I want to see if we can can fill out the dispute box together so who would like to share an activating event yes what is your activating event so stock market gyrations sort of up and down in the stock market okay very good and in activating event we don't want to have any sort of interpretation to it it's just just the facts what happens up in it what were some thoughts that you have the belief the belief box so I don't know how to respond and uncertain about how to respond what...
else okay so in the consecuences box some of the feelings he had you felt anxious but what else okay so let's bought a couple more beliefs usually there's a number of thoughts if you start digging a little bit we have gyrations in the stock market I'm uncertain about what to do what does it mean that you're uncertain what are the consequences of being uncertain why do we care if you're uncertain I might lose money this might be painful if I lose a lot of money I might get in trouble by my significant other if I lose lots of money okay you're feeling anxious and do you do anything do you sell do you buy do you turn off the computer or what do you do so I really try better okay okay so what he feels anxious and so he tries to get more information all right so the way you decide whether or not you need to do a dispute box it's whether or not the consequences are something that was undesirable so he's feeling anxious he starts digging for more information should we challenge the thoughts that he had I might lose money this is going to be terrible this might be bad I don't want this to happen should we challenge those thoughts ok so there's maybe a different behavior and he could consult an expert I would say one thing that we can do it sounds like your behavior get more information was something that was very constructive probably helpful it might be consulting an expert it might just be doing more research on company stock that you fought...
the anxiety is something that you know anxiety is a funny thing a little bit of anxiety can be helpful you get too much anxiety and it's not so helpful it's overwhelming and it's distracting and it's not productive so we might want to think about disputes or thoughts that he could use to turn down the anxiety so that he's at his maximum level of functioning so what might be some thoughts in the dispute box that could help him feel a little as anxious it's temporary this is the nature of the market what goes up comes down and vice versa okay it may go up any time what else I have a tax write-off okay with what else is probably no worse off than he was okay so this is a long-term process I can't focus so much on the immediate and what's happening so you guys get it you sort of get the sense of how he could think in different ways to manage the consequences and in this case we wanted to turn down the anxiety just a bit probably keep the same

coping

behavior because it seems like it was fairly constructive so that's just a quick look at one

cognitive

intervention you can do ABC DS for just about anything the greater the emotional charge the more difficulty it is to come up with a dispute a lot of times we do this in group therapy settings where people can do each other's dispute box so they get the hang of how to do their own if you remember when we were talking about

stress

management we mentioned that you could intervene really at any...
point along that pathway in the

stress

process the next opportunity we had after the

stress

ors was to look at an individual's appraisals or how they're thinking about a

stress

or for primary appraisals it's how you are thinking about the

stress

or itself is it a big deal is it going to matter how painful is it going to be is this something that's important to me or to my family should I worry about it common errors that people make in terms of amplifying unnecessarily amplifying their

stress

response are overestimating the likelihood that a bad event will occur remember a

stress

or can be something that you're anticipating it doesn't necessarily have to have happened yet overestimating the badness or the negative consequences of a

stress

or so this is magnification of possible negatives worst case scenarios that might happen overestimating the duration or permanence of a

stress

or and only focusing on worst-case scenarios so again this may be a habit or it may just be with this particular event but teaching someone to step back and look at that primary appraisal and to look at how accurate that appraisal has been I know this is a lot of words and I won't go through all of these different questions but it's questions that you can ask yourself in order to reassess the accuracy or the helpfulness of your primary appraisal you know this is not don't worry be happy' stuff this is just take a step back and say am I looking at in a balanced...
helpful way am I making a realistic appraisal of the situation and what this is going to take and what it will mean to me the answer may be yes you are taking a very realistic look the answer may be no you can step back reassess and maybe change that appraisal the other thing that we can do is decide whether or not to think about it at all if we look at this is from the healthy mind healthy body handbook by Sobel and Ornstein their idea is that essentially in this day and age probably in every day and age but they talk about in modern society we have too little time and too many

stress

ors and there's just no way that you can possibly pay attention to every possible thing that might go wrong takes too much energy takes too much time and you just would not be able to cope so they suggest a way of triaging or of separating or sorting out the different

stress

ors that are in your life and then deciding consciously where to direct your attention where you would start to roll up your sleeves and what you can really let go they recommend that you divide your

stress

ors into two categories important or unimportant you can already see that the unimportant stuff probably shouldn't get priority look at things that are changeable or unchangeable if we're talking about rolling up your sleeves and trying to change something you better make sure it's changeable first what will be most important of those four categories are things that are important high-priority and things...
that are changeable so if you only have a limited amount of time energy resources you want to focus on what's most important to you what's going to be most changeable so examples include arguments with a partner problems with your boss or quitting's quitting smoking all are important all are very changeable now it is true that we do not have complete control over our lives or our choices or the

stress

ors that we must face a lot of times maybe in your job maybe with the family that you have or the family you married into there may be other

stress

ors that you just have to deal with there may be jobs that you're asked to do that you just have to do I'm reminded of I think some very wise advice from a first mentor of mine who explained that there would be jobs along the way in academia and Alsip elsewhere that you really don't want to do and he said Jason I want you to always remember that a job not worth doing is not worth doing well if you got to do it so be it but don't go for the A+ if it's not that important so we can look at primary appraisals we can try to recalibrate we can take a step back and decide if we even want to think about it at all if it deserves any of our time or our energy we can also look at secondary appraisals and remember secondary appraisals are about our estimations of our ability to cope the resources that we have to face a particular

stress

or here are some of the errors that amplify a

stress

response is overestimating...
what it will take to cope with the

stress

or so imagining something is going to take a lot more than it actually will to resolve under estimating your personal ability to cope a lot of times people forget that they may have been through a lot they may have developed a fairly substantial skill set and they may underestimate what they're able to do they underestimate or forget important

coping

resources such as time money energy or knowledge they may underestimate or underutilize friends or family believe that they don't have the support that they actually have or they may be just unable or unwilling to tap into those two supports to ask for help that they might need so the question is why do we have this tendency to under or over estimate it could either be primary appraisals or secondary appraisals why aren't we sort of spot-on accurate in our appraisals you know and I think the reason has to I don't know if I know the answer I think it has to do with the fact that we're not perfect information processors we're not computers our estimations are influenced by our emotions they're influenced by our values they're influenced by our current mood states at the time oftentimes they're influenced by anxiety so if you're feeling very anxious you're feeling very vulnerable maybe negative things have happened to you recently in your past it's going to affect the kinds of appraisals that you make the other impact on appraisals if you look...
at there's been studies done where they asked people to estimate the likelihood that they'll be struck by life the likelihood that they will be hit by a car people tend to be okay in terms of their estimates unless there's been a recent news story or something the media has told them and you see this transient but fairly replicable blip in the over estimation of how much at risk or how in danger they are from that particular

stress

or that particular threat so a lot of influences that can push our estimations around this is really just recommending that people take a step back and say okay what's going into this estimation is it my mood is it my history is it my values maybe it's something in my environment that's caused me to over underestimate again I won't read through all of these questions but these are intended to help you improve the accuracy of your secondary appraisals asking yourself realistically what resources are needed water the high and a low estimate so it's okay to think of the worst-case scenario but you should also be sure that you think of the best-case scenario you know not not rose-colored glasses not Pollyanna but if you're looking at things at their worst possible case look at the flipside just look at the full spectrum the full continuum and then make an estimate of how probable those different outcomes might actually be we're going to talk about how to elicit and how to tap into social supports a little bit...
later but I think that that learning that skill of knowing who's in your inner circle and what those people in that inner circle can provide can really help us in terms of improving the accuracy of our secondary appraisals okay so let's go ahead and do another exercise this is also a

cognitive

exercise but a little more specialized this one is on explanatory style I'll explain what that is after we do the exercise so explanatory style is is roughly the explanations that we give ourselves about why stuff happens good stuff bad stuff neutral stuff we always seem to need an explanation of why did that happen so what I have here is a hypothetical and I want you just to write down what you believe caused this event to a curve you're just filling in the blank no right or wrong answer the hypothetical event is your boss selects you as employee of the month and gives you a large raise this event happened because blank so it is write down what you think caused this event to happen you've got an Employee of the Month you got a large raise this happened because blank and I'll ask for a volunteer and Alex print explain what those ratings are are about so who wants to to share what you wrote down yes so this event happened because what okay because I found dirty pictures of him with someone who wasn't his wife so you got Employee of the Month and you got a large phrase there's no right or wrong answer again we're interested in consequences of how that...
answer the consequences of coming up with that kind of answer so we want to look at in terms of explanatory style three different dimensions internal stable or global so what's the cause due to something within me or something I did or is it due to external factors like luck so what would you say on a scale of one to seven one it's totally external seven it's totally internal where would you put that a one okay so it's something that the boss did I might move it up a few notches because you decided to do something about what the boss did but but you're right it was sort of triggered by if he had never done that this maybe wouldn't have happened so there's definitely a big external piece to it the stable dimension is is this a one-time only event or is this something that's going to keep happening again and again in the future so an unstable explanation is is random luck a stable explanation would be I have a lot of intelligence so that intelligence is going to follow me in different areas of my life so do you say this is stable or unstable a one-shot deal or is it going to keep on happening so pretty unstable kind of a one-shot deal and global is is it just going to affect you in your job or your relationship with your boss or is it going to affect you everywhere your family your friends your social life what do you think so it's pretty isolated so here it's external it's unstable and they call it specific the opposite of global now...
when you have your actual explanatory style measure there's a number of different hypothetical events and it's averaged over both positive and negative events and the reason this is important is because we found that explanatory style is related to an individual's risk for depression and in general if a person explains negative events as it's my fault it's never going to change and it's going to affect me everywhere that tends to predispose them towards depression depressed people also when they have a positive event happen they say I can't take any credit nothing positive whatever happen again and it was really just a one-shot deal so really the the attributions the explanations you gave us for that event would fit more in the depressogenic category it's just one event though so it's not your style so you would would need to average it over a number of other events so where did this stuff come from and I think it's important to understand a little bit of the history because it helps us see some of the implications of it and I think it also helps us decease where the evolution of of science or research from animal studies up to human levels so this was the work of Marty Seligman and many of you have heard of learned helplessness or learned optimism before he in the late 60s and early 70s also at University of Pennsylvania different building from Aaron Beck they were working completely separately and he was interested in dog studies...
didn't have a tournament a name at the time but it eventually became called learned helplessness and the paradigm was something so we have a large rectangular cage and there was a divider in the center of the cage on one side there was a metal floor on the other side it was just a terrycloth floor he would place the dog on the metal side of the cage administer a mild electric shock was unpleasant the dog would jump to the other side it's variable reflexive doesn't take a lot to explain why that happens did several repetitions of that too dog always jump to the other side next part of the experiment you put a divider a metal wall really in between those two sides of the cage you administer an electric chop shock the dog tries to escape but cannot it hits the divider can't go anywhere keeps trying to escape cannot go through several repetitions of that until finally the dog learns there's nothing I can do I'm just going to quit trying so they just lay down and they become helpless essentially the most important part of the experiment is the last part where he takes out the divider in that cage so now the dog can escape he administers the electric shock and the dog does nothing so they actually reach and physically and pull the dog to the other side just showing hey you can just move to the other side put the dog back on the metal side administer the electric shock the doc goes nowhere the dog has learned to become helpless and so when so those earlier...
experiences of being unable to escape it doesn't take a lot to extrapolate this to people to see that people who have make may have grown up in circumstances where escape was impossible where there was abuse children are fairly powerless they may have developed the same sense of learned helplessness so that even though they're now adults their lives have changed their environments are different they now have resources now they can escape they don't take advantage of those resources because they learned to be helpless there was a glitch in this theory though despite its appeal and that's not everyone who has these aversive events not everyone who's been abused as a child grows up to develop learned helplessness in fact it's less than the majority there's only a subset of folks that go on to become helpless so why is that in the event the answer that eventually emerged was it has to do with their explanatory style kids who are being abused who said it's my fault it's never going to change it's going to be like this everywhere they went on to become helpless kids who said this is messed up this is not me it's not always going to be like this there are places where it's different this is not going to last forever they did not become helpless and they were able to survive or even transcend the circumstances that they were given as children so explanatory style helped us to understand how some people go on to be resilient and why...
others are unable to do that I want to talk a little bit about mood shifting in the moment and we've already really done sort of one exercise of mood shifting the ABCD exercise can help us to have at least transient changes in our mood it's not a magic wand it doesn't take away all of your anxiety there may still be anxious about the stock market but hopefully what it does is it at least decreases the severity of the intensity of those feelings when some people do their ABC DS they often will rate the initial feeling of anger sadness depression on a 1 to 100 scale they finish the exercise and they rewrite their feelings and a lot of times they'll see a 20 30 50 percent drop in the intensity of their negative emotions certainly better than doing nothing at all there's a couple of other interventions that we can use to at least temporarily shift an individual's mood I want to talk a little bit about

cognitive

reprocessing or a form of journaling you want to talk about a selective attention exercise so for journaling you know the idea is not new it's been around for a very long time that maybe keeping a diary is a good thing keeping a diary is sort of a cathartic experience it can get a lot of the feelings out and on paper it's a way to relieve

stress

it's maybe even a structured way to capture thoughts and to do a little bit of problem-solving well finally someone and that someone is James Panabaker at the University of Texas decided to test...
out this particular theory and to see if journaling was something that was helpful both in terms of mood but also in terms of an individual's physical health so like a lot of academic psychologists he first started studying students to see if it was a viable idea and then moved to more medical in real-world populations so his paradigm was essentially to bring the students into the lab half of them are told to write about a very serious event that happened to really sort of dig into it ruminate about it write about it for about 20 minutes or so the other group they're also writing but they're writing about something very neutral about the weather about trees about something that really doesn't have an emotional charge he has them do this over a number of weeks gives them mood measures looked at who went to student health during that time did anyone develop symptoms and as you can imagine in this healthy population there weren't a lot of health effects for the students but there was a market mood effect and in fact students who wrote about these charged negative events actually reported a better mood as a consequence of this journaling process sort of interesting they weren't wallowing in it they were reprocessing rethinking and eventually changing the way they felt about that particular event Pennebaker was rightly challenged to say well hey let's take this to patients who have real disease maybe chronic diseases and let's see if there's any...
healthy effect so Pennebaker is graduate students and others who've picked up this paradigm have looked at a number of different patients and I'll give you just a couple of examples here there was a study looking at patients who had chronic and fairly severe moderate to severe asthma put them in the same paradigm they were told to think about the most negative events in their lives either most recent negative events or in the past or the largest magnitude negative events the others were told to write about something relatively neutral and not emotionally charged they did this over a period of weeks and they measured something called fev1 that's a forced expiratory volume of air so how much air you can breathe out of your lungs really quickly in one second the more you can bring out breathe out the greater your lung capacity so it's a sign of improvement for folks who have pulmonary problems they found that for individuals who are writing about the emotionally-charged negative events they actually haven't it had an improvement in fev1 other studies looked at the severity of symptoms and rheumatoid arthritis same sort of results patients who wrote about the negatively charged events had better results looking at patients who are HIV positive they found that their cd4 counts a type of immune cell actually went up there was not a difference in terms of their outward appearance in terms of their physical health who was getting opportunistic infections or not...
but there was a difference if you were to look at their immune cells in under a microscope they had a a larger number of cd4 counts it's not a magic bullet doesn't work for everyone it neither helped nor hurt bereaved subjects but I think it's an interesting paradigm that I'm sure will get a lot more research on in terms of what's the exact dose what types of events should you write about who will this help and is there a population that might actually be hurt from doing this sort of intervention we should always remember the potential for harm even in our most promising interventions ok the next exercise I wanted to do is one borrowed from Rachel Riven here there's a lot of variants that's out marty selling men who now does positive psychology research has also done research on a variant of this this is something to change your selective attention and in the process to change your mood so why don't I have you answer three questions if you can just jot them down in your notes section so one question is name one thing that surprised you today the second question not name one thing that moved you today and I mean emotionally moved you so don't write down your car and the third is described one thing that inspired you so one thing that surprised you one thing that moved you one thing that inspired you now this is an exercise that we've done informally with our medical students and we encouraged our third year medical students to do it...
they've just left the classrooms they're on the board's incredibly smart motivated empathic students but they suddenly find themselves feeling incompetent and they find themselves terrified that they might hurt someone because they don't know what to do so they go home at the end of every day remembering every single mistake remembering everything they did wrong and feeling absolutely terrible about themselves so we wanted to give them an exercise to help them shift their attention and to improve their mood so it takes five seven minutes at the end of each day think about something that surprised you today on the wards in your clerkship think about something that moved you think about something that inspired you but how about let's hear from one of you who would like to volunteer these three things that you down how about a volunteer yes so one thing that surprised you today a client was born in a place you used to live overseas one thing that moved you today conversation with your husband and one thing that inspired you today a phone interview for a potential new job and how was that inspired so she got to talk about her accomplishments and realize that she's actually done a lot so in really just a few minutes very simple exercises we've

cognitive

ly shifted your attention to things that are positive things that are inspirational things that are emotionally moving and helped you to savor not something that's made up not something that's...
false false but something that happened in your day that may have slipped away because it wasn't negative and I think we naturally hold on more tightly to negative things that happen and we forget the things that that are positive we forget to savor our successes this is a quick way five to seven minutes at the end of each day that we can do that there are a couple of examples I wanted to show you of

behavioral

mood shifting so changing your mood at least transiently doesn't have to do with

cognitive

exercises we'll talk about activity scheduling they'll remind you of some relaxation exercises that might help and wanted to put in a plug for physical exercise we know that it's not only good for your body it's actually good for your mind both in terms of improving your emotional state but also in terms of improving

cognitive

function you know we talked a lot today about how puzzles and sort of

cognitive

challenges can keep your mind sharp actually aerobic exercise has a larger magnitude effect than those

cognitive

puzzles you can still do them both you can do them both at the same time if you want but physical exercise I think is very much an unsung hero sematic has to do with your body so somatic quieting is how to quiet your body how to turn down the

stress

response so an exercise we're not going to do but I wanted to show you it's part of a

behavioral

exercise for depression but I think it's also an important way for us to step back in to...
reflect on the choices that we make in terms of how we spend our time and then behaviors in which we engage a lot of times at the beginning of therapy we'll ask a patient to do an activity record or an activity schedule we give them a calendar this one's a little bit shortened just because I ran out of room there's a box pretty much for every hour throughout the week and we just asked them to fill it in at the bottom of it we asked them to rate their mood on a scale of 1 to 10 where 10 is the best mood ever or the best mood on that scale and 1 is their worst mood we then have them bring it in and we just look for patterns we look for days that were high mood days where they're things you were doing were there people that you were around that raised your mood we look for days that were low mood days were there things that you were doing or not doing that really pushed your mood down we also look for opportunities there may be sections of unstructured time or where there's just fillers and I think of TV as sort of a filler or internet surfing is sort of a filler it can be an important distraction at times but if there's large chunks of it I think that's an opportunity for a person to make a different

behavioral

choice that may have a different impact on their mood so we get them to bring in data we look for patterns we try to see relationships between behaviors and moods and then the next step is we actually want them to schedule a couple of pleasant...
things to do and you would be surprised but for many people this is a very difficult idea of scheduling something that's fun it almost seems antithetical to the notion as if fun things are just supposed to happen or social activities or social contacts are just supposed to happen I would say we need to give them as much or more attention as we give to our appointments that we schedule those certainly take up a lot of time we're not necessarily going to have a positive mood fact but it's not just the pleasant activities that we want to schedule we actually want a well-balanced diet of activities so we want some things that bring us pleasure some things that are distractions some things that help us feel connected to our families or friends we also need activities that give us a sense of competence give us a sense of mastery now an activity that recently lifted my mood was cleaning out my garage it was not a pleasant activity I'm not one of those cleaner organizer people that likes to do that but at the end of the activity I thought wow I did it I did it it's finished it's accomplished it had a mood boosting effect now I don't want all my week full of those kinds of activities I probably want at least a few of those in my week let's talk a little bit about the relaxation response and I know in dr. Kim Andy's lectures and others they talked about the

stress

response a sort of all the negative that happens when

stress

gets turned up fortunately...
for us we are made with all of these internal mechanisms that help us to stay in balance one of those is the relaxation response or the activation of the parasympathetic nervous system the the sort of yang to the end of the

stress

response system herb Benson's been writing about this since the 1970s and has been exploring different ways to help us to get into a state of relaxation where it's not just a mental or emotional phenomenon but we actually see changes in our respiration heart rate blood pressure and so on fortunately for us there are a lot of different ways to reach a state of relaxation different things tend to be preferred by different people you can make your own choices about what you like it tends to involve some form of focused concentration so it could be focusing on your breathing it could be focusing on a yoga posture it could be focusing on a mantra it could be focusing on a prayer it could be focusing on an image but it's some sort of focused conversation that decreases the chatter of the mind it usually involves a quiet environment but I've certainly had patients that are able to do this very noisy environments it's a matter of what you're used to and it requires a passive attitude I've do a lot of

stress

management with folks and I often have usually sort of younger men will come in and say I'm gonna be the best relaxer that you've ever seen I'm going to learn this better and do this faster than anyone else and so...
right away I know that sort of where we need to start that it is not about accomplishment or achievement it's that's the wrong attitude to have as I mentioned there are lots of different pathways to achieve the relaxation response and I just have a couple of examples here there are a lot of fantastic programs at the Bay Area in fact the OSHA Institute over at Mount Zion also has a number of programs as well in your reference list I read the last slide and also on the first page of the handout there's a number of books that you might turn to to get some ideas about what you can do to reach a relaxation response so the last portion of what I wanted to talk about in the next 10 minutes or so is what I've called depth

coping

it can certainly improve your mood transiently so the mood in the present but we're really talking about building that foundation of finding a source of sustenance that will feed you through the lean times that will give you the support that you need to carry you through we'll talk about connection and relationships we'll talk about meaning and how those help to promote personal growth perspective and balance so for connection if you look at the research on happiness you look at the research on subjective well-being you look at the research in positive psychology really any way you slice it the most common and the most consistently replicated predictor of well-being is relationships does it have to be a romantic relationship it can...
be a relationship with a sibling it can be a relationship with the best friend but it's about relationships and I think we really do ourselves and maybe our children a disservice not investing as much time and teaching about how to have relationships as we do teaching reading writing and arithmetic we should definitely add in a relationship class or more those relationships though aren't necessarily just about relationships with other people they could be relationships with pets they could be relationships with plants even there's some interesting literature there they could be relationships to a higher power however you choose to define that higher power or your spirituality but first I wanted to keep us down on earth and to look at our social supports or our relationships with other people and wanted to do just a quick exercise we won't debrief this one but but I want you just to give it a whirl and see if you can just write this right on the slide that's on your page what you do for this exercise this is a series of concentric circles here's you right in the center of the circle and I want you to think about your social support network so that so people that you can turn to for help when you need it and I want you to write them somewhere on this circle for people who are closest to you maybe your significant other best friend you might be in your inner circle someone who's a friend but you still have some walls up around them they'll be in...
this next level someone who's an acquaintance might be a little bit further out then outside the circle or all the other people in the world or co-workers or people you just don't really have so why don't you go ahead and just write down the name to sort of those top people who are in your social support network you'll write down your name and their position will depend on how close they are to you so why don't we go ahead and write those down and I'll tell you how we use this exercise clinically so in a clinical setting after persons been given some time to write the names down in the social support circle the first thing I look for is whether or not there any names there certainly had the experience where there are no names that a person can put on the sheet at all or you might notice that all of the names are actually on the outside so no one has even made it into these these outside rings for other people they may have a lot of folks in the outside but they're very guarded they don't have a lot of intimate relationships so there's no one in the inner circle at all so first I look for the number of the quantity of social supports then I look for the quality I look for the level of intimacy now there's no right number of intimate friends that a person's supposed to have it looks like it really just takes one close friend to give you the health protective effects that you need from social support in general however it's...
recommended that you have at least two close social supports and I think the idea is if you put all your eggs in one basket something happens to that basket you're in trouble so you want at least a couple of different supports the other thing that I look at though is not just who is on the map and how close are they to you but then how have the person think about what type of support is that person good at providing there's a lot of different kinds of support some supports very practical can you give me money can you give me a ride to the doctor can you help me do my laundry some of it might be informational support can you give me advice can you help me problem-solve and sort of work aloud and brainstorm about this problem some folks are really good at that and other types of support maybe emotional support who's a really good listener whose shoulder do I want to use to cry on when I need to do that your job as the person who needs support is to know what type of support you need then to turn to the right person to get that kind of support there are a few things more frustrating than needing emotional support and going to your problem solver and all they try to do is to come up with solutions and they don't really give you what you need it's partly their fault for not understanding what you need it's partly your fault for not either expressing it or maybe going to the wrong person to begin with so the last thing I wanted to talk about is is meaning in...
our search for meaning the importance of meaning in our lives and as I was thinking about meaning the classic book that came to mind for me is a book called man's search for meaning it's a book written by Viktor Frankl actually about fifty almost almost fifty years or so ago and let me tell you a little bit of the story about Viktor Viktor Frankl for those of you who don't know he was a psychiatrist he was Jewish he lived in Germany pre-world War two he and his large extended family they were arrested they were put in a Jewish ghetto and they were eventually put into concentration camps he as a psychiatrist began to look at the individuals who are in the camp mostly men in his particular camp and noticed that some of them died very quickly some of them actually survived despite looking like they absolutely should not have survived so he began to wonder what is it that gives a person that will to live what is it that gives a person that ability to keep going despite the circumstances around them what he comes up with is this life has a meaning to the very to the last breath the possibility of realizing values by the very attitude with which we face our destiny furring exist at the very last moment he who has a why to live can bear with almost any how he who has a why to live can bear with almost any how for Viktor Frankl his why was his family and in particular he would think about his wife and he had planned out his second wedding ceremony aware he was proposed to...
her who he would invite what the guest list would be what the menu would be those of you who have had weddings know how many details go into it and how time-consuming it is but that was his purpose reuniting with his wife with his family with his parents with his children with his siblings that's what got Viktor Frankl through the camps when the war ended and he was liberated from the concentration camp he discovered that he and his sister were the only two that had survived so here again he was forced with trying to find a new meaning a new why a new reason to go on living and that reason became he wanted to share his insights with the rest of the world he wanted to share what he had learned about the importance of meaning and helping us to endure or maybe even transcend suffering so he wrote the book man's search for meaning he went on to found his own school of therapy called logotherapy which I think has been so successful there's still a logotherapy school in Germany actually a couple in Europe but it's been so successful really this idea of the importance of of meaning of looking for that Y has really been absorbed has been integrated in almost every therapeutic school of thought finding the why or finding that source of meaning helps us to endure not just large sufferings but also small sufferings and certainly the the daily hassles of life as well when I think of it more in sort of the daily hassles or the

stress

level I think of a story that's...
shared by Steve McPhee he is a a physician here at UCSF founder of our palliative care service a very much beloved respected compassionate teacher mentor and clinician he has a story for the medical students and I believe their white coat ceremony they sort of get their white coats take the Hippocratic oath it's very sort of moving and meaningful for them he tells a story about choices that they need to make and the story goes something like this he starts off and this is the first day of school so they're all taking notes in there they're all very serious and says you know you have some choices ahead of you and probably the most important choice that you need to make is what kind of doctor you're going to be sounds normal so far and what I mean by kind of doctor is you have to decide if you're going to have a gas tank or if you're going to have solar panels some of the pins drop and they're wondering now what's wrong with this guy he said what do you mean by that is if you're a doctor with a gas tank and you go to see your first patient and maybe it's challenging take some energy burns off some fuel you do a good job you go to the next patient you burn off some more fuel but it's taxing but you do a good job you go to the next patient you burn off some more fuel and by the end of the day you've done a good job but your gas tanks on empty and that's what you take home to your family the alternative is to be a doctor who has...
solar panels you see your first patient it's difficult it's challenging it requires energy but in the moment you realize what a privilege it is to be invited so intimately into the life of another person to be given the opportunity to make a meaningful and lasting difference that privilege shines on you radiates on your shoulder panels and it feeds your soul you go to the next patient it takes energy go the next patient it takes energy and by the end of the day you're physically tired but your soul is fully charged and that's what you take home to your family so you decide gas tank or solar panels again in that situation you still have a

stress

ful job it's still physically exhausting but there's been a perspective shift there's been a reconnection with that source of meaning there's been an appreciation of the why there's been an appreciation of the privilege of the honor really that I think each of us can find in our everyday lives so I hope over the course of the talk today I know it's been sort of a fast whirlwind that you have some ideas of maybe things that you can try at home just pick one of them try it a couple of times on your own it might be a B C DS it may be journals it might be reading more about explanatory style it may be looking at your appraisals and reading through those questions it could also be activity scheduling finding a way to reach the relaxation response or hopefully have caused you to think a little bit about...
the importance of relationships and especially about the importance of meaning and connection I thank so we do we do have some time for questions if folks have any questions I'm happy to answer it yes so the question is if you have two children who've been abused why is it that one of them says it's not my fault it's going to change there's other things out there whereas the other child says if it's me you know I we don't know exactly what there is a relationship between a parents explanatory style in their child's explanatory style maybe it's learning maybe it's innate if you look at qualitative studies of people who have been abused that have been resilient they found a couple of different things and probably the most important factors they found a surrogate of some kind so there's a teacher there's a coach there's a minister there's a neighbor there's somebody that maybe sees what's going on and says hey you know what it's not you we're going to get you out of this things are going to change may not know that abuse is occurring but they provide that alternate theory that alternate explanation that the child hopefully can pick up and learn and use and apply to their own life the question is with

cognitive

behavioral

therapy what age range is it good for essentially you know the youngest I've seen it used is for kids who are 5 or 6 years old or so it changes in nature because it you know it's a...
complicated to do disputes and to sort of there's a lot of language that's involved in it when they do it with kids they use a comic books and cartoon characters and they come up with stories and they'll talk about trying to remember some of they had Polly the pessimist and Allie the optimist and things good things and bad things happen to both of these characters and they come up with different explanations so they learn through narratives they learn through stories then they make their own comic books in their own stories then they talk about the relationship to their own life so slightly different methodology but the same general general principles are used yes so the question is really about the value of optimism or pessimism and is there sort of an optimal range the bias is to say optimism good pessimism bad that's actually not true we did a study we with Marty selling Seligmann and myself we did a study of law students and we had the idea that pessimism might actually be a constructive trait in law school to always see the flaw to always see the crack to always amplify the negative to do that we actually found that the students who succeeded the most in law school were mildly pessimistic now if they were were were highly pessimistic they did not do well they were more on the depressed side but mild pessimism at least in that profession was helpful would be interesting to do that study looking at physicians if you think about it you might want your...
physician to be a little bit pessimistic to look think about all the bad things that might be happening to take care of them to test for them to hopefully prevent them but that study hasn't been done so I think there is a role for pessimism there there's a role for optimism but probably in the mild range in either direction so that's a it's a great question it's a question about setpoint when we hear about weight people talk about well is there a weight setpoint some people are just meant to be heavier some people are meant to be thinner is there a set point for emotion are some people just born happy and are some people born sad and I think you know for anyone who had maybe more than one child or more than one niece and nephew you know they come into the world with dispositions and so I think there's definitely a genetic or innate component to that I'd like to think though that that it's not you're a set point it's a set range so there's a mount of variability within the range that you're biologically able to achieve now the study that Ellen's referring to is a study by Ronnie jenoff Bullman she's a social psychologist and she looked at two groups of fairly unusual patients the first group were individuals who had recently won the lottery they'd become new millionaires so very happy it's a big event for most people they think it will make all their dreams come true what she found actually is you get this this...
this temporary spike in happiness and excitement and all the things you might imagine they buy bigger houses and bigger cars and so on within a 12-month period their level of self-reported happiness is back down to where it was before they actually won the lottery and I think that has to do maybe with a misunderstanding of what makes people happy it's not more money it's not a bigger house it's not a bigger car it's relationships and if money helps you have better relationships which it doesn't really if it did help you have better relationships you might see more of a difference the other groups you looked at though were people who had a very negative event happened to them these were folks who had been in a motor vehicle accident and who had become paraplegic so they had become paralyzed from the waist down as you can imagine that became very depressed they became very di

stress

ed it causes huge changes in your life a huge

stress

on your family so you see a big dip in their mood but in about 12 months as they had adjusted to their new way of life they had returned to about the same level of functioning and happiness that they had before the accident actually occurred those are fairly specialized groups of patient but I think it makes a fairly persuasive argument that we're at a particular level and even if you have big events that happen there is this pressure to return back to that same level I'd like to think we can bump that around a bit but it...
doesn't take accidents or illness or money to do that I think it really takes relationships it takes connection it takes it takes meaning to do that yes right so so she's asking about the exercise was who's there to support you and it seems like you're on a lot of other people's circles that they turn to you for support and at times that feels like a privilege but at times feels like a burden really and I think you know you have to decide for yourself in any social support relationship with those people on your circle there should be a reciprocity there should be times when you're the listener and they're the talker but there should be other times when they listen and if there's not that sense of reciprocity it's probably time to re-examine and rethink that relationship if you can if that doesn't work out maybe they should move to the further circles the further away from sort of your core supports yes so an important strategy will be sort of ahead of time if you can anticipate a

stress

or is occurring to do a little bit of preparation some advanced chling inning to meet that

stress

or you might do some advanced thinking about the appraisals and hopefully rallying your supports to be ready if that

stress

or should occur you're right that can certainly minimize the magnitude of a

stress

response you might have right and very important if the

stress

or is very strong you're right okay how about one one more question all the way in the...
back so the question is about an individual's willingness to participate if you can still get positive outcomes or not and I think really the the foundation of

cognitive

therapy is that as it's a collaborative partnership between the therapists in between the patients so there doesn't have to be buy-in really to get the kinds of gains that you would hope for if you're stuck in a situation where you have someone who needs help and they're not willing to get that help you can you know encourage them to see a

cognitive

therapist you can buy them the right books you can maybe share in

behavioral

interventions with them we know physical activity is a good

stress

ful in of

stress

intervention take them for walks you can help schedule dual pleasant activities with one another that might help to give them some respite or some relief from a

stress

ful situation but in terms of actually getting them to sit down to do the homework if they're not willing to do it I'm not sure that there's a whole lot you're going to gain from that so thank you so much for your time and your attention again I would encourage you you