MODULE 12 - Less Stress, More Care

MODULE 12 (GEC 1: Less Stress, More Care) LESSON 12: LESS STRESS, MORE CARE

LESSON OBJECTIVES At the end of this lesson, you should be able to: 1. explain the effects of stress to one's health; 2. examine cultural dimension of stress and coping; and 3. design a self-care plan.

LEARNING CONTENT INTRODUCTION The American Psychological Association (2017) has these statements about stress: "Stress is often described as a feeling of being overwhelmed, worried, or run-down. Stress can affect people of all ages, genders, and circumstances and can lead to both physical and psychological health issues. By definition, stress is any uncomfortable 'emotional experience accompanied by predictable biochemical, physiological, and behavioral changes.' Some stress can be beneficial at times, producing a boost that provides the drive and energy to help people get through situations like exams or work deadlines. However, an extreme amount of stress can have health consequences and adversely affect the immune, cardiovascular, neuroendocrine and central nervous systems." Since stress is inevitable to life, we have to learn how to handle and cope up with it. More so, we have to be familiar with other approach to a healthy lifestyle, which is self-care.

ABSTRACTION Stress and Human Response The American Institute of Stress (AIS) has distinguished different •types of stress and the human response to it. Hans Selye defined stress as the body's nonspecific response to any demand, whether it is caused by or results in pleasant or unpleasant stimuli. It is essential to differentiate between the unpleasant or harmful variety of stress termed distress, which often connotes disease, and eustress, which often connotes euphoria. Eustress is stress in daily life that has positive connotations, such as marriage, promotion, baby, winning money, new friends, and graduation. On the other hand, distress is stress in daily life that has negative connotations such as divorce, punishment, injury, negative feelings, financial problems, and work difficulties (AIS 2017). During both eustress and distress, the body undergoes virtually the same nonspecific responses to the various—positive or negative stimuli acting upon it. However, eustress

causes much less damage than distress. This demonstrates conclusively that it is how an individual accepts stress that determines ultimately whether the person can adapt successfully to change (AIS 2017). Selye hypothesized a general adaptation or stress syndrome. This general stress syndrome affects the whole body, Stress always manifests itself by a syndrome, a sum of changes, and not by simply one change (AIS 2017).

The general stress syndrome has three components: 1. The alarm stage — represents a mobilization of the body's defensive forces. The body is preparing for the "fight or flight" syndrome. This involves a number of hormones and chemicals excreted at high levels, as well as an increase in heart rate, blood pressure, perspiration, and respiration rate, among others. 2. The stage of resistance — the body becomes adåptive to the challenge and even begins to resist it. the length of this stage of resistance is dependent upon the body's innate and stored adaptation energy reserves and upon the intensity of the stressor. Just as any machine wears out even if it has beenoroperly maintained, the same thing happens with living organisms—sooner or later they become the victim of this constant wear and tear process. The acquired adaptation is lost if the individual is subject to still greater exposure to the stressor. The organism then enters into the third and final stage. 3. The exhaustion stage — the body dies because it has used up its resources of adaptation energy. Thankfully, few people ever experience this last stage.

Stress diseases are maladies caused principally by errors in the body's general adaptation process. They will not occur when all the body's regulatory processes are properly checked and balanced. They will not develop when adaptation is facilitated by improved perception and interpretation. The biggest problems with derailing the general stress syndrome and causing disease is an absolute excess, deficiency, or disequilibrium in the amount of adaptive hormones. For example, corticoids, Adrenocorticotropic Hormone (ACTH), and growth hormones are produced during stress. Unfortunately, if stress is induced chronically, our defense response lowers its resistance since fewer antibodies are produced and an inflammatory response dwindles (AIS 2017). In the article "Understanding Stress Response" of the Health Harvard Journal (2017), it further discussed chronic stress and human body response: "Chronic stress is unpleasant, even when it is transient. A stressful situation—whether something environmental, such as a looming work deadline, or psychological, such as persistent worry about losing a job—can trigger a cascade of stress hormones that produce well-orchestrated physiological changes. A stressful incident can make the heart pound and breathing quicken. Muscles tense and beads of sweat appear." This combination of reactions to stress is also known as the "fight-or-flight" response because it evolved as a survival mechanism enabling people and other mammals to react quickly to life-threatening situations. The carefully orchestrated yet near-instantaneous

sequence of hormonal changes and physiological responses helps someone to fight the threat off or flee to safety. Unfortunately, the body can also overreact to stressors that are not lifethreatening, such as traffic jams, work pressure, and family difficulties. Over time, repeated activation of the stress response takes a toll on the body. Research suggests that chronic stress contributes to high blood pressure, promotes the formation of artery-clogging deposits, and causes brain changes that may contribute to anxiety, depression, and addiction. More preliminary research suggests that chronic stress may also contribute to obesity, both through direct mechanisms (causing people to eat more) or indirectly (decreasing sleep and exercise) (Health Harvard 2017). The stress response begins in the brain. When someone confronts an oncoming car or other danger, the eyes or ears (or both) send the information to the amygdala, an area of the brain that contributes to emotional processing. The amygdala interprets the images and sounds. When it perceives danger, it instantly sends a distress signal to the hypothalamus (Health Harvard 2017). When someone experiences a stressful event, the amygdala, an area of the brain that contributes to emotional processing, sends a distress signal to the hypothalamus. This area of the brain functions like a command center, communicating with the rest of the body through the nervous system so that the person has the energy to fight or flee. (Health Harvard 2017). The hypothalamus is a bit like a command center. This area of the brain communicates with the rest of the body through the autonomic nervous system, which controls involuntary body functions like breathing, blood pressure, heartbeat, and the dilation or constriction of key blood vessels and small airways in the lungs called bronchioles. The autonomic nervous system has two components, the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system functions like a gas pedal in a car. It triggers the fightor-flight response, providing the body with burst of energy so that it can respond to perceived dangers. The parasympathetic nervous system acts like a brake. It promotes the "rest and digest" response that calms the body down after the danger has passed (Health Harvard 2017). After the amygdala sends a distress signal, the hypothalamus aOtivates the sympathetic nervous system by sending signals through the autonomic nerves to the adrenal glands. These glands respond by pumping the hormone epinephrine (also known as adrenaline) into the bloodstream. As epinephrine circulates through the body, it brings on a number of physiological changes. The heart beats faster than normal, pushing blood to the muscles, heart, and other vital organs. Pulse rate and blood pressure go up. The person undergoing these changes also starts to breathe more rapidly. Small airways in the lungs open wide. This way, the lungs can take in as much oxygen as possible with each breath. Extra oxygen is sent to the brain, increasing alertness. Sight, hearing, and other senses become sharper. Meanwhile, epinephrine triggers the release of blood sugar (glucose) and fats from temporary storage sites in the body. These nutrients flood into the bloodstream, supplying energy to all parts of the body (Health Harvard 2017). All of these changes happen so quickly that people are not aware of them. In fact, the wiring is so efficient that the amygdala and hypothalamus start this cascade even before the brain's visual centers have had a chance to fully process what is happening. That is why people are able to jump out of the path of an incoming car even before they think about what

they are doing. As the initial surge of epinephrine subsides, the hypothalamus activates the second component of the stress response system known as the hypothalamic pituitary adrenal (HPA) axis. This network consists of the hypothalamus, the pituitary gland, and the adrenal glands. The HPA axis relies on a series of hormonal signals to keep the sympathetic nervous system— the "gas pedal"—pressed down. If the brain continues to perceive something as dangerous, the hypothalamus releases corticotropinreleasing hormone (CRH), which travels to the pituitary gland, triggering the release of ACTH. This hormone travels to the adrenal glands, prompting them to release cortisol. The body thus stays revved up and on high alert. When the threat passes, cortisol levels fall. The parasympathetic nervous system—the "brake"— then dampens the stress response (Health Harvard 2017). Persistent epinephrine surges can damage blood vessels and arteries, increasing blood pressure and raising risk of heart attacks or strokes. Elevated cortisol levels create physiological changes that help to replenish the body's energy stores that are depleted during the stress response. But they inadvertently contribute to the buildup of fat tissue and to weight gain. For example, cortisol increases appetite, so that people will want to eat more to obtain extra energy. It also increases storage of unused nutrients as fat. Chronic low-level stress keeps the HPA axis activated, much like a motor that is idling too high for too long. After a while, this has an effect on the body that contributes to the health problems associated with chronic stress (Health Harvard 2017).

Techniques to Counter Chronic Stress Several techniques to counter chronic stress were presented in the same article (Health Harvard 2017): 1. Relaxation response Dr. Herbert Benson, director emeritus of the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, has devoted much of his career to learning how people can counter the stress response by using a combination of approaches that elicit the relaxation response. These include deep abdominal breathing, focus on a soothing word (such as peace or calm), visualization of tranquil scenes, repetitive prayer, yoga, and tai chi. Most of the research using objective measures to evaluate how effective the relaxation response is at countering chronic stress have been conducted in people with hypertension and other forms of heart disease. Those results suggest the technique may be worth trying, although for most people it is not a cure at all. For example, researchers at the Massachusetts General Hospital conducted a double-blind, randomized controlled trial:of 122 patients with hypertension, ages 55 and older, in which half were assigned to relaxation response training and the other half to a control group that received information about blood pressure control. After eight weeks, 34 of the people who practiced the relaxation response—a little more than half—had achieved a systolic blood pressure reduction of more than 5 mm Hg, and were therefore eligible for the next phase of the study, in which they could reduce levels of blood pressure medication they were taking. During that second phase, 50% were able to eliminate at least one blood pressure medication—significantly more than in the control group, where only 19% eliminated their medication.

2. Physical activity People can use exercise to stifle the buildup of stress in several ways. Exercise, such as taking a brisk walk shortly after feeling stressed, not only deepens breathing but also helps relieve muscle tension. Movement therapies such as yoga, tai chi, and qi gong combined with fluid movements, with deep breathing, and mental focus, all of which can induce calm. 3. Social support Confidants, friends, acquaintances, co-workers, relatives, spouses, and companions all provide a life-enhancing social net, and may increase longevity. It is not clear why, but the bufféring theory holds that people who enjoy close relationships with family and friends receive emotional support that indirectly helps to sustain them at times of chronic stress and crisis.

The Cultural Dimension of Stress and Coping Ben Kuo (2010) reviews studies on cultural dimensions of stress and coping. His study, "Culture's Consequences on Coping: Theories, Evidences, and Dimensionalities," published in the Journal of Cross-Cultura/ Psychology had the following findings: Stress and coping research constitutes one of the most intensively studied areas within health, social, and psychological research because of its broad implications for understanding human well-being and adaptation. Early thesis on stress and coping, the interwoven relationship of culture and stress responses was implicated, conceptually. The thesis postulated that a person's internalized cultural values, beliefs, and norms affect the appraisal process of stressors and the perceived appropriateness of coping responses. Accordingly, these cultural factors delimit the coping options available to an individual in the face of stress. As follows, stress and coping are universal experiences faced by individuals regardless of culture, ethnicity, and race, but members of different cultures might consider and respond to stressors differently with respect to coping goa19, strategies, and outcomes. Kuo's study identified and revealed compelling evidence for cultural variations and specificities on coping based on theoretical and empirical findings generated over the last two decades' cultural coping research. Based on the broad problem-versus-emotion-focused coping nomenclature, repeated studies have pointed to the prevalence of "emotion-focused," "indirect," "passive," or "covert," "internally target," or "secondary control" coping among individuals of Asian backgrounds, as well as, to a lesser extent, among individuals of African and Latino backgrounds. Specifically, the avoidance, withdrawal, and forbearance coping methods are common among Asians, while spiritual, religious, and ritualbased coping are common among African-Americans and African-Canadians. Additionally, spiritual and religious coping and coping through family support are common among individuals of Latino/Latina backgrounds (Kuo 2010). Furthermore, emotion-focused coping has been shown to be beneficial (e.g., reducing distress) forAsian-Americans and Asian-Canadians in dealing with various stressors, including family conflicts and racial discrimination. Problemfocused coping has also been found to be effective for Asian-Americans and Asian-Canadians in responding to male gender conflicts, racial discrimination, and cross-cultural adjustment. For non-Asians,

emotion-focused coping was shown to be negative in increasing stress for African-American adult caregivers but problem-focused coping was shown to be negative in exacerbating stress for Hispanic-American college students in facing family conflicts, As evident, the existing knowledge on the adaptive quality of different coping strategies is currently incomplete and inconclusive and necessitates further research (Kuo 2010). The current review also highlighted the salience of "collective coping" approaches among culturally diverse individuals, including Asians, AfricanAmericans, and LatinoAmericans, based on more recent research. This distinctive domain of coping represents the collective and interdependent characteristics of many ethnic minorities which is a critical aspect of coping, overlooked by both the extant coping and the cultural coping literature until recently. As has already been demonstrated in a number of recent published studies, to fully represent and account for the coping system of ethnic minority individuals, an integrated approach incorporating conventional and culture-based collective coping measures is imperative (Kuo 2010). Finally, this review also points to coping's link to: (a) broad societal climate, such as collectivism-individualism and independent-interdependent cultural norms; (b) individuals' acculturation and ethnic identity; (c) primary/internally versus secondary/externally controlled orientations; (d) accessibility and attitudes toward seeking social and family support; and (e) degrees of religious/spiritual beliefs and identifications. Together, these findings further underscore the significance of person-cultural environment interaction in the coping process and provide corroborating evidence in support of the contextual and transactional theories of coping (Kuo 2010). However, the said syntheses need to be interpreted with caution in view of several limitations. First, it should be noted that the way in which types of coping were defined, categorized, and measured; varied quite significantly from study to study and would likely have skewed the findings and the conclusions drawn and reduced the comparability across studies. Second, the relationship between coping methods and coping outcomes is not straightforward but is moderated by a constellation of contextual and personal factors as suggested by the theoretical models reviewed earlier. Empirical data, in fact, have evidenced the effects ofa person's perceived "intensity" and "controllability" of the stressor and cultural orientations (e.g., acculturation, self-construals) on coping. Lastly, it should be recognized that an individual's actual coping system often comprises a complex and diverse range of coping behaviors. For instance, Chinese-Canadian adolescents were found to engage in collectivistically based coping, in conjunction with individualistically. based coping when dealing with interpersonal conflict, adjustment stress, and gender role-related stress. Those qualitatively and functionally opposite coping strategies should not automatically be construed as mutually exclusive within culturally diverse individuals (Kuo 2010).

Self-care Therapy A positive way to counter stress is self-care therapy. Nancy Apperson (2008) of Northern Illinois University has provided steps for self-care:

Stop, breathe, and tell yourself: "This is hard and / will get through this one step at a time." During an unexpected event or crisis, we are faced with dealing with a new reality and it takes time to incorporate what happened into our everyday lives. Identify the steps you need to take first, write them down, and focus on each step one at a time. If you look at everything you have to do, you will become ovenNhelmed. Remember you can only do one thing at a time and focus exclusively on that one thing. Acknowledge to yourself what you are feeling. All feelings are normal so accept whatever you are feeling. Once you recognize, name, and accept your feelings, you feel less out of control. You can then find a comfortable place to express your feelings. During periods of extreme stress and grief, it is very hard to hold back your feelings, particularly your tears and anger. This is normal so describe this as grieving or sadness or anger. You are not falling apart. You are grieving or feeling angry or sad. It is important during this time of intense feelings to own your feelings and NOT hurt yourself or lash out at someone else. Find someone who listens and is accepting. You do not need advice. You need to be heard. Sharing our story is how we begin to accept whatever happened and integrate it into our new reality. It may be that you just need to let go of your expectations of how things should be and talking about your feelings and beliefs is the beginning of that process. Maintain your normal routine as much as possible. Making everyday decisions—deciding to get dressed, doing the dishes, or going to work—gives you a sense of control and feels comforting as it is a familiar activity. Be realistic with what you can do and remember everything right now will take you longer to do. Avoid making major decisions based on the stress you feel right now. Allow plenty of time for a task. You will not be as productive as you normally are. Accept how much you are able to do right now and recognize it will not be this way forever. During periods of extreme stress, prolonged stress, or after a crisis, your ability to concentrate and focus on tasks is diminished and it will take time for your concentration to return so give yourself extra time and be gentle and accepting of yourself and what you can do. Take good care of yourself. Remember to: a. Get enough rest and sleep. Sleep at least six hours and not more than nine hours. If you are having difficulty sleeping, listen to peaceful or slow music and/or do progressive relaxation before you go to sleep. Sleep helps our body heals and strengthens our immune system. b. Eat regularly and make healthy choices. Skipping meals, particularly breakfast, contributes to fatigue, mood swings, and poor concentration. Healthy food choices (not high in simple sugars) maintain blood sugar level, energy, and concentration of the body. c. Know your limits and when you need to let go. Some problems are beyond our control. if something cannot be changed, work at accepting it for what it is. Resist the urge to fix the unfixable or try to control the uncontrollable. Sometimes a mantra helps: "It is what it is, I just need to accept it." For things within your control, remember that change takes time. If you are holding on and need to let go, journalabout it.

d. Identify or create a nurturing place in your home. A rocking chair, a nice view, and a soothing music are important components to a nurturing place. Twenty minutes of spending in a rocking chair reduces both your physical pain and anxiety. It is like giving yourself a hug. Music and nature sounds nurture our being and lifts our spirits. e. Practice relaxation or meditation. Go to your nurturing place and listen to guided relaxation tapes. Time spent in meditation or prayer allows your mind and body to slow down and let go of the stress. Take a mental vacation in the midst of stress by relaxing your body, shutting your eyes, and visualizing yourself in your favorite vacation spot or quiet haven. f. Escape for a while through meditation, reading a book, watching a movie, or taking a short trip. Self-compassion Therapy Self-compassion is another way to counter stress. Kristin Neff (2012) has discussed self-compassion in her article, "The Science of Self-Compassion." "Self-compassion entails being warm and understanding toward ourselves when we suffer, fail, or feel inadequate, rather than flagellating ourselves with self-criticism. It recognizes that being imperfect and experiencing life difficulties is inevitable, so we soothe and nurture ourselves when confronting our pain rather than getting angry when life falls short of our ideals. We clearly acknowledge our problems and shortcomings without judgment, so we can do what is necessary to help ourselves. We cannot always get what we want. We cannot always be who we want to be. When this reality is denied or resisted, suffering arises in the form of stress, frustration, and self-criticism. When this reality is accepted with benevolence, however, we generate positive emotions of kindness and care that help us cope. Self-compassion recognizes that life challenges and personal failures are part of being human, an experience we all share. In this way, it helps us to feel less desolate and isolated when we are in pain."

Self-compassion Phrases Neff provided self-compassion phrases when feeling stress or emotional pain, perhaps when you are caught in a traffic jam, arguing with a loved one, or feeling inadequate in some way. It is helpful to have a set of phrases memorized to help you remember to be more compassionate to yourself in the moment. You can take a deep breath, put your hand over your heart, or gently hug yourself (if you feel comfortable doing so), and repeat the following phrases:    

This is a moment of suffering. Suffering is a patt of life. May I be kind to myself. May I give myself the compassion I need.

These phrases capture the essence of the three components of selfcompassion. The first phrase helps to mindfully open to the sting of emotional pain. (You can also just simply say "This is really hard right now" or "This hurts.") The second phrase reminds us that suffering unites all living beings and reduces the tendency to feel ashamed and isolated when things go wrong in our lives. The third phrase begins the process of responding with self-kindness rather than self-criticism. The final phrase reinforces the idea that you both need and deserve compassion in difficult moments. Be experimental with the phrases. Other phrases that may feel more authentic in a given situation are: "May I accept myself as I am," "May I forgive myself," or "May I learn to accept what I cannot change." (Neff 2012)

Self-compassion and Emotional Well-being One of the most consistent findings in the research literature is that greater self-compassion is linked to less anxiety and depression. Of course, a key feature of self-compassion is the lack of self-criticism, and self-criticism is known to be an important predictor of anxiety and depression. However, self-compassion still offers protection against anxiety and depression when controlling for self-criticism and negative effect. Thus, self-compassion is not merely a matter of looking on the bright side of things or avoiding negative feelings. Selfcompassionate people recognize when they are suffering, but are kind toward themselves in these moments, acknowledging their connectedness with the rest of humanity. Selfcompassion is associated with greater wisdom and emotional intelligence, suggesting that self-compassion represent' a wise way of dealing with difficult emotions. For instance, selfcompassionate people engage in rumination and think suppression less often than those low in self-compassion. They also report greater emotional coping skills, including more clarity about their feelings and greater ability to repair negative emotional states. Self-compassion appears to bolster positive states of being as well. By wrapping one's pain in the warm embrace of self-compassion, positive feelings are generated that help balance the negative ones (Neff 2012).

Self-compassion, Motivation, and Health Research supports the idea that self-compassion enhances motivation rather than selfindulgence. For instance, while self-compassion is negatively related to perfectionism, it has no association with the level of performance standards adapted for the self. Selfcompassionate people aim just as high, but also recognize and accept that they cannot always reach their goals. Self-compassion is also linked to greater personal initiative—the desire to reach one's full potential. Self-compassionate people have been found to have less motivational anxiety and engage in fewer self-handicapping behaviors such as procrastination than those who lack self-compassion. In addition, self-compassion was positively associated with mastery goals (the intrinsic motivation to learn and grow) and negatively associated with performance goals (the desire to enhance one's self-image) found on the study of Deck in 1986. This relationship was mediated by the lesser fear of failure and perceived self-efficacy of self-compassionate individuals. Thus, selfcompassionate people are motivated to achieve, but for intrinsic reasons, not because they want to garner social approval. (Neff 2012).

Self-compassion versus Self-esteem Research indicates that self-compassion is moderately associated with trait levels of selfesteem as one would expect, given that both represent positive attitudes toward the self. However, self-compassion still predicts greater happiness and optimism as well as less depression and anxiety when controlling for selfesteem. Moreover, the two constructs differ in terms of their impact on well-being. Also, self-esteem had a robust association with narcissism while self-compassion had no association with narcissism. In contrast to those with high self-esteem, self-compassionate people are less focused on evaluating themselves, feeling superior to others, worrying about whether or not others are evaluating them, defending their viewpoints, or angrily reacting against those who disagree with them. Selfesteem is thought to be an evaluation of superiority/inferiority that helps to establish social rank stability and is related to alerting, energizing impulses and dopamine activation. While self-esteem positions the self in competition with others and amplifies feelings of distinctness and separation, self-compassion enhances feelings of safety and interconnectedness (Neff 2012).

Self-compassionate Letter An example of a self-compassion exercise is the self-compassionate letter. This exercise has been used in therapeutic programs. Below are the steps in doing the self-compassionate letter exercise as provided by Neff (2012): 1. Candidly describe a problem that tends to make you feel bad about yourself, such as a physical flaw, a relationship problem, or failure at work or school. Note what emotions come up—shame, anger, sadness, fear—as you write. 2. Next, think of an imaginary friend who is unconditionally accepting and compassionate; someone who knows all your strengths and weaknesses, understands your life history, your current circumstances, and understands the limits of human nature. 3. Finally, write a letter to yourself from that perspective. What would your friend say about your perceived problem? What words would he or she use to convey deep compassion? How would your friend remind you that you are only human? If your friend were to make any suggestions, how would they reflect unconditional understanding? 4. When you are done writing, put the letter down for a while and come back to it later. Then read the letter again, letting the words sink in, allowing yourself to be soothed and comforted.

Less Stress, Care More We should be in control of the stress that confronts us every day. Otherwise, when we are overwhelmed by stress, it can be detrimental to our health. Self-care and self-compassion are two ways to positively confront stress. We should love and care for our self more and more each day.

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American Psychological Association. n.d. "Five TIPS to Manage Stress." Accessed October 31 , 2017. http://www.apa.org/helpcenter/manage-stress.aspx. American Psychological Association. n.d. "Understanding Chronic Stress." Accessed October 31 , 2017. http://www.apa.org/helpcenter/understandingchronic-stress.aspx. Apperson, Nancy. 2008. "Tips For Taking Care of Yourself During Stressful Times." In Faculty Development and Instructional Design Center, Northern Illinois University (Online). Accessed October 31, 2017. https://www.niu.edu/ facdev/resources/crisis/tipsforstress.shtml. Harvard Health Publishing. n.d. "Understanding the Stress Response." Accessed October 31, 2017. https://www.health.harvard.edu/staying-healthy/ understandingthe-stress-response. Kuo, Ben. 2010. "Culture's Consequences on Coping: Theories, Evidences, and Dimensionalities." In Journal of Cross-Cu/tural Psychology. Vol. 42 Issue 6, 1084— 1100. Accessed October 31, 2017. https://doi. org/10.1177/0022022110381126. Neff, Kristin. 2012. "The Science of Self-Compassion." In Compassion and Wisdom in Psychotherapy edited by C. Germer and R. Siegel. New York: Gilford Press. Accessed October 31 , 2017. http://self-compassion.org/wp-content/ uploads/publications/SC-Germer-Chapter.pdf. Roth, Susan, and Lawrence Cohen. 1986. "Approach Avoidance, and Coping with Stress." In American Psychologist. Accessed October 31, 2017. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.455.6019 &rep=repl &type=pdf. Tan, Michael L. 2006. "Stress and Filipino." Philippine Center for Investigative Journalism. Accessed October 31, 20M 7. http://pcij.org/stories/stress-andthefilipino/. The American Institute of Stress. n.d. "What is Stress?" Accessed October 31, 2017. https://www.stress.org/what-is-stress/