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DOCUMENT RESUME

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Whitman, Neal A.; And OthersStudent Stress: Effects and Solutions. ASHE-ERICHigher Education Research deport No. 2, 1984.Association for the Study of Higher Education.; ERICClearinghouse on Higher Education, Washington,D.C.National Inst. of Education (ED), Washington, Db.ISBN-0-913317-11-X.84400-82-0011115p.PubliCations Ddartment, Association for the Study ofHigher Education, One Dupont Circle, Suite 630,Washington, DC 20036 7.50, nonmembers; $6.00,members).Information Analyses - ERIC Information AnalysisProduets (071)

MF01/PC05 Plus Postage.College Environment; *Coping; Graduate MedicalStudents; *Graduate Stbdents; Higher Education; LawStudents; Medical Students; *Profesrlional Edbettion;*Stress Management; Stress Variable; *StudentAdjustment; Student College Relationship; StudentNeeds; *Undergraduate Students

Stresses expetienced by college students at differenteducational'ievels are considiired, along with ways that colleges canhelp reduce destructive forms of stress. After discussing how stressand coping are related, problems istlitining stress and coping areconsidered, and models are proposed for understanding stress. .

Following an overview on the way that stress and coping relate to therole of student, descriptions are provided of environmental settings,sources of stress are.given,oand solutions are presented forundergraduate students, graduate students, law students, medicalstudents, and medical residents. Solutions suggested for reducingdistress in students include: stress i3oculation (e.g., informingstudents in advance, f what difficulties they might face); improving

- campus mitntal.health services; organizing peer counseling andself-help groups; improved orientation for new graduate students;.greater flexibility in core.requirements; expanding the'role offaculty advisors; giving earlier and more frequent exams for lawstudents; deemphasizing grades in low schoolx basing appointment tothe law review on writing skills rather than class.rankriAprovingorientation for first --year medical students and residents; and bettercounseling and support groups for medical students and residents.(SW)

*******************it*********Q****************************************** Reproductions supplied by EDRS are the best that can be made * -

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ESolutions

ILU.

Neal k WhitmanliwidC. Spode*:2Iate CIA

ASKEERICIktir EducationBanta Repons 1984,

ASH* soMce

Report 2.

ER10

"Up

--Student-Stress:--Effects and Solutions

by Neal A. Whitman, David C. Spend love. and Claire H. Clark

ASkE-ERIC Higher Education Research Report No. 2. 1984

Prepared by

Cle_aringh.duse cm Higher.EdwoionThe George Washington University

Puhli3hed by

A ssociatio4 for the Study of Higher Education

Jonathan D. Fife.Series Editor

att as:Whitman, Neal A.:-Spendlove, David C.; and Clark. Claire H.Sitedent So al

Education Research RepOrt No. 2. Washington, DEC.: Associa-- °don for the Study of Higher Education, 1984.

--;-The-ERIC-Ckaringhouse.oraligberlducationinyitelindividualsto submit proposals for writing monographs for the HigherEducation Research Report series. Proposals must include:

. 1. A detailed manuscript proposal of not more than five pages.2. A 75-word summary to be used by several review committees .0

for the initial screening and rating of each proposal.3. A vita.4. A writing sample.

ISSN 07374292ISBN 0-913317-41-X

Clearinghouse on Higher EducationThe George Washington Um .ersPyOne Dupont Circle, guite 630Washington. D.C. 20036

MHO Association for the Studi.of Higher EducationOne Dupont Circle, Suite 630Washington: D.C. 20036

This publication was partially prepared with funding from theNations! institute of Education. 1344,1splitirgent of Education.under contract no. 400.82-00,11.-Tire expressed in thisreport do not necessarily affect the positions or policies of NIEor the Department.

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ASHEEitIC HIGHER EDUCATION RESEARCHREPORT SERIES

CONSULTING EDITORS,

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, _Robert H. Atwell ..

Vice President.

,Ionws L. BessProfessor of Higher EducationNew York Upiversity

Hunter R. BoylanDirector, Kellogg instituteA ppalachian,State University

K. Patricia CrossHarvard University

Estelle A. FIshbeiaGeneral Counsel °

The Johns Hopkins University

Donald R. GerthP .'dentCatifornib State University at Dominguez-Hilf----

Fred HarckroadProfessor of Higher EduoationUniversity of Arizona

Richard B. HeydiagerAssistant to theNice President for Academic AffairsUniversity of Minnesota

Patricia A. Hollander.wyer

Buffalo. N.Y.:

Normal) D. KurlandExecutive DirectorUniversity of the State of New YoikThe State Education Department

Doha LombardiConsultant

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rRichard Lqpsdale .

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Professdr of Educational AdministrationNew York University,

Linda Kock Lorimer ` 'Associate Getrrol Co tinselYak University

Yrrgaa-B7NorsibyDirector .

Affirrdatiie Action ProgramsUniversity of Michigan

Eugene OliverDirector, University Office of School & College RelationsUniversity of Illinois-Champaign .

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Harold OrionsLawyer

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Marianne Phelis.

Assistant Provost fur Affirmative ActionThe George Washington University

Gary K. ProbstProcessor of Readitiig .

Prince Georges Community College

Robert A. Scott a

Director of Academic AffairsState of Indiana Commission for Higher Education

Cliff SjogrenDirector of AdmissionsUniversity of Michigan

Al SmithAssistant Director of the Institute of Higher Education &

Professor of Instructional Leadership & SupportUniversity of Florida

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CONTENTS

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Executive Summary I-

Stress and Coping 0.The Relationship between Stress and Coping 6 ,

%bat Is Stress? ._...18,

Models -.4- 9Coping 12

Potential Effects of Stress on Students 1,6

College Students 2121Environamptal Settirg

Sourtes of Stress 24 'Solutions 26

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:Graduate Students 30

'outSetting 30

Soui ces of Stress . 33

Solutions - 44irLaw Students _ A9Environmental Setting 49Sources of Stress 51

Solutions, 56

Medical Students and ResidentsEnvironmental Settirig .

Sources of StressMedical StudentsSolutionsMedical StudentsSOurces of Stress---Medical ResidentsSolutinnsMedical Residents

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Concluding RecommeiridationsStressorsReactive CopingActive CopingFurther Research

References

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la'FOREWORD

A faculty/ administrator discussion of student stressgenerally generates a variety of emotional responses. Fromthe hardliners or academic elitists, the response is one ofindifference that can be summed -up'with-FresidentitirryTruman's: "If yOu can stand the heat, get out of thekitchen." The opposite reaction. often held by counaelorsand student persdnnel workersvfo6ses on a desire tominimize or eliminate all stress faced by students due to thebelief that it has a negative effect on learning.

Authors Neal A. Whitman, Director of EducattonalDevelopment in the Departmerit of Family and CommunityMedicine, David C. Spendltwe and Claire H, Clarke, bothfaculty members in the School of Medicine, all of theUniversity of Utah, demonstrate in this repck that stress canbe both positive and negative. It can help achieve aninstitution's vials, but also can be a destructive force withvery negative consequences. Therefore,at is extremelyimportant for faculty members and administrators to be wellaware of the results of student stress when they evaluate anddevelop academie-arid adininistritive policies andprocedures.

With an understanding of the research on stress andcaping,\ faculty memberslind administratOrs can better:

evatuate the student's environmental setting,identify the sources of stress,makinformed judgements on changes needed in,order ltdtto exceed the "optimal level" of stressthatdelica'te balance of the positive and negative factors.

By so doing; faculty and administrators can provide aneducational atmosphere with maximum learning and socialgrowth that avoids the extreme levels of. stress thatcontributeto unnecessarily high student attrition rates.

Jonathan D. FifeSeries EditorProfessor and DirectorLRIC Clearinghouse on Higher EducationThe George Washington University

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EXECUTIVE SUMMARY

What Is Stress sod Wow Does It Affect Students? .

''Stress is any situation that evokes negative thoughts andfeelings in a person. The same situation' is not evocative orstressful fcr. airpeople, and all people do not experiencethe same negative thoughts and feelings when stre*sed.Oneimoderthat is useful in understandingstress amongstudents is the person-environment model. According toone variation of this model. stressful events can be ap-praised by an individual as "challenging" or "Ihreatening"(Lyarus 1966). When students appraise their education asa challer.gc, stress can bring them a sense of competenceand an increased capacity to learn. When education is seenas a threat, however. stress can elicit feelings of helpless-ness and a foreboding sense of loss. '

'44-criticai,issuc concerning stress among students is itseffect on learning. The Yerkes- D.xlson taw (1908) postu-lates that individuals under low and high strip learn the StreSsfuileast and that those under moderate stress learn the most. events can beA field study (Silver 1968) and laboratory tests (Hockey1979) support he notion that excessive stress is harmful to appraised bystudent& performance. an individual

Mechanisms that explain why students perform badlyunder stress include "hypervigilance" (excessive alertness ,to a stressful situation remitting in panicfor example.overstudying for an exam) and "premature closure" or(quickly choosing a solution to end a stressful situation

, "threatening.",for example. rushing.through an exam). .

What Is Stressful for Ilodergroduotes? ..Students react to-college in a variety of ways. For some .students, college is stressful because it is an abrupt change

' from high schom. For others. separation from home is asource of stress. Although som stress is necessary forpersonal growth to occur. the ount of stress can over-whelm a student's ability to cope.

Since World War II. changes in American 10her educa-tion include growth iri the size and complexity of institu-

`tions and increased diversity among students. A conse,quence pi that rapid growth has been a kiss of personal

, attention- to students, One measure of excessive stress:that is. distressoin college students is the use of mental 'health, services. Although some students. may bring psychi-atric problems to the college campus. symptoms commonly,

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Student Stress

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.mreported by campus psychiatrists portray a general picture %

of pool - related stress. for example, the inability to doAool work and the fear of academic failure (Ellis 1969). 0

A second measure of distress in college Students is thedrOpout rate. Although nationwide figures are difficult toobtain, itis estimated that 50 percent of entering freshmendo not finish ctillege four years later (Hirsch and Keniston1970). Studies of college dropouts associate dropping outwith the aversive side of the -Ight of flight- foimula; thatis, students, feeling mismatch between themselves andtheir college, wish to distance themselves from,the sourceof sircss, the college environment Walk 197t Hirsch and'Keniston 1970; Katz et al. 1969).

Solutions suggested for'reducing distreis in collegestudents include "stress inoculation"for exampk, in- e,forming students in advance o1 what difficulties they mightface and encouraging them, to develop their own strategiest, achieve personal goals. Other suggestions inch* im-proving campus mental health services and organizing peacounseling and self-help groups.

Whatis Stressful for Graduate Students?The accelerated growth in undergraduate programs has 1

.also been felt in graduate schools, resulting in an oversup-ply of Ph.D.s. Consequently, graduate students, facing I

poor employment oppot tonities when they finish their ir

doctoral programs, feel stress assoc(ated with the uncer'4tainty of their career choice and future prespects.

Often, graduate students perceive that faculty exertgreat 'Iowa over their lives and feet that they live in a stateof substantial powerlessness (Altbach 1970). Anothersource of stress is the difficultyaof achieving social inti-macy. Either it is difficult to find a mate or maintain a'relationship with an existing one. Graduate students tend,to lack the time. the opportunity; or both to developinter-personal relitionships (Hartshorn 1976).

Specific tasks digt produce stress in graduate studentsare preliminary exams and the doctoral dissertation. Fearof academic faildre relatedto these tasks is a definitestressor (Kjerulffa.nd Wiggins 1976: Kolko 1'40).

Solutions for alleviatitg distress include in.proved orien-tation for new graduate students, more flexibility in corerequirements, and expanding the role of faculty advisors.

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What 14Streadel for Law Students?The Socratic method; ()eloped at Marver4 in the 1870s.still characterizes law education today. Certlin problemsare associated with tee approach. however. it puts theteacher in complete control of the classroom, leavingstudents with little control over bow they relate to thematerial being,taught in class. Related to the Spoiticmethod.is the issue of feedback. Law students receive Tittle.. -feedback in class and litijeleedback about their academicperformance until after first semester exams (Ellin wood,Meyerson, and Pat41983).

4w students feel that grades are emphasized exces-sively and see the :aw school as a screening program forlaw firms. the best of which interview only students whohave made law review. Often, when students do not ranknear the top of their class at the end of the first semester,they give up trying because their best efforts were notrewarded (Silver 1968).

- In an effort to deal with the lack of feedback, somestudos rely on hops feedback; for example, studentswho well in.an ungraded legal, writing s*mina* believe .

they will rank high in the 'lass. The extent to which stu-dents rely upon false feedback to relieve their anxietiesmight be counterproductive if they begin to avoid adequatepreparation for exams.

Suggestions to relieve distress among law studentsinclude giving earlier and more frequent exams. provid-ing positive feedback in class, deeinphasizing grades, andbasing appointment to the law review on writing skillsrather than on class rank tEllinwood. Meyerson, andPaul 1983).

What Is Stressful foie Medipl Students and Residents?Medical education includes four yeari of medical schooland three to five years of residency training in a teachinghospital. Premedical educationsin college is in itself stress-ful because of the keen competition to get into medicalschool. Competitioncontinues in medical school among*students eager to get into the residency program df theirchoice. For some residents, competition continues forthose Who wish to earn the status of -chief resident" in theprogram and to wits a postrescdency fellowship.

Student Stress 3

A major stressor for firstyear medical students is theamount and complexity'of material to be learned. Stud tn1feel academic pressure because nearly all tteir classmateswere superioccollege students (Gaensbaaer and Mizner1980). Fatigue is often cited as a stressor in the second .

year, and many researchers describe it. hypochondriacalphenomenon by which medical students .tnagine they havethe disease they are studying (Bojar 1971: Saslow 1956).

In the third year. medical students begiq patient care.but they are low en the totem ',tile., Acceptanceof deathand dying enteives as a key issue in coping with suss. Forsome medical students, true clinical years become routineand the fourth year is less stressful.

When medical school graduates enter the first year ofresidency training (the internship), they find themselyesagain low on the totem pole, and overwork and sleepdeprivation become major stressors. Lack of personal timecontinues to stress residints in their second and thirdyears.

. Solutions to help medical students and residents cope .

with stress include improving orientation for first-yearmedical students and residents. Better counseling andmore support groups are recommended. Providing morefree time in the medical school curriculum and residencytraining is eine° cited; but the requirements to achievecompetency in medicine seem to preclude hiajor'renudtionein the workload.

What Overall Appreiches Are Recommended?Stress is necessary to challenge students to learn. What is'needed are approaches to reduce the negative aspects 0(6stress (distress) that lessen students' learning and perforin-ance. The key to reducing distress is providing studentswith % feeling of control over their education, infor.nationabout what to expect, anefeedback regarding what can 6e .

done to in.orove their performAnce. Students who do notfeel helpless will adopt their own coping strategies.

Reactive coping, that is, dealing with oee's own thoughtsand feelings. can be facilitated by accessible professionaland peer counseling. student support groups. and Adequatefaculty advising. Active coping, that is, dealing with the 'actual Stressful situations or events, can be strengthenedby providing students with early success.

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Good teaching can not be overestimated as a key to# preventing and minifnizing distress among students. Of

° course, faculty may not be good teachers if they are them-. selves stressed and if they feel unrewarded for good teach-,

ing. How to reduce, stress atrodg faculty and reward goodteaching art questions for further study.

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,STRESS AND COPING

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It is Monday morning, and when I walinto the centralbuilding I can feel my stomach clench. For the next 5days I will assume that I am somewhat less intelligentthan anyone around me. At most moments, I'll alsosuspect that the privilege I enjoy was confirred as some

-kiwhat I do, I will nokdo tt well enough; and When I fail Iknow that I will burn with shame. By Friday my nerveswill be so brittle from sleeplessness and pressure andintellectual fatigue that I will not be certain I can makeit through the day. After years 4'1 have begun tosmoke cigarettes again; lately, l' seem to be drinking alittle every night. I do not have the time to read a.nckelor magazine and I am solar removed from the news ofthe world events that I often feel as if I've fatten off thedark side of a planet. l am distracted at must times andhare difficulty keeping up I. conversation, e'en with, mywife. At random instances, I am likely to be stricken withacute feelings of panic, depression, indefinite need, andthe pep talks and irony I practice on myselfintly seemsto make it worse (Throw 1977, p: 9).

These thoughts, feelings, and behaviors of a first-year .

law student describe many of the symptoms associated-c. . with stress and some insight into how one can cope with

_:"t-feelings of powerlessness in a stressful situation:This._..-

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chapter examines concepts of stress and coping and how--.these concepts relate to being a student, First, it disculseshow stress and coping are related. Second, it describesstress, paying particular attention to problems with itsdefinition and the models that are used.to hell) understandit Third, it describes coping, also discussing problems withits definition and the different ways people cope. Finally.the chapter discusses how stress and coping relate to theTole of student and how colleges and universities can hell)redtice destructive farms of stress.

The Rebtionshi .i between Stress and CopingThe concepts of stress and coping are neutral. Althoughpeople Commonly see stress as negative and coping aspositive, the relationship is not that simple. Suress can bepsychologically positive or negative, and the means ofcoping can be effective or ineffective in meeting the chal.

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lenge presented by the stressful situation. The potential forstress to be either positive or negative was destrits.td .

nearly 80 years ago:Individuals under no stress or extremestress learn the least and those' under Optirwm lcvels ofstress learn the most (Yerkes and Dodson 1908). In otherwords, a curvilinear relationship in the tbrra of aft invertedU exists between stress and learning. A more riser. look'at this relationship cites several supportintstudies ofanimals and humans (Hockey 1979),

This same curve can be used to describe coping. McClel-land et al. (1953) used a ring-toss game with school chil-dren that demonstrated how theYerkes-Dodson law works.They found that some children coped with the challengeof tossing the ring ontoa post by standing directly overthe post so that they were always successful. A secondgroup of childrer stood so far away from the post that its

was almost impossible to achieve success. Whi!ft it ap-peared that the second group were creating thi greatestchallenge for themselves, both-groups were actually com-prised of children who were Novo-need achievers." Thesedon4group, seemingly greatly challenged, were actuallyleft With a convenient excuse. By making the task toodifficult, they were not responsible for failure. A thirdgroup was described as "high-need achievers." Thesechildren dealt with the challenge in the game ty making thetoss difficult but achievable. The high -aced achieverscontinually adjusted their position to the post so that theywere continually challenged -but not-overwhelmed.

This phenomenon ,:an be likenid to the "overload prin-ciple" in biology (Hershey and Blanchard 1972); for exam-pk, in weight rifting, one can increase strength by liftingweights that are difficult but realistic enough to stretchmuscles. Strength cannot be increased by performing tasksthat are too easy or that will injure muscles. Likewise.effective coping requires recognizing the extent of thestress one is experiencidg and balancing resources to avoidovercompensation or undercompensation.

Balancing resources for coping is similar to the biologicalnotion of homeostasis, a concept developed by the physiol-ogist Bernard in the late nineteenth century (Stye 1976),Ore of the most characteristic features of living beings isthe ability to maintain the constancy of their internal envi-ronment despite changes in the surroundings. This power

Individualsunder nostress orextreme stresslearn the leastand thoseunder -

optimum". . .

stress learnthe most.

Student Stress 7

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to maintain constancy later became known as homeostasis.A simple metaphOr helps illustrate this concept. Whenwindows are opened to the cold air, an added stress isintroduced so that the furnace makes every effort to main-'taro room temperature. More fuel for the furnace is re-

taxed with a psychological stressor, increasing amounts ofenergy are required to keep them psychologically bal-anced. When coping with the stress of a difficult exam, forexample, students maintain psychological balance bytemporarily cutting back on socializing, spending moretime studying, and planning to take a day off froni studiesafter the exam.

What Is Stress? -*

Defining and describing stress poses major conceptualproblems. Reactions to stress have bien described asarousal, depfession, anxiety, boredom, anger, physical

, discomfort,and discomfort in general. The physical symp °toms associated with psychological and physical steess arechanges in heart rate,lood pr.sure, and skin conduc-Olney and various hormonal responses. In addition tophysical symptoms, stressful situations produce psycholog-ical, cognitive, behavioral, and social reactions. A classicstudy of stress among graduate students defines stress as"discomforting responses of persons in particular situa-tions" (Mechanic 1978, p. 7). This ilefinition deemphasizesstress in terms of the nature of the event and emphasizes itaccording to the meaningindividuals give to it. .

Although thisidefinition helps clarify an unwieldy con-.

cipt, it also suggests some important questions aboutstress. Is stress a situational or a behavioral response? Forexample, when a student is faced with an exam, is stressproduced by the exam itselforthe-way-the-student-responds to the exam? If stress is the'response, how is itdifferent from coping? For example, is worrying about atest an example of stress or of coping? How many peoplehave to act in a distressed manner for a situation to beconsidered stressful? And finally, how intense must thereaction to the stressful situation bb to be consideredstressful? .

Despite the vast amount of research on stress. an under-standing of the concept is still limited and plagued with

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problems (Chan 1977; 'Payne. Todd, and Burke 1982). Infact, not until 1966 was a distinction made between chal-lenging and threatening stressors (Lazarus 1966). Positivestress is associated with 'situations that provide challengeand growth, but negative stressor distressis associatedwith threatening situations. One problem with the researchis that it has not been adequately designed tc look at causalrelationships (Payne. Todd, and Burke 1982). Another

., Problem is that too many studies 'focus'on determiningpersonality traits related to stress and coping. Yet person-ality traits have not been successful predictors of howpeople cope and thus who is at risk for distress (Folkman1982)!

Much of the literature on stress takes a fairly static viewof the concept (Folkman 1982). What makes the phenome-non of stress so complex, however, is that it is dynamic,partly because as individuals cope with stress. they leainto adapt; thus, what is stressful is constantly changing.Mechanic's definition (1978), which reflects the inherentindividual nature of stress. allows for this dynamic qual-ity; it is perhaps the most adequate definition of the ce-cept to date.

Brief definitions. however. do not sufficiently describeconcepts. Various stress models are necessary to morefully understand the concept.

ModelsThree stress modelsthe medical-biological. the psy-choanalytical. and the person-environment--are discussed .in the literature. Hans Selye. a physician. is probablyidentified with the medical model more than any otherindividual. Selye'S model includes both psychological andbiological stressors ail is more commonly known as thegeneral adaptation syndrome (Selye 1982). This model .desedbe% the way in.which.the body's biochemical de-fenses mobilize in response to psychological and biologicaldem .nds (Selyn 1982). The biological way in which humans .adapt to environmental demands is,similar to biologicalresponses of other animals andeven plants.

The general adaptation syndrome is a three-stage biologi-cal process in response to a stressor: In the initial stage,called the alarm react;on. the body makes a biochemicalresponse in an effort to mobilize defensive forces.. During

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the alarm reaction, the body becomes overwhelmed anddies or enters a second stage, culled resistance, in which itresponds in a different biochemical way. if the body isunable to adjust because of the s,everity and continuedexposure to stress, the third stage, exhaustion, results. Thebody's abilitU to ackm t is finite, and with cort;nueu expo-sure it gradually wears out, similar to a machine. AlthoughSelye's model (sometimes called the "wear and tear"model) has been used to explain psychological strew, otherresearch shows that the body reacts very differently to

e. stress, depending on whether thcostressor is biological orpsychological (Baum, Singer, and Baum 1981).

The psychoanalytical model focuses on the individual'sconflicts between biological and societal pressures. Freudreferred to defenses as efforts made to protect oneselfinstinctual biological demands that are in conflict withenvironmental pressures (Mechanic 1978). Freud's daugh-ter, Anna later specified nine possible defensemechanismsitie ego uses when the individual is anxiousfegression, repression, reaction formation, isolation, Undo;ing, projection, introjection, turning against the elf, andreversal. These defense mechanisms have in common thecharacteristics of denial, falsification, and the disiortion 'ofreality, and they operate at an unconscious level. Although

'Mechanic mentions a few studies in which the psychoana-lytical framework has been used to study stress, this'modelsuffers from a lack of validity, particularly in relation tostudents. Because psycboan'lysis was developed to under-stand neurotic behaviors rather than normal reactions )bstress, the model does not take into account healthy as-pects of effective problem solving in which denial, falsifica-tion, and distortions of reality are not necessarily used.The model is not used to look at factors that contribute tostress in the environment; rather, it focuses on intrapsy-chic processes.

The person-environment model appears to be mostappropriate for understanding stress among studentsAlthough the model has a number of variations. basiccomponents include "the external and internal forces ofstimulus conditions of stress reactions and the interveningstructures ale nrocesses that determine when and in whatform the stress reactions will occur" (Lazarus 1966, p. 13).

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What makes an event stressful is the degree to which itis perceived as threatening, harmful, or challenging (Laza-rus 1966). When an event is appraised as challenging,overcoming the stressor seems more hopeful; but when itis appraised as threatening, a sense of potential loss and

between challenge and threat is im ant because'individ-Duals who are inclined to see events as challenging demon:strate more confidence in their ability to adapt and willcope differently from those who picture the same event as

,threatening (Baum, Singer, and Baur; 19(31). Appraising asituation as threatening car evoke a response that is evenmore harmful than the actual event; therefore, secondaryappraisals are used to weigh the dangers and benefitsassociated With the initial response (Lazarus 1966). Thus,individuals are continually involved in a dynamic processof appraisal and reappraisal of the stressful situation andtheir reactions telt Because each Individual responds tothe environment differently, this view constitutes a person-environment model of stress.

A crucial aspect of the appraisal is control. Numerousstudies suppoit the idea that having control and perceivingoneself as having control over adverse outcomes have theeffect of reducing stress: "lf I can stop the roller coaster, Idon't want to get off" (Miller 1980)° Predicting and receiv-ing information about adverse outcomes also help one fellin control and appear to be as beneficial as actually havingcontrol (Glass and Singer 1972). These concepts worktogether in this way:,

Someone in the neighborhood is throwing a big, noisyparty. Neighbor A is told to complain if he can no longertolerate the musk and frivolity, although he refrainsfrum-doinK srrbecarrse-ofseif-imposed-vrelrointreleNeighbor B receives no such communication. The partyfestivities are equally disruptive to the neighbors. De-spite this it is likely that Neighbor ;I (who believes thathe can complain but never does) wit' be less disruptedby the festivities than will Neighbor B (who will prob-ably spend the whole night stewing and might eventu-ally tip of she police us a "concerned citizen") (Miller

4940. p. 71).

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Neighbor A experienced less stress becaule be receivedinformation about controlling the situation. The faet.that,he chose not to exert control made no difference becausehe at least had the perception of being in control. NeighborB was more disturbed *awe nothing suggested he hadcontrol. Furthermore, Neighbor B will experience increas-ing levels of stress if he sees himself as helpless (Abram:son, Gabber, and Seligman1980). -

Three basic sources at situational stress represent theenvironmental side of the person-environment model ..(Lazarus and Cohen 1977). First are cataclysmic events 'sudden and powerful events affecting large numbers ofpeople, such as war, natural disasters, or economic depres-sion. The second Source of stress is similar in its sudden-ness and powerfulness, but it differs in that few people areaffected. Such evemi include illness, death, personalfailure, or any personal loss. It is important to distinguishbetween these two sources of stress because it is likely thatless, psychological damage occurs during cataclysmicevents where more people can share their emotions and,compare their behavior with others. The third category ofstress involves "daily hassles " -.- ongoing and ch: Alioproblems for which one has adapted at same lev'l bat thatstill can take a psychological toll over time. Such problemsinclude dissatisfaction with one's marital relationship,living in *crowded environment, and problems with trafficto and from work.

The person-environment model is a general and simpleexplanation of psychological stress that is *idely acceptedin the litefeture,Tbe model provides a isefid frameworkfor analyzing psychological stress experienced by students.The educational environment combined with students'thoughts and psychosocial backgrounds form the -essential ,

ingredients necessary to understand stress among students.

Coign . ,

Stress and coping work together in a balance. 'Copingbehaviors seem to be directly related to characteristics ofthe source of stress'! (Baum, Singer, and Baum 1981. p.24). Characteristics of the source of stress change at leastin the mind of the isolividual, depending upon the copingmechanism used,

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....=111A major reason for confusion about coping is that no

adequate theoretical efamework or classification systemexists for understanding the concept (Folkman 1982). Re-search on coping is oriented too much toward personality

l traits, ah approach that assumes individual behavior is simi:lar in different situations (Folkman 1982).-But coping is a dy-namic process that occurs within the personenvironmentmodel: ,-

Coping efforts are made in response to stressful apprais-als that signal harm or loss, threat, or challenge. harmor loss refers tn dito:age that has already occurred,threat refers to harm or loss that has not yet occurredbut is anticipated, and challenge refers to an anticipatedopportunity for mastery or gain. If the coping effortsthat ure :nitiated in response to a stressful appraisalchange the relationship between Ilk person and theenvironment by altering the situation andlor by changingthe person's feelings about it, new appraisals or reap-praisals are made which in turn engender new coping.efforts and so on (Folltman 1932, p. 97).

In this dynamic process, the person and the environmentare interdependentreach influencing aid in turn beinginfluenced by the other. Thus, the environment acts uponthe person, who in turn acts upon the environment, which

. acts upon the person, and so on. .

The differences in meaning between adaptation, coping,mastery, and defenses are confused (White 1974). Adapta-tion refers to the process of developing automatic patternsthat takeover mindlessly when stressful events occur. Liferevolves around daily events ti, at were once stressful butnow are not so because of the process of adaptation. Cop-

. ing refers to the mechanisms that help one through anevent.to which he has not adapted. Coping is not a mind-less process; it involves conscious efforts on the part of theindividual under stress (White 1974), The first-yearlawstudent, for example, as often said to be under ektremestress and thus uses various coping mechanisms, but thestress of the first year seems to lessen somewhat as thestudent adapts'during the second and,third years. Coping

-refer; to psychosocial mechanisms that are used wAen

Student Stress

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normal adaptivemeasures do not work: A main focus of. this monograph is on coping-rather than adaptation.

Lazarus, Averill, and °pion's definition of coping (1974)reflects White's distinction between coping and adaptation.Coping is "ixoblewsolving efforts made by an individualwhen the demands he faces are highly relevant to hiswelfare (that is a situation of considerable jeopardy orpromise) and when these demands tax his eaptive re-sources" (Laza:Ns. Averill. and Onion 1974, p. 250). Es-sentially, coping is used to help actualize some promiseassociated with the challenge of positive stress or to takethe individual out of jeopardy when threatened with dis-tress.

Individuals use both problem-focused and emotion-focused coping (Folkman 1982). Suhjecti in Folkinan'sstudy almost always used both types of coping. but theway in which the stressor was appraised affected the de-gree to which one type was used over the other. Individ-uals who saw the stressful situation as overwhelming weremore likely to use emotion-foctieed coping, and as suchtheir coping consisted mainly of reguliting their emotionalresponses to the problem. If the individuals thought thatthe situation was manageable, however, they were morelikely to use problem-focused coping to directly alter thesource of stress. Problem-focused and emotion-focusedcoping can facilitate or impede each other (Nicsitart...I982) the case with the student who*nintrzes t1ie signifi-cance of a test (emotion-focused coping) and does notstudy adequately (prbblem-focused 'coping). Folkman'sbasic classification of problem- and emotion-focused cop-ing is similar to Mechanic's earlier ideas about coping .(1978), but perhaps her most important contribution is notthat she developed a classification system but that shesupported her system with research.

Stress and coping compose a complex within the person-environment model. The boundaries between stress andcophig become blurred such that the way in which hi:livid-

. uals cope can produce stress and even affect the stress();itself. For example, the stressful event fit s: evokes a re-sponse on the part of the individual (sec figure 1). Thisresponse involves both feelings (depression, anxiety, for,excitement, for example) and an appraisal of the stresses.Second, the individual reacts to these initial evocative ,

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FIGURE ISTRESI.COPING COMPLEX .

STRESSFUL EVENT* OR SITUATION

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ACTIVE 41--

/

14).4,

It t

LOPING

responses by using emotionfocused coping to regulate theresponse to the stressfurevent. Regulating one's ownemotions does not directly chalige the stressfd event ittelf.For example. if a student is upset about failing a test, he orshe might cope by exercising, going to a movie, drinkingexcessively, and/or giving oneself a pep talk. Althoughthese methods of coping will usually facihtite'the individ-ual's rdappraisal of the stresspr, they do not directly .

chance the stressor itself. Tile way in which one copeswith ore's own reactions, however, affects the thoughtsand.behaviors associated with the more active or directway of coping with the stressor. The third part of thecomplex is the active or problt di-focused coping; it can .

include effective study methods, talking to a professorabout retaking a test, or withdrawing from a class. Afterinitiating such actionsothe indiiidual will likely receive :feedback about .he consequences. The stress-coping i3om-plea incorporates the'person-environmeni model becttusethe person and the stressor constantly affect ea,* other. -

REACTIVE

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Student Stress

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Demographic variables as well as personal characteris-tics influence how an individual appraises stressful situ*.tionsvid copes with them. Three specific demographicvariables influence students: race..sex. and marital stew" .

At all levels of higher education. race can be a critical_ factor when minority students enter programs previously

denied to them. The potential for stress is further increasedif minority students lack traditional academic preparationand minority faculty as role models., Sex is a critical factor when men or women enter afield

. where they previouslyillad been underrepresentedforexample, women in law and men in nursing. Bias exhibitedby faculty and other students'may contribute to students'stress. As with stUdents. the lack ante modelsin the faculty may decrease the chance otttudentmentorrelationships.

Marriage can be a positive or negative factor in stressamong students. For some marrietstudents. support from

. one's spousecan provide additional sociarsupport. Forothers, schooling can negatively affect the marriage or viceversa. Thk likelihood of negative irapat is increased whenstudents see their role as student as childlike, in cantina totheir role as spouse and possibly parent asadult.

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Potential Effects of Stress on Students,

By definition, being a student mean4iperiencing stress.Ideally. a student will experience stress as a clallenge andbe left with .a sense of competency, hope. and an increasedcapacity to learn. but many students experience distress,in which the threat of the educational process elicits help-iessness and aforboding sense of loss. Further, the level-%opm unental context in which yog students find themselvescan add increasing levels of stress. Seven developmentalvectors'operatc in the university student's life: achievingcompetency. nianagingemotidnOtWrtalautenomous.establishing an identity, freeing inlayer relationships,clarifying purpose, and developing integrity (Chickering1969). Therefore, being a student means one is experienc-ing a great deal of developmental transition and change;these changes affect attitudes, interests, values, aspira-tions, and intellectual abilities more frequently for studentsthan for nonstudents of the same age (Chickening 1969).

16 ,

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a

A crucial issue concerning distress among students is its'. effect on performance anelearnina, u.y.it of the research

concerning the effects of stress on cognitive abilities hasbeen accomplished' in a laboratort setting with a tightlycontrolled design (Hockey 1979). Perhaps the major excep-tion is the vast amount of research that has validated theYerkes-Dodson law. which demonstrates tOat high or lowstress produces the poorest performers. 'Doe study (Silver1968) showed that law students described as low or high inrelation to levels of anxiety peifstrmed more'podflythanthose whose levels of anxiety werealemibed as midlevel).

Although studies supporting the Yerkes-Dodson lawshow that distress is harmful to performance. this law doesnot help one undejskind exactly What students do when

. they are undenstress that contributes to poor performance.The research to date is inadequate in looking directly atspecific behaviors that relate stress to peiformance amongstudents. One way of understanding how stress mightrelate to stidents' performance is to look at the literaturethat focuses on cognitive problemilfi relation to stress anddecision making. Another way To understand this issue isto look at the literature on human performance.

Hype vigilance adversely affects cognitive functioningand decision making (Janis 1932). Hypervigilance. similarto Selyes alaroit reaction. refers to excessive alertness toall signs of potential threat: fi thus results in a diffusion of

'. attention. When individuals become hypervigilant. theyfeel panicked and as a result become cognitively lac&cunt. Turco/ (1977) describes a first-year law student whopanics allots:a test and spends hour after houiobsessivelyikudyingSinute details and even reading materialfrthat isperipherally related to the course of study. Panicked stu-denp are not able to focus o'n the most important issues in

. the cqurse and thus perform poorly on exams Hypervigi-lance. s characterized by a strong motivation to engage in athorough search and appraisal. but continued threats be-come diversions that make attentiveness to the task, of

'studying indiscriminate.Prentature,elosure (that is. quickly choosing a solution to

end b stressful situationperhaps by rushing through anexam) is another consequence of high stress in decisionmaking (Janis 191)2). The disadvantage of premature do-

Prematureclosure isfatconsequenceof high stressin decision-making

Student Stress 17

sire is that one's prohlem-iolving abilities are diminishedbecause Alternative solutions are not generated. fhe stu-dent, more than the nonstudent, is faced with both socialand intellectual transition (C'hickering 19691; thesktransi-tions might create dilemmas that could put student: inparticular At risk of pr mature closure. Thu', it is possililethat a student appeat4 poorly prepareVor a test because

r he responded with superficial ansviers mightbe experienc-ing a high degree cf stress that manifests itself with prema-ture closure.

. "Although the extra attentiveness associated with hyper.vigilance seems to be opposite the superficirditi associatedwhat premature closure. it is not too difficlt to imagiiu.how both problems could (hut not 1wie.essarily) occur together to adversely afffet students' perfornuince. For ".example, the obsessive student who is threatened byCourse material and becomes hypervigilant Might not havethe cognitive abiliy to integrate ideas in anYmeaningfurway. This lack of integration might lead to prematuric!ostrie in which only a4mall and perhaps superficial partoftthe material , displayed on a test. This example alsoreflects the narrowing of attention and the taskairrele4atbehavior that is associated with high stress (Janis 1982)..

Prolonged exposure to envirar.mental stressors and/or to'Aron...titian overload results in cognitive fatigue-4oficient resthe of attention to perform deinaqding tasks .(Cohen 1980). Negative aftereffects on performance aremagnified when the individualadoes not feel in control ofthe stressor.

Stress also :.:sults in soma social aftereffects (Cohen .

1980). Exposure OS unpredictable and uncontrollable eressleads to degreased sensitivity to othersdecreases in .helping, decreases in recognition of individual dikter:eels.and increases in aggression. These social effectswould atleast indirectly diminish students' performance to thedegree that an adequate support system helps Mediatestress (Cobb.1976).

A fundamental assumption in Cliickering"..1 book (1969) ist

that "colleges and universities will be edircationgly effec-tive only if they reach students 'where they live; only ifthey connect significantly with those concerns of centralimportance to the students" (p. 3). One concept that canhelp students deal with stress is "stress inocniation

is

9C

chenbaum 1977), Strest,inoculation it used to protectindi9iduals from the disriptive and demoralizing effectsassociated with decisions 'that have a high potential fornegative consequences. When using stress inoculation, thestudent first receives information describing what it Is liketo experience the negative consequences and how someconsequences can be avoided. Merely receiving informa-tion about a stressful event has the effect of reducing stressbecause the individual is better able to mobilize resourcesin preparation for the event. For example, during an orien-tation for firstyear law students, the subtle and intimidat-ing "garner students play with each other to gain a com-

.. petitive edge were vividly described. Merely exposingdestructive games probably helped students to recognizethem for what they are and thus helped eliminate the in-timidating effects. In fact.'such an approach would make itdifficult for a student to seriously play the games if heknows that ogler students would recognize what he isdoing.' Meichenbaum's.stress inoculation training program

(1977) incombrates information giving by first &Scribingthe nature of stress reactions to help individuals concept u-

N..alizethem. Second, individuals actually reheafse how they,would use coping skills. Third .individuals act out thenewly learned skills in role plays and/or practice (hernia .actual situations. A similar approach is used with newphysicians beginning a residency progra,-, videotapedvignettes of destructive interactions between new phy :, ,

cianiand various health care professionals are s nu)help anticipao effective coping.

Part of a stress inoculation program inv es facultymembers' beinias specifieas possib ut the expects-tions of the programs and course ey teach. A forumwhere older students share c riences about how they ,

coped and where the ins t outs of the educlitional pro-gram are described can help inoculate students againstsevere stress. Stres(inoculation helps students feel incontrol and thuireduce the unpleasantness of the situa-tion. z/

An effective stress inoculation program could be ow-_ pared" to an astronaut's preparation for space flight. Before

their first liftoff into space, astronauts experience numer-ous simulated liftoffs and space trips in which they are

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faced ovekand over with a wide" variety of possible threat-ening problems. Thus, during their first trip into space,they are so prepared for almost any dangerous,situationthit iheir responses to these situations are automatic.When students can anticipate and have some idea about'how to control problems rheyhave never encountered,they are better prepared to cope with stress. They willthen be better able to focus their energies on-the promisesthe educational process holds'rather than the potentialjeopardies.

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COLLEGE STUDENTS,

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Eavirnemeatal SetterStress is a product of interaction between an individUal andthe environment. Therefore, before looking at the nature ofstress among college.students, it is helpfulto considerbriefly, the college environment. Whilentany are aware thatthe first college in what would become the United Stateswas Harvard, fewer know that before the end of its.secondyear, the college closed.when itudents complaints ofbeatings and poor foodforced the resignation of the firstmaster of the new college (Lockmillei 1969). This incidentsuggests not that studentelardships characterize thehistory of American higher education but that. while somesources of stress are related to conditions of their times,stress also can be understood in the nature of colleges andinstitutions. In other'worgsotress among students occursinthe contexrof traditions (historical) and conditions .,

(contemporary). "What our colleges-do. tends either to begoverned by tradition or to be infOrovised in the face of ,diverseusually unanticipatedpreisufes" (Sanford1967a. p. 1). ,

The aim of The American College, a multiauthoredvolume, was to sum up what was known of the effects onWiden:is of going to college. In the preface to the 1967edition. Sanford noted that, since the book was first pub-lished in 1962, the Free Speech Movement had occurred at.the Berkeley campus of the University of California. Be-cause The American College ")Ook up cudgels on behalf ofthe individual student and his development before campusunrest began to be widely noted," Sanford ch to dthe volume as "an analysis of what all the shoot hasbeen about ' (1967a, p. vii).

ironically. Clark Kerr, the president where all theshooting" took place, already had written an insightfulbook about changes that precipktated student unrest. InThe Uses of the University (1963), Kerr observed that,because of the iniportance of knowledge to national eco-nomic and social growth. the nature and quality of theuniversity has,been reshaped. "Old concepts of faculty-student relations, of research, of faculty - administration

. roles are being changed at a rate without parallel" (p. vii).Kerr coined the term "multiversity" io describe the emergence of large, multipurpose institutions:

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Student Stress 210 in

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The University started as a single communitya community of astets and students. It may even be said tohave had a soul in the sense of central animating princi-ple. Today the large AmeriCan university is, rather, awhole series of communities (p. 1). '

Smith and Berhsteii (1979). describing Kerr's multiversity'as a "multiunit university," asked whether bigget is better:"Do they [organizations] become enervated when theyexpand past a certain point? In particular, do colleges anduniversities functionpoorly as learning communities when

very write? We believe the answer often is

Some statistics dramatize the accelerated growth ofhigher educationsinceWorld War 11: 6

,-,From 1959 to 1974, total enrollment increased 300percent.

( In 1950; 75 percent of students were enrolled in col-leges and universities with fewer than 2,000 students;by 1974, only 30 percent wore enrolled in such institu-tions.in 1950, only I0 institutions enrolled more than 20,000students; in 1974, there were 95 such institutions -

(Smith and Bernstein 1979, p. 2).

Increases iu Untitutional size negatively affect students'personal development, with fewer opportunities to partici-pate in extracurricular activities and to work closely withfaculty (Smith and Bernstein 1979, p. 17). Personal values

. change. Levels of cheating increase with the size of aschool; students at large institutions feel relatively anony-mous in relation to the student body as a whole and feel,less responsibility for upholding community values (Bow-ers 1964). While showing concern for colleges that "are toosmall to be effective in the use of their resources or in thebreadth of the program they offer their students," theCarnegie Commission on Higher Education also decriestile "cult of gigantism" (1971). The costs of bigness in-dude: .

loss of personal attention to studentsloss of personal acquaintance among faculty members

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, increase in administrative complexitylo increase in disruptive events on campusft loss of the chance to serve new areas with new cam-

puseslass of the stance to diversify with new and differenttypes of campuses (p. .

Of course, not all colleges are large. Yet "universitycolleges" that are part of a university with big graduateprograms, such as Yale or Michigan, or are adminis-tratively independent, such as Amherst, Oberlin, orVassar, provide a model that other colleges regard as de-sirable:

Drawn by emulation on ohe side and pushed by accredit-ing agencies on the other, an increasing.number ofterminal colleges hire Ph.D.s from the leading graduateschools even though they fear the implies of men whomay not be happy or complacent at alerminal college,and who may also make others less happy or complacent(Jencks and Riesman 1969, p. 25k,

'In addition to accelerating size and to the emulation ofgrowing institutions by other institutions, the environmen-tal setting includes an increased diversity in the 'types of

- students seeking a college education.

Higher education in the anited States until aboitt 1940'was largely for the elite; from 1940 to 1970, we moved tomass higher education; and from 1970 to 2000; we willmove Pr, universal-access higher educationopening itto more elements of society than ever before (CarnegieCommission 1971, p, 9).

Higher education in the Unik.dStates is a "mosaic ofdiffering institutions, goals; standards, and attitudes. , . . Itsis diverse, complex, and subject to rapid change' (Lock-miller 1969, p. 1). Stress is predictable in such an environ-ment:

Given the diversity among students and the increasingsue and complexity of the university campus, it is likelythat many students are far from disco'vering the opti-

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Student Stress 23o

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7..11041r. 11414, ,.

mim conditioni for themselves. or their campuses. . . .

Stress is seen as the consequenceof an inadequate fit ofstudent needs and goals with the college environment(Falk 1975. p. 27).

Within the context of diverse students with differingneeds coping with complex institutionsi. curry* environ-mental factors that mayexacerbate stress include the risein college expenses. increased competition to get intograduate and professional school. and an uncertain jobmarket for-college graduates. "Time. money, land] gradepoint averages lurk like closet monsters for these youths.threatening to snatch away chances they know the) needto become that they are capable of beinr (Deltfille 1983,p. 71).

Sources of StressA theme of this monograph is that stress among students isrooted in the past and the present. In other words, thereare both continuities and discontinuities. The continuity ofstress has occurred not just over decades, but over centu-ries (Katz 1975). This continuity of stress is rooted in theinherent challenges colleges pose to incoming highiehooigraduates. The discontinuity of stress -that is, new condi-tions-..includes student activism in the 1960s and cynicismregarding change in the 1970s (Kati 1975. pp. 248-49).Although current conditions can exacerbate student stress.the basis for stress is rooted in the challenges colleges havealways posed for students. For,many students, college isan abrupt change from high school. The college years bringseparation from home and parents, academic demands aregreater thin those in high school. and students face ques-tions about personal identity and career choice. Someauthors emphasize the importance of the first two monthsof college (Walker and Beach 1976); others warn of the"sophomore slump," which occurs in the spring semes-ter of the freshman year when freshmen "expect so muchand get so little" (Schoonmaker 1971. p. 103) kegardlessof when pealeatements occur, all four years, of collegecan be viewed as a period of transition and change. To agreat extent. college poses a majoiifiltenge in an indi-vidual's life.

4.

With challenge comes thpromise of jeopardy. Thepotential for reward or punikhment is great, dependingupon success or failure.

The picture that emerges from our four-year study ofcollege students is that of a wide variety of patterns inwhich individuals react and develop during the collegeyears, The college environment is a highly controlling -one, and it creates stress in many students. Some indi-viduals are well enough equipped psychologically toutilize both the opportunities and the obstacles of thecollege environment for the purpose of their own growth.At the other end of the spectrum are those whose needsfor passivityfor being told what to dohave become somuch a part of their lifestyle that they do not experiencethe conditions of the environment as stressful or inhibit-ing. In between are the bulk of students, whose livesnever reach an adequate self-awareness and . . . whosedemdnds and constraints discourage their spontaneity(Katz et al. 1969, p.

Most educators have recognized that stress is 'necessaryfor growth. The problem has beenjo provide an optimumlevel of stress. The differences-between "good stress" and"bad stress" have,been recognized (Sherburne 1966, p.343). Some educators have seen the need for psychiatric "help as evidence of "bad stress." An early study.of studentpsychiatric problems reported on the class that entered theUniversity of Bc keley in the fall of 1961 as freshmen (Ellis1969). Of the 3,474 entejng sftldents. 493 (14 percent) usedthe psychiatric clinic the student health service over afour-year period. It would be simplistic to say that theinstitution caused these students' problems, as almothalf of them reported previous counseling or psychother-apy. Nevertheless, their reasons for seektng psychiatrichelp at Berkeley portray a gcneral picture of stress: depres-sion, inability to do school work, nervousness, anxiety,and so on.

Another measure of stress is the college dropout rate.Again, white assignment of "cause" seems pointless, if notimpossible, dropping out must be teen as the fleeing side ofthe "fight or flight" formula. In another study of Berkeley

Student Stress

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Factors thatmayexacerbatestress includethe rise incollegeetpenses,increasedcompetition

. . and anuncertain jobmarket.

25

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students, 9 percent of an entering class\ left and 'returned to .

school, and 50.percent left and did not return (Katz et al.1969). In a review ot the literature, under 50 percentpfentering freshmen students nationwide finished college fouryears later (Hirsch and, Kerdston 1,70). Thb decision toleave loge a crisis="a moment of intensified anxi-ety and st , a turning points and the culmination of along process of reflection and growing dissatisfaction"(Hirsch and Kcniston 1970, p. 4).

College dropoutsluive been described as students who,in the face of environmental challenges, chose to changeneither themselves nor the environment (Falk 1975).Rather, they chose to increase the distance between thein-

, selves and the,Iource of stress, the college environs seat.Again, the image of college dropouts evokes "fight orflight," with flight being the chosen strategy. The "interac-tional stress" model of students' characteristics and envi-ronmental features has some,support (Falk 1975). Stress isthe consequence of a "mismatch" between student andcollege, but more systematic and quantitative research isneeded to articulate the dynamics of the interaction be-tween students and the college environment (Falk 1975).No satisfactory answer has yet been found-to the question

'of what is the optimum rate of development for collegestudents (Sanford 1967b, p. 55). Students "develop when .stress is great enough to challengetheir prior modes ofadaptation, but not sogreat as to induce defensive reac-lions," but "how much stress does each student need?"(Sanford 196Th, p. 52). Unfortunately, no one has yetanswered that question.'

It is difficult to specify the sources of stress for collegestudents because they. comprise a diverse group located atdiverse institutions. However, 50 percent of the collegestudents who seek counseling complain of difficulty study-ingor of anxiety, tension, and depression related to poorgradesior fear of doing poorly in courses (Blaine andMcArthur 1971. p. 163).

SolutionsThe reduction of stress in college students begins with their .

taking more vitrol over their college education. Walkerand Beach ( .976), wr. ing primarily for minority students,.recommend that, in getting ready for college, students

34 \s,

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.r.,flginviout what to expect. Indeed, they offer* mole ofsocial, , and academic factors incoming students

,Punt

a feeling of greater isoladqg in college than in lighschoola greater variety of social and economic backgroundsin fellow students than was true in high school class-matesa much greater variety of class size and teaching stylesin college than in high schoola tendency to base grades more on written work thanon class performancegreater personal responsibility for allocating timemore competition in college than in high schoolkss feedback about progress than in high school(p. 94). $

This identification of differences and similarities betweenhigh school and college is a form of the stress inoculationdescribed earlier. It is a way for students to gain controlover their environment.

The lack of feedback, the last item on Walker andBeach's list, is an i factor because feeling incontrol is influenced by h information and feedback.Infrequent information ut how students are doing mayindicate a lack of feedback to students. A solution is toprovide freshinen with midsemester grades.

A sense of control comes as students become indepen-dent:

The independent person makes his own decisions andcontrols his own life. He understands the world he livesin and knows what he wants from it. He can distinguishbetween important and trivial issues, and does notsquander his time or energy on meaningless, seif.destructive protests about trivialities (Schoonmaker1971, p. 17).

lb become independent, college students should analyzethemselves, analyze "the System," and "take what we canoffer". (SchoOnmaker'1971, p. 20). That approach CIP.1 besummkized as "help us help you" (p. 22). It fits veil into

Student Stress. 35

7

the person-environmeil model, addressing the source ofstress identified by Palk; a peer match' between studentand college. The solution is fbr students to work out arelationship with the system that helps them define them-selves and reach their own goals (School rsaker 1971;Walker and Beach 1976).

A different approach -- "let us help you"is to providemental healthlervices for college students (Blaine andMcArthur 1971).

We are agreed, educator and psychiatrist alike, that Mtcollege should not be turned into a sanitarium. Never-theless, attention must be paid to the feelings as well.asintellects of people in education, if the college experi-

. ence is to count as a major factor. . During the pasttwenty-five years or so, we have come to learn that theemotional climate of a school has profound implicatka;for the effectiveness of the education it offers (Farns-worth and Mustier 1971, p. 2).

Other helpers have other roles. Thefole of the collegepsychologist, for example, is changing from "a mentaltester whose ivriamentarium consisted of a 'ew intelli-gene tests's-iv someone'whose practices "include assess-ment of intellectual functioning, the assessment of person-ality, diagnosis. therapy, guidarict, and personnel assess- .

meet" (McArthur and Dinklage 1971, p. 28). Faculty havea role in counseling and referral: "The essential duty of theteacher who is attempting to help a student is io be a sym:pathetic listener" (Dalrymple 1971, p. 19).

A third approach to reducing stress is "help yourself byhelping other students." College students themselves makeexcellent peer counselors, "promoting their own adapta-tion to college in the context of helping others': (Giddanand Austin 1982, p. ix). For example, the Telephone Conn-seling Service at Florida State University offers threemajor types of services: (1) informationfor example, howto drop a course; (2) crisis intervention counseling bytrained volunteers; and (3) referrals to campus and commu-nity agencies for problems that could not be resolved by asingle telephone call (ICalafat and Schulman 1982). Otherself-help programs at Florida State University include amultimedia carter guidance prograni, a campus drug infer-

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oration center, and q student-operated academic adifiqingservice. Whatever the program, hqwever, certain steps arenecessary to make peer programs work: defining theneeds,. identifying the administration's and students' per7spectives, and planning Went" evaluation **the stets. ,

A of the self-help approach is a program at SanState College in which freshmen were recruited into

" and "clans" (Finney 197S). A tribe of SO student'smet monthly as part of some extra social activity and attwo Weekend marathuns each semester. Each clan of 10students met twice a week to discuss school. Based onnaestionnaire, students in the program felt that their panic-ipition helped them handle their own problems.

A unifying theme is dear among these three approachesto reducing stress in college. Attempta to prevent or mini-mize distress focus on giving_ students a greater feeling ofcontrol over their campaii enVironment. information, feed-back; and social support are essential ingredients.

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GRADUATE STUDENTS

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vIronmentel Sett* -Al Yale graduated the first Ph.D. in 1861, mosteducators mark the official beginning of graduate educationat Johns Hopkins. University in 1876. The founding ofJohns Hopkins is worth reviewing because it helped toshape the position that graduate students still hold today.

Johns Hopkins was a Wealthy 13hhimoremerehant whomade his fortune from the IMO Railroad. He provided inhis win for the establishment of a new university and tiltthe details to a board of trustees, who visited other univer-sities and brought consultants tooBaltimore. What theylearned was lhat;the last thing America needed was an-other college. They also learned that the bait person to,build up an institutioi quite different from a college wasDaniel Coit Gilman. Gilman had been president of theUniversity of California since 1872, where the trustees

"'frustrated his attempt to build a new type of institution. Bybringing Gilman to Johns Hopkins, the trustees demon-strated their desire that Jonas Hopkins become an 'additionto American higher edircation rather than a rival to existinginstitutions (Gilman 1961; Rudolph 1962),

The model for graduate education at Johns Hopkins wasthe German university; with its emphasis on research.

-Thut, Johns Hopkins developed as a faculty- centeredinstitution, where students provided the teachers withstimulationthe opposite of the traditional English coliege,mimic', where teachers were theoretically engaged in thestimulation of students (Rudolph 1962).

While many American educators welcomed the doctoialdegree, philosopher-psychologist William James wrote afamous essay in 1903.."The PhD. Octopus," in which hecriticized the national movement towatd thePh.D. and itseffects on.his own institution4larvard. Although most

, universities did not go so far as Johns Hopkins in its em-phasis on faculty, the collegiate tradition was altered asinstitutions added graduate studies. Thus, Ameritian uni-versities were foUnded on two different national Patternsa German university model for graduate study, superim-posed on the English college that had been the model forAmerican underigadtate educationAnd "the resultingstrain has character; ed American higher education eversince" (Hartnett and)Catz 1976, p.

30.0 0

This strain has been sacrum of stress for both college .

aid graduate students. On the one hand. college studentslearn that many faculty find their rewards in researchrather than in teaching. On the other band. Odom* s14.dents learn that, when faculty do emphasize midi%often it is done to accommodate undergraduate rather thannraduatestudents.

In addition to the historical strain on graduate studentsresulting from the hybrid nature of American universities,two trends in American graduate education in the 1960sprovided an additional source of stress for graduate stu-dents. First. durintthe 1960s the production of Ph D.snearly triplid.

Going to graduate school.,an event which was typicallyreceived with a mlxtule of astonishment and admira-tion as recently as the 1950s. increasingly became an al-most expected next step for many college seniors duringthe halcyon days of the sixties (Hartnett and Katz1976, p. 8).

In addition to more individuals seeking doctoral degrees,more institutions began to offer,doctoral degrees.

Along with She increase-in graduate students, a second--and related trend in the 1960s wns the growth in federal

fianding. By the late 1960s, many graduate students werebeing supported by government funds. Together. these twotrends of growth in numbersef students and in financialsupport by the federal government have made the graduateexperience increasingly impersonal:

Many academic departments. which began as small.intimate groups of scholars with mutual concerns andinterests, blossomed into large collections of diverseindividuals. Furthermore, the increased levels offederal funding created a vicious circle all its own. Thegrant money made expansion possible to be sure, but thenewly acquired faculty then needed to obtain moremoney for support and further expansion. . . . At thesame timeand most likely as a consequenceconcernfor students was neither respected nor rewarded (Hart-nett and Katz 1976, p. 11).

Growth innumbers ofstudents andin ffedera 1.

ha*made thegraduateexperienceincreoinglyimpersond.

*Student Stress 31

WzaYe141,-"

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lA addition'tonbelistoriad strain on graduate eduashinand the pressures provided by growth and expansion in the.1960s, the environment of graduate bducation has posedfiuther challenges in the 1970s and 1990s-4be oversupplyof ph.D:s and the scarcity of oppornmities. Mostacademic traders did not anticipate this trend (Ma, :sew1970). Campus visits and interviews. an examinatioh of "w

plannifig documints. slid questionnaires resulted in anImpressionistic interpretation" that

- - emerRe; Iasi a picture of gr.- image and professionaleducation in wh;. h enrollments, problems, costs,hoped-fur-significance-are expanding rapidly. ... Thoseresponsible for the expansion believe that they are re-

..4ponding to dear deman.ds for professionevnanpower.for research and for service . .4 andfarther that in someway or other ti.e society will provide the recessary

artclal support..Whareito emerges it eonsidsrebkpram-ape:iv with status. pulite, and growth duinstitutions seeking to expand graduate and researchcapabilities, even if this should mean neglect of othereducational vdlues (Mayhew 1970. p. j).

A

'Unfortunately. not only did most educators not foresee

the oversupply of doctoral candidates and the lessened..demand for dortotal graduates, the response to thesechanges has been slow. Moat graduate departments havenot stimulated many malor programchanges (Breneman1975).

Mayhew (1970)distinguished "developing" front "devel-oped" institutions. Developing institutions in particular.while hoping for increased federal support, Were inclinedIR assuine that sig.: appropriations would prin:ide. not Maxfor educational programs but also for fliculty rtsearch (p.3). Not surprisingly, the impact of pow employment op:"portunities and reduced federal support for graduate stu-dents has mast Iffectpd the less prestigious departments.usually )ocatgd in poorlyAanced private universities andin the lesser known institinioqs(Breneman 1975).

The environmental, setting a graduate student enterstoday is at a crossroads:

32

40 .

,r+, 17.

,I'

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After nearlyn century of vigorous growth and expan-sion. after a decade of generous treatment from federalgrant agencies, and after years of being viewed withadmiration and awe by large segments of the American,societyboth for what it did for society at large and eh*individuals wh;, passed through its laboratories, li-braries, and seminar rooms -- graduate education hasarrived at a new point in its history. A creative andimaginative response is clearly needed to insure thelonrange future arid viability of American graduateeducation (Hartnett and Katz 1976. p. 14).

What are graduate students supposed to accomplish inthis environmental setting? They are in the universityprimarily to earn advanced degrees. They take courses.write research papers. and fulfill other departmental obliga-tions. After passing required preliminary examinations,doctoral candidates write a dissertation. In most cases,these tasks are very difficult. Why are graduate students

. willing to undertake them?

Whet James and other critics predicted at the beginningof the century has in substantial measure come about:the tentacles of the "octopus" have reached out andcaught all too many whose- sole reason for subjectingthemselves to the discipline of the Ph.D. is the prestige_endowed on the job shade certain (Nisbet 1979, p. 516).

Within this milieu, it is not surprising that many graduatestudents'experience stress.

Sources at StressAlthough the oversupply of Ph.D.s and the discouragingjob market may be recent sources of stress for graduatestudents. other sources probably are not different fromthose experienced by graduate students a generational*Sources of stress forraduate students are inherent in theuniversity environment, although current social changes,such as an unstable economy. might complicate one'scoping with the stress (Altbach 1970; Hallecle`1976: Val-dez 1982).

Student Stress

'11

r

33

.

.

Five conditions of graduate student life cause "friction,disaffection, and general unhappiness":

I.' Graduate students are adults in every sense of theterm but are often treated as children by their univer-sities.

2. Graduate students are often woefully exploite' by.individual professors, departments and universities,by way of inadquate remuneration for work per-formed, work loads which almost preclude promptcompletion of academic work, or occasional plagia-rism by senior professors of students' original work-

3. Graduate sit teat are subject to arbitrary treatmentby professors, departments or institutions and havefew means of resisting such treatment. '

4.; Graduate students are often almost totally dependenton their professors or deparlmen.t for a livelihood, forcertification as a scholar, and possibly for futureacademic positions.

5. The role of a graduate student as a teaching or re-search colleUgue with a senior professor is oftenambivalent (Ahbach 1970, p. 565).

While a number of positive factors are associated withgraduate student life (for example, a strong subculture thatoften provides psychological support), on balance thegraduate student lives and works in a state of substantial

2. powerlessness. "It is into the student's academic' perform--, ance that the ultimate feeling of powerlessness enters. Fter

it is upon the judgment of senior faculty members that hiscareer depends" (Altbach 1970, p. 565).

Because evaluation of a graduate student's work re-quires great discretion, particularly in judging a doctoraldissertation, "the 'agaries of the decision-making process

i are a cause of substantial frustration and strain" (Altbach1970, p. 567). "Even when the student has confidence inthe criteria of judgment and in the honesty of the profes-sors involved, it is still with a feeling of anxiety that heenters into academic relationships" (Altbach 1970, p. 576).When students lack faith in the fairness and reliability ofthe evaluation system, they may eggage in strategies tobeat the system as a way of coping with the situationforexample, "cultivating the Rood opinion of a professor by

.

34

A cl

v

establishing some sort of personal relationship with him"(Sanford 1976, p. 23).

In addition to a sense of powerlessness, some graduatestudents experience a feeling of ambiguity in their role asteaehing assistants. It too is a source of stress. The emer-genci of the "departmental insurgencies" by teachingassistants at Wisconsin is a source of stress that, whilerelating to a temporary phenomenon such as the student'revolution inlhe late 1960s, nay also be rooted in the .

nature of graduate education (Altbach 1970). For example.the role of teacher may be stressful because the'rewaids forgraduate students, like their faculty, lie in research, notteaching. Graduate students have always been expected toteach, yet in most cases they have had no prior teachingexperience and are given little or no guidance by their faculty.

In one case, a patient known as Carl had done fairly wellin graduate school until he assumed the role of teachingassistant.

In his teaching role, hefelt strange and nervous. Evenstanding up before a group dnd attempting to impartknowledge seemed to him to be pretentious and phony.He could not make demands on his students. He refusedto evaluate them and could not accept the possibilitythat his own superior expertise put him in a somewhatdifferent position than he was in as an andergoduate(Halleck 1976, p. 165),

Carl had been a political activist as an undergraduate. andHalleck found it difficult to determine whether Carl'sproblems with assuming responsibility as a teaching assist-ant were based on political ideology or on some underlyingpersonal problem, In any case, "even the limited authorityof the graduate position was for him quite stressful" (Hal-leck 1976, p. 165), .

The value of this case study and of others is that asource of stress although, relfrat.xl to socialsonditions suchas student militarism in thii 11)60s and the overproductionof Ph.D.s in the 1970s, Tay also be rooted in the nature ofgraduate educationFonexample, maladaptive behaviorscan be traced to two tirlieless needs of graduate students::the need for meaningfullactivity and the need for intimacy(Halleck 1976): With regard to the search for meaningful

IP

Student Stress43

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36

activity. "many of the minor anxieties and depressions thatbring graduate studerits to the psychiatrist seem to berelated to a profound fear of loss of potentiality that thestudent relates to the processes of specialization" (Halle.:elt,_1976, p. 163). in other words, graduate study by its very '-nature requires the student to become a specialistinsome cases a subspecialistin a field of study. By choos-ing one tocus, graduate students by necessity must limittheir inquiries. Choosing a specialized field of study is adifficult choice and is accompanied by uncertainty:

Graduate students today are aware of the rapid rate oftechnological change, the impact of new scientific dis-coveries, and the impact of the irtformation explosion.They appreciate that whatever they learn today is likelyto be obsolete tomorrow. They fear specialization andbelieve that it will isolate them from too many aspects ofreal life. The pursuit of excellence in one relatively Ilimited area of human knowledge seems to be almoststifling and alienating in a world that is characterized byrapid change (Halleck 1976. p. 163).

With regard to the need for intimacy, "dissolution ofrelationships is currently the primary cause of emotionaldisorders among graduate students (Halleck 1976..p. 167). Although is sues Mating and mating are criticalfor most unmarred adults in their twenties, some problemsare unique to graduate students, "To achieve intimacy withothers. one must first have the opportunity to meet othersin a climate that allows intimacy to develop" (Halleck1916, p.. I 69).. The following Kilian is apparent: "Graduatestudents who work with only a few people and who arelikely to see the same individuals day 41 and day out canfind themselv6s easily rutted into an extremely isolated,lonely life" (Halleck 1976. p..1691.

Graduate school and individual)carcers put stress unpersonal relation chips (Hartshorn 76). The humlin drivefor social intimacy is compromised i the lives of marriedgraduate students. Because graduate udies can becumean all-consuming endeavor. lack of co municatiun andlack of recreation time can be major sou es of dissatisfac-tion. Financial issues are a prominent co ern fin mustmarried graduate students (Gilbert 1982).

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The need for meaningful activity and social intimacy ismade MOM difficult to fulfill when graduate studenti go to anew school for their graduate trainingthe case for mostgraduate students. When they arrive at their new campus.firstyear grasivate students are like freshmen. Their situft-don can be more difficult than that of freshmen. however.because there are no orientation and social activities to .

' welcome them (Halteck 1916).Starting.gradvate school involves many life changes in

addition to moving to a new place. Valdez (1982) used theHolmes and Rahe Social Readjustment Rating Scale(SRRS) to study 33 firstyear doctoral students at a schoolof social welfare in the northeast. The SRRS is an instru-ment that assigns life change units (ECUs) to life eventsthat require adaptation or coping. Each life event is as-signed a.weight. For example. "death of a spouse" isassigned 100 LCUs. "minor violation of the law" 11LCUs. In Valdez's study. the firstyear graduate studentswere asked to respond in terms of their first three monthsof graduate school, According to the SRRS. a score-of 300indicates "major crisis." The mean score fot the itudontsin Valdez study was 313. One-third of the students fellinto the "major crisis" level: another third experienced"moderate crisis." Only two students were "below crisis"level.

Valdez's conclusion was that a considerable number oflife events occur among first }ear graduate students andthat graduate students may as a isult be undergoing con-siderable stress 0982. p. 36). This statement is by itsnature conditional because every individual perceives lifechanges differently and responds to them differently. Ar.event that is a "major crisis" for one person is "mild" foranother. Nevertheless, regardless of how individuals viewchanges in their lives. educators slioukl view the first yearof graduate school as a period of extraordinary change.

Thus far. the picture of graduate students that hasemerged is of adults who may feel:

powerless because of their dependence on facultymcrnbcrs'judgmcntsambiguity about their role as teachers of undergradu-:tte .-tudents .'

Union Sires.% 37

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thwarted in their need for meaningful activity becauseof the impersonal nature of their department's and thenarrow focus of their studiesfrustrated in their need for social intimacy because ofthe difficuhy of attracting and/or maintaining personalrelatioriships and I

* overwhelmed from the many changes in their lives, ..especially in the first year of graduate school.

In this milieu, graduate students experience specific situa- -, lions as stressful; that is, certain predicaments evoke_

negative feelings like discomfort and anxiety and provoketask - oriented responses. In one study to identify thesetypes of situations, ICjerulff and Wiggins (1976) asked astratified random sample of graduate students from theDepartment of Psychology at the University of Illinois todescribe stressful situations they had experienced sinceentering graduate school. In particular, they were asked toconcentrate on situations that had led them to considerdropping out of graduate school. Ten male's and five fe-males responded, providing 18 different situations. Thestressfid situations, which the investigators organized intothree categories (academic failure, interpersonal problems,and fate-failure) appear in table 1. The examples of situa-tions imagined by these graduate students certainly under-score the potential for jeopardy.,Even if these situationsare not experienced by any particular graduate student.they at least provide a basis for worry.

A stressfid event can become a distressful one (Kolko1980, p. 12). Negative thoughts can follow a stressfialevent, resulting in negative emotional states and in poten.'Bally counterproductive behaviors (see table 2). ,

The preliminary examination for Ph.D. candidacy isanother stressful situation for many graduate students. Onestudent reported bn his postexam worries as follows:

As time went on, my doubts began to increase more andmore. . . . I became more and more pessimistie.1 wasquite sure' hadn't passed. h sort of reached the climaxthe day they made the decision. . . . 'Just couldn't goover to the building and wait for the results. So I camehome and nobody was there and I sort of paced the floora bit. Theft (another student) came in and told me that

46

V.

-,

..

TABLE 1STRESSFUL SITUATIONS

Academic FailureYoia flunk qualifyingexams.

You are asked toleave school be.cause you are slowon your mastersthesis.

You make a "D" ina graduate course.

You're slow tc.think up an idea for

. a dissertation andwant to stay ingraduate school afifth year. but thedepartment cannotsupport you.

You Nub up a classpresentation ingraduate seminar.

Your faculty advi-sor criticizes your

" in-class discussionhabits.

No one likes youridea for your disertation and you feelhopeless.

Source: Kjerulft and Wiggins 1976.

InterpersonalProblem;

A faculty memberis angry with youfor not analyzinghis data duringfinals week.

Your faculty advi-sor mikes arbitrarycriticisms on yourmaster's thesis.

You are in a re-search group withsomeone you dis-like intensely.

Your faculty advi-sor tells you thatyou spend toomuch time trying tobe a good teacher.

Your programchairman is a hos-tile. difficult personand you are consid-ering leaving.

Your research advi-sor is very distantand unhelpful.

Fate-FailureVou feel lost ingraduate school andfind it a drag.

You are afraid youand your mate willnot be able to getjobs near eachother after gradua-tion.

Your subjects arenot showing up andyou feel very unin-terested and unen-thusiastic aboutyour study.

You are unex-pectedly pregnant.

Your mate acceptsa job offer

.elsewhere beforeyou are finishedwith graduateschool

he had passed and I heard that (another student friend)had passed, and they began toperstaide me to call up. Iwouldn't call up and I was quite positive at the time thatI had failed the whole business. I was very anxious'andvery upset, ., . . Finally. about seven (Moat decided Wcall ap (a focally member) and no one answered, So Iwent to the building around eight o'clock. I heard that

Stade* Stress 47 39.

.

AN iXAMPLETABOF ACADEMIC STRESS

SituationYou hatwojweelts to prepaie for an exam and to complete awritten assignment. The week before you' couldn't spend as muchtime on coursework as you needed because of msearch andloryour job. It's the first test and the first written assignment foreach course. and you really wanted to do well on both.

Cognidefts1 It's only the beginning of the term and 1. m already be Md.

How will I get caught up?

1. It will be terrible if I don't do well on this first assignment!

Feelings/Emotions, )(' Drend working so hard over the next two weeks.

\/ 2 Afraid pf tieing poorly, apprehensive.\ \ 3. Angry that resetirch/job had required so much time.

( I 4. lquitrated that I didn't have more-bine to spend ot) course-work.

5. Despondent over possibility of failing at the beginning.

Behaviori. Cdniplain to friends and classmates abOut situation.

2. Stay up late worrying about performance. .3. Refuse several inviations for leisure activities to improve

productivity.4. become irritable and short with people.

5. Begin looking for an alternative career.

Source: Kolko 1980.

he would be there. I was really completely shook up. Ittook about everything I could do just to walk up thestairs and go in. I was quite convinced that I had jailed.and t:e thing that bothered me was that 1 tried rational-izing everything and saying that it really wasn't thatimportant and that I could take it over again, and soforlh. : ... The thing that bothered me more than any-thing else was I thought! had jailed, but it was a ques-tion of how 1 could accept the failure (Mechanid 1978, p. 1).

Mechanic's study of how students perceived and re-spondel to these exams was conducted in 1960, originally

It CI

'0.°?-,

published in 1962, and republished in 1918 with a newforeword by the author. Not only was this study a break-through when it was conducted and reported: it remainsthe best qualitative study of how people come tofeel stressand how they deal with it. In the study, 22 students agreedto participate (the three who refined gave pressures oftime as their reason). During weekly and bimonthly inter-views, including interviews, before and after the examina-tion. Mechanic interviewed each student approximately 10times. Four weeks before the examination, students andfaculty completed questionnaires, and four weeks after theexamination, students completed a questionnaire. Me-chanic also occasionally interviewed faculty and spousesof students. He observed interaction;; in the departmentand attended a faculty meeting concerned with the exami-nations.

Based on this comprehensive qualitative collection ofdata. Mechanic found that communkation was kkeyfactor. Because students had no fully rational basis forpreparing for the preliminary exam, they attempted togauge their activities by observing each other. Throughsocial comparison. students anticipated their own capabil-ity to prepare for the examinations and evaluated their ownprogress. A favorable comparison increased a student'sconfidence: an unfavorable One prOvoked a feeling ofdiscomfort. Because communication could lead to bothcomfort and discomfort, therefore, students often commu-nicated with caution.

The major contribution of Mechauk's study is hisdescription of the interplay between coping and defensemechanismsthat is, bow.people deal with the challengeand bow they deal with their feelings about the challenge.For example; when a student feels self-doubts as a result ofsocial comparison. negative feelings can seem to handicapattempts at coping like concentration and study. On theother sand, a student who feels too self-assured runs therisk of not harnessing enough energy to concentrate andstudy.

Thus, within the setting of graduate school, the graduatestudent is faced with a gamut of specific challenges. Ofthese challenges. the preliminary examination is perhapsthe penultimate. Writing a doctoral dissertation is certainlythe ultimate. Faced by a variety of difficult challenges. it is

When astudent feelsself.doubts. . . negativefeelings canserve tohandicap.attempts atcoping.

Student Stress9

41

4

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: 1

not surprising that many graduate students consider drop-ping out of school Weiss 1970). Over :me :bird of therespondents to Heitors questionnaire interrupted theirstudies or had been tempted to drop out of the doctoralprogram.

In most cases, students ascribed their doubts to pres-sures which demanded coping mechanisms other itanthose used to resolve academic problems. For the mostpart, the pressures generated self-doubts that debilitatedthe respondent's interests or caused him to question thewisdom of investing his energies in the demands of the"system" (Heiss 1970.p. 177).

The specific reasons why graduate students weretempted to give up their quest of a Ph.D. are shown intable 3. These reasons are related-to the-categories in table1. "Stress of passing hurdles** Ms under the category"academic failure." **family problems" under Interper-sonal problems:* and "disillusionmeot with graduateeducation" under "fate-failure."

One estimate. difficult to substantiate. is that nearly SOpercent of the people woo enter graduate school withintention to complete a doctoral degree never finish Weiss1970). Without knowing for certain what the rate of incom-pktion is nationwide, one can still infer that it is high.Although "doctoral candidates woo never complete theirdissertations. and therefore fail to earn the Ph.D.. have notbeen a topic of much systematic study" (Jacks et al. 1%3.p. 74). their reasons are again related to acadethic failure.interpersonal problems. and fate-failure (se- table 4).

Another manifestation of distress among graduate students is the prevalence of emotional disorders. Areviewrecords of the University of Wisconsin student psychiatrysection foond 'that gradure students were second only tofreshmen in terms of using psychiate is services (Halleck1976), -Efforts to establish the ini3dence of use of mentalhealth facilities by graeuate students at other universitiesreve i similar findings" thalleck 1976. p. 161). An ear-lier repo (Nelson 1971) Ids& found that a high proportionof students requiring the us.. of Harvard's mental healthunit were graduate students.. although appraimately onehalf of the students in Nelson's study (19711 nad es-

42 50

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TABLE 3REASONS WHY GRADUATE STUDENTS WERE

TEMPTED TO DROP OUT

Reason Pineal*Disillusionment with graduate education 44.4

!feed of 'study 40.5

Stress of passing hurdles 37.0

Faculty lack of interest in studemt. 26.0

Lack of interest in field 25.2

Financial problems 22.5

Altdentic problems 16.0

. ?oor retationship with advisor 13.8

Family problems 12.2.

Uncertainty about draft status 12.2

/Health problems 6.3

'Poor relationship with sponsor 5.9

Percentages total more than 100 because individuals gave more than oneexample.

Source: Heiss 1970.

s

TABLE 4\ REASONS FOR LEAVING DOCTORAL PROGRAMS

., . . Reason Percent*\ Financial difficulties 44

Poor working relationship with advisor and/orcommittee 44

Substantive problems with research for the dissertation 36

Personal or emotional problems 36

Receipt Of an attractive job offer 32

Interference of paid work with work on dissertation 28

Family demands 24

Lack of peer support 20

Loss of interest in earning a Ph.D. 12

Percentages total more than 100,because individuals gave more than oneexample.

Source' Jacks' al. MO.

r

.

Studeni Stress1

43, M

1

tablishqd psychoneuroticsymptoms. it is not possible tolink the causes of theie problems to distress in graduate

'school. in fact. students may have brought these Problemswith them to graduate school. Even so. approximately one-fourth of the students did not.have Well-established mentalillness in the traditional sense. and their problems were .

"frequently related to specific and clearly seen dream-*stances- of graduate gchool (p. 321). One student, forexample.,". felt socially inadequate and very concernedat his hesitation to develop warm relationships withwomen" (p. 322). In this case. his problems happened tostem from his family relationships. but the drive to fulfillthe need for social intimacy requires a social setting thatencourages companionshipsomething not commonlyfound in the graduate school environment.

The sources of stress for graduate students stem in partfronban environmentaketting that poses numerous chal-lenges. In the face of these.chaffenges. some students copeeffectively and are strengthened by the experiences. Oth-ers do not cope as well and are distressed by graduateschool. Given that many graduate students do not succeed.or they succeed but And the experience distressing. thechallenge to administrators. faculty. and students is todevelop graduate study "that encourages maturity andfosters 'a growing self-dignity and ripe poise' " (Nelson1971. p. 333).

SolutionsProposals to minimize stress should take into account thatsome stress is beneficial but that unnecessary stress is animpediment. "Some degree of stress is inescapable (in thatit underlines to the student the importance of the course heis undertaking). but it seems only commonsense to takeevery possible step to cut out sources of needless anxiety-(C:eugh 1972. p. 86). Requirements for advanced degreesshould be challenging yet achievable. While a basic themeof the literature is that needless distress can be preventedby providing students with appropriate levels of control.the numerous course requirements of many doctoral pro-grams provide graduates with little control. particularlycarry in the program. .*Most of the psychological stressand educational disillusionment resitting from too littleindependeace seems to occur during the,firsfyear of gradu-

44

ate study, when many students are locked his, a rigidpattein of required courses and examinationi Weiss 1970.p.°283). A graduate student agree's:

ask you to think for a mown; of the numbee of -re-quired" courses that are part of your program. is itnecessary. as graduate students. most uf whom havehad professional eeperienc e. to be supervised aidsteered through a program? is uSere au opportunitypursue those areas that we wish to pursue as graduatestudents, indeed is there any time left in our programs todo this? Do kraduute students have un opportunity toparticipate in the planning of curriculums of highiereducation? Do we have the opportunity to 'press ourfeelings and concerns about the future of our field tothose who will ultimately make curriculum and programdecisions? (Norman 1970, p.

Both Heiss and Norman recommend that doctoral studentsbe allowed to play a greater role in designing their ownacademic programs.

Related to the issue of control ate the concepts'of infor-mation, feedback, and predictability. "Lack of necessaryinformation and explanation, so that students feel them-

. selves in the dark, is a potential muse of stress" (Cleugh1972. p. 87). Entering graduate students can be assigned a"buddy" before they arrive on campus to help providethem with the information they need (Valdez 1982). Orien-tation activities for graduate students should be "no lesscomprehensive than those for freshman undergraduates"(Halleck 1976. p. 175).

Students also need feedbackinformation about currentperformance that can be used to guide future perform-anceto feel in control. It is ironic that graduate programsthat use "pass-fail" grading to reduce anxiety niay actuallybe increasingit unless students receive some other form offeedback as well. Small group conferences, colloquium.and informal meetings are possible settings where studentscan receive information about the quality of their wrrit(Heiss 1970).

Graduate studeho tend to have two types of respossesto the tasks expected of them: "Tfie gamesman attempts toperform fewer tasks for more rewards, while the grind

Student Stress 45

performs ail of the tasks expected of hiM for the rewanlsalready promised" (Sanford 1976, p. 1): Based cin interviews with 72 graduate students in the departmentschemistry, economics, and English at the University ofCalifonsia at Berkeley, Sanford found that:in extremecases, both gamesmen rind grinds may be unable to seehow the system Qui or Coped with by any means otherthan their own" (p. 11. The recommendeesolution is todiscourage both extremes by increasing the flexibility inprogram requirements and evaluation methods so thatgraduate students fed they cap cope by means other than"beating the system" or "grinding it out."

Feeling incontroi also requires feeling that what will beexperienced in graduate.sclsbol isredictable. But "ageneral belief (exists) among students that grading andevaluating are haphazard lad mechanicol" (Heiss 1970, p.'t2S), and graduate students sonsetinerfeel that how theirdissertation research will be judged is unpredictable(Altbach 1970).

One solution to lack of control and related shortcomingsin information, feedback, and predictability is a moresubstantial role for the advisor in the graduate student'slife. Advisors can contribute substantially to creating aPositive environment for graduate students. They can t

provide "positive, nonverbal cues and overt expressions ofinterest in a student's welfare" as well as."open discussionof the developmentil issues confronting a student" (Buy?:and Mayo - Chamberlin 1983, p. 410). to advisor can helpreduce the stress associated with the doctoral dissertationby helping the student articulate and assess alternatives sodist he or she can develip the topic earlier in the programand by supporting the student during topic development,research, writing. and oral defense (Baigar and Mayo-Chamberlin 19K1. p. 413).

The solutions for reducing distress among graduate stu-dents have focused thus far on the environment, for exam- .

pie by providing orientation for new students, by increas-ing students' involvement in planning, mid by enhancing

Abe role of advisors. Other solutions focus on improvingthe student's ability to cope with stress. Kolko (1980)recommends specific strategies for solving problems andmanaging time that "can be employed to facilitate one'sadjustment to graduate school" (p. 9). Sthomunaker (1911)

46 4

stf

4

also addresses the issue of one's personal adjustmakt tograduate school. First, because graduate school isdemanding, he suggests that only students willing to ake

, a complete commitment go. Once in gradigue schoolstudents should realize that after afew weeks many u-dents'thing they are not intelligent enough to continu :

"They experience a graduate-school version of the ftesh-man jitters. -'The work seems overwhelmingly difficult andtheir classmates seem to be much more intelligent thanthey are" (p. 286)..Students feeling this stress shouldrealize that other'students, because of their own feelings ofstress, engage in gamesmanship. consequently. in theirattempts to impress each other, graduate students becomeeven more confused and frightened. Graduate studentswho start having doubts about their own abilities should

. not mit up a front when they are not familiar with termsand authorities.

Admit your own ignorance because it is pot stupidity: infact. awareness of your ignorance is the first step towardovercoming it. You do not know these terms and authori-ties, nor do A ou need to know them now., You wereaccepted hcause'you have the brains to hear them,dm!, if you have the courage to admit your ignorance,you will make much better use of the time that otherpeople waste trying to impress each other (Schoonmaker1971, p. 2136).

Others advocate that professional counseling be mademore available to graduate students. in fact. Nelson (1971)recommended that more therapeu:ic hours should beavailable for graduate students than for undergraduates.Better counseling services would help when "pain. anxi-ety. and pressure reach a point for many beyond any stressthat might be justified as encouraging effort and productiv-ity" (Katz. and Hartnett 1976, p. 272).

Undoubtedly. solutions for distress will have to be'tailored to the needs of individual departments and schools4nd the involvement of both facult y and students is noes

y to formulate solutions. The impetus for change ispresent in both teacher and learner:

Anxiety states are frequently experienced by students inpursuit of graduate degrees. As professor of these stst-

Student Striss 47

1141bMir

NI,

4

dents we need to ask ourselves some hard, penetratingquestions.' itat are the causes of anxiety expressed inthe educational milieu? Can we differentiate betweenmanifestations of anxiety that students must accept andlive with from neurotic anxiety? What are the earmarks ,

of non-productive anxiety-ridden behavior? Is the educa-tional program contributing to the non-productive expe-riences? (Montgomery 1972, p. 24).

What all of this boils down to is that we must begin toassume responsibility for our present state of Iffe.'Wemust not, as all minorities have learned, wait forchanges to be initiated from above or, without. They will ,

only occur from within. A very long time ago someonesal me the definition of security was the freedom to beand feel insecure! Perhaps we as graduate studentsshould ponder this for awhile (Norman 1970, p. 4).

4

LAW STUDENTS

**.

ihsvireamental SettingThe history of egal education fo:lows the familiar patternof other professions like medicine, nursing, and pharmacy.Before the turn of the century, lawyers trained primarily inapprenticeships, but by 1940 admission to the bar with fewexceptions meant thatone had to have three years offormtd legal education. The specific way that the lawprofetosion and legal education developed historically helpsone updentand the cultivation of stress in law school.

During the colonial period, lawyers were viewed withsuspicion and distrust. They were perceived as "mostlypettifoggers, or minor court eked suchlts deputy sher-iffs, clerks. and justices who stirred up litigation for thesake ofpetty court fees" (Harno 1953, p. 18). 'Phis nega-_tive view began to change OM* the lifter part of the1700s, when predominately lawyers were involved in thewriting of the Declaration of Independence and the Consti-tution. Leg d education in the United States during thecolonial period was desultory. In fact,,because no coursesof law were offered in colleges and there were no indepen-dent law schools. apprenticeships were the only form oftraining except for a few extremely scarce law books.During the end of the 1700s. as attitudes toward lawyersbecame more positive, the first efforts toward formal legaleducations arose when Thomas Jefferson founded a chair oflaw at William and Mary College (1779). Shortly afterward,various professorships of law were established at a numberof colleges. The men who filled these teat Ling positionsSitw the practice 6f law as more than a craft and their roleas that of developing statesmen (Harno 1953).

The Litchfield Massachusetts Law School, opened in1794, was the first independent law school in the UnitedStates. During its 50 years of existence. the LitchfieldSchool was never associated with a college; in fact, it wasstaffed by faculty who were all practicing attorneys Iteducational orientation was therefore practical rather *I

theoretical. One remarkable quality of the LitchfieldSchool was that over 25 percent of the school's graduat sbecame prominent national leaders.. Numerous U.S., senators and representatives. cabinet members. governors.Supreme Court justices. and vice-presidents graduatedfrom this school. Indeed. Litchfield provided a tremendousboost to the prestige of the legas profession.

Student Stress 49

A major setback in legal education occurred atLitchfield's zenith, however. In 1828, Andrew Jacksonspearheaded the "new democracy," a movement thatstrongly deemphasized the need for fog mal education. Withrespect to the legal profession, "in its implication thiscreed seemed to hold that all male citizens had the inherentright to practice law" (Harno 1953, p. 39). Partly as aresult of Jacksonian democracy, for several decades lawschools were seen as merely peripheral and in fact unnec-essary in the education of lawyers. During this period, forexample, not only was Harvard Law School plagued withpoor attendance, but in one year only four students en-roiledeuen-though-the-qualifications toenter were merelythat the student be of good moral character and be at least19 years of age. Throughout the mid-1800s, the prestige ofthe legal profession was again at a low point; it was notuntil the late nineteenth and early twentieth centuries thatlasting and critical developments in formal legal educationbegan to occur.

The transition of colleges to universities was conctirrontwith changes in the practice of law that profoundly affec'edlegal education (Johnson 1978). Universities were notsatisfied merely to train the individual in the craft of law;rather, they saw legal education as a scientific endeavor.

t the same time, various bar associations were upset atthe influx of immigrant lawyers. They viewed immigrantlawyers as pi/orly trained, of improper birth, ignoble iiheyadvelised for business), creators of unnecessary litigation,and threats to both professional ethics and fundamentalvalues of American life (Johnson 1978). A.major concernof the elite members of the bar was to control economiccompetition. Bar associations saw legal education as a wayto "cleanse" the profession, and. thus, practitioners whowere trained under the apprentice system and originallyviewed formal education as unnecessary began to supporthigher academic standards as a way to screen admission tothe profe ;ion,

Harvard led the change in the 1870s by replacing facultywho were primarily practitioners with career law profes-sors committed to the scientific study of law, This transi-tion saw no systematic and sustained discussion on howbest to teach young men and women in legal techniquesand professional values. and so legal education developed

-,1 , .r I'

as a piecemeal adjustment to academic changes and profes-sional concerns (Johnson !978). During the 1870s, Har-vard's admissions requirements.-curticolum, and teachingMethods evolved and later became the standard for almost\all law schools in the United States. Both the Socratic and 'the case methods were developed at Harvard in the 1870s;they are still commonly used 1 c* rent legal educaticn.The academic changes and professional concerns M thattime led to a number of problems that are directly or indi-rectly associated with the stress that law students (acetoday.

One problem is that the Socratic method puts the lawprofessor in complete control of the classroom; the stu-dents' role is only to answer questions from the professor,not to ask an Students have little control over how theyrelay to the material being taught in class. Second, legaleducation has become a screening instrument in the ex-treme because the most prestigious law firms choose theirclerks almost exclusively from among the top 10 to 20percent of the class. Third. career law professors comefrom the ranks of the most successful law students. Thecentury-etd methods of legal education are perpetuated bythose who have been rewarded most by the system; there-fore, changing legal education becomes less likely (Silver1968). Fourth, efforts to make legal education more ana-lytical and less craftlike mean that the practical aspects oflawthat is, negotiating skills and courtroom practicereceive less emphasis. Second- and third-year law stu-dents. in particular. want more practical training and pro-fessors with practical experience (Pipkin 1976).

Sources of StressCompared to the amount of literature on stre amonggraduate and medical students, there is a d rth of materialabout stress and law students. Further, much of the mate-rial about law students is anecdotal; relatively, few actualscientific studies have focused on the topic. `.

A comprehensive study of six law schools in the UnitedStates, however, found that students entered law sehltdprimarily because of an intrinsic interest in the subject aa desire for professional training and intellectual stimula- "tion (Stevens 1973). According to this study. the extrinsicrewards of income and prestige were of less value to these

Student Stress

i

students. In considering the sources of stress discUssed inthis section, one might ask first .to what extent the intrinsicinterest in the subject of law is discouraged or encouragedand whether students are left more challenged to learn as a%suit of the stress or discouraged and helpless and thusless interested in the intrinsic rewards. These questions arecentral to the issue of whether or not law schools providean optimum atmosphere in which to learn.

The Socratic teaching method has been cited as a majorsource of stress among law students. When this teachingmethod is used, students receive little if any feedback tohelp evaluate their performance, The Socratic methodopenly emphasizes the competitive nature of law beforethe student has a chance to become familiar with the basicmaterial to be learned (Silver 1968). The student is askedto answer the professor's questions and criticize-the pre-vious student's remarks and, because the professor rarelycomments on a student's answers, the student often is leftfeeling that an answer was inadequate (Silver 1968). Thisteaching method encourages a great deal of hostility be-tween students (Stone 1971). It creates problems withmorale; the relatively quiet students tend to make disparag-ing comments to each other about those who seem to enjoyanswering the professor's questions (Throw 1977). One-third of the students in one study actually felt degraded bythe Socratic method of teaching (Stevens 1973); themethod is more a source of frustration than of enlighten-ment (Silvet 1968). One-third of the law students in anothersurvey felt the Socratic method to be substantially orseverely distressful (Ellin wood. Mayerson. and Paul 1983).One faculty member from the University of Utah LawSchool, however, maintains that over the past decade theuse of the Socratic method has declined and no schoolcurrently uses it as the principal method of teaching.

Partic'ularly related to the Socratic method are the con-cerns about feedback. Law students receive little or nofeedback about their performance until after the first se-mester. A lack of feedback was a source of substantial orsevere stress in 51 percent of the law students in one sur-vey (Ellinwood, Mayerson. and Paul 1983). Out of a needto reduce the stress associated with little feedback, lawstudents eventually develop their own methods of bogusfeedbackwhat an individual develops in his own mind

52

that generally has nothing to do with actual performancethat ultimately prove iniXective (Silver 1968).

Undue importance is placed on grades at the end of thefirst year of law schoolpartly because of a lack of earlierfeedback. This undue pressure, however, is more likely theresult of the fact that one's career opportunities as a law-yer are largely determined by the end of the first yearperhaps even as early as the end of the first semester.Generally, the top 10 percent cf the class is given theopportqnity to write for the school's law review, which isconsidered such a high honor that the most prestigious lawfirms actively recruit mainly those students. The studentswho do not "make law review" or who are not in the top10 to 20 patent of their class are rarely invited to inter-view with prestigious firms. Law schools rarely help stu-dents in the lower ranks find interviews with less presti-gious firms cm porations. or government agencies.

The amount of pressure on grades is relatively unique tolaw school because in no other university setting do gradeshave the importance at such an early point in one's educa-tion. Of 17 potential items causing stress among law stu-dents in one survey, getting grades that did not reflect themount of effort invested proved to be the most stressfulitem (Ellinwood. Mayerson. and Paul 1983). The secondmost stressful item was the importance placed on classrank. At least 60 percent of the students surveyed in thatstudy felt substantial or severe levels of stress related toeach of these two items.

This inordinate pressure for high grades. particularly inthe first year. likely has a detrimental effect on learningand thus contributes to the sharp decline in intellectualinterest in subsequent years (Stevens 1973). It is as thoughthe students worked as hard as they could but disco.,tredthat getting the best grade was out of reach. The s revs--related to gradesscan have a devastating e on learningfor some students. One student who actively participatedin class and seemed to offer insightful answers to profes-sors' questions abruptly and permanently stopped class-room participation shortly after discovering that his per-formance on the exams was average (Turow 1977).

The stress associated with grades also is associated withineffective study habits (Patton 1968). Patton asked thosein his study to name what stood out most in any way about

Student Sirc

The stressrelated togrades.canhave adevastatingeffect onlearning forsome students.

$3

the first year in law school. The moscommon responsereferred to)4teling--being confused, afraid, or uncertain,for example. The students who were to overcomethese distrashl feelings were the one who tended to have

grades. Such students were f i to study unsystem-were,unable to atVust to the differences in

teaching methods between undergradusIe educatiotrandlaw school. The poorer students tended to focus on an-swers to legal problems rather than on te*raing the processused to analyze legal issues; they focuse4 on content rather'than method. Acco,Jing to one student wbo performedPout':

1 don't know that I could put my finger on any one thing.I would say that the amount of work and,* uncertaintywith which I approached finals, not really knowing whatI was expected to have and how well I was doing allalong. In other words, there was no basis forme to.compare myself with other students or Rompare myselfon a scale of knowledge . . . with what T altould have had(Patton 1968, p. 29).

After the first semester, tension was related piimarily togrades, with students who had the worst grades feeling themost tension (Stevens 1973).

Another source of stress is the distarce students feelfrom the faculty. Although most university students likelyshare this same concern, unique qualities of legal educa-tion emphasize the differences between students and fac-ulty (Watson 1968). It is not uncommon to find law pr'ks-sors who sky that their teaching is directed plimitrily to theintellectually elite student or to those students in 'the top 10percent of the class. Furthermore, although law professorsmight care for their students, they often feel unable toteach the majority effectively and so focus their efforts onthose students who are most responsive to what theyteach, failing to recognize the emotional cues of distressfrom the majority (Watson 196$). The psychologicil dis-tance also occurs as a result of some professors' inappro-priate brutalityopenly insulting students and psychologi-cally cutting them to ribbons. Some professors justify theirbehavior as preparation for the stress of the courtroom orfor the stress of negotiating. In the adversarial environment

62

.of the legal world. however. the opposing attorney doesnot have the protection of being "the professor" whocarries on a one-sided battle.

Lqwstudents cope with these sources of stress in differ-ent ways. Several ways they use to avoid stress likely have

a deleterious effect on learning inaw school (Stevens1973). "Most interviewees felt that the prevalent teachingmethod not only discouraged student participation but alsoforced students to design avoidance tactics to allow thepeacefdl functioning of their personal learning mecha-nisms" (Stevens 1973. p. 644). Some of the avoidancetactics included not attel.velng class. personally requestingthe professor not to call on them, not returning to classafter a break. making highly equivocal statements, andstating they were not prepared when in fact they were butfeared answering questions. The most common means ofavoidance, according to Stevens. was the statement, 'I'mnot prepared." ironically, for many students the experi-ence of law school encourages them to avoid and relin-quish aggressive skills to feel comfortable with their learn-ing environment (Watson 1968).

Perhaps in an effort to deal with their own sense ofhelplessness. many students rely on false feedback asconfirmation that they will perform well on exams (Silver1968). For example. some students believe that becausethey are older, married, make "good" comments in ciass.had a high LSAT score. or did well in their legal writingseminar (a nongraded exercise), they will rank high in theclass. The extent to which students rely on such feedbackto relieve their anxieties might be counterproductive andeven harmful if they begin to avoid adequate preparationfor exam's.

The nature of coping seems to change dramatically forstudents after the first year when anxieties seem reduced.This change is perhaps partly the result of adapting to theenvironment or feeling a diminished commitment to dowell in law school. If law students believe that their effortsarc not a reflection of their grades. it is not hard to Imaginehow commitment to perform well could decrease. A ran-dom sample of students from seven law schools found an;.pparently cynical view of legal education from students intheir last year:

Student Stress 55

c6

. ....te-e

On the average third year students re,- ...wed that lawwas not taught ht law school in a systematic and orderlyfashion, that class attendance war unrelated to obtain-ing high grades, that cramming Jor exams was as effec-tive as regular study, that case briefing was not aneffective way to learn law, and that grades were givenlargely to aid firms in liking rather than as feedback onprogress (Pipkin 1976, p. 1173).

As law students_beginio sec their e 'cation in these;terms, it is not surprising that they e avoidance tech-niques and become less committed to the process of learn-ing. The adaptation to the stress of law schoo! after thefirst year might to a large extent merely be resignation.

Solutions...A Prom a historical perspdctive, legal education in the twentieth century developed in large part out of pressures tolimit the number of people entering the practice of law.

4AI The extent to which the perceptions of students are true

. that grades are used primarily for Fving purposes ratherUlan for feedback would lead one to conclude that the.....original purpoies of legal education might still exist. Todecrease cynicism and increase ambiti -n, students musthave the perception that the primary focus of education islearning rather than aiding 'Arms in hiring.

Most author s who have studied stress in law schoolstrongly recommend more frequent and useful feedback,which can be accomplished by;

communicating with students about the meaning ofgradesassigning more frequent exams and papers and provid-ing instruction in study techniquesoffering positive reinforcement by means other thangrading--for example, by acknowledging a goodquestion in class or by praising the class when stu-dents are prepared rather than chastising them onlywhen they are ill prepared (Ellinwood, Meyerson. andPaul 1983. p. 28).

Pipkin (1976) asked students to rank the importance of 24possible changes in law school and found that "more

56

feedback on academic progress" (p. 1184) was rankedsecond after smaller classes.

Merely acknowledging the stress associated with theSocratic method will likely have the effect of reducingstress. But other recommendations regarding the methodwould likely reduce stress:

professional education training for law facultymore organized progression through course material,following the syllabusless reliance on the traditional case book methOd(Ellinwood. Mayerson, and Paul 1983, p. 28).

Although Pipkin's subjects (1976) did not let that theSocratic teaching method should change, they stronglyrecommended changes in the conicohm that would alterthe preValenci: of the Socratic method. Students asked formore focus on the teaching of practical skills and morefaculty who had actual experience in the practice of law.Of 24 changes in legal education suggested, the thirdthrough sixth most recommended charges regarded helpingstudents gain practical skills and Man careers (Pipkin1976). It is likely that a more practical approach to traininglawyers would often include methods other than Socraticteaching. Some law schools (Stanford and Harvard. forexampk) have recently developed programs to train stu-dents in negotiation and courtroom skills. Such trainingspecifically acts as a form of stress inoculation before theactual practice of being an attorney.

If students believe that their efforts are not reflected ingrades and that the current importance of gradesadverselyinfluences effective study techniques. then perhaps theimportance of grades should be deemphasized. Otherforms of feedback are likely more helpful in improvinglearning. The following suggestions would likely helpdeemphasize grades:

stop posting grades; mail or distribute them individu-allystop ranking: issue grades onlybase selection for the law review more on writingskills'

In fact. Stanford University recently implemented this practice.

0

Student Stress 57

F

facilitate off-campus interviews at small law firms,public interest law practices. utilities, corporations.and sovernment agencies (Elhnwood. Meyerson, andPaul 1983, pp. 28.30).

As more effcr* is made to help find jobs for students whoare not in the top 10 to 20 percent of the class. it is likelythat the stress associaiz-4 with high grades would be re-duced.

Faculty who are supportive of students likely have abeneficial effect in reducing siren and even increasing!earning. In fact, greater support from faculty has beenmore strongly adsociated with reducing stress than thesuPP011 of one's family (Ellinwood. Meyerson, and Paul1983). Warm and friendly relationships between facultyand students positively affect students' expectations andtheir sense of ambition (Stevens 1973). Approximately one-third of the students in Stevens's survey did not perceivetheir faculty as warm and cordial, and over one-third of thestudents in Ellinwood. Meyerson. and,Paul's report feltsubstantial Or severe stress be9kuse they-were unable toestablish rapport with faculty/ In Stevens's survey. theperceived warmth of the studentlfaculty relationship wasassociated more strongly with ambition than was classrank, but ironically for many students. a high class rankopened the way to warmer relations with faculty, Rapportbetween students and faculty can be increased by:

assi, 4:ng each student a faculty advisor/friendespecially during the first yearfor the faculty, trying to communicate with students inways other than just in the classroomorganizing more student/faculty social eventsparticipating in events organized by studentsnot focusing on law review dtudents in class discus-sion (Eliinwood, Meyerson, and Paul 1983. p. 28).

Better relationships between students also help reducestress. First-ye student in one study whospent timeassociating with u r class students were much morerelaxed and spent s time formally discussing coursematerial than those studentswho did- not have these associ-

\

58

66

arions (Stevegst 1973). It is not known whether students'performance improved as a result of these associations.Even if it did not, however, the fact that the associations

stress means that it is worthwhile to increase'formal contaci between students in different classes.

In summary, students begin law scbcil intrigued withlaw, but over three years their interest is greatly dimin-

., ished. Law students' interest inlaw can be maintained ifgrades are deeinphasized and if feedback is more relevantand timely. poved 'relationships between faculty antst#ents#4increaseitpracticil -riing and career plan-ning will also help reduce stress and increase students'ambition to become attorneys. The concern is that thesame historical compulsions that encouraged the develop.ment of form : legal education might still have an inordi-nate presence. Thus, law schools can still be under pres-sure to maintain the role of screening agents for law firms.Law students are quite cynical about the process acidpurpose of their education (Pipkin 1976). It is likely that aslegal education increasingly focuses on benefiting morethan the top 20-percent of a class, both the cynicism and °

overwhelming distress will give way to an improved learn-ing environment.

..

,

Student Stress $9,

.

MEDICAL STUDENTS AND RESIDENTS

EaviraimmenteltSeffingThe entho process of medical education is often viewed isan 11- to 12-year continuum, includinglour years of pre-orofessional study in college (premed), four years of medi-cal school, and three to four years of graduate medicaleducation in a teaching rospital (internship and residency).The student% in medical school are referred to as 4under-graduate" rittllical students, even though they are collegegradiates. Residency training is referred to as "graduate"medical educanwi. Beyond this formal training, the physi-

.. cian is expected Pt pursue lifelong learning through contin-uing education.

Medical education as it exists -today is vastly differentfrom early medical trainint, wring the early colonizationof America, it was relatively simple: Students learned froma practitioner who, as preceptor, taught them skills.aadknowledge. By the time of the American Revolution, theshortcomings of precentorships were becoming recog-nized, and the idea of the medical school was introduced.Most nineteenth century medical schools, hotiever, wereproprietary Institutions, not nonprofit colleges. Courseswere didactic, intended to supplement but not offer clinical .teaching. Generally. they had low standards of teachingand poor facilities, and they admitted any student whOcould pay the required tuition. Tile proprietary schools,because they competed with each other as well as schoolsaffiliated with universities, even attempted to make dui,programs more attractive by offering free trips to EurCeupon graduation to those students who paid fees regularlyand in cash for three years (Stevens 1970. Therefore.anyone who could afford it could obtain ; medical degreeand practice medicine. .

in 1904, the American Medical Association establishedthe Council on Medical Education to begin efforts to up-grade medical education and to become the AMA's agencyfor implementing educational change. Over time, the coun-cil became an important regulating agency ir, establiOinghigh standards in medical schools and in strengthening theAMA's influence in medical education. Perhaps the mostpowerful event in helping the subsequent success of theseefforts was the Fkxner Report.

The Romer Report of 1910is today considered one ofthe most important events in the history of medical educe-

... ..

Lion. After visiting every medical school in he country.Abrahain Flexner issued a report exposing the generallyinadequate and substandard state of medical education inthe United States. With the exception of only three medi-01 schools (Harvard. Western Reserve, and Johns-Hop-kins) that were given fall angers!. most other schoolswere a scribed, for example; as "utterly wretched." "out-and-out commercipl enterprises." or "wholly inadequate"(Stevens.1971. p. 67).

The Flexner Report strongly recommended that medics:schools employ full-time faculty and that both hospital andlaboratory facilities be available to medical students. It*commended that admissions standards for students beestablished and thatthe qualifications of the medical schoolfaculty be raised. Flexner urged that the Johns Hopkinsprogram be used as a model of medical educationthat abachelor's degree with certain wemcdical courses berequired for admission. that the university be responsiblefor graduate-level medical education. and that teaching andresearch be integrated within the institution.

As a result of the Flexner Report and strong publicsupport. most of the 400 or so proprietary schools wereeliminated so that by 1920, only SO schools were accred-ited. Because the only source of medical school ratingscontinued to be the AMA's Council on Medical Education.it was able to function as an effective monopoly over theregulation of medical education.

Between 1920 and World War II. medical schools contin-ued the long process of professional reform. cOntinuing tofollow the standards recommended by the Flexner Report.Aetna time. the format of two undergraduate years ofbasic sciences followed by two years of clinical education.still generally practiced today, was instituted.

following World War 11, the affiliation of hospital teachingprograms with university medical schools became increas-ingly common. As a result. residency training also becameincreasingly available and wasp° longer viewed as somethingextra; rather. specialization was qiiokly becoming the ruleinstead of the exception. The number of certified specialiststripled between 1940 and 1951 (Dktrick and Berson 1953).and by 1980 that number had again substantially increased.

Initially. each national specialty assumed responsibilityfor the accrsditati?n of its own resider..4 program becase

Student Stress 61

/

American medical schools did not want to become in-volved with.specialty training. It w,s not until 1972 that theresidency accreditation structure was finally reformed and 1- -all graduate programs across the country were governedby one committee and the policies and standards it set.,This new committee. the Liaison Committee on Graduate'Medical Education, was a logical and probably inevitable'extension of the already existing Liaison Committee onMedical Education that had been establishNI for under.'graduate education in 1942. Thus. a continuity in mediealtraining was finally underway.

Until the emergence of that continuity in 1912, medicaleducation had been divided into two essentially distfictphases --tie undergraduate program leading to the A.D.'degree and the Oduate program leading to certification ina specialty. With the modernization of medicine, however, \has come a "blurring of the traditional boundaries betweenundergraduate 4nd graduate medical education" (Cooper1974, p. 49).

Goode, in hii analysis of the characteristics of the pro-fession. summarizes well the historical outcomes achievedby the medical profession:

The medical profession had not only met the basic crite-ria of beiitg a service occupation supported by pro-longed training in a specialized knowledge, but further-more, it ad determined its own standards of educationand teal ingrhotsuccessfully demanded high-caliberstudent , had ,tafred its own licensing and admissionboards, had Shaped legislation in Its own interests. haddevelopfd stringent professional sanctions. had becomea ter. Id occupation and was free ok formal lay evalua-tion an control (cited in Cockerham 1982, p. 135).

A finall tor shaping the history of medical educationremains toe mentionedmedical research. During WorldWar II: the .S. government so successfully supportedtechnologi abd war - related Medical research that afterthe war the vernment continued to generously financemedical reoea h in a wide vat iety of areas. Private founda-tions cage rical disease organizations also becamegenerous sources of finding. As a result, ti%is emphasis on

research was and still is very influential in directing theocus of medicine and its subsequent impact on medical

cation. For the 20 years following World War 11:

The name of the game was laboratory and clinical re-. search, and academic wpointments and promotions

were tied to research productivity, reaching and patientcare were necessary evils and "teaching materials."which were patients with esoteric diseases or those onwhom a research project was being conducted. were theprincipal occupants of the wards of university hospitals(Gellhorn 1979. pp. 158-59). -

The production of biomedical research publicationsreached spectacular proportions, contributing to a signifi-cant irterease in biomedical knowledge. The effect of thisera of highly financed research was that all potential medi-cal students, to be capable of understanding and contribut-ina to the field of biomedical knowledge. had to be of su-perior intellect and have a scientific background. Thus be-gan the extremely rigorous and highly emphasized science-related background of the physician-to-be.

As the system of medical education developed ov 'r theyears, students have pointed to several structural c, 1-

nents of their educational process, running tie continuumfrom premedical education through rtsidency training; its"built-in sources of stress." One of the firo ,ignificantsources of stress facing the would-be physician *ris wellbefore medical school,, ii the preparation for n.edicalschool. The overwhelming majority .,f medical schoolsrequire biology, inorganic and organic chemistry, physics.and mathematics with calculus. Because the gmde pointaverage (GM) and the Medical College Aptitude Test(MCAT) are the two statistks of greatest iaterest to admis-sions committees. competition for grades is typically re-lentless.

Serious college stuaents often bypass., when ,. c, vilvie.required courses for premedical students betaiLle theywish 10 avoid the disparate competitiveness end p, cov-cupation with grades which sourly colour learnin.e..Many young men and women who enter college with the*aspiration to enter medicine are so distressed by the

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obsession of their premedical contemporaries withgrades that they abandon their career plan Wellborn1979, p. 160).

Over the years it has becom common knowledge that \cheating and perhaps even sabotage occur on a large scaleas students strive to attain a GPA high enough to impressadmissions committees. A common complaint amongstudents I- that medical schools and colleges disagree toomuch on W14.4. is required of a medical student, Manystudents feel ill advised and note that if they could do itover again, they would take more courses in the humani-ties because they feel the need for a broader background(Sierles-, Hendrick, and Circle 19i0).

The typical format imposed u . .'n medical students istwo year, of basic sciences f. . . by two years of clinicalstudy. Basic science courses are ught almost exclusivelyin the classroom; they are a great, ource of disappointmentand stress to many medical students. Most students havejust completed four years of highly competitive hard science in premedical education, only to graduate back to thestatus of undergraduate. Their idealized expectations ofhelping people, treating patients, and fighting disease aremet with longer classroom hours, even more complex .scientific learning, continued competition. and liMe if anycontact with patients. Disillusionment is common, andstudents complain overwhelmingly that too much team-ing is forced and that much of it seems irrelevant to pa-tient care.

Built-in sources of stress also occur for those in resi-dency programs. A more or less unspoktn assumption hasevolved that "everyone in medical school goes into aspecialty field." In the past, only a small per:entage ofthose graduating from medical school went on to specializein graduate training programs, but today over 93 percent ofthose graduating from medical school specialize. Thispressure is difficult to ignore.

Along with the pressure to specialize comes the stress ofcompetition for acceptance into a residency program,including not only the field of one's choice but also tin;medical school of one's choice. Competition does not end.however, with one's acceptanze into a residency program.Rather, it intensifies. The title of chief resident during the

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third or fourth year, for example, corks status for whichcompetition takes place during the first mo years. Thoseinterested in pursuing fellowships after residency mustcompete to demonstrate competence in those qualities thatare sought in academic medicine. And some programs inmedicine today still adhere to a pyramid syitema resi-dency program that can graduatelonly five students at theend of three years but that nevertheless accepts 10 stu-dents in the first year.. Weeding °in the extra five studentsunnecessarily pushes stress to its extreme.

The element of age is yet another potential cause ofstress that is built into the structure of graduate medicaleducation. At the minimum, if students have never (sincethe first grade) taken a break in their education, they willbe at least 26 years old when applying to a residency train-ing program. While the vast majority of their contempo-raries will already have graduated and achieved somedegree of financial and social independence, physicians-to-be are still competing for schools and out of necessitystill financially and socially dependent.for many, thisprolonged state of competition and dependence requiresa wealth of coping skills that may not necessarily beavailable. i

Two additionatsources of stress common to both pre-medical and medical education are a result of recentchanges in the economic structure of the United States.First, available financial support is continually dwindlingas government loans and stipends ate cut back substan-tially or cut out all together. In fact, governmeat loans orstipends for graduate medical students are essentiallynonexistent. The competition for scholarships has ofcourse become ferociously competitive, leaving moststudents in the 1980s to create their own program of finan-cial support. According to the American Association ofMedical Colleges (AAMC), the average indebtedness upongraduation of a medical student today ranges from $35,000to $50,000, with payback typically beginning within sixmonths of graduation from msidency..

The situation of indebtedness then leads to the secondproblemthe maldistribution aphysicians. Newly gradu-ated physicians hesitate to practice in a small communitywhere their earning may not be as great or as con-sistent as in an urban en ironment. It is understandable

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that for most graduates, the ability to at last afford somelong-awaited possessions for self and familyas well as tomake loan payments -- tales on some priority. Addition-ally, most graduates prefer tobuild a new practice in alarger city or near a medical center where the facilitiesandconsultations to which they are accustomed are readilyAvailable. The Graduate Medical Education NationalAdvisory Committee warns, however, that a significantoversupply of physicians in many urban areas and in cer-lain specialties is likely by 1990. This possibility representsone more concern that medical students and residents mustconsider in their choice of medica! specialty.

Today's medicatstudents are expected to be the creamof the nation's crop. Inherent within any such extensiveand highly structured system is the built-in potentiiii forstress. .

Sources of StressMedical StudentsA longitudinal study of a sample of Ht.. yard students(Vaillant 1977) demonstrated that "potentially stressfulevents may generate incapacitating responses or triggeradaptive mechanisms that eventually lead to renewedstrength" (Mumford 1983, p. 436). Whether stressfulevents "generate incapacitating responses" "triggeradaptive mechanisms" speaks to the compkx interactionbetween the demands of medical school and the copingmechanisms available to students. The four-year medicalcurriculum can be conceptualized as presenting the studentwith a series of adaptive and developmental tasks Molar1971; Gaenshauer and Mizner 1980; Lief et al. 1960; Pfeif-fer 1983). An article written by Gaensbauer and Mizner(1980) is partiCularly helpful in this conceptualization. Ithypothesizes that students' emotional problems derive asmuch from the nature of the developmental stresses theymust face as from their own individual vulnerability andthat to study these developmental stresses might provefruitful in determining what types or coping strategies ortasks would be most helpful. -To do so, Gaensbauer andMizner reviewed the files of all students who had soughtpsychiatric consultation at the University of ColoradoMedical School over the preceding 10 years. They thencategorized the timing and the nature of the coosultations.

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From that information, they attempted to "identify recur-ring themes which might reflect specific developmentalissues which must be dealt with by all medical students"(p. 61). The following discussion of stress among medicalstudents uses Gaensbauer and Minter's work as a point ofdeparture and identifies the specific developmental tasksthat confront students and the ensuing stresses likely tooccur when they are not successfully managed.

First yearDuring the first year of medical school, academic' pressures

o rank as the greatest source of stress in students' lives(Boyle and Coombs 1971). Academic pressures include thecomplexity of the material to be learned and the competi-tion; students no longer stand out as academically superiorbecause nearly everyone in their class is academicallysuperior. Fear of failure may arise for perhaps the first timein a student's life, Therefore, an initial task for the first-year student is to determine personal capabilities ia thisnew context and to perform in a manner that equals one'sability, while maintaining a sense of adequacy. Failure todevelop such coping strategies is likely to result in de-creased self - esteem, depression. and anxiety. Commonresults of the un ...iccessful resolution of these tasks arewithdrawal from competition and inability to perform atone's best level.

A freshman medical student was seen approximately twomonths after the beginning of school because of severeanxiety around the time of examinations and seriousdoubts about whether he could handle the academic

__stresses of meditat school. lie described long-standingproblems of low self-esteem, particularly in comparisonwith his lusher and older sister, who had had brilliantacademic careers. His choice of medicine had been anattempt to stake out an area of excellence for himself' bycombining his scientific interests with his ability to re'atehumanistically to others. The competitive, heavily scien-tific orientation of the first two years had thrown himinto the high pressure academic situation in which hefelt most ill at ease,, and he became increasingly anxiousand depressed. Reassurance and the opportunity to

During thefirst ofmedicalschool,academicpressures rankas the greatestsource of[student]stress.

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ventilate his concerns were sufficient to signfficantlyallay his doubts (Gaensbauer and Mizner 1980, p. 60.,

Mother major source of stress for freshmen medicalstudents is the vast quantity of material to be learnedsovast in fact that there is no way to learn it at all. The tasktherefore becomes one of setting self-imposed limits on theamount of material to be learned. For many medical stu-dents, who by nature have an "obsessive-compulsive"make-up, the feeling of less than complete mastery is verydifficult to accept. For those who cannot accept this toler-ance for some uncertainty in their learning, the result isoften extreme anxiety and the feeling of being "driven" tothe extent that psychological intervention is required.

In addition to academic demands, a.third major stress(actually a result of the first two) is apparentthe lack oftime for personal and social relationships. Social relation-ships at this time are typically disrupted as Mends fromcollege move on and entrance into medical school oftenmeans a move away from home. Giien.the immense de-stands on one's.time, the task of reestablishing and build-ing new social relationships may prove very difficult. Thestudent has a growing sense of the sacrifices that a careerin medicine will require, and even though adaptation tosuch sacrifices will be required throughout medical schooland residency. the potential for maladaptive coping isparticularly great in the first year. A common mistake offirst-year medical students (a maladaptive coping strategy)is to make academics a higher priority than personal andemotional needs. The resulting risk is one of loneliness andalienation from supportive relationships, including maritalpartners. Another maladaptive coping strategy is to seekbituations ,that will meet the student's need for dependencyut demand little in return for example, moving back

home with parents who will provide financial and emo-tional support or selecting a readily availabk spouse whowill do the same. To the extent that such choices representa kind of psychosocial regression, the long-term outcomeis no apt to be or live even though in the short run such achoice does appear workable.

A final source of stress for freshmen students evolvesfrom the discrepancy between their lofty expectations of

A °IR

.medical school and what medical school tuns out to be.For students:

the mystique of the ftedical school 5 strong, and fromthe beginning there are disappointmentspoor lectures,inadequate material, 'repetitive material, fragmeitationof subjects, and a lack of coordination. It only helped ulittle to recognize an exaggerated high level of aspira-tion, which ioems(fies disappointment (Rosenberg 1971,p. 213r.

in trying to summarize the many and varied disappoint-ments they had experienced, these students coined aphrase, the "double message," to describe bow they felt.Faculty talked about treating patients but taught basicsciences, talked about awareness of the 'total situation buttaught fragmented disease and symptoms, disparagedstudying trivia yet called x it on examinations, and in-sisted on laboratory sessions yet looked the other waywhen students copied down the right SUISWCFS because timewas too short for real experimentation. Such game playingstarts the process of disillusionment early for many medi-cal students.

Second yearThe major stresses in the second year appear to highlightthe issue of commitment for m^nv medic& students. Fa-tigue is increased (longer hours in the claf,sroom and continued pressure to perform on examinations) and still thereis little or no actual patient contact. Students therefore findthemselves needing to.determine how much they want tobe doctors. They must decide whether they can make thecommitment to work as long and as hard as they must withfew immediate rewards. Students able to come to termswith this issue will likely learn to persevere and toleratehard work. Students unable to come to terms with theissue are likely to have feelings of doubt or resentment thatwill continue to affect both current and future perform-ance, in:luding.patient cm.

A second major stress of the secondtear is j)ie exposureto clinical preslems in pathology, pharmacology, andpsychiatry. The impact of these courses on studtats can

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produce considerable anxiety and hypochonddasislabnor-mal anxiety over one's health, often with imagined ill-nesses). For medical students, hypochondriasis has anadded twist: Students think they have or may get whateverdisease they are studying. This occurrence is commonenough that it is lightheartedly referred to .s "medicalstudents' disease." The phenomenon is not to be takenlightly. however (Bojar 1971; Hunter, Lohrenz, andSchwartzman 1964; Saslow 1956; Woods. Natterscat. andSilverson 1%6). Thus, another major task arises for thesecond-year medical student;to develop a sense of de-tachment about the study of disease and illness withoutlosing sight of its human implications. Inability to achievethis task can result in preoccupation with one's health andsevere stress, which in turn interfere with the student'sability to learn important material.

A second year student was referred because of abdorni-nul and chest pains which were felt to be ntusculoskc-k-tal and tension related. A mild elevation of blood pres-sure had been found during a recent physical exantina-lion. There was a strong family history of cnrdiovascso-kir disease on both sides. A maternal uncle had died sad-

. denly of a heart attack several months earlier. On his;other's side, his grandfather and an uncle had died ofcardiovascular causes. Studying pathology stimulatedhis thinking about all the possible diseases he mighthave. Lectures on the cardiovascular system had beenso distressing that he had stopped attending them. Ashort-tirm supportive psfehotherapeutk experience en-abled him to put his blood pressure findings in perspec-tive and allowed him to return to class (Gaensbauer andMizaer 1980. p. 64).

A third major stress during the second year carries overfrom the first yearlack of time for family, friends, andrecreation. The result is often a feeling of dehumar :Lationderiving from this "tunnel vision"; it occurs when stu.dents' excessive academic demands preclude time for anypursuit of pergonal needs or interests.

Third yearMany authors regard the third year as most important tothe student's identity as a physician (Gaensbauer and

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Mizner 1980). Beginning with this year, students movefrom the relatively impersonal learning of theory to a roleIn which they must apply the theorywith less structureand less regular feedback than they have had for the psi(six yeast The question of being able to manage compe-tently arises in students' minds.

The most intense of experiences to confront and createstress for the third year student is that of death and dying.Acceptance of death and of one's own helplessness incertain situations Li a crucial task for students. 'fhpse whohave difficulties coping with thii stress may find that theytend to withdraw frbm such situations dr feel unable toempathize with patients and their families or attemptoverly heroic forms pf treatment that fail to take intoaccount the wishes of patients and their families. Studentsmight also attempt to cope with this type of situation byregarding the patient as a biomedical problem rather thanas a whole perton with whom one might closely identify.

A third-year medical student had received poor evalua-tions on his initial clinical rotations. Problem behavioron the wards had alternated between absences from thewards at times when he was expected and the aggressivetaking on of responsibilities for which he was not quali-fied without consultation with star Much of his behav-ior could be traced to his inability to tolerate feelings ofhelplessness in the face of so many sick and dying pa-tients. His intolerance of this stress was ultimatelxofsuch severity that he was requested to withdraw fromschool (Gsensbauer and Mizner 1980, p. 65).

Contact with patients, with 141 its emoti.mal intensity,and everyday less interesting proSkms"cati provoke acrisis related to issues of intimacy and closeness. There-fore, students must learn to develop a ;olerance for emo-tionally intense situations yet maintain an empatheticinvolvement with patients.

?long with learning to interact-with patients in a clinicalsetting comes learning to interact with other medical staff,often in pressured situations. Medical students begin tosense a familiar pattern occurring in their education proc-esscontinually graduating to a new "undergraduate" role(from college. the first two years of medical school, and

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now to the clinical setting). Students must be able to toler--ate-beinveld-what-te-de and to have their mistakes contin-

ually pointed out without becoming unreasonably anxious,angry, or depressed. A common stress reaction is perform-ance anxiety, especially during oral presentations andwhen learning clinical procedures. Learning to toleratereceiving orders; having one's errors delineated, and beingthe low person in the lieraray of ward personnel (wherenu'ses have more practical knowledge than do students) is

.nqior task. Failure to do so win likely result in overtanxiety whenever in the clinical setting, argumentativenessand hostility (both coming from and directed to the stu-dent), and lowered self-estitem from the inability to make asignificant contribution to the health team.

Lack of time for family, friends, and recreation con-tinues to be a major concern for third-year students (somerank idlest} (Edwards and Zimet 1976). Medical studentsare therefore still experiencing the feelings oidehumaniza-tion and disillusionment that accompany this major sires-sor, which at this point may well fit into the category of..chronic stress.

Fourth yearThe fourth yeaiis usually less stressfid for students thanthe previous three years. Clinical work is essentially simi-lar to the third yea, and students have more time forelectives in areas where their interests are greatest. Re-quests for therapy by fourth-year students are typicallyfewer (Gaensbauer and Mizner 1980; Hunter, Prince, andSchwartzman 1961; Pfeiffer 1983): The es eats that provokethe most stress at this time reflect concerns about gradua'tion and the ability to perform responsibly as "real" phy-sicians.

A fourth-year student expressed concern about hisadequacy as a clinician. including concern that he had amemory disturbance which interfered with his ability toremember clinical material. lie had recently returned toa clinical rotatio$ after eight months of nondinicalelectives. and also had had to make a decision aboutapplication for internships the previous week. He haddecided to apply for an internship in a subspecialtywhich he perceived as a quite circumscribed field, the

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sailor reason being "I think 1 can handle it." Doubts'about his clinical competence and memory had persisteddespite the foci that he had never failed a course, norhad his qualifications for being a physician ever beencalled into question by instructors. In a brief psycho-therapy, drawing attention to.the immediate precipitantsOlds seeking kelp. and to his overly critical self,-/assessment was sufficient to relieve much ofhit anxiety(Gaensbauer and Mizner 1980. P. 66).

Additional sources of stress at this time center aroundthe prospect of ending a phase in one's life and.moving on,a type of loss for some students. Competition for residencypositions and indecision over choice of specialty are afroprominent (Adsett 1968). And fourth-year students find iheamount of noneducatiolal service they are required toperform a major source of stress.

The lack of time for family and friends continues to be amajor concern (Edwards and Zimet 1976). This source ofstress speaks to the need to develop coping strategies thatwill assist in striking a proper balance between one's per-

- sonal and professimal life (Hunter. Lohrenz. and Schwartz-man 1964). Compromise is imessary but to some extentlikely to be painful because time spent in either moles-sional or personal activitiestwill detract from the other.The attempt to make these compromises as satisfactoryas possible is an ongoing challenge.

It appears that medical students, despite the long hoursof study, competition, and social isolation that begin earlyin the preparation for medical school. "enter medicalschool openly idealistic about the practice of medicine andthe medical profession and feel that medicine is the best of311 professions, but that during the course of medicalschool students develop a cynical attitude toward the dailyroutine of medical school" (Becker et al. 1961). A morerecent study confirms this statement, describing medicalschool as "the process of disillusionment" (Schwarz etal, 1978).

SolutionsMedical StudentsThe concept of stress inoculation (Meichznbar 1977)suggests that to provide students with information, feed-back, and choices would be to offer great protection fromthe disruptive and demoralizing effects associated with

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decisions that hive a.high potential for negative conse-quences. Perhaps then solutions involving this concept -

could prove usefid in bringing to a halt or at least minimiz-inkthe "process of disillusionment" so prevalent amongmedical students.

A crucial place to begin is before medical students Ivorbegin medical school, that is. during premedical educationif!unkenstein 1968: Gottheil et al: 1969 Huebner. RoYer./ and Moore 1981). Many studints havio,nlY vague notionsof what it means to be a physician itrioday's world. Tothem the p..:sicisn is the old-fashioned stereotypethekind. fatherly gentleman who uses his vast supply ofknowledge to cure his patients. To avert the problems thatarise when the actual situation is found to be'substantiallydifferent from this romanticized notion. students needmore info, =dim' about what the life 'of& physician isreally like. One solution is to provide students with first-hand experience by having access to older and respeatal, 'individuals to whom they could go for advice or to folio*during a typical day in the office or hospital (Fir,.elstein1968).

A second solution is to provide studenti with informa-tion and the potential for more re control, that is, a formal-ized orientation for all incbming freshmen. A recentlyrevised orientation program at the UniversitrofMissauri-

Columbia School of Medicine includes the essential ingre-dients for successful orientation:

The new program was less formal, less intimidating. :

more supportive. and mot rsonak the program in-cluded counseling about potential stresIors. expecte-

. Mons, time management, evaluation. and grading fin-e

eluding the dean's letter;. Spouses and childrenparticipated in various orientation events. A studenthandbook was drafted to provide follow-up informationabout governance, administration. health care. counsel-ing. evaluation and grading. clerkships, and specialtychoke. A series of class meeting and workshops duringyeirs 2 and 3 introduced students to a strategy ofA4quencing clerkships and of preparing for decision mak-ing regarding specialty areas and specific residencyprogram clioic-s (Huebner Royer. and Moore 1981,p. 557).

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Such an extensive and practical orientation should helpthose students with unrealistic expectations to adjust themto a more realistic level, thereby preventing the greaterdissatisfaction with medical school that occurs when ex-pectations and realities are mismatched (Gottheil et al.1969).

A third solution, in response:to consistent complaintsfrom stkdents, is to clarify the curriculum and professors'evaluatio9s of students. The issues of information, feed-back, a9d choices arc again applicable. Students rightlyexpect bleai course olgectives and criteria for evaluationand feedback as quickly as possible on examinations.Clarifying the curriculum also includes the workload ex-pected. Professors should be selective in the topics theydecide to cover. The challenge offered to the student mustbe great enough to facilitate optimal learning but not so

t as to inhibit learning (the Yerkes-Dobsoit law dis-cussed earlier).

A professor's ability to successfully plan the curriculumand pruvioe timely evaluation is often a reflection of theability to be a good teacher. Thus, a fourth solution isapparent: Teaching must be professionalized and given thesame prestige as other faculty activities. Because theemphasis in most medical schools Is on research and con-sultation, the quality of te2ehing has not improved. Mostfaculty have never been taught any pedagogical tech_niques; rather they are expected to perpetuate the myththat excellermeirrresearch makes for excellence in teach-ing. Until merit in teaching like merit in research is re-warded, this situation is unlikely to chime.

The lack of time for family, Wends, and recreationresults for many studer.ts in feelings of dehumanization.depression. and dependency and in passive. Mechanizedcoping styles that eliminate emotions and feelings in thename of better survival. A suggested solution for prevent-ing these results involves increasing the flexibility of themedical school curriculum (Pfeiffer 1983). AltIrnativecurricular tracks might be offered that would allow for theoption of completing medical school over a longer periodof time. Not only would a more prolonged and less intensesetting increase students' comfort with learning vastamounts of material; it would cow allow more time forachieving those necessary developmental tasks of indepen-

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dente. intimacy, and seltactualizan n. More flexibilitywould also allow for more part-time ork, which wouldresult in increased financial independence. And all studentswould benefit from definite breiks andyacation time whenthey can relax away from the stress of edicine.-A.flexiblecurriculum offers perhaps the most rtunity for supdents to assume more control over their ives, because thechoices really are accessible and attainab .

Another solution is to reevaluate the ing system."Does the bell-shaped gradingssystem with all the anxietyit engenders really describe the ability of f h a bighlyselected group of students?" (Pfeiffer 1983, . 133). Whatof those few students who receive lower s? Becausethe differences are so minor, how important they?Schools that must continue this traditional gratng formatshould be espectallY supportive of the students whosescores fall toward the lower end of the curve. \

The final suggested solution is to appoint a medicalschool ombudsman. A new program currently underway atStanford University MedicarCenter illustrates this solution(Weinstein 1983). In response to the charge that the medi-cal school environment helps to train and develop foal-adaptive pat:erns in their students, the associate dean ofstudent affairs established the Committee on the Well-Being of Medical Students and House Staff. The task ofthis gr.up was to assess the problems and needs of both .populations. It was comprised of students from each yearselected by the medical students' organization, three Louseofficers who volunteered out of their own interests, andseveral academic and cliidcal faculty who were selected bythe associate dean because they had shown interest instudent affairs in the past. A survey assessed those titresperceived a, problematic for students and their partners,and the comnuttee generated proposals to alleviate theproblems. The medical school ombudsman, appointedasthe result of one of the committee's proposals, has beenshown to be consistently beneficial. Students have been,:ble to channel their grievances and to effect change,typically around issues of academics, teaching quality,'student-teacher relationships, and student services. "Somedistress can be relieved by such simple techniques asproviding information and appointing individuals as ativo-

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rates with clearly defined roles in relation to those intraining" (Weinstein 1983, p. 380)

One of the most crucial roles to be fulfilled by an om-budsman is that of developing and sanctioning mechanismsenabling students to seek professional help without stigma.Students without this mechanism are usually unwilling toseek assistance from colleagues, instructors, or i',1rapistswithin the medical schodl for fear that it may be a sign ofweakness that will affect their reputation and record.Indeed, in many schools the sark ...Arson who writesletters of recommendation and promotion simultaneouslyacts asstudent counselor or therapist. An obvious ,onOict

;ntertst 'lay in this situation; students become soconcerned about confidentiality that they will unlikelyapproach this person. choosing instead to continue underunrelieved stress with increased feelings of helplessness. Ina recent survey of 114 medical schools, counseling serviceswere available but underused as a result of poor communi-cation about their availability and concern about confiden-tiality (Seigle, Schuckit, and Plumb 1983). The followingmodel counseling program could help increase the use ofcurrently available services:

I. Group seminars should be organized to discuss emo-tional conflicts in medicine and effeciive coping. -

Information about personal counseling could beprovided or referrals could be made directly from thegroup. Confidentiality should be guaranteed andemphasized.

2.. Quarterly announcements or bulletins about counsel-ing should provide acress to information when stu-dents are most receptive.'

3. Counseling should be separated from the studentaffilits office qua it would scot be t unsit Ned asoverlapping w.. responsibitities suchas evaluations.

.4. Faculty members showid be mouraged and trainedto recognize stress among students and refer them tothe appropriate-contacts,

5. Formalized referral to psychiatrists in the communityshould be made through the student health service ora valified person outside of the dean's office.

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o. Personal counseling should be strictly confidentialwith repeated assurances. Seeking or receiving coun-seling should never be used for promotion or dismis-sal (Seigle, Schuckit, and Plumb 1983. p. 545).

The medical profession should be able to serve as a modelin the recognition, referral, and treatment stress inmedical students so that they as physicians will be bettertrained to deal with their own stress and the stress of theirpatients as well.

In all cases, eachmf these suggested solutions to helpreduce and prevent distress among students i; imple-mented primarily by the medical school system itself.While students' impact and support is inherent throughout,coopelation from the medical school is required. Anotherapproach is to, implement solutions entirely independent ofthe menical school system. These solutions address the

. issue of What medical students can do to help themselves.One dike most usefu: and well-documented solutions

generated primarily by students is i he development of'student support groups (Gaensbauer and Mizner 1980;Huebner, Royer, andMoore 1981; Pfeiffer 1983; Siegel andDonnelly 1978; Webster and Robinowitz 1979; Weinstein1983). Although receptive medical school faculty facilitatethe establishment of student groups. curriculum conitnit-tees do not formally1icknOwledge them, fior is creditgiven. Students typically initiate the organization of agroup by demonstrating interest or need to trusted facultyand then as a group determine content, time. and durationfor the particular group. Content for support groups varieswidely, but for all the purposes arc, the same: to obtainsupport and to get some relief from the stresses of me 'Ica!education Some read nonmedical literature, others seek toget information on residency programs and specialties.others form study groUps and tutorials, others meet withtheir spouses. Members of the groups share frustrationsabout school and their personal lives, establish closefriendships with peers and faculty, and learn stress- andtime-management techniques.

Belonging to and being accepted us a member or thegroup was u very important factor for me personally. Ifound it very helpful to be in u setting where we could

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all, to some degree. shed the facade of cool self-assurance that we were encouraged to build for our-selves during our "in-hospital" lives. and share moreof ourselves (Webster and Robinowitz 1979, p. 60).

Another solution to reduce stress is living arrangements(Huebner, Royer. and Moore 1980. Stress appears 10 beless for those ruing with a spouse or cohabitant and great-est for those living alone. Evettthough time spent with asignificant other is time taken away from studying. themediating effects on stress of interpersonal relationshipsand psychological support systems is an important payoff,

A final ^elf-help solution suggested to medical students isto seek out a faculty member with whom a ions-termrelationship can be developed. For many. this cultivationof a mentor has proved useful in gaining a role model.academic advice. and a trusted friebd within the systemwho can offer support anti counsel from firit-hand expe-rience., .

It is commonly accepted that medical education is a timeof stress. Stuoints develop strategies for and styles ofcoping with this stress to survive. typically at the expenseof those nearest to them, including themselves.:. is ironicthat in the training of a profession for wnich compassion.warmth. and caring are considered essential ingredients inthe care of patients individuals in training must undergo somany personal deprivations. Perhaps the greatest concernis that students will adhere to those short-term. survival-oriented styles of coping when they become practicingphysicians. The development of a gm:iter repertoire ofcoping mechanisms should result in confining stress tomoderate levels. where learning ability's optimal.

=IBMStress ,appearsto be lesi forthose.livingwith a spouseor cohabitantand greatestfor thoseliving alone.

Sources of Stress Medical Residentslithe first :ars of medical school are a "process of disitlu-sionment." witat then might the next three to five years ofresidency be called? The stresses s'iesidency training areat least as significant as those of medical school (Weinstein1983): many authors assert that residency training is morestressful that .nedical school. especially the first year.known as the internship (COusins 1981: Miller 1981:Siegeland Donnelly 1978: Valko and Clayton 1975).

&rodent Sims

Or.;

I have been able to meet with meaical students awlphysicians at various stages in their training and theircareers. The weakest link in the entire chain of physiciantraining, it seems to me. is the ordeal known as theinternship. More specifically, I refer to the theory that itis necessary to put medical school graduates throng.. ahuman meat grinder before they can qualify asfledged physicians (Cousins 1981. p. 377).

The internship year is "a time of insecurity anal lack ofconfidence. of frustration and anxiety. of ano:oie anddisillusionment (Bates. Hinton. and Wood 1973. p.And the American Medical Association has labeled first-year residents-as a group "at risk" for becoming impaired(Tokarz, Bremer, end Peters 1979). What 'eh about thenature of the internship year that jeopardizes the physic&akentotional health of those immersed in it?

Internshipifirstiear residencyOne of the first sources of stress an intern encounters ISthe actual geographical move to a new state and city and tnew medical school, and the 1.3familiar housing, shopping,transportation, and social ltworks he or she eacounters.Lack of a formalized, friendly, and useful orientation forinterns and their spouses is a common complaint and an

/ongoing source .1 stress because individuals must maketheir own way in this new environment. Many unmarriedinterns have no immediately available sources of socialsupport to help make the transition less stressful. Thistransition from medical school to residency Voften cor-pared to the transition from premedical school to medicalschool.. The sources of stress involved in the change aresimilar. as is the inability or unwillingness of the medicalschool system to make the transition les-t ttresslid.

The internship year is a critical period for young physi-cians and their ability to learn successful coping strategies.It is clearly an important bridge between student and full-fledged professional and thus a time of role change. Theimplications of this role change are vaned, and each is spoten:al source of stress. Fiat, interns must simultane-ously become prima y care providers and teachers ofmedical students wl de once again finding thentielvvs at thebottom of the raining and hospital hierarchy. This sinus-

88

titan often translates into little emotional orphysical sup-port in matte's work. The goal of an intern therefore oftenbecomes one of mere survival. 'Perhaps the one facfog mostconsistertty cited as a major source of stress is 1;..;.k ofder; the result of a workload greater than 100 hours per'we* tAsken and Raham 1983; Friedman, Bigger. andKorntAd 1971; Friedman, Kornfeld, and Bigger 1973;Valko and Clayton 1975). Over one-third of the house staffmembers in oue study felt that their efficiency was signifi-cantly compromised because of overwork (Wilkinson.Tyler. and Varey 1975). Reactions by sleep - deprived in-terns include a significant increase in errors, difficulty inthinking, sensitivity to criticism; depersonalization, aninaprropriate affect and Hack humor; and deficits in recentmemory (Friedman, Kornfeld. and Bigger 19731. Longhours cause irritability and declining abilities to deal withfamily and interpersonal relations (Wilkinson, Tyler. andVarey 1975). It appears probable that Interns' ability focope successfully (to balance the de'ree of stress encoun-tered and the coping strategies available) may well beaffe,-.ed most by the night call schedule and the relatedloss of steepespecially when one considers that the mostfrequently sed coping strategy for sleep-deprived internsis to spend all their free time 'eeping.

The internship may have squally important effect onthe u:tern's personal development as well. Coping mecha-nisms the intern relies upon to dea with the stresses of thisyear may well be a key facto: in futire personal and pro-fessional development and well-being. Continually usingstrategies during internship that encourage emotionaldetachment ir-dealing with patients and family (strategiestypically learned and develop:Ai:luring medical school)may result in the development of habitually avoiding feel-ings. This detached concern is then likely to permeate bothpe-sonal and professional life.

It makes me i dull and unintereging, person, When 1 gethome after a night on call. if it's been a busy night, I'msort of a blob. I want to be fed, I want to take a showerand I want to go to bed. Creature comforts are upper-most in my lee usually. It takes a real effort and some-times some coaxing by my wife to get met-) come out ofmy shell add relate to ker. Fatigue dulls your sensitivi-

0

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ties and your ability to relate to other people and toenjoy tire, It makes you irritable, angry, more suscepti-ble to being ticked off by minor inconveniences. You'remore likely to be an unattractive person to relate to. . .

The luck of sleep one the ridiculous hours are outra-geous. There's no reason for it, Its an economic reason,an initiation mt. Maybe there's something to say fordealing with sires* over those long hours of time thatmakes you a better person, but you don't 'tarn more,there's a point of,diminishing returns in delivering care.just think that's outrageous (Callan 1983. pp. 59.62).

Second- and doiratyear residentsSecond. and third-year residents are also subject to avariety of stressors, some that are merely continuationsand others that are specific to the last years of residencytraining. Continued stressors include the lack of free timefor leisure, recreation. and family, and financial problemsand responsibilities. Just as the medical school environ-ment presented a great many stresses and prtssures thatgreatly impeded the attainment of an adult identity part ofand apart from the professional role and the formation oflong-term intimate relationships, so does residency. Issuesof independeme also arise for residents because of theprolonged state of dependency that medical education hasimposed upon them. The inability to move successfullythrough these developmental tasks often results in isolationand devession (Valko and Clayton 1975), marital problems(Bates and Carroll 1975), emotional instability (Tokarz.Bremer, and Peters 1979), ar.d disillusionment about medi-cine (Bates, Hinton, and Wood 1973).

Major s1ressors specific to the latter part of residencye a separation crisis and studying for the medical board

examination.,

Every year shortly after New Year, the third year resident tends to experience unusually emphatic feelings of .

turmoil and stress...During this time there typicallybe more arguments with staff more tardiness, delin-quency. sloppier record keeping, and louder complain'ngand back-biting. The intensity and yearly regularity ofthis phenomenon suggest that each class of graduating

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residents experiences a form of separation crisis (Merkeland Walbroehl 1980 p. 366).

This phenomenon is not unlike adolescents' acting outtheir separation crises'when their time for departure fromfamily occurs. Residents, because of their prolonged de-pendency, are like adolesc..sits6at graduation they mustdepart with their newly acquired adult identity as physi-cirts. Studying for the medical board examination at thissame time increases' both stress and fatigue. A typicalmethod of coping to make the separation easier is thereforeto find fault with everything and everybody. This fault-finding justifies the need and desirability to leave in theminds of residet4s, Unfortunately, other star and youngerresidents are too often unawsre that such a crisis exists;they react in an equally disagreeable. offended, and angrymanner. The rate and quality of learning are compromisedwhen this negative state is allowed to continue.

&JuliansMedical ResidentsRecommendations to prevent and reduce stress for medicalresidents are similar to those for undergraduate medicalstudents, and they too fall into the categories of,,help from

,the medical school structure and self-help.The first suggestion, like that for undergraduate medical

students, is to proiide a formalized orientation for all newresidents and their spouses. Typically, new interns arefrom another state and/or another part of the country.Information about such mundane matters as eveningmeals, bus service to outlying hospitals, reasonably pricedhousing. and low-cost counseling services for residents andtheir spouses can make the lives of residents easier; such aprogram has in fact been implemented in a.pilot project atthe Stanford Medical School (Weinstein 1983). In addition,clearly stated requirements for patient care, leant init, andteaching shook' result in more mutual than discrApahtex tetations among residents and faculty. ,

Another obvious but surprisingly neglected solution is toredesign the work schedule. To provide an interityith 'fewer continuous working iecurs and therefore more sleepand more personal time is reasonable (Callan 1983). Flexible-time residencies have also t .ten suggested (Howell 1974;

.

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IL..11 IIP..."."70.0

Shapiro and Driscoll 1979). Probably not widely under-stood is the requirement that all residency programs offerflexible -time residencies; unspoken expectations. however,usually prevent their use by other than a fewAsuallywomen with young children or pregnant women dote to':livery. Perhaps the reason such scheduling is not more

widely used is that even though flexible -time schedulesenable two people to sh...re one position and earn half thesalary, each still works two-thirds of the timeor over 60hours per week!

Residents, unlike medical students. do not receive rzgu-lar feedback to know whether they are meeting require-ments and satisfying expectations. Therefore, providingconsistent feedback throrih formalized channels wouldhelp alleviate the stress provoked by uncertainty. Feed-back' should include praise for work well done as te ell asclarification of areas needing further work. It is nrissarynot only to provide assistance in effecting change but alsoto provide it early in the year so that the resident hasadequate me in whic% to make the change.

Te assist residents in deiling with the stresses surround -in separation crises, residency programs would do well tosponsor retreats and workshopt on coping with variousaspects of a medical career. Practical application of thetheory that information increases -rte's perception ofconteol, which in turn reduces stress, might case he transi-tion from resident to independent practice by fozusingretreats and workshops on subjects such as office- andtime-management skgit. Allowing third-year residentsmore privileges, less on-call duty, and the title of "on-callsenior staff"' can reinforce their beliefs in their owe: readi-ness to separate (Miller 1981).

A final solution that can be implemented by residents aswell as the medical school system is the e,tablishment ofsupport groups for residents and their spouses. Support&naps enceinage reflection and provide and strengtheninterpersonal support, They help to short-circuit a falseassumps'w that is learned early during internship, that is.the implicit expectation that this is the way medicine worksand that this is how the life of a r :,ysician must be Mem-bers of a support group have the opportunity to acquiregreater ability to deal with persona! issues in a professionalsetting. a sense of decreased competitiveness with fellow

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'residents and staff, and the explore ion of alternativecoping mechanisms (Siegel and Donnelly 1978).

One group of interns, whose coping styes were com-prised of both active and regulating strategies (Luarui.1966), were mor.: likely to be rated as high performers thanthosb whose coping style relied on only one or the other(Brent 1961). A greater coping repertoire makes possible awider range t f responses to stress, higher satisfaction, and,when combi. td with a high level of ego development, highperformance ..s well.

Overall, an educational experience in medicine should beabk to demonstrate that it can live up to its own dictum."above all do no harm." Unfortunately, the reality may beotherwise. The solutions that have been offered can helpeducatorrand students reduce the stress that may resuS inharm and thus compromise health and learning. Increasedinformation, feedback; and choices are the essential ingre.dients that make successful stress management and thusoptimal learning and well-being likely.

Surds g Stress

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CONCLUDING RECOMMENDATIONS

Stress is admittedly a necessary ingredient itt challengingstudents to learn. Yet the overwhelmingly negative formsof stress that generally serve to-threaten and discourage :k. iing rather than to provide challenge and hope ned4 toberedueed.

Universities represent a lamp/part of the environmentalforce that influences stress initudents. The stress-copingcomplex des...ibed in the first chapter outlines three points(stressors, reactive coping, active coping) where the uni-versity community can make positive interventions: Al-though each of the previous cimpters offered specificsolutions for vasious student groups, the monograph con-cludes by suggesting institutional efforts to help moststudents maintain a sense.of control eve, their lives aweachpoint on the stress-coping complex. The issue of controland its importance in reducing stress is a guiding principlein these suggestions.

The chapter presents numerous ideas to help reducedistress in students. Some of the ideas suggested are beingused at many universities. The render is cautioned; haw -eves, to evaluate the eft'ectiveness of the programs usedimplement these ideas rather than merely accept them.ashelpful or necessary.

A major concerti is that any rehabilitation of eduationalprograms will cost more money at a time when manyeducational prograinurt currently faced with dramatically_.___shrinking budgets: Most of the suggestions througlibut thismonograph, if implemented, would cost little. Decreasingbudgets, however, are certain ultimately to adversely .

affect the quality of teaching and thus result in the increaseof stress among students.

StressorsWhat constitutes a stressor and one's reactions to it often --

differ from individual to individual. Ihis difference ispartly the result of individuals' having varying emotional.social, and cognitive resources to cope with stress andvarying psychosocial histories an surd stressful events. Thefollowing presc'riptions to reduce distress associated with'higher education are therefore oriented toward preventionof a wide variety of harmful stress reactions that can occur

8694

among students. The principles of control discussed earlierin the monograph and the closely related issues of informa-tion, feedback. dud choice are inherent pans of the sugges-tions given. The suggestions specifiCally cover both stu.dents' orientation and helping students feel more controlover issues related to curriculum.

Students need to become familiar with the services andactivities (transportation, housing'. on- or off-campusrecreation, health services, counseling services, financialservices. day care facilities, to name a few) within theuniversity and the local community. Because the needs ofindividual students vary, many ways of informing them arepossible -- pamphlets, handouts, meetings, and/or socialevents. The point of orienting students to services andactivities is ultimately to help them feel at home in theirenvironment. This portion of the orientation would likely

: best be accomplished within each academic disciplineforexample, graduate. law, and medical programs. Under-graduates ought 'to be-provided this type of orientation in agroup setting thin is small enough for students to feelcomfortable asking questions.

An orientation for parents, spouses, and any significanto hers should be provided to help them anticipate students'needs and the anticipated stresses associated with beingclosely involved with a student. Spouses ofinore seniorstudents could discuss how they "survived" and how theywere able to effectively give and receive support..Spousesof senior students could share a survival list of general dosand don'ts with new students.

A number Of formal and informal methods of orientationcould help students better understand the academic re-quirements and pressures of their education. Informally,students become academically oriented through contactwith peers and more advanced students. Informaldiscussions with advanced students about which class totake from wiMm and how to do well in a particular coursehelp 4t least Make an unfamiliar setting more familiar; suchcontacts can thus help reduce stress in students (Stevens1973). Inform,' contacts with faculty (for example, stu-dent/faculty parties and socials) can also benefit studentsand likely held them feel more hopeful about their futureacademic endeavors (Stevens 1973).

11.....111,Student Stress

WM.The' point oforienting,students toservices andactivities is

to helpthem feel athome in theirenvironment.

QS

A number of more formal approaches arc possible:

scheduled meetings for senior students to orient newstudents to specific academic programs and facultya student '"buddy" system in which a senior studenthelps orient a specific new studewmeetings between faculty in each academic disciplineand students to discuss how to succeed in the variousprograms, typical roadblock% for students, and com-mon responses to stressan orientation meeting at the end of one °nits firstclasses of the semester between the faculty memberand st nts who are new to the school or the aca 1:

demica foal during orientation sessions. on the challenges.consectitences of mastery. hope. students' needs, andfaculty members', availability to students rather thatron the threatening aspects that often foster an inordi-nate fear of failureinformaaion front faculty about how students can bestlearn from them (for example. by memorizincontent.solving problems. analyzing problems witKnot necevsarily herding solutions. integrating concepts into thelarger theoretical framework. discovering the ansuersto questions. problems. and issues). Students can beunnecessarily confused when they do not understandthat the method of learning they are accustomed todoes not apply in some courses or academic disci.plines.

Faculty can be paniculerly reduciiig stress bymerely explaining that anxiety and self-doubt are ubiqui-tous among students. The stress of being a f-..dent isaggravated when on believes that Otis alone with suchfeelings.

Another way to help reduce unn essary stress is to givestudents control, information; and edback regarding,thecur "culum itself, The following ways can help studentsdeal with stress involving the curriculum

testing courses before they are taught11 helping stude..s perceive .hemselves as successbil

early in their coursework

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, providing alternative ways to`demonstrate mastery(quizzes, exams. papers. one-On-one discussions withprofessors)proViding feedback that is specific rather than general,.descriptive rather than evaluative, informative rather-than advice-giving, well timed, not demeaning whennegative, and positive when deservedgiving specific feedback toThe class as a wale whenthe problems are common to many students or whenmany students have demonstrated masteryensuring students' ongoing participation in the develtopmeni of curriculumallowing students to evaluate course material anctt heteacher's performance.

In one graduate course on behavior modification ofchildren, the professor used types of reinforcement forgraduate students' performance similar to those.he recom-mended be used for children. Interestingly enough. thegraduate students in this course regularly commented onhow effective such free-pent and seemingly childlike rein-forcement was in increasing their own ;merest and effort inmastering the course material One is often left wonderingwhy positive feedback 1J students is not more commonlyused when it likely can have an advantageous effect onboth students' learning and the reduction of stress.

Reactive CopingThe thoughts and feelings evoked by students when theyare faced with a stressful t.vent vary as much as how eachchooses to cope with his own reaction to a stressor. With-out the universities' directly providing any help for stu-dents feeling stressed, students will find their own effectiveor ineffective ways to cope. Some will choose to talk witha friend or family member: others will work their frustra-tions out in a gymnasium or use other forms of recreation.Others will choose alcohol. drugs, excessive eating. orother forms of ceif- defeating behavior. Other than provid-ing recreational services for students. universities couldmake a number of services available to help students withtheir reactions to strcssors. Many of theselservices wouldbe particularly helpful to the student who is feeling help-less or who has not developed a network of support or

. .

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n

ways of effectively coping with the stress of school. Thefollowing forms of peer counseling have proved effective:

telephone counseling services that provide informa-tion, crisis intervention, and referral servicesacademic advicedrug information and services -,student outreach services

::,

student support groupS(Oiddan and Austin 1982).

Faculty can also provide an important service in helpingstudents with their reaction to stress. Faculty who havebeen identified as sensitive to students' needs could beused as student advocates. Student-faculty retreats (proba-bly preferable for students bond the undergraduate level)could Yelp faculty and students become better acquaintedand allow each to constructively air their concerns aboutvarious academic issues.

Most universities provide a student counseling center. Anumber of technologies used by student counseling ser-vices can help reduce stress:

systematic.desensitian ;On-Oar biofeedback

meditationexercv.estress inoculationdarifica:ion of values

: assertiveness traminjprogressive relaxationthe combating of disabling thinking (McKay, Davis.and Fanning 1981: Matson 19801.

Active CopingCertainly, the three points in the .tress- coping complex arenot mutually exclusive. Some of the points suggested tohelp students actively solve their own problems could alsofall under wl.ys to.reduce stressor, and to help studentswith their own.reactions. Nevertheless, the followingsuggestions are perhaps best used-al, methods to helpstudents the their own problemsolving abilities.

.

When individuals feel hopeful about an outcome sur-rounding a stressful event. they arc more likely to spend

98

their energies on active probleh solving and less likely tospend them coping with their own distressful thoughts andfeelings (Folkman 1980. If universitiesand especiallyindividual faculty memberswant to encourage effectiveproblem solving, they ought to consider how to instill hope

- in their students. For example:4

use teachers whom students evaluate posNely toteach a number of the beginning coursesreward faculty in a meaningful way both for goodteaching and student advisingprovide a responsive way of handling students' corn:plaints. including faculty members' handling their owncomplaints from students as well as the university'sdeveloping a forma' systemprovide part-time programs to help accommodatestudents' personal needsuse timely feedback so that students can correctacademic problems before it is too late or realize thatthe professor believes they are mastering the coursematerial-provide information regarding various methods others-use to successfully master course-material.

Good teaching alone will net only help eliminate thestress associated with poor teaching but will also improveactive coping as each student begins to feel that he ismastering course material. Perhaps an important way toeliminate students' distress is to ensure good teaching andto reward those who teach well in ways that directly bene-fit their careers.

Further ResearchTo better understand the nature of stress among students.it is also important to understand how faculty stress affectsthe student/faculty relationship. However.-Only a fewpublished studies focus on the issue of faculty stress. It isvery likely that within the student/faculty relationshipexiAs a feedback loopso that students' and faculty mem-bers" stress reactions affect each other. Ultimately. [Ixemotional climate created in the classroojn affects teach-ing, leas ning. and students' stress reactions. More research

,

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in this area is incial to improve understanding of stressamong students.

With respect to undergraduate students. it would beuseful to see theieffects better teachers for introductorycourses have on reducing stress and on encouraging per-formance beyond the undergraduate years. One obviousdifficulty with this suggestion is that often the best'teachersprefer to teach and work with more senior or graduatestudents. '.

Research about graduate students could focus more onspecific graduate programs. What are the stresses uniqueto MBA programs. nursing. social work, enginiering? Suchresearch is necessary to more accurately understand'andbe helpful to specific graduate stucknt groups.

Relatively few studies look at stress among law students.Further. most of the information about stress among lawstudents is anecdotal. Many of the actual studies havemethodological problems, largely because of their retro-spective design. questionable group comparisons, andinability to generalize the results beyond Ivy Leagueschools. More descriptive studies with improved designsacross a wider spectrum of law schools will increase theunderstanding of stress among this student population.

Stress among medical students and residents hasCIiiiiibeen researched more than for other student groups. The'benefit of more oescriptive studies of this population isprobably not as greitt as a greater focus on interventionstrategics. More research is needed to determinE howmedical schools can most effectively intervene to help theirstudents and residents reduce stress. .

Finally. improved teaching ultimately helps to reducestudent stress. This oeliei suggests that faculty develop-ment programs should focus not only on improving (cach-ing but also on determining the nature of the relationshipbetween stress among students and the quality of teaching.

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The ERIC Clearinghouse on Higher Education abstracts andindexes the current literature on higher education for thewNa-iional Institute of Education's monthly bibliographic journalReptOres in Education; Most of these publications are availablethrough the ERIC Document Reproduction Service (EDRS) Forpublications cited in this bibliography that are available fromED4S, ordering number and price are included. Readers whowish to order a publication should write 'to the ERIC DocumentReproduction Service. P.O. Box 190, Arlington, Virginia 22210.When ordering, please specify the document number. Documentsate available as noted in microfiche (MF) and baper copy.(PC).Because prices are subject to change, it is advisable to check thelatest issue of Resources in Education for current cost based onthe number of pages in the publication.

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ASHEERIC HIGHER EDUCATIONRESEARCH REPORTS '

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Starting in 1981, the Association for the Study of Higher Educa-tion assumed cosponsorship of the Higher Education ResearchReports with'the ERIC Clearinghouse on Higher Education, Forthe previous 11 years. ERIC and the American Association forHigher Education prepared and published the reports. ,

Each-reTRwrirtifrdefintrive-analybis of a Lough higher educa=---tion problem. based on a thorough research of pertinent literatureand institutional experience's. Report topics. identified by anational survey. are written by noted practitioners and scholarswith prepublication manuscript reviews by experts.

Ten monographs in the ASH E-ERIC Higher Education Re-search Report series are published each year, available individu-ally or by subscription. Subscription to 10 issues is $55 regular;$40 for members of AERA. AAHE, and AIR; $35 for members ofASHE. (Add $7.50 outside U.S.) '

Prices for single copies, including 4th class postage and han-dling. are $7.50 regular and $6.00 for members of AERA. AAHE.AIR. and ASHE. If faster 1st class postage is desired for U.S.and Canadian orders. for each publication ordered add $.75; foroverseas. add $4.50. For VISA and MasterCard'payments. giiecard number. expiration date, and signature. Orders under $25must be prepaid. Bulk discounts are available on orders of 10 ormore of a single title. Order from the Publications Department,Association for the Study of Higher Education, One DupontCircle, Suite 630, Washington, D.C. 20036, (202) 296-2597. Writefor a complete list of Higher Education Research Reports andother ASHF. and ERIC publications.

1981 Higher Education Research Reports

I. Minority Access to Higher EducationJean L. Preer

Institutional Advancement Strategies in Hard TimesMichael I). Richards and G'rald Sherratt

3. Functional Literacy in the College SettingRichard C. Richardson, Jr:, i(alliryii J. Martens. andElisabeth C. Fisk

4. indices of Quality in the Undergraduate ExperienceGeorge P. KA

5. Marketing in Higher EducationStanley M. Grabowski

6. Computer Literiicy in Higher EducationFrancis E. Masot

7. Financial Analysis for Academic UnitsDonald L. Walters

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8. Assessing the Impact of Faculty Collectiie BargainingJ. Victor Baldridge. Frank R. Kemerer. and Assoiates

9. Etrategic Planning, Management, and Decision MakingRobert G. Cope

10, OrganizatianaLCumulunication.inMigher EducationRobert D: Gratz and Philip J. Salem a

- 4932 Higher Education Research Reports

I, Rating College Teaching: Criterion Studies of StudentEvaluationof-Instruction Instruments

Sidney E. Demon

2., Faculty Evaluation: The Use of Explicit Criteria forPromotion, Retention, and Tenure

Neal Whitman and Elaine Weiss

3. The Enrollment Crisis: Factors. Actors, anclimpactsJ. Victor Baldridge, Frank R. Kemerer. and Kenneth C.Green

4. improving Instruction: Issues and Alternatives for HigherEducation

Charles C. Cole. Jr.

5. Planning for Program Discontinuance: From Defath toDesign

Gerlinda S. Melchiori

6. State Planning, Budgeting. and Accountability: Approachesfor Higher Education

Carol E. Floyd

7. The Process of Change in Higher Education InstitutionsRobert C. Nordvall

8. Information Systems and Technological Decisions: A Guidefor Non-Technical Administrators

Robert L. Bailey ,

9. Government Support for Minority Participation in HigherEducation

Kenneth C. Gwen

10. The Department Chair: Professional Development and RoleConflict . .

David B. Booth

1933 Higher Education Research Reports

I. The Path to Excellence: Quality Assurance in Higher- EducationLaurence R. Marcus. Anita 0. Leone. and Edward D.Goldberg r

Student Stress MI

2. Faculty Recruitment. Retention, and Fair Employdient:Obligations and Opportunities

John S. Waggaman

3. Meeting the Challenges: Developing Faculty CareersMichael C. 7'. Brookes and Katherine L. German

4. Raising Academic Standards: A Guide to LearningImprovement

Ruth ?Wiwi Keinsig

S. Serving Learners at a Distance: A Guide to ProgramPractices

Charles Feasley

6. Competence. Admissions. and Articulation: Returning to theBastes in Higher Education

Jean L. Pree

7. Publit. Service in Higher Education: Practices and PrioritiesPatricia H. 01430,1

8. Acad,..eic Employment and Retrenchment: Judicial ReviewantikOinistrative Action

Robert M. Hendrickson and BarbaraX Lee

9. Burnout: The New Academic DiseaseWinifred Albizu Melendez and Rafael M. de Guzman

10. Academic Workplace: New Demands. Heightened TensionsAnn E. Austin iind Aldo F. Gamson

1984 Higher Education Research Reports

I. Adult Learning: State Policies and institutional PracticesK. Patricia Cross and Anne-Marie McCartali

2. Student Stress: Elkets aQ Solution.Neal A. II pitman. David C. Spendlove and Cldire,H.Clark

UV.

NEAL A. WHITMAN is Director of Educational Developmentin the Department of Family and Community Medicine atthe University oplitall School of Medicine. Dr. Whitmanhas worked as an administrator and teacher in healthprofessional schools since 1971. His handbooks on lectureskills (There Is No Gene for Good Teaching) and on groupdiscuss' rairAlternatives Lecwring Students to Death)are being used by faculty at over 300 institutions. In 1982,Dr. Whitman coauthored Faculty Evaluation: The Use ofExplicit Criteria for Promotion, Retention, and Tenure,AAHE-ERIC Higher Education Research Report No. 2.

DAV1P C. SPENDLOVE is a faculty mem ber at the Universityof Utah School of Medicine. Dr. Spend love has counseledindividuals and couples, including university students, overthe past 12 years. His research has.focused on learnedhelplessness and depressionin women. Dr. Spend love hasconducted seminars and group sessions on stress for medi-cal students and residents, law, students, and faculty.

CLAIRE H. CLARK is a,faculty member at the Ljnlversity ofUtah School of Medicine. She has worked in higher educa-tion since 1976, both as researcher and teacher. At themedical school, her teaching is predominantly related tocommunication and interviewing skills, the doctor/patientrelationstip, and stress and coping. Dr. Clark's researchinterests and publications fnclude perspectives on the careof patients from the family physician, facilitating chajge Inclients with unhealthy lifestyle behaviors the effects offamily on health and well-being, and the mlationship be-tween stress and teaching among law, medical, and univer-sity faculty.

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