Final Tips and Summary

Welcome to the final posting of this blog. You have learned so much about stress over the past few weeks, and it has been a pleasure to be your guide. It's now time for a few final stress management strategies and to summarize some of the key points. Let's get started.

Nutrition

You already know that eating a well-balanced diet is important for physical health, but it is also an important component for psychological stress reduction. Food can be comforting as well as nutritious, especially if it is a source of vitamin B6 (Billingsley, Collins, & Miller, 2007). Stress depletes your stores of vitamin C, which is needed to keep your immune system working properly (Torkos, 2011). Good dietary sources of vitamin B6 include lean animal proteins, dried beans, eggs, whole grains, and nuts. Vitamin C is highest in oranges, brussels sprouts, strawberries, red and green peppers, tomatoes, and kiwi.

Aromatherapy
There are many literature studies supporting the use of essential oils as part of holistic nursing care. Essential oils have been used since ancient times. Inhaling their scent works on the central nervous system, affecting either the sympathetic or parasympathetic branch, depending on the oil used. Numerous studies demonstrate the usefulness of using lavender to calm and relax (Cook, 2008). In one study, it reduced test anxiety in nursing students through relaxation and lowered blood pressure (McCaffrey, Thomas, & Kinzelman, 2009). A quick guide to the best essential oils for stress relief can be found here:

                                      Top 5 Essential Oils For Stress Relief

Look for a good reference book to guide you further in your exploration of the uses for essential oils. It will guide you in how to use them, making your own blends, and give reliable sources to purchase your own.

Yoga

The Hindu practice of yoga began in India over 2,500 years ago and continues to gain popularity in our western world. The postures, called asanas, quiet the mind, strengthen the body, provide flexibility, and draws focus on breathing techniques. Studies have shown that yoga decreases the perception of stress, but it also works at the physiological level by activating the sympathetic nervous system responses and is beneficial to the immune and endocrine systems as well (Diamond, 2012; Hayes & Chase, 2010). Look for a class to join so you can benefit from the social support and instructor guidance. There are also many good video tapes on the market that are geared toward all ability levels. This is my favorite stress-reducing strategy!

Final Strategies
Finding the right stress reduction strategy that benefits you most might be a trial and error process. These are only a small representation of possibilities. Other ideas might include making a list of the three most pressing tasks of the day and checking them off one by one so you can view your accomplishments, organizing yourself in such a way that each day takes care of itself, recruiting friends or family to help with meals or childcare, or just making sure that you get enough sleep each night. Perhaps you would like to learn about progressive muscle relaxation, breath work, or meditation. Maybe prayer would help. A friend of mine walks trails and prays, benefiting from being outdoors in the fresh air, enjoying the seasons and colors, while getting some exercise and praying. What a great way to multi-task and reduce stress! Here are a few final links for you to explore:

                                            Progressive Muscle Relaxation

                                     Stress Management for Nursing Students

                          Nursing Students: Balancing School, Work, and Family

                                                           Summary
At the beginning of this blog, you learned that stress is both a physical and psychological reaction in response to stressors when the body can no longer cope or adapt. Although not all stressors are negative, the body does not differentiate between good and bad stress. Unrelieved or chronic stress can cause illness. Resilience or coping helps to change both the physical and psychological responses, and strategies are aimed at solving the problem or changing the emotion. The sympathetic branch of the nervous system is activated during stressful situations, and the parasympathetic branch brings the body back into balance. Stress causes a wide host of illness and disease. It's not just the major stressors in life that are a challenge; so are the every day small things. There are many ways you can reduce your stress, but you have to make a conscious effort to work at it. While life will always be stressful, we can take steps to counteract it, leading to a healthier, happier, more blissful life. You owe it to yourself. Please remember to seek professional medical help if life feels overwhelming to you. Help is only a phone call away. Thank you for tuning in.

Namaste,
Kay, your BlissfulNurse

References:

Billingsley, S. K., Collins, A., & Miller, M. (2007). Healthy student, healthy nurse: A stress management workshop. Nurse Educator, 32(2), 49-51.

Cook, N. (2008). Aromatherapy: Reviewing evidence for its mechanisms of action and CNS effects. British Journal of Neuroscience Nursing, 4(12), 595-601.

Diamond, L. (2012). The benefits of yoga in improving health. Primary Health Care, 22(2), 16-19.

Hayes, M., & Chase, S. (2010). Prescribing yoga. Primary Care, 37(1), 51-89.

McCaffrey, R., Thomas, D. J., & Kinzelman, A. O. (2009). The effects of lavender and rosemary essential oils on test-taking anxiety among graduate nursing students. Holistic Nursing Practice, 23(2), 88-93.

Torkos, S. (2011). Stress busters. Better Nutrition, 73(10), 34-38.

More Coping Strategies

Exercise
Moderate exercise is an excellent way to relax and reduce stress. While this may seem counterproductive due to increased cardiovascular and muscle activity, it does decrease stress levels overall, provides a temporary diversion, and perhaps most importantly, strengthens the body so it is more efficient when stressful situations are encountered (Smith, 2007). Be sure to work up endurance slowly to avoid injury and burnout. Try making it a social event with friends or family, and make sure it is something you enjoy (Campbell, 1996). This also ties into the social support that is an important aspect of stress management that you learned about in the previous posting.

Music

Music has been widely used to calm the mind and body since ancient times. Parents use it to soothe fussy babies, and it is widely used in hospice work (Young-Mason, 2002). Music targets the autonomic nervous system by slowing it down or speeding it up, depending on the type of music chosen. Slower tempo music of 60-80 beats per minute slows brain waves and reduces the stress hormone cortisol (Yehuda, 2011). Next time you feel overwhelmed, try some slower, quieter music such as this:

                            Eventide by Michael Hoppe

Color 

Everyone has heard the expressions "red with rage" and "green with envy." Associating colors with emotions is nothing new. Do you feel energized when you wear that bright red shirt or serene in the light blue sweater? Color therapy is actually an ancient healing modality according to Willis (2007), dating back to Egyptian times when persons were treated in rooms of specific colors. Color light therapy is being used here in the U.S. and also in the United Kingdom and  works by activating the sympathetic and parasympathetic nervous system (Saito & Tada, 2007). Try a leisurely stroll in a garden or wooded path, or spend a few minutes looking at the blue sky. Try changing the colors you wear or paint a room in your home a soothing blue or green color.

In my final posting, you will find a few final tips and links that may be helpful, along with a summary of all you have learned these past few weeks. See you soon.

References:

Campbell, S. J. (1996). Maxed out? Mellow out with these personal stress management strategies. The American Journal of Maternal/Child Nursing, 21(3), 123-126.

Saito, Y., & Tada, H. (2007). Effects of color images on stress reduction: Using images as mood stimulants. Japan Journal of Nursing Science, 4(2), 13-20.

Smith, E. (2007). Healthy lifestyles. Just relax! Easier said but can be done. International Journal of Childbirth Education, 22(3), 9-12.

Willis, P. (2007). Healing with colour therapy. Positive Health, (134), 9-11.

Yehuda, N. (2011). Music and stress. Journal of Adult Development, 18(2), 85-94.

Young-Mason, J. (2002). Music therapy: A healing art. Clinical Nurse Specialist 16(3), 153-154.

Coping Strategies

      

Stop, Breathe, Reflect, and Choose

When you recognize the signs of stress creeping in, stop for a moment, focus on taking a few deep breaths, ask yourself if your response is to something real or imagined, and then choose a way to either confront the stressful situation in a healthy way, or reframe your thinking to the perceived threat (Harvard Health, 2011). An example of this strategy in action would be waking up sick with a fever, chills, aches, and nausea on the morning of nursing competencies. The panic stems from the fear of failing the class and quickly escalates into thinking that you will be dismissed from the program, bringing shame to everyone who knows you, and thinking of how much money you've already spent on school. The better response in this situation is to stop, breathe, realize that everyone gets sick and that this is just bad timing, and then call your instructor to let him or her know you are ill and cannot attend class. This is a more rational thought, and your instructors are more understanding than you think.

Make an Attitude Adjustment
That's right. Adjust your attitude to reflect positive thinking. This is a reminder of the video clip you watched in the previous blog posting. Sometimes stress can be relieved simply by thinking about that silver lining in an otherwise rather dark cloud, or consciously changing the way we view a situation (Banga, 2000; Campbell, 1996). When our children were younger, they would often use the dinner hour to vent their negative encounters. It quickly became my most dreaded time of day! Our solution was to allow them to put those feelings out there, but they had to counteract one negative with one positive event. We called this "Best and Worst." They still remember it to this day, and we now laugh when our talk becomes so negative that we resurrect the Best and Worst mandate. Could you start a Blessing Jar where you write each of the things you are thankful for on small slips of paper and put them into a beautiful jar, reading them when the going gets tough? Campbell (1996) suggests making different lists: one for the positive things in life, another for what you like about yourself, and another for what is positive about your work (students, that means school for you!). Can you make each list have 20 entries? What other creative ways can you change your thinking? Positive thinkers live longer, most likely due to lower levels of stress hormones and inflammatory chemical responses (Harvard Health, 2011).

Social Support

Research literature is abundant with studies linking social support to better health in every area imaginable, from postpartum depression and depression in general, to coronary artery disease, job satisfaction, better parenting, wound healing, spiritual health and more. Some suggestions are to volunteer; join a group doing anything you might be interested in from exercise to hobbies or church; adopt a pet; use today's technology to your advantage by learning how to text or Skype to stay in touch; be a friend to someone who needs just what you have to offer - your friendship.

 These are just the first three of our coping strategies that you can ponder over. In the next posting, you will learn more.

References:

Banga, K. (2000). Stress management: A step-by-step process. Nurse Educator, 25(3), 130, 135.

Campbell, S. J. (1996). Maxed out? Mellow out with these personal stress management strategies. The American Journal of Maternal/Child Nursing, 21(3), 123-126.

How to prevent and manage stress. (2011). Stress management: Approaches for preventing & reducing stress, (pp.10-28). Boston, MA: Harvard Health. Retrieved from http://www.health.harvard.edu

Measuring Your Stress

So, are you ready to take a test or two? Does the mere mention of taking a test set off your stress response?





Don't worry - you are the only one who will see these results. These tests will help you to assess your stress level and let you see a measurable effect. There are many tests like these. Some only focus on the major stressors, while others look more at the day-to-day stressors and your attitude. Attitude is linked with resiliency and coping skills, which you learned about earlier. Having a positive attitude is the first step toward solving the issue causing stress. Of course it is not easy having a positive attitude about everything all the time. In that case, allow yourself to be human and experience the emotion of the stress, but then move on.

Click on the links below to learn about your personal stress levels.

http://www.pedagogy-inc.com/Home/Resources/General/Adult-Stress-Scale.aspx

http://www.avera.org/mckennan/health/stress/inventory/

http://www.mayoclinic.com/health/stress-assessment/SR00029  (This is an excellent website that provides links to a wealth of stress-related topics including symptoms, chronic stress, identifying the sources of stress, the relationship between food and mood, and resiliency, just to name a few.)

Begin thinking about the various ways you relieve your stress, as I just may choose one of your ideas to share more in depth in the final blog postings. To get you started, please see the video link below:

Stress Management: Changing Your View of a Stressor - Healthy Lifestyles courtesy of Healthclips - Healthclips Videos :: NurseTogether

The Negative Effects of Stress

In my last post, you learned that there were actually three stages of the stress response: alarm, resistance, and exhaustion. All of these stages are potentially harmful. You also learned that sympathetic branch of the autonomic nervous system (ANS) is responsible for initiating this response. It is helpful to think of the ANS as being automatic, or what the body does without any effort on our part. It affects every body system in preparation for fight-or-flight while the parasympathetic nervous system slows the body back down and brings balance back to the body, or homeostasis. It, too, is without effort on our part. Remember that sympathetic nervous system activity is not inherently bad, because it allows us to escape potentially dangerous situations, like avoiding car accidents or being burned while cooking. The following videos explain this concept well.

This video has some narrative and explains in both words and cartoon, which may be more appealing for those of you who are audio learners.

One more image here that shows the sympathetic nervous system response to stress, which may help to understand why prolonged stress can be damaging to health.

All of this activity within the body takes its toll on our health, physically, psychologically, emotionally, even spiritually. In fact, the list is so long that we could use another entire blog just to explore the effects! Here are some highlights from Harvard Health Publications (2011):

• anxiety
• depression
• diabetes
• headaches
• heart issues (chest pain, arrhythmias, or heart attack)
• insomnia
• pain (all sorts, and everywhere!)
• slowed wound healing

The American Holistic Nurses Association (2012) also provides a comprehensive list that includes:

• increased use of cigarettes, alcohol, and drugs
• poor attitude
• increased risk of stroke
• gastrointestinal disorders
• sexual and reproductive dysfunction
• poor attention that affects memory, concentration, and learning

Whew! That was a lot of information to take in! How many of you were nodding your heads in agreement throughout the videos or reading the above lists? Now you know why it is so important to manage your stress in healthy ways. Don't forget to check out the references below to learn just a bit more about those effects of stress. Next time you visit, you will be directed to take a stress test, an inventory of sorts, that will allow you to see just how stressed you are by the events in your life. Then we will finally be ready to explore those stress management ideas, which is why you tuned in. Thank you for reading through all this information that gives you the knowledge and encouragement you need to try something new for the sake of your health!

References:

American Holistic Nurses Association. (2012). Effects of stress. Retrieved from http://www.ahna.org/Resources/StressManagement/EffectsofStress/tabid/1810/Default.aspx

Understanding the stress response. (2011). Stress Management: Approaches for preventing and reducing stress (pp.2-6). Boston, MA: Harvard Health Publications. Retrieved from www.health.harvard.edu

The Stress Response

Selye's research on stress revealed that the body undergoes a physical response to stress, regardless if the stress is physical or emotional, actual or perceived, distress or eustress. He called this the general adaptation syndrome, and it consists of three stages: alarm, resistance, and exhaustion.

During the alarm phase, the body is exposed to the stressor. The autonomic nervous system is engaged. This branch of the nervous system is responsible for the fight-or-flight response. Begin thinking about what is happening during this stage. If the stress is not neutralized at this point, the individual becomes susceptible to illness and disease. Much energy is expended during this hyper-aroused state.

It is during the resistance phase that attitudes and coping skills are employed as we try to counteract the stressor itself. Illness can occur during this phase as well, especially if the source of stress becomes chronic. This diagram is good for a number of reasons. First of all, the sheer size of the resistance phase allows imagination of all the potential stress alleviators in our arsenal! We see how it only takes a "little" stress to set off the alarms. We also see how long our bodies can survive in resistance mode before reaching the exhaustion phase, which also results in illness, or even death.

Start thinking about the various ways your body responds negatively to stress, our next topic. You will then have an opportunity to measure your own stress before we finally begin the best part: exploring some great strategies that just may help you regain a little balance in life!

More on Coping

Everyone copes with stressful situations differently. What do you do when you are stressed? Do you handle it positively or negatively? Positive coping skills fall under two main categories: problem-focused or emotionally based (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011) Strategies that are problem-focused attempt to solve the issue through examining the situation without the heat of emotion, explore possible solutions, and actively work with one of the solutions. Emotional strategies help us work through the feelings or emotions, substituting good feelings for those negative ones such as anxiety, anger, frustration, even sadness. Both categories can be very helpful at alleviating stress because they address the problem in different ways. Let's look at some examples:

Now see if you can place each of these coping strategies into either the problem-based or emotion-based column:

1. Obtaining a second opinion about a recommended surgery.
2. Making a "to do" list of priorities.
3. Eating a bowl of ice cream.
4. Packing a healthy lunch instead of buying from the cafeteria. (Careful on this one!)
5. Asking for clarification in order to complete a paper or project.
6. Baking a treat for your colleagues or peers.

Can you come up with additional ideas? I encourage you to post comments on your personal coping strategies as a way to share this learning experience, and ask you to identify them as being problem or emotion based. Another way of thinking about emotion-based coping strategies is that they make you feel better, but do not solve the problem. Yet coping with stress has much to do with changing our attitude. Attitude is a reflection of our belief in managing stress (Potter, Perry, Stockert, & Hall, 2013). When our attitude is better, our minds become clearer so we can devise solutions to the problems or stressors.

In our next segment, we will explore the stress response.

References:

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-surgical nursing. Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of Nursing (8th ed.). St. Louis, MO: Elsevier Mosby.

Resiliency or Coping

Is this what you feel like doing when overly stressed? (please click on the link below)

<iframe width="420" height="315" src="http://www.youtube.com/embed/ZwP47xAZmBs" frameborder="0" allowfullscreen></iframe>

While this is undoubtedly a normal reaction, everyone would agree that screaming does not change the stressful situation one iota, does it?

In the last posting, you were asked to come up with your own list of physiologic and emotional/psychological stressors. You also learned that there is a difference between what we normally think of as stress (the negative aspect) and eustress, or positive stressors. Remember that the human body does not differentiate between the two. Somehow we need to achieve a sense of balance.

Resilience is the ability to adjust to or recover from change (Merriam-Webster, 2009). Think about it as being flexible, but not breaking. With resilience, you have developed some problem-solving strategies. For example, if you become anxious and stressed over an upcoming exam or deadline, you can prepare yourself by studying for the exam, seeking clarification from your instructor, or forming a study group. You could pace your workload or delegate tasks in order to meet the deadline. What other problem-solving strategies can you think of?

Coping is being abe to deal with demands, problems, or difficulties (Merriam-Webster, 2009). As amusing as the video clip was, it does not demonstrate any of the elements of reliency or coping. While some of the stressors we encounter every day cannot be helped, the goal is to find ways of solving the problem, or at least lessening the effects.

Stay tuned! You will soon learn how to go from



                Stressed                                  to                         Blissful



Different Kinds of Stressors

You probably already knew that there are many different kinds of stressors, or events that require the body to adapt in some way. According to Lewis, Dirksen, Heitkemper, Bucher, & Camera (2011), these stimuli can be  
   
          * physical
          * emotional/psychological

Can you list three stimuli for each of these categories? Go ahead and take a minute to jot down your ideas. When you are finished, look at the list below:

These are definitely examples of negative stressors, and you undoubtedly came up with some great examples of your own.

But as previously eluded, not all stressors are bad. Look at the following example:

The good stress is what Selye termed eustress. Stress can serve as motivation for positive results, including training for that marathon, taking childbirth classes, changing your diet or exercise habits, applying to nursing school, saying "yes" to the right person, and purchasing a lottery ticket. Eustress can help us to change ourselves and grow into better persons. We can use our stress to help us become nurses through all the required studying, to advocate for change, and even to learn how to do something new (i.e. start an I.V., drive a stick shift car, cook a gourmet meal to please and impress our friends). Unfortunately, the human body does not differentiate between the two. Unrelenting stress, or the inability to achieve a neutral state between excitement and rest, manifests itself in symptoms, which we will explore more in depth soon.

But isn't it nice to learn that not all stress is bad, or harmful? In research, eustress has been linked to concepts such as having hope or meaning, and being managable (Nelson & Cooper, 2005). It can be something to savor (Simmons & Nelson, 2001) - yes, savor! Relishing the knowledge that you are on the path to becoming exactly who you want to be should be satisfying, even though the journey is often fraught with both distress and eustress.

For more information on the topic of eustress, please visit:

                                                 The Positive Effects of Stress

In the next post, we will explore the concept of resiliency or coping.

References:

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-Surgical nursing. Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby.

Nelson, D., & Cooper, C. (2005). Guest editorial: Stress and health: A positive direction. Stress and Health, 21(2), 73-75. doi:10.1002.smi.1053

Simmons, B. L., & Nelson, D. L. (2001). Eustress at work: The relationship between hope and health in hospital nurses. Health Care Management Review, 26, 7-18.

How Would YOU Define Stress?

Here is a short one-question quiz for you:

Stress can be defined as...
     a.  Something that causes physical or psychological tension; it can cause illness.
     b.  When an experience exceeds an individual's resources or ability to cope.
     c.  The physiological response of the body in the presence of environmental stressors.
     d.  A perceived threat to an individual's ability to cope or adapt.
     e.  An emotionally negative and unpleasant feeling.
     f.  All of the above.
    
If your first response was thinking "Stress is what happens when entering nursing school!", there are many who would agree with you! But seriously, let us examine each individual answer so that we can learn together.

The dictionary defines stress in answer A (Merriam-Webster, 2009). Yet exposure to stress does not always cause illness. Stress can be a platform for positive action or change. Studying for a test, polishing up a resume, making the decision to eat healthier after binging on too much pizza that resulted in a stomach ache are all examples.

Answer B is also good. These experiences can be internal or external events (Haber, Krainovich-Miller, McMahon, & Price-Hoskins, 1997). An example of an internal event might be not getting enough sleep, which results in not being able to focus in class and not fully understanding the topic, eventually causing you to door poorly on the test. This in turn will cause more stress. An external event might be exposure to a pathogen and not having the ability to fight it (because you didn't let your body get enough rest!), resulting in infection.

Answer C is an excellent choice. Hans Selye conceptualized stress as a response to environmental stressors, which can be physical or emotional, pleasant or not, and they cause the body to adapt (Lewis, Collier, & Heitkemper, 1996). This is known as the General Adaptation Syndrome, which we will look into more a bit later.

If you chose answer D, this is also correct. Psychologist Richard Lazarus focused his theory on stress from the standpoint of perception (Lo, 2002). This can explain why something that stresses one person terribly is handled fairly well by another.

Did you choose answer E? This is true also (Obrist & Buchi, 2008). Yet think about the stress you feel preparing to celebrate Christmas or anticipating the birth of your first child or grandchild. Are these really negative and unpleasant, or rather excitement? Hopefully you are beginning to see that not all stress is bad.

If you chose answer F, hooray for you!

By choosing this as the best answer, you already have a good understanding about what stress is. We are now ready to move on to learning more about negative and positive stressors. See you soon!

References:

Haber, J., Krainovich-Miller, B., McMahon, A. L., & Price-Hoskins, P. (1997). Comprehensive Psychiatric Nursing (5th ed.). St. Louis, MO: Mosby.

Lewis, S. M., Collier, I. E., & Heitkemper, M. M. (1996). Medical-surgical nursing (4th ed.). St. Louis, MO: Mosby.

Lo, R. (2002). A longitudinal study of perceived level of stress, coping and self-esteem of undergraduate nursing students: An Australian case study. Journal of Advanced Nursing, 39(2), 119-126. doi:10.1046/j.1365-2648.2000.02251.x

Mich, F. C. (Ed.). (2009). Merriam-Webster's collegiate dictionary (11th ed.). Springfield, MA: Author.

Obrist, B., & Buchi, S. (2008). Stress as an idiom for resilience: health and migration among sub-Saharan Africans in Switzerland. Anthropology & Medicine, 15(3), 251-261.

Managing Your Stress

Welcome to this blog, where we will explore many of  the ways you can learn how to manage your stress.  Although this information is published with nursing students in mind (I am an aspiring nurse educator), anyone will be able to benefit and hopefully learn something new.

Everyone would agree that life is stressful, right? Of course. We encounter stress each and every day.  Stressors might be good, bad, or both. Yet our bodies do not differentiate between the two. Chronic stress is what really takes a toll on us. It might be easy to say to ourselves "Just deal with it."  But how? Why does one person seem to breeze through life, seemingly unaffected by all the little ups and downs, while another person suffers physical, psychological, emotional, or spiritual distress? That is a tough question to answer. It has to do with a combination of resiliency and coping skills. When we have resources to manage our stress, we feel better, because we have learned to counteract the stressful event(s) by doing something that helps us adapt. 

One of my favorite philosophies is that we cannot always control what happens to us, yet most of the time we can control our reaction to it. Exceptions are accidents and illnesses, although those can arguably be said to be somewhat controllable factors as well. But understanding that we have control over managing our stress is the core principle of stress reduction.

In future postings within this blog, stress will be defined. We will explore how the body interprets stress and some of the various types of stress. You will have the opportunity to take a stress inventory test that identifies certain stressors and allows you to see a measurable effect. Finally, you will learn about many different ways to control your stress and hopefully choose one or two that are a good fit for you and your lifestyle. It's all about trying to achieve a balance, because life will always throw curve balls.

Please note: The information in this blog is to provide a general overview of stress and some useful tools to help you manage your stress. It is not meant to replace the care provided by your own medical professional. If you are suffering, please do not hesitate to seek additional help.