Chapter 25 PSYCHOLOGICAL WELL-BEING
Psychological Well-BeingChapter 25PSYCHOLOGICAL WELL-BEINGANGELA M. YARNELL, PhD*; ERIN S. BARRY, MS†; and NEIL E. GRUNBERG, al FitnessPsychological Well-BeingFOUNDATIONS OF PSYCHOLOGICAL WELL-BEINGBehaviors Relevant to Psychological Well-BeingCognitive Processes Relevant to Psychological Well-BeingEmotional Factors Relevant to Psychological Well-BeingMILITARY LIFE AND PSYCHOLOGICAL WELL-BEINGPsychological Well-Being and the Service MemberPsychological Well-Being and the Military FamilyKEY INDICATORS OF PSYCHOLOGICAL WELL-BEINGPositive AffectMindfulnessMeaning and PurposeSocial SupportUnit CohesionCore ValuesPSYCHOLOGICAL WELL-BEING AND THE MILITARY MEDICAL OFFICERRole of the Military Medical OfficerGuidance to the CommanderPSYCHOLOGICAL WELL-BEING RESOURCESSUMMARY*Major, Medical Service Corps, US Army; Research Psychologist, Behavioral Biology Branch, Center for Military Psychiatry Neuroscience Research,Walter Reed Army Institute of Research, Silver Spring, Maryland†Research Assistant Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland‡Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland363
Fundamentals of Military MedicineINTRODUCTIONThe part can never be well unless the whole is well.The highest achievement by humans is happiness.The philosophies of Plato and Aristotle are relevanttoday for understanding the concept of psychologicalwell-being. Plato expressed the idea that a human ismade up of parts that contribute to a physical, psychological, and spiritual whole and that all parts thatconstitute the whole must be healthy for the being to bewell. Aristotle built upon his mentor’s philosophy byadding that the ultimate goal of humans is happiness.He characterized this state as an achievement becauseit requires effort.Military service members, their families, and civilians may strive to achieve or maintain psychologicalwell-being. However, the life of a military servicemember involves challenges and situations thatdiffer from civilian life. The US military has beenan all-volunteer force since 1973, and people who—Plato (circa 425–347 bce)—Aristotle (circa 384–322 bce)decide to serve are willingly signing up for a lifestylethat includes occupational stress; the possibility ofdangerous, life-threatening encounters; and separations (sometimes frequent) from significant others.These lifestyle requirements may make the peoplewho choose military service different from peoplewho do not. Research findings aid understanding andimprovement of the lives of service members and theirfamilies in all areas, including that of psychologicalwell-being.Military medical officers (MMOs) play an important role in identifying individual, family, and unitopportunities to sustain or improve psychologicalwell-being among those they serve. In addition tocaring for patients, MMOs must advise commandersand maintain and practice self-care.DEFINITIONSWell-BeingA state of health and wellness, the ability to judgelife positively,1–3 and to achieve a balance betweenpositive and negative affect.4 In general terms, wellbeing refers to physical, emotional and psychologicalconditions.Psychological FitnessPsychological fitness is one of eight components ofTotal Force Fitness,5 and includes internal resources,external resources, and operational outcomes. Internalresources are present to some degree within every individual. They include awareness, levels of optimism,coping, decision-making, engagement, and activedisengagement. External resources are not intrinsicto an individual; they originate from the environment and include training, leadership, and variousfitness and wellness programs. Operational outcomesrepresent the consequences of applying internal andexternal resources to a circumstance. These outcomesinclude quality of life, mental health, sleep, drug use,and suicide. For example, an individual who is psychologically fit may have excellent coping skills andseek out wellness programs to deal with challengingsituations, avoid risky behaviors, and enhance quality of life. Psychological fitness has been identified as364a positive and valued state that should be achieved tohelp optimize human performance. Utilization of thethree components described above help individualsreach that goal.Psychological Well-BeingIntegrated concepts of well-being and psychological fitness are crucial to understanding psychologicalwell-being (PWB). PWB includes the following sixcomponents of positive psychological functioning6,7:1. Positive evaluations of oneself and one’s pastlife (self-acceptance).2. A sense of continued growth and development as a person (personal growth).3. The belief that one’s life is purposeful andmeaningful (purpose in life).4. The possession of quality relations with others (positive relations with others).5. The capacity to manage effectively one’slife and surrounding world (environmentalmastery).6. A sense of self-determination (autonomy).Approaching and achieving these components ofpsychological fitness help achieve the goal or stateof PWB.
Psychological Well-BeingFOUNDATIONS OF PSYCHOLOGICAL WELL-BEINGPWB is an important component of human performance optimization. It can be discussed independently, but it impacts and integrates with states of socialand physical well-being. For example, poor PWB maylead to diminished social and physical well-being.8All conditions of well-being are needed for humanbalance and health.Positive PWB is associated with biological correlatesthat protect health,9 and the development of PWB forphysicians can help them adapt to demands of themedical profession.10 A good understanding of PWB canhelp the MMO to (1) optimally care for patients (servicemembers and families); (2) appropriately advise commanders with regard to how PWB of service membersand families impacts readiness and performance ofservice members; and (3) maintain and practice self-care.Behaviors Relevant to Psychological Well-BeingTo understand PWB and how to achieve or help others to achieve it first requires consideration of behaviors, cognitions, and motivations, as well as spiritualfactors, that contribute to PWB. These factors must beintegrated for each individual seeking to achieve PWB.Behaviors that affect PWB include exercise, leisureactivities, eating, sleep, drug use, and sexual behavior.These behaviors may have a positive or negative effect.ExerciseIndividuals who exercise are more satisfied withtheir lives and happier than individuals who do notexercise.11 Specifically, individuals who exercised twoto three times per week are less depressed, angry, andstressed; are more trusting; and perceived their healthto be better compared to people who do not exercisemuch.12 Exercise is important for everyone, but maybe especially beneficial for people with physical health(eg, cancer, cardiovascular diseases, arthritis, and sexual dysfunction) and psychological problems (eg, majordepression13); pregnant women14; and teenagers.15Leisure activities also enhance PWB.16 Activitieslike tai chi17; yoga18; and group activities19 improvePWB by reducing stress and anxiety, improving mood,increasing self-esteem, and reducing social isolation.Satisfaction with leisure activities clearly correlateswith benefits to PWB.20EatingProper nutrition (eg, eating fruits, vegetables, leanmeat, fish, and whole grains) is linked to positivePWB21,22 and fewer depressive symptoms,23 whereasa diet of processed or fried foods, refined grains,sugary products, and beer is associated with pooreroutcomes.21 Comfort foods—typically, foods high insugar and carbohydrates—can enhance PWB acutely.Eating ice cream, for example, is associated with increased positive affect.24 However, too much intake ofthese kinds of foods can lead to excessive weight gainthat may decrease PWB over time.Food deprivation generally decreases PWB and isrelated to psychological distress.25 The term “hangry”has been coined to describe situations in which a person is angry as a result of hunger. Although this wordmay be amusing, it is a fairly common phenomenonand is possibly related to decreases in self-control asa result of hypoglycemia. Low glucose in the prefrontal cortex, the area of the brain responsible for selfcontrol, may be related to increases in aggression andviolence.26 When the prefrontal cortex is deprived ofenergy, such as in the case of hypoglycemia from noteating, an individual may experience reductions inself-control. Being hangry is an interesting emotionalmanifestation of a state of physiological need that isimportant to consider in terms of well-being.SleepPeople spend more than a quarter of their livessleeping, and quality sleep affects performance andPWB.27 Most healthy adults need 7 to 9 hours of sleepeach night.28 However, most individuals, includingmilitary personnel, do not get enough sleep (or enoughquality sleep). Lack of sleep negatively affects PWB.Chronic insufficient sleep is related to increased experience of pain (eg, body pain, back pain, and stomachpain) as well as compromised optimistic outlook andsocial functioning (eg, rating on friendliness, efficiency,and sociability).29 Getting 8 hours of sleep increasesoptimistic outlook and social functioning.29Drug UseDrug use can affect PWB, whether legal (eg, alcohol,nicotine, caffeine, or drugs prescribed to the user) orillegal (eg, street drugs such as opiates, prescriptiondrug abuse, or inappropriate use of performance enhancing drugs). Licit drugs are used by many peopleto enhance PWB and to attenuate stress.30 However, itis important to understand the health risks of repeateddrug use, including physical health dangers and decreases in PWB when drug dependence develops andduring abstinence from addictive drugs (both licit365
Fundamentals of Military Medicineand illicit).30 Illicit drugs also are sometimes used toenhance PWB acutely, but long-term effects usuallylead to decreases in PWB for psychobiological, social,and legal reasons. MMOs must be aware of the effectsdrug use has on PWB and educate commanders andpatients about these potential dangers.Sexual BehaviorBeing sexually active is linked to better physicalhealth and likely to PWB. Lack of a healthy sexual relationship or being in an unhealthy sexual relationshipis associated with poor PWB. For example, in women,self-reported sexual dissatisfaction is correlated withlower PWB.31 Further, unwanted sexual behaviors(ranging from verbal comments, nonverbal communication, or uninvited touching to sexual assault)have powerful and lasting negative effects on PWB.Of particular relevance to the military community,it has been reported that women who deployed to acombat zone were more likely to have experiencedsexual stressors than female service members whodid not deploy.32 In addition, sexual abuse has beenassociated with decreased PWB (eg, depression andpoor body image).33Cognitive Processes Relevant to PsychologicalWell-BeingCognitive processes include attention, awarenessor perception, thoughts, and beliefs. Cognitions bothaffect and reflect PWB.AwarenessAwareness is an aspect of consciousness that entailsa perception of one’s environment. The manipulationof awareness (eg, mindfulness) affects well-being. Forexample, individuals who are able to balance workand life demands, and completely detach from workduring off hours, are more satisfied with their lives,have less stress, and fully engage while at work.34Mindfulness, used by marines and soldiers, is associated with decreases in perceived stress35 and increasedperformance.36Beliefs and AppraisalsThe experience of stress or negative emotionsdepends on a person’s beliefs or attitudes aboutthe situation or the way in which he or she assessesor appraises the situation. For example, having anoptimistic outlook can lead to better PWB. The term366optimism is used to describe the extent to whichpeople hold generally favorable expectancies for theirfuture.37 Optimism is related to increases in PWB,38while pessimism (belief that bad things will happenin the future39) decreases PWB. Specifically, optimismis related to indicators of better psychological andphysical health; responses to adversity; emotionalwell-being; and relationships.37 In contrast, pessimismis related to less life satisfaction40 and more depressivesymptoms.40,41 The ability to generate vivid mentalimagery of positive future events, instead of focusingon negative thoughts or “thinking traps” (eg, catastrophizing), results in better PWB.42Religiosity and spirituality are also related toPWB.43–46 In particular, spiritual fitness enhancesresilience, health, and well-being.47 Spiritual fitnessrefers to domains related to the human spirit (eg, values, feelings, aspirations) encompassed by spiritualbeliefs and practices, but is not specific to a particularreligion or faith.48ResilienceThe American Psychological Association definespsychological resilience as “the process of adaptingwell in the face of adversity, trauma, tragedy, threatsor significant sources of stress.”49 Resilience factorsrepresent individual or group-level variables thatcontribute to a decrease in the negative reactions tostressors.50,51 Individual resilience factors include effective behavioral and cognitive coping skills. Groupresilience factors may relate to effective leadershipor support from the unit. An interesting analysis ofsurvey data collected from deployed service members (Mental Health Advisory Team [MHAT-VI])indicated that although soldiers reported similarrates of combat exposure, there was little similarityin scores on a measure of PTSD symptoms.52 Thisanalysis highlights the marked variability in responseto stressor exposure experienced by individual service members and suggests differential effects ofresilience factors.Resilience and resilience training are receivingsubstantial attention in the military to help servicemembers prevent and recover from physical andpsychological stressors. It is noteworthy that “thriving” (to grow and develop subsequent to stress suchthat the individual becomes stronger53) is an ideal thatmaximizes PWB. The MMO plays a key role in translating the science behind resilience into practical andapplicable tools that unit commanders and individuals can use to enhance their ability to deal with stress,thereby enhancing PWB.
Psychological Well-BeingEmotional Factors Relevant to Psychological WellBeingPositive emotions enhance and reflect PWB,whereas negative emotions are inversely related toPWB. Individuals who are skilled at recognizing andregulating their own emotions and the emotions of others are said to be high in emotional intelligence. Highemotional intelligence is related to increased PWB.54Emotional arousal (or stress) is related to performance and psychological state following the classicYerkes-Dodson inverted U-shaped function (Figure25-1). Some individuals seem to thrive under extremestress (eg, Navy SEALS and other special operationsforces), and the point at which the effects of stress gofrom positive to negative differs from person to person. Many factors seem to affect this point, includinggenetics, prenatal environment, childhood stress, personality, resilience, and other factors. The relationshipbetween PWB and particular levels of arousal or stress,therefore, depend on the individual and on situations.Medical professionals experience job stress andburnout. These demands are negatively related toPWB. Further, individuals who lack social supportfrom supervisors and coworkers display worse PWBand more unfavorable work outcomes.55LowMediumHighFigure 25-1. Depiction of the Yerkes-Dodson Law of OptimalArousal. As one’s arousal or stress level increases, so doesperformance and hedonic (or emotional) state; however,when stress is high and exceeds one’s coping ability, performance and hedonic state decrease.Data source: Yerkes RM, Dodson JD. The relation of strengthof stimulus to rapidity of habit-formation. J Comp NeurolPsychol. 1908:459–482.Adapted from: odson.svg.MILITARY LIFE AND PSYCHOLOGICAL WELL-BEINGMilitary service affects the PWB of service membersand their families. It ultimately affects units and themilitary community, readiness, training, and even theachievement of military missions.Psychological Well-Being and the Service MemberMilitary researchers have investigated the psychological effects of war for decades. Modern conflictswith increased survivability have shed new light on therelationship between stressful and traumatic encounters and individual health and performance. Thereis now a greater appreciation for this relationship,and increased attention is paid to the role of mentalor behavioral health in readiness to fight and fitnessfor duty. Greater emphasis is now placed on holistichealth, patient-centered care, individualized medicine,and reduced stigma. The services now recognize thatmilitary life affects PWB in service members and theirfamilies and that this impact is present in home, garrison, deployed, and combat situations.Despite the stressful and often dangerous nature ofmilitary service, active duty military members are morelikely to psychologically thrive than civilians. This thriv-ing may occur because of beneficial resources associatedwith military service, including job security and financialcompensation.56 For instance, a majority of Army officers(70%) report satisfaction with pay.57 Although manyjunior soldiers (about 30%) report financial hardship,58it is not clear if these concerns predated enlistment (eg,existing debt) or developed during military service. Freefinancial counseling and educational services are offeredby the military and may help soldiers improve their financial situations and reduce stress. Other advantageousresources available to service members include tuitionassistance, tax-free housing, subsidized childcare, freemedical care, special pay, and bonuses (for retention ofsoldiers with specific skills).The military culture also offers social benefits thatcontribute to PWB. Social support and unit cohesionare both important determinants of PWB for servicemembers. In addition, high levels of perceived support from the community, unit leadership, and baseagencies reduced service members’ concerns abouttheir spouses’ ability to cope with deployment-relatedstressors.59 This perception of support for the nondeployed spouse mitigates one potential stressor on thedeployed service member.367
Fundamentals of Military MedicineLeadershipAnother key variable for PWB in the military, givenits hierarchal structure, is leadership. Quality of lifein the military is highly dependent on leadership.57Survey data collected from deployed service membersindicate that strong leadership was significantly correlated with improved morale and cohesion, fewermental health problems, and fewer ethical violations.60Similar surveys of comparisons across 28 platoonsrevealed that leaders who exhibit positive behaviorssuch as clear thinking, while not displaying negativebehaviors such as showing favoritism, helped to reduce effects of combat exposures.61Combat StressDespite the benefits of military service, there areobvious risks and potentials for poor outcomes withregard to PWB. To a certain extent some reactions todeployment-related stressors are expected. The Department of the Army coined the term “combat stressreactions” to describe the physical, emotional, cognitive, and behavioral reactions to these stressors andhas defined it as “expected, predictable, emotional,intellectual, physical, and/or behavioral reactions ofa Soldier who has been exposed to stressful events incombat.”62 This definition normalizes the reaction tocombat-related stressors and also provides a framework to identify and assess maladaptive responses,with the intention of early intervention. Of thesevarious reactions, service members are most likely toreport physical symptoms to their medical provider.These reactions represent physiological responsesand arousal to combat stressors. Muscle tension, sleepdisturbances, and headaches are physical symptomsthat may be reported by service members experiencing combat stress. It is imperative that medicalproviders understand how reactions to combat stresscan manifest physically and how they may presentin patients.InjuryThese stressful or traumatic exposures can havedeleterious effects on PWB. In the last decade extensiveresearch has been done on the effects of combat onmental health, indicating increased rates of posttraumatic stress disorder (PTSD), depression, anxiety, substance abuse, and other functional impairments.51,63,64Some believe that combat-related PTSD may be anoccupational hazard of military service.65 Aside fromthe psychological effects of stress exposures resultingfrom combat, service members suffer from physicalinjuries as well. Injured veterans are more likely to368suffer from PTSD and mood-related disorders thannoninjured veterans.66 The relationship between physical injury and negative psychological effects may be (a)direct—physical injury may cause biological changesthat affect psychological state; (b) indirect—physicalinjury may disrupt behaviors in ways that are psychologically upsetting; or (c) by other means such asdisrupting sleep, which can inhibit both physical andpsychological recovery.TransitionsExperiences during deployment have a great effecton how a service member transitions back into thegarrison environment. In their model of deploymentto-home transition, Adler and colleagues describe thefollowing factors67: deployment variables (experiences, anticipation of homecoming, meaningfulness); postdeployment variables (physical, emotional, cognitive, and social); quality of life (health, work, relationships);and other reintegration moderators like decompression, developing a narrative, unit variables, and anticipation of deploying again.Deriving meaning from work while deployed andin garrison is particularly important for PWB. Findingmeaning in work is associated with enhanced motivation and well-being.68 If service members find theirwork while deployed to be meaningless, they mayexperience anger and resentment, leading to negativeimpacts on PWB. There may be less meaning associated with work upon return from deployment as well,for various reasons including a decrease in arousalassociated with work in the postdeployment environment. Decreases in arousal postdeployment can leadto increased risk-taking behavior. This behavior mayinclude unsafe driving, leading to more road accidentsand even increased death rates due to accidents inthe year following deployment.69 Transition homecan be difficult for all service members, regardless oftheir combat experience or mental health status, andshould be appropriately planned, monitored, and assessed. Military medical providers play a key role inthis entire process.Psychological Well-Being and the Military FamilyThe transition to life at home for service memberswith families can also have a great impact on familyrelationships and on the PWB of family members. Military life has substantial impact on service members’
Psychological Well-Beingspouses and families. Family members experiencevarious stressors such as relocation, social isolation,separation, and fear of or actual injury or death ofthe service member. The stressors may positively ornegatively impact the PWB of the family member,depending on a number of variables. The wars in Iraqand Afghanistan have brought the longest familyseparations since World War II.70 More than half of allcombat deployments left at least one dependent family member behind.58 These separations are difficultfor service members and their families, and familystability is negatively affected by prolonged separationbecause of deployment.71Spouse Well-BeingFor female spouses, the length of separation issignificantly associated with poor well-being.72 Morespecifically, deployment has been related to decreasesin health-promoting behaviors including exercise,social interaction, rest, safety-related behaviors,73 andgreater perceived stress74 for the nondeployed spouses.Further, nondeployed spouses often have psychopathological problems including major depression orgeneralized anxiety disorder; emotional, alcohol, orrelated family problems; and functional impairment inwork and life,75 sleep disorders, acute stress reactions,and adjustment disorders.76Care for Wounded WarriorsIn addition to the effects of family separation, the demands associated with current wars include increasedsurvival but greater care requirements for woundedwarriors.57 Specifically, PTSD can be a secondarytraumatic stressor for family members. In one study,PTSD symptoms reported by military members predicted increased symptoms in their female spouses.77The MMO can impact these associations by includingfamily members in the treatment services for PTSD andeducating the family about combat-related reactions.60These steps may help improve treatment outcomes forthe service member and lessen the impact of mentalhealth problems on the family. Education for familymembers about physical injuries (eg, traumatic braininjury and limb amputation) is important so theyunderstand the symptoms associated with these injuries (eg, fatigue, memory loss, frustration, and angryoutbursts) and do not blame the service member.78Relationship QualityGiven that deployment has clearly identified effectson service members and their significant others’ wellbeing, it is no surprise that there are further impactson intimate relationships and satisfaction. Maritalrelationships are affected by military service,79 specifically in the following ways: disproportionate work–family balance80; preparing for or recent return from deployment81; difficulty communicating, reestablishingemotional bonds, or renegotiating roles andresponsibilities82; and physical or mental health concerns for one orboth partners.57,83,84Marital satisfaction is negatively correlated withPTSD and depression, although it is not significantlyrelated to combat exposure by itself, suggesting thatother factors are involved.85 MMOs should be awareof these strains on marriage and relationships uniqueto military service and incorporate them into theirpractice and interactions with patients and families.CopingIn addition to the perception of stress, coping styleis predictive of PWB in female military spouses ofdeployed service members, and style of coping varies based on rank of spouse, whether she grew upin a military family, and experience of a previousdeployment separation.73 The ability of the spouse orfamily member to cope with the stress of military lifeand deployment is important. In a study of spousesfrom an Army infantry division, problem-focusedcoping strategies were more frequently endorsedthan emotion-focused coping strategies. Problemfocused coping refers to changing or modifyingthe fundamental cause of stress, whereas emotionfocused coping refers to strategies that are effectivein the management of unchangeable stressors.86–88Problem-focused coping was related to fewer depression symptoms, especially in instances where theindividual perceived little control over the situation.89In addition, access to social networks and sources ofsocial support—similar to the situation for servicemembers—is critical for families. Support from community and unit positively correlated with families’ability to adapt to stress.90 Spouses who did not meetcriteria for major depressive disorder or PTSD weremore likely to report positive effects from deployment(more independence, more self-confident problemsolving) than spouses who met criteria for majordepressive disorder or PTSD.82Although separations because of military service arestressful and are associated with adverse psychologicalhealth outcomes, these separations are quite differentfrom separations during past wars because of current369
Fundamentals of Military Medicinetechnology (email, phone, video call) that increase opportunities for communication and connectedness. Also,Internet and virtual communities may increase connectedness of family members to available sources of support.70EmploymentMilitary spouses’ employment is another importantfactor that affects PWB of military family members.Working contributes to the overall satisfaction of military spouses, providing additional compensation, personal fulfillment, independence, and other benefits.91Unemployment can act as a chronic stressor92 andnegatively affect PWB.93 Education level of militaryspouses also may play a role in better PWB.ChildrenChildren of service members also are affected bymilitary separations. Children in military families,unlike most civilian children, live with the concernthat their parent may be injured or killed during acombat deployment,94 which may lead to emotionaldifficulties.95 Length of the parent’s deployment andthe parent’s rank (a variable that likely represents acomplex set of family circumstances) are related toPWB. There is some evidence that child neglect andmistreatment increase for the children of enlistedservice members during a combat deployment. 96Increases in interpersonal violence in general are associated with combat deployment97 and the lengthof deployment.98 It is important for the MMO to beaware of these potential issues for family members,especially children. Additionally, the MMO can assistthe unit command in preventing these poor outcomesassociated with military service and deployment byeducating them about the relationship between certain factors discussed here. For example, engagingin military-sponsored activities seems to enhancewell-being.99KEY INDICATORS OF PSYCHOLOGICAL WELL-BEINGKey concepts relevant to PWB include positive affect; mindfulness; purpose and meaning in life; socialsupport; unit cohesion;
life positively,1–3 and to achieve a balance between positive and negative affect.4 In general terms, well-being refers to physical, emotional and psychological conditions. Psychological Fitness Psychological fitness is one of eight components of Total Force Fitness,5 and includes internal
Part One: Heir of Ash Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 Chapter 21 Chapter 22 Chapter 23 Chapter 24 Chapter 25 Chapter 26 Chapter 27 Chapter 28 Chapter 29 Chapter 30 .
TO KILL A MOCKINGBIRD. Contents Dedication Epigraph Part One Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 Part Two Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18. Chapter 19 Chapter 20 Chapter 21 Chapter 22 Chapter 23 Chapter 24 Chapter 25 Chapter 26
DEDICATION PART ONE Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 PART TWO Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 Chapter 21 Chapter 22 Chapter 23 .
About the husband’s secret. Dedication Epigraph Pandora Monday Chapter One Chapter Two Chapter Three Chapter Four Chapter Five Tuesday Chapter Six Chapter Seven. Chapter Eight Chapter Nine Chapter Ten Chapter Eleven Chapter Twelve Chapter Thirteen Chapter Fourteen Chapter Fifteen Chapter Sixteen Chapter Seventeen Chapter Eighteen
18.4 35 18.5 35 I Solutions to Applying the Concepts Questions II Answers to End-of-chapter Conceptual Questions Chapter 1 37 Chapter 2 38 Chapter 3 39 Chapter 4 40 Chapter 5 43 Chapter 6 45 Chapter 7 46 Chapter 8 47 Chapter 9 50 Chapter 10 52 Chapter 11 55 Chapter 12 56 Chapter 13 57 Chapter 14 61 Chapter 15 62 Chapter 16 63 Chapter 17 65 .
HUNTER. Special thanks to Kate Cary. Contents Cover Title Page Prologue Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter
Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 . Within was a room as familiar to her as her home back in Oparium. A large desk was situated i
Introduction to Literary Criticism. Definition and Use “Literary criticism” is the name given to works written by experts who critique—analyze—an author’s work. It does NOT mean “to criticize” as in complain or disapprove. Literary criticism is often referred to as a “secondary source”. Literary Criticism and Theory Any piece of text can be read with a number of different .
