This study, based on a stratified (by decade of production) random sample of 1,221 animated cartoons and 4,201 characters appearing in those cartoons, seeks to determine the prevalence of alcohol-related content; how, if at all, the prevalence changed between 1930 and 1996 (the years spanned by this research); and the types of messages that animated cartoons convey about beverage alcohol and drinking in terms of the characteristics that are associated with alcohol use, the contexts in which alcohol is used in cartoons, and the reasons why cartoon characters purportedly consume alcohol. Approximately 1 cartoon in 11 was found to contain alcohol-related content, indicating that the average child or adolescent viewer is exposed to approximately 24 alcohol-related messages each week just from the cartoons that he/she watches. Data indicated that the prevalence of alcohol-related content declined significantly over the years. Quite often, alcohol consumption was shown to result in no effects whatsoever for the drinker, and alcohol use often occurred when characters were alone. Overall, mixed, ambivalent messages were provided about drinking and the types of characters that did/not consume alcoholic beverages. Data collected in recent years indicate that alcohol use is fairly widespread in the youth population and that drinking beyond initial experimentation is commonplace. More than one-third (35.8%) of the 13–14-year olds reported having used alcohol at least once in their lives  of the media effects studies conducted during the past few decades have learned that exposure to media messages, particularly visual electronic media messages, leads to changes in people’s beliefs, attitudes, and/or behaviors . Typical8% of thel et al.  in theirl et al.  in theirl et al.  found thMoreover, several media effects researchers have also reported associations between television viewing behaviors and alcohol use behaviors among young people. For example, Tucker  reportedand . This eliminates from the present study such types of animation as claymation , pixilation , and puppet animation . The cartoons chosen for the study sample were selected randomly from among all cartoons produced between the years 1930 and 1996 by all of the major animation studios. Before drawing the final sample of cartoons that would be viewed and coded for this work, the researchers had to develop a comprehensive and inclusive sample frame of cartoons produced by the aforementioned animation studios. Published filmographies  was chosen for four reasons: 930 was c the era A stratified (by decade of production) random sampling procedure was used to ensure that cartoons from all decades were represented equally in the study sample. This stratification procedure was necessary because very different numbers of cartoons have been produced during different decades , thereby leading to the risk that a general random sample (as differentiated from this study’s stratified random sample) might have led to an overrepresentation of certain decades during which greater- or lesser-than-average numbers of alcohol-related portrayals were provided.Cartoons on the sample list were obtained via numerous methods, including purchases of commercially available videocassettes from retail outlets, rentals of commercially available videocassettes from video rental outlets, videocassette purchases from catalog distribution companies, 16 mm film purchases from private animation collectors, and trading with private animation collectors to obtain VHS-format copies of needed cartoons in exchange for providing them with copies of cartoons they desired for their personal viewing/collections. In many instances, copies of the sample-listed cartoons needed for this project were provided by the animation studios themselves, in an effort to cooperate with this research study. Some of the cartoons on the sample list were taped from network television and cable television stations, too, although this was done primarily when other sources for obtaining these cartoon episodes were cost prohibitive or not readily available to the researchers. Recognizing that some cartoons appearing on television – particularly older cartoons that were originally made for showing in movie theaters prior to motion picture main attractions – have been edited for content, every effort was made to guarantee that the copies of cartoons obtained via taping from the television were complete and unedited.This study uses a content analysis approach to examine the types of messages that cartoons provide about alcoholic beverages and drinking. Data collection for this research entailed viewing the cartoons contained on the project’s sample list and recording detailed information on predesigned, pretested, pilot tested, fixed-format coding sheets. Prior to beginning their viewing and coding work for this study, research assistants underwent an intensive training that familiarized them with the data that the study strived to collect, the rationale underlying the coding of each piece of information, and the decision-making procedures that should be used when recording information from each cartoon. To make sure that all people involved in the viewing/coding  process implemented the decision-making procedures in a similar manner, intercoder reliability coefficients were calculated periodically throughout the project. Reliability estimates consistently have fallen above 0.80 for all major measures, and were at least 0.90 for all of the variables used in the analyses reported in the present article, indicating a very high level of intercoder reliability for this research.X number of drinking-related messages for every Y min of viewing time), the proportion of all cartoons containing different types of alcohol use-related content, and so forth. N = 1,221 for this dataset.To understand the information that this study contains, it is best to conceptualize the database as consisting of three smaller datasets. Dataset No. 1 focuses on the cartoon itself as the unit of analysis and contains macro-level variables that provide prevalence-type information. Among several others, this dataset includes such measures as the cartoon’s length; number of characters of each gender, race, age group, and so forth; number of major and minor characters using alcohol; number of alcohol-related references made in the cartoon; and number of depictions of alcoholic beverages in the cartoon. This dataset facilitates analyses indicating the rate at which alcohol use portrayals are provided in the cartoons , monsters, ghosts, etc.], providing detailed information that is of value when trying to interpret the types of messages that cartoons provide about who it is that uses alcohol. This dataset contains information about each major character’s gender, age, race, ethnicity, marital status, level of intelligence, attractiveness, physique, occupational status, level of goodness or badness, and other demographic-type and descriptive information. In addition, Dataset No. 2 consists of data about the number of acts of violence, aggression, and prosocial behaviors (and limited information about the types of these behaviors involved) that the characters have committed. This dataset’s information is useful for examining such things as whether substance users are more likely to be male or female, old or young, attractive or unattractive, intelligent or unintelligent, violent or non-violent, prosocially oriented or not prosocially oriented, “good guys” or “bad guys,” and so forth. N = 678 for this dataset.Dataset No. 3 provides detailed information about each portrayal of alcohol use. Such information as the type of alcohol used, the amount used, the effects – if any – that were shown to result from drinking, descriptive information about other characters shown to be present when the alcohol use occurred, the purported reason(s) why the drinking was taking place, and the location and social context of the drinking use were all captured in this dataset. In this research, codes were reserved for four types of alcoholic beverages. The first type of alcohol was beer, which included beer, ale, and stout. The second type is coded was wine, which included wine, champagne, port, and sherry. The third category was distilled spirits, which included liqueurs, all types of mixed drinks, and shots of “hard liquor.” Finally, generic alcohol was coded, which entailed those situations in which a beverage was portrayed to be alcohol even though its specific type was indeterminable based on the cartoon’s content. Usually, generic alcohol was identifiable as an alcoholic beverage by virtue of the alcoholic beverage container being marked with an “XXX,” the shape of the beverage container, or based on the effects shown to result from the use of the liquid .use, the character must have an alcoholic beverage in his/her/its mouth or be trying to ingest alcohol. No particular amount had to be taken in order for use to be coded, as long as the intent/attempt-to-use criterion just mentioned was met. Depictions of alcoholic beverages are defined as instances in which the cartoon showed the actual beverage in question without also showing it being ingested. For example, if a cartoon were to show a bottle of beer lying on a table but no character drank from it, this would be coded as a depiction of alcohol. Finally, references to alcoholic beverages, drinking, or the effects of consuming alcohol are defined as those situations in which a cartoon or a cartoon character mentions an alcoholic beverage type, using an alcoholic beverage, or the effects resulting from drinking when alcohol itself neither was used nor shown in the cartoon. For example, if a character were shown to have a hangover and comment to another character that he couldn’t believe that he drank so much the night before, this would be considered a reference to the effects of drinking, since the alcoholic beverage itself is not shown and its use is not portrayed.This study entailed recording three types of alcohol-related content: alcohol use; depictions of alcoholic beverages; and references to alcoholic beverages, drinking, and/or the effects of consuming alcohol. To be coded as an act of alcohol One of the key focal points of this research is examining what “types” of characters, based on their gender, race, age, “goodness” or “badness,” among other characteristics, are shown to be alcohol users. The operational definitions of these concepts are, in most instances, quite complex to describe succinctly, since numerous coding rules were developed for each construct to guarantee high levels of intercoder reliability. Rather than provide detailed explanations of each construct’s operational definition here, readers who wish to learn more about the specific ways in which these concepts were defined are encouraged to contact the lead author for additional information.p < 0.05.All statistical analysis undertaken in conjunction with this research was performing using the Statistical Analysis System (SAS) software, version 9.1.3. Prior to undertaking any analysis of the project data, the appropriate power analyses/computations were conducted. All statistical analysis was performed with a minimum power of 0.8, which is the standard that is generally accepted for use in the social sciences . Many ofAlcohol use was portrayed in 3.2% of the cartoons coded. The average cartoon with any characters using alcohol contained approximately two  such characters consuming alcohol. Of the different types of alcoholic beverages that could be consumed, beer was the most common, accounting for 35.6% of all alcohol use in the cartoons studied. Next most frequently consumed were, respectively, wine (27.8%), distilled spirits (25.6%), and generic alcoholic beverages (11.1%).Table Depictions of alcoholic beverages were found in 5.6% of the cartoons coded. When a cartoon depicted an alcoholic beverage without also showing it being consumed, the average cartoon did so nearly three times . Alcohol-related references involving neither consumption nor depiction of the beverage were found in 3.4% of the cartoons coded, with the average cartoon with any alcohol-related reference approximately two references to it . Overall, about 1 cartoon in 11 (9.3%) incorporated alcohol into its plot in one way or another. When alcohol was brought into a cartoon’s storyline, it showed up an average of three times  during the course of the cartoon.Another way to examine the preceding prevalence information – one that helps to put these prevalence figures into their proper perspective – is to convert it into rates presenting the number of alcohol-related messages per hour of viewing time. When computing an hour of viewing time, we assume that a typical hour of television viewing of children’s programing consists of 45 min of programing and 15 min of commercial time. It is, therefore, a conservative estimate of the actual prevalence of alcohol-related content in the cartoons since, by recently established federal law, programs broadcast during the hours considered “children’s programing time” must contain no more than 15 min of commercials. Our data indicate that the typical hour of cartoon viewing will expose viewers to two alcohol-related messages . Over the course of a “typical” week’s television and video viewing [approximately 18.3 h spent by children ], a reasDepictions of alcoholic beverages have become significantly less frequent over time  , followed by a noticeable increase during the 1990s . Figure alcohol-related references has changed over time – a relationship that was found to be statistically significant and curvilinear . Essentially, alcohol-related references declined in frequency fairly steadily from the 1930s until the 1980s , and then increased very sharply to their highest levels ever during the 1990s . As time has gone on, cartoons have been containing significantly fewer characters using alcohol , a decline that is demonstrated quite clearly in Figure F1, 1219df = 10.93, p < 0.001) and minor  characters alike.F2, 1218df = 9.75, p < 0.0001). This is shown in Figure t = 2.98, p < 0.003), there was a sharp, statistically significant increase  that brought the prevalence of any alcohol-related content to nearly its highest level ever.Given the preceding, it is not surprising that the overall presence of alcohol  has declined significantly over the years  and loss of coordination (which occurred in 70.8% of these instances). All other effects resulting from drinking were shown quite infrequently. Examples include becoming unconscious (16.7%), increased happiness or sociability (12.5%), increased relaxation (4.2%), becoming interested in another character sexually (6.3%), arguing or physically fighting with other characters (4.2%), increased sleepiness (4.2%), coughing (2.1%), hallucinating (2.1%), increased rowdiness (2.1%), becoming sick (0%), among others. In all, characters were equally (un)likely to experience positive effects as a result of their alcohol use  as they were to experience negative effects from their alcohol use , as both categories of effects were observed in 20.8% of all instances involving alcohol consumption.In nearly one-half (46.7%) of all instances in which alcohol use occurs, drinking is shown to result in no physical effects of any kind. When effects Table With regard to race, all of the characters with a codable raceRegarding age, 2.1% of the characters present when alcohol was consumed were infants, children, or adolescents. This is much lower than the 21.4% figure representing the proportion of all characters in the cartoons that fall into these age groups. Another 1.4% of the cartoon characters that were present when alcohol was used were classified as elderly, which is somewhat smaller than the proportion of cartoon characters that were coded as elderly (3.4%).In terms of the physical attractiveness of the characters that were portrayed in the presence of alcohol use, 11.8% of them were coded as above average in attractiveness – nearly triple the percentage of all cartoon characters that were coded as good looking (4.4%). Conversely, only 4.2% of those present when one character consumed alcohol were classified as being unattractive, which is comparable to the 5.4% of characters that coded were classified as being physically unattractive.these settings (44.7%) entailing rather generic outdoor locations in the country . When drinking was portrayed as an indoor activity, it occurred most often in characters’ homes  or in bars, taverns, or saloons . Somewhat surprisingly, there were no portrayals of alcohol use in conjunction with sporting events or such occasions as birthday parties, weddings, anniversary celebrations, or other holiday celebrations.The locations and social contexts of drinking episodes were highly varied in the cartoons coded. Most commonly, alcohol use occurred in outdoor settings (52.2%), with nearly one-half of The purported reasons for cartoon characters’ use of alcohol were rather varied. The single most common explanation of cartoon characters’ use of alcohol was that they simply enjoyed the taste of alcohol or because they liked to drink, which accounted for 12.2% of all use portrayals. The next most common reason for using alcohol was to become drunk (7.8%), followed by using alcohol to be more sociable or “to be part of the crowd” (5.6%). It is worth mentioning that in 40.0% of all alcohol use portrayals, drinking occurred for no reason whatsoever. That is, based on the cartoon’s events and the context in which the alcohol use occurred, there was no inference to be made as to why the drinking was happening.t = 3.84, p < 0.0001). In great part, this finding was “driven” by the substantially greater perpetration of violence among drinking characters than among non-drinking characters , although alcohol users were somewhat less verbally aggressive than their non-drinking counterparts . Caucasian characters were far less likely to be alcohol users than non-whites were . Elderly characters were much more likely than their child, adolescent, or adult counterparts to ingest alcohol . Alcohol users were more than three times as likely as non-users to be portrayed as physically unattractive compared to characters that did not use alcohol . In terms of their overall classification as a “good guy” versus a “bad guy” (versus those of mixed traits and those classified as being neither good nor bad), alcohol users were twice as likely as non-users to be classified as “bad guys” .Table t = 0.68, n.s.).Drinkers and non-drinkers did not differ, from a statistical point of view, in terms of their gender breakdown  watch contain a modest amount of alcohol-related content. Although the frequency with which alcohol-related messages are portrayed has declined over the years , readers should bear in mind that many of the cartoons produced during the 1930s, 1940s, and 1950s  are still broadcast on network and cable television today rs e.g., , 32, 33,rs e.g.,  in her cCigarette smoking is continually associated with social success, sexual attractiveness, a healthy demeanor, exciting sporting activities… and so on. What else could an American adolescent want?Of even greater interest and importance, we feel, is the information that this study can provide about the things that young people learn about alcoholic beverages and drinking when they watch animated cartoons. Overall, they are provided with mixed messages about alcohol use. On the negative side, cartoon characters that use alcohol are more violent, more likely to be shown to be physically unattractive, and more likely to be depicted, overall, as “bad guys” compared to cartoon characters that did not use alcohol. Conversely, cartoons convey quite clearly that using alcohol is associated with a variety of socially desirable qualities, and they present this message in many ways: Males, who our culture values more and stigmatizes less than females, are more than three times more likely than females to be shown to be present when alcohol is used. Similarly, Caucasians, who our culture favors over people of color, also have a much-greater-than-average chance of being shown to be present when alcohol is used. Likewise, physically attractive characters are three times more likely to be associated with alcohol-drinking characters than physically unattractive characters are – once again remaining consistent with our cultural emphasis on beauty. All of these messages (and others similar to them) convey and reinforce an important notion to viewers: “good,” “desirable,” “culturally valued” people are the ones who are associated with alcohol users. This is the type of socialization message that is likely to make young people want to experiment with alcohol so that they, too, can be part of a socially desirable group of people. It is the same kind of message that Johnston et al. , pp. 3–4do serve to reinforce the ideas that drinking is good and that it can lead to feeling soothed and relaxed. This type of message exemplifies Bales’ , then proceed to diving with sharks (which they find boring), and then decide to participate in the annual running of the bulls in Pamplona, Spain (which they find exhilarating). Throughout all of their adventures in the cartoon, alcohol remains uninvolved… again until the last 15 s of the cartoon. At that time, both of the characters are shown toasting one another with umbrella-adorned presumed-to-be-alcoholic beverages, to congratulate one another on finding a suitable and thrilling adventure. After raising their glasses in celebration, the cartoon ends. No alcohol is consumed.One final thing that we would like to highlight from our findings – something that is not very evident from the data presented in this article – is that cartoons with alcohol-related content that does not glamorize drinking or make alcohol use seem appealing tend to present messages about alcoholic beverages and drinking that normalize these things. This is perhaps most evident when one looks at the frequency  and the nature of cartoons’ alcohol-related depictions and references. Regarding the latter, we have found that, in most instances in which cartoon characters mention alcohol or the effects of drinking without actually consuming alcohol, and in most instances in which alcoholic beverages are shown on-screen without being used, the inclusion of these references and depictions is unnecessary – some might even call it gratuitous – to the flow and development of the cartoon’s storyline. Two examples from cartoons that from later in the study’s period of investigation will illustrate the point here:Both of these examples illustrate the preceding point quite well: The inclusion of the alcohol-related content in these particular cartoons was unnecessary, not really enhancing or facilitating the plots of these cartoons at all. Nevertheless, in both instances – instances that we feel represent a fairly common trend among the types of alcohol depictions and references seen in the animated cartoons we have been studying – the alcohol-related content was innocuous enough. It is cartoons’ frequent presentation of these unnecessary yet primarily benign messages about alcohol that leads us to conclude that, when they are not making alcohol seem appealing to viewers, cartoons make alcohol seem “normal,” “natural,” “harmless,” and “benign” to viewers. Perceptions such as these, while unlikely to induce young people to experiment with alcohol or to continue using it once their experimentation has begun, are, in our opinion, likely to foster the impression that there is nothing wrong with trying alcohol, nothing to be lost by drinking, and so forth. Perhaps this accounts, at least in part, for youths’ involvement with alcoholic beverages.and/or indirectly, based on what they observe others – including others appearing in the mass media – doing or saying. As Kunkel et al.  are positive in nature. This conclusion is quite similar to that reached by Penkoff (and by associating few truly negative consequences with alcohol use, why wouldn’t young people want to experiment with drinking?!Ultimately, we believe that the frequent inclusion of alcohol-related content in animated cartoons, coupled with the frequently pro-drinking messages about alcohol use that the cartoons provide, combine to tell audiences that alcohol is a normal, positive aspect of life. Cartoons tell people that drinking only sometimes has an effect on the drinker  Penkoff . With thThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This paper applies the Biobehavioral Family Model (BBFM) of stress- related illness to the study and treatment of an adolescent with intractable asthma. The model is described, along with supportive research findings. Then a case study is presented, demonstrating how the model is clinically applied. We tell the story of an asthmatic adolescent presenting for therapy due to her intense asthmatic crises, and the case is presented to exemplify how the BBFM can help understand the family-psychobiological contribution to exacerbation of disease activity, and therefore guide treatment towards the amelioration of severe physical symptoms. Facets of the patient’s intra-familial interactions are consistent with the BBFM, which support clinical validation of the model. In the case described, it is likely that additional asthma medications would not have had the desired ameliorative effect, because they did not target the family relational processes contributing to the symptoms. The recognition of the influences of family relational processes on the disease was crucial for effective intervention. The therapy incorporates and weaves together BBFM understanding of family patterns of interaction and physiological/medical concerns integrated with Bowenian intervention strategies. This case study validates the importance and usefulness of BBFM for intervention with stress-sensitive illnesses such as asthma. Research has demonstrated that the family plays a decisive role in physical as well as emotional health . FamilieMinuchin and colleagues  in their. .The BBFM was originally developed to understand how family process influences chronic illnesses, such as inflammatory bowel disease  and asthd delayed).The BBFM is a biopsychosocial model, which posits that particular family relational patterns influence and are influenced by the psychological and physiological processes of individual family members. The model proposes multiple pathways through which family relational stress and emotions may influence a child’s health .The BBFM model rests upon a systems conceptualization of disease, one that embraces the psychosocial-mind–body perspective. The conceptualization features a continuum of psychological and physical disease, which varies according to the relative proportions of psychosocial and biological influence on the disease process.Psychosocial and biological factors interact as they influence a disease. They represent mechanisms or pathways of biobehavioral influence. The pathways are assumed to be bidirectional, such that having a disease elicits psychosocial and emotional stress, and psychosocial and emotional stress evokes the disease process. BBFM specifies pathways by which the family plays a pivotal role in these psychobiological processes.Both physical and psychological disease can be conceptualized in terms of a continuum of relative contribution of psychological and biological  influence. Consistent with the biobehavioral continuum of disease presented above, the BBFM is broadly applicable to any disorder, psychological or physical, in which there is a psychobiological pathway.The BBFM posits that family emotional climate, quality of parent-parent relations, parent–child relational security and biobehavioral reactivity (emotion regulation/ dysregulation) are processes that influence one another and collectively either buffer or potentiate psychobiological processes influencing disease activity in stress-related illnesses . The modFamily emotional climate refers to the overall intensity and valence of emotional exchange. It colours all aspects of family relationship, and therefore it is probably a key factor contributing to emotional status and outcomes in family members. A negative family emotional climate includes hostility, criticism, verbal attacks, etc., and is similar to the criticism construct of Expressed Emotion (EE). Positive aspects include warmth, affection, support, affirmation, etc. Family emotional climate is characterized by the intensity and balance of negative and positive emotional exchange among family members. This balance or imbalance can be construed as reflecting one aspect of family-level emotion regulation or dysregulation.Several family relational process factors contribute to family emotional climate. For example, proximity, which is defined as the extent to which family members share personal space, private information, and emotions. Generational hierarchy refers to the extent to which caregivers are in charge of the children by providing nurturance and limits through strong parental alliance and absence of cross-generational coalitions. Proximity and Generational Hierarchy derive from Wood’s theoretical differentiation of the Minuchin’s construct of “boundaries” [ndaries” . Parentandaries”  refers tndaries” . Responsndaries” , but it Relational Security is a construct related to attachment. The importance of integrating attachment and family systems theory is evidenced by recent theory and research.  the effect of stress and emotional challenge to disease processes through psychobiological pathways. Biobehavioral reactivity involves hypothalamic-pituitary-adrenal axis (HPA), autonomic nervous system processes, neuroendocrine and immune processes. Depending on which physiological processes are activated or deactivated during patterns of emotion dysregulation, such processes may influence physical and emotional disorders depending upon the disease-specific psychobiological pathway by which such effect can take place . BiobehaTo date no single study has tested the BBFM in its entirety, but studies of children with inflammatory bowel disease, epilepsy, Psychogenic Non-epileptic Seizure Attacks, PNEA and asthma ,5,11 repIt is noteworthy that BBFM conceptualizations are consistent with ‘Family Systems Theory’ introduced by Murray Bowen . Bowen’sFurthermore, we would like to clarify the uniqueness of the notion ‘Family systems theory’. In this article, the term ‘Family systems theory’ refers to the Bowen family systems theory. Bowen theory is essentially different from most other family approaches as Kerr (1981), Bregman 2004), among others, argue. It is a theory about human behavior that is rooted in thinking about natural systems. Bowen family systems theory is about the emotional functioning of the human species. The theory postulated that the human family is a multigenerational, natural, living system and that the emotional functioning of each member of the system affects the functioning of the other members in predictable ways .""The term ‘psychosomatic family model’ refers to a different theoretical model. Minuchin, Rosman, and Baker’s open systems model of the “psychosomatic family” comprises a constellation of family patterns of functioning and somatic patterns of disease activity and illness behavior in chronically ill children (1975).""Bowen introduced the notions of emotional forces for ‘togetherness’ and differentiation’. The togetherness amalgam is bound together by assigning positive value to thinking about the other before self, living for the other, sacrifice for other, love and devotion and compassion for others, and feeling responsible for the comfort and wellbeing of others’. In contrast, “the differentiating force places emphasis on “I” in defining the foregoing characteristics. It is the ‘responsible I’ which assumes responsibility for one’s own happiness and comfort and avoids making demands on others”. Differentiated self is defined as: “one who can maintain emotional objectivity, while at the centre of an emotional system in turmoil and, at the same time, actively relating to the important persons of the system”.Problems occur when differentiation is compromised by various family and individual factors. Bowen identified a number of mechanisms by which families transmit problematic emotional processes across generations: the family projection process, emotional cut-off, and levels of parental differentiation. Bowen’s conceptualizations also are important because they offer internal mechanisms by which family interactions and emotions may influence the individual’s body state. Bowen suggested that many of the family emotional processes reflect individuals’ unconscious, anxiety-driven survival responses, responses that involve emotional and bodily processes together. Bowen calls these automatic responses ‘emotional reactivity’. Individuals whose behavior is characterized by high emotional reactivity are considered to be poorly ‘differentiated’: they find it difficult to think explicitly about their behavior and feelings  and also to distinguish their thoughts and feelings from those of others within a relationship system. These notions tie in well with ‘Responsivity’, a key construct in Wood’s model. Responsivity is conceptualized at both family and individual levels. At the family level, interpersonal responsivity is defined as the degree or intensity with which people respond physiologically, emotionally, and behaviorally to one another. At the individual level, responsivity influences, and is influenced by, biobehavioral reactivity, defined as the degree of intensity with which an individual responds physiologically to stimuli .While Bowen’s model specifies internal processes influencing individual physiology, Wood’s model  identifiin the U.S. according to W.H.O.[Asthma is one of the most common diseases in childhood, currently affecting an estimated 7.1 million children under 18 years old, to W.H.O.. In the to W.H.O.. Asthma to W.H.O..These episodes may be triggered by environmental stimuli such as allergens, environmental tobacco smoke, cold or warm air, perfume, pet dander, moist air, exercise, or emotional stress. The resulting airway narrowing causes symptoms such as wheezing, shortness of breath, chest tightness, and coughing. Asthma is ideally treated by daily controller medications supplemented with short acting bronchodilators.Asthma is caused by both environmental and genetic factors, the interaction of which is not fully understood[; Onset of asthma in a child is likely determined by a complex interaction of genetic vulnerability, environmental exposure to respiratory infections, allergens, irritants, or environmental smoke and psychological influences such as maternal distress [The model assumes that directions of causal effect are circular, but the current focus is on the child’s physical and emotional outcomes.nderstood; Onset odistress  and stredistress . A theorThe patient was at the time of treatment a 15-year-old girl. She lived in a rural area near Sparti in Greece with her biological parents and her two younger sisters (10 and 12 years old). Her parents were low income farmers, and financial problems stressed the family. The patient was brought to therapy by her parents, after recommendation of the family doctor, because her asthma was unstable, despite adhering to her asthma medication. The patient had severe asthma. She was treated with inhaled corticosteroids except for the time of crises, when she was treated with stronger medications, such as injections and bronchodilators, such as theophylline. Despite this aggressive treatment regimen, she still had frequent attacks, requiring emergency intervention and hospitalization. Her family doctor believed her to have life-threatening asthma.The patient was isolated from friends and she felt quite ashamed of herself, because of her asthma attacks. She had poor grades, something that was a source of criticism from her parents. When she came to therapy she felt depressed, and thought that there was no solution to her problems.The initial session was scheduled with the patient and her parents, who were unwilling to participate and preferred to wait in the waiting room until their daughter would be ‘examined’. They declared that they could not see any reason to visit a psychologist, and they came because the physician insisted they should come. According to the patient, they, like many Greek parents, thought that asthma was a totally physical disease with no psychological components. The parents refused to participate, so it was impossible for the therapist to treat the whole family. It is important to note that this family’s attitude and bias against psychologists and therapy was consistent with Greek cultural beliefs and attitudes in this realm. Such cultural attitudes are well documented in many research studies, including one that took place in 30 countries and was held by Georgas et al. .Since the family was reluctant to participate in the sessions, and such reluctance was consistent with Greek attitudes, I believed that the success of therapy would be most supported by respecting these cultural beliefs and attitudes, rather than by challenging them. Furthermore, in my judgment, it was likely that the family would have taken their daughter out of treatment rather than submit themselves to therapy. Therefore, I had to rely upon the patient’s accounts and descriptions of her family.We allow that there is always a subjective element introduced when a therapist tries to assess and /or understand a person’s or family’s attitude towards one another. However, even direct observation of family interaction occurs through a subjective lens. Consideration of such “limitations” is an epistemological debate. That is to say, some orientations would argue that it is the experience of the patient, as reported by the patient, that impacts on that person’s function, not what the “objective” observer would perceive and experience. Observation alone thus may not provide insight into how the interactions are experienced by the patient. Ideally both perspectives would be available. However in the absence of direct observation, one must listen carefully and broadly to the informant (the patient in this case) to establish convergent evidence for any perception, interpretation, assessment or conclusion about family function. This was the stance taken by the therapist in this case).The treatment was guided by Wood’s BBFM and by Bowenian family intervention theory. Based on BBFM assessment, we observed the following:The patient’s family did not communicate much. Her father was emotionally absent and quite critical, and perhaps depressed, as his income was quite low, and he had to accept his father-in-law’s financial help. The patient’s father’s depressive behavior contributed to her emotional difficulties. This observation was consistent with BBFM research findings, which demonstrated pathways of effects of paternal depression on the child.The patient’s mother was compliant with almost every person in her family, but had sentiments of bitterness that she never expressed. It was forbidden in the family to express emotions or needs. The patient could not remember whether her parents had ever argued. The patient commented that they never shared emotions, even negative ones, since they rarely communicated openly, apart from the occasions when her father was critical towards her mother. It appeared from the patient’s descriptions that her parents had a very distant relationship, and were withdrawn and disengaged from interaction. They did not look at one another while talking, nor show facial expressiveness to one another. According to the patient, her father appeared not to listen when mother was talking to him. Throughout the sessions, the therapist learned of the patient’s impasse in trying to communicate with her parents, and her description of fruitless efforts to exchange opinions with her parents, who indeed, according to her description, did not speak other than to utter words necessary to accomplish the task at hand..At the same time, it appeared that an extreme “alliance” between the patient and her mother existed in which the patient became the “parentified”, “triangulated” child. The patient had observed that when the two parents were tired because of the verbal or non-verbal complaints they exchanged, they turned towards the patient and attributed to her responsibility for their fatigue. Alternatively, her mother would scapegoat the patient by complaining that her daughter accomplished her tasks very slowly. She wondered, “How the patient could ever be married one day with such a slow pace of housekeeping”.In addition, there were no clear family boundaries or roles. Since her parents had a distant relationship with one another and others in the family, they lost control of the family. They could not provide care and nurturance to their children. The patient assumed a parental role. She was responsible for her two younger sisters when her parents worked in the fields. She had to nurture them, and prepare them for school. In addition to being parentified towards her siblings, she was also parentified towards her mother.The patient shouldered the housework in order to protect her mother from her father’s criticism. Her mother made all the decisions for her family, but then received criticism when something did not work. The patient took steps to protect her mother from this, by making sure that everything in the house was working well, or by being extra supportive towards her mother. Her mother depended almost exclusively upon this young girl, who was unable to verbalize her negative feelings, mainly because of her fear that she might upset and emotionally distress her mother. There were also weak boundaries among the three generations. The patient’s father strongly aligned psychologically with his family of origin, which repeatedly “exploited” both him and his wife. Also, given that her mother’s father offered money to assist the household, he asked a great deal from the patient’s parents. In addition, her mother’s parents forced her parents implicitly –and sometimes explicitly- to vote and become active members of the political and social parties they belonged to. Furthermore, both grandparents imposed upon the patient’s parents to work for them on weekends, although they could have afforded someone else to help. Thus both parents became victims of “exploitation”  by their families of origin where neither limits nor personal boundaries existed. Roles were tragically divided between those of “exploiters” and “victims”. The patient’s parents were the “victims” of their parents’ “exploitation”, The patient’s mother was the “victim” of the father’s “exploitation”, and the patient was the “victim” of the mother’s “exploitation”.Since the spouses were alienated from each other, they avoided discussing matters that concerned them in order to maintain a barely tolerable relationship. The patient reported that she “felt” the negative emotional relationship between her parents. The lack of warmth, respect, and tenderness described seemed to contribute to the negative family emotional climate, which in turn added to the patient’s distress . In addiMost of the time the patient was neglected with regard to her need for secure attachment and parental support. For example she was neglected in terms of her need to have a real discussion in a calm manner, to be supported in her first efforts to discuss her feelings towards her parents, and her intense feelings of loneliness and helplessness. Thus, the patient was functionally and essentially neglected, and insecurely attached to her parents, which stemmed from inadequate parenting. It was clear that no one cared, nor even suspected, that the stressful family situation overloaded the patient emotionally. These experiences over time contributed to a parent–child relational insecurity and distress in the child, which has been shown to contribute to asthma disease activity ,8.In contrast, when the patient became ill from asthmatic crises, her parents were really worried, and stopped neglecting her. They took good care of her, making sure that she would stay in bed and take her medication. These were the only occasions when the patient’s parents were united, and when other problems did not occupy their focus of attention. On the other hand, the patient’s asthmatic incidents caused further disruption of familial relationships. Her parents’ anxiety increased during asthmatic crises, because they were afraid lest their child would die. The patient could not breathe easily, and at times she could not breathe at all. Her parents were also tired because of lack of sleep, due to their staying awake next to their daughter’s bed. Also they were obliged to miss some days of work, because they could not pay for a nurse. These factors contributed to the family’s overall stress and instability, and subsequent neglect of the patient, which would, in turn, stress her and worsen her asthma in a cyclical spiral.The patient’s family thus fluctuated from extremely low levels of responsivity to extremely high levels of responsivity. The family members were psychologically and emotionally distant, only to be reunited and share their distress and worry after an asthma attack. There were also extreme levels of responsivity between the patient and her mother, which exacerbated maladaptive emotional and psychological resonance through emotional contagion . The patDuring difficult family times, the patient would become increasingly depressed, and she reported feeling “overwhelmed”. The patient’s emotional state was mainly depressive and hopeless. She felt lonely, misunderstood and unable to cope with specific situations. Research shows that these feelings are related to autonomic dysregulation accompanied by worse airway function and disease activity in child asthma ,5. AfterThe patterns of BBFM relational stress described above, provided the formulation of the patient’s family contextual situation, and guided the intervention process with clear direction and focus.The long-term asthma control medications included inhaled corticosteroids (Pulmicort), leukotriene modifiers (singulair),combination inhalers (Symbicort) and Theophylline daily. These medications were judged as the most effective medications in order to keep asthma under control. Before the psychotherapeutic intervention, she had often acute severe asthmatic crises, during which she ought to go either to clinic or in the hospital. She ought to be hospitalized, be injected and receive oral corticosteroids. After counseling, she learned to set limits and manage herself, so that she could prevent asthmatic crises. Thus, she was neither hospitalized nor she receive oral corticosteroids during and after psychological counseling.The patient was treated by a physician for asthma and by a psychologist (first author) for her emotional and family difficulties. The psychotherapy lasted 6 months, with weekly sessions, followed by planned follow-ups. Since the family was unwilling to participate, the therapist used Bowenian theories  and inteThe treatment addressed specific dimensions of BBFM that were particularly problematic for the patient. For example, her parents’ troubled relationship was discussed, and the patient was helped to realize that it was not appropriate for her to buffer her mother from her father. D. was helped with this by elaborating on concrete examples derived from her own descriptions: were her interventions effective? No… How did her interventions influence her parents’ interactions? They did not… This line of inquiry helped the patient to realize that her interventions were not effective. She was also helped to realize that it is not appropriate by coming to realize that it was damaging to herself, and that it is not a teenager’s responsibility to sacrifice her health for her parents, especially if it was not helping them. Thus, the triangulation was challenged, and it began to diminish, and a process of self-differentiation was shaped, encouraged and reinforced .differentiation. Nonetheless, Greek families do typically help their adolescents and young adults achieve differentiated functioning [To support the patient’s differentiation and to decrease the effect of the depressing family emotional climate, the therapist focused on appropriate adolescent developmental tasks. Adolescence is a key time in a young woman’s life. She needs to be encouraged to form her own identity and life. In Greece, it is very difficult, and not expected, for a young adult also to be completely independent financially, which may undermine adolescent ctioning . However“individuality” has not been considered a virtue for hundreds of years, unlike in the US where is held in high value[It is important to note that there are additional cultural aspects to take into account in assisting an adolescent to “differentiate”, For example, in some cultures family members may “violate” each other’s boundaries without problematic outcomes. For example, boundary invasion is usually observed in Greek families. In Greece igh value. In concThe patient was helped to introduce amusement activities for herself into her weekly program. She started to go to the pool and to take care of herself while avoiding being caught in triangulations. Her family unfortunately, but predictably, resisted the patient’s differentiation. They made comments such as: “Nowadays, children do not respect their parents. You have started recently to become rude and selfish, as if you did not know how many problems we face. If you do not care for your family, who will?”in setting boundaries, in concert with an attitude of respect towards her parents, in the face of these challenges.This resistance influenced the young girl negatively, as she was inspired to help her parents and sisters to live a more fulfilling life despite their problems. The therapist supported the patient At the same time, occasions in which the crises occurred were thoroughly studied by the patient and the therapist in collaboration. They addressed “process questions”, with regard to the familial relations and the role of patient in the mesh of these relations. Questions raised were: “If your mother had a dispute with your father or sister, how would you deal with it?” “Did she ask you to comfort her or did she blame you for not having helped before?” “How did you feel inside?” “What did you do?” Or “When your father blamed his parents-in–law for causing a conflict, what went on inside you?” The patient was assisted in observing that a correlation existed between the depression and the despair that she was experiencing, and the occurrence of asthma crises. The patient also gradually came to realize that she was neither responsible for, nor did she have the capacity to resolve, the unsolvable problems of her family. She also came to accept that it was not her duty to provide solutions to, or exclusively support, her mother .differentiation. She was assisted in expressing her distress and despair verbally, at least during sessions. Realizing and verbalizing her feelings helped her to start observing herself and her interactions with her family. Also, it was important for her to be able to determine her “self space” and her personal limits and to decrease her guilt and self-blame. Through trial and error assignments, she was encouraged to question her own maladaptive patterns. For example, “was the feeling of constant guilt for her behavior towards her unsatisfied parents a useful attitude?” “Could she become less afraid of her parents’ reactions?” She was assigned small experiments in order to test, herself, the consequences of her relatedness to her internal and external emotional environment .Another objective was to psychologically support and to reinforce the patient’s The concept of Biobehavioral reactivity helped the patient a great deal. The concept enabled her to understand and identify her “psychosomatic” limits. She started writing a diary, where she noted the internal and external events that preceded and succeeded the asthmatic crises. She was encouraged to take a distance and study the interactions’ sequencing. A very effective technique here to encourage differentiation was the technique of writing a diary. This technique was suggested by my supervisor (Bowenian therapist Dr. N. Charitos), and is amply evidenced in Dr. Penn’s approach  to familThis helps the person to realize a personal internal space’s existence, space that usually is absent in ‘enmeshed’ families, as Minuchin describes them  It also These self-observations fostered a clear view of her sensitivity, her personal limits with regard to her asthmatic crises. These changes were neither easy nor automatic. The patient was caught in a pattern of being the problem- solver for her family. It was difficult for her to relinquish this role, but changes did occur in small steps .differentiation of herself. Thus, she became able to assertively explain why she chose to say “no” to her family in certain circumstances. She expressed respect towards her parents and caring towards her sisters, but she explained that it was beyond her physical abilities to support her family at the expense of her health. Writing down her observations regarding the relationships in her family helped her realize the triangles she was involved in with her parents, and how the weak boundaries between her parents and her grandparents created a ‘togetherness amalgam’, in which she was entangled. It took quite a bit of time before the patient could set limits, and dare speak up for herself to her family, when they intrusively sought inappropriate support from her. Successful treatment requires substantial experiential practice, because insight is not sufficient to evoke lasting change [Simultaneously, re-thinking her life style, and examining her feelings from a more rational perspective, contributed to her increasing competence, self- awareness and g change ,22.The follow-ups were every two weeks for the first year and every month for the second year. Sessions focused on helping the young adolescent stabilize her new differentiation and her improved psychosocial adjustment. At the end of treatment, the patient’s asthmatic symptoms were controlled, so that she could avoid asthmatic crises and hospitalization. Moreover she was emotionally content and engaging in developmentally appropriate activities. Her family was still a source of sadness and stress for her, but she was able to sustain her own physical and emotional well being without severing her ties with her family.Of course, in the above mentioned conclusions there are limitations, which are due to the fact that all the observations are based on a single case study.In this case study, the family patterns observed and the manner in which they impacted on the patient’s emotional and physical compromise were consistent with the findings of research testing the BBFM. The fact that the patient’s health improved by means of psychotherapy, focusing on these family patterns without any changes in her medical-pharmaceutical care, constituted another piece of evidence for the important role of these factors in the development and course of illness. Given these limitations, we think that that a biopsychosocial approach is necessary in the treatment of diseases in which there is a psychobiological pathway. Such approaches could “break” the vicious cycle of maladaptive biopsychosocial interactions, thus yielding better therapeutic results, without a need for an increase in the dosage and side effects of medication. The BBFM provides specific targets upon which to focus a biopsychosocial intervention.Note: Term definition:“Stress” is the organism’s response to stressful conditions or stressors, consisting of a pattern of physiological and psychological reactions, both immediate and delayed.“Onset of illness” is defined by the appearance of clinical symptoms of disease.“Predisposing factors” are longstanding behavior patterns, childhood experiences, and durable personal and social characteristics that may alter the susceptibility of the individual to illness.“Precipitating factors,” in contrast, influence the timing of illness onset; the term refers for the most part to more or less transient changes in current conditions or characteristics, and it is such changes that constitute our present subject of inquiry.“Chronic disease” refers here very generally to syndromes which are of long duration and are noninfectious.“Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal”.The authors declare that they have no competing interests.MT conducted the treatment, conceptualized the presentation of the model as case study and wrote the main parts of the article. OA and PA discussed treatment and the application of the model to the case with the first author. Prof. BW participated with the first author in the written conceptualization of the presentation of the model as applied to the case. All authors read and approved the final manuscript.“ Dr. BW participation on the study was partially supported by a grant (1R01MH064154) from National Institute of Health, USA.


With increasing interest in the use of urban green space to promote human health, there is a need to understand the extent to which park users conceptualize these places as a resource for health and well-being. This study sought to examine park users’ own reasons for and benefits from green space usage and compare these with concepts and constructs in existing person-environment-health theories and models of health. Conducted in 13 public green spaces in Sheffield, UK, we undertook a qualitative content analysis of 312 park users’ responses to open-ended interview questions and identified a breadth, depth and salience of visit motivators and derived effects. Findings highlight a discrepancy between reasons for visiting and derived effects from the use of urban green space. Motivations emphasized walking, green space qualities, and children. Derived effects highlighted relaxation, positive emotions within the self and towards the place, and spiritual well-being. We generate a taxonomy of motivations and derived effects that could facilitate operationalization within empirical research and articulate a conceptual framework linking motivators to outcomes for investigating green space as a resource for human health and well-being. Over half of the World’s population lives in urban areas . Urban lThe personal benefits of interaction with urban nature include improved cognitive functioning ,20, reduin situ observation  the green space also provided an opportunity to “be in the sun” while for another participant it was an opportunity for “fresh air, [to] hit a few golf balls” [P41]. Non-nature reasons for use emphasized the physical nearness of the space to one’s home or work and the available facilities, such as play areas for children, events and, for one individual, the fact that “it’s free, so might as well use it” [P78]. Comments about the peace and quietness of the place as well as “it’s a nice place to be” [P40] illustrate the more intangible components of the park features theme. Two theory-based themes, place identity and place attachment, also emerged as visit motivations capturing the identity from or feelings of attachment to the park. Mentioned minimally, these are illustrated by comments such as “[I] grew up here and played here as a child so [I am] familiar with it” [P273] and “feels like a second home” [P188], respectively. The third most frequently mentioned motivator was a child. Reasons for bringing children largely mirrored those that brought adults to the parks. Physical pursuits encompassed almost half the comments with “play” a recurrent activity for children. Examples include “bring children to play” [P162] or “take kids to park to let them run off energy” [P25]. For 33 individuals children were the primary visit motivation. While play dominates, social, nature, unstructured time, and park features were also present. The cognitive domain, fourth in endorsement, contained a theme related to purposeful mental pursuits ; it is analogous to the physical pursuits theme that described activities that engage the body. Within this theme is a small but interesting collection of comments coded as purposeful work. For some, engagement with the green space itself constituted that purposeful work, for example, through “keeping an eye on the park, picking rubbish  up on my route” [P277]. Only five green space users specifically mentioned coming for mental restoration, considered characteristic of Attention Restoration Theory. These types of comments were either the first or second mentioned and almost exclusively described as taking a break or getting away from work.i.e., “[to] look at kids playing with bikes and skates” [P2]. The social dimension was the only mentioned reason for eight participants; it was more frequently coupled with motivations from the other identified domains. For example, one participant combined social time with dog walking and bird watching: “[I come to] walk the dog, meet friends and look at wildlife, birds in particular” [P247].The fifth dimension, social, was less present as a motivator. The green space was primarily a meeting point, a place for socializing; one participant spoke of this aspect in terms of people watching, The final domain to emerge from participants’ comments was unstructured time. While it had the fewest number of comments, the motivation described was distinct. One participant described this as “wander through woods...today I decided to just explore and see where paths lead me” [P203]. The comments within this domain suggested a purposefully unplanned period of time.Participants’ 527 comments describing how they feel after leaving the park were grouped into seven domains: physical, affective, place attachment, spiritual, cognitive, global well-being, and social . Most participants identified benefits in the physical domain, which included themes associated with the physical body. “Relaxed” was the single most commonly mentioned word although some participants provided greater imagery, such as “wound down a bit” [P82] and “bit mellow because of greenery in the city” [P30]. Over three-quarters (85%) of comments within the relaxed theme were mentioned first. The revitalized theme, made up of four codes, was clearly distinct in tone and is captured by comments such as “recharge your battery” [P111] or “[a] bit more energized; revived having had fresh air/exercise” [P47]. While most individuals felt positive physical states, a few felt depleted  or uncomfortable.Two domains, affective and place attachment, together represented park users’ emotions, either within oneself or feelings about the park. The majority of personal feelings were positive  although some people felt strongly positive, such as joyful or exhilarated. Exemplar comments from the affective domain included, “come up feeling fed up, leaving feeling great” [P241] and “happy because [you] have seen wildlife [you] would not have seen at home” [P187]. Comments capturing the emotions toward the place included, “I just love it, even on cold, rainy days” [P61] and “[I] considered joining a gym but realized it was more enjoyable to come to the park for walking” [P187]. For some participants the resultant emotional state was contingent on context, such as another’s behavior, the activity, or the weather. A minority of individuals had neutral  or, more rarely, negative feelings. The latter were generally based on either the deteriorated condition of the park, such as the participant who was “disappointed, upset by condition of park” [P34] or a perceived lack of safety as noted by an individual who felt “relieved because it can be unsafe and isn’t welcoming” [P272]. A spiritual domain emerged as the fourth most commonly mentioned derived effect with comments organized into two themes. Expressions of tranquility, made up of six codes, reflected a sense of peace akin to being in a sacred place; examples of more detailed responses included “calms you down—out of hustle and bustle” [P92] and “go from peace to rat race; feel peaceful here” [P94]. The experience of being unified with and a part of a larger reality was found in comments about a connection to nature  and the euphoric feeling of being outside of the built environment  is an exemplar. Use of urban green spaces contributed to cognitive health through providing opportunities for satisfaction and mental restoration. Satisfaction related to accomplishing a specific task  or a sense of contentment with how one has spent one’s time . Fewer comments directly pertained to the restoration of attention. This effect was captured by the comment, “got things in perspective because I’ve done a bit of mulling things over and everything is put in its place after being here” [P217]. i.e., “find it quite interesting—always notice something new” [P208]. Another person experienced spiritual, physical, and emotional well-being: “peace of mind, relaxing; listening to birds, watching wind, birds fly kind of calms me; feel fantastic, had a bit of fresh air” [P113]. Perhaps the clearest statement that encapsulated this holistic health effect was from the individual who came to go “jogging” and whose derived effect description touched on almost all health domains: “relaxed, quite joyful, peaceful, despite noise one hears in park, quite clear-headed actually, therapeutic—being here is therapeutic” [P20]. A small number of participants conveyed a sense of global well-being. The unspecified nature and broad content of the comments associated with two codes within this domain  suggested that an important general effect was occurring. For example, one participant stated they “feel a bit better even if quite [a] subtle feeling” [P276] while another left “look[ing] forward to next time I will come to park, [I] feel healthy, [I’ve] had a walk, [and I’m] happy” [P40]. A further examination of instances where participants gave several answers showed that many were describing multiple aspects of health. For example, one individual felt physical effects of “more relaxed, refreshed really” and mental stimulation, Only six participants mentioned the social benefit of feeling connected to others. One individual, who came for the facilities, expressed this effect as “caring—feel more inclined to think about people as individuals rather than just lump together in a category, particularly in terms of teenage boys in skatepark” [P66]. A comparison between the identified domains  providedfull of fresh air), interconnected (connected to nature), and value of park (nice space). The affective and spiritualdomains (19% and 13% respectively) emerged only as effects derived from park use; affective states were largely positive (70%). Additional differences between visit motivations and effects included the presence of unstructured time as a driver (2%) and global well-being (3%) as a derived effect. The physical body domain was the largest for both, representing 52% of visit motivation  and 41% of derived effects (mainly relaxed) responses. Cognitive and social domains were also jointly present. In both instances these were a small proportion of responses. Attention restoration was an identified visit motivation for five individuals while only 17 indicated it as a derived effect. Place attachment, a fairly insignificant visit motivation theme, became a notable post-park effect domain comprising 14% of the overall responses. Children, a prominent visit motivation, appeared only as explanations for accomplishment or satisfaction, captured by codes within the cognitive derived effect domain. Nature, a central visit motivation theme within the space quality domain, was located at the derived effect code level within the themes of revitalized , play for children, purposeful mental pursuits, social gathering, and purposefully unplanned time. Seven domains described the derived effects: physical, affective, place attachment, spiritual, cognitive, global well-being, and social. Participants identified feeling physical effects such as relaxation and revitalization, positive emotions, attachment towards the place, spiritual tranquility and connection, cognitive satisfaction, an overall sense of health, and social connection. An examination of the relationship between visit motivation and the ensuing state identified that walking resulted in largely positive effects across multiple domains including physical, affective, place attachment, spiritual and cognitive. Relaxation, while rarely cited as a visit motivation, was central to how park users felt afterwards and was associated with a wide range of visit motivations. Our analysis identified the complexity of motivations for park use and the multiple aspects of individual well-being that can result from time in urban green space. The focus of this study was to understand the place of health and well-being in urban park usage. Comments from urban green space users Visit motivations provided by participants in this study broadly mirror findings from previous research into the use of urban green space worldwide: UK: , NetherlThe qualities of the place itself, the majority of which were nature-related comments, were clearly important reasons for park use among participants in this study. While in keeping with other studies ,35, by sConcepts from sense of place literature and Attention Restoration Theory featured minimally as participant identified motivators. The few comments within the cognitive dimension were largely represented by pursuits that involve the mind (reading) with only five individuals specifically identifying the desire for a break. This differs from studies of urban parks that have used closed-ended checklists in which the opportunity to “escape the city”  or “get The interesting presence of a desire for unstructured time, for both adults and children, perhaps highlights recognition of its rarity in our modern world ,88. Its As a whole, visit motivations minimally identified the use of urban green space for the explicit “pursuit of health”. Participants never used the word “health”, and while physical pursuits dominated the coded responses, most of which centered on walking, walking in parks was more often incorporated as part of a daily routine rather than a purposeful health walk. Our findings remind us of the multiplicity of ways in which ordinary park users conceptualized park use, highlight the minimal explanation provided by any one theory, and underscore the need for a fuller consideration when measuring—and seeking to promote—urban green space for healthy living.i.e., stress levels, has been investigated by other researchers such as a large-scale Danish study [Comments associated with having been in an urban green space described a complex set of effects usually experienced by the park users in this study. The major derived effect was “relaxed”, a physiologic state in which the person experiences decreased respiratory rate, heart rate, and muscle tension , which ish study  that fouThe identified broad spectrum of positive emotions relates to empirical work in the emerging field of positive psychology  which haThe other affective component identified in this study is place attachment including positive feelings towards the green space, such as love or gratitude. The experience of love or gratitude, themselves positive emotions, has been found to promote individual well-being ,102,103 The expressed feelings of tranquility and interconnectedness, interpreted here as spiritual and previously documented to occur in wilderness settings , suggestComments pertaining to cognitive health emphasized the satisfaction gained from having achieved one’s aims and from how one has spent time, implying a “fit” or “match” between what the setting offers and one’s purposes. This is illustrative of the concept of compatibility, posited as an important component of a cognitively restorative environment ,42. Howeet al. [In general, our data support a derived effect of positive well-being for individuals. Wellness has been defined as “a condition obtained when a person achieves a level of health that minimizes the chances of becoming ill…achieved by a combination of emotional, environmental, mental, physical, social, and spiritual health” . This deet al.  found thOur findings suggest the need to use a broad conceptual framework for considering the relationship between personal motivators, the natural environment, and individual health, one that takes into account the reports of green space users and is reflective of holistic benefits in multiple dimensions for the individual: physical, mental, emotional, social, and spiritual . We emphasize here that when users of urban green space are directly asked to identify their motivations or how they feel after being in the space, they give more reasons and benefits than suggested by any one existing theory or identified through the use of a closed-ended checklist drawn from previous research. Our findings suggest that theories and models may need to be combined to understand the range of motivations and effects for the individual. Understanding these components can inform future research by suggesting the selection of existing validated scales or the need for newly constructed scales to test hypotheses derived from the model. The results of this study also suggest a conscious parsing of motivators and effects that have been confounded in previous studies using structured scales. This is indeed one of the strengths of qualitative research that calls us to generate new theory or models to more fully explain the phenomena under study. Limitations stem from decisions related to sampling, the data recording method, interpretation of the data, and the research setting. Ours was a purposive sampling of actual green space users. The sample size and the diversity of responses did not allow investigation of socio-demographic  or use  differences. Data, collected primarily as written notes by the interviewer, may have lost some richness of the participants’ language. Inter-rater reliability was not calculated to assess our coding scheme and some comments could be interpreted differently . The data were, however, examined using an iterative process that sought to resolve differences in the conceptual mapping of quotes between researchers from different disciplines . Lastly, findings clearly pertain to the individuals using the park settings being studied and the limited time frame of “today” thus the research does not address historical or socio-cultural use of public spaces.in situ measures of relaxation (both self-report and objective). Important directions for future research include a larger sample to allow analyses of group differences and further examination of the dynamic relationship between visit motivation and the post-park experience. Different cultural contexts and different types of natural environments would provide insight into the universality of the findings. Research could also usefully focus on disentangling distinctions between concepts such as a general love of nature and a love of a specific place. A crucial way to advance the field is measure development, including standardized closed-ended self-report questions that reliably measure the range of identified health domains as well as Our results fit into a wider picture of efforts to promote healthy behaviors and plan sustainable urban environments. Although we recognize that further investigation to establish linkages would be necessary, our findings offer some suggestions worthy of inclusion in the dialogue on these matters. Physical pursuits, particularly walking, were the most often stated reason for visiting a park. As a low cost antidote for increasingly sedentary urban lifestyles, park-based physical activity could contribute to addressing the obesity and overweight epidemic for both adults and children  as well Urban green space is emphasized in policy documents across the world and is considered a key dimension of the sustainable city ,116,117.in situ, provide a weighted taxonomy that illustrates the breadth, depth and salience of the reasons people use parks and the effects experienced. People choose to visit urban green space for many reasons, including both their own personal motivators and ones related to the space itself; healthful physical activity is but one of these motivators. Green space has the potential to provide several types of holistic health benefits including relaxation, positive emotions about self and environment, tranquility, revitalization, and satisfaction. The dominant benefit identified is relaxation and, given its demonstrated importance in health promotion, more research is warranted to understand this process. Efforts to investigate or promote urban green space as a health resource need to carefully account for the multiplicity of motivations and benefits identified by users. The preservation and expansion of green space could be framed as a health benefit to individuals, which may provide an additive rationale for environmentally sound policy decisions. Much has been written about the importance of incorporating nature into the built environment from the perspective of cultural and societal values ,120, eco


The origin of kindness is a mystery. Where do giving and altruism come from: were they inherited on the wings of natural selection – a gift bestowed upon us via the inching, evolutionary march of sacrificial amoeba, selfless penguins, and charitable baboons? Or is altruism a unique refinement, a singular human triumph over ‘nature bloody in tooth in claw’? Darwin called this his greatest single riddle and ever since thinkers have tried to crack it.One hundred and fifty years of attempts to crack the mystery of altruism can teach us a lot about how prior ideological commitments find their way directly into the scientific enterprise. Beginning with the debate between “Darwin’s bulldog”, Thomas Henry Huxley, and the Russian anarchist prince Peter Kropotkin, the history of such attempts tells a story of direct contact, and mutual interplay, between social, political and scientific thought. Whether it is the Chicago ecologists of the 1920s through 1940s, arguing for group selection and the “superorganism” as Fascism tore through Europe, or John von Neumann and the progenitors of Game Theory touting a belief in the utter selfishness of the “maximizing agent” as they modeled games on their swivel chairs at RAND, theories of altruism and cooperation have been closely linked to scientists’ own understanding of the moral good and its social consequences.Neurogenetics and fMRI studies are showing today that kindness may be located in our genes and in particular parts of our brain. Coupled to animal behavior studies, brain damage studies, evolutionary psychology logic, and mathematical modeling, they are supposedly pointed in the direction of cracking the altruism mystery. But precisely for this reason, we need to remember the fate of George Price, who will be the focus of this presentation. The achievements and tragedy of this hitherto forgotten American genius chemist-turned-evolutionist-turned-homeless vagabond, I will argue, provide salutary lessons regarding our understanding of altruism, as well as the limits of scientific inquiry. “Even if all possible scientific questions be answered”, the twentieth century philosopher Ludwig Wittgenstein wrote, “The problems of life have still not been touched at all. Of course there is then no question left, and just this is the answer”. Price's incredible life story will be presented to argue this point.