Stress, Coping, and Development, 2nd Edition: An Integrative Perspective

STRESS, COPING, AND DEVELOPMENT

Stress, Coping, and Development An Integrative Perspective SECOND EDITION

CAROLYN M. ALDWIN Foreword by Emmy E. Werner

THE GUILFORD PRESS New York London

©2007 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number:

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Library of Congress Cataloging-in-Publication Data Aldwin, Carolyn M. Stress, coping, and development : an integrative perspective / Carolyn M. Aldwin ; foreword by Emmy E. Werner. — 2nd ed. p. cm. Includes bibliographical references and index. ISBN-13: 978-1-57230-840-4 ISBN-10: 1-57230-840-0 (cloth : alk. paper) 1. Stress (Psychology) 2. Adjustment (Psychology) 3. Stress (Psychology)— Research. 4. Adjustment (Psychology)—Research. 5. Developmental psychology. 6. Mind and body. I. Title. BF575.S75A42 2007 155.9′042—dc22 2006101615

About the Author

Carolyn M. Aldwin, PhD, is Professor and Chair of the Department of Human Development and Family Sciences at Oregon State University, Corvallis. She received her doctorate from the University of California, San Francisco, in 1982 and was a National Institute of Mental Health postdoctoral scholar in Human Development, Environmental Demands, and Health. Dr. Aldwin received a FIRST award from the National Institute on Aging for her study of psychosocial factors affecting health in aging early in her career; she has published more than 70 articles and chapters in these areas and recently coedited the Handbook of Health Psychology and Aging for The Guilford Press. Dr. Aldwin is a fellow of both Divisions 20 (Adult Development and Aging) and 38 (Health Psychology) of the American Psychological Association, as well as of the Gerontological Society of America.

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he second edition of the New Oxford American Dictionary (2005) defines stress as “a state of mental or emotional strain or tension resulting from adverse or very demanding circumstances,” coping as “the ability to deal effectively with something difficult,” and development as a “specified state of growth or advancement.” Readers of the second edition of Stress, Coping, and Development may, on occasion, experience some mental strain in dealing effectively with the contents of this book. But they will be richly rewarded for their efforts! Carolyn Aldwin’s integrative perspective is bound to advance their understanding of a body of stress research that has resulted in thousands of scholarly publications and hundreds of new coping scales since the first edition of her book was published in 1994. I am in awe at the scope of disciplines that Aldwin draws upon for this enterprise. They range from anthropology to sociology and developmental psychology; from immunology and neuroendocrinology to philosophy and comparative religion. Each of the perspectives presented (from cellular repair mechanisms to “mindful coping”) extends the boundaries of stress and coping research. Aldwin does a masterful job in helping us navigate through the maze of conceptual and measurement issues that confront anyone brave enough to do research in this field—indeed, some two-thirds of her book deals with these topics. She also introduces the reader to statistical issues in coping research that are quite complex. Aldwin’s cogent discussion of methodological issues points to a certain paradox: The statistical models in coping research are becoming vii

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more sophisticated, but the actual measurement of stress and coping strategies is still quite crude and relies heavily on self-report questionnaires that seem to multiply at an alarming rate—from about 70 “coping scales” in 1994 to more than 200 in 2006. Aldwin argues persuasively that research on stress and coping needs to take a transactional and longitudinal perspective, focusing on people’s lives over time and on the social and cultural context in which they grow up. But in the research reviewed in the last third of her book—on topics such as coping and health, developmental changes in stress and coping, and stress as an impetus for psychosocial development—she cites only a handful of longitudinal studies that have focused on “coping with traumatic stress” and “transformational coping.” In a related field, there has been a virtual explosion of research on the phenomenon of resilience, the process that leads to positive adaptation despite significant life adversities. There are now more than a dozen large-scale longitudinal studies of this phenomenon in North America, Europe, Australia, and New Zealand that extend from childhood into adulthood. Their findings can be profitably linked up with the results of contemporary research on stress and coping. I have spent most of my professional life observing and documenting the extraordinary capacity of human beings to overcome great odds. Occasionally I have found it helpful to reread my favorite Grook, or aphorism, written by the Danish physicist and poet Peit Hein in the darkest days of World War II, a time that gave many of my generation an opportunity to cope with traumatic stress. It deals with wisdom, one of the key concepts in the theory of adaptation Aldwin presents in the final chapter of her book. The Road to wisdom? Well, it’s plain and simple to express: Err and err and err again, But less and less and less.

I trust that Aldwin’s book will become a helpful guide for both graduate students and seasoned professionals in the behavioral sciences who are willing to cross disciplinary lines to find that road. EMMY E. WERNER, PHD University of California, Davis

Preface

Preface

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n the first edition of this book, published in 1994, I noted the explosion of research into stress and coping processes. Now, more than a decade later, there are an additional 186,000 articles on stress and 37,000 articles on coping in the literature! Clearly there is a need for an update, as there have been substantial strides in the knowledge that stress and coping researchers have garnered in the past 12 years. Given the massive amounts of literature, however, it is impossible to review every article. Thus, I have been forced to be selective, relying on the many excellent reviews of specific areas as well as on articles that are seminal in the field. I have tried to be as comprehensive as possible and have myself learned a great deal. For this edition, I have provided general updates to nearly all sections of each chapter and have spent considerable time on what I perceive to be exciting new areas. These include stress-related growth (Chapter 15); social and cultural aspects of coping, including dyadic coping (Chapter 13); as well as new approaches to coping, such as experience sampling, emotion regulation, and religious coping (Chapter 7). We have also become much more sophisticated in our knowledge of the physiology of stress, and the current edition also reflects that change (Chapter 4). Chapter 11, the coping and health chapter, includes a new section on coping and physiology. Chapter 14, which reviews both child and adult developmental coping research, has also been greatly expanded to include the many new coping studies in child development as well as the new and very promising emphasis on self-regulation. It also ix

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includes new sections on young adulthood and midlife. Finally, the last chapter (16) includes what I hope will become an overarching paradigm for stress and coping research, which combines the self-regulation approach from child development with the new self-development approaches in adult development, expanding upon the earlier discussion on intentionality in development. The past 12 years have also seen major controversies. During the 1980s, there were calls to abandon stress research, given certain definitional problems. During the 1990s, there were calls to abandon coping research for similar reasons. In my opinion, this would be tantamount to “throwing out the baby with the bath water” and, to my mind, premature. The point is, coping is complicated. Nearly three decades ago Pearlin and Schooler (1978) warned that there was no “magic bullet” in coping research, and the research has borne this out. There is simply no single strategy that works for everyone, in every place, at every time. Rather, the nature and effects of coping are highly contextualized and reflect individual motivations, interpersonal dynamics, and factors that may be situation or culture specific. Thus, it is understandable that those who wish for simple answers would be frustrated, and point to the confusion in the literature as a reason to abandon ship. On the contrary, this seems to me to be a gloriously rich conundrum that offers a wonderful window into the complexity of adaptation. Why do the problem-focused strategies work for one type of problem and not another? For one person and not another? At one point in an illness trajectory and not another? Why are emotion-focused strategies, meant to decrease negative affect, so often correlated with psychological distress? Are there emotion-focused strategies that actually do decrease distress? It is true that our coping measures have been rather crude, but there are increasingly sophisticated measures that I think may be very promising. Toward that end, I have also provided an updated list of coping measures in Chapter 8, including ones published in other languages. This chapter also includes a new review of the debate over retrospective versus experience-sampling assessments of coping. The past 12 years have also seen a quantitative leap in analytical tools for multivariate and longitudinal data analysis. Consequently, I have updated the methods chapter (9) with an admittedly somewhat simplistic overview of these new techniques. In the first edition, I descried the problem that our analytical techniques were not yet up to the sophistication of our models. Now that the analytical techniques are catching up, they are often so new and so complicated—and use their own “magic language”—that many individuals, especially those who have not graduated in the past 5 years or so, are not familiar with the terminology, their uses, and their assumptions. By providing a nonmathe-

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matical description of these terms, I hope to offer a lifeline to those who are drowning in a sea of LISREL, latent growth curves, hierarchical linear models, and longitudinal trajectories of all kinds. I am particularly pleased by the fact that the literature on the positive aspects of stress, or stress-related growth, as it is now called, has really taken off (Chapter 15). The whole field of positive psychology is, I think, a very favorable development, although it is not without its critics (see Lazarus, 2003). The importance of religious coping has also come to the forefront, reflecting the general increase in religiousness seen during the past decade, and Chapter 16 provides a “new take” on why religious coping is often effective. It is still true, however, that too often closely related fields use different terminology to refer to what are similar if not identical constructs. For example, in developmental psychology, there has been a flurry of studies on self-regulation (see Eisenberg & Zhou, 2000). There are also parallels in the adult development literature between primary and secondary control (Schulz & Heckhausen, 1998), assimilative and accommodative processes (Brandstädter, 1999), and problem- and emotionfocused coping. In cognitive psychology, a lot of interest has been generated by processes used to compensate for cognitive declines (see Dixon, 1996). Researchers in that area are also struggling with many of the same issues as are those in the coping literature, such as, Is compensation conscious or unconscious (see Dixon & Bäckman, 1995)? Again, it is not possible for one person to thoroughly review all fields, but I hope at least to encourage others to examine developments in these other fields to inform their own work, and I would suggest that these other fields would benefit from the richness of stress and coping research. As usual, I am indebted to many people for their contributions to this volume. I would like to thank all of my colleagues who were gracious enough to send reprints and preprints. It was not possible to cite all of these often wonderful studies, but I have done my best. My graduate student Daria Boeninger spent many hours doing literature searches and finding articles for me, in a very organized fashion, that made this revision possible. My former graduate students and now colleagues Drs. Diane Gilmer and Loriena Yancura have worked with me on other reviews of the stress and coping literature, from which I have borrowed liberally for this update. Dr. Ana Paula Cupertino, another former graduate student and now colleague, graciously helped me to organize and track down references for the first draft of this revision and once again provided me with quiet places to work in Brazil, which helped me enormously in finishing this revision. Dr. Crystal Park at the University of Connecticut was very generous with her time in reading nearly all of the chapters of this book and providing extremely cogent comments. Dr.

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Megan McClelland at Oregon State University read the developmental chapter and had some very helpful suggestions. The graduate students in both my 2004 University of California, Davis, spring quarter class on Aging and Adaptation and my Oregon State University winter quarter 2005 class on Stress and Coping across the Lifespan also read drafts of chapters and provided useful feedback. Sungrok Kang provided an especially close reading of the book, and Amanda Taylor stepped in and helped with the final compilation of the references. Sandra Frye was extremely helpful in the production of the manuscript, for which I am truly grateful. My sisters, Drs. Mary Bisson (now happily the former chair of the Department of Biology at the University at Buffalo, State University of New York) and Lois Aldwin (a biochemist specializing in immune system assays), have been my “secret weapons” in understanding the biology of stress. They both have been unfailingly patient in answering questions and explaining particularly tricky bits. Once again my editor, Seymour Weingarten, demonstrated yeomanlike patience through the many missed deadlines of this book. I also must thank the thousands of men and women in the Normative Aging Study and the Davis Longitudinal Study who have generously shared their so often extremely painful experiences in coping with stress and trauma in their lives. The recounting of their struggles has given rise to many of the insights into the adaptive process presented in this volume and is the impetus for my research into resilience and stress-related growth. Finally my husband and colleague, Rick Levenson, has been unfailingly supportive. He has mastered the use of humor as a coping strategy in interpersonal interactions, for which I am profoundly grateful. He has pushed me to take alternative perspectives and often has forced me to look more deeply into answers that I thought at first to be obvious but then, on closer inspection, were shown to be lacking. And he didn’t complain (much) at the stacks of reprints that once again adorned our house in the service of this revision. For his patience and humor, I would like to dedicate this book to him. CAROLYN M. ALDWIN

Contents

Contents

CHAPTER 1

Introduction and Purpose of the Book

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Mind–Body Transactions 2 Person–Environment Transactions 7 Organization of the Book 9

CHAPTER 2

Why Is Stress Important?

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Intrinsic Interest 13 Relevance of Stress to Psychosocial Models of Adaptation 15 Relevance of Stress to Biomedical Models of Adaptation 17 Summary 22

CHAPTER 3

Definitions of Stress

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Components of the Stress Process 25 Stress as a State of the Organism 27 Stress as an External Event 28 Stress as a Transaction between the Person and the Environment 31 The Role of Emotions and Cognition in Reactions to Stress 34 Summary 36

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The Physiology of Stress

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Neuroendocrine Responses to Stress 37 Immune Responses to Stress 46 Cellular Resistance to Stress 52 Summary 53

CHAPTER 5

Design and Measurement Issues in Stress Research

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General Observations 55 Design Issues in Stress Research 57 Problems in Causal Directionality 59 Different Approaches to Stress Measurement 62 Which Measure to Use? 79 Clinical Interviews 80 Laboratory Stressors 81 Summary 82

CHAPTER 6

Why Is Coping Important?

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Intrinsic Interest 86 Mythopoetic Roots 86 Changes in Social Roles 88 Relevance of Coping to Psychosocial Models of Adaptation 91 Relevance to Biomedical Models of Adaptation 93 Differentiating between Adaptation, Coping, and Emotional Responses 95 Summary 97

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Theoretical Approaches to Coping

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Person-Based Definitions of Coping 100 Situational Determinants of Coping 113 Cognitive Approaches 115 More Recent Approaches to Coping and Adaptation 117 Summary 125

CHAPTER 8

Measurement of Coping Strategies Coping Styles versus Coping Processes 129 Retrospective versus Experience-Sampling Approaches 134 Factor Structure Instability 136 General versus Specific Coping Strategies 139

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xv Rating Scales 141 Summary 144 Appendix 8.1. Bibliography of Coping Scales 145

CHAPTER 9

Statistical Issues in Coping Research

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Mechanisms of Coping Effects 161 Statistical Analyses for Testing Mediating and Moderating Effects 166 Longitudinal Analysis of Stress and Coping Data 175 Summary 180

CHAPTER 10

Coping and Mental Health

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Confounds between Assessment and Outcome 182 Situational Modifiers of Coping Effects 183 Patterns of Coping 186 Coping Effort 187 Causal Directionality and Coping Interventions 189 Individual Differences in Coping Effectiveness 191 What Is the Appropriate Outcome of Coping Strategies? 192 Summary 193

CHAPTER 11

Coping and Physical Health

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Adaptation to Illness 197 Coping and Illness Outcomes 202 Summary 207

CHAPTER 12

Coping with Traumatic Stress

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Defining Trauma 211 Posttraumatic Stress Disorder 212 Coping with Trauma 220 Summary 238

CHAPTER 13

Sociocultural Aspects of Coping Social Aspects of Coping 239 Culture and Stress 245 Culture and Coping 257 Institutions as Coping Mechanisms 266 Summary 270

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CHAPTER 14

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Developmental Studies of Coping

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Coping in Infancy and Childhood 272 Developmental Changes in Stress and Coping in Adulthood 292 Summary 304

CHAPTER 15

Stress-Related Growth and Transformational Coping

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Arguments for the Developmental Implications of Stress 308 Stress as an Impetus for Psychosocial Development 315 Stress as an Impetus for Physiological Development 332 Models of Positive and Negative Stress Outcomes 336 Summary 340

CHAPTER 16

Self-Regulation, Self-Development, and Wisdom

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Transactionism and Coping 342 Free Will versus Deterministic Models of Adaptation 345 Mindful Coping and Wisdom 354 Summary 357

References

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Index

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STRESS, COPING, Introduction and Purpose AND DEVELOPMENT of the Book

CHAPTER 1

Introduction and Purpose of the Book

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homas Kuhn (1970) demonstrated that, from time to time, paradigm shifts occur in science and society—that is, a fundamental assumption about the nature of the world changes. The ascendance of the germ theory of disease represents one paradigm shift, relativity theory another. I believe we are currently undergoing another paradigm shift— from causal reductionism to transactionism. Simply put, in causal reductionism the occurrence of an event is reduced to its underlying cause, whereas in transactionism the occurrence of an event is understood to arise from the mutual influence of a number of factors. This paradigm shift has profound implications not only for research and clinical practice but also for the fabric of society and how we conduct our everyday lives. Clearly there is still tension between the old reductionist paradigm and the new transactional one. This is perhaps most apparent in the explosive growth in genomic science during the past two decades. On the one hand, the immense amount of information generated by the Human Genome Project, which allows us to understand more precisely the mechanisms underlying a variety of complex phenomena, can be seen as strengthening the reductionist model. But the sheer mass of information has also given rise to a systems biology approach that seeks to integrate this mountain of information by using mathematics and statistics (Pennisi, 2003). Using this technique, biologists are investigating complex topics 1

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like cell signaling, the development of limbs in fetuses, and how yeast adapt to changes in nutritional environments. This shift is occurring in many different branches of science. It is most noticeable in studies on the relations between the mind and body and those between the person and the environment, but other disciplines, including biology and subatomic physics, are also shifting to a transactionist paradigm. I will argue in this book that research into the psychological and physical effects of stress, and how they are modulated by coping efforts, has been instrumental in effecting this paradigm shift in the psychosocial and biomedical sciences. A primary focus of this book will be on bringing together literature from a variety of fields that examines transactions, both between the mind and body and between the person and the environment, within the context of stress, coping, and adaptation research.

MIND–BODY TRANSACTIONS During the 17th century René Descartes proposed a fundamental dualism between mind and body. The mind was held to engage in abstract thought and language, which was separate and distinct from the operations of the body (Eccles & Robinson, 1984). This Cartesian dualism has been a cornerstone of the reductionist paradigm underlying the biomedical sciences. It assigned the study of the physiological workings of the body to science and consideration of the mind and soul to philosophy. It was further assumed that, being distinct, the mind and the body were influenced by completely different factors and that little communication occurred between the two. Cartesian dualism was expressed in the disease model of illness, or the basic biomedical model (Virchow, 1863). This model, prevalent for the past 150 years, has held that illness results from external agents that disrupt the body’s normal functions, such as bacterial and viral agents, toxins, and carcinogens of various kinds. Research focused on the mechanisms by which external agents damaged health and on how that damage could best be repaired. This model was later expanded to include disruptions caused by internal agents, that is, faulty genes. A corollary assumption underlying the reductionist model has been that of unidirectional causality—that is, a → b → c. In biomedical terms, this means that illness is caused by exposure to an agent a that disrupts the biochemical functioning of system b that in turn leads to symptoms c. These symptoms can only be abated by restoring the functioning of system b, either by eliminating the offending agent from the body (e.g., through antibiotics) or by restoring the biochemical balance. This as-

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sumption about causality focused research on the basic biochemical constitution of the body, and the amount learned has been tremendous. In Kuhn’s (1970) terms, this paradigm has been extremely successful in advancing knowledge. But any assumption holds within itself the seeds of its own limitations. As more and more was learned about physiology and biochemistry, the complexity of that information vastly increased. It became readily apparent that a simple causal model was inadequate to describe many phenomena (von Bertalanffy, 1969). Because physiological regulation of different systems involves a highly complex series of feedback loops among multiple variables, more and more conditions and limitations were placed upon simple causal models. Although invading germs or bacteria may create a necessary condition for a particular illness, they may not be sufficient to create the illness(rather, disease results from a highly complex interaction between host systems and disease agents. For example, it can readily be demonstrated that tuberculosis results when a person is infected with tuberculin bacteria, which causes inflammation and consequent scarring of organs, especially the lungs. Characteristic symptoms include fatigue and coughing up blood and sputum. Eventually death occurs as more and more of the target organs become damaged. These symptoms can be alleviated by a course of antibiotics, proper nutrition, rest, and, if necessary, surgery to remove the damaged parts of affected organs. However, epidemiological studies of tuberculosis and other illnesses demonstrated that many more people had been exposed to or actually carried the bacterial or viral agents than came down with the disease, and the disease model had to be expanded to include the concept of host resistance—that everyone was not equally affected by an invading agent. Investigation of host resistance to this and many other diseases resulted in the discovery of the immune system, the enormously complex system by which the body can destroy invading agents, isolate and break down toxins, and help repair damage to organs. In many instances, disease symptoms actually represent the body’s attempt to repel the invading agents rather than any active damage by the agent. Thus, simple causal models of illness are of necessity coming to be replaced by highly complex models demonstrating interaction among multiple agents. As Kuhn (1970) pointed out, the more conditions and limitations that are placed upon a model, the more unwieldy it becomes and the more likely it is to be replaced via a paradigm shift. But this heightened understanding of the complexity of interactions leading to disease states was not sufficient to effect the paradigm shift from physiological reductionism to mind–body transactionism. One can study any organ system in finer and finer detail without having to aban-

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don Virchow’s (1863) model. It is only when one begins to study interactions across levels of analysis that reductionism breaks down. In other words, simple causal mechanisms assumed closed systems, to use von Bertalanffy’s (1969) terms. That is, there is a circumscribed number of variables that are internally interacting and are relatively immune to outside forces. For example, classical textbook descriptions of the circulatory system detail its components, such as the heart, veins and arteries, capillaries and arterioles, and its regulators, such as the sympathetic and parasympathetic branches of the autonomic nervous system (ANS). But, as one begins to study the circulatory system and how it becomes diseased in greater detail, it becomes readily apparent that the circulatory system is not a closed system but an open one—consisting of a large number of components that are influenced by external forces. The circulatory system interacts not just with the ANS but also with the central nervous system (CNS) via the neuroendocrine system and the immune system. It is also influenced by an individual’s behavior—what he or she eats, smokes, and drinks, as well as whether or not and how he or she exercises. Other influences include the level of stress in an individual’s life and his or her personality, cognitive style, and social relations. Thus, the tools provided by the medical model and physiological reductionism that allowed us to understand in greater and greater detail the workings of the body also uncovered the limitations of that paradigm. No organ system is a completely closed system. Rather, all are subject to regulation by the brain via the neuroendocrine and immune systems (Ornstein & Thompson, 1984). The psychological sciences imitated the biomedical ones in expressing Cartesian dualism as unidirectional physiological reductionism—that is, psychological processes could be reduced to their neurophysiological bases. In the most extreme statement of this point of view, the mind was viewed as an “epiphenomenon” of the brain. While many more complex models do exist in modern psychiatric theories of mental illness, the dominant tendency is still to ascribe causality to biochemical mechanisms. For example, if one finds that depressives who commit suicide have much lower levels of serotonin than nonsuicides, the standard assumption is to ascribe the suicidal behavior to that neurotransmitter imbalance and to treat depressive disorders by restoring the neurotransmitter balance through drugs. However, equally plausible alternative explanations include the possibility that the suicidal ideation creates the serotonin imbalance or that there are mutually reinforcing feedback loops between the two. Certainly, the fact that cognitive-behavioral therapy is as good or better than antidepressants in alleviating depression (Gloaguen, Cottraux, Cucherat, & Blackburn, 1998) indicates that depression involves complex interactions between physiology and experi-

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ence. This is highlighted by a recent study by Caspi and his colleagues (2003), which demonstrated that depression results from interactions between alternative forms of the gene that regulates serotonin uptake and exposure to stressful life events. Elegant arguments that the mind is not solely reducible to the brain have been proposed by Eccles and Robinson (1984), based upon the neuropsychology and linguistics literature, and by Walker (1970), based upon physics. Although Popper and Eccles (1977) proposed the term “dualist–interactionism” to describe the relationship between the mind and the brain, the construct of transactionism may be more appropriate in describing this relationship. According to transactionists such as Lazarus (1966; Lazarus & Folkman, 1984) and Appley and Turnbull (1986), dualist–interactionist models are incomplete because they imply that two agents are mutually creating a phenomenon but nonetheless remain independent and unchanged. Transactionism, on the other hand, assumes that the two agents are not independent but are mutually affected by the transaction. Figure 1.1 illustrates the difference between physiological reductionism, interactionism, and transactionism, using emotions as the dependent or caused phenomenon. In the top section, the arrow indicates that the brain causes the emotions. For example, serotonin is hypothesized in older, simpler models to cause negative emotions. The middle part of the figure illustrates interactionism: that the brain and the mind (cognition) both affect emotions. Using stress terminology, one would say that the appraisal of a threat, combined with a genetic propensity to overproduce adrenaline, would result in excessive feelings of anxiety. In

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EMOTIONS

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Interactionist Model BRAIN

MIND EMOTIONS

Transactionist Model

FIGURE 1.1. Comparison of different causal models of emotions.

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transactionism, the dependent variable (in this case, emotions) in turn influences both the brain and the mind. Thus, through the medium of emotions, the brain and the mind mutually affect one another. From a transactionist viewpoint, the mind is no longer reducible simply to the workings of the brain, nor, as a colleague of mine once whimsically put it, is the brain a mere epiphenomenon of the mind. Rather, the state of mind influences the workings of the body, while the state of the body influences cognitive and emotional processes. Both can be changed as a result of the transaction. For example, continuing anxiety may affect both physiological functioning and appraisal processes. Psychiatric understanding of depression is gradually shifting from a simple neurochemical imbalance model to one that is refocusing on the structure of the brain. One of the most exciting areas of research involves the interrelationships among stress, hippocampal size and functioning, and depression. Traumatic or chronic stress may result in high levels of stress hormones such as cortisol, which differentially damage the hippocampus (Sapolsky, 1999). In turn, hippocampal size has been correlated with depression (Do, Payne, Levy, MacFall, & Steffens, 2002). Current thinking is that some antidepressants work not by changing biochemical imbalance but by stimulating the growth of new neurons in the hippocampus (Manji et al., 2003). The role of coping in this system has yet to be investigated, but clearly that is an important link in this system. Sperry (1993) suggested that this cognitive revolution in psychology has formed the basis for the current paradigm shift in the sciences in general. The seemingly simple addition of bidirectional arrows has enormous implications, not only for the manner in which science is conducted but also for much of everyday life. The body is no longer a mechanical device that sometimes requires repair. The emphasis has been slowly shifting to a disease prevention model, especially given the prevalence of chronic disease among a rapidly aging population. People are now much more aware of the impact of psychological stress on their bodies and may try to reduce that influence through myriad methods. In California, claims for stress-related disability or workmen’s compensation have increased dramatically during the past two decades. On the other side of the equation, millions of Americans now avidly pursue physical fitness as a way of helping to manage their psychological states. In short, the fabric of our lives has changed tremendously as a direct result of this paradigm shift. A transactionist paradigm has greater implications also for the study of adaptation, implications that have not yet been fully understood within psychology. In any scientific endeavor it is extremely important to examine one’s assumptions, understand their implications for

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how the world is thought to function, and formalize hypotheses. Studies of stress and coping form a laboratory, as it were, for examining the role of transactional processes in adaptation. Thus, an additional purpose of this book is to explore the implications of a transactionist paradigm for stress, coping, and development. Two assumptions of transactionism are particularly relevant to stress and coping research. First, variables mutually influence each other, both within and across levels. If the mind and brain do transact, then, being regulated by the brain, organ systems are subject to influence by the mind and, in turn, anything that affects the mind (e.g., society and culture). Thus, seemingly distinct levels of analysis—sociocultural, psychological, and biological—are all linked. Further, how a culture or society is structured has implications for an individual’s physiological wellbeing, not only through the direct allocation of resources (Pearlin, 1989) but also through influencing characteristic psychological states and stress levels (Colby, 1987). Second, transactionist models of necessity imply developmental processes in that the focus of any transaction is change. Thus, a parallel paradigm shift in developmental sciences involves dynamic systems theory— positing that there are mutually influential changes over time (e.g., Ford & Lerner, 1992). Most stress theorists focus on the immediate situation and try to show, for example, how appraisal affects coping, which in turn affects both the outcome and appraisal processes. However, a transactionist model implies a strong possibility that both the mind and the body are altered as a result of their transaction. Theorists such as Schonpflug (1985) and Hobfoll (2002) have implied this in their economic models of stress and coping as resource depletion–conservation. However, there is no reason to assume that a stress transaction has exclusively negative outcomes but rather may have positive ones as well, as is implied by Meichenbaum’s (Meichenbaum & Cameron, 1983) stress inoculation theory and Dienstbier’s (1989) construct of stressinduced “toughness.” Aldwin and Stokols (1988) have presented various approaches to modeling change, whether positive or negative, shortterm or long-term, that can result from stressful interactions. Indeed, the whole area of “posttraumatic growth” is one of the most exciting new areas in psychology (see Tedeschi & Calhoun, 2004).

PERSON–ENVIRONMENT TRANSACTIONS Thus, transactionism has broad implications for the study of stress and coping in that it can link both environmental (e.g., sociocultural) and developmental perspectives to biomedical findings. Figure 1.2 presents the

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view of coping as seen from the reductionist, interactionist, and transactionist perspectives. The top part of Figure 1.2 represents the reductionist, or stimulus-response (S-R), model of coping behavior. In this model, coping behaviors are viewed as simple responses to stressful environmental stimuli. The middle part of Figure 1.2 represents the interactionist model. Coping is hypothesized to be a function of personal and environmental characteristics. For example, the use of coping strategies is influenced by personality characteristics, such as emotionality (Bolger, 1990), as well as by the type of stressor or environmental demand (Mattlin, Wethington, & Kessler, 1990). The standard transactionist point of view (see, e.g., Lazarus & Folkman, 1984) examines transactions only within the context of a single stressful episode. In this model, personal and environmental variables influence appraisal, which determines the type of coping response. Coping outcomes, in turn, influence the appraisal process. Yet, inspection of the bottom part of Figure 1.2 suggests that coping outcomes not only influence appraisal processes within the stress context but also may have effects on both the person and the environment. For example, how a person copes with a particular stressful situation may add to his or her coping repertoire or may alter a person’s outlook on the controllability or uncontrollability of the environment (e.g., locus of control or explanatory style). Further, how an individual copes with a problem may alter the environment, affecting not only whether a particular problem is solved but also whether and how the problem arises for other individuals. Legal action to resolve racial or sex discrimination cases, for example, may provide the means for other individuals to cope with similar

STRESS

COPING

Reductionist Model STRESS

PERSONALITY COPING

Interactionist Model STRESS

PERSONALITY COPING

Transactionist Model

FIGURE 1.2. Comparison of different causal models of coping.

Introduction and Purpose of the Book

9

problems. Thus, the implications of a transactionist viewpoint extend beyond the individual stressful context to wider developmental or social situations. In stress and coping research, the environment has been viewed primarily in interactionist terms, that is, as a stimulus or source of stress, or less frequently as a source of resources for coping with stress (e.g., social support). However, a transactionist view suggests that the environment has a much more extensive role than simply its function as a stimulus or a resource. For examples, physical and social environments play a role in shaping not only the choice of coping strategies (de Ridder, 1997; Mechanic, 1978; Thoits, 1986) but also the impact of that strategy (Zautra & Manne, 1992). Further, in most theories, coping is assumed to have some effect on the problem, but studies generally focus only on its effect on the individual’s well-being. From a transactionist point of view, more attention needs to be paid to the effect of coping on the environment, whether its effect on the immediate problem or on others in the situation (DeLongis, Bolger, Kessler, & Wethington, 1989). If, as Mechanic (1978) so radically suggested, coping strategies are primarily a function of cultural patterns and institutions, then how an individual copes not only has an effect on the immediate problem but also adds to the cultural repertoire of coping strategies (Aldwin, 1985).

ORGANIZATION OF THE BOOK This book explores the themes presented in this introduction from the perspective of the paradigm shift in the psychological and biomedical sciences. However, any paradigm shift is accompanied by much dissension and argument as various opposing factions argue for the status quo or for different directions of change. This dissension is obvious in the area of stress and coping. Rather than attempt to promote any one particular school or theory of stress and coping, we will take an “elephant in the dark” stance. That is, no one school or theory is complete and correct—the differing approaches all have strengths and limitations, and in some circumstances the approaches are not so much in conflict but are actually addressing quite disparate parts of the “elephant.” By examining the historical context and conceptual assumptions underlying different approaches, we will attempt to clarify the nature of some of the debates in the field and to show precisely where the conflict lies and how the differing approaches might be integrated, where possible. It is also true that research methods have lagged far behind the theoretical conceptualization, especially in psychology. Thus, key methodological issues of relevance to both the conduct of research and its inter-

10

STRESS, COPING, AND DEVELOPMENT

pretation will also be considered. Again, rather than advocate any particular technique, we will discuss the strengths and weaknesses of the various ways in which stress and coping are measured and which techniques may be useful for differing research questions and contexts. As with any scientific discipline, the field of psychology has gone down many blind alleys, in part because psychologists have made simplified assumptions for the sake of constructing theoretical models, but also in part because they have allowed their research—and to a certain extent their clinical work—to become divorced from the realities of everyday life. In many ways, this divorce has been useful—the best of psychological research has often shown that “conventional wisdom” is markedly and decidedly wrong. But this divorce can also be responsible for pursuing assumptions down blind alleys, as when Watson tried to reduce thought to microscopic workings of the musculoskeletal system underlying speech or when Hull tried to reduce memory to muscle action. Thus, putting psychology into its everyday context is important not only as a check against wrong assumptions but also is a didactic tool, a bridge for students to connect their own experiences to psychological theory. These three concerns with theory, method, and relevance influence the structure of this book. Chapter 2 discusses conceptual issues in stress research and why the construct of stress and how it is researched are important to our everyday lives. Chapter 3 discusses the different definitions of stress and how the assumptions implicit in these definitions influence the type of research that is conducted. Our knowledge of the impact of stress on physiology has been greatly enhanced during the past decade, and this update will reflect that increased sophistication by devoting a new chapter (Chapter 4) to that topic. Chapter 5 addresses issues in stress measurement and methodology, and pays special attention to new techniques for assessing daily stress processes as well as ecological momentary assessments. While the stress literature has been reviewed extensively, there have been surprisingly few exhaustive reviews of the coping literature (but see Aldwin & Yancura, 2004; Folkman & Moskowitz, 2004); the subsequent chapters attempt to fill that gap. Initially paralleling the construction of the chapters on stress research, Chapter 6 addresses conceptual issues in coping research; Chapter 7, definitions of coping; and Chapter 8, the measurement of coping strategies. Issues in stability and change in the factor structure of coping will be reviewed. Appendix 8.1 also includes a partial nonannotated bibliography of coping measures that should prove useful to both researchers and students. Chapter 9 discusses some of the methodological and statistical issues in understanding

Introduction and Purpose of the Book

11

the effects of coping. The statistics and design section is enhanced by including newer structural equation, hierarchical, and longitudinal models. Chapter 10 reviews the literature on coping and mental health outcomes, and Chapter 11 addresses coping and physical health outcomes. Our understanding of the neuroendocrine and immune systems has exploded during the past decade, and, as we shall see, the coping and health outcomes literature has been struggling to keep up. Chapter 12 examines how individuals cope with trauma and includes a new section on coping with the aftermath of the 9/11 terrorist attacks. A major limitation of stress research is that it has been almost strictly a psychological endeavor. However, there is a growing recognition that social and cultural contexts affect stress and coping processes. Chapter 13 reviews the small but growing body of research that demonstrates the interpersonal and social influences on appraisal and coping processes and that shows how work in medical anthropology might radically alter our view of how coping works. This book also places the study of stress and coping in a larger developmental context. In part, this is accomplished in Chapter 14 by reviewing the coping literature in special populations—children and the elderly—as well as providing theoretical overviews of changes in coping across the lifespan. Thus Chapter 15 reviews studies on stress-related growth. In our rush to document the negative aspects of stress, we may have overlooked its positive aspects—stress as an impetus for growth and development, and transformational coping as the manifestation of a lifelong quest for greater mastery and understanding. While research in this area has also greatly increased during the past 12 years, reviews of that literature are also scarce, and the revisions to this chapter will address that gap. Chapter 16 provides a summary of the various themes developed in this book and how they relate to the transactionist perspective espoused in this chapter. It also examines deterministic versus nondeterministic models of adaptation. In the 13 years since this book was first published, a greater acceptance of the importance of volition in adult development and adaptation has occurred (see Brandstädter, 1999), especially in the context of positive psychology (Seligman & Csikszentmihalyi, 2000). In summary, within the field of stress and coping, this book provides some insights into the nature of conceptual and methodological debates in the field in order to allow researchers and students to best decide which particular approaches and assessment techniques are most relevant for them. In addition, integrating developmental psychology, especially adult developmental psychology, with an understanding of the

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STRESS, COPING, AND DEVELOPMENT

nature of adaptation provided by stress and coping studies will enhance both fields. Adding a developmental perspective to studies of adaptation may provide an impetus to reconsidering the types of outcome measures that are used; and adding an adaptation perspective to developmental psychology may provide greater insight into the role of the environment in promoting development, in both childhood and adulthood.

STRESS, Why Is Stress COPING, Important? AND DEVELOPMENT

CHAPTER 2

Why Is Stress Important?

T

he construct of stress is important on a number of levels. First, stress is intrinsically interesting, as the casual perusal of any bookstore, newspaper, or television news program would indicate. Second, stress is highly relevant to psychosocial models of adaptation. As we shall see, a transactionist viewpoint subsumes many of the current models of mental illness. Third, stress is also relevant to biomedical models of adaptation and has transformed our notions of health, the maintenance of good health, and the treatment of illness.

INTRINSIC INTEREST Stressful events are of almost unparalleled importance to people. For example, the evening news can be seen primarily as a means of transmitting information about stressful events—whether or not these events directly affect us. Television news focuses primarily on natural disasters, accidents and tragedies, economic dislocations, conflicts between powerful individuals (generally politicians but sometimes movie stars or sports celebrities), deaths, crimes, and punishment. Positive events are reported only rarely, and then often in the context of individuals who are struggling to overcome tremendous odds or handicaps. A large percentage of our daily conversations focus on stressful events that happen to ourselves and others: deaths, divorces, job problems, car accidents, problems at school or work, illnesses (major or minor), and everyday “hassles” in general—missed buses, car problems, 13

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STRESS, COPING, AND DEVELOPMENT

bureaucratic inconveniences, and the copying machine breaking down (again) at work. Certainly soap operas focus almost exclusively on the negative life events that happened to (or were provoked by) the characters. One can only speculate on the reasons for this interest. Perhaps watching others struggling and grieving provides a form of catharsis, a way of discharging unhappiness and anger in a safe, nonthreatening context, as the ancient Greeks thought. Thus, it may be more comfortable to express anger over crooked politicians rather than to confront directly unethical practices in our own work contexts. Perhaps interest in stress has an evolutionary function. Many studies during the past two decades have demonstrated that heightened emotions enhance memory, that is, we are more likely to remember emotionally charged events (Davidson, 2003). This phenomenon appears to be regulated by the basolateral region of the amygdala as well as by other neural structures such as the hippocampus (McGaugh, 2002). By remembering sources of trauma, we may be more likely to learn from our mistakes and avoid dangerous situations in the future. Similarly, by attending to dangers and trauma that others face, we may learn of sources of danger in the hope of avoiding them or may vicariously learn about coping strategies, successful or unsuccessful, that others have used for dealing with problems. Interestingly, some have argued that the sort of “flashback” memory seen in posttraumatic stress disorder (PTSD) qualitatively differs from ordinary, more discursive, memory of trauma (Brewin, 2003). Interest in stress can also be seen in a larger social context. Many years ago, Durkheim (1933) posited that emotional arousal in a group setting functions primarily to enhance feelings of community and group solidarity. Although usually applied to group rituals involving large crowds (such as football games), one could also argue that the arousal of emotion through news reporting of stressful events also can function to increase communitas, either directly or indirectly. For example, reports of major natural disasters also depict rescue efforts and directly invite participation by providing information on how the viewer can help (generally by providing money or goods to rescue agencies). At the very least, news reports of disasters provide a shared social context and topics of conversation for individuals in a community or nation. Thus, the intrinsic interest in stress may stem from psychological, biological, and/or social causes. Whatever the reason, it is clear that stress, and how people cope with it, is intrinsically interesting for large numbers of people, both in the academic and general communities. Studies of stress have also had a major impact on psychosocial models of adaptation and on biomedical models of disease.

Why Is Stress Important?

15

RELEVANCE OF STRESS TO PSYCHOSOCIAL MODELS OF ADAPTATION Early models of mental illness focused primarily on internal processes as the source of psychological problems. Psychoanalysis, for example, related mental illness primarily to hidden or unconscious conflicts between the id, ego, and superego, stemming from early childhood fixation in psychosexual stages. Environmental events may trigger these conflicts, but the primary problem lies within the individual. Similarly, biomedical models try to relate symptoms to neurotransmitter imbalances, which are thought to be causal mechanisms underlying psychological distress. If a depressed person exhibits lower levels of serotonin, it is thought that the lack of serotonin causes the depressive symptoms. In both types of models, the cause or source of mental illness lies solely in the individual’s makeup. Sociologists and anthropologists, on the other hand, have long pointed to the major roles that society and culture play in provoking both psychological distress and the way in which it is expressed. For example, Hollingshead and Redlich (1953) first pointed to the relationship between social class and mental illness: individuals in lower socioeconomic (SES) groups were more likely to suffer from schizophrenia, but those in the upper classes were more likely to report neuroses. From this point of view, the origin of mental illness may lie not so much within the individual but within the environment, such as the social structure and the way in which strains are distributed within society (see National Advisory Mental Health Council, 1996, for a review). The old view was that people who have marginal roles within a society, such as the poor, are more likely to exhibit signs of emotional and social disorder because of inadequate socialization to what are considered normative social roles and behavior (Howell, 1973). Of course, this has given rise to an ongoing debate about which comes first—socioeconomic status or mental illness? The downward mobility hypothesis argues that individuals who have psychological problems tend to do badly in the economic marketplace and thus become members of the lower social classes, while the social causation theory argues that it is one’s position within the social structure that creates the problems that give rise to mental illness. For example, some have argued that it is the economic injustice and discrimination against individuals in lower classes, who are often minorities, that most affects mental health. A study of depression among Native Americans, who have several times the rate of depression experienced among the general population, found that perceived discrimination was strongly related to depression (Whitbeck, McMorris, Hoyt, Stubben & LaFromboise, 2002). The problem was not poor socializa-

16

STRESS, COPING, AND DEVELOPMENT

tion to roles in the dominant society: Individuals who engaged in traditional Native American practices had lower rates of depression than those who did not. Similarly, Chandler, Lalonde, Sokol, and Hallett (2003) investigated reports of high suicide rates among Native American adolescents in Canada. They found that tribes that were actively engaged in activities to preserve and promote their traditional culture (often by suing the government for abrogation of rights) had dramatically lower rates of suicide than those tribes that were not resisting. Anthropologists have observed that what constitutes abnormal behavior is a result more of cultural norms than of individual psychodynamics. As Margaret Mead (1928) pointed out many years ago, what constitutes acceptable behavior in one culture may be considered abnormal and a treatable illness in another. To illustrate the importance of culture in the origin of mental illness, anthropologists also point to the existence of culture-bound illnesses, or disorders that are specific to particular cultures, such as amok in the Philippines or “bear illness” among the Aleuts (see Kleinman, 1980; Kleiman & Seeman, 2000). (Both of these illnesses involve public displays of extreme violence in a nonetheless ritualistic manner.) Thus, culture plays an important role in both the formation and expression of mental illness. (See Chapter 13 for further discussion of this issue.) Models of stress and psychosocial adaptation can provide a link between these disparate viewpoints on the origin of mental illness. Stress models acknowledge the importance of environmental effects on mental health, but they also recognize that there are individual differences in vulnerability to stress. Thus, the onus for mental illness shifts from being solely the “fault” of the individual or simply a function of social roles and cultural norms to a recognition that there are multiple factors engendering psychological distress, some of which may be beyond individual control. Turner (2003) argues that the past half-century of research has demonstrated overwhelming evidence that cumulative adversities or exposure to stress accounts for a great deal of the variation in the relationship between social class and mental illness. The construct of vulnerability to stress is very important, because it can tie together a number of different approaches to adaptation. Vulnerability to stress may be a function of either personal or social characteristics. Personal vulnerabilities may stem from an individual’s history, such as exposure to traumatic situations earlier in life or a biological propensity to manic depression. Thus, this construct can encompass both psychodynamic and biological approaches to mental health. However, vulnerabilities may also stem from one’s position in the social environment, such as poverty, racism, few economic opportunities, and the like (Evans, 2004; Pearlin, 1989; Turner, 2003), which may make it

Why Is Stress Important?

17

more likely that certain individuals will experience stressful events. They may have particularly adverse reactions to the events and may take longer to recover. The construct of vulnerability nonetheless acknowledges that personal problems may indeed be due to one’s social or physical environment and thus can also encompass environmental approaches to adaptation. A corollary construct is goodness of fit (Kahana, Lovegreen, Kahana, & Kahana, 2003; Magnusson & Toerestad, 1992). The same environment might be stressful to some persons because it requires capacities or preferences that they do not have; yet, it might be a comfortable or stimulating environment for individuals who possess those capacities or have those preferences. For example, one person may prefer a work environment with predictable, routinized tasks and might find it difficult to deal with a more unstructured environment with chaotic, unpredictable tasks. Another person may find the first environment boring and the second challenging and stimulating. Thus, the construct of goodness of fit recognizes the importance of contextualism and asserts that there are very few causal absolutes in psychology. Simply put, situations alter circumstances. Environmental situations need to be evaluated by their effects on individuals, and individual adaptation needs to be understood in the context of particular environmental constraints. Thus, a stress and coping approach to psychosocial adaptation acknowledges the contribution of both the person and the environment and seeks to understand the particular environmental context and personal skills and resources that provide for optimum adaptation. Further, a transactionist viewpoint emphasizes that the person and the environment are not independent contributors to stress and coping but, rather, mutually affect each other for good or for ill.

RELEVANCE OF STRESS TO BIOMEDICAL MODELS OF ADAPTATION For over 2,000 years, philosophers and scientists have been debating whether the mind and body are separate or integrated entities and, if integrated, the nature of the relationship (see Eccles & Robinson, 1984). The study of the effects of stress on physical health has been a great impetus to systematically investigating how the mind and body interact. As discussed in Chapter 1, the biomedical model of disease, as enunciated more than a hundred years ago by Virchow (1863), specified that individuals become ill due to external agents. Any illness can potentially be cured if the agent is known. A person gets a cold, a heart attack, or cancer because an external agent (a germ or other toxin) infects the body, producing structural and physiological changes that are solely re-

18

STRESS, COPING, AND DEVELOPMENT

sponsible for all symptoms. If the agent is identified and neutralized, the body recovers. However, it is now widely recognized that this model is too simplistic. Not everyone who is exposed to a cold virus or tuberculosis becomes ill. Rather, the state of an individual’s health reflects a dynamic interaction between environmental forces and physiological resilience. There is increasing evidence that the latter is in part affected by psychological states. The past 20 years have seen an explosion of research into the psychosocial factors that affect health, including personality, stress, coping, and social support (for reviews see Aldwin & Gilmer, 2004; Dickerson & Kemeny, 2004; Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002; Krantz & McCeney, 2002; Kubzansky & Kawachi, 2000). The idea that stress can affect physical health is not at all new. In folk wisdom, people have been said “to die from a broken heart” or “to work themselves into an early grave.” Similarly, people can be “scared to death,” or fright can “turn your hair gray overnight.” What is new is that we are beginning to discover the physiological pathways that mediate between stress and health. These pathways involve interactions between the neuroendocrine and immune systems. The field that studies these relationships is called psychoneuroimmunology (Ader, 1981; Ader, Felten, & Cohen, 1991). Psychoneuroimmunology seeks to understand the relationships among the psyche, or mind, the neuroendocrine system, and the immune systems, as well as the role of these relationships in maintenance of health or vulnerability to illness. Figure 2.1 presents what might be called a basic, or generic, model illustrating the principles of psychoneuroimmunology. Stress activates negative affect, or emotions. We may feel angry, sad, or frustrated in response to a stressful episode. There are wellknown physiological changes that accompany such emotions. Our hearts pound, we may breathe heavily (increase in heart and respiratory

NEUROENDOCRINE CHANGE STRESS

NEGATIVE AFFECT

HEALTH OUTCOMES

IMMUNE SYSTEM CHANGE

FIGURE 2.1. Standard psychoneuroimmunology model of stress and health.

Why Is Stress Important?

19

rates), we may turn beet red or deathly pale (changes in peripheral vasodilation), or we may feel “butterflies” in the stomach (decrease in parasympathetic system activation). A century ago, both William James (1890) and Walter Cannon (1915) recognized the link between emotions and the neuroendocrine system, although they differed somewhat in their beliefs about causal directionality between the mind and the body (see Chapter 4). Thus, Figure 2.1 shows all relationships as bidirectional. Figure 2.1 also shows stress and emotion affecting the immune system. In 1964 Solomon and Moos coined the term “psychoneuroimmunology,” but it was not until the early 1980s that Ader and Cohen (1982) made a remarkable discovery. Using classical conditioning techniques on laboratory mice, they paired a noise with injections of a drug that suppressed the immune system’s functioning. After a few trials, they then injected saline instead of the drug. The immune function still became suppressed when the mice heard the noise. Ader had demonstrated a stimulus–response association between the perception of a noise and immune system responses. In other words, the immune system was capable not only of learning but also of responding to a psychological stimulus. After that initial discovery, hundreds of studies have demonstrated intimate links between the mind, the brain, and the immune system (for reviews, see Gruenewald & Kemeny, 2007; Kiecolt-Glaser et al., 2002; Rabin, 1999). For example, there are receptor sites for neurotransmitters and catecholamines on immune cells such as T lymphocytes (Smith, 1991). This suggests that the immune system is hard-wired, so to speak, to respond to the mind and that this is not an accident but something that evolved for a reason. Further, there is also clear evidence that the immune system can alter neurological function, as when it triggers fevers (Dantzer, 2004). From Cannon’s (1915) point of view, it makes perfect evolutionary sense that the neuroendocrine system would respond in the manner that it does to strong emotion and stress. The “fight–flight” response, extreme activation, is highly adaptive in that it allows an organism to respond more vigorously in stressful situations, to fight harder or to run faster. We’ve all experienced this: “I was so scared! I’ve never run so fast in all my life!” Stress may also increase beta endorphin levels, which may block the experience of pain and allow people to function even while badly injured. However, why is it adaptive for the immune system also to respond to stress and emotions? Are we meant to become ill if we get upset? This is a conundrum only if the effects of stress are understood solely in the context of immune system suppression. Stress also activates the immune system, at least initially (Kiecolt-Glaser et al., 1992; Monjan, 1981). Such activation is highly adaptive in that it may temporarily pre-

20

STRESS, COPING, AND DEVELOPMENT

vent a person from becoming ill at a time that calls for increased performance. (I have often observed that students are more likely to get colds after final examinations than immediately before or during them!) If one is injured, an activated immune system can help to prevent infection and can also assist in repairs. Thus, immune system activation may be an integral response to adaptive challenges. However, even relatively mild stressors such as examinations may suppress immune function (Marucha, Kiecolt-Glaser, & Favagehi, 1998), and chronic stressors (Cohen et al., 1998; Glaser, Kiecolt-Glaser, Malarkey, & Sheridan, 1998) or traumatic situations (Solomon, Segerstrom, Grohr, Kemeny, & Fahey, 1997) can suppress immune function for substantial periods of time, even years, especially if one develops symptoms of PTSD, such as intrusive thoughts (Ironson et al., 1997). Thus, in order to respond optimally to challenges and threats, there must be a synchronized activation of the mind and the neuroendocrine and immune systems. It is widely assumed that emotions are the “glue,” as it were, that ties the whole system together. In other words, emotions, both positive and negative, may mediate the relationship between stress and physiological outcomes. As shown in Figure 2.1, stress is assumed to activate the emotions, which affect the neuroendocrine system, which in turn affects the immune system. Together, these influence the overall state of our health. However, these models may be simplistic. Work by Baum and his colleagues (Baum, Fleming, & Singer, 1983) on the Three Mile Island disaster has shown that the occurrence of stress can affect both neuroendocrine and immune system function independent of its emotional impact. Cohen, Tyrell, and Smith (1993) also found that the influence of stress on susceptibility to a cold virus did not appear to be mediated through negative affect. Similarly, Yancura, Aldwin, Levenson, and Spiro (1996) also found that the effects of coping on the metabolic syndrome were not mediated through affect. Either individuals are not accurately reporting their emotions, perhaps due to repression, or there exist other pathways between stress and the neuroendocrine and immune systems. Both personality (Segerstrom, 2000) and social support (Uchino, Cacioppo, & Kiecolt-Glaser, 1996) may also play a role. Figure 2.2 depicts alternative pathways that may be interesting to investigate. One of the most interesting areas in biology today is the discovery of cellular-based mechanisms to reduce the effects of stress. Heat shock proteins (hsps) are complex systems that can mitigate the effects of stress at the cellular level in a number of different ways, including defusing free radicals or reactive oxygenating species (ROS), refolding proteins that have sustained structural damage, assisting DNA repair mechanisms, or encouraging highly damaged cells to undergo apoptosis (Sartori &

Why Is Stress Important?

21 NEUROENDOCRINE CHANGE

STRESS

NEGATIVE AFFECT

HEALTH OUTCOMES

IMMUNE SYSTEM CHANGE CELLULAR CHANGE

FIGURE 2.2. Modified psychoneuroimmunology model of stress and health.

Scherrer, 2003). They may also be involved in the regulation of immune function (Pockley, 2003). However, as of this writing, only one article has examined psychosocial factors and hsps (Lewthwaite, Owen, Coates, Henderson, & Steptoe, 2002). In summary, the study of stress is highly relevant to understanding biomedical adaptation. It is revealing how intimately the mind, the neuroendocrine system, and the immune system are related, which suggests that a more holistic or multifactorial approach to understanding physical well-being is needed. It also provides support for the old Roman saying Mens sana, mens corpora, or “A healthy mind, a healthy body.” The most common complaint about the stress field is that the construct of stress is very amorphous. As we shall see in Chapter 3, researchers use different definitions of stress, depending upon their field of work and assumption system. Some, such as Kasl (1983), have gone so far as to suggest that the construct is so vague and so amorphous that it should be discarded. Alternatively, it can be argued that the various definitions of stress exist precisely because it is a very important construct with ramifications across a variety of endeavors. Different fields and philosophical traditions have come up with their own approaches to defining stress. Stress is a multifaceted and overdetermined phenomenon with ties to anthropology and sociology; developmental, personality, social, clinical, community, and environmental psychology; and physiology and medicine. Although this may create a certain amount of vagueness as the definition crosses disciplinary boundaries, it also provides an unparalleled opportunity for integrating different disciplines.

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SUMMARY While it is unlikely that a psychosocial Einstein will discover the “unifying field theory” of the behavioral and social sciences, the construct of stress does provide a common ground that can integrate scientific approaches in a variety of fields. Thus, the construct of stress provides a framework in which the interplay between environmental, psychological, and physical factors can be seen. It thereby represents a bridge linking many different areas of scientific and clinical endeavors, providing a broader and more comprehensive understanding of human adaptation within a transactionist framework. As such, it may be one of the most important constructs in the clinical and social sciences today.

STRESS, COPING, Definitions of StressAND DEVELOPMENT

CHAPTER 3

Definitions of Stress

T

he term “stress” is in such common usage that, at first glance, its meaning seems straightforward and in little need of definition, except perhaps for some minor clarifications here and there. After all, we all know what stresses us, what it feels like to be stressed—or “stressed out,” in common parlance. Indeed, the Oxford English Dictionary assures us that the term has been in use since at least the 18th century. The problem is, of course, that the term has been in such common usage that it has taken on a variety of meanings. For example, it is both a noun and a verb. As a noun, “stress” can refer to external events or to an internal state. Similarly, the verb “stress” can be active, as in “to stress,” or passive, as in “to be stressed.” If the term “stress” is understood to refer to external events, what types of events does it refer to? Should only negative events, such as being unemployed, be considered stressful, or can positive events, such as being promoted, also result in stress? Are only major events stressful, or can minor incidents also be troubling? Is stress to be understood as only those events that have negative consequences, or can stressful events sometimes have positive consequences? If the term refers to internal states, do we mean psychological states, as in emotional distress, or physiological ones? Note that some researchers use the term “stressor” to refer to external events and use the term “strain” to refer to internal stressful states (Pearlin & Schooler, 1978). From a transactionist viewpoint, however, 23

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this distinction between external and internal states is hard to justify, given the importance of cognitive appraisal processes in the perception of stress. Further, many disciplines have studied one aspect or another of stress—ranging from the biological sciences such as physiology, biochemistry, and neurophysiology; through the psychological sciences, such as psychoanalysis, personality, learning theory, developmental psychology, and social ecology; to the social sciences, such as anthropology, sociology, and military history. Not surprisingly, the referents to the term “stress” vary across the fields, adding to the confusion. Studies of stress have included such diverse topics as men who are in combat; mice that are rotating slowly on a drum; commuters who are languishing in traffic jams; pigs that are being shipped to market; students who are taking exams; people who are working on bomb squads; workers on assembly lines; the effect of drought on trees; massive dislocations of whole populations; and so on. It is not surprising that some have called for abandoning the term altogether, reasoning that, by seeming to apply to almost everything, “stress” really is too amorphous a term and really does not apply to anything (Kasl, 1983). For a number of reasons, this criticism of the term “stress” may be tantamount to throwing the baby out with the bath water. First, most researchers are quite precise about what they mean by “stress” in specific studies. Physiologists conducting studies on animal models of stress are almost always interested in the particulars of stress as a physiological state, focusing on the minutiae of neuroendocrine and immunological reactions. With notable exceptions, psychologists and sociologists generally concentrate on the definition of an external occurrence and on the individual’s emotional reaction to it. Second, the fact that studies of stress are conducted at different levels of analysis should be cause for hope rather than despair. As mentioned in the preceding chapter, stress can be a common point for discussion across a number of disciplines, hopefully providing a pathway to integrate these disciplines. Indeed, the field of psychoneuroimmunology attempts to do just that. Although it is widely used, the term “stress” is not applied in a vague or ill-defined way. Nor is it a reified construct, an idea created by academics with little concrete reference to the real world. Rather, stress refers to that quality of experience, produced through a person– environment transaction, that, through either overarousal or underarousal, results in psychological or physiological distress. As we shall see, this overarching definition of stress incorporates most of the elements that researchers have used for identifying and studying the effects of this phenomenon.

Definitions of Stress

25

COMPONENTS OF THE STRESS PROCESS In order to sort through some of the initial confusion surrounding the use of the term “stress,” Mason (1975) identified three definitions of stress, or three ways in which the term “stress” has been used. Stress can refer to (1) an internal state of the organism (sometimes referred to as “strain”); (2) an external event (or “stressor”); or (3) an experience that arises from a transaction between a person and the environment. Table 3.1 presents the various components of the stress process, based loosely on Mason’s categorization. Note that the table should by read only as a set of sequential columns; sympathetic activation can attend trauma or chronic role strain; a hassle may be short-term or chronic, and so forth. The table is meant primarily as a heuristic device to indicate the enormous complexity of the stress process. As indicated in Table 3.1, stress as an internal state of the organism can refer to physiological, emotional, and cellular reactions. Studies of physiological reactions to stress focus on the peripheral and central nerTABLE 3.1. Components of the Stress Process Strain

Stressor

Transactions

Physiological reactions

Emotional Types of reactions stress

Temporal Cognitive dimensions appraisals

Intensity

Sympathetic activation

Negative affect

Duration

Harm/Loss

Weak

Parasympathetic suppression

Emotional Life events numbing

Rapidity of onset

Threat

Moderate

Other neuroendocrine stimulation/ suppression

Lower positive affect

Fluctuation Challenge

Trauma

Hassles/ daily stressors

Immune suppression/ enhancement

Aversive physical environment

Benign

Heat shock protein activation

Chronic role strain

Concern for others

DNA repair mechanisms suppression/ enhancement

Cumulative adversity

Annoyed

At a loss Controllable/ uncontrollable

Strong

Ambiguous

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vous systems as well as neuroendocrine and immune system function. During the past 10 years, there has been a growing interest in stressprotective mechanisms at the cellular level. Physical stressors such as free radicals (also known as reactive oxygen species, or ROS), wreak havoc on structures within the cell because they have a free electron that damages the configuration of various molecules, including DNA, and makes them malfunction. Emotional reactions to stress generally refer to negative feelings such as anxiety, anger, and sadness, although shame, guilt, or feeling bored may also be considered stress reactions (Lazarus, 1991). While the focus in stress research is usually on negative affect, some attention has been paid to positive affect, generally in the form of opponent processes— that is, positive emotional states that arise as a sort of backlash to negative ones, as when a parachute jumper feels elated after initial feelings of terror (Solomon, 1980; see also Chapter 12). Emotional numbing, however, can also occur and is common with trauma or highly stressful life events such as bereavement or being diagnosed with a terminal illness. While the common assumption is that stress has negative physiological effects, it would be more accurate to perceive stress as having an activating effect, which at times can be positive as well as negative, depending upon a variety of factors. Indeed, as we will discuss later, stress, whether at the cellular or organismic level, can eventually result in greater resilience to future stressors (see Chapter 15). The second type of definition of stress refers to the external environment. The earliest studies of stress focused on major trauma, such as combat and natural disasters. This characterization was later expanded to include major life events such as marriage, divorce, bereavement, or being laid off or starting a new job. Other researchers have focused on noxious environmental characteristics such as noise, overcrowding, or pollution. Others prefer to focus on more common problems, such as the chronic role strain of a bad marriage or being impoverished, while some examine the hassles or daily stressors of everyday life. There are a number of temporal dimensions of stress that deserve greater study, such as its duration, its rapidity of onset, and its linkage or spread. The animal literature indicates that the physiological effects of stress may be very different, depending upon whether the stressor is short-term, chronic, or intermittent (Dienstbier, 1989), while the studies on bereavement suggest that the suddenness of death might also affect the severity of its negative effects (Parkes & Weiss, 1983). Finally, a stressor might have a limited, easily delineated, effect, or it might start a chain reaction of events that reaches across domains. This chain reaction is termed “linkage” (Pearlin, 1989). For example, loss of a job could lead to long-term economic problems, which in turn could lead to a di-

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vorce, which in turn could lead to estrangement from children, and so forth. Finally, stress can be characterized as an experience arising from transactions between a person and the environment, especially those transactions in which there is a mismatch between an individual’s resources and the perceived challenge or need. In this schema, an individual’s cognitive appraisal of stress—the recognition of harm, loss, threat, or challenge—must be present for any emotional or physiological reactions to occur (Lazarus & Folkman, 1984). These researchers have focused on how stress is perceived, or appraised, on its perceived characteristics (e.g., threat, harm, or loss), and on the severity of the problem. Most (although not all) researchers would agree that these are the major components of the stress process. However, there are some fundamental disagreements among different schools of thought. These disagreements generally fall into one of two categories. First, regarding stress as an organismic state, researchers often disagree about whether there are general or specific reactions to stress—that is, whether all stressors evoke one general reaction or whether different stressors evoke specific reactions. Second, researchers emphatically disagree about the nature of causal directionality across the categories—that is, they disagree about which comes first: cognitive, emotional, or physiological reactions to stress. For example, do we first react physiologically to stress, then emotionally, or do emotional reactions drive both the physiological and cognitive processes? In addition, researchers also disagree about causal directionality between a person and the environment. Does the environment cause emotional and physiological reactions, or does an individual’s internal state alter his or her perception of the environment and somehow evoke problems? This section will review the major debates in the field concerning the conceptualization of stress using the framework that Mason (1975) first delineated. We will attempt to provide additional insight into various debates and, where possible, suggest means by which differing positions can be reconciled.

STRESS AS A STATE OF THE ORGANISM Think of how your body might feel just before a big exam. Your face might be flushed or very pale, your palms might be sweaty, your hands might be trembling a little, and your mouth might be dry. These are peripheral nervous system reactions. If you have “butterflies” in your stomach, your heart is pounding, and you start hyperventilating, then your autonomic nervous system is reacting. Both are mediated by the ac-

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tions of the sympathetic and parasympathetic nervous systems, in conjunction with the endocrine system—hence the term “neuroendocrine stress reactions.” Now think of how you might feel during final exams week. You might have a cold or gingivitis (a gum inflammation). Your allergies or ulcers might get worse, or you might develop a rash. These reflect immune system disturbances, also a common reaction to stress. There has been such an incredible increase in our understanding of the physiology of stress since the first edition of this book that a new separate chapter (Chapter 4) is devoted to it. Nonetheless, it is important to understand that we are hard-wired physiologically to respond to stress and that stress responses can involve nearly every system in the body.

STRESS AS AN EXTERNAL EVENT Historically, stress has been viewed as a noxious external stimulus impinging upon the organism. For millennia it has been common knowledge that people could die from stressful events or lifestyles. We say that someone was “scared to death,” “died of a broken heart,” or “worked himself into an early grave.” External sources of stress may be either physical or sociocultural.

Physical Stressors Physical stressors include both trauma, which threatens immediate bodily harm (such as speeding cars, tornadoes, or fires) and aversive environmental conditions, which may have subtler but nonetheless harmful effects, such as pollutants, noise, and the like. A “sick building” is a good example of a subtle physical stressor. In buildings in which the windows are sealed, workers may be exposed to low levels of harmful chemicals such as formaldehyde (common in carpet backings and office furniture), paint residues, cleaning compounds, or fumes given off by copying machines, which may not be immediately noticeable but can result in headaches, irritated eyes, rashes, and increased susceptibility to viral infections. Migraine headaches can be triggered by the flickering of improperly shielded fluorescent lights, and central heating and cooling systems that decrease humidity levels may result in irritated mucous membranes that in turn lead to nosebleeds and greater susceptibility to respiratory infections. Poor ventilation can also increase the concentration (and, thus, virulence) of infectious agents. Further, poorly designed work stations may result in mechanical stress, leading to eye and muscle strain; typists, computer operators, supermarket checkers, and musicians

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may be particularly susceptible to repetitive motion injuries such as carpal tunnel syndrome. An interesting study by Evans and Jacobs (1982) has suggested that physical stressors such as poor air quality may interact with social ones to result in increased symptomatology. Evans found that residents in the Los Angeles area who lived in highly polluted neighborhoods had more symptoms when they were exposed to stressful life events than did individuals who lived in areas with cleaner air. Some of the adverse effects of poverty may result from living in environments that subject individuals to a wide variety of noxious stressors (Evans, 2004).

Sociocultural Stressors While stressful life events such as job loss or divorce are often seen by psychologists as occurring randomly or perhaps arising from an individual’s psychological problems, sociologists are more likely to see the source of life events as embedded in the social structure. Pearlin (1989) has argued that stress arises as a function of the distribution of social resources as well as an individual’s status and roles. A lack of social resources either increases the probability of a stressful life event or heightens its stressfulness once it occurs. For example, having little disposable income can force a student to buy an older car with high mileage. This car may be more likely to break down (a hassle), and the student may have little money to repair it, forcing him or her to make hard choices between rent, food, and car repair (to say nothing of leisure), thereby increasing the situation’s stressfulness. Furthermore, stressful life events may be linked; in Pearlin’s terms, a primary event may lead to a secondary stressor. For example, our student may lose a much-needed job (a stressful life event) due to a lack of reliable transportation. Note that secondary stressors are not necessarily less stressful than primary stressors and may even be more distressing, depending upon the circumstances. During a lecture in Brazil, I used the student car example in a lecture on stress and coping (Aldwin, 2002). To my surprising, the students started giggling at this example. When asked why, they replied that they found it amusing—not one of them owned a car and, instead, took public transportation, walked, or biked to school, which was at the top of a very tall hill. The wealthiest had small motorbikes. Clearly, culture influences the types of stressors individuals may face! One of the earliest studies of stress in the external environment was conducted by Calhoun (1962), who examined the effects of crowding on rats. He allowed rats to reproduce in a severely restricted environment. Under these conditions, social pathology among rats increased, typified

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by various measures of aggression, including fighting and rape. More important than crowding per se was restricted access to such basic necessities as food and water. Increased violence was most prevalent when there was only one narrow access route to the food; when multiple pathways to the same amount of food were provided, the negative effects of crowding decreased. In other words, low levels of resources (so long as they are sufficient to sustain life) are not necessarily stressful, but inequities in the distribution of resources are more problematic. Several decades of subsequent research has confirmed that crowding is also stressful to humans but that these effects are exacerbated when combined with poverty (Evans & Saegert, 2002). The structure of social roles may also introduce opportunities for stress. Pearlin (1989) identified four types of chronic role strain. Role strain can consist of overload, as in having too much to do. Interpersonal conflict within roles (arguments with a spouse, child, or coworker) may be a source of role strain, as is interrole conflict as well (e.g., juggling parenting and work roles). Role captivity (such as being unable to quit an onerous job due to financial obligations) may be particularly problematic, as is role restructuring (e.g., a daughter who becomes a caretaker for her parents). There are also ambient strains, like living in poor neighborhoods, especially violent ones, and strains that may arise from informal or elective roles (arguments with friends or fellow members of a social organization). Pearlin (1989) emphasized that the social and personal context is instrumental in determining the outcome of a stressor. Not all role exits or restructuring are necessarily stressful. Exits from roles that are very stressful may be very positive (e.g., leaving a job that one hates or leaving a difficult marriage). Thus, stressors cannot be evaluated without knowledge of both the social and the personal context. Interestingly, Schrier and Evans (2003) suggested that stressors that are evolutionarily “old” might be easier to adapt to than those that are more recent. They found that children exposed to such “new” stressors show higher increases in cortisol than those exposed to “old” stressors. Certainly these psychosocial and sociocultural stressors can overlap. Nowhere is this better exemplified than in the environments of poor children. Evans’s (2004) review showed that such children are exposed to higher levels of family violence and conflict, more dangerous neighborhoods, and higher levels of air and water pollution.

Temporal Characteristics There are a number of temporal dimensions of stress that deserve greater study—most obviously, for example, its duration. The animal literature suggests that the physiological effects of stress may be very different, de-

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pending upon whether the stressor is short-term, chronic, or intermittent (Dienstbier, 1989). This was brought home to me when I was piloting a combat exposure scale on men in the Normative Aging Study. The scale had been developed on the basis of experience in the Vietnam war, and the length-of-exposure item went up to only about 24 months. One merchant marine veteran whom I interviewed explained that he had been at sea for over 5 years during World War II, and while he had only seen action a few times, the threat of German submarines was ever present. He was not sure how to respond—the amount of actual combat exposure was only about 2 weeks, but exposure to the threat of combat lasted over 5 years. Thus, this sailor had been subject to low-level chronic stress punctuated by intermittent intense stress. Was this sailor more or less stressed than a Vietnam veteran who had served an 18-month tour of duty with moderate combat exposure? Did the intermittency allow for recuperation and restoration, as Dienstbier (1989) would hypothesize, or did the chronic, day-after-day, low-level stress of always having to be alert for U-boats lead to a state of exhaustion, as Selye (1956) might have hypothesized? Rapidity of onset is another interesting stress parameter. On the one hand, we know that the anticipatory phase of a problem is very stressful— waiting to be laid off, for example. A commonly voiced opinion is that it would be better to die quickly of a heart attack than to linger slowly with cancer. Yet, being able to anticipate a problem also means that we can prepare for it, both emotionally and practically. While experienced parachutists generally have only mild cardiovascular reactions to a jump, Epstein (1982) related the case of a professional who had fallen asleep in the plane. When he jumped, his heightened cardiovascular reactions resembled those of a novice. Epstein speculated that the nap resulted in a lack of preparation time; because the parachutist did not engage in his normal coping behavior, his reactions were more severe. If the onset of a problem is too gradual, however, it may interfere with normal appraisal processes. Ecologists have coined the term “slow catastrophes” to refer to problems—such as overpopulation and the greenhouse effect—that begin very gradually but may have disastrous consequences in the long run. Thus, the temporal patterning may have profound implications for both coping behavior and the effect of a stressor.

STRESS AS A TRANSACTION BETWEEN THE PERSON AND THE ENVIRONMENT From Lazarus’s point of view (Lazarus & Folkman, 1984; Lazarus, 1991), depicting stress merely as an external event ignores individual dif-

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ferences in the perception or appraisal of stress. What is stressful for one individual at one point in time may not be stressful for another individual or the same individual at another point in time. For example, losing a job may have a very different meaning or very different consequences for a teenager as opposed to a middle-aged man. If a teenager loses at job at a fast-food restaurant, chances are very likely that he or she can easily find another at a different establishment. A middle-aged factory worker or manager, however, may have a very difficult time finding other work. Thus, the same life event, job loss, may be more or less stressful depending upon its individual and social context. In this model, stress can also be seen as a combination of environmental demands and individual resources, and cognitive processes are central. According to Lazarus, the perception of stress, or its appraisal, depends upon the extent of the environmental demand and the amount of resources that an individual has available to cope with that demand. Theoretically, the person first recognizes that there is a problem and then determines what resources are required to deal with that problem. Stress results from an imbalance between the requirements of the environmental situation and one’s ability to cope with it. For example, a car’s breaking down is somewhat stressful for most people, a more or less minor occurrence that requires either the knowledge and ability to fix the car oneself or sufficient money to hire a mechanic to fix it. But, for a homeless family living in a car, its mechanical failure might well be an insurmountable problem creating extreme stress. In the Lazarus and Folkman (1984) theory, five types of appraisal are generally identified: harm, threat, loss, challenge, or benign. However, there are other types that may also be important, such as concern over others’ problems (Aldwin, 1990). Further, the one-stressor, oneappraisal, one-emotion model (Smith & Lazarus, 1993), though conceptually elegant, may not capture the complexities of everyday life. In a study that included over 1,000 interviews with older men, we found that very few individuals used only one appraisal—most used at least two (Aldwin, Sutton, Chiara, & Spiro, 1996). Further, in pilot testing, we found that these five appraisals did not fit all of the situations, and we included three additional ones. Some problems were simply annoyances, while others were concerns over other people’s problems (usually those of a close friend or relative), while for some types of problems our respondents indicated that they were simply at a loss for what to do next. Further, a follow-up study showed that most of the men responded to problems with anger, regardless of the appraisal (Yancura, Aldwin, & Spiro, 2002). Presumably it is more culturally acceptable for men in our culture to respond to problems with anger rather than with sadness or grief.

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The other dimension of appraisal that is important is the problem’s severity, which may in part be related to what Folkman and Lazarus (1980) termed “secondary” appraisal. Perceived severity of a problem is a function of the (mis)match between environmental demands and individual resources, as mentioned earlier. Sociologically inclined researchers often object to the primacy of appraisal in this model. They point out that there are objective external circumstances (such as the unemployment rate) that do not depend upon an individual’s perception. Further, centering stress upon cognitive appraisal gives too much credence to rational cognitive processes and implies that stress is solely dependent upon subjective perception without much regard to objective factors (see Hobfoll, 1989, for a review of this position). However, it is a mistake to believe that a cognitive appraisal approach neglects environmental considerations. On the contrary, it seeks to understand how stress is a product of both the environment and the individual. Obviously, some environmental characteristics are so overwhelming as to result in a nearly universal experience of stress (as in major traumas such as wars, devastating earthquakes, etc.). However, most environments are more ambiguous and more subject to individual interpretations. Without an understanding of how this interpretation occurs, it is impossible to understand an individual’s experience of and response to stress. It could be argued that the centrality of appraisal processes may apply more to social than to physical sources of stress. Most people will react without thinking to an imminent source of physical danger of which they are at least minimally aware (e.g., jumping out of the way of a speeding bus). Further, subtle stressors, such as being in a sick building, may have negative effects without the individual’s even being aware of their source. However, it is also true that, given repeated exposure, individuals may learn to appraise imminent sources of physical danger very differently as they develop specific coping strategies. People drive on highways every day, where the slightest wrong move can (and often does) result in death; Boston pedestrians learn to avoid without effort seemingly homicidal Boston drivers; parachutists come to love stepping out into empty space thousands of feet above the earth. It is also likely that a person with a chronic respiratory ailment such as asthma may find even very subtle problems with sealed buildings intolerable. And, as in Calhoun’s (1962) experiment with rats, the perceived access to physical resources may be more important than the actual level of resources, even in rats. Thus, appraisal processes may also play a role along with physical stressors. Lawton and Nahemow’s (1973) construct of environmental compe-

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tence is relevant to this argument. This theory, originally promulgated in the context of aging and person–environment models, argued that an older person’s functional ability reflected an interaction between the difficulty of the environment and the individual’s resources. Some environments are so difficult that very few people could be considered “competent” within them—for example, at 17,600 feet, the base camp at Mount Everest is an extremely strenuous environment. Others are too easy and do not contain enough stimulation or challenges (e.g., most skilled nursing facilities, at least for the residents). However, most environments fall between these two extremes. A two-story home with one bathroom on the second floor is not a problem at all for most seniors, but for one with serious mobility problems that environment might simply be too difficult. Thus, one cannot determine the functional ability of a person only by assessing the individual’s own capacity; rather, some knowledge of the environmental challenges and resources is critical. Similarly, one cannot determine whether or not most environments are stressful unless one has some knowledge of the resources of the individuals in them. Another major criticism of the appraisal model of stress lies in its emphasis on the primacy of cognition, as opposed to emotion. Several theorists have argued that emotions are primary—that one becomes aware that a problem exists because of one’s emotional reaction to an event.

THE ROLE OF EMOTIONS AND COGNITION IN REACTIONS TO STRESS James–Lange versus Cannon The James–Lange hypothesis (James, 1890; Lange & James, 1922) held that the body’s emotional (visceral) reaction to stress occurred prior to and resulted in conscious responses. We run, therefore we are afraid; we fight, therefore we are angry. Cannon (1929), however, believed that neural processing was primary (with pathways originating in the thalamus). Cannon pointed out that the viscera have very slow reaction times and that the perception of and reaction to stress takes place very quickly. Therefore, neural (e.g., mental) processing must occur first. Schachter and Singer (1962) attempted to test the James–Lange hypothesis by injecting subjects with adrenaline in order to stimulate sympathetic nervous system arousal and then by putting them in either an aversive or a congenial environment. Subjects who had been injected with adrenaline showed stronger responses to the environment—and, thus, were said to “label” their emotions in the context of the environment. However, attempts to replicate this study have generally had little success (Marshall & Zimbardo, 1979).

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Lazarus versus Zajonc The James–Cannon debate has its modern counterpart in a similar debate between Lazarus (1982, 1984) and Zajonc (1984) as to whether cognitive or emotional reactions are primary in stress reactions. Lazarus argued that the cognitive processes of appraisal are central in determining whether a situation is potentially threatening or harmful, and thus cognition determines both the perception of stress and the individual’s emotional reaction to it. Zajonc, however, argued that simple awareness should not be equated with cognition and that emotional reaction to stress occurs before and may be at odds with cognitive reactions. The debate hinges on the definitions of emotion and cognition. Zajonc’s implicit definition of cognition is similar to logical, conscious thought, whereas Lazarus’s definition is closer to general awareness. It is true that one does need to become aware of a stress before one reacts to it. However, is that awareness primarily emotional or rational? In other words, do people become angry or afraid first and then impute a reason for their feelings, or do they define and recognize a situation as threatening and then emotionally react to it? Put in these terms, it becomes clear that the answer is: both. On some occasions, we may react first and think later; on other occasions, we may not become upset until we fully realize the threat in the situation. Implicit in this debate is the assumption that consciousness is unitary and that all neurological processing is sequential: first emotions, then cognition, or vice versa. However, current work in neuropsychology makes it abundantly clear that consciousness is not unitary—there are often multiple and parallel processing systems that may be more or less independent of each other (see Carver & Scheier, 1999, for a review). In short, critiques of the centrality of appraisal in stress theory are correct when they argue that people are not rational beings who coldly analyze environmental conditions and come to logical conclusions. However, I believe that this is a caricature of the appraisal process. The awareness of a stressful condition (whether it is harm, loss, threat, or challenge) may arise in a number of ways. We may intuit a problem, as when “a little voice” tells us that something isn’t quite right, that danger is imminent, and that we must stop and find out what is wrong. We may also use logical analysis to determine that the present course of action will eventually result in harm of some sort. At other times it seems as if the body can react before the mind has a chance to recognize the danger, as when a soldier “instinctively” dodges a blow before he is even fully aware that one is coming. All of these are examples of the appraisal process, whether it is conscious or unconscious, rational or irrational. It seems to me a truism that a person must be aware of a problem before

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he or she begins to cope with it—however that awareness is defined or comes about—again, with the exception of the imperceptibility of some nonetheless noxious physical stressors. Indeed, Lazarus’s later work (1991, p. 153) underscores the widely held proposition that there are indeed two modes for imputing meaning to a situation, “one conscious, deliberate, and under volitional control, the other automatic, unconscious, and uncontrollable” (emphasis in the original). Further, these two modes are understood to operate in an often simultaneous and parallel fashion and may in fact be contradictory. Epstein (1994) termed this dichotomy “rational” versus “experiential.” This may be best illustrated with phobias. An individual may consciously be aware that accidents in an elevator or airplane are statistically unlikely but nonetheless be consumed with dread. Thus, cognition and emotion inform each other. People may use logical reasoning to calm themselves, or they may develop elaborate cognitive justifications (rationalizations) for overblown emotional reactions.

SUMMARY There is little argument about the various components of the stress process (see Table 3.1). Rather, differences among stress researchers arise primarily because of the varying degrees of emphasis put on individual components and because of disagreements about the causal ordering of the components. Sometimes the debate is healthy and forces us to rethink our positions with greater clarity. At other times, however, feuds arise, passing on through generations of academics, usually over the ordering of two little boxes in a labyrinthine maze of boxes depicting what are actually rather similar views of the stress process. A transactional framework is integrative, because it acknowledges the importance of all of these components. Stress is, indeed, partially a function of the environment, but it is also partially a function of the internal characteristics of the individual (whether psychological, hormonal, or immunological). It makes little sense to ignore one at the expense of the other. Rather, it is of greater importance to trace out the manner in which these transactions occur. Further, it is quite likely that, depending upon the context or the individual, differing components may assume more or less significance. The recognition of multidirectionality between the components also renders the exact causal sequencing less important. The important point is to understand clearly which components of the stress process are important in a given context and to make sure that the appropriate concepts and tools are being utilized, whether in research or clinical work.

STRESS, The Physiology COPING, of Stress AND DEVELOPMENT

CHAPTER 4

The Physiology of Stress

A

s noted in the preceding chapter, human bodies are “hardwired” to respond to stress. In general, when we think of stress responses, we think of neuroendocrine responses, such as rapid heart rates, greater alertness, and the capacity for bursts of energy. The immune system also responds to stress and also regulates stress responses. But there are also stress response mechanisms at the cellular level that are phylogenetically very old—in other words, they are found in simple organisms such as amoebas, in plants, and in animals. Indeed, the sheer number and redundancy of physiological systems designed to cope with stress suggest that the ability to respond to stress is terribly important in adaptation.

NEUROENDOCRINE RESPONSES TO STRESS General Stress Reactions If you examine the functions of the sympathetic nervous system listed in Table 4.1, it is fairly obvious that increased arousal of the sympathetic nervous system prepares an organism for action. Blood is diverted from the intestines and other vegetative activities and is transferred to the brain and the striated muscles. Blood pressure, heart rate, and respiration rate increase, allowing more oxygen to flow to the brain and muscles. The increase in blood sugar provides more energy, and the increase in blood clotting defends against cuts. These changes enable greater physical and mental effort on the part of the organism. (Piloerection is 37

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TABLE 4.1. Functions of the Autonomic Nervous System Sympathetic nervous system • Increases blood pressure, heart rate, respiration rate, and perspiration. • Increases blood sugar and blood clotting. • Dilates pupils. • Causes piloerections (goose bumps). • Decreases saliva, mucus, and gastrointestinal motility. • Diverts blood from intestines to brain and striated muscles. Parasympathetic nervous system • Controls digestion. • Maintains and conserves bodily resources. • Decreases blood pressure, heart rate, respiration rate, etc. • Generally opposes sympathetic activation but sometimes acts in consort.

important for furred species. Hair standing on end makes a cat, for example, look much larger and intimidating, and also provides protection against bites.) Walter Cannon (1939) termed this type of sympathetic nervous system arousal the “fight–flight” reaction. In response to a threat or stress, the fight–flight reaction makes it possible for an organism to more effectively meet such challenges through mobilizing its mental and physical abilities. People often find that they run much faster when being chased by a dog than when out for their morning jog; athletes talk about “getting pumped up” or “getting the adrenaline flowing” to achieve peak performances. Indeed, that is exactly what happens. As early as 1915, Cannon showed that when cats are exposed to barking dogs, epinephrine or adrenaline is released into their bloodstream. Cannon hypothesized that the perception of a threat activates the thalamus (now we know it is the hypothalamus), which stimulates the pituitary gland to release hormones that activate the adrenal glands, which lie on top of the kidneys. The adrenal medulla, or center, releases epinephrine (adrenaline) and norepinephrine (noradrenaline), which stimulate sympathetic nervous system activation (see Figure 4.1)—hence, the fight–flight reaction. Once the threat is removed, parasympathetic activation returns the body to homeostasis by decreasing blood pressure, heart rate, and respiratory rate, returning the body to a vegetative state that promotes gastrointestinal activity. The effect of a sudden sympathetic nervous system arousal on someone with underlying cardiovascular disease may lead to a stroke or myocardial infarction (heart attack). However, prolonged sympathetic nervous system arousal can lead to serious physical problems and death in even relatively healthy individuals. Cannon described the case of an

The Physiology of Stress

39 Hypothalamus Pituitary Gland

Anterior Lobe

Posterior Lobe

Growth hormone (GH) Thyrotropic hormone (TH) Follicle-stimulating hormone (FSH) Luteinizing hormone (LH) Prolactin or Luteotropic hormone (LTH) Melanocyte-stimulating hormone (MSH) Adrenocorticotropic hormone (ACTH)

Vasopressin Antidiuretic hormone (ADH) Oxcytocin

Adrenal Glands Adrenal Medulla

Adrenal Cortex

Catecholamines Epinephrine (adrenaline) Norepinephrine (noradrenaline)

Steroids Corticosteroids (cortisone, cortisol) Glucocorticoids Mineralocorticoids

FIGURE 4.1. Components of the neuroendocrine system.

Australian aborigine who was cursed by a local “witch doctor” and who died a few days later of no obvious organic cause, such as disease. Cannon termed this phenomenon “voodoo death” (despite the fact that vodun is only found in the Caribbean and Brazil) and thought that it derived from overactivation of the sympathetic nervous system. Essentially, increased blood pressure decreases circulating blood volume by forcing liquids out of the vascular system and into the surrounding tissues. If this process goes on long enough, the blood volume is eventually insufficient to sustain adequate blood pressure levels, the arterioles dilate in an attempt to increase blood flow, and blood pressure can drop dramatically, leading to shock and cardiovascular arrest. This reaction may be aggravated by lack of food and drink (aborigines so cursed may stop ingesting food and liquids), but, nonetheless, it is a direct effect of stress. Thus, one can literally be “scared to death.” Animals can also be frightened to death. For example, transportation of animals, even domesticated ones, can result in death (Backstrom & Kauffman, 1995). Among pigs this is called porcine stress syndrome; mortality rates are even higher among wild animals. Paradoxically, trying to protect deer in an overpopulated area from hunting by transporting them to other areas usually results in the death of those animals

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transported, in part from stress. I even remember reading a London Times article about an okapi in the Berlin zoo that died of fright during a Wagner music festival. Apparently “Ride of the Valkyries” is simply too scary! Cannon believed that any threat resulted in the fight–flight reaction and that such a reaction is a general response to any stress, physical or social. He believed that the body responds to all threats in a similar manner, whether or not that manner is immediately relevant. That is, we respond with the same sympathetic activation to negative performance evaluations from our supervisors as our ancestors did to carnivorous predators. In reacting to sudden physical threats, it makes a great deal of sense for the body to be able to run away very quickly, or even to challenge the predator with enhanced strength (and blood clotting ability). However, the same physiological response is not generally appropriate to social and verbal challenges (although increased blood flow to the brain should—but does not always—help with witty repartees). Physical violence is not an appropriate response to employers’ chastisements (although work-related violence is unfortunately on the rise). Forty years ago, Dubos (1965) argued that the necessity to suppress direct physiological response to modern challenges results in diseases of adaptation. For example, increases in blood pressure and blood clotting without the physical release of actually running or fighting may eventually result in hypertension and cardiovascular disease. Thus, Dubos believed that the current epidemic of cardiovascular disease has resulted in part from the body’s response to verbal and social challenges as if they were direct physical threats without the attendant release from physical activity. Hans Selye’s (1956) “physiology of dirt” expanded on Cannon’s flight–fight theory in two ways. First of all, Selye focused attention on the corticosteroids, which are released by the adrenal cortex, or top layer of the adrenal glands. He also expanded on Cannon’s homeostatic process by describing three stages in reaction to stress. The first, or alarm, stage is similar to Cannon’s fight–flight reaction but involves the adrenal glands as well as the hypothalamic–pituitary axis. However, Selye noticed that some organisms became inured to the stressor. In the second stage, adaptation, there is a return to physiological homeostasis, or perhaps augmented functioning. In the third stage, exhaustion, the organism may fall ill or die if the stress continues. The models of Cannon and Selye are similar in that they posit general or universal reactions to stress. Thus, heightened sympathetic reaction will occur regardless of whether the stressor is a physical predator or a college exam and whether the organism being stressed is a man or a mouse. More recent researchers, however, have suggested that there are

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more specific reactions to stress that can vary depending on the stressor or the individual.

Specific Reactions to Stress In many ways, the field of psychosomatic medicine is predicated upon individual differences in reaction to stress. Alexander (1950) proposed that different emotional states underlie different psychosomatic illnesses. For example, heart disease was thought to be related to underlying chronic patterns of hostility, while asthma involved unconscious anguish due to separation from the mother. Different types of environmental stress could result in particular emotional conflicts, which in turn provoked specific under- or overarousal of particular systems, eventually leading to organic problems. Given the difficulty in establishing the presence of underlying un conscious conflicts, this psychosomatic theory developed the “weak organ” theory—namely, that stress resulted in different illnesses, depending upon the physiological (genetic) weaknesses of the individual (see Wiener, 1977). In this model, stress is thought to result in either heart disease or asthma, depending upon the constitutional weaknesses of the individual. For example, individuals high in hostility exhibit greater increases in blood pressure under stress than those low in hostility, thus providing a possible mechanism through which hostility can result in heart disease (Hardy & Smith, 1988). Early work by Lazarus and his colleagues (reviewed in Lazarus, Averill, & Opton, 1974) suggested that there are individual differences in physiological reactions to stress. They investigated the effect of stress on end organs, or the outward manifestations of sympathetic arousal. These include heart rate, respiratory rate, and galvanic skin response (GSR), which reflects the amount of perspiration on the skin. They found individual differences in the patterning of responses. For example, some individuals’ heart rates increased in response to stress, whereas other individuals’ heart rates decreased though they perspired more. While sympathetic arousal did occur, the manifestation of this arousal varied across individuals. Thus, there may be individual differences in the patterns of physiological reactions to stress. Further, there was early evidence that different types of stressors may evoke different physiological reactions. Mason (1971) subjected rats and monkeys to different types of stress, including hunger, inadequate nutrition, and cold. He found that there were “stressor profiles,” such as specific neuroendocrine reactions that varied depending on types of stress, and concluded that reactions to stress were specific, not general.

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It is now well established that there are both individual differences in as well as situation-specific responses to stress, and that the physiology of stress is much more complicated than originally thought. For example, within the sympathetic nervous system (SNS), there are different subsystems that can be activated independently (Jänig & McLachlan, 1992). Further, we know much more about the timing of and interaction between different stress-regulating systems in the body. The SNS constitutes the immediate reaction to stressors, and consists of two major subsystems (Gevirtz, 2000), both of which result in the release of catecholamines (epinephrine and norepinephrine, also called adrenaline and noradrenaline). In the first system, the SNS neurons use norepinephrine to stimulate target organs and to immediately increase the heart and respiratory rates and decrease gastrointestinal activity, which allow more circulating blood to reach the muscles more quickly, giving them more nutrients and taking away toxins such as lactic acid generated by motor activity. Norepinephrine also serves to increase muscle strength and mental activity. The second system also results in the release of catecholamines, but indirectly via the adrenal medulla. In the sympathetic–adrenomedullary (SAM) system, the sympathetic nerves directly stimulate the adrenal medulla to release both epinephrine and norepinephrine into the bloodstream, which then also affect the target organs (see Figure 4.2). The pathways are, in fact, redundant, which signals the importance of being able to respond immediately to stress for adaptation.

FIGURE 4.2. Two pathways in the stress activation of the sympathetic nervous system.

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Hypothalamic–Pituitary–Adrenocortical Axis and the Anabolic/Catabolic Balance Catecholamines are toxic, and too prolonged an exposure damages the organs that are being activated (Sapolsky, 1998). Thus, activation of the hypothalamic–pituitary–adrenocortical (HPA) axis occurs not simply as a stress response, but is a way in which the body tries to reduce the toxic effects of SNS exposure. For example, SNS stimulates the inflammatory response of the immune system (see below), which, if prolonged, can damage various organ systems. HPA activation suppresses the immune system in an attempt to prevent this damage. The HPA axis is presented in Figure 4.3. The stressor, which includes chemical toxins, mechanical stress (such as physical exertion or exposure to heat or cold), and psychosocial problems (more precisely, the perception of threat or harm), stimulates the hypothalamus to secrete corticotropin-releasing hormone (CRH). In turn, CRH stimulates the anterior lobe of the pituitary to release adrenocorticotropic hormone (ACTH) into the bloodstream. The adrenal cortex, or outer part of the adrenal gland, releases corticosteroids, which are fat-soluble molecules that use cholesterol as a component. Cell walls are also made up in part by cholesterol. This allows them to cross cell membranes and enter every cell in the body. This is why stress can affect nearly every organ system. Corticosteroids include both glucocorticoids and mineral corticoids. Glucocorticoids have a wide range of effects. They can suppress immune

FIGURE 4.3. Stress activation of the hypothalamic–pituitary–adrenocortical axis (HPA).

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function, raise metabolic rates, and stimulate the release of glucose into the body. They can also affect sex hormones and thus influence fertility. Depending upon the duration of the stressor, they can either stimulate or suppress growth hormone (Sapolsky, 1998). Mineral corticoids regulate systems such as calcium metabolism. HPA activation is a slower system, taking about 20 minutes to activate, but it allows for a more sustained response to stressors. The problem is that prolonged exposure to glucocorticoids also has toxic effects. Long-term immune suppression can leave us vulnerable to infectious agents such as bacteria or viruses and may also interfere with the immune system’s surveillance against cancer cells. Thus, there are feedback mechanisms set up to decrease glucocorticoid levels if they get too high. For example, there are receptors in the hippocampus that monitor and help regulate the amount of cortisol in the blood system. However, prolonged or repeated exposure to high levels of cortisol can damage these receptors. Sapolsky (1992, 1999) proposed that this may result in poorer regulation of cortisol and may be a result in hippocampal damage, leading to memory problems in late life. However, sometimes individuals exposed to prolonged chronic stress, such as those who have posttraumatic stress disorder, have lower levels of cortisol (Yehuda, 2000) because cortisol levels have simply been depleted, exhausting their ability to mount a stress response. This can be very serious. For example, these individuals may be chronically fatigued and unable to exercise precisely because this requires increases in blood pressure and blood glucose levels. With a functioning stress response, these systems simply cannot respond, and the person is easily fatigued (Gruenewald & Matsumoto, 1999). Epel, Burke, and Wolkowitz (2007) have argued that a systems approach needs to be taken to properly understand neuroendocrine responses to stress. In particular, increased levels of any one hormone may be less important than the “anabolic/catabolic balance.” In general, anabolic processes are those that result in healthy growth in bone, muscle, skin, and other tissues, while the complementary catabolic processes break down components for fuel or as a process of continual restructuring. For example, bone density reflects a dynamic process in which calcium is deposited in bone cells (anabolic process) but taken from bone cells when needed for other functions such as muscle contraction (catabolic process). Cortisol and catecholamines are catabolic because they break down substances to generate energy, while other hormones such as growth hormone and the sex hormones (estrogen and testosterone) are anabolic because they increase bone mass and muscle size, deposit fat in the appropriate cells, and so on. Prolonged exposure to stress (and high levels of cortisol) may disrupt the anabolic/catabolic balance, resulting in

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decreased muscle mass, bone density, and fat deposits in the abdomen (Dallman, Pecoraro, & la Fleur, 2005).

Flight, Fight—or Affiliate? Cannon’s now famous “fight–flight” response has been criticized as being too simplistic and ignoring the social component of the stress response. Taylor et al. (2000) have hypothesized that women’s responses to stress may be more characterized by the oxytocin–estrogen–endogenous opioid system, which constitutes the neurological underpinnings of the attachment and caregiving systems. Oxytocin is a hormone secreted by the hypothalamus as well as the ovaries and testes. It initially was identified as a major factor in lactation and nursing behavior as well as “maternal responsiveness.” However, it is also found in men and may play a role in sperm ejaculation and sexual behavior. While oxytosin is suppressed by stress and cortisol, it has also been shown to reduce the adverse effects of stress and to be an antianxiolytic, especially in the presence of social support (Heinrichs, Baumgartner, Kirschbaum, & Ehlert, 2003). Taylor et al. (2000) argue that fleeing under stress may be difficult or impossible for pregnant women or mothers of infants and also may put their offspring at risk. Therefore, they suggest that it was evolutionarily important for women to tend first to infants if there were external stressors. Further, experimental research shows that women are much more likely than men to seek social support under stress. Therefore, they added a “tend and befriend” dimension to Cannon’s original fight–flight dichotomy. Elsewhere (Aldwin & Gilmer, 2004), we suggested that this type of affiliation may also be important in men’s adaptation. Certainly field studies show that men often have larger social networks than women and also seek social support in stressful situations, albeit to a somewhat lesser extent than women (Taylor, 2007). Men also feel protective of their families and friends under stress. Still, this recognition of the social aspect of stress responses is an important extension of Cannon’s original two-dimensional response. Therefore, we proposed a triune model of stress responses, which includes fight, fight, and affiliate. This threedimensional space allows for a more complex understanding of individual differences in response to stress, as well as for personality, gender, and contextual influences. For example, one could easily hypothesize that individuals who are hostile may be more likely to fight in response to stress while those who are shy may be more likely to flee. Women may be more likely to affiliate under stress, but both men and women may change their stress responses to be more protective if young children are

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involved. Of course, in such extreme cases as, for example, the collapse of the World Trade Center towers, individuals may find themselves running blindly without any recollection of how long they have been running. Whether this triune model is a useful way to organize the stress field, however, remains to be seen.

IMMUNE RESPONSES TO STRESS The immune system is an extremely complex mechanism that regulates the body’s reaction both to external threats and to internal malfunctions (for overviews of this topic, see Aldwin & Gilmer, 2004; Cohen & Herbert, 1996; Gruenewald & Kemeny, 2007; Kiecolt-Glaser et al., 2002; Rabin, 1999). External threats include bacteria, viruses, parasites, and toxins; internal threats consist of malfunctioning cells. One of the great wonders of the immune system is that it learns to differentiate between self and other. Each cell in the human body has an identifier unique to that person, called a human leukocyte-associated (HLA) molecule. These are on the cell membrane, are genetically determined, and allow the immune system to readily distinguish its own cells from those of invaders, which include bacteria, viruses, and parasites. For example, bacteria proliferating in the bloodstream are recognized by the immune system as foreign and then attacked. Viruses cannot proliferate on their own; rather, they work by taking over the DNA or RNA of a cell to manufacture copies of themselves. Usually this results in a change on the surface of the cell membrane, which alerts the immune system to the invader. However, the AIDS virus is particularly deadly because not only does it take over an immune system component, the T cells, but it hides within the cell and does not appear to make easily recognizable membrane changes—so it is difficult for a person’s own immune system to recognize these dangerous cells. The immune system can also be activated by inert molecules such as pollen or dust. Thus, an antigen is anything that activates the immune system. The immune system can also recognize cells that have started malfunctioning, such as precancerous cells.

Innate Immunity The simplest type of immune reaction to invaders is called innate immunity, or nonspecific defenses, and may include fevers, vomiting, defecation, and urination, which rid the body of pathogens (see Dantzer, 2004). This type of defense, however, can be extremely costly. High fevers (those that are 105 degrees Fahrenheit or above) can result in blind-

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ness, brain damage, and death. Vomiting and diarrhea can be very effective ways of ridding the body of food- or water-borne illnesses, but the resulting dehydration and electrolytic imbalance can be fatal. Indeed, one of the leading causes of infant mortality in developing nations is diarrhea. Thus, the immune system also has a more effective and less costly form of defense, called “cellular immunity.” In innate immunity, cells such as phagocytes (including granulocytes, monocytes, and neutrophils) recognize invaders and literally “eat” them—hence “phagos,” which is Greek for “eat.” These cells roam the circulatory system or are sometimes embedded in membranes such as those lining the nose, and they engulf whatever invader they come across. Macrophages (big eaters) are similar but much more effective because they can be directed by the lymphocytes toward specific types of cells and can eat 10 times the number of cells as, say, neutrophils (Guyton & Hall, 1996). Basophils do not eat cells but instead secrete noxious chemicals to kill invaders such as parasites.

Acquired Immunity In contrast to innate immunity, “acquired immunity” reflects the fact that the immune system “learns” to identify specific types of antigens and develops tools that are specific to that antigen. Further, the immune system has a memory. Once a specific type of immune response is learned, it remembers which components are necessary for combating the antigen, and it will manufacture more of that specific component when challenged. This is one reason why young children seem so susceptible to every infection that comes along—their immune systems are literally learning the “vocabulary” of bacteria and viruses. Until they have been exposed to a particular type of bacteria or virus, they will not have the appropriate antibody in their repertoire (unless they are nursing and can utilize their mothers’ immune defenses). Vaccinations work by administering either a dead or very weak version of bacteria or virus so that a child’s immune system can learn to make the correct antibodies without much risk of the child’s becoming seriously ill. Some vaccinations, such as gamma globulin shots for hepatitis, work by directly providing the immune system with copies of the appropriate antibody (IgG). However, viruses can mutate very rapidly, and the immune system must always be developing new antibodies for the mutations, which is why one needs to get a flu shot every year. Bacteria can also mutate rapidly, and the overuse and incorrect use of antibiotics may result in drug-resistant strains of bacteria. If a person does not take the full complement of antibiotics, for example, all of the bacteria may not be killed, and the surviving ones will be more drug-resistant.

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Further, if a particular strain of bacteria or virus is provided with very hospitable vectors, or hosts, it can develop into a much stronger (or more virulent) version (Whiteside et al., 1993). For example, the homeless are very hospitable vectors for tuberculosis (TB). Due to nutritional deprivation, loss of sleep, and stress, the homeless often have highly weakened immune systems. The TB virus is airborne, and being exposed to coughs in a crowded shelter is often a perfect environment for the transmission of TB. Due to lack of medical care, the homeless may not seek treatment until the TB is fairly far advanced, and their chaotic living conditions may make it difficult for them to consistently take their antibiotics for the requisite number of months to completely destroy the infection. Some public health officials worry that our neglect of the health and well-being of the homeless may result in a dramatic increase in particularly virulent forms of TB (Villarino, Geiter, & Simone, 1992). Thus, the immune system has to be constantly learning to recognize new enemies and manufacture new antibodies. However, errors can arise in learning, and the immune system may attack normal cells, resulting in autoimmune diseases such as rheumatoid arthritis. Sometimes viruses manufacture antigens that are very similar to a naturally occurring protein, and the immune system may get confused and attack a “good” protein. It is thought that multiple sclerosis (MS) and some types of Type 1 (insulin-dependent) diabetes, especially when it arises in adulthood, are due to invading viruses that generate antigens that the immune system confuses with the nerve sheaths (in MS) or the beta cells that manufacture insulin (in diabetes). Thus, the viruses can disable an organism by getting the immune system to attack a crucial function. There are a great many components to the immune system, and researchers are still identifying subcomponents. However, the components of acquired immunity are generally categorized into two broad divisions: humoral immunity, which includes antibodies or immunoglobulins, and cellular immunity, which includes a variety of cell types (T cells and NK cells) that either directly challenge invaders (or malfunctioning cells) or mediate humoral immunity (B cells). While both T and B cells derive from precursor cells in the bone marrow, T cells are matured in the thymus.

Humoral Immunity Unlike phagocytes (or T cells), B cells do not engulf or lyse (break open) antigens but instead generate antibodies. Also called immunoglobulins, these are complex protein chains that specifically agglutinate or bind antigens together so that they can be more easily removed from the body. Other antibodies serve to identify antigens to T cells or to basinophils,

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which then destroy the antigens by lysing their cells (often by using hydrogen peroxide). At other times, the macrophages or T cells can identify antigens to B cells and stimulate them to produce antibodies, which then agglutinate this specific type of antigen. There are five major types of antibodies or immunoglobulins: IgA, IgD, IgE, IgG, and IgM. (I use the acronym MADGE to remember these, despite the different order of presentation.) Note that there are also many subtypes of each antibody. Antibodies are generally specific to particular antigens, although if the molecular shape of antigens is similar enough, some cross-reactivity may occur. Sometimes an antibody may react to more than one antigen, which is called multispecificity.

Cellular Immunity Cellular immunity refers to activated or mature T cells. Through a process that is still poorly understood, the thymus processes the immature or “naive” T cells (also called rosettes), differentiates them into specific types of T cells, and selects those that can recognize a particularly antigen. The thymus also destroys T cells that would self-react. There are many different types of cells and somewhat different naming conventions for them. Some types of T cells, such as cytotoxic T cells (cT), directly recognize and lyse cells that are abnormal in some way, either because they are infected with bacteria or viruses, are cancer cells, or in general have the wrong HLA complex on their cell membranes (such as those in transplanted organs). These are also called effector cells. In contrast, helper T cells, also known as CD4+ cells, do not directly lyse cells but instead generate molecules called cytokines that stimulate other parts of the immune system. Cytokines, also known as interleukins, have different functions but in general help in communicating between and regulating the different parts of the immune system. For example, interleukin-4 (IL-4) stimulates B cells to produce antibodies, whereas interleukin-2 (IL-2) assists in cell maturation. Macrophages can also release interleukin-1 (IL-1), which causes T cells to proliferate. IL-6 is involved in inflammatory processes. When an organism is exposed to antigens, there is a massive increase in the number of T cells (as well as other components of the immune system), in part due to the stimulating influence of helper T cells and macrophages. This results in inflammation and other immune symptoms. For example, the fevers, aches, runny nose, and lethargy commonly associated with colds or the flu are actually side effects of the actions of the immune system against the invading virus. The same is true of the redness, tenderness, and swelling associated with bee bites. Allergic reactions and asthma are caused by an inappropriate or exces-

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sive proliferation of IgE. Similarly, phlegm and pus in wounds are largely dead bacteria and immune cells. The massive increase in T cells is physiologically very costly, and it is thought that the immune system induces lethargy so that it can redirect available energy supplies to producing T cells. While inflammatory responses are necessary in the short run, in the long term they are in and of themselves toxic and may result in problems such as autoimmune disorders, chronically inflamed nerves, and even heart disease, which is now largely thought of as an inflammatory process. Thus, the immune system uses suppressor T cells, also known as CD8 cells, to decrease immune reactions. In many ways, the ratio of CD4+ to CD8 cells may be a better indicator of the healthiness of the immune system than is the absolute level of any one component. Memory T cells constitute the “library” that the immune system consults in order to see if it can recognize a particular antigen. If a particular antigen is in its library, the immune system can thus stimulate the appropriate cell proliferation much more rapidly than if the thymus has to take the time to figure out the precise antibodies needed to repel that specific invader. This allows the immune system to prevent the occurrence of illness—that is, it can overwhelm the invaders before they have a chance to proliferate too widely. Thus, in some ways, the immune system actually becomes more efficient with age—at least until very late in life, when there are fewer rosettes and the immune system takes much longer to mount challenges to new invaders that it has not seen before (Weksler & Szabo, 2000). Natural killer (NK) cells have been receiving increasing attention as an important immune system component. Unlike T and B cells, they can independently attack viruses and parasites without requiring presensitization (Murasko & Bernstein, 1999). Low levels of NK cells have also been associated with chronic virus infection and autoimmune disease (Whiteside, Bryant, Day, & Herberman, 1990). More importantly, NK cells have a surveillance function in the fight against tumor proliferation. By a currently unknown mechanism, NK cells have the capacity to identify cells that are mutating into tumor cells. By destroying these cells, NK cells help fight against cancer. Depending upon the circumstances, precancerous cells can arise very frequently, and thus a weakened NK cell system can have serious consequences.

Immune System Assays There are two basic kinds of immune system assays: structural and functional measures. Structural assays refer to counts of the number of par-

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ticular types of immune system antibodies or cells and constitute the most common and reliable way to assess immune function (Virella, 1993). However, simple counts of B and T cells may not be good indicators of immunocompetence; it may be more important to determine how well these cells are functioning. B cell functioning is generally determined by how many antibodies they produce when stimulated by mitogens (usually PHA or con A—hence, the term “con A proliferation assay”). Researchers determine what proportion of cells NK cells can lyse and also examine CD4+/CD8 reactivity. However, reactivity may be hard to quantify consistently, and some of the assays may be not only less than reliable but also subject to lab drift (differences across labs or across time within labs).

Stress and Immune Function The relationship between stress and immune system functioning is complex, but stress and other psychosocial factors have been associated with the functioning of various components of the immune system, including antigens, CD4+/CD8 ratios, and NK cells (for reviews, see Aldwin & Gilmer, 2004; Cohen & Herbert, 1996; Gruenewald & Kemeny, 2007; Kiecolt-Glaser et al., 2002; Rabin, 1999; Solomon & Benton, 2001). In part, the impact of stress depends upon the duration and intensity of the stressor. Very short-term stimulation, such as laboratory stressors, may actually increase or stimulate immune functioning, but acute stressors, such as students’ examinations, suppress a variety of immune functions. The influence of chronic stress is most profound and long-lasting. For example, there is an extensive literature on caregiving stress that suggests that immunosuppression may last long after the stressor has ended (Glaser et al., 1998). Nevertheless, while experimentally creating a stress-immune system-illness chain has proven difficult (Kaplan, 1991), a number of carefully controlled studies have started constructing this chain. Cohen, Tyrrell, & Smith (1991) conducted an experiment in which different types of stress were related to the “success” of a viral infection (how much the cold virus proliferated after exposure) and cold symptoms. Further, Cohen et al. (1998) showed that individuals who reported chronic interpersonal stress were more likely to come down with a cold following exposure to a rhinovirus. Kiecolt-Glaser, Page, Marucha, MacCallum, & Glaser (1998) showed that students under stress had lower levels of cytokines (which regulate the inflammation and healing process) and small experimentally induced wounds took longer to heal. However, most of the work, especially in humans, is

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correlational instead of causal—and thus must be viewed with caution. It many ways, it is easier to show stress, immune-suppression, and illness links in individuals who are already ill. Zautra et al. (1998) studied women with rheumatoid arthritis and showed that interpersonal stressors were associated with immune system changes in T cells and IL-2, which in turn were associated with physician ratings of disease activity. Similarly, stress has been associated with lower CD4+ cell counts in HIVpositive men, which in turn is often associated with a more rapid progression of the disease (Nott & Vedhara, 1999). While the mechanisms through which stress affects the immune system are not clearly understood at this point, the central nervous system and the immune system have complex bidirectional relationships, and there is evidence, at least in animals, that the brain monitors immune system processes (Dunn, 1989). Given that the various components of the immune system need to communicate in order to function, it is not surprising that there are receptor sites for neurotransmitters on immune system cells. (Neurotransmitters may be more aptly termed “communication peptides,” since they are found in nearly every organ in the body and do not seem to be limited simply to transmitting neuronal commands.) Further, changes in the immune system may also have cognitive and psychological effects (for reviews, see Dunn, 1989; Smith, 1991). Thus, stress-induced emotions, neuroendocrine functions, and the immune system may usefully be examined in a transactional framework.

CELLULAR RESISTANCE TO STRESS Cells can also be stressed, which can lead to their malfunctioning and even to death. There are a large number of factors that can create stress at the cellular level, including exposure to biochemical toxins, radiation, heat, and cold. Perhaps the most pervasive source of stress is reactive oxygenating species (ROS), the so-called free radicals. Free radicals are molecules, usually oxygen, that have an imbalance in their number of electrons. These are generated when processing oxygen for energy in the cell, or by the immune system when it seeks to destroy bacteria and other invaders by squirting them with ROS such as hydrogen peroxide or superoxides. ROS can seriously disrupt the functioning of the cell, often by damaging the conformation of proteins, especially in sensitive organelles like mitochondria, which are the power houses of the cell. There are a number of ways in which cells can protect themselves from stress. There are naturally occurring antioxidants such as super-

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oxide dismutase (SOD), which can absorb or distribute extra electrons, thereby counteracting ROS. Other chemicals such as vitamin C, lipoic acid, and acetylcarnitine also act as antioxidants and serve to protect the cell (Calabrese, Giuffrida, Calvani, & Butterfield, 2006; Hagen, Moreau, Suh, & Visioli, 2002). Other stress-protective mechanisms at the cellular level include DNA repair mechanisms and heat shock proteins (hsps). Hsps have a number of functions, including refolding damaged proteins back into their proper structure and regulating the enzymes necessary for repair (Sartori & Scherrer, 2003). Hsps received their name because they were first identified in plants that were subjected to heat stress. The importance of these DNA repair mechanisms and Hsps is underscored by the fact that they are highly conserved across species, that is, they can be found in nearly all living cells from bacteria through mammals and may be a major regulator of the aging process (Calabrese et al., 2006; Jurivich, Qiu, & Welk, 1997). As mentioned earlier, only one article has examined psychosocial factors and hsps (Lewthwaite et al., 2002). They found elevated levels of hsps in individuals with low SES, high social isolation, and (for women only) high levels of psychosocial distress. How psychosocial factors can impact stress resistance and vulnerability at the cellular level is, at this point, unknown.

SUMMARY There are many complex ways in which the body responds to and counteracts the effects of stress, include neuroendocrine responses, immune responses, and cellular responses. In a sense, the approaches that emphasize general and specific reactions to stress are complementary rather than competing. Stress does involve mobilization of the SAM and the HPA axis as well as the immune system and cellular responses. However, within that general framework, there may be variations due to individual differences in patterns of reactivity or to stressor characteristics. Which approach is appropriate depends upon the specific stressors or responses to stress under investigation. Different types of problems or stressors require different levels of analysis. For example, obtaining very precise neuroendocrine profiles in reaction to stress may be nearly impossible in a field setting. Confounding factors such as sleep patterns, nutrition, and activity level cannot be controlled. In such settings, more general measures of sympathetic nervous system arousal may be more appropriate. However, more precise physio-

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logical measurements may be necessary for studies that seek to define mechanisms between personality, stressors, and specific disease outcomes, such as hostility and coronary heart disease. Nonetheless, stress clearly affects the whole body, and the roles that psychosocial factors such as coping play in moderating the effects of stress will take up the remainder of this book.

STRESS, Design and COPING, Measurement AND DEVELOPMENT Issues

CHAPTER 5

Design and Measurement Issues in Stress Research

T

he sheer amount of research on the effects of stress during the past quarter-century has been extraordinary. A review by Vingerhoets and Marcelissen (1988) counted nearly 10,000 articles published during the decade between 1976 and 1985. Since 1986, more than 60,000 articles on stress have been published in psychology! A search of PubMed yielded more than 238,000 articles in total! Obviously, a review of all of this literature is beyond the scope of this (or any) book. However, there are a few general observations that can be made. Further, a number of extremely crucial research design issues have emerged, an understanding of which is essential to conducting adequately designed studies on stress. In this chapter, the different types of stress instruments are briefly reviewed.

GENERAL OBSERVATIONS It has been established, beyond doubt, that stress is associated with negative health outcomes in almost a bewildering array of illnesses, ranging from backaches and headaches to heart disease and, perhaps, cancer. (For reviews of the health effects of stress for various illnesses, see Aldwin & Gilmer, 2004; Duijts, Zeegers, & Borne, 2003; Krantz & McCeney, 2002; Turner & Wheaton, 1995; Vitaliano, Zhang, & Scanlan, 2003). The mechanisms for this broad spectrum effect of stress almost 55

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certainly lie within the neuroendocrine and immune systems (see Chapter 4), but the specific details are still being worked out. A number of general observations, however, can be made. Contrary to Holmes and Rahe’s (1967) initial hypothesis, positive stressful events per se do not appear to have adverse health effects. Most research shows that negative or undesirable rather than positive events precipitate symptoms (Rabkin & Streuning, 1976; Turner & Wheaton, 1995). In fact, there are some studies suggesting that positive events may buffer or mitigate the adverse effects of negative or undesirable events, although there is a great deal of inconsistency in the findings (Doyle, Wolchik, Dawson-McClure, & Sandler, 2003; Reich & Zautra, 1981). Thoits (1983) cautioned that undesirable events may be better predictors of psychological symptoms, but total events may be better predictors of physical health symptoms. This may be because the so-called positive events may have many negative characteristics. A promotion or a new job may initially entail an increase in workload, or a new marriage may get off to a rocky start. In general, going through a negative event, like a divorce, may have more serious health consequences than experiencing a positive event such as marriage. Further, stressors that are thought to be uncontrollable are generally more distressing than those that are more likely to be under an individual’s control (Reich & Zautra, 1981). For example, quitting a job may be less stressful than being fired. Similarly, initiating a divorce from a spouse may be less stressful than being divorced (Wilder & Chiriboga, 1991). The uncontrollability of the event may explain why natural disasters and other types of trauma are so stressful. Perhaps the most important thing to remember about stress research is that the relations between stress and health outcomes, although broad in scope, are relatively modest in effect sizes. The correlations between stress and health outcomes are typically in the .20s–.40 range. Overall, this is a positive finding, because it suggests as a species that we are rather resilient to stress. Unlike some laboratory rats, we tend not to become ill at the slightest bit of adversity! However, the relatively modest relation between stress and health increases the difficulty in establishing a definitive causal relationship between a stressor and a particular disease, because not everyone who experiences stress will become ill, and if he or she does become ill, the type of illness developed may depend upon the degree of exposure to pathogens, genetic propensities to disease, nutritional status, and so on. It is much easier to establish a relationship between stress and flare-ups of existing conditions, such as rheumatoid arthritis (Revenson & Felton, 1989), than it is to implicate stress in the etiology of a new illness (but see Cohen et al., 1991). While the link between stress and incidence of

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cardiovascular disease is relatively weak and somewhat inconsistent, there is a stronger relationship between stress and poor outcomes in individuals who are already ill (Aldwin & Gilmer, 2004).

DESIGN ISSUES IN STRESS RESEARCH There are additional problems to be considered in the design of any stress and health study. First, what is the timing of the event under study, and what is the particular health outcome? Any specific disease, especially chronic illnesses such as heart disease or cancer, may take decades to develop. How reasonable is it to propose that a particular stressor may affect this etiology?—unless, of course, stress can be seen as a trigger that helps to precipitate full-blown disease from underlying preclinical pathologies, in which case it would be reasonable to expect a relationship between stress and disease, if—and only if—there existed such pathologies. Similarly, it is also unreasonable to expect that illnesses with relatively short incubation periods, such as colds, will be greatly affected by an event that could have occurred up to a year earlier unless that event has ongoing ramifications for day-to-day existence (which many do). Thus, for any study it is critical to consider issues regarding the timing of the stressor and the probable etiology of the particular illness under study. The second major issue for consideration is whether the appropriate types of stressors have been identified for the particular age or ethnic group being studied. The inappropriateness of items to particular populations may lead to incorrect conclusions about the relationship between stress and health outcomes in various groups. For example, an early review by Paykel (1983) found little relationship between stress and health among the elderly, primarily because the types of events then studied were more relevant to younger groups than to older ones. Only when age-specific inventories were developed did the relationship between stress and health emerge (Aldwin, 1990). Given that life stage, social structures, and cultural values may determine both the occurrence of particular types of stressors and the ways in which various events are perceived (See Chapters 13 and 14), it is imperative that the stress measure used in any given research project be both culturally and developmentally appropriate. An additional issue that has yet to be resolved is whether the effects of stress on well-being are cumulative (i.e., additive) or multiplicative. Most stress research assumes that stress is cumulative: There is a direct linear increase in symptoms, negative affect, and so forth coincident with incremental increases in stress. This is indicated by the fact that we

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sum the number of life events checked or add up the ratings and then correlate them with an outcome measure. However, it is entirely possible that the effects of stress are multiplicative. That is, having two stressful life events may multiply the stress effects by more than a factor of two. Early work by Rutter (1981), for example, found that most children could cope readily with one major stressful event, such as the death of a parent. However, the death of a parent in conjunction with other stressful circumstances, such as poverty or mental illness in the remaining parent, often proved overwhelming. (See Aldwin, Levenson, and Spiro, 1994, for a corroborating example of the nonlinear effects of combat exposure on mental health in later life.) It is equally possible that stress may have an asymptotic effect, that is, after three or more stressors, the increase in symptoms would reach its maximum possible level. The point is that we simply do not know what the dose–response curve is between stress and various health outcomes; nor do we know how that curve varies among individuals, although studies by Brown and Harris (1989) and Surtees (1989) have begun to address some of those issues. Nonetheless, cumulative stress is thought to have more adverse consequences than isolated life events (Evans, 2004). Even the duration of stress effects is a matter of some debate. The general wisdom holds that the psychiatric effects of stressful life events usually dissipate within 6 months to 1 year (Depue & Monroe, 1986; Norris & Murrell, 1987), while the effects of mere hassles dissipate within a day or two (DeLongis, Folkman, & Lazarus, 1988). However, some of the trauma literature suggests that posttraumatic stress disorders may linger for decades, as with Pearl Harbor survivors (Wilson, Harel, & Kahana, 1989) and World War II prisoners of war (Page, Engdahl, & Eberly, 1991). Even studies of regular soldiers suggest that the effects of combat exposure can be detected even after 50 years have passed (Aldwin & Levenson, 2005; Spiro, Schnurr, & Aldwin, 1994). Much of the work in stress research has been directed toward the conceptualization and measurement of stress and, to a large extent, to overcoming barriers in the larger scientific community concerning the physiological effects of psychosocial phenomena. Thus, it is not surprising that such elemental questions as dose-response and timing of stress effects have not yet been definitively delineated. In fairness, it should also be acknowledged that stress effects are highly probabilistic phenomena, being dependent on myriad contextual and personal factors. Thus, it may not be possible to develop clear-cut curves. At best, one can determine population risk rates, such as the temporary increase in deaths due to coronary heart disease (CHD) during the first year of widowhood, documented by Parkes and Weiss (1983). However, it is also understood

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that generalizing from a population risk to an individual risk is not possible, at least not without committing the ecological fallacy. Clearly, most of the recent work in stress research has emphasized individual differences in response to stress, and, as we shall see later, many have argued that how individuals cope with stress is more important in developing psychological and physical reactions to stress than is simple exposure to a stressor.

PROBLEMS IN CAUSAL DIRECTIONALITY One of the thorniest design issues in stress research remains the interrelations among stress, personality, and health. Despite the strong evidence that stress is related to health, assessing the causal directionality in this relation remains problematic. On the one hand, higher stress scores may reflect rather than cause poor health. Someone with a chronic disabling illness, for example, may well experience more hassles in the struggle to do everyday chores; more role strain in relation to finances, work, and marriage; and may even be subject to more negative life events. On the other hand, a serious problem in studies that rely primarily on selfreports of stress and health may be that a third factor, personality style, is confounded with both types of assessment and creates a spurious association. Both of these problems with causal directionality have resulted in a series of classical interchanges in the literature. Lazarus and his colleagues (DeLongis, Coyne, Dakof, Folkman, & Lazarus, 1982; Kanner, Coyne, Schaefer, & Lazarus, 1981; Lazarus & Folkman, 1984) have consistently argued that subjective appraisals of stress are more effective in predicting health outcomes because they take into account the meaning of the event to the individual. Individual characteristics (i.e., beliefs, values, and commitments) and contextual factors (i.e., the timing and duration of the stressor) may conjointly influence the degree to which any particular event may be stressful. Due to a variety of factors, being laid off a job provides an excellent example of the lack of uniformity in stress effects. For example, the degree to which being laid off is stressful may depend upon personal factors such as age and commitment to the lost job (e.g., losing a job at McDonald’s when one is 16 years old is much less stressful than losing a managerial position when one is 50 years old). Or losing a job may be particularly stressful depending upon contextual factors, such as a high general unemployment rate that may increase the duration of unemployment, the recent purchase of a house that has depleted one’s savings, or a spouse who is also laid off. Thus, Lazarus argued that the so-called ob-

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jective ratings of life-event stress that assign “life-change units” to specific life events do not take into account these individual differences, and thus subjective ratings of stress are inherently better predictors of health outcomes than these “objective” ratings. This emphasis on individual differences in the meaning of events was underscored by a prospective study of bereavement by Wortman and Silver (1989). They found that nearly one-third of bereaved spouses did not appear to be distressed at any point up to a year after the death, contrary to general expectations of extreme distress traditionally associated with conjugal bereavement. In a challenge to the position championed by Lazarus and his colleagues, Dohrenwend, Dohrenwend, Dodson, and Shrout (1984) criticized as potentially confounded with prior mental health status subjective measures of stress that rely upon individual appraisals. That is, individuals who are depressed or who have high levels of emotionality, for example, may be more likely to perceive everyday occurrences as stressful. We all are familiar with individuals who “catastrophize” and overreact to very minor problems. Thus, the Dohrenwends have argued that subjective indices of stress such as hassles may be reflecting rather than causing mental health problems. Only objective stress measures, in their view, can demonstrate that psychosocial stress causes problems in both psychological and physical health. In response, Lazarus, DeLongis, Folkman, and Gruen (1985) had clinical psychologists identify the items that potentially reflected mental health problems and reanalyzed their data omitting these items. They still found that these “uncontaminated” hassles were better predictors of physical health than life events, a finding confirmed by Rowlison and Felner (1989). In an escalation of the conflict, Schroeder and Costa (1984) attacked life events (and stress measures in general) for being confounded with personality characteristics as well as with preexisting health status. They separated “contaminated” life events—that is, those judged to reflect prior health status or personality—from “uncontaminated” ones. For example, “trouble paying bills” was judged to be contaminated by neuroticism, while “being laid off” was thought to be a more objective stressor. They found that only the “contaminated” life events were associated with health outcomes and concluded that “contamination factors . . . inflated the overall event–illness correlation” (p. 860). In turn, Maddi, Bartone, and Pucetti (1987) criticized the Schroeder and Costa rating scheme for both its lack of theoretical rationale and its lack of clarity in the grouping procedure used. They pointed out, for example, that difficulty in paying bills may derive from being laid off— and, thus, terming one “contaminated” and the other as “uncontami-

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nated” makes a spurious and insupportable distinction. They used their own grouping procedure and found that “uncontaminated” life events were actually better predictors of health, both cross-sectionally and longitudinally, than were so-called contaminated events. The problem with both sets of arguments is, of course, that none of these studies actually assessed the factors with which the stressors were thought to be confounded, namely, prior mental health and emotionality. On the basis of self-report data, it is impossible to determine whether an event was due primarily to environmental happenstance or an individual’s prior maladaptation. Someone may be laid off through no fault of his or her own but because his or her firm lost a big contract; another person might have had a problem with alcohol and the supervisor used an economic slowdown as an excuse to lay off the troublesome employee. Only longitudinal data with assessments of the putative confounding agent can answer the questions raised by the Dohrenwends and Costa and his colleagues. My colleagues and I examined these issues in two longitudinal studies. In the first study, we examined the relationship between mental health and economic stress (Aldwin & Revenson, 1987). We had baseline measures of mental health and economic stress and obtained followup measures a year later, during which time the unemployment rate had risen by several points. We showed that people with poorer mental health at Time 1 were more likely to report economic strain at Time 2 when the economy had worsened, demonstrating that people with poorer mental health were more likely to experience stress. Nonetheless, even controlling for mental health at Time 1, economic stress did have adverse health effects at Time 2, especially if the economic problems appeared to be chronic. This demonstrated that stress could have adverse effects in and of itself, not due to its acknowledged confound with prior mental health status. A subsequent study also used longitudinal data to examine the issue of personality, stress, and mental health (Aldwin, Levenson, Spiro, & Bossé, 1989). Drawing upon the Normative Aging Study archives, we utilized a measure of emotionality assessed in 1975 and administered life events, hassles, and mental health measures in 1985 to a large sample of older men. We showed that both life events and hassles were correlated at about the same level (~.20) with the personality assessment 10 years earlier, partially confirming the concerns of the Dohrenwends, Schroeder, and Costa. That is, individuals higher in emotionality were more likely to report hassles, even 10 years later, but they were also more likely to report life events. Nonetheless, both life events and hassles contributed independent variance to mental health, even controlling for preexisting emotionality.

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In other words, personality, stress, and health are, to a certain extent, confounded with one another. While this confound needs to be recognized in studies, especially cross-sectional ones, longitudinal studies confirm that stress can cause negative health outcomes, regardless of prior personality and health status. The debate over causal directionality between personality, stress, and health has also provided useful insights into the nature of the stress process. Rather than thinking of the stress process only in terms of confounds, the bidirectionality (or rather, multidirectionality) between personality, stress, and health actually provides strong support for the transactionist viewpoint. Once again, by focusing on unidirectional causality (does stress cause health problems or only reflect them? or is personality causing everything?), only parts of the process are being highlighted. Yes, the concerns of the Dohrenwends and the personality psychologists are real: The perception of stress is in part a reflection of prior personality and mental health. However, that is precisely the point of a transactionist perspective. Appraisal is a function of both the person and the environment. Nonetheless, that does not diminish the very real and independent contribution that stress makes to mental and physical health—and, perhaps, even to changes in personality (see, e.g., Aldwin, Sutton, & Lachman, 1996b; Schnurr, Rosenberg, & Friedman, 1993). These issues in the design of stress research and causal directionality should be borne in mind as we consider the various ways that stress can be measured.

DIFFERENT APPROACHES TO STRESS MEASUREMENT How a researcher chooses to measure stress depends upon both the research question and the way in which stress is conceptualized. Generally, researchers who define stress in terms of environmental demands study extremely stressful environments or individual life events, while those preferring definitions emphasizing the transaction between the person and the environment tend to study everyday stressors or hassles. Stress can also be studied in a laboratory situation, using standardized stressors such as mental math or cold pressor tests, in which pain is induced by immersing an arm in very cold water. The overall goals of the different approaches are usually similar—to determine the manner in which stress relates to some health outcome, whether it is physical or mental health, through either self-report or some physiological indicator of stress (except, of course, for those studies that seek to examine the precursors of stress or its distribution in a population).

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In truth, the differences between various approaches to stress measurement are not necessarily clear-cut, and there is much overlap at both the conceptual level and the measurement level. The distinction between hassles and chronic role strain can be blurred, as is that between life events and trauma. Clinicians who study PTSD among combat veterans argue that there is a qualitative difference between the two categories, with trauma leading to a physiological state characterized by flashbacks, nightmares, and hyperreactivity, whereas life events “just” lead to depression and anxiety. Are the differences simply a matter of degree of stressfulness? When is a motor vehicle accident a traumatic experience, a life event, or just a “hassle”? In part, the various conceptions of stress can be differentiated using a two-dimensional space defined by duration on the x-axis and severity on the y-axis (see Figure 5.1). Traumas tend to be of relatively short duration and characterized by life-threatening severity, either to oneself or others. On the other hand, conditions lasting for long periods of time that are not immediately life-threatening can be considered chronic role strain. Some life circumstances such as living in a war-torn area or an impoverished violent barrio are a combination of chronic stress punctuated by short periods of trauma. Life events may be of varying duration, but they differ from role strain in having clearly defined endpoints. Ongoing marital problems, for example, are role strain; divorce is a life

FIGURE 5.1. Comparison of the duration and severity of different conceptions of stress.

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event starting with separation and ending when the divorce papers are signed. Note that chronic role strain may well lead to a life event (and vice versa). A hassle is an event of short duration that is usually minor; however, a hassle may be embedded in the context of an ongoing life event or role strain that may increase its severity. Waiting in a restaurant for a spouse who is a little late may be a hassle; if, however, the spouse is chronically late and this is a major bone of contention in the relationship, that hassle may be experienced as very stressful and may even precipitate a life event (i.e., separation). Baum, Cohen, and Hall (1993) pointed out three problems with simply using duration as a way of distinguishing between acute versus chronic stressors. As noted earlier, the distinction may become somewhat arbitrary. For example, someone with an acute health problem might have a successful operation that cures him or her (or at least leads to remission), but nonetheless might have persistent fears of the recurrence of the stress. Further, acute stressors may result in changes in appraisals, leading to chronic stress. For example, a woman whose spouse has cheated on her may become highly sensitive and regard even innocuous situations as potentially threatening. Finally, the curious thing about chronic stressors is that people can and do adapt and in some ways not even notice chronic problems. Driving on the freeway is an excellent example. As novice drivers, it was terrifying for most of us. However, now we do it daily without giving it much thought, although motor vehicle accidents are one of the leading causes of death and are the major source of trauma for Americans (Norris, 1992). Nonetheless, studies that have contrasted different ways of measuring stress have usually found that they contribute unique variance to whatever outcome is under study. For example, Serido, Almeida, and Wethington (2004) contrasted four different models of chronic stress and daily hassles. They found surprisingly little overlap between chronic role strain and daily hassles, and both contributed separately to psychological distress. The following is not an exhaustive list of all stress indices, or ways in which stress is assessed. It is simply meant to be a guide to some of the most basic approaches to stress. The emphasis is on indices used in quasi-experimental research, that is, self-reported stress. However, laboratory research will also be briefly discussed.

Trauma Trauma can be divided into three types: natural and technological disasters; war and related problems such as famine; and individual trauma.

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Natural and Technological Disasters Natural disasters include events such as tornadoes (Wallace, 1956), major fires (Lindemann, 1944), and earthquakes (Nolen-Hoeksema & Morrow, 1991). Technological disasters include nuclear reactor problems, such as that at Three Mile Island (Baum et al., 1983) or Chernobyl (Giel, 1991), and the Buffalo Creek flood, which was caused by improper storage of industrial waste on a massive scale (Erikson, 1976). There are a number of shared characteristics of major disasters. First, there is often little or no warning that the event is about to occur. Disasters, whether created by nature or technology, may often happen very rapidly and with little notice, such as the 2004 tsunami that was centered on Indonesia. Even when there is adequate warning, as with such weather-related disasters as floods or hurricanes, people are often quite adept at ignoring or minimizing warnings (Janis & Mann, 1977). Second, disasters generally occur in a relatively short time frame. Earthquakes, tornadoes, volcanic eruptions, or nuclear disasters generally take place in a defined, discrete period of time. The aftermaths of disasters obviously may extend over much longer periods, but disasters tend to be focal stressors. (Long-term environmental disasters may be better conceptualized as chronic stressors—see below.) Third, disasters involve extreme threats, up to and including the loss of lives. Not only are the individual and his or her family threatened, but survivors may witness the deaths of others, often on an immense scale. Fourth, natural and technological disasters provide individuals with very little chance to exercise personal control. There is usually not very much that one can do in an earthquake or massive flood except to try to escape, if possible. Interestingly, people who attempt to exercise control, primarily by engaging in rescue or relief efforts, often after the event itself, may show the least psychological trauma after the event (Erikson, 1976). Finally, disasters happen to many people simultaneously. Rather than an individual or isolated event, a disaster may feel like generalized chaos. It is not unusual for victims of such catastrophes to feel that the whole world is coming to an end. While this may initially create a great deal of stress, it also provides the opportunity for community support subsequent to the event. After a disaster, people often talk about how supportive everyone was, how they pulled together, or how they were in awe of heroic efforts that people made to help others. A good example is the 1989 Loma Prieta earthquake in the San Francisco Bay Area. Most loss of life occurred because a freeway ramp collapsed in Oakland in a very poor neighborhood. There was widely televised coverage of ordi-

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nary citizens risking their own lives to rescue people trapped in automobiles. Of course, there are circumstances under which such community cohesion does not occur, as when the physical and social structure of a community is damaged and people are dispersed (Erikson, 1976). Nonetheless, the group nature of disasters is a key characteristic that sets them apart from individual life events.

War War shares some characteristics with technological disasters in that war occurs on a massive scale, to a general community, and involves extreme threats and exposure to death. On the other hand, there is usually ample warning (except, of course, in the case of surprise attacks, such as that on Pearl Harbor or the World Trade Center). War also differs from other disasters in that it usually occurs over a relatively long period of time. Further, soldiers (and sometimes citizens) engage in purposeful activity designed either to defend themselves or to attack the enemy, which may produce a sense of control. This purposeful activity is often coordinated with other soldiers in the unit, which may generate extremely close social ties. While no one would dispute the traumatic nature of combat and its deleterious effect on soldiers, civilians, and the environment, one very curious phenomenon is the positive effects that combat can have on individuals. Elder and Clipp (1989) were among the first to study these effects, which included increased sense of mastery, enhanced self-esteem, improved coping skills, and the development of leadership skills and close personal friendships (see also Wilson et al., 1989). Indeed, the extent to which veterans construed their military experience as a positive one decreased the likelihood of experiencing symptoms of PTSD in later life (Aldwin et al., 1994). Further, moderate combat exposure may actually improve psychological functioning in the long run (Schnurr et al., 1993). (A more in-depth discussion of the positive aspects of stress is presented in Chapter 15.)

Individual Trauma Unlike the situation in disasters or wars, sometimes life-threatening trauma happens to only an individual or a few people. Trauma may include major accidents and violent crimes such as rape and incest. Only accidents or crimes involving severe injury and (perceived) threat to life should be classified as trauma. There is a qualitative difference between having a purse snatched, on the one hand, and being beaten to within an inch of one’s life, on the other; between having too many drinks at a

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party and going further with a date than one intended, on the one hand, and being kidnapped and raped repeatedly at gunpoint, on the other. Failing to differentiate between hassles, life events, and trauma in dealing with individual problems leads only to trivializing very real traumatic episodes and blowing minor ones out of proportion. Since there is good evidence that trauma per se can have lifelong consequences (see Chapter 12), there is good reason to keep this distinction in the literature.

Measurement of Extreme Stress Studying natural and technological disasters can often provide extremely interesting insights into human behavior under extreme stress. Wallace’s (1956) descriptions of the similarity of behavior when people are in shock is a particularly good example. However, disasters are, by definition, extremely rare. The past few years have seen the development of a number of scales that assess trauma, often for specific types of trauma such as torture or combat (for a review, see Miller, 1997). For example, the Combat Exposure Scale is a widely used measure in studies of veterans (Keane et al., 1989). This instrument attempts to quantify aspects of this stressor by identifying different components of the combat experience (see Table 5.1). These include being subjected to enemy fire, seeing dead comrades, killing others, and so forth. Not only are different stressful characteristics of combat identified, but an attempt has been made to quantify the intensity and duration of such characteristics. Obviously, this approach to detailing precise environmental aspects of this type of technological disaster may be generalized to other disasters, but, to our knowledge, no one has as yet published such a scale. An alternative approach is to assess generalized trauma, which is usually defined as the lifetime exposure to extreme stressors, such as TABLE 5.1. Questions from the Combat Exposure Scale 1. 2. 3. 4.

Did you ever go on combat patrols or have other very dangerous duty? Were you ever under enemy fire? Were you ever surrounded by the enemy? What percentage of men in your unit were killed, wounded, or missing in action? 5. How often did you fire rounds at the enemy? 6. How often did you see someone hit by incoming or outgoing rounds? 7. How often were you in danger of being injured or killed (i.e., pinned down, overrun, ambushed, near-miss, etc.)? Note. Data from Keane, Fairbank, Caddell, Zimmering, and Bender (1985).

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combat, rape, or natural disasters. Norris (1992) has developed a simple checklist, which does not attempt to assess the environmental characteristics or psychological impact of the trauma but serves primarily as an extremely useful epidemiological tool to assess the extent to which populations have experienced various traumas. Interestingly, the trauma that was the largest source of cases of posttraumatic stress disorder was not war or natural disasters but rather automobile accidents. General trauma is a relatively new and exciting area of research. There is some indication that exposure to trauma may be a better predictor of health outcomes and mortality than either more general life events or personality characteristics (Felitti, 1991; Hallstrom, Lapidus, Bengston, & Edstrom, 1986; Scherg & Blohmke, 1988). Further, there has been growing interest in the possible lifelong effects of early childhood trauma (Felitti et al., 1998; Goodwin & Stein, 2004; Kessler & Magee, 1993).

Life Events Life events are generally thought of as major events—such as bereavement, divorce, or job loss—that happen to individuals. A cardiologist named Wolff (1950) asked his patients to maintain diaries and observed that they often reported experiencing a stressful life event 6 months to a year before becoming ill. He suggested that any change, whether positive or negative, requires adaptational energy and thus predisposes an individual to illness. An example of a positive event would be a new job or marriage; the comparable negative event would be a job loss or divorce. The Schedule of Recent Events (SRE) was a standard list of events, while the Social Readjustment Rating Scale (SRRS) added an “objective” rating for each item (Holmes & Masuda, 1974; Holmes & Rahe, 1967). Several hundred respondents rated the amount of adaptation or “lifechange units” (LCUs) that each event was thought to entail (see Table 5.2). On a scale of 500, respondents on average thought that the death of a spouse required the most amount of life change and thus assigned the highest number of LCUs to this life change. Individuals with more than a certain number of LCUs in the past year were considered at risk for developing disease.

Measurement of Life Events Since the development of the SRRS by Holmes and Rahe, the number of stressful life event inventories has mushroomed. Widely used inventories include the Psychiatric Epidemiological Research Interview (Dohrenwend, Krasnoff, Askenasy, & Dohrenwend, 1978), often used in community

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TABLE 5.2. Sample Items from the Social Readjustment Rating Scale Rank order

Item

Mean lifechange value

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Death of a spouse Divorce Marital separation Jail term Death of close family member Personal injury or illness Marriage Fired at work Retirement Marital reconciliation Change in health of family member Pregnancy Sex difficulties Gain of new family member Business readjustment

100 73 65 63 63 53 50 47 45 45 44 40 39 39 39

Note. Data from Holmes and Rahe (1967).

surveys, and the Life Experiences Survey (Sarason, Johnson, & Siegel, 1978), most often used in college settings. Others have developed scales for use in specific populations, such as children and adolescents (Coddington, 1972), Hispanics (Cervantes, Padilla, & Salgado de Snyder, 1990), African Americans (Watts-Jones, 1990), and older adults (Aldwin, 1990; Krause, 1986; Murrell, Norris, & Hutchins, 1984). For a list of stressful life event scales, see Turner and Wheaton (1995). Zalaquett and Wood (1997) also provide a useful review of a number of stress measures. These inventories share a number of characteristics, including being relatively short (generally fewer than 100 items) while still covering a broad range of types of stressors. The inventories may be simple checklists or may consist of stress rating scales. Checklists ask respondents simply to indicate whether a particular event happened during the time period under study (often a year), whereas stress rating scales ask respondents to rate how stressful the problem was for them, often using four- or five-point scales ranging from “not at all stressful” to “extremely stressful.” A major debate in the history of stress research has been whether to use “objective” ratings, that is, weights developed by judges to show how much change or stress an event is presumed to entail (presumed stress), checklists, or stress rating scales (perceived stress) (e.g., Chiriboga, 1992). Basically, which strategy is used depends upon whether the re-

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searcher is interested in the respondent’s subjective experience of stress or wishes to focus on some relatively “objective” indicator of stress levels (see the earlier discussion on causal directionality in stress research). For all of the theoretical emphasis on the importance of meaning of an event to the individual, Turner and Wheaton (1995) observed that simple stressful life event checklists do just as well in predicting health outcomes as do scales that include subjective ratings of the events. Generally, the period of time covered by life event scales ranges from 6 to 18 months, which has led some researchers to question the accuracy of individuals’ memories. Stressful life event inventories are self-report measures and are thus subject to questions of reliability and validity—that is, will individuals respond in a similar fashion to multiple administrations of the questionnaire, and do the measures fairly accurately reflect the stresses in individuals’ lives? A common mistake is to assume that standard psychometric properties of scales developed to assess personality characteristics, such as internal reliability, are applicable to life event checklists. Measures of internal reliability such as Chronbach’s alpha test the extent to which items tap an underlying construct. To the extent that life events reflect environmental change, they should not correlate highly with one another. Some life events, like retirement and divorce, for example, are likely to be orthogonal. Further, in studies examining test–retest reliability, it may be very difficult to determine whether responses on the inventory have changed because respondents experienced a new stressful life event or because the one previously reported no longer falls into the time scale. Still, there is no doubt that the memory of stressful life events may be fairly inaccurate (Jenkins, Hurst, & Rose, 1979; Raphael, Cloitre, & Dohrenwend, 1991). Kessler and Wethington (1986; cited in Brown, 1989) have identified three sources of inaccuracies in life event reporting. The respondent may not realize the level of information required by the researcher; the respondent may be embarrassed to reveal certain problems; or the respondent may genuinely forget. Further, individuals who fill out life event checklists are prone to “telescoping,” or inaccurately remembering more distant events as happening more recently (Wethington, Brown, & Kessler, 1995). Brown (1989) has argued that a semistructured interview that he developed, titled the Life Events and Difficulties Schedules (LEDS), surmounts those difficulties in life event reporting by providing a supportive context and a series of probes that encourage self-revelation. Further, interviews often provide aids such as calendars that can get more accurate timing of life events (Wethington et al., 1995). Given these difficulties, it is not surprising that other researchers have attempted to find alternative ways of assessing stress and its effects.

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Four different approaches have been tried: role strain (chronic stress), hassles, ecological momentary assessments (EMAs), and laboratory experiments.

Role Strain and Chronic Stress Sociologists, community psychologists, and social ecologists often examine stress as a systematic contextual phenomenon rather than as more or less random events occurring to individuals. Sociologists in particular are interested in how the structural characteristics of a particular society or culture result in stress experienced by individuals or even changes in macrolevel indicators of pathology (Mechanic, 1974; Pearlin, 1989). Wheaton (1996, p. 57) defines chronic stress as “an ongoing openended problem located in the structure of the social environment.” He identified nine types of chronic stress. Threats refer to the continuing possibility of harm, characterized by a sense of vulnerability. An abusive spouse or living in a high-crime or war zone are examples of stress due to chronic threat. However, he also sees threats to one’s identity as a type of chronic stress. For example, students who go on to college are often used to being one of the top students (as they were in high school). However, expectations are much higher in college, and a student may find his or her self-identity as an “A” student to be persistently challenged. Long-term conflicts, especially when they reflect unresolved issues, are a major source of chronic stress. Uncertainty may also give rise to chronic stress and is defined as “unwanted waiting for an outcome” (Wheaton, 1996, p. 62). For example, uncertainly as to whether or not one’s company is going out of business can be extremely stressful. In some cases, resolution—whether good or bad—can be less stressful than not knowing what will happen. Demands and complexity are characteristics that refer primarily to role overload—specifically, a person “feels pulled by multiple, independent, immediate, and uncontrollable demands that cannot be put aside” (Wheaton, 1996, p. 58). In the current economic downturn, economists have touted the increase in worker productivity. For most of us, however, that simply means that we are working harder and harder, often doing the jobs that two or three people used to do, or working with much less support than we previously had. However, role underload can also be a problem and is often associated with being in a boring, deadend job. Similarly, underreward refers to situations in which one’s work or behavior is not adequately compensated or rewarded. Structural constraints refer to problems in the social environment that can result in resource deprivation and restriction of choice. For ex-

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ample, living in a very impoverished neighborhood can result in lack of access to basic services such as a grocery store, jobs, and decent schools. Wheaton (1996) devised a chronic stress measure by first asking open-ended questions about problems that frequently occur to individuals. Content analysis revealed 90 items, which were subsequently narrowed down to 60. Sample items are presented in Table 5.3.

Work Stress Stress relating to the workplace has been a special focus of role stress research for sociologists. Stressors may involve workload; speed of work; dangerous or toxic working conditions; poorly designed environments; interpersonal discord with supervisors, employees, colleagues, or clientele; discrimination based on ethnicity or sex; and frustrations related to the social organization of the workplace (see Hepburn, Loughlin, & Barling, 1996). The Work Environment Scale (Moos & Moos, 1983) is a good reference for examples of the types of stressors that people face in the workplace. Much work has been done in the past decade delineating the types and consequences of work stress. As in studies of life event stress, some researchers have focused on particular types of occupations, while others have examined broader work role issues. A classic example of studies of specific workplace stress is Rose’s (1978) research on air traffic controllers. Monitoring tasks tend to be very stressful because they involve a great deal of effort expended on maintaining alertness. Air traffic controllers not only must monitor and coordinate the activities of multiple planes but also must bear in mind that the consequences of error are very severe. One small error in judgment or lapse in attention could potentially result in several hundred deaths. Thus, it is not surprising that Rose found evidence of higher TABLE 5.3. Sample Chronic Stress Items from the Stress Measurement Survey • • • • • • • • • • •

You’re trying to take on too many things at once. You don’t have enough money to buy the things you or your kids need. You have a lot of conflict with your boss or coworkers. You want to change jobs or career but don’t feel you can. You have a lot of conflict with your spouse. You wish you could have children but you cannot. You don’t have enough time for a social life. You are often afraid you will be mugged, assaulted, or robbed. The place you live is too polluted. Your church/religion demands too much. You have a parent who is in bad health and may die soon.

Note. Data from Wheaton (1996).

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rates of stress-related disorders, such as elevated blood pressure, stomach ulcers, and so forth. More recent work has focused on other types of structural problems, such as shift work, that can disrupt a worker’s biorhythms and result in myriad health problems (see Parkes, 2002). Much of the work focuses on the interaction between the person and the environment. A good example of such research was conducted by Carrere, Evans, Palsane, and Rivas (1991) on San Francisco bus drivers, who were shown to have very high stress levels. Not only must they deal with urban traffic and congestion on a daily basis, but they also must handle a sometimes hostile and even dangerous public, all the while adhering to a very rigid timetable with severe penalties if they are off by even a few minutes. However, not all bus drivers reacted to the stressors in the same way. Bus drivers with Type A personalities were found to perceive their work environment as more stressful and to have higher levels of urinary catecholamines than those with the calmer Type B personalities. A central construct in the work stress literature is that of control. Over a decade’s worth of research by Frankenhauser and her colleagues (1980) in Sweden on assembly-line working conditions have clearly demonstrated that workload is not nearly as problematic as the inability to control the pace of one’s work. Workers given even the illusion of control had lower levels of harmful urinary catecholamines than those who worked at the same pace but believed that they had no control over the pace of the assembly line. Work by Karasek and Theorell (1990) provides a good example of an attempt at a more generalizable theory of workplace stress. Building on the studies on control, Karasek and Theorell have hypothesized that the experience of stress arises from the interaction between two factors, responsibility and control, also specifically termed “job latitude” and “psychological demands.” High-strain jobs are those in which the individual has a great deal of responsibility but little control over the way in which tasks are done, the lot of many secretaries, waitresses, and factory workers. Active jobs are very demanding but also allow for a great deal of control. These are the high-prestige jobs of physicians, lawyers, and executives. There are a few occupations with high control but relatively low demands, such as these of scientists, repairmen, and architects, that are thought perhaps to be the least stressful of positions. Passive jobs, such as those for watchmen and janitors, provide few opportunities for control but also place low psychological demands on the worker. These jobs are thought to be about average in stressfulness but boring and “mind-deadening” in nature. Karasek and his colleagues have completed several longitudinal studies that strongly suggest that high-responsibility/

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low-control workers are more likely both to develop coronary heart disease and to die from it (for reviews, see Cottington & House, 1987; Karasek & Theorell, 1990). Thus, work role stress may involve physical, social, and psychological demands that, absent adequate resources to cope with this stress, may have deleterious consequences. However, most researchers agree that unemployment per se is generally more stressful than work stress. Further, Coyne and DeLongis (1986) have argued that relationship stress may have more deleterious consequences than work stress, especially for women (Almeida, McGonagle, Cate, Kessler, Wethington, 2003).

Poverty Poverty is associated with multiple stressor exposure (Evans & English, 2002). Literally dozens of studies have shown that those with lower socioeconomic status have higher levels of morbidity and mortality (for reviews, see Adler, Epel, Castellano, & Ickovics, 2000; Marmot, 2003). This occurs in both countries with private and those with socialized medicine, so the difference is not necessarily due to inequities in access to health care. And while lower SES is associated with poorer health behavior habits (e.g., higher levels of smoking, more obesity, and less exercise), controlling for these variables weakens, but does not eliminate, this relationship. Further, this relationship exists internationally for nearly all illnesses, with the exception of breast cancer among women and cirrhosis of the liver in France. There is a major initiative in the United States to eliminate this health disparity between economic classes by 2010. Perhaps one reason for this disparity is the difference in exposure to chronic role strain.

Chronic Role Strain Rather than focus on one stressor, Pearlin and Schooler (1978) have argued that chronic role strain, defined as enduring problems related to specific social roles, is a better indicator of the stressfulness of an individual’s life than isolated life events—and thus should be a better predictor of well-being. They have focused on four primary roles, including marital, parental, occupational, and household economics, and have devised scales assessing both the strains that occurred in those domains and the coping strategies specific to those types of problems. In Pearlin and Schooler’s scales, three categories of items defined marital strain: nonacceptance by spouse, nonreciprocity in give-andtake, and frustration with role expectations. Categories applying to parent strain included failure of a child to live up to parental standards of

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behavior, nonconformity to parental aspirations and values, and disregard for parental status. Four categories of items defined occupational strain: inadequacy of rewards, noxiousness of work environment, depersonalization, and role overload. Finally, household economic strain was defined by difficulty in acquiring the necessities of life and paying monthly bills. Pearlin and Schooler found that role strain was a good correlate of emotional distress related to that specific role. Further, subsequent studies (Pearlin, Lieberman, Menaghan, & Mullan, 1981) have demonstrated that the effect of life events is primarily mediated through changes in role strain. In other words, Pearlin and his colleagues believed that life events have deleterious effects because they cause disruptions in people’s ongoing relations with their spouses, children, jobs, or finances. Often it is a combination of problems in several roles that may contribute to difficulties in individual adaptation. For example, Brown and Harris (1978) found that women who were most likely to be depressed were single parents who had young children under the age of 5, financial difficulty in making ends meet, and were socially isolated. Similarly, most people do not find retirement that stressful; however, those who do usually have other problems, such as financial difficulties, major health problems, or bereavement issues (Bossé, Aldwin, Levenson, & WorkmanDaniels, 1991). In other words, retirement may become problematic if there is not enough money to cover basic expenses or if one’s dreams of a retirement life are shattered by the death of a spouse or by illness. Other researchers have focused on the extent to which stress in one role “bleeds” over into stress in another role, or on whether the domains are relatively independent (Pearlin et al., 1996). In general, stressors that proliferate across domains are more stressful and more likely to have adverse health effects than those that remain within a particular domain. In general, work stress appears to affect marital relations for men, while for women marital stress appears to create strain at work (Coyne & DeLongis, 1986). Serido et al. (2004) also showed that chronic role strain can moderate the effects of hassles on psychological distress. For example, those who felt they had little control over home demands (a chronic stress) reported more distress in response to work hassles. Role strain approaches are interesting because they suggest that there may be systemic social causes of psychological distress. Rather than being related to neuroticism, as some personality psychologists have suggested (McCrae & Costa, 1990), stress is viewed as resulting from the way in which our lives are structured by our sociocultural milieu. The failure to understand this may lead to some unfortunate gaffes. For example, during the Los Angeles riots of the 1990s, a clinical

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psychologist on a local news program suggested that, had the rioters learned better coping skills, they would not have expressed their frustration in violence. This statement blithely ignored the loss of 80,000 of the 115,000 manufacturing jobs in South Central Los Angeles and the massive unemployment problem caused by structural changes in the economy. For the most part, stresses arising from collective behavior may be effectively coped with only by collective action, not by individual coping efforts, unless the individual has sufficient power to effect structural change. This issue will be addressed further in Chapter 13. In many ways, the research emphasis has shifted from role-related strain to chronic stress (Lepore, 1995), especially in the area of chronic illness and caregiving for others with chronic illness (e.g., Gottlieb, 1996). In particular, the caregiver burden has been studied extensively (see Gottlieb & Wolf, 2002; Kiecolt-Glaser et al., 2002; Vitaliano et al., 2003; Zarit, Todd, & Zarit, 1986). Many elderly people have some form of chronic illness, and some problems, such as dementia, pose serious caregiving problems. Interestingly, there is some evidence that, over time, caregiving roles may come to be perceived as less stressful if successful adaptation can occur (Townsend, Noelker, Deimling, & Bass, 1989). Indeed, research by Beach, Schulz, Yee, and Jackson (2000) has shown that nearly half of all caregivers do not report feeling stressed but, rather, perceive benefits in taking care of ill loved ones. Nonetheless, there is a small but consistent relationship between caregiver stress and health problems. Caregiving for spouses with Alzheimer’s disease appears to be especially problematic (Vitaliano et al., 2003), and these adverse effects on health may last for up to a year after the loved one’s death (Kiecolt-Glaser et al., 2002).

Hassles: Daily Stressors or Microstressors Lazarus and Folkman (1984) have argued that an individual’s appraisal of a situation is primary in determining whether it is stressful and that everyday stress or hassles have a greater effect on health than relatively rare life events. These include environmental problems (noise, pollution), mechanical malfunctions, standing in line for errands, and the like. Sample items from the Brief Hassles Inventory (DeLongis et al., 1988) are presented in Table 5.4. Hassles are assessed using a daily diary method. Rather than ask an individual to recall events that may have happened several months ago, individuals are asked to record the number and severity of hassles that occurred that day. Typically, the time period under study is a week or longer. This technique was developed precisely to preclude the types of recall difficulties seen with life event inventories. Further, it is also ac-

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TABLE 5.4. Sample Items from the Hassles Scale • • • • • • • • • • • • •

Problems getting along with fellow workers. Hassles from boss or supervisor. Planning or preparing meals. Too many things to do. Not enough time for entertainment and recreation. Too many interruptions. Troublesome neighbors. Not enough time for family. Rising prices of common goods. Side effects of medication. Not getting enough sleep. Being lonely. Inability to express oneself.

Note. These are generally time-limited in some way, asking individuals to rate how difficult or frequent these were in the past day, week, or month. Data from DeLongis et al. (1988).

knowledged in this methodology that any given episode may have both positive and negative aspects. Thus, individuals are asked to rate “uplifts” as well as hassles. During the past 10 years, a number of other daily diary measures have emerged, often directed at a more general problem or sometimes shortened for ease of administration. (For a review of many of these scales, see Lepore, 1995.) While most of these scales are self-report, Almeida, Wethington, and Kessler (2002) have pioneered a telephonebased daily stressors approach called the Daily Inventory of Stressful Events (DISE). The DISE and other daily hassles measures are distinct from life events or chronic stress measures in that they are typically given multiple times over a given time period. This allows one to distinguish between-subjects variance from within-subjects variance (Mroczek, Spiro, Almeida, & Pafford, 2006); studies examining the relationship between stress and health outcomes such as pain often show different patterns of outcomes depending upon whether within- or between-subjects analyses are done (see Chapter 9). Several studies have suggested that hassles are better predictors of both psychological and physical health outcomes than life events are (DeLongis et al., 1982; Holahan, Holahan, & Belk, 1984; Kanner et al., 1981; Rowlison & Felner, 1989; Weinberger, Hiner, & Tierney, 1987). That is, when both life events and hassles are entered into the same regression equation, the contribution of hassles to health outcomes weakens or even eliminates the relationship between life events and health outcomes. However, these studies need to be viewed with some caution, given the different statistical distributions of life events and hassles scales. Life

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events being rather rare, life events scales typically have very low means (generally between 1 and 2 items) and thus usually have Poisson distributions (i.e., most people report between 0 and 2 items, with a rapid drop after 2 life events). Hassles scales, on the other hand, do tap more widespread problems and thus tend to have much better variances and distributions. Statistically speaking, the scale with the better variance is usually going to be a better correlate than another scale with a highly skewed variance (depending, of course, on the distribution of the outcome variable). So, the strength of hassles versus life events in predicting health outcomes may in part be due to a statistical artifact. It is difficult to believe, for example, that losing a spouse has fewer health effects than being stuck in traffic a few times. However, there may also be systemic patterns in hassles that would truly provide superior predictive power for health outcomes. As with chronic role strain, the effect of life events on health outcomes may be mediated through an increase in hassles (Aldwin, Levenson, Spiro, & Bossé, 1989; Wagner, Compas, & Howell, 1988). It is also possible that chronic hassles may prove to be more enervating than life events. Indeed, at one point Lazarus (1990) equated daily hassles with chronic role strain. This may have been somewhat premature. As mentioned earlier, work by Almeida and his colleagues (Almeida & Horne, 2004; Serido et al., 2004) has shown that these are distinct sources of stress that may nonetheless interact in some highly interesting ways.

Ecological Momentary Assessments Larson, Csikszentmihalyi, and Graef (1980) pioneered an interesting technique called ecological momentary assessments (EMAs). The respondents are given beepers that go off either at random or at predetermined times, and the individuals record whatever it is that they are doing at that moment. This technique can be very useful in portraying contextual or temporally specific information. This early study using this technology showed that young girls with eating disorders do not necessarily report abnormally high levels of conflict with their families—except with their mothers in the kitchen. Stress researchers such as Stone and his colleagues (1998) and Jamner and his colleagues (Henker, Whalen, Jamner, & Delfino, 2002) have significantly developed the technology in this area. Respondents can be given Palm Pilots that are programmed to go off at either preset or random intervals. These may also contain short questionnaires that the respondent can fill out directly on a PDA (personal digital assistant), and the data can be sent automatically to the researcher’s computer. While Stone and his colleagues feel quite strongly that these provide

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much more accurate depictions of daily stress and coping processes, others are not so sure. First of all, agreement between daily retrospective reports and EMAs is often quite high, with correlations in the .70s and .80s. When there is disagreement between the EMAs and daily diaries, it is not necessarily clear which one is more accurate. Are people simply misremembering the events of the day when they fill the diaries out at night? Has some sort of psychological processing occurred that changes individuals’ memories of the events? Or were people simply too much in a hurry to fill out the questionnaire on the PDA accurately? Further, the types of questionnaires that can be programmed into a PDA are of necessity rather brief, and their ecological validity can be called into question. Nonetheless, this new technology is quite exciting. PDAs can even come with sensors that can detect such things as cigarette smoke, so one can analyze stress and other instigators of deleterious health habits.

WHICH MEASURE TO USE? While life events, chronic role strain, and hassles are conceptually and statistically related, they are nonetheless distinct constructs, and either equating them or saying that one should be measured at the expense of the other may be ill advised. In terms of employment, for example, being laid off a union job with high wages (life event) may force an individual to take a lower-paying job with no health benefits (role strain) that also requires a longer commute (hassles). These cascade effects between different levels of stressors may make them statistically confounded but nonetheless conceptually distinct constructs. (Interestingly, this cascade could conceivably go in other directions: Too long a commute may lead a person to leave one job and take another that turns out to be less suitable.) Rather than using simple multivariate regression techniques, in which one variable is pitted against another, studies using path analysis or structural equation modeling (SEM) that allow the examination of the joint (rather than competing) effects of life events and hassles on health outcomes have generally found these alternative stress measures to be correlated with each other but nonetheless to contribute separate variance to health outcomes (Aldwin et al., 1989; Zautra, Reich, & Guarnaccia, 1990). The same appears to be true for life events and chronic role strain (Pearlin et al., 1981) as well as chronic role strain and hassles (Serido et al., 2004). (To my knowledge, no published studies have sought to relate all three types of stress measures.) Thus, at this stage in our knowledge, it is probably useful to retain as many ways of

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examining stress as possible until we have clearer conceptions of exactly how they work.

CLINICAL INTERVIEWS Some have argued that self-report stress questionnaires in general are inaccurate. As noted earlier, people are often unwilling to reveal what are often very private problems, they may not understand exactly the types of information that the researcher is looking for, or they may have compartmentalized their emotions so well that it simply does not occur to them to report something. Brown (1989) developed a semistructured interview, titled the Life Events and Difficulties Schedules (LEDS), that provides a supportive context and a series of structured probes that allows for more complete reporting. With mail surveys, my experience suggests that about 25% of any community sample reports that they do not have a problem, whether minor or major, during the past month. When I piloted a stress and coping self-report questionnaire with the men in the Normative Aging Study, I found that a similar proportion of the men said that they had no problems. In interviews, however, many of these same men did reveal problems. Sometimes they had resolved a problem—and therefore no longer considered it to have been a problem. Other men were dealing with chronic role strains such as being the primary caretaker for a dying wife; as long as there had not been a recent flare-up or crisis, it did not occur to them that they had a “problem.” By switching to interviews rather than a self-report mode, we were able to decrease to less than 10% the number of men who reported “no problems” (Aldwin, Sutton, Chiara, & Spiro, 1996). Clinical interviews may be especially useful when exploring a new area about which relatively little is known, when studying potentially very sensitive subjects like AIDS or incest, or when dealing with a population that might have very different views of what constitutes stressors, either due to age (children, older adults) or culture. For example, typical stress questionnaires do not include items assessing worry about “La Immigré,” breaking cultural taboos, offending ancestors, or whether your unmarried daughter has lost her virginity—all potent sources of stress in various cultures. Interviews may also help in getting a better idea of the stress process—how a problem unfolds over time, whether or not it “bleeds” into different domains, and so forth. However, lists of stressful events or hassles are often useful in prompting recall; in an interview, unless one has very complete probes (which can become tedious), if the respondent does not mention something, it may not be

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clear whether it did not occur or whether the respondent simply did not report it. Further, regarding the time and personnel it takes to administer the interviews and the time it takes to code them, interviews are usually much more expensive to administer than questionnaires. Consequently, one is often limited to very small samples. Thus, like any other technique, stress interviews can be very useful, but they also have certain limitations.

LABORATORY STRESSORS Controlled laboratory experiments are one way of addressing causality in biopsychosocial phenomena (Aronson, 1980). While the bulk of laboratory stress experiments are conducted with animals, some studies are also conducted on humans. The types of stressors typically utilized in human research in a laboratory include mild electric shock, mental arithmetic, and a cold pressor test. In this procedure, the subject’s arm is submerged in cold running water, which rapidly becomes very painful but which does no harm (to noncardiac patients, that is). Another procedure is to mimic an everyday life situation, as in Frankenhauser’s (1980) studies using assembly lines, or by showing films that have distressing content, such as circumcisions or industrial accidents (Lazarus, Speisman, Markoff, & Davison, 1962). Another procedure that is commonly used is to use social pressure or evaluation to create mild stressors such as public speaking (Blascovitch & Katkin, 1993; Feldman, Cohen, Hamrick, & Lepore, 2004). The advantages of studying stress in a laboratory is that the stressors are clearly defined and delimited, and specific responses of the neural, endocrine, and immune systems can be carefully investigated. Laboratory studies are also very useful in examining specific elements of the stress process, for example, whether Type A persons show greater physiological reactivity to stress. A classic example of the usefulness of laboratory research is an early study by Lazarus and his colleagues (Lazarus et al., 1962). They showed undergraduates very stressful films and manipulated the types of appraisals used. For example, some people were asked to empathize with the subject of the film, and others were urged to use clinical detachment. Lazarus was able to demonstrate that physiological reactions to stress were affected by the types of cognitive processes that people used. However, there are ethical limits to the amounts and types of stress that individuals (and animals) can be subjected to in a laboratory setting. Ader (1981) has argued forcefully that placing laboratory mice on a slowly rotating drum is sufficiently stressful to evoke changes in neuro-

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endocrine and immune function and that more stressful procedures, such as electric shock, restraint, food deprivation, social isolation, and swimming until nearly (or actually) drowned, are unnecessary. In addition, serious questions remain about the generalizability of laboratory studies to actual stressful episodes. If Type As do not show greater increases in blood pressure than Type Bs when doing mental arithmetic, does this mean that the two types will also react equally calmly to being cut off in traffic? Kiecolt-Glaser and her colleagues (Marucha et al., 1998; Glaser et al., 1999) have recently devised an interesting approach to studying the physiology of stress. They make small wounds either on individuals’ skin or sometimes gums and then study the effects of naturalistic stressors (such as examinations in medical students) on healing time, as well as the physiology of healing (e.g., recruitment of immune system cells to fight off infection). This rather unique approach combines a controlled laboratory approach with a naturalistic stressor and thus constitutes a highly useful crossover approach between field and laboratory studies. Among the relatively new technologies being tested in field assessments of physiological reactivity are portable heart monitors and telemetry devices. The respondent may carry a beeper and at random intervals may be asked to write down what he or she is doing at the moment. In this way, physiological reactions, such as heart rate in response to actual field stressors, can be monitored. There are some obvious limitations to this technique. There are problems with compliance; there are times when it is simply not possible to stop what one is doing and write something down, field notes get lost, and so on. Also, only a limited range of physiological reactions can be assessed; those that require urine or blood samples, for example, cannot be utilized in such studies. Thus, at the present moment, laboratory studies are indispensable in examining the neuroendocrinology of stress.

SUMMARY Given the variety of types of stress measures, the question of what type of stress should be assessed in any given study is a matter of some debate. There are cogent arguments for assessing individual stressful episodes, life events, hassles, chronic role strain, and EMAs, as well as for conducting laboratory experiments. Which procedure should be assessed depends in large measure upon the specific research question and on the type of health outcome. Obviously, a laboratory study will do little toward examining regional differences in stress levels. In some ways, the “cleanest” studies relate one particular event to a specific health out-

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come (e.g., bereavement and heart attacks). However, such particular events tend to be rare, and clearly there is a more general relationship between stress and health. The temporal parameters of the study and the type of health outcomes being assessed should guide the choice of stress measure. In studies that assess fluctuating and immediate health outcomes, such as blood pressure or immune measures, one should use more process orientation (e.g., daily stressors) or a laboratory experiment in which the timing, severity, and duration of the stressor can be controlled. One should not expect that a major life event that might have occurred at some point during the past year will necessarily affect ongoing physiological process measures. However, when assessing major health outcomes such as disease, it is less likely that a relatively minor stress will eventuate in, say, a heart attack or cancer, and such studies should focus on more major life events, chronic role strain, or trauma. The point is that all of these procedures are valid and, to a certain extent, overlapping indicators of the general construct we call stress. As in the tale of the elephant and the blind man presented in Chapter 1, each type of procedure allows us to examine only one segment of a much larger issue. To argue whether one should only assess life events or hassles or only chronic role strain or conduct laboratory experiments is analogous to arguing that in order to understand the elephant one should only examine its trunk, ears, legs, or tail. Obviously, we need as many different ways of assessing stress as possible in the hope that one day we will be able to “construct an entire elephant,” as it were. While the evidence that stress has adverse impacts on health is firmly established, it is also true that not everyone becomes ill or even distressed when faced with a stressor. Individuals have differing resources and vulnerabilities when facing stress in their lives, which can moderate the effects of stress. There is increasing evidence that how one copes with stress, even major trauma, may be more important for at least mental health outcomes than the occurrence of the stressor itself. How one copes with physical illness may also affect its outcome; some coping strategies appear to hasten death, whereas others can delay it. Thus, the remainder of this book will be devoted to examining the ways of coping, exploring the various ways in which it has been conceptualized; examining measurement, design, and statistical issues, investigating their relations to outcomes and how the context may modify those outcomes; and lastly, examining cultural influences on coping and how coping develops.

STRESS, Why Is Coping COPING, Important? AND DEVELOPMENT

CHAPTER 6

Why Is Coping Important?

I

once had occasion to look up the definition of the work cope in the 1955 revised edition of the abridged Oxford English Dictionary (OED). To my surprise, the venerable OED provided the following definitions: “1. A long cloak or cape. . . . 2. An [ecclesiastical] vestment. . . . 3. Anything resembling a cloak, canopy, or vault. 4. The outer portion or case of a mould” (p. 391). The word could also mean “to furnish with a cope”; “to strike,” or “come to blows.” The term also had relevance to animal husbandry, in that the verb “cope” could mean “to cut the beak of a falcon” and “to tie or sew up the mouth of a ferret.” It could also refer to the shock of combat, or an encounter. The term “coping” referred primarily to masonry or brickwork. Embedded among these myriad definitions was only a hint as to what could be considered current usage: “To be or prove oneself a match for,” or “to contend successfully with.” Indicating how much the culture and usage of the term has changed, the 1980 Oxford American Dictionary gives “to manage successfully” (p. 189) as the primary definition for “cope.” Contemporary American culture has become nearly obsessed with stress and how to cope with it. Examples of this interest can be found in the most cursory inspection of any of the media. Self-help books abound, providing sage (or not so sage) advice on the best ways to cope with personal shortcomings, the opposite sex, work, illnesses, parents, children, and so forth. Every day millions of people avidly read the ad84

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vice columns in newspapers, where various pundits attempt to resolve problems for people in a variety of areas, including personal problems, disputes between family members or coworkers, problems with etiquette, pets, plants, older parents, health, finances, and so forth. The Boston Globe regularly runs a column entitled “Confidential Chat” in which people write in with problems and solicit advice from other readers. The advice that is sought ranges from minor problems, such as how to locate a particular pattern for knitting a shawl, to major problems, such as how to handle a hyperactive child or whether to move to another state. The same phenomenon can be seen on the broadcast media. The talk shows often deal with everyday problems, which can range from the relatively mundane, such as problems with retirement, to the bizarre and titillating. The panels generally include “formal” experts, such as psychologists or lawyers, and “informal” experts, such as individuals who have gone through such an experience. Television also broadcasts numerous “illness-of-the-week” movies, which depict individuals and families coping with a variety of illnesses, usually life-threatening or disfiguring. Soap operas not only depict people in trying circumstances but also provide role models for coping with problems (usually in the most negative way possible—lying, cheating, stealing, and seeking revenge). “Reality” shows often pose stunning problems for a group of people to test their coping and survival skills. People also turn to formal sources of support, such as psychiatrists, psychologists, social workers, and religious figures. Time-honored custom also leads individuals to turn to folk advisers, such as hairdressers, bartenders, astrologers, fortune tellers, mediums, channelers, and so forth. This interest has been paralleled in the academic literature. Since Coelho, Hamburg, and Adams’s (1974) seminal book entitled Stress, Coping, and Adaptation, over 38,000 articles on coping have appeared in the literature, as indicated by a computer search of PsychInfo. These studies range from general works on the structure of coping to very specific articles on how individuals cope with particular stressors, usually chronic illnesses. (See Chapters 10 and 11 for reviews of this literature.) Since the publication of the first edition of this book, more than 22,000 articles have been published. This explosion of interest in coping has its roots in several domains. As with stress research, the importance of studying how people cope with stress can loosely be divided into three areas: intrinsic interest, relevance for psychological models of adaptation, and relevance for biomedical models of adaptation. We will explore the reasons for the interest in coping in each of these three domains.

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INTRINSIC INTEREST Studying how people cope with stress is intrinsically interesting. Since stress is so much a part of everyday life, how people successfully manage stress has immediate personal relevance. As noted earlier, the widespread depiction of coping strategies in the media attests to their importance. It is as if individuals, in their quest for mastery and control in their own lives, have insatiable interest in acquiring new strategies by observing the coping strategies of other individuals, whether real or fictional. Intrinsic interest in coping stems in part from its mythopoetic roots—the ideal of the hero who braves tremendous odds to accomplish some crucial task. However, the rapid change in common usage of the term “coping” and the explosion of interest in the construct noted above suggests that this preoccupation may also be driven by social changes— namely, changes in the demands of social roles as well as possible changes in social character.

MYTHOPOETIC ROOTS The construct of “coping with stress” is rooted in a basic interest in heroic action under adversity. Heroes are people who have braved harsh circumstances in their search for some higher goal, which can be either personal or collective. In fairy tales, a young prince must conquer dragons and demons in his quest to win the beautiful princess. King Arthur’s knights fought bravely against villainous knights and invading Saxons. Heroes have also been “founding fathers” or revolutionary leaders, military figures such as Robert E. Lee or George Patton, or people associated with extraordinary personal characteristics, such as saints or religious leaders. Modern heroes can be grouped into three basic types: those who brave physical hardships, those who provide leadership during times of social upheaval, or those who cope with personal trauma in ways that, for whatever reason, prove inspiring to others. Heroes who brave physical hardships include explorers, astronauts, war heroes, and test pilots. These men (and a sprinkling of women) have demonstrated fearlessness and resolve in the face of life-threatening dangers. Chuck Yeager’s ability to escape from exploding experimental supersonic jets and to survive despite a burning parachute and jumpsuit is a notable example (Yeager & Janos, 1985). Some heroes give their lives to try to protect others—the New York City policemen’s and firemen’s courage in trying to rescue people from the World Trade Center on 9/11 is perhaps the most recent well-known example.

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Television, having substituted rock stars and actors for heroes for so many years, may now be belatedly generating more interest in real-life heroes. The Public Broadcasting System showcased an action-adventure series depicting real-life exploits in foreign lands that often entailed a great deal of danger. Another network aired a program that reenacted the real-life experiences of police officers who had been cited for their bravery, generally with the officer explaining his or her behavior. Unfortunately, the attempt by current reality shows to reintroduce “heroes” into contemporary popular culture seems somewhat artificial and ultimately banal. The latest twist on this is the confusion of celluloid heroes with reallife ones. I’m quite convinced that one reason the California electorate chose Arnold Schwarzenegger as governor in 2003 is because he routinely played a hero who could swoop into a situation and solve problems when no one else could. Certainly California’s budgetary woes seemed to be an insurmountable problem, and part of his appeal may have been his screen image as someone who could fix any problem. Some heroes have the courage and integrity to combat social ills or to provide leadership in times of social upheaval, despite grave personal risks. In this country, individuals such as Martin Luther King, Jr., and Robert Kennedy led the fight against institutionalized racial prejudice— and were assassinated for their efforts. In the Soviet Union, men such as Andrei Sakharov and Natan Sharansky suffered terribly in their public fight against totalitarian repression. Sharansky’s (1988) work Fear No Evil is a remarkable account of the coping strategies that he used to maintain his personal integrity amidst the indignities of Soviet gulags. Other real-life persons’ heroics stem from facing physical limitations and life-threatening illnesses with strength and dignity. Lou Gehrig was a famous New York Yankee baseball player who developed a disabling and fatal disease, amyolateral sclerosis. His inspiring farewell speech to fans at Yankee Stadium stands as a classic example of fortitude and steadfastness in the face of certain disability and death. Gehrig’s celebrated speech has its modern-day analogues in pro basketball player Magic Johnson’s announcement that he was infected with the AIDS virus; in the late actor Christopher Reeve’s courageous efforts on behalf of quadriplegics; and in bicyclist Lance Armstrong’s remarkable recovery from metastasized cancer to win the Tour de France an unprecedented seven consecutive times. A large part of the interest in how people cope with stress is due to its connectedness with such admired traits as courage, integrity, and fortitude. Yet, academic studies of coping are but a pale reflection of such interests. Neither the terms strength, courage, fortitude, and bravery nor

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attempts to operationalize these constructs appear in our scientific research—at least not until very recently. Instead, we cautiously examine problem-focused and emotion-focused strategies, such as making plans of action or using wishful thinking, with appropriate caveats about how little we actually know about the process. As Aldwin and Revenson (1987) have pointed out, we have become fairly proficient at identifying coping strategies that are associated with poor outcomes, but we know relatively little about strategies that are associated with positive outcomes. However, the recent upsurge in positive psychology (Seligman & Csikszentmihalyi, 2000) is clearly an attempt to redress this imbalance in psychology. Indeed, Peterson and Seligman (2004) have developed instruments to measure these “character strengths and virtues.”

CHANGES IN SOCIAL ROLES The current avid interest in coping suggests that people are having profound difficulties in dealing with personal problems and may be a reflection of the major social upheavals of the past few decades. As I argue later (see Chapter 13), the general manner in which individuals cope with stress is largely dependent on social norms that indicate the acceptable ways of coping with particular problems. With social change, those norms often become inapplicable, and new ways for handling both new social problems and old ones must be generated. Unfortunately, this generation is usually done at the individual level—that is, individuals must work out new ways of coping with problems and then seek to bring about changes in the social or legal system to reinforce those new patterns of coping. During the past 50 years, there has been a massive shift in social roles that has created new problems and has required new ways of coping with old problems. The entry of women into the workforce, social mobility, racial integration, and changes in family structure have created new problems for which there are no socially prescribed and routinized methods of coping. People must learn new ways and generate new solutions; thus, it is not surprising that they seek information in as many different ways as they can. Consider the position of the first African American in a managerial position or a woman as the first female law partner. The standard methods of dealing with problems in a work setting may simply not be appropriate for these individuals. They may not easily fit into expectations of corporate culture, and their very existence in nontraditional roles may generate new problems that require novel solutions. A study of women

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in the health professions schools done in the mid-1970s, for example, found that many schools simply did not have the infrastructure to cope with female students—for example, there were neither surgical gloves in the appropriate sizes nor on-call rooms for female interns and residents (Women’s Action Program, 1976). Common assumptions about the capacities of African Americans and women and the most appropriate approach to social interactions had to be confronted, and changes had to be made in the interaction styles of pioneer individuals and their coworkers. For example, an influx of women into the workplace created new difficulties in terms of separating work and personal lives. Forty years ago among middle-class women, jobs were held primarily by young unmarried women who often used the workplace as a means of meeting potential husbands. Nowadays women mostly separate their work from their personal lives and often refuse to date coworkers in order to avoid complications that might derive from having to work with former lovers. Thus, women needed to learn new ways of coping with unwanted sexual advances and have instituted changes in the legal structure. For example, women and men can use the threat of a lawsuit for protection against sexual harassment in the workplace. Similarly, African Americans and other ethnic and sexual minorities have had to discover new ways of coping with bigotry, both conscious and unconscious, and have also used the courts as ways of both legitimizing new forms of adaptation and providing new resources for coping. Thus, changes in social roles have created new problems for which we are still trying to come up with new ways of coping, both on an individual and societal level. Changes in women’s roles also presaged changes in family structure. Elder and Caspi (1988) have argued that the entry of women into the labor force during the Great Depression and World War II had a massive effect on expectations for marital roles, which eventually led to an increase in the divorce rate. Thus, the old modes of relating between spouses changed as women gained more economic leverage, and this same leverage made it possible to leave unhappy marriages. The role expectations that men and women had of married life, based upon observing their parents’ interactions, were no longer appropriate; and people had to forge new modes of coping with changes in role requirements and the resultant conflicts. The extremely high divorce rate is one indication of the difficulty that individuals face in developing new modes of interaction within the family. In turn, the changes in marital roles and the divorce rate created new difficulties in raising children. The capacity to manage day care arrangements even in intact families with two working parents requires

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new skills. Solutions include such diverse options as drafting the grandmother, hiring in-house help, sharing one full-time job, taking jobs on different shifts, using family-based or institutional day care, starting a home-based business, or some combination of these. In divorced families, things may become even more difficult. Half of the nation’s children experience the divorce of their parents (Grych & Fincham, 1997). The baby boomers and generation X were the first cohorts to have to cope with this problem on such a massive scale. How does one deal with warring and bitter parents? How does one learn to be a “weekend father,” maintain civil relations with an ex-spouse in a joint custody situation, or introduce a new spouse into a family? Given these massive changes in social roles, it is not surprising that people seem to have lost their bearings. They are forced to cope with new problems caused by social changes for which there are no ready or pat answers, and they thus turn to one another and the media for examples. The good news is that people do adapt. As divorce becomes nearly normative, children of divorce are no longer stigmatized as they were in previous generations. Social institutions have adapted to this new reality. Joint custody is now the norm rather than a rarity, and there is a growing movement toward mediation of divorce settlements rather than acrimonious legal battles. These changes came about because it is now widely recognized that how parents cope with their own divorce greatly affects the well-being and long-term outcome of their children (Hetherington, Elmore, Chase-Lansdale, Kiernan, & Friedman, 2004). Thus, macroeconomic changes lead to changes in social roles, which in turn affect families. How parents cope with these changes directly affects the well-being of their children (Conger & Conger, 2002). In turn, people coping with social change demand changes in their social institutions that make these new transitions less stressful.

Changes in Social Character The widespread interest in coping may also reflect changes in social character. According to Riesman (1961), the mid-20th century witnessed a shift in the American national character from an “inner-directed” population, “whose conformity is insured by their tendency to acquire early in life an internalized set of goals,” to an “outer-directed” population, “whose conformity is insured by their tendency to be sensitized to the expectations and preferences of others” (p. 8). I would argue that not only goals but also preferred adaptive strategies are implanted at an early age in inner-directed types. The old strategies were manifested in proverbs such as “Honesty is the best policy,” “Keep a stiff upper lip,” and “Count your blessings.” These adages re-

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flected preferred modes of dealing with problems—adherence to certain codes of honor, such as honesty, suppression of emotion (especially in men), and the acceptance of responsibility for problems. When one was confronted with life’s problems, these “internal gyroscopes” often spelled out what were the right actions: obedience to authority, loyalty to country and family, and the avoidance of lying, cheating, or stealing. With the growth of outer-directedness, individuals look more toward the behavior of others in similar situations and what their peers deem acceptable strategies. The “internal gyroscopes” have been replaced by situationalism and an acute sense of the relativity of values. Rather than an internal guide of what should be the morally correct behavior in a situation, an outer-directed individual may be more concerned with the opinion of others in the immediate setting and the immediate consequences of his or her actions. Thus, each problem becomes unique and requires its own individual solution, vastly complicating adaptational processes. The benefit of an outer-directed stance is its flexibility and frequent sensitivity to the needs of others in the situation; the disadvantage is that it leaves individuals unduly subject to peer pressure and requires constant choice or decision making. No wonder individuals seek to increase the size of their coping repertoires and (of necessity) turn to others for advice on strategies.

RELEVANCE OF COPING TO PSYCHOSOCIAL MODELS OF ADAPTATION In Chapter 2, two contributions of the construct of stress to psychosocial models of adaptation were identified: (1) its ability to combine environmental and personal factors with the development of mental illness through the construct of vulnerability to stress, and (2) the notion of goodness of fit—namely, that psychosocial adaptation is in part a match between the demands of a situation and the capacities of an individual. Coping research also combines environmental and personological perspectives by showing that how individuals respond and deal with stress is a combination of multiple factors. This overdetermination of coping behavior allows for flexibility in adaptation. People modify what they do in order to take into account both environmental exigencies and personal preferences. How well one copes is also in part a matter of “goodness of fit” between environmental demands and individual resources. Some believe that individuals can be categorized as “good” or “bad” copers. They assume that competence in one domain is a personological characteristic that will generally be manifested in other domains. Aldwin

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(1982a) examined this assumption in an early study of coping among middle-aged men and women in different domains: work and family. The men, generally middle managers, exhibited good coping skills in work situations, relying mainly on an array of very sophisticated problem-focused strategies. In family situations, however, they appeared to feel much less competent and would say things like “I don’t deal with crying babies. I let my wife handle it.” The women, on the other hand, were adept at dealing with family problems; but the few women who did work, mainly lowerlevel secretaries and clerks, were far less skilled and were more likely to use emotion-focused strategies in work situations. Thus, whether one is a “good coper” or a “bad coper” depends largely upon the types of skills that one brings to a particular environmental context. Thus, the construct of coping with stress reemphasizes these two contributions of stress models, but it also extends our understanding of psychosocial adaptation in three important ways. First, the addition of the construct of coping to the stress paradigm emphasizes that people are neither passive responders to environmental circumstances nor are they guided solely by inborn temperament. By actively responding to environmental circumstances, individuals can learn to adapt to and overcome adversity. Not only do people change themselves, but they can also learn to modify their environments. Second, this last characteristic of coping actions—that they are learned behaviors—also has implications for the treatment of psychological problems. In many cultures, including our own, psychological problems and mental illness are stigmatized, and people who have sought such help are often deemed suspect. In the early 1970s, U.S. Democratic Senator Thomas Eagleton was effectively banished from his vice-presidential candidacy when he revealed that he had at one time been treated for depression. Such stigmatization is a logical outgrowth of the view that psychological abnormalities are mainly due to innate physiological or psychological problems; such attitudes can be a barrier to seeking treatment for problems. More recently, increased recognition that “normal” individuals may have difficulty coping with specific problems and that anyone can learn new skills has somewhat lessened the prejudice against mental illness. Third, the idea that coping is flexible and to some degree learned allows for the development of intervention programs that seek to remedy specific problems (Folkman & Moskowitz, 2004). Rather than suggest that some individuals are inherently defective, a stress and coping approach argues that some individuals do not have the appropriate skills needed to cope with particular sets of problems. Therapists such as Minuchin (1974) have argued that some individuals have learned maladaptive ways of coping with problematic situations that serve to

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maintain rather than eliminate problems, but with appropriate intervention new strategies can be learned. During the 1992 presidential campaign, Democratic candidates Bill Clinton and Al Gore both admitted to having been in family therapy, the former for treatment of his brother’s alcohol abuse and the latter for help in dealing with a son’s serious illness, and little or no stigma was attached to these admissions. This attitude shift reflects changes in social norms relating to how individuals should cope with problems. Even then, however, the two candidates were careful to indicate that these were situation-specific problems and not a reflection of their own general mental health. By destigmatizing emotional or psychological problems, the stress and coping approach to psychosocial adaptation allows more people access to the skills they need to cope with their particular set of problems. After all, everyone “has stress,” and there is little stigma attached to increasing coping skills. For example, stress management courses are now routinely offered in the workplace, and telephone counseling services for parents at risk of abusing their children are called parental stress hotlines. Certainly, some individuals are more vulnerable than others. But it is much easier for a person to acknowledge that he or she may need help in handling a specific type of problem than submit to a label of neurotic, hysteric, or depressive. This is not to say that the learning of coping skills is the only purpose of therapy—far from it. Obviously, therapy includes many other dimensions, including medication and self-knowledge. However, by focusing on coping skills, therapy may become more accessible to individuals who would not otherwise risk the potential stigmatization of psychotherapy. Thus the construct of coping with stress is preferable in that it allows for an innate flexibility in psychosocial adaptation. Inasmuch as stress arises from the interaction (or transaction) between the person and the environment, the management of problems and the attendant negative affect is also a function of multiple factors. Adaptation may require both environmental and personal change. The strength of the concept of coping lies in its flexibility—its ability to respond both to the requirements of the situation and to personal needs. Adaptive strategies are thus malleable—people can learn new skills, either in self or environmental management, that can allow them to transcend difficult problems.

RELEVANCE TO BIOMEDICAL MODELS OF ADAPTATION It is commonly observed that stress accounts for only a modest amount of the variance in health, with correlations between stress measures and

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self-report physical health typically ranging in the .20s and .30s. In other words, not everyone succumbs to illness under stressful conditions, or, more precisely, every experience of a stressful episode does not lead to ill health. While this fact is often interpreted as a problem in stress research indicative of the weakness of the construct, another interpretation is that this relatively low correlation is actually positive—it is a tribute to humans’ adaptive capacity that, unlike some laboratory mice, we do not become ill with every stressor. The problem, then, becomes one of trying to determine why stress sometimes results in ill health and at other times does not. Obviously there are a number of factors that are relevant. One is physical hardiness: Some individuals may not be genetically susceptible to particular illnesses, while others may be in good physical condition, which much research has shown is protective against the adverse effects of stress (e.g., Roth & Holmes, 1985). Nutritional status and immediate state of health (e.g., how tired one is) are also factors. The impetus for the study of coping strategies is a direct result of this recognition of individual differences in response to stress. The idea is that somehow coping mitigates the adverse effects of stress. (See Chapter 9 for a discussion of coping strategies as mediators, moderators, and buffers.) However, we have yet to work out exactly how stress buffering happens; indeed, only a few studies have actually demonstrated it (see Aldwin & Yancura, 2004, for a review). Studies that look at the mitigating effects of coping often use psychological outcomes, while studies with good physical health measures simply assume that individuals who do not become ill are “good copers,” with little or no attempt to assess the recent coping strategies actually used. Further complicating the issue is that, according to Pearlin and Schooler (1978), it is unlikely that researchers will find a “magic bullet” coping strategy that is good for all people under all circumstances. Instead, we will need to define a taxonomy of coping actions and determine what works under disparate circumstances and for which individuals. Nonetheless, if we can demonstrate a relationship between coping and physical health, this would open up exciting possibilities for preventive medicine. Individuals may be able to protect their health by learning to deal effectively with stress. The second way in which the construct of coping is important for biomedical adaptation involves how individuals cope with illness. That is, once individuals become ill, it is necessary to face certain adaptive tasks. In the case of chronic or other serious illness, these tasks include following medical regimens, maintaining emotional stability, and establishing workable relationships with medical personnel. Individual differences in the course of illness may be due in part to how successful indi-

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viduals are in coping with these adaptive tasks (Moos & Schaefer, 1984). A number of new studies suggest how individuals cope can affect the course of their illness and even their survival time (see Chapter 11).

DIFFERENTIATING BETWEEN ADAPTATION, COPING, AND EMOTIONAL RESPONSES Adaptation is an overarching construct that includes concepts such as defenses, mastery, and coping strategies (White, 1961). It is also important to differentiate among general adaptation or management skills, coping strategies, and emotional responses. Everyone develops certain management skills to help him or her deal with life. Aspinwall and Taylor (1997) developed the concept of proactive coping, which is used to prevent the occurrence of problems. We brush our teeth to prevent cavities and gum disease, develop a morning routine that enables us to get to school or work on time, manage driving on the freeway or negotiate the subway to get to work, develop a routine for dealing with common tasks at work, learn how to comfort a small child, and so forth. To the extent that these become routinized and everyday skills that forestall stress, they are no longer coping strategies per se but life management skills (Aldwin & Brustrom, 1996). As White (1961, p. 48) pointed out, “Nobody has chosen going to school for the sixty-third time as an occasion for coping.” Management skills may have developed out of learning to cope with a problem but, once routine, are no longer considered coping strategies, although they may be coping resources, or what Antonovsky (1979) has called generalized resistance resources. (As we shall see in Chapter 8, management skills are different from coping styles. Coping styles are considered to be characteristic ways of handling problems; in contrast, management skills refer to situation-specific skills used to forestall or avoid problems.) Some strategies such as anticipatory coping straddle the boundary between management skills and coping styles (Aspinwall & Taylor, 1997; Folkman & Moskowitz, 2004). Anticipatory coping involves actions that are designed to prevent or minimize problems that are likely to occur in the relatively near future. For example, making sure one has sufficient gas in the tank before driving late at night is preferable to running out of gas and having to call a friend to come and get you. Again, to the extent that such activities become part of our everyday routine (e.g., always filling up the tank on Saturday afternoon for the next week’s commute to avoid waiting in line Monday mornings), it is a management skill. However, when an anticipatory action is undertaken for a

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relatively novel problem, or when its outcome is uncertain, then it becomes more of a coping strategy. Until recently, anticipatory coping was little studied, with the exception of medical procedures (Bush, Melamed, Sheras, & Greenbaum, 1986) and laboratory studies of anticipated shock (e.g., Thompson, Dengerink, & George, 1987). However, a small but growing literature has emerged in the past few years that is presently exploring approaches to anticipatory and proactive coping (Greenglass, 2002; Schwarzer, 2001; Schwarzer & Knoll, 2003). On the other hand, involuntary emotional reactions should also not be considered coping strategies. Gasping with pain because you stepped on a nail is not generally considered to be a coping strategy per se, and being sad or depressed is generally considered to be an outcome of the stress and coping process. However, expressing emotions (having a good cry, yelling at someone, moaning and groaning with pain) may be either emotion- or problem-focused coping (or both), since it has a purpose. Admittedly, this distinction can become rather arbitrary, since the difference between voluntary and involuntary emotional reactions can become rather blurred at times (see Compas, Connor, Osowiecki, & Welch, 1996). However, it is important to distinguish between coping strategies and their purported outcomes; if they are confounded at the outset, we will never be able to get objective indicators on which strategies “work” in which situations (Lazarus, 1983). Coping strategies are thought to consist of both cognitions and behaviors that are directed at managing a problem and its attendant negative emotions (Folkman & Lazarus, 1980). In a transactional scheme, stressors arise because of a perceived shortfall of resources needed to deal with a problem; once the resources have been developed, the situation is no longer perceived as stressful—unless, of course, the situation (or its meaning) somehow becomes altered and the routines are no longer adequate. Consider driving on the freeway. For the novice driver, this is a highly stressful procedure: The person must maintain awareness, figure out how to merge in traffic, learn how to read the intentions of other drivers, and so forth. Once a person has mastered the task, driving on the freeway becomes more of a management skill than a coping behavior— unless, of course, something changes that increases the difficulty of the task, such as hazardous driving conditions. A meaning change may also require coping strategies: Routine traffic congestion, which ordinarily requires simple management skills, may become suddenly stressful if it threatens to make a person late for a crucial appointment. The hallmark of coping strategies is that they require effort—whether conscious or unconscious—in their task of managing negative affect and stressful situations, whether temporary or chronic.

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SUMMARY The study of coping is fraught with difficulties (see Coyne, Thompson, & Racioppo, 2000; Lazarus, 2000; Somerfield & McCrae, 2000). As we shall see in the next chapters, there are many unanswered questions about to how to conceptualize and measure coping, and, indeed, some believe that the study of coping should be replaced with an examination of stress–personality interactions. However, the study of coping strategies is important in and of itself. Not only is there is a great deal of intrinsic interest, but focusing on stress and coping behaviors has implications for the flexibility of the adaptational process and destigmatizes seeking help for problems. Further, the study of stress and coping processes represents a methodological breakthrough for psychology. Most prior research has focused either on self-reported personality, attitudes, and feelings, on the one hand, or observed behaviors in experimental settings, on the other. This is the first time that there has been a concerted effort in the field of psychology to have people systematically self-report on their own cognitions and behaviors in specific contexts. As we shall see, the introduction of self-report questionnaires has created a number of conceptual and methodological difficulties but is exciting in its implications for psychology as a whole.

STRESS, COPING, Theoretical Approaches ANDtoDEVELOPMENT Coping

CHAPTER 7

Theoretical Approaches to Coping

A

s we saw in the preceding chapter, the study of coping has its roots in the recognition that there are individual differences in reactions to stress—that is, similar stresses may have varying effects on different people. For example, individuals can respond in many different ways to a reprimand by a supervisor at work. Some people may shrug it off; others may argue with the supervisor, trying to convince him or her that the evaluation is faulty. Some people may react with tears and spend the rest of the day complaining to coworkers, others may become angry and quit the job or threaten the supervisor with violence. Some may acknowledge the problem and resolve to improve their job performance. Yet others may become involved in office politics and seek to sabotage the supervisor in some way. The purpose of studying coping strategies is to understand why people differ so greatly in their responses to stress and how differing responses relate to well-being. The theoretical orientation of a researcher or clinician directs the types of factors that he or she considers in studying influences on coping. Simply put, a clinician will focus on such person factors as personality characteristics, values, and commitments if he or she believes that the origin of coping strategies lies with the person. In the example given above, one explanation for the differences in the hypothesized coping strategies is that these individuals differ in their personality characteristics, such as emotionality; those low in emotionality may simply shrug off the confrontation with the supervisor, those high in emotionality may react with 98

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tears or aggression, either verbal or physical. In contrast, those who acknowledge problems and respond in a socially appropriate manner (assuming we can tell what that is) are thought to be more mature or higher in ego strength. (The Machiavellian style depicted in the last example is rarely investigated in the stress and coping literature.) The astute observer will note that a strictly person-based approach implicitly assumes environmental constancy—namely, that all of the individuals in the cited example are responding to the same situation, a reprimand from the supervisor. A situation-based approach would argue that environmental demands or situational characteristics evoke differing coping strategies. This approach argues that stimulus characteristics need to be considered. For example, we do not know whether the reprimand is justified. If it is, acknowledgment is appropriate; however, if it is not, anger may be understandable. Given that this is an interpersonal situation, the characteristics of the other individuals may affect the type of coping strategies used. The individual who responded hysterically may have been previously subjected to sexual harassment by the supervisor and is now being unduly criticized in an attempt to get her to quit. By spending the day talking to people, she may be trying to determine whether there is enough support in the office from her fellow coworkers to file charges. Finally, macrocharacteristics of the situation, such as the structure of the working conditions, also should be considered. The person who responded with Machiavellian scheming might be working in a federal agency. The supervisor may be incompetent and adversely affecting the functions of the office. However, in an entrenched bureaucracy, it is nearly impossible to directly effect changes in personnel; therefore, otherwise perfectly upstanding individuals may resort to Machiavellian scheming in order to work indirectly to oust people by making their working conditions unbearable. Borrowing from the discussion in Chapter 1, a person-based approach assumes that person → coping. A situation-based approach assumes that situation → coping. The interactionist approach that most stress and coping researchers accept is that the person + the situation → coping. Thus, the person who responds with anger to his supervisor’s reprimand could be both high in hostility and reacting to an unjustified reprimand. As we noted in Chapter 1, there is a fourth approach: the transactionist approach. In this instance, the person, situation, and coping mutually affect one another in a process that evolves over time (see Figure 1.2). This approach requires a larger, or more contextual, view of the situation and specifies that coping behavior may change in response to its effects on the situation (Lazarus & Folkman, 1984). In the example above about the federal bureaucracy, an incompetent supervisor has un-

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justifiably rebuked the employee. From the employee’s point of view, the supervisor has become an impediment to the smooth running of the office and the completion of tasks. By resorting to Machiavellian scheming, however, the employee sets off a bureaucratic firestorm that uses up a great deal of the office’s resources—that is, the personnel spend most of their time engaging in office politics and very little on the actual tasks at hand. Thus, the coping strategy has made the situation worse and has further increased the employee’s distress, at least in the short run. At this point, the employee may reassess his or her coping strategies and decide whether to continue on that course of action or modify it in some fashion. Thus, the person, situation, and behavior become enmeshed in an admittedly circular process. However, this process can also be seen as developmental in nature (see Chapter 15). This chapter will review both person- and environment-based theories of coping and will address basic issues in coping research, such as consistency and change across situations. In addition, newer models have expanded the domain of coping to focus on proactive and anticipatory coping, life management skills, and the importance of meaning.

PERSON-BASED DEFINITIONS OF COPING Person-based approaches to the study of coping posit that personality characteristics are primary in determining how people cope with stress. Person-based approaches can be loosely divided into three schools: psychoanalytic, personality trait, and perceptual styles.

Psychoanalytic Traditions The study of coping strategies has its roots in psychoanalytic descriptions of defense mechanisms, which are directed primarily toward internal conflicts. According to Anna Freud (1966), defense mechanisms are the ways in which the ego wards off anxiety and exercises control over impulsive behaviors, affects, and instincts. Basically, anxiety arises from unconscious conflicts between the id and the superego. The ego, with its primary emphasis on reality testing and mediation between environmental and internal demands, tries to defend against this overwhelming anxiety by distorting reality or metamorphosing instinctual demands. Defense mechanisms are manifested primarily as symptoms and are characterized by automatic, rigid reactions. Anna Freud (1966) identified several major defense mechanisms, including suppression, denial, projection, reaction formation, hysteria, obsessive–compulsive behaviors, and sublimation. Suppression and de-

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nial involve varying forms of the refusal to acknowledge an event or feelings. To return to our example of the confrontation with the supervisor, an individual suppressing the episode may try not to think about it; someone who is in denial will literally “forget” that it ever happened and deny it if queried. In contrast, rather than forget the event, the hysteric will inappropriately focus attention on it, thus magnifying the problem—by spending the day crying in the bathroom, for example. An obsessive–compulsive will also focus attention, but in a different manner. The next time the supervisor requires the employee to perform a task, the employee may spend so long checking and rechecking every step of the project that he or she misses the deadline. Projection and reaction formation are similar in that they both involve casting off one’s own feelings about an event. In projection, an aggressive coper might think that the reprimand was unjust and may feel that the work is fine; the supervisor just had it in for him or her. This individual has attributed his or her own feelings of anger to someone else. In reaction formation, a person inverts his or her own feelings, turning anger into admiration, for example. But this person may later react inappropriately, either by not bothering to actually improve performance or by becoming overly upset at the inevitable emergence of flaws in the supervisor. On the other hand, the “mature” coper could also sublimate by using the anger to accomplish the next task better. If this individual were a reporter, he or she could write a scathing political exposé; if this person were on the maintenance crew, he or she could work off anger physically by scrubbing things harder. In this model, the type of coping behavior used has very little to do with either the actual environmental stimulus or what the individual does to solve the problem. Rather, the focus of defense mechanisms are to regulate emotions—to reduce anxiety by whatever means possible. Thus, behaviors, feelings, and cognitions evoked by a stressful situation are determined by the individual’s personality structure, which was developed in early childhood and is thus not readily mutable. Defense mechanisms can be used fleetingly and only under conditions of great trauma, or they can be become habitual. For example, a common initial reaction to the sudden death of a loved one is denial. Confronted with the death of a son in a car accident, an understandable reaction is to think, “Oh, no, they’ve made an error. That’s not my son in the morgue—it’s someone else.” Denial, however, may become habitual, as in the case where the mother refuses to believe that her son is dead and continues to set a place for him at the dinner table every night. In this model, both the fleeting and permanent denial are caused by personality structure. Shapiro (1965) posited that people can become characterized by

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their predominant use of a particular mechanism. Shapiro focused on four major styles. The obsessive–compulsive style is characterized by rigidity, distortion of the experience of autonomy, and the loss of reality. Paranoids also suffer from a loss of reality but are primarily characterized by suspicious thinking. The hysterical style is characterized by both repression and hyperemotionality, while the impulsive style is characterized by rapid, thoughtless action and a lack of planning. One limitation of this approach is that it focuses primarily on poor adaptation—individuals who are thought of as “neurotics.” Several psychoanalytic thinkers have attempted to circumvent this approach by suggesting adaptive hierarchies.

Defensive Hierarchies One problem with understanding coping efforts primarily in terms of defense mechanisms is that these mechanisms are, by definition, maladaptive in that they distort reality. However, most of us are not that maladaptive—at least most of the time. Vaillant (1977) attempted to deal with this limitation by redefining defense mechanisms in terms of adaptive styles, with the explicit assumption that some defense mechanisms can be healthy and adaptive. Vaillant (1977) utilized data from the Grant Study (begun in the 1930s), a longitudinal study of college men who were judged “mentally healthy” and then were followed up at several points over their life course (Vaillant, 1993, Vaillant & Mukamal, 2001). His primary focus was on the development of adaptive mechanisms and how they were related to long-term outcomes. Although Vaillant recognized that adaption requires people to “alter themselves and the world around them” (1977, p. 13), he concentrated on the regulation of emotion and the preservation of ego integrity. Vaillant arranged the defense mechanisms in a hierarchy from projective through mature mechanisms (see Table 7.1), which also doubled as a developmental progression across the lifespan. He broke from traditional psychoanalytic theory in recognizing that the use of defense mechanisms is not inherently pathological but serves to maintain ego integrity under difficult circumstances. The higher categories, however, are considered more effective and adaptive than the lower ones. The American Psychiatric Association now describes defenses primarily in terms of adaptive hierarchies (Cramer, 2000). As Table 7.1 indicates, Vaillant identified four levels of defense mechanisms: projective, immature, neurotic, and mature. The hierarchy is based primarily upon how much distortion of reality is involved in each mechanism, with the lower mechanisms involving more distortion

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TABLE 7.1. Vaillant’s Hierarchy of Defensive Mechanisms Level I. Projective mechanisms Denial Distortion Delusional projection Level II. Immature mechanisms Fantasy Projection Hypochondriasis Passive–aggressive behavior (turning against the self) Acting out Level III. Neurotic mechanisms Intellectualization (isolation, obsessive behavior, undoing, rationalization) Repression Reaction formation Displacement (conversion, phobias) Dissociation Level IV. Mature mechanisms Sublimation Altruism Suppression Anticipation Humor Note. Data from Vaillant (1977).

and, thus, more pathology. Returning to our example, the aggressive coper who attributes his own anger to his supervisor is using an immature mechanism, the person who turned his or her anger into unrealistic admiration is using a neurotic mechanism, while the person who sublimates is using a mature mechanism. In Vaillant’s scheme, the projective mechanisms involve major delusions, such as denial—the inability to acknowledge that the episode even occurred. Delusional projection would involve a paranoid fantasy, for example, that the supervisor has been working for years to destroy the employee. Such paranoia may be accompanied by extreme reactions such as physical violence. Vaillant then applied this hierarchical categorization to the interview materials acquired over 30 years of study with the Grant Study men, graduates from a particular class at an Ivy League school. He demonstrated that as people grow from young adulthood to midlife their characteristic defensive styles often change from immature to more mature. The men who used more immature mechanisms in later life were judged less adaptive or successful, defined primarily in the context of career achievement and marital stability. Further, individuals who developed mature coping strategies tended to be happier and to live longer,

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and many of these findings were replicated in other longitudinal samples that included both women and men from lower socioeconomic groups (Vaillant, 1993; Vaillant & Mukamal, 2001). Vaillant (1993) presented three models for the ways in which the ego matures: neurobiology, social learning theory, and assimilation– imprinting. From a neurobiological standpoint, neuronal maturation processes continue into adulthood, which are hypothesized to enable individuals to develop such higher ego processes as becoming more tolerant of paradox, being able to use sublimation, and so forth. From a social learning viewpoint, people learn more mature defense mechanisms through both learning processes and social support. As Vaillant (1993) concluded: “Learning as well as heredity plays a major role in our choice of defenses. Sublimation hurts less than masochism; altruism is better paid than reaction formation; humor wins us more friends . . . than wit” (p. 332). In addition, social support facilitates the maturation of defenses by enhancing a sense of safety and self-esteem and reinforcing the use of more mature defenses. However, Vaillant thought the assimilation model of ego development was more complete. From his case histories, he felt that “what was most critical to resilience was not social supports but the ability to internalize those supports” (p. 332). He identified several ways in which adults internalized loved ones, ranging from very immature incorporation and introjection to more mature idealization and identification. Basically, in incorporation or introjection, people unconsciously take in “undigested” significant others—Norman Bates’s taking on the identity of his deceased mother in the movie Psycho would be an extreme example. In more mature identification or idealization, we can recognize and integrate both the positive and negative aspects of loved ones. Yet, Vaillant still insisted that defense mechanisms are unconscious—even those involving planning and anticipation. As he put it, “Paranoids cannot become altruists by an act of will” (pp. 103–104). Yet, he went on to say, “But, through therapy, maturation, and loving relationships people learn more mature styles of self-deception” (p. 104). Thus, Vaillant is very ambivalent about what is conscious and unconscious in adaptation; on the one hand, his eloquent case histories are convincing demonstrations of unconscious processes in adaptation; on the other hand, they equally and clearly demonstrate that development and use of more mature coping strategies occur at least partially through conscious effort. Haan (1977) sought to integrate the idea of adaptive processes with defense mechanisms in a largely psychodynamic framework. In contrast to Vaillant’s approach, however, Haan maintained that defense mechanisms are inherently pathological and constructed a hierarchy of adapta-

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tion based upon the extent to which the strategies used reflect conscious or unconscious processes. She identified 10 basic, or generic, ego processes that can be expressed in three modes (see Table 7.2). The first mode, coping, is conscious, flexible, and purposive, and permits moderate expression of emotion. The second mode, defensive, is compelled, negating, and rigid and is directed toward anxiety rather than the problem. The third mode, fragmentation, or ego failure, most clearly distorts “intersubjective reality” and is automated, ritualistic, and irrational. The 10 generic processes are further divided into four functions: cognitive, reflexive–intraceptive, attention-focusing, and affective– impulse regulation. Note that these ego processes not only are directed toward anxiety reduction (the last category) but also function to regulate cognitive processing, to provide self-reflective capacity, and focus attention.

TABLE 7.2. Haan’s Description of the Properties of Coping, Defense, and Fragmentation Coping processes

Defense processes

Fragmentary processes

Appear to involve choice and are, therefore, flexible, purposeful behavior.

Turn away from choice and are, therefore, rigid and channeled.

Appear repetitive, ritualistic, and automated.

Are pulled toward the future and take account of the needs of the present.

Are pushed from the past.

Operate on assumptions that are privatistically based.

Are oriented to the reality requirements of the present situation.

Distort aspects of present requirements.

Close the system and are nonresponsive to the present.

Involve differentiated process thinking that integrates conscious and preconscious elements.

Involve undifferentiated thinking and include elements that do not seem part of the situation.

Are primarily and unadulteratedly determined by affect needs.

Operate with the organism’s necessity of “metering” the experiencing of disturbing affects.

Operate with the Flood the person assumption that it is with affect. possible to magically remove disturbing feelings.

Allow various forms of affective satisfactions in an open, ordered, and tempered way.

Allow gratification by subterfuge.

Allow unmodulated gratification of some impulses.

Note. Adapted from Haan (1977). Copyright 1977 by Academic Press. Adapted by permission.

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In Haan’s scheme, a particular generic process can be expressed differently and with varying levels of pathology in the three modes. As Table 7.3 illustrates, the third cognitive function, “means–ends symbolization,” can be seen as a problem-focused strategy, at least in the coping mode. In this mode, means–end symbolization is expressed in logical analysis of the problem, a process underlying most attempts to resolve problems. In the defense mode, means–end symbolization becomes rationalization, or an attempt to justify one’s actions. In the fragmentation mode, however, means–end symbolization degenerates into confabulation, when someone simply makes up a story in an attempt to defend him- or herself. According to Haan, people cope when they can and defend when they must. In other words, if the situation is not very stressful, the ego will cope, which is described as being purposeful, flexible, adhering to intersubjective reality, and permitting affective expression. But under stressful circumstances, the ego preserves integrity by greater or lesser distortion of reality. Defensive strategies are compelled, negating, rigid, and are directed toward anxiety rather than toward the problem. Fragmentation most clearly distorts intersubjective reality. It is automated, TABLE 7.3. Haan’s Taxonomy of Ego Defenses Modes Generic processes

Coping

Defense

Fragmentation

Cognitive functions 1. Discrimination 2. Detachment

Objectivity Intellectuality

Isolation Intellectualizing

Symbolization

Logical analysis, rationalization

Concretism Word salads, neologisms Confabulation

3. Means–ends

Reflexive–intraceptive functions 4. Delayed response Tolerance of doubt Immobilization 5. Sensitivity Empathy Projection 6. Time reversion Regression Ego regression

Ambiguity Delusion Decompensation

Attention-focusing functions 7. Selective awareness Concentration

Denial

Distraction, fixation

Affective–impulse regulations 8. Diversion Sublimation

Displacement

9. Transformation 10. Restraint

Reaction formation Repression

Affective preoccupation Unstable alternation Depersonalization, amnesia

Substitution Suppression

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ritualistic, and irrational, and adheres to privatistic (e.g., idiosyncratic) formulae. Successful ego processes are not defined by their content or effects, but are defined a priori by which processes are used. However, these modes are not orthogonal; Haan admits that generally a mixture of coping and defensive strategies is used. Development consists of gaining progressive control over behavior, shifting from defensive to coping modes. Haan’s theory has some very positive and interesting aspects. Nonetheless, there are several limitations to Haan’s theory. The main problem lies in her a priori categorization of the three modes into adaptive and maladaptive processes and in the conditions under which the three modes are used. In part, Haan’s theory is too neatly categorical. For example, she believes that people can use rational, coping modes when not under too much stress and defensive modes when the stress is too great—an extension of classical Freudian hydraulics. However, as can be noted by any casual observer, people can and do act in a rational, focused manner under situations of extreme environmental demand— during combat and disasters, for example (see Chapter 12). Further, others besides Vaillant have argued that defensive processes are not necessarily pathological. For example, under certain limited circumstances, denial can have beneficial effects by granting a brief respite that allows an individual to gather strength (Lazarus, 1983). Horowitz (1976, 1986) has described the sequelae to extremely stressful events in terms of the phases of denial and numbness of affect alternating with intrusive memories. Horowitz believes that this process, while unconscious and probably defensive, is not pathological in that it provides a means of working through or adjusting to the event. This allows the information to be gradually incorporated so as not to overwhelm the person. The primary problem with hierarchical, teleological systems is that they tend to be expressions of the dominant cultural mode, and, as such, may be limited to that culture. For example, as future-oriented, differentiated thinking and as the “open, ordered, and tempered” expression of affect, Haan’s criteria for coping is clearly culture-bound. As we shall see in Chapter 13, some cultures have very different modes of regulating affect, preferring either indirect expressions of affect or decidedly “nontempered” ones. Psychoanalytic approaches to coping tend to utilize qualitative interview data that are often rich and replete with often poignant everyday examples. There can be little doubt that some people at some points use defenses of which they are largely unaware. Having conducted or supervised over 1,000 interviews on how individuals cope with both everyday problems (see Aldwin, Sutton, & Lachman, 1996b) and extremely serious problems (Aldwin, Sutton, Chiara, & Spiro, 1996), those interviews

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in which people do use defense mechanisms such as denial are simply qualitatively different than those that are relatively more straightforward. Lazarus (1995) characterized these types of interviews as being highly inconsistent. Indeed, our rule of thumb for coding defenses such as denial involved explicit inconsistencies. For example, individuals would indicate on a rating scale that the problem was serious but then would deny experiencing any negative affect. If one probed for whether they felt angry or sad, they would respond with coping strategies (“Oh, I just don’t think about it”), and when asked how they coped, they would reply that they didn’t because they were not upset! However, developing scales or quantitative indices of defense mechanisms may be more problematic. Both Haan (1977) and Bond, Gardiner, Christian, and Sigel (1983) have developed scales that purport to assess defense mechanisms. However, Cramer (2000) has been fairly critical of these attempts, arguing that there is a logical problem in their basic premise—if defense mechanisms are unconscious, how can people report them using a self-report inventory? It is true that, in retrospect, some people may realize that they were denying or projecting, but my guess is that most do not. Indeed, the psychometrics on these scales tend to be relatively poor (Cramer, 2000). However, another way of depicting this distinction is to substitute the terms “voluntary” and “involuntary” for “conscious” and “unconscious.” Compas et al. (1996) point out that many of the responses to chronic stress are actually involuntary. For example, repetitive intrusive thoughts are involuntary. Indeed, anyone who has stayed awake all night worrying can attest to the difficulty in controlling such thoughts. People can nonetheless report on them. Further, strategies can slip back and forth between voluntary and involuntary. For example, people can and do learn to control problem behaviors and cognitions such as intrusive, repetitive thoughts. Kornfield (1993), for example, recommends that individuals number or name particular sequences in an effort to create some distance and break the repetitive cycle. To further muddy the waters, some processes that individuals use to deal with chronic stress may go unnoticed. For example, Repetti and her colleagues conducted a series of studies tracking changes in social behaviors as a function of work stress (see Repetti & Wood, 1996). They found that on days of high stress men would tend to withdraw from interaction with their families that night. However, “social withdrawal may be more of an automatic response than a voluntary or conscious effort to reduce stress . . . [and] may not be recognized by the stressful individual as a coping strategy” (Repetti & Wood, 1996, p. 196). Using daily diary studies of couples, Bolger, Zuckerman, and Kessler (2000) showed that the most effective social support was that which was not

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even recognized by the recipient. Further, Compas et al. (1996) also point out that some initially conscious behaviors can rapidly become relatively unconscious or reflexive if one has habituated to a situation. Thus, adaptation may involve unconscious, semi-conscious, and conscious thoughts and behaviors in a complex dynamic.

Coping as Personality Traits Early coping studies asked “How do people differ in their responses to a particular type of stress?” and grouped individuals into different adaptational types or coping styles. A very early example of this is a study that characterized different ways of adapting to retirement (Reichard, Livson, & Peterson, 1962). In this qualitative study, retirees were classified into five different types. “Rocking-chair men” were content to sit in their rocking chairs on the porch, passively watching the world go by, whereas the “armored men” took a very active stance toward life—for example, by getting involved in community activities or going on trips— and in general were overactive, primarily to ward off anxieties. The “angry men” were extremely discontent, spending most of their time complaining about things, while another complaining group was labeled the “self-haters.” Finally, the “mature men” accepted themselves and had few regrets. From these descriptions, one can easily imagine that these men responded in these ways to most things in their lives, not just to retirement. Similarly, Wortman and Silver (1989) characterized four stable coping styles following bereavement. Surprisingly, there were individuals who never appeared distressed, while others could be classified as acute grievers, chronic grievers, and those who experienced a delayed reaction. Millon (1982) stated: “Personality styles characterize the more or less everyday manner in which people approach the events of their lives. It is these typical ways of coping . . . that may contribute to illness and the manner in which individuals deal with it” (p. 11). Based on earlier work by Lipowski (1970) and Leigh and Reiser (1980), Millon described eight ways in which individuals characteristically deal with health problems. Individuals who use the introversive style of coping tend to be “emotionally flat,” using a cognitive coping style called minimization. These individuals tend to ignore, deny, or rationalize their problems and are often quiet and untalkative. They can be oblivious to the implications of their illness and primarily wish to be left alone. In contrast, individuals using the cooperative style follow advice religiously, as long as they do not have to assume responsibility for themselves. They need care and reassurance and may see illness as a “relief.” People using the sociable coping style tend to be talkative, outgoing, and

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charming, although undependable. They are disinclined to deal with serious problems, viewing illness as a strategy to gain attention. Individuals who are highly motivated to regain their health are sometimes characterized as having a confident style. The sick role signifies a major threat to their self-image as independent and invulnerable. They are unduly concerned with status and may display arrogance and a disdain for others. A similar stratagem is the forceful style, wherein individuals are aggressive, hostile, and domineering. They are also unwilling to accept the sick role and forcefully attack the problem, sometimes to the extent of ignoring the seriousness of their injuries (e.g., by inappropriately exercising an injured limb or climbing stairs during a heart attack). Individuals using a respectful style may also see illness as a weakness and may want to conceal or deny problems. In contrast to the hostile style, these individuals are unduly responsible and conforming, becoming “model” patients. However, these people may have rigid routines and inflexible daily schedules, which makes coping with the disruptive aspects of illness difficult. Finally, individuals characterized by a sensitive style may be “longsuffering” and “self-sacrificing.” They may be difficult patients in that they are likely to reject reassurance and to complain a great deal. In some ways, this characterization of coping styles is preferable to simple approach–avoidance dichotomies (see below) in that it allows for a more complex description of the ways in which people behave in an illness situation. Such characterizations may also be clinically useful and do not necessarily entail the sort of pathology attendant upon descriptions based upon defense mechanisms. Nonetheless, most of these styles are described in ways inclusive of pathology—perhaps individuals who are coping well with physical illnesses do not come to the attention of clinicians. However, it is also possible that a clinician utilizing this schema may tend to “pigeonhole” people in inappropriate ways. Depending upon the sensitivity and skill of the staff, the same patient may be self-reliant or complaining, denying or compliant. In other words, strict personality approaches ignore environmental demands that may shape an individual’s behavior.

Coping as Perceptual Styles In contrast to psychoanalytic conceptions, the perceptual style approach to coping focuses less on how individuals deal with emotions and more on how they deal with information. The earliest typology was called repression–sensitization (Byrne, 1964). Repressers were defined as individuals who avoid or suppress information, while sensitizers were indi-

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viduals who seek or augment information. This dichotomy has appeared in the literature in many different guises, including nonvigilant–vigilant (Averill & Rosenn, 1972), selective inattention–selective attention (Kahneman, 1973), reducers–augmenters (Petrie, 1978), blunting–monitoring (Miller, 1980; Miller & Mangan, 1983), and rejection–attention (Mullen & Suls, 1982). Currently, the terminology most commonly in use is approach–avoidance (for a review of this construct, see Roth & Cohen, 1986). Lazarus et al. (1974) provided three major criticisms of the repression– sensitization typology. First, measures of repression–sensitization are highly correlated with anxiety. Second, there appears to be little consistency of perceptual style across situations. Finally, general measures of repression–sensitization do not predict actual coping behavior (Cohen & Lazarus, 1973), although situation-specific measures have been shown to be useful in particular circumstances (see Miller & Mangan, 1983). Further, one could argue that there are patterns rather than styles in how one processes incoming information. Horowitz (1976) and Lazarus (1983) have argued that individuals alternate between phases of denial and intrusiveness. Pennebaker, Colder, and Sharp (1990) refer to these types of coping theories as “stage models of coping.” For example, a violent trauma may first threaten to overwhelm the ego, and denial or blunting may serve a very useful purpose in protecting the individual. However, too much denial can prevent a person from taking appropriate action, as in the case of the middle-aged man with chest pains who runs up the stairs to prove that he is not having a heart attack rather than go to the emergency room. In the intrusive phase, images and memory come flooding back, as when combat veterans or rape victims experience flashbacks. Stroebe and Schut (1999, 2001) have proposed a Dual Process Model of coping, which proposes that individuals alternate between positive and negative appraisals, approach and avoidant coping, and so on. Each of these orientations has different goals, and both approaches may be necessary, depending upon the stage of the problem and the level of resources available. While some people have very sharp swings between denial and intrusion, others simply use denial as a way of maintaining hope. As Lazarus (1983) recounted, persons with terminal cancer may be planning the next year’s vacation on one day and crying the next because they know that they only have a few weeks to live. People may also vary in the extent to which they use approach or avoidance processes in different areas of their lives. In my dissertation on middle-aged men and women (from an earlier generation), I found that men very often used problem-focused coping at work and emotion-focused or avoidant coping at home,

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whereas women used opposite tactics (Aldwin, 1982a). Perhaps people use approach strategies in situations in which they have adequate coping resources and in which they feel comfortable in dealing with problems, and perhaps they are more likely to use avoidant strategies in situations with which they feel less comfortable. Thus, rather than coping styles per se, one could refer to approach–avoidance as coping modalities that are differentially used, depending upon the interaction or transaction between the person and the situation; only a few individuals may be consistently characterized by one or the other. Dichotomizing coping strategies into two broad modalities provides certain benefits. It is simple and elegant and can be used to classify a broad number of different strategies. Some have argued anew for dividing coping strategies into two or three broad categories (Amirkhian, 1990; Endler & Parker, 1990). However, this runs the danger of oversimplifying the construct. After all, if one is truly interested in understanding what constitutes efficacious coping, then knowing simply that someone “approached” a problem is insufficient. We would need to know the quality of that approach: Was it organized or disorganized, hostile, compliant, or assertive? When people avoided a problem, did they do so by going on a week-long drinking binge or by reading a book to get their minds off it for a little while? Further, as we have seen, approach and avoidance are not mutually exclusive categories. The conjunction of how they are used is undoubtedly critical. For example, one may blunt emotions by denying responsibility but still engage in problem-focused coping (Aldwin, 1991). Thus, the construct of approach and avoidance can be a useful informing organizing principle, but our understanding of coping should not be forced into such a procrustean bed.

Personality and Coping There is no doubt that personality influences both the appraisal of stress as well as the use of coping strategies within stressful situations (O’Brien & DeLongis, 1997; Watson, David, & Suls, 1999). In particular, individuals high in neuroticism (emotionality) tend to report more stressful events and hassles, and they are more likely to cope in ways that increase emotional distress, such as the use of alcohol or other drugs, denial, and so on. However, it would be a mistake to simply reduce stress and coping processes to personality traits. For example, using longitudinal data, Aldwin et al. (1989) showed that emotionality, life events, and hassles, while interrelated, nonetheless contributed independent variance to psychological distress. Bolger (1990; Bolger & Zuckerman, 1995) showed that personality influences coping but that coping mediates the relation-

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ship between personality factors such as neuroticism and psychological distress. In general, personality accounts for more of the variance in emotion-focused coping than in problem-focused coping (Hooker, Frazier, & Monahan, 1994; Long & Sangster, 1993). This is supported by Folkman, Lazarus, Dunkel-Schetter, DeLongis, and Gruen (1986), who assessed coping over five occasions. They found that emotion-focused coping was moderately stable, whereas secondary appraisal (and presumably problem-focused coping) was much more variable. Aldwin et al. (1996b) drew upon a transactional approach to examine the relationship between personality and coping. They suggested that there were feedback mechanisms that could either strengthen existing personality processes or set into motion others. For example, individuals who are high in mastery would be expected to use more problemfocused coping. Assuming that their use of this strategy was successful, this should reinforce perceptions of mastery. Similarly, those high in emotionality will be more likely to use strategies that reinforce and exacerbate emotional distress. However, a series of setbacks, or failures to cope successfully with problems, can reasonably be assumed to shake one’s beliefs in one’s own mastery, perhaps decreasing future mastery levels. Conversely, for individuals initially high in neuroticism who successfully resolve problems, it is reasonable to expect that their mastery and positive affect levels may increase and neuroticism decrease. Indeed, Mroczek and Kolarz (1998) found that positive affect increased with age, primarily among those who were initially high in neuroticism and subsequently decreased. Further, Fournier, de Ridder, and Bensing (2003) found that optimism decreased over time in multiple sclerosis patients.

SITUATIONAL DETERMINANTS OF COPING In contrast to personality theories, proponents of the situational determinant approach to coping argue that the types of strategies that individuals use to cope with problems depend on environmental demands. That is, the characteristics of different types of stresses “pull for” different types of solutions and coping processes. To take examples at random, the way in which an individual copes with the death of a spouse could be very different from the way in which that same person deals with the limitations imposed by rheumatoid arthritis or the strategies used in finding a new job after being laid off. Early studies often conducted in-depth observations and detailed empirical descriptions of individuals dealing with problems of particular interest such as disasters. The focus was on broad, general adaptive responses

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to a major life change or problem rather than specific behaviors in everyday situations. In some ways this is not dissimilar to psychoanalytic approaches in that such research typically involves the intense observation of small numbers of individuals and relies upon interviews and personal observations. It differs, however, in being empirically rather than theoretically oriented. That is, such researchers often did not try to develop a general model of human behavior that is applicable across a range of contexts and problems, but rather simply asked, “How do people respond to this particular stressor?” This approach has produced many classical works, including Wallace’s (1956) description of psychological responses to a tornado, Lifton’s (1968) study of the survivors of Hiroshima, and Erikson’s (1976) examination of the Boulder Creek disaster. Of course, this simple question generally evokes complex answers, and these authors in particular sought to identify general processes that give insight into human nature. There is a fair amount of evidence showing that individuals do respond in varying ways to different types of stressors (for reviews, see Folkman & Moskowitz, 2004; Mattlin et al., 1990). There are a number of ways in which situations can be categorized. One way is to determine whether the situation has already had harmful effects (such as a loss), has the potential for future harm (e.g., entails a threat), or has potentially positive outcomes (i.e., it can be seen as a challenge) (Brown & Harris, 1978; Lazarus, 1966; McCrae, 1984). Alternatively, a researcher can classify the stressors according to their content types, such as illness, death, interpersonal problems, or hassles (Billings & Moos, 1984; Folkman & Lazarus, 1980; Mattlin et al., 1990). The general research strategy is to ask individuals to relate multiple problems and compare coping responses across problems. Such studies are often longitudinal. For example, the Folkman and Lazarus study followed individuals every month for a year and asked them to relate problems each month. In general, individuals utilize coping strategies that are directed more toward the emotions in loss circumstances, such as illnesses or deaths, whereas coping strategies are directed more toward problems that are practical and interpersonal when threat or challenge appraisals are involved. Thus, individuals adapt their coping techniques to the demands of the situation. Pearlin and Schooler (1978) categorized stressors according to five major social roles: work, marital, parental, household economics, and health. They found that distinctly different coping strategies are used in different social roles. Strategies, such as disciplining a child, that are used in coping with parental problems are simply not appropriate in other social roles, such as difficulties with a supervisor at work. Further, even similar strategies may have differential effects across situations. For

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example, Pearlin and Schooler found that problem-focused strategies might relieve psychological distress with interpersonal problems but would have little effect at work.

COGNITIVE APPROACHES Cognitive approaches to coping are based on four assumptions. First, how an individual copes with a problem is largely dependent upon his or her appraisal of the situation. Generally, appraisal is considered to be a conscious evaluation of whether a situation is benign, threatening, involves a harm or a loss, or constitutes a challenge (Lazarus & Folkman, 1984). If a situation is benign, no coping is needed. Theoretically, a situation that is threatening or challenging will evoke attempts to solve or ward off the problem (problem-focused coping), whereas a situation that involves harm or loss will be more likely to evoke palliative coping, which attempts to decrease or assuage the negative emotions evoked by a stressor. Thus, in cognitive models, adaptation is conscious—that is, individuals appraise the type of problem and its severity and decide how to cope with problems based on prior experience. Second, cognitive approaches assume that individuals are flexible in their choice of coping strategies and modify their strategies according to the demands of the particular problem. That is, they assume some degree of situational specificity; individuals are not uniformly consistent in how they approach problems but rather take into account environmental contingencies. The term “coping styles” is anathema to such theorists, because it implies that coping is consistent—a function of personality— rather than a blend of personal preferences and environmental demands. Thus, cognitive theorists believe that one must tie any reports of coping strategies to a particular problem. The third assumption is that coping efforts include both problemand emotion-focused strategies that are directed at the problem and at the emotions, respectively. Cognitive theorists do not attempt to arrange coping efforts hierarchically. Although controlling the emotions might facilitate efforts to solve or manage a problem, it is also likely that solving or managing a problem satisfactorily is one of the best ways of managing emotions. There is now little doubt that individuals consciously seek to regulate their emotions (Stanton & Franz, 1999), which has some very interesting implications for theories of adult development. In psychodynamic theories, affect is automatically regulated by the ego via the unconscious mechanisms of defense. By contrast, in the cognitive model, the self is actively and consciously trying to manage both internal and external pro-

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cesses. As is shown in Chapter 16, this construct of self-determination in the management of stress has interesting implications for theories of adult development. Finally, cognitive theorists also do not assume a hierarchy of adaptiveness. Rather, they take an empiricist approach: The task is to identify which coping strategies are used in specific situations and the conditions under which the strategies do or do not promote positive adaptation. For example, rather than assume that denial is of necessity maladaptive, Lazarus (1983) described conditions under which denial can be a useful tool—for example, by allowing individuals to maintain hope in seemingly hopeless situations. It would be safe to say that the majority of coping researchers currently have adopted at least some aspects of the cognitive approach— that is, they rely upon self-descriptions of coping behaviors, generally in the form of checklists. However, many researchers, either implicitly or explicitly, continue to regard the use of coping strategies primarily as a function of personality, either by simply not specifying a target situation or by inadequately doing so (e.g., McCrae & Costa, 1986). And, indeed, the extent to which coping strategies are a function of both the person and the environment is a matter of some debate (but see Hooker et al., 1994). De Ridder and Kerssens (2003) designed a series of 20 vignettes to examine the relative contributions of personality and environment to coping, varying the ambiguity, social context, and type of concern. Basically, they found that the within-subjects variance was greater than the between-subjects variance. In other words, personality did influence coping—especially when it was considered in the aggregate—but people clearly varied their coping strategies in response to situational demands. The cognitive approach to coping has come under a great deal of criticism lately. Some have felt that the huge amount of effort going into the study of coping has yielded fairly little in the way of actual knowledge and advancement of our understanding of the adaptive process (Coyne & Racioppo, 2000). Others argue that coping almost always occurs in a social context and that the social dynamics of interaction have not been as well studied (Hobfoll, 2001). Some point out that studying coping only in problematic situations may yield equivocal results and that examining broader adaptive processes such as anticipatory or proactive coping may yield a better picture of adaptation (Aspinwall & Taylor, 1997; Greenglass, 2000). Yet others argue that we should pay more attention to positive coping (Folkman & Moskowitz, 2000; Frydenberg, 2002; Snyder, 2000), especially the importance of “making meaning” (Schwarzer & Knoll, 2003). Others argue that the specific strategies one uses may be less important than their efficacy (Gottlieb &

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Rooney, 2004; Zautra & Wrabetz, 1991). Thus, we will review some of the more recent theoretical approaches to coping.

MORE RECENT APPROACHES TO COPING AND ADAPTATION The past few years have seen a broadening and strengthening of the study of coping, with several new theoretical approaches. These can roughly be divided into five areas: broadening the range of coping to examine proactive and anticipatory coping, as well as management skills; positive coping and making meaning; elaborating on the social aspects of coping; religious coping; and coping efficacy. These newer approaches will be briefly introduced in this section; fuller treatment will be provided in those chapters dealing with substantive issues in trauma, health, and development.

Motivational Approaches to Coping Skinner and Wellborn (1994) have argued for a motivational approach to stress and coping. From this perspective, stress arises from threats to basic psychological needs, such as relatedness, autonomy, and competence. Coping is thus “an organizational construct that describes how people regulate their own behavior, emotion, and motivational orientation under conditions of psychological distress . . . [and] encompasses peoples’ struggles to maintain, restore, replenish, and repair the fulfillment of these needs” (p. 112). This theory is explicitly developmental in nature in that it differentiates between long-term and short-term outcomes. In the short term, coping serves to manage the individual’s engagement with the situation (as opposed to simply withdrawing from it), while the long-term outcomes refer to development in the personality, social, and cognitive domains. Not surprisingly, the notion of coping as emotion regulation has become more dominant in the child psychology literature (Eisenberg, Fabes, & Guthrie, 1997) and is addressed further in Chapter 14.

Broadening the Range of Coping Aldwin and Brustrom (1997), in their review of coping with chronic illness, noted that the use of coping strategies sometimes decreases over time. They argued that people develop routines to deal with chronic stressors that minimize the occurrence or severity of those stressors. For example, for chronic illnesses such as asthma, hypertension, or diabetes, developing routines for medications, diet, and exercise may help to pre-

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vent flare-ups of problems or delay the progression of these illnesses. When individuals are initially diagnosed with an illness, they may have to try a number of different coping strategies until they find a routine that works for them. So, the number of coping strategies actually decreases over time, both as a result of having fewer crises to deal with and also as a result of having identified which strategies are most effective. To the extent that these behaviors become routinized, they may no longer to considered active coping efforts but rather habitual ways of managing a chronic condition. Aspinwall and Taylor (1997) distinguished among coping strategies, anticipatory coping, and proactive coping. Coping strategies are active efforts to manage a stressful problem and the attendant negative emotions, while anticipatory coping are strategies used to mitigate an event whose occurrence is nearly certain (Folkman & Lazarus, 1985). For example, if one knows that a midterm examination is eminent, studying for this exam may decrease its perceived stressfulness and promote optimal performance. In contrast, proactive coping refers to more general “efforts undertaken in advance of a potentially stressful event to prevent it or to modify its form before it occurs” (Aspinwall & Taylor, 1997, p. 417). This includes five stages: 1. Resource accumulation. This might be called “saving for a rainy day.” As mentioned earlier, the definition of stress includes situations that tax or exceed an individual’s resources. Resources may include both material and social “goods” as well as temporal resources—in other words, not overscheduling oneself so that there is time to deal with unanticipated problems. Our lab has been working on developing a proactive coping scale (Kelly & Aldwin, 2001; Kelly, Shiraishi, & Aldwin, 2003). To obtain a cross-cultural prospective, we showed the scale to a Brazilian student in the lab. Looking at the items, which involved saving for a rainy day, doing preventive maintenance, and the like (see Table 7.4), she burst out laughing and said, “How American! You know what Brazilian proactive coping is like? You spend every night in the cafes, and then you have many friends to help you if something goes wrong!” Different cultures may have varying ideas of what types of resources are most important in coping with stress. 2. Identification of potential stressors. This involves the ability to screen the environment as well as to be sensitive to internal cues that something might possibly go wrong. Adolescents are particularly good at blithely ignoring the potential dangers inherent in a given environment or planned action, which may be one reason why they are so accident-prone. Many years ago, an undergraduate in our lab (now a fa-

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TABLE 7.4. Proactive Coping Scale Please indicate how frequently you do each of the behaviors in the following items on a scale of 1 to 5, where 1 = Never and 5 = Always. (If something is not applicable, please write in 0.) 0 = Not Applicable 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

I am saving toward a major purchase like a house or college tuition. I keep an emergency kit in my car. I have annual physical exams. I keep an eye out for problems in the neighborhood. I ignore noises I don’t understand in my car. I balance my checkbook. I put money away for retirement. I run out of gas in my car. I am late for appointments. I feel like I’m never caught up. I plan my vacations months in advance. I am late paying bills. I don’t get involved in my friends’ problems. I am aware of my environment and watch for potential dangers. I do school/work assignments the day before they are due. I only go to the doctor when I am sick. I find it difficult to set aside money for emergencies. I don’t want to hear about my kid’s problem unless it’s really important. I try to be aware of my partner’s needs before problems arise. I get my teeth cleaned. I go from crisis to crisis. I change the oil in my car. I keep an eye on one of my older neighbors. I floss my teeth. I carry a credit card balance. I exercise. I believe people should take care of their own problems at work. I childproof my house when children are over. I get my work done well ahead of time. I do better when I don’t try to plan things out.

______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

mous cognitive neuroscientist) once recommended driving at 80 miles an hour on rural Hawaiian roads during a trip to the Western Psychological Association meetings. He was correct in that, physically, the road was engineered well enough to accommodate such speeds, in terms of width, smoothness of the surface, and being banked on curves. However, there were social hazards—many slow farm vehicles, hidden driveways, and the like—that made such a plan highly dangerous. This is undoubtedly why youths under the age of 25 are not allowed to rent cars in Hawaii! 3. Initial appraisal. Once having identified a potential problem, ini-

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tial appraisal processes come to the fore, in which the individual tries to understand the potential import of the situation and its likelihood of occurrence. I have often been impressed by the ability of mothers of young toddlers to keep an eye on potential hazards resulting from their children’s actions, which allows them to respond extremely quickly if real problems arise. 4. Initial coping efforts. Having identified a potential problem, one can take action to try to forestall it. For example, my colleagues in Boston once sent out samples of stored blood, frozen using liquid nitrogen, for analysis in a colleague’s lab at the University of California at Davis. I sent an e-mail to my Davis colleague that the samples had arrived but did not receive a reply. After a couple of hours, I decided to track down the package, as I was worried about its not being properly stored. This turned out to be a fortuitous strategy, because the package had been misaddressed and put aside by the secretary to be dealt with at a future date. Luckily, we were able to track down the package and it was duly rescued unharmed. 5. Elicitation and use of feedback. The fifth and final stage involves determining whether the event actually developed, whether or not preliminary efforts were effective, and what was learned about the stressor. In the example just cited, my preliminary effort (an e-mail to a colleague) did not receive a response, and thus I was worried that this was not effective and checked to see if the event (the package being mislaid) had actually developed (it had). Luckily, the more serious problem, damage to or destruction of the samples, was averted. I learned that, under some circumstances, having a touch of OCD (obsessive–compulsive disorder) is not necessarily a bad thing! Schwarzer and Knoll (2003) proposed a slightly different schema. They identified four types of coping—reactive, anticipatory, proactive, and preventive. Reactive coping is used in dealing with a past or present stressor, while anticipatory coping is used to deal with a pending threat that is likely to occur in the near future. However, they distinguish between preventive and proactive coping. Preventive coping is similar to Aspinwall and Taylor’s proactive coping, but Schwarz and Knoll (2003, p. 396) added a personal growth dimension to their conception of proactive coping. “Proactive coping reflects efforts to build up resources that facilitate promotion toward challenging goals and personal growth. Coping becomes goal management instead of risk management. Individuals are not reactive but proactive in the sense that they initiate a constructive path of action and create opportunities for growth.” In other words, going to college to escape a poverty-stricken life could be seen as proactive coping. It is not dealing with any particular threat but rather a

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reorganization of one’s goal structure in order to minimize or avoid certain types of problems. In doing so, of course, one may face a whole host of new problems, but, within a specific goal context, they may be appraised as challenges rather than undesirable stressors. Several other researchers have started combining motivational elements or goal orientations with coping in developmental frameworks, which will be reviewed in Chapter 14.

Meaning Making People often seek to find some sense or meaning in the midst of highly stressful situations. “Making meaning,” also called cognitive reframing, involves trying to make sense of the problem. It is generally considered to be a positive strategy and can be characterized as “looking for the silver lining” or as trying to find benefits in a problem. Some researchers have suggested that making meaning may be most often used in coping with extreme stressors, such as trauma (Mikulincer & Florian, 1996) or major losses (Wortman, Battle, & Lemkau, 1997). Cognitive reframing may include a reorganization of existing cognitive–motivational structures or a reappraisal or reinterpretation of the event. For example, a pre-med student who has done poorly on an examination may interpret this as a “wake-up call” and redouble his or her efforts; others may decide that medical school wasn’t really what they wanted to do and be secretly relieved that now they can switch to a major in something they would much prefer to do. Folkman and Moskowitz (2000) differentiated between situational versus global meaning making. They argue that situational meaning making is more of an appraisal processes but one that is nonetheless related to coping. Coping by infusing meaning into a situation is related to positive affect. In contrast, global meaning refers to more fundamental assumptions about the world. Taylor (1983) identified three dimensions of adaptation: meaning, mastery, and self-enhancement. Global meaning making may be most evident during under conditions of extreme trauma or severe loss, and is addressed further in Chapter 12. This search for meaning may be an extremely painful process and associated, at least initially, with greater distress (Lieberman, 1996; Wortman et al., 1997), but it may also set the stage for posttraumatic growth (Aldwin & Sutton, 1998; Tedeschi, Park, & Calhoun, 1998). Not surprisingly, then, there is contradictory evidence in the literature as to the positive or negative effects of making meaning. Davis, NolenHoeksema, and Larson (1998) differentiated between sense making and benefit finding. Sense making refers to finding a reason (which may be positive or negative), while benefit finding is more generally positive.

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Tennen and Affleck (2002, p. 401) argued that benefit reminding is a coping strategy in and of itself. “Benefit reminding as a coping strategy is conceptualized as an effortful, more or less frequent use of benefit cognitions to ease the stressful impact of a situation.” For example, a parent whose child was seriously injured might keep repeating: “It could have been worse. At least he’s alive.” Park and Blumberg (2002) found that meaning making mediated the impact of a writing intervention in individuals with trauma. Over time, it decreased stress appraisals of the situation and reduced intrusive thoughts. The importance of meaning making as a coping strategy is further explored in Chapter 8.

Social Aspects of Coping The past decade has seen a growing recognition that coping is not simply an individual endeavor. In other words, coping does not occur in a (social) vacuum. As one group of researchers put it, “Even the Lone Ranger had Tonto” (Dunahoo, Hobfoll, Monnier, Hulsizer, & Johnson, 1998). Lepore (1997) noted that stress—especially chronic stress—almost always impacts not just on the individual but upon his or her family. O’Brien and DeLongis (1997) argued that how an individual copes can facilitate the coping of others in the family, or it may interfere with or restrict it. For example, providing social support, whether in the form of instrumental action, advice, or emotional support, may help the other member of the dyad cope with a problem. But all too often there is a mismatch between the coping strategies used by couples. For example, in dealing with the chronic or life-threatening illness of a child, husbands often prefer to suppress emotional reactions and actively try to discourage their spouse from expressing emotions. This leads them to suppress their own distress, which, over time, can make them feel isolated and alone and lead to marital distress (Gottlieb & Wagner, 1991). Further, individuals may have to choose between strategies that make them feel better and those which make their spouse feel better. For example, Coyne and Smith (1991) examined coping in dyads in which the husband had had a heart attack. If the wives coped in such a way as to minimize problems, the husbands were less distressed but the wives were more distressed. But if the wives coped to decrease their own distress, that of their husbands increased. In general, there appears to be a “catch-22”—confrontive coping and expressing emotional distress tend to evoke withdrawal and avoidance on the part of the spouse, which in turn increases destructive or maladaptive coping such as wishful thinking or rumination, often resulting in increased emotional distress. However, suppressing emotional distress, especially because one feels that the

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spouse is not supportive, also leads to increasing distance and marital strain. O’Brien and DeLongis (1997) argue that individuals—especially those under chronic stress—need to use relationship-focused coping. This consists of two general strategies: empathic coping and compromising. In general, the use of empathic coping is associated with less distress on the part of both members of the dyad. A good example of empathic coping is provided in Preece and DeLongis (2005). In one of their studies, an older man was the primary caregiver to his wife, who had Alzheimer’s disease (AD). One of their favorite activities was the daily bath he gave her. However, as she became more confused, she no longer consistently recognized him and became very distressed when he tried to bathe her. Rather than forcing the issue, this man understood that being bathed by a man whom she didn’t recognize was distressing to her; he arranged for a female home health aide to come in and bathe her, which his wife gladly accepted. This man was wise enough to put aside his own feelings of hurt and rejection (one of the most difficult aspects of caregiving for an AD patient is when they no longer recognize you) in order to look at the problem from his wife’s perspective and come up with a solution to the problem. The strains of coping with chronic stress, however, may make it more difficult to engage in adequate relationship coping. The “cost of coping” (Lepore, 1997) may leave fewer resources to deal with one’s spouse’s distress—or relationship problems in general—which may help explain the very high rate of divorce in families undergoing serious chronic stress, such as having a severely handicapped child. Compromise is another important strategy in relationship coping, but it has yet to be studied extensively (Preece & DeLongis, 2005). Clearly, much more work is needed in the area of dyadic coping.

Religious Coping As a graduate student working on the Berkeley Stress and Coping Project, I volunteered to analyze the “other” responses from the first administrations of the Ways of Coping Checklist for its revision. The primary coping response that was missing from this inventory was the use of prayer. As is common knowledge, many people pray when confronted with serious problems. From reading the transcripts of the interviews, it was clear that the use of prayer was complex. Sometimes individuals used prayer as a source of problem-focused coping (e.g., asked for healing or for some other type of material aid), but sometimes it was emotion-focused (as when people simply found prayer comforting). At

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other times, it clearly involved an element of social support. For example, people would take comfort in knowing that others in their congregation were praying for them or their loved ones. Others simply saw their deity as someone they could talk to about their problems. For example, one woman, when asked who she spoke with about her problem, said “Jesus.” When questioned further, she said that Jesus was the only one with whom she had spoken. This created a coding problem—it hadn’t occurred to us to include “deity” as a category under social support! Pargament, Koenig, and Perez (2000) hypothesized that religious coping has five key functions: meaning, control, comfort/spirituality, intimacy/spirituality, and life transformation. All religions offer a framework for the understanding and interpreting of events, whether one is trying to understand God’s will or how karma or kismet is affecting one’s life. Further, religion can provide at least the illusion of control in the face of uncontrollable circumstances. Taking comfort in “being in God’s hands” or taking refuge in Allah or the Lord Buddha can provide a sense of relief and peace even in extremely stressful circumstances. Religion may also foster intimacy or a sense of comradery with others. In many ways, a religious community is a ready-made social support network. Most religions provide some sort of social safety net. Mormons divide their community into wards that provide material and emotional support to distressed members of their community; donating to the poor is one of the five pillars of Islam; and sangha (community) is one of the three pillars of Buddhism. Finally, religion can have the power to transform individuals’ lives. There are countless examples of epiphanies in all of the world’s religions; 10-step programs are based upon Jung’s initial advice to use stressful times as a way of opening up to the divine. Pargament and his colleagues (2000) have tried to assess these different functions of coping. During the past decade, a number of studies of religious coping have been published (for a review, see Harrison, Koenig, Hays, Eme-Akwar, & Pargament, 2001). The prevalence of religious coping has been studied primarily among clinical or hospitalized samples. Among these groups, the use of religious coping is quite high, with estimates ranging from 60% to nearly 90%. In general, the use of religious coping is associated with better mental health, but more ambivalent results have been found with physical health. It would be a mistake to think that religious coping is uniformly beneficial, however. Pargament et al. (2000) found that there was a negative aspect to religious coping. In particular, feeling as if God had abandoned them, was punishing them, or that they were being judged by others in the congregation not only led to worse outcomes but actually

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seemed to hasten death among seriously ill patients (Pargament, Koenig, Tarakeshwar, & Hahn, 2001).

Coping Efficacy Finally, the other major trend is coping research is the recognition of the importance of coping efficacy. In some ways, the choice of coping strategies may be less important than how well one executes that strategy. For example, Aldwin and Revenson (1987) showed that there was an interaction between efficacy and problem-focused strategies. Individuals who used relatively few coping strategies but who thought they had solved the problem were least psychologically distressed. Those who had used relatively few problem-focused strategies but who thought they had mishandled the problem were most distressed. Similarly, those who used interpersonal negotiation effectively were not distressed, but those who used a lot of interpersonal negotiation to no avail were extremely distressed.

SUMMARY Coping is defined as the use of strategies for dealing with actual or anticipated problems and their attendant negative emotions. While individuals actively attempt to handle problems, their emotional responses and strategies may not always be fully conscious. The social and cultural environment can influence both the appraisal of stress and the use of coping strategies in both direct and subtle ways. Thus, coping is an overdetermined phenomenon. During the past decade, the field of coping has expanded beyond the notion of an individual coping with one specific problem. Rather, it is now clear that individuals actively work in ways that either increase or decrease the occurrence and prevalence of stress in their lives. Further, they do not cope in a social vacuum. While we have known for decades that social support is important for coping, we are just now understanding that how an individual copes is facilitated or constrained by the coping of others in the environment. Coping has effects on others in the environment—what is helpful for the individual may create more problems for the spouse or children, and vice versa. The importance of meaning has come to the forefront of the field of coping, although many problems in conceptualization and measurement still need to be worked out. Finally, coping has also moved beyond the individual in that it is now understood to possibly involve the transcendent. Individuals can and do use their relationship with the religious community and their conception

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of a higher power to find meaning and even transform their lives. However, even the use of religious strategies is not necessarily an unalloyed blessing, as it were. In other words, coping affects adaptation in extremely complicated ways. It would be wonderful if the world were simple enough that psychologists could make recommendations such as: engage in instrumental action and all your problems will be solved—or, trust in the Lord and all will be fine. But it simply is not that easy. Coping involves adaptational costs, and it constrains and is constrained by the social environment. As we will see in Chapter 10, just trying to solve the problem does not always work. Further, assessing coping strategies used by individuals presents unique challenges, and, as we shall see, no one scale attempts to measure all of the facets of coping.

STRESS, COPING, Measurement of Coping ANDStrategies DEVELOPMENT

CHAPTER 8

Measurement of Coping Strategies

T

he most controversial issue in the field today is how to assess coping. While nearly everyone agrees that coping is a (or even the) crucial variable in understanding the effects of stress on health, nearly everyone disagrees on how it should be measured. I think this is due to the fact that we are in the midst of developing a new technology in psychology and the social sciences. Traditionally, psychology has relied upon three basic techniques. With the first technique, experimental or laboratory-based research, the stimulus and the response are clearly defined and measured in a specified or controlled setting. The second technique, personality research, has traditionally relied upon “paper-and-pencil” tests of personality (and values), in which individuals self-attribute characteristics (e.g., “I am usually kind and patient”) or state various preferences indicating values (e.g., “I would prefer to go sea kayaking rather than read a book”). In personality research, psychometric properties such as internal and crosstime reliability are critical, and external validity is most often tested against other paper-and-pencil instruments. The third technique, qualitative research, studies what people actually think and do in real situations and has been primarily used by anthropologists, qualitative sociologists, and clinicians. For classic examples of this kind of work, see Coles (1977), Erikson (1976), or Lifton (1968). These researchers con127

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duct field studies by interviewing people and relying upon their own insight into the culture or processes, or various coding techniques, to make sense of this information. Recently, however, there has been a substantial increase in qualitative research, as reflected in the establishment of new journals devoted primarily to qualitative research. In stress research, we ask individuals for standardized self-reports of events that they experienced, which, as we have seen, has involved many problems in reliability and validity. In coping research, we ask people to tell us not only what they did, or how they behaved, in a particular circumstance, but also what they thought and how they handled their emotions, using a standardized format. In other words, we are combining two different techniques, borrowing from both personality research and qualitative field studies, and exactly how one goes about constructing these measures and evaluating their reliability and validity has been largely a matter of trial and error, although I believe that the second and third generations of coping scales are in many ways substantial improvements over some of the original measures. In many ways, the assumptions underlying the two techniques and their goals conflict, as do the research strategies. Hence the controversy. There are several basic (albeit related) debates that fuel this controversy. First, should we assess coping styles, which are thought to be stable characteristics of individuals, or coping processes, which are fluctuating strategies that change in response to demands by the person or the environment? Second, should the content of items be general enough to apply to a variety of situations, or should they be specific to particular kinds of situations? Third, do we want very rich, complicated descriptions of coping strategies (which are often psychometrically messy), or should we try to identify simplifying dimensions that are thought to underlie more complex characterizations and that are psychometrically much more satisfying (i.e., approach–avoidance)? Fourth, should we use ratings for scale items that assess coping effort or simply dichotomous items to indicate whether or not a particular coping strategy was used? Finally, several new issues have arisen in the literature. These include the stability of the factor structure of coping measures—a particularly thorny issue. Further, the accuracy of retrospective accounts of coping of been challenged, with some asserting that experience sampling is a superior technique. Finally, several studies have begun to examine narrative or qualitative ways of assessing coping, while others have focused on particular types of coping strategies, for example, the use of counterfactuals. This chapter addresses each of those issues in turn. In addition, Appendix 8.1 lists many of the various coping inventories currently in use, grouped according to the typologies delineated in Chapter 9.

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COPING STYLES VERSUS COPING PROCESSES The study of coping is rooted in the widespread observation that there are individual differences in how people react to and deal with stress. Since Stouffer’s (1949) early study of American soldiers and combat fatigue, now called posttraumatic stress disorder, researchers have known that some people simply do not have the resources to deal with major trauma and that they therefore succumb to psychiatric disorders very quickly under stress. For example, nearly one-third of combat casualties in World War II were psychiatric in nature (Friedman, 1981). Since then, the search has been on to identify the person and environmental factors that lead to adverse stress reactions, which can be divided into three basic (and often conflicting) orientations. Clinical and personality psychologists focus on the personality factors associated with vulnerability (or resilience) to stress. These are assumed to be stable characteristics of the individual and are often referred to as coping styles. In contrast, sociologists and social psychologists are more likely to examine the ways in which the environment is organized that can lead to vulnerability or resilience on the part of individuals, that is, structural barriers in accessing resources. The transactional or process approach seeks to combine these two orientations, and posits a dynamic transaction between the person and the environment (see Chapter 7). In other words, coping is thought to vary within individuals, depending upon the situational context, and within contexts, depending upon individual differences. Coping strategies are hypothesized to be complex and dynamic, changing in response to their effects on the environment. What can be confusing is that, methodologically speaking, these approaches at first glance appear to be very similar. Most rely on “paperand-pencil tests,” questionnaires that list a variety of coping strategies. The measurement distinction between these points of view lies primarily in the accompanying instructions on the coping questionnaire to the respondents, a point often overlooked by many researchers. As we have observed, coping styles or trait approaches assume that there are stable characteristics of the individual that account for differences in reactions to stress. Thus, these approaches traditionally use a standard personality trait format of self-descriptors to infer coping styles (Haan, 1977). More recent approaches ask the respondent what he or she usually does to handle problems without referring to a specific problem (Endler & Parker, 1990, 1994). Thus, the coping style approach assumes consistency within individuals across stressors, without regard to environmental demands. Note that some inventories such as the COPE (Carver, Scheier, & Weintraub, 1989) have alterna-

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tive instructional modes that enable researchers to assess coping styles or processes. In contrast, sociologists such as Pearlin and Schooler (1978) have assumed that the choice of coping strategies is primarily a function of the social context, specifically role demands. They may ask questions such as “How do you cope with problems with your spouse?” or “How do you cope in raising your children?” Thus, social approaches link specific role-related behaviors to role strains, for example, trying to establish better communications with a spouse or restricting privileges when a child is disobedient. This approach assumes consistency within role domain but inconsistency across roles. The process approach does not assume consistency either within or across situations or roles. Rather, it asks respondents to recollect what they did in a particular stressful episode, usually occurring during the past week or month, although some researchers simply tie the coping to a life event during the past year (e.g., Moos, Brennan, Fondacaro, & Moos, 1990). Some researchers use a diary approach, which asks respondents to fill out questionnaires each evening concerning problems during the day (Stone & Shiffman, 1992), or by using experience sampling techniques (Stone et al., 1998). Process approaches permit examination of both the person and the environmental influences on coping strategies. There are a number of methodological problems with all of these approaches toward assessing coping. Approaches based upon coping styles make three assumptions. The first is that generalized self-descriptors of coping styles translate reliably into actual behaviors in a specific situation. This notion has been challenged by Lazarus and his colleagues. For example, early work by Cohen and Lazarus (1973) demonstrated no relationship between trait measures of repression–sensitization and actual approach–avoidance behavior in coping with surgery, although strategies that ask individuals to describe more specific approach–avoidance behaviors in medical settings may prove a little more accurate (Miller, 1980). There is also some suggestion that people high in neuroticism may use more emotion-focused coping in stressful circumstances (Bolger, 1990). However, there is as yet no indication that coping strategies in general may be mapped onto specific personality traits in a one-to-one fashion. To get around this, some researchers will ask how a respondent generally copes with problems, which leads us to the second assumption. The second assumption is that individuals do cope consistently with different types of problems. The handful of published studies that have examined coping across time have generally found rather modest correlations, mostly in the .20s and .30s (Fondacaro & Moos, 1987; McCrae, 1989), and studies that look for situational differences in coping behav-

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iors always find them (e.g., de Ridder, 1997; Folkman & Lazarus, 1980; Mattlin, Wethington, & Kessler, 1990). Further, how individuals cope with a given problem such as exams (Folkman & Lazarus, 1985) or breast cancer (Heim, Augustiny, Schaffner, & Valach, 1993) also changes over time, depending upon the varying situational demands. Ogrocki, Stephens, and Kinney (1990) examined the relationship between state (process) and trait coping measures. In this study of caregivers of relatives with Alzheimer’s disease, respondents were asked to state how they usually coped with caregiving problems in two settings: at home and at the nursing home. State–trait measures were moderately correlated, ranging from .25 to .47. Not surprisingly, the trait measures were more strongly related to a global measure of well-being. However, examining across situations, the state measures were more strongly correlated with each other than were the trait measures. This suggests that the state measures may be more accurate assessments of coping behaviors than the trait measures are. Carver and Scheier (1994) also found that coping style and coping process measures were only weakly related to one another, although Ptacek, Smith, Espe, and Raffety (1994) found that averaging daily measures across time did correlate reasonably well with retrospective measures, with stability coefficients ranging from .47 to .58. Further, emotion-focused coping may be more consistent than problem-focused strategies (Folkman et al., 1986). Nonetheless, measures of coping styles tend to be only weakly correlated, at best, with measures of coping used with actual problems (Todd, Tennen, Carney, Armeli, & Affleck, 2004). It is true that persons routinely respond to questionnaires that ask them how they usually cope with problems, which would seemingly be prima facie evidence for the existence of coping styles. However, there are marked concerns over whether individuals’ generalized descriptions of coping styles accurately describe coping behaviors in specific situations (Folkman & Lazarus, 1980; see also Carver & Scheier, 1994). Anecdotal evidence leads many researchers to suspect that persons who believe they do one thing actually do quite another. Individuals may overestimate their own performance, thinking that, in general, they only use strategies that they think are adaptive. One 80-year-old respondent could not understand why I bothered to study how individuals cope with stress. “Everyone knows,” he said, “that what you do is sit down and analyze the problem and then solve it calmly and rationally.” At that point, his wife of 50 years burst out laughing and said, “You’ve never done that in your life!” Sadly enough, when this man’s wife died a few months later, his primary coping behavior was first to engage in a mad whirlwind of activities to ward off depression (he took six courses concurrently at a local junior college), and then, when that failed, he went

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to bed for several months with a bottle of alcohol and had to be hospitalized. Not all problems are amenable to rational analysis, and how individuals think that they usually cope could be very different from their actual behavior under stress. Process approaches attempt to solve this problem by asking the respondents to recollect a very specific (and preferably very recent) episode and to recount their cognitions and behaviors in coping with that one episode. The assumption is that this is a more accurate technique that minimizes distortions in self-presentation. Using this technique, people have clearly been shown to modify their coping strategies in response to different types of problems (Billings & Moos, 1984; de Ridder, 1997; Folkman & Lazarus, 1980; McCrae, 1984; Mattlin et al., 1990). Manifestly we use different strategies, depending upon situational demands. For example, simple reflection on our own behaviors reveals that how we deal with a small child crying is very different from the strategies used to study for an exam. However, reliance upon a recent stressful episode as the mechanism for evoking self-reported coping cognitions and behaviors unleashes another set of difficulties, with one of the primary difficulties being diversity in the types of problems that evoke the behavior. For example, in one survey that we did the types of problems reported by the respondents ranged from a tiff with a boyfriend to the murder of grandchildren in a restaurant robbery (Aldwin & Revenson, 1987). Trying to examine individual differences in coping strategies in this context is inevitably confounded with variability in stressors. One can mitigate this problem by controlling for situational characteristics, such as perceived stressfulness of the problem, general type of problem (e.g., relating to health, bereavement, work, or interpersonal conflict), or appraisal characteristics such as a threat to well-being or actual harm already done (McCrae, 1984). In doing so, however, there is still the problem of variability in the stimulus. Even with a broad category such as work stressors, there may be distinct dissimilarities in problem characteristics that may affect the choice of coping strategies. Dealing with an irate supervisor, for example, may require strategies different from those used in dealing with a broken machine. One way of getting around this difficulty is to study individuals who are all undergoing a similar stressor, such as surgery or a specific chronic illness. A favorite stressful context for stress and coping re searchers is midterms or finals, for the obvious reason that in a university setting it is easy to find subjects. Using this technique, researchers have shown that coping is clearly a fluid process, influenced by personality characteristics (Bolger, 1990; Friedman et al., 1992; Long & Sangster, 1993), situational demands (Folkman & Lazarus, 1986; Heim et al.,

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1993; Mattlin et al., 1990), and even the social and physical characteristics of the setting (Mechanic, 1978). De Ridder (1997, 2000) has published some very elegant work using an experimental paradigm that presents individuals with different scenarios that systematically covary stressor characteristics such as the controllability of the problem. This has allowed her to examine both how coping strategies shift across problems and the relative contribution of personality and environment to the use of coping strategies. In general, she finds that stressor characteristics account for more of the variance in coping strategies than personality does, although personality clearly influences the choice of strategies across situations. The key criterion in determining whether to use a process or style measure must be the research question at hand. If one wishes to know how well a student is going to perform on a specific test, then knowing how the student prepared for that particular test (a process measure) is critical. However, if one is trying to predict a student’s overall gradepoint average, knowing how the student usually copes with tests (a style measure) might be better. Similar to the debate between life events and hassles research, process measures are better for predicting immediate outcomes, while style measures may be better for predicting long-term outcomes (e.g., Tennen, Affleck, Armeli, & Carney, 2000). Another way in which researchers have recently addressed this problem is to develop coping scales that are specialized, either in terms of the situations to which they apply or in terms of the strategies that are measured. This undoubtedly accounts for the proliferation of scales that are specific to particular illnesses (see Appendix 8.1). Asking people what they usually do to solve the discrete problems presented by chronic illnesses is a way of trying to bridge these two approaches, as is focusing on highly specific strategies such as the use of counterfactuals in traumatic situations. My particular preference is for process measures, given my mistrust of people’s generalized descriptions of their behavior. A good example of this is that depressed persons often present themselves and their situations as helpless and hopeless. However, when one examines actual strategies used in stressful situations, depressed people have been shown to use more strategies than those who are not depressed (Coyne, Aldwin, & Lazarus, 1981; Folkman & Lazarus, 1986) although it’s quite possible that they are ineffective in their coping strategies (which is why they try so many different types of strategies). I certainly would not try to predict who would come down with a serious chronic illness from an examination of only one episode of coping 10 years earlier, given my belief in the variability of coping across situations. Thus, the issue devolves, to a certain extent, upon matters of

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personal and disciplinary preference and, as always, the specific question that a researcher has in mind.

RETROSPECTIVE VERSUS EXPERIENCE-SAMPLING APPROACHES Recent years have seen an interesting twist to the coping styles versus process controversy. Although process-oriented researchers have argued that asking individuals how they coped in specific situations yields more accurate data than general questions about coping styles, some have argued that even grounding coping reports in specific situations is inaccurate because it is retrospective. Coping process measures often ask individuals to identify a specific problem, but that problem could have occurred days, weeks, or even months earlier (or, in the case of trauma researchers, sometimes years). All of these time scales are subject to retrospective bias—that is, individuals may not remember precisely what they did, or they may remember their coping efforts as more positive (or negative) than they actually were. Further, a critical problem with coping data based on situation reports is that we are seeing people at their worst. In any given survey, about a third of the people do not report having a problem. This could be because they didn’t actually have a problem (so we only end up studying people who are unhappy) or because they didn’t consider their situation a “problem.” In a pilot study we did that compared survey responses with interviews, we found that we could reduce the “no-problem” percentage to 10% (Aldwin, Sutton, Chiara, & Spiro, 1996). Many of the people who reported having no stress on a questionnaire did reveal problems in an interview setting, in part because we used prompts but also clearly because there were a process of cognitive restructuring. For example, some of the men who reported on questionnaires that their lives were “completely fine, no problems” revealed in the interviews that they were the primary caretakers for terminally ill wives. These men were actively providing both emotional and instrumental support for their wives, doing housework, overseeing medication schedules, taking them to the doctors, and so forth. They could report their anguish and worries for the future in the interviews and also provided information on strategies that they used for managing their emotions, usually distracting themselves with chores, work, or gardening. However, if the wife’s health had been stable in the past week (the time period in question), they did not consider themselves to have “problems.” These men managed to dissociate their public self-presentation from their private self. By defining themselves as not having “problems,” they

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were using social conventions to regulate their self-presentation (and probably their emotions, as well). There is also a legitimate concern that people who have solved a problem successfully may fail to even (retrospectively) recognize it as a problem. For example, once I pilot tested a self-report stress and coping instrument in a federal housing facility for the elderly. One 80-year-old man asserted that he had had no problems whatsoever in the past month even though he was manifestly in a rather frail condition. A social worker overheard his firm denials to my gentle probings for a problem and said, “Why, Mr. So-and-so, don’t you remember? You had a big fight with your wife last week, and she threw a knife at you!” To which the elderly gentleman replied, “Yes, but she missed me, so it really wasn’t a problem!” (Aldwin, 1992). Thus, an alternative approach is to use ecological momentary assessment (EMA) or experience-sampling (ES) approaches. In this type of approach, individuals are given watches or Palm Pilots and beeped either at specific or random times during the day, and then report whether or not they are having a problem, how they are coping, and what they are feeling. Stone et al. (1998) have argued that even daily retrospective coping approaches are inaccurate when compared to this method, as only about half of the variance is shared between these two types of measures. In truth, however, the correlations between these two ranged from .7–.8, and, as several authors have pointed out, if there is a disagreement between two measures, it is difficult to determine which one is more accurate. As Folkman and Moskowitz (2004) point out, experience sampling designs may also have problems. Subjects were asked repeatedly to recall their coping efforts, which may have resulted in some coping not being reported, perhaps because the participant thought he/she already had reported it. Further, the momentary focus may result in reports of very concrete, discrete events thereby missing ongoing problems or more abstract, complex problems. The momentary assessments might also elicit literal reports of specific thoughts and actions, and miss the broader conceptualizations of coping that are better perceived with the benefit of some retrospection such as those that involve finding meaning. (pp. 749–750)

Further, because one must minimize the reporting burden in EMA designs, the measurement tends to be highly abbreviated and often consists of short one-item “scales” of questionable reliability. Nonetheless, EMA designs are much better at capturing fluctuations or variations in stress, coping, and affective states, and they may relate better to such health

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problems as pain, whose levels may also fluctuate (Tennen et al., 2000). EMA and other daily process approaches may also be difficult to analyze, which is discussed further in Chapter 9.

FACTOR STRUCTURE INSTABILITY In response to the advocates of process-oriented coping instruments, researchers who prefer the simplicity of coping styles argue that the process measures of coping are simply too psychometrically messy. Specifically, several researchers (Amirkian, 1990; Coyne & Racioppo, 2000; Endler & Parker, 1990; Somerfield & McCrae, 2000) have criticized the most generally used process measure, the Ways of Coping Scale (WOCS) (Folkman & Lazarus, 1980; Folkman et al., 1986) for having an unstable factor structure and poor internal reliability on the subscales. Schwarzer and Schwarzer (1996) have pointed out that all of the extant scales have problems with the stability of their factor structure—thus, the problem is not limited to the WOCS. According to this line of reasoning, any change that appears to occur across situations using process measures of coping is primarily due to the unreliability of the instrument rather than to any important con tribution of the situational context per se. By focusing only on approach– avoidance coping, Amirkian (1990) as well as Endler and Parker (1990) have been able to demonstrate that their measures of coping styles are psychometrically superior to process measures and thus have argued that trait measures are generally superior to process measures. The problem with this line of reasoning is that these researchers are taking the criteria for what constitutes good personality instruments and inappropriately applying them to field instruments. Personality traits are supposed to tap stable characteristics of the individual. Thus, these traits should have high test–retest reliability. Further, personality measures assume some inaccuracy in self-description and are thus highly redundant, using several different items to tap one construct, which in turn generates good internal reliability. Process instruments designed to be used in a field setting, however, are specifically designed not to be stable. These instruments are meant to tap variability and change, making them almost by definition unreliable. Further, a certain amount of vagueness in the wording of items was done purposefully so that the items would be applicable across a variety of situations. Thus, it is not surprising that the meaning of the item may change across situations; therefore, factor structures may also shift a bit. But it can be argued that this is a result of the instruments’ accurate reflection of reality rather than of poor scale construction. For example, in

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problems involving interpersonal tensions, making a plan of action may appropriately include talking to the person who caused the problem. However, in dealing with a strictly practical problem such as changing a bicycle tire, talking to the person who caused the problem is simply not appropriate (assuming that the flat tire was due to natural causes and not some act of sabotage). Thus, it is not surprising that items could cluster slightly differently, depending on the characteristics of the situations with which people are coping. Actually, changes in factor structures across situations can tell us a great deal about the types of demands of a situation. For example, the factor structure of the WOCS may change systematically when the target population consists of patients undergoing serious illnesses, such as rheumatoid arthritis or cancer (Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992). This demonstrates that the characteristics of serious illness change coping patterns, but it does not mean that the WOCS is defective. De Ridder (1997) showed clearly, using an experimental design in which situation characteristics were systematically varied, that changes in factor structures reflected changes in situational demands in a meaningful way. Factor structures and internal reliability may also vary because coping is a process that can change over time. While it is true that penciland-paper instruments do not tap the process of change in strategies over time in that people do not tell you “First I did this, and then I did that” (Coyne, 1992), the unreliability of the instrument may actually reflect the process of coping. Examination of any one checklist of coping strategies tied to a particular episode will almost invariably reveal what appear to be marked inconsistencies in individuals’ accounts of what they did. For example, respondents often check off “Made a plan of action and followed it” and “Decided nothing could be done.” In reality, these may not be contradictory statements. The strategies may be sequential—that is, individuals first tried to solve the problem, failed, and then decided that nothing could be done, or their initial assessment of the problem was that nothing could be done, but then they looked more closely and found possibilities for active intervention. Or the statements might refer to different aspects of the problem. A husband may come to the painful realization that nothing can be done about the fact that his wife is dying but still may take active measures to ameliorate her pain and discomfort. Thus, checking off both active and passive strategies on a coping instrument may not be contradictory at all, but it certainly wreaks havoc on the internal reliability of subscales and the orthogonality and stability of the factor structure. Skinner, Edge, Altman, and Sherwood (2003) took on the difficult task of trying to sort out the maze of different factor structures and cop-

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ing strategies that exist in the literature. They provided an elegant review of the problem with factor structures and concluded that the problem with the factor structure for coping strategies is that the latter were not mutually exclusive—that is, coping strategies may have multiple functions, and their meaning and efficacy may change according to the circumstances. Further, they argue that this situation is not helped by the use of fairly simple dichotomous inventories, such as approach–avoidance, because strategies can be seen as either approach or avoidant, depending upon the context, or an avoidant strategy may facilitate later problemfocused coping. Take, for example, cognitive reappraisal. Fundamentally uncontrollable stressors such as bereavement are simply not amenable to approach-based coping strategies. In those situations, cognitive reappraisal efforts are appropriate and effective. That is, a widow may comfort herself with the idea that the death of her husband was actually welcome, given the amount of suffering that her husband had gone through during the months (or sometimes years) before his death. This cannot be interpreted as an avoidant strategy. On the other hand, cognitive reappraisal may be a way of avoiding problems. For example, a necessary confrontation with a boss or a coworker may be avoided by saying “Oh, it really doesn’t matter anyway.” However, in the long run lack of effort in resolving the situation can result in a worsening of problems. Finally, cognitive reappraisal may facilitate problem-focused efforts. A young athlete might be unduly anxious about an upcoming contest as a result of thinking “If I don’t win, I won’t get the scholarship, and I’ll never go to college, and my life will be a failure.” In this circumstance, a little judicious cognitive reappraisal might enable the athlete to relax enough to perform really well: “Hey, what have I got to lose? If I win, great. If I don’t, I’ll figure out some other way to get to college.” Thus, the same overarching strategy—cognitive reappraisal—may be an approach strategy, an avoidance strategy, or simply the only possible thing to do in a situation. Further, its effectiveness is also dependent on the situation. Mattlin et al. (1990) found that reappraisal was most effective in dealing with losses such as bereavement but was counterproductive in dealing with everyday problems if reappraisal was not accompanied by problem-focused coping. Thus, the combination of coping strategies could influence the efficacy of any one particular strategy. This is also true of many other emotion-focused strategies—distraction, for example. Distraction may be a useful time-out strategy. Reading a book, going to a movie with a friend, or even watching television may serve a recuperative function that enables further and more effective problem-focused efforts. Using distraction at

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the cost of abandoning other attempts to solve the problem, however, is maladaptive. Skinner et al. (2003) recommended that researchers try a hierar chical approach—that is, identify general overarching modes as secondorder factors that subsume first-order, more differentiated, types of coping strategies. Interestingly, the 13 potential higher-order “families” of coping that they identified look similar to the early factor analyses of the Ways of Coping and include problem solving, support seeking, escape, cognitive restructuring, social withdrawal, information seeking, and emotional regulation/expression. They also include, however, such additional strategies as rumination, negotiation, delegation, opposition, self-pity, and the rather curious amalgam of distraction and acceptance. Further, the first-order factor structures are basically items. However, the idea of coming up with a hierarchical structure with a simpler higher order is a good one, although, as they point out, it is not at all clear yet what that higher-order structure should be. Nonetheless, it might also help to solve the dilemma of whether one should use general or situation-specific coping strategies.

GENERAL VERSUS SPECIFIC COPING STRATEGIES A related issue concerns the generalizability or specificity of items in a coping measure. If a scale is devised that is highly specific to a given circumstance, it may work well in that situation but not be generalizable to other situations. On the other hand, if a scale is devised in which the wording is vague enough to be relevant to many situations, the scale may not “fit” a particular situation very well. For example, “Made a plan of action and followed it” is sufficiently vague to apply to many situations, but its vagueness may make it less than useful in any given situation. On the other hand, “Replaced buttons with Velcro” may be a highly useful strategy for individuals coping with rheumatoid arthritis but would be completely inapplicable in most other situations. Obviously, coping style researchers prefer coping instruments with items that are worded in a general fashion. It would be hard to assume that substituting Velcro for buttons is directly a function of personality (as opposed to, say, suggestions by a nurse or fellow member of a selfhelp group). On the other hand, approaching problems rationally and persevering in trying to find solutions to problems may well be a personality characteristic. However, one person’s perseverance is another person’s perseveration, or someone may think that he or she is being persistent when, from another person’s point of view, he or she is “beating a

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dead horse,” as it were. Thus, trying to get specific instances of behavior allow for a more accurate assessment of actual coping behavior used. This is particularly important when trying to identify strategies that are useful in coping with specific problems. For example, a clinician may be developing a manual to be used in helping clients deal with particular problems, for example, a chronic illness such as rheumatoid arthritis. While exhortations to perseverance may be motivational, specific suggestions may be more meaningful, such as coming up with different ways of opening cans and bottles or substituting Velcro for buttons. Further, specific coping scales may be used to pursue in greater detail interesting theoretical questions about particular types of stressors, such as trauma. Examples of such strategies include self-blame (Davis, Lehman, Silver, Wortman, & Ellard, 1996; Delhanty et al., 1997), “undoing” (Davis, Lehman, Wortman, & Silver, 1995), and “temporal orientation” (Holman & Silver, 1998). The problem with specific inventories, however, is that, slightly different versions of a construct may yield contradictory results. For example, normally self-blame is associated with greater psychological distress. However, in some traumatic situations self-blame may actually provide for a sense of control (JanoffBulman, 1979; but see Frazer, 1990). For example, a woman who has been physically assaulted might blame herself because she left a window open or approached a strange car; presumably if she avoids these behaviors in the future, she will be “safe.” Contrary to this position, however, are findings concerning the effects of the coping strategy of “undoing.” This involves the use of counterfactuals (if only I had not . . . ). Davis et al. (1995) found that the more that subjects used undoing in coping with trauma, the more distress they reported, even controlling for general rumination. Further, specific instruments cannot be used for examining some of the basic questions in coping research, such as stability and change in coping strategies across situations. Further, being able to compare the efficacy of coping strategies across situations (and studies) may also require a more generally worded scale. However, this may sacrifice predictive validity, as we have seen. Lazarus (1990) has suggested an intermediate approach—namely, that individuals use a general coping scale such as the WOCS but modify it to fit particular situations. Theoretically, this would allow some degree of comparability across studies while minimizing the loss of predictive validity for any one study. However, Endler and Parker (1990) have criticized this approach on methodological grounds. In their view, item substitution or addition could affect the factor structure of the scale, thus increasing the difficulty of arriving at a consensus on the structure of coping strategies. Nonetheless, interest in scales that are tailored to spe-

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cific situations still runs quite strong, as indicated by the rapid increase in the number of specialty scales enumerated in Appendix 8.1. Another possibility is to take the approach recommended by Skinner et al. (2003). If one could identify a hierarchical structure, one could theoretically identify situation-specific strategies for the firstorder factors that would nonetheless maintain the second-order structure. However, what that second-order factor would consist of is, at this point, an open question. Skinner et al. (2003) did have an interesting suggestion: We argue that a distinction can profitably be made between families of coping as good news or bad news on the basis of three factors: their long-term developmental consequences, their subjective experience, and their current qualities. If one takes the coping system, which includes not only the individual’s way(s) of coping but also the specific stressor(s) and demands, individual appraisals, and currently available personal and social resources, as the focal unit, then a particular pattern of coping can be considered diagnostic of the state of the entire system. The target state of interest to this distinction is whether it is “good” or “bad” for the organism, basically whether the individual can handle the demand or is overwhelmed by it. (p. 230)

This would be an interesting psychometric approach to coping, but until then, whether one assesses specific or general coping items in any particular study depends entirely upon the purpose of the study. The methods used in any particular research design must always defer to the research question. This point cannot be overemphasized.

RATING SCALES Coping scales either can be simple checklists of dichotomous items, requiring respondents to indicate whether a particular strategy was used, or they can have some sort of rating scale attached to each item, requiring respondents to indicate the extent to which each strategy was used. Each approach has its strengths and limitations. Dichotomized items provide little information about the way in which a strategy was used. As we have already seen, how much a particular tactic is used may strongly influence whether it is effective or maladaptive. For example, employing a little bit of distraction may be helpful, while overreliance on it may be harmful. Scales with dichotomous items also have less variance and are more likely to be skewed or kurtotic, which limits their predictive validity. Further, the internal reli-

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ability of scales with dichotomous items also tends to be lower than those using rating scales. Using a rating scale entails certain advantages, both with internal reliability and with predictive validity. There are also disadvantages. The items on coping strategy scales are almost invariably a heterogeneous mix of cognitions and behaviors, and the same rating scale may need to be interpreted differently depending on the affordance characteristics of the item. In an elegant study, Stone and his colleagues (Stone, Greenberg, Kennedy-Moore, & Newman, 1991) criticized the rating scale on the revised WOCS because the wording (“To what extent did you use each of the following strategies: not at all, a little, somewhat, and a lot”) can be interpreted in four ways: frequency, duration, effort, and usefulness. For example, talking to someone who could do something about the problem could have been done several times—or it could have been done once but for a long time. Or the individual could have put a lot of effort and planning into one talk. Under each of these conditions, respondents could have indicated “somewhat” or “a lot.” From Stone and his colleagues’ point of view, this is unacceptable, because it means that people are not necessarily interpreting the rating of each item in the same way: For some people and some items, extent means one thing, and for other people and other items it means one of several other things. Our concern is the obvious one: what is the meaning of combined ratings of duration, frequency, usefulness, and effort? A single scale measuring differing dimensions in unknown ways may result in a scale that is not interpretable. Imagine that two different subjects each spoke to an aggressive and antagonistic landlord for five min[utes] to complain about a rent increase. When these subjects rate the extent to which they “approached the person who caused the problem” on the WOC, the first respondent might give this item a low rating because the conversation was of short duration. On the other hand, the second respondent might give this item a high rating, reflecting the great deal of effort that it took to approach this difficult landlord. In this scale, the scale would reflect more coping on the part of the 2nd subject than the 1st, whereas, in fact, their actual coping behaviors were topographically similar. Thus, the problem of subjects using different dimensions to rate coping items is a serious one when specific thoughts and behaviors are being evaluated. (Stone et al., 1991, p. 657)

I am reminded of the scene from Woody Allen’s Annie Hall in which the two protagonists are both seeing their respective therapists. Annie Hall complains that they have sex too much—at least three times a week. Annie Hall’s lover complains that they almost never have sex—

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only three times a week. Exactly the same behaviors may have widely discrepant meanings to different individuals. The transactionist approach is predicated upon the fact that knowing whether something happened is less important than the meaning of the occurrence to the individual. From the therapists’ point of view, knowing exactly how many times Annie Hall and her lover had sex each week is less important than knowing that one felt burdened and the other felt deprived. Similarly, although both subjects in Stone’s example may have talked to their respective landlords for 5 minutes, the second respondent may have been much more reticent, and it may have been much harder for this student to talk to the landlord than it was for the first student. Thus, even though the duration of the coping efforts was identical, the effort, mobilization, and probably the outcome were not identical. The student for whom the task was more difficult probably expended more emotional energy—and, thus, it would be appropriate to rate the coping strategy as drawing in more effort. Further, one could also hypothesize that the second student’s blood pressure and catecholamine responses were much stronger, which would be in keeping with using higher coping ratings. I was a member of the Berkeley Stress and Coping Project when it was decided to switch from a dichotomous to a four-point rating scale. We agonized for some time over how to word the rating scale. We considered using wording that variously reflected frequency, duration, or effort. But we had to reject each one, given that some were more appropriate than others to different items. As Stone and his colleagues have correctly pointed out, effort, frequency, and duration are overlapping but not identical constructs. What if an individual used a coping strategy only once but for a long time or quite intensely? We could not untangle this Gordian knot, and thus fell back on using the admittedly subjective and vague terminology “extent to which you used each strategy.” However, we felt strongly enough that the amount of coping effort expended was too important to ignore, despite the fuzziness that it added to the scale. In part, the difficulties in assessing anything are due to Heisenberg’s Uncertainty Principle. In essence, the measurement process in and of itself distorts the thing it is measuring. Using dichotomous items may be more objective in that individuals may more reliably indicate whether they used a strategy, but this distorts the picture that one obtains of coping by not assessing the extent to which the coping strategy was used. As we have seen, using a little distraction or cognitive reappraisal may be different from using too much. On the other hand, attaching a rating scale distorts the picture because it is a much more subjective assessment. However, one could argue that its subjectivity provides a more

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complex and perhaps more accurate picture of the coping effort involved and enhances its predictive validity. Having used both simple scales with a few dichotomous items and more complex scales with many subjectively rated items, I generally find that the latter are simply better predictors of psychological and physical outcomes. Nonetheless, the idea of using an “elastic ruler” in scales is not a comfortable one. But I cannot help wondering whether the same sort of elasticity would not emerge if one applied Stone’s elegant design to rating scales in general (or even dichotomous items). As we have seen, even simple frequencies may be interpreted in many varying ways by different individuals, and even dichotomous items may be subject to divergent interpretations. For example, what if the two students mentioned above had fleeting thoughts of taking revenge on their landlord. One student is more compulsive than the other and dutifully checked off “Had unrealistic fantasies about how the situation may turn out.” The other student may not have felt that he actually did this, because the thought was so fleeting. Given the vagueness of many cognitive coping strategies, what is the threshold for saying that, yes, one actually did this? Or, for that matter, saying “Yes, this is generally true of me” or “No, this is not usually true of me” on coping styles measures? My hypothesis is that there always are individual differences in how people interpret the response formats to items on psychological testing in general. If true, a strict positivist would argue that this would call into question all of psychological testing. However, a pragmatist would argue that this is simply a form of noise in the assessment instrument. All assessment instruments, whether used by psychological, biological, or physical scientists, have tolerances for various degrees of noise—or uncertainty, to use Heisenberg’s terminology. Obviously, an important goal is always to minimize noise. However, there are often various sources of noise, and sometimes trying to minimize one source increases another. Psychologists try to decrease noise by using multiple items that assess the same underlying construct. But psychology, especially personality and cognitive social psychology, by definition deals with subjective experiences. Sometimes this should be exploited, not minimized.

SUMMARY As we have seen, the assessment of coping strategies is still a matter of great contention. Coping style theorists prefer assessing a small number of strategies, which are presumed to be stable across situations and time and which may or may not be unconscious. Sociologists and social psychologists tend to look at multiple strategies that are often situation-

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specific and assume that coping is proactive, conscious, and a matter of socialization. Process theorists try to straddle these two approaches, seeking to identify several strategies that might be applicable to specific situations, and believe that coping is largely conscious. As such, process theorists are criticized by the clinicians for paying insufficient attention to personality traits and by the social theorists for paying insufficient attention to situational demands. Even within the process approach, controversies rage about whether retrospective, daily process measures, or EMA research designs are most appropriate. The increase in complexity of designs has also led to an increase in complexity in data analysis, as we will see in Chapter 9.

APPENDIX 8.1. BIBLIOGRAPHY OF COPING SCALES In 1987, Aldwin and Revenson identified over 20 coping scales and listed them in an appendix. For the first edition of this book, I updated this list to over 70 bibliographic references to scales and included them as an appendix to this chapter. The following is a partial list of some 200 such references to coping scales as of 2004. While most entries have been published, I included a handful of presentations or unpublished manuals when these were often used or cited in other works. This edition’s list differs in three substantial ways from the last version. The first list focused on scales published in English, given the difficulty of accessing and reading journals published in other languages. However, the study of coping has truly become an international endeavor, and so much work has been done in Europe and Asia that I felt it important to at least acknowledge some of these efforts. Much of this work has been done in German, so I’ve divided the list into German and then other European languages (including French, Spanish, Czech, Norwegian, and Dutch), Asian languages, and other. I am certain that work has been done in other countries, including Italy, Russia, and Egypt, but for practical reasons I relied primarily on PsychInfo to find the bibliographic references, and PsychInfo does not include journals from those countries. My apologies to any of my international colleagues whose scales are not included in this bibliographic listing. Second, there has been a huge proliferation in the number of scales directed toward children and adolescents—so much so that I put them into their own category, with subcategories for pediatric scales (those used in clinical settings or for particular illnesses) and special populations (e.g., athletes). Third, there is a tendency in the field to devise scales that assess highly specialized strategies, such as the use of counterfactuals under traumatic circumstances, benefit finding, or religious coping. Thus, I have added a new category that includes those types of scales.

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However, I still excluded scales whose primary purpose was to assess other things, for example, specific emotions like anxiety or hostility, or generalized competence or development. While some of these scales included coping subscales, their primary focus was not on coping, and so they were omitted. Occasionally review articles are included that specify more scales than can be economically presented in this review.

Psychodynamic, Interview, or Observational Approaches Aldwin, C. M., Sutton, K. J., Chiara, G., & Spiro, A., III. (1996). Age differences in stress, coping, and appraisal: Findings from the Normative Aging Study. Journals of Gerontology: Psychological Sciences, 51B, P179 Andrews, G., Singh, M., & Bond, M. (1993). The Defense Style Questionnaire. Journal of Nervous and Mental Disease, 181, 246–256. Bond, M., Gardiner, S. T., & Siegel, J. J. (1983). An empirical examination of defense mechanisms. Archives of General Psychiatry, 40, 333–338. Brown, G., & Harris, T. (1978). Social origins of depression: A study of psychiatric disorder in women. New York: Free Press. Diaz-Guerrero, R. (1979). The development of coping style. Human Development, 22, 320–331. Gleser, G., & Ihilevich, D. (1969). An objective instrument for measuring defense mechanisms. Journal of Consulting and Clinical Psychology, 33, 51– 60. Harburg, E., Blakelock, E. H., & Roeper, P. J. (1979). Resentful and reflective coping with arbitrary authority and blood pressure: Detroit. Psychosomatic Medicine, 41, 189–202. Horowitz, M. J., & Wilner, N. (1980). Life events, stress, and coping. In L. Poon (Ed.), Aging in the 1980s (pp. 363–374). Washington, DC: American Psychological Association. Joffe, P., & Naditch, M. P. (1977). Paper and pencil measures of coping and defense processes. In N. Haan (Ed.), Coping and defending (pp. 280–297). New York: Academic Press. Plutchik, R., & Conte, H. R. (1989). Measuring emotions and their derivatives: Personality traits, ego defenses, and coping styles. In S. Wetzler & M. M. Katz (Eds.), Contemporary approaches to psychological assessment: Clinical and experimental psychiatry (pp. 239–269). Philadelphia: Brunner/Mazel. Vaillant, G. E. (1977). Adaptation to life. Boston: Little, Brown. Vaillant, G. E. (1993) The wisdom of the ego. Cambridge, MA: Harvard University Press. Wiedl, K. H., & Schottner, B. (1991). Coping with symptoms related to schizophrenia. Schizophrenia Bulletin, 17, 525–538. Zeidner, M., Klingman, A., & Itskowitz, R. (1993). Children’s affective reactions and coping under threat of missile attack: A semiprojective assessment procedure. Journal of Personality Assessment, 60, 435–457. Zeitlin, S. (1980). Assessing coping behavior. American Journal of Ortho-Psychiatry, 50, 139–144.

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Coping Styles or Personality Approaches Beckham, E. E., & Adams, R. L. (1984). Coping behavior in depression: Report on a new scale. Behaviour Research Therapy, 22, 71–75. Brandstädter, J., & Renner, G. (1990). Tenacious goal pursuit and flexible goal adjustment: Explication and age-related analysis for assimilative and accommodative strategies of coping. Psychology and Aging, 5, 58–67. Byrne, D. (1964). Repression–sensitization as a dimension of personality. In B. A. Maher (Ed.), Progress in experimental personality research (Vol. 1, pp. 170– 220). New York: Academic Press. Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: A theoretically-based approach. Journal of Personality and Social Psychology, 56, 267–283. (Note: This can be scored in terms of coping styles or situation-based coping strategies.) Cohen, C. I., Teresi, J., Holmes, D., & Roth, E. (1988). Survival strategies of older homeless men. Gerontologist, 28, 58–65. Dunahoo, C. L., Hobfoll, S. E., Monnier, J., Hulsizer, M. R., & Johnson, R. (1998). There’s more than rugged individualism in coping. Part 1: Even the Lone Ranger had Tonto. Anxiety, Stress, and Coping: An International Journal, 11(2), 137–165. Endler, N., & Parker, J. D. A. (1990). Multidimensional assessment of coping: A critical evaluation. Journal of Personality and Social Psychology, 58, 844–854. Endler, N. S., & Parker, J. D. A. (1994). Assessment of multidimensional coping: Task, emotion, and avoidance strategies. Psychological Assessment, 6, 50–60. Epstein, S., & Meier, P. (1989). Constructive thinking: A broad coping variable with specific components. Journal of Personality and Social Psychology, 57(2), 332– 350. Feifel, H., Strack, S., & Nagy, V. P. (1987). Degree of life-threat and differential use of coping modes. Journal of Psychosomatic Research, 31, 91–99. Hall, D. T. (1972). A model of coping with role conflict: The role behavior of college educated women. Administrative Science Quarterly, 17, 471–487. Hamilton, J. A., Haier, R. J., & Buchsbaum, M. S. (1984). Intrinsic Enjoyment and Boredom Coping scales: Validation with personality, evoked potential and attention measures. Personality and Individual Differences, 5, 183–193. Kaiser, D. L. (1991). Religious problem-solving styles and guilt. Journal for the Scientific Study of Religion, 30, 94–98. Marcus, G., & Forster, J. (1988). Assessing self-efficacy during marital separation. Journal of Divorce, 11, 77–85. Martin, R. A., & Lefcourt, H. M. (1983). Sense of humor as a moderator of the relation between stressors and moods. Journal of Personality and Social Psychology, 45, 1313–1324. Miller, S. M. (1980). When is a little information a dangerous thing? Coping with stressful events by monitoring versus blunting. In S. Levine & H. Ursin (Eds.), Coping and health (pp. 145–170). New York: Plenum Press. Millon, T., Green, C. J., & Meagher, R. B. (1979). The MBHI: A new inventory for the psychodiagnostician in medical settings. Professional Psychology, 10, 529– 539.

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Mullen, B., & Suls, J. (1980). The effectiveness of attention and rejection as coping styles: A meta-analysis of temporal differences. Journal of Psychosomatic Research, 26, 43–49. Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61(1), 115–121. Roger, D., Jarvis, G., & Najarian, B. (1993). Detachment and coping: The construction and validation of a new scale for measuring coping strategies. Personality and Individual Differences, 15, 619–626. Rosenbaum M. (1980). A schedule for assessing self-control behaviors: Preliminary findings. Behavior Therapy, 11, 109–121. Weinberger, D. A., & Schwartz, G. E. (1990). Distress and restraint as superordinate dimensions of self-reported adjustment: A typological perspective. Journal of Personality, 58(2), 381–417. Wells, J. D., Hobfoll, S. E., & Lavin, J. (1997). Resource loss, resource gain, and communal coping during pregnancy among women with multiple roles. Psychology of Women Quarterly, 21(4), 645–662.

Situation-Based Approaches General Aldwin, C. M. (1994, August). The California Coping Inventory. Paper presented at the Annual Meeting of the American Psychological Association, Los Angeles, CA. Aldwin, C. M., Sutton, K., & Lachman, M. (1996). The development of coping resources in adulthood. Journal of Personality, 64, 91–113. Amirkhan, J. H. (1990). A factor analytically derived measure of coping: The Coping Strategy Indicator. Journal of Personality and Social Psychology, 59, 1066– 1074. Kottke, J. L., Cowan, G., & Pfahler, D. J. (1988). Development of two scales of coping strategies: An initial investigation. Educational and Psychological Measurement, 48, 737–742. McCrae, R. R. (1984). Situational determinants of coping responses: Loss, threat, and challenge. Journal of Personality and Social Psychology, 46, 919–928. Moos, R. H., Cronkite, R. C., Billings, A., G., & Finney, J. W. (1982). Health and Daily Living Form Manual. Stanford, CA: Social Ecology Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. Pearlin, L., & Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19, 2–21. Sidel, A., Moos, R. H., Adams, J., & Cody, P. (1969). Development of a coping scale. Archives of General Psychiatry, 20, 225–233. Stanton, A. L., Kirk, S. B., Cameron, C. L., & Danoff-Burg, S. (2000). Coping through emotional approach: Scale construction and validation. Journal of Personality and Social Psychology, 78, 1150–1169.

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Stone, A. A., & Neale, J. M. (1982). A new measure of daily coping: Development and preliminary results. Journal of Personality and Social Psychology, 46, 892– 906. Tobin, D. L., Holroyd, K. A., Reynolds, R. V., & Wigal, J. K. (1989). The hierarchical factor structure of the Coping Strategies Inventory. Cognitive Therapy and Research, 13, 343–361.

Ways of Coping Scale (Original—Includes References Regarding Scoring) Aldwin, C., Folkman, S., Coyne, J., Schaefer, C., & Lazarus, R. S. (1980, August). The Ways of Coping Scale: A process approach. Paper presented at the annual meeting of the American Psychological Association, Montreal, Quebec, Canada. Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle-aged community sample. Journal of Health and Social Behavior, 21, 219–239. Parkes, K. R. (1984). Locus of control, cognitive appraisal, and coping in stressful episodes. Journal of Personality and Social Psychology, 46, 655–668. Vitaliano, P., Maiuro, R. D., Russo, J., & Becker, J. (1987). Raw versus relative scores in the assessment of coping strategies. Journal of Behavioral Medicine, 10, 1–18. Vitaliano, P., Russo, J., Carr, J., Maiuro, R., & Becker, J. (1985). The Ways of Coping checklist: Revision and psychometric properties. Multivariate Behavioral Research, 20, 3–26.

Ways of Coping Scale (Revised—Includes References Regarding Factor Structures) Aldwin, C., & Revenson, T. A. (1987). Does coping help?: A reexamination of the relation between coping and mental health. Journal of Personality and Social Psychology, 53, 337–348. Dunkel-Schetter, C., Feinstein, L. G., Taylor, S. E., & Falke, R. L. (1992). Patterns of coping with cancer. Health Psychology, 11, 79–87. Folkman, S., & Lazarus, R. S. (1985). If it changes it must be a process: A study of emotion and coping during three stages of a college examination. Journal of Personality and Social Psychology, 48, 150–170. Folkman, S., Lazarus, R. S., Dunkel-Schetter, C., DeLongis, A., & Gruen, R. (1986). The dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology, 50, 992–1003.

Coping Scales for Specific Situations or Populations Occupational Scales Cooper, C. L., Sloan, S. J., & Williams, S. (1988). Occupational stress indicator: Management guide. Windsor, UK: NferNelson.

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Edwards, J. R., & Baglioni, A. J. (1993). The measurement of coping with stress: Construct validity of the Ways of Coping Checklist and the Cybernetic Coping Scale [Special issue. Coping with Stress at Work]. Work and Stress, 7, 17–31. Kinicki, A. J., & Latack, J. C. (1990). Explication of the construct of coping with involuntary job loss. Journal of Vocational Behavior, 36, 339–360 Latack, J. C. (1986). Coping with job stress: Measures and future directions for scale development. Journal of Applied Psychology, 71, 377–385. McElfatrick, S., Carson, J., Annett, J., Cooper, C., Holloway, F., & Kuipers, E. (2000). Assessing coping skills in mental health nurses: Is an occupation specific measure better than a generic coping skills scale? Personality and Individual Differences, 28, 965–976. Medeiros, M. E., & Prochaska, J. O. (1988). Coping strategies that psychotherapists use in working with stressful clients. Professional Psychology: Research and Practice, 19, 112–114. Nowack, K. M. (1990). Initial development of an inventory to assess stress and health risk. American Journal of Health Promotion, 4, 173–180. Osipow, S. H., & Spokane, A. R. (1983). A manual for measures of occupational stress, strain, and coping. Odessa, FL: Psychological Assessment Resources. Schonfeld, I. S. (1990). Coping with job-related stress: The case of teachers. Journal of Occupational Psychology, 63, 141–149. Wilder, J. F., & Plutchik, R. (1982). The AECOM coping scales. Annals of Stress Research.

Older Adults Cheng, T. Y. L., & Boey, K. W. (2000). Coping, social support, and depressive symptoms of older adults with Type II diabetes mellitus. Clinical Gerontologist, 22, 15–30. Feifel, H., & Strack, S. (1989). Coping with conflict situations: Middle-aged and elderly men. Psychology and Aging, 4, 26–33. Quayhagen, M. P., & Quayhagen, M. (1982). Coping with conflict: Measurement of age-related patterns. Research on Aging, 4, 364–377.

Family Scales McCubbin, H. I., Dahl, B., Lester, G., Benson, D., & Robertson, M. (1976). Coping repertoires of families adapting to prolonged war-induced separations. Journal of Marriage and the Family, 38, 461–471. McCubbin, H. I., McCubbin, M. H., Patterson, J. M., Cauble, A. E., Wilson, L. R., & Warwick, W. (1983). CHIP—Coping Health Inventory for Parents—an assessment for parental coping patterns in the care of a chronically ill child. Journal of Marriage and Family, 45, 359–370. McCubbin, H. I., Olson, D. H., & Larsen, A. S. (1982). Family crisis oriented personal scales. In D. Olson, H. I. McCubbin, H. Banes, A. Larsen, M. Muxen, &

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M. Wilson (Eds.), Family inventories (pp. 101–120). St. Paul: University of Minnesota, Family Social Science. McCubbin, M. A. (1991). CHIP Coping Health Inventory for Parents. In H. I. McCubbin & A. I. Thompson (Eds.), Family assessment inventories for research and practice (2nd ed., pp. 181–199). Madison, WI: University of Wisconsin– Madison. Nachshen, J. S., Woodford, L., & Minnes, P. (2003). The Family Stress and Coping Interview for families of individuals with developmental disabilities: A lifespan perspective on family adjustment. Journal of Intellectual Disability Research. Special Issue on Family Research, 47, 285–290.

Coping Scales for Clinical and/or Health Situations Aalto, A.-M., Haerkaepaeae, K., Aro, A. R., & Rissanen, P. (2002). Ways of coping with asthma in everyday life: Validation of the Asthma Specific Coping Scale. Journal of Psychosomatic Research, 53, 1061–1069. Amir, S., Rabin, C., & Galatzer, A. (1990). Cognitive and behavioral determinants of compliance in diabetics. Health and Social Work, 15, 144–151. Burt, M. R., & Katz, B. L. (1988). Coping strategies and recovery from rape. Annals of the New York Academy of Sciences 528, 345–358. Butler, R. W., Damarin, F. L., Beaulieu, C., Schwebel, A. I., & Thorn, B. E. (1989). Assessing cognitive coping strategies for acute postsurgical pain. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 41–45. Coyne, J., & Smith, D. A. F. (1991). Couples coping with a myocardial infarction: A contextual perspective on wives’ distress. Journal of Personality and Social Psychology, 61, 404–412. Felton, B. J., & Revenson, T. A. (1984). Coping with chronic illness: A study of illness controllability and the influence of coping strategies on psychological adjustment. Journal of Consulting and Clinical Psychology, 52, 343–353. Grey, M., Boland, E. A., Davidson, M., Li, J., & Tamborlane, W. V. (2000). Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life. Journal of Pediatrics, 137, 107–113. Jalowiec, A., Murphy, S. P., & Powers, M. J. (1984). Psychometric assessment of the Jalowiec Coping Scale. Nursing Research, 33, 157–161. Knussen, C., Sloper, P., Cunningham, C. C., & Turner, S. (1992). The use of the Ways of Coping (Revised) Questionnaire with parents of children with Down’s syndrome. Psychological Medicine, 22, 775–786. Lipowski, Z. J. (1970). Physical illness, the individual, and the coping process. Psychiatry in Medicine, 1, 91–102. Manne, S. L., & Zautra, A. J. (1990). Couples coping with chronic illness: Women with rheumatoid arthritis and their healthy husbands. Journal of Behavioral Medicine, 13, 327–342. Prochaska, J. O., Velicer, W. F., DiClemente, C. C., & Fava, J. (1988). Measuring the process of change: Applications to the cessation of smoking. Journal of Consulting and Clinical Psychology, 56, 520–528.

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Regan, C. A., Lorig, K., & Thoresen, C. E. (1988). Arthritis appraisal and ways of coping: Scale development. Arthritis Care and Research, 1, 139–150. Rosensteil, A. K., & Keefe, F. J. (1983). The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment. Pain, 17, 33–44. Valentiner, D. P., Foa, E. B., Riggs, D. S., & Gershuny, B. S. (1996). Coping strategies and posttraumatic stress disorder in female victims of sexual and nonsexual assault. Journal of Abnormal Psychology, 105, 455–458.

Child and Adolescent Scales General Ayers, T. S., Sandler, I. N., West, S. G., & Roosa, M. W. (1996). A dispositional and situational assessment of children’s coping: Testing alternative models of coping. Journal of Personality, 64, 923–958. Brodzinsky, D. M., Elias, M. J., Steiger, C., & Simon, J. (1992). Coping Scale for Children and Youth: Scale development and validation [Special issue. Does Environment Really Contribute to Healthy, Quality Life?]. Journal of Applied Developmental Psychology, 13, 195–214. Causey, D. L., & Dubow, E. F. (1992). Development of a self-report coping measure for elementary school children. Journal of Clinical Child Psychology, 21, 47–59. Cheng, S.-T., & Chan, A. C. M. (2003). Factorial structure of the Kidcope in Hong Kong adolescents. Journal of Genetic Psychology, 164, 261–266. Compas, B. E. (1987). Coping with stress during childhood and adolescence. Psychological Bulletin, 101, 393–403. Connor-Smith, J. K., Compas, B. E., Wadsworth, M. E., Thomsen, A. H., & Saltzman, H. (2000). Responses to stress in adolescence: Measurement of coping and involuntary stress responses. Journal of Consulting and Clinical Psychology, 68, 976–992. Dise-Lewis, J. E. (1988). The Life Events and Coping Inventory: An assessment of stress in children. Psychosomatic Medicine, 50, 484–499. Ebata, A. T., & Moos, R. H. (1991). Coping and adjustment in distressed and healthy adolescents. Journal of Applied Developmental Psychology, 12, 33–54. Elwood, S. W. (1987). Stressor and coping response inventories for children. Psychological Reports, 60, 931–947. Erickson, S., Feldman, S. S., & Steiner, H. (1997). Defense reactions and coping strategies in normal adolescents. Child Psychiatry and Human Development, 28, 45–56. Fabes, R. A., Poulin, R. E., Eisenberg, N., & Madden-Derdich, D. A. (2002). The Coping with Children’s Negative Emotions Scale (CCNES): Psychometric properties and relations with children’s emotional competence. Marriage and Family Review, 34, 285–310. Fanshawe, J. P., & Burnett, P. C. (1991). Assessing school-related stressors and coping mechanisms in adolescents. British Journal of Educational Psychology, 61, 92–98. Finnegan, R. A., Hodges, E. V. E., & Perry, D. G. (1996). Preoccupied and avoidant coping during middle childhood. Child Development, 67, 1318–1328.

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Frydenberg, E., & Lewis, R. (1990). How adolescents cope with different concerns: The development of the Adolescent Coping Checklist (ACC). Psychological Test Bulletin, 3, 63–73. Frydenberg, E., & Lewis, R. (1996). A replication study of the structure of the adolescent coping scale: Multiple forms and applications of a self-report inventory in a counselling and research context. European Journal of Psychological Assessment, 12, 224–235. Fuehr, M. (2002). Coping humor in early adolescence. Humor: International Journal of Humor Research, 15, 283–304. Glyshaw, K., Cohen, L. H., & Towbes, L. C. (1989). Coping strategies and psychological distress: Prospective analyses of early and middle adolescents. American Journal of Community Psychology, 17, 607–623. Halstead, M., Johnson, S. B., & Cunningham, W. (1993). Measuring coping in adolescents: An application of the Ways of Coping Checklist. Journal of Clinical Child Psychology, 22, 337–344. Harter, S. (1982). The Perceived Competence Scale for Children. Child Development, 53, 87–97. Jacobs, G. A., Phelps, M., & Rohrs, B. (1989). Assessment of anger expression in children: The Pediatric Anger Expression Scale. Personality and Individual Differences, 10, 59–65. Jorgensen, R. S., & Dusek, J. B. (1990). Adolescent adjustment and coping strategies. Journal of Personality, 58, 503–514. Little, T. D., Lopez, D. F., & Wanner, B. (2001). Children’s action-control behaviors (coping): A longitudinal validation of the Behavioral Inventory of Strategic Control. Anxiety, Stress, and Coping: An International Journal, 14, 315–336. Myers, M. G., & Wagner, E. F. (1995). The Temptation-Coping Questionnaire: Development and Validation. Journal of Substance Abuse, 7, 463–479. Patterson, J. M., & McCubbin, H. I. (1987). Adolescent coping styles and behaviors: Conceptualization and measurement. Journal of Adolescence, 10, 163–186. Ryan-Wenger, N. M. (1990). Development and psychometric properties of The Schoolagers’ Coping Strategies Inventory. Nursing Research, 39, 344–349. Sandstrom, M. J. (2004). Pitfalls of the peer world: How children cope with common rejection experiences. Journal of Abnormal Child Psychology, 32, 67–81. Spirito, A., Stark, L. J., & Williams, C. (1988). Development of a brief coping checklist for use with pediatric populations. Journal of pediatric psychology, 13(4), 555–574. Swiatek, M. A. (2001). Social coping among gifted high school students and its relationship to self-concept. Journal of Youth and Adolescence, 30, 19–39. Wertlieb, D., Weigel, C., & Felstein, M. (1987). Measuring children’s coping. Journal of Orthopsychiatry, 57, 548–560.

Clinical/Pediatric Ammerman, R. T., Lynch, K. G., Donovan, J. E., Martin, C. S., & Maisto, S. A. (2001). Constructive thinking in adolescents with substance use disorders. Psychology of Addictive Behaviors, 15, 89–96.

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Bachanas, P. J., & Blount, R. L. (1996). The Behavioral Approach–Avoidance and Distress Scale: An investigation of reliability and validity during painful medical procedures. Journal of Pediatric Psychology, 21, 671–681. Blount, R. L., Bunke, V., Cohen, L. L., & Forbes, C. J. (2001). The Child–Adult Medical Procedure Interaction Scale—Short Form (CAMPIS-SF): Validation of a rating scale for children’s and adults’ behaviors during painful medical procedures. Journal of Pain and Symptom Management, 22, 591–599. Blount, R. L., Cohen, L. L., Frank, N. C., Bachanas, P. J., Smith, A. J., Manimala, M. R., & Pate, J. T. (1997). The Child–Adult Medical Procedure Interaction Scale—Revised: An assessment of validity. Journal of Pediatric Psychology, 22, 73–88. Budd, K. S., Workman, D. E., Lemsky, C. M., & Quick, D. M. (1994). The Children’s Headache Assessment Scale (CHAS): Factor structure and psychometric properties. Journal of Behavioral Medicine, 17, 159–179. Force, R. C., Burdsal, C., & Klingsporn, M. J. (1988). An analysis of socialized coping in outcome data of a residential treatment program for boys with behavior problems. Multivariate Experimental Clinical Research, 8, 251–265. Haverkamp, F., & Noeker, M. (1998). Short stature in children—a questionnaire for parents: A new instrument for growth disorder-specific psychosocial adaptation in children. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 7, 447–455. Hymovich, D. P. (1984). Development of the Chronicity Impact and Coping Instrument: Parent Questionnaire (CICI:PQ). Nursing Research, 33, 218–222. Myers, M. G., & Brown, S. A. (1995). The Adolescent Relapse Coping Questionnaire: Psychometric validation. Journal of Studies on Alcohol, 57, 40–46. Phipps, S., Fairclough, D., Tye, V., & Mulhern, R. K. (1998). Assessment of coping with invasive procedures in children with cancer: State–trait and approach– avoidance dimensions. Children’s Health Care, 27, 147–156. Reid, G. J., Gilbert, C. A., & McGrath, P. J. (1998). The Pain Coping Questionnaire: Preliminary validation. Pain, 76, 83–96. Schanberg, L. E., Keefe, F. J., Lefebvre, J. C., Kredich, D. W., & Gil, K. M. (1996). Pain coping strategies in children with juvenile primary fibromyalgia syndrome: Correlation with pain, physical function, and psychological distress. Arthritis Care and Research, 9, 89–96. Schlundt, D. G., Rea, M., Hodge, M., Flannery, M. E., Kline, S., et al. (1996). Assessing and overcoming situational obstacles to dietary adherence in adolescents with IDDM. Journal of Adolescent Health, 19, 282–288. Spirito, A., Overholswer, J., & Stark, L. J. (1989). Common problems and coping strategies II: Findings with adolescent suicide attemptors. Journal of Abnormal Child Psychology, 17, 213–221. Spirito, A., Stark, L. J., Williams, C. (1988). Development of a brief checklist to assess coping in pediatric populations. Journal of Pediatric Psychology, 13, 555– 574. Spitzer, A. (1992). Coping processes of school-age children with hemophilia. Western Journal of Nursing Research, 14, 157–169.

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Varni, J. W., Waldron, S. A., Gragg, R. A., Rapoff, M. A., Bernstein, B. H., Lindsley, C. B., & Newcomb, M. D. (1996). Development of the Waldron/Varni Pediatric Pain Coping Inventory. Pain, 67, 141–150. Walker, L. S., Smith, C. A., Garber, J., & Van Slyke, D. A. (1997). Development and validation of the pain response inventory for children. Psychological Assessment, 9, 392–405. Weinstein, P., Milgrom, P., Hoskuldsson, O., Golletz, D., & et al. (1996). Situationspecific child control: A visit to the dentist. Behaviour Research and Therapy, 34, 11–21. Zeman, J., Shipman, K., & Penza-Clyve, S. (2001). Development and initial validation of the Children’s Sadness Management Scale. Journal of Nonverbal Behavior, 25, 187–205.

Special Populations Anshel, M. (1996). Coping styles among adolescent competitive athletes. Journal of Social Psychology, 136, 311–323. Kowalski, K. C., & Crocker, P. R. E. (2001). Development and validation of the Coping Function Questionnaire for adolescents in sport. Journal of Sport and Exercise Psychology, 23, 136–155.

Scales Assessing Specialized Strategies Aspinwall, L. G., Sechrist, G. B., & Jones, P. R. (2005). Expect the best and prepare for the worst: Anticipatory coping and preparations for Y2K. Motivation and Emotion, 29(4), 357–388. Davis, C. G., Lehman, D. R., Silver, R. C., Wortman, C. B., & Ellard, E. H. (1996). Self-blame following a traumatic event: The role of perceived avoidability. Personality and Social Psychology Bulletin, 22, 557–567. Davis, C. G., Lehman, D. R., Wortman, C. B., Silver, R. C., & Thompson, S. C. (1995). The undoing of traumatic life events. Personality and Social Psychology Bulletin, 21, 109–124. Delhanty, D. L., Herberman, H. B., Craig, K. H., Hayward, M. C., Fullerson, C. S., Ursano, R. J., et al. (1997). Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents. Journal of Consulting and Clinical Psychology, 65, 560–567. Greenglass, E. R. (2002). Proactive coping and quality of life management. In E. Frydenberg (Ed.), Beyond coping: Meeting goals, visions, and challenges (pp. 37–62). New York: Oxford University Press. Holman, E. A., & Silver, R. C. (1998). Getting “stuck” in the past: Temporal orientation and coping with trauma. Journal of Personality and Social Psychology, 74, 1146-1163. Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61(1), 115–121.

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Pargament, K. I., Koenig, H. G., & Perez, L. M. (2000). The many methods of religious coping: Development and initial validation of the RCOPE. Journal of Clinical Psychology, 56, 519–543. Tennen, H., & Affleck, G. (2002). Benefit-finding and benefit-reminding. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology. (pp. 584–597). London: Oxford University Press.

Foreign-Language Scales German Bodenmann, G., & Perrez, M. (1992). An experimentally induced stress in dyadic interactions (EISI) experiment [Experimentell induzierter stress in dyadischen interaktionen. Darstellung des EISI-experiments]. Zeitschrift für Klinische Psychologie, Psychiatrie und Psychotherapie, 40, 263–280. Erdmann, G. (1984). Investigations on the modification of psychophysiological stress responses by stress-experience [Untersuchungen zur modifikation der Psychophysiologischen reaktionen in einer belastungβtituation durch erfahrung. Archiv für Psychologie, 136, 301–315. Franke, G. H., Maehner, N., Reimer, J., Spangemacher, B., & Esser, J. (2000). First evaluation of the Essener Coping Questionnaire (EFK) in visually handicapped patients [Erste ueberprüfung des essener fragebogens zur krankheitsverarbeitung (EFK) an sehbeeintraechtigten patienten]. Zeitschrift für Differentielle und Diagnostische Psychologie, 21, 166–172. Hampel, P., Dickow, B., & Petermann, F. (2002). Reliability and validity of the German Coping Questionnaire for children and adolescents [Reliabilität und validität des SVF-KJ]. Zeitschrift für Differentielle Und Diagnostische Psychologie, 23(3), 273–289. Hardt, J., Petrak, F., Egle, U. T., Kappis, B., Schulz, G., & Kuestner, E. (2003). What does the FKV measure? An examination of the Freiburger Fragebogen zur Krankheitsverarbeitung in patients with varying diseases [Was miβt der FKV? Eine ueberprüfung des freiburger fragebogens zur krankheitsverarbeitung bei patienten mit unterschiedlichen erkrankungen]. Zeitschrift für Klinische Psychologie und Psychotherapie: Forschung und Praxis, 32, 41–50. Hauser, E., Freilinger, M., Skyllouriotis, M., & Zacherl, S. (1996). Function and structure of families with chronically ill children [Funktion und struktur von familien mit chronisch kranken kindern]. Psychotherapie Psychosomatik Medizinische Psychologie, 46(11), 379–384. Ising, M., Weyers, P., Janke, W., & Erdmann, G. (2001). The psychometric properties of the SVF78 by Janke and Erdmann, a short version of the SVF120 [Die guetekriterien des SVF78 von Janke und Erdmann, einer kurzform des SVF120]. Zeitschrift für Differentielle und Diagnostische Psychologie, 22, 279–289. Klauer, T., & Fillipp, S.-H. (1993). Tierer scales for studying sickness. [Tierer skalen zur krankheitsbewaeltigung (TSK)]. Goettingen, Germany: Hogrefe Verlag fuer Psychologie.

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Klauer, T., Fillipp, S.-H., & Ferring, D. (1989). The Questionnaire for the Assessment of Forms of Coping with Illness: Scale construction and preliminary findings on reliability, validity, and stability [Der “Fragebogen zur Erfassung von Formen der Krankheitsbewaeltigung” (FEKB): Skalenkonstruktion und erste befunde zu reliabilität, validität und stabilität]. Diagnostica, 35, 316–335. Krohne, H. W., Roesch, W., & Kuersten, F. (1989). Assessment of coping with anxiety in physically threatening situations [Die erfassung von angstbewaeltigung in physisch bedrohlichen situationen]. Zeitschrift für Klinische Psychologie. Forschung und Praxis, 18, 230–242. McCubbin, H. I., McCubbin, M. A., Cauble, E., Goldbeck, L. (2001). Fragebogen zur elterlichen Krankheitsbewältigung: Coping Health Inventory for Parents (CHIP)—Deutsche version. Kindheit und Entwicklung, 10, 28–35. Muthny, F. A. (1988). Evaluation of patients’ coping with illness by patients, physicians, and hospital staff: Similarities, differences, and their possible significance [Einschaetzung der krankheitsverarbeitung durch patienten, aerzte und personal: Gemeinsamkeiten, diskrepanzen und ihre moegliche bedeutung]. Zeitschrift für Klinische Psychologie. Forschung und Praxis, 17, 319–333. Neumer, S., Margraf, J., Janke, W., & Erdmann, G. (1997). A review of the Stress Process Questionnaire (SVF) [Testrezension zu Streβverarbeitungsfragebogen (SVF)]. Zeitschrift für Differentielle und Diagnostische Psychologie, 18, 75– 80. Perrez, M., Berger, R., & Wilhelm, P. (1998). Assessment of stress and coping in the family: Self-monitoring as a new approach [Die erfaβung von belastungserleben und belastungsverarbeitung in der familie: Self-Monitoring als neuer ansatz]. Psychologie in Erziehung und Unterricht, 45, 19–35. Rathner, G., & Zangerle, M. (1996). Coping strategies of children and adolescents with diabetes mellitus: A German version of the Kidcope [Copingstrategien bei kindern und jugendlichen mit diabetes mellitus: Die deutschsprachige version des KIDCOPE]. Zeitschrift für Klinische Psychologie und Psychotherapie, 44(1), 49–74. Schwarzer, C., Starke, D., & Buchwald, P. (2003). Towards a theory-based assessment of coping: The German adaptation of the Strategic Approach to Coping Scale. Anxiety, Stress, and Coping: An International Journal, 16, 271–280. Seiffge-Krenke, I. (1989). Coping with everyday problem situations: A coping questionnaire for adolescents [Bewältigung alltäglicher problemsituationen: Ein coping-fragebogen fuer jugendliche]. Zeitschrift für Differentielle und Diagnostische Psychologie, 10, 201–220. Tschuschke, V., Denziger, R., & Gaissmaier, R. (1996). Ulmer coping manual (UCM). Inhaltsanalytische erfassung von bewältigungsreaktionen—Definitionen, abgrenzungen, und beispiele. Unpublished manuscript (3rd ed.). University of Ulm, Department of Psychotherapy. von Salisch, M., & Pfeiffer, I. (1998). Anger regulation in children’s friendship: Devel-

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opment of a questionnaire [Aergerregulierung in den freund-schaften von schulkindern-entwicklung eines fragebogens]. Diagnostica, 44, 41–53. Widmer, K., Bodenmann, G., Cina, A., & Charvoz, L. (2001). The Freiburg Stress Prevention Training for Couples: Meaning of training quality for couples and change in partner quality in the long term [Das freiburger stresspräventionstraining fuer paare (FSPT): Die bedeutung der trainingsqualitt für die compliance der paare und veraanderungen der partnerschaftsqualität im Laengsschnität]. Zeitschrift für Klinische Psychologie, Psychiatrie und Psychotherapie, 49, 262– 278.

Other European Coutu, S., Dubeau, D., Provost, M. A., Royer, N., & Lavigueur, S. (2002). Validation of French version of questionnaire: Coping with Children’s Negative Emotions Scale—CCNES [Validation de la version francaise du questionnaire: Coping with Children’s Negative Emotions Scale—CCNES]. Canadian Journal of Behavioural Science, 34, 230–234. Dijkstra, I., van den Bout, J., Schut, H., Stroebe, M., & Stroebe, W. (1999). Coping with the death of a child: A longitudinal study of discordance in couples. Gedrag und Gezondheid: Tijdschrift voor Psychologie und Gezondheid, 27, 103–108. Garnefski, N., Kraaij, V., & Spinhoven, P. (2001). Negative life events, cognitive emotion regulation and emotional problems. Personality and Individual Differences, 30, 1311–1327. Karlsen, B., & Bru, E. (2002). Coping styles among adults with Type 1 and Type 2 diabetes. Psychology, Health and Medicine, 7, 245–259. Kluwin, T., Blennerhassett, L., & Sweet, C. (1990). The revision of an instrument to measure the capacity of hearing-impaired adolescents to cope. Volta Review, 92, 283–291. Kraaimaat, F. W., Bakker, A., & Evers, A. W. M. (1997). Pain coping strategies in chronic pain patients: The development of the Pain Coping Inventory (PCI) [Pijncoping-strategieen bij chronische pijnpatienten: De ontwikkeling van de Pijn-Coping-Inventarisatielijst (PCI)]. Gedragstherapie, 30, 185– 201. Kraaimaat, F. W., & Evers, A. W. M. (2003). Pain-coping strategies in chronic pain patients: Psychometric characteristics of the pain-coping inventory (PCI). International Journal of Behavioral Medicine, 10, 343–363. Lindqvist, R., Carlsson, M., & Sjoeden, P.-O. (2000). Coping strategies and styles assessed by the Jalowiec Coping Scale in a random sample of the Swedish population. Scandinavian Journal of Caring Sciences, 14, 147–154. Palha, A. P., Araujo, D., Lourenco, M., Nunez, J. S., & Vaz, L. (1993). Rheumatoid arthritis: Some psychosomatic aspects [Artritis reumatoide: Algunos aspectos psicosomaticos]. Actas Luso-Espanolas De Neurologia, Psiquiatria y Ciencias Afines, 21, 9–13. Plancherel, B., Bolognini, M., Nunez, R., & Bettschart, W. (1993). How do early ad-

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olescents face the difficulties? A French version of the A-Cope questionnaire [Comment les Pre-Adolescents Font-ils face aux difficultes? Presentation d’une version francaise du questionnaire A-Cope]. Schweizerische Zeitschrift für Psychologie, 52, 31–43. Plancherel, B., Camparini, N., Bolognini, M., & Halfon, O. (2000). Coping strategies and stress in early adolescents [Les strategies d’ajustement au stress chez les preadolescents. Evaluation a partir d’un entretien clinique semi-structure et du questionnaire A-COPE]. European Review of Applied Psychology/Revue Europeenne De Psychologie Appliquee, 50, 175–185. Richaud de Minzi, M. C. (2003). Coping assessment in adolescents. Adolescence, 38, 321–330. Roeder, I., Boekaerts, M., & Kroonenberg, P. M. (2002). The Stress and Coping Questionnaire for Children (School version and Asthma version): Construction, factor structure and psychometric properties. Psychological Reports, 91, 29–36. Sarmany Schuller, I. (2000). Need for structure and coping processes. Ansiedad y Estres, 6, 39–45. Schaufeli, W., & Van Dierendonck, D. (1992). The reliability and validity of the Utrecht Coping List: A longitudinal study among school-leavers [De betrouwbaarheid en validiteit van de Utrechtse Coping Lijst. Een longitudinaal onderzoek bij schoolverlaters]. Gedrag und Gezondheid: Tijdschrift voor Psychologie und Gezondheid, 20, 38–45. Schraggeova, M., & Roskova, E. (2000). Risk from the view of evaluation and coping [Riziko z pohl’adu hodnotenia a zvladania]. Ceskoslovenska Psychologie, 44, 515–527. Soriano, J., & Monsalve, V. (1999). Assessment, coping and emotion in patients with chronic pain [Valoracion, afrontamiento y emocion en pacientes con dolor cronico]. Boletin De Psicologia (Spain), 62, 43–64. Strizenec, M. (2000). Religion and coping: Empirical verification of their interaction. Studia Psychologica, 42, 71–74. van Zuuren, F. J., de Groot, K. I., Mulder, N. L., & Muris, P. (1996). Coping with medical threat: An evaluation of the Threatening Medical Situations Inventory (TMSI). Personality and Individual Differences, 21, 21–31.

Asian Chan, D. W. (1994). The Chinese Ways of Coping Questionnaire: Assessing coping in secondary school teachers and students in Hong Kong. Psychological Assessment, 6, 108–116. Kudoh, T. (1986). A study of the feeling of loneliness in pubertal youth. Japanese Journal of Psychology, 57, 293–299. Shek, D. T. L., & Cheung, C. K. (1990). Locus of coping in a sample of Chinese working parents: Reliance on self or seeking help from others. Social Behavior and Personality, 18, 326–246. Shek, D. T. L., & Tsang, S. K. (1993). Coping responses of Chinese parents with pre-

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school mentally handicapped children. Social Behavior and Personality, 21, 303–312. Suzuki, T., Yoda, A., Koshikawa, F., Sugiwaka, H., Shimada, H., Seto, M., & Agari, I. (1997). Development of the short-form version of Life Style Index-J. Japanese Journal of Health Psychology, 10, 31–43. Xiao, J., Xiang, M., & Zhu, C. (1995). Coping behavior of 587 adolescent students: Age, sex and coping style. Chinese Mental Health Journal, 9, 100–102.

Other Gil, T. E., Litman, A., & Nadav, M. (1994). A Hebrew version of the Millon Behavioral Health Inventory: Preliminary results—brief report. Israel Journal of Psychiatry & Related Sciences, 31, 121–125.

STRESS, COPING, Statistical Issues in Coping AND DEVELOPMENT Research

CHAPTER 9

Statistical Issues in Coping Research

T

here are some critical methodological issues concerning the mechanisms of the relation between stress, coping, and health. As such, some of the stress and coping literature can be statistically complex. Not only are there key constructs that need to be addressed, but understanding the statistical means by which the constructs are tested is crucial. Quite often, researchers simply assume one particular model, or assume that coping must be working in a particular way, without actually having adequately tested different models. Thus, before reviewing the literature on coping and health, some understanding of what the different models are and how they are tested is important and is the raison d’être for this chapter. Further, there is increasing interest in longitudinal studies of stress and coping, especially for daily diary studies, and thus some of the newer longitudinal statistics used for assessing and predicting change will also be included.

MECHANISMS OF COPING EFFECTS There are three possible ways in which coping can affect well-being. First, there may be direct effects on health outcomes. Second, the effects of coping on health may be mediated through another variable, such as medical compliance. Third, coping strategies may moderate or buffer the effects of stress on health. (For a classic discussion of mediating and 161

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moderating effects in the social sciences, see Barron & Kenny, 1986.) The statistical mechanisms for investigating these effects will be reviewed in the following section.

Direct Effects Most studies of coping and well-being implicitly assume a direct effects model; by simply using a correlational or regression analysis, such studies assume that particular coping strategies are simply linked to particular types of outcomes. That is, the more that problem-focused coping is utilized, the lower the psychological or physical distress. This is a simple bivariate approach to the problem and assumes that the nature of the relation between coping and well-being looks like that depicted in Figure 9.1. In short, coping is assumed to have direct causal effects on whatever outcome variable is under study. Thus, if a coping strategy or style is correlated with lower blood pressure levels, shorter hospital stays, or better affect, it is assumed that somehow the coping strategy has directly affected physiological or psychological processes. While this is certainly possible (and, to my mind, probable in some instances), this simplistic assumption is probably incorrect in many cases and may account for the often quite modest effect size of coping in such studies. Simply associat-

FIGURE 9.1. Direct relationship between coping and distress.

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ing coping with health outcomes through correlational or group differences techniques tells us nothing about the all-important question of the mechanism(s) through which coping affects health. By examining moderating and mediating effects we can begin to understand such mechanisms and thus examine the nature of the link between the mind and the body.

Mediating Effects Some of the effects of coping on health problems may be mediated or indirect rather than being direct effect(s). In other words, coping strategies may not directly affect physiology (e.g., lower cholesterol levels) but rather may indirectly affect health outcomes through a change in a health behavior habit (e.g., quitting smoking), which in turn leads to decreases in cholesterol. For example, it has been observed that women diagnosed with breast cancer who use more active forms of coping live longer than women with more passive coping styles (Greer & Morris, 1975; Morris, Greer, Pettingale, & Watson, 1981). The conclusion that many people immediately draw is that coping directly affects immunocompetence, which is why these women live longer. However, it is also plausible that actively coping women do other things, such as quit smoking, start exercising, improve their nutrition, and faithfully adhere to their medical regimen, all of which are known to affect immunocompetence. Thus, coping may not have a direct effect on physiology but only an indirect or mediating effect by leading to other behaviors that do directly affect physiology. For example, one 80-year-old woman I know had severe osteoporosis. Her spine had broken so many times that her ribs were resting on her hip bones. Her physician told her that there was nothing he could do and that she should simply go home, go to bed, and await death. “Doctor,” retorted this spunky woman, “I refuse to accept your diagnosis. There must be something that I can do.” Laughing, the physician told her that he liked her spirit and said that he would recommend her for an experimental program at the local research university. This retired nurse adhered faithfully to the regimen of injecting herself periodically with calcium and a special type of vitamin D, and her bone density did increase, thus extending her lifespan. In this instance, there would be a statistical association between active coping style and bone density, but it would be a mistake to assume that the link was direct and that coping affected calcium metabolism and, thus, longevity. Rather, this effect was indirect because this woman’s active coping style led her physician to recommend her for an experimental program that did affect her calcium metabolism and, thus, her quality and length of life. There can be an as-

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sociation between coping strategies and physiological outcomes that are not direct but mediated through practicing health behavior habits, taking advantage of medical opportunities, and adhering to medical regimens.

Moderating Effects Most of the literature on moderating effects, also known as buffering effects, involves the effects of social support on health outcomes (e.g., Dooley, 1985; Finney, Mitchell, Cronkite, & Moos, 1984). However, the observations in that area are directly relevant to coping mechanisms as well. The resolution of this argument is crucial not only in determining whether coping is largely based on personality characteristics or interactions between the person and the environment but also to discovering how coping affects psychological and physical health. As we have seen, the direct effects model proposes that coping will be associated with a given outcome regardless of the level of stress. In this model, active or direct coping will always be associated with good outcomes, no matter how stressful the problem. In contrast, the buffering model posits that coping has an effect on outcomes only to the extent that coping moderates the effects of stress on the outcome. That is, active coping will affect outcomes only because it reduces the negative effects of stress, especially at higher stress levels. Why is this question of direct versus buffering mechanisms important? In social support research, it is thought to be important because it reveals something about the underlying mechanism of how social support relates to health outcomes (House, Landis, & Umberson, 1988). For example, we know that married men tend to live longer than single men. If this is because having a spouse helps reduce stress, then we suspect that social support from a spouse enhances physical health by reducing the deleterious effect of stress—in which case, there should be a significant statistical interaction effect between marital status and stress on health. In other words, unmarried people or those with poor marriages will experience more symptoms under high stress, while those with good marriages will not have more symptoms, because they are protected from the negative effects of stress by social support. If, on the other hand, being married has only a direct effect, then we may suspect that social support per se is not that important, but rather that healthier people are more likely to be married. Thus, married people might have better health regardless of the stress level. This is especially important in quasi-experimental designs, that is, naturalistic studies that use surveys or interviews to assess existing levels of social support. In these studies, social support is thought to have a di-

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rect causal effect on health only if there is an interaction effect between stress and social support on health outcomes. If there is only a direct effect, then it is entirely possible that social support is confounded with something else (like personality or health), which may be the key causal link. Obviously in experimental studies social support can be shown to have causal effects regardless of the existence of any interaction, because one can externally manipulate the social support variable. Lynch’s (1979) studies of the effects of a nurse’s touch on the heart rate of patients in cardiac intensive care units is a good example of the latter. In coping research, the interpretation of direct versus buffering effects may be more complex. Aldwin and Revenson (1987) suggested that direct effects support the idea of personality-based coping, whereas interaction effects support a model of coping based on person–situation interactions. In other words, if a particular strategy such as avoidant coping shows only direct effects and no interaction effects, then people who use this strategy often are more likely to be distressed regardless of the external environment, which suggests an underlying problem in psychopathology. On the other hand, if coping has a moderating effect, then this suggests that what an individual does in a particular situation may decrease (or enhance) the effects of stress. In other words, deducing the mechanism through which coping affects health outcomes aids in answering the more basic question of whether coping is primarily a function of personality or is a joint expression of the effects of both the person and the situation. It is also possible that direct versus moderating effects can be interpreted vis-à-vis the causal effects of coping on health in the same manner as social support and health. For example, let us suppose that expressing emotions is associated with increased blood pressure. If threat minimization results in lower blood pressure regardless of stress level, then one could argue that the relationship between threat minimization and blood pressure is simply a function of preexisting personality characteristics; calm, phlegmatic people may have lower blood pressure in general. However, if threat minimization is associated with lower blood pressure primarily under conditions of high stress, one could argue that this coping strategy serves to buffer the effects of stress on high blood pressure and thus may have causal effects regardless of personality. It is also true that in a quasi-experimental setting, it may be impossible to totally rule out the preexisting effects of personality. In this instance, a better study would involve an experimental design in which people are taught how to use a particular coping strategy and then observe its effect on physiological outcomes (e.g., Lazarus et al., 1962). Nonetheless, an interaction effect provides some evidence that coping has a causal effect on health outcomes. If true, this means that people may be taught to cope in ways

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that can enhance their health, which is one reason why the study of coping is so important.

STATISTICAL ANALYSES FOR TESTING MEDIATING AND MODERATING EFFECTS More complex models of the effects of coping require more complicated statistics, and some researchers may be put off by the difficulty of using these statistics. This section will provide a brief and somewhat simplified guide to the statistical calculations involved in more complex studies of coping and its effects. In general, there are two types of statistical procedures used to examine direct, mediating, and moderating effects in coping research: regression equations and structural equation models. Regression equations examine multiple predictors of a single outcome variable. Useful statistics generated by the regression equations are the B and the beta (ß), which are simply the unstandardized and standardized estimates, respectively, computed for each variable in the model. Bs are the absolute amount a predicted variable (Y) changes as a function of x, while ßs are the relative amount vis-à-vis other variables in the model. Betas can be thought of as partial rs. If the B and ß are positive, that means that there is a positive association between the independent variable and the outcome measure. In other words, the higher the stress, the more symptoms are reported. If the B and ß are negative, there is a negative association between the independent variable in the outcome measure—that is, when more problem-focused coping is used, fewer symptoms are reported. Thus, a regression equation will indicate whether a particular variable is significantly associated with the outcome, as well as the direction of the association. Another useful statistic generated by regression equations is the R2, which refers to the amount of variance in the dependent, or outcome, variable accounted for by the independent variables. If, for example, the R2 term for the equation is .25, we know that our independent variables account for 25% of the variance in the outcome measure. There are many different types of regression equations. Hierarchical regression equations allow one to determine the amount of independent variance accounted for by each variable (or, sometimes, sets of variables) in each step, referred to as the change in R2, or ∆R2. If the ∆R2 for a particular variable is significant, this means that the variable in question accounts for additional variance over and above the amount accounted for by the variables that were entered in earlier steps. This should not be confused with stepwise regression, in which the computer picks the independent variables that significantly relate to the outcome measure and

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then generates an overall R2. As we shall see, hierarchical regressions are used to examine both mediating and moderating effects. Alternatively, many researchers are turning to structural equation modeling (SEM), including path analysis and latent variable analysis such as LISREL (Joreskog & Dag, 1993), to examine both mediating and moderating effects. Path analysis is simply a series of regression equations that trace out the direct and indirect pathways between a predictor variable and an outcome (or multiple outcomes), while latent variable analyses are path models that include factor analyzing the measures to generate the “purified” or latent variable structure. Note that, in depicting a latent construct, the standard procedure is to use an oval, while the indicator (or directly measured) variables are put in boxes. In SEM, one tests the goodness of fit of the model—in other words, does the predicted model deviate significantly from the observed model? In the best model, the X2 would be insignificant, that is, the predicted model would not significantly differ from the observed data, and the various goodness of fit indices would be high (e.g., GFI ≥ .95)—and the error variance (root mean square error of approximation) should be low (e.g., RMSEA ≤ .05). Path modeling can be a rather simple procedure. Most programs allow the researcher to draw the models and then run them, instead of having to input covariance matrices and numerically specify fixed versus free paths, error terms, etc., which do, however, allow one more control over the more esoteric components of the model. Generally, SEM models that examine latent variable effects are somewhat more difficult to interpret but may be more flexible than path models. However, there is also much room for nonsense with SEM procedures. Some researchers simply dump variables into equations, turn the crank, as it were, and let the model run, without a modicum of theory to underlie either the choice of variables or their order in the model, which generally results in uninterpretable models. Garbage in, garbage out, as they say. Nonetheless, theoretical models carefully specifying moderating and/or mediating hypotheses, combined with judicious use of SEM modeling, can lead to some very exciting research.

Mediating Effects Let us return to the example used earlier, in which a researcher noted an association between problem-focused coping and bone density but wondered if the effect was mediated through compliance with medical treatment. Mediated effects can be tested by using either hierarchical regression or SEM. The simplest way is to compute a set of nested or hierarchical regressions (see Barron & Kenny, 1986). In this model, stress

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(and whatever covariates are in the model) are entered in the first step to predict the outcome, bone density. In the second step, coping is entered. In the third step, the hypothesized mediators are entered—in this instance, vitamin D and calcium injections. If these health behavior habits significantly reduce the ß between coping and bone density, then the health behavior habits are said to mediate between coping and bone density (see Figure 9.2). Ideally, the ß between coping and bone density becomes nonsignificant, which clearly shows a mediating effect. However, often it is reduced but still remains significant. In this case, the effect may be partially mediated through health behavior habits, but clearly some direct effects remain—or perhaps another potential mediator, like smoking, exists. Sometimes the effect is extremely clear—for example, the ß, although significant, is halved (e.g., from .6 to .3). A .3 ß may still be significant, but the effect is clearly reduced. However, what if the ß is reduced from .3 to .22? Is that a significant effect? Cohen and Cohen (1975) recommend testing for the significance of the differences between ßs, using the Sobel test. (A convenient online calculator for the Sobel test can be found at www.unc.edu/~preacher/sobel/sobel.htm.) In this instance, a structural equation model would be constructed that looked like Figure 9.3. This model assumes that coping is measured using three problem-focused indicators, while compliance is assessed using two indicators—the percentage of times the vitamin D shot was

FIGURE 9.2. Direct and mediated effects.

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λ

λ

λχ

β β

λ

λ

FIGURE 9.3. Coping and bone density.

taken, and the percentage of prescribed calcium doses taken. Finally, bone density was directly assessed. If all of the effect of coping is mediated through compliance, than the ß between coping and bone density (ß13) would be insignificant, while the ßs between coping and compliance (ß12) and then between compliance and density (ß23) would both be significant. One should also check to make sure the indirect path is significant—sometimes the strength of the ßs is insufficient to generate significance for the indirect path. Alternatively, one can construct two different models, one in which there is a mediated effect and one in which there is not, and then compare the goodness of fit of both models. In particular, one should examine the change in X2, to determine whether the mediated model is significantly better than the nonmediated model. So, if the equation with the mediated term is a better fit to the model, and if the change in X2 is significant, then one can conclude that the mediated model is the preferred model.

Moderating Effects Early studies of coping illustrated moderating very simply by dividing respondents into “bad” or “good” copers (e.g., Locke et al., 1984). Among the “bad” copers, there would be a positive correlation between stress and outcomes, whereas among the “good” copers there would be little or no relationship. In other words, “good” coping buffered or reduced the negative effects of stress on an outcome. The coping mechanisms were thus thought to protect an individual against the adverse effects of stress. In more recent research, direct versus buffering models are usually tested with hierarchical regression equations (Finney, Mitchell, Cronkite,

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& Moos, 1984). This mitigates against the problems associated with dividing people (more or less arbitrarily) into groups (Cronbach & Snow, 1977). In a hierarchical regression model, first the stress variable, then the coping strategy, and then the interaction term are entered into the equation in separate steps. The interaction term is generated by multiplying the coping variable by the stress variable. In hierarchical regression terms, determining whether coping has a direct or buffering effect is entirely dependent on whether the ∆R2 for the interaction term is statistically significant. If it is not significant, then coping (assuming its ∆R2 is significant) is said to have a direct effect. In other words, the association between coping and outcome exists regardless of the level of stress that the individual is facing. On the other hand, if the interaction term is significant, the coping variable is said to have a buffering or moderating effect. That is, the relation is dependent upon the degree of stress that an individual is facing. An example is in order. Let us suppose that a researcher wants to know whether problem-focused and emotion-focused coping have direct or buffering effects on depressive symptoms in people undergoing a divorce. The researcher would construct a hierarchical regression equation in which the variable indicating the stressfulness of the divorce is entered in the first step, the coping variable in the second step, and the stress × coping interaction term in the third step. Let us suppose that the outcome of the hierarchical regression for emotion-focused coping shows significant ∆R2s and positive ßs for both the stress and coping variables, but the interaction term is not significant. This means that the more stressful the divorce and/or the more emotion-focused coping used, the worse the depressive symptoms. Because the interaction term is not significant, emotion-focused coping is said to have a direct rather than a buffering effect. In other words, the use of this strategy will increase symptoms regardless of how stressful the divorce is. Our hypothetical hierarchical regression equation for problemfocused coping, however, yields a different result. Let us suppose that the stress variable accounts for a significant 12% of the variance and has a positive B of .25, the coping variable accounts for an additional 8% and has a negative B of .20, and the interaction term account for a significant 5% of the variance and also has a negative B (–.07). In this example, problem-focused coping is said to moderate the effect of stress on depression. Note that it is entirely possible that the direct effect of coping will be statistically insignificant, but the interaction term is significant. In other words, the correlation (or partial correlation, controlling for stress) between coping and the outcome measure may appear to be

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nonsignificant. If researchers do not use a hierarchical regression equation to look for interaction effects, they may erroneously conclude that a particular coping strategy has no effect on the outcome measure. If the interaction term is significant, before we can say that problem-focused coping buffers, or decreases, the adverse effects of stress on depression, it is necessary to determine how problem-focused coping is moderating the effects of stress. This is done by solving the equation in such a manner as to generate three lines (Cohen & Cohen, 1975)—in this instance, the effect of coping under high stress, medium stress, and low stress—and then graphing those lines. The regression equation is a simple algebraic equation. Let x1 = stress, x2 = coping, a = the intercept, and Y = the outcome, or depressive symptoms. Remember that the interaction term was generated by multiplying the stress term (x1) by the coping term (x2). The researcher then constructs the basic equation: Õ = B 1 x 1 + B2 x2 + B 3 x 1 x 2 + a or, in this instance, Õ = .25 x1 – .20 * x2 – .07 x1 x2 + a This simply says that depression equals .25 × stress level –.20 × coping level –.07 × the interaction term (plus a, the error term or intercept, which stands for everything else that is not being directly measured but which nonetheless can affect depression). Note that the Bs rather than the ßs must be used when calculating the lines. Then, the researcher calculates what would constitute high, medium, and low stress, generally operationalized as the mean + 1 standard deviation (SD), the mean, and the mean –1 SD, respectively. The researcher then calculates high, medium, and low levels of problem-focused coping by using the same technique. (Sometimes the SD is greater than the mean, resulting in a negative number that is difficult to interpret. I usually just substitute 0 for the low term to simplify things.) Recollecting high school algebra, three points are needed to generate a straight line. Thus, the regression equation needs to be solved nine times. For the first three solutions, substitute the high-stress value for x1 and then solve the equation for low, medium, and high coping (x2). Repeat this procedure substituting the medium-stress value, and then the low-stress value, for x1. Then graph the three lines. If a buffering effect exists, the graph should look something like Figure 9.4. In other words, if a respondent uses a lot of problem-focused coping, there is no relationship between stress and depression (the bottom line). If, on the other

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FIGURE 9.4. Classic buffering effect.

hand, the respondent only uses a little or no problem-focused coping, there is a strong and positive relationship between stress and depression (top line). Note that it is possible to get a moderating effect in which the coping strategy actually enhances the effects of stress. This may happen if the ß for the interaction term is positive—in which case, the graph may look something like Figure 9.5. In other words, the more this particular

FIGURE 9.5. Enhancing effect.

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coping strategy is used, the stronger the relationship between stress and depression. It is also possible to get interaction effects that may look something like Figure 9.6. With this type of interaction effect, a coping strategy may have a very different effect, depending upon the seriousness of the problem. For example, ignoring a problem may be a very good strategy if the problem is fairly minor (in common parlance, “not sweating the small stuff”). However, ignoring a serious problem may have disastrous effects. Alternatively, this type of interaction pattern may be common if the coping strategy has a situation-specific effect. In this case, one computes “dummy,” or dichotomous, variables indicating the situation (preferably –1, 1) and then simply multiplies the dummy variable by the coping strategy. For comparison purposes, solving an equation in which the interaction term is not significant will generate three parallel lines. In that case, the graph will look something like Figure 9.7. There are several things that can go wrong when using a hierarchical regression equation to examine interaction effects. If the lines generated by solving the equation are not straight but rather are curved, this means that there is a calculation error at some point. First-order regression equations by definition generate straight lines, which may or may not accurately depict the relation between stress, coping, and outcomes. It is entirely possible that there is a nonlinear relation between, say, stress and depression—in which case, one can look for nonlinear effects by including squared (or even higher-order) terms (in other words, x12)

FIGURE 9.6. Complex interaction effect.

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FIGURE 9.7. Direct effect.

in the regression equation. To my knowledge, no one has tried to examine nonlinear interaction terms in stress research. The other problem is multicollinearity. This results when the variables being multiplied to generate the interaction term are strongly correlated, as stress and coping variables often are. An unfortunate effect of multicollinearity is “bouncing betas,” in which the direction of the ßs can shift, sometimes dramatically, depending upon which variables are in the equation (Cohen & Cohen, 1975). For example, on the first step of the hierarchical regression equation, stress may have a positive ß. Once the interaction term is entered, however, stress may have a negative ß (hence, the term “bouncing betas”). This does not mean that higher stress levels reduce symptoms. Rather, multicollinearity produces a statistical artifact that can distort the true picture of the results. Multicollinearity may be reduced by “centering” the terms around zero by subtracting the respective means from each of the variables. Centering the terms reduces the magnitude of the correlations between the independent variables, thus reducing multicollinearity. (Note that these are nonlinear transformations, since different values are subtracted for each variable.) Sometimes researchers will construct a hierarchical equation that includes multiple coping strategies and their interaction terms. In this procedure, the stress variable is entered in step 1, the several coping variables in step 2, and their several respective stress × coping interaction

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terms in step 3. This procedure has the beneficial effect of parsimony in that only one regression equation is generated. However, this procedure greatly enhances the problem of multicollinearity. I think this is best avoided by generating separate regression equations for each coping strategy. Generally, the magnitude of interaction effects is rather small— often about 1% of the variance. Thus, one must have a large enough sample size, or enough statistical power, to ensure that an effect is not erroneously disregarded. This lack of power is actually very serious. McClelland and Judd (1993) report that interaction effects might be more difficult to find in field (as opposed to experimental) settings, and very large sample sizes may be required to have sufficient power to correctly judge the significance of interaction effects. Thus, we may have been erroneously concluding that coping does not buffer stress when in actuality we simply do not have enough power (i.e., a sample of sufficient size) in most instances to adequately test for the significance of interaction terms. Recently, some statisticians have begun to question the wisdom of including interaction terms in a regression equation to test moderating effects (von Eye & Schuster, 1998). There is some concern that (1) centering may distort the data, (2) the multiplicative terms might actually be examining nonlinear rather than interaction effects, and (3) there has been a lack of theoretically based usage of this technique. However, interaction effects can be highly effective in demonstrating the situational specificity of coping strategies as long as their use is theory-driven. SEM can also be used to examine interaction effects. The most common way is to stratify the sample on the moderator, dividing the sample into two different groups (e.g., high and low problem-focused coping) and then comparing the SEM equations for the two groups. Alternatively, one can also include interaction effects with latent variable models (see Kenny & Judd, 1984).

LONGITUDINAL ANALYSIS OF STRESS AND COPING DATA During the decade since the first edition of this book, more researchers have been using longitudinal data in their stress and coping designs, generally for one of two reasons. The most common reason is to examine the efficacy of stress and coping variables in predicting disease incidence or outcomes. The second is to examine change in stress or coping processes. Daily diary studies present particular analysis challenges and will be discussed separately.

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Predicting Outcomes The most common design is to use Time 1 data (e.g., stressful life events) to predict the development of disease, or, among those who have disease, to predict mortality or the reoccurrence of a specific event. The most commonly used statistic in this instance is a Cox proportional hazards model (Cox & Oakes, 1984). This is a special form of logistic regression that in general has dichotomous outcomes—that is, disease/no disease— and provide odds ratios, or the risk of developing the disease. Note that in these models there is usually a comparison group. Thus, one might contrast smokers with nonsmokers or those who have any stressful life events with those who have none. Thus, the odds ratio is always interpreted relative to a group. An odds ratio of 1 indicates that there are no differences between the two groups. A ratio greater than 1 indicates that there is a greater risk, while one less than 1 indicates that there is a lower risk. A confidence interval provides a range and indicates significance, and, to be significant, must not go through 1. Thus, an odds ratio of 1.6 with a confidence interval of .2 to .4 indicates that there is a statistically significant (60% in this instance) increased risk of, for example, smokers having breast cancer than nonsmokers. However, an odds ratio of 1.2 with a confidence interval of .9 to 1.10, means that the 20% increase in risk is not statistically significant. The Cox proportional hazards model differs only in that it provides a relative risk ratio (RR) that includes a time component—that is, what is the relative risk of a smoker versus a nonsmoker developing disease over a given period of time? Sometimes, however, the outcome variable is continuous, not dichotomous, and logistic regressions are not appropriate. For example, a researcher may be interested in the relationship between coping and depression. A simple cross-sectional design may not be appropriate, because one cannot determine causal directionality, that is, poor coping such as rumination may lead to higher levels of depression (NolenHoeksema, 2000), or depressed individuals may use poorer coping strategies in general (Coyne et al., 1981). To examine the ability of coping to predict change, one can either calculate change scores from Time 1 to Time 2 (e.g., T2 – T1) or use residualized regression equations, in which one uses hierarchical regression to covary out the dependent variable at T1. Cronbach and Furby (1970) argued strongly against using simple change scores, because they do not take into account baseline measures, or the clinical significance of differences in the import of different parts of the scale. Take, for example, body temperature. A change in body temperature from 98 to 100 means that an individual has a slight temperature; a change from 104 to

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106 can be fatal. A residualized regression takes into account baseline levels, and thus may provide a more accurate picture. Rogosa (1988), however, has argued that simple change scores can be very informative, especially when there is no reason to assume that there are these clinically significant cut-off points. In some instances, it is reasonable to suppose that there may be bidirectional causal influences, such as that between coping and depression. In this instance, a cross-lagged panel design, such as that depicted in Figure 9.8, may be most appropriate. In this instance, we examine both coping and depression at T1 and T2. At Time 1, we cannot ascertain causal directionality—hence the curved arrow, which indicates only that these two covary. The top lines ß13 and ß24 indicate the autocorrelation, or how stable each of the variables are. The cross-lagged indicators examine the relative predictive ability. That is, ß14 indicates the ability of coping to predict depressive symptoms at T2, controlling for depressive symptoms at T1, while ß23 indicates whether depressive symptoms at T1 can predict change in coping from T1 to T2. Comparing the two ßs allows you to estimate causal directionality. However, this estimate may be somewhat inaccurate if there are differences in autocorrelation between the two variables. For example, if one is assessing a coping styles measure that is presumably stable, the autocorrelation would be relatively high, with a cross-time correlation of .6. However, depressive symptoms may fluctuate, and their cross-time correlation would only be .3. Thus, there is less remaining variance to predict in coping styles than in depressive symptoms, and one would almost always find that coping could predict change in depressive symptoms more than the other way around. However, if one were using a

β13 β14 β23 β24

FIGURE 9.8. Cross-lagged panel model.

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coping process measure, which is presumably less stable, then one might be more likely to find bidirectional influences.

Estimating Change Sometimes the research question is simply whether or not there is change in either stress or coping variables. Change can be measured in one of four different ways (see Caspi, Bem, & Elder, 1989). Mean-level or absolute change assesses whether a variable increases or decreases. For example, we know that the level of hassles and of life events fluctuates with age, depending upon what type of stressor is measured (Almeida & Horn, 2004). Paired t-tests or, better, repeated-measures ANOVAs (analyses of variance) can be used to assess whether the mean level of something has changed over time. (Repeated measures are better because they control for correlated errors, for example, response biases that can inflate estimates of stability.) Correlational change refers to rank-order stability, that is, whether individuals maintain their relative rank order across time. Thus, if one takes a coping styles approach, it is reasonable to suppose that Martin may score higher on avoidant coping than Reneé at both time points, and thus the correlation may be relatively high. If, however, coping is situation-specific, then one would expect the cross-time correlation to be relatively low. Structural change refers to the relations among the variables. For example, if coping strategies mean different things to older versus younger people (or are utilized differently in different age groups), then the factor structure may change over time. For example, it is not uncommon for a 2-year-old to kick and bite to express frustration; hopefully by the time an individual is 20, this type of coping behavior no longer occurs. Thus, the items assessing this strategy would be so infrequently endorsed in a sample of 20-year-olds that they would not load on any factor, although they might be strong indicators of aggression in a 2-year-old. Finally, ipsative or idiothetic change refers to individual differences in change. For example, if Martin reports more stress over time but Reneé reports less, in aggregate the change may be 0, and thus one would incorrectly conclude that there is no change. However, there are individual differences in how people change, and these can be tracked by more complex statistics that examine trajectories of change, such as growth curve models.

Analyzing Daily Diaries Daily diaries and experience sampling designs present particular analytical challenges because by definition they require the use of longitudinal

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statistics, as there are multiple assessments, either across or even within days. These are highly useful designs, because they can examine either within-subjects or between-subjects effects. For example, Tennen and his colleagues (Tennen et al., 2000) have shown that within-subjects designs can show greater effects of coping on pain than do between-subjects designs. That is, individual fluctuations in coping may better predict dayto-day changes in pain (within subjects) than do individual differences in the use of particular coping strategies (between subjects). Affleck, Zautra, Tennen, and Armeli (1999) provide an excellent review of the best means of analyzing such data. The most commonly used is some sort of multilevel modeling procedure, variously called two-stage growth curve models (Rogosa, Brandt, & Zimowski, 1982), hierarchical linear modeling (Bryk & Raudenbusch, 1992), or random effects models (Garrett, Laird, & Ware, 1982). Simply put, in the first stage of these models, trajectories are calculated for each individual (within subjects). For various statistical reasons, it is often better to calculate the overall trajectory for the sample (fixed effects) and then calculate individual deviations from that mean trajectory (random effects).1 These models yield an intercept, slope, and goodness-of-fit measure for each individual for each of the variables in question. Thus, one can track both pain and coping, and see how they covary across time. One can also use latent growth curve models (McArdle & Bell, 2000), which are longitudinal structural equation models, which have two or more time points. Mplus (Muthén & Muthén, 2000) is a new program that can identify patterns within latent growth curves. In the second stage of the model, the researcher can then predict group or between-subject differences in individual trajectories, or how individual trajectories covary. Thus, one could ask, for example, if individuals with eating disorders have more pronounced negative emotional reactions to social criticisms over time than do individuals without eating disorders (e.g., Steiger, Gauvin, Jabalpurwala, Séguin, & Stotland, 1999). The other good thing about these types of models is that they can readily accommodate unbalanced designs and/or those with missing data. For example, in the Normative Aging Study, we collected data on different time schedules depending upon the respondent’s age, with older 1For

example, one can simply calculate regression equations for each person to generate individual trajectories. However, if the person has no change, the root mean squared error (RMSE) term can be 0, and thus it is not possible to get a goodness-of-fit estimate, because one cannot divide the slope by 0. It is highly unlikely that an individual will have the identical slope to the mean, and thus looking at individual deviations from the mean slope will almost always yield interpretable data.

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men getting more frequent assessments. This created difficulties, because the older statistics such as repeated measures MANOVAs (multivariate analyses of variance) required that all respondents have data at all time points, which were preferably evenly spaced. Trajectory models, however, can better accommodate missing or unbalanced data because they simply estimate what that response would have been, based upon the individual’s trajectory. In any daily diary or experience sampling study, missing data may be a problem—obviously, the greater the number of assessments, the more likely there are to be missing data. These models are highly complex, and there are still many technical debates going on as to their proper usage (Bauer & Curran, 2003). For example, often it is useful to center individuals’ trajectories (to avoid multicollinearity, as the time X person, or within-subjects term, is an interaction), but one can obtain different results depending upon whether one centers using the group mean or the individual’s mean. Nonetheless, these newer models are extremely useful in that they allow research to test more sophisticated models, especially in field settings.

SUMMARY The good news is that we are generating more complex models of adaptation, and the statistical techniques are becoming sophisticated enough to allow researchers to examine these more interesting models. The bad news is that these new statistical techniques are in themselves highly complex and may be difficult to use and interpret. However, it is important to understand that they are simply tools that can be put to very good purpose and are well worth the effort.

STRESS,and Coping COPING, Mental AND HealthDEVELOPMENT

CHAPTER 10

Coping and Mental Health

T

he past few years have seen some dramatic incidents of student violence, such as the massacre at Columbine High School and the case of the graduate student at Stanford University who shot several members of his dissertation committee. In these types of incidents, the students who murdered their fellow students and colleagues were subjected to what they felt was unbearable stress and chose to retaliate in particularly heinous ways. At an individual level, these can be seen as failures to cope— individuals who saw no alternatives and could do nothing else with the rage and despair they felt than to lash out at others. Sometimes individuals cope in ways that are self-destructive, such as turning to drugs and alcohol, or other “acting-out” behaviors such as unsafe sex with multiple partners, gambling, shopping to excess, shop lifting, and the like. For reasons that are not clear, Twenge’s (2000) analysis of multiple archival studies found there has been an increase in mental health problems such as anxiety in more recent cohorts. One possible reason is a failure to cope with stress on a massive level, making it imperative to understand what are the most effective ways to cope with stress. Much of psychotherapy involves teaching individuals new and presumably more effective coping strategies for dealing with both problems in the environment and ways to regulate their emotions. Thus, it makes a certain amount of sense to study how individuals cope in order to determine what are the best ways to achieve an individual’s goals, and the vast majority of coping research utilizes mental health outcomes. In general, the research over the past 20 years has found that how 181

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individuals cope with stress is related to their mental health status. Stress and coping variables can account for as much as 50% of the variance in outcomes such as depression or psychological symptoms (Aldwin, 1991; Aldwin & Revenson, 1987; Folkman, Chesney, Pollack, & Coates, 1993). In a meta-analysis of the relationship between coping and health outcomes, including mental health, Penley, Tomaka, and Wiebe (2002) found that problem-focused coping was, in general, related to better mental health. Indeed, it makes a certain amount of intuitive sense that solving the problem is the best way to decrease emotional distress. When we were interviewing male participants in the Normative Aging Study about their coping strategies and asked them how they handled their emotions, many cited only problem-focused strategies (see Aldwin, Sutton, Chiara, & Spiro, 1996). A typical response was “What did I do about my emotions? Well, I fixed the problem!” However, in Penley et al.’s (2002) review, all of the other coping strategies, including social support and a variety of emotion-focused coping scales, were associated with higher levels of psychological symptoms. This is a succinct statement of a paradox in much of the coping literature. The definition of emotion-focused coping is that it regulates or controls the negative affect resulting from stress so that problem-focused efforts can be maintained (Folkman & Lazarus, 1980; White, 1961). But in nearly every study of coping, emotion-focused coping is associated with increased distress, and sometimes problem-focused coping is as well (Aldwin & Revenson, 1987; Folkman & Moskowitz, 2004; Stanton, Danoff-Burg, Cameron, & Ellis, 1994; Stanton, Kirk, Cameron, & Danoff-Burg, 2000). If the function of emotion-focused coping is to decrease stress, why then do our measures almost uniformly show positive relations with symptoms? It has been somewhat disappointing to many that the literature has been quite muddled, to say the least. Put simply, due to a large number of individual and situational constraints, there is no “silver bullet” in coping that works for everyone. However, in the midst of conflicting and counterintuitive results, a much more complex picture of adaptation has emerged. We have a much better understanding of the conceptual and methodological problems involved in relating coping strategies to mental health, and much of this chapter will be devoted to delineating those problems.

CONFOUNDS BETWEEN ASSESSMENT AND OUTCOME Stanton and her colleagues (Stanton et al., 1994, 2000) directly addressed this paradox in studies on the effect of emotion-focused coping. Many of the items on emotion-focused coping scales may be confounded with psychological distress or psychopathology, and inclusion of these

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items may inflate the relationship between emotion-focused coping and outcome measures of distress. For example, rumination is often associated with depression (Nolen-Hoeksema, 2000); similarly, intrusive thoughts is a hallmark of PTSD. Thus, the item “Went over the problem again and again in my mind” may be conflated with the outcome measure. Second, as many others have noted, emotion-focused strategies that work in one situation may be ineffective in other circumstances. Stanton et al. (1994) collected a variety of emotion-focused items and had psychologists rate them as to whether they were independent of or confounded with emotional outcomes. Next, they administered these items to undergraduates and found two factors. Unconfounded coping items included taking time to express emotions and examining them. Confounded items include getting angry, becoming tense, self-blame, and blaming others. Not surprisingly, the confounded items had much higher correlations with emotional distress outcomes. Surprisingly, there were interesting interactions with sex; opposite patterns were found for men and women between the unconfounded emotional approach coping measure and a variety of measures of outcome. For men, this measure was associated with higher levels of hostility and depression and lower levels of life satisfaction, while women showed the opposite pattern. There was also a three-way interaction with control. This gender differential held only for low-control conditions. For high-control situations, emotional approach coping was unrelated to outcomes. Stanton et al. (2000, p. 1154) expanded this approach by developing a scale that included both emotional processing (e.g., “I take time to figure out what I’m really thinking”) and emotional expression (e.g., “I let my feelings come out freely”). Again, gender differences were seen in the correlates for these scales, especially emotional processing, which was more strongly related to various personality variables for women than for men. There was an interesting though complex interaction between emotional processing and emotional expression for both men and women. High processing and high expression were related to an increase in depressive symptoms, but low processing with high expression was related to few symptoms, as was high processing with low expression. There are other types of positive emotion regulation strategies (see Aldwin, Sutton, & Lachman, 1996b), but most of the coping inventories that were used in the research reported below use the older confounded scales. Thus, care must be taken in interpreting these results.

SITUATIONAL MODIFIERS OF COPING EFFECTS Coping strategies have situation-specific effects—that is, a given strategy may have one effect in a particular situation and the opposite ef-

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fect in another. Enough studies have demonstrated this phenomenon now that researchers ignore this complicating factor at their peril. As mentioned earlier, some studies have shown that problem-focused coping decreases emotional distress and that emotion-focused coping increases it (Felton & Revenson, 1984; Mitchell, Cronkite, & Moos, 1983; Mitchell & Hodson, 1983), but others have reported the opposite pattern (Baum et al., 1983; Marrero, 1982). Several studies have demonstrated that the controllability of the stressor affects the ability of coping to reduce stress. In general, problem-focused coping decreases psychological symptoms in situations appraised as controllable, while emotion-focused coping is associated with lower symptom levels in situations appraised as uncontrollable (Mattlin et al., 1990; Park, Folkman, & Bostrom, 2001; Terry & Hynes, 1998; Vitaliano, DeWolfe, Maiuro, Russo, & Katon, 1990; but see Macrodimitris & Endler, 2001). Coyne and Racciopo (2000) have correctly pointed out that people do use problem-focused coping in uncontrollable situations. For example, when a loved one has died, customary funeral rituals often require a high degree of planning and organizing, which may involve the use of problem-focused coping strategies. Indeed, one could argue that the elaborateness of the requisite planning is a way to distract individuals who might otherwise be overcome by grief. For example, when various members of my husband’s Southern family died, it fell to me, as the wife of the only surviving child of that generation, to organize the funerals. Southern funerals are highly elaborate procedures, and rely on a great deal of tacit knowledge—and I, as a “Yankee,” had no clue as to what to expect. For example, the day after my husband’s favorite aunt died, people started showing up at 7:30 in the morning with fried chicken or pies (for which I was completely unprepared). The funeral home gave me a large box full of various things that were a complete mystery to me. Luckily, some kind “fictive kin”—a distinctly Southern type of extended family in which people who aren’t blood relations are nonetheless considered to be part of the family— took me under their wings and explained the procedures to me. For example, the page of numbers on sticky paper—one of the mysterious things in the funeral home box—was to keep track of the veritable army of dishes that appeared from various well-wishers and mourners. The numbers were to be placed on the bottom of the dishes in the same order as the individuals signed in on the numbered guest book. Luckily, my gaffes—including not keeping proper track of the dishes—were excused because of my intrinsic handicap of being a Yankee. Organizing the various funerals and wakes, and figuring out details of the estate, kept us very busy. In other words, even seemingly uncontrollable situations often

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entail secondary demands, for which problem-focused coping strategies are appropriate.1 While such activity may temporarily help to forestall active distress, the main problem—loss of a loved one—is nonetheless uncontrollable and will need to be faced eventually, usually through the use of emotionfocused strategies. However, some individuals may use frenetic activity to forestall this painful process—thus, high levels of problem-focused activities may end up just increasing distress. Others oscillate between problem-focused and emotion-focused coping, as suggested by Stroebe and Schut’s (1999, 2001) Dual Process Model of coping. The situation-specificity of coping efficacy might explain the contrary results of the Baum et al. (1983) study cited earlier, which examined people coping with the Three Mile Island nuclear reactor shutdown. In this situation, problem-focused coping, especially trying to do something about the bureaucratic problems that led to the difficulty, probably did result in increased emotional distress, while trying to forget about the problem (about which most people could do little anyway) might well have reduced distress. Deciding to ignore a problem that is eminently solvable, however, will most likely increase psychological distress (Aldwin & Revenson, 1987). Note that associations between coping styles and health outcomes are also affected by the environmental context. A review by Roth and Cohen (1986) identified the controllability of the problem as a key in evaluating the effectiveness of approach–avoidance coping styles. They identified two other factors: the point in time that the outcome is assessed and the goodness of fit between the coping style and situational demands. In their review, Mullen and Suls (1982) found that avoidant strategies were more effective in reducing emotional distress in the short term while approach strategies were more effective over the long term. In other words, studies may show differing effects of approach–avoidance coping, depending upon the time elapsed since the beginning of the particular problem under study. Similarly, whether or not a coping style will result in increased or decreased distress also depends on the fit between the style and the stressor. A classic study by Miller and Mangan (1983), for example, found that blunters and monitors (another name for avoidance vs. approach copers) differed in whether they wanted full disclosure by their physicians before an operation. Blunters became more distressed when given additional information, whereas monitors became less distressed. Finally, the stressfulness of a situation may also affect the relation 1I

am indebted to Daria Boeninger for this observation.

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between a particular coping strategy and mental health. Many problems are minor and self-limiting, and ignoring minor problems is often a reasonable strategy. Similarly, many problems are ambiguous as to their severity, and using threat minimization until more information is obtained may also be sensible. For example, getting a Type 2 result from a Pap smear may indicate incipient cancer—or it may indicate a technical problem, such as the physician assistant’s failure to spray the whole slide with the fixative. Taking a “wait-and-see” attitude until receiving results of the follow-up Pap smear is much better than focusing on and obsessing over the problem. Mobilizing a great deal of effort and support for relatively minor problems may end up resulting in greater stress levels— making a mountain out of a molehill, as it were. However, failure to mobilize when faced with an imminent threat to life, such as ignoring a lump in one’s breast, could have disastrous consequences for one’s physical and mental health. Thus, it is imperative to examine statistical interactions between degree of stress (and/or its controllability) in order to demonstrate that coping buffers stress effects (see Chapter 9). Other contextual effects concern the reactions of others in the environment. For example, disclosure is a strategy that is often highly effective in individuals coping with trauma. However, if the disclosure is met with negative affect, such as anger, disgust, blame, or abandonment, then the degree of disclosure is related to higher levels of negative affect (Silver, Holman, & Gil-Rivas, 2000; Stephens & Long, 2000). In summary, there are interaction effects between situational characteristics and the use of coping strategies or styles that moderate the relation between coping and health outcomes. One key to successful coping may be the ability to moderate both the type and the degree of effort used in coping with different kinds of stressors. There is an old prayer attributed to St. Francis of Assissi that sums this up nicely: “Oh, Lord God, grant the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” Unfortunately, one cannot always know this, nor can one always predict the reactions of others.

PATTERNS OF COPING While most studies examine the individual or joint contributions of specific coping strategies to mental health, a few researchers have suggested that the pattern, or coping profile, may be more important than the use of any one particular strategy. For example, avoidant coping used in conjunction with problem-focused coping may decrease the adverse effects of stress; however, avoidant coping in the absence of problem-focused

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coping may increase distress, especially in those situations judged to be controllable (Mattlin et al., 1990). Vitaliano, Russo, and Maiuro (1987) have suggested using ratios to calculate the use of coping strategies. In other words, the proportion of problem-focused to emotion-focused coping may be more important than the absolute amount of problem-focused coping per se. Further work has suggested that coping profiles, defined as an individual’s pattern of coping strategies—namely, relative reliance on some and deemphasis of others—may be a more efficacious way of understanding the ways in which individuals cope with stress (Vitaliano et al., 1990). Danoff-Burg, Ayala, and Revenson (2000), in their study of rheumatoid arthritis (RA) patients, noted that there was evidence for the cooccurrence of coping strategies. For example, it is not unusual for people to report using both emotional catharsis and social support. For RA patients, problem-focused coping and relaxation often went together. Given that relaxation is often advocated as a pain management technique, it makes sense that relaxation is actually a problem-focused rather than emotion-focused strategy in this context. However, it may well be that alternating brief periods of rest with periods of activity may permit individuals with chronic illnesses to function more normally. Alternatively, some strategies used in combination may have adverse effects, as evidenced by the Stanton et al. (2000) article referenced earlier, where the combination of emotional expression and emotional processing heightened depression. Somerfield (1997) has argued for more of a systems approach in studying how individuals cope with cancer, but it is likely that combinations of strategies are also seen in other situations as well. Perhaps rather than factor-analyzing coping scales, we should be examining clusters of strategies and how these clusters relate to outcomes.

COPING EFFORT Serious problems often result in a great deal of psychological distress and require strenuous coping efforts. This results in an unfortunate statistical confound between stressor severity, coping, and distress; studies that do not take this confound into account often show that all of the coping strategies used in the study are associated with increased distress (e.g., Spurrell & McFarlane, 1993). This may be especially a problem for studies of traumatic stress, given the positive correlations between degree of stressfulness and coping effort across a broad spectrum of coping strategies (see Aldwin & Yancura, 2004). Often, such studies use simple correlations or regression equations to associate stress with outcomes that neither control for stress levels nor utilize interaction terms to ex-

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amine stress buffering. Vitaliano’s proportional scoring for coping strategies, reviewed in the preceding section, may be one way of controlling for coping effort; using structural equation models with stress ratings as an exogenous variable is another. Simply entering stress ratings into any regression equations would also help control for this problem. Another complicating factor is that there may be a nonlinear relation between coping and outcomes. As indicated earlier, sometimes a small amount of avoidant coping is useful, especially if it facilitates problem-focused coping. To the best of my knowledge, however, no one has ever examined nonlinearity in the relation between coping and mental health in a systematic way—namely, by entering second- or even third-order terms into a regression equation.2 Alternatively, one could ask the respondent to rate the effectiveness of the coping strategies used, thus distinguishing between effort and efficacy. Aldwin and Revenson (1987), for example, found that extensive use of negotiation as a coping strategy decreased psychological symptoms only when the respondent thought it was effective; when negotiations were not perceived to be effective, extensive use of this strategy increased distress. Instrumental action also had different effects on mental health, depending upon its perceived efficacy. Individuals who used only a little instrumental action but who perceived that it worked reported the fewest psychological symptoms. Presumably they found the situation easy to handle and were pleased at the outcome of their efforts. On the other hand, individuals who used only a little instrumental action and who did not think they handled the situation very well reported the most psychological symptoms. Perhaps they felt that if they had tried harder, they might have been able to solve their problem. Thus, it is not surprising that the past decade has seen a marked increase in research on coping efficacy. In general, researchers distinguish between generalized control beliefs and coping efficacy, which is situationspecific (Bandura, 1997). Zautra, Hoffman, and Reich (1996) have proposed a slightly different division: the belief in one’s ability to handle aversive circumstances as well as to produce positive events. Zautra and Wrabetz (1991) developed measures of these two types of efficacy, and found that older adults maintain their sense of efficacy even when faced with disability and the loss of autonomy (Reich, Zautra, & Guarnaccia, 2Second-

and third-order terms refer to squared and cubed variables. Squaring a term allows one to look for quadratic relationships (e.g., U-shaped or inverted U-shapes), while cubing can reveal more complex patterns such as sine curves. To do this, simply center the initial term—in this case, a coping strategy—by subtracting the mean to reduce multicollinearity, then either use multiplication to get the squared or cubed terms. A hierarchical regression equation is then used to examine separately each of the terms to determine their significance, using change in R2.

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1989; cf. Aldwin, Sutton, Chiara, & Spiro, 1996). Cross-time analyses showed that coping efficacy was moderately stable but that positive event efficacy was quite variable and probably more situational (Zautra et al., 1996). Further, among the RA patients that Zautra and his colleagues have been studying, these two types of efficacy have different correlates: coping efficacy is negatively related to psychological distress and adverse physiological changes, whereas positive event efficacy is related to the maintenance of activity levels (Zautra et al., 1989). Note that perceived coping efficacy is not always related to positive outcomes. When faced with extremely difficult problems such as caregiving for a loved one with Alzheimer’s disease, the situation generally gets worse despite one’s best efforts. A longitudinal study by Gignac and Gottlieb (1996) found that coping efficacy at Time 1 was related to more pessimistic future expectations and more coping by meaning making several months later at Time 2. They suggest that the initial perceptions of coping efficacy were perhaps unduly optimistic. However, individuals who had poorer coping efficacy at Time 1 were more likely to use more behavioral coping efforts at Time 2, suggesting that individuals who perceived their efforts as less than adequate were motivated to increase their subsequent coping efforts.

CAUSAL DIRECTIONALITY AND COPING INTERVENTIONS An alternative explanation for why coping strategies are often associated with increased distress is that coping strategies are reflecting, rather than causing, psychological distress. Individuals who heavily utilize the type of emotion-focused coping assessed in typical inventories may be doing so because they are in acute distress and are having difficulty in controlling their emotions. Thus, someone who indicates that he or she “tried not to think about it” very frequently may actually have been obsessing about a problem and unable to stop thinking about it. As Billings and Moos (1984) pointed out, emotional discharge and efforts used to control emotions may not be adequately distinguished in most scales (see also Stanton et al., 1996). Coyne et al. (1981) first examined this problem by assessing the differential use of coping strategies, assessed over a 9-month period, between chronic depressives and putative normals. Coyne and his colleagues found that chronic depressives used more coping in general, but they also used more emotion-focused coping than individuals who were not depressed. Rather than being more passive and helpless, as Seligman’s (1975) learned helplessness theory of depression would suggest, these depressives were struggling very hard to control both their external environment and their internal milieu. Apparently, however, they were

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not very successful despite putting forth massive amounts of effort. This finding was later confirmed in a separate study by Folkman and Lazarus (1986). Not only is it possible that depressives cope in a manner different from others, but it is also possible that being depressed leads to greater exposure to stressors. For example, Russell and Cutrona (1991) found that depressed older adults were more likely to report both more life events and more hassles during the months subsequent to the study. It is relatively easy to construct a “cascade” model of stress, coping, and depression in which an individual copes poorly with an initial stressor, leading to depression, which in turn leads to a greater likelihood of future stress, and so on (Aldwin & Stokols, 1988; Pearlin et al., 1981). For example, if an adolescent turns to drugs or alcohol as a means of coping with the death of a father, this drug use in turn may lead to problems with his mother, his school, and perhaps ultimately the authorities. It is equally possible, of course, that positive cascades may happen. Aldwin, Sutton, and Lachman (1996b) posited that problem-focused coping leads to greater mastery, which in turn leads to better long-term outcomes. In turn, this should build up coping resources that either decrease the likelihood of the occurrence of future stress or mitigate its negative impact. As we will see in Chapter 15, life course theory (Elder & Shanahan, 2006) posits turning points in individuals’ lives that may trigger either positive or negative adaptive spirals. One way of circumventing the problem in causal directionality is to examine coping intervention studies. As Coyne and Racioppo (2000) point out, coping interventions—programs that teach individuals more effective coping strategies—often show at least moderate effects (see also Antoni, 2003). For example, Mohr and Goodkin’s (1999) review of interventions for depression in patients with multiple sclerosis (MS) found that psychotherapy was as effective as drug therapy in decreasing depression. Interventions that focused on increasing coping skills were much more effective than those that focused on insight. However, Kennedy, Duff, Evans, and Beedie’s (2003) study raises a cautionary note. They designed a coping intervention based upon Lazarus and Folkman’s (1984) theory, called the Coping Effectiveness Training (CET) Programme, for patients with spinal cord injuries, who are generally at high risk for developing depressive symptoms. They did find that the intervention group showed a decrease in depression and anxiety as compared to matched controls. However, they could not find a change in the pattern of coping strategies, as assessed by a coping checklist. However, Antoni et al. (2001) did find that a coping intervention increased benefit finding, which in turn was related to decreased depression and cortisol

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(Cruess et al., 2000). This brings up the next problem, individual differences in coping effectiveness.

INDIVIDUAL DIFFERENCES IN COPING EFFECTIVENESS A somewhat disturbing possibility, from a methodological viewpoint, is that the same or similar coping strategies may have varying effects in different people. Vitaliano and his colleagues (Vitaliano, DeWolfe, Maiuro, Russo, & Katon, 1990) conducted an intriguing study in which they examined the relations between coping, perceived controllability, and depression in a variety of patient populations. They found that the relations between appraisal, coping, and symptoms were not consistent across samples. Problem-focused coping led to decreased depression in controllable situations only for the nonpsychiatric groups. They concluded that their “goodness-of-fit” hypothesis did not work in psychiatric samples because of the distortion in the latter groups’ cognitive processes. Another possible interpretation is the confusion between coping effort and coping efficacy referred to earlier. For the most part, our coping scales are set up to determine whether a person used a particular strategy. However, we do not assess whether that strategy was successfully used by that person. As mentioned earlier, someone who is obsessively ruminating about a problem may “try not to think about the problem” but fail, whereas someone else may use the same strategy but succeed. This might explain the findings of the Kennedy et al. (2000) study referred to earlier. In this study, the coping intervention was effective in reducing depression, but there were no mean differences in the frequency of coping strategies used. However, this study did not assess how effectively they were used. There is a methodological conundrum here. On the one hand, Lazarus and his colleagues (Folkman & Lazarus, 1980; Lazarus & Folkman, 1984) have strong arguments in favor of assessing the process of coping as opposed to simply assessing its outcome. For example, only by examining the use of strategy and then relating it to outcome can one scientifically investigate the utility or destructiveness of any particular strategy—a position that I find intuitively and methodologically appealing. However, it is also clear from the numerous interviews that I have done that the same strategy can be used both effectively and ineffectively by different individuals. Further, Aldwin and Revenson (1987) clearly showed that the interaction coping strategies and coping effectiveness were highly important in predicting mental health outcomes, primarily for problemfocused coping.

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Another possibility is to redesign our coping inventories to better reflect the qualitative manner in which a strategy is used. For example, two people try negotiating with their work supervisor about a problem. One person becomes arrogant and insulting when discussing the problem, but the other manages to remain relatively politic and arrives at a successful conclusion. As they presently exist, coping scales cannot differentiate between these two very different approaches: They simply ask respondents to indicate whether the problem was discussed. Certainly future work should attempt to include qualitatively differentiable strategies, as well as some assessment of coping effectiveness, both with the problem and with the emotions (see Aldwin et al., 1996).

WHAT IS THE APPROPRIATE OUTCOME OF COPING STRATEGIES? Most studies of coping and mental health utilize symptom checklists, often focusing on depressive symptoms. By restricting our investigation of the outcomes of coping strategies to psychological symptoms, we may be unduly limiting our understanding of why people cope in the manner that they do. A clinician might hypothesize that for some individuals maintenance of symptoms has adaptive functions. By maintaining emotional distress about one set of problems, some individuals may be able to exert control over a different area. For example, demonstrated vulnerability may increase dependency upon a loved one, in an attempt to ensure that he or she will not leave. Rather than limit our outcomes to symptomatology, we might wish to try to discover what goals the individuals seek to accomplish when they cope with stressful circumstances. Another interesting possibility lies in the recognition that positive affect and negative affect appear to be orthogonal dimensions (Watson & Clark, 1984). To the extent that we measure only the negative dimension (e.g., symptoms), we could be overlooking the strategies that maintain the positive dimension (see Folkman & Moskowitz, 2000). A sense of mastery is one of the most positive outcomes of coping with stress. Individuals can feel that they have accomplished something and can develop a new sense of confidence that they have successfully negotiated a difficult work problem, developed new skills, or had new understanding or compassion for others. Pearlin and his colleagues (1981), in their classic longitudinal study, found that problem-focused coping was unrelated to current psychological symptoms but did serve two functions. Problemfocused coping was positively related to feelings of mastery. Further, it also helped to decrease the likelihood of future recurrences of stressors. Note, however, that coping with one particular problem may have little effect on generalized mastery. Revenson and Felton (1989), for example,

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found that the use of problem-focused coping in dealing with rheumatoid arthritis did not generalize one way or the other to overall feelings of mastery. However, Aldwin et al. (1996b), in their study of coping with a major low point, did find that positive coping (which included both problem- and emotion-focused items) was associated with higher mastery levels. A follow-up study by Sutton (1998) did find that positive coping with a major low point increased mastery levels over a 5-year period. The question of beneficial outcomes of coping with stress are further addressed in Chapter 15. Finally, it should be emphasized that stress outcomes should be a multidimensional construct and that individuals may trade off gains in one area for losses in another, or short-term outcomes for long-term ones. For example, a study of physicians coping with mistakes found that those who coped by accepting responsibility for the error experienced more distress, but were also more likely to make changes in their practices, which presumably would decrease the risk of future mistakes (Wu, Folkman, McPhee, & Lo, 1993). Thus, more studies are needed that examine multiple outcomes, both positive and negative, as well as outcomes at different levels of analysis, for example, biological, psychological, and interpersonal. This topic is addressed further in Chapter 15.

SUMMARY As we have seen, the relationship between coping strategies and psychological symptoms is highly complex, involving a number of theoretical as well as methodological issues. First, there may be confounds in the relationship between our coping measures and our outcomes, and it is extremely important to design studies and use coping inventories that eliminate or at least decrease these confounds. Second, there are situational modifiers of effects of coping strategies on mental health as well; what “works” in one situation may well increase distress in another. Learning to recognize opportunities and constraints in situations may be a critical component in positive adaptation. Third, the overall pattern of coping strategies may be more predictive of mental health than the use of any particular strategy. Learning how to balance the relative use of different strategies is crucial. Fourth, there is a statistical confound between stress, the amount of effort individuals exert, and psychological distress; failure to deal with this confound may well result in a spurious positive relationship between coping and distress. Fifth, there are as yet unresolved issues in causal directionality: Although coping may be linked to psychological symptoms, it is not clear whether coping causes these symptoms or whether

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distressed individuals simply cope differently than nondistressed people. Longitudinal studies are needed to try to disentangle these relationships— or, more likely, to understand how negative cascades come about. Sixth, there may be individual differences in the effectiveness of coping strategies: Some people may cope in a qualitatively different fashion than others, a difference that may not be readily apparent on our current coping inventories. We need to develop better ways of tapping into such qualitative differences in the utilization and effectiveness of coping strategies. Finally, we tend to assess a narrow range of outcomes, mainly different forms of psychological distress, and we may be missing whole classes of outcomes for which coping strategies are effective. In many ways, the situation is even more complex when it comes to relating coping to physical health.

STRESS,and Coping COPING, PhysicalAND Health DEVELOPMENT

CHAPTER 11

Coping and Physical Health

I

n 1979 Norman Cousins wrote a remarkable book entitled Anatomy of an Illness. In it, he described his harrowing experience with a very painful life-threatening illness whose cause was uncertain. Cousins had just returned from a stressful, exhausting trip to Russia when he developed quite terrifying and painful symptoms. What was remarkable about his experience was the way in which he coped with his illness. When the attending physicians could not make an immediate diagnosis, he called in his own experts and began experimenting with alternative treatments, including massive doses of vitamin C. He decided that hospitals were stressful environments because of their inadequate food, intrusive nursing routines, and restrictive rules and regulations—and, therefore, were no place to recover from illness. Consequently, he checked himself into a hotel, ate gourmet food, and rented funny movies, including comedies by the Marx Brothers and the Three Stooges, having discovered that laughter was about the only thing that eased his pain. As he put it, a good belly laugh kept the pain away for about a half-hour. Within a relatively short period of time, he recovered. A very different approach to illness was taken by former President Jimmy Carter’s sister Ruth Carter Stapleton, who developed breast cancer in midlife. Being deeply religious, rather than fearing death, she welcomed it, since she had a strong belief in the afterlife and heavenly rewards. Refusing all but palliative medical treatment, she died swiftly, within 3 months. When I was in graduate school, I became friendly with an 80-yearold woman who lived in my apartment building. A cultured and often 195

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charming woman, she related many delightful tales of growing up in Vienna in a wealthy and musical family. However, my friend also carried a heavy lifelong burden that made her very bitter and angry. As a young girl she fled the Holocaust with only the contents of one suitcase. Despite having exit visas for her parents, she was unable to extract them, and they died in a concentration camp, along with most of her relatives. For reasons that I never fully understood, she blamed her only surviving sister for her parents’ death (Vaillant might say that she was projecting her own feelings of guilt onto her sister). My friend developed colon cancer, and, despite excruciating pain, she refused all medications, taking at most half an aspirin. In the hospital, she refused to speak to a psychiatrist, turning her face to the wall. She was a very difficult patient, complaining bitterly about nearly everything and screaming in pain for hours on end. She suffered terribly for many months until she was finally medicated against her will, fell into a coma, and died. All three of these individuals were coping with life-threatening illnesses in very different ways and with very different outcomes. All three were exerting control of a kind. Cousins went to extraordinary lengths to control his environment and his own treatment regimen, which resulted in a cure—or at least a remission of sorts. Stapleton also exerted control, although in her instance she willingly chose death for religious reasons. My friend also went to extraordinary lengths to exert control over her environment. By doing so, however, she only increased her own suffering—and also that of her sister, who was her primary caregiver. In all of these cases, the way in which these individuals coped with the stress of an illness affected both its course and its outcome. The study of coping strategies highlights individual differences in how people deal with stress, a process that may moderate the adverse effects of stress on health. Some people “fall apart” under stress, others emerge “sadder but wiser,” and yet others seem to thrive in a stressful environment. Ten years ago there were only a handful of studies that linked coping with health outcomes, but in the past few years the number of studies has greatly increased, and there are a number of metaanalyses and reviews dealing with coping and various health outcomes, including general reviews (see Aldwin & Yancura, 2004; Folkman & Moskovitz, 2004; Penley et al., 2002; Roesch & Weiner, 2001), neuroendocrine outcomes (Biondi & Picardi, 1999), animal studies (Koolhaas et al., 1999), cancer (Garssen & Goodkin, 1999; McKenna, Zevon, Corn, & Rounds, 1999; Petticrew, Bell, & Hunter, 2002) and arthritis (Tennen & Affleck, 1996; Zautra & Manne, 1992). The purpose of this chapter is to provide an integrative overview of the coping and health literature, including both mental and physical health. Given that there is as yet no consensus about the best way of mea-

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suring coping (see Chapter 8), there is concomitantly no consensus as to the “best” way to cope, either to protect mental health (see Chapter 10) or physical health. Indeed, Pearlin and Schooler in 1978 believed that there were no “magic bullets”—no coping strategies that would work for every individual in every situation—and that observation still holds true today (see Folkman & Moskowitz, 2004). Nonetheless, there appear to be some interesting patterns in the literature suggesting that coping strategies mitigate (or sometimes enhance) the effects of stress on health under particular circumstances. However, as we shall see, the effects are highly contextual.

ADAPTATION TO ILLNESS Much of the coping and physical health literature is devoted to understanding the strategies used in coping with various illnesses and medical procedures. Chronic illnesses such as heart disease, diabetes, rheumatoid arthritis, cancer, and AIDS have been of particular interest (for reviews, see Aldwin & Gilmer, 2004; Garssen & Goodkin, 1999; Stanton, Collins, & Sworowski, 2001; Tennen & Affleck, 1996; Zautra & Manne, 1992). Given the graying of America, not only have chronic illnesses become more prevalent, but also improvements in treatment have resulted in people living longer with chronic illnesses. Indeed, it is important to differentiate between illness and disability. With proper exercise, nutrition, and adherence to medical regimes, people with chronic illnesses, especially if they are diagnosed before much tissue or structural damage has been done, may lead relatively healthy and normal lives for some time. Thus, it is important to understand the process of adaptation to illness.

Adaptive Tasks Moos and Schaefer (1984) identified seven major adaptive tasks in coping with illness. The three illness-related tasks are (1) dealing with the physiological consequences of the illness, including symptoms, pain, and disability; (2) dealing with the treatment and hospital environment; and (3) developing and maintaining good relations with health care workers. The four more general tasks are (1) maintaining some sort of emotional equilibrium; (2) maintaining a sense of self, including competence and mastery; (3) maintaining good relations with family and friends; and (4) preparing for future exigencies. An early qualitative study by Weitz (1989) of 23 men coping with AIDS nicely illustrates many of Moos and Schaefer’s points. Weitz

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pointed out that dealing with uncertainty is a major problem for individuals with chronic illnesses. Generally speaking, before these people with AIDS (they referred to themselves as PWAs) were diagnosed as HIV (human immunodeficiency virus) positive, they used denial and delayed getting tested. Given the variable length of time between being diagnosed as HIV positive and actually contracting AIDS, testing would not necessarily decrease uncertainty but would increase the stigma and anxiety felt by the PWAs. Thus, the PWAs would attribute their symptoms to myriad other causes, such as the flu, drug use, being “run down,” and so forth. Even when their symptoms became so bad that they sought the help of physicians, their doctors often refused to test them, either because the doctors were using threat minimization themselves or because they were simply not very knowledgeable about AIDS. Thus, the PWAs had to overcome not only their own defenses but also those of the medical staff. Once diagnosed, most PWAs searched for meaning as a way of reducing anxiety. Two developed “positive” explanations that were probably delusional, although they did undoubtedly serve to reduce anxiety. For example, one man had experienced a series of bad romances that left him suicidal, and “he believed that God had given him AIDS as a way of providing the extra incentive he needed to avoid any further romantic entanglements” (Weitz, 1989, p. 274). Another thought that God had given him AIDS so that he could share his faith with others and show that “even gays can go to heaven.” Others blamed themselves for their promiscuity or drug use. The PWAs who had the most distress were those who thought that, while some people may deserve to get AIDS, they themselves did not. Four to six months after diagnosis, most of the men were doing better. Uncertainty had been decreased, and the men had learned how to assert some control over a portion of their lives and how to accept not having control over other aspects of their lives. For example, on some days they felt fine, but on other days—often without warning—they were incapacitated. Often, the PWAs chose to avoid making any plans as a way of protecting themselves against disappointment, although at the cost of increased frustration. Some of the PWAs were very active in their treatment regimens. They maintained hope by participating in experimental treatments, moderating their diet, and exercising when they felt well enough. They also learned to avoid possible sources of infection, not only obvious ones like friends with colds but also nonobvious potential sources of infection like bathroom mold. Some PWAs who did not fit researchers’ requirements got their physicians to lie for them so that they would be eligible for experimental treatments. Others cadged the drug AZT by borrowing

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from friends who were in experimental programs or by using physicians’ extras (often left over when an experimental subject died). One young man who was eligible for experimental treatments enrolled in three different programs so that he could get medications for his friends who were not eligible! Death was one “future exigency” with which the PWAs had to cope. Several of the men had accepted death and had made plans for suicide if their quality of life became too poor. One person hastened death by throwing away his medications. He reasoned that if was going to die anyway, he might as well get it over with. Thus, these men demonstrated a wide range of coping strategies in their adjustment to chronic illness. Most people eventually adapt to physiological pain and disability after an initial period of struggle. In their review, Stanton, Collins, and Sworowski (2001) found that up to half of patients who are coping with a major chronic illness may have diagnosable cases of depression or anxiety disorders, at least in the short run. However, presuming that the patient survives, after a year most individuals return to premorbid levels of mental health. However, other problems may persist. For example, cancer patients may have impaired body esteem (Katz, Rodin, & Devine, 1995), while a third of heart disease patients may have persistent problems with psychosocial functioning and quality of life (Ell & DunkelSchetter, 1994). Cox and Gonder-Frederick (1992) found that patients with diabetes also returned to pre-morbid levels of depression after the first year of diagnosis, but they also found that diabetics may in general have higher rates of depression than people with no chronic illness, as do patients with rheumatic disease (DeVellis, 1995). Interestingly, Chesney and Folkman (1994) found that there was a secular trend over time in HIV/AIDS patients that indicated that adverse psychological reactions were decreasing, indicating a greater acceptance of the illness, although Ickovics et al. (2001) cautioned that women with HIV may report more depressive symptoms than men. However, Stanton et al. (2001) conclude that most individuals adapt fairly well to chronic illness, in part due to coping processes.

Coping with Pain and Medical Procedures The study of coping strategies within an institutional setting yields some surprising information. We generally think of coping as something that is done by the individual. And, indeed, how much pain individuals experience is partially due to beliefs and cognitions about pain, as well as their coping strategies. In particular, a variety of studies have shown that catastrophizing significantly increases both acute and chronic pain (see Turk, 2001, for a review). Nonetheless, much of the work on coping

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with pain and medical procedures focuses on institutional practices and on how modifications in these practices can alleviate pain and suffering for the individual patient. A number of reviews have shown that coping interventions, and especially pain interventions, can be remarkably successful (Coyne & Racioppo, 2000; Turk, 2001). For example, Gatchel and Baum (1983) found that a number of different techniques could be used effectively to reduce pain from medical treatments and from acute and chronic injuries. These techniques include biofeedback, hypnosis, and various forms of cognitive imaging. In addition, pain clinics, which teach individuals with chronic illness various techniques for coping with pain, may be very effective. In general, providing patients with control, even over timing and dosage of their medication, can reduce both the perception of pain and the use of analgesics. Devine (1992) conducted a meta-analysis of 191 studies and found that patients who received pain management interventions were released from hospitals more quickly in nearly 80% of the studies. Pain control can be further improved by adding specific coping skills training to standard pain management treatment (Kole-Snijders et al., 1999). A meta-analysis by Suls and Wan (1989) sought to identify which types of pain intervention are most helpful: providing sensory information, procedural information, or some combination thereof. Sensory information includes descriptions about what the patient may feel as a consequence of this information; procedural information includes descriptions of what happens during a specific medical procedure. Informed consent, which provides a great deal of procedure information, is assumed to be beneficial, although not all researchers agree. Providing information may actually increase pain, discomfort, and perhaps even risk (Langer, Janis, & Wolfer, 1975), especially in people who prefer coping by blunting (Miller & Mangan, 1983). For example, once I was exhorting a group of senior citizens to become more informed about their health management, and one older man strongly challenged this recommendation. “I don’t want to know what’s wrong with me,” he said, “I just want the doctor to fix it.” Individuals who are highly anxious may react adversely to information about risks, or an insensitive manner on the part of the physician may create undue anxiety. Contrast these two statements: “You have a 15% chance of dying during this operation” versus “Eighty-five percent of individuals make it through this operation just fine.” Thus, it is not surprising that Suls and Wan (1989) found that procedural information in and of itself yielded few benefits. In contrast, patients who received sensory information had less neg-

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ative affect and lower levels of self-related pain than to controls. Semsory information was also more effective in reducing pain than procedural information alone. However, interventions that provided both types of information were by far the most effective in reducing pain and negative affect. Nonetheless, there was considerable unexplained variance in outcomes that could not be accounted for by demographic characteristics or the study’s setting (i.e., field vs. laboratory). Auerbach (1989) identified some key factors that might modify the efficacy of such coping interventions. As with approach–avoidance coping, the controllability of the situation plays an important role. That is, providing problem-focused interventions may be helpful in controllable situations (e.g., regulating diabetes or asthma), whereas emotion-focused interventions may be helpful in uncontrollable situations (e.g., surgery for a facial tumor). Again, the timing of the intervention may be important. Faust and Melamed (1984), for example, found that children benefited most from a film about their medical procedure when the children were admitted to the hospital the day before the procedure. If they were admitted to the hospital on the day of the procedure and were shown the film, they derived little benefit, presumably because they were too anxious to pay much attention to the film. Auerbach (1989) has also confirmed Miller and Mangan’s (1983) original observation of a personby-situation interaction in the efficacy of coping interventions. Blunters were made more anxious by the provision of too much information. The coping resources that individuals can utilize may also affect the level of functional ability in people with chronic pain. In their review, Jensen, Turner, Romano, and Karoly (1991) reminded us that many individuals with chronic pain rarely seek medical services and continue to work productively. Jensen and his colleagues identified three major psychosocial factors that affect psychosocial adjustment to pain: control beliefs and attributional style, self-efficacy and outcome expectancies, and coping strategies. In general, people who believed they could control the pain, avoided catastrophizing and feelings of helplessness, and those who used active coping strategies were less depressed, reported less pain and were less likely to take on a sick role that prevented them from fulfilling everyday obligations. More recent work confirms that psychosocial interventions can be effective in pain management, even with serious illnesses such as cancer (Syrjala & Abrams, 1999). A meta-analysis also showed that hypnosis can be very effective in pain relief (Hawkins, 2001). However, pain is a highly complex phenomenon, and interventions may well interact with individual, contextual, and cultural factors (Gatchel & Turk, 1999).

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COPING AND ILLNESS OUTCOMES The results of studies of coping and illness outcomes are less straightforward. On the one hand, there are many anecdotal instances in the field of medicine about individuals affecting the course of their illness (e.g., Cousins, 1979), and clearly there are differences in how well individuals participate in their health management, comply with medical regimes, and utilize positive health behaviors (e.g., exercising, moderating diet, avoiding smoking and excessive alcohol consumption, etc.), all of which should affect illness outcomes. On the other hand, demonstrating this statistically is more problematic, and there have been some surprising and nonintuitive results in this literature, which will be addressed below. Further, it is a mistake to believe that the course of illness is always under individual control; after all, we will all die of something. Nonetheless, there have been a number of studies linking coping with outcomes for cancer, heart disease, and diabetes mellitus, among other illnesses (McCabe, Schneiderman, Field, & Skylar, 1991). There are two critical issues in this field. The first concerns the issue of moderator effects, that is, whether circumstances alter the effect of coping on health outcomes. The second is whether active problem-solving coping, on the one hand, and denial and emotional repression, on the other, have positive or negative effects on the outcome of illness.

Moderator Effects A variety of personal and contextual factors may moderate the effects of coping on health outcomes. Zautra and Manne (1992) reviewed studies of coping with rheumatoid arthritis. Many of the studies found that the level of degree of pain experienced was associated with differential use of coping strategies, but the results varied as a function of personality disposition and family environment, as well as coping efficacy and illness characteristic factors such as the stage of the illness or its severity. For example, among women with rheumatoid arthritis in relatively good health, relying on others led to increased psychological distress. For women in poorer health, relying on others led to lower levels of distress (Reich & Zautra, 1995). A similar result was found by Helgeson, Cohen, Schulz, and Yasko (2000) in their study of breast cancer patients. Spiegel and Giese-Davis (2003) had found fairly dramatic effects on mortality for participating in support groups—women with advanced breast cancer lived approximately 18 months longer if they were in a support group. This study and others like it led to a large increase in the availability of support groups for women with breast cancer and other illnesses. However, Helgeson et

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al. (2000) found that the effects varied as a function of the degree of support women already had. Those who had little natural support or who had fewer personal resources seemed to benefit the most from support groups in terms of positive physical functioning, but participating in support groups was actually harmful for women who already had high levels of support. This is probably due to a sort of stress-contagion effect—that is, individuals who are in distress may create more distress in their social networks. Further, the effects of coping may vary by type of disease. Affleck et al. (1999) compared the effects of coping between patients with rheumatoid arthritis (RA) and those with osteoarthritis (OA). RA is a general autoimmune system disorder in which antigens attack not only joints but also internal organs. Thus, the pain may be nonspecific, and functioning can vary from day to day, often very dramatically. In contrast, OA is a disease of wear and tear on the joints. While people can and do have good and bad days, the pain is generally localized and specific to movement. In patients with OA, emotion-focused coping (seeking support and venting) was associated with decreased pain, but in patients with RA it increased pain. Affleck et al. (1999) suggested that these differences were due to the response of the caregivers, who may find the symptoms of RA less comprehensible and thus may be less sympathetic. Once again, the effects of social support seeking are moderated by the response. In other illnesses, coping may have indirect or mediated effects on outcomes. Specifically, coping may affect physical health via its impact on affect. In a study of AIDS patients, Billings, Folkman, Acree, and Moskowitz (2000) found that seeking social support predicted an increase in positive affect, which, in turn, was related to fewer physical symptoms. However, avoidant coping was associated with an increase in negative affect, which was related to higher levels of physical symptoms. Coping may also be related to disease progression. One crosssectional study found that individuals diagnosed with AIDS were lower in planful problem solving than individuals who were only HIV-positive— that is, those who had been exposed to the virus but who had yet to develop a full-blown case of the disease (Krikorian, Kay, & Liang, 1995). A prospective study of asymptomatic HIV-positive men and women confirmed these results. Vassend, Eskile, and Halvorsen (1997) found that individuals who used avoidance and passive coping were more likely to develop symptoms, while those who used planful or problem-focused coping had a slower progression of HIV symptoms. Similarly, Mulder, Antoni, Duivenvoorden, and Kauffmann (1995) found that HIV-positive men who used active confrontational coping had a slower disease progression over the course of a year. The rate of progression of HIV is often

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a function of decline in a type of helper T cell called CD4+. The HIV virus “hides” in these cells, uses them to replicate themselves, and then destroys them, leaving individuals vulnerable to what are called “opportunistic” infections. Thus, it is noteworthy that individuals who used avoidant coping had a more rapid decrease in CD4+ cell counts over seven years (Mulder, de Vroome, van Griensven, Antoni, & Sandfort, 1999), which may help explain the earlier finding of a slower progression of HIV symptoms in those actively confronting the problem. At best, there is only weak evidence to indicate that how an individual copes affects the development of cancer (Garssen & Goodkin, 1999). However, coping strategies do affect adaptation to illness. For example, women with breast cancer who used confrontive coping reported fewer adverse effects from chemotherapy than did those who used avoidant strategies (Shapiro et al., 1997). Further, coping may affect the progression of cancer. A few early studies found that women who used active coping styles lived longer, especially if they were diagnosed early and had nonmetastatic cancer (Greer, 1991; Greer & Morris, 1975; Morris et al., 1981). In contrast, a more recent study of women with breast cancer showed that repressors had elevated levels of mortality, with a risk ratio of 3.7 (Weihs, Enright, Simmens, & Reiss, 2000). Not all studies have this dramatic a result. Buddeberg et al. (1996) found problem-focused coping (tackling and self-encouragement) was associated with decreased mortality risk, while those who expressed distrust and pessimism had higher mortality risk. However, the effects were quite modest. In their meta-analysis, Petticrew et al. (2002) found that the results of coping and cancer survival studies are often quite inconsistent. Different cancers have varying rates of progressions and are more or less amenable to treatment. Treatments are often very arduous and require a fair amount of stress tolerance and organization. Thus, it makes a certain amount of sense that problem-focused coping should be associated with better outcomes for these diseases, while avoidant coping should be associated with poorer ones. However, these results may vary by stage, severity, and type of disease. Further, there is some suggestion that the effects of coping may be partially mediated by affect. If true, this would explain why the response of others in the environment may affect the efficacy of coping in decreasing distress and thus delay the progression of symptoms.

Active Coping versus Repression and Disease Type The situation-specificity of coping and disease may be best illustrated by comparing active versus repressive coping strategies. The series of British studies on coping and breast cancer referred to earlier, for example, has

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suggested that active coping styles were prognostic of longer periods of remission, especially in early nonmetastatic cancer (Greer, 1991; Greer & Morris, 1975; Morris et al., 1981). These studies were supported by the work of Temoshok and her colleagues (1985) on melanoma. They suggested that women with “Type C personalities,” characterized by emotional repression, were much more likely to have poor outcomes. Further, helplessness may also result in poorer prognoses in cervical cancer (Goodkin, Antoni, & Bloom, 1986). In contrast, Dean and Surtees (1989) found that women using denial had better outcomes in breast cancer 3 months postsurgery. Cooper and Faragher (1992) reviewed a series of studies they had conducted concerning the interrelationships among stress, coping, and personality in women with breast cancer. Combining all three of these variables together provided some interesting results. The use of denial was associated with positive outcomes, whereas anger was associated with negative ones. Older women were more likely to have breast cancer, and they were also more likely to have Type C personalities. Interestingly, including age in the regression equations eliminated the effect of Type C personality on breast cancer, and it also eliminated the effects of loss stressors on outcomes. However, age did not eliminate the effects of coping. Therefore, some of the effect of personality and stressors on health outcomes may be confounded with age, but coping appears to have independent effects. A review by Levy (1991) suggests that the relationships among coping, psychological adjustment, and cancer remission may vary over time. Visintainer and Casey (1984) found that melanoma patients who used problem-focused coping also reported more psychological distress at diagnosis, but 9 months later they also had higher levels of natural killer (NK) cell activity, an immune system component that attacks tumors. Similarly, Rogentine and his colleagues (1979) found that denial predicts relapse 1 year postdiagnosis. Some of the strongest work on the connection between coping and the course of cancer was a series of studies by Fawzy and his colleagues (Fawzy, Cousins, Fawzy, Kemeny, & Morton, 1990; Fawzy, Kemeny, et al., 1990; Fawzy et al., 1993). In this project, Fawzy and his colleagues conducted a coping intervention with melanoma patients and examined their coping effectiveness, affect, immune function, and survival. The coping intervention consisted of a structured 6-week group intervention that included health education, training in both problem-solving skills and stress management, and psychological support. At the end of the intervention, the experimental subjects had more positive affect and were more likely to use active behavioral coping. At a 6-month assessment, the intervention group also had better immune functioning, with a

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greater percentage of large granular lymphocytes and more NK cells, as well as better NK cell cytotoxic activity. Affect was correlated with immune cell changes rather than with coping strategies, suggesting that the effects of coping were mediated through affect, much as the psychoneuroimmunological model presented in Chapter 2 suggests (see Figure 2.1). At a 5-year follow-up, nearly one-third of the control group had died, but less than 10% of the experimental group had died. Higher distress levels and more active coping at baseline were significantly associated with longer survival, as was an increase in active coping. On the other hand, an active coping stance may have more deleterious effects with hypertension and heart disease. For example, stronger beliefs in personal mastery or control predicts more severe coronary atherosclerosis (Seeman, 1991), while high monitoring styles may be associated with hypertension (Miller, Leinbach, & Brody, 1989). In contrast, people who use denial during hospitalization for acute coronary disease may have fewer subsequent episodes of angina (Levenson, Mishra, Hamer, & Hastillo, 1989). In his review, Powers (1992) found that people using denial after cardiac trauma may be less anxious, have shorter hospitalization periods, and have lower risks for subsequent morbidity and mortality. However, if denial is used during the trauma, it may be associated with a delay in seeking help. A common observation is that some men have been known to climb stairs during mild heart attacks to convince themselves that they are not having a heart attack! It would appear that coping strategies have differing effects, depending upon their timing and the type of illness. Denial at the beginning of a serious illness may have deleterious effects if it results in a delay in seeking treatment. I know of women who have died of breast cancer because they were too afraid to get a mammogram to see if a suspicious lump were indeed cancer; it was easier to deny until it was too late for efficacious treatment. Postdiagnosis, problem-focused coping may, in the short term, increase distress, whereas denial or repression may decrease it. Some denial may be beneficial in cardiovascular disease, because active coping that may increase emotional distress may also increase blood pressure and general cardiovascular responses (Dolan, Sherwood, & Light, 1992; Light, Dolan, Davis, & Sherwood, 1992; Vogele & Steptoe, 1992), exacerbating cardiovascular disease. However, under certain conditions, stress may actually enhance immune system response (Dienstbier, 1989), although stress is often assumed to have immune-suppressive effects (see Chapter 4). Thus, problem-focused coping, although it may increase distress, may also aid in fighting cancer. This is highly speculative, of course, and I know of no study that contrasts cancer and cardiovascular disease outcomes using standard as-

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sessments of denial. However, it might explain a puzzling finding by Aikens, Wallander, Bell, and Cole (1992). In a carefully done study, they found that, as expected, stress was associated with poorer metabolic control among type I diabetics. However, an active form of coping, learned resourcefulness, was also associated with poorer metabolic control, a finding that was unexpected. To the extent that active coping increases psychological distress, at least in the short term, the side effects of this coping strategy may harm those physiological processes that are vulnerable to stress. Finally, how family members cope with a patient’s illness may also be important for illness outcomes. For heart patients, how the spouse copes may be critical. Bandura and Waltz (1984), for example, found that the best predictor of a male patient’s adherence to a medical regime was the encouragement and support of his spouse. Further, Coyne and his colleagues (Coyne, Ellard, & Smith, 1990; Coyne & Smith, 1991) presents some troubling data. Cardiac patients did better when their spouses suppressed their own anxiety and allowed the patient more control. However, the psychological and physical cost to the spouse was high. But strategies that improved psychosocial functioning among the spouses had deleterious effects on the cardiac patients. Thus, it may be important to understand not only the way in which an individual is coping with a medical problem but also the manner in which an individual is interacting with his or her family.

SUMMARY In 1974, Coelho et al. published the papers from the first conferences on coping and adaptation. At that time, coping was seen as a potentially critical intermediary factor moderating the effects of stress on health. Certainly, the research during the ensuing decades has borne out that assumption. As shown in this review, coping clearly has profound implications for health. However, the picture that has emerged is much more complex than was initially thought. The two most critical themes that have emerged are that the effects of coping are modified by both the timing and the stressor context. Problem-focused coping, generally perceived as a panacea in most situations, may actually have deleterious effects in uncontrollable situations and in those in which psychological activation may have adverse effects on physiological activation. In contrast, denial, which is generally perceived as antithetical to psychological health, may have positive effects (at least in small doses) if situations are uncontrollable or if it serves to maintain emotional (and perhaps) physi-

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ological equilibrium, at least in the short term. Coping that results in feelings of helplessness and hopelessness, on the other hand, always has adverse effects. Nonetheless, the potential for clinical intervention is clear. Intervention directed either at medical personnel or at individuals and their families can clearly be efficacious. Interventions that serve either to reduce threat or to enhance individual feelings of control (where appropriate) have been unequivocally demonstrated to have positive effects on both mental and physical health. What is needed now is more research on the strategies that serve what Antonovsky (1979) has called a “salutogenic” (i.e., health-promoting) effect in situations such as illness (cf. Taylor, Lichtman, & Wood, 1984). Aldwin and Stokols (1988) called for the examination of both the positive and negative outcomes of coping on four levels: physiological, psychological, social, and cultural (see also Stanton et al., 2001). It may be especially important to determine how individuals trade off effects in these different domains as well as to study short-term versus long-term effects. A woman undergoing a divorce, for example, may well decide to smoke to alleviate immediate psychological distress even though she knows that smoking has adverse physical effects and may lead to greater depression in the long run. Or, as in Coyne and Smith’s (1991) study, a wife may decide to cope in a way that helps her husband even though it may increase her own distress. Finally, social activists such as the problemfocused copers in the study of Three Mile Island by Baum et al. (1983) might cope in ways that, in the long run, will do the society as a whole a great deal of good, although it might be associated in the short run with increased psychological and physical distress for themselves (and perhaps their families as well). Thus, in order to understand what constitutes “good” or “bad” coping, we need to know the purpose of a strategy, what its costs and benefits are, and how efficaciously it was used—a far cry from our current technology of correlating strategies with measures of psychological distress or a person’s survival time. Take, for example, the three cases with which we began this chapter, Norman Cousins, Ruth Carter Stapleton, and my 80-year-old friend. If we were correlating coping strategies with survival time, Cousins would clearly be the winner. His extensive use of problem-focused strategies, conceptualization of alternatives, and use of humor clearly contributed to his survival. However, my friend, who used both intro- and extrapunitive strategies that made both her life and that of her sister a living hell, survived longer than did Ms. Stapleton, who had accepted her fate and looked forward to death. Was my friend a “better coper” than Ms. Stapleton? I think not. Did my friend’s coping strategies achieve the goals she wanted? Probably—if her goal, as I suspect, was to

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punish both herself and her sister for surviving the Holocaust while their parents died in Buchenwald. However, it is not sufficient to assume that coping is successful if it has achieved the individual’s goals. These goals may involve, for whatever reason, increase in suffering, either on the part of the individual or that inflicted on others in the environment. Clearly there must be a way of evaluating the goal. Nor do I wish to suggest that we should discontinue doing studies that simply associate coping with the relatively simple outcomes that we have. Certainly Fawzy et al. (1993) showed that coping was a very powerful predictor of survival rates from cancer. However, life is very complicated, much more so than our current technology allows us to model. Lower levels of psychological distress and even survival time are only two possible goals of coping strategies. Quality of life and the achievement of an individual’s own goals should also be included in research on coping with illness.

STRESS,with Coping COPING, Traumatic AND Stress DEVELOPMENT

CHAPTER 12

Coping with Traumatic Stress If it didn’t result in death or permanent injury, I figured it wasn’t important. —Female POW in Iraq during the Gulf War, describing how she coped with her brutal treatment

I

n 1956, anthropologist A. F. C. Wallace described the reactions of victims of a deadly tornado in Worcester, Massachusetts. The tornado was especially shocking because it was so unexpected in this New England factory town. Wallace’s powerful descriptions emphasized the uniformity of the Worcesterites’ reactions: They were stunned, numbed, and alternated between walking around in a daze and crying uncontrollably. The only people who did not seem totally dazed were those engaged in rescue efforts, such as policemen, firemen, and physicians. But even among these people, Wallace observed evidence of profound cognitive impairment. For example, physicians routinely sewed up wounds without noticing that they had not been cleaned, and much of the rescue work had to be redone. During the past 10 years, we have seen a tremendous increase in our understanding of trauma and how it affects both mental and physical health. We now have a much better understanding of the pathways through which, and the circumstances under which, trauma may result in both short- and long-term impairment (for reviews, see Aldwin & Yancura, 2004; Dougall & Baum, 2004; Green & Kimerling, 2004; Schnurr & Green, 2004b). Studies of how people cope with trauma make some of the most fas210

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cinating reading in psychology. Classic works include Lindemann’s (1944) study on the Cocoanut Grove fire, Bettelheim’s (1943) and Frankl’s (1962) recollections of survival in Nazi concentration camps, Lifton’s (1961) study of Chinese thought-reform camps, Erikson’s (1976) study of the Buffalo Creek disaster, and Sharansky’s (1988) experiences in a Soviet gulag. Bettelheim’s descriptions of the changes in psychological reactions with each phase of the experience, the sources of individual differences in appraisal and coping, and the ways in which coping and defense mechanisms contributed to survival in the extreme environment of the concentration camps presaged much of the current literature on coping with trauma. Frankl’s recollections of his experiences in concentration camps were the impetus for much of the current interest in the importance of meaning and transcendence. While there has been some overlap with the general literature on stress and coping, for the most part the trauma literature has evolved somewhat independently. The purpose of this chapter is to briefly summarize this trauma literature, drawing links, where appropriate, to the larger stress and coping literature.

DEFINING TRAUMA As elucidated in Chapter 4, trauma differs from other stressors in that such events threaten severe injury—up to and including loss of life— usually has a rapid onset, and often occurs to many individuals at once. Admittedly, this is a rather stringent definition of trauma. However, it is similar to that proposed by McCubbin and Figley (1983), in which “catastrophic” stress is defined as “sudden and extreme threat to survival which is associated with a sense of helplessness, disruption, destruction, and loss” (p. 220). The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) takes a similar approach. Traumatic stress is defined as events that involve serious threat to life or physical integrity, either of oneself or significant others (e.g., the destruction of a home or community that evokes feelings of extreme terror and helplessness). Others define traumatic events as those that shatter peoples’ beliefs that they live in a meaningful, predictable world (Benner, Roskies, & Lazarus, 1980). Epstein (1991) identified four types of cognitive schemas that may be damaged during trauma: beliefs about the benignity of the world, the possibility of justice, the trustworthiness of other people, and self-worth. However, these broader definitions could easily apply to many stressful life events and chronic role strains—for example, being arrested, especially for something one did not do; being stuck in a low-

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level, poor-paying job with little autonomy; being cheated out of due recognition for one’s role on a project at work; or even parenting a particularly difficult adolescent, which could easily make one a bit jaundiced about justice, trustworthiness, and self-worth. Indeed, it would be difficult to conceive of any major stressor that did not at least challenge one of these cognitive schemas. Limiting trauma to extreme stressors has a number of advantages. First, defining trauma in this manner identifies the most objective of stressors. Neuroticism may well play a role in the occurrence of life events, hassles, and chronic role strain, but the experience of earthquakes, wars, concentration camps, and so forth usually has little to do with one’s personality characteristics. The distribution of trauma is not completely random—exposure to crime and even combat may reflect socioeconomic status, for example. However, the experience of certain types of trauma, such as war or natural disasters, often occurs fairly randomly or to entire communities—and, thus, personality predispositions to stress may be less of a factor than in other quasi-experimental stress research. Second, such trauma often requires the complete mobilization of resources if one is to survive—and, as such, provides an important picture of the use (and importance) of coping resources and strategies. Third, as noted in Chapter 4, trauma has a qualitatively different “feel” than other stressors—even major life events. The hyperreactivity and flashbacks of posttraumatic stress disorder are generally associated with combat or other major trauma, not with everyday stress or even chronic role strain (see below). One potential problem with limiting trauma to this stringent definition is whether it includes incest. Incest is generally considered to be highly traumatic, although it may not be life-threatening per se. However, molesters often use threats of harm, either to the child or his or her family, to ensure compliance and secrecy. Even if the molester is a parent who does not make such threats per se, damage to such a primary bond may evoke basic fears about survival. Children of divorce, for example, may express fears about the availability of food and whether the refrigerator will be empty (Wallerstein & Blakeslee, 1989). Children have fewer resources to cope with stress than adults do; thus, incest may have broad and very negative repercussions (Roth & Lebowitz, 1988), which merits its inclusion in the trauma category.

POSTTRAUMATIC STRESS DISORDER Posttraumatic stress disorder is a psychophysiological response to trauma characterized by six criteria (American Psychiatric Association, 1994).

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The first two criteria that are essential to a PTSD diagnosis are traumatic exposure (Category A) and reexperiencing symptoms (Category B), at least one of which must include intrusive recollections, distressing dreams, flashbacks, intense distress when exposed to something that triggers recollections of the trauma, and heightened physiological reactivity to these reminders. Category C includes avoidance or numbing of affect, while hyperarousal symptoms (Category D) include insomnia, irritability/anger, difficulty in concentrating, hypervigilance, and exaggerated startle responses. The key elements for diagnosis of PTSD, however, include duration (Category E) and severity (Category F): Symptoms must last at least 1 month, and they must cause clinically significant distress. Further, PTSD symptoms have different trajectories: For many people, symptoms abate after a few months, but for others they may last for decades or they may be intermittent (Schnurr, Spiro, Aldwin, & Stukel, 1998; Wilson et al., 1989). For example, one clinician who diagnosed PTSD for the Department of Veterans Affairs told me of a client who was a Korean War veteran. He showed no war-related problems at all for several decades, until he reached age 50. He was giving a presentation at a board meeting for his business when, all of a sudden, everyone sitting at the table “changed” into Asians and seemed to be speaking Chinese, which absolutely terrified him and led him to seek therapy. Similarly, I was once conducting a research project with largely World War II veterans regarding the long-term effects of combat exposure. One respondent in his 70s called me and explained that he could not fill out the questionnaire because, every time he tried to, he kept seeing blood all over the pages. Although he had not even thought about World War II for decades, filling out the questionnaire brought up old traumatic memories, which manifested themselves in the form of nightmares and extremely real visions of blood splattering on the questionnaire. I assured him that he did not have to fill out the questionnaire and urged him to come in and talk to someone about this experience—which he did.1

PTSD among Combat Veterans Combat veterans have been most extensively studied by various researchers. In earlier wars, PTSD was termed “shell shock” or “combat fatigue.” An early study by Stouffer (1949) estimated that as many as one-third of combat casualties on the battlefield during World War II 1It

is important for researchers conducting studies on trauma to make sure that clinical backup is available just for cases such as these.

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were psychiatric in nature. Among Vietnam veterans, lifetime prevalence rates of PTSD are estimated to be as high as 30%, with as many as 15% having active cases at any one period of time (Schlenger, Kulka, Fairbank, & Hough, 1992). However, the rates among World War II veterans may be lower, but the rates among prisoners of war (POWs) is often as high as 50% (Spiro, Schnurr, & Aldwin, 1994). Among the most severely traumatized—World War II POWs in Japanese concentration camps—lifetime PTSD rates were 84%, with current rates at 59% (Engdahl, Dikel, Eberly, & Blank, 1997). In other words, 50 years after the event, over half of the POWs were still actively experiencing PTSD symptoms. Friedman and colleagues (Friedman, Schnurr, Sengupta, Holmes, & Ashcroft, 2004) recently reviewed the prevalence of PTSD in different wars. The prevalence of PTSD among Gulf War veterans was about 10% (Kang, Natalsen, Mahan, Lee, & Murphy, 2003). This is much lower than the 30% estimate for the Vietnam war but similar to current estimates of PTSD (16%) among soldiers returning from service in Iraq (Hoge et al., 2004). However, Friedman et al. (2004) are concerned that this figure among veterans from the current conflict may increase, based upon an earlier study that showed that the rates of PTSD among Gulf War veterans nearly doubled between the time they returned from duty and at their reassessment 2 years later (Wolfe, Erickson, Sharkansky, King, & King, 1996–1997). Clearly the rates of trauma exposure among Iraq war veterans is very high. Hoge et al. (2004) compared rates of trauma exposure with a similar sample who had served in Afghanistan. For example, nearly all of the army and marine veterans reported being shot at in Iraq and seeing dead bodies or human remains, as opposed to two-thirds and less than half, respectively, in Afghanistan; over half were responsible for the deaths of others, as opposed to 12% in Afghanistan. Thus, it is not surprising that rates of distress, including depression and PTSD, are higher in Iraq war veterans (16%) than in Afghanistan war veterans (11%). Interestingly, Fontana, Rosenheck, and Brett (1992) found in a study of Vietnam veterans that having experienced someone’s attempts to kill or injure you was the best predictor of PTSD. However, witnessing or participating in atrocities was the strongest predictor of general psychiatric distress and suicide attempts. Thus, adhering to the Geneva Conventions concerning the treatment of others in wartime may be not only important in terms of ethics and to ensure proper treatment of our own prisoners of war but also may be protective of our soldiers’ mental health after discharge.

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PTSD in Civilian Populations PTSD is not limited to combat veterans. In the United States, PTSD prevalence rates are about 5–6% for men and 10–12% for women; about 8– 10% of traumatized men and 20–31% of traumatized women develop PTSD (Schnurr & Green, 2004a). The most common source of trauma in the United States is car accidents (Norris, 1992). In many areas throughout the world, war and various ethnic, religious, and political conflicts are the most common source of trauma. Indeed, Krippner and McIntyre (2003) argue that war increasingly has been impacting civilian populations. They cite statistics by Kolb-Angelbeck (2000), who estimated that during World War I nearly all (95%) of those killed were combatants. However, in the recent spasms of ethnic, religious, and regional violence, it is thought that 90% of those killed were civilian noncombatants. Obviously these estimates may be somewhat high and need to be verified (to the extent possible). While the rape of women and the killing of children has been “collateral damage” of warfare for thousands of years, and individual invaders such as Genghis Khan would often kill all of the inhabitants of a particularly recalcitrant town, the wholesale slaughter of populations is a new and bloody page in our history. The psychological, physical, and cognitive toll on civilian populations is great. In war-torn areas, lifetime prevalence rates of PTSD may be very high; over a third of Algerian individuals have experienced PTSD at some point in their lifetime (De Jong et al., 2001). People who are exposed to multiple sources of trauma may have even higher rates. For example, Afghan women have lived through several protracted wars, endured in miserable refugee camps in Pakistan and Turkey, and were horribly brutalized by the Taliban, who routinely beat and even shot women for trivial offenses such as riding bicycles or speaking in public. Physicians for Human Rights (1998; cited in Fish & Popal, 2003) have found that nearly half of the Afghan women surveyed met the diagnostic criteria for PTSD. Children may be especially vulnerable to PTSD; McIntyre & Ventura (2003) found that nearly 90% of Angolan adolescent refugees from particularly bad war-torn areas suffered from PTSD. Torture victims also have high rates of PTSD. Moisander and Edston (2003) compared help-seeking torture victims from six different nations (Bangladesh, Iran, Peru, Syria, Turkey, and Uganda). They found that most of the victims were primarily male (except in Uganda), well educated, and had strong political affiliations. The most common forms of torture included falada, or bastinada (being beaten on the soles of the feet), suspension, electrocution, and isolation. Nearly 80% of these torture victims met the criteria for PTSD, and more than a third were sui-

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cidal. While these rates may be high, as this was a help-seeking population, there is no doubt that the consequences of torture are quite severe.

Individual Differences in Vulnerability The psychological consequences of trauma exposure and PTSD have been well documented, including depression, substance abuse, and a variety of psychological disorders, including personality disorders as well as poor marital histories and occupational disruption (Schnurr & Green, 2004a). The children in McIntyre and Ventura’s (2003) study performed well below their nontraumatized comparison groups in mental, physical, and cognitive functioning. However, not everyone exposed to traumatic situations develops PTSD; rates are a function of both individual differences in susceptibility to traumatization as well as situation characteristics. Norris et al. (2002) reviewed 160 studies of disaster victims and found that children and youths are more likely to experience psychological sequellae from traumatization, as were individuals from developing nations and those involved in mass violence (as opposed to natural disasters). Among adults, women, the middle-aged, those with a history of psychiatric disorders, and those with secondary stressors were most likely to be distressed. A recent population study by Cardoza et al. (2004) in Afghanistan found very high rates of PTSD, anxiety, and depression, particularly among women, the disabled, and the poorly educated. However, coping strategies that helped included the use of religious prayer and beliefs as well as focusing on simply obtaining or improving the basic necessities. Ethnic minorities may also be more likely to develop PTSD, although Friedman et al. (2004) caution that some of this may be due to differential exposure. For example, soldiers who are members of an ethnic minority may be more likely to be in combat situations. Friedman et al. (2004) calculated the risk for PTSD among different groups of veterans from Vietnam, adjusting for age and combat exposure. African Americans’ unadjusted rate was nearly twice that of European Americans, but, adjusted for age and combat exposure, they were 20% less likely to develop PTSD. By comparison, the adjusted rate for Hispanic veterans was lower—but still 24% higher than among European Americans—while the adjusted rate for ethnic Hawaiian veterans was actually higher—and nearly three times higher than for European Americans! Interestingly, Japanese Americans appeared to be quite resilient, exhibiting about half the rate of PTSD found among European Americans. Norris et al. (2002) also found that disaster relief workers were surprisingly resilient. Nonetheless, there are instances of mass violence in which nearly

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the whole population has been affected, such as the killing fields in Cambodia and the genocide in Rwanda. When a whole population has been traumatized, it may be extremely difficult to return to normal levels of functioning, and youths in particular may continue cycles of violence, as illustrated by Foreman (2003) in his discussion of a case study of a troubled adolescent who had survived the killing fields of the Khmer Rouge. For example, although the Southeast Asians (Cambodian, Hmong) make up only a small proportion of Asian American youths in California, they are vastly overrepresented in the California Youth Authority (see Lim, Levenson, & Go, 2000). Psychologists have been participating in the various reconciliation programs in South Africa and Rwanda in an attempt to facilitate healing in those cultures (Fisher, 2003). A few years ago, I spent an evening visiting with Afghan refugees living in the San Francisco Bay area. A young man, a mujahadeen who had fought against the Soviets, demonstrated some PTSD symptoms. He described in vivid detail the sensations he felt the first time he had killed someone, how the knife felt going into the soldier’s ribs, and so forth. Clearly he was still struggling with his memories. The older men, in their 70s, had come to terms with their long exposure to war and torture in a somewhat unusual way. These elderly Afghans were laughing about one man who had the “distinction” of having been tortured by three different regimes. “Go on,” they said, “tell our guests what crimes you committed to have deserved so much torture!” When the man confessed that he had tried to overthrow these three different regimes, the elderly Afghans howled with laughter, tears streaming down their eyes. (It reminded me of the “gallows humor” that emergency room personnel and combat physicians often exhibit as a way of getting through extremely traumatic situations.) Nonetheless, the “man of distinction” looked a good 10 years older than his compadres, and died soon thereafter.

PTSD and Physical Health An increasing amount of attention has also been paid to the long-term effects of PTSD on physical health. In their review, Green and Kimerling (2004) found that a lifetime history of trauma exposure tends to be associated with poorer self-reported health. Among women, sexual assault is associated with problems in various organ systems, including reproductive health symptoms. There is also weaker evidence for a number of other illnesses, including infectious diseases and chronic illnesses such as asthma, hypertension, and diabetes. A number of studies have documented that combat exposure is associated with poorer health outcomes; POWs in particular may experience lifetime poor physical health due to the torture and abuse they ex-

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perienced (Page et al., 1991). A good example of this is U.S. Senator John McCain’s chronic back problems, stemming from his torture in Vietnam. For reasons only poorly understood, losing a limb is associated with higher rates of cardiovascular disease in later life (Modan et al., 1998). Not surprisingly, people who have been exposed to trauma often have higher health care costs (Walker, Newman, & Koss, 2004). There has been increasing interest in the effects of trauma and PTSD on neuroendocrine and immune systems. The pattern of results suggests that trauma has impacts that are subtly different from those associated with either acute or chronic stress. In their review, Friedman and McEwen (2004) demonstrate that chronic stress and PTSD impact both the hypothalamic–pituitary–adrenocortical and sympathetic–adrenal– medulla systems, resulting in HPA dysregulations, increased CRF, sympathetic nervous system arousal, increased adrenergic reactivity, startle responses, and sleep disturbances. However, there are other impacts that differ between the two types of stress. Chronic stress is associated with increases in endogenous opioids but decreases in thyroid hormones, while the opposite may be true for PTSD. Both may result in immunosuppression but increases in inflammatory cytokines. One of the current controversies is whether cortisol levels are higher than normal or actually lower than normal in traumatized individuals. Remember that elevated cortisol levels are a central component of physiological reactions to stress, but some studies have found that trauma victims have lower cortisol levels. Yehuda (1997) argued that the reason that PTSD patients have low cortisol levels is that there is an increase in the number of glucocorticoid receptors, which makes the HPA system supersensitive to cortisol. Thus, the body acts as if there were elevated cortisol even though levels may actually be low. Alternatively, Rasmussen and Friedman (2002) have suggested that gender differences may be the cause of this discrepancy: studies with premenopausal women and traumatized children tend to show elevated levels, while those with male combat veterans tend to find reduced levels. However, an interesting study by Mason, Giller, Kosten, and Wahby (1990) suggested that PTSD patients may have remarkable fluctuations in cortisol levels. In a study of hospitalized combat veterans with a PTSD diagnosis, Mason et al. found that cortisol levels were quite low on admission but were high during a phase of their treatment when they were reexposed to the trauma and then returned to low levels just before discharge. Thus, cortisol levels may vary, depending upon a variety of stressful circumstances, but may be more labile in those with PTSD. Relatively few studies have been published examining trauma and immune functioning. Dougall and Baum (2004) reviewed 15 studies.

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Eight found patterns consistent with acute stressors—namely, increased circulating levels of peripheral lymphocytes and NK cells. This increase in circulating peripheral lymphocytes is thought to reflect their release from the lymph nodes and the spleen in response to stress; indeed, such a response could easily be seen as helpful in situations that are likely to result in bodily injury. However, the proliferation and responsivity of these lymphocytes are often impaired, although that is not true for the NK cells. However, five of the trauma and immune functioning studies reviewed by Dougall and Baum found changes more similar to those seen with chronic stress, namely, suppression of both cell numbers and function. Two found both types. This inconsistency is due in part to the timing of the stressor. Traumatic events can be either short-term, such as an earthquake or automobile accident, or they may reflect chronic conditions, such as ongoing abuse, combat, or chronic PTSD. The trajectory of recovery of immune system function after exposure to trauma varies by study. Some studies show that those individuals who develop PTSD may have long-lasting immune suppression (McKinnon, Weisse, Reynolds, Bowles, & Baum, 1989), but studies of combat veterans sometimes show higher levels of immune cells (Boscarino & Chang, 1999). The effects of trauma on the immune system may be moderated by such factors as controllability and health behaviors; excessive smoking and drinking may also suppress immune function. As mentioned earlier, some of the effects of trauma on physical health are direct, that is, if an individual is physically maimed through a car accident, war situation, or torture, then there can be lifelong sequellae. However, as several researchers have pointed out, most of the trauma (in this country, at least) is not accompanied by physical injury or exposure to illness (Kulka et al., 1990; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). In their integrative review, Schnurr and Green (2004b) argue that much of the effect of trauma exposure on physical health is mediated through PTSD. Although the literature is mixed, most studies find that much of the variance is mediated through PTSD, although some is mediated through comorbid conditions such as depression or anxiety (for a review of the effects of these factors on physical health, see Aldwin, Levenson, & Gilmer, 2004). Schnurr and Green (2004b) identified several pathways through which PTSD can affect morbidity and mortality. First, there may be effects on the neuroendocrine and immune systems, as noted earlier. Second, there may be other types of psychological problems, such as depression, anxiety, poor coping, and the like, which in turn lead to health risk behaviors as well as changes in symptom perception and labeling of physical symptoms. In turn, these two factors can affect illness behavior,

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that is, levels of self-reported symptoms, utilization of medical services, and functional ability. Finally, both the health risk behaviors and the illness behaviors may affect morbidity and mortality. There is much evidence to support various aspects of Schnurr and Green’s (2004b) model, but, to our knowledge, no one has yet tested these elements in one comprehensive model. Nonetheless, if true, then clearly interventions to help individuals cope with trauma so that PTSD does not develop may be the best means of protecting their health status.

COPING WITH TRAUMA For a number of reasons, studying how individuals cope with trauma and its aftermath may be particularly crucial for understanding the adaptation process. First, accounts of coping with trauma are fascinating reading and have a great deal of intrinsic interest. Magazines such as Reader’s Digest, for example, routinely include stories about how people survived airplane crashes, avalanches, shark attacks, and other assorted disasters, as well as stories about women who fought off serial murderers or rapists, football heroes who recovered from certain quadriplegia, war heroes who survived POW camps, and so on. The news media also play up such stories, spending a large proportion of airtime (and column space) on families who survived a blizzard for several days, children who were dug out of wells, puppies who fell down drain pipes, to mention only a few typical stories. There are even television programs that feature rescue workers responding to emergency calls, to say nothing of the current spate of “reality” television shows that create artificial stressful situations to see who “wins.” The stories provide a satisfying (if somewhat illusory) sense of control: You can survive anything, they seem to say, if you just have enough courage, tenacity, faith, a little technical knowledge, and, of course, a lot of luck. Second, trauma provides an interesting opportunity for the study of extreme stressors that would never be replicable in a laboratory: Things occur in real life that would never be approved by human subjects review boards—or animal rights review boards, for that matter. One cannot—and should not—subject humans or other animals to extreme trauma in order to study its psychological or physical consequences (see Ader, 1981, for arguments against using anything more than mild stressors in animals). Epstein (1991) has argued that traumatic situations provide an unparalleled opportunity to examine the structure of personality.

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To study the structure of an atom, he stated, one needs an atom smasher. Trauma functions as an atom smasher for the study of personality—and of adaptive processes in general. Third, trauma is often unanticipated and may require immediate mobilization of seldom-used resources. Most people are not trained to cope with trauma (with the exception of military or medical personnel) and must thus improvise and develop new strategies very quickly. Unlike many life events or hassles, traumatic events often have long-term effects, which allows one to examine the process of adaptation over time. Finally, if indeed the level of trauma is increasing in the world, due to an increase in terrorist attacks and the targeting of civilians in ethnic, political, and religious conflicts, then understanding how individuals cope with trauma and, if necessary, helping them to develop coping skills both have important implications. In an impassioned plea for psychologists to help the victims of war, Hobfoll (2002) argued: The cognitive revolution and, now, a biological revolution are desperate attempts to once again reenter the laboratory and avoid at all costs the real issues facing the world—not because these areas cannot be adopted to the study of the real world, but because they are used as barriers to exclude those who do wish to conduct such studies. The major centers of U.S. learning in psychology want to reinstate an ivory tower psychology and return to the earlier ideology of physics as a model for psychology. From the ivory tower, the real-world problems that a volume such as this faces head-on are too dirty and too removed from the “experimental laboratory,” with clear assignment of cause and effect, even if that cause and effect repeatedly has been shown to be largely artefact. (p. xii)

As we shall see, the many “real-world” studies that have been done on coping with trauma during the past 10 years have provided insight into how to help people adapt. It should be noted that the majority of individuals facing trauma do not develop long-term problems, and indeed, how individuals cope with trauma and any short-term psychological distress often has a large bearing on whether or not individuals go on to develop PTSD (Arsenio, Wheately, Sledge, Race, & Carlson, 1986; Bleich, Gelkopf, & Solomon, 2004; Mikulincer & Florian, 1996; Wolfe, Reane, Kaloupek, Mora, & Winde, 1993). The process of coping with trauma may be more important for mental health outcomes than the exposure to trauma itself. This has been shown to be so both retrospectively (Fairbank, Hansen, & Fitterling, 1991; Zeidner & Hammer, 1992) and prospectively (Solomon, Mikulincer, & Avitzur, 1988; Solomon, Mikulincer, & Benbenishty, 1989).

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Phases of Coping with Trauma Accounts of initial reactions to trauma are often quite remarkable. People sometimes report that time seemed to slow down so that they could act much more quickly; others froze and seemed paralyzed, unable to respond; yet others dissociated and felt as if they were not a part of what was happening. I remember reading an account of the time that Dr. Stanley Livingston, the African explorer, had been mauled by a lion. The lion, he said, had picked him up in his mouth and shaken him, just like a cat does to a mouse. The man said that he now knew what the mouse felt: nothing. While it was happening, his mind went numb. He felt no pain, as if his experience were happening to someone else. Attention may become very focused: it is not uncommon for soldiers who have been wounded in battle to initially feel no pain or even notice that they have been wounded until after the heat of battle. Early researchers focused on identifying different phases of coping with trauma, which seem to vary by type of trauma. This section will briefly review coping phases for concentration camps, rapes, and natural disasters. Somewhat more attention will be given to accounts of concentration camps, in part because of the richness of the qualitative literature in this area. However, more recent research has largely abandoned stages, and this section has been updated accordingly.

Concentration Camps Bruno Bettelheim (1943), a psychologist who survived Nazi concentration camps, maintained his sanity in part by studying adaptation to the camps in a systematic manner and even enlisting two assistants in his efforts. Bettelheim’s efforts were remarkable not only because of their context but also because he demonstrated person–environment fit interactions in adaptation even under this extreme stressor. He identified four stages in the concentration camp experience: “initial shock” of being a prisoner, transportation to camp and “initiation” to it, the process of “adapting,” and “final adaptation.” However, different types of prisoners reacted to these stages differently. Besides Jews, there were political prisoners, Jehovah’s Witnesses and other conscientious objectors, criminals, homosexuals, people who objected to working conditions, and “personal” prisoners, that is, wealthy people being held for ransom by various Nazi officials. In the “initial shock” phase, the different types of prisoners manifested very different responses. The criminals and political prisoners were least distressed. Although anxious about the future, the criminals were pleased at seeing people from higher socioeconomic brackets re-

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duced to their own level, while the political prisoners saw their own arrest as indicative of their importance. Those from the upper classes, on the other hand, maintained a belief that they would be released, that their families would pay to free them—and, indeed, many of them did get released. The few who were not successfully ransomed maintained a self-imposed isolation as a way of retaining their sense of superiority. The middle-class inmates were most distressed because they could perceive no justification for their arrest: They had no consistent philosophy which would protect their integrity as human beings, which would given them the force to make a stand against the Nazis. . . . They could not question the wisdom of law and of the police, so they accepted the behavior of the Gestapo as just. What was wrong was that they were made objects of a persecution which in itself must be right, since it was carried out by the authorities. (Bettelheim, 1943, p. 426; emphasis in original)

When the middle-class prisoners realized their true situation, they seemed to disintegrate, because their worldview was shattered. They were the only ones to commit suicide at this stage; often those who did not kill themselves became very antisocial when they reached the camps—cheating on their fellow inmates, becoming spies for the Nazis, and so on. The transportation to the camp and the “initiation”—what the Nazis called “welcome”—involved some of the worst torture that the prisoners would experience. At the camp, the guards tortured each prisoner to break down his or her resistance; the few who did resist were killed. Bettelheim survived this by dissociating—which is about the only possible thing to do under such extreme stress (Figley, 1983). His goal throughout was to remain alive and internally unchanged. New prisoners in general coped through dissociation and regression. Curiously, minor insults on the part of the guards seemed to be resented more than major ones. While altruism is an important coping strategy during traumas like natural disasters (Smith, 1983), Bettelheim reported that the Nazis quickly suppressed altruistic acts by punishing the whole group if one person tried to protect or help someone else. The prisoners quickly learned that trying to help only resulted in even worse conditions—and, thus, natural leaders were suppressed. In the “adapting” stage, the prisoners no longer seemed to cope via dissociation. Their focus narrowed to the camp and how to survive in it. They reverted to daydreams about how important, warm, or loved they would be once they got out, even while many were abandoning dreams of ever getting out. In his description of Norwegian concentration camp

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survivors, Eitinger (1980) also found that the coping strategies of building up an “inner world” and of idealizing the world outside the camps were nearly universal. In the “final adaptation” stage, the personality of the prisoners changed into what the Gestapo wanted—namely, more useful subjects of the Nazi state. “Old” prisoners—those who had been there at least 3 years—often identified with the aggressor and incorporated Nazi values. They would zealously enforce the rules among the newer prisoners, even rules that had been discontinued by the Nazi guards. For example, one Nazi guard on a whim ordered the prisoners to wash their shoes inside and out with soap. However, the shoes became as hard and heavy as stones, resulting in severe damage to the feet, and the order was never repeated. Nonetheless, many of the old prisoners continued washing their shoes, and forced the new prisoners to do this as well. The old prisoners would not admit to accepting Nazi values, but engaged in rationalization to justify their behavior. For example, the newer prisoners often wanted to sabotage their work, but the older prisoners would argue against this, saying that after the war Germany would need those buildings, or that one should always do one’s best, no matter what. This identification with the aggressor was sometimes taken to an extreme: Practically all prisoners who had spent a long time in the camp took over the Gestapo’s attitude toward the so-called unfit prisoner . . . A newcomer who did not stand up well under the strain tended to become a liability for the other prisoners. Moreover, weaklings were those most apt eventually to turn traitor. Weaklings usually died during the first weeks in the camp anyway, so it seemed as well to get rid of them sooner. So old prisoners were sometimes instrumental in getting rid of the unfit. . . . That this was really a taking-over of Gestapo attitudes can be seen from the treatment of traitors. . . . The way in which they were tortured for days and slowly killed was taken over from the Gestapo. (Bettelheim, 1943, p. 448)

Viktor Frankl (1962) was a psychiatrist who also made a scientific study of the various concentration camps that he was in as a way of preserving his sanity. He described three phases to the experience—slightly different from, although similar to, Bettelheim’s: the time directly after admission, the period of entrenchment in camp routine, and release and liberation. As with Bettelheim, the initial reaction consisted of shock and disbelief, but Frankl also included the experience of “being overcome” by a grim sense of humor and curiosity. After the first initial selection at Auschwitz, in which 90% of prisoners who arrived on the train were

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marched to the gas ovens for immediate execution, the remaining 10% were systematically brutalized, stripped of all possessions, denuded of all body hair, subjected to torture, and then marched off to showers for their own “cleansing”: Thus the illusions some of us still held were destroyed one by one, and then, quite unexpectedly, most of us were overcome by a grim sense of humor. We knew that we had nothing to lose except our so ridiculously naked lives. When the showers started to run, we all tried very hard to make fun, both about ourselves and about each other. After all, real water [as opposed to cyanide gas] did flow from the sprays! Apart from that strange kind of humor, another sensation seized us: curiosity. . . . Cold curiosity predominated even in Auschwitz, somehow detaching the mind from its surroundings, which came to be regarded with a kind of objectivity. At that time one cultivated this state of mind as a means of protection. . . . In the next few days our curiosity evolved into surprise. (Frankl, 1962, pp. 14–15)

The surprise stemmed from discovering the extent to which they could adapt to such harsh conditions—surprise that they did not develop respiratory disease even after being forced to stand in cold air for several hours after the showers, that they could go without sleep for much longer periods than they imagined, that they could sleep under impossible conditions, or that they did not develop gum disease despite not being able to brush their teeth. (I suspect that in this initial stage their immune systems were greatly stimulated; see Chapter 4.) Not surprisingly, information seeking was rampant, and most considered suicide at some point. These reactions began to change after a few days. During the second phase, entrenchment into camp life, the prisoners became apathetic and emotionally deadened. Reality narrowed simply to survival in the camp, which involved the development of various problem-focused strategies, including hoarding bits of food, casually robbing the dead or dying for better clothes, developing elaborate systems to warn of the approach of guards, and humoring the Capos—prisoners who ran the work groups— to gain access to more resources. The prisoners also fantasized a great deal about food and home. Frankl’s account differed markedly from Bettelheim’s in his emphasis on the positive strategies that the inmates used. While many did become cruel and did engage in despicable behavior, torturing and killing fellow internees, Frankl documented the use of humor, art, and altruism as coping strategies that were consciously employed: Humor was another of the soul’s weapons in the fight for selfpreservation. . . . I practically trained a friend of mine who worked

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The prisoners also put on a type of “cabaret” from time to time, trading jokes, singing songs, and reciting poetry, even though it meant missing their evening ration of soup. The altruism of the prisoners (and sometimes even the guards) made life possible in the camps. According to Frankl, the prisoners often looked out for one another. While they tried to protect themselves, they also tried to protect their closest friends and sometimes people who were simply fellow countrymen. More experienced inmates would give advice about survival strategies to newcomers, often risking terrible retribution from the Nazis. While it was strictly forbidden to rescue anyone who was committing suicide, the prisoners tried to watch other inmates who were judged to be suicide risks in order to prevent these inmates from making any attempts to kill themselves. Frankl recounted one episode in which a starving man was being sought for stealing a few pounds of rotten potatoes. The Nazis threatened to withhold food from everyone for 24 hours unless the inmates produced the man. While there was much grumbling, not one of the 2,500 men in the camp gave up the name of the culprit, even though the Nazis did carry out their threat. Frankl himself provided both individual and sometimes collective psychotherapy for other inmates, in addition to his occasional official duties in taking care of typhoid victims—which usually amounted only to the distribution of half an aspirin to a few of his patients.2 For Frankl, the maintenance of a sense of meaning or purpose in life was critical to survival. If an inmate lost that, he or she also lost the will to live—and often died. Most important of all was spiritual growth and development. In spite of all the enforced physical and mental primitiveness of the life in a concentration camp, it was possible for spiritual life to deepen. Sensitive people who were used to a rich intellectual life may have suffered much pain (they were often of a delicate constitution), but the damage to their inner selves was less. They were able to retreat from their terrible surroundings to a life of inner riches and spiritual freedom. (Frankl, 1962, p. 35) 2After

reading this, I finally understood why my friend described in Chapter 11 would only take half an aspirin, despite suffering terribly from colon cancer.

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Frankl related several instances of what can only be called transcendent states that he experienced in the midst of this terrible suffering. He felt that these experiences allowed him to maintain his sense of dignity and self-worth, to not become “worse than an animal.” In the final analysis it becomes clear that the sort of person the prisoner became was the result of an inner decision, and not the result of camp influences alone. Fundamentally, therefore, any man can, even under such circumstances, decide what shall become of him. . . . The way they bore their suffering was a genuine inner achievement. It is this spiritual freedom—which cannot be taken away—that makes life meaningful and purposeful. (Frankl, 1962, p. 66)

Frankl is not the only person to note the link between spirituality, maintenance of meaning and the preservation of dignity even under intolerable circumstances. Lifton (1961) detailed a similar process in a Catholic priest held in a Chinese Communist concentration camp, and Sharansky (1988) provided a similar account in his experiences in a Soviet gulag. Indeed, as we will see shortly, the importance of spirituality and making meaning as a means of coping with extreme stressors has become of central importance in the study of trauma in the past decade (see Aldwin & Yancura, 2004, for a review). In some ways, Frankl’s account of the third stage—postliberation— was the saddest. Having deadened their emotions for so long, the inmates could not immediately experience joy at their new freedom. It took a while for everyday emotions to return, which was sometimes aided by the recounting of their experiences. The former prisoners ate prodigious amounts, which is hardly surprising. Bettelheim’s “identification with the aggressor” emerged anew in some of the inmates. Some became ruthless oppressors, justifying their behavior by their own terrible experience. Many also became bitter and disillusioned. Persons who had kept themselves alive with the thought of reunion with a loved one had a particularly difficult time when they discovered the extent of their losses. However, Frankl believed that most of the survivors eventually recovered. Lomranz (1990) reviewed the literature on the long-term adaptation of the Holocaust survivors and identified two further stages: laying foundations and maintenance. During the “laying foundations” period, survivors built a new life: finding a country in which to live, learning the language and the customs of that country, finding a way to make a living, and building a new family. This period often lasted for several years. During the maintenance period, the survivors developed a reasonably stable mode of adaptation. Lomranz identified three different pat-

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terns. In keeping with McCubbin, Olson, and Larsen’s (1982) caution that adaptation to traumatic stress is not just an individual matter but involves the entire family, Lomranz based his three modes on different types of “family culture”: Different kinds of family cultures were created, depending on the survivors’ personalities, histories, perceptions of the Holocaust, assumptive worlds, and resources. . . . Some families exhibited a somewhat forced happy atmosphere, emphasizing the importance of external appearance. Others were pervaded by a more solemn mood, and the atmosphere at times resembled continuous mourning. Boundaries and privacy were discouraged, and it was often a complicated matter to develop intimacy. Nutrition, body care, and material support often substituted for emotional closeness. . . . Many of the families . . . develop[ed] a traditional, authoritarian, constricted atmosphere. There was little delegation of authority. (Lomranz, 1990, pp. 110–111)

The families also differed in both the degree and manner in which the Holocaust was discussed. Some people were open about their experiences and “bore witness” publicly, writing their memoirs and engaging in various Holocaust-related projects. However, if the survivors complained and exhibited trauma-related symptoms, family members often retreated from them. Thus, it is not surprising that in many families, especially the authoritarian ones (and, presumably, the “forced happy” ones), the Holocaust was a taboo subject. Some did not discuss their experiences even with their spouses; others hid their feelings so well that extended family members did not even realize they had been in the camps. For many people, denial and suppression worked well for decades. Lomranz believed that the maintenance period lasted only until old age, because the developmental tasks in late life would force the survivors to change their mode of adaptation, especially among those who used denial and repression to control their emotions. In late life, the inevitable loss of loved ones would remind the survivors of the many other loved ones they had lost. Life review is also a developmental task in late life and underlies ego integration or despair; but Lomranz questions whether the Eriksonian requirement to accept one’s life as necessary, unique, and inevitable in order to achieve ego integration is realistic, given the totally unacceptable experience in the death camps. The Kahanas and their colleagues have also been studying late life adaptation to the Holocaust (for a review see Kahana, 1992). These studies have been more rigorous than most in that they have used standard indicators of mental and physical health as well as stress and cop-

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ing measures. Whereas many studies had utilized clinical or treatmentseeking populations, the Kahanas and their colleagues have studied nonclinical populations. Further, they have carefully compared Holocaust survivors who emigrated to the United States and Israel with ethnically similar groups of people who emigrated before the war. According to research done by the Kahanas and their colleagues, survivors were generally in worse physical and mental health than the comparison group. The survivors reported more physical symptoms, primarily “psychogenic ones” such as ulcers, but often did not report differences in more serious illness such as cancer or arthritis. Survivors also experienced intrusive thoughts regarding their trauma (75% experienced this at least once a week) and reported slightly more psychological distress and lower morale. However, their social functioning was often higher than that of the comparison group. Despite less education, their income was considerably higher. They were more likely to be employed and had “superior job histories.” They also had more stable marriages (75% were married to other Holocaust survivors) and fewer residential moves. Survivors were also more likely to participate in community activities and evinced greater feelings of responsibility toward their communities. When asked whether experiencing the Holocaust affected coping with problems in late life, some (45%) confirmed Lomranz’s hypothesis that it made coping more difficult, but 26% said it made it easier (“Once you survive the Holocaust, you can survive anything”) (Kahana, 1992, p. 164). Nearly all said they were “different” as a result of their experiences. Nearly half (46%) saw themselves as negatively affected, but 34% reported strengths and positive features. Of those who reported positive sequellae, nearly half (46%) reported better coping resources and strength of character, 36% were more appreciative of life, and 27% saw themselves as more humane, empathetic, and compassionate toward others. Personality, coping, and social support variables were correlated with positive affect. These included Holocaust experiences with family and friends, having an altruistic attitude toward the world and an internal locus of control, and having a spouse who was also a survivor (Kahana, 1992). Additional analyses on the Israeli samples (Harel, Kahana, & Kahana, 1988) found that a combination of variables predicted 52% of the variance in the psychological well-being among survivors: better physical health, higher instrumental coping, lower use of emotional coping, and less use of social concern, as well as marriage to a Holocaust survivor, fewer life crises, communication with coworkers, and not being resigned to fate. Thus, physical health, stress and coping, the utilization of social resources, and attitudes toward life accounted

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for a large proportion of the variance in psychological well-being in later life among Holocaust survivors. Kahana et al. (1998) have argued that Holocaust survivors are best characterized as experiencing “chronic traumatic stress,” defined as “residual internalized stressors that originate from the trauma and continue to afflict survivors on an indefinite basis” (p. 318). In other words, the trauma of the Holocaust was imbedded in the stressful life events leading up to the concentration camps, and unfolds in and is exacerbated by ongoing life events and other stressors. These are characterized by intrusive memories, living with fear and mistrust, psychological and social isolation, and living with trauma. More than half (61%) of Holocaust survivors interviewed in this study said they think about their experiences daily or several times a week, even though fewer than a fifth met the criteria for PTSD. Intrusive memories are simply something they live with, as is an often pervasive sense of fear and mistrust. For example, friends of mine who were associated with a Public Guardians’ office told me about a case in which they took over guardianship of the estate for an old man who was a Holocaust survivor. Being mistrustful of banks, he had “saved” his money by wrapping each individual bill in a gum wrapper; his small apartment was literally awash in gum wrappers nearly 3 feet deep—because, of course, not all of them held money. It took my friends nearly 8 hours one Saturday to unwrap all of the gum wrappers; they recovered several thousand dollars for their client. These feelings of fear, isolation, and stigma lead many of the survivors to use avoidant coping. However, they also had exaggerated fears for the well-being of their children. On a more positive note, they tended to dismiss the chronic problems of late life as trivial as compared to their experiences in the camps. A number of observations can be made from these often remarkable accounts of this trauma. First, one would think that the overwhelming “environmental press” of a Nazi concentration camp would obviate any individual attempts at coping and adaptation. However, there were clear differences in how individuals responded to the camps: Bettelheim saw only bestiality, whereas Frankl also saw courage, altruism, and even transcendence. Second, coping strategies changed over time in response to the changing demands of this traumatic experience: initial dissociative reactions gave way to emotional numbing, which facilitated problem-focused attempts at survival. Third, the inmates consciously developed a number of problem-focused strategies for survival, which included information seeking, analysis of the ways of avoiding the worst of the punishments and gaining access to more resources, and sharing resources and devel-

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oping innovative ways of using them. Emotion-focused strategies included emotional numbing, the use of fantasy to provide a respite from camp life, the conscious use of humor, and seeking spiritual growth. Fourth, Frankl noted that the goal of coping behaviors was not necessarily survival: many felt that maintaining personal integrity was a higher goal and would engage in altruistic acts that they knew would shorten their own lifespans, or they would refuse to perform what they perceived to be immoral acts even if it meant not surviving. As Frankl put it, “the best of us did not survive.” Coping after the traumatic events is also critical to adaptation. Lomranz and the Kahanas documented individual differences in adaptive strategies after the Holocaust that had various costs and benefits. Coping strategies, the utilization of social resources, and attitudes toward life accounted for over 50% of the variance in psychological wellbeing in late life, which suggested that adaptive strategies were critical for recovery from this trauma. Finally, many if not most of the Holocaust victims carried lifelong physical and emotional scars; however, nearly a third reported having developed in positive ways from this most onerous of experiences, such as developing more coping resources, greater strength of character, and more humaneness.

Rape, Incest, and Sexual Abuse In an early study of rape victims, Burgess and Holmstrom (1976) suggested that in a traumatic experience there are three different phases that elicit different types of coping strategies. In the first or threat phase, the three types of strategies included cognitive assessment concerning the nature and severity of the threat, verbal tactics, and physical action. While one-third of the women whom Burgess and Holmstrom interviewed used multiple strategies, an equal number used none, due to physical or psychological paralysis. During the second phase—the attack itself—a greater range of strategies was identified. Problem-focused coping included physical action (fight or flight) as well as cognitive and verbal strategies. Emotionfocused strategies included affective responses (crying or screaming), psychological defenses (mainly emotional numbing and dissociation), and physiological reactions, including vomiting, passing out, and urinating. (One could also argue that these physiological reactions could be viewed as problem-focused strategies, if they were used purposefully to deter the attacker.) In the third phase, immediately after the attack, the strategies utilized included bargaining for freedom, freeing oneself, and alerting others (seeking social assistance and/or reporting the rape to authorities).

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Others have studied longer-term reactions to rape. Ward (1988) argued that most victims use defense mechanisms, including repression– suppression, rationalization, intellectualization, denial, undoing, regression, minimization, dramatization, and displacement of anger. Cohen and Roth (1987) studied 72 rape victims who were contacted via news paper advertisements. These women reported higher levels of psychological distress than normative samples, but lower than women assessed immediately after a rape. The more force used in the rape, the greater the distress. Surprisingly, the length of time since the rape occurred was negatively related only to intrusive thoughts; Cohen and Roth argued that other symptoms decline only in the first 3 months after a rape and then remain relatively stable. In general, women who reported the rape to the police and confided in someone relatively quickly (or sought professional help) did better than women who only tried to repress the problem. Harvey, Orbuch, Chalisz, and Garwood (1991) confirmed that rape victims who confided in someone quickly had better outcomes than those women who confided later. However, the response of the confidant was also important: Women whose confidants responded negatively had poorer outcomes than women with supportive confidants (see also Silver et al., 2000; Stephens & Long, 2000). Although the tendency is to assume that trauma has long-term negative outcomes, this might not be the self-perception of the victims. Burt and Katz (1987) found that over 50% of the rape victims in their sample felt that they had changed in a positive direction, and fewer than 15% felt that they had changed in a negative direction. Burt and Katz factoranalyzed these women’s responses and found four growth factors: improved self-concept, self-directed activity, less passivity, and less stereotyped attitudes. A more recent study by Frazier, Conlon, and Glaser (2001) confirmed that many, if not most, women who had been raped reported perceived benefits, especially if they had good social support, used approach and religious coping, and had a sense of control over the recovery process (Frazier, Tashiro, & Berman, 2004). In general, incest victims tend to be worse off than adult women who were raped (Harvey et al., 1991), in part because children have fewer psychological resources to cope with stress than adults do (Roth & Lebowitz, 1988). Silver, Boon, and Stones (1983) interviewed 77 women (identified through a newspaper advertisement) who had experienced incest. In contrast to Burt and Katz’s (1987) study, only 20% of the incest victims reported positive outcomes. These women were primarily those who did have confidants and who were able to “make sense” out of the event, mainly through the victims’ understanding of their father’s behavior as a function of family dynamics (e.g., due to the mother’s illness or unavailability) or as a result of the father’s mental illness or character disorder.

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Unlike Cohen and Roth’s (1987) study, in which characteristics of the rape were related to later distress, Draucker (1989) did not find that various qualities of the incestuous experience were related to psychological distress in adulthood (although the 103 women ranged in age from 18 to 64, which may have blurred these effects). However, how the women coped with the problem (by searching for meaning, developing a sense a mastery, and enhancing self-esteem through downward comparisons) did relate to depression, self-esteem, and social role functioning in the expected manner. One of the more controversial episodes in recent psychological history was the publication of a meta-analysis of the long-term effects of sexual abuse (Rind, Tromovitch, & Bauserman, 1998). Among male college students, there were actually very few long-term effects of such abuse; rather, what effects there were tended to be mediated by family functioning. Boys whose families demonstrated good psychosocial functioning showed little or no long-term adverse effects in adulthood. Unfortunately, this study was picked up by a propederasty website as “proving” that they were doing no harm. This, in turn, raised an uproar in Congress, which put pressure on the American Psychological Association (APA) to retract the article. The APA took the unusual step of sending the article to a new set of reviewers to assess its psychological merits. These reviewers concluded that the meta-analyses in the article had indeed been conducted correctly and that the article adhered to the accepted scientific criteria for such analyses. Nonetheless, the APA considered withdrawing the article, which raised a huge uproar among psychologists. For example, an e-mail signed by most members of the Department of Psychology at Harvard University was circulated threatening to resign en masse if the APA caved in to such political pressure, and the article was not withdrawn. In critiquing this article, it should be noted that male college students are a fairly resilient group. The female college students reviewed by Rind et al. (1998) were more likely to develop PTSD from child sexual abuse, and it is likely that individuals who are deeply troubled may have a hard time achieving the requisite academic qualifications or emotional stability necessary for going to college. It is also likely that duration of trauma exposure may well influence the long-term outcomes: isolated incidence may not have long-term effects, but long-term abuse may have more severe effects. Nonetheless, supportive families may well be an important component of resilience to stress (see Chapter 13). Further, sexual abuse (and other trauma) may not necessarily interfere with coping abilities. Reis and Heppner (1993) compared stress and coping measures in a small sample of mother–daughter pairs from incestuous families (in which males were the perpetrators) with a nonclinical sample. Not surprisingly, both mothers and daughters from incestuous

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families perceived their families as significantly more stressful than the comparison sample. Although the mothers from incestuous families perceived themselves as worse copers, there were no differences between the two groups of mothers on the family coping scale. Further, abused daughters did not differ on any of the coping or distress measures from the comparison daughters. Reis and Heppner (1993) argued that there is a role reversal in incestuous families, with girls having a great deal of responsibility. They may become relatively resourceful because they have take on the mother’s role to compensate for her ineffectiveness. However, inspection of the items on the coping scale used in this study revealed few negative or harmful coping strategies. The mothers’ perception of themselves as ineffective (with which, apparently, the authors concurred) was not reflected in the family coping scale, suggesting that the scale did not include a full range of coping strategies. Thus, the harm that these girls experienced may not have been reflected in the measures used. Nonetheless, the pattern of results from these rape and incest studies is similar to that found in the Holocaust studies. How one copes with the events, especially after the fact, may be more important to mental health over the long run than the existence of the trauma itself. However, just because individuals may be resilient to stressors and other trauma does not justify the perpetration of abuse on others. Indeed, such behaviors violate Kant’s categorical imperative—not to use other individuals as objects in the furtherance of one’s own goals—and, as such, are inherently amoral.

Natural Disasters According to Smith (1983), the effects of natural disasters are most significant if they are sudden, unexpected, or prolonged, and if they occur at night. While much research attention has been focused on the most devastating disasters, most are not that traumatic. “In fact, disasters may have some ‘therapeutic’ features. It is not uncommon for victims to express positive feelings from participating in the community recovery process. A sense of adequacy, mastery, increased community solidarity, and general optimism often comes from collectively responding to the challenges of a crisis” (Smith, 1983, p. 124). Smith (1983) identified four phases of adaptation to a natural disaster. The first, or heroic, phase occurs during the event and immediately afterward. This phase is often characterized by altruism. The second, or honeymoon, phase is characterized by social solidarity and cleanup efforts. In the third stage, disillusionment can set it. People might withdraw from community efforts and express negative feelings toward gov-

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ernmental agencies, especially if there is less aid than expected. Finally, in the reconstruction phase, individuals assume responsibility for their own recovery and rebuild their community. To a certain extent, this somewhat rosy picture of the effects of a natural disaster may be limited to countries like the United States that have a great deal of resources, including stringent building codes that limit the devastation that occurs and reasonably efficient governmental responses to crises. In other countries, the effects of natural disasters can be more devastating and recovery much more difficult. An earthquake of a 5.0 magnitude on the Richter scale that often causes only minor damage in California could result in thousands of deaths in countries such as Iran, Mexico, or China, which do not have stringent earthquake building codes. In Bangladesh or rural India, there may be few, if any, adequate roads, which often delays rescue efforts for days, resulting in widespread deaths due to secondary causes such as typhoid fever. If there is widespread destruction and loss of life, the consequences of a natural disaster may last for years. Some of the most moving descriptions of psychological reactions to a disaster are provided by Lifton (1968), who conducted firsthand interviews with survivors of Hiroshima. While it was not a “natural” disaster, most residents had no idea that they had been bombed, and responded as if it were some sort of natural disaster. Many thought that the whole world was simply dying. As one Protestant minister said: “The feeling I had was that everyone was dead. The whole city was destroyed. . . . I thought all of my family must be dead—it doesn’t matter if I die. . . . I thought this was the end of Hiroshima—of Japan—of humankind” (quoted in Lifton, 1968, p. 22). One young boy was pinned down under debris: “There were roof tiles and walls—everything black— entirely covering me. So I screamed for help. . . . And from all around I heard moans and screaming. . . . I thought that I too was going to die” (quoted in Lifton, 1968, p. 21). The few people who survived were often stunned and behaved like automatons, wandering around in a daze. Many were so badly burned and disfigured that even their closest relatives could not recognize them. One sociologist described the unreality of the scene: Everything I saw made a deep impression—a park nearby covered with dead bodies waiting to be cremated. . . . Very badly injured people evacuated in my direction. . . . The most impressive thing I saw was some girls, very young girls, not only with their clothes torn off but with their skin peeled off as well. . . . My immediate thought was that this was like the hell I had always read about. . . . I had never seen anything which resembled it before, but I thought that [if] there should be a hell, this was

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As with the concentration camps, many people described themselves as emotionally numbed. One noncommissioned officer who was in charge of mass cremations found that he could do his job with little difficulty: “After a while they became just like objects or goods that we handled in a very businesslike way. . . . Of course I didn’t regard them simply as pieces of wood—they were dead bodies—but if we had been sentimental we couldn’t have done the work. . . . We had no emotions. . . . I was temporarily without feeling” (quoted in Lifton, 1969, p. 31). This emotional numbing often lasted for months. Others were racked with survivor guilt—why had they survived when most of their loved ones had not? Thus, it is not surprising that even within the United States exposure to disasters has been associated with chronic stress and symptoms of PTSD. This may be especially true when the disaster is technological than when it is natural (for a review, see Baum & Fleming, 1993). Technological disasters are those disasters that result from the use (or often misuse) of technologies such as nuclear power or from inadequate industrial safety measures, for example, at chemical or petroleum processing plants or in mine shafts. For reasons that are not hard to understand, disasters are more distressing when they are thought to involve human carelessness, greed, or indifference to the fate of others. Reactions to natural disasters are very similar to other sources of trauma, such as concentration camps and rapes. We will next examine whether coping with trauma is different than coping with regular stressors.

Differences and Similarities between Coping with Trauma and Everyday Coping There are certain similarities between coping with trauma and everyday coping. As we have seen, people undergoing trauma utilize analysis and problem-focused action, social support, negotiation skills, humor, altruism and prayer. However, there are also marked differences. First of all, people in traumatic situations may have much less conscious control over their coping strategies. Emotional numbing is a hallmark of emotion-focused coping during trauma. Further, the use of defense mechanisms such as denial and distortion may be much more marked. Even among people trained to deal with trauma, such as soldiers, paralysis may occur. Solomon (1993) recounted the experience of a crack paratrooper during the Yom Kippur war:

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I saw dying men, soldiers of mine, who’d been training for several months, call me to help them. I want to go over, but I can’t! My legs won’t carry me. Even if it might have been possible to reach them, I couldn’t have gone. I wanted to walk, but I found myself crying. I was sweating, crying, and trembling. I was shaking, shaking like a leaf. A madness of fear. . . . I was rooted in one spot. I was lying there and couldn’t get up. (p. 43)

Second, confiding in someone may play a more central role in coping with trauma. Although social support is widely recognized as important in adapting to stress, surprisingly, in the coping literature this strategy is generally associated with negative outcomes (Monroe & Steiner, 1986). However, most trauma studies show that confiding in others is associated with better outcomes (Pennebaker, Barger, & Tiebout, 1989; Pennebaker & O’Heeron, 1984; Silver et al., 1983), especially if confiding receives a positive response (Harvey et al., 1991). In both literatures, having a supportive family is seen as crucial to adaptive coping (Coyne & Downey, 1991; McCubbin & Patterson, 1983), while involvement in community efforts is much more important in trauma literature, especially natural disasters (Smith, 1983). Third, the process of coping with trauma may last for a much longer time than coping with everyday problems. Horowitz (1986) showed that a traumatic event may initially lead to outcry, then denial, which in turn may be followed by intrusive memories, flashbacks, and obsessive review. Individuals may oscillate between denial and obsession until they begin the process of working through—namely, acceptance and the development of adequate coping skills. It is also not unusual for such reactions to be delayed, sometimes for months or even years (cf. Solomon, 1993). As noted earlier, how one copes with problems after the trauma may be more important to recovery than the initial exposure to trauma. In general, problem-focused coping appears to lead to better outcomes, while emotion-focused strategies such as wishful thinking and denial are associated with higher levels of PTSD symptoms. Finally, trauma researchers highlight the development of meaning and transformation of the self to a much greater extent than is common in the general coping literature (Epstein, 1991; Mikulincer & Florian, 1996; Roth & Newman, 1991; Silver et al., 1983). Making meaning entails reappraisal or reinterpretation of not only the event but also the context of the event in a person’s life, which may involve the reorganization of existing cognitive–motivational structures as well. Wortman et al. (1997) argue that events such as the loss of a child or spouse may also entail a search for meaning but may be associated with poorer outcomes. Those individuals who say “Why me?” or “Why my family?” may have

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a hard time accepting the loss and coming to some sort of accommodation. However, others note that this search for meaning may be painful in and of itself, but it may also set the stage for posttraumatic growth (Aldwin & Sutton, 1998; Tedeschi et al., 1998) (see Chapter 15). While some studies of trauma use standard coping measures, others focus on single strategies such as self-blame (Davis et al., 1996; Delhanty et al., 1997), “undoing” (Davis et al., 1995), and “temporal orientation” (Holman & Silver, 1998). Self-blame in everyday situations is generally associated with poor outcomes; in traumatic situations it may be associated with positive outcomes, as it provides at least the illusion of control (Janoff-Bulman, 1979; but see Frazer, 1990). A similar strategy is “undoing”—defined as the use of counterfactuals, for example, “If only I had not . . . ” This may be an attempt to provide one with the sense of control, and/or it may involve a large element of self-blame. Davis et al. (1995) found that it was positively correlated with distress, even controlling for general rumination. Some of the most intriguing aspects of the coping-with-trauma literature are the suggestions that trauma may constitute a major avenue for personality change in adulthood. For example, Schnurr et al. (1993) examined change in MMPI (Minnesota Multiphasic Personality Inventory) scores from college to midlife as a function of combat exposure. They found that MMPI scores were most likely to improve in men who had moderate levels of combat exposure, compared to those who had heavy exposure or none at all. The creation of a new identity may partially explain why so many people report positive outcomes of coping with trauma. These types of outcomes will be discussed in greater detail in Chapter 15. In short, coping with stress is not simply an expenditure of resources but can result in the development of new coping resources as well.

SUMMARY Studies of how individuals cope with trauma provide an unparalleled opportunity for studying human adaptation. While trauma can be devastating, the vast majority of traumatized individuals do not go on to develop PTSD. These studies emphasize that the coping process changes over time as a result not only of the changing demands of the stressor but also of the changing needs of the self. The function of coping is not only to regulate the situation and the emotions but also to maintain ego integrity and human dignity under overwhelming conditions. Further, the ultimate outcome of coping can be seen as transformational—both of the self and of the larger community.

STRESS, COPING, Sociocultural Aspects AND of Coping DEVELOPMENT

CHAPTER 13

Sociocultural Aspects of Coping

I

n the first edition of this book, this chapter focused primarily on cultural aspects of coping as a predictor of coping strategies. There was so little work on this subject 12 years ago that I hoped at the time to contribute to the growing sense that culture is an important factor in the stress and coping process (see also Greenberg, Lengua, & Calderon, 1997; Markus & Kitayama, 1994). However, since then there has been growth in the recognition of not only cultural but also social aspects of coping, including gender, social support, and the influence of families. Thus, I decided to expand this chapter to include those topics as well as to update the review of culture and coping.

SOCIAL ASPECTS OF COPING The social aspects of coping covered here start with gender differences in coping. We will then consider the ways in which the social context can affect the use of coping strategies, giving special consideration to the family.

Gender Differences in Coping One of the most important social distinctions is gender. To the extent that social roles are still gender-based, it is not surprising that many 239

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studies find gender differences in both stress and coping. A consistent issue in stress and coping research is whether women are more vulnerable to stress than men. As de Ridder (2000) notes, there is a long history of research showing that women are more likely to express emotional distress than men, and there have been three basic stances in the literature. First, this may be a methodological artefact: Women more willing to reveal stress and distress. The second hypothesis is stress exposure: Women face more stress than do men, especially those who juggle work and parenting roles (see Gove, 1972). As de Ridder (2000) points out, not all of the difference in emotional distress can be explained by women’s greater openness; nor is there much evidence that women are more exposed to stressors, although some have pointed out that stressful life event inventories do not necessarily include stressors that women often face, such as gender discrimination or spousal abuse. This leaves the third hypothesis, stress vulnerability: Women are more vulnerable to stress due to poor coping or lack of coping resources. Cultural stereotypes suggest that men engage in more problemfocused coping (Diehl, Coyle, & Labouvie-Vief, 1996; Lazarus & Folkman, 1984; Stone & Neale, 1984) as well as that which involves more aggression (Hobfoll et al., 1994), while women use more emotionfocused coping (Enaler & Parker, 1990; Folkman & Lazarus, 1980; Stone & Neale, 1984) and also seek more social support (Carver et al., 1989; Rosario, Shinn, Morch, & Huckabee, 1988). These emotionfocused strategies include distraction, prayer, and tension release (Stone & Neale, 1984). Some studies report that men may use more avoidant strategies, such as “doing nothing” (Veroff, Julka, & Douvan, 1981) or using drugs and alcohol (Sigmon, Stanton, & Snyder, 1995). Further, the use of emotion-focused strategies may reflect the fact that women are better at “working through” their emotions under stress and are more aware of them (Stanton et al., 1994). However, it is possible that gender differences in the types of problems that men and women report may account for some of these differences. Indeed, in studies in which the respondents are faced with similar problems, there are often no sex differences in coping (Hamilton & Fagot, 1988; Porter & Stone, 1995; Ptacek, Smith, & Zanas, 1992). This suggests that social constraint may play an important role in the choice of coping strategies (Rosario et al., 1988). In other studies in which men and women are faced with similar problems, gender differences sometimes emerge. For example, Hooker, Manoogian-O’Dell, Monahan, Frazier, and Shifrin (2000) compared spousal caregivers for patients with Alzheimer’s disease and Parkinson’s. For patients with Parkinson’s disease, there were no gender differences in their spouse’s coping, but for those with Alzheimer’s disease, wives

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were less likely to use problem-focused coping than were husbands. Other studies have also found gender-by-situation interactions in coping. Folkman and Lazarus (1980) found no overall gender differences in the coping strategies of men and women on the aggregate level, but men were more likely to use problem-focused strategies with work problems, and women with family problems. The men in the Berkeley Stress and Coping sample tended to have occupations that afforded them more control than did the women in the sample, who were often employed part-time at rather low-level service jobs (Aldwin, 1982a). Gender difference in coping tends to be more pronounced in individuals who adhere to traditional gender roles (Abraham & Hansson, 1996). However, there is much contradiction in the literature, and even different meta-analyses may find different results. In one meta-analysis of couples coping with infertility, Jordan and Revenson (1999) found that women sought more social support and used more escape–avoidance, planful problem solving, and positive reappraisal. Another meta-analysis was conducted by Tamres, Janicki, and Helgeson (2002), who argued that some of the confusion in the literature stems from the fact that different studies define coping in very different terms. For example, emotion-focused coping in one study may consist primarily of emotional expression, while in others it may also include avoidant behaviors, and so on. Tamres and colleagues (2000) attempted to examine whether there are gender differences in coping by disentangling different types of coping and then contrasting dispositional effects (whether due to biological or socialization differences) with situational effects on coping. In some respects, the findings of Tamres et al. (2002) are similar to those of Jordan and Revenson (1999). They found that women simply report more coping behaviors than do men, including active coping. Women were also more likely to use social support, engage in positive reappraisal and prayer, but also rumination and wishful thinking. However, there were clearly situational differences. Women used emotionfocused coping more for health problems (both their own and those of others), while men used venting more for both work and relationship problems. The only consistent gender difference that occurred across situations was in seeking social support. This supports Taylor et al.’s (2000) supposition that women are more likely than men to “tend and befriend” under stress. De Ridder (2000) cautions that some of the gender differences in coping may be due to recall bias reflecting social constraints. For example, in a comparison of trait versus momentary assessments of coping, Porter et al. (2000) found that the greater use of social support and catharsis reported by women was found only in the retrospective recall condition; using ecological momentary assessments, there were no gen-

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der differences. In another study using ecological momentary assessments, Mohr et al. (2003) found that women were more likely to continue experiencing negative moods, which is consistent with NolenHoeksema’s (2000) suggestions that women do ruminate more than men. In summary, whether or not men and women cope differently is a highly complex problem. The cultural stereotype—that men use more problem-focused coping while women use more emotion-focused coping— simply does not hold up. If dispositional measures of coping are used (e.g., in instruments that ask “How do you usually cope with stress?”), men may report more problem-focused coping and women more social support and more emotional expression, but the gender differences in problem-focused coping disappear in studies that examine situationspecific strategies. When respondents are faced with similar problems or when momentary assessments are used, some meta-analyses suggest that women use more problem-focused coping. Further, even the muchvaunted findings that women use more emotional expression may disappear. In Mohr et al.’s (2003) study, there were time-of-day differences— negative interpersonal events had greater effects on mood in the morning for men, but in the evening for women. Further, there are clearly interaction effects with situations, as noted earlier in the meta-analysis by Tamres et al. (2002). It is likely, however, that the gender differences in rumination may hold up, but more studies are needed that specifically include this as a coping strategy. Finally, some of the confusion in the literature may be due to cohort effects—to the extent that gender differences in coping may reflect adherence to more traditional social roles, a study that examines the effect of age of sample may help clear up some of this confusion.

Social Context of Coping As mentioned earlier, coping does not exist in a vacuum but rather is highly influenced by contextual factors, especially the social environment. Indeed, Thoits (1986) argued that social support serves to regulate the stress and coping context. Support networks provide feedback about the veridicality of our appraisals. Social support also helps to regulate the coping process. Network members may provide suggestions as to which coping strategies to use, or suggest that the current coping may be problematic. Note that these suggestions may not always be helpful— indeed, diabetic adolescents who turn to their peers for coping strategies may have worse metabolic control than those who turn to their parents (Marrero, 1982).

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For example, in an early study of the ways in which graduate students coped with doctoral examinations, Mechanic (1978) emphasized the role that interpersonal interactions and modeling played in determining the strategies used. The graduate students developed belief systems about the best ways in which to cope with this stressful situation on the basis of their own prior experience with tests as well as their observations of the concomitant efforts of other graduate students preparing for exams. Students consulted others in their attempts to appraise the situation, wishing to know how important the exams were, whether they were likely to be difficult or easy, and so forth. Further, whom they consulted also affected how they coped with the problem. One group of students whose offices were somewhat isolated developed a very characteristic way of coping: They decided that the examinations did not require much preparation and hence did not make the effort to study as much as was required. Not surprisingly, as a group they also did less well on the examinations than the more centrally located students, who developed a more realistic appraisal of the importance of the examination and of the degree of effort required to study for them. Mechanic described coping as a consensual process because of the collective beliefs that developed about the exam and that guided individual efforts in preparation. The social context may provide a referent for coping with illness. Taylor (1983) examined what she termed “upward” versus “downward” comparisons in women coping with breast cancer. Women who compared their situations to others and decided they were coping worse had poorer physical outcomes, while those who felt that they were doing fairly well tended to have better outcomes. Different age groups may use the social context in different ways. For example, younger people tend to ask for more unconditional support from their network to approve their appraisals and coping strategies, whereas older individuals tend to ask for specific feedback on the efficacy of their strategies (Labouvie-Vief, DeVoe, & Bulka, 1989). My hunch is that younger people’s coping is more affected by the social context, that is, they are more likely to succumb to peer pressure in both how they appraise problems and how they cope with them, while older adults are more likely to be able to appraise and cope relatively autonomously. But that remains an open question.

Families and Coping Most of us are embedded in families, and thus our coping can resemble a delicate dance in meshing our emotions and coping strategies with others’ (cf. Berscheid, 2003; Repetti, Taylor, & Seeman, 2002). While positive

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social interactions within families may be one of the most protective stress factors, especially if the social support is seen as reciprocal (Gleason, Iida, Bolger, & Shrout, 2003), all too often interpersonal tension disrupts the coping process (Rook, 2003). While emotional distress does tend to negatively affect spouses, this relationship can be attenuated during normative, anticipated stressors such as preparing for a bar exam (Thompson & Bolger, 1999). However, in chronic conditions, having to suppress one’s feelings in order to avoid upsetting the spouse can result in a negative adaptive spiral. For example, women with lupus who feel that they have to hide their symptoms from their spouse have high levels of negative affect (Druly, Parris Stephens, & Coyne, 1997). Dyadic coping tends to be studied most in the context of caregiving for chronic illnesses. In general, people are more likely to turn to their spouse for caregiving and then their adult children. While early studies focused on the stressfulness of caregiving (Zarit et al., 1986), more recent studies have found many positive aspects of caregiving (Beach et al., 2000). Although caregiving for a spouse or parent who has Alzheimer’s is undoubtedly the most stressful type of caregiving (Vitaliano et al., 2003) and often has long-term adverse impacts on health (Kiecolt-Gleser et al., 2002), Beach et al. (2000) found that half of their national sample did not find caregiving for AD patients stressful. In part, this may be due to various forms of dyadic complementarity in coping strategies. Indeed, with very old couples, it is often difficult to tell who is the caregiver and who is the recipient of care, as both members may have substantial impairment but nonetheless provide what support they can. Gilmer and Aldwin (2002) provide the example of an older rural couple whose health needs required them to make a 90-mile round-trip drive every week to a local medical center. The wife had AD and was too impaired to navigate the environment, while the husband’s arthritis made it physically impossible for him to manipulate the controls of the car. There was no public transportation, and so their solution was that she drove while he navigated! How parents cope may also affect the children. DeLongis & Preece (2002) found that in step families in which wives used confrontation in coping with family problems, the husbands tended to withdraw from the stepchildren, which in turn resulted in a poorer relationship between the wives and their stepchildren. Conger and Conger (2002) reviewed a series of studies they have conducted that show that the impact of macroeconomic strain on children is mediated through family dynamics. Parents who were depressed as a consequence of economic strain used poorer parenting strategies, which in turn adversely affected the mental health of their children. Unfortunately, these studies did not examine coping strategies directly, but they are nonetheless highly suggestive.

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Thus, coping is almost always conducted within social contexts. There are complex transactions between others in the social environment who influence appraisal and coping strategies and who are in turn influenced by the strategies that one uses. Families (and coworkers) who are able to successfully synchronize their coping efforts and provide reciprocal support may experience low levels of emotional distress under times of stress, and even better physical health (Franks & Parris-Stephens, 1996), but unfortunately others in the situation may experience only exacerbated emotional distress. The social context, however, is embedded within the cultural context, which also influences how individuals cope.

CULTURE AND STRESS As the old saying goes, a fish is the worst creature to ask about water. Similarly, the influence of culture on the stress and coping process is so pervasive that it is little noticed—except when one is in a different cultural context and the contrast between how one expects others to react and how they actually behave becomes striking, often uncomfortably so. One of the best anecdotal studies was presented by Bateson (1968), who described her experience of losing a premature infant when doing fieldwork in the Philippines: On the afternoon of that day I was able to describe, so that my husband and I would be prepared, the way in which Filipinos would express sympathy. They show concern, in this as in many other contexts, by asking specific factual questions and the primary assumption about those who have suffered a loss is that they should not be left alone. Rather than a euphemistic handling of the event and a denial of the ordinary course of life, one should expect the opposite. Whereas an American will shake hands and nod his head sadly, perhaps murmuring, “We were so sorry to hear,” and beat a swift retreat, a Filipino will say, “We were so sorry to hear that your baby died. How much did it weigh? How long was labor?” Etc., etc. Had I not been in a position to make these generalizations and predictions the most loving behavior on the part of the Filipinos, genuinely trying to express concern and affection, would have seemed like a terrible violation and intrusion. In order to handle the affront and to control myself against breaking down in the face of sudden reminders of grief, I would have had to impose a rigid self-control that would have reinforced in the Filipinos the belief that many hold, that Americans don’t really grieve. . . . Some societies organize their recognitions of bereavement around an effort to help the bereaved control himself and forget, while other societies are geared to help him express and live out his grief. (quoted in Levine, 1973, pp. 17–18)

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Not surprisingly, psychologists tend to see coping as a function of an individual’s personality or social context, while anthropologists view coping as primarily a function of the individual’s (sub)culture—two (seemingly) diametrically opposed views. On the surface, it would appear that the psychological and anthropological viewpoints are diametrically opposed. However, Markus and Kitayama (1997) argue that cultural imperatives are insinuated within an individual’s emotional system, such that it “feels good” to cope in ways that are culturally sanctioned. However, being forced by situational pressures (or cross-cultural contact) to cope in ways which are not sanctioned by one’s culture can lead to discomfort, hence Bateson’s distress in being forced to disclose matters that in our culture are generally considered too painful to be made public. Nonetheless, this argument does not reconcile the problem of culture and individual differences After all, the very definition of coping is the study of individual differences in response to stress. If there is a strong cultural component to the process, then would this not by definition negate the emphasis on individual differences? This contradiction is apparent only if one holds a monolithic viewpoint of culture—namely, that it affects every individual in the culture in the same way. Several decades ago, the cultural anthropologist A. F. C. Wallace (1966) defined cultures in terms of “mazeways.” A mazeway consists of patterns of beliefs, values, and commitments, as well as expected behaviors, resources, and so forth, that shape individual behavior. There may be different pathways inside the mazeway for different subcultural groups, such as males and females, or for different socioeconomic or ethnic subgroups. Thus, a culture does not affect individuals in a uniform manner, and different groups adhere to different parts of the mazeway. In U.S. and northern European culture, for example, it is more acceptable for a woman to cry than it is for a man, but in southern European and some Arabic cultures, it is much more acceptable for men to cry. At different historical times and in different modern subcultures, violence as a means of conflict resolution has been more or less acceptable. Duels were once an acceptable means of resolving insults or competing social claims; historians tell us that fisticuffs and even duels were common among congressmen during the 19th century. Thus, the types of stressors that an individual encounters, and the range of acceptable coping strategies, are determined in part by an individual’s position in the mazeway. Culture can affect the stress and coping process in four ways. First, the cultural context shapes the types of stressors that an individual is likely to experience. Second, culture may also affect the appraisal of the stressfulness of a given event. Third, cultures affect the choice of coping

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strategies that an individual utilizes in any given situation. Finally, the culture provides different institutional mechanisms by which an individual can cope with stress. A sociocultural model of stress, coping, and adaptation is presented in Figure 13.1. Cultural demands and resources affect both situational demands and individual resources, both of which in turn affect the appraisal of stress. In addition, cultural beliefs and values influence not only individual beliefs and values but also the reactions of others in the situation, which also affect the appraisal of stress. How an individual copes is affected by four factors: the appraisal of stress, the individual’s coping resources, the resources provided by the culture, and the reactions of others. Further, the outcome of coping not only has psychological and physical outcomes but also social and cultural outcomes (see Aldwin & Stokols, 1988). As we have seen previously, how an individual copes affects not only that person but also others in the immediate social environment. Further, to the extent to which an individual (or groups of individuals) modify or create cultural institutions in the process of coping with a problem, they also affect the culture, providing a means of coping for others facing similar problems. Grassroots movements such as Mothers Against Drunk Driving and the development of support groups for different illnesses or bereavement are good examples of this phenom-

FIGURE 13.1. A sociocultural model of stress, coping, and adaptation.

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enon. Thus, the sociocultural viewpoint of coping emphasizes that coping behavior nearly always occurs in a social context and is both affected by that context and contributes to its change (Gross, 1970). As mentioned earlier, the patterns of stressors that individuals are likely to face is profoundly affected by their (sub)cultural context. This section will discuss two ways in which culture can affect the experience of stress. First, certain stressful life events can be seen as normative— that is, most individuals in a given culture or cultural subgroup will experience a particular event at specified times in their lives. Adolescent puberty rituals are one example of a normative life event; retirement is another. Second, by differentially allocating social resources, cultures pattern the types and levels of stress that individuals are likely to experience, as well as the appraisal of this experience. For example, contrast the types of stressors faced by inner-city children versus those in an affluent suburb. While the latter may face achievement-related problems such as the fierce academic competition in top-ranked schools and the anguish of whether they can live up to the achievement expectations of the parents, get into an Ivy League college, and so forth, the former may face more fundamental problems, such as problems in housing, nutrition, and family stability, as well as inadequate schools, which impair the possibility of learning. Further, the inner-city child often faces violence on the way to, or even inside, school.

Cultural Patterning of Normative Stress While life events can be considered as events that occur somewhat randomly to individuals, closer inspection reveals that whether a particular event occurs and the manner in which it occurs often reflect cultural beliefs and practices. As we shall see, the sanctioning of the occurrence of stressful events for individuals may also be a means for cultures to solve larger problems. Since it is often easier to understand such processes in foreign cultures, we will first discuss adolescent puberty rituals, then retirement in American culture, as examples of normative stressful life events.

Puberty Rituals Victor Turner (1969) provided some of the most interesting insights into the nature of rituals in general and puberty rituals in particular. In some cultures, there is a relatively abrupt transition from childhood to adulthood that is demarcated by a ritual. This may be done on an individual basis, as when a Navajo youth spends several days in isolation in the

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wilderness awaiting a dream that will reveal his adult role, or it may be performed in a group setting, perhaps for a cohort of young girls who have started menses in the previous year. While the actual form of puberty rituals varies from culture to culture, Turner (1969) identified several key elements common to many. First, the youth is required to revoke or eschew the child identity. This is achieved through the giving away of childhood toys and other property, the renunciation of a childhood name, and changes in physical appearance, such as shaving the head or wearing ritual clothes. Second, the youth enters a liminal stage, in which he or she is neither child nor adult and which may be typified by social isolation, sequestering of the group in special quarters, and certain ritual foods, clothing, or baths. Third, the youth faces an extremely stressful ordeal, often involving public scarification or mutilation of the body. How the youth endures the pain may often be a key feature in determining adult roles and status. Fourth, the youth is given a new adult identity, characterized by a new name, adult clothing, secret knowledge, and the like. In Euro-American culture, there are very few normative puberty rituals. Bar mitzvahs (and bat mitzvahs for girls) are practiced in the Jewish subculture. However, these occasions are not very stressful, other than the relatively minor stress of public speaking. Few would concede that these 13-year-olds are now adults. Clearly, puberty rituals are not a necessary or unavoidable stressor. So, why would some cultures choose to subject their youths to such extreme stress? According to Turner (1969), the severity or arduousness of puberty rituals is in part a function of early childhood rearing practices. In some cultures, children, especially male children, are allowed nearly continuous access to the mother. Nursing may last for several years, and the child may sleep with his mother or other female relatives for many years. In order to enforce incest taboos, it becomes necessary to forcefully separate youths from their mothers and other female relatives and to completely change identities and customary practices. Alternatively, one could argue that in subsistence cultures, with their abbreviated lifespan, it is necessary to accelerate the acquisition of adult roles and functions in order to ensure the reproductive survival of the group. A ritual abruptly demarcating the transition from childhood to adulthood may serve this function. In modern industrial cultures, with their longer lifespans and prolonged period of dependent adolescence, such rituals are no longer necessary—and, indeed, would be counterproductive. Whatever the explanation, it is clear that cultures may sanction the occurrence of certain stressful life events. Retirement provides a good example of such an event in this culture.

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Retirement Prior to World War II, retirement was not a widespread phenomenon. In agrarian cultures, relatively few individuals lived to an advanced age, and most worked until death or disability forced them to stop. Women typically had children until menopause, extending the period of child rearing. While certain cultures may have provided different roles for the elderly, mandated withdrawal from economic activity is a relatively new phenomenon. Sociologists have argued that the creation of the retirement status was primarily a governmental response to an economic crisis: the Great Depression (Quinn & Burkhauser, 1990). At that time, there were simply too few jobs. Older workers needed to be encouraged to leave the workforce so that younger workers could gain employment. Obviously, economic safeguards were needed to provide sustenance for the newly retired (and for those elderly who could not find employment); so, the Social Security Administration was created to soften the blow of mandatory retirement. (This was also a way of cycling more money into the economy, by transferring income from workers to older people to be spent on maintenance requirements, such as housing, food, and healthcare.) This institutional solution to a social problem, though, had adverse consequences for some individuals, who now experienced a new stressful life event: retirement. Indeed, early research on retirement (Rosow, 1974) described this as an anomic, highly stressful, state with few social norms or functions to provide structure to everyday life. Retirement was thought to have adverse effects on physical and psychological health. However, the widespread creation of pension plans decreased the economic stresses associated with retirement and allowed retirees to pursue leisure activities. New roles have been created for the elderly. Many engage in what Ivan Illich (1981) has called “shadow work”: noneconomically compensated activity that is nonetheless vital for the maintenance of society. These activities include providing child care for grandchildren so that adult daughters can reenter the labor market, providing care for disabled spouses or parents, and volunteering in soup kitchens, literacy programs, and the like (see also Antonucci & Jackson, 1990). Thus, retirement is no longer perceived as a highly stressful life event. Fewer than one-third of retiring males in one middle-class sample found retirement to be more than “a little” stressful (Bossé et al., 1991), and health problems may be more of a cause than a consequence of retirement (Ekerdt, Baden, Bossé, & Dibbs, 1983). Thus, one way in which cultures can influence the stress process is

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by mandating the experience of particular life events by certain subgroups within a culture. These events often denote changes in social status, such as puberty rituals, retirement, or O-level examinations (crucial educational exams common in British and other schools). They are often highly stressful, but the distress may be mitigated through other social institutions (e.g., pensions). The mandating of such events is often a response to other social problems, that is, certain social goals are achieved, consciously or unconsciously, through subjecting certain populations to stress at specific points in the life cycle. Though often normative, culturally mandated stressful life events may also occur at irregular intervals, as when the federal government constricts the monetary supply to combat inflation, knowing that such a restriction will inevitably lead to unemployment, temporary or otherwise, on the part of vulnerable populations (see Aldwin & Revenson, 1986, for a discussion of this issue). This leads us to a discussion of the second way in which cultures can influence the experience of stress: through the allocation of resources.

Resource Allocation and the Appraisal of Stress Arsenian and Arsenian (1948) proposed that cultures can be characterized as “tough” or as “easy.” Their basic premise was that individuals can be characterized in terms of goal-driven behavior. Cultures vary in the number and quality of goals aspired to by individuals. Further, resources and access to the paths through which one achieves socially sanctioned goals are not distributed equally among individuals or subgroups within the culture. A tough culture is one that provides few valued goals and that severely restricts access to the pathways through which an individual may achieve that goal. In contrast, an easy culture is one that provides multiple valued goals and relatively easy access to at least one of these goals. In one Pacific Island culture, for example, there were three basic goals: material wealth, political power, and spiritual leadership. These three goals were mutually exclusive; one could aspire to one and not the others. By virtue of the kinship structure, nearly every adult male in the culture could expect to achieve one of the three goals. This would be considered an “easy” culture. Another example of culturally patterned stressors is that all cultures have mechanisms for educating the young. The difficulty of those systems, the importance attributed to them, and the means by which success is documented vary across cultures. In many British-style systems, elementary and secondary education is very difficult, and achievement is documented primarily through a rigid and universal examination system (O-level examinations). Access to higher education is

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determined solely through performance on those examinations. In Asian cultures, such as Japan and Korea, which follow the British model, success on O-level examinations is valued very highly, and the amount of stress that elementary and secondary school students experience is very high. By contrast, in American school systems, elementary and secondary education is somewhat less rigorous, and there are multiple pathways to higher education (e.g., later attaining a graduate equivalency diploma or making up skills in community colleges). However, higher education is generally much more rigorous, and the stress experienced by college students is consequently higher. (See Aldwin & Greenberger, 1987, for a discussion of these issues.) Arsenian and Arsenian hypothesized that tough cultures would take their toll on both the mental health of individuals and the social health of the community. In cultures with severely restricted goals and unequal access to paths, individuals are expected to exhibit psychological problems, such as alcoholism, drug abuse, and suicides. Similarly, in tough cultures, crime is expected to flourish as people pursue goals through illegitimate means. While industrialized countries are thought to provide a greater range of goals than those found in traditional agrarian societies, in reality there may be one overarching goal—such as material wealth—access to which may be severely restricted for some people. From this perspective, it is not surprising that inner-city youths’ aspirations to material wealth may be just as strong as that of relatively affluent suburban youths. However, for inner-city youths the legitimate means of gaining such wealth are very limited, and thus it should come as no surprise to cultural anthropologists that robbery, prostitution, and drug dealing would be prevalent within this group. The stress of inadequate access to resources is compounded by the undue stress resulting from the violence accompanying such illegal activities as robbery, prostitution, and drug dealing; and severe mental and physical health problems may be very prevalent (see also Colby, 1987). As tempting as it may be to derive a unidimensional scheme on which to array cultures—from “easy” to “tough”—Wallace’s (1966) conception of mazeways argues for a more complex perspective. Obviously, cultures in which famine and war are prevalent are objectively more stressful than more prosperous and peaceful societies. However, from a mazeway perspective, the types of stressors faced by individuals within a culture vary according to gender, socioeconomic status, and ethnicity. American culture may be considered a relatively easy culture for affluent white Americans but a very tough one for inner-city youths or Native Americans.

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Resource and Appraisals: Objective or Subjective? There is an ongoing debate in the literature as to whether stress is “objective” or “subjective” (see Chapter 3). This debate has recently been rekindled in an interchange between Hobfoll (2001) and Lazarus (2001). Hobfoll has long argued against a cognitive appraisal approach to stressors, arguing that environmental resources and challenges are real and do not need such an element of subjectivity interjected into them. Lazarus (2000) responded that appraisals have always been based on the evaluation of what resources are available to meet the environmental challenge, and indeed his definition of stress is dependent upon a mismatch between demands and resources. Further, most people have reasonably veridical evaluation of their environments, and thus appraisals are not necessarily that subjective. The earlier discussion of the impact of culture on stress may shed a somewhat different light on this debate. Clearly, cultures distribute resources—or, more precisely, provide access to resources—differently for different components of cultural mazeways. This creates “objective” conditions of ease and difficulty. However, perceptions of those resources are always seen through cultural filters. For example, in Egypt, a daughter’s virginity is a resource, the loss of which is a grave blow to the family in that it calls into question the marriageability (and thus the ability to form strategic economic alliances) of not only the daughter in question but also her siblings. In America, however, virginity is not looked upon in the same way and would not be considered a family resource. Thus, appraisals are a combination of environmental circumstances, individual needs, and access to resources, as well as cultural beliefs and values. What is missing in this equation, however, is a system for understanding which values are important for stress appraisals and for coping, and how they have their effect, which an understanding of cultural syndromes may provide.

Cultural Syndromes A standard demarcation in anthropology is to divide cultures into those that are individualistic versus collectivistic (see Heider, 1958). Western cultures are thought to be more individualistic—that is, they are thought to value independence and autonomy—while Asian cultures are thought to be more collectivistic, that is, the self is determined more by one’s role in the family and society, and interdependence and cooperation are highly valued (see, e.g., DeVos, 1973). Thus, an easy stance would be to argue that Western cultures are more stressful than Asian ones, given the larger level of social support that the latter are thought to have.

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However, cross-cultural research on social support has shown that this is too simplistic a dichotomy. For example, Aldwin and Greenberg (1987), in their study of Korean American and European American students, found that the former were less likely to access social support than the latter. Students expressed reluctance to tell others about their problem. Often they were too embarrassed to tell their parents about their difficulties in adapting to a college environment, fearing that they would “lose face,” and they were also reluctant to confide in their peers, because they did not want their problems broadcast throughout their social network. Similarly, Takahashi, Ohara, Antonucci, and Akiyama (2002) conducted a cross-cultural study of social support in Japan and the United States, and also found that the Japanese were less likely to confide in either their spouses or their children than were Americans. Part of the problem with both studies is that social support may be expressed differently in these cultures. Americans rely greatly on verbal expressions, but Asians may rely more on behaviors. For example, in the Aldwin and Greenberger study, one young woman said that she had not spoken with anyone about her problem. Yes, when asked who was most helpful, she readily named her sister. When asked about this apparent contradiction, she said, “I don’t have to tell my sister that I have a problem. She knows when I am unhappy and will try to cheer me up, like by taking me to the movies.” Similarly, in Japan, confidant status is indicated by who one bathes with, but this could not be used as an item in U.S. studies, as it has a very different connotation here! Triandis (1995) has proposed a cultural two-space in which one dimension is individualism–collectivism and the other is vertical–horizontal. Verticality refers to the hierarchical dimension. Thus, individualistic cultures such as in the United States that are also hierarchical emphasize competition, as individuals compete with one another to “win” positional goods, such as better jobs, wealth, desirable mates, and so on. Le and Levenson (2005) found vertical individualism to be associated with higher scores on narcissism and neuroticism. However, cultures can be individualistic but also horizontal or egalitarian. Swedish culture, which emphasizes individual self-reliance but also equality and cooperation, is a good example of this. Similarly, collectivist cultures may also be vertical—in which they emphasize authoritarianism and obedience, such as traditional Chinese or Japanese culture—or horizontal, which deemphasize both individualism and competition. It would make sense that horizontal cultures, regardless of whether they are individualistic or collectivitistic, may be less stressful than vertical cultures. Indeed, horizontal individualist cultures, such as Sweden, Iceland, and Denmark, score higher on measures of subjective well-being than do vertical individualist cultures (Diener & Oishi,

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2000). This model may provide a fruitful approach to studying cultural differences in stress and coping. For example, in some collectivist cultures, being special in any way may be appraised as a threat. A classic example of this is provided by Rubel (1969). In Mexican American culture, it was thought that children could become ill if someone outside the immediate family praised or admired them (mal ojo). Once ill, the child could only become well if the outsider patted the child in such a way as to remove the mal ojo. Thus, in close-knit Mexican American families (at least of a couple of generations ago), praise for a child from an outsider constituted a stressful event, in marked contrast with the pride that an Anglo-American mother, in an individualistic vertical culture, may feel when her child is praised as someone special. Based on Triandis’s (1996) model, one could hypothesize that collectivist cultures, especially those that are more horizontal, should find certain types of stressors less stressful than those in either individualistic or in collectivist/hierarchical cultures. For example, African Americans were less likely to be stressed in caregiving situations (Haley et al., 2004; White, Townsend, & Parris-Stephens, 2000) and reported less perception of burden in caregiving situations than European Americans (Knight, Silverstein, McCallum, & Fox, 2000). Surprisingly, a separate study of Asian American caregivers found that they were more likely to be stressed than European Americans (Youn, Knight, Jeong, & Benton, 1999). This is likely to be due to the fact that much of the caregiving burden in Asian cultures falls on daughters-in-law, who traditionally have very difficult relations with their husband’s parents in these collectivistic albeit very vertical cultures. For someone within a culture, this difference between cultures in the appraisal of stress may be difficult to fathom. In giving a talk in Mexico on this subject one time, I tried to dramatize this difference by using the example of premarital sexual activity on the part of adolescents (Aldwin, 1985). In some cultures, such as Mexico, premarital sexual activity, especially on the part of daughters, is perceived to be a terrible problem that can bring dishonor to the whole family, and in some cultures such sexual activity can even be used to justify the killing of the daughter, as in Egypt. In other cultures, such as Tahiti, premarital sexual activity on the part of adolescents is considered normative and even desirable. Some members of the audience became very upset, and one person argued that in “higher” cultures such behavior was very properly viewed as disgraceful. My reply that the Swedes considered such behavior as normative evoked even more distress! A little closer to home, my late mother-in-law, Liz, related a very funny episode. A liberal southern Methodist, she married into a kosher

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Jewish family during World War II. Liz and her infant son lived with this family in New York while her husband was in the service. Trying to help out in whatever way she could, she cooked a large elaborate meal. Throughout the meal, her mother-in-law cried silently, with tears streaming down her cheeks. Unknowingly Liz had essentially destroyed the kitchen equipment by failing to observe the ritual separation of utensils used for meat versus dairy products required in kosher kitchens! While a tad comical in retrospect, at the time this was an extremely stressful problem for all concerned. A classic distinction is between etic and emic approaches to crosscultural research. In an etic approach, a framework is developed in one culture and applied to others. For example, an early study by Swartz, Elk, and Teggin (1983) tried to measure stress by using Holmes and Rahe’s (1967) stressful life event measure in South Africa, and they found that it correlated very little with standard distress measures. Very different findings may result when an emic method is applied—that is, when indigenous models are allowed to develop within cultures. For example, Ingstad (1988) examined a similar stressful situation in two different cultures. She interviewed Norwegian and Botswana parents who had a disabled child. The Norwegian parents were more likely to appraise this incident as a disastrous problem. They felt guilty for this occurrence and had vague thoughts that it was a punishment from God. In contrast, the Botswana parents were more likely to attribute the problem to the breaking of a taboo or to an ancestor’s anger. As one woman who had given birth to a brain-damaged child put it, “I know it was caused by the difficult delivery, but I think it happened because I did not take good enough care of my mother when she was dying from cancer” (Ingstad, 1988, p. 357). The Botswanans tended not to feel guilty, because the majority of conditions were attributed to witchcraft, or sorcery, caused by a (sometimes unknown) enemy. The Botswanans also tended to feel that the child’s disability was not a terrible tragedy, in part because of the general difficulty of their lives. They were more likely to believe that the disability, rather than a punishment from God, was a positive sign of God’s trust in their ability to care for a disabled child. A similar situation can be seen in Hmong culture, a tribal society that originated in Laos and Cambodia and counts many among the most recent immigrants to the United States. There was recently a court case in California concerning the right to refuse medical treatment. One Hmong family had a child with a club foot, which the family refused to have surgically repaired. In American culture a child having such a disability is stigmatized, and there is a large literature on the difficulties that children with disabilities face. However, in Hmong culture, such children are considered “lucky,” because they have taken upon them-

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selves the bad karma that might otherwise attach to the family—thus, the family refused to have the club foot “fixed.” The doctors sued the family; their lawyers presented scientific evidence about the lifelong problems that can ensue from failure to treat this easily repaired deformity. The lawyers for Hmong family, however, showed that the child evidenced none of these negative sequellae, and in fact was happy, well adjusted, and did well in school. To the best of my recollection, the judge sided with the family in their right to refuse medical treatment. Thus, the same problem may be appraised (and presumably coped with) very differently, depending upon indigenous belief and value systems. It is now routine to develop stress measures that are particular to specific cultures and/or contexts. However, sometimes contextual constraints can overwhelm ethnic or cultural differences. For example, the Multicultural Events Scale for Adolescents (MESA) was used by Gonzales, Tein, Sandler, and Friedman (2001) to examine the types of problems specifically faced by youths in multicultural urban settings. The items in its eight subscales assess problems in the family context (troubles, conflicts, and economic stress), problems with peers, and community problems, which include difficulties with school, violence in the community, perceived discrimination, victimization, and acculturation. Interestingly, within this context, they found few ethnic differences in either the means or covariance matrices, suggesting that very difficult environments may minimize cultural differences.

CULTURE AND COPING Given that the choice of coping strategies may be an inherently social process, it should not be surprising that cultures may influence how individuals cope with stress. While there is an extensive literature on how culture affects adaptational processes (Bateson, 1972; Colby, 1987; Dubos, 1965), much of the anthropological literature has focused on the ways in which psychological disorders vary by cultures, with much debate about whether there are culture-specific mental illnesses (such as amok in Indonesia, susto in South America, or ataque among Puerto Ricans in New York) or whether the structure of psychological disorder (e.g., depression, schizophrenia) is universal, with only the symptom content varying. (For a review of these issues, see Kleinman, 1980.) Nonetheless, it is clear that cultures may differ in the ways in which emotion is expressed. Less attention has been paid to the more general ways in which culture can influence the use of coping strategies. Mechanic (1974) argued that the ability of individuals to acquire coping skills and their success

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depends upon the efficacy of the solutions that the culture provides and the adequacy of the institutions that teach them. Further, Antonovsky (1979) stated that culture . . . give[s] us an extraordinarily wide range of answers to demands. The demands and answers are routinized: from the psychological point of view, they are internalized; from the sociological point of view, they are institutionalized. . . . A culture provides . . . ready answers . . . with keening for a death, an explanation for pain, a ceremony for crop failure, and a form for disposition and accession of leaders. (pp. 117–118)

More specifically, it is necessary to examine studies that document differences in coping behavior by (sub)cultural groups. The few studies that have examined cross-cultural differences published since the first edition of this book have been largely atheoretical, often with small samples, and usually utilizing qualitative data. However, in recent years the situation has started to improve, with larger studies using both quantitative and qualitative methodology in different ethnic groups (Coles et al., 2002; Haley et al., 2004; Knight et al., 2002). As I see it, cultures may differ in their preferred means of both emotionfocused coping and problem-focused coping. Differences in emotion-focused coping center around issues of emotional control versus emotional expression, as well as the patterning of emotional expression. Cultures may also differ in generalized attitudes toward control and instrumental activity—preferences for external or internal control and direct versus indirect approaches to mastery.

Culture and Emotion-Focused Coping Control, as opposed to the expression of emotional responses to stress, is a major dimension along which cultures may vary. The Bateson anecdote based on her Philippines fieldwork, cited at the beginning of this chapter, is a good example of this. Americans tend to perceive grief as an emotion that should be controlled in public and expressed only in private, while Filipinos (and many other cultures) permit the public expression of grief. In general, northern European cultures tend to prefer emotional control—the proverbial British “stiff upper lip.” Many other cultures, however, sanction emotional expression, often in stereotypical ways. In the coping literature, this has been studied primarily in (sub)cultural differences in response to pain. Zborowski (1952) provided one of the first studies of ethnic differences in coping with pain. Among hospitalized patients, individuals

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from Italian and Jewish ethnic groups exhibited the most expressive behavior in response to pain (including groaning and moaning). In contrast, both Irish American and what Zborowski termed “Old American” patients tried to minimize their pain and to effect a kind of stoicism. Withdrawal from other people when in pain was most characteristic of Old American patients, whereas Jewish patients expressed more anxiety and worry about their pain. These behavioral differences clearly reflect cultural beliefs about the best ways to manage pain and differences in the acceptability of emotional expression. Since the Zborowski study, a number of researchers have investigated cultural and ethnic differences in coping with pain in both clinical and laboratory settings (for reviews, see Moore, 1990; Zatzick & Dimsdale, 1990). Several studies have confirmed Zborowski’s original findings (Koopman, Eisenthal, & Stoeckle, 1984; Lipton & Marbach, 1984; Zola, 1966). Interestingly, Chinese respondents in Moore’s (1990) study had a category of pain, called suantong, that is apparently unique to their culture. Suantong pain can be best described as an itchy, dull, or stabbing pain caused by inflammation. The Chinese described tooth drilling in a dental context as suantong, or a dull pain, not requiring chemical anesthesia, in contrast to the Americans, who characterized drilling as a sharp pain requiring pain relievers. However, not all studies have demonstrated cultural differences in the perception and expression of pain; in part, such differences depend upon the racial–ethnic groupings utilized in the research. Zatzick and Dimsdale (1990) offered two generalizations in their review of this literature. First, various studies have shown that there are no cross-cultural differences in the perception of a pain threshold, that is, the ability to discriminate painful stimuli. This argues that any differences in pain tolerance are not neurophysiological in origin but rather are cultural. Second, studies that utilized racial groupings (e.g., white vs. black) were less likely to find differences in coping with pain than studies that utilized ethnic groupings. That is, there may be ethnic differences within racial groups, such as Zborowski’s initial findings of differences between Italian Americans and Irish Americans. Zatzick and Dimsdale emphasized that members of an ethnic group by definition share cultural beliefs about the most appropriate manner in which to cope with and express pain. An even more intriguing possibility is that there may be cultural patternings in the expression of emotion up to and including the manifestation of mental illness. For example, some conceptions of culture-specific mental illness view these as temporary states and culturally sanctioned reactions to stress, which are not necessarily inherently pathological as long as they remain short-term reactions (Garrison,

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1977; Maduro, 1975; Weidman, 1979). These syndromes are often manifested under quite specific and usually highly stressful situations. For example, ataque among Puerto Ricans in New York is used to describe a particular syndrome characterized by extreme emotional expression, fainting spells, and fuguelike behavior, often self-destructive, which the person may or may not remember later. For example, one woman, when informed that her son had an accident, started screaming, fainted, and then leaped up and tried to jump out a window (Garrison, 1977). According to Garrison, ataque is the expected behavior under certain circumstances, including a death in the family or witnessing acts of aggression that the individual is powerless to stop (e.g., a husband beating a child). Similarly, “falling out,” a quasi-epileptoid state found among American, Haitian, and Cuban blacks, occurs in situations in which an individual feels extreme fear or rage, under stressful conditions at school or in sports competitions, or in highly crowded situations. Falling out serves to remove individuals temporarily from these stressful conditions, thus functioning to regulate emotions (Weidman, 1979). Current psychological theories of stress and coping assume that emotions should be controlled and their expression minimized. For example, Pearlin and Schooler (1978) defined coping as “any response to external life strain that serves to prevent, avoid, or control emotional responses.” This viewpoint reflects the attitude of northern Europeans and Anglo-Americans toward emotional control. In other cultures, however, less emphasis may be placed on emotional control, and displays of emotion may be deemed appropriate and desirable. Indeed, among Puerto Ricans in New York, failure to have an ataque under culturally specified situations may be seen as a sign of being cold- or hard-hearted (Garrison, 1977). In studies of coping effectiveness, contemporary psychological work operationalizes “successful coping” as that which is associated with the fewest psychological symptoms under stress (Folkman & Lazarus, 1980). However, this may reflect only the attitudes of some cultures regarding appropriate coping behavior and outcomes. If emotional expression, or even specific psychological symptoms, are mandated coping responses to stress in certain cultures, then it would be misleading to characterize only those strategies associated with a few symptoms as effective coping strategies. Rather, it is important to understand what is perceived to be effective coping in any given culture. Emotional expression may have important problem-focused functions in particular social situations. In the example noted above, a Puerto Rican woman may have an ataque in order to attract her husband’s attention and distract him from beating his child. The expression

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of psychological symptoms can be seen as an indirect attempt to control a social situation (see Szasz’s [1961] discussion of psychological symptoms as oblique attempts at communication). Paradoxically, emotional expression may actually be viewed as a form of instrumental activity, albeit an indirect one. Saunders (1977) described zar possession states among Egyptian women primarily as an indirect means of influencing husbands in a culture in which direct influence is prohibited. Thus, a woman may only be able to escape from intolerable demands by becoming seriously ill or may impose demands upon her family by using the zar spirit that possesses her to insist upon certain goods or services (including a sewing machine!). It may be more difficult to document ethnic differences in general types of coping strategies. For example, Gonzales et al. (2001) found no differences in coping strategies between African American, European American, and Latino adolescents, but they used a generalized coping inventory that was not tied to any particular stressor. Knight et al. (2000) did find that African Americans were more likely than non-African Americans to use emotion-focused coping in caregiving situations, and Lee and Brennan (2002) also found them more likely to use emotionfocused coping in dealing with visual impairment. Qualitative studies suggest that African Americans are also more likely to use religiousbased coping strategies such as prayer in caregiving situations (Louikissa, Farran, & Graham, 1999) carry as well as their own health problems, such as visual impairments (Lee & Brennan, 2002) and breast cancer (Ashing-Giwa et al., 2004). Latinas may show similar patterns (Abraido-Lanza, Guier, & Revenson, 1996). These few studies suggest that ethnic groups in the United States may use more emotional expression and religious coping, but clearly more work needs to be done to confirm these findings. Not surprisingly, there are also cultural differences in the patterning of emotional responses. For example, Cole, Bruschi, and Tamang (2002) compared the emotional responses of children from the United States with two different ethnic groups in Nepal, the Brahmans (a group that migrated from India), and the Tamang, an indigenous group. The Brahman and the U.S. children were more likely to respond to problems with anger, and the Tamang with shame. However, Brahman children preferred not to communicate their emotions, while both the U.S. and Tamang children were not so reticent. Nonetheless, Brahman children said they were also more likely to show happiness in difficult situations than children in the other two groups. There also complex interactions with age. Older Tamang children were less likely to show anger than younger ones, but older American children were more likely to demonstrate anger. Thus, there are complex interactions

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between culture, situation, and age that impact upon emotion-focused coping.

Culture and Problem-Focused Coping In general, problem-focused coping is defined as an attempt to control or manage a stressful situation. Since Rotter’s (1966) seminal work on locus of control, there have been literally thousands of studies examining control and psychological adaptation. Not surprisingly, many of the cross-cultural studies of coping behavior have focused on control or mastery. In a review of studies using the Hoffman Inkblot Test to determine coping styles, Diaz-Guerrero (1979) concluded that Mexican children exhibit more passive or self-modifying coping styles than American children, who are more likely to receive high ratings for active coping styles. In a multinational study that administered a self-image questionnaire, Offer and his colleagues (Offer, Ostrov, & Howard, 1981) also concluded that American adolescents were more likely to use active coping styles, compared to their Irish or Australian peers. Interestingly, Israeli teenagers were seen as the most active and mastery-oriented of all the groups. These studies, however, only inferred coping behavior from personality measures and did not directly assess the use of coping strategies in specific stressful situations. A number of studies have found differences in the amount of problemfocused coping used by members of different cultures. For example, Etzion and Pines (1986) examined coping and burnout among Israeli and American human services professionals. They concluded that the greater use of active coping strategies among Israelis contributed to the generally lower prevalence of burnout in this highly stressed profession. Western conceptions of control generally dichotomize into active versus passive, internal versus external, and so forth. More recent theories suggest dividing the types of control into primary (i.e., environmental) and secondary (i.e., emotional). Heckhausen and Schulz (1995) argued that primary control is preferable and that secondary control is exercised as a fall-back position. However, Reynolds (1976) argued that an active versus passive dichotomy may be too simplistic and suggested a more complex view: Instead of an active-struggling versus a passive-acceptance dichotomy, I would suggest that a more useful contrast between Oriental and Western approaches to problem solving lies in the locus of preferred activity. One’s phenomenological reality is a product of one’s inner state and objective reality. By manipulating either factor it is possible to change

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phenomenological reality. It seems that, in very general terms, the West is more accepting of activity directed toward changing objective reality. . . . But I must reemphasize that the Japanese value is not passive resignation. It is simply tactical. Certain sorts of problems are held to be best handled by indirection and internal change. (pp. 110–111)

A good example of indirect coping is provided by Sue (personal communication, 1982), a clinical psychologist specializing in Asian cultures. He was consulted by a woman who had difficulties with her inlaws. Given cultural strictures concerning the relations between in-laws, this woman could not directly confront her in-laws with the problems they were causing her, nor would her husband confront his parents— certainly the advice that a Western clinician not sensitive to cultural differences would suggest. Instead, Sue suggested that the woman enlist the aid of a sympathetic uncle who could intercede on her behalf. The uncle, who was the mother-in-law’s older brother and who, therefore, was in a position of authority over her, was invited to dinner. While not directly addressing the problem, the uncle’s remarks concerning how tired the daughter-in-law looked were sufficient warning to convince the motherin-law to move out, thereby solving the problem. This woman could not use the type of direct action sanctioned by Western values but could exert control through indirect action. Thus, preference for indirect action should not be confused with passivity. Locus of preferred activity should not be confused with current conceptions of locus of control, which simply refers to beliefs concerning whether an individual can directly affect the external environment. The locus of preferred activity, in contrast, refers to the realm in which an individual chooses to exercise control, for example, controlling internal reactions to a problem. Nor should acceptance of a problem be confused with a passive stance. Brickman and his colleagues (1982) have argued for a distinction between responsibility for the occurrence of an event versus responsibility for its solution, or outcome. Individuals may not have much control over the occurrence of a particular event, but the recognition of that lack of control does not necessarily preclude instrumental activity. Aldwin (1991), for example, found that older individuals may deny responsibility for the occurrence of an event and even its management but yet use just as much problem-focused coping as younger people. (This topic is discussed in greater detail in Chapter 14.) Acceptance may prove to be a buffer against stress and may mitigate against stress and excessive self-blame. In a test of the learned helplessness theory of depression, Coyne et al. (1981) found that chronic depressives were no less likely to try to exert control over their environment

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than nondepressives were. On the contrary, depressives were less likely to accept that some situations are not amenable to control and more likely to try to exert control over ungovernable situations. The depressives were apparently less able to perceive which situations were amenable to control and to adjust their activities accordingly; consequently, they were more likely to blame themselves for things going wrong. This finding was subsequently confirmed by Folkman and Lazarus (1986). Cultural beliefs in fate (sometimes known as karma or joss in Asian cultures), where they do not lead to passivity, may aid in absolving an individual of an undue sense of failure or incompetence or in warding off depression. McCarty et al. (1999) compared Thai and American youths and distinguished among primary control (over the environment), secondary control (over one’s self), and relinquishing control. While in general Thai youths were more likely to use secondary control, especially with regard to problems with authority figures such as parents and in separation situations, there were some interesting culture-by-situation interactions. American youths, for example, were five times more likely than Thai youths to use secondary control for physical injuries. This supports Wallace’s (1966) notion of culture as a mazeway in that one cannot expect all individuals from a given culture in all contexts to cope in a particular way, but rather there are complex culture–situation interactions, as well as probable three-way interactions, that also include individual characteristics, which determine coping. As noted earlier, coping in a nonculturally prescribed manner may result in greater stress. Hwang (1979) examined how men coped with residential crowding in Taiwan. Lower socioeconomic groups coped in ways characterized by lower self-confidence and fatalism. Regardless of social class, men who used coping styles that emphasized traditional cultural values and interpersonal cooperation experienced less interpersonal stress and lower symptom levels. Coping styles that emphasized self-assertion and achievement enhancement, however, were associated with more interpersonal stress, psychosomatic disorders, and depression. Shek and Cheung (1990) have argued that cultures may be divided into those that place greater reliance on the self (internal locus of coping) and those that rely more on others (external locus of coping). The example provided earlier by Sue (personal communication, 1982) is a good instance of the latter. Kashima and Triandis (1986) applied Heider’s (1958) classic distinction between individualistic and collectivistic cultures to one type of coping behavior: self-serving bias. According to attribution theory, people tend to credit themselves for success and to attribute failure to external circumstances (for a review, see Zuckerman, 1979). Kashima and

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Triandis hypothesized that self-serving bias was more important for individualistic cultures, as a consequence of their emphasis on self-reliance and the implied greater threat of failure. In a controlled experiment contrasting the attributions of Japanese and American students, Kashima and Triandis found that their hypotheses were only partially supported. American students used self-serving biases only in relatively ambiguous circumstances; when the task was less ambiguous, the two groups of students tended to use similar attributions. Thus, the situational context can modify cultural influences on coping strategies. Even among individuals using active problem-focused coping, there may be ethnic differences in preferences for types of direct action. Caplovitz (1979) studied differences in preferences for coping with inflation among various American ethnic groups. Controlling for income level and impact of inflation, there was considerable overlap in the types of strategies used. However, Anglo-Americans were most likely to try to curtail expenditures by decreasing their standard of living, African Americans were most likely to spend time hunting for bargains, while Spanish-speaking groups were most likely to share with family members or neighbors. Similarly, Lee and Brennan (2002) found that African Americans were more likely to seek professional help in coping with problems of everyday living impairments due to loss of vision, while European Americans were more likely to seek out optical devices such as magnifying glasses. In the Lee and Brennan (2002) study, ethnic groups differed in how they utilized social support. European Americans with visual impairment avoided social situations and were reluctant to seek social support. They were more likely to rely on spouses and friends rather than immediate family, but were most interested in social support groups for the visually impaired that shared coping information. In contrast, African Americans were heavily reliant upon their family members and turned to them for emotional support. Abraido-Lanza et al. (1996) also found that Latinas relied heavily on family members rather than friends. Interestingly, bicultural individuals may develop two separate coping repertoires, depending upon the cultural context. Kiefer (1974), for example, found that Nissei second-generation Japanese Americans appeared to have different rules of behavior, depending upon whether the problematic situations involved other Japanese Americans or individuals outside their cultural group. Aboriginal adolescents in Australia also appear to use different strategies in coping with conflicts arising from demands made by parents and/or the traditional culture and those made by Western-style teachers in the mission school (Davidson, Nurcombe, Kearney, & Davis, 1978). This construct has been updated by LaFramboise, Coleman, and

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Gerton’s (1995) treatise on bicultural competence. Rather than viewing incompletely acculturated individuals as defective or at-risk, they argue that individuals may develop competence in two (or more) cultures. Such individuals are thought to have a larger coping repertoire and be more adaptive than less well versed individuals. When Vargas-Reighley (2005) attempted to test this theory in a sample of Chicano(a) and Southeast Asian middle schoolers; however, she found very little relationship between an assessment of this construct and actual coping behavior, and relatively few differences in the use of coping strategies between the two groups. However, she did find culture-by-situation interactions in the effectiveness of coping: for the Southeast Asian youths, problem-focused coping was related to better outcomes in academic situations, while for the Chicano(a) youths stress and coping in the family context had more impact on well-being. In summary, sociocultural groups appear to generate not only consensual belief systems concerning the origin and meaning of stressors but also beliefs concerning the most appropriate means of both emotionand problem-focused coping. These beliefs may be situation specific. Further, trying to cope in ways that run contrary to the general cultural ethos may increase stress even though those same strategies used by members of a different culture may be efficacious in reducing emotional distress. Even more rarely examined, however, are the more generalized institutions that cultures provide to individuals in order to help them cope with problems.

INSTITUTIONS AS COPING MECHANISMS Mechanic (1974) argued that, to a large extent, the efficacy of an individual’s coping is dependent upon how well the culture provides a range of coping resources and transmits coping skills. Thus, coping strategies are influenced not only by cultural beliefs concerning the most appropriate means of handling specific types of problems but also by social and cultural institutions for problem solving and tension reduction (Mechanic, 1978). Some examples of institutionalized assistance in coping are obvious. The legal system is the formal means of conflict resolution, and a crosscultural comparison of legal systems might provide interesting insights into the cultural beliefs that govern those processes. For example, it is interesting that in Euro-American cultures that emphasize personal control relatively little individual control can be exercised in the court system, where decisions are made primarily by lawyers and judges. In other cultures such as in Mexico and Saudi Arabia, where seemingly less

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emphasis is placed on personal control, plaintiffs may have much more influence over the amount and type of punishment meted out to the perpetrator (Nader, 1985). In addition to formal systems for conflict resolution, all cultures provide some form of ritualized advice that may consist of religious counselors, professional ones (e.g., psychiatrists, psychologists, social workers, etc.) or quasi-formal support groups such as Alcoholics Anonymous. Tseng (1978) argued strongly that fortune telling may be a sort of folkcounseling service. Clients typically present a wide variety of problems concerning health, business, academic examinations, marriage, and so forth, and receive not only interpretations as to the causes of their problems but also specific suggestions as to how to cope. This is so prevalent in some Asian cultures that Shek and Cheung (1990) included an item assessing the consultation of fortune tellers on the Chinese Coping Inventory. Hsu (1976) found that advice provided by Taiwanese diviners was usually culturally conservative—that is, individuals were advised not to be too aggressive or ambitious and to behave in ways that were appropriate for their social role and status. Certainly this is reminiscent of the advice that newspaper columnists in the United States provide. It may also be that turning to astrologers and fortune tellers for advice may be more prevalent in this culture than is usually thought, as the example of Nancy Reagan suggests. Nonetheless, cultures usually provide a variety of institutions that give advice to individuals. What type of advice is sought, and the source of that advice, may depend in part upon the ethnic group or social class to which an individual belongs (Neighbors, Jackson, Bowman, & Gurin, 1983). Finally, rituals of various sorts may also be viewed as cultural mechanisms that aid individuals in both emotion- and problem-focused coping. Wallace (1966) described a number of goals, categories, and functions of rituals: All ritual is directed toward the problem of transformations of state in human beings and nature. Sometimes the goal is to ensure the quickest and most thorough transformation into an end state desired by the ritual actor; sometimes the goal is to prevent an undesired transformation from occurring. Sometimes the target is an individual; sometimes it is a group. Sometimes the transformation is a minor one, a correction which will restore equilibrium and status quo . . . sometimes it is a question of radical transformation of the system, the attainment of a new level of equilibrium or even of a new quality of organization. (pp. 106–107)

Through their symbolic ability to transform personal and situational states, rituals provide an opportunity for individuals and social

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networks to cope with various stresses. Funeral rituals help to serve these functions for the bereaved, marriage rituals for newlyweds, and rites of passage for individuals undergoing status transitions. Among other things, rituals focus social support on individuals who are undergoing a transition, and in general they provide a sense of closure for one part of an individual’s life, allowing him or her to make the transition to a new life (Constantinides, 1977). Obviously, some rituals are better at this than others are (the retirement luncheon, for example, is a ritual that at best may provide a sense of closure but that may do little toward helping the retiree cope with his or her change in status). Further, healing rituals, which often take place in a quasi-ritual context, provide a significant source of both advice and social support for individuals who are undergoing a crisis or who may have problems of adaptation in general (Good, 1977; Obeyesekere, 1977; Spiro, 1978). Wallace (1966) hypothesized that there exists a dynamic balance among the types of stressors typically faced by individuals in a culture and the culturally sanctioned means of coping with them. Thus, having a child out of wedlock may not be very stressful in Tahitian or Swedish cultures because it is common for kin to adopt babies from young girls with little or no shame involved. However, Wallace hypothesized that undue stress arises when there is a mismatch between culturally patterned stressors and coping responses. If the pattern of stressors changes to cross-cultural contact, technological or social change, natural disasters, famine, war, and so forth, then the typical means of coping with problems may no longer “work,” and there may be an increase in social problems such as alcoholism, divorce, child abuse, and psychiatric problems. At that point, it is incumbent upon individuals within a culture to derive new patterns of problem solving. This often occurs through what Wallace termed “revitalization movements,” usually religious in nature, which establish new patterns of beliefs, values, and adaptive behaviors. Revitalization movements are often characterized by a desire to return to traditional values or, conversely, to develop a new Utopian society. Clearly the Islamic Revolution in Iran in the 1970s was in response to too-rapid culture change and would have been nicely predicted by Wallace’s theory. However, revitalization movements are not always successful in their attempts to reorganize societies. Through a series of case studies, Wallace cautioned that failure on the part of revitalization movements (usually through inflexibility or an inability to accommodate to the powers that be), or an inability to invent new adaptational patterns, can ultimately result in the death of the culture. It is tempting to apply Wallace’s theory to the urban crisis that exists not only in America but throughout the world today. The change from an agrarian to a technological society displaces thousands of agri-

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cultural families. In England’s Industrial Revolution, these displaced workers migrated to America, displacing Native Americans. Currently, however, most displaced agricultural workers flee from the countryside to the city, as typified by the migration patterns of African Americans from the rural South to the northern industrial cities or of Mexican workers to the United States. Old cultural patterns, which may have been adaptive in an agrarian culture, are no longer appropriate to an urban situation. This, compounded with systematic denial of access to resources, has resulted in extreme stress on African American culture, resulting in typical patterns of social pathology (such as crime, drug and alcohol abuse, child abuse, and other forms of violence). From Wallace’s perspective, the Nation of Islam movement is a fairly typical revitalization movement that offers new beliefs, values, and adaptive patterns (e.g., emphasis on self-reliance, avoidance of drug and alcohol use, adherence to a work ethic, emphasis on family integrity). Unfortunately, it also increases in-group solidarity through the demonization of other ethnic groups, which brings it into direct conflict with the dominant culture. Thus, whether or not this (or some other revitalization) movement will be successful remains to be seen. The point to be emphasized, however, is that the relation between culture and individual coping is not unidirectional—rather, individual behaviors can reinforce or change existing patterns of coping. Grass roots movements are often examples of individuals banding together to develop and provide alternative means of coping with some social problems. As Good (1977) pointed out, the coping techniques described by psychologists refer to what the individual may do in those situations in which he must act alone or on his own resources. . . . It is a major characteristic of man as distinguished from other organisms, however, that one of his major management techniques is that of developing an organization that will handle the threat, or of creating an environment in which the threat does not occur. Of course individuals act, as always, but they are manipulating some type of organization or structure that has been set up. (p. 59)

Thus, individuals manipulate existing organizations or structures, but they may also create them through the development of new organizations, legislation, or the development of new procedures and services. Therefore, it is important to understand not only that cultures affect individuals’ coping behaviors but also that individuals’ coping behaviors can affect their culture. Indeed, recognition of the fact that individuals can and do change cultures provides the only ray of hope for overturning the culture of violence that is fast developing in various parts of the globe.

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SUMMARY Cultures influence the types of stressors that individuals experience through the sanctioning of normative life changes or through patterns of resource allocation. They also influence the appraisal process, through beliefs and values prevalent within a wider cultural setting or developed through consensual processes in more specific social situations. Further, cultures may define certain coping behaviors as more appropriate than others; and what is deemed appropriate is not uniform within a culture but, rather, varies as a function of the individual’s position in the cultural mazeway. Finally, the relationship between the individual and the culture is bidirectional. Not only do people cope in ways that affect other individuals, but through the modification or development of new organizations, structures, and attitudes, an individual or group of individuals may affect social change.

STRESS, COPING, Developmental Studies AND of DEVELOPMENT Coping

CHAPTER 14

Developmental Studies of Coping Coping and development seem inherently inter-connected. No account of coping is complete without acknowledging the central role that age-graded factors play in shaping an individual’s adaptation to stress. . . . Likewise, no account of development is complete without a consideration of how individuals respond to stress. —SKINNER AND EDGE (2002, p. 77)

A

s noted earlier, perhaps the most important aspect of coping for adaptation is that it is flexible: rather than a person’s adaptational style being “set in stone” due to genetics or fixation at early stages of personality development, coping strategies are thought to be plastic, to develop in the course of dealing with the ever-changing stress in the environment. This assumption leads naturally to questions of how (and when) the various coping abilities develop and how (and whether) they change over the life course. The past decade has seen a tremendous increase in coping studies in both young and old populations. Although many gaps still exist, understanding the development of coping strategies and what is “normal” and “abnormal” coping at different ages can greatly expand our understanding of the development of psychopathology and mental health throughout the life course. This chapter addresses these questions, first surveying the literature 271

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on coping in infancy and childhood and then examining the rather scanty literature on adult developmental processes.

COPING IN INFANCY AND CHILDHOOD At first blush, the idea that infants “cope with stress” seems odd. To the untrained observer, they appear primarily to eat, sleep, eliminate, and, of course, cry. However, to the extent that coping strategies can be seen as basic attempts to regulate both the external and the internal environment, humans clearly engage in regulatory actions starting at a very early age—perhaps even prenatally. William James thought that infants experienced the world as a “blooming, buzzing confusion,” an inherently meaningless and (by implication) stressful place. Early psychoanalysts rhapsodized about the “oceanic” blissfulness of the womb and the stress of emerging into the harsh, cruel world. Folk wisdom held that infants were blind, deaf, and dumb—as it were, little more than a crudely functioning alimentary canal. However, we have known for some time that all of these views are incorrect (Bower, 1977). The past decade has witnessed improved theoretical frameworks for understanding coping in infants and young children. However, instead of the term “coping,” many developmental psychologists utilize the terms “self” and “emotion regulation.” Shonkoff and Phillips (2000) define self-regulation as in many ways similar to how social and clinical psychologists define coping: “People . . . react to changing events and then . . . regulate their reaction” (p. 93). Self-regulation consists of “learning to wait before acting, self-monitoring, and acquiring the ability to organize segments of behavior sequentially” (p. 103). In other words, self-regulation consists of learning to delay action, being aware of both what one is feeling and thinking as well as how one is presenting oneself, and making a plan of action or an organized plan of behavior. The emotion regulation theorists do add some interesting perspectives that are often not explicitly included in adult coping theories— namely, the fact that emotion regulation is often based on attention regulation, and the inclusion of the underlying motivation for the behavior. For example, Eisenberg and Zhou (2000) state that emotion regulation is defined as the process of initiating, maintaining, modulating, or changing the occurrence, intensity, or duration of internal feeling states and emotion-related physiological processes, often in the service of accomplishing one’s goals. . . . In our view, emotion regulation often is accomplished through effortful management of attention (e.g., attention shifting and focusing, cognitive distraction) and cogni-

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tions that affect the interpretation of situations (e.g., positive cognitive restructuring), as well as through neurophysiological processes. . . . In contrast, emotion-related behavioral regulation is the process of initiating, maintaining, inhibiting, modulating, or changing the occurrence, form, and duration of behavioral concomitants of emotion . . . includ[ing] the control and modulation of facial and gestural reactions and other overt behaviors. . . . Misregulation [is] the lack of behavioral regulation or ineffective coping (regulation) attempts. (p. 167)

In other words, emotion-focused coping is both cognitive and behavioral, as the early coping theorists understood (Folkman & Lazarus, 1980). What is new is the explicit understanding that cognition involves not just thoughts or attempts to suppress feelings; rather, cognitive attempts to regulate emotions depend upon one’s ability to regulate attention. A highly successful intervention for children with anger problems teaches children to first recognize the emotion they are feeling, to understand how that emotion results in behavior, to be able to inhibit negative behaviors, and finally to be able to substitute more prosocial behavior and emotion expression (Greenberg, Kusché, Cook, & Quamma, 1995). In the adult coping scales, acknowledgment is given to expressing emotions, or (trying not to let my feelings show,( but this is not as sophisticated as recognizing the extremely subtle use of verbal and nonverbal emotional expression to regulate social interaction. In studying infant and early child development, the links among neurological, cognitive, emotional, and social development are much more explicit, and frontal lobe development and attendant ability in executive functioning plays a large role in children’s use of coping strategies. In addition, the difference between involuntary and voluntary coping strategies also becomes more apparent, with some arguing that early coping strategies tend to be involuntary while voluntary strategies emerge in early childhood (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001).

Fetal Coping? Rather than a timeless, quiet void, the womb is actually a very noisy place. Not only is the fetus privy to the heartbeat and digestive noises of the mother, but environmental noises can also be clearly perceived inside the uterus, which is known by any mother who has had to leave a concert because her fetus was kicking at the noise. (Indeed, it is rather incredible that the myth of this supposedly serene intrauterine environment ever had any credence!) The fetus responds not only to environmental noise and light but

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also to the mother’s movement, nutritional intake, and even her stress hormones (Field, 1991). Pregnant women will often tell of having to modify their behaviors so as not to upset the fetus—avoiding spicy foods, loud concerts, arguments, certain sitting or lying positions, and so forth—especially in the last trimester, when the fetus can express its displeasure by kicking. (One pregnant friend of mine complained bitterly of her fetus’s uncanny ability to aim its kick at her bladder when displeased!) To the extent that coping is defined as intentional behavior, however, it is difficult to credit a fetus with exhibiting coping strategies per se. Certainly kicking, hiccupping, arm waving and the like can be seen as automatic responses of the nervous system, similar to a startle reflex in response to sudden environmental change or stimulation. It is interesting, though, that fetuses have been observed to suck their thumbs in utero. Again, while sucking is primarily an instinctual response, it is also undoubtedly soothing—perhaps a primitive first attempt at emotionfocused coping. Indeed, in premature neonates, nonnutritive sucking reduces physiological stress responses to invasive procedures, decreases fussiness and crying, and may even promote weight gain (for a review, see Field, 1991).

Coping in Infancy The first 3 months of life can be characterized as a shift from intrauterine to extrauterine regulation of physiological processes (Mirmiran & Lunshof, 1996). There are large cultural differences in how this is accomplished, but most babies are reasonably flexible and slowly learn to regulate circadian rhythms, eating and digesting, and the like. However, premature and medically fragile infants have a much more difficult time in this transition. They have a harder time developing stable physiological rhythms and are less predictable, less likely to make eye contact, smile, vocalize, or evince positive affect, and are, in general, fussier and more difficult to raise (Beckwith & Rodning, 1996). When upset, nearly all babies will suck their own thumb for comfort. Other such early behavioral forms of emotion-focused coping include rocking, distracting oneself by playing with toes, or, if nothing else works, fussing and crying (Karraker & Lake, 1991). Crying—the major way of communicating to caregivers that assistance is required—also follows a developmental sequence. Crying tends to increase in frequency until around 6–8 weeks and then decreases until about 12–16 weeks. Parenting practices appear to influence this. Babies who have responsive caregivers also shift more quickly into other forms of communication than crying (Crockenberg, 1981). Babies who are car-

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ried more tend to be more easily soothed. While their crying may be as frequent, it is of much shorter duration. Colicky babies follow the same trajectory, although they spend much more time crying (Shonkoff & Phillips, 2000). Emotions are biologically rooted, and infants at a very early age display negative emotions such as fear, anger, and distress as well as positive emotions such as being happy. The development of emotions in infancy and early childhood often parallels neurological development, especially in the frontal lobes. Physical states (being hungry, thirsty, cold, or wet) largely determine the emotional reactions of infants. Temperament also plays a large role in regulating emotions in infancy and early childhood (Compas et al., 2001; Eisenberg, Fabes, Shepard, et al., 1997; Rothbart, 2004). Temperament is also highly labile in the first 3 months but becomes more stabile after 4 months. About 20% display negative reactions to novel stimuli, suggestive of high anxiety. Nonetheless, only 13% of children who are highly anxious at 4 months are still in the same category by age 4 (Kagan, Snidman, & Arcus, 1998), suggesting that most learn to regulate their emotional reactions. Interactions with parents and other caregivers play an extremely important role in this regulation. Babies utilize social referencing—that is, they look to the emotional expression of the caregiver to help interpret their social surroundings (Baldwin & Moses, 1996), which is influenced by the quality of the attachment relationships (Laible & Thompson, 1998) as well as by explicit parental “coaching” of the “appropriate” emotional expression in social situations (Miller & Sperry, 1987). Clearly, this process is aided when there is a “goodness of fit” between parental and infant temperaments (Rothbart, 2004). A good example of this is the behavior of children and their parents at the child’s first birthday party. Such novel activity is often very confusing for a child, and he or she will look to the parents for the appropriate interpretation of the danger or safety of this novel situation. The parents, in turn, use exaggerated facial expressions to indicate that the child should be happy and pleased about being inundated with gifts—in American culture, at least—even though most would seem to be just as happy playing with the wrapping! Clearly, culture guides what the “appropriate” emotional response is in any given social situation, as well as the best means of expressing that emotion. Cultural differences in the expression of emotion occur at very early ages (Zahn-Waxler, Friedman, Cole, Mizuta, & Hiruma, 1996). Further, growing up in a difficult or stressful environment, such as one that is full of marital strife, can lead to difficulties in emotional regulation, and, in those with difficult temperaments, perhaps affective disor-

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ders of their own (Zahn-Waxler et al., 1988). Learning to recognize and regulate emotions is partially regulated by verbal interactions with parents (Zahn-Waxler, Radke-Yarrow, Wagner, & Chapman, 1992). In turn, recognition can lead to better emotional regulation (Thompson, 1990). In general there is a gradual shift from direct calming of the child by the parent to helping the child develop ways of regulating his or her own emotions (Thompson, 1990). In the first few years of life, children learn to develop strategies to control their emotions using purposeful strategies, which can provide a basis for more successful coping in later life (Kochanska, Murray, & Harlan, 2000). Early longitudinal studies done at the Menninger Clinic by Lois Murphy and her colleagues provide very nice examples of young infants’ attempts to regulate both their internal and external environments (Murphy & Moriarty, 1976). Even young infants will try to manipulate their physical environment. They will bat at encroaching blankets, wriggle to obtain a more comfortable position, and make motor efforts to retrieve a lost nipple. Not only are there individual differences in the amount or type of stimulation desired, but even very young infants will try to regulate the amount of incoming stimulation by closing their eyes, turning their heads, falling asleep, or, if all else fails, crying loudly when they are overstimulated. An infant even a few weeks old will solicit social stimulation through eye contact, smiles, and gurgling, but will turn away if too much stimulation is proffered. Certainly infants are also able to modulate their cries in order to signal the type of distress they are experiencing (e.g., hunger, wetness, fright). Further, Bell and Harper (1977) clearly demonstrated that infants modify and regulate their parents’ behavior as well. One of Murphy’s most important discoveries concerned the infant’s ability to regulate stress by alternating periods of effort with rest: “Ronald at twenty-eight weeks was seen to struggle for thirty-five minutes in his effort to master getting up on all fours. During this period he pushed strenuously until he was tired, then flopped down on the floor, sucking his thumb until he was rested enough to try again. This alternation of effort and rest went on until he finally succeeded” (Murphy & Moriarty, 1976, p. 91). However, the pattern of approach–avoidance alternation did vary among infants. Some children recovered easily, others took much longer periods. Nonetheless, an important task of infancy appears to be to learn how to regulate the internal environment sufficiently to engage in more or less sustained problem-focused efforts. Some babies seem to find this an easier task than others, and difficulty in self-regulation in infancy correlates with similar problems in later childhood. Murphy and Moriarty (1976) observed that the “best outcomes” were among those children whose parents recognized and encouraged their infants’ at-

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tempts to cope with problems and who were sensitive to their infants’ needs and rhythms. More recent research has confirmed that caregiver sensitivity is basic to the development of secure attachment, which in turn affords a strong basis for the development of many kinds of emotional and social competence that develop among toddlers.

Coping among Toddlers In studying infant and early childhood development, the links among neurological, cognitive, emotional, and social developmental levels are much more explicit, and clearly frontal lobe development plays a large role in children’s use of coping strategies. For example, problem-focused coping strategies grow out of emerging capacities for executive functioning, again, paralleling the development of the frontal lobes. These require three basic skills (Shonkoff & Phillips, 2000). The first involves attention. The infant must be able to orient to the external environment, learn to anticipate events, and represent the world symbolically (Barkley, 1996). Second, the infant must learn means–ends behavior, as studied extensively by Piaget (1952), as well as to represent the world symbolically through the use of language. The third is through self-control, which also requires the ability to monitor the self and to respond appropriately to requests, and to inhibit, delay, or initiate behavior, as appropriate. Thus, Lewis, Zimmerman, Hollenstein, and Lamey (2004) argue that there is a developmental shift in coping strategies at around 18–20 months, paralleling changes in the frontal lobe at about the same time. The ability to exercise control develops rapidly from about 18 to 30 months (Vaughn et al., 1984). Emotion regulation also develops in early childhood, and cultural differences in the expression of emotion emerge at an early age. Preschool children in the United States are more likely to express negative emotion than their Japanese counterparts (Zahn-Waxler et al., 1996), although Japanese children express more guilt and shame (Kornadt, Hayashi, Tachibana, Trommsdorff, & Yamauchi, 1992). Further, Thai children who are referred to clinics for problems are more likely to be overcontrolled, whereas American children are generally undercontrolled (Weiz et al., 1987). In part, this may stem from differences in the meaning attributed to the social expression of emotion (Eisenberg & Zhou, 2000). For example, in the United States, shyness in children is interpreted as reflecting fearfulness (and therefore is undesirable), whereas in China it is seen as reflecting social maturity. Certainly toddlers have a much greater range of coping resources than infants. Their greater physical coordination and mobility and the development of language make manipulating the physical and social en-

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vironment much easier. However, they are still highly dependent upon their parents or other caretakers for solutions to many problems, although many infants show an almost distressingly strong desire for autonomy. The “terrible twos,” protestations of “Me do it!” and toddlers’ almost insatiable curiosity and tendency to get into everything can be seen as their active attempts to increase their coping repertoire and their ability to manipulate both the physical and the social environment. Further, toddlers are able to solicit social support under stress with strategies other than crying. A parent is often used as a security object, with the child running toward, touching, clinging, or sometimes simply making eye contact with the parent when frustrated, angry, or frightened—at least for securely attached toddlers. While toddlers’ emotional responses to stressors in the environment are still fairly undifferentiated (Cummings, 1987), they may nonetheless take a more active role in trying to regulate their emotions. While thumb sucking and rocking are still prevalent, many toddlers emotionally invest in a transitional object, such as a favorite blanket or stuffed animal, which can provide an important source of comfort when stressed. Toddlers may also develop less endearing habits, such as masturbation. The same sort of alternating effort and rest, or problem- and emotion-focused coping, occurs in toddlers as well. Note, however, that the emotionfocused coping efforts still appear to be primarily behavioral rather than cognitive, but nonetheless parallel cognitive development.

Coping among Preschoolers Preschoolers are much more aware of their social environment than are younger children (Cummings, 1987), and they have a larger coping repertoire that allows for much more differentiated response to the environment. They are better able to balance the need for autonomy with the need for cooperation (Murphy & Moriarty, 1976), and they recognize that different coping strategies “work” better with some people or situations than others. Wheedling may work best as a strategy with Daddy, naked aggression can be directed against siblings and friends, while crying and fussing may work best with Mom. Indeed, Band and Weisz (1988) claim to be able to differentiate between emotion-focused crying and problem-focused crying. According to Compas, Worsham, and Ey (1992), the ability to generate multiple solutions to interpersonal problems emerges around ages 4–5, but more sophisticated means–ends thinking does not appear until ages 6–8, when concrete operational thinking develops. Defense mechanisms such as repression, denial, and displacement can be observed in preschoolers (Murphy & Moriarty, 1976; Wallerstein

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& Kelly, 1980). For example, Cummings (1987) found that preschoolers who appeared unresponsive to a social stressor (adults arguing in the next room in an experimental setting) were nonetheless more likely to report feeling “mad” and were subsequently more verbally aggressive toward a playmate. Wallerstein and Kelly (1980) observed that preschoolers whose parents were divorcing would often flatly deny that their father was no longer living in their house (one even insisted that he was sleeping in her bed!) but would express fears that some monster might come and eat them up. Further, Murphy and Moriarty (1976) observed that, under duress, nearly all preschoolers would “regress in the service of the ego,” that is, they would lose recently acquired skills, such as bladder control. Alternatively, they might take up earlier abandoned behaviors, such as thumb sucking or reattaching to a transitional object. Acting in a more infantile manner often gets the parents to focus more attention on them, a reassurance that preschoolers desperately need. Parents are still the primary source of social support for preschoolers. The presence of older siblings and grandparents can provide an alternative source of support, albeit one used less frequently. However, preschoolers’ limited ability to conceptualize and verbalize their problems means that friends are not generally a source of social support, as far as this construct is typically understood. Further, they are also still egocentric and often unable to see others’ perspectives. Nonetheless, parents strongly influence the development of coping strategies in young children. Kliewer, Sandler, and Wolchik (1994) suggested that parents do this in three ways. First, parents can coach their children as to the appropriate emotional responses and coping strategies. Second, they can also model these themselves. Skinner and Edge (2002) suggest that parents’ responses to children’s distress often set the stage for either an escalation or deescalation of emotional distress. Finally, they can create a home environment that is conducive to different types of coping by their own responses to children’s distress, for example, that may encourage or discourage disclosure, avoidant behaviors, and so on.

Coping in Middle Childhood One of the most consistent findings in the child coping literature is the dramatic increase in emotion-focused coping between the ages of 6 and 9 (Altschuler & Ruble, 1989; Band & Weisz, 1988; Brown, O’Keefe, Sanders, & Baker, 1986; Compas et al., 1992; Wertleib, Weigel, & Feldstein, 1987). During this age period, children become more able to verbalize and differentiate their feelings. They also become much more adept in calming themselves, although they still tend to become overwhelmed when they cannot manage their feelings.

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Wallerstein and Kelly (1980) relate the rather touching anecdote of a 6-year-old whose parents were divorcing and who could not go to sleep at night. The child’s strategy for calming himself was to pin a note at the foot of his bed, telling himself that it was all right and that he should go to sleep now. Older children are better able to use cognitive distraction and self-reassuring statements (Altschuler & Ruble, 1989). Further, children become much more differentiated in the types of emotion-focused coping they use. Spirito, Stark, Grace, and Stamoulis (1991) found that the situation greatly affects which strategies children use. With academic problems children were more likely to use cognitive restructuring and self-criticism, but the children blamed others when dealing with friends and siblings. Not surprisingly, they were also more likely to yell at siblings and peers than at parents or teachers. There are clearly parental influences on coping in middle childhood as well. Valiente, Fabes, Eisenberg, and Spinrad (2004) conducted a daily diary study of stressful events with children and their parents. Parents reported on their emotional expression. While fathers’ emotional expressivity was not associated with constructive coping by their children, the mother’s expression of negative emotions was inversely associated with the child’s constructive coping, especially those under high stress. Maternal supportiveness, however, was associated with constructive coping. Children in middle childhood are also more able to seek social support outside their immediate family (Bryant, 1985). Interestingly, it is between ages of 6 and 9 that gender differences in seeking social support emerge, with girls seeking more support than boys (Frydenberg & Lewis, 1990; Wertlieb et al., 1987), a pattern that continues into adulthood. With the development of language and symbolic reasoning in early to middle childhood comes more cognitively oriented attempts at emotionand problem-focused coping, including such strategies as cognitive reframing, self-talk to calm emotions, and the like (Compas et al., 2001). In addition, at this age beliefs concerning the controllability of the environment become more realistic, judgments of control become more differentiated, and control may be associated with more problem-focused coping. Indeed, Weisz (1986) suggested that a key developmental task in childhood involves learning to distinguish between those situations in which persistence pays off and those in which it does not. However, the few studies that have directly examined the relation between age and problem-focused strategies have variously found increases, decreases, and stability (Compas et al., 1992). Closer examination of this literature suggests a number of possible reasons for this inconsistency. Again, the situational context may play an important role. While overall there appears to be no change, problem-focused coping

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may increase in interpersonal situations but may decrease in less controllable situations such as medical or dental examinations (Compas et al., 1992), thus canceling each other out in the aggregate. Further, age effects may vary by type of problem-focused coping. One study that found a decrease in overall problem-focused coping with age also conducted a closer examination of this issue by identifying four different subtypes (Band & Weisz, 1988). Only one subtype decreased with age: a strategy called “problem-focused avoidance” (e.g., hiding under the bed to avoid going to the dentist). As children gain in coping resources and are better able to discriminate between controllable and uncontrollable problems, it makes sense that this type of problemfocused strategy would decrease. While children of all ages overwhelmingly use avoidant strategies, these tend to shift from escapism or behavioral strategies to cognitive distraction (Altschuler & Ruble, 1989; Elwood, 1987), although there are undoubted individual differences in the rates at which this occurs. However, rumination may also increase in middle childhood (Broderick, 1998), especially among those with female-oriented identities (Broderick & Korteland, 2004). Rumination is problematic because it is a coping style that is associated with depression and has been blamed for the higher rates of depression among young girls that emerges around puberty. According to Nolen-Hoeksema (1991), men are socialized to use distraction in response to depressive moods, while women are socialized to be attentive to emotional reactions, which may lead them to ruminate about their problems, thus maintaining or enhancing depressive feelings. An early study by Compas, Orosan, and Grant (1993) hypothesized that the higher rate of depression is because there may be gender differences in the types of emotion-focused coping that also emerge in adolescence. However, a later study by Compas, O’Connor-Smith, and Jaser (2004) offers an alternative interpretation of the increase of depressive symptoms from childhood to adolescence—namely, the greater cognitive abilities of adolescence allow for negative interpretation of past events and a negative expectation for future events. However, temperament may also influence coping, either directly—through promoting or suppressing certain types of coping—or through moderating the effects of coping. For example, children with temperaments low in attentional control may find it more difficult to use cognitive strategies to regulate emotion, and those who are more pessimistic may not find positive reinterpretation to be very effective. Most of the studies reviewed here are cross-sectional. However, Eisenberg and her colleagues conducted a 6-year longitudinal study of coping in children from ages 4–6 to 10–12, using teacher ratings of cop-

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ing styles at four points in time (for a review, see Losoya, Eisenberg, & Fabes, 1998). In general, they found modest correlational stability of .23 to .38 for instrumental action, with correlations as high as .57 for aggressive coping. The other strategies, however, were often not significantly associated across time, indicating considerable individual variability in the developmental trajectories of coping strategies. Examination of mean-level changes in coping strategies revealed that both instrumental action and positive cognitive restructuring increased over time, while social support fluctuated, decreasing and increasing in a cubic pattern. Both venting and aggressive coping decreased over time, especially from ages 4–6 to 8–10. However, avoidant coping and “doing nothing” increased over time, suggesting that with age children become more adept at inhibiting inappropriate action. In general, the relationship between coping strategies and outcomes in children tends to parallel that of adults (Compas et al., 2001; Losoya et al., 1998). For example, problem-focused coping is usually associated with lower distress, fewer behavioral problems, and better social adjustment, while avoidant coping is associated with greater distress, except with uncontrollable stressors, and in those situations in which avoidance is used to keep problems from escalating (Tolan, Guerro, & MontainiKlovdahl, 1997). Nonetheless, the capacity for problem-focused coping increases in middle childhood. By age 6, most children can plan simple sequences, but the ability to plan complex sequences does not typically emerge until adolescence (Welsh, Pennington, & Groisser, 1991).

Coping in Adolescence On the positive side, problem-focused coping in adolescents should become more sophisticated with the onset of formal operations (Greene & Larson, 1991). Further, a decrease in egocentrism should allow for better interpersonal negotiation skills. For example, arguments among children in grammar school often consist of little other than competing assertions (“Is too!” “Is not!”) or, at best, appeals to authority (“Says who?” “My Daddy, that’s who!”). In contrast, adolescents are more capable of reasoned arguments, although the reasoning often appears rather selfserving, perhaps reflecting the return of egocentricity in adolescence (Elkind, 1985). Good problem-focused coping skills in adolescence have been associated with a measure of “optimal adjustment” based on Erikson’s first six stages (Jorgensen & Dusek, 1990). A preliminary study suggests that humor may also emerge as an important strategy for coping with stress and uncertainty at around age 12 (Führ, 2003). With boys, the humor tends to be aggressive and sexual,

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while girls tend to use humor as a way of cheering themselves up. Plancherel & Bolognini (1995) found that boys in early adolescence were more likely to use humor than were girls, but they did not differentiate between types of humor. Saper (1990) argued that the development of a sense of humor in adolescence is critical for positive mental health and that humor has the same beneficial physiological effects in adolescents as it does in adults. Parents still have a large influence on coping strategies. Wolfradt, Hempel, and Miles (2003) found that parental warmth was most associated with active coping in adolescents. A German study found that secure attachment was associated with more active coping and an integrated social network, while those with insecure attachment styles vacillated between help seeking and avoiding others (Seiffge-Krenke, 2004). Interestingly, this longitudinal study found that attachment and coping were relatively stable from adolescence to early adulthood, but also found reciprocal causality—that is, those with “dysfunctional” coping styles in adolescence were more likely to have insecure attachment styles in adulthood. In contrast, Zhang and Labouvie-Vief (2004) found marked fluctuation in attachment styles from adolescence to early adulthood. Nonetheless, fluctuations in attachment covaried with changes in coping in the expected manner: during periods of feelings of secure attachment, adolescents used more “integrative” coping, but more defensive coping with insecure attachment. Clearly, having good relations with parents helps adolescents to cope with the myriad problems that they can face. McCubbin, Needle, and Wilson (1985) found that adolescents who had good family problemsolving skills were less likely to engage in the use of alcohol, drugs, or cigarettes to cope with stress. Further, adolescents from families who can express emotions in a healthy manner and resolve conflicts demonstrate better coping and less use of avoidance and substance abuse (Perosa & Perosa, 1993). Nonetheless, adolescents may turn more to their friends and siblings for social support than to their parents (Murphy & Moriarty, 1976), especially if there is family discord (Wallerstein & Kelly, 1980). There are exceptions: Children of divorce may not turn to their siblings if there is a high level of family conflict (Grych & Fincham, 1997). Further, it is in adolescence that some types of maladaptive coping strategies are adopted—namely, using drugs, alcohol, or cigarettes to reduce distress (although, sadly, even younger children have started imitating their elders in this regard, with undoubtedly even more devastating consequences, given their neurological immaturity). There may also be developmental changes in self-soothing. In general, adolescent girls use more self-soothing strategies than boys. However,

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younger male adolescents are more likely to use physical activities such as bicycle riding to calm themselves down, while older males are more likely to use sexual activities (Horton, 2002). One strategy that may be particularly dangerous for a teenager is social withdrawal. Spirito, Overholswer, and Stark (1989) examined stress and coping processes among three groups of adolescents: suicide attempters, distressed teens, and nondistressed teens. Suicide attempters were mainly distinguished by having more problems with their parents than did the other two groups and by withdrawing more from others under stress. Distressed teens who did not attempt suicide were actually higher in wishful thinking and resignation than those who did attempt suicide. Very young children use primarily behavioral forms of emotionfocused coping: sucking thumbs, rocking themselves, hugging transitional objects, and so forth. In grammar school, this gradually shifts to verbal reassurances and then to purely cognitive strategies as children learn how to calm themselves down, cheer themselves up, and generally, learn to manage their emotions in a culturally appropriate manner. It is possible, however, that some individuals never really master these internal techniques but continue to rely more on behavioral emotion-focused strategies. Perhaps they have “difficult” or “sensitive” temperaments that are more difficult to regulate, or it may be that their early environment was too chaotic or stressful to permit acquisition of these skills, perhaps due to parental incompetence. Once they reach adolescence and have more access to licit and illicit substances, they may turn to these external ways of modifying internal states. When used to excess, however, alcohol, nicotine, and various other pharmaceutical agents may actually intensify negative affect in the long run, thus creating more problems than they solve. If true, then this suggests that a more effective drug abuse prevention program would concentrate on improving cognitive emotion-focused coping strategies in preteens and adolescents in order to provide more adaptive alternatives. However, coping interventions in adolescents may be particularly difficult and sometimes may have opposite effects from those intended (Frydenberg et al., 2004); so, much more work is needed in this area.

Children and Extreme Stress A large part of the children’s literature has been devoted to children’s coping under extremely stressful circumstances. At least two areas have generated enough studies to merit reviewing: children of divorce and children coping with illness and medical procedures.

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Children of Divorce One of the most dramatic shifts in American culture during the past 50 years has been the increase in divorce rates (Wolfinger, 2005). Divorce rates have risen over the past century, but nearly doubled from the mid1960s to 1980. Since then they have more or less leveled off, at the annual rate of about 20 per 1,000 marriages; one out of two new marriages will end in divorce. Currently, half of all children can expect to experience a divorce. Given that second marriages have higher divorce rates, many children can expect to experience at least two divorces, and some more than that. However, as divorce has become rather normal, its negative effects have dramatically declined. Early studies suggested problematic outcomes for children. There is highly consistent evidence that children of divorce have lower rates of well-being in adulthood. They have higher rates of drug abuse, have less education, lower SES status, higher rates of divorce, and even enhanced risk of mortality (for reviews, see Amato, 2001; Wolfinger, 2005). Clearly, this is a stochastic process—not all children of divorce end up realizing these potential risks, and the vast majority of children of divorce function quite well (Hetherington & Kelly, 2002). The question is: What are the factors that predict poor outcomes in children of divorce? Wolfinger (2005) identified six possible explanations for why children of divorce often have a harder time than children from intact families. These include father absence, early marriage, parental conflict, economic difficulties, residential downward mobility, and predivorce difficulties. However, he argues that these sociodemographic factors alone cannot account for the poorer adult functioning of children of divorce, and further argues that psychological factors must also be important. While some have focused on poor interpersonal skills (e.g., d’Amato, 1996), it is likely that coping strategies may also play a role in adaptation to divorce. While meta-analyses show some greater problems for children of divorce, the effects tend to be small, with highest effect sizes for delinquency (Amato, 2001; Amato & Keith, 1991). In general, girls have more favorable outcome than boys, and Hetherington and Kelly (2002) suggest that the added responsibility given to girls in divorced families may promote competence. In these meta-analyses, there is no clear evidence for age effects. Interestingly, Wolfinger (2005) argues that the impact of divorce on psychological functioning in children has weakened over the past 30 years. In part this may be due to the lessening stigma of divorce, but we have also become much better at coping with divorce, in

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part because of the early studies documenting the unfortunate outcomes of poor coping by divorcing parents and by children. Judith Wallerstein and her colleagues (Wallerstein & Blakeslee, 1989; Wallerstein & Kelly, 1980) and Mavis Hetherington and her colleagues (Hetherington & Kelly, 2002) have conducted the earliest longitudinal studies of children of divorce. For the past two decades, Wallerstein and her colleagues have followed over 100 children, initially ranging in age from toddlers to adolescents. These early studies leave no doubt that for children divorce is highly stressful. Children become emotionally distraught, often showing great anger at the parent whom they perceive (rightly or wrongly) to have caused the divorce, and their school work and peer relationships may suffer, at least temporarily. Further, the effects of divorce on adaptation appear to vary by age (as well as gender and temperament) in her study. Very young children may regress, throw wild tantrums, blame themselves for “causing” the divorce, and become very fearful about where they will live and whether they will have enough to eat. Adolescents may take advantage of their relatively independent status and withdraw from the family, spending more time with friends. Those in middle childhood are more likely to “take sides” and become used as allies in parental battles, much to the detriment of their mental health (although remember that meta-analyses show at best equivocal support for age differences in the effects of divorce). One particularly valuable aspect of Wallerstein’s study is the longterm follow-up. While some children appear to emerge relatively unscathed, other children appear to experience long-term adverse effects. According to Wallerstein, a key variable affecting children’s outcomes following divorce is sufficient contact with both parents. If the parents and children managed to work out some sort of reasonable modus operandi and the children enjoyed the support of both parents and were sheltered from their strife, the long-term effects of divorce can be minimal. However, all too often the noncustodial parent (usually the father) had only intermittent contact with his children or sometimes disappeared completely. In this instance, the children can suffer greatly, unless, of course, the father was highly abusive or mentally ill, in which case cessation of contact was preferable. In Wallerstein’s study the extent to which the children clutched at any vague glimmer of a demonstration of love or caring from their mostly absent fathers was very poignant. While widely cited in the popular press (and state legislatures), there are many limitations to Wallerstein’s study. The setting was a clinic, and at least some of the families were referred by the courts as being particularly troubled. Thus, the sample may have been experiencing more problems than the norm. Further, the lack of a comparison group renders generalization problematic. Although some of these children clearly have

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poor outcomes, one cannot tell from this study whether their proportion is significantly greater than would be expected among children coming from intact families. In their longitudinal research, Hetherington and Kelly (2002) also reported that boys in divorced families and children in remarried families showed more problems in adjustment than did children from nondivorced families. However, they stressed that most children of divorce are reasonably well adjusted. While the child’s temperament, quality of family relations, and extrafamilial factors contributed to individual differences in adaptation to divorce, the biggest factor appeared to be parental competence. Nonetheless, several studies with control groups have called into question to what extent children from divorced families are more troubled than those from intact ones (Enos & Handal, 1986; Kurdek & Sinclair, 1988). For example, Compas and Williams (1990) examined stress, coping, and psychological adjustment in single- and two-parent families for both the mothers and their children. Not surprisingly, single mothers reported lower incomes and more stress than married mothers. They were also more anxious and depressed, which was partially due to their lower incomes. Interestingly, single mothers also used more problem-solving coping and positive reappraisal, supporting the “growth spurt” Wallerstein and Blakeslee (1989) reported among some of their divorced mothers. However, no significant differences emerged between the children from these two types of families in stress levels, problem behavior (using both standardized self-ratings and parental reports), or coping strategies. Compas and Williams’s (1990) further examined the relationship between parental distress and child distress separately for the two types of families. In two-parent families, a mother’s psychological symptoms were clearly correlated with her child’s hassles and behavior problems. However, the children in the single-parent families seemed unaffected by their mother’s psychological distress. The only significant correlation was between a mother’s hassles and her assessment of her child’s behavior problems, and obviously the behavior problems may be a source of the mother’s hassles rather than being caused by them. It would seem that the single mothers in this study went to great pains to protect their children from their own psychological distress. Thus, there appear to be inconsistencies in the literature concerning the degree of long-term adverse effects of parental divorce among children. There have been enough studies on the effect of divorce on children to conduct meta-analyses. These studies show that, while children from divorced families are more likely to show greater maladjustment, the difference is quite small, with a mean effect size of only –.23 (Amato, 2001; Amato & Keith, 1991). The effect sizes for academic achievement, social

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adjustment, self-concept, and mental health problems are often smaller. Nonetheless, these children are at some risk for developing mental health problems, especially boys, and parental divorce may also affect later dating behavior and marital stability. Marriages involving one adult child of divorce have a 29% higher rate of divorce; those in which both spouses are children of divorce have nearly double the rate of divorce (Wolfinger, 2005). Perhaps Rutter’s (1981) admonition on children and stress is instructive here. In his longitudinal studies of children’s reaction to stress, Rutter found that most children were fairly resilient and could readily rebound from experiencing a major adverse life event. However, with multiple adverse events, or when a life event was coupled with other adverse circumstances such as poverty, poorer long-term outcomes were more likely (see also Hetherington, 1984; Werner & Smith, 1982). As Grych and Fincham (1997) point out, divorce is not distributed randomly throughout the population. Younger parents, especially those with a family history of divorce, with more than two children, and with less education, are more likely to divorce—and more likely to be at risk for experiencing additional adverse live events, which may increase their vulnerability (Hetherington, Cox, & Cox, 1985). Sandler and his colleagues have conducted a series of studies showing that the coping strategies used by children have important effects on the outcomes of parental divorce. Sandler, Tein, and West (1994) found that active coping, as well as distraction, predicted lower levels of depressive symptoms postdivorce, although avoidance, wishful thinking, and seeking social support were related to poorer adjustment. Mazur, Wolchik, and Sandler (1992) found that children who used negative coping strategies (e.g., catastrophizing, personalizing, and overgeneralizing) were more anxious and had more behavior problems, while “positive illusions” were associated with less aggression. The stress of divorce may also lead to rumination. However, Weyer and Sandler (1998) found that coping efficacy led to a decrease in rumination in children coping with divorce. In other words, those who thought they were coping successfully were less likely to continue rumination in response to divorce. These studies suggest that interventions to support children’s coping may help the long-term outcomes of parental divorce.

Pediatric Coping Studies The vast majority of children in the United States undergo various medical procedures, from immunizations and medical tests as part of a well-child examination to highly invasive medical procedures for life-threatening

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illnesses (Peterson, Oliver, & Saldana, 1997). Nearly 20% of children have a chronic illness, with the most common being asthma. About 5% of children have multiple chronic conditions (Kliewer, 1997). Certainly children find medical procedures very threatening, since they have limited ability to understand either the purpose or the consequences of the procedures. As Peterson et al. (1993) remarked, a common fear among children who undergo venipuncture is that all of their blood may leak out! Children with leukemia, heart disease, or other serious chronic illnesses are of special interest. They are often subjected to medical procedures that are especially terrifying. Steward (1993) has videotaped dozens of children who were undergoing stressful medical examinations. One particularly poignant example involved a 5-year-old girl who was screaming in terror as the nurses held her down for a spinal tap. She made it very clear that she was convinced that they were going to kill her. Obviously, understanding the ways in which children cope with such procedures can help medical staff facilitate the most adaptive coping. Further, many children need to be active collaborators in the management of chronic illnesses such as asthma and diabetes. Thus, we need to understand and facilitate the coping strategies in such children. Many of the early pediatric coping studies focus on simple approach– avoidance coping strategies. In her review of eight studies that used various means of identifying approach–avoidance coping, Peterson (1989) found that most studies demonstrate positive consequences of approach coping in children, regardless of how this coping is assessed. Further, distress was reduced for children by preparing them for medical procedures with information via films or by role playing with dolls. However, a minority of children prefer exclusively avoidant coping strategies, which unfortunately has been sufficient justification for hospital administrators to discontinue such efforts. Other approaches to pediatric coping take a more ecological point of view. For example, Kazak (1989) argued that a social ecological perspective must be taken when studying stress and coping among chronically ill children. In this model, the family is viewed as a relatively homeostatic system, and a change in behavior of one family member elicits homeostatic responses from the others. Thus, behaviors that might normally be viewed as “maladaptive” may actually be very adaptive under these extremely demanding conditions. For example, rigidity is seen as a negative trait but may be adaptive when rigid adherence to a medical regime is absolutely necessary for survival (Kazak, Reber, & Snitzer, 1988). Further, the social context may modify the relation between a particular coping strategy and outcomes. For example, Lumley, Abeles, Melamed, Pistone, and Johnson (1990) examined the interaction be-

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tween a mother’s coping behaviors and her child’s temperament during a stressful medical procedure. Regardless of whether approach–avoidance coping was used, it was the asynchrony of the coping behaviors in the parent–child dyad that was related to distress. Thus, when both members of the dyad used either avoidant or approach coping, the child exhibited less distress. However, approach coping in children was related to greater distress if the parent used avoidant coping, and vice versa. Two rather surprising observations can be made about the pediatric coping literature. The first is how well children and their families appear to cope with chronic illness. Differences in coping behaviors among children with cancer and those without are relatively few (Bull & Drotar, 1991), and the few that exist appear to be due more to the severity of the problem than to the illness per se (Ritchie, Caty, & Ellerton, 1988). Indeed, Wells and Schwebel (1987) found no differences in psychological disturbance or family dysfunction between chronically ill and normal children. However, children whose illnesses involve cognitive or sensory impairment have more adjustment problems (Lavigne & Faier-Routman, 1992). Coping does influence how children adapt to chronic illness. In general, children who use problem-focused coping have better outcomes than those who use emotion-focused coping (Band, 1990; Delamater, 1992). In part, the use of problem-focused coping strategies reflects family characteristics such as cohesion, flexibility, expressiveness, and affection. However, how children cope and its effectiveness may vary as a function of age. Younger children in particular are more likely to have very frightening misconceptions, which may make them more anxious and render coping less effective (Kliewer, 1997; Peterson et al., 1997). The second surprising thing about the pediatric literature is that some children with chronic illness may show positive benefits from stress. More recent studies have found positive outcomes in chronically and even seriously ill children, such as being more responsible (Mellin, Neumark-Sztainer, & Patterson, 2004). This will be addressed more in the next chapter.

Summary of Children and Coping The past decade has seen many advances in the study of children’s coping, and a number of interesting observations (or perhaps hypotheses) can be drawn. From a very young age, children attempt to modify their internal and external environments. Obviously, in infancy, the tools with which to do this are very few and fairly primitive and rely primarily on reflexes. However, as children develop, their coping repertoire increases and may shift from primarily behavioral actions to more cognitive ones.

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Developmental changes in emotion regulation have emerged fairly clearly in the literature; these changes can perhaps best be described as a shift from simple self-calming behaviors, such as thumb sucking and rocking, to verbal reassurances and more cognitive control over both the internal and external manifestations of emotion. Developmental shifts in the utilization of social support are also obvious; infants and toddlers depend primarily on their parents for support, which later gradually shifts more to peers in middle childhood and adolescence. Unfortunately, developmental changes in problem-focused coping have not emerged as clearly from the literature. In examining this issue, it is a little surprising that stress and coping researchers have not drawn more on the cognitive development literature (but see Band, 1990; Greene & Larson, 1991). Certainly, both adequate appraisal processes and problem-focused coping must of necessity rest upon cognitive skills for comprehending the physical and social environment, as well as problemsolving skills and the ability for abstract reasoning. It is also surprising that stress and coping researchers have not drawn more upon Kohlberg’s (1984) moral reasoning paradigm, which would seem to be highly applicable in coping with stress in everyday life. It may be that our conceptualization of problem-focused coping is still too simplistic to permit examination of developmental issues. Nonetheless, it is true that very simple means must be used to examine coping in children, but both child and adult coping studies could benefit from a closer examination of the problem-solving literature. A recurring theme is the resiliency of children, which will be addressed in greater depth in Chapter 15. Given the proper support, children can bounce back from even extremely stressful situations, such as divorce or a chronic illness. Kliewer’s (1997) theoretical account of how parents influence the development of coping strategies is a very useful model, but requires more empirical testing. Adolescence may be a particularly crucial time, since adolescents have access to external means of emotion-focused coping, such as alcohol and drugs, which may prove harmful if used in excess. Finally, in the first edition of this book, I ended this section with a plea for intervention studies to determine ways to promote adaptive coping and coping skills training in children. The past decade has witnessed a number of very useful interventions for children, which range from specific ways of coping with particular types of problems to very broad programs to teach children general emotion regulation skills and competence (for reviews, see Flay & Collins, 2005; Greenberg et al., 1997; Wolchik & Sandler, 1997). However, much work still needs to be done for interventions for adolescents, which often have paradoxical effects (Frydenberg et al., 2004). An interesting approach that combines devel-

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opment and contextual approaches is to do interventions with adults in hopes that they will influence their children’s outcomes. For example, Even Start programs involve simultaneous interventions with parents and children at risk (Duch, 2005). Clearly more work is needed to determine the long-term effects of such interventions.

DEVELOPMENTAL CHANGES IN STRESS AND COPING IN ADULTHOOD Ten years ago, relatively few studies had been conducted that examined coping and aging. At that time, those handful of studies were basically of two types, those that examined defensive mechanisms and those that examined coping strategies. However, the past decade has witnessed an impressive increase in the scope of studies of the development of coping and adaptive strategies in adulthood, including emotion regulation in adulthood (Carstensen, Mikels, & Mather, 2006), changes in goaloriented coping strategies (Brandstädter & Rothermund, 2003), and selective optimization with compensation (Freund & Baltes, 2002). Further, researchers have begun to study the development of coping strategies not just in late life but in midlife and young adulthood as well. The earlier developmental theories of coping, however, often took a lifespan perspective, and we will begin with a reexamination of these before considering coping at different life stages.

Lifespan Perspectives Gutmann (1974) presented the first study of how adaptive strategies change in adulthood. Using TAT (Thematic Apperception Test) cards, he observed a shift in mastery styles that appears to occur across the lifespan. In young adults, responses to TAT cards reflected active mastery— that is, they were more likely to describe active patterns that were directed toward confronting and resolving problems. In contrast, the themes emerging from the stories told in response to TAT stimuli by middle-aged adults reflected what Gutmann termed “passive” mastery techniques—that is, these adults tended to tell stories involving the acceptance of problems and resignation to them. In contrast, the stories of older adults reflected what Gutmann termed “magical mastery”—that is, the stories seemed to resolve themselves, or they would focus on what Gutmann thought of as irrelevant aspects of the picture. Gutmann attempted to show that this decremental developmental shift occurred cross-culturally when he compared various Israeli ethnic groupings with patterns seen in the United States. However, there are a number of problems with this study. Re-

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sponses on TATs do not necessarily reflect the actual use of coping strategies in everyday problems. Further, alternative explanations for the phenomenon that Gutmann observed are possible, including age differences in education and socialization to Western norms. To the extent that younger members of other cultures are more exposed to Western culture and education patterns, it is to be expected that a more active stance might be seen. Surprisingly, there have been no published attempts of which I am aware to replicate this pattern. In part, this may be because the use of projective techniques has fallen into disfavor in contemporary psychology. However, as a graduate student, I attempted to replicate Gutmann’s study by applying his coding scheme to the TATs gathered as part of the Transitions Study (Lowenthal, Thurnher, & Chiriboga, 1975), at that time a 10-year longitudinal study of adolescents, young adults, empty nesters, and preretirees. While the sample size was very small, and insufficient for publication, the pattern of results that I found was interesting. When I coded for mastery content, I was unable to replicate Gutmann’s observations. However, when I coded for the amount of energy that the respondents put into their stories, I was able to find age-related patterns. Thus, although there is little evidence for a clear decrement in defensive styles with age, Gutmann’s schema is useful because it can lead to an examination of how acceptance of problems changes with age and how coping efforts might change—observations to which we will return later. In contrast, Vaillant (1977) suggested that there is an incremental developmental process occurring across the lifespan, characterized by a shift from neurotic or immature defensive styles in early adulthood to more mature defensive styles among the middle-aged (see Chapter 8). Immature adaptive mechanisms are characterized by fantasy, projection, hypochondriasis, passive–aggressive behavior, and acting out, while neurotic mechanisms are characterized by intellectualization, repression, reaction formation, and displacement. Mature mechanisms, on the other hand, include sublimation, altruism, anticipation, and humor. Using longitudinal open-ended data from a sample of high-functioning Harvard men, Vaillant found that, as men age, most (but not all) use more mature defensive mechanisms. More importantly, the use of mature mechanisms was associated with greater social competence, as indexed by length of marriage, upward mobility, number of children, and so forth. A standard criticism of this study is that it was done on male Ivy League college alumni, and the degree of generalizability to the larger population is unknown. Further, the study relied exclusively on ratings of defense mechanisms from open-ended material. Thus, Vaillant, Bond, and Vaillant (1986) sought to replicate this study by using a longitudinal sample that initially consisted of older children who were at high risk,

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having been labeled as juvenile delinquents (or predelinquents). Although ratings were used in this study, a more standardized index of defense mechanisms (Bond, Gardner, & Sigel, 1983) was also used. The same pattern of relations between mature defense mechanisms and social competence was observed, but unfortunately no relations with age were presented. While Vaillant (1993) also applied his rating scheme for defenses to a sample of Terman study women and the severely disadvantaged controls of the juvenile delinquent study, no developmental trends were presented, although, using a variety of indicators, he did show that those who achieved mature defenses tended to be more adjusted. An early study by Costa, Zonderman, and McCrae (1991) provided a more systematic study of cross-sectional correlations between age and three different defense mechanism inventories, using relatively equal samples of both men and women. These inventories were administered to varying numbers of respondents over an 8-year period, rendering interpretation difficult. Further, only correlations with age were presented, so it is difficult to draw any definitive conclusions from this study, given the well-known confound between age, period, and cohort effects (see Levenson, Aldwin, & Spiro, 1998). However, it would seem that the more problematic mechanisms, such as projection and “maladaptive action pattern,” were negatively correlated with age, whereas repression– denial mechanisms were positively correlated. Whitty (2003) did find that younger adults were more likely to use immature defense mechanisms, while middle-aged and older adults were more likely to use mature defense mechanisms. Further, the use of mature defense mechanisms was associated with higher levels of purpose in life. It makes a certain amount of intuitive sense that, with age, people become more adept at dealing with life’s problems. These intrinsic developmental processes may be better understood in terms of experience. As people age, they are exposed to a greater variety of problems, and hopefully through this process have learned which types of coping strategies are generally ineffective and which types can achieve their goals in various situations. Some individuals may develop self-limiting lifestyles through which they manage to avoid many problems by severely restricting their range of activities, or they may cling to ineffective means of coping with problems (Lowenthal et al., 1975). But, in general, through experience, people may increase their coping repertoires and become more able to successfully cope with difficulties. Further, a certain amount of repression or denial may be useful at older ages. Certainly it is a truism that 80% of the elderly rate their health as better than average, and some problems may be best ignored rather than confronted. As noted in Chapter 8, Cramer (2000) severely criticized self-report inventories for defense mechanisms. As she correctly pointed out, de-

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fense mechanisms are by definition unconscious, so it is unlikely that individuals can report on what defense mechanisms they use. Thus, more recent theories rely upon changes in goal structure. For example, Freund and Baltes (2002) have been developing a theory of adaptation that relies upon selection, optimization, and compensation. That is, with age, individuals must become increasingly selective in choosing where to address their efforts. Some problems will become ignored; others will be focused on. For the latter, individuals will select strategies that optimize the goals and problems they have chosen to focus on and compensate for any deficits they may have in the performance of strategies to obtain their goals. Similarly, Brandstädter (1999) argues that there is a change from assimilative to accommodative coping in adulthood. That is, in early adulthood, individuals face problems for which problem-focused strategies are appropriate. However, in later life, the problems often faced are those that are uncontrollable, such as the death of a spouse. Thus, accommodative or emotion-focused coping strategies are more appropriate. For example, Rothermund and Brandstädter (2003) found that compensatory actions to cope with physical deficits were common up until the age of 70 or so, at which time older individuals switched to accommodative strategies—presumably because their health had deteriorated past the point where compensatory strategies were more effective than accommodative ones. Similarly, Carstenson et al. (2006) have also proposed a lifespan perspective on adaptive strategies that is motivation-based. However, they have argued that with age comes an increasing emphasis on deriving meaning from one’s experiences and fewer attempts to expand one’s horizons. Young adults are more interested in expanding their social networks, increasing their knowledge base and coping repertoires, and in general exploring new situations and experiences. In the second half of life, adults are more interested in selecting environments that promote emotion regulation and in spending their time in meaningful occupations and with close friends and loved ones. Carstenson et al. (2006) hypothesized that older adults’ coping will be more focused on the regulation of both emotions and responses. In many ways, lifespan theories focus on the decrease in psychological and physical energy with age. Both Baltes (1987) and Hobfoll (2001) have proposed an increase in energy conservation in later life. That is, normal healthy adolescents and young adults have an abundance of energy, and they can afford to expend large amounts of energy on how they cope with stress. For example, college students routinely “pull allnighters” to study for examinations—and then sleep for 18 hours straight during break to compensate. Older adults find it more difficulty

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to compensate for such extreme energy expenditures, and thus learn to be more judicious in their coping efforts—a point to which we will return later. In some ways, these theories echo Gutmann’s (1974) initial observation—that there is a change in adaptive strategies with age. However, rather than simple active–passive dichotomies, newer studies focus on more subtle changes. While Schulz and Heckhausen (1998) have suggested that in early life individuals engage in primary control (problem-focused coping) and resort to secondary control (emotionfocused coping) in later life when they can no longer exert environmental control, others argue that with age comes increasing emotional complexity and subtlety (Labouvie-Vief, 1990). Others have challenged this view, arguing that control is a multidimensional construct that may change in more subtle ways (Skaff, 2007). Further, not all cultures argue that primary control is preferable—in many cultures, emotion regulation is seen as the key to effective action. Skinner (1995) suggests that with age individuals become more philosophical about what sorts of things they can—or want to—control. Contrasting two popular songs may help clarify this distinction. During the 1960s when the baby boomers were young, Marvin Gaye sang “I’m going to make you love me—yes, I will, yes I will!” Some 20 years later, an older (and wiser) Bonnie Raitt crooned wistfully “I can’t make you love me—if you won’t. You can’t make a heart feel something it won’t.” Skinner (1995) argues that realistic appraisal of what is and is not controllable permits more effective action, not less. Thus, a combination of these theories suggest that, with age, individuals may become less interested in direct action and more interested in meaning, more selective in the types of problems that they deal with, and more judicious in the expenditure of energy to obtain their goals. This generalization ignores, of course, the fact that development in adulthood is highly individual, and it is unlikely that one hypothesized trajectory describes all individuals. Nonetheless, empirical studies focusing on stress, coping, and regulation strategies at different stages of the lifespan can be extremely interesting.

Stress and Coping in Young Adulthood In many ways, young adulthood is a stressful time. Younger adults typically report higher levels of both stressful life events and hassles than do middle-aged or older adults (for reviews, see Almeida & Horn, 2004; Aldwin & Levenson, 2001). In part, this reflects the composition of stressful life event scales, which often include events more common in

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younger adulthood such as starting a job, getting married or divorced, having a new baby, getting fired, and so on. However, younger adults also report more hassles, in part due to the acquisition of new roles (such as work, marriage, parenthood, and the like). The evidence concerning coping strategies is less clear. Despite the thousands of studies done on stress and coping in college students, relatively few studies have examined age-related changes in coping in young adulthood. Shiraishi and Aldwin (2004) hypothesized that there should be a change in coping strategies, given the well-documented increase in mastery that occurs in early adulthood (McCrae et al., 1999; Parker & Aldwin, 1994). Using data over a 5-year period, they showed that there was a decrease in negative coping strategies, such as lying or trying to make others feel guilty, and expressing hostility. However, they did not show a change in instrumental action, nor any changes in coping efficacy. However, other studies suggest that there is an increase in emotion regulation or emotional maturity that occurs in early adulthood (Aldwin & Levenson, 2005). For example, Roberts, Caspi, and Moffit (2001) found an increase in emotional stability and mastery from late adolescence to the early 20s. Presumably, the development of emotional stability decreases the impulsivity that so often characterizes adolescence. Arnett (2001) found that the ability to accept responsibility for one’s own actions was one of the major hallmarks of development in the transition to adulthood. His position echoes Vaillant’s—emotionally immature individuals are more likely to blame others for their problems, such as when students blame a professor’s animus for their poor grades—but, with increasing age, young adults become more mature. Young adults also develop the ability to self-generate goals and goal-directed behaviors (Arnett, 2001). Brandstädter (1999) also recognized the ability to selfgenerate goals as an important ingredient in his theory of self-development. Aldwin and Levenson (2005) identified two more characteristics of emotional maturity—the ability to accept criticism but also the ability to work in a group. In other words, the development of emotional maturity means the ability to regulate internal and external expression of emotion and to develop sufficient judgment to regulate action as well as to judge the motivation of others. How these rather abstract concepts translate into coping strategies, however, is more difficult to determine. But it is likely that emotionally mature individuals may judge situations to be less stressful, may be better able to perceive and utilize resources more effectively, and thus may have better outcomes from their coping strategies.

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Stress and Coping at Midlife As Siegler (1997) pointed out, relatively little work has been done on stress and coping processes at midlife. Aldwin and Levenson (2001) reviewed what little literature exists. Although the so-called midlife crisis is probably overrated (Whitbourne, 1986), as is the empty-nest syndrome and “menopausal depression,” a few stressful life events are normative in late life. First, parental bereavement is nearly a hallmark of midlife. For example, Martin, Matthews, and Rosenthal (1993) reported that 85% of people in their early 40s have at least one living parent but 80% of individuals in their 60s have no remaining parent. Being widowed is fairly common in midlife, especially for women; nearly half of all widows are in their 60s or younger (Troll, 1973). Further, there is some evidence to suggest that people who are widowed in midlife have higher rates of mortality than those who are widowed in later life, even controlling for lifestyle variables such as health behavior habits (Johnson, Backlund, Sorlie, & Loveless, 2000). Thus, in midlife one begins to face losses that may lead to the reexamination of one’s life and goals. It would also be reasonable to suspect that midlife would be a time of heightened hassles. For example, individuals in midlife often have positions of responsibility at work, which presumably would lead to higher levels of work stress. If they have children, it is likely that they are coping with adolescents—a widely recognized stressor. However, individuals in midlife report fewer hassles than younger adults (Chiriboga, 1997), although Almeida and Horne (2004) found a differential pattern of increases and decreases, depending upon the type of stress. Aldwin, Shiraishi, and Levenson (2002) examined whether stress has different effects in young adulthood versus midlife . They found that chronic stress resulted in increases in acute symptoms in early adulthood, but chronic illnesses in midlife. Thus, individuals who are susceptible to chronic illnesses may be more likely to begin to develop them in midlife if they face chronic stressors. However, in many ways individuals in midlife are at the height of their coping abilities (Denney, 1989). They use more problem-focused coping than do older adults (Aldwin, Sutton, Chiara, & Spiro, 1996), and Baltes and Staudinger (2000) found that individuals in midlife were highest in practical knowledge. Kelly (2006) found that middle-aged adults reported higher levels of proactive coping, suggesting that in midlife individuals are more adept at arranging their lives to minimize the occurrence of stressors. This hypothesized heightened ability to cope in midlife may be one reason why middle-aged adults report fewer hassles than do younger adults.

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Stress and Coping in Late Life Physiologically, older adults are more vulnerable to physical stressors such as heat stress, as the thousands of deaths during Europe’s heat wave in 2003 revealed so sadly. This is because neither their cardiovascular systems nor their immune functions respond as well to challenges as in younger adults (for a review, see Aldwin & Gilmer, 2004). Not surprisingly, older adults are more likely to face health problems—especially chronic illnesses—than are younger adults. A corollary is that they are also more likely to face bereavement—for their spouses, friends, and sometimes even their adult children. Overall, though, they tend to report both fewer life events and fewer hassles (Chiriboga, 1997). The reasons for older adults reporting fewer problems is unclear. On the face of it, they should report more problems—given that many are coping with their own health problems and we know that rates of disabilities go up with age. Further, many are coping with caregiving for parents, spouses, and other relatives such as aunts, uncles, and even siblings. It is not unusual for 80-year-olds to report that they had no problems in the past week or the past month—even though they have sensory limitations, heart disease or diabetes, and are likely caregiving for an ill spouse. Aldwin et al. (1996b) hypothesized that there may be a shift from acute stressors to chronic stressors in late life. As long as chronic stressors are being managed adequately, they may not be perceived as “problems.” Only if there is a crisis requiring some sort of extraordinary intervention such as hospitalization does a chronic illness or stressor rise to the level of being a “problem.” Alternatively, there may also be differences in the ways that problems are assessed by older adults. For example, individuals over the age of 65 regarded the attack on the Twin Towers as less stressful than younger adults (Park, Aldwin, & Snyder, under review). Why this might be the case is unclear. Boeninger, Shiraishi, and Aldwin (2003) tested three hypotheses for this general finding, including personality change, change in situations, or developmental change. In other words, older individuals may be less neurotic (see Mroczek & Kolarz, 1998), they may be coping with problems that are less stressful, or they may have developmental changes such as increased experience with prior stressors that make them perceive current problems as less stressful. Boeninger et al. found that neither personality nor situational factors mediated between age and perceived stressfulness, and concluded that the tendency for older adults to perceive problems as less stressful may reflect their greater experience. Findings are mixed as to whether older adults are more vulnerable to psychosocial stressors. Various studies have shown that, compared to

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middle-aged adults, they are less vulnerable (Johnson et al., 2000), more vulnerable (Mroczek & Almeida, 2004), or show no differences in response to psychosocial stressors (Aldwin et al., 1996b). In part, this may be because the literature is also very mixed as to whether there are developmental changes in how older individuals cope (for a review, see Aldwin, Yancura, & Boeninger, 2007). While some early studies suggested decreases in problem-focused coping with age (Folkman, Lazarus, Pimley, & Novacek, 1987), others showed that older adults use similar levels of problem-focused coping (Aldwin, 1991; Felton & Revenson, 1984; Irion & Blanchard-Fields, 1987). Interestingly, while older adults may be more likely to regard situations as not being their responsibility, they may nonetheless cope to solve or manage the problem, presumably thereby decreasing emotional distress (Aldwin, 1991). More recent studies show how effective coping strategies are maintained in later life (Aldwin et al., 1996; Hamarat et al., 2001; Whitty, 2003), especially in older adults with good health. Zautra and Wrabetz (1991) found that older adults considered themselves successful in coping with both chronic health problems and loss, and their perceived efficaciousness was associated with less distress, even in the face of health complications and setbacks. Even impaired older adults are quite capable of generating novel coping strategies in the face of new problems, and their ability to do so may be predictive of successful aging (Brennan & Cardinali, 2000). Aldwin, Sutton, Chiara, and Spiro (1996) examined this stress and coping from midlife to late life using 1,000 interviews from the Normative Aging Study (NAS) on men ranging from ages 45 to 90. The men reported on a problem that had occurred during the past week, ranging from relatively minor problems with home repair to extremely serious legal and health problems. Many NAS men mentioned spontaneously that they no longer got as upset as they did when they were younger; and, indeed, the older men reported fewer problems, appraised them as less stressful, and reported fewer negative emotions than did the middleaged men. Many were more accepting of the fact that problems can and will happen, and seemed to be better able to take things in stride. The older men were less likely to use interpersonal confrontation and escapism as strategies. While they reported fewer strategies, there were no differences in their perceived coping efficacy, again suggesting that they were more effective copers. I suspect that most (but not all) men and women learn to weed out ineffective strategies as they grow older and, ceteris paribus, avoid such strategies as escapism. Further, I also suspect that the nature of control changes, shifting more from an external focus to an internal one, similar

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to Reynolds’s (1976) construct of preferred locus of activity (see Chapter 13). As Altschuler and Ruble (1989) remarked, learning to differentiate between controllable and uncontrollable stressors is an important developmental task in childhood, and this learning process may continue in adulthood as we confront increasingly complex problems. Perhaps the acceptance that Gutmann (1974) observed in older adults is not passivity per se but the recognition that some problems resolve themselves and others are not resolvable. Being able to be more selective about which problems to actively pursue may be a very adaptive strategy, especially in a time of decreasing resources (e.g., energy). Indeed, Gutmann’s (1987) revision of his theory did recast this withdrawal into something closely resembling transcendence in late life. Thus, there may be a shift in emotion-focused coping in later life. In one of the earliest studies on coping strategies and age, McCrae (1982) found that older adults use fewer escapist and hostile strategies. Several studies have found that older adults use less escapism or avoidant coping (Aldwin, 1991; Felton & Revenson, 1987; Irion & Blanchard-Fields, 1987). These changes in adaptive strategies appear to be very important for mental health in later life. In Aldwin’s (1991) study, age was negatively correlated with depression—a result often found in community samples. However, the path model demonstrated that age was only indirectly related to depression through its effect on stress appraisal, coping, and perceived efficacy variables. In other words, the older adults reported better mental health than did the younger ones, but only because they had changed the way in which they appraised and coped with stress. Interestingly, older abusers of drugs and alcohol may not show the same age-related decreases in stress appraisals, and they are more dissatisfied with their coping efforts than elders who are not substance abusers (Folkman, Bernstein, & Lazarus, 1987). Individuals who do use avoidant coping may be more likely to abuse alcohol in later life (Moos, Schutte, Brennan, & Moos, 2004). Note that avoidance is not denial, however; older individuals may be very adept at strategies to minimize their problems. They may also rely more on anticipatory coping and management strategies to minimize both the occurrence of problems and their severity, as well as using many compensatory strategies. This is supported by anthropologists Johnson and Barrer (1993), who observed adaptive strategies used by the very old—those over 80 years of age: First, to make their lives more manageable, they organize objects in their environment to enhance their functioning on the activities of daily living. They are able to increase their mobility through the use of canes and walkers. Hand railings are often installed in bathrooms and on stairs.

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STRESS, COPING, AND DEVELOPMENT Hearing aids and amplifiers on telephones improve their hearing, and magnifying glasses permit them to read. The living surroundings also are often narrowed and simplified. Some homes have been stripped of all extraneous objects to make housekeeping easier. Other environmental changes concern rearranging furniture so that there is always something to grasp onto or to break a fall. Second, coping with limitations on their mobility outside the home is more challenging. When walking outdoors, some respondents use a grocery cart filled with bags of cement to stabilize themselves. Other individuals who are still able to walk independently exercise caution. One woman shops at a distant grocery store, because it is at the end of a bus line and seats are available on her return trip. . . . One respondent who still drives plots out the streets and plans his exact route in order to avoid getting lost, while another drives around the block rather than making a left turn at a busy intersection. Third, to enhance their control over the environment, routinization of daily activities is a common strategy. In attempts to create a predictable environment, days are scheduled so there is neither too much nor too little to do. . . . This highly structured routinization of daily activities results in the ritualization of the routine aspects of daily life, a process by which the mundane aspects of their lives take on more significance. (pp. 73–74)

Johnson and Barrer (1993) also provided clues as to why older individuals may appraise their problems as less stressful: First, respondents commonly de-emphasize their health problems by the use of positive comparisons. Namely they use their age peers as a reference point to define their own health as superior. No matter how frail and debilitated these respondents are, they point to many others who are in worse shape. . . . One woman who was unable to stand up unassisted described her health as better than others because she didn’t have “breathing or heart problems.” . . . A second type of appraisal results in the dissociation of one’s body from an illness episode or disease state. For example, one 89year-old woman had been hospitalized twice in the previous year. A bout with pneumonia was passed off, “It was nothing. Look at me, you can tell nothing happened.” Some months later she had a serious allergic reaction to seafood. “It was not my body that had anything to do with it. It was the clam chowder” . . . A third type of appraisal constricts their sense of personal control over their health. Often a sense of inevitability, fate, or luck dominate their discussions. “I’m like an old car—the parts are wearing down.” Such a fate is often viewed as natural. . . . These positive views are expressed even among those with high impairment. “What

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can I say, I’ve had bypass surgery, I now have shingles, I’m isolated and lonely, I’m losing my strength and my confidence in myself. But glory to God, I’m feeling well.” (p. 75)

These are excellent illustrations of a number of strategies, include Baltes’s (1987) “compensation with selective optimization,” Taylor’s (1983) positive comparisons for health problems, Taylor and Aspinall’s (1997) anticipatory and proactive coping, and Aldwin and Brustrom’s (1997) suggestion that chronic illnesses may be less problematic as individuals learn to use management strategies to avert acute episodes. An important strategy that older individuals use is dyadic coping. For example, older couples often use dyadic coping strategies when compensating for memory problems. In a series of studies reviewed by Dixon (1999), older adults who were allowed to consult with each other during memory tasks performed just as well as the younger adults. Anyone who has spent time with older pairs has witnessed this phenomenon—of asking the spouse what was someone’s name, or where was it that something had occurred. Indeed, it is quite common to see older couples using dyadic coping strategies to compensate for a variety of deficits. For example, Gilmer and Aldwin (2002) studied old-old and youngold couples in which one member of the dyad had recently been hospitalized. They found that joint coping strategies were often used, and it was very difficult often to determine who was the caregiver and who was the care recipient. Further, Berg, Meegan, and Deviney (1998) argue that collaborative efforts are very important not just in coping strategies but also in appraisal processes as well. Further, such collaborative strategies may be direct, in that both members of the dyad may share problem-solving strategies, or they may be indirect, as when one member of the dyad rearranges his or her schedule or actions to facilitate coping in the partner (Meegan & Berg, 2002). However, it is not only older couples who cope using collective strategies. Lawrence and Schigelone (2002) suggest that older adults living in communal situations may use more reciprocal assistance as a way of compensating for declines in individual resources. Nonetheless, the importance of stress and coping strategies in later life may be a key to good adaptation, even in the face of illness and disability. To the extent that we have learned to understand our limited role in stress, are able to detach from situations as appropriate, and decrease maladaptive strategies, we may be able to maintain good mental health in later life.

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SUMMARY Not surprisingly, developmental shifts in coping strategies are easier to document in childhood than in adulthood. In childhood, emotionfocused coping appears to shift from external, behaviorally oriented strategies to internal, cognitively based ones. Problem-focused coping becomes more differentiated and context-specific as coping repertoires increase with age. As adults, hopefully we learn how to differentiate between problems that are essentially uncontrollable, those that will probably resolve themselves, and those for which effort is fruitful. We may become less easily upset (although certainly not always), and may actually engage in less coping if we have learned which strategies “work” in a given situation. In midlife, one may be at the height of one’s coping powers. Certainly the strategies that very old adults use are aimed at conserving energy, whether through distancing, denying responsibility for the problem, or relying on others to help solve problems, either through the use of social support or through collaborative coping efforts. Clearly, though, not everyone learns to cope efficaciously. Some people rely more and more on drugs and alcohol or continue to cope in ways that are damaging either to the problem, oneself, or others in the situation. What is less well understood is that coping is not simply a homeostatic mechanism but can be intrinsically developmental, or transformational, which is the topic of the next chapter.

STRESS, COPING, Stress-Related Growth AND andDEVELOPMENT Transformational Coping

CHAPTER 15

Stress-Related Growth and Transformational Coping Sweet are the uses of adversity, which, like the toad, ugly and venomous, wears yet a precious jewel in his head. —SHAKESPEARE, As You Like It (Act I, Scene II)

My years in the military were the most painful years of my life. They were also the most useful. —NORMAN MAILER (National Public Radio, Fall 1992)

Pain and suffering can have a steeling—a hardening—effect on some children, rendering them capable of mastering life with all its obstacles. —MANFRED E. BLEULER (cited in Anthony, 1987a)

The potential for human strengths lies in not turning away and ignoring negative events, but in reconstruing them in ways that are more constructive, creative, and adaptive. —MISCHEL AND MENDOZA-DENTON (2003)

S

tress is so ubiquitous that it seems intuitively unlikely that its effects on adaptation are solely negative. Shakespeare’s writings are particularly adroit in reminding us of that (“The ill wind which blows no man to good”). Indeed, much of the clinical anecdotal literature has suggested that people may perceive benefit in undergoing extreme stress, such as cancer (Rollin, 1986; Stanton, Bower, & Low, 2006) or neardeath experiences (Wren-Lewis, 2004). People have gone so far as to say things like, “Having cancer is the best thing that has ever happened to 305

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me” (Weisman, 1979). A more precise statement was provided by a woman who had AIDS: “AIDS isn’t the best thing that happened to me. The way that I choose to have it, is the miracle. . . . The best thing that happened . . . to me is that I have made a decision to be proactive in a positive way” (quoted in Massey, Cameron, Ouellette, & Fine, 1998, p. 347). Perhaps the most astonishing example of stress-related growth was provided by the great professional bicyclist Lance Armstrong. A good professional cyclist, he was diagnosed and treated for serious metastatic cancer. After recovering from this disease, he went on to win the Tour de France, the most arduous bicycle race in the world, an unprecedented seven straight times. He credited his experience with cancer as having given him the focus and impetus he needed to perform this amazing feat. In a similar vein, surprisingly some 83% of breast cancer patients in one study reported positive outcomes from their experience with the disease (Sears, Stanton, & Danoff-Burg, 2003). However this might be, psychologists have been slow to take up study of this phenomenon, in part reflecting the difficulty of overcoming Cartesian dualism and convincing bench scientists that psychosocial stress can have negative physiological effects. For the past several decades, isolated researchers and clinicians have suggested that stress may have positive effects (e.g., Finkel, 1974; Frankl, 1963). However, only during the past 10 years or so has there been any systematic research into this topic—indeed, the past 10 years have seen a dramatic shift in attitudes toward the positive aspects of stress. For example, when I first presented a talk about this in 1992 at an international conference, the reaction from my colleagues was, to say the least, rather hostile. As an “acid test” of this phenomenon, my colleagues and I examined the positive effects of combat (Aldwin et al., 1992). To my surprise, my colleagues were very upset, even saying that my respondents must have been lying! But science can move quickly, and 4 years later at the same conference when I reported on an update to the earlier study (Aldwin, Sutton, & Lachman, 1996a), these same colleagues did not find the results surprising at all—their attitude was, “So what? Of course people can perceive benefits from stress!” Indeed, the past decade has seen many studies examining this phenomenon—enough so that there have even been meta-analyses of this phenomenon (Stanton et al., 2006) as well as reviews of the various measures of this phenomenon (Linley & Joseph, 2004). Nonetheless, we are still at the very beginning of the study of this phenomenon—so much so that we still do not yet have a common terminology. It has variously been called posttraumatic growth (PTG; Tedeschi & Calhoun, 2004), stress-related growth (SRG; Park, Cohen, & Murch,

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1996), thriving (O’Leary & Ickovics, 1995), flourishing (Ryff & Singer, 1998), perceived benefits of stress (Aldwin, Sutton, & Lachman, 1996b; Calhoun & Tedeschi, 1991), and benefit finding (Affleck & Tennen, 2002), among others (see Tedeschi & Calhoun, 2004, for a more complete list). While all of these are similar, there are subtle differences. Tedeschi and Calhoun (2004, p. 1) define SRG as “positive psychological change experienced as a result of the struggle with highly challenging life circumstances,” and they divide it into five types: stress inoculation, increases in mastery and competence, changes in perspectives and values, strengthening of social ties, and spiritual development. In general, the researchers who use the terms “thriving” or “flourishing” focus almost exclusively on self-reported positive outcomes of a variety of types, whereas those using “perceived benefits of stress” or “benefit finding”— acknowledge the subjectivity of self-attributed growth. I prefer the term “stress-related growth” for several reasons (see Aldwin & Levenson, 2004). First, not all growth is necessarily transformational. That is, individuals may gradually increase in competence, that is, mastery and coping skills, or even empathy, compassion, and wisdom. While some individuals may experience sudden transformations, fundamental insights into one’s self that result in qualitative changes, others may experience more gradual change. Second, individuals can grow not only from highly traumatic circumstances but also from regular life events and even daily stressors. Third, individuals who are helping others in crisis may experience stress-related growth vicariously, as we shall see. Fourth, even transformational change may require more ordinary, gradual development to be sustained. Finally, many studies of “posttraumatic growth” do not necessarily study trauma, but rather everyday or chronic stressors. Thus, stress-related growth encompasses posttraumatic growth but is more inclusive of different types of change and development. Where possible, I will use the SRG term but, when necessary, will adhere to the terms used by researchers in individual studies. There are still a number of unresolved issues, including whether it is possible to distinguish between “true” growth and illusion/denial. In the 1994 version of this chapter, I used the term “transformational coping,” which admittedly has not yet caught on (but see Zautra, 2003) but still emphasizes what I think is important about this phenomenon—namely, that the occurrence of the stress or trauma is less important than how one copes with it, not only in terms of negative outcomes such as PTSD (Ozer, Best, & Lipsey, 2003) but also for stress-related growth (see Bellizzi & Bank, 2006). The purpose of this chapter is to review the evidence of the stress and coping process as a transformational and developmental phenome-

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non. Indeed, it can be argued that stress may be a necessary condition in order for individuals to grow as human beings. First, I review philosophical and psychoanalytic literature supporting this viewpoint. Second, I review the growing literature on stress-related growth, both in adults and in children. Then I review the physiological literature on the positive aspects of stress on neuroendocrine and immune function as well as a new phenomenon called hormesis. Finally, I examine theoretical models that may account for these “anomalous” outcomes of stress.

ARGUMENTS FOR THE DEVELOPMENTAL IMPLICATIONS OF STRESS This section will only briefly touch upon some of the major philosophical, religious, and psychoanalytic perspectives on the developmental role of pain and suffering. This review is meant to be only a brief introduction to this topic and is presented primarily for heuristic reasons, on the assumption that most stress and coping researchers, myself included, may be relatively unfamiliar with these notions. For a more in-depth discussion, see Tedeschi and Calhoun (1995).

Philosophical Perspectives From time immemorial, philosophers have attempted to understand the reason for the existence of pain and struggle. For example, Plato argued that pleasure and pain form one dimension and that one cannot exist without the other. That is, the experience of pleasure exists only relative to the existence of pain. Tragedy played a central role in Greek thinking, with heroes pursuing their daimon, or inner sense of destiny, in the face of fate or gods (see Norton, 1974). Rather than tragedy being an outgrowth of heroes pursuing their daimon, however, it is possible that tragedy is the means through which heroes uncover their daimon. According to Norton (1974), Silenus held that people are like clay figurines that have an inner core of gold. The daimon is that golden inner figure. How that inner figure is uncovered, however, is unclear. Perhaps tragedy—or stressful episodes—provides a means by which individuals can “knock off” the outer clay covering and thereby discover (or develop) the golden inner figure. Kierkegaard (1843/1985) believed that despair was an absolutely essential precondition for development in adulthood. He posited three stages of adult development: the aesthetic, the ethical, and the stage of faith. He believed that despair was necessary in order for humans to progress through the stages of adult development. Only by facing and

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fulfilling the demands of each stage can one achieve the “despair” necessary to “leap” to the next stage. Using modern terminology, substituting the more mundane term “stress” for the more poetic term “despair,” one can conjecture that stress is a necessary prerequisite for advancing through the stages of adult development—an assumption, as will be seen, that is echoed in the writings of Erikson (1950).

Religious Perspectives From a stress and coping perspective, religious beliefs and practices can be seen as a cultural means of providing people with ways of appraising, and coping with, stress (see Chapter 13). Certainly, religious frameworks provide a meaning for the occurrence of stress, and spiritual figures such as priests and ministers spend a great deal of their time providing support for people in transition, whether by means of marriage, birth, or death. The presentation here is meant to provide only a simple guide to some religious beliefs as they might apply to stress and coping processes. Space and time limitations do not permit all of the religious belief systems to be covered, nor the differences within belief systems associated with different sects of any given religion. For example, Christian sects may vary markedly in their attitude toward pain and suffering (to say nothing of the different branches of Judaism, Buddhism, Hinduism, and Islam). In addition, with a given religious tract, there may be markedly contradictory advice that can be viewed as recognizing the necessity for a contextualist approach: different problems call for different strategies. For example, Christ’s admonishment to “turn the other cheek” is balanced by his angry eviction of the money lenders from the temple. Further, religions present idealistic goals that may or may not be followed in everyday life: Christians “turn the other cheek” probably as often as Buddhists practice detachment. Thus, one cannot make overarching statements about Christian, Buddhist, or atheistic coping styles. Nonetheless, comparison of the overarching beliefs of different religions provides interesting cross-cultural perspectives on beliefs relevant to the stress and coping process. Vedantic Indian religions are sometimes collectively (but somewhat erroneously) referred to as Hinduism. From this perspective, suffering is part of maya, or illusion. The only way to transcend suffering is to free oneself from the cycle of birth and rebirth. This cycle is necessary for people to “work off,” as it were, bad karma, or fate, resulting from wrong actions in previous lives. One’s progress on this task is indexed by the station to which one is born, whether as an animal or in a particular caste. Thus, the extent to which one suffers in life is due in part to the

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karma accrued in previous lives. From this perspective, one has little control over the occurrence of stressors. However, the extent to which one copes with these stressors in an ethical or appropriate way may affect one’s future life. The cycle is only broken once one achieves samadhi and is no longer required to undergo the cycle of birth and rebirth. The Hindu classic the Bhagavad Gita (translated by Mascaro, 1986) presents an interesting twist on this process. In this rather radical presentation, all action is predetermined. If people cannot and do not have free will—if they have no control over problems or how they cope with them—then the process through which one progresses through the cycle to avoid pain and suffering is unclear. Yet, even within the Bhagavad Gita there are calls for the necessity of making an effort to behave in a righteous manner. As mentioned in previous chapters, the ability to attribute to fate things that go wrong can markedly reduce anxiety and may be an efficacious coping strategy, especially if it does not get in the way of making appropriate coping efforts. The Buddhist framework is rather similar, but the Buddhists more clearly distinguish between pain and suffering. In this framework, pain is unavoidable, but people’s attitudes and behaviors can affect the degree to which they suffer. (This attitude is reminiscent of current distinctions in the psychological literature on pain; see Chapter 11.) The key is to learn to detach from the world, particularly from desires, which are seen as the source of suffering. If one is indifferent to worldly success, for example, one will not suffer if worldly success is not achieved. Suffering flows only from attachment to material, psychological, or social needs. Some Buddhist sects go so far as to encourage meditation on oneself as a putrefying corpse, to extinguish one’s attachment to one’s self. From this standpoint, the existence of stressors is far less important than one’s appraisal of them, and the detached stance, or the avoidance of commitments, is the only way to avoid suffering. Suffering and pain also play a central role in the Judeo-Christian perspective. In this framework, suffering stems from the original sin, the fall of Adam and Eve from paradise, and, as such, is an inherent part of the human condition. As a result of eating the forbidden fruit from the Tree of Knowledge at the urging of Satan, Adam and Eve were banished from Eden and were then subject to work stress (having to earn their bread by the sweat of their brow), illness, and labor pains, among other difficulties. The metaphysical importance of Christ’s suffering was to make possible human salvation: the chance to avoid suffering, not in this life but in the next. To the extent that individuals have sufficient humility and fortitude to endure suffering and to avoid the pleasures of sin, they may attain the unending joy of heaven. In contrast to the Buddhist view of the centrality of appraisal, how one copes with temptations and

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stressors is paramount: Rather than avoiding suffering, one should embrace it as a way of identifying with the suffering of Christ (see John Paul II, 1984). Both the Bible, in the Book of Job, and the Koran explicitly state that suffering is a means by which God tests people: “Be sure we shall test you with something of fear and hunger, some loss in goods or lives or the fruits (of your toil)” (11:155–157, translated by Ali, 1946). However, in keeping with an emphasis on a merciful God, the Koran is somewhat more explicit in its suggestion that stress is tempered with mercy: “God does not compel a soul to do what is beyond its capacity” (11:285; translated by Cleary, 1993, p. 18). In Islam, suffering is crucial to encouraging remembrance of God. For example, a hadith, or saying, of the Prophet Mohammed suggests that illness is a way of God’s drawing people closer to him—a belief that some Christians also share (see Lewis, 1962, pp. 96–97). However, others such as Kushner (1981) explicitly reject the idea that God causes suffering as a means of testing or encouraging remembrance. Kushner argued that stress is simply a part of life and God is a source of comfort and strength under duress. Some Sufi writers take a more explicitly developmental perspective. Rumi, in The Mathnawi (translated by Whinfield, 1973), remarks that evolution progressed from an inanimate stage (rocks), through plants, to animals and then people. Humans alone have the capacity to “soar higher than the angels.” Ibn Arabi, in his Bezels of Wisdom (1980) believes that stress plays an important role in this developmental process. From his perspective (an admittedly heretical one from the point of view of orthodox Islam), Adam and Eve’s eating fruit from the Tree of Knowledge, with its attendant suffering, was absolutely critical to be able to soar “higher than the angels.” Through the exercise of free will, humans can fall lower than animals (i.e., further away from God) or can soar “higher than angels” (i.e., can become closer to God than the angels, who cannot exercise free will, which is an attribute of God). Thus, seen in a long-term view, the fall of Adam and Even was not the source of original sin but, rather, was indicative of the human possibility of development through knowledge and the development of the capacity of free will. Suffering, then, is a means, not of salvation, but of the development of specific capacities. In some ways, Taoism is the most explicit of the major religions in suggesting the best way to appraise stress and develop both coping and management skills. In this system, stressful events arise from within the individual: “Good and bad thoughts are the cause of events, receiving blessings and bringing on misfortune are the effect of events” (Liu, translated by Cleary, 1988, p. 10). Like the Buddhists, the Taoists also emphasize detachment but are more explicit about the importance of

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preserving equilibrium in order to increase vitality and not disperse energy by becoming unduly worried about events. The construct of yin and yang is used to emphasize contextualist approaches to coping and the importance of maintaining flexibility when handling problems. Taoists advocate the development of virtues by associating with good people and by practicing humility, patience, perseverance, and perspicacity. Once having achieved harmony with oneself and with nature, then “your nature and destiny are up to you, not up to Heaven” (Liu, translated by Cleary, 1988, p. 14). Nearly all of these religions have practices that utilize stress in one form or another, mainly through abstinence and deprivation. Most religious traditions, for example, utilize some form of fasting as a way of increasing concentration, especially during meditation. Many traditions also utilize procedures that involve detachment from pain, including the yogic practice of walking across burning coals, the Shiite practice of selfflagellation, and the Native American Sundance ritual. Some Christian mystics also utilized pain as a way of achieving ecstatic states (Underhill, 1961) in a manner reminiscent of Solomon’s (1980) opponent process, which will be described in greater detail later (see p. 333). While it is tempting to dismiss these practices as a form of masochism, their widespread use in religious practices suggests that they have some sort of utility. Perhaps learning to tolerate voluntarily experienced pain allows one to maintain equanimity in the face of the involuntary pain that we so often face in our everyday lives. Thus, all religions have characteristic attitudes toward human pain and suffering. In all of these frameworks, pain and suffering are inescapable aspects of being human—another way of saying that stress is ubiquitous. However, in Buddhism and Hinduism, suffering is an indication that one is caught up in maya—and, therefore, suffering is to be eliminated, not by changing the environment but by altering one’s appraisal of stress and by developing detachment. In Judeo-Christian-Islamic perspectives, one could argue that coping is more central—how one deals with the inevitable “slings and arrows of outrageous fortune.” Stress, whether unsolicited or self-inflicted, is seen as an opportunity to develop the virtues of patience and fortitude or to develop more fully as a human being. Taoism seems to combine both perspectives, advocating appraisal, specific coping processes, and the development of wisdom. Further, the world’s major religions have rather similar attitudes toward life’s travails. All of them see suffering as an integral part of the human experience, and all prescribe adult development as a means of transforming suffering into something meaningful as well as mitigating it. Thus, it is not surprising that religious coping is one of the best predictors of stress-related growth, as we shall see shortly.

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Psychodynamic Perspectives Psychodynamic perspectives can be seen as supporting the developmental aspects of stress. According to Freud (1927), the ego develops through the necessity of mediating between the demands of the id, the environment, and the superego. Thus, the stress generated by unfulfilled (or unfulfillable) demands requires the development of new and more adaptive psychic structures. This theme was expanded upon by ego psychologists such as Adler (1956), who held that individuals’ achievements often stemmed from a compensation for defects. Thus, oratorical skills can develop from an initial speech defect and athletic competence from physical limitations. Clearly, this is not the only mechanism through which individuals can develop outstanding skills and achievements, but the stress associated with limitations may provide an impetus for such skills to develop. Erikson (1950) described development as consisting of eight stages through which individuals progressed by resolving developmental crises peculiar to each stage, such as ego integrity versus despair in later life. Implicit in his theory is that development occurs only through facing and resolving the problems inherent in each stage. Although the evidence for the sequencing and timing of Erikson’s adult stages is as yet slim (see Aldwin & Levenson, 1994), he has identified major developmental problems that individuals can face in adulthood. For example, Erikson (1950) claimed that the central problem for youths is intimacy versus isolation, which is resolved through either a successful marriage or through the inability to fundamentally relate to others. Yet, careful reading of the original indicates that not only intimacy or isolation issues but all of the developmental crises can arise at many different times in the life course, a point also reiterated by Gilligan (1982). Intimacy versus isolation may be especially relevant during times of major stress upon families, as when a child becomes chronically or terminally ill. Many clinicians have remarked that, under such stress, marriages can fall apart. Yet, other families report an increased closeness, a drawing together that sustains them through the ordeal (Coyne & DeLongis, 1986). Once again, stress can be seen as a catalyst that brings to the forefront important developmental issues that can be coped with more or less “successfully,” if “success” can be defined as increasing capacity to cope with future stress and to develop characteristics important to adult development, such as the capacity for intimacy. In many ways, Jung (1966) was the most explicit of the dynamic theorists in stating the importance of stress for development in adult-

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hood. For Jung, individuation consists in making conscious hitherto unconscious needs and agendas. One way this is done is through the generation of crisis situations, which force individuals to take stock of their lives, allowing the expression of needs and the development of capacities that had lain dormant. Mental illness, then, is perceived as a way in which the unconscious generates a crisis, which occurs to individuals who have very strong potential for growth and individuation. This theme was echoed by some of the ego psychologists, such as Hartman (1950), who were fascinated with the relation between schizophrenia and creativity, especially among children of schizophrenic parents (for a review, see Anthony, 1987a). More recent formulations suggest an interesting developmental aspect of loss in late life. Tornstam (1994) argued that the losses in late life result in a type of interiorization called gerotranscendence, which he described as an increasing feeling of . . . communion with the spirit of the universe; a redefinition of the perception of time, space, and objects; a redefinition of the perception of life, death, and a decrease in the fear of death; and an increasing feeling of affinity with past and coming generations. . . . [Ego transcendence involves] a decrease in the interest in superfluous social interaction; a decrease in the interest in material things; a decrease in self-centeredness; and an increase in time spent in meditation. (pp. 208– 209)

In other words, the disengagement often exhibited by adults in very late life may not reflect an alienated withdrawal from social roles but rather an increasing detachment from external definitions of the self, a state that both Tornstam (1994) and Vaillant (2002) characterize as almost “zen-like.” Levenson, Aldwin, and Cupertino (2001) have argued that loss is the developmental impetus for gerotranscendence. They reasoned that the losses faced in late life—of family, friends, social roles such as work and parenting, as well as personal attributes such as youthful good looks or athletic prowess—trigger a reexamination of the self, resulting in changing definitions of the self. Thus, the psychodynamic literature can be interpreted as indicating that struggles with either stage-related crises or individual stressors are ways in which the ego develops. Indeed, one could argue that without stressors and crises of various sorts ego development could not occur. If these theorists are correct, it should be possible to discover in the more recent scientific literature examples of positive outcomes of stressful events. The next section reviews these findings.

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STRESS AS AN IMPETUS FOR PSYCHOSOCIAL DEVELOPMENT Stress-related growth has been studied mostly in adults. However, a related phenomenon called “resilience has been studied in children, and that literature will also be reviewed here.

Positive Aspects of Stress in Adulthood Anecdotal evidence for the positive aspects of stress in adulthood is very common. I maintain a file of newspaper clippings of various people, including the rich and the famous, who attribute positive outcomes to highly negative events. I will quote from an article by Linda Ellerbee that appeared in a Sunday San Francisco Chronicle-Examiner (March 23, 1993): A year and a month ago I was diagnosed with breast cancer. What do I know now? I know that trying to figure out this last year is a lot like trying to bite a basketball. You see, there’s been so much good that has happened. I remember back in the beginning, right after I’d found out the terrible news, a friend who’s HIV positive told me that there would be positive things that would come to me because I had a life-threatening illness. I remember laughing at him. Better living through cancer? Puleeze. Today I begin to understand how right he is. . . . I am . . . happier than I’ve ever been in my life.

Ellerbee attributed her happiness not only to the fact that she had survived a bout with cancer but also to the fact that she had learned to appreciate her family and her work, had quit smoking, and had started exercising—so that she felt very healthy and energetic. She stated that “everyday life seems to me now to be a great good gift” and continued: “You think I sound like Pollyanna? You think maybe I’m making this up, trying to put a good face on a bad deal? I’d like you to meet 300 friends of mine who feel pretty much as I do [referring to a meeting of breast cancer survivors]. . . . Now, we can’t all be lying, can we?” I could quote liberally from many other biographical and literary sources. The positive effects of stress do not appear to be anomalous in the general community and have received increasing attention during the past decade. Although most research on stress in adulthood has focused on identifying negative sequelae, a growing number of studies have found evidence for positive outcomes of stressful experiences in adulthood. Some researchers have even reported a significant correlation between stress

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and positive affect (DeLongis et al., 1988; Zautra et al., 1990), while Chiriboga (1984) reported that life events were equally likely to result in positive and negative outcomes. Tedeschi and Calhoun (2004, p. 1) have defined stress-related growth as “positive psychological change experienced as a result of the struggle with highly challenging life circumstances,” elucidating five specific types: stress inoculation, increases in mastery and competence, changes in perspectives and values, strengthening of social ties, and spiritual development. This emphasis on positive aspects of stress was prefigured by Elder and Clipp (1989), who suggested that exposure to combat stress could result in either pathogenic or positive developmental effects. Drawing upon the experiences of members of the Berkeley and Oakland Growth and Guidance Studies, they identified 18 positive and negative outcomes of military experience. The positive outcomes included learning to cope with adversity, self-discipline, a broader perspective, development of lifelong friends, and valuing life more, whereas negative effects included separation from loved ones, combat anxiety, and loss of friends. The undesirable experiences generally referred to losses and negative affective states, whereas positive experiences were more likely to refer to skills or resource acquisition. Men who had been in heavy combat were most likely to list coping, self-discipline, and valuing life as positive outcomes, but they were also more likely to have emotional problems at service exit and later in life. Aldwin et al. (1994) confirmed this pattern of results, using more quantitative measures, as did Dohrenwend et al. (2004), using a sample of Vietnam veterans. However, Ursano, Wheatly, Sledge, Rahe, and Carlson (1986) cautioned that the men who identified such resources did not necessarily differ in tests of positive mental health.

The Inoculation Effect The inoculation effect has been much discussed in the clinical literature and, indeed, underlies many behavioral clinical treatments, including desensitization (Epstein, 1982; Meichenbaum, 1985). Briefly, it suggests that undergoing stressful experiences may render future similar experiences less distressing, in part through an increase in the individual’s coping repertoire. Certainly, we all remember the first time we entered a classroom, went on a first date, or drove on the freeway. Indeed, sometimes our mastery becomes so complete that we can scarcely remember why we were afraid in the first place. For example, a study by Farrace, Biselli, Urbani, Ferlini, and De Angelis (1996) showed that student pilots manifested increased levels of both cortisol and enhanced growth hormone—a typical response to stress. Their teachers, however, only evi-

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denced higher growth hormone levels, indicating that they had adapted to the stressor and now experienced primarily positive effects. My favorite cinematic example of this comes from the movie 9 to 5. There is a very funny scene in which the character portrayed by Jane Fonda timidly confronts a huge copying machine for the first time. Fonda’s character punches the confusing array of buttons nearly at random, and the copier spews forth multicolored paper all over the room, nearly burying her. The scene suddenly shifts to the next time that she is copying something, and the machine obediently churns out the correct number of copies, all neatly collated and stapled. However, the inoculation effect may not necessarily be limited to similar experiences. For example, Ruch, Chandler, and Harter (1980) found that women who had experienced a moderate amount of stress during the preceding year showed better recovery from rape than those who had experienced either many or no stressful events during the same period. Indeed, Rutter (1987) has suggested that the lack of experience with stressors may be a vulnerability factor. Aldwin, Sutton, and Lachman (1996b) asked male respondents in the Normative Aging Study whether anything earlier in their past had helped them to deal with a current problem. The overwhelming majority of the men could recount prior stressful experiences that helped them. To our surprise, however, only 20% drew upon experiences that were similar to the ones they were currently dealing with. This leads us to conclude that in some ways individuals were discussing what Antonovsky (1979, 1987) called generalized resistant resources. That is, individuals learn basic skills that can help them in many different types of situations.

Increases in Mastery and Competence Second, successfully coping with a stressful experience may increase desirable personality characteristics such as self-confidence or an internal locus of control, especially for individuals who were previously lacking in these characteristics. For example, Cook, Novaco, and Sarason (1982) investigated the effects of boot camp on recruits’ locus of control. They found a significant interaction effect between locus of control and the supportiveness of the drill sergeant. Recruits with an external locus of control who developed good relations with the drill sergeant acquired more of an internal locus of control—that is, they felt they were more able to control themselves and their environment. Similar recruits whose drill sergeants believed in strict discipline and used training procedures to unnecessarily increase stress did not show such gains. Pearlin et al. (1981) also documented increases in mastery in adults who underwent stressful experiences.

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Carver and Scheier (2003) argue that there are three basic human strengths: persistence, disengagement, and growth, all of which can be developed through coping with highly stressful circumstances. Persistence is an admirable practice that allows individuals to overcome adversities and to achieve goals despite daunting barriers. However, at some point, persistence can become perseverance, and thus disengagement— knowing “when to fold them,” as it were—is also important. For most individuals, goals are not set in stone, and individuals can and do disengage from goals that may be unobtainable and refocus on those that are more within their reach. Brandtstädter and Rothermund (2003) argue that the ability to do so is most protective of mental health, even in very difficult circumstances. Finally, individuals can grow when challenges are placed on them. Aldwin et al. (1994) examined the long-term effects of military service and combat. While many reported negative outcomes, we found that most of the men had reported positive outcomes, including an increased coping capacity and sense of mastery (see also Elder & Clipp, 1989). Having survived combat, and even accomplished difficult goals under extreme stress, gave many men a sense of their own prowess. One man recounted a battlefield promotion. The platoon was receiving heavy fire, and his immediate officers had been killed. He was put in charge and told to get his men out of there. He did so successfully, and later in life he would remember this achievement when faced with difficult tasks, telling himself that if he could lead his men to safety, he could accomplish this task too. Individuals who were able to perceive benefits from their military experience had lower levels of PTSD symptoms. This finding is supported by Casella and Motta (1990), who found that the men who did not develop PTSD after exposure to combat were characterized by an ability to derive positive meaning from their combat experiences. In a follow-up study with British veterans, Aldwin and Levenson (2005) argued that military service and combat can promote emotional maturity. We defined emotional maturity as having six characteristics: increased emotional stability; the ability to accept responsibility for one’s own actions; the ability to self-generate goals and goal-directed behavior; sufficient ego development to identify pathways to goals, to cope with barriers to those goals, and to identify alternative pathways if necessary; the ability to tolerate critical feedback; and the ability to work independently. Further, we showed that individuals with higher levels of emotional maturity also had lower levels of health problems in very late life. Elder, Gimbel, and Ivie (1991) have argued that military experience can constitute “turning points” in individuals’ lives, especially for those who had previously experienced hardships. Increases in positive capacities are not limited to individuals but,

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rather, can also be seen in collective circumstances. Scudder and Colson (1982) described the effects of forced relocation (due to the construction of a dam) on tribes in Africa. The initial effects of forced relocation were clearly deleterious. Lives were extremely disrupted, and mortality rates increased, especially among the very young and the very old. Yet, in the long run, tribes that had experienced relocation often developed more diverse economies and creative solutions to cultural problems than did tribes that were not forced to relocate. Bloom (1996) detailed a number of social transformations that occur as a result of trauma, including an increase in collective compassion. She detailed an example of the Hugenots and the Jews in France during World War II. The Hugenots, a Protestant sect, had been severely oppressed by the Catholic regime. They developed an ethos of solidarity and resistance to persecution. Thus, during World War II, when the Jews were being persecuted by the Nazis, they offered sanctuary, and in the small village of Le Cahambon some 3,000 Huguenot villagers managed to rescue 5,000 Jewish refugees, many of whom were children. Perhaps the most remarkable example of collective growth under trauma is the Tibetan monks. Severely persecuted by the Chinese, the remaining few Tibetan monks fled the country, mainly for India. I once heard an interview with the Dalai Lama, their spiritual leader, about this experience, and what benefit could possibly come out of this. The Dalai Lama calmly said that their diaspora had resulted in Tibetan Buddhism’s being spread all over the world—something that would never have happened had the Chinese not invaded Tibet and attempted to eradicate Tibetan culture.

Changes in Perspectives and Values Undergoing stressful experiences, especially extremely threatening ones, may change both an individual’s perspective on problems and his or her value hierarchy. For example, collective trauma may reduce in magnitude the effects of merely personal problems. Thus, suicide rates and admissions to mental hospitals decrease during times of war (Antonovsky, 1979; Keegan, 1984). After nearly dying, individuals often report a change in perspective, a decreased interest in material well-being and petty hassles, and an increase in focus on family and/or spirituality (Wren-Lewis, 2004). (Note that these changes can occur regardless of whether or not a respondent had a “near-death experience.”) Indeed, it is not at all unusual for cancer and heart disease patients to remark, like Linda Ellerbee in the earlier example, that they had found renewed appreciation of family and work. The men in the Normative Aging Study whom I interviewed about

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the types of resources that they drew upon when coping with problems often mentioned experiences such as combat trauma or the death of a child. After having undergone extreme stressors, everyday hassles no longer seemed important to them. One man explained that he had been shot down in the Pacific and spent the night bobbing about in the water with a fierce battle raging around him. He promised himself that if he managed somehow to survive that night, nothing was ever going to bother him again—and, he said, nothing has. Perhaps the well-documented decrease in stress ratings with age reflects a lifetime accumulation of experiences with which to make a comparison regarding the relative importance of individual stressors. Cozzolino, Staples, Meyers, and Samboceti (2004), intrigued by the reported decrease in materialistic values found after near-death experiences and in posttraumatic growth, developed an experimental manipulation involving reflecting on death. They found that experimentally induced death reflection did indeed decrease materialistic values and increase intrinsically unselfish behavior. However, simply increasing mortality’s salience did not have the same effect—and indeed generated greedier behavior among the high extrinsics. Le (2005) also found that values moderated the relationship between trauma and stress-related growth. She found that individuals who were high in conformist values were less likely to report stress-related growth, whereas those high in values reflecting openness were more likely to report growth. Thus, values may change as a result of experiencing trauma, but preexisting values may make stress-related growth more or less likely.

Strengthening of Social Ties Another well-documented positive effect of stress is a strengthening of social ties. After every natural trauma, television reporters invariably use clips of people talking about how great it was that everyone pulled together and pitched in. Indeed, Quarantelli (1985) statistically documented a decrease in psychiatric hospitalizations, drug use, liquor sales, and even crimes following a devastating tornado in one community. Obviously, this does not always occur, especially for individual stressful events. Indeed, the existence of negative social interactions for people undergoing problems such as cancer is also well documented (Rook, 1984). Nonetheless, the possibility of strengthened social ties clearly exists. Not only can social ties strengthen during trauma, but they also may promote stress-related growth. For example, Weiss (2004) found that simple measures of social support were unrelated to stress-related

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growth, but that confiding in others was. Lechner and Antoni (2004) have argued that support groups for individuals may be a powerful way of inducing SRG. Further, Bloom (1996) found that collective action, which also strengthens social ties, may be a major way for whole cultures and societies to transform after a collective trauma such as war or genocide. Various reports of vicarious stress-related growth have found that husbands of women with breast cancer also reported the phenomenon (Manne et al., 2004; Weiss, 2002). Arnold, Calhoun, Tedeschi, and Cann (2005) also discussed reports of vicarious SRG among therapists. One researcher I know exemplifies this. She was interviewing a woman who was dying of AIDS who said that she would be happy as long as she died in her husband’s arms. This led the researcher to evaluate her own relationship, and she found that she did not have this type of closeness with her own spouse. She divorced him and found a new spouse with whom she is much happier.

Spiritual Development and Wisdom Increased spirituality is commonly reported as an outcome of severe stressors and trauma (Tedeschi & Calhoun, 2004). Sometimes this takes the form of joy and buoyancy (Wren-Lewis, 2004); at other times people may feel a deeper relationship with God, or simply be more focused on meaning and less on material goods (Park, 2006). Religion and spirituality, which can deepen as a result of trauma (Ano & Vasconcelles, 2005), predict SRG (Shaw, Joseph, & Linley, 2005). Further, religion and spirituality are usually, but not always, beneficial to people coping with trauma. For example, Pargament et al. (2001) found that individuals who felt they were “abandoned” by God had decidedly worse outcomes than individuals who were able to find sources of support in religion. Indeed, Shaw et al. (2005) found that intrinsic religiousness and religious openness were more likely to be associated with SRG. However, they caution that our knowledge and definition of what spiritual development means—at least in psychology—is fairly sketchy, and much more work is needed to understand this phenomenon. Several authors have been exploring the link between SRG and wisdom. Linley (2003) identified three dimensions of wisdom. The first is the recognition and management of uncertainty; the second is the integration of affect and cognition; and the third is the recognition and acceptance of human limitations. Levenson et al. (2001), following Curnow (1999), identified four components of wisdom, including selfknowledge, detachment, integration, and self-transcendence. They ar-

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gued that loss and uncertainty force a reexamination of the self, leading to a decrease in illusions (McKee & Barber, 1999). This, in turn, can result in detaching from problematic goals and beliefs, both of which may allow for better psychological integration. These processes can promote self-transcendence, which is defined as a detachment from biological and social conditioning and a decrease in reliance upon externals for definitions of the self. For example, Beardslee (1989) reviewed a series of in-depth qualitative studies that he conducted on civil rights workers, survivors of childhood cancer, and adolescents with emotionally disturbed parents. Surprisingly, the most striking finding was an increase in self-understanding, which was defined as an internal psychological process through which an individual makes causal connections between experiences in the world at large and inner feelings. The process of self-understanding leads to an explanatory and organizing framework for the individual. This organizing framework develops over time and eventually becomes a stable part of the individual’s experience. Self-understanding requires not only the presence of thought and reflection about oneself and events, but also action congruent with such reflection. In mature self-understanding there is an emotional importance tied to the organizing framework that has evolved: the individual believes that self-knowledge is valuable, takes the process of selfunderstanding seriously, and devotes time and effort to it. (p. 54)

Other aspects of self-understanding include a realistic appraisal of both situational demands and the individual’s personal capacities for action, a willingness to change and develop new skills when necessary, and a problem-focused orientation toward the world. In addition, the individuals in Beardslee’s studies also evidenced increases in empathy, altruism, and generativity and had a strong sense of ego integrity. In short, these characteristics described by Beardslee are what lifespan developmental psychologists have described as wisdom (Baltes & Staudinger, 2000; Levenson, Jennings, Aldwin, & Shiraishi, 2005). However, not everyone develops wisdom and other aspects of stress-related growth, and studies have begun to examine the factors that predict this phenomenon.

Predictors of Stress-Related Growth A number of different studies have examined the predictors of stressrelated growth, a few of which have been mentioned in the preceding section. In general, these fall into five categories: stressor characteristics, demographics, personality, social support, and coping.

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Stressor Characteristics In general, researchers have found that stress-related growth is not unique to any particular type of stress. It has been studied in the context of illnesses such as cancer (Bower et al., 2005; Stanton et al., 2006; Bellizzi & Bank, 2006) and AIDS (Folkman, Moskowitz, & Ozer, 1996), combat (Aldwin et al., 1994; Dohrenwend et al., 2004; Elder & Clipp, 1989), rape (Frazier, Tashiro, & Berman, 2004), natural disasters (McMillen, Smith, & Fisher, 1997), loss (Bonnano, 2004), and the 9/11 terrorist attack on the World Trade Center (Ai, Cascio, Santangelo, & Evans-Campbell, 2005), to mention only a few. It is clear from these studies that, in general, the higher the stressfulness of the event or trauma, the higher the levels of stress-related growth. The primary issue is whether there is a linear or nonlinear relationship. It makes a certain amount of intuitive sense that there would be a curvilinear relation between degree of stressfulness and stress-related growth. That is, growth may be most likely to occur under conditions of moderate stress, which could promote developmental change, but that extreme stress might overwhelm individuals to such an extent that growth would be difficult. However, most studies that have examined this issue find linear relationships (Aldwin et al., 1994; Stanton et al., 2006), supporting Tedeschi and Calhoun’s (2004) assertion that it is major trauma that results in transformational growth. However, Stanton et al. (1994) caution that most studies do not include extremely stressed individuals, and the ones that do may find nonlinear relationships. For example, the one study that included individuals with highly metastatic cancer (Stage 4) found a curvilinear relationship, with people with Stage 2 cancers higher in posttraumatic growth (PTG) than either Stage 4 or Stage 1 (Lechner et al., 2003). Similarly, there is a marked increase in accidents and suicides 5 years after a war (Centers for Disease Control, 1987); perhaps the most traumatized individuals may not survive long enough to participate in these often retrospective studies.

Demographics In general, studies suggest that women and younger individuals are more likely to report stress-related growth. While studies in different ethnic and social groups are relatively rare, they confirm the existence of PTG in other groups, although there are too few to determine whether it is more or less prevalent (Tedeschi & Calhoun, 2004). Stanton et al.’s (2006) review, which was limited to cancer patients, did not find consistent support for demographic differences. While some studies did find that younger individuals were more likely to report stress-related growth,

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others did not. Further, there were both positive and negative relationships between socioeconomic status and SRG, depending upon the stage and type of illness. Stanton et al. (2006) also found very little support for gender differences—at least among those facing cancer. Tomich and Helgeson (2004) did find some interesting SES and ethnicity predictors of PTG among breast cancer patients. They found that women with lower SES status and Latinas and African American women reported higher rates of PTG. They speculate that these groups of women may have had greater experience in coping with uncontrollable stressors and thus were more practiced at gleaning benefits from stressful situations.

Personality It would also make intuitive sense that individuals who are high in optimism would be more likely to experience SRG (see Affleck & Tennen, 1996; Tedeschi & Calhoun, 2004). In general, there is modest support for this in the cancer literature, although, surprisingly, measures of hope appear to be unrelated (Stanton et al., 2006). This importance of optimism as a predictor of SRG was recently supported by Bellizzi and Bank (2004) and Updegraff and Marshall (2005), although other studies have failed to show it (e.g., Park & Fenster, 2004). Some studies find that extraversion is associated with PTG (Sheikh, 2004). While Stanton et al. (2006) found no relationship between neuroticism and PTG, Bonnano (2004) argues that, under certain circumstances, individuals who are high in neuroticism may benefit most from undergoing stressful experiences. McFarland and Alvaro (2000) provide one caveat to this—some aspects of SRG appear to occur as a result of negative retrospective bias—that is, the more that individuals believe they have grown from a stressor, the more negative they rate their preexisting personality.

Social Support As mentioned earlier, social support appears to be a major factor in SRG, especially in community-based traumas such as natural disasters. Indeed, in McMillen et al.’s (1997) comparison of three natural disasters, the degree to which the community rallied around and provided one another with support appears to be the major factor in developing PTG. Further, PTG levels moderated the relationship between the degree of stressfulness of the trauma and the development of PTSD symptoms. However, not all studies find a consistent relationship between social support and PTSD (Stanton et al., 2006), and Weiss (2004) presents some convincing evidence that having a confidant is more important for

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developing SRG than simply being imbedded in a social network. This idea is supported by the trauma and PTSD literature, which in general also finds that having a supportive confidant is more important in healing than global social support (see Chapter 12).

Coping What is striking about the studies that do compare different categories of predictors of SRG is that in nearly every study coping strategies are far and away the strongest predictors (Park & Fenster, 2004; Stanton et al., 2006). Basically, coping strategies that are problem-focused (Bellizzi & Blank, 2006) and that involve cognitive reappraisal (Sears et al., 2003), benefit finding (Tennen & Affleck, 2002; Tomich & Helgeson, 2004), or religious coping (Ano & Vasconcelles, 2005; Shaw et al., 2005) are positively associated with SRG. However, Pargament, Magyar, Benore, & Mahoney’s (2005) cautionary observations on the use of negative religious coping in the context of trauma should be noted. Thus, how one copes with major trauma may be more important in the development of psychological and spiritual growth in adulthood than the existence of the trauma per se. Whether any of these coping strategies are actually transformational, however, is still a question. Most researchers use standard measures of coping, and, with the exception of a new measure of “benefit reminding” (Tennen & Affleck, 2002) and possibly “meaning making” (Park & Blumberg, 2002), none is specific to SRG. The term “benefit reminding” is appropriately cautious, given the major concerns about distinguishing between real growth, positive illusions (Taylor, Kemeny, Reed, Bower, & Gruenewald, 2000), and outright denial. Indeed, Tomich and Helgeson (2004) found that benefit finding too early in the cancer process can lead to more negative outcomes, suggesting that these women may have been more in denial. While illusions may be beneficial to maintain hope, Maercker and Zoellner (2004) suggest that illusion while using approach coping may be beneficial but that illusion linked with avoidant coping may have highly adverse consequences. Lechner and Antoni (2004) caution against what they call “pseudogrowth” and “the tyranny of positive thinking.” They argue that there is inappropriate pressure on cancer patients to be “positive,” and they remind us that patients’ feelings of anguish and helplessness are quite real and must be acknowledged. Indeed, Maercker and Zoellner (2004) argue that both positive and negative emotions are necessary for growth. Further, most studies find a correlation between PTSD symptoms and PTG. Tedeschi and Calhoun (2004) argue that the type of disruption concomitant with PTSD symptoms is necessary (but not sufficient) for

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growth, given that one’s previous paradigm needs to be “shattered” before transformational growth can occur. Aldwin and Levenson (2004) argued that SRG need not necessarily be transformational, but may be slow and linear. This may be particularly true of increases in coping competence. Changes in values and perspectives, however, may well be sudden and discontinuous. This is similar to Janoff-Bulman’s (2004) distinctions among three explanatory models of PTG: (1) strength through suffering, (2) psychological preparedness, and (3) existential reevaluation. Whether SRG is a unitary or multidimensional construct is still a matter of some controversy, but clearly personality, coping, and individuals’ resources all play a role in its development in adulthood. The next section will address whether SRG also occurs in children.

Positive Aspects of Stress in Children Only a handful of studies have specifically examined SRG in children. Salter and Stallard (2004) conducted a qualitative analysis of children involved in traffic accidents. Nearly half of the children (42%) reported some SRG, primarily vis-à-vis philosophy of life; a third of these children also exhibited signs of PTSD. PTG has also been reported among Hispanic adolescents (Milam, Ritt-Olson, & Unger, 2004), who found older teens were slightly more likely than younger ones to report PTG due to such stressors as bereavement or divorce of parents, while those who were substance abusers were less likely to experience PTG. Certainly Beardslee’s (1989) study on self-knowledge among terminally ill children qualifies as an early SRG study. However, the bulk of the research on the positive aspect of stress has been conducted in the resilience framework. Resilience is defined as “a dynamic developmental process reflecting evidence of positive adaptation despite significant life adversity” (Cichetti, 2003, p. xx). Resilience is subtly different from SRG in that it posits positive adaptation despite adversity, while SRG posits increases in positive adaptation because of adversity. This careful distinction may have emerged because few would be willing to suggest that adversity is somehow “good” for children; the emphasis has been on protective factors rather than growth-related ones. Nonetheless, it is likely that the dynamics are similar. Nearly 30 years of work has gone into documenting children who function well despite undergoing extreme hardships, such as growing up with a mentally ill parent (Garmezy & Masten, 1986), or being in poverty in Hawaii (Werner & Smith, 1982, 1992), Boston (Felsman & Vaillant, 1987; Long & Vaillant, 1984), London (Rutter, 1987), or in

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other highly stressful inner cities (Cowen, Wyman, Work, & Parker, 1990; Wyman, Cowen, Work, & Parker, 1991). What is remarkable is that nearly all of these studies have found not only that a large percentage of such markedly stressed children do remarkably well but also that similar factors appear to buffer the effects of stress, regardless of cohort, social class, or ethnicity. The three basic factors are cognitive skills, temperament, and social integration (Garmezy & Masten, 1986).

Cognitive Skills A nearly universal finding is that children with a higher level of intelligence, generally assessed through IQs, are more likely to be resilient. This makes a great deal of sense. More intelligent children are more likely to develop better and more realistic coping strategies. Further, more intelligent children may function well at school, which provides them with a source of achievement and self-esteem that can buffer other stressors. The one exception to this general rule is a study by Luthar (1991). However, her sample consisted of female adolescents, and some have suggested that there is a cultural bias against intelligence in pubescent girls (Gilligan, Lyons, & Hanmer, 1990). Masten and Powell (2003) reviewed work from Project Competence, which has been tracking the development of psychosocial competence among children at high risk for the past 30 years. They found that intelligence moderates the effects of adversity on conduct: Children with few cognitive resources are much more likely to develop antisocial personality disorders under high adversity than are those with more resources. Having good executive functioning (planning) skills and being able to regulate attention are also important resources.

Temperament Resilient children are often deemed to have “sunny” dispositions (Garmezy, 1983) or are perceived by their parents to be “easy babies” (Wyman et al., 1991). Such children may be temperamentally protected from depression or neuroticism, which may allow them to face stress with great equanimity. Others have commented on higher levels of selfesteem and self-efficacy in these children (Cowen et al., 1990). Sunny dispositions may also contribute to resilience by increasing the likelihood of positive interactions with adults and other children. An alternative way of understanding this is that some children find self-regulation easier than others (see Chapter 14); the ability to maintain a positive mood in the face of stress is extremely important. Interest-

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ingly, Sandler, Wolchik, Davis, Haine, and Ayers (2003, p. 222) suggested that “temperament sets the boundary conditions for those who can effectively use different coping strategies.” They review studies showing that temperament moderates the relationship between coping and mental health outcomes. Further, the influence of temperament on mental health may be mediated by appraisal—children higher in negative emotionality were more likely to use threat appraisals. It makes sense that temperament may be a source of the individual differences in coping effectiveness discussed earlier. The very same strategy may have different results, depending upon the affective tone with which it is used. Take, for example, a child’s request for help. Children with a “sunny” temperament may request aid with a “winning smile,” and be more successful than children who ask by whining, crying, or acting out.

Social Support Social interactions also play an important role in the development of resilience. The presence of at least one supportive adult, either within or outside the immediate family, is absolutely crucial (Werner & Smith, 1982). Consistent and supportive discipline from at least one parent is also important (Wyman et al., 1991). Further, in those families with a mentally ill parent, identification with the healthy parent is also critical (Garmezy, 1983). In adolescence and young adulthood, finding a mate who is both stable and supportive may be one way out of a troubled past (Vaillant, 1993; Werner & Smith, 1992). In their review, Luthar and Zelazo (2003) referred to “supportive proximal environments” and argued that a supportive family, as well as a supportive community, was extremely important in developing resilience in children. There are a couple of caveats to this general observation. First, Rutter (2003) points out that being close to an antisocial parent can set a child up for various types of problems that might include conduct disorders and substance abuse. The second is the problem of enmeshment. Hammen (2003), in her review of children of depressed parents, noted that some can become too close to their children, not allowing them to develop autonomy or a healthy sense of their own self as distinct from their parents. This may also result in various mental health problems. An early study we did examining predictors of chronic alcohol problems in adulthood found that the men who had little childhood stress and high support levels were most likely to have chronic problems (Aldwin, Levenson, Cupertino, & Spiro, 1998). This counterintuitive finding can be nicely described as a problem with enmeshment. Thus, the source of support may have positive or negative characteristics (see Rook, Mavandadi, Sorkin, & Zettel, 2007).

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Wolin and Wolin (1993) are critical of the idea that vulnerable children are “rescued” by a supportive adult. As clinicians who have intensively studied resilience in adult children from troubled families, the Wolins believe that resilient children actually seek out social support, sometimes in quite innovative ways. They presented a case study in which a young girl with a totally dysfunctional family carefully cultivated a relationship with a somewhat depressed and isolated older man who lived next door. The older man would often sit on the porch, not doing much of anything. The young girl spent some months working up to a relationship with this man. First, she played where he could see her for a few weeks, jumping rope on the sidewalk in front of his house. Then she initiated contact gradually, first by shy smiles and then hellos. The older man would go for short walks around the neighborhood, and she began asking if she could join him. Eventually, they developed a very close relationship, much to the benefit of both parties. Thus, having a supportive relationship requires effort from both parties. The Wolins identified a number of coping strategies that they believe lead to vulnerability and resilience. Strategies to be avoided include dwelling on the past; blaming parents for one’s own failures; and seeing oneself as a helpless, hopeless victim. Resilient children and adults found and built on their own strengths; improved deliberately and methodically on their parents’ lifestyles; married consciously into strong, healthy families; and worked hard at building a cohesive family. The Wolins systematized their clinical observations into seven categories of resiliency: 1. Insight—understanding that the parent is troubled, not “normal,” and that the parent’s behavior is not the child’s fault. 2. Independence—separating from troubled families and carefully regulating contact so as not to be drawn into the parent’s problems. 3. Relationships—cultivating positive interactions with others and marrying well. 4. Initiative—finding ways of managing stressful environments, through trial and error, perseverance, and “chunking” of tasks into manageable bits. 5. Creativity—finding creative solutions to problems and actively trying to transform negative things into positive ones. 6. Humor—using humor to mitigate negative situations and transform them. 7. Morality—differentiating right from wrong and adhering to moral action as the source of greatest strength.

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While there is a general consensus on the factors leading to resilience in children, many researchers are quick to point out that there is no such thing as a child who is completely invulnerable to stress (Anthony, 1987a); rather, such children show a “checkerboard” of competence and vulnerabilities that may change over time (Murphy & Moriarty, 1976). For example, children of alcoholics who seemed resilient as very young children can develop serious internalizing problems (depression and anxiety) by adolescence (Zucker, Wong, Puttler, & Fitzgerald, 2003). Many studies such as Cowen et al.’s (1990) found no differences in anxiety or depression between stress-resilient and stress-affected children. In their review, Luthar and Zelazo (2003) indicate that one of the major problems for the field of risk and resilience are the children who are behaviorally or academically competent but nonetheless have serious symptoms of anxiety and depression. Thus, Rutter (1987) emphasized that resilience to stress should be viewed as a process, a person–environment interaction, rather than as a characteristic of the individual per se. A central theme of this chapter, however, is not only that people can withstand stress but also that they may also benefit in some fashion from having undergone stressful experiences. Within the child literature, evidence for this supposition is still weak but nonetheless intriguing. While studies of parental loss generally show increased vulnerability to psychiatric disorder (for a review, see Sandler et al., 2003), others have found scientific and artistic genius to be associated with bereavement in childhood (Albert, 1983; Eisenstadt, Haynal, & Rentchnick, 1989; Simonton, 1984). Perhaps the isolation that such children may experience allows them to explore and develop their creative abilities. However, it is also possible that there is a confound with parental age. Older parents often have children who excel in various endeavors; however, the parents’ age puts their children at greater risk for bereavement. To my knowledge, no studies of bereavement and genius have attempted to control for parental age. Nonetheless, this observation of early childhood stress and genius is supported by Goertzel and Goertzel’s (1962) study of more than 400 famous men and women in the 20th century. They found that over 75% of these exemplars were highly stressed in childhood by physical handicaps or defects, difficult parenting, broken homes, or poverty. Of course, in the absence of a control group, no definitive conclusion can be drawn from this observation, but the finding is still intriguing. Eisendstadt et al. (1989) extended this observation and not only found that parental loss was more common than not among artistic, political, and scientific leaders but also argued that orphanhood was almost a sine qua non for leadership. Why would growing up with psychosocial and physical stressors result in high achievement? Obviously, Adler’s (1956) compensation mech-

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anisms can be seen to play a role. In addition, highly intelligent children may flee into creative or scientific endeavors to escape from an intolerable home life. Anthony (1987b) drew upon Piaget’s biography for a case study: One of the direct consequences of my mother’s poor mental health was that I started to forego playing for serious work very early in childhood; this I did as much to imitate my father (a scholar of painstaking and critical mind who taught me the value of systematic work) as to take refuge in a private and nonfictitious world. I have always detested any departure from reality, an attitude which I related to this important influential factor of my early life, namely my mother’s poor mental state. (Piaget, 1952, p. 237; emphasis in original)

While scientifically oriented children may “flee into reality,” artistically oriented children may “flee into fantasy.” Interestingly, Anthony (1987a) suggested that the somewhat schizoid ability to go off into flights of fancy, or to have thin ego boundaries, may actually be a buffer against stress rather than a result of stress. As Hartman (1950) pointed out, the ability to see things differently from other people, to fantasize and regress in the service of the ego, is practically a sine qua non for scientific and creative achievement. In keeping with the transactional model, the process probably goes both ways. Creativity and fantasy may provide a useful coping resource and, in some cases, may be facilitated by a highly stressful environment. In other instances achievement may simply be necessary for survival. Work by Glen Elder (1999) provided the clearest example of how stress can promote positive adaptation in children. Elder found that the effects of economic deprivation during the Great Depression had differential effects on middle- and working-class children. During the Depression, deprived children were more emotionally sensitive and generally more psychologically distressed than nondeprived children. The economically deprived working-class children were less adaptive on most measures than their nondeprived peers and continued to experience difficulties into adulthood. Over time, however, the middle-class children appeared to profit from their experience: they matured more quickly; were more likely to be responsible, industrious, and achievement-motivated; and set clearer goals for themselves than their nondeprived peers. This trend continued into adulthood. Surprisingly, Kahana (1992) found a similar pattern of high achievement, stable marriages, and close relations with children among survivors of the Holocaust. Werner and Smith (2001) cautioned that resilient children may pay a price for their good adaptation. As adults, those who had been classified as resilient children reported higher rates of physical illness. Further,

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Elder (1992, personal communication), in informal observations about the mortality rates among the Berkeley and Oakland samples, suspected that his adaptive children of the Great Depression may have had somewhat shorter life spans than their nonstressed peers. Thus, one may adapt to stress and even derive some strengths from the experience, but there may be losses nonetheless. Zautra (2003) has argued strongly that positive and negative affect are parallel processes that are not necessarily mutually exclusive. Thus, stressors and negative coping tend to evoke psychological distress, while positive coping strategies that lead to SRG may result in positive outcomes. SRG does not appear to alleviate psychological distress in and of itself; however, to the extent that it can evoke positive affect, this is turn may be associated with better psychological and physiological outcomes. Thus, adaptation to stress may be seen as a balance between positive and negative processes. It would be unrealistic to think that one can avoid all negative consequences, but, by using transformational coping and focusing on benefits, one can strengthen what positive outcomes can be gleaned in difficult situations.

STRESS AS AN IMPETUS FOR PHYSIOLOGICAL DEVELOPMENT Given that behavioral scientists have spent the past 40 years trying to convince the world that psychosocial stress can have adverse physiological effects, it seems odd that one would then try to determine what are the positive physiological outcomes of stress. However, it is important to understand two basic principles. The first is that the body is always in a delicate balance between anabolic and catabolic processes—that is, processes that build things up and those that destroy them. Take the skeleton, for example. Osteoblasts and osteoclasts work together to extract calcium from the bone when needed for other physiological processes such as pregnancy, lactation, and muscle contraction, and store it there for future need. It has been estimated that the total bone mass in the skeleton turns over about every 5 years due to this combined action of breaking down and building up. Sometimes breaking down is the impetus for future building up, as in the development of increased muscle mass. Epel et al. (1998) argued that stress can provoke both anabolic and catabolic processes, depending upon the timing, duration, and pattern. They hypothesize that physical thriving may occur when anabolic processes are greater than catabolic processes. Physical thriving is defined here as any physiological changes brought about as a result of facing stressors that leave one with greater physiological resilience than she or he had before facing adversity. We can also

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identify thriving as when the stressor is a disease or other health threat, and one remains more healthy than expected, given the physiological challenge. So physical thriving can refer both to enhanced health and to one’s health status above the expected baseline in response to a stressor. (Epel et al., 1998, p. 303)

Second, the body has a large number of mechanisms for dealing with stress, not only at the neuroendocrine level but also at the cellular level, including DNA repair mechanisms and heat shock proteins (hsps) (see Chapter 4). There is a school of thought that argues that stress can induce activity in these cellular defense mechanisms, leading to a phenomenon called hormesis (Calabrese & Baldwin, 2002), in which exposing organisms to low levels of a stressor can result in resistance to higher levels—even those that could be lethal in nonexposed animals. For example, flatworms exposed to nonlethal doses of heat or low levels of radiation are more likely to survive subsequent lethal doses (Lithgow, White, Hinerfeld, & Johnson, 1994; Lithgow, White, Melov, & Johnson, 1995). Similarly, exposure to low doses of radiation is associated with increased longevity in humans (Holtzman, 1995). Chiueh, Andoh, and Chock (2005) reviewed evidence suggesting that both cardiac and neurological cells can be subjected to a nonlethal preconditioning procedure, such as deprivation of oxygen, that can lead to hormesis. This effect can be mediated by heat shock proteins as well as by nitrous oxide synthase, which helps regulate mRNA and other protective proteins. It is important to remember that physiological regulation, or homeostasis, is achieved through a sort of dialectic in which one substance turns on a particular process and another turns it off. This can set the stage for what Solomon (1980) termed “opponent processes,” in which a small initially negative (or positive) response is followed by its opposite. This has been most widely used with addiction studies in which the initial euphoria of the drug is followed by its opponent process (negative affect). As the receptor cites on the cells degrade, more and more of the drug is needed to evoke the initial euphoria, and the opponent process becomes stronger and stronger. Thus, there are a number of mechanisms through which stress can have positive effects. We will next review some of these effects on the neuroendocrine and immune systems.

Neuroendocrine System Some of the earliest literature on the anomalous or positive outcomes of stress examined the effects of stressing young mice or rats, sometimes referred to as “infant-handled” rats. Subjecting infant rats during the first 10 days of life to environmental stressors such as handling or mild electric shock can have certain beneficial effects on later behavior and

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neuroendocrine functioning (Denenberg, 1964; Levine, 1966; Levine, Haltmeyer, Karas, & Denenberg, 1967). According to Gray (1971), these rats mature at a more rapid rate, including earlier appearance of body hair, opening of the eyes, myelinization, locomotion, and puberty. In adulthood, infant-handled rats may also exhibit more exploratory behavior and may show characteristic neuroendocrine responses to stress. Generally, this consists of greater and more rapid neuroendocrine responses, accompanied by a more rapid return to baseline levels. Interestingly, this same pattern of neuroendocrine response is also exhibited by alpha or dominant males in baboon colonies (for a review, see Sapolsky, 1993). Intrigued by the findings on the effects of infant handling in rats, anthropologist J. Whiting and his colleagues utilized cross-cultural data to examine whether there are parallel effects of exposure to environmental stress in human infants (for a review, see Landauer & Whiting, 1981). In a variety of samples, mean adult physical stature was shown to be significantly greater in cultures with stressful procedures in infancy (e.g., circumcision, scarification, sleeping apart from parents) than in those cultures that carefully protect infants from stressful stimulation. Interestingly, early vaccination (before age 2) also appears to enhance physical growth, apart from any effect on morbidity and mortality. Dienstbier (1989) developed a neuroendocrine model of “physiological toughness” that can result from stress, drawing in part on earlier work by N. E. Miller (1980). Rather than viewing physiological arousal as exclusively negative, Dienstbier marshaled an impressive array of evidence demonstrating positive effects. For example, increases in catecholamines were shown in numerous studies to be positively correlated with better performance on a variety of tasks, and increases in adrenaline also correlated with lower levels of neuroticism and hassles. Dienstbier (1989) distinguished between SAM (sympathetic– adrenomedullary) arousal, mediated by catecholamines, and HPA (hypothalamic–pituitary–adrenocortical) arousal, mediated by corticosteroids. Exposure to stressors can result in what Dienstbier termed the “ideal pattern” of sympathetic nervous system arousal: low catecholamine base rates, rapid increases in response to stress, and then a quick return to baseline. “When energy-generating catecholamine responses are elicited in the context of potential control, for which effective instrumental coping responses are likely to lead to success, then positive emotional attributions and responses are likely” (Dienstbier, 1989, p. 87). In contrast, chronically elevated catecholamine base rates are correlated with poorer psychological adjustment and health problems, and “the pattern for cortisol arousal is for low base rates and delayed cortisol responses with challenge or stress” (Dienstbier, 1989, p. 87).

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Toughening is divided into passive and active types. “Passive toughening” occurs via exposure to shock or cold and does not require action on the part of the organism. “Active toughening,” in contrast, requires regular activity such as swimming in cold water or aerobic exercise. Successful coping with a challenge is also seen as a mode of “active toughening.” Note, however, that the temporal patterning of stressors is important. Intermittent stress, which allows for recovery between episodes, is associated with better catecholamine and cortisol arousal patterns. However, with continuous stress, the organism does not have a chance for recovery, resulting in both catecholamine and cortisol depletion, similar to Selye’s (1956) third stage in the general adaptation syndrome, exhaustion. Levine (2001) recently criticized these types of studies, arguing that it is not the stress of infant handling that leads to these neurophysiological changes but rather the behavior of the mother. If the duration of the separation is brief, the mother responds to the pup by licking it all over. Licking and touching also promote the production of growth hormone (see Field, 1991). However, if the duration is too long, the mother may shun or ignore the pup, and loss of maternal support can certainly lead to increased vulnerability. In a carefully controlled study, Hilakivi-Clarke, Wright, and Lippman (1993) confirmed that infant handling in rats led to increased growth and resistance to future stress. Further, mother rats who were handled while they were pregnant had offspring who were less likely to develop breast tumors when injected with a chemical that causes breast cancer in rats than offspring of mother rats who were not handled (Hilakivi-Clarke, 1997). Hilakivi-Clarke, Clarke, and Lippman (1994) suggest that the mother rat’s ability to cope with stress during pregnancy decreases its progeny’s susceptibility to breast cancer. Stress-related changes in estrogen may affect differentiation in the development of breast tissue, leading to subsequent risks for breast cancer. Further, Frolkis (1981) showed that daily exposure to mild stress increased rats’ longevity by about 18%. Epel et al. (1998) examined the ability of women to adapt to intermittent stressors by examining their cortisol reactivity. Women who scored high on a measure of SRG were more likely to adapt to a repeated stressor, showing the classic spike of cortisol but returning rapidly to baseline, while those with lower SRG scores did not show this pattern of adaptation. More recent studies by Antoni and colleagues have found associations between SRG and reduced serum cortisol levels. For example, D. G. Cruess et al. (2000) conducted cognitive-behavioral therapy with women in early-stage breast cancer. Compared to controls, women in the intervention group had higher levels of both benefit finding and reduced serum cortisol levels; further, benefit finding mediated between behavior interventions and lower cortisol levels.

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In short, exposure to stress, whether in young or adult organisms, can result in future physiological responses that are more adaptive and less harmful to the organism if such exposure allows for adequate recovery time and does not result in catecholamine and cortisol depletion. Note, that while single doses of tranquilizers given to animals undergoing toughening manipulations had positive effects (Gray, 1981, 1983), chronic use of alcohol, tranquilizers, or beta blockers may prevent physiological toughening (Dienstbier, 1989). However, in humans, SRG appears to have salutary effects on the physiological ability to adapt to chronic stress.

Immune System Infant-handled rats also develop more robust immune systems in later life, as assessed by strength of response to immune challenges (Solomon & Amkraut, 1981). In adulthood, exposure to environmental stressors such as noise and spatial disorientation can enhance immune system functioning and retard tumor growth rates in mice and rats (for reviews, see Sapolsky, 1998). The critical factors in immunoenhancement appear to be the duration and timing of stress. Counterintuitively, chronic stress may enhance immune system functioning if it occurs prior to exposure to chemical carcinogens and viral or bacterial agents. However, if stress occurs after the exposure to the noxious agent, it may decrease immune capacity (Solomon & Amkraut, 1981). Dienstbier (1989) also reviewed evidence suggesting that the physiological toughening effects of stress can also be seen with the immune system. Thus, although common wisdom believes that stress impairs immune function, under certain conditions stress can actually enhance immune capacity. Antoni and his colleagues have done a series of studies on men who are HIV-positive, using the cognitive behavior therapy manipulation mentioned earlier in D. G. Cruess et al. (2002). They have found that this intervention improves immune functioning, using a variety of indicators, including IgG titers to herpes simplex virus (S. Cruess et al., 2000) as well as CD5+ cell counts (Antoni et al., 2005). These are in part mediated through reductions in cortisol levels. It would be interesting to see whether benefit finding, thought to increase as a function of this type of intervention, also mediated the enhanced immune function.

MODELS OF POSITIVE AND NEGATIVE STRESS OUTCOMES Maslow is reputed to have said that “If your only tool is a hammer, then you will tend to treat everything like a nail.” The seduction of psycho-

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logical thought by simplistic deterministic models has led to the often unexamined assumption that a → b and only b. It appears somewhat heretical to suppose that not only can a → b, but a → not b as well. In other words, within standard models, how can the same stimulus (i.e., stress) lead to one outcome (negative effects) but also its opposite (positive effects)? After all, we tend to interpret our statistics in rather unidirectional ways. Interpreting a correlation of, for example, .3, we are apt to say that there is a modest relationship between, say, stress and physical symptoms—implying, of course, that stress leads to an increase of physical symptoms and, for the time being, ignoring all those instances of stress that led to decreases in symptoms but got masked in aggregate by the greater preponderance of negative effects (DeLongis et al., 1988). Similarly, when we conduct an experiment, find our F test significant, examine the cells, and discover that our manipulation worked in the expected direction, we conclude that X causes Y. All of the people who ended up in the unexpected cells (“off the diagonal”) are conveniently ignored, due, it is supposed, to “error”—unless, of course, we remember to look for interaction effects and include the types of data that may help to account for seemingly anomalous effects. Thus, it seems odd to propose that opposite effects can derive from the same stimulus, whether in different people or contexts, or within the same people but at different times, or even simultaneously, but the bulk of the studies reviewed in this chapter that looked for both positive and negative consequences found them—even in the same people! Thus, a comprehensive model of adaptation must of necessity be able to account for both the negative and the positive sequelae of stress. O’Leary, Alday, and Ickovics (1996) have provided an excellent review of the different models of stress-related growth. All of the models they review are reasonably similar, but their emphases differ somewhat. Tedeschi and Calhoun (2004) focus on transformational change, which at its heart focuses on fundamental changes in one’s worldview. Others focus on more gradual, incremental changes and the processes that underlie them. Schaefer and Moos (1996) focus more on cognitive reappraisal processes as well as environmental resources that can help support positive adaptation. Park and Ai (2006) focus on the importance of meaning making, which differs somewhat from simple cognitive appraisal in that Park and Ai more explicitly tie this sort of cognitive processing to an individual’s goal structure. Meaning-making refers to working to restore global life meaning when it has been disrupted or violated, typically by a major traumatic life event. “Meaning-making” involves coming to see or understand the sit-

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It seems to me that our theories are at the point at which we are beginning to understand the components of the process. There must be a certain level of internal resources (e.g., cognitive competence, ego strength, and so on) and a certain level of external resources (e.g., supportive parents, confidants, and even community supports). Further, it is clear that how one copes with the stressor is key, in terms of cognitive reappraisal, meaning making, certain types of religious coping, and instrumental action. These are hypothesized to result in outcomes such as increased competence and emotional maturity, heightened social ties, changes in values, goals, and perspectives, increased resilience to future stress, and even spiritual development (Tedeschi & Calhoun, 2004). But still many questions remain—seemingly “invulnerable” or “thriving” children may go on to develop serious depression or anxiety later in adolescence, and clearly some adults are using denial or undue optimism. Clearly, stress-related growth cannot be only a matter of denial, social desirability, or retrospective bias, given the physiological work showing long-term changes in HPA responsivity in both people and animals. However, there are still many questions as to how this occurs, and as yet no one has traced out the developmental trajectories of this phenomenon— that is, how long do these value perspectives or enhanced social ties last? How do we differentiate between denial and growth, coping processes that attempt to find benefit, and the actual beneficial results themselves? I think it is time for researchers to draw more upon theories of developmental change and focus more on the dynamics of change and how it occurs in different contexts and for different individuals. Sometimes this change may be slow and incremental, and even mild stressors may stimulate this process. For example, Janoff-Bulman’s (2004) first two types—strength through suffering (increased competence, emotional maturity, and mastery) and future preparedness—may follow relatively slow trajectories, while her third category, existential reexamination, may well be provoked primarily through trauma. But existential reexamination, meaning making, and changes in goals are played out over time and require internal and external changes to be sustained, which may be a slow process. Similarly, the slow increase in competence and emotional maturity may at some point set the stage for rapid transformations. Bonnano (2004) cautions that there may be individual differences in these types of developmental trajectories. From a developmental science perspective, a number of process details may need to be understood. First is the relative balance of positive and negative affect. Larsen, Hemenoer, Norris, and Cacioppo (2003)

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argue that both positive and negative affect are required for growth to occur; however, the efficacy of their relative balance may vary by the stressfulness of the problem. For example, extreme negative affect in the context of minor stressors is unlikely to lead to growth, and the same is true for primarily positive responses in the face of trauma (which is likely to be denial). Rather, a balance is needed, which may vary not only by situational factors but also by individual. Second, Mischel and Mendoza-Denton (2003) suggest that there is both “cool” and “hot” processing, and the trick is to use “cool” processing to regulate the more motivational “hot” processing, avoiding extreme emotional change. One way of doing this is to use the context to understand the limits of both the positive and the negative. For example, thinking “I’m a success!” after acing one exam may set oneself up for failure in future examinations if it leads to a belief that studying isn’t really necessary—as would thinking “I’m a failure” after flunking one exam. Mischel and Mendoza-Denton argue that one should always look to the context to provide perspective—that is, “I’m a success when I study hard!” or “I’m a failure when I don’t bother to study.” Third, while the availability of resources may be a sine qua non for growth, I never fail to be bemused by certain individuals’ ability to see and utilize resources while others seem to be incapable of doing so. One particularly resourceful former student was especially adept at this. A standard moral development scale asks individuals to solve dilemmas, one of which involves a pharmacist who is charging far too much for a drug that is necessary to keep one’s spouse alive. Expected responses are either to steal the drug or to allow the wife to die to avoid stealing. This student, however, said he would simply network to find the pharmacist’s source and obtain the drug that way! For SRG to occur, it should be clear that individuals’ coping is likely oriented toward generating resources rather than simply using them. Thus, coping that focuses on increasing knowledge, skills, or compassion may be more likely to result in SRG than simply solving the problem. Just as more psychological distress occurs when stressors proliferate across domains (Pearlin, Aneshensel, Mullan, & Whitlatch, 1996), so too growth may occur when the development of resources spreads across domains. Further, most of our current models seem to be overfocused on cognitive benefits; the ability to generate tangible benefits, not only for oneself but for others, is also important. Remember, the Chinese written symbol for “crisis” means both “danger” and “opportunity.” How individuals and communities learn to see and to realize the opportunity in stressors is as yet a process not well understood. Finally, development occurs not just through increases but through losses as well (Levenson et al., 2001). Losing bad habits, self-defeating

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beliefs, outmoded definitions of the self, or “delusional” worldviews may be necessary first steps for the development of resources. Stressors provide a great opportunity for goal-motivated losses.

SUMMARY There is a fair amount of evidence from a wide variety of sources that stress can have positive effects. Not only has this hypothesis been derived from philosophical, literary, and anecdotal sources, but there is solid evidence from both the child and adult developmental literature as well as studies of neuroendocrine and immune function. The key to understanding the positive aspects of stress lies in how the individual (or individuals within a culture) copes with a given stressor. Rather than simply a homeostatic function, the more important role of coping may be transformation. Clearly, we need more information on how individuals can transform themselves through the process of coping with stress, as well as increase their personal competence and empathy. The ability to transform a situation is also of extreme importance—to be able to perceive and act upon opportunity in crises. Thus, transformational coping may be the key to positive mental health.

STRESS, COPING, Self-Regulation, Self-Development, AND DEVELOPMENT and Wisdom

CHAPTER 16

Self-Regulation, Self-Development, and Wisdom

I

n this book, I have tried to bring together physiological, psychological, developmental, social, and cultural perspectives on the process of how individuals cope with stress, as well as to delineate methodological issues involved in both the measurement of stress and coping and in understanding their implications for health. The danger in any such endeavor is, of course, indigestion. When faced with overwhelming masses of information, how can one make sense of any huge corpus? Given the often conflicting theoretical and methodological stances, wherein lies the truth? What is needed is an overarching framework that will provide a context for understanding which conflicting results are actually contextspecific and which are really mutually exclusive, as well as provide a “meaning web” that allows patterns to emerge that simplify and clarify the relations among the masses of variables that fall under the “stress and coping” rubric. In 1994, I began this book with the statement that a paradigm shift is currently under way in science—a shift from reductionism to transactionism. I argued that a transactionist viewpoint is necessary for understanding highly complex phenomena such as stress, coping, and adaptation, in all their myriad facets—hence, the “elephant in the dark” metaphor. The past 12 years, though, have added an additional layer of complexity, the notion of self-regulation (Eccles & Wigfield, 2002; Eisenberg, Fabes, & Guthrie, 1997), which brings an interesting perspective of intentionality to adaptation (see Howard, 1993). Interest341

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ingly, intentionality has also come to the forefront in lifespan developmental theory, in the form of self-development (see Brandtstädter, 1999; Elder, 1998; Greve, Rothermund, & Ventura, 2004; Hooker & McAdams, 2003; Levenson & Crumpler, 1996). Combining these two perspectives may well provide an overarching framework for much of the stress and coping literature, which will be explored in this chapter. First, however, I provide a summary of what I feel may be the seven most important findings in the material reviewed in previous chapters.

TRANSACTIONISM AND COPING The complexity of the subject matter notwithstanding, a number of conclusions about the process of coping with stress can be made, drawing upon a transactionist perspective. First of all, it is eminently clear that simply categorizing coping as “approach” or “avoidance” is inadequate in most situations. The subtleties of different types of approach or avoidant coping strategies militate against this. Depending upon the type of strategy and the extent of its use, avoidant strategies may facilitate or inhibit problem-focused efforts. Avoidant strategies can facilitate problem-focused strategies if they serve as a “time-out” that enables individuals to regroup their resources. Further, qualitative differences in the types of approach coping may lead to their being effective or ineffective. The literature is absolutely clear that both the source and the effect of coping strategies are contextual. That is, people use different strategies at varying phases of the problem, often shifting back and forth between approach and avoidant coping. Moreover, these strategies have different effects, depending upon the circumstances. Using avoidant coping in controllable circumstances may increase psychological distress and the seriousness of the problem, but such strategies may be useful in uncontrollable circumstances. Approach coping, while generally useful, may have detrimental effects if used in uncontrollable situations. Thus, it is important to understand the motivation behind the coping behavior. Second, variations in the use of coping strategies are in part a function of individual predilections. However, the evidence is overwhelming that situational demands modify coping responses, as do the behaviors of others in the social context. Further, there are cultural and class differences in what are considered to be appropriate responses to stress, to say nothing of differences in appraisal processes. Thus, approaches that exclusively examine personality-based coping strategies may be methodologically “cleaner” in that such scales may have more reliable factor structures and better internal validity, but their external validity is lim-

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ited, on both a theoretical and a practical level. Further, the newer coping scales, which have a more regulatory orientation, may have better factor structures despite being process measures (Stanton et al., 2000; Aldwin et al., 1996b; Aldwin, Shiraishi, & Cupertino, 2001). Third, standard approaches to coping may overemphasize control over the environment and the emotions. While instrumental action may often be the best approach, sometimes deferring action, or simply letting events play themselves out, may be better strategies. Many minor stressors are by nature self-limiting, and ignoring them may be the best strategy. Given that so many coping strategies show negative statistical associations with outcomes, many of the strategies seem only to make a problem worse. Further, there are dangers in suppressing legitimate emotions; indeed, many cultures encourage the expression of emotions and deem suppression to be unhealthy. Stanton et al.’s (2000) work clearly indicates that there are different ways of processing emotions that may lead to more or less efficacious outcomes. Fourth, researchers must differentiate between coping effort and coping efficacy. Simply put, more coping is not necessarily better coping. The level of effort made should be appropriate to the demands and importance of the stressor. The most efficacious coping may well be that which expends the least effort, whereas expending great effort in relatively trivial circumstances may be ineffectual and associated with negative outcomes. To complicate an already overly complex situation, highly stressful situations may activate both great coping effort and distressing emotions. Thus, statistically examining the relation between coping and outcome may be extremely tricky and may require more sophisticated methods. The use of simple correlations or regression equations will most likely yield equivocal results: In the literature one can find examples of problem-focused coping alternately bearing positive and negative, relations to outcomes and sometimes none at all. One must control for the degree of stressfulness of the problem or the level of coping effort, or one must utilize interaction terms with coping efficacy for a more accurate picture of the effect of any given coping strategy. An added difficulty is that coping does not occur in a social vacuum. The responses of others to one’s coping efforts may profoundly affect their efficacy, as we saw with trauma research. Ordinarily, disclosure is considered to be an extremely important coping strategy for individuals who have undergone trauma, but when others react negatively, this may worsen distress (Silver et al., 2000). Fifth, the effects of coping strategies must be examined on a variety of levels, including physiological, psychological, social, and cultural. Strategies that may have benefits on one level may entail undue costs on others. Coping with work problems in a way that maximizes career suc-

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cess, for example, may create health or family problems. The challenge is to come up with “mini–max” strategies—those that minimize costs and maximize benefits, both within and across domains—which is not an easy thing to do. To my knowledge, no one has attempted to develop a coping measure that assesses this process. Further, coping strategies not only affect the immediate situation but may also affect the larger sociocultural environment. Individual or collective coping strategies can affect cultural mores and/or institutional structures, either through changing perceptions about what constitutes appropriate coping strategies or through changing the availability of coping resources for a given problem. The shift in the impact of divorce detailed in Chapter 14 is an excellent example of this. Collective attempts to deal with the problems of divorce has led to a shift in the laws regulating divorce and the dividing up of assets. Further, better understanding of the family dynamics impacting children’s adaptation has led to more emphasis on mediation and more self-monitoring to preserve the children’s well-being (Hetherington & Kelly, 2002). Sixth, examining only the negative aspects of stress yields a partial picture of the effects of coping strategies. The evidence is clear that psychosocial stress can have positive effects, whether this is in terms of “physiological toughening,” the development of mastery and selfesteem, enhanced perspectives on life, or a larger coping repertoire for use in future stressful situations. Indeed, it makes good evolutionary sense that successful organisms benefit from adversity in ways that make future adaptation easier, or at least more probable. However, some minimum level of resources is required to prevent maladaptive spirals from occurring, and sometimes overwhelming “environmental press” or simple bad luck can prevent any benefits from being derived from a stressful circumstance. But rather than view coping as merely the expenditure of resources (Hobfoll, 2002), the literature suggests that coping can involve the development of resources as well, not just for the individual but also for others as well. Finally, the effects of coping strategies must also be examined over time. Most models of adaptation are homeostatic: they assume that coping serves primarily as a deviation-countering device. Indeed, many problems are relatively minor or self-limiting, and coping serves primarily homeostatic functions. Aldwin and Revenson (1987), for example, found that problems that were solved using a minimum of effort were associated with the lowest amount of distress. However, coping strategies may also set in motion deviation-amplification processes that may result in long-term changes that can be either positive or negative (Aldwin & Stokols, 1988; Caspi, Roberts, & Shiner, 2005). On the one

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hand, it is all too easy to utilize ways of coping that are expedient in the immediate circumstances but that have adverse long-term consequences. Conversely, being able to tolerate immediate stress may be beneficial in the long run. For example, many students find preparing for an exam very stressful. Decreasing this stress in the short run by using avoidant strategies— going to a movie, playing video games, or watching television—may make the student feel better temporarily but has negative consequences for future achievement if such distractions result in a lack of preparation for the exam. However, learning to tolerate the stress associated with studying may decrease distress during the actual exam and may facilitate achievement. Differentiating between short- and long-term outcomes may be especially important for traumatic stressors. Given that the traumatic experiences may result in a fundamental change in identity that unfolds over a long period of time, delineating the long-term effects of traumatic stress may require a chaos model approach, in which initially small differences in coping may lead to dramatically different outcomes over time. In other words, self-regulation processes—knowing how much stress one can tolerate and being able to regulate that degree of stress in the service of long-term goals—play a key role in long-term adaptive strategies. However, self-regulation is predicated upon levels of selfawareness and intentionality, which brings us to a larger problem in psychology today: the issue of free will versus determinism.

FREE WILL VERSUS DETERMINISTIC MODELS OF ADAPTATION In addition to a tension between reductionism and transactionism, there is a related paradigmatic crisis occurring in psychology: the problem of determinism versus free will. Philosophical psychologists and neuroscientists have been arguing for decades (reprising a couple of thousands of years of debate in religion and philosophy) about whether or not free will exists (see Bandura, 1989; Bennett & Hacker, 2003; Sappington, 1990; Sperry, 1988; Zhu, 2004). In its effort to become a bona fide scientific discipline, psychology has sought to develop deterministic models of human behavior. In psychoanalytic models, behavior is thought to be determined by largely unconscious forces, the interplay between the id and the ego, and shaped by early childrearing practices. This model was next replaced by environmental conditioning: behavior was a result of rewards and punishments, either in the current environment or in an individual’s past history. Currently, much of psychology still appears entranced with deterministic

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models driven by biology, in terms of either genetic endowment or neurological structure (Rowe & Rodgers, 2005). A transactional approach obviates these relatively simplistic models, showing that behavior is a complex and dynamic composite of a variety of sources. Yet, a transactional model is incomplete if it does not address the other central conundrum within the field: Does human behavior simply reflect the confluence of a mass of influences, or does its understanding require the inclusion of volition as a construct? Sappington (1990) reviewed a number of approaches to the free will versus determinism debate. He would describe this last example of the theoretical psychologist as the “libertarian” stance: although humans are faced with both internal and external constraints on their behavior, people are always free to make choices that are not determined by outside factors. An intermediate position between libertarianism and the “hard” determinism of psychoanalysis, behaviorism, behavior genetics, and cognitive neuroscience may be termed “soft” determinism, which holds that people make choices but that the choices are determined by other factors. In other words, if a person has a choice between working and playing and chooses to play, that choice is strongly influenced by both external factors and personal history. Psychologists from several different fields have argued for the inclusion of volition and free will in the scientific study of psychology. Contrary to Skinner’s (1971) assertion that free will makes the scientific study of psychology impossible, Bandura (1989) and Howard and Conway (1986) have argued persuasively that including volitional constructs in research designs increases the amount of variance that can be accounted for in statistical models of human behavior. However, Sappington (1990) noted that data suggesting that conscious choices can account for the bulk of variance in human behavior do not alter the basic issue of whether the choices themselves are ultimately determined by factors outside the person. If conscious choices can ultimately be explained in terms of factors such as environmental stimuli, genetic structures, or past learning history, then this would support the soft determinist position. Because the data on conscious choice do not address the issue of the origin of choice, they do not allow one to decide between the libertarian or the soft determinist position. (p. 26)

Howard (1973) provided a novel approach to this issue. Rather than a simple dichotomy, free will versus determinism, he argued for two relevant dimensions, determinism versus nondeterminism and self-determination versus nonagentic mechanism. In other words, some phenomena are de-

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termined and others are random. However, the determining cause may be nonagentic (e.g., caused by something outside of the aware self, whether that is in the external or internal environment). Tageson (1982) suggested that free will is not a given but can develop as a result of cognitive maturation, environmental options, and becoming aware of the unconscious influences on behavior. To the extent that an individual can become aware of these influences, he or she can learn to compensate for them. While Sappington (1990) admitted the intuitive appeal of Tageson’s model, he argued that this model is still limited in that it cannot account for how an individual becomes aware of unconscious influences or learns to choose among options.

Self-Regulation and Self-Development As was noted in Chapter 14, the past decade has witnessed an increased focus on the development of self-regulatory processes in childhood. While there are many such schema, they share a number of characteristics (see Eccles & Wigfield, 2002; Eisenberg et al., 1997). First of all, individuals need to be self-aware: they must monitor their thoughts, feelings, and behaviors. Second, they must be able to consciously direct and sustain their attention, either toward the problem in order to find a solution or to manage the problem, or away from it, for example, to decrease distressing ruminations or to provide a respite from stress. They must also be able to direct their attention to the most relevant aspects of the problem and not flounder about in less relevant details. Third, they must be able to monitor their behavior, be aware of the impact of their own actions on others in the environment, and be able to modulate that behavior in order to achieve their goals. Fourth, they must be able to evaluate their own efforts and adjust them accordingly. Eisenberg et al. (1997) identify three types of regulation: Optimal regulation involves the flexible use of regulatory mechanisms, relatively high use of constructive modes of regulation such as activational control, attentional control (e.g., attention shifting and focusing), planning and problem solving, and moderately high use of inhibitory control. Underregulation is less flexible and involves relatively low use of generally constructive modes of regulation such as attentional control, inhibition control, activational control (the ability to initiate and maintain behavior, particularly behaviors that are not pleasurable), planning and direct problem solving, and other modes of emotion regulation such as cognitive restructuring. Due to the lack of regulation of both emotion and emotionally driven behavior, impulsively acting out

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Self-regulation is also becoming an important construct in health psychology, both for the management of health behaviors such as smoking abstinence and weight control, and indeed has formed the basis for 20 years of intervention in health psychology (Boekaerts, Maes, & Karoly, 2005). Further, this construct is also becoming central to theories of the management of chronic illnesses in late life (Leventhal, Forster, & Leventhal, 2007). According to Boekaerts, Maes, and Karoly (2005): “Self-regulation implies choice, consistency, and continuity of movement over time; and these three C’s critically depend on having access to a well-integrated goal hierarchy. Individuals, who are aware of what their goals are and how their goal system functions, are in a better position to steer and direct their behavior” (p. 150). Along parallel lines, adult developmentalists are beginning to examine goals in self-development and how these may change in a systematic way in adulthood. Brandtstädter (1999) hypothesizes a shift from assimilative to accommodative goal structures in later life, in which assimilative processes involve active attempts to manipulate the environment to achieve goals (problem-focused coping) while accommodative processes involve redirecting goals to reflect limitations in either the self or the environment (emotion-focused coping). Rothermund and Brandtstädter (2003) have conducted several studies showing that failure to adjust goals in this manner results in higher levels of psychological distress in later life. Similarly, Schulz and Heckhausen (1998) have also theorized about a shift from primary to secondary control in later life (but see Skaff, 2007). Fung, Rice, and Carstensen (2005), on the other hand, have argued that goal shifting in later life is not just a matter of reaction to losses but, rather, reflects proactive motivational shifts due to a shift in the awareness of time constraints, leading to a choice to pursue emotional goals. Hooker and McAdams (2003) have pointed out that goal setting is a very important “layer” of personality, and, in the above theories, both the types of goals and the process for achieving them form much of the impetus for development in adulthood. Further, this development is seen as a conscious attempt to regulate the self in the service of goal attainment. For Brandtstädter (1998), the self is both the producer and the product of intentional self-development (Brandstädter, 1999; see also Greve, Rothermund, & Ventura, 2005). He argues that three basic processes should be considered. First, how does intentional action develop, and what behavioral and cognitive processes underlie it? Second, how

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do beliefs about intentionality and competence affect its development? Third, how does the self both produce and serve as the product of intentional self-development? Combining a transactionist viewpoint with a developmental one suggests a possible resolution to this problem of free will. To a large extent, our behavior is determined—by our biology, our culture, the immediate situation, our developmental level (whether cognitive or socioemotional), and our past history. We respond automatically and often quite unconsciously to various stimuli. Depending largely upon our cultural backgrounds, we respond with shock and horror to the loss of virginity in our daughters, to sexual activity between adults and children, or to Serbian marksmen targeting Moslem children at play. Such shock is only “natural”—until, of course, one finds a culture that has completely different assumption system as to what is “natural.” However, it is within a stressful situation that uncertainty arises. By definition, stress arises when our coping resources—our usual way of doing things—are inadequate to the demands of the situation. As Acredolo and O’Connor (1991) have suggested, uncertainty may be a prerequisite for development. Uncertainty—and all its attendant uncomfortable emotions—is the impetus for a reexamination of our current schemata. According to Acredolo, uncertainty marks the beginning of change in Piaget’s schemata of cognitive development. A very young child will be absolutely certain that the tall, thin glass holds more than the short, wide glass. With a slightly older child, one can watch the uncertainty on her face when confronted with two seemingly inexorable “facts”: The amount of liquid being poured back and forth is constant, but the tall, thin glass apparently holds more than the short, wide one. This uncertainty allows the child to reexamine her old schemata, and develop new, more sophisticated, levels of cognition. Indeed, one could argue that uncertainty is a prerequisite for psychological change. Similarly, choice and the exercise of free will are impossible unless one recognizes how decisions are made and what influences them. Uncertainty in stressful situations in adulthood may lead one to reexamine one’s behavior, thoughts, feelings, and motivation, and learn to recognize unconscious influences on behavior, whether situational, cultural, or personal. The recognition of influences, then, allows for the development of choice and thus free will is an inherently developmental phenomenon. Elsewhere (Aldwin, 1992), I have argued that stress provides the impetus for development in adulthood. As Baltes (1987) noted, one of the central conundrums for the field of adult development is whether development in adulthood exists. While psychologists such as Erikson (1950), Kohlberg (1984), and Loevinger (1977) have described developmental patterns in adulthood that they held to be universal, sociologists

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such as Dannefer (1984) and Featherman and Lerner (1985) have argued that there is no universal developmental sequence in adulthood, because roles and cultures vary so widely that there is no one sequence of stages that describes the adult life course in different demographic groups. However, stressful experiences can be seen as providing a universal context for development in adulthood. While the content of a stressful experience varies across social roles or cultures, the experience of stress is universal. The process of coping with stress provides a means through which development can occur. When coping with stress, people are provided an opportunity to develop the capacities and skills that are deemed admirable by a particular culture. However, there is no universal sequence that all adults go through, largely because such development is volitional (see Brandstädter, Krampen, & Heil, 1986). One can extend this hypothesis concerning stress and adult development to the problem of determinism versus free will. When stress occurs, the old and largely determined way of doing things is shown to be inadequate or limited. Stress, then, provides the opportunity for the exercise of choice. We can, of course, choose to adhere to the old, comfortable way of doing things, but that choice may entail unacceptable costs, which may include failure, social isolation, or even insanity. However, a stressful event may force us to develop new ways of perceiving situations and modes of behavior. Thus, free will is a characteristic that can develop through the process of coping with stress, to the extent that uncertainty leads to greater reflection and, paradoxically, greater self-regulation and self-determination. The development of free will is undoubtedly a gradual process. Vaillant (1993) was correct to talk about the impossibility of simply “willing” something to happen. Someone can no more “will” a sense of humor than I can “will” myself to suddenly be able to run a marathon. However, this is too simplistic a notion of what the exercise of free will entails. It is not a magical wand that suddenly makes everything different. Rather, one can set into motion and sustain a process through which one’s goals can gradually be achieved—whether that involves a sense of humor, athletic prowess, or something else entirely. Note that in this model stress does not “cause” this development but, rather, provides an opportunity. Negative adaptive models may be equally or perhaps more likely. In some ways it is easier to envision the negative process, using chaos and deviation amplification models (see Aldwin & Stokols, 1988). In most circumstances, initially small deviations can be easily countered and behavior returned to “normal.” However, factors may intervene that set off a deviation amplification process, resulting in a maladaptive spiral. Using the language of Markov chain analysis, a statistically improbable behavior can result from a chain of

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relatively minor events. Each small event increases the probability of the next one, and the improbable behavior becomes greater with each step. Runyan (1978) described the process through which a person becomes a heroin addict. No one wakes up one day and says, “Oh, I think I’ll become a heroin addict today,” nor does anyone specifically formulate a goal to become an addict. Rather, the process involves a series of small incremental decisions that gradually lead to a serious constraint on behavior. According to Runyan, the process begins by living in a neighborhood in which there are addicts. One gradually gets to know them and may befriend some. Being a friend, one might start doing favors that may involve helping the addicts obtain drugs. Then one might start being a drug user oneself. People typically begin by snorting heroin or smoking it in cigarettes or with marijuana, believing themselves to be stronger than others or less vulnerable to its effects. The use of the drug may increase until the person needs to directly inject it into veins to get the required effect. The person is finally addicted, and his or her whole life may narrow to serving that addiction, to the detriment of work, family, health, and self-respect. Similarly, no one “decides” to become a schizophrenic. But an adolescent under stress (and who perhaps has a biological propensity for neurotransmitter imbalances) may act in ways that alienate others. He or she may become more and more withdrawn. Social isolation cuts one off from social regulation of cognition and affect, and one’s thought processes and emotional states may become more and more bizarre, which in turn increases the isolation. Self-neglect can lead to inadequate nutrition, exercise, and sleep, which in turn further increase the neurotransmitter imbalance, often abetted by the use or overuse of alcohol and drugs. At some point the neurochemical imbalance may become so extreme (or even permanent) that antipsychotic medications are essential to reduce symptoms. In a transactional model, intervention can (and should) be done at multiple levels. Bradshaw (1993) developed a coping skills training approach with schizophrenics that substantially reduced recidivism, but it was tailored to helping schizophrenics cope with their particular symptoms rather than focusing on general coping skills. Thus, stress can set into motion deviation amplification processes that can easily be seen to result in poor mental and physical outcomes and loss of the ability to exercise control. However, as detailed in Chapter 15, there is ample evidence that this deviation can be positive as well. Take, for example, Piaget’s response to his schizophrenic mother. He fled into scientific endeavors, which brought him into more contact with his father. One can easily imagine a positive feedback cycle, in which approval from his father caused Piaget to pursue his scientific studies, which in combination with his high intelligence led him to start publish-

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ing scientific papers in early adolescence, which led to more societal approval, and so on. The point is that stress can create deviance, and deviance can be either positive or negative (or, most likely, some combination thereof). However, as Sappington (1990) pointed out, chaos models are themselves deterministic. In chaos models, behavior may not be predictable, but it is still determined—the complexity of the interaction between multiple forces simply makes the eventual path unpredictable. A “soft” deterministic model is also congruent with chaos theory. Thus, the ability to demonstrate both negative and positive adaptive spirals is not conclusive proof that stress provides a context for the development of free will per se. Sappington’s critique of Tageson’s model of free will as a developmental process is based upon a missing link: How do people become aware of unconscious influences on their behavior? As indicated earlier, stress can create an uncertainty that leads people to more closely observe and examine their behavior. Stated in stronger terms, stress and especially trauma can challenge or even destroy one’s whole assumption system about personal safety, justice, the nature of interpersonal relations, and one’s role in the world. This destruction of the self must be dealt with in some way; a new self must be constructed. In the vernacular, people often speak of “picking up the pieces.” Interestingly, this can also be understood in the context of a reintegration of one’s goal structure (Boekaerts et al., 2005). As reviewed in Chapter 12, the end result of the process of coping with the aftermath of trauma is the creation of a new identity—which is why such coping behavior is often a better predictor of outcomes than the original exposure was. Rather than seeing it as developing a new identity under stress, Greve (2005) argues that at times individuals pursue personality change in order to preserve their identity. In other words, most individuals have a reasonably continuous sense of self, despite obvious situational and developmental changes in beliefs, values, and behaviors. He hypothesizes that individuals change in order to maintain their core identities. For example, a heart attack in middle age can challenge one’s identity as a youthful, healthy person. In order to maintain one’s health, the individual may well change health behavior habits, quit smoking, change his or her diet, and even try to change personality characteristics such as uncontrolled anger. These changes are made in the service of continuity. However, negative changes are also possible. Let us assume that negative spirals have a higher probability of occurrence than do positive ones. After all, it is relatively easy to blame others for failures—my boss had it in for me, my ex-husband was a louse, and so forth—or to internalize victimization as the justification for pathological, self-destructive,

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or even criminal behavior. Negative spirals generally require the expenditure of less energy and, therefore, are easier to set into motion. Positive adaptive spirals may be much more difficult to set into motion, since they require a fair amount of energy expenditure, especially in resourcepoor environments. One must develop and coordinate sufficient cognitive, social, financial, and institutional resources to achieve goals. The further along one is on a negative spiral, the more resources one must acquire and expend to reverse this process. In order to overcome adverse influences, one must become aware of them, determine their source, and figure out how such influences work. Conscious decisions are often required to set into motion and to maintain positive spirals. Note that such consciousness is not an “either/or” phenomenon; rather, it develops gradually and can be instigated and/or supported by others in the environment, until one learns how to recognize possible options, estimate what the likely outcome of different coping strategies may be, and instigate and sustain courses of action by marshaling both internal and external resources.

Religion, Self-Regulation, and Self-Development During the past 10 years, there have been many studies showing a positive association between religion and health (Miller & Thoreson, 2004). In general, many of the effects of religion on health are thought to be attributable to better health behavior habits and social support, although many studies have found independent effects of religiousness. Another possibility is that religiousness and religious coping are related to positive outcomes through their enhancement of self-regulation. Religions posit desirable and undesirable characteristics and encourage their adherents to develop the former and suppress the latter. Take, for example, the seven deadly sins in Christianity: pride, envy, gluttony, lust, sloth, anger, and greed. We know that gluttony (overeating), anger (hostility), and sloth (avoidance of work and exercise) lead to poor physiological regulation and poorer health. But greed for material gain, envy at the possessions or abilities of others, and overweaning pride may also result in poorer emotional regulation. At their best, religions also provide ways of developing self-regulation (Levenson, Jennings, Aldwin, & Le, 2006). For example, Christians are enjoined to practice certain virtues to help combat the “deadly sins”— patience is the antidote to anger, liberality to greed, diligence to sloth, kindness to envy, abstinence to lust, and humility to pride. (By humility here is meant not abasement but rather a recognition of personal limits, similar to Mischel and Mendoza-Denton’s [2003] recommendations visà-vis recognizing contextual limits on failures and achievements.) All of

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the world’s major religions—Buddhism, Islam, Judaism, Vedanta, and Taoism—at their best promote temperance, self-control, patience, and compassion. At their worst, of course, religions can promote intolerance, injustice, and hatred. I can’t resist mentioning Gandhi’s versions of the seven deadly sins: wealth without work; pleasure without conscience; science without humanity; knowledge without character; politics without principle; commerce without morality; and worship without sacrifice. How this differs from the prior list is that it puts values and virtues squarely within the social arena, as opposed to the merely personal. Thus, individual human development must occur within the context of not only one’s own life but also within the greater social good. Thus, religions also provide a coherent goal structure that can promote the construct and practice of self-development in adulthood. Levenson et al. (in press) examined these goals and argued that they all involve rather similar conceptions of wisdom. In addition to providing a coherent goal structure, the inner core of most religions utilize some sort of meditation, the effect of which is precisely to promote self-awareness (through such tasks as watching the breath or counting steps, etc.), to increase the ability to focus attention (by using mantras, watching thoughts arise, praying the rosary, or centering on the heart), and to regulate the autonomic nervous system, usually through controlling the pattern of breathing. Thus, the impact of religion on health may be mediated through its promotion of self-regulation. At the basis of all such processes is mindfulness.

MINDFUL COPING AND WISDOM In some ways it is easier to understand mindlessness than mindfulness. Mindlessness involves premature cognitive commitment, as typified by the adherence to stereotypical thoughts and actions. Langer (1989) provided a charming example of this. A friend of hers always cut off the end of a roast before baking it. When queried as to why she did this, she looked puzzled and said, “That’s how my mother always did it.” She called her mother for an explanation, who replied, “That’s how my mother always did it.” The friend then called her grandmother, who explained that the pot in which she baked roasts was too short, so she always had to cut the ends off of them! Mindless actions and thoughts are perpetuated not only in ourselves, but can persist for generations. Mindfulness, on the other hand, involves being able to step outside of our categories. We set limitations on our cognitions and our actions by assuming “that’s the way things are” or “that’s as much as I can do.”

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First, however, one must become aware of these types of limitations. In experiment after experiment, Langer showed that it is possible to alter those cognitions through very simple interventions, which in turn lead to increased performance. For example, students generated more creative solutions to problems when the teacher simply said, “X may be something,” implying that it actually can be something else. Telling students that others had solved a seemingly insoluble problem led to solutions, even if others actually had not solved the problem. Conversely, it may be possible to induce mindlessness through the manipulation of context. For example, professional women who were able to solve complex math problems became unable to solve them when asked to assume a subordinate role, that is, when one person was designated as the “supervisor” and the other as the “assistant.” Recognizing that explanations are conditional may be a critical factor in the development of creativity and genius. A Nova program on Nobel Prize-winning physicist Richard Feynman demonstrated this nicely. Feynman’s salesman father was a frustrated scientist, and he tried to impart his love of knowledge and scientific curiosity to his son. For example, when Feynman was quite small, he asked his father why the ball in his wagon rolled to the back whenever he started to pull the wagon forward. His father thought for a moment, and said, “Son, nobody really knows. We have a name for it—it’s called inertia—but nobody really knows why it happens.” This sort of conditional explanation—recognizing that naming something does not mean that one understands it—precludes premature cognitive commitment and encourages greater reflection. In contrast, Feynman also played intellectual games with his children, but it was always clear that he knew the answers, that the world was concretely defined. This may encourage intelligence, but not creativity and originality. Stressful events such as a major illness or the death of a parent in childhood may also lead to uncertainty, which could lead to a better capacity for reflection. This capacity may account for some of the association between parental death and genius noted in Chapter 15. In addition, such children are by definition deviant. I once attended a talk by Isabel Allende, who was reflecting on why she became a writer. “I never fit in,” she said. “I always saw things a little differently from other people.” One could also hypothesize a chain of possible events leading from parental bereavement to genius. Such children may feel a little different. Lacking two parents, they may not be socialized in the usual manner, or they may be uncertain of themselves and their social skills may be a little awkward. Such children may tend to spend more time alone. If artistically inclined, they may spend a lot of time fantasizing or drawing; if scientifically inclined, they may spend a lot of time reading or thinking. In

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many ways, “seeing things differently” from others may be very stressful, but it may also be very useful. It is also easy to see how “not fitting in” could lead to negative spirals; hence, the dual outcomes of juvenile delinquency and genius may be attributable to parental bereavement. The relevance of the mindfulness construct to creative and effective coping is obvious. When confronted with stressors, we may make automatic assumptions that limit our options. We fall into stereotypical roles and reactions that often are not necessary and may create additional stress. Getting upset over trivia is a good example of this. Another mindful technique is the ability to see alternative possibilities in everyday tools. Similarly, the ability to perceive opportunities in problems is an example of mindfulness par excellence and is one of the foundations of stress-related growth. Thus, mindful coping involves the ability to perceive different options in situations. Mindful coping also involves awareness of one’s internal states as well as the effect one is having on the problem and others in the environment, and thus it is also the foundation for self-regulation. More importantly, though, effective coping does not involve only developing opportunities and resources for oneself but also should benefit others. As Lerner, Theokas, and Jelicic (2005, p. 39) note: “A key structural value of all societies (that is, a universal structural value of all societies) is that individuals’ regulation of their person–context relations makes positive contributions to self, family, community, and society.” Heckhausen (1999) argued that the relative dearth of biologically based predetermination of behavior gives rise to a highly regulatory requirement on the part of the human individual and the social system. The social and cultural system and the individual have to regulate behavior so that resources are invested in an organized and focused way, and that failure experiences lead to an improvement rather than to a deterioration of behavioral means. (p. 8)

Of course, what is considered to be a positive contribution may vary across cultures (Elder, 1998), but the important point to note is that effective coping not only serves one’s own goal structure but also helps develop resources for others. Clinicians may be quick to point out that this process of developing mindful ways of coping is very reminiscent of what they seek to achieve with their clients in therapy. Self-observation, development of new perspectives, liberation from crippling negative emotions, enhancement of self-knowledge, and the establishment of new modes of coping are often therapeutic goals. But these are also key components in the development of wisdom.

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There are several different models of wisdom in the literature, but they can roughly be divided into three categories: (practical knowledge( or social competence (Baltes & Staudinger, 2000), personality (including kindness, compassion, and a sense of social justice; Helson & Srivastava, 2002), and self-transcendence (Levenson, Jennings, Aldwin, & Shiraishi, 2005), which is defined as the ability to transcend external definitions of the self, as well as biological and social conditioning. In the latter model, individuals who are wise are able to take perspective on their problems, become less angry and upset, feel a sense of connectedness with past and future generations, and are able to see through illusions (McKee & Barber, 1999). No matter how one defines it, the process of coping with stress can result in the development of wisdom—which one could argue is the goal of human development.

SUMMARY The study of coping with stress has progressed a great deal during the past decade. The challenge facing the field is to understand the ways in which individuals cope to creatively solve problems or, better yet, to prevent problems from occurring in the first place (the much-lauded but littleunderstood construct of anticipatory coping). Above all, coping must be seen as a means for human development, whether that development is viewed in terms of mastery, ego integrity, individuation, wisdom, or free will. In order to accomplish this, we must facilitate communication and mutual respect among researchers, clinicians, and, especially, our respondents, who so painfully disclose to us their struggles to cope with problems.

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Index

Index

Page numbers followed by an f or t indicate figures or tables. Abuse, sexual, as trauma, 231–234 Acceptance, coping and, 263–264 Accommodative coping. See coping, accommodative Acquired immunity, 47–50 Acting out, 103t Active coping strategies, 204–207 Active toughening, 335 Adaptation biomedical models of, 17–21, 18f, 21f coping and, 271 coping with trauma and, 223–228 defense mechanisms and, 104–105 differentiation between coping, emotional responses and, 95– 96 free will vs. deterministic models of, 345–346 to illness, 197–201 natural disasters and, 234–235 psychosocial models of, 15–17 psychosocial models of adaptation and, 91–93 transformational coping and, 337 Additive nature of stress, 57–58 Adolescence, 248–249, 282–284

419

Adrenal glands, 39f, 42f, 334. See also Hypothalamic–pituitary– adrenocortical (HPA) axis Adrenaline, 39f Adulthood late life and, 299–303 lifespan perspectives of coping during, 292–296 midlife and, 298 transformational coping and, 315– 322, 349–350 young, coping and, 296–297 Adversity, as type of stress, 25t Affective-impulse regulation, coping and, 105, 106t AIDS, 197–199, 203–204, 306. See also HIV Air quality, as type of stress, 28–29 Allergic reactions, 49–50 Altruism, 103t, 231, 293 Amygdala, memory and, 14 Anabolic/catabolic balance, 44 Anterior lobe, 39f Antibodies, 47, 48 Anticipation, 103t Anticipatory coping, 95–96, 120, 293

420 Anxiety, 5–6, 330 Appraisal of stress, 32–33, 119–120, 251–257 Cognitive, 25t Approach copers, 185, 342 Arthritis, coping and, 187, 203 Asian coping scales, 159–160 Assessment, mental health and, 182– 183 Asthma, 49–50 Asymptotic effects of stress, 58 Attachment, coping and, 274– 277 Attacks, rape, incest, sexual abuse and, 231 Attention, coping and, 111 Attention focusing, coping and, 105, 106t Autonomic nervous system (ANS), 4, 27–28, 38t Avoidance copers, 185, 186–187, 301–302, 342

B B cells, 48, 51 Bar mitvahs, 249 Bargaining, rape, incest, sexual abuse and, 231 Basophils, 47, 48–49 Bat mitvahs, 249 Behavior, 273, 347–348 Benefit finding, 121, 145, 156, 190, 307, 326, 335, 336 Benefit reminding, 325 Bereavement, 26 Beta endorphins, 19 Biomedical models, 2–3, 17–21, 18f, 21f, 93–95 Blunters. See Avoidance copers Body–mind transactions. See Mind– body transactions Buddhism. See Religious coping Buffering mechanisms. See Moderating coping effects Burnout, 262

Index

C Cancer, 204–206, 305–306, 315, 335 Cannon hypothesis, 34 Cardiovascular disease, 38–39, 41, 56–57, 58–59, 206–207 Cartesian dualism, 2–5 Catabolic/anabolic balance, 44 Catastrophization of stressors, 60 Catecholamines, 39f, 334 Causal directionality, 59–62, 189–191 Causal reductionism, 1, 2–5, 5f, 8f CBT. See Cognitive-behavioral therapy (CBT) CD4+ cells, 49, 50, 51, 204 CD8 cells, 50, 51 Cellular immunity, 49–50 Cellular resistance to stress, 52–53 Central nervous system (CNS), 4 Change, statistical absolute, 178 estimation of, 178 Idiothetic change, 178 Ipsative, 178 Mean-level, 178 Children. See also Development coping and, 290–292 divorce and, 285–288 illness and, 288–290 measurement of coping strategies and, 152–153 social aspects of coping and, 243– 245 transformational coping and, 326– 332 Christianity. See Religious coping Chronic role strain. See Role strain Circulatory system, 4 Civilian populations, posttraumatic stress disorder (PTSD) in, 215–216 Clinical coping scales, 151–152, 153–155 Clinical interviews, 80–81 Cognition behavior regulation and, 347–348 children and, 327

Index cognitive reappraisal and, 138 coping and, 96, 105, 106t, 115– 117 emotion-focused coping and, 273 middle childhood and, 280 as neuroendocrine reaction to stress, 42f in reaction to stress, 34–36 Cognitive-behavioral therapy (CBT), 4 Cold, as type of stress, 41 Collectivist cultures, 253–257 Combat, 26, 66, 67t, 213–214 Community, emotion and, 14 Compensation with selective optimization, 303 Competence, 317–319, 348–349 Complexity, 71 Concentration camps, 222–231, 331 Conflict resolution, coping and, 266– 267 Conflicts, 71 Consciousness, 35–36 Contextualism, 17, 342 Conversion, 103t Cool processing, 339 COPE, 129–130 Coping accommodative, 295 assimilative, 295 biomedical models of adaptation and, 93–95 changes in social roles and, 88–91 cognitive approaches to, 115–117 conclusions, 125–126 cultural factors on. See Cultural considerations; Sociocultural stressors development and. See Development differentiation between adaptation, emotional responses and, 95– 96 effects, 161–166 effort, 187–189 individual differences in, 191–192 integrative, 283

421 interactionism and, 8f interventions, 92–93, 189–191 as an intrinsic interest, 86 measurement of. See Measurement of coping strategies mental health and, 180 as mode of ego defense, 106t mythopoetic roots of, 86–88 outcomes and. See Outcomes overview of, 84–85 magical mastery coping 292–293 passive mastery coping 292–293 patterns of, 186–187 as perceptual styles, 110–112 personality and, 112–113 as personality traits, 109–110 person-environment transactions and, 7–9 physical health and. See Illness processes of, 129–134 properties of, 105t psychoanalytic traditions of, 100– 109 psychosocial models of adaptation and, 91–93 recent approaches to, 117–125, 119t reductionism and, 8f research on. See Research considerations situational determinants of, 113– 115 social factors on. See Sociocultural stressors strategy outcome and, 192–193 styles of, 129–134, 147–148 theoretical approaches to, overview of, 98–100 transactionism and. See Transactionism transformational. See Transformational coping with traumatic stress. See Trauma wisdom and, 354–357 Coping Effectiveness Training (CET), 190–191

422 Coronary heart disease (CHD). See Cardiovascular disease Correlational change, 178 Corticosteroids, 39f, 40, 43f, 44, 334–335 Creativity, transformational coping and, 329 Cross-reactivity, 49 cT. See Cytotoxic T cells (cT) Cuban culture, coping and, 260 Cultural considerations. See also Sociocultural aspects of coping African Americans and coping, 260, 261 children and, 277 Botswana culture, coping and, 256 Brahman culture, coping and, 261– 262 British culture, coping and, 251– 252 Chinese culture, coping and, 254– 255, 259 conclusions, 343–344 coping and, 88–91, 257–266 cultural patterning of normative stress and, 248–250 Danish culture, coping and, 254– 255 differences among various ethnic groups and, 259–260 education and, 252, 254 Egyptian culture, coping and, 253, 261 Euro-American culture, coping and, 249, 255, 261, 264, 266 Filipino culture, coping and, 246 Haitian culture, coping and, 260 Hmong culture, coping and, 256– 257 Icelandic culture, coping and, 254– 255 Individualistic cultures, coping and, 253–257 Irish American culture, coping and, 259

Index Israeli culture, coping and, 262 Italian culture, coping and, 259 Japanese culture, coping and, 254– 255, 277 Jewish culture, 249, 256, 259. Korean American culture, coping and, 254 Latino culture, coping and, 261, 266 infancy and, 275 measurement of coping strategies and, 149–152 mental illness and, 15–16 Mexican Americans and, 255 Mexican culture, coping and, 266– 267 Native American culture, coping and, 312 Nepalese culture, coping and, 261– 262 Norwegian culture, coping and, 256 Pacific Island cultures, coping and, 251 problem-focused coping and, 262, 264 puberty rituals and, 249 Puerto Rican culture, coping and, 260–261 resource allocation and, 251–257 Saudi Arabian culture, coping and, 266–267 South African culture, coping and, 256 Southeast Asian culture, coping and, 266 Swedish culture, coping and, 254– 255 Taiwanese culture, coping and, 264, 267 Tamang culture, coping and, 261– 262 Thai culture, coping and, 264, 277 stress and, 245–248 stressors and, 57 toddlerhood and, 277 transactionism and, 7

Index Cumulative nature of stress, 57–58 Cytokines, 49, 51 Cytotoxic T cells (cT), 49

D Daily diaries, 178–180 Daily stressors, 25t, 26, 76–78, 77t, 83, 307 Dangers, appraisal and, 33 Defecation, 46 Defense mechanisms adolescence and, 283 Haan’s taxonomy and, 105t , 106t preschool years and, 278–279 psychoanalytic traditions and, 100–109 Defensive hierarchies, Vaillant, 102– 109, 103t immature, 102–109, 103t mature defense mechanisms, 102– 109, 103t, 293 neurotic defense mechanisms, 102– 109, 103t Delusional projection, 103t Demographics, stress-related growth and, 322–323 Denial, 100–101, 103t, 236, 278– 279, 301 Depression Cartesian dualism and, 4–5 children and, 281, 330 cultural considerations and, 257 late life and, 301 longitudinal analysis of stress and coping data and, 177f socioeconomic status (SES) and, 15–16 stigmatization and, 92 stress effects and, 60 transactionism and, 6 Design issues, stress research and, 57–59 Deterministic model of adaptation, 345–346

423 Development adolescence and, 282–284 conclusions, 290–292, 304 of ego, 104 extreme stress and, 284–290 fetal, 2, 273–274 fetal period and, 273–274 infancy and, 274–277 late life and, 299–303 lifespan perspectives of, 292–296 middle childhood and, 279–282 midlife and, 298 overview of, 271–272, 272–273 preschool years and, 278–279 psychodynamic perspectives of, 313–314 toddlerhood and, 277–278 transformational coping and, 315– 322, 326–332 young adulthood and, 296–297 Diaries, daily. See Daily diaries Direct effects, 162–163, 162f, 168f Disease model of illness, 2–3. See also Biomedical models Displacement, 103t, 278–279 Dissociation, 103t, 230, 302 Distortion, 103t, 236 Distress, coping and, 162f Divorce, 26, 89–90, 285–288 DNA repair mechanisms, 25t, 53 Dual Process Model of coping, 111, 185 Dualism, Cartesian, 2–5 Dualist interactionism, 5 Duration, 25t, 30–31

E Ecological momentary assessments (EMA), 78–79, 135 Economic considerations. See Socioeconomic status (SES) Effector cells, 49 Effects, coping direct, 162–163, 162f, 168f mechanisms of, 161–166

424 Effects, coping (continued) mediating, 163–164, 167–169, 168f, 169f moderating, 164–166, 169–175, 172f, 173f, 174f, 202–204 transactionism and, 344–345 Efficacy, coping, 125, 188, 191–192, 343 Effort, coping and, 187–189, 343 Ego, 104, 106t Ego development, models of 104 Ejaculation, 45 Emic approach to cross-cultural research, 256 Emotion. See also Mental health coping and, 258–262, 273, 295, 301 infancy and, 275 processing/expression of, 183 in reaction to stress, 34–36 reactions to stress and, 25t regulation of, 272–273, 297 stress and, 14 toddlerhood and, 277 Emotional responses, differentiation between coping, adaptation and, 95–96 Employment stress, 26, 32, 72–74, 88–89 Endocrine system. See Neuroendocrine system Endorphins, 19 Environment. See Person– environment transactions Environmental considerations constancy and, 99 demands, 71 goodness of fit and, 17 immune response and. See Immune responses infancy and, 276 as source of stress and, 25t, 26 toddlerhood and, 277–278 transactionism and, 343 Environment–person transactions. See Person–environment transactions

Index Epinephrine, 39f Estimation of change, 178 Etic approach to cross-cultural research, 256 European coping scales, 156–159 Exercise, psychological states and, 6 Experience-sampling (ES) approaches, 134–136 Experiential mode of imputing meaning, 36 External events, 25–31

F Factor structure instability, 136–139 Family life. See also Development; Life events; Marriage adolescence and, 283 coping and, 89–90 measurement of coping strategies and, 150–151 social aspects of coping and, 243– 245 transformational coping and, 328– 332 Fantasy, 103t Fate, 264 joss, 264 karma, 264, 309–310 Feedback, coping and, 120 Fertility, 44 Fetal development, systems biology approach and, 2 Fetuses, coping and, 273–274 Fevers, 46 Fight–flight response, 19, 38–40, 45– 46 Flashback memory, 14, 212, 213 Foreign-language coping scales, 156– 160 Fragmentary processes, 105t, 106t Free radicals, 20, 52–53 Free will model of adaptation, 345– 346, 349–352 Fright. See Fight–flight response Funerals, coping and, 268

Index

G Galvanic skin response (GSR), 41 Gastrointestinal activity, as neuroendocrine reaction to stress, 37, 42f Gender considerations, 218, 239–242 Generalized resistant resources, 317 Genomic science, growth of, 1 German coping scales, 156–158 Glucocorticoids, 39f Goal management, 120, 348–349 Goodness of fit, 17, 185 Granulocytes, 47 GSR. See Galvanic skin response (GSR)

H Hassles, See Daily stressors Heart rate, as neuroendocrine reaction to stress, 41, 42f Heat shock proteins (hsps), 20–21, 25t, 53 Hebrew coping scales, 160 Helper T cells, 49 Heroes, coping and, 86–88 Hierarchical regression equations. See Statistical analyses, coping effects and Hierarchies, defensive, Defensive hierarchies Hinduism. See Religious coping Hippocampus, 14, 43f HIV, 197–199, 203–204, 306 Holocaust, 222–231, 331 Hormones adrenocorticotropic hormone (ACTH), 39f antidiuretic hormone (ADH), 39f estrogen, 44, 45 follicle-stimulating hormone (FSH), 39f growth hormone (GH), 39f luteinizing hormone (LH), 39f luteotropic hormone (LTH), 39f

425 melanocyte-stimulating hormone (MSH), 39f oxytocin, 39f, 45 sex hormones, 44 thyrotropic hormone (TH), 39f Host resistance, 3, 18 Hosts, immune response and, 48 Hot processing, 339 Hsps. See Heat shock proteins (hsps) Humor, 103t, 282–283, 293, 329 Humoral immunity, 48–49 Hunger, as type of stress, 41 Hypochondriasis, 103t Hypothalamic-pituitaryadrenocortical (HPA) axis, 43–45, 43f Hypothalamus, 39f. See also Hypothalamic–pituitary– adrenocortical (HPA) axis Hysteria, coping and, 100–101

I Identification of potential stressors, coping and, 118–119, 119t Illness. See also Immune responses active vs. repressive coping strategies and, 204–207 adaptation to, 197–201 children and, 288–290 conclusions, 207–209 coping and, 87 disease model of, 2–3. See also Biomedical models general observations and, 55–57 late life and, 300 mental. See Mental health outcomes and, 202–207 overview of, 195–197 posttraumatic stress disorder (PTSD) and, 217–220 Immune responses. See also Illness acquired immunity and, 47–50 activation of, 19–20 function of, 26 immune system assays and, 50–51

426 Immune responses (continued) innate immunity and, 46– 47 stress/immune function and, 51– 52 suppression of, 18–19 transformational coping and, 336 trauma and, 217–220 Immunoglobulins, 48–49 IgA, 49 IgD, 49 IgE, 49, 50 IgG, 49 IgM, 49 Incest, as trauma, 231–234 Independence, transformational coping and, 329 Infancy, coping and, 274–277 Initial shock phase of coping with trauma, 222–223 Initiation phase of coping with trauma, 223 Initiative, transformational coping and, 329 Innate immunity, 46–47 Inoculation effect, 316–317 Insight, transformational coping and, 329 Institutions as coping mechanisms, 266–269 Intellectualization, 103t Intensity of stress, 25t Intentionality, 348–349 Interactionist model, 5, 5f, 8f Interests, 13–14, 86 Interleukins, 49 Internal state, strain as, 25 Interpersonal conflict, 30 Intervention, coping skills and, 92– 93, 189–191, 208 Interviews, clinical, 80–81, 107–108, 146 Intrinsic interests, 13–14, 86 Islam. See Religious coping Isolation, 103t

Index

J James–Lange hypothesis, 34 Judaism. See Religious copings

L Laboratory stressors, 81–82 Lazarus hypothesis, 35–36 Legal system, coping and, 266–267 Libertarianism, 346 Life events factors determining stress effects from, 59–61 general observations and, 57–59 stress measurement and, 68–71, 69t as type of stress, 25t, 26, 29–30 Lifespan perspectives of stress and coping, 292–296 Liminal stage of development, 249 Longitudinal analysis, stress and coping data and, 175–180, 177f

M Macrophages, 47, 49 Marriage, 26, 89–90, 268. See also Divorce Mastery, transformational coping and, 317–319 Meaning, 36, 96 Meaning-making, 121–122, 337–338 Measurement of coping strategies conclusions, 144–145 coping styles vs. coping processes and, 129–134 factor structure instability and, 136–139 general vs. specific coping strategies and, 139–140 overview of, 127–129 rating scales and, 141–144 retrospective vs. experiencesampling approaches and, 134–136

Index Measurement of stress choice of, 79–80 defense mechanisms and, 107–108 ecological momentary assessments and, 78–79 hassles and, 76–78, 77t life events and, 68–71, 69t overview of, 62–64, 63f role strain and, 71–76, 72t trauma and, 64–68, 67t Media, coping and, 87 Mediating coping effects, 163–164, 167–169, 168f, 169f Medical procedures, coping and, 199–201 Memory coping and, 303 emotion and, 14 flashbacks and, 14, 212, 213 Memory T cells, 50 Mental health. See also specific conditions assessment/outcome confounds and, 182–183 causal directionality/coping interventions and, 189–191 conclusions, 193–194 coping effort and, 187–189 coping strategy outcome and, 192– 193 cultural considerations and, 257 incest and, 232 individual differences in coping effectiveness and, 191–192 overview of, 181–182 patterns of coping and, 186–187 psychodynamic perspectives of, 314 situational modifiers of coping effects and, 183–186 socioeconomic status (SES) and, 15–16 Microstressors. See Daily diaries Middle childhood, coping and, 279– 282 Midlife, coping and, 298

427 Mind-body transactions, 2–7 Mineralocorticoids, 39f Moderating coping effects, 164–166, 169–175, 172f, 173f, 174f, 202–204 Monitors. See Approach copers Monocytes, 47 Morality, transformational coping and, 329 Motivational approaches to coping, 117, 342, 348–349 Multiplicative nature of stress, 57–58 Multispecificity, 49 Mythopoetic roots of coping, 86–88

N Natural disasters, 26, 65–66, 234– 236 Natural killer (NK) cells, 50, 51 Nazi concentration camps, 222–231, 331 Nervous system, 4, 27–28, 38t Neurobiology, ego development and, 104 Neuroendocrine system biomedical models of adaptation and, 17–21 fight-flight response and, 45–46 general stress reactions and, 37– 41, 39f hypothalamic-pituitaryadrenocortical (HPA) axis and, 43–45 mind-body transactions and, 4 specific stress reactions and, 41– 42, 42f stress and, 25t, 26, 27–28 transformational coping and, 333– 336 Neurotransmitters, 19 Neutrophils, 47 Noise, 26 Nonspecific defenses, 46–47 Noradrenaline, 39f Norepinephrine, 39f, 42f

428 Normative stress, cultural patterning of, 248–250 Numbing, 230 Nutrition, as type of stress, 41

O Observational approach, to measurement of coping strategies, 146 Obsessive-compulsive behaviors, 100–101, 103t Occupational scales, measurement of coping strategies and, 149– 150 Odds ratios, 176 Older adults, 150, 299–303 Onset of stress, 25t, 31 Opponent processes, 26 Organism, state of, 27–28 Osteoarthritis, coping and, 187 Outcomes coping strategies and, 192–193 illness and, 202–207 mental health and, 182–183 prediction of, 176–178, 177f transformational coping and, 336– 340 Overcrowding, 26, 29–30

P Pain, coping and, 199–201 Paradigm shifts, 1 Parasympathetic suppression, 25t, 38t Partial mediation, 168f Passive toughening, 335 Passive–agressive behavior, 103t Perceptual styles, 110–112 Personality coping and, 109–110, 112–113, 147–148, 205 coping and trauma and, 229–230 interactionism and, 8f transactionism and, 8f

Index transformational coping and, 324 wisdom and, 357 Person-based definitions of coping coping as perceptual styles, 110– 112 coping as personality traits, 109– 110 personality and coping and, 112– 113 psychoanalytic traditions and, 100–109 Person–environment transactions, 7– 9, 27, 31–34, 330 Perspective change, transformational coping and, 319–320 Perspiration, as neuroendocrine reaction to stress, 41, 42f Phagocytes, 47 Phases of coping with trauma concentration camps and, 222–231 natural disasters and, 234–236 rape, incest, sexual abuse and, 231–234 Philosophical perspectives of coping, 308–309 Phobias, 103t Physical environment, as type of stress, 25t Physical health. See Illness Physical limitations, coping and, 87 Physiological reactions to stress cellular resistance to stress and, 52–53 conclusions, 343–344 immune response and, 46–52 neuroendocrine responses to stress and, 37–46 transformational coping and, 332– 336 types of, 25t Piloerection, 37–38 Pituitary gland, 39f. See also Hypothalamic–pituitary– adrenocortical (HPA) axis Pollution, 26 Porcine stress syndrome, 39–40

Index Positive thinking, 325–326 Posterior lobe, 39f Posttraumatic growth, as new area of study, 7 Posttraumatic stress disorder (PTSD) coping and, 212–220 immune suppression and, 20 memory and, 14 transformational coping and, 318, 325–326 Poverty. See Socioeconomic status (SES) POWs. See Posttraumatic stress disorder (PTSD); War Prayer. See Religious coping Prediction of outcomes, 176–178, 177f Preschool years, coping and, 278– 279 Preventative coping, 120 Prisoners of War (POWs). See Posttraumatic stress disorder (PTSD); War Proactive coping, 120 Proactive Coping Scale, 119t Problem-focused coping, 186–187, 258, 262–266, 281–282 Process, stress, 25–27, 25t Processes, coping, 129–134 Processing, cool/hot, 339 Projection, 100–101, 103t Projective defense mechanisms, 102– 109, 103t Prolactin, 39f Proteins heat shock, 20–21, 25t, 53 refolding, 20 Pseudo-growth, 325–326 Psychoanalytic traditions of coping, 100–109 Psychodynamic approach to measurement of coping strategies, 146 Psychodynamic perspectives on transformational coping, 313– 314

429 Psychological symptoms. See Mental health Psychoneuroimmunology, 18–21, 18f, 21f Psychosocial models of adaptation, 15–17 Puberty rituals, 248–249

R Range of coping, broadening, 117– 121 Rape, as trauma, 231–234 Rating scales, 141–144, 145–160. See also specific scale titles Rational mode of imputing meaning, 36 Rationalization, 103t Reaction formation, 100–101, 103t Reactive coping, 120 Reactive oxygenating species (ROS), 20, 52–53 Reality, distortion of, 102–103 Reductionism, causal. See Causal reductionism Reflexive–intraceptive function, coping and, 105, 106t Reframing, cognitive, 280 Regression equations. See Statistical analyses, coping effects and Relationships. See Social aspects of coping Religious coping, 123–125, 309–312, 353–354 Repression, 103t, 204–207, 278–279 Research considerations approaches to stress measurement and, 62–64, 63f causal directionality and, 59–62 clinical interviews and, 80–81 conclusions, 82–83 design issues as, 57–59 ecological momentary assessments and, 78–79 general observations and, 55–57 hassles and, 76–78, 77t

430 Research considerations (continued) introduction to, 55 laboratory stressors and, 81– 82 life events and, 68–71, 69t longitudinal analysis of stress and coping data and, 175–180, 177f measure choice and, 79–80 mechanisms of coping effects and, 161–166 researcher bias and, 98 role strain and, 71–76, 72t statistical analyses for testing mediating/moderating coping effects and, 166–175, 168f, 169f, 172f, 173f, 174f trauma and, 64–68, 67t Residualized regression equations, 176 Resiliency, children and, 291, 330 Resistance, host, 3, 18 Resource accumulation, coping and, 118 Resource allocation, 251–257 Resource deprivation, 71–72 Resources, coping, 95, 221, 317, 338–339 Respiratory rate, as neuroendocrine reaction to stress, 41 Restriction of choice, 71–72 Retirement, 250–251 Retrospective sampling approaches, 134–136 Revitalization movements, 268– 269 Rheumatoid arthritis (RA), coping and, 187, 203 Risk management, coping and, 120 Rituals, coping and, 248–249, 267– 268 Role strain, 25t, 30, 71–76, 72t, 74– 76, 88–91 Roles. See Role strain Rosettes. See T cells

Index

S Schizophrenia, 257, 351 Science, shift of to transactionism paradigm, 2 Self-blame, 238, 263–264 Self-destructive behaviors, 181 Self-determination, 350 Self-development, 347–353, 353–354 Self-regulation, 347–353, 353–354 Self-soothing, 283–284 Self-transcendence, 357 Self-understanding, transformational coping and, 321–322 SEM. See Structural equation modeling (SEM) Seniors, 150, 299–303 SES. See Socioeconomic status (SES) Sexual abuse, as trauma, 231–234 Sexual behavior, 45, 253, 282–283 Shell shock. See Posttraumatic stress disorder (PTSD) Sick buildings, as type of stress, 28– 29 Situational determinants of coping, 113–115, 148–149, 183–186 Skeletal system, 332 Social aspects of coping, 122–123 Social character, 90–91 Social considerations, transactionism and, 7 Social context of coping, 242–243, 320–321, 324–325, 328–332, 343–344 Social learning theory, ego development and, 104 Social Readjustment Rating Scale, 69t Social roles, 88–91 Socialization, minority cultures and, 15–16 Sociocultural aspects of coping. See also Sociocultural stressors conclusions, 270, 343–344 culture and coping and, 257–266 culture and stress and, 245–257, 247f

Index institutions and, 266–269 social aspects of coping and, 239– 245 Sociocultural stressors, 25t, 26, 29– 30. See also Sociocultural aspects of coping Socioeconomic status (SES) coping and, 251–257 mental illness and, 15–16 stress measurement and, 74 as type of stress, 26, 29–30 Spirituality, 227, 321–322. See also Religious coping Stage modes of coping, 111 Statistical analyses, coping effects and, 166–175, 168f, 169f, 172f, 173f, 174f Stepwise regression. See Statistical analyses, coping effects and Steroids, 39f Stigmatization, depression and, 92 Strain, 25, 25t Stress appraisal of, 32–33, 119–120, 251–257 biomedical models of adaptation and, 17–21, 18f, 21f children and, 284–290 components of stress process and, 25–27, 25t coping with. See Coping defining, 23–24 emotion/cognition and, 34–36 environment/coping imbalance and, 33 as an external event, 28–31 growth from. See Transformational coping infancy and, 275–277 interactionism and, 8f as an intrinsic interest, 13–14 measurement of. See Measurement of stress normative, 248–250 person–environment transactions and, 7–9, 27, 31–34

431 physiology of. See Physiological reactions to stress psychosocial models of adaptation and, 15–17 reductionism and, 8f research on. See Research considerations as the state of the organism, 27–28 transactionism and, 5–6, 8f types of, 25t Stress-related growth, 11, 305–308, 312, 315, 316, 320–323, 337–338 Stressors catastrophization of, 60 demographic considerations and, 57 identification of potential, 118– 119, 119t laboratory, 81–82 stress process and, 25, 25t transformational coping and, 323 traumatic. See Trauma Structural change, 178 Structural constraints, 71–72 Structural equation modeling (SEM), 79 Styles, coping, 129–134 Sublimation, 100–101, 103t, 293 Suicidal ideation, Cartesian dualism and, 4–5 Support. See also Family life children and, 328–332 coping and, 237, 242–243, 313 cultural factors on, 254 middle childhood and, 280 transformational coping and, 320– 321, 324–325 Suppression, 100–101, 103t Suppressor T cells, 50, 51 Sympathetic activation, 25t, 38–40, 38t, 42f, 334 Systems biology approach, rise of, 1

T T cells, 47, 48–49, 50, 51, 204 Taoism. See Religious coping

432 Tasks, adaptive, 197–199 Technological disasters, 65–66 Television, coping and, 87 Temperament, children and, 327–328 Temporal dimensions of stress, 25t Testosterone, 44 Thai culture, coping and, 264, 277 Thematic Apperception Test (TAT), 292 Threats, 71, 231 Toddlerhood, coping and, 277–278 Torture, 215–216, 222–231 Toughening, 335, 344 Transactionism adaptation and, 346 children and, 331 coping and, 8f, 342–345 defined, 1 mind–body transactions and, 5–7, 5f person–environment transactions and, 7–9, 8f Transactions mind–body, 2–7. See also Biomedical models person–environment, 7–9, 25, 25t, 27 Transformational coping in adulthood, 349–350. See also Adulthood in children, 326–332 Holocaust and, 237–238 models of positive and negative stress outcomes and, 336–340 overview of, 305–308 philosophical perspectives of, 308– 309 physiological development and, 332–336 positive aspects of stress in adulthood and, 315–322 predictors of stress-related growth and, 322–326 psychodynamic perspectives of, 313–314 religious perspectives of, 309–312 wisdom and, 341–342, 354–357

Index Trauma adapting stage of coping with, 223–224 concentration camps as, 222–231 conclusions, 238 coping and, 187–188, 210–211, 220–221 defining, 211–212 differences/similarities of coping and, 236–238 final adaptation stage of coping with, 224 posttraumatic stress disorder (PTSD) and, 14, 20, 212–220 stress measurement and, 64–68, 67t as type of stress, 25t, 26 Tuberculosis, 3

U Uncertainty, 71 Underreward, 71 Undoing, 103t Urination, 46

V Values, transformational coping and, 319–320 Vasopressin, 39f Vectors, 48 Vomiting, 46 Vulnerability, 16–17, 216–217

W War, 66, 67t, 213–214 Ways of Coping Scale (WOCS), 136– 137, 140, 142, 149 Weddings, coping and, 268 Wisdom, 321–322, 341–342, 354– 357. See also Transformational coping Work stress. See Employment stress Workman’s compensation, stress and, 6

Z Zajonc hypothesis, 35–36