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date: 25 February 2020

Stress, Health, and Coping: An Overview

Abstract and Keywords

New technologies, new multidisciplinary approaches, scientific curiosity, and popular demand have all contributed to the growth in the stress, coping, and health research enterprise over the past 30 years. Much of this research originally focused on establishing that stress was in fact harmful to mental and physical health. As these harmful effects became evident, interest grew in coping processes that could mitigate them. Then, in the 1990s, a number of factors converged to generate interest in resilience and well-being in the face of stress. The scope of coping expanded accordingly, and new forms of coping that generated and sustained resilience and well-being were identified and explored. The chapters in this volume are written by leaders in the field who offer authoritative reviews and provocative critiques of where the field is now and exciting previews of new directions in which stress and coping research is headed.

Keywords: Stress, coping, resilience, new directions

The research literature on psychological stress, coping, and health is impressive in its breadth, depth, and complexity. Scientists are exploring the causes and manifestations of stress at every level of analysis, from the micro levels of the genome and cell to the macro levels of culture and society. The continuous and rapid development of new technologies and the concurrent emergence of new multidisciplinary fields of inquiry open the way to new theoretical models, new hypotheses, and new discoveries.

And there is a ready market for these new research findings: a public that has an insatiable appetite for information and advice about how to cope with the stress that pervades daily life. A Google search showed approximately 1.4 million entries for “self-help books on coping.” A similar search at Amazon.com showed approximately 2,100 book titles. Although these self-help books, as well as magazine articles, DVDs, blogs, and other media, are all well intended, many are simplistic and uninformed by science.

Background

Two central themes characterize much of the research literature on psychological stress: (a) the wear and tear of stress on mental and physical health and (b) well-being and resilience in the face of stress. The first theme dominated the field for about 30 years, beginning with the publication of Richard Lazarus’ seminal book Psychological Stress and the Coping Process (Lazarus, 1966). Research during those years produced substantial evidence of undesirable outcomes associated with stress. The stress of bereavement, for example, was shown to be associated with documented increases in morbidity (p. 4) and mortality (Stroebe & Stroebe, 1987); the stress of caregiving was shown to be associated with deleterious effects on immune functioning (Kiecolt-Glaser et al., 1987); and anger and hostility, emotions often experienced in stressful situations, were shown to have harmful effects on the cardiovascular system (Booth-Kewley & Friedman, 1987). More recently, as several chapters in this volume attest, attention has turned to the genetic, biological, psychological, and social mediating pathways through which stressful life circumstances take their toll on mental, social, and physical functioning.

Interest in how to mitigate the harmful effects of stress, otherwise known as coping, followed quickly. Questions initially dealt with how to conceptualize coping (Coelho, Hamburg, & Adams, 1974). It was viewed as a mature defense mechanism (Vaillant, 1977), as a stable aspect of personality (Miller, 1987), and as a dynamic process shaped by situational demands and the person’s resources for coping (Folkman & Lazarus, 1980). Regardless of how coping was conceptualized, these earlier approaches shared a concern with the regulation of negative emotions and distress. The study of well-being and resilience in the face of stress during this period was confined largely to the literature on children (e.g., Murphy, 1974).

The picture changed in the 1990s when a dramatic increase of interest in stress-related resilience signaled a new phase of exploration across the social and behavioral sciences (Bonnano, 2009). Processes that contribute to the maintenance of well-being during stressful situations as well as processes that contribute to recovery in the aftermath became popular topics at conferences and in journals. Ideas came from the emerging area of positive psychology (Seligman & Csikszentmihalyi, 2000), growing recognition of the human capacity to find benefit (Affleck & Tennen, 1996) and grow in the face of stress (Tedeschi, Park, & Calhoun, 1998), and heightened awareness of the benefits of positive emotions (Fredrickson, 1998) and their role in the stress process (Folkman, 1997). As will be evident in the chapters that follow, our understanding of stress and coping processes is broadened significantly by addressing both themes.

Organization

This volume is organized in six sections: developmental perspectives on stress and coping; social aspects of stress and coping; models of stress, coping, and positive and negative outcomes; coping processes and positive and negative outcomes; assessing coping; new technologies and concepts; and coping interventions. The titles of the sections suggest distinct content, but as will be evident, the discussions in each chapter often cross content areas. The final chapter synthesizes the discussion, offers comments, and suggests directions for future research.

Developmental perspectives on stress and coping

Stress is experienced at every age, and at every age individuals try to cope with it. Developmental perspectives are essential for understanding how stress and coping processes change from childhood through old age.

Carolyn Aldwin (Chapter 2) views stress and coping processes in terms of trajectories over the life span. Aldwin has three goals in her chapter: to examine how stress processes change over the lifespan, how coping processes change, and whether vulnerability to stress varies systematically at different life stages. She points out that stress, coping, and health reflect life-long processes that develop or change through all phases of life as a result of biological factors, individuals’ behaviors, and socio-contextual influences. Aldwin’s review addresses interesting questions concerning changes in the content and frequency of three categories of stressors—traumas, major life events, and hassles—from early childhood through older ages. These changes, Aldwin argues, reflect the sociocultural and socioenvironmental circumstances of the individual’s life. In contrast to changes in stressors, Aldwin believes that changes in coping have to do with changes in the individual’s own skills and capacity for learning. Aldwin also provides an overview of the history of stress and coping theory and measurement that serves as a good framework for the chapters in this volume.

Ellen Skinner and Melanie Zimmer-Gembeck (Chapter 3) focus on the concept of perceived control. Low perceived control is associated with vulnerability and helpless ways of coping at every age. Young children with low perceived control show less persistence, focus, and concentration on difficult tasks, try out less sophisticated hypothesis testing strategies, and stop working on the tasks as soon as possible and select easier future tasks. Children high in perceived control, in contrast, are oriented towards mastery of difficult tasks, which Skinner and Zimmer-Gembeck refer to as mastery-oriented coping. Skinner and Zimmer-Gembeck discuss how mastery-oriented and helpless ways of coping may change in their form across infancy, childhood, adolescence, adulthood, and old age; how the development of perceived control may contribute (p. 5) to qualitative shifts in how coping is organized as people age; and how coping itself may constitute a proximal process that shapes the development of perceived control. The authors use a multilevel approach and highlight the importance of social contexts, relationships, and partners in shaping both coping and perceived control.

Skinner and Zimmer-Gembeck distinguish three types of control: regulatory beliefs that guide actions, including coping; strategy beliefs, or generalized expectancies about the effectiveness of certain causes (such as effort, ability, powerful others, luck); and capacity beliefs, or generalized expectancies about the extent to which the self possesses or has access to potentially effective causes. The authors discuss the development of these beliefs from childhood to young adulthood. In the final section of their chapter, Skinner and Zimmer-Gembeck discuss the reciprocal relationship between perceived control and coping, noting that the ways people cope “is the grist from which perceptions of control are shaped.”

Social aspects of stress and coping

The individual who experiences stress and engages in coping does so within a complex social context. At the macro level, societal factors influence the stress process—for example, by affecting stress exposure or social expectations regarding male and female coping behavior; these gender differences can further be influenced by biology. At the micro level, stress is often interpersonal in its origin, and the subsequent coping processes between or among the involved parties are intricate and highly dynamic.

Vicki Helgeson (Chapter 4) asks a fundamental question: Do the harmful effects of stress differ for men and women, and if so, in what ways? She begins by exploring the sources of observed sex differences in stress, including gender differences in exposure to various types of stressors, differences in gender roles, and gender differences in the encoding and recall of stressful events. Helgeson moves on to explore gender differences in health outcomes and whether they are associated with gender differences in stress exposure or gender differences in vulnerability; she then shifts to gender differences in coping and its relationship to health. The review indicates a number of gender differences in coping, with an overall difference being that women generally report doing more of most types of coping. Helgeson highlights a challenging conundrum, namely that sex differences in coping are inherently confounded with other variables such as status, gender roles, and social roles, and that these variables also affect the relationship between coping and health.

Shelley Taylor (Chapter 5) explores affiliative responses to threat, which Taylor and her colleagues refer to as Tend and Befriend theory. At the heart of this theory is the assumption of a biological signaling system that is activated when the individual’s affiliations fall below an adequate level, a condition that can occur in response to stress.

An appealing characteristic of the Tend and Befriend thesis is its relevance at multiple levels of analysis. For example, affiliating with others serves to calibrate the biological stress systems that regulate responses to stress across the lifespan. It also affects the regulation of the stress response on an acute basis, and serves several practical functions with respect to stress. Taylor discusses the role of brain opioids, including oxytocin and endogenous opioids peptides, in the mitigation of separation distress. Taylor also explores possible genetic pathways that are just now being identified. Taylor returns to the social support literature and uses Tend and Befriend theory to explain the seemingly contradictory finding that having a strong social network appears to be beneficial, whereas actual support transactions are often not. She suggests the interesting hypothesis that the beneficial effects of social networks may be “a basic biopsychosocial process that depends heavily on proximity and/or awareness of others’ availability more than on the explicit social support transactions that have been so widely studied.”

Tracey Revenson and Anita DeLongis (Chapter 6) tackle the complex topic of dyadic coping, highlighting both societal influences and interpersonal processes. They have chosen to examine the chronic physical illness of one partner in order to understand couples coping processes more generally. Revenson and DeLongis state that dyadic coping recognizes mutuality and interdependence in coping responses to a specific shared stressor, such that couples respond to stressors as interpersonal units rather than as individuals in isolation. They review theoretical frameworks of dyadic coping, setting them in their historical context within individual stress and coping models. They turn to the empirical literature on couples coping with illness to examine which models have been supported and where there are gaps. Central to all frameworks is the influence of gender and social role on couples coping. The authors also discuss “relationship-focused coping,” cognitive and behavioral efforts to manage and sustain social relationships during stressful episodes. (p. 6) “Maintaining relatedness with others,” argue Revenson and DeLongis, “is a fundamental human need, as fundamental to coping as is emotion or problem management.” Relationship-focused coping involves efforts to maintain a balance between self and other, with the goal of maintaining the integrity of the marital relationship above either partner’s needs. The chapter concludes with an informative review of the current state of methodology for studying couples coping and challenges for the next generation of research.

Models of stress, coping, and positive and negative outcomes

A fascinating theme in the current literature is how people maintain well-being while they make their way through profoundly stressful situations, coping with intense distress and attending to instrumental demands. Whether early in each chapter’s discussion or towards the conclusion, the chapters in this section all call for models that address both aspects of the stress process. The fact that these models are formulated in settings that differ markedly from each other reinforces their relevance to the stress process across settings.

Stevan Hobfoll (Chapter 7) has developed Conservation of Resources (COR) theory, which he describes in this chapter. COR considers both the costs of stress and the processes associated with resilience, described in terms of alternating (and sometimes concurrent) cycles of resource gains and resource losses. Resources refer to those things that are universally valued, such as health, well-being, peace, family, self-preservation, and a positive sense of self. Hobfoll places great importance on environmental conditions that foster and protect the resources of individuals, families, and organizations, or that impoverish people’s resource reservoirs.

COR theory has been supported in a wide range of studies, including a program of research in Israel on the Al Aqsa Intifada and the effects of terrorism. Hobfoll makes an interesting distinction between resistance and resilience. A resistance trajectory was defined as having no more than one symptom of depression and no more than one post-traumatic stress (PTS) symptom at either of two time points. A resilience trajectory was defined as having symptoms of depression or PTS at the outset and becoming relatively free of symptoms over the period of study. A sizeable minority of study participants fell in each of these two groups. Hobfoll’s discussion of resilience centers on the concept of engagement, which is related to discussions of meaning in later chapters. He and his colleagues found that depression and engagement were not highly related, showing that people can stay committed and involved in life tasks, even in the midst of significant exposure to trauma and stressful environmental conditions. This theme, too, is relevant to discussions in later chapters. Hobfoll also reports finding post-traumatic growth positively correlated with PTS symptoms in several, although not all, studies. Hobfoll’s discussion of societal dimensions in relation to these findings is illuminating and provocative.

Margaret Stroebe (Chapter 8) studies bereavement. Stroebe begins by examining bereavement’s health consequences, the question of what constitutes adaptive coping, and the links between coping and health. Stroebe’s discussion illustrates the importance of critical review. In her discussion of risk factors for morbidity and mortality, she highlights fundamental methodological challenges and quagmires that can lead to erroneous conclusions; she reviews evidence that refutes convictions about desirable responses to bereavement held during the latter part of the 20th century, such as convictions that “grief work,” social sharing, emotional disclosure, and the seeking of social support are important for overcoming the impact of bereavement. She also points to evidence that challenges widely held convictions about the detrimental effects of processes such as denial, repression, and avoidance.

Stroebe includes a review of the strengths and weaknesses of theoretical models of bereavement, and concludes with a description of the Dual Process Model (DPM) she developed with her colleague, Henk Schut. The model is organized around two stress and coping themes: “Loss-orientation,” which refers to the bereaved person’s processing of some aspect of the loss experience itself, and “Restoration-orientation,” which refers to the focus on secondary stressors that are also consequences of bereavement. The model allows for full exploration of both past- and future-oriented bereavement-related coping and the processes through which people can address both stress-related harms and the restoration of their well-being. The DPM model has been translated into intervention, and results are promising. Stroebe assigns great importance to coping interventions for bereavement: “even though one cannot change the harrowing reality of the death of a loved one, it is possible to influence the ways that bereaved persons cope with and appraise their loss, and intense suffering can thereby hopefully be lessened.” This statement is broadly generalizable, as will be become evident throughout this volume.

(p. 7) Alex Zautra and John Reich (Chapter 9) describe a generic model of resilience in the face of stress that takes into account both positive and negative domains of experience. Referring to the recent interest in positive states under conditions of stress, the authors state: “This new paradigm has raised stress and coping approaches into a framework that models the extent to which personal strengths and other psychosocial resources contribute to the prediction of resilience, independent of the catalogue of risks and vulnerabilities identified within the person and his or her social network.” Zautra and Reich refer to this as a resilience model of well-being. Their model specifies three features of resilience: recovery that is swift and thorough; sustainability of purpose in the face of adversity; and growth, or new learning.

Zautra and Reich argue for the importance of assessing both positive and negative domains of life experience in order to examine the independent effects of positive events over and above the effects of stressful negative events. Zautra and Reich apply the resilience model to organizations and the neighborhood and community, creating a natural complementarity to Hobfoll’s perspective.

Michele Tugade (Chapter 10) continues in the dual process mode by distinguishing two distinct though interacting process models of coping. One model focuses on the intersections between positive and negative emotions, and the other model focuses on the interplay between automatic and controlled processes. Both models explore the mechanisms that promote resilience in the midst of short-term and long-term stressors in one’s life. Although the issue of automatic versus controlled processes has long been a topic of discussion in the appraisal literature (e.g., Scherer & Ellsworth, 2009), where the issue of the role of subconscious appraisals, or appraisals below the level of awareness, versus appraisals that can be self-reported is often debated, it is not often discussed in relation to coping as Tugade does in this chapter. For example, Tugade points out that positive affect can be activated automatically in the midst of a stressful experience, helping to downregulate the negative experience. She focuses in particular on sensory experiences that can activate positive affect, such as when the feel of warmth from a cup of tea soothes an individual, and interrupt the trajectory of the stressful episode. Tugade reports evidence for the comparative physiological benefits of automatic versus controlled emotion regulation and suggests that with practice, controlled processes can become automatic.

Sonja Lyubomirsky (Chapter 11) concludes this section with a theoretical model of hedonic adaptation that explains the process through which people adapt to the positive as well as negative emotional effects of situations. Lyubomirsky frames her discussion with the Hedonic Adaptation to Positive and Negative Experiences (HAPNE) model developed with her colleague, Ken Sheldon. In the HAPNE model, initial gains in well-being associated with a positive life change or drops in well-being associated with a negative life change erode over time via two separate paths. The first path specifies that the stream of positive or negative emotions resulting from the life change may lessen over time, reverting people’s happiness levels back to their baseline. The second path specifies that the stream of positive or negative events resulting from the change may shift people’s expectations about the positivity (or negativity) of their lives, such that the individual now takes for granted circumstances that used to produce happiness or is inured to circumstances that used to produce unhappiness.

According to Lyubomirsky, people can control the extent and speed of their hedonic adaptation by developing and practicing relevant skills. Using several “happiness interventions” as illustrations, Lyuobomirsky describes how effortful strategies and practices can instill new ways of thinking and behaving and thereby preserve well-being in the context of stress and trauma, producing potentially lasting increases in well-being in their absence. In an interesting segue to the next section, Lyubomirsky refers to research that shows trying to make sense of a positive event hastens adaptation; the individual can slow down the adaptation process by savoring without trying to explain it. Conversely, it is better to try to make sense out of negative events; it helps cool the negative emotions.

Coping processes and positive and negative outcomes

A logical next step is to learn more about coping processes that sustain well-being and resilience in addition to coping processes that regulate distress. The chapters in this section address both types of coping, but the emphasis is on the more recently defined arena of coping processes that sustain well-being and resilience in the face of stress. Within this arena, meaning-making has emerged as a dominant theme. The discussions review ways of conceptualizing coping in relation to meaning-making.

Crystal Park (Chapter 12) describes meaning in terms of global meaning (what individuals believe (p. 8) and desire) and situational meaning (what is happening in the stressful context). Individuals experience stress when they perceive a discrepancy between the two levels of meaning. The discrepancy motivates individuals to reconcile the discrepancy through coping processes such as modifying the situational meaning through reappraisal processes, social comparisons, goal substitutions, or problem-solving. The meaning-making process should lead to better adjustment to the extent that it produces a satisfactory product, meaning made.

Park’s review indicates the adjustment of those who try unsuccessfully to make meaning is poor compared with those who are successful in meaning-making and those who do not engage in meaning-making to begin with. However, Park states that more sophisticated research is needed, including better measurement of meaning-related constructs, improved research designs, further specification of the content of global beliefs, interpersonal aspects of meaning-making, and the use of interventions.

Kenneth Pakenham (Chapter 13) provides a comprehensive discussion of benefit-finding and sense-making. Benefit-finding refers to finding benefits in adversity, whereas sense-making involves the development of explanations for adversity. Pakenham’s review illustrates the many levels in which each of the meaning-based coping processes must be considered. He begins with theory, moves through measurement, observational research at the individual level, followed by research at social and community levels, and concludes with intervention. Pakenham also reviews theoretical frameworks that have specified roles for benefit-finding and sense-making. The wealth of theories illustrates the many ways in which scholars from diverse perspectives think about these aspects of meaning.

For his own research with multiple sclerosis patients, Pakenham developed theory-based multidimensional scales for sense-making and benefit-finding. While improved measurements appear to resolve certain questions, they also tend to uncover new ones. For example, Pakenham reflects on a question discussed in the literature about how we determine the validity of self-reported benefits: Are they real or are they imagined? These issues notwithstanding, Pakenham provides a highly informative review of the literature on benefit-finding and sense-making and health at the individual level, the interpersonal level, and the community level and in relation interventions.

In his fascinating discussion of religion and coping, Kenneth Pargament (Chapter 14) points out that although there are many parallels between the religious and non-religious coping literatures, religious coping has its own special qualities.

Pargament defines religion as “a search for significance in ways related to the sacred,” and its role in the stress process is determined by the availability of religion and perceptions that it can offer compelling solutions. Pargament defines these concepts and offers an excellent review of the relevant literatures. Although religion can be involved in every facet of the stress process, it has a particularly powerful role following crises because, Pargament observes, it offers responses to the limits of personal power, or the problem of human insufficiency. But the use of religion for coping does not always lead to improved outcomes. Pargament reviews the conditions under which religion is beneficial and when it is not. The discussion of religious struggle that can ensue when life events challenge or shatter existing beliefs is of special relevance to the whole issue of meaning-making in the face of profound stress. Pargament also includes a section on clinical interventions that integrate spirituality.

Gail Ironson and Heidemarie Kremer (Chapter 15) discuss many facets of the coping process within the setting of HIV/AIDS. This setting is of great interest because it represents coping with what is now a chronic, serious illness. They present a Functional Components Approach to stress and coping, which addresses three components of the stress and coping paradigm: the stressor, the self, and the reaction of the self to the stressor. This is followed by a review of the HIV coping literature organized by approach and avoidant coping, cognitive coping, coping styles, social support, and nonspecific stress-reducing activities. In their final section Ironson and Kremer provide an overview of spirituality and coping with HIV in relation to appraisal, coping, physical health, and psychological health, and they also review spiritually oriented coping interventions for people with HIV. They emphasize how spiritual coping gives the individual more options and choices about how to see and deal with stressful situations.

Carsten Wrosch (Chapter 16) focuses on a central aspect of meaning, goals. He notes that “goals are important because they are the building blocks that structure people’s lives and imbue life with purpose, both in the short run and on a long-term basis …goals motivate adaptive behaviors, direct patterns of life-long development, and contribute to defining a person’s identity.” But there are times goals cannot be attained, and Wrosch devotes this chapter to the (p. 9) important subject of the self-regulation of unattainable goals.

Wrosch’s review of theoretical models on the self-regulation of unattainable goals distinguishes two broad categories of responses: goal engagement processes through which the person continues to invest time and effort in pursuit of a threatened goal, and the exact opposite response—abandoning the threatened goal, managing the emotional consequences of failure, and engaging in other meaningful goals. Overall, the literature shows that goal disengagement and goal reengagement capacities are independent constructs. Goal disengagement capacities are associated with reduced levels of negative aspects of well-being such as negative affect or depressive symptoms, while goal reengagement capacities are more closely associated with positive aspects of subjective well-being such as positive affect or purpose in life. These two processes exemplify the two overarching themes in stress and coping research described earlier: mitigating stress-related harm and sustaining positive well-being.

Lisa Aspinwall (Chapter 17) discusses proactive coping, which refers to anticipating and/or detecting potential stressors and acting in advance either to prevent them altogether or to mute their impact. Proactive coping blends coping with self-regulation, the processes through which people control, direct, and correct their own actions as they move toward or away from various goals. Aspinwall reviews research in new domains of application for the proactivity concept, such as the management of stigma and discrimination, predictive genetic testing for familial disease, health promotion, and the management of chronic illness. She also describes what is known about those who undertake proactive coping efforts, what determines whether such efforts will be successful and whether and in what ways the potential for proactive coping may differ across different situations. Aspinwall also includes a review of recent developments in the study of future-oriented thinking to help understand whether, how, and with what success proactive coping efforts may be undertaken, as well as the kinds of goals that people seek to manage proactively.

Assessing coping: new technologies and concepts

The coping measures developed during the 1970s and 1980s reflected the diversity of conceptualizations of coping that characterized that period. Vaillant (1977) used qualitative analysis and clinical judgment to evaluate ego processes, with mature processes defined as coping. Miller (1987) developed a measure of a coping style, monitoring and blunting, that was an aspect of personality. Most of the other new measures approached coping contextually by asking the thoughts and behaviors people used to cope with specific stressful encounters. These measures were multidimensional, the number of dimensions and their content based in part on theory and in part on empirical factor analysis—for example, the COPE (Carver, Scheier, & Weintraub, 1989), the Coping Inventory for Stressful Situations (Endler & Parker, 1990), the Coping Strategies Indicator (Amirkhan, 1990), and the Ways of Coping (Folkman & Lazarus, 1980).

It is probably safe to say that most researchers in the field of stress and coping share a frustration with the vast majority of coping assessment tools that are currently available. The chapters in this section describe advances in assessment that are responses to shortcomings in existing measures. These chapters serve as models for how to develop coping measures that produce interpretable, theoretically relevant data. (See also Pakenham, Chapter 13, for another example.)

Annette Stanton (Chapter 18) observed that many of the earlier measures of emotion-focused coping were seriously flawed because they tended to confound coping with outcomes. Her response was to conceptualize Emotional Approach Coping (EAC), which addressed the confounding problem by focusing on emotion regulation in terms of two dimensions: processing emotion and expressing emotion. Stanton expended great effort in developing a valid and reliable measure of EAC and its two emotion-regulating functions, paying meticulous attention to theoretical relevance and psychometric characteristics.

Stanton used the EAC measure in a number of studies, first testing the direct effects of EAC. She and her colleagues, as well as other researchers, conducted a number of cross-sectional and longitudinal studies that showed beneficial effects of emotion expression in diverse settings. The benefits of emotion processing were less obvious. Stanton then asked about the moderating effects of attributes of the individual and environment, and in a further elaboration of the model, she asked about possible pathways through which EAC might promote positive outcomes. Her chapter thus illustrates the full developmental process, from diagnosis of the weaknesses of available measures, to the careful development and application of a new measure in studies of direct effects, which lead to further elaboration (p. 10) of moderators and mediating pathways of the underlying theoretical model.

Mark Litt, Howard Tennen, and Glenn Affleck (Chapter 19) take on a very different measurement challenge: capturing the dynamic quality of coping. They point out that although coping was initially construed as dynamic and transactional in nature, most models of coping have been unidirectional and have treated coping as a static outcome of the constituent factors. The authors provide an incisive review of diverse approaches to the assessment of coping, distinguishing clearly among methodologies and enumerating their limitations. The review highlights the dearth of attempts to assess the transactional nature of the stress process in which each variable influences the other: appraisal and coping influence outcomes that in turn influence subsequent appraisals and coping. But new technologies for daily and momentary assessment, allied with multilevel statistical techniques, now allow a more detailed understanding of how coping works. The authors describe several promising applications of near-real-time ambulatory assessment and intensive micro-longitudinal study designs, including novel applications in the areas of gene–stress interactions and coping vulnerability and resilience as “behavioral signatures.” The authors then move on to discuss the adaptation of intensive measurement of coping to understanding mechanisms of treatment. Drawing on interventions in the contexts of addiction and pain, the authors review studies that test the effects of coping interventions on coping skills and the relationships between coping skills and outcomes. The issues that can be addressed with the methodologies that Litt et al. summarize are at the center of questions about the actual role of coping in the stress process.

Coping interventions

Ultimately, research should lead to clinical interventions that help people manage stress and improve their well-being. The chapters in this section provide examples of theory-based interventions that illustrate the translation from theory and research into practice, and the daunting complexity involved in understanding what transpires during a coping skills intervention and how it affects outcomes.

Judith Tedlie Moskowitz (Chapter 20) offers a comprehensive review of coping interventions that emphasize the regulation of positive affect. The deliberate manipulation through intervention will be key to determining whether positive states actually are protective during periods of stress. This chapter is a valuable resource for researchers who want to pursue this line of inquiry. The substantial array of interventions Moskowitz reviews is evidence of the recent heightened interest in positive states during stress, also reflected in a number of chapters in this volume (e.g., Hobfoll, Chapter 7; Zautra and Reich, Chapter 9; Tugade, Chapter 10; Park, Chapter 12; Pakenham, Chapter 13; Pargament, Chapter 14). Moskowitz discusses single-component and multicomponent interventions. Examples of components include positive events and savoring, acts of kindness, positive reappraisal, setting attainable goals, focusing on personal strengths, loving-kindness meditations, forgiveness, and laughter. Moskowitz clarifies issues regarding measurement of affect, with special attention to high- versus low-activation affects, and discusses design issues that need to be addressed in future studies. Overall, it appears that the positive coping interventions do foster well-being and are acceptable to participants.

Michael Antoni (Chapter 21) studies stress, coping, and coping intervention in the context of HIV/AIDS. As noted earlier with respect to the chapter by Ironson and Kremer, stress and coping processes are pertinent throughout the course of HIV disease. For example, the initial transmission of HIV is through behaviors that are often maladaptive responses to stress; stress affects the compromised immune system; stress is caused by treatment side effects; and there is interpersonal stress associated with disclosure of an HIV-positive serostatus. Antoni’s group developed CBSM, a 10-week, group-based stress-management program that combines anxiety-reduction techniques with cognitive-behavioral techniques (CBT) to help manage the stress associated with HIV disease. Antoni uses this intervention to examine psychosocial and biobehavioral mechanisms that can explain the effects of stress and coping interventions on health outcomes in persons with HIV. Studies of CBSM, and findings from other CBT-based interventions, show improved mental health outcomes in persons with HIV. Further, participants in CBT-based interventions who show psychological effects also demonstrate changes in endocrine and immunological parameters. Antoni’s discussion illustrates the benefits of working with a clinical condition that is well characterized at multiple levels of analysis, and of having a truly interdisciplinary approach to investigating the effects of interventions on diverse pathways through which stress and coping can affect health.

(p. 11) In Chapter 22, I synthesize findings, offer my own opinions, and suggest where researchers might want to focus their attention next.

Conclusion

The chapters in this volume address diverse aspects of the stress process, from antecedents of stress appraisals to the health-related outcomes of coping. The authors are leading researchers in the field, and the perspectives they share are expansive and well informed. The voices of the authors are varied, but the content forms a coherent narrative about stress, health, and coping punctuated with fascinating questions waiting to be addressed.

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