There Shan App to Strand Tra

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free ebooks ==> www.ebook777.com The Resilience Handbook

How are people and communities able to prevail despite challenge? What helps them bounce back from adversity and even grow in knowledge and understanding? And can this resilience be taught? During the past decade, exciting scientific advances have shed light on how resilience operates from neurons to neighborhoods. In The Resilience Handbook, experts in the science of resilience draw on human and animal research to describe the process of resilience and follow its course as it unfolds both within individuals and in social networks. Contributors also highlight the promise of new interventions that apply what we know about resilience processes to bolster positive health, and raise some of the pressing questions and issues for the field as it matures. This handbook is designed to be used by students as an invitation to a burgeoning field; by researchers, as a framework for advancing theories, hypotheses, and empirical tests of resilience functions; and by clinicians, as a comprehensive and up-to-the-minute integration of theory and practice. Martha Kent is a research scientist at the Phoenix VA Health Care System and a member of the Resilience Solutions Group at Arizona State University. Mary C. Davis is a professor in the department of psychology at Arizona State University and a member of the Resilience Solutions Group. John W. Reich is an emeritus professor of psychology at Arizona State University and the coeditor of the Handbook of Adult Resilience.


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The Resilience Handbook Approaches to Stress and Trauma

Edited by

Martha Kent, Mary C. Davis, and John W. Reich

free ebooks ==> www.ebook777.com First published 2014 by Routledge 711 Third Avenue, New York, NY 10017 Simultaneously published in the UK by Routledge 27 Church Road, Hove, East Sussex BN3 2FA © 2014 Taylor & Francis Routledge is an imprint of the Taylor & Francis Group, an informa business The right of the editors to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging in Publication Data The resilience handbook : approaches to stress and trauma / edited by Martha Kent, Mary C. Davis, and John W. Reich. pages cm Includes bibliographical references and index. 1. Resilience (Personality trait) 2. Stress (Psychology) I. Kent, Martha (Research scientist) II. Davis, Mary C. editor of compilation. III. Reich, John W., 1937- editor of compilation. BF698.35.R47R47117 2013 155.2'4—dc23 2013008550 ISBN: 978–0–415–69987–7 (hbk) ISBN: 978–0–415–81883–4 (pbk) ISBN: 978–0–203–13530–3 (ebk) Typeset in Galliard by Swales & Willis Ltd, Exeter, Devon

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free ebooks ==> www.ebook777.com Contents

List of Contributors Acknowledgments Introduction

viii xi xii

SECTION 1

Resilience as Adaptive Process to Stress and Trauma Part A: Resilience as Biobehavioral Adaptation 1 Seeking and Loss in the Ancestral Genesis of Resilience, Depression, and Addiction

1

3

JAAK PANKSEPP

2 The Roles of Predictive and Reactive Biobehavioral Programs in Resilience

15

MATTIE TOPS, PHAN LUU, MAARTEN A. S. BOKSEM, AND DON M. TUCKER

3 Approach/Engagement and Withdrawal/Defense as Basic Biobehavioral Adaptations: Resilient Transcendence of a Popular Duality 33 MARTHA KENT

4 Introduction to Allostasis and Allostatic Load

44

GRETA B. RAGLAN AND JAY SCHULKIN

Part B: Resilience as Intrapersonal Process 5 The Automatic Basis of Resilience: Adaptive Regulation of Affect and Cognition

53 55

SUSANNE SCHWAGER AND KLAUS ROTHERMUND

6 The Regulatory Power of Positive Emotions in Stress: A TemporalFunctional Approach CHRISTIAN E. WAUGH

73

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Contents

7 Responding to Trauma and Loss: An Emotion Regulation Perspective

86

MATTHEW TYLER BODEN, MADHUR KULKARNI, ASHLEY SHURICK, MARCEL O. BONN-MILLER, AND JAMES J. GROSS

8 Music as an Agent of Resilience

100

DONALD A. HODGES

Part C: Resilience as Interpersonal Process 9 Oxytocin and Attachment Facilitate a Shift From Seeking Novelty to Recognizing and Preferring Familiarity: The Key to Increasing Resilience?

113

115

MATTIE TOPS, FEMKE T. A. BUISMAN-PIJLMAN, AND C. SUE CARTER

10 Social Touch and Resilience

131

MARY H. BURLESON AND MARY C. DAVIS

11 Empathy and Resilience in a Connected World

144

GRIT HEIN

12 An Attachment Perspective on Resilience to Stress and Trauma

156

MARIO MIKULINCER AND PHILLIP R. SHAVER

13 Using the Caregiver System Model to Explain the Resilience-Related Benefits Older Adults Derive From Volunteering

169

STEPHANIE L. BROWN AND MORRIS A. OKUN

Part D: Resilience as Social Process

183

14 Resilience Is Social, After All

185

ALEX J. ZAUTRA

15 Developmental Social Factors as Promoters of Resilience in Childhood and Adolescence

197

BEKH BRADLEY, TELSIE A. DAVIS, JOANNA KAYE, AND ALIZA WINGO

SECTION 2

Resilience Interventions Part A: Activating Interventions 16 Behavioral Activation as a Treatment for Depression: Theory, Neurobiologic Effects, and Potential Linkages to Resilience GABRIEL S. DICHTER, MORIA SMOSKI, ROSELINDE K. HENDERSON, AND SONA DIMIDJIAN

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209

211

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17 Resilience Training for Action and Agency to Stress and Trauma: Becoming the Hero of Your Life

227

MARTHA KENT AND MARY C. DAVIS

Part B: Intrapersonal Interventions

245

18 Different Strokes: Empathy, Individual Characteristics, and Helping

247

ALICIA J. HOFELICH AND STEPHANIE D. PRESTON

19 Forgiveness Interventions and the Promotion of Resilience Following Interpersonal Stress and Trauma

256

NATHANIEL G. WADE, JERITT R. TUCKER, AND MARILYN A. CORNISH

20 Resilience Interventions With a Focus on Meaning and Values

270

CRYSTAL L. PARK AND JEANNE M. SLATTERY

Part C: Interpersonal Interventions

283

21 The Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Model: A Treatment Approach to Promote Resilience

285

CHRISTINA M. HASSIJA AND MARYLENE CLOITRE

22 Promoting Resilience After Trauma: Clinical Stimulation of the Oxytocin System

299

JESSIE L. FRIJLING, MIRJAM VAN ZUIDEN, SASKIA B. J. KOCH, LAURA NAWIJN, DICK J. VELTMAN, AND MIRANDA OLFF

Index

309

free ebooks ==> www.ebook777.com Contributors

Matthew Tyler Boden, PhD, Program Evaluation and Resource Center, Center for Health Care Evaluation, Veterans Administration, Menlo Park, CA. Maarten A. S. Boksem, PhD, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands; and Rotterdam School of Management, Erasmus University, Rotterdam, the Netherlands. Marcel O. Bonn-Miller, PhD, Center for Health Care Evaluation/Center for Excellence in Substance Abuse Treatment and Education, Veterans Administration/Philadelphia VAMC, Menlo Park, CA/Philadelphia, PA. Bekh Bradley, PhD, Mental Health Service, Atlanta VA Medical Center, Atlanta, GA; and Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA. Stephanie L. Brown, PhD, Department of Preventive Medicine, Stony Brook University, Stony Brook, NY; and Institute for Social Research, University of Michigan, Ann Arbor, MI. Femke T. A. Buisman-Pijlman, PhD, Department of Pharmacology and Department of Psychiatry, University of Adelaide, Adelaide, South Australia, Australia. Mary H. Burleson, PhD, Department of Psychology, Arizona State University, Tempe, AZ. C. Sue Carter, PhD, Translational Research in Neural Medicine, Research Triangle Institute International, Research Triangle Park, NC. Marylene Cloitre, PhD, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA; and New York University Langone Medical Center, New York, NY. Marilyn A. Cornish, MS, Department of Psychology, Iowa State University, Ames, IA. Mary C. Davis, PhD, Department of Psychology, Arizona State University, Tempe, AZ. Telsie A. Davis, PhD, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA. Gabriel S. Dichter, PhD, UNC-Chapel Hill, Chapel Hill, NC. Sona Dimidjian, PhD, Department of Psychology, University of Colorado at Boulder, Boulder, CO.

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free ebooks ==> www.ebook777.com Contributors ix Jessie L. Frijling, MS, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. James J. Gross, PhD, Department of Psychology, Stanford University, Stanford, CA. Christina M. Hassija, PhD, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA; and Stanford University School of Medicine, Stanford, CA. Grit Hein, PhD, Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Zurich, Switzerland. Roselinde K. Henderson, MA, Department of Psychology, University of Colorado at Boulder, Boulder, CO. Donald A. Hodges, PhD, Music Research Institute, University of North Carolina at Greensboro, Greensboro, NC. Alicia J. Hofelich, PhD, Department of Psychology, Williams College, Williamstown, MA. Joanna Kaye, BA, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA. Martha Kent, PhD, Research Service, Phoenix VA Health Care System, Phoenix, AZ; and Department of Psychology, Arizona State University, Tempe, AZ. Saskia B. J. Koch, MS, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. Madhur Kulkarni, PhD, Center for Health Care Evaluation, Veterans Administration, Menlo Park, CA. Phan Luu, PhD, Department of Psychology, University of Oregon; and Electrical Geodesics, Inc., Eugene, OR. Mario Mikulincer, PhD, Department of Psychology, Interdisciplinary Center Herzliya, Herzliya, Israel. Laura Nawijn, MS, Department of Psychiatry, Academic Medical Center, Amsterdam, the Netherlands. Morris A. Okun, PhD, Department of Psychology, Arizona State University, Tempe, AZ. Miranda Olff, PhD, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and Arq Psychotrauma Expert Group, Diemen, the Netherlands. Jaak Panksepp, PhD, Department of Anatomy, Pharmacology and Physiology, College of Veterinary Medicine, Washington State University, Pullman, WA. Crystal L. Park, PhD, Department of Psychology, University of Connecticut, Storrs, CT. Stephanie D. Preston, PhD, Department of Psychology, University of Michigan, Ann Arbor, MI. Greta B. Raglan, BS, Research, American College of Obstetricians and Gynecologists, Washington, DC; and Department of Psychology, American University, Washington, DC.

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Contributors

Klaus Rothermund, Department of Psychology, Friedrich Schiller University, Jena, Germany. Jay Schulkin, PhD, Research, American College of Obstetricians and Gynecologists, Washington, DC; and Neuroscience, Georgetown University, School of Medicine, Washington, DC. Susanne Schwager, Department of Psychology, Friedrich Schiller University, Jena, Germany. Phillip R. Shaver, PhD, Department of Psychology, University of California at Davis, Davis, CA. Ashley Shurick, BS, Department of Psychology, Stanford University, Stanford, CA. Jeanne M. Slattery, PhD, Department of Psychology, Clarion University of Pennsylvania, Clarion, PA. Moria Smoski, PhD, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC. Mattie Tops, PhD, Department of Clinical Psychology, VU University of Amsterdam, Amsterdam, the Netherlands. Don M. Tucker, PhD, Department of Psychology, University of Oregon; and Electrical Geodesics, Inc., Eugene, OR. Jeritt R. Tucker, MS, Department of Psychology, Iowa State University, Ames, IA. Dick J. Veltman, MD, PhD, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and Department of Psychiatry, VU University Medical Center, Amsterdam, the Netherlands. Nathaniel G. Wade, PhD, Department of Psychology, Iowa State University, Ames, IA. Christian E. Waugh, PhD, Department of Psychology, Wake Forest University, Winston Salem, NC. Aliza Wingo, MD, Mental Health Service, Atlanta VA Medical Center, Atlanta, GA; and Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA. Alex J. Zautra, Department of Psychology, Arizona State University, Tempe, AZ. Mirjam van Zuiden, PhD, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.

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free ebooks ==> www.ebook777.com Acknowledgments

This volume has its source in a number of activities, the most immediate one being the resilience panel presented at the 2010 meeting of the International Society for Traumatic Stress Studies, entitled “Modes of Resilience in the Treatment of Stress and Trauma: Characteristics and Interventions.” The development of this panel in the context of treatment approaches to posttraumatic stress brought to the fore processes involved in resilient adaptations to stressful challenges. The study of resilience as strength-based adaptation has been a central focus of the Resilience Solutions Group at Arizona State University. We appreciate the ongoing explorations with the members of this group, details of whom can be found on the Web site: http://www.asu.edu/resilience. The research activities and discussions of this interdisciplinary group have sustained abiding vibrant interests that are reflected in the publication of a preceding handbook on adult resilience, the editing of a special journal issue, and the present volume focused on resilience approaches to stress and trauma. We wish to thank the Research Department of the Phoenix VA Health Care System and the assistance of the Phoenix VA library staff members Vicki Armstrong and Mark Simmons. John Reich gratefully acknowledges the love and continuing support of his wife, Deborah, and Mary Davis that of her husband, John Anderten. Martha Kent thanks her husband, Dale Kent, for building a computer stand that will allow her to also work while standing at the computer, a lovely choice, as well as uncomplaining help with countless computer questions and problems.

free ebooks ==> www.ebook777.com Introduction Martha Kent, Mary C. Davis, and John W. Reich

This volume views resilience as a process rather than as a set of traits, outcomes, and risk, or protective factors, a focus that will allow the emergence of constituent elements of resilience from the research literature. Included is a review of interventions that impact adaptation to challenge and threat in ways that result in improved functioning and well-being. Future needs and directions emerge from chapter discussions throughout the volume. When considering what is really basic to resilience, the question quickly becomes a heuristic in search for its elementary constituents. We side with the simple definitions (e.g. Szanton, Gill, & Thorpe, 2010; Zautra, 2009) that see resilience composed of three elements: resilience as a sustained adaptive effort that prevails despite challenge, as a bouncing back and recovery from a challenge, and as a process of learning and growth that expands understanding, new knowledge, and new skills. Szanton and colleagues refer to this threesome as resistance, recovery, and rebound and growth. Resilience preserves and promotes the individuals and their contexts, as it simultaneously keeps harm at bay. What are the characteristics that enhance and, at the same time, shield in ways that evolve into growth and a life of quality (Goodwin, 1999)? When considering resilience as a process, it is evident that resilience is markedly embodied, something that involves the physical being of the person, and that it is dynamic, an action the person as a living organism does. Thus, the focus of this book will be on what happens with dynamic embodied persons when they express or demonstrate resilience, that is, when they prevail, bounce back, and grow from what is learned in a positive adaptive process. Our emphasis will include resilience interventions that enhance resilience and achieve gains in adaptation. At the top of most dictionary definitions of “process” is an understanding of the word as a feature of nature, “a natural phenomenon marked by gradual changes that lead toward a particular result,” such as in the process of growth (Merriam-Webster, 2011). The “process” has a beginning, has a progression as it unfolds in multiple physical and behavioral aspects, and moves toward the result and outcome. From the varied, abundant resilience literature we will piece together parts that form a solid and comprehensive understanding of resilience as a process. Across a wide range of writings the emergence of a consistent set of features can be grouped into three categories: intrapersonal qualities or inner processes of the person, interpersonal qualities or qualities of relationships, and social resilience or qualities of relationships to larger groupings. Not addressed is how a resilience response is initiated and begun. Discussions and studies of how resilience might get started are nearly entirely missing, while an emphasis on the end, outcome, or result of resilience abounds, to an extent where outcome and protective factors most frequently define resilience. This emphasis on outcome

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xiii

and protective factors has frequently rendered opaque resilience as a coherent biological and behavioral process that is as coherent as the fight–flight response and as adaptive. We propose to start with the beginnings of resilience as a process and follow its course as it unfolds from person to context in the following steps: (1) initiation of resilience, (2) intrapersonal resilience, (3) interpersonal resilience, and (4) social resilience. We also aim to present main exemplar treatments of these groupings that: (a) show significant empirical support, and (b) are important components of positive adaptation and protect or promote well-being. Resilience as outcome will not be covered, since much of the resilience literature represents this perspective well. The following is a selection, partly informed by the features of resilience found in the adult resilience literature (e.g. Fry & Keysers, 2010; Kent & Davis, 2010; Reich, Zautra, & Hall, 2010), and the large developmental literature summarized in a variety of sources (e.g. Luthar, 2006; Masten, 2001; Rutter, 2006). Resilience begins with the initiation of the first responses that occur in the face of challenge. Of relevance are qualities of attentional control, particularly attention that can override environmental demands, that selects, and that has direction and focus. It is executive attention that is not stimulus driven and responsive to the environment but is characterized by initiative, is voluntary or emanates from the individual, and is planned (Corbetta & Shulman, 2002). Another feature supporting initiation of a resilience response includes unconscious aspects such as anticipation or the preparation to respond in a ready manner, such as the action tendency of positive emotions supporting openness and approach. Resilience as process is next reviewed at the intrapersonal, interpersonal, and social levels, taking into account the modality and context of this process. At the intrapersonal level the modality can be attentional flexibility (Schwager & Rothermund, Chapter 5), positive emotion resources (Waugh, Chapter 6), increased emotion regulation skills (Boden, Kulkarni, Shurick, Bonn-Miller, & Gross, Chapter 7), and resilience through music (Hodges, Chapter 8). Process at the interactive interpersonal level includes affiliation (Tops, Buisman-Pijlman, & Carter, Chapter 9), social touch (Burleson & Davis, Chapter 10), empathy (Hein, Chapter 11), attachment (Mikulincer & Shaver, Chapter 12), and caregiving and volunteering (Brown & Okun, Chapter 13). The larger social context is treated at the adult level (Zautra, Chapter 14) and developmental level (Bradley, Davis, Kaye, & Wingo, Chapter 15). We identify empirically tested interventions that support the above resilience processes. Interventions that initiate resilience are represented by activation treatment approaches (Dichter, Smoski, Henderson, & Dimidjian, Chapter 16) and approaches that support agency (Kent & Davis, Chapter 17). Intraindividual resilience to strengthen participants’ inner resources for buffering stress include forgiveness (Wade, Tucker, & Cornish, Chapter 19) and meaning making and values (Park & Slattery, Chapter 20). Interactive interindividual interventions include interpersonal skills training (Hassija & Cloitre, Chapter 21) and an oxytocin/social contact preventative intervention (Frijling, van Zuiden, Koch, Nawijn, Veltman, & Olff, Chapter 22). Resilience interventions based on group processes and tested with larger social groupings appear to be in various phases of development or lack the empirical support of clinical trials and will not be reviewed. The above outline is summarized in Table P.1. The chapters of this volume are organized into two sections: empirical studies of resilience and the resilience interventions. Within each section there are parts that treat biobehavioral, intrapersonal, interpersonal, and social processes of resilience that cover specific expressions of these broader topics.

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Introduction

Table P.1 Summary of Resilience as an Adaptive Process and Resilience Interventions Initiation

Intrapersonal

Resilience as adaptive process: SEEKING Counterregulation Panksepp Schwager & Rothermund

Interpersonal

Social

Affiliation/oxytocin Tops, Buisman-Pijlman, & Carter

Adult social Zautra

Developmental social Bradley, Davis, Kaye, & Wingo

Prospective control Tops, Luu, Boksem, & Tucker

Positive emotions Waugh

Social touch Burleson & Davis

Transformation Kent

Emotion regulation Boden, Kulkarni, Shurick, Bonn-Miller, & Gross

Empathy Hein

Allostasis Raglan & Schulkin

Music Hodges

Adult attachment Mikulincer & Shaver Caregiving Brown & Okun

Resilience interventions: Activation Empathy Dichter, Smoski, Hofelich & Preston Henderson, & Dimidjian Action–agency Kent & Davis

Forgiveness Wade, Tucker, & Cornish

Skills training Hassija & Cloitre

Insufficient empirical clinical trials

Oxytocin stimulation Frijling, van Zuiden, Koch, Nawijn, Veltman, & Olff

Meaning and values Park & Slattery

SECTION 1: RESILIENCE AS ADAPTIVE PROCESS TO STRESS AND TRAUMA Neurobehavioral approaches to adaptive responses to stress offer models and examine qualities of attention, emotion regulation, social connections, touch, attachment, and empathy as resilient approaches. Part A: Resilience as Biobehavioral Adaptation Jaak Panksepp examines basic flexible life-preserving behavioral and emotional patterns that form action systems supported by mammalian physiological and cortical makeup. He identifies seven networks, which include SEEKING, RAGE, FEAR, sexual LUST, maternal CARE, separation-distress PANIC/GRIEF, and joyful PLAY. These are survival circuits that regulate life processes and survival needs. Depression results from overactivity of the separation-distress PANIC/GRIEF system and from diminished SEEKING or the diminished desire to engage with the world. Therapeutic approaches can promote the euphoriaenthusiasm of the SEEKING system and the positive social emotions of LUST, DARE, and PLAY. Mattie Tops, Phan Luu, Maarten A. S. Boksem, and Don M. Tucker discuss two brain pathways for behavioral control. The ventral corticolimbic pathways have specialized in

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reactive behavioral control that incorporates fast associative learning that is adaptive in lowpredictable environments. This contrasts with dorsal control pathways that specialized in guiding behavior proactively by context models formed in long-term memory that are adaptive in high-predictable environments. The reactive systems produce momentary experiences close in time and space, and are emotion-focused. Context model control is less immediate, includes positive experience, and allows active coping. Tops and colleagues discuss the involvement of these programs in the development of resilience. Martha Kent samples models of approach/engagement and withdrawal/defense and of resilient flexibility to threat and challenge at biobehavioral, cognitive, and affective levels. Studies of stress mechanisms have moved from concepts of homeostasis and reactive regulation to allostasis and long-term flexibility. At the cortical level the prefrontal cortex is seen as widely interconnected and widely involved in behavioral and systemic responses to threat in circuits involving the hippocampus, amygdala, and others. Recent studies consider reactive and prospective behavioral control systems. Greta B. Raglan and Jay Schulkin review allostatic regulation and the physiology of change, emphasizing longer-term anticipatory and feed-forward systems in contrast to reactive homeostatic regulation. Allostatic regulation allows coping even with severe changes and recovery from trauma. Allostatic load refers to the reduction of physical and psychological ability to rebound from acute or prolonged stress. The implications of allostatic regulation and allostatic load for resilience are discussed. Part B: Resilience as Intrapersonal Process The inner life contributes to adaptive resilience through emotion regulation that includes automatic regulation, positive emotions, and music. Susanne Schwager and Klaus Rothermund propose counter-regulation principles in which attention is automatically oriented towards stimuli that are opposite in valence (positive or negative) to the current affective motivational focus. Counter-regulation may facilitate the processing of positive (or negative) aspects of a situation. Counter-regulation prevents the escalation or the emergence of chronic states and supports sensitivity to danger, thus promoting adaptive coping with critical life-events. Christian E. Waugh starts with the robust evidence that resilient people are characterized by experiences of positive emotions during stress. He proposes a process model of how positive emotions might be beneficial during stress. Stressors have distinct temporal phases, including anticipation, preparation, engagement, recovery, and an inter-stress period. He suggests that the influence of positive emotions on stress depends on when the positive emotions occur during the stressor, such as in stress anticipation or stress recovery. Future studies may benefit from adopting a process-model approach. Matthew Tyler Boden, Madhur Kulkarni, Ashley Shurick, Marcel O. Bonn-Miller, and James J. Gross describe a new model linking adaptive emotion regulation to positive outcomes, including posttraumatic growth, and maladaptive emotion regulation to negative outcomes, including posttraumatic stress. Emotion regulation is conceptualized as the strategies people use to modify what emotions they feel, how they feel them, and how they use and express their emotions. Contextual factors and emotion-specific factors influence when and how emotion regulation strategies are adaptive and maladaptive. Donald A. Hodges explores music as a universal agent of resilience and coping with the circumstances of life through the examples of the role of music in enabling Jews to maintain their traditions during 2,000 years of exile, or the singing of the anthem We Shall Overcome

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Introduction

by civil rights activists, or a cellist of Sarajevo performing during the Siege of Sarajevo. Research evidence for the use of music for survival ranges from anthropology, through sociology, psychology, medicine, and biochemistry, to cutting-edge data from neuroscience. Part C: Resilience as Interpersonal Process Resilience is supported by interpersonal processes that regulate stress through such mechanisms as neuroendocrine functions of oxytocin, social touch, empathy, attachment, and caregiving. Mattie Tops, Femke T. A. Buisman-Pijlman, and C. Sue Carter address the capacity of attachments to increase resilience in the face of stress and to resist addiction. Dopamine may be involved in the “wanting” aspect of reactive reward processing, while oxytocin as seen in attachment may be more related to “liking.” Obtaining a reward may increase the “liking” but, through satiety, decrease the “wanting” of that reward. Continued drug use reduces liking and increases the wanting of drugs. By contrast, strong partner relationships progress from approach or “wanting” to “liking.” Oxytocin may be involved in balancing this shift between wanting and liking, between the reactive reward systems and prospective “internal working models,” thus increasing resilience. Mary H. Burleson and Mary C. Davis review evidence for physical affection and other forms of touch as a major mechanism by which social contact enhances well-being. They discuss the importance of friendly and nurturant touch for the formation and conduct of social relations in normal human development. Social touch influences directly or indirectly psychological and physiological responding within a number of different contexts. Touch indicates physical presence and may signal support or other resources for resilience. Grit Hein emphasizes the crucial role of empathy in interpersonal human emotions. She reviews empirical work on empathy, from the perspective of both the empathizer and the recipient of empathy. She covers recent contributions from the newly emerging field of social neuroscience. She discusses the link between empathy and resilience during aversive events, such as stress and physical pain, and raises important questions for future research. Mario Mikulincer and Phillip R. Shaver consider the importance of John Bowlby’s concept of attachment for emotion regulation and mental health. Research shows that attachment security acts as an inner resilience resource during periods of stress and distress. Attachment security promotes reliance in the use of more constructive coping strategies, fosters positive appraisals of the world, the self, and others, and allows people to maintain emotional equanimity in times of stress. Finally, the sense of attachment security allows people to devote mental resources to activities that facilitate psychological growth and the development of personality. Stephanie L. Brown and Morris A. Okun hypothesize that providing support to another person (helping behavior) promotes the physical and psychological well-being of the helper. It improves the helper’s mood and relationship satisfaction, and reduces the negative states of sadness. Helping behavior is associated with accelerated recovery from depression and reduced mortality among caregivers. Volunteering was also associated with reduced risk of mortality. Why volunteering has these beneficial outcomes is analyzed. An overview of the caregiver system model of active help and stress regulation is presented. Part D: Resilience as Social Process Resilience as expressed in interactions with larger social groupings is treated in the context of adult and developmental adaptation.

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Alex J. Zautra identifies three components of successful resilient striving: recovery, sustainability, and growth. Whereas individual resilience emphasizes the personal capacities to recover and even grow stronger following stress, social resilience emphasizes how people work together to overcome adversity. In social resilience recovery is a return to homeostasis after social loss, which is sustained through continued social engagement, and which grows through new learning. This chapter illustrates how social resilience can be examined and how to intervene and enhance the capacity of people and groups to work and live well together. Bekh Bradley, Telsie A. Davis, Joanna Kaye, and Aliza Wingo focus on aspects of adverse childhood experiences (ACEs). Most individuals exposed to ACEs do not develop later health, mental health, and behavioral problems. This chapter focuses on empirical and theoretical knowledge related to developmental, social, and communal factors that benefit later resilience. These include proximal factors (e.g., family environment) and distal factors (e.g., neighborhood and community factors). During sensitive developmental periods the skills associated with resilience may be best nurtured.

SECTION 2: RESILIENCE INTERVENTIONS Activation and agency are illustrated by empirically tested resilience interventions that enhance strengths in response to depression, stress, and trauma. These chapters are followed by interventions that focus on intrapersonal processes and on interpersonal processes to enhance resilient functioning. Part A: Activating Interventions Gabriel S. Dichter, Moria Smoski, Roselinde K. Henderson, and Sona Dimidjian review behavioral activation (BA) treatments for depression as a structured and validated reinforcement-based psychotherapy method that reduces avoidance behaviors and increases engagement with rewarding stimuli. Behavior change is the primary mode of the intervention. Increases in values-consistent goal-directed behaviors are theorized to increase energy, motivation, and positive thinking. Recent functional magnetic resonance imaging (fMRI) data suggest that BA therapy for depression impacts striatal reward centers of the brain and prefrontal brain regions governing cognitive control of emotional processes. These findings help to illuminate the pathophysiology of major depression and mechanisms for interventions. Martha Kent and Mary C. Davis identify three characteristics of good survival in extreme situations: approach/engagement, social relatedness, and an efficient stress response. They recognized that resilience and traumatic experiences both occurred in the same extreme environments. They identified the structure of action as the important element of resilience that is prospective and goal directed rather than reactive to the immediate environment. Posttraumatic stress disorder (PTSD) is seen as a disorder of action and agency, which are restored through experience-dependent simulation. The re-experiencing of approach/ engagement and social relatedness episodes from childhood and early adult times is applied in a return to traumatic episodes. Supporting neuroscience literature and a clinical trial are reviewed.

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Introduction

Part B: Intrapersonal Interventions Interventions that bolster intrapersonal processes through empathy, forgiveness, and meaning making and values are reviewed. Alicia J. Hofelich and Stephanie D. Preston report a series of studies on factors that affect success and failure in empathy. They find that expressions of empathy depend on the shared experience in empathy. People display their needs in different ways, and the observers’ own experiences influence observer responses. Although not an intervention, their finely grained studies reviewed here can inform empathy and compassion training interventions. For Nathaniel G. Wade, Jeritt R. Tucker, and Marilyn A. Cornish, forgiveness in the face of interpersonal injuries is an adaptive and resilient response to stress and trauma. People can be assisted in attaining forgiveness that is associated with numerous positive outcomes. Forgiveness interventions increase hope and personal well-being, and reduce anger, rumination, and psychological problems such as depression and anxiety. Crystal L. Park and Jeanne M. Slattery describe meaning-making processes in the context of stressful events. Some interventions increase general levels of meaning in life by promoting a more authentic and existentially aware life. Other interventions follow exposure to potentially traumatic or highly stressful events. These help individuals cope with and make meaning from their encounters and help to identify areas of positive change and growth. Current research and future directions are summarized. Part C: Interpersonal Interventions Strengthening interpersonal adaptation is emphasized in affective skills training and narrative story telling and by an innovative approach to stimulate the oxytocin system after trauma. Christina M. Hassija and Marylene Cloitre pay particular attention to the integration of self-efficacy and emotion regulation with interpersonal effectiveness. Skills Training in Affective and Interpersonal Regulation (STAIR) followed by Narrative Story Telling (NST) is an example of a resilience-building treatment that promotes the acquisition and/or strengthening of emotional and interpersonal capacities. Support for the efficacy of this model as a treatment for PTSD and other co-occurring trauma sequelae are reviewed. Jessie L. Frijling, Mirjam van Zuiden, Saskia B. J. Koch, Laura Nawijn, Dick J. Veltman, and Miranda Olff review the presence or absence of social support as modulators of stress and fear reported by many studies. A familiar supportive person attenuates heart rate responses, diminishes cortisol responses to a stressor, and decreases brain activity in areas related to threat. Oxytocin (OT) facilitates bonding, parental behavior, and social contact. These investigators are testing the effectiveness of intranasal OT and social support in preventing PTSD in randomized controlled trials. They review issues in an OT stimulation approach that may be helpful for oxytocin-based interventions.

REFERENCES Corbetta, M., & Shulman, G. L. (2002). Control of goal-directed and stimulus-driven attention in the brain. Nature Reviews Neuroscience, 3, 201–215. Fry, P. S., & Keysers, C. L. M. (Eds.). (2010). New frontiers in resilient aging: Life strengths and wellbeing in late life. New York: Cambridge University Press. Goodwin, B. (1999). Reclaiming a life of quality. Journal of Consciousness Studies, 6, 229–235.

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Kent, M., & Davis, M. C. (2010). The emergence of capacity-building programs and models of resilience. In J. W. Reich, A. J. Zautra, & J. S. Hall (Eds.), Handbook of adult resilience (pp. 427–449). New York: Guilford Press. Luthar, S. S. (2006). Resilience in development: A synthesis of research across five decades. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology (2nd ed., pp. 739–795). Hoboken, NJ: Wiley. Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227–238. Merriam-Webster. (2011). Retrieved from Web site. Reich, J. W., Zautra, A. J., & Hall, J. S. (Eds.). (2010). Handbook of adult resilience. New York: Guilford Press. Rutter, M. (2006). Implications of resilience concepts for scientific understanding. Annals of the New York Academy of Sciences, 1094, 1–12. Szanton, S. L., Gill, J. G., & Thorpe, R. J. (2010). The society to cells model of resilience in older adults. Annual Reviews of Gerontology and Geriatrics, 30, 5–34. Zautra, A. J. (2009). Resilience: One part recovery, two parts sustainability. Journal of Personality, 77, 1935–1943.



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Resilience as Adaptive Process to Stress and Trauma

Part A Resilience as Biobehavioral Adaptation



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Seeking and Loss in the Ancestral Genesis of Resilience, Depression, and Addiction Jaak Panksepp

In the context of basic mammalian adaptation, resilience refers to the intrinsically endowed capacities of an organism to manage challenges in a life-preserving manner. For humans it is the ability to maintain composure and equanimity along with creative and productive life problem solving in the face of repeated vicissitudes. Resilience refers to basic flexible lifepreserving behavior patterns that are promoted by mammalian affective systems of the brain and the organism’s interaction with the environment. Fundamental brain emotional systems consisting of primary-process emotions mediate rewarding and punishing states (Panksepp, 1998, 2005; Panksepp & Biven, 2012). Such primal affective systems ramify widely in the brain, establishing hierarchical bottomup controls that often dictate the more developmentally programmed top-down controls. Animal research tells us more about the bottom-up controls than human research, since we have access to deep brain mechanisms. Human research has much more to say about the topdown controls than animal brain–behavior relationships, since humans can provide direct verbal descriptors of the internal cognitive features of their minds. In sum, animal research tells us much more about the cross-mammalian affective foundations of mind, while human research is vastly more informative about higher mental abilities, many of which are truly unique to humans. But the lower subcortical mind that elaborates affective consciousness (Panksepp, 2007a) is a critical platform upon which higher human mental abilities are constructed, and is supported by the vastly expanded neocortex. This nested hierarchical view is illustrated in Figure 1.1. This nested hierarchical arrangement consists of the intrinsic, foundational emotional systems of the brain, termed primary process. These systems not only generate instinctual forms of action readiness (Darwin, 1872; Panksepp, 1982) but are also experienced as primal affective states (Panksepp, 1998, 2005). Higher cognitive elaborations, or tertiary processes, are linked to emotional feelings, the feelings that intrinsically guide not only behavioral choices but patterns of thinking and cognitive styles that lead to top-down controls. The bridge between the primary-process feelings and higher cognition is the vast intermediate layer or secondary-process brain functions that control learning and memory. Secondary process arises from and represents deeply unconscious processes of the brain. This intermediate bridge allows the affective states to interface effectively with the environment and to provide knowledge for the higher mental apparatus to generate complex perceptions, thoughts, and ideas of human cognitive consciousness. This higher-order tertiary mind stuff is almost impenetrable in animal research subjects, especially since most of it is learned developmentally and culturally through vast plastic potentials of our expanded cortex. My focus will be largely on the foundational layer of the BrainMind,1 critical for affective consciousness. It has received the least attention in neuroscientific and psychological


Jaak Panksepp

Twe-Way er "Circular" Causatien Tertiary-Process Cognitions Largely Neocortical Top-down Cognitive Regulation

Bottom-Up Influences on Ruminations and Thoughts

Secondary-Process Learning Largely Upper Limbic Top-down Conditioned Responses

Bottom-Up Learnlng and Development

Primary-Process Emotions Affects Deeply Subcortical

Nested BrainMind Hierarchies Figure 1.1 Nested hierarchical structure of primary, secondary, and tertiary affective processes. The figure illustrates how nested hierarchies are integrating lower brain functions into higher brain functions that exert top-down regulatory control of behavior at mature development. Adapted from Northoff, Wiebking, Feinberg, & Panksepp (2011).

studies of the human mind. The interactions of these distinct types of consciousness—affective and cognitive—can be described as state-and-channel functions of the brain (Panksepp, 2003). Their interactions are not well understood, but we can be confident that the emotional-affective mind is evolutionarily very ancient and homologous (genetically similar) in all mammals. The cognitive layer is more recent and is capable of diverse cognitive learning about oneself and the world. Determining how these levels of mind can be integrated will be a challenge and a great opportunity for 21st-century psychology and neuroscience as well as the topic covered here—the interrelations of mental health and resilience. The reason that affective forms are best understood neuroscientifically through brain– behavior studies of other animals, while cognitive forms are much easier to study in humans, is simple. We can directly manipulate and monitor the subcortical affective/emotional activities in animals, since those evoked states are clearly rewarding and punishing; in humans, such work cannot be conducted. Animal research opens a window into human emotional primes and their mammalian neuro-evolution that can be explored empirically. My guiding premise will be that adaptive strengths and weaknesses of mammalian functions will be manifested dramatically in the construction of the higher cognitive mental apparatus of humans (Solms & Panksepp, 2012), one that promotes sustainable positive affect, optimism, and resilience as well as establishes chronic negative affect and pessimism. Cognitive functions surely contribute to the emergence of affects, but their affectively desirable and troublesome features originate in the ancient psychological processes that arise from below the neocortex.

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free ebooks ==> www.ebook777.com Seeking and Loss in the Ancestral Genesis of Resilience 5 The social resilience of animals and humans depends heavily not only on the intrinsic (genetic) strengths and weaknesses of the primary-process emotional level, but also on how well these plastic systems have been molded by learning and the developmental/epigenetic changes that result from the world in which organisms find themselves. In this chapter, I will focus mainly on one psychiatric condition, depression, while concurrently highlighting how early developmental joyful play experiences can modify an individual’s capacity for future affective-resilience adaptations. A key position is that we can discover new therapeutic approaches through our biological understanding of the brain substrates of specific emotions. Finally, preclinical animal models can promote a foundational understanding of human positive and negative socio-affective systems that can be shifted toward more adaptive resilient paths through epigenetic molding of the primary-process affective networks as well as via individual learning. These can promote the construction of the higher mental abilities along either enthusiastic-sanguine trajectories or negativistic-cynical ones (see a recent overview in Narvaez, Panksepp, Schore, & Gleason, 2012).

THE PRIMARY-PROCESS EMOTIONAL STRUCTURE OF THE MIND Abundant preclinical investigations with animal models in the field of affective neuroscience have now illuminated various primary-process genetically provided emotional networks of the brains of all mammals that have been studied. The largest amounts of data have come from laboratory rats, which are remarkably playful, prosocial animals and, as omnivorous opportunists, have existed alongside humans throughout history. All evolutionarily dedicated circuits for basic emotional systems are subcortically concentrated (see Panksepp & Biven, 2012 for the most recent summaries), leaving abundant room—a vast blank slate— for social constructions and elaboration in the higher reaches of the human brain, especially the neocortex (Panksepp, 2007a). Indeed, since the needed neuroscientific understanding cannot ethically be harvested from human research, animal work is critical for achieving progress in certain psychological areas of ultimate human concern: How do affective feelings arise from neural activities? Modern brain imaging can highlight many interesting correlates and higher brain regions of interest, but it can tell us little about the details of the subcortical primes. The lower brain is so interwoven with diverse positive and negative affective systems that fMRI is often only effective in discriminating distinct affects at the nerve terminal regions of such systems, such as the nucleus accumbens for the SEEKING2 system (Knutson & Greer, 2008) or the amygdala and associated circuits within the “limbic lobe” for FEAR (Heimer & Van Hosen, 2006; Panksepp, Fuchs, & Iacabucci, 2011). The emotional primes are coherent unconditioned action systems of the mammalian brain. At a minimum, they consist of the following seven networks: SEEKING, RAGE, FEAR, sexual LUST, maternal CARE, separation-distress PANIC/GRIEF (henceforth PANIC), and joyful PLAY. The capitalization serves to distinguish primary-process affective networks common to all mammals from vernacular terms, such as interest, anger, or anxiety, and their particular cognitive manifestations arising from interactions with the world. The emotional primes were identified with deep brain stimulation (DBS). The critical, replicable fact is that, wherever in the brain one can evoke distinct and coherent emotional responses with DBS, one can routinely demonstrate that those brain-state shifts always can be used as “rewards” and “punishments” in simple approach/anticipation and escape/punishment learning tasks (Panksepp, 2011).


Jaak Panksepp

THE FUNCTIONS OF EMOTIONAL PRIMES These affective networks are “survival circuits” that regulate life processes. Affects exist because they promptly indicate whether animals are on the paths of increased or decreased survival. Affects intrinsically anticipate the future, and they are major guides in the genesis of learning through neuropsychological “laws of affect” that have remained elusive. For instance, although the mammalian brain may not have any evolutionarily dedicated “social-attachment system,” it does have various affective-emotional circuits that rapidly mediate attachments through social-emotional learning. PANIC arousal in young animals is indexed by characteristic isolation calls as animals experience social isolation distress, a state that initially activates a vigorous general purpose SEEKING response to re-establish social reunion. If that fails, animals become inactive, in a sickly way that resembles depression. In contrast, social reunions are experienced positively—through secure and confident positive social feelings created, in substantial part, by release of brain opioids and oxytocin (Panksepp, 1981, 1992). Such rewarding states, aroused by reunion with caretakers, are the affective “glue” that helps constitute specific social attachments and attunements. As noted, such emergent secondary-process learning results from various primary-process neuroaffective dynamics mediated by rewarding neurochemistries such as endogenous opioids and oxytocin (Nelson & Panksepp, 1998). If re-attachment succeeds consistently, reinforcing independence, resilience is promoted. To the extent that it fails, animals succumb to chronically clingy and depressive affect, as John Bowlby (1980) well recognized in humans. Because of social-ecological proximities, such rewarding states typically link youngsters to their primary caretakers, whose nurturant CARE networks are designed to promote sustained positive affective social and physical warmth, touch, and sustaining feeding activities. To the extent that nurturant CARE is provided consistently, maturation is enriched by secure social attachments that form the foundation of mammalian resilience. This provides youngsters with a “secure base” as they mature, promoting rich and developmentally diverse social dynamics that ultimately promote positive PLAY engagements, which help cement friendships, creating cohesively supportive social structures, and the living environmental supports for optimal resilience. This is true for both humans and rats. Animals that have had abundant play during early development, which can partly be fulfilled by human tickling, are more psychologically robust as they mature (Cloutier, Panksepp, & Newberry, 2012; Panksepp, 2008). To the extent that such processes do not proceed well throughout development, the incidence of mental disorders, especially depression, is increased (reviewed in Watt & Panksepp, 2009; Panksepp & Watt, 2011). This level of understanding is especially important for the goal of developing new therapies that generate positive affect and promote resilience. The accrued knowledge already has important implications for understanding the fundamental social-emotional nature of both animals and humans and the role of primal emotionality in mental development and the genesis of affective disorders.

DIMINISHED RESILIENCE AND THE GENESIS OF DEPRESSION I will now expand on this neuroscientific version of the emergence of depression. Sustained overactivity of the separation-distress PANIC/GRIEF system is only one-half of the equation. It is one gateway to the psychic pain and increasing of depression. Another major part of this equation arises from diminished SEEKING, which reflects a downward affective spiral that arises from the diminished desire to engage with the world. This reflects

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free ebooks ==> www.ebook777.com Seeking and Loss in the Ancestral Genesis of Resilience 7 a weakening of the most widely expressed basic positive affective emotional network of the brain, whose substrates at the primary-process level we have called the SEEKING system. Other investigators called it the “the Brain Reward System” (e.g., Haber & Knutson, 2010), or “wanting” (Berridge, Robinson, & Aldridge, 2009), which is a good secondary-process term, or “reward prediction error” (Schultz & Dickinson, 2000), which is a reasonable cognitive-computational tertiary-process concept. There is perhaps no better psychological description of this rewarding state than “desire” which promotes “euphoria” (for discussions see Panksepp & Moskal, 2008; Wright & Panksepp, 2012). Of course these states are created by vast orchestras of underlying neurochemistries and neurodynamics that remain barely understood. On the heels of the psychic pain and demoralization from chronic overactivity of the PANIC circuitry, the diminished arousability of the SEEKING system solidifies the emerging amotivational state that characterizes full-blown depression (Coenen, Schlaepfer, Maedler, & Panksepp, 2011; Panksepp & Watt, 2011). Parenthetically, both over- and under-arousal of these respective circuits can promote drug addictions, often reflecting an individual’s desperate attempts to restore psychic homeostasis (for a psychobiological overview see Zellner, Watt, Solms, & Panksepp, 2011). Opioids are remarkably effective in alleviating feelings of social loss and sadness. Similarly, the psychic emptiness of diminished desire (depletion of SEEKING urges) promotes the amotivational depleted psychic state of depression (Panksepp, 2010). The amotivational depleted state can be temporarily alleviated by psychostimulants, such as cocaine and amphetamines. However, overuse activates BrainMind opponentprocesses that further intensify feelings of psychic depletion. Depressive affect is constituted by the ensuing feelings of emptiness and an amotivational lack of desire (see analysis in Watt & Panksepp, 2009). These downward spirals are solidified by the depletion of dopamine. Brain dopamine and its capacity to facilitate exploration and enthusiasm are critical for keeping all positive emotional-motivational systems tuned. Such affective neuroscience perspectives begin to illuminate key questions and dilemmas of biological psychiatry: why depression feels so bad and why existing antidepressants are only marginally effective, an observation highlighted by recent findings from STAR*D studies (Rush, 2007). From our perspective, it is because preclinical behavioral neuroscience research has not addressed one key underlying issue that can only be understood neuroscientifically—the deep nature of the relevant emotional affects (see Panksepp, 2012). Aside from our own work, neuroscientists have hardly started to study the psychic pain arising from the PANIC system, and the psychic enthusiasm arising from the SEEKING system. Many still see the SEEKING system as the key mediator of sensory pleasure or only cognitive-computational parts of a whole organism. These higher parts are represented by the “wanting” and “reward prediction error” perspectives. In order to understand psychiatric disorders as well as the nature of resilience, it is the primal affects that need central consideration, because they are directly tied to the organism’s survival. These are not just sensory parts, such as taste and touch, or homeostatic ones of thirst and hunger. The reason for inattention in biological psychiatry to the foundational primary nature of the SEEKING system is perplexing. It may be an entrenched remnant of “nevermind” behavioristic biases in animal brain research. In our estimation, more effective non-addictive medicines and neurobehavioral approaches can be found that promote the euphoria-enthusiasm power of the SEEKING system and can concurrently promote the three positive social emotions of LUST, CARE, and PLAY. It is among their shared (dopamine) and unique (various neuropeptide) positive affective neurochemicals that effective neurobehavioral and medical antidepressants may be found.


Jaak Panksepp

Indeed, by using such affective neuroscience strategies, new neurobiological resilience-building approaches and medicines can be identified. The beneficial exercise of the SEEKING systems may be achieved through a number of neurobehavioral approaches, such as regular physical exercise or therapies that focus on behavioral activation (Dichter, Smoski, Henderson, & Dimidjian, Chapter 16, this volume), agency building (Kent & Davis, Chapter 17, this volume), psychological coherence (Toomey & Ecker, 2007), and others. The first such targeted medication, GLYX-13 (see Burgdorf, Panksepp, & Moskal, 2011), recently passed Phase 2 FDA approved human testing. The resilience topics explored in this volume open the way to synergistic psychological strength-building approaches.

ON THE SHORTCOMINGS OF PAST PRECLINICAL AND MEDICINAL APPROACHES TO DEPRESSION As a result of the behaviorist bias of the Anglo-American animal research tradition, preclinical depression research during the last four decades of the 20th century focused most heavily on the consequences of global stress (McEwen, 2007) and brain norepinephrine and serotonin dynamics (see Panksepp, 2004)—namely on those widely ramifying neurochemical pathways that modulate practically everything that animals do. It was, and still is, deemed scientifically inappropriate to consider the nature of emotional feelings in animals, because their minds are deemed to be either non-existent or scientifically impenetrable. Accordingly, various key psychiatrically relevant questions, such as the nature of affect, have remained widely neglected. The consequence is that few new psychiatric medicines have been developed in the past half-century of brain research (Panksepp, 2012). Few investigators in animal research have asked why depression feels so horrible. In contrast, our provisional answer is that the most common instigating negative feelings arise from excessive and sustained arousal of PANIC networks that set in motion cascades of brain changes whereby the lifeaffirming euphoric potentials of SEEKING are depleted (Coenen et al., 2011). In contrast to general behavioristic and pure molecular neuroscience approaches, affective neuroscience strategies seek preclinical models that directly stimulate the relevant negative affective systems of the brain, such as the midbrain’s dorsal periaqueductal gray, while monitoring changes in affect with measures that describe capacities to sustain positive social affect (Wright & Panksepp, 2011). In rats, diminished positive affect is monitored by an objective “psychoassay”—sustained reductions in a validated indicator of enthusiastic internal states, namely the 50 kHz ultrasonic vocalizations (USVs) that arise from the brain SEEKING/PLAY circuits. Those playful, joyous sounds of social eagerness are well-validated indicators of euphoric positive affect (Burgdorf, Wood, Kroes, Moskal, & Panksepp, 2007). Under natural conditions, these positive affective vocalizations are never more highly expressed than during the rough-and-tumble play of juvenile rats (Panksepp, 2007b) that can be simulated and even further amplified by human tickling. The natural social play of juvenile rats, as well as systematically evoked playfulness and joy, can be achieved by human tickling of rats. This approach has yielded procedures for the discovery of antidepressive, resilience-promoting neurochemical pathways in the brain. Our search for new joy-pathways was initiated by microarray monitored brain gene expression changes in adolescent animals that had just experienced abundant social PLAY. Such play arouses the mesolimbic dopamine energized SEEKING circuitry that is confluent with the transhypothalamic medial forebrain bundle (MFB; for a modern anatomical description of this important positive motivational system in humans see Coenen, Panksepp,

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free ebooks ==> www.ebook777.com Seeking and Loss in the Ancestral Genesis of Resilience 9 Hurwitz, Urbach, & Mädler, 2012). By studying the gene expression effects of social play on the brain, we identified a variety of candidate biochemical systems as antidotes for depression (for related work using a social defeat model see Burgdorf et al., 2011, and Krishnan & Nestler, 2008). We also identified clues for the treatment of other disorders such as autism (Moskal, Burgdorf, Kroes, Brudzynski, & Panksepp, 2011). Our strategy in searching for an antidote for depression was to look among the various neurochemical candidates for pathways that directly promote positive social affect and neuropsychological potentials for resilience through the “power of PLAY.” There are good reasons to believe that the long-term recruitment of such mental energies could help counteract various recalcitrant childhood problems (such as childhood impulsivity) through the capacity of such prosocial activities to promote both socialization and brain maturation (Panksepp, 2007b). We conducted various lines of research to evaluate the credibility of our juvenile play model as an entry point into understanding positive social affect. Indeed, we found that play evoked widespread neuronal activation changes within the brain (Gordon, Kollack-Walker, Akil, & Panksepp, 2002), suggesting interesting clinical possibilities. Play could also beneficially “fertilize” the brain by promoting other depression-related growth factor pathways, such as Brain Derived Neurotrophic Factor (BDNF; Gordon, Burke, Akil, Watson, & Panksepp, 2003; Gordon et al, 2003) and Insulin-Like Growth Factor 1 (Burgdorf, Kroes, Beinfeld, Panksepp, & Moskal, 2010), which are diminished in depression. For instance, BDNF promotes antidepressant genetic cascades in the brain that oppose the hippocampal damage that often accompanies depression (McEwen, 2007). In this context, it is noteworthy that our preclinical resilience-promotion through positive affect consisted of the systematic tickling of rats that resulted in hedonic 50 kHz USVs under strict experimental control. This approach has promoted antidepressant-like effects in animal models, such as hippocampal neuronal growth (Wöhr et al., 2009), as well as increased animal well-being (Cloutier et al., 2012). To re-emphasize a key point, since these 50 kHz USVs have been mapped onto the mesolimbic dopamine “energized” SEEKING system (Burgdorf et al., 2007), investigators can now readily monitor state shifts in euphoric eagerness that have the potential to counteract depressive affect. Furthermore, along with the negative 22 kHz USVs, those positive USVs can be formally used to index experienced social affective shifts in rats, which can illuminate the underlying affective changes that characterize depression (Kroes, Burgdorf, Otto, Panksepp, & Moskal, 2007).

TREATING SYMPTOMS VERSUS RESTORING STRENGTHS: THE CASE OF DEEP BRAIN STIMULATION (DBS) ANTIDEPRESSANT THERAPIES As interventionists, we have a choice of treating the pain or evoking strengths. Affective neuroscience concepts are providing a platform for the advanced use of DBS as novel interventions for treatment resistant depressions (Bewernick et al., 2010; Mayberg, 2009; Schlaepfer et al., 2008). Indeed, the separation-distress PANIC system may be one gateway to depression in its ability to maintain much of the psychic pain so characteristic of depression. The PANIC circuitry originates in the midbrain periaqueductal gray (PAG), ascends through the dorsomedial thalamus, and terminates in anterior cingulate forebrain regions. DBS-induced disruption of this system may account for treatment effectiveness by inhibiting the upper anterior cingulate areas of the PANIC system that helps generate and sustain the psychic pain of depression. DBS can also be applied to promote relevant psychological strengths. Thus, an equally


Jaak Panksepp

important advance in DBS antidepressant therapy may be to facilitate arousal of the SEEKING system in order to restore the desire of depressed people to be active agents in the world. To the best of our knowledge, the SEEKING system is critically important for generating eager “intentions-in-action”—the enthusiastic, spontaneous engagement with affordances in the environment—that are so deficient in depression. This system seems to be the foundation of personal “agency.” Indeed, several studies have already found solid antidepressant effects from DBS applied to key terminal regions of the SEEKING system in the ventral striatum (e.g., nucleus accumbens), where the initial evidence of a treatment response is the tendency of individuals to begin planning pleasant activities for the future (Schlaepfer et al., 2008). Considering that SEEKING arises from the trans-hypothalamic medial forebrain bundle (MFB), we have suggested that DBS applied to this pathway should promote significant antidepressive effects (Coenen et al., 2011, 2012). Indeed, results from a preliminary clinical trial on seven treatment resistant depressive patients by colleagues have already yielded positive results in six of seven patients treated with DBS (V. A. Coenen & T. E. Schlaepfer, personal communication). This work is beginning to fulfill our goal to interface our growing understanding of these affective systems with human emotional functioning in order to achieve a better understanding of psychiatric disorders (Panksepp, 2004, 2006).

IN SUMMATION: AFFECTIVE NEUROSCIENCE APPROACHES TO EMOTIONAL MINDS AND RESILIENCE The affective neuroscience approach to understanding the emotional mind of all mammals (Panksepp, 1982, 1998, 2005) makes two key assumptions that allow us to address important and difficult questions in basic psychological research and clinical practice in ways that are novel and productive. First, primal emotions and their associated feelings have evolved to do something specific in relation to biologically significant life-challenging situations. They are not mere epiphenomena, as is commonly assumed in behavioral neuroscience. Second, the experience aspects of primary-process emotions—specific kinds of affects that have been built into the brain and shared homologously by all mammals—serve three key adaptive “purposes”: (a) They highlight key survival and reproductive demands in the ambient environment, with positive affects indexing situations that increase and negative affects that decrease an animal’s chances of surviving to reproduce. (b) They motivate organisms to behave in ways that promote survival and reproduction by providing a psychobehavioral compass that leads to individual safety and reproductive success. (c) They promote the construction of memory through neural systems that strengthen learned behaviors by yet unfathomed “laws of affect.” These laws should replace the behaviorist “law of effect” based on “rewards” and “punishments” that modify the frequencies of particular behaviors, a law that never considered the inner psychological lives of humans or other animals. Experienced affects are survival-enhancing, adaptive codes to anticipate biological survival demands, just as hunger anticipates our long-term need for energy rather than a drastic reduction of existing supplies. Affects are not psychological epiphenomena, but the emissaries of critical brain adaptations that promote life. Accordingly, we advance an emotional-affective view of all mammalian species. The reason the behaviorist and affective neuroscience approaches can finally be brought together is simply because, everywhere in the brain that one can evoke coherent instinctual emotional behaviors using DBS, one can demonstrate that the evoked internal states are rewarding or

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free ebooks ==> www.ebook777.com Seeking and Loss in the Ancestral Genesis of Resilience 11 punishing. It is critical to appreciate the fact that experienced affects are functional. Positive affects automatically signal to animals that they are on paths likely to increase their fitness. Negative affects inform them that they are in life-diminishing/threatening situations and provide neural “reinforcement” for unconditional escape and learned avoidance strategies. Thus, among these emotional primes, four mediate affectively positive behavioral urges: namely SEEKING, LUST, CARE, and PLAY, with the last three heavily utilizing the SEEKING urge. And three mediate affectively negative emotions: RAGE, FEAR, and PANIC. There are other primal affects, such as the many sensory and homeostatic ones that are of less relevance for understanding resilience and the lack thereof. Because the primal emotion systems are probably important for the genesis of depression and other psychiatric disorders, we have developed a scale to evaluate the strengths and weaknesses of the primal emotions in humans (Davis & Panksepp, 2011). This measure may be of substantial value to psychologists and psychotherapists by providing a common metric to estimate the status of the primal emotions in the lives of their subjects and clients. A composite of high scores on the three positive subscales (SEEK, CARE, and PLAY) may index general “positive affect” and resilience. A composite high measure of the three negative subscales (ANGER, FEAR, and LONELINESS) may index lack of resilience. The ratio of the two may combine the positive and negative affective tendencies into a supraordinate factor that could serve as an overall measure of psychological health and capacity to face the world with resilience.

CONCLUSIONS An understanding of the neural infrastructure of emotional processes can promote our understanding of resilience and inform the crafting of new therapeutic approaches. This knowledge can help clinicians to consider new psychotherapeutic approaches, including better utilization of positive affects that arise from the SEEKING and PLAY systems. I have briefly summarized how we can harness the SEEKING system to build up positive social affects that diminish the psyche-destructive forces of sustained PANIC and the overwhelming feelings of the psychic pain of separation distress. This will establish desirable BrainMind states for the promotion of resilient states. In this short review, I have drawn only marginal attention to the vast terrain of “granular” neuroscientific detail that underlies the surface layer of psychological functions and that need to be sifted through before we really understand the foundations of such global concepts as resilience. But clinicians need to understand that the level of relevant anatomical, neurochemical, and neurogenetic detail can already fill several volumes. My goal here was simply to provide an overview of the affective neuroscience research program we have undertaken in order to point to and clarify the underlying brain emotional systems and their neurobiologies that support human thriving. This emphasis is particularly important to the downhill cascade of negative affects that can promote clinical depression. We can finally understand the neural nature of the various basic emotional affects of mammalian brains. We anticipate that these global brain states represent a critical law of nature that can illuminate psychiatric and psychotherapeutic practice: Those biobehavioral and neuroendocrine functions that promote positive affects will facilitate long-term psychological learning and resilience. Those biobehavioral functions that promote negative affects will hinder resilience. Most of the time organisms negotiate both in adaptive life-enhancing ways. Although there are many evolutionary levels to the brain and mind, most not yet very well understood at


Jaak Panksepp

either neuroscientific or psychological levels, we do know the following with some assurance: Those systems that promote negative affects are destructive to mental health. In contrast, maneuvers that can promote positive affective coherence and integration will enhance mental health. These factors hold for humans as well as other creatures with whom we still need to learn how to share the earth. When we finally understand the affective nature of their minds, we will begin to have a firm science of our own. That knowledge will transform our search for new mind medicines and improve the effectiveness of our psychotherapies.

NOTES 1. The expression “BrainMind” represents Panksepp’s solution to the mind-body dualism, as discussed at some length in Appendix C (Panksepp, 1998, p. 336). BrainMind refers to the dual-aspect monistic ontology in which brain and mind are “two sides of the same coin.” In BrainMind emotional affects are part of the instinctual emotional action systems of the brain that are homologous across all mammals. The BrainMind represents “nested hierarchies” of control, as represented in Figure 1.1. BrainMind is used interchangeably with MindBrain (see Panksepp & Watt 2011). 2. The upper case terms of SEEKING, RAGE, FEAR, PANIC, LUST, CARE, and PLAY are affective designations that refer to genetically endowed brain emotional operating systems. They are in upper case in order to alert the reader that these designations represent scientiﬁc rather than vernacular usage; speciﬁcally they represent neural systems of the brain (see Panksepp, 1998, p. 51).

REFERENCES Berridge, K. C., Robinson, T. E., & Aldridge, J. W. (2009). Dissecting components of reward: “Liking,” “wanting,” and learning. Current Opinion in Pharmacology, 9, 65–73. Bewernick, B. H., Hurlemann, R., Matusch, A., Kayser, S., Grubert, C., Hadrysiewicz, B., et al. (2010). Nucleus accumbens deep brain stimulation decreases ratings of depression and anxiety in treatment-resistant depression. Biological Psychiatry, 67, 110–116. Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. New York: Basic Books. Burgdorf, J., Kroes, R. A., Beinfeld, M. C., Panksepp, J., & Moskal, J. R. (2010). Uncovering the molecular basis of positive affect using rough-and-tumble play in rats: A role for insulin-like Growth Factor I. Neuroscience, 163, 769–777. Burgdorf, J., Panksepp, J., & Moskal, J. R. (2011). Frequency-modulated 50kHz ultrasonic vocalizations: A tool for uncovering the molecular substrates of positive affect. Neuroscience and Biobehavioral Reviews, 35, 1831–1836. Burgdorf, J., Wood, P. L., Kroes, R. A., Moskal, J. R., & Panksepp, J. (2007). Neurobiology of 50kHz ultrasonic vocalizations in rats: Electrode mapping, lesion, and pharmacology studies. Behavioral Brain Research, 182, 274–283. Cloutier, S., Panksepp, J., & Newberry, R. C. (2012). Playful handling by caretakers reduces fear of humans in the laboratory rat. Applied Animal Behaviour Science, 140, 161–171. Coenen, V. A., Panksepp, J., Hurwitz, T. A., Urbach, H., & Mädler, B. (2012). Human medial forebrain bundle (MFB) and anterior thalamic radiation (ATR): Diffusion tensor imaging of two major subcortical pathways that may promote a dynamic balance of opposite affects relevant for understanding depression. Journal of Neuropsychiatry and Clinical Neurosciences, 24, 223–236. Coenen, V. A., Schlaepfer, T. E., Maedler, B., & Panksepp, J. (2011). Cross-species affective functions of the medial forebrain bundle—Implications for the treatment of affective pain and depression in humans. Neuroscience and Biobehavioral Reviews, 35, 1971–1981. Darwin, C. (1872). The expression of the emotions in man and animals. London: John Murray. Davis, K. L., & Panksepp, J. (2011). The brain’s emotional foundations of human personality and the Affective Neuroscience Personality scales. Neuroscience and Biobehavioral Reviews, 35, 1946–1958.

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free ebooks ==> www.ebook777.com Seeking and Loss in the Ancestral Genesis of Resilience 13 Gordon, N. S., Burke, S., Akil, H., Watson, S., & Panksepp, J. (2003). Socially-induced brain “fertilization”: Play promotes brain derived neurotrophic factor transcription in the amygdala and dorsolateral frontal cortex in juvenile rats. Neuroscience Letters, 341, 17–20. Gordon, N. S., Kollack-Walker, S., Akil, H., & Panksepp, J. (2002). Expression of c-fos gene activation during rough and tumble play in juvenile rats. Brain Research Bulletin, 57, 651–659. Haber, S. N., & Knutson, B. (2010). The reward circuit: Linking primate anatomy and human imaging. Neuropsychopharmacology Reviews, 35, 4–26. Heimer, L., & Van Hosen, G. W. (2006). The limbic lobe and its output channels: Implications for emotional functions and adaptive behavior. Neuroscience and Biobehavioral Reviews, 30, 126–147. Knutson, B., & Greer, S. M. (2008). Anticipatory affect: Neural correlates and consequences for choice. Philosophical Transactions of the Royal Society B: Biological Sciences, 363, 3771–3786. Krishnan, V., & Nestler, E. J. (2008). The molecular neurobiology of depression. Nature, 455, 894–902. Kroes, R. A., Burgdorf, J., Otto, N. J., Panksepp, J., & Moskal, J. R. (2007). Social defeat, a paradigm of depression in rats that elicits 22-kHz vocalizations, preferentially activates the cholinergic signaling pathway in the periaqueductal gray. Behavioral Brain Research, 182, 290–300. Mayberg, H. S. (2009). Targeted electrode-based modulation of neural circuits for depression. Journal of Clinical Investigations, 119, 717–725. McEwen, B. S. (2007). Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological Reviews, 87, 873–904. Moskal, J. R., Burgdorf, J., Kroes, R. A., Brudzynski, S. M., & Panksepp, J. (2011). A novel NMDA receptor glycine-site partial agonist, GLYX-13, has therapeutic potential for the treatment of autism. Neuroscience and Biobehavioral Reviews, 35, 1982–1988. Narvaez, D., Panksepp, J., Schore, A., & Gleason, T. (Eds.). (2012). Human nature, early experience and the environment of evolutionary adaptedness. New York: Oxford University Press. Nelson, E., & Panksepp, J. (1998). Brain substrates of infant–mother attachment: Contributions of opiods, oxytocin, and norepinephrine. Neuroscience and Biobehavioral Review, 22, 437–452. Northoff, G., Wiebking, C., Feinberg, T., & Panksepp, J. (2011). The “resting-state hypothesis” of major depressive disorder—A translational subcortical–cortical framework for a system disorder. Neuroscience and Biobehavioral Reviews, 35, 1929–1945. Panksepp, J. (1981). Brain opioids: A neurochemical substrate for narcotic and social dependence. In S. Cooper (Ed.), Progress in theory in psychopharmacology (pp. 149–175). London: Academic Press. Panksepp, J. (1982). Toward a general psychobiological theory of emotions. Behavioral and Brain Sciences, 5, 407–467. Panksepp, J. (1992). Oxytocin effects on emotional processes: Separation distress, social bonding, and relationships to psychiatric disorders. Annals of the New York Academy of Sciences, 652, 243–252. Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotion. New York: Oxford University Press. Panksepp, J. (2003). At the interface between the affective, behavioral and cognitive neurosciences: Decoding the emotional feelings of the brain. Brain and Cognition, 52, 4–14. Panksepp, J. (Ed.). (2004). Textbook of biological psychiatry. Hoboken, NJ: Wiley. Panksepp, J. (2005). Affective consciousness: Core emotional feelings in animals and humans. Consciousness and Cognition, 14, 19–69. Panksepp, J. (2006). Emotional endophenotypes in evolutionary psychiatry. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30, 774–784. Panksepp, J. (2007a). Neurologizing the psychology of affects: How appraisal-based constructivism and basic emotion theory can co-exist. Perspectives in Psychological Sciences, 2, 281–296. Panksepp, J. (2007b). Neuroevolutionary sources of laughter and social joy: Modeling primal human laughter in laboratory rats. Behavioral Brain Research, 182, 231–244. Panksepp, J. (2008). Play, ADHD and the construction of the social brain: Should the first class each day be recess? American Journal of Play, 1, 55–79.


Jaak Panksepp

Panksepp, J. (2010). The neurobiology of social loss in animals: Some keys to the puzzle of psychic pain in humans. In G. MacDonald & L. A. Jensen-Campbell (Eds.), Social pain: Neuropsychological and health implications of loss and exclusion (pp. 11–52). Washington, DC: American Psychological Association. Panksepp, J. (2011). The basic emotional circuits of mammalian brains: Do animals have affective lives? Neurosciences and Biobehavioral Reviews, 35, 1791–1804. Panksepp, J. (2012). The vicissitudes of preclinical psychiatric research: Justified abandonment by big pharma? Future Neurology, 7, 113–115. Panksepp, J., & Biven, L. (2012). The archaeology of mind. New York: Norton. Panksepp, J., Fuchs, T., & Iacabucci, P. (2011). The basic neuroscience of emotional experiences in mammals: The case of subcortical FEAR circuitry and implications for clinical anxiety. Applied Animal Behaviour Science, 129, 1–17. Panksepp, J., & Moskal, J. (2008). Dopamine and SEEKING: Subcortical “reward” systems and appetitive urges. In A. Elliot (Ed.), Handbook of approach and avoidance motivation (pp. 67–87). New York: Taylor & Francis. Panksepp, J., & Watt, J. (2011). Why does depression hurt? Ancestral primary-process separationdistress (PANIC) and diminished brain reward (SEEKING) processes in the genesis of depressive affect. Psychiatry, 74, 5–14. Rush, A. J. (2007). STAR*D: What have we learned? American Journal of Psychiatry, 164, 201–204. Schlaepfer, T. E., Cohen, M. X., Frick, C., Kosel, M., Brodesser, D., Axmacher, N., et al. (2008). Deep brain stimulation to reward circuitry alleviates anhedonia in refractory major depression. Neuropsychopharmacology, 33, 368–377. Schultz, W., & Dickinson, A. (2000). Neuronal coding of prediction errors. Annual Review of Neuroscience, 23, 473–500. Solms, M., & Panksepp, J. (2012). The “Id” knows more than the “Ego” admits: Neuropsychoanalytic and primal consciousness perspectives on the interface between affective and cognitive neuroscience. Brain Science, 2, 147–175. Toomey, B., & Ecker, B. (2007). Of neurons and knowing: Constructivism, coherence psychology, and their neurodynamic substrates. Journal of Constructivist Psychology, 20, 201–245. Watt, D. F., & Panksepp, J. (2009). Depression: An evolutionarily conserved mechanism to terminate separation-distress? A review of aminergic, peptidergic and neural network perspectives. Neuropsychoanalysis, 11, 5–104. Wöhr, M., Kehl, M., Borta, A., Schänzer, A., Schwarting, R. K., & Höglinger, G. U. (2009). New insights into the relationship of neurogenesis and affect: Tickling induces hippocampal cell proliferation in rats emitting appetitive 50-kHz ultrasonic vocalizations. Neuroscience, 163, 1024–1030. Wright, J. S., & Panksepp, J. (2011). Toward affective circuit-based preclinical models of depression: Sensitizing dorsal PAG arousal leads to sustained suppression of positive affect in rats. Neuroscience and Biobehavioral Reviews, 35, 1902–1915. Wright, J., & Panksepp, J. (2012). An evolutionary framework to understand foraging, wanting and desire: The neuropsychology of the SEEKING system. Neuropsychoanalysis, 14, 5–39. Zellner, M. R., Watt, D. F., Solms, M., & Panksepp. J. (2011). Affective neuroscientific and neuropsychoanalytic approaches to two intractable psychiatric problems: Why depression feels so bad and what addicts really want. Neuroscience and Biobehavioral Reviews, 35, 2000–2008.

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The Roles of Predictive and Reactive Biobehavioral Programs in Resilience Mattie Tops, Phan Luu, Maarten A. S. Boksem, and Don M. Tucker

In this chapter we propose a theory in which behavior (broadly comprising relevant cognition, emotion, and behavior) and physiology are coordinated and integrated by a number of separate behavioral and physiological programs, for convenience termed here biobehavioral programs. We propose that resilience may vary over time and between persons, depending on which program exercises control over behavior. More specifically, we will describe two main biobehavioral programs that control behavior adaptively in low-predictable and in highly predictable environments respectively. Behavior and emotions guided by the first program are highly reactive, while behavior and emotions controlled by the second program are guided by models of behaviors that are optimal in their own contexts and that have been consolidated in memory to form context models. Here, we will argue that interventions and experiences that increase resilience may accomplish this by shifting control from the reactive program to the context model program. Ventral corticolimbic control pathways in the brain are crucially involved in reactive behavioral control that includes fast associative learning, seen as highly adaptive in unpredictable environments. By contrast, dorsal corticolimbic control pathways are specialized for slow stable learning that is adaptive in highly predictable environments. Dorsal control pathways guide behavior in a feed-forward fashion by using models of the context that are stored in long-term memory. The reactive system produces a momentary, immediate sense of awareness in which emotional events and stimuli are experienced as close in time and space. Because of this immediacy of emotional experience, reactive control is associated with emotion-focused coping. By contrast, in episodes where context models guide and control behavior, emotional experience is less immediate and overwhelming. In addition, context models that are successfully used in predictive control will tend to include representations of positive experiences and outcomes. This positive bias and these less intense emotions enable active coping through confronting both negative and positive affective events and stimuli. We will discuss how these programs are involved in the development of resilience. We propose that, during evolution, biobehavioral programs developed to orchestrate different aspects of behavioral and physiological control systems; each program adapted to a particular set of contexts and conditions (Tops, Boksem, Luu, & Tucker, 2010). Aspects of the control systems include arousal, information processing biases, action control, specific cognitive operations, and, importantly, specific motivation. We draw on Panksepp’s (1998) levels of affective mind-brain organization to illustrate the depth and breadth of these biobehavioral programs, which we see as integrating primary process emotions that arise from evolutionarily provided subcortical operating systems, secondary process emotions that reflect basic emotional learning and memory processes as reflected in classical and operant conditioning, and tertiary process emotions or the higher emotional functions of thought and


Tops, Luu, Boksem, and Tucker

deliberation included in episodic/autobiographical memories, symbolic thought, and communication (Panksepp, 1998; Panksepp, Chapter 1, this volume). Our discussion does not focus on differences between primary, secondary, and tertiary process aspects of emotions but on ventral and dorsal corticolimbic system programs in which each combines specific elements at all three process levels. Finally, we propose that resilience can be increased in reactive individuals (i.e., persons in whom the reactive control program tends to dominate) by increasing capacities to shift toward context model biobehavioral programs. The brain appears equipped with mechanisms to make this shift, and individuals often display such a shift during skill acquisition and performance learning. Resilience may be increased through the application of similar learning mechanisms to the control of behaviors and emotions in negative environments. In the following sections, we first describe the two types of control systems, reactive and context model programs. Then we discuss mechanisms for shifting between these two control systems and discuss how they bolster resilience. Finally, we review evidence for how this shift may be applied to strengthen resilience through certain interventions, experiences, and behaviors such as emotion regulation, impulse control or “cool” vs. “hot” control, mindfulness meditation, and certain psychopharmacological agents. We discuss the evidence for how this shift may be involved in strengthening resilience through the cultivation of positive emotions. We also consider the relation of our model to other theories that explain the effects of emotions on cognition and resilience.

THE VENTRAL AND DORSAL CORTICOLIMBIC CONTROL PATHWAYS OF THE REACTIVE AND CONTEXT MODEL BIOBEHAVIORAL PROGRAMS We have argued for an evolutionary process underpinning the development of partially separate ventrolateral and mediodorsal control pathways that supported two behavioral programs adapted to different environments (Tops & Boksem, 2011a, 2012; Tops et al., 2010), as illustrated in Figure 2.1. The first program, termed the reactive program, incorporates the ventral corticolimbic control pathways, including inferior frontal gyrus (IFG), anterior insula (AI), amygdala, and anterior medial temporal lobe. The reactive program promotes fast associative learning that is adaptive in low-predictable environments. The reactive program contrasts with the second program, termed the context model program, which incorporates the dorsal control pathways that include posterior cingulate cortex, precuneus, posterior medial temporal lobe, and dorsolateral prefrontal cortex. The dorsal control pathways are specialized for guiding behavior with context models that are formed and kept stable by slow learning, a specialization that is adaptive in predictable environments. Context models are formed in long-term memory by the predictability of the environment/context. In low-predictable environments, effective context models generally cannot be formed quickly nor used to control behavior quickly in adaptive ways. Instead, behavior is guided reactively by momentary feedback from environmental stimuli through ventral corticolimbic control. This reactive guidance by momentary environmental stimuli is associated with attention focused on stimuli that are urgent and close in time and space. Those stimuli can be positive (“I have to catch that reward that is in my reach before it gets away”) or negative (“I have to get away from that danger before it gets me, because I’m in its reach”). By contrast, there is less urgency and focus on the moment (i.e., less narrow, more global focus

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free ebooks ==> www.ebook777.com The Roles of Biobehavioral Programs in Resilience 17 Dorsal Control Pathway

Ventral Control Pathway

Dorsal Visual Pathway

Lateral view

ventral Visual Pathway

Medial view

Figure 2.1 Left: Primary direction of corticolimbic traffic for organizing output from limbic integration toward specific action modules in the motor cortex. Two separate control paths are routed from limbic networks through the frontal lobe to the motor cortex. A ventrolateral pathway proceeds from the olfactory cortex through the orbital frontal lobe to the lateral frontal cortex before reaching the ventral premotor and motor cortices (ventral/bottom arrows). A mediodorsal pathway proceeds from the cingulate gyrus through the medial frontal cortex to the dorsolateral frontal cortex to the premotor and motor areas on the lateral convexity of the hemisphere (upper/dorsal arrows). Right: Primary direction of corticolimbic traffic for integrating perception from specific modules in the sensory cortex (in this case the arrows start from the visual area) toward the limbic cortex shown for dorsal (upper arrows) and ventral (bottom arrows). From Tucker (2007), copyright.

in time and space) when behavior is guided by context models in feed-forward fashion (“I will plant these seeds now, so that I have food for the coming winter, just like last year,” or “I will repair the fence around my chicken pen, so that foxes will not steal the eggs”). Table 2.1 summarizes the ventrolateral and dorsomedial control models. Classical work has shown that states of affective arousal carry resource information (physiological resources such as glucose levels and the condition of muscles, as well as social resources) and that these states are associated with implicit perceptions of coping abilities (Thayer, 1989). Only in low-predictable environments is it necessary to have a continuous readout of the level of available resources to inform immediate action. In the ventral corticolimbic control pathway, via the IFG and AI, information about the level of resources is combined with emotional or “drive” information that biases the direction of action either towards (i.e., approach behaviors like craving, hunger, love, trust) or away from (i.e., avoidance behaviors like disgust, pain, distrust) a target object (Tops & de Jong, 2006; Tops et al., 2010). This directional drive property may have developed from functions of the gustatory cortex that is situated in the insula. The directional drive bias and information about resources are further combined with relevant target information and, depending on circumstances, with priming or preparation for action responses and with matching autonomic responses. Together, the continuous readout of the direction of drive, resource levels, and orientation to potential targets enables fast, opportunistic action on the spur of the moment.



Table 2.1 Comparison of Ventral and Dorsal Control Pathways: Summary Features of Ventral Corticolimbic Control and Dorsal Corticolimbic Control Ventral corticolimbic control pathway Environment: Low predictable

Dorsal corticolimbic control pathway High predictable

Behavior: Direct sensitivity to + and – environmental influences or stimuli Reactive guidance—by momentary feedback from environment Attention focus is on urgent stimuli, narrow Close in time and space Focus on negative or positive stimuli Fast associative learning: fast opportunistic action, spur of the moment Ventral control bias = distressed in most environments

Less direct responsivity to environmental influences or stimuli Predictive context model guidance formed in longterm memory feed-forward model Less urgent, less narrow More global focus in time and space Positive emotional bias Slow learning previous experience with specific context; episodic memory, prospective self-related; simulate and predict future events that build on previous experience (context models) Dorsal control bias = not distressed in most environments

Brain functions: Inferior frontal gyrus (IFG) Anterior insula (AI) Amygdala Anterior medial temporal lobe Ventral striatum

Dorsolateral prefrontal cortex (dPFC) Posterior cingulate cortex Precuneus Posterior medial temporal lobe Dorsal striatum

The posterior cingulate cortex and precuneus, which are connected to the dorsal striatum and dorsolateral prefrontal cortex, are considered the dorsal endpoint of the rostral-ventral to caudal-dorsal gradient within the cortex, and as mediators of the dorsal control pathway. This may seem at odds with findings that identify these areas as important for self-reflection and as central to the “default mode network” that is active at rest and deactivates during many cognitive tasks. However, it is important to realize that self-reflection may be possible only at rest, and when performing habitual actions (in which the dorsal striatum is important), since attention in both cases is not involved with other processes. Self-reflection may involve activation of memories of the self in contexts (context models). Although retrieval and action control may partly dissociate during self-reflection, true context model-guided control is informed by previous experiences with specific contexts and involves engaging in increasingly automated or habitual behaviors. The default mode network has been proposed to support the ability to perform internal mentation by providing a platform for assembling dynamic internal mental models and scenarios (Buckner & Carroll, 2007). Typically, these scenarios would contain elements of autobiographical episodic memory and self-related prospective thoughts. It has also been suggested that the purpose of continuous internal mentation may be to act as a simulator and predictor of future events that are built from previous experiences (i.e., context models). In many situations and for many tasks, dorsal and ventral systems will collaborate and interact in the control of behavior. For example, findings support the interactions between IFG and dorsal frontal areas. When IFG implements reactive (momentary) immediate action according to the information from contextual signals, dorsal frontal cortical areas simultaneously implement “predictive” episodic motivation control and sustain control over behavioral episodes. The dorsal control is achieved through information conveyed from

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free ebooks ==> www.ebook777.com The Roles of Biobehavioral Programs in Resilience 19 temporally remote events (or context models), from the history of actions and outcomes, and from implementation of feed-forward control of behavioral patterns and their integrated action sequences. However, temporary as well as relatively stable biases for reactive control may result from temperament, unpredictable dangerous or urgent situations, perceptions of unpredictability after trauma or inconsistent parenting, and interactions between these factors. By contrast, a bias for context model-guided control may stem from a different temperament, and may follow consistent parenting and a predictable, secure early environment that favors exploration and the development of context models (i.e., internal working models of Bowlby’s attachment theory, 1988).

DORSAL AND VENTRAL MECHANISMS OF RESILIENCE The reactive and context model behavioral programs associated with ventral and dorsal control systems, respectively, have evolved because they are adaptive in certain environments and circumstances. Both the dorsal and the ventral programs are associated with talents and sources of resilience. However, while the reactive ventral programs are directly sensitive and responsive to both negative and positive environmental influences (including the social environment), the dorsal programs make use of context models and are, thus, less responsive to environmental influences. Because of this different responsivity of these biobehavioral programs, individuals who are biased towards dorsal control will generally not be distressed in most environments and adapt well. On the other hand, individuals who are biased toward ventral control may experience distress in many different environments. Such individuals may benefit from an increased capability to shift to dorsal control. We will focus on increasing resilience through shifting from ventral to dorsal control (i.e., from reactive to context model), because we believe this process is involved in various interventions or mechanisms that bolster resilience. We will discuss several examples in the following sections. We propose that resilience can be increased in reactive individuals by increasing capacities to shift to context model biobehavioral control programs. The brain is actually equipped to make this shift, a shift that is often evident during the learning of skills. Resilience may be increased by similar learning mechanisms that are applied to behavioral and emotional control in negative environments. Human and animal studies identify three elementary learning systems in the stages of skill acquisition. One system represents rapid and focused acquisition of new skills during threats and violations of expectations. The second system is a gradual process of updating a configural model of the environmental context. These two learning systems correspond to the ventral and dorsal corticolimbic control pathways discussed above. During learning, the ventral system is strongly involved in the early phase of learning, while the dorsal control system comes online later as learning progresses (Luu, Shane, Pratt, & Tucker, 2009). The engagement of each system during the course of learning is dependent on the nature of the events within the learning task. Certain tasks may express a third system, the habitformation system in the dorsal striatum. Recent behavioral studies in both humans and rodents have found evidence that performance in decision-making tasks depends on two different learning processes: one encodes the relationship between actions and their consequences and the second involves the formation of stimulus–response associations (Balleine & O’Doherty, 2010; Luu, Shane, Pratt, & Tucker, 2009). These two learning processes are thought to govern goal-directed and habitual actions, respectively. It appears likely that cooperation or competition between these sources of action control depends on the third learning system, which incorporates the cortico-basal ganglia network within which the



striatum is embedded and that mediates the integration of learning with basic motivational and emotional processes (Balleine & O’Doherty, 2010; Luu et al., 2011). Neurophysiological studies on connectivity pathways in animal brains (Haber, Fudge, & McFarland, 2000; cf. Joel & Weiner, 2000) demonstrate an interface between ventromedial (limbic), central dorsal (associative), and dorsolateral (motor) striatal regions via the midbrain dopamine cells (ventral tegmental area, substantia nigra), as well as via cortical areas, which form an ascending spiral between regions, as illustrated in Figure 2.2. We argue that this ascending spiral mediates functional shifts from reactive ventral control towards dorsal feed-forward and context model-guided control, to habitual control (Tops & Boksem, 2012). In reactive persons, resilience can be increased by a shift from reactive ventral to dorsal context model-guided control. We will discuss some examples in the following sections.

SHIFTING FROM REACTIVE TO CONTEXT MODEL CONTROL: IMPLICATIONS FOR RESILIENCE A host of intervention strategies have been developed to bolster individuals’ capacities to manage difficult life circumstances and challenges. Included among these strategies are positive affect enhancement and emotion regulation, cognitive reframing, and mindfulness meditation, each of which may increase resilience in reactive individuals by enabling a shift from reactive ventral to dorsal context model control. In the next sections, we discuss the mechanisms whereby these strategies may contribute to resilience strategies.

Control pathways

Ventral: IFG Anterior insula

Dorsolateral motor Posterior lateral putamen Dorsomedial associative Anterior caudate Ventromedial limbic NAcc

Habit Routine resilience

Dorsal: PCC Precuneus DLPFC

Striatum

Context models Feed-forward

Reactive Feedback

Figure 2.2 Schematic representation of an interface between ventromedial (limbic), central/dorsomedial (associative), and dorsolateral (motor) striatal regions, via ventrolateral corticolimbic and dorsomedial corticostriatal control pathways and via the midbrain dopamine (DA) cells (ventral tegmental area and substantia nigra, not shown), which form an ascending spiral between regions. The ventromedial striatum influences the central striatum, and the central striatum influences the dorsolateral striatum. This chapter argues that this ascending spiral mediates functional shifts from reactive ventral control towards dorsal feed-forward and context model-guided control, to habitual control. Resilience in reactive persons can be increased by the shift from reactive ventral towards dorsal context model-guided control. IFG = inferior frontal gyrus (ventrolateral prefrontal cortex); PCC = posterior cingulate cortex; DLPFC = dorsolateral prefrontal cortex; NAcc = nucleus accumbens/ventral striatum. Adapted from Tops and Boksem (2012).

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free ebooks ==> www.ebook777.com The Roles of Biobehavioral Programs in Resilience 21 Positive Affect Positive and Negative Affect and Attentional Scope One way to increase resilience is to cultivate positive affect, which is thought to broaden attentional scope and mindsets (e.g., Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008). Some of the theories on affective influences over attentional scope and resilience originated in part from earlier work by Tucker, Luu, and colleagues (e.g., Luu et al., 2011; Tucker, Luu, & Pribram, 1995), as does our own theory. We propose that certain positive affects increase resilience by inducing a shift from reactive ventral control to dorsal context model control. However, while other affective theories focus on dichotomies, our approach distinguishes between three classes of affects that each reflect a different underlying system: (1) reactive approach-related affects that are in most cases positive; (2) reactive avoidancerelated affects that are in most cases negative; and (3) affects related to context model control that are associated with optimism and a positive affective bias but that also allow the simultaneous confronting of both negative and positive affective events and stimuli. We will argue that our present model incorporates classical findings in this field, as well as recent findings not covered by previous models. Friedman and Förster’s (2010) literature review shows that positive emotional states and implicit affective cues expand the scope of attention (global focus) and that negative emotional states and implicit affective cues constrict the scope of attention (local focus) at both the perceptual and the conceptual levels. They conclude that a large and growing body of research supports the model and the assumptions that originated from Tucker and colleagues’ neuropsychological work and theory (e.g., Derryberry & Tucker, 1994; Luu, Tucker & Derryberry, 1998; Tucker & Williamson, 1984). The early studies were, thus, collectively inspired by a set of converging empirical and theoretical contributions (e.g., Fredrickson et al., 2008; Luu et al., 2011; Luu et al., 2009; Schwartz, 1990). From the theory of Tucker, Luu, and colleagues, our present model retains the hypothesis that the systems associated with the context models are biased towards positive emotion, optimism, self-efficacy, and confidence because the context models are based on previous predictive successes and positive outcomes. Our model also retains a reactive system that focuses on avoiding punishment and harm, but makes one important adjustment in adding reward to the reactive system in which both the avoidance of harm and seeking reward narrow space and time. This additional appetitive reactive reward-oriented system incorporates recent findings of Gable and Harmon-Jones within the expanded framework of our model. These authors report several studies in which reactive positive (appetitive, e.g., hunger) reward motivation facilitates a local focus (Gable & HarmonJones, 2008; Harmon-Jones & Gable, 2009). Our model also incorporates findings from Förster and colleagues (e.g., Förster, 2009; Förster & Tory Higgins, 2005; Liberman & Förster, 2009). Their results show that a global attentional focus is associated with larger psychological distance in time and space, “promotion focus,” prospection, high power, and a focus on similarities (which is compatible with the formation of configural context models). In contrast, a local attentional focus is associated with small psychological distances in time and space, “prevention focus,” low power, and a focus on differences (consistent with ventral object processing). There is an inherent positive bias in dorsal/feed-forward control. However, this does not involve exclusion or avoidance of negative affect. On the contrary, expectations of positive outcomes enable the individual to confront negative affect. It would not be adaptive or



plausible if negative affective information were excluded from context models. Context models are formed by averaging and configurally integrating many neutral, positive, and negative affective experiences with a bias towards positive successful outcomes. Hence, separate positive and negative affective dorsal systems do not seem to make sense, nor does an exclusively positive affective system that excludes negative affective experience. While the dorsal system integrates positive and negative affect and confronts both with a positive bias, for ventral reactive systems it makes more sense that positive/approach and negative/avoidance affects are processed at least partly by separate systems, as is supported by evidence (Small, Zatorre, Dagher, Evans, & Jones-Gotman, 2001). Notice that, because approach and avoidance actions are opposite in direction and thus mutually exclusive, dominance of ventral reactive control is characterized by a single bipolar dimension with highly inversely coupled affect (positive in reactive approach, and negative in reactive avoidance). In contrast, in dorsal context models both positive and negative emotions are integrated and confronted. This means that, in context models, positive and negative emotions do not form the opposite poles of a single dimension, but can occur independently and simultaneously. We will elaborate on this in the next section. This pattern is evident in research on optimism. Optimists do not avoid negative information, especially not when confronting negative affect and information that is important for active coping. Rather, avoidance of negative information is related to passive coping, while optimism and active coping are associated with processing both positive and negative information and affect (e.g., Aspinwall, Richter, & Hoffman, 2001). Nevertheless, there remain both a positive bias in the dorsal control and a special importance that is placed on the negative reactive avoidance system. It should be noted that the negative reactive avoidance system is critical for survival in some acute situations. This explains why the literature supports the positive affect–global focus bias and the negative affect–local focus bias, while certain more subtle negative affect–global biases and positive affect–local biases have been discovered only recently. Related distinctions between different types of positive affects are offered by several investigators. Drawing on the review by Derryberry and Tucker (1994), the broadenand-build theory of Fredrickson (1998) describes positive affect in a way that is consistent with the predictive context model control system. According to this theory, some positive emotions broaden an individual’s momentary thought–action repertoire: joy triggers the urge to play, interest triggers the urge to explore, contentment activates the urge to savor and integrate, and love activates a recurring cycle of each of these urges within safe, close relationships. The broadened mindsets arising from these positive emotions are contrasted with the narrowed mindsets activated by emotions associated with specific action tendencies, such as attack or flight (by emotions associated with reactive approach or avoidance; see also Gable & Harmon-Jones, 2008). Panksepp (1998) similarly recognizes a positive affect system associated with play and seeking beyond simply obtaining rewards. These theories along with our model make the distinction between the positive affect related to reactive approach and the kinds of positive affects that are adaptive in stable, predictable, or comfortable environments and that allow for a broadening of attention and cognition (Carver, 2003; Fredrickson, 1998; Gable & Harmon-Jones, 2008; Panksepp, 1998). This broadening of attention in the dorsal mode serves the function of guiding exploratory behavior by integrating and constructing context models, reading contexts, and flexibly and optimally selecting and switching between context models. We suggest that Fredrickson’s “building” in the “broaden-and-build theory” reflects the building and utilization of context models that “build” and bolster resilience.

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free ebooks ==> www.ebook777.com The Roles of Biobehavioral Programs in Resilience 23 The Independence or Bipolarity of Positive and Negative Affect The present model can explain another resilience-related aspect of positive and negative affect that is covered by Zautra and colleagues’ dynamic model of affect (Reich, Zautra, & Davis, 2003; Zautra, Berkhof, & Nicolson, 2002; Zautra, Reich, Davis, Potter, & Nicolson, 2000). Reich, Zautra, and Davis argue that, when the environment is safe and predictable, it is relatively easy for people to engage in complex, differentiated, and multidimensional processing of the surrounding environment and of their own positive as well as negative affective reactions in response to that environment. However, in more demanding and unpredictable situations attention becomes more focused on the most immediate and necessary behaviors and information in the environment. Thus, perceptions and attributions become more narrow and the experiences of positive or negative states “collapse into a single bipolar dimension with highly inversely coupled affect” (Reich et al., 2003, p. 70). The inverse relationship between positive and negative affect in times of stress seems to reflect a direct relationship between the severity of the stress and the strength of the bipolarity (Bisconti, Bergeman, & Boker, 2004). For example, in longitudinal studies of people suffering from chronic pain syndromes, Zautra and Smith (2001) found that, when pain was more pronounced, the presence of positive affect was predictive of a weaker relationship between pain and negative affect. In other words, as pain escalates, positive affect appears to play an increasing role in the regulation of negative affect (Zautra & Smith, 2001). In a study that controlled for current levels of distress, recently bereaved resilient individuals had weaker correlations between self-reported negative affect and positive affect, suggesting relatively greater independence in affect and less bipolarity (Coifman, Bonanno, & Rafaeli, 2007). By contrast, for those individuals who had chronically elevated symptom levels similar to complicated (prolonged, unabated) grief reactions, positive and negative affect were more strongly inversely correlated, suggesting less independence between affects and greater bipolarity (Bonanno, Goorin & Coifman, 2008). Our model predicts the same pattern as the dynamic model of affect. Because of the immediacy of emotional experience, reactive control is associated with emotion-focused coping and with related simplified and rapid responding by systems that are specialized for approach vs. avoidance actions. By contrast, the emotional experience in predictive control is less immediate and overwhelming. Moreover, the successful context models that are shaped and used in predictive control will tend to include representations of positive experience and outcomes. To repeat Aspinwall et al.’s (2001) findings on optimistic individuals, positive bias and less intense emotional experiences enable active coping through a confrontation of both negative and positive affect. Figure 2.3 shows that in dorsal systems both positive and negative affective information are stored in and retrieved from highly integrated context models, while ventral systems have specialized antagonistic reactive approach and reactive avoidance systems that create the experience of a bipolar reactive affect dimension. Although the reactive approach and avoidance systems express their characteristic emotions and motivations, they are not exclusively positive or negative (Friedman & Förster, 2011). Nevertheless, it can generally be said that reactive approach will be associated with positive emotions such as stimulus-triggered appetition and that reactive avoidance will be associated with negative emotions such as acute fear. Our model is compatible with the dynamic model of affect in that our model predicts that a shift from reactive ventral control to context model-guided dorsal control will decrease the bipolarity of positive and negative affect and increase resilience (e.g., Coifman et al., 2007).



Feed-forward control guided by context models Positive and Negative Affect Dorsal Ventral

Reactive Approach Reactive Positive Affect

Reactive Avoidance Reactive Negative Affect

Figure 2.3 Positive and negative affect as associated with three temperamental influences on behavior that reflect different behavioral programs. A reactive system for approaching rewards and a reactive system for avoiding threats or punishment form a bipolar reactive approach–avoidance dimension, and both interact, collaborate, and compete with, and are dampened by, a system guided by context models. Guidance by context models allows for active coping and increased resilience in which both positive and negative affective contents can be confronted simultaneously. This figure is adapted from Tops, Boksem, Luu, & Tucker (2010) and inspired by Figure 1 in Carver, Johnson, and Joormann (2009), who, in turn, noted the influence of Mary Rothbart and others.

Reactive Affect and Perceived Resources The apparent direct relationship between the severity of the stress and the strength of the bipolarity (previous section; Bisconti et al., 2004) is predicted by our reactive ventral and dorsal context control model discussed earlier. To review briefly, classical studies demonstrate that affective arousal states carry resource information (physiological resources of glucose levels, muscle condition, etc.; social resources). These arousal states are linked to implicit perceptions of coping abilities (Thayer, 1989). In the IFG/AI cortical pathways, the information about the level of resources is combined with emotional or “drive” information that biases the direction of action either towards (approach) or away from (avoidance) a target object (Tops et al., 2010; Tops & de Jong, 2006). Thus, in reactive control, affect should be either positive or negative at any given moment. The continuous readout of available resources is needed only in low-predictable environments to allow for immediate action. In predictable environments, perceived levels of resources will be more tonically and stably derived from context models (see also Dambrun et al., 2012). We will next discuss the model of Larsen, Cacioppo, and coworkers as it relates to our model and to the dynamic model of affect (Larsen, Hemenover, Norris, & Cacioppo, 2003). An important parameter of the Larsen et al. model is the severity of the stressor and the resulting coactivation of positive (approach) and negative (avoidance) emotional systems. For optimal health outcomes, their model posits that mild stressors should predominantly activate the positive emotional system, but severe stressors should coactivate the positive and negative emotional systems to enable active (problem-focused) coping (Folkman & Moskowitz, 2000; Larsen et al., 2003). Aspinwall and colleagues (2001) offer an explanation that seems

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free ebooks ==> www.ebook777.com The Roles of Biobehavioral Programs in Resilience 25 in line with the model of Cacioppo and Larsen and with Thayer’s theory. They argue that positive mood or experiences may serve as signals of resources that allow people to confront negative information. That is, the presence of a positive mood may be a signal that one’s current resources are sufficient to deal with the task at hand. If resources are perceived to be inadequate, one may be motivated to preserve short-term well-being by denying or arguing against the information. However, if resources are perceived to be sufficient, one may be able to process such information veridically. In the case of optimism, the belief that future events are likely to be good may provide a chronically high estimate of one’s affective resources and control capacities, resulting in the belief that one can overcome the costs of attention to negative information in most situations. We suggest that the explanation and model of Aspinwall and colleagues and of Cacioppo, Larsen, and colleagues reflect control that is guided by context models, which enables active coping in times of stress. Emotion Regulation Emotion self-regulation is an important aspect of resilience. It is also closely related to such approaches as the cultivation of positive affect, a kind of emotion regulation. Recent fMRI studies show that the ventral corticolimbic control network in the brain is involved in aspects of emotional (and physical) pain, emotion intensity, and emotional contagion (Craig, 2009). This network appears to be involved in a reactive and emotion-focused mode of regulating an intense experience of the emotional moment (e.g., by passively suppressing the emotional experience or expression). By contrast, the dorsal corticolimbic control network seems to be involved in goal-directed emotion self-regulation that serves feed-forward control and emotion dampening. This is achieved by regulating the activity in components of the ventral system such as the amygdala (for reviews see Ochsner & Gross, 2005; Phillips, Drevets, Rauch, & Lane, 2003a, 2003b). Willpower and Cool Versus Hot Control Research on stress often focuses on the amygdala. However, we think that, in humans, the cortical control areas such as IFG and anterior insula are important. A meta-analysis of anxiety activation in the brain by Etkin and Wager (2007) showed specifically that social anxiety was associated with right IFG activation. Several studies found that the right IFG is able to inhibit amygdala activity in response to negative stimuli or during emotion regulation. Notice that, although the right IFG is consistently active in social anxiety, it is also consistently implicated in neuroimaging studies of “cool” (i.e., relatively emotionally neutral) behavioral control. In this section, we make the argument that the right IFG is not part of the “cool” system (dorsal control can be better described as “cool”), but is part of the “hot” (i.e., emotionally reactive) ventral system (it is a control area of the “hot” system, e.g., keeping salient items in working memory or inhibiting responses, expression, or affect). The involvement of the right IFG in emotion inhibition and emotional (expressive) suppression in social anxiety may result from the association of social anxiety with social subordinance, which requires concealing and suppression of spontaneous emotional expressions. An important promoter of resilience is willpower or the ability to control impulses. In predictive systems, context models can assist in directing behavior towards long- and shortterm goals. In reactive systems, goals and motivational stimuli can be held active by redundant attentional and working memory processing that may actually lead to perseveration or obsessional behavior and rumination (Tops et al., 2010; Tucker et al., 1995). We adhere



to the view that mediodorsal areas implement sustained episodic motivation control over behavioral episodes, guiding voluntary behavior based on the history of actions and outcomes (Tops & Boksem, 2012) and on context models. When action outcomes are unfavorable and/or context models suggest that it is better to stop the particular endeavor and do what “experience has taught is best for you,” the endeavor will be abandoned in favor of flexible and adaptive switching to alternative endeavors or exploration. However, adapted to unpredictable environments, the ventrolateral prefrontal cortical controls of reactive systems may perseverate in order to exploit a potential opportunity (Tops et al., 2010). In this case, maintenance of drive and retrieval and/or maintenance of goals in working memory may keep goals active over time and, in the face of resistance, may help to implement effortful control of behavior in the service of the activated goals. An influential dual-system framework has been proposed to aid in understanding the processes that enable or undermine self-control or “willpower,” as exemplified in the delay of gratification paradigm (Metcalfe & Mischel, 1999). A cool, cognitive “know” system and a hot, emotional “go” system were postulated. The cool system is cognitive, emotionally neutral, contemplative, flexible, integrated, coherent, spatiotemporal, slow, episodic, and strategic. It is the seat of self-regulation and self-control. The hot system is the basis of emotionality, including fears as well as passions. It is impulsive and reflexive. Initially it is controlled by innate releasing stimuli (thus, literally under “stimulus control”). It is fundamental for emotional (classical) conditioning, and it undermines efforts at self-control. The balance between the hot and cool systems is purportedly determined by stress, developmental level, and the individual’s self-regulatory dynamics (Metcalfe & Mischel, 1999; cf. Phillips et al., 2003a, 2003b). The above description shows striking similarities with the present model, suggesting that the cool system can be mapped onto the dorsal control systems while the hot system can be mapped onto the ventral control systems. However, in earlier work (Tops & Boksem, 2011a; Tops et al, 2010), we noted the importance of distinguishing between dorsal and ventral prefrontal forms of cognitive control, and the frequent failure of most models and theories to do so. Here, we discuss a few examples of the tendency to ascribe “cool” to cortical control and “hot” to subcortical control, which we think ignores the fact that ventral cortical control is an intrinsic part of a fundamentally “hot” corticolimbic system. The first example involves preschoolers who were classified on the delay-of-gratification task as less able to delay gratification and who later showed low self-control abilities in their 20s and 30s. These individuals were tested 40 years later on “hot” and “cool” versions of a go/no-go task. The low delayers performed more poorly than did high delayers when having to suppress a response to a happy face but not to a neutral or fearful face. In an imaging study (Casey et al., 2011), the right IFG/AI differentiated between no-go and go trials to a greater extent in high delayers, whereas the ventral striatum showed exaggerated activation in low delayers (Casey et al., 2011). Similarly, a review of the modern neuroimaging literature on brain structure, function, and connectivity in attention-deficit/hyperactivity disorder (ADHD) and conduct disorder showed that ADHD is characterized predominantly by abnormalities in IFG, striatal, and parietotemporal networks that mediate “cool” cognitive functions associated with the disorder. This was contrasted with dysfunction in “hot” networks including the amygdala in conduct disorder (Rubia, 2011). In a similar vein, Bechara (2005) suggested that addiction is the product of an imbalance between two separate, but interacting, neural systems that control decision making: an impulsive, amygdala system for signaling pain or pleasure of immediate prospects, and a reflective, prefrontal cortex system for signaling pain or pleasure of future prospects.

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free ebooks ==> www.ebook777.com The Roles of Biobehavioral Programs in Resilience 27 These examples show that the “coolness” of less reactive, context model-guided mediodorsal control is not typically discriminated from the “coolness” of the ventrolateral cognitive control elaborations of the reactive (“hot”) systems themselves. Although dorsal context model-guidance systems may, at first glance, appear more cognitive compared to ventral reactive systems, each of them involves motivation and emotion and controls that continued to develop during evolution. The reactive systems produce a momentary, immediate sense of awareness, an experience of emotional stimuli as being close in time and space. However, the resulting intensity (“hotness”) of incentives and drives is controlled by “willpower,” the ventrolateral prefrontal controls that enable behavioral persistence in the face of distraction, temptation, and resistance (Tops & Boksem, 2010). However, the kinds of control, such as behavior or emotion inhibition and anxious rumination, may not be associated with subjective “cool” (Tops & Boksem, 2011b). By contrast, emotional experience in predictive control is less immediate and overwhelming (more “cool”); moreover, the successful context models that are shaped and used in predictive control will tend to include representations of positive experience and outcomes. To reiterate, this positive bias and the less intense emotions enable active coping through confronting both negative and positive affect. The fact that self-regulation can involve the prefrontal controls of the “hot” ventral system may explain why self-control is often followed by subsequent breakdown of self-control (“rebound”). The ventral system type of self-control involves behavioral suppression that is similar to the freezing or tonic immobilization responses from which it is derived. During behavioral suppression, behavioral impulses that are triggered by pleasure or fear drives are inhibited. However, the motivational drive activation is not inhibited, such that, when opportunity arises and inhibition can be lifted, the drives can be enacted. Hypothetically, the prolonged activation of the drive during behavior suppression may increase the activation in ventral drive systems, which may make self-control more difficult subsequently, increasing the chance of behavioral rebound (Levine, 1997; Schmeichel, Harmon-Jones, & Harmon-Jones, 2010). Moreover, there may be a role for the continuous affective readout at the level of the right IFG/AI that we discussed in the earlier section on dorsal and ventral corticolimbic control pathways and the section on reactive affect and perceived resources. The continuous affective readout appears to keep track of the momentary level of resources the individual has in order to control his or her environment, be it social or physiological resources. This may be why negative affect, low social resources (social exclusion), and low physiological resources (blood glucose level) are associated with reduced self-control (DeWall, Baumeister, & Vohs, 2008; Gailliot & Baumeister, 2007). In our evolutionary history, when levels of resources were low, more opportunistic behavioral strategies may have been adaptive (Del Giudice, Ellis, & Shirtcliff, 2011). Mindfulness Meditation Mindfulness meditation is increasingly included in therapies and interventions to increase resilience. Comparable to the cultivation of certain kinds of positive affect and emotion regulation, mindfulness meditation may increase resilience by inducing a shift from ventral reactive control toward dorsal context model-guided control (Figure 2.2). The mindfulness approach promotes detached observation, which has the effect of increasing the individual’s capacity to tolerate difficult emotions. The accompanying exposure transforms such emotions into innocuous states. Reactive tendencies to inhibit or otherwise to avoid sensations are prevented by increased capacity for tolerance and cool awareness. Awareness of context and of the whole range of choices available at any given moment is increased (Kent &



Davis, 2010). Mindfulness meditation is reflexive and goes with conscious access to the rich features of each experience and enhanced metacognition and self-regulation skills (Lutz, Slagter, Dunne, & Davidson, 2008). Mindfulness practice allegedly leads one to a clear but less emotionally reactive awareness of the autobiographical sense of identity that projects back into the past and forward into the future. In other words, it appears that the availability and guidance by context models are increased, thereby decreasing pure reactivity and increasing resilience. In contrast to the open monitoring style of meditation, such as in mindfulness, the focused attention/concentrative style of meditation entails the capacities for monitoring the focus of attention and detecting distraction, disengaging attention from the source of distraction, and redirecting and engaging attention on the intended object (Lutz et al., 2008). We have proposed that these are typical IFG attentional functions (Tops & Boksem, 2011a). In both focused attention and open monitoring meditation there is focus on the moment, which may function to prevent ventral frontal involvement in elaboration, inhibition, and rumination. Although neuroimaging research on meditation is complicated by individual differences in strategies and nonlinear effects of proficiency (Lutz et al., 2008), there is support for involvement of ventral system areas in focused attention meditation and of dorsal system areas in open monitoring meditation. For example, in a study of practiced novices and expert Buddhist monks the most consistent effect was the deactivation of the precuneus or posterior cingulate cortex (dorsal system areas) during focused attention meditation in contrast to activation of these areas during open monitoring meditation (Manna et al., 2010). In another study, subjects were scanned while they adopted either a reflective, extended self-reference that links experiences across time in memory (which may involve the dorsal system) or a momentary experiential self-reference centered on the present moment (possibly ventral reactive). The experiential focus yielded reduced activity in dorsal system areas such as medial prefrontal cortex, posterior cingulate cortex and hippocampus, and increased engagement of ventral areas such as in the insula, secondary somatosensory cortex, IFG, and inferior parietal lobule (Farb et al., 2007). These results suggest a fundamental neural dissociation between two distinct forms of self-awareness consistent with the dorsal and ventral programs, which are generally integrated but can nevertheless vary within and between individuals in relative activation. Taken together, the evidence suggests that mindfulness meditation may increase resilience by inducing a shift from ventral reactive control towards dorsal context model-guided control.

CONCLUSION We presented our model of the ventrolateral corticolimbic control pathways and the mediodorsal corticolimbic control pathways, and posit that they that are interacting but are also partly separable through their respective adaptations to environmental conditions that differ in the level of predictability (Tops et al., 2010). The reactive systems produce a momentary immediate sense of awareness, of sensing emotional stimuli as being close in time and space, and a tendency for emotion-focused coping. By contrast, when control is guided by context models, emotional experience is less immediate and overwhelming, has a wider temporal focus, has a sense of the past and the future, includes representations of positive experience and outcomes, and allows active coping through confronting both negative and positive affect. The biobehavioral programs associated with ventral and dorsal control systems are evolved adaptive systems that are successful in certain environments and circumstances. Both systems

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free ebooks ==> www.ebook777.com The Roles of Biobehavioral Programs in Resilience 29 represent talents and sources of resilience. The reactive ventral programs are sensitive and responsive to both negative and positive environmental influences. In the dorsal programs, the context models are dominant, are less responsive to environmental influences, and are experienced as less distressing. In the ventral programs, individuals become easily distressed in many environments. They may benefit from an increase in the ability to shift to dorsal control. We think that shifting from ventral towards dorsal control is a mechanism that is involved in various processes that increase resilience. We believe that awareness of the underlying brain mechanisms may help investigators to develop more targeted and effective interventions to assist individuals in becoming more resilient. Knowledge of these mechanisms may inform interventions as to which instruments and strategies to select and how to combine them for different persons and contexts, how to sustain gains, and how to best measure them.

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Derryberry, D., & Tucker, D. M. (1994). Motivating the focus of attention. In P. M. Niedenthal & S. Kitayama (Eds.), Heart’s eye: Emotional influences in perception and attention (pp. 167–196). New York: Academic Press. DeWall, C. N., Baumeister, R. F., & Vohs, K. D. (2008). Satiated with belongingness? Effects of acceptance, rejection, and task framing on self-regulatory performance. Journal of Personality and Social Psychology, 95, 1367–1382. Etkin, A., & Wager, T. D. (2007). Functional neuroimaging of anxiety: A meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. American Journal of Psychiatry, 164, 1476–1488. Farb, N. A., Segal, Z. V., Mayberg, H., Bean, J., McKeon, D., Fatima, Z., et al. (2007). Attending to the present: Mindfulness meditation reveals distinct neural modes of self-reference. Social, Cognitive and Affective Neuroscience, 2, 313–322. Folkman, S., & Moskowitz, J. T (2000). Stress, positive emotion, and coping. Current Directions in Psychological Science, 9, 115–118. Förster, J. (2009). Relations between perceptual and conceptual scope: How global versus local processing fits a focus on similarity versus dissimilarity. Journal of Experimental Psychology General, 138, 88–111. Förster, J., & Tory Higgins, E. (2005). How global versus local perception fits regulatory focus. Psychological Science, 16, 631–636. Fredrickson, B. L. (1998). What good are positive emotions? Reviews of General Psychology, 2, 300–319. Fredrickson, B. L., Cohn, M. A., Coffey, K. A., Pek, J., & Finkel, S. M (2008). Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources. Journal of Personality and Social Psychology, 95, 1045–1062. Friedman, R. S, & Förster, J. (2010). Implicit affective cues and attentional tuning: An integrative review. Psychological Bulletin, 136, 875–893. Friedman, R. S., & Förster, J. (2011). Limitations of the motivational intensity model of attentional tuning: Reply to Harmon-Jones, Gable, and Price (2011). Psychological Bulletin, 137, 513–516. Gable, P. A., & Harmon-Jones, E. (2008). Approach-motivated positive affect reduces breadth of attention. Psychological Science, 19, 476–482. Gailliot, M. T., & Baumeister, R. F. (2007). The physiology of willpower: Linking blood glucose to self-control. Personality and Social Psychology Review, 11, 303–327. Haber, S. N., Fudge, J. L., & McFarland, N. R. (2000). Striatonigrostriatal pathways in primates form an ascending spiral from the shell to the dorsolateral striatum. Journal of Neuroscience, 20, 2369–2382. Harmon-Jones, E., & Gable, P. A. (2009). Neural activity underlying the effect of approach-motivated positive affect on narrowed attention. Psychological Science, 20, 406–409. Joel, D., & Weiner, I. (2000). The connections of the dopaminergic system with the striatum in rats and primates: An analysis with respect to the functional and compartmental organization of the striatum. Neuroscience, 96, 451–474. Kent, M., & Davis, M. C. (2010). The emergence of capacity-building programs and models of resilience. In J. W. Reich, A. J. Zautra, & J. S. Hall (Eds.), Handbook of adult resilience (pp. 427–449). New York: Guilford Press. Larsen, J. T., Hemenover, S. H., Norris, C. J., & Cacioppo, J. T. (2003). Turning adversity to advantage: On the virtues of the coactivation of positive and negative emotions. In L. G. Aspinwall & U. M. Staudinger (Eds.), A psychology of human strengths (pp. 211–225). Washington, DC: American Psychological Association. Levine, P. (1997). Waking the tiger. Berkeley, CA: North Atlantic Books. Liberman, N., & Förster, J. (2009). Distancing from experienced self: How global-versus-local perception affects estimation of psychological distance. Journal of Personality and Social Psychology, 97, 203–216.

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free ebooks ==> www.ebook777.com The Roles of Biobehavioral Programs in Resilience 31 Lutz, A., Slagter, H. A., Dunne, J. D., & Davidson, R. J. (2008). Attention regulation and monitoring in meditation. Trends in Cognitive Sciences, 12, 163–169. Luu, P., Jiang, Z., Poulsen, C., Mattson, C., Smith, A., & Tucker, D. M. (2011). Learning and the development of contexts for action. Frontiers in Human Neuroscience, 5, 159. Luu, P., Shane, M., Pratt, N. L., & Tucker, D. M. (2009). Corticolimbic mechanisms in the control of trial and error learning. Brain Research, 1247, 100–113. Luu, P., Tucker, D. M., & Derryberry, D. (1998). Anxiety and the motivational basis of working memory. Cognitive Therapy and Research, 22, 577–594. Manna, A., Raffone, A., Perrucci, M. G., Nardo, D., Ferretti, A., Tartaro, A., et al. (2010). Neural correlates of focused attention and cognitive monitoring in meditation. Brain Research Bulletin, 82, 46–56. Metcalfe, J., & Mischel, W. (1999). A hot/cool-system analysis of delay of gratification: Dynamics of willpower. Psychological Review, 106, 3–19. Ochsner, K. N., & Gross, J. J. (2005). The cognitive control of emotion. Trends in Cognitive Sciences, 9, 242–249. Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. New York: Oxford University Press. Phillips, M. L., Drevets, W. C., Rauch, S. L., & Lane, R. (2003a). Neurobiology of emotion perception I: The neural basis of normal emotion perception. Biological Psychiatry, 54, 504–514. Phillips, M. L., Drevets, W. C., Rauch, S. L., & Lane, R. (2003b). Neurobiology of emotion perception II: Implications for major psychiatric disorders. Biological Psychiatry, 54, 515–528. Reich, J. W., Zautra, A. J., & Davis, M. C. (2003). Dimensions of affect relationships: Models and their integrative implications. Review of General Psychology, 7, 66–83. Rubia, K. (2011). “Cool” inferior frontostriatal dysfunction in attention-deficit/hyperactivity disorder versus “hot” ventromedial orbitofrontal-limbic dysfunction in conduct disorder: A review. Biological Psychiatry, 69, e69–87. Schmeichel, B. J., Harmon-Jones, C., & Harmon-Jones, E. (2010). Exercising self-control increases approach motivation. Journal of Personality and Social Psychology, 99, 162–173. Schwarz, N. (1990). Feelings as information: Informational and motivational functions of affective states. In E. T. Higgins & R. M. Sorrentino (Eds.), Handbook of motivation and cognition: Foundations of social behavior (Vol. 2, pp. 527–561). New York: Guilford Press. Small, D. M., Zatorre, R. J., Dagher, A., Evans, A. C., & Jones-Gotman, M. (2001). Changes in brain activity related to eating chocolate: From pleasure to aversion. Brain, 124, 1720–1733. Thayer, R. E. (1989). The biopsychology of mood and arousal. New York: Oxford University Press. Tops, M., & Boksem, M. A. S. (2010). Absorbed in the task: Personality measures predict engagement during task performance as tracked by error negativity and asymmetrical frontal activity. Cognitive Affective and Behavioral Neuroscience, 10, 441–453. Tops, M., & Boksem, M. A. S. (2011a). A potential role of the inferior frontal gyrus and anterior insula in cognitive control, brain rhythms and event-related potentials. Frontiers in Cognition, 2(330), 1–14. Tops, M., & Boksem, M. A. S. (2011b). Cortisol involvement in mechanisms of behavioral inhibition. Psychophysiology, 48, 723–732. Tops, M., & Boksem, M. A. S. (2012). “What’s that?” “What went wrong?” Positive and negative surprise and the rostral-ventral to caudal-dorsal functional gradient in the brain. Frontiers in Psychology, 3, 1–5. Tops, M., Boksem, M. A. S., Luu, P., & Tucker, D. M. (2010). Brain substrates of behavioral programs associated with self-regulation. Frontiers in Cognition, 1, 1–14. Tops, M., & de Jong, R. (2006). Posing for success: Clenching a fist facilitates approach. Psychonomic Bulletin and Review, 13, 229–234. Tucker, D. M. (2007). Mind from body: Experience from neural structure. New York: Oxford University Press. Tucker, D. M., Luu, P., & Pribram, K. H. (1995). Social and emotional self-regulation. Annals of the New York Academy of Sciences, 769, 213–239.



Tucker, D. M., & Williamson, P. A. (1984). Asymmetric neural control systems in human self-regulation. Psychological Review, 91, 185–215. Zautra, A. J., Berkhof, J., & Nicolson, N. A. (2002). Changes in affect interrelations as a function of stressful events. Cognition and Emotion, 16, 309–318. Zautra, A. J., Reich, J. W., Davis, M. C., Potter, P. T., & Nicolson, N. A. (2000). The role of stressful events in the relationship between positive and negative affects: Evidence from field and experimental studies. Journal of Personality, 68, 927–951. Zautra, A. J., & Smith, B. W. (2001). Depression and reactivity to stress in older women with rheumatoid arthritis and osteoarthritis. Psychosomatic Medicine, 63, 687–696.

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Approach/Engagement and Withdrawal/Defense as Basic Biobehavioral Adaptations Resilient Transcendence of a Popular Duality Martha Kent

Resilience has been difficult to classify. Is it a bipolar concept, the positive of negative, flourishing despite adversity versus distress, injury, and illness because of adversity? Or is it a unipolar gradation of adaptation to challenge? Or is it both, depending on acute or chronic conditions, the rescue offered in an emergency or the lasting care of friendship? These are some of the questions about resilience examined in this chapter. “Two is not always better than one”; so declare Keren and Schul (2009) in their assessment of dual-system theories predominant in a number of cognitive areas. The same could be said of dual-system models and theorizing in most of psychology. Keren and Schul’s reasons for the prevalence of two-system theories, their strengths and limitations, are useful to keep in mind at the outset of this volume, not only to enrich our thinking about resilience but also to bring to the fore the possibility that resilience may do both: integrate bimodal with unimodal theories and processes in attempts to capture its complexity. The authors point out that dichotomies are congenial to human cognition in formulating idealized extreme poles that both oppose and complement each other. Two-system models tell a good story, make apparent sense, and provide classification schemes that help to order complexity. Binary concepts, such as nature versus nurture, are easier to formulate and to comprehend. As higher order explanations, they extend a wide reach in subsuming lower order phenomena. The advantages of scope and simplicity are offset by limitations and costs in empirical accuracy, precision of predictions, or guiding future research. Perhaps most important for resilience are the obstacles to growth and progress of a field and the inability to represent phenomena that are not necessarily binary but integrative and continuous. These limitations may have kept resilience submerged for so long. The physiological study of adaptation to threat may have led the way in developing binary models, starting with Cannon’s homeostatic model. However, the study of physiological functions has also led the way in showing the shortcomings of homeostasis in proposing allostasis as a process that could account for prospective, long-term flexible physiological anticipation of changing conditions. Homeostatic set points gave way to a range of variation. Sterling and Eyer’s (1988) concept of allostasis has led to more accurate conceptualization of anticipatory adaptation. For many years the study of emotions was similarly dominated by dichotomous models of positive and negative emotions that have progressed to more finely grained understanding of emotions (for a review see Reich, Zautra, & Davis, 2003; Zautra, 2003). The study of resilience has undergone a similar evolution. The representation of resilience as the positive pole of good outcomes is making room for more process-oriented models. Resilience as an adaptive process may integrate binary and unimodal approaches (e.g., Tops, Luu, Boksem, and Tucker, Chapter 2, this volume).


Martha Kent

This chapter will review a brief sampling of dichotomous models and the evolving complexity in models of resilience. Resilience places the question of what sustains life squarely at the center. When life is most threatened, the struggle to stay alive becomes critical and skills for approaching what sustains even in the midst of harm become the tools for flexible adaptation. We set out to look for what kept people alive in extreme environments of human-made adversity. We found them in the destructive events of the past century: the Gulag where Eugenia Ginzburg (1967, pp. 220–221) chanted poetry in her cell, the Holocaust transport with girls wearing ribbons in their hair (Berenbaum, 1993, p. 198), the bombing of a city and a boy playing his violin (M. Leet, personal communication, 1984), in the prisoner-ofwar prison, nicknamed Hanoi Hilton, where Robert Shumaker (This Emotional Life, 2010) tapped code to other inmates, and the boy who helped his kidnapped classmates escape from the collapsing cave in Chowchilla, California (Terr, 1979; for details see Kent & Davis, Chapter 17, this volume). We recognized resilient adaptations in the developmental literature of children who grew up well even in disadvantaged conditions, protected by such factors as close contact with one or more persons and doing well in school (Luthar, 2006; Masten, Best, & Garmezy, 1990). What these diverse survivors had in common was an attitude of approach and engagement with their circumstances in ways that kept them well. Much better known and more extensively studied than approach and engagement is the withdrawal from or defending against threat, such as the fight–flight response. Approach/ engagement are generally seen and studied as adaptations to benign conditions while withdrawal/defense are response tendencies made to adverse and threatening ones. However, resilience is a flexible response that finds approach/engagement even in threatening circumstances, as the above examples of survivors attest. We will review a sampling of models of approach/engagement and withdrawal/defense and of resilient flexibility we encountered in our search for basic processes of human adaptation. We present a brief outline of our impressions in Table 3.1 as a convenient sketch of large areas of research. A fuller discussion follows the sequence of the table.

DICHOTOMOUS MODELS Research on adaptations to threat has usually focused on the distressed and traumatic responses people made to their adverse circumstances. The past century has explored in rich detail the neurobiological responses to threat. The literature on stress has long recognized an efficient response to threat as essential for good adaptation, as first captured in Cannon’s (1932/1963) vivid formulation of fight–flight, in Selye’s (1956) general adaptation syndrome (GAD), and reflected in the concepts of allostasis and allostatic load (McEwen & Seeman, 1999; Sterling & Eyer, 1988). It is this literature that has postulated dynamic reciprocating mechanisms in adaptations to threat. A number of models have advanced concepts of approach/engagement and withdrawal/defense and described them at the physiological, neuroendocrine, cortical, and biobehavior levels. Physiological Models At the most basic physiological level, approach and withdrawal are expressed in the body’s coordinated mobilization of resources during challenge and the restoration of resources during rest and recovery. The sympathetic nervous system (SNS) responds with maximal

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Brain Functions

Neuroendocrine

Physiological/ Neuroendocrine

Modalities

Aversive Environment/Context

Maroun (2003), Garcia (1999) Pruessner (2008); Davidson (2010) Davidson (2000)

Hippocampus…………………………………………… HPA Axis

Left Hemisphere……………………………………….... Right Hemisphere

LeDoux (2000)

Panksepp (1998)

W. Schultz (2002)

Carter (2005); Uvnäs-Moberg (2005)

Sapolsky (1994); Yehuda (2006)

Porges (2001)

Sterling & Eyer (1988); McEwen & Stellar (1993)

Selye (1956)

Cannon (1938)

Authors

Prefrontal Cortex……………………………………….. HPA Axis, Amygdala

Amygdala

Seeking System………................................................. Disgust; Rage/Anger

Dopamine Reward Circuit

Oxytocin/………………………………………….......... HPA Axis Vasopressin

HPA Axis Cascade: CRH, ACTH, Cortisol

Ventral Vagus Engagement................................................................. Sympathetic (SNS)

Anticipatory Mechanisms Allostasis....................................................................... Allostatic Load

Autonomic Nervous System (ANS) Parasympathetic (PNS) ................................................. Sympathetic (SNS) Homeostasis Hypothalamic-Pituitary-Adrenal (HPA) Axis

Nonaversive Environemnt/Context

Physiological Models

Models

Table 3.1 Selected Models of Approach/Engagement and Withdrawal/Defense in Diverse Areas: Physiological, Neuroendocrine, Brain Functions, Affect, Cognition, and Action


Integrative: action; internal, external; neurobehavioral

Integrative: positive/negative affect & cognition; neurobehavioral

Modalities

Table 3.1 Continued

Unpredictable Environment/Context

Siegel (2007) Hayes (2004) Dichter (Chapter 16) Cloitre (Chapter 21) Kent (Chapter 17)

Acceptance & Commitment

Activation

Skills Training

Resilience Action-Agency Training

[Beck (1979), Foa (2000)]

Mindfulness

New Approaches Strength focused

Aversive/Unpredictable Environment/Context [Traditional Therapies] [Symptom focused]

Rothermund(Chapter 5)

Accommodative Assimilative Regulation………...…...…...…...…...…....................... Regulation Counter-regulation

Therapeutic Models

Tops (Chapter 2)

Reich, Zautra, Davis (2003)

Authors

Predictive Control……………...…...…...…...…...…... Reactive Control Neurobehavioral Context Model

Dynamic Model of Affect Independence of + & Polarization of + and – Emotion…………………………………………………... Emotions

Predictable Environment/ Context

Affective/Cognitve Models

Models


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mobilization of energy for an emergency and the parasympathetic nervous system (PNS) with the restoration of bodily functions by promoting digestion, growth, reproduction, and immunity, functions that are suppressed during sympathetic responses. Physiological changes and behavioral responses prepare for active coping (Engelman, Landgraf, & Wotjak, 2004; Koolhaas et al., 1999) in the face of challenge. Cannon (1932/1963) coined the expression fight–flight to capture the acute response to threat of the sympatho-adrenergic system (SAS). Selye applied the phrase general adaptation syndrome (GAS) for nonspecific responses of the chronic stress he observed in animals subjected to various stressors. He pioneered the glucocorticoid component of a chronic stress response and thought that these hormones formed part of a signaling system that involved the pituitary and adrenal cortex. This precursor signaling system forms the essential components of the hypothalamicpituitary-adrenal (HPA) axis involved in passive coping (Engelman et al., 2004; Koolhaas et al., 1999) and the regulatory transmitter cascade of corticotropin releasing hormone (CRH), adrenocorticotropin hormone (ACTH), and glucocorticoids that include the wellrecognized hormone cortisol. Cannon’s concept of homeostasis and fixed set points proved unsatisfactory in representing a more flexible anticipatory process termed allostasis (Sterling & Eyer, 1988) and allostatic load (McEwen & Stellar, 1993). While homeostatic internal regulation reflects reactive responses within a range of set points (e.g., body temperature), allostasis represents a long-term flexible physiology that changes by anticipating the demands from a changing environment (see review in Chapter 4). Allostatic load refers to the reduced capacity of an organism to rebound from repeated or chronic stress, resulting in hyperactivation of the HPA axis, altered cortisol levels, and compromised physiological and psychological functioning. A physiological model focused on positive adaptation of engagement is Porges’s (2001) polyvagal theory. According to the theory, humans evolved to survive not only via a robust, sympathetic fight–flight response but also via the capacity for social engagement with which they are endowed from birth. The mechanisms supporting social engagement are: (1) the neural regulation of the muscles of the face and head, allowing infants to signal caregivers from birth, and (2) the myelinated ventral vagus regulation of the autonomic nervous system. In this social engagement system, the visceral stimulation for mobilization of fight–flight would inhibit the expression of social engagement. However, increased activity through the ventral vagus would promote social engagement behaviors and visceral states of calm in a flexible manner. The ventral vagus fosters calm behavior by inhibiting the sympathetic influences to the heart and thereby dampening the HPA axis. It acts as a “brake” that modulates heart rate by slowing and speeding heart rate and allowing rapid engagement and disengagement and easy switching from social engagement to defensive strategies with others. It allows engagement while disabling defense in a flexible adaptation. Neuroendocrine Models Models of approach/engagement and withdrawal/defense at the neuroendocrine level are embedded in the core functions of main neurotransmitters, among them dopamine and oxytocin. One example is Panksepp’s (1998) SEEKING system, which he describes in terms that share a surprising resemblance with approach/engagement. SEEKING is a “foraging/ exploration/investigation/curiosity/interest/expectancy” system involved in exploring the environment with energy and excited anticipation. Frustration of this vigorous expectancy triggers rage/aggression. Panksepp proposes that this intersection of seeking and aggression forms two neural circuits that express mutually inhibitory interactions (1998, p. 191). He


Martha Kent

locates the seeking behavioral system in the brain dopamine circuit. Electrical stimulation of the ascending dopamine circuit evokes active exploration, engagement, interest, and curiosity, terms that are so similar to the qualities we observed in the “good survivors” (described in Kent & Davis, Chapter 17, this volume). Of note is the observation that seeking behaviors within this system are not motivated by reward or conditioning but reflect the organism’s innate tendency for engagement. Oxytocin (OT), the neuropeptide of affiliation, forms an anti-stress system with calming and restorative effects that overcome avoidance and defensive behaviors, and that foster approach behaviors (Uvnäs Moberg, 2005). Oxytocin is distributed in various brain areas and modulates autonomic, homeostatic, and endocrine processes (Carter, 2007; Insel, 1992; Young & Wang, 2004). Since OT can move through the brain by diffusion rather than through synaptic transmission or the circulatory system, it has broad pervasive effects in the brain (Landgraf & Neumann, 2004). An extensive animal literature describes the role of oxytocin in the regulation of affiliative responses, mating, pair-bond formation, parenting, and attachment (Lim & Young, 2006). Human research is hampered by OT’s limited blood–brain barrier penetration. However, Heinrichs and colleagues (Heinrichs, Baumgartner, Kirschbaum, & Ehlert, 2003) have pioneered intranasal OT for delivery of OT to the brain and have measured its effects on perceived stress and cortisol in relation to social support (Heinrichs et al., 2003), increases in trust (Kosfeld, Heinrichs, Zaak, Fischbacher, & Fehr, 2005), and the ability to infer emotional states (Domes, Heinrichs, Michel, Berger, & Herpertz, 2007). Oxytocin modulates social cognition, perception, and behavior by fostering a broad spectrum of social approach behaviors. The calming affiliative effects can be evoked by a range of sensory stimuli: touch, warmth, and environmental and psychological positive interaction (Uvnäs Moberg, 1998). It should be noted that feelings of calm and connection are slower to emerge and less obvious in contrast to the immediate dramatic sympathetic responses of fight–flight (Uvnäs Moberg, 2005). The injection of intranasal oxytocin or promotion of social bonds to prevent the development of PTSD is described by Frijling and colleagues (see Chapter 22, this volume). Brain Functions At the cortical level, dynamic interactions of neural circuits are involved in inhibitory or activating regulation of the HPA axis in response to homeostatic challenge, among them the prefrontal cortex (PFC), the hippocampus, and the amygdala. Herman et al. (2003) make the useful distinction between real and predicted stressful stimuli. Real stressors represent responses of the body to sensory visceral stimuli (e.g., pain, hemorrhage) and are considered to be “reactive.” By contrast, predicted or “anticipatory responses” activate the HPA axis in the absence of sensory stimuli and physiological challenge, as they anticipate rather than react to homeostatic disruption. Memory-dependent aspects of anticipatory responses are very important in determining HPA response. The prefrontal cortex (PFC) orchestrates the behavioral and systemic responses to threat. Rodent models show that the PFC is highly sensitive to stress and undergoes significant remodeling after stress exposure. In humans stress-induced cortical changes are reflected in impaired executive functions such as cognitive flexibility, working memory, attention, and goal-directed behavior and decision making. The PFC is highly interconnected with the rest of the brain. Two pathways are particularly relevant in stress modulation. The first is the bi-directional connection between the PFC and the amygdala (Garcia et al., 1999). The second is the reciprocal connection between the PFC and the hippocampus that is important

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for episodic memory and memory for environmental context processing. Particularly significant is the medial prefrontal cortex (mPFC). In rats and primates, the mPFC shows a high density of glucocorticoid receptors, early stress-induced gene expression, and ascending and descending projections, making it centrally important in HPA regulation (Holmes & Wellman, 2009). Exposure to stressors activates this network of the mPFC, hippocampus, and amygdala (Maroun & Richter-Levin, 2003). Many studies replicate the inhibitory effect of stress on the PFC. Of note is that stressful events suppress synaptic plasticity in the two brain areas that are most central to memory formation, the hippocampus and the mPFC. Fear thus “blocks” the higher order behaviors involved in working and episodic memory, in attention, and in cognitive flexibility that are mediated by the hippocampus and PFC. This “blockade” allows and fosters the more automatic responses that are dependent on subcortical areas, such as the amygdala. Recent studies differentiate between dorsal and ventral aspects of the mPFC in regulating HPA activity (Davidson, 2000), but not always with consistent results. Pruessner et al. (2008) find a profound bilateral deactivation of the limbic system, showing dorsal and ventral deactivation of mPFC to social stress. This deactivation underscores what is lost here: The higher limbic structures (i.e., hippocampus, mPFC) and the PFC generally provide tonic inhibition of the HPA axis. When exposed to stress, these structures reduce their activity, thus disinhibiting the HPA axis that initiates the cascade of stress hormone release. The resulting impaired negative feedback contributes to further deactivation, PFC and hippocampal hypoactivation, and further HPA axis dysregulation.

BEYOND DICHOTOMOUS MODELS Certainly since Darwin, dichotomous models have dominated the study of emotions, particularly since these models defined emotions as action tendencies or readiness tools of survival that had developed from more primitive actions. In evolutionary terms, emotions are seen as responding to basically two types of stimuli, appetitive and aversive. This biphasic organization is represented in many theories: Schneirla’s (1959) proposed approach–withdrawal behaviors to reach beneficial conditions and avoiding harm, mediated by low intensity or high intensity environmental stimuli; Konorski’s (1967) preservative or protective dichotomy; Osgood, Suci, and Tannenbaum’s (1957) semantic valence of pleasant–unpleasant and calm–aroused activation dimensions; and Russell’s (1980) and Watson, Clark, and Tellegen’s (1988) circumplex model of emotions consisting of pleasant–unpleasant and activated–deactivated dimensions, with most emotion terms occupying a circular configuration around these two orthogonal dimensions. At the physiological level, Davidson relates hemispheric asymmetry to cortical activation–inhibition in which left prefrontal activation is associated with higher behavioral activation and right hemisphere activation with behavioral inhibition (Davidson, 2000). At the same time, a more finely grained understanding of the bipolarity of emotions emerged with the work of Bradburn and Caplovitz (1965) in discovering the independence of positive and negative emotions. An individual’s reports of happiness did not indicate anything about his unhappiness. In a detailed review Reich, Zautra, and Davis (2003) identified conditions under which emotions were independent or inversely related: Positive and negative emotions functioned largely independently of each other most of the time, but emotions were dichotomized under conditions of threat. Zautra, Berkhof, and Nicolson’s (2002) study on workers’ emotions under high and low stress found that positive and negative feelings were nearly independent of one another under low stress. During stressful


Martha Kent

conditions, positive and negative feelings showed an inverse relationship. The more negative feelings a person indicated, the fewer positive feelings he expressed. Their dynamic model of affect (DMA) addresses directly the independence of positive and negative affect (bivariate) versus the unidimensional inverse relationship (bipolar) in relation to the environment and its stress and uncertainty. These relationships are reflected in cortical and neuroendocrine functions (see review by Reich, Zautra, & Davis, 2003). The increasing study of flexible adaptive responses is evident in a number of resilience models and resilience treatment approaches. In his predictive model, Mattie Tops (Tops, Luu, Boksem, & Tucker, Chapter 2, this volume) proposes a biobehavioral theory that coordinates and integrates separate behavioral and physiological programs that control behavior and resilience over time. Two main biobehavioral programs control adaptive behavior in low-predictable and in highly predictable environments. One program operating in lowpredictable environments is highly reactive and is based on fast associative learning. It is supported by ventral corticolimbic control pathways and produces a momentary immediate sense of awareness of stimuli and events as being close in time. Behavior and emotions controlled by the second program are guided by models of behaviors optimal in their own contexts and that are consolidated in memory to form context models. These are formed through slow learning, are adaptive in highly predictable environments, are less immediate, and allow feed-forward goal-directed behavior. They are supported by dorsal corticolimbic pathways. Resilience may be increased through experiences that shift control from reactive programs to context model programs. Moreover, context models, because they are slower to respond and less overwhelming, allow for the experience of both positive and negative emotions and potentially for the transformation of reactivity to prospection. Table 3.1 concludes with studies of therapeutic approaches made to the same environment, one that is aversive and unpredictable. Up to this point, approach/engagement was seen as a response that occurred in safe and predictable environments, while withdrawal/ defense occurred in aversive and unpredictable environments. New developments in therapeutic approaches have broken out of this mold. These approaches apply capacities of approach/engagement to aversive experiences. Examples are mindfulness therapies (Segal, Teasdale, & Williams 2004) that emphasize attention to moment-by-moment experience, whether pleasant or unpleasant, turning toward particular content of sensation or thoughts with openness and acceptance, and acceptance of automatic content rather than striving to solve the problems of that content. The emphasis is not on changing the thoughts but on changing one’s relationship to them, thus disengaging and acquiring independence, and on responding to actual events rather than to private events. Further elaborations of these processes are found in acceptance and commitment therapy (ACT; Hayes, 2004). Behavioral activation therapy addresses the anhedonia and avoidance in depression with approaches that increase pleasant events and encourage attainment of goals and proactive engagement (Dichter, Smoski, Henderson, & Dimidjian, Chapter 16, this volume). Skills training (Hassija & Cloitre, Chapter 21, this volume) aims to foster adaptive emotional and social skills in acute and chronic traumatic states. Kent and Davis (Chapter 17, this volume) review the neuroscience literature that establishes action as a critical component of resilience and describe a clinical trial for training resilience. These approaches restore capacities and strengths that have been compromised or lost in traumatic experiences. Finally, although not reviewed here, the latest developments in resilience studies address disorders associated with excessive reward, such as affluence or overeating in obesity, and their destructive effects on health and adaptive functions. Methods for restoring resilience are exemplified in the current investigations of Luthar and Barkin (2012) on

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affluence in a study comparing adolescent functions in affluent and in inner city high schools (Luthar & Barkin, 2012). Our own work is conducting a clinical trial on resilience brain training to counter obesity in a population of American veterans (Kent, Kurtz, Haller, Purdom, & Parrington, 2012). Too much approach/engagement of all that is pleasant and rewarding has major consequences for optimal adaptation and resilience that are as serious as an excess of distress and withdrawal/defense responses to traumatic events. The former result in disorders such as addiction, delinquency, narcissism, and excessive materialism in contrast to the disorders of mood, anxiety, and self-/other injury of the latter. Approach/engagement and withdrawal/defense are optimally adaptive when resilience qualities include flexible agency and self-direction in the service of a life well lived, the new frontier of resilience studies.

REFERENCES Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Berenbaum, M. (1993). The world must know: The history of the Holocaust as told in the United States Holocaust Memorial Museum. New York: Little, Brown. Bradburn, N. M., & Caplovitz, D. (1965). The structure of psychological well-being. National Opinion Research Center, Monographs in Social Research. Chicago: University of Chicago. Cannon, W. B. (1963). The wisdom of the body. New York: Norton. (Original work published 1932) Carter, C. S. (2005). Biological perspectives on social attachment and bonding. In C. S. Carter, L. Ahnert, K. E. Grossmann, S. B. Hrdy, M. E. Lamb, S. W. Porges, & N. Sachser (Eds.), Attachment and bonding: A new synthesis (pp. 85–100). Cambridge, MA: MIT Press. Carter, C. S. (2007). Sex differences in oxytocin and vasopressin: Implications for autism spectrum disorder? Behavioural Brain Research, 176, 170–186. Davidson, R. J. (2000). Affective style, psychopathology and resilience: Brain mechanisms and plasticity. American Psychologist, 55, 1193–1214. Domes, G., Heinrichs, M., Michel, A., Berger, C., & Herpertz, S. C. (2007). Oxytocin improves “mind reading” in humans. Biological Psychiatry, 61, 731–733. Engelman, M., Landgraf, R., & Wotjak, C. T. (2004). The hypothalamic-neurohypophysial system regulates the hypothalamic-pituitary-adrenal axis under stress: An old concept revisited. Frontiers in Neuroendocrinology, 25, 132–149. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35. Garcia, R., Vouimba, R. M., Baudry, M., & Thompson, R. F. (1999). The amygdala modulates prefrontal cortex activity relative to conditioned fear. Nature, 402, 294–296. Ginzburg, E. S. (1967). Journey into the whirlwind (P. Stevenson & M. Hayward, Trans.). New York: Harcourt Brace Jovanovich. Hayes, S. C. (2004). Acceptance and commitment therapy and the new behavior therapies. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 1–29). New York: Guilford Press. Heinrichs, M., Baumgartner, T., Kirschbaum, C., & Ehlert, U. (2003). Social support and oxytocin interact to suppress cortisol and subjective responses to psychosocial stress. Biological Psychiatry, 54, 1389–1398. Herman, J. P., Figueiredo, H., Mueller, N. K., Ulrich-Lai, Y., Ostrander, M. M., Choi, D. C., et al. (2003). Central mechanisms of stress integration: Hierarchical circuitry controlling hypothalamopituitary-adrenocortical responsiveness. Frontiers in Neuroendocrinology, 24, 151–180. Holmes, A., & Wellman, C. L. (2009). Stress-induced prefrontal reorganization and executive functions in rodents. Neuroscience and Biobehavioral Reviews, 33, 773–783.


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Insel, R. R. (1992). Oxytocin – A neuropeptide for affiliation: Evidence from behavioral, receptor autoradiographic, and comparative studies. Psychoneuroendocrinology, 17, 3–35. Kent, M., Kurtz, J. L., Haller, M. M., Purdom, C., & Parrington, D. J. (2012, November 1). Treating PTSD and its comorbidities: The case of PTSD and obesity. Paper for the 28th Annual Meeting, International Society for Traumatic Stress Studies, Los Angeles. Keren, G., & Schul, Y. (2009). Two is not always better than one. Perspectives on Psychological Science, 4, 533–550. Konorski, J. (1967). Integrative activity of the brain: An interdisciplinary approach. Chicago: University of Chicago Press. Koolhaas, J. M., Morte, S. M., De Boer, S. F., Van der Vegt, B. J., Van Reenen, C. G., Hopster, H., et al. (1999). Neuroscience and Biobehavioral Reviews, 23, 925–935. Kosfeld, M., Heinrichs, M., Zaak, P. J., Fischbacher, U., & Fehr, E. (2005). Oxytocin increases trust in humans. Nature, 435, 673–676. Landgraf, R., & Neumann, I. J. (2004). Oxytocin and vasopressin release within the brain: A dynamic concept of multiple and variable modes of neuropeptide communication. Frontiers of Neuroendocrinology, 25, 150–176. LeDoux, J., & Phelps, E. A. (2000). Emotional networks in the brain. In M. Lewis & J. M. HavilandJones (Eds.), Handbook of Emotions (2nd ed., pp. 157–172). New York: Guilford Press. Lim, M. M., & Young, L. J. (2006). Neuropeptidergic regulation of affiliative behavior and social bonding in animals. Hormones and Behavior, 50, 506–517. Luthar, S. S. (2006). Resilience in development: A synthesis of research across five decades. In D. J. Cohen & D. Cicchetti (Eds.), Developmental psychopathology (2nd ed., pp. 739–795). Hoboken, NJ: Wiley. Luthar, S. S., & Barkin, S. H. (2012). Are affluent youth truly “at risk”? Vulnerability and resilience across three diverse samples. Development and Psychopathology, 24, 429–449. Maroun, M., & Richter-Levin, G. (2003). Exposure to acute stress blocks the induction of longterm potentiation of the amygdala–prefrontal cortex pathway in vivo. Journal of Neuroscience, 23, 4406–4409. Masten, A., Best, K. M., & Garmezy, N. (1990). Resilience and development: Contributions from the study of children who overcame adversity. Development and Psychopathology, 2, 425–444. McEwen, B. S., & Seeman, T. (1999). Protective and damaging effects of mediators of stress: Elaborating and testing the concepts of allostasis and allostatic load. Annual New York Academy of Sciences, 896, 30–47. McEwen, B. S., & Stellar, E. (1993). Stress and the individual: Mechanisms leading to disease. Archives of Internal Medicine, 153, 2093–2101. Osgood, C., Suci, G., & Tannenbaum, P. (1957). The measurement of meaning. Urbana: University of Illinois. Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. New York: Oxford University Press. Porges, S. W. (2001). The polyvagal theory: Phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42, 123–146. Pruessner, J. C., Dedovic, K., Khalili-Mahani, N., Engert, V., Pruessner, M., Buss, C., et al. (2008). Deactivation of the limbic system during acute psychosocial stress: Evidence from positron emission tomography and functional magnetic resonance imaging studies. Biological Psychiatry, 63, 234–240. Reich, J. W., Zautra, A. J., & Davis, M. C. (2003). Dimensions of affect relationships: Models and their integrative implications. Review of General Psychology, 7, 66–83. Russell, J. A. (1980). A circumplex model of affect. Journal of Personality and Social Psychology, 39, 1161–1178. Sapolsky, R. M. (1994). Why zebras don’t get ulcers: A guide to stress, stress-related diseases, and coping. New York: W. H. Freeman.

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Schneirla, T. (1959). An evolutionary and developmental theory of biphasic processes underlying approach and withdrawal. In M. Jones (Ed.), Nebraska Symposium on Motivation (pp. 1–42). Lincoln: University of Nebraska Press. Schultz, W. (2002). Getting formal with dopamine and reward. Neuron, 36, 241–263. Segal, Z. V., Teasdale, J. D., & Williams, M. G. (2004). Mindfulness-based cognitive therapy: Theoretical rationale and empirical status. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 1–29). New York: Guilford Press. Selye, H. (1956). The stress of life. New York: McGraw-Hill. Sterling, P., & Eyer, J. (1988). Allostasis: A new paradigm to explain arousal pathology. In S. Fisher & J. Reason (Eds.), Handbook of life stress, cognition and health (pp. 629–649). New York: Wiley. Terr, L. C. (1979). Children of Chowchilla: A study of psychic trauma. The Psychoanalytic Study of the Child, 34, 547–623. This Emotional Life (Series). (2010). PBS. Uvnäs Moberg, K. (1998). Oxytocin may mediate the benefits of positive social interaction and emotions. Psychoneuroendocrinology, 23, 819–835. Uvnäs Moberg, K. (2005). The oxytocin factor: Tapping the hormone of calm, love, and healing (R. Francis, Trans.). Cambridge, MA: Da Capo Press. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scale. Journal of Personality and Social Psychology, 54, 1063–1070. Yehuda, R. (Ed.) (2006). Psychobiology of posttraumatic stress disorder: A decade of progress. Annals of the New York Academy of Sciences, 1071. Boston, MA: Blackwell. Young, L. J., & Wang, Z. (2004). The neurobiology of pair bonding. Nature Neuroscience, 7, 1048–1054. Zautra, A. J. (2003). Emotions, stress, and health. New York: Oxford University Press. Zautra, A. J., Berkhof, H., & Nicolson, N. (2002). Changes in affect interrelations as a function of stressful life events. Cognition and Emotion, 16, 309–318.


Introduction to Allostasis and Allostatic Load Greta B. Raglan and Jay Schulkin

Human responses to adversity are as variable as humans themselves, resulting in dramatically different reactions to the same experience. Following a stressful event, some people find themselves spurred into positive action, some are able to continue with their former existence, and some might be burdened with a sense of hopelessness, anxiety, or depression. Accompanying these unpredictable psychological states are internal physical experiences that are equally variable. Gaining an understanding of how to foster positive outcomes in the face of stress or trauma requires an appreciation of the interrelatedness of the body’s regulatory systems as well as its plasticity in the face of change. We must attempt to understand the positive outcomes as well as the breakdown of functioning in order to invest in systems that encourage recovery and health. In the following chapter, we discuss allostasis as a model for understanding vulnerability and resilience in human responses to adversity.

ALLOSTASIS AND HOMEOSTASIS Allostasis describes an organism’s ability to adapt to and anticipate diverse environmental forces. Internal regulation rarely exhibits a simple reflex in the face of change, but instead adjusts to a variable environment. Allostasis describes animals’ adjustment to changing circumstances through anticipation of change as well as the ability to control the internal milieu in responding to social and environmental contexts. Allostasis was built upon prior dominant theories in order to help explain the anticipatory behaviors seen in higher order species (Schulkin, 2011). In the mid-19th century, Claude Bernard greatly advanced our understanding of digestion and other topics. Today, Bernard is best remembered for ideas he held about the interaction of an organism with its environment. Bernard stated that an inert body, obedient to cosmic conditions, is linked with all their variations, while a living body on the contrary remains independent and free in its manifestations; it seems animated by an inner force that rules all its acts and liberates it from the influence of surrounding physicochemical variations and disturbances. (Bernard, 1865/1957). He believed that the mechanisms of a living body maintained a perfect balance despite external environmental changes and that more advanced species were more capable of achieving stability independently of the environment (e.g., a mammal is more “advanced” than a

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free ebooks ==> www.ebook777.com Introduction to Allostasis and Allostatic Load 45 reptile because it regulates its own body temperature). This is the first description of the concept that we now know as homeostasis. Bernard (1865/1957) described the “milieu intérieur,” or the internal milieu, as a state within an organism that created an environment insulated from external changes. Therefore, a person’s liver is not sensitive to external changes, because it is bathed in the internal milieu that buffers it from outside changes. While this idea was not unheard of, Bernard expanded it with claims that animals had systems in place that maintained constancy in their internal states. This compensatory system enabled the internal milieu to adjust to the external environment in order to maintain internal equilibrium. In the early 20th century Bernard’s ideas were expanded by, among others, Walter Cannon, whose work would result in one of the most influential theories of human behavior (Cannon, 1932). Cannon introduced the world to the term homeostasis, which he described in terms of the interactions of multiple systems that maintained physiological balances within narrow limits (Cannon, 1929). Cannon’s process differed from Bernard’s in that he allowed for some modulation and change within the internal milieu rather than proposing a completely static state, as Bernard had envisioned (Cannon, 1932). His pioneering work theorized that a single hormone or chemical messenger might be able to affect multiple organ systems in different ways in order to maintain equilibrium or spur a response (Cannon, 1929, 1932). The concept of allostasis was introduced as a counterpoint to homeostasis in order to explain the physiology of change and adaptation to diverse circumstances as well as the behavioral and physiological anticipation of future events (Sterling & Eyer, 1988). Allostatic regulation emphasizes a central state of the brain and the ability of the central nervous system and related hormonal systems to maintain relative internal constancy under changing circumstances (Schulkin, 2003; Sterling & Eyer, 1988). These external changes range from temperature fluctuations to the effects of interpersonal trauma. Although homeostasis largely emphasizes restoring deficits rather than anticipating them, a key feature of survival for animals is anticipatory regulation that allows them to respond to or prepare for events before they occur. Humans in particular are not simply reactive; they anticipate and adjust to possible future changes in the face of variable environments (Schulkin, 2003), such as gathering and saving food to ensure survival throughout the year. The lives of most animals are characterized by multiple unpredictable events that occur on a daily basis. This unpredictability, combined with the need for stability and consistency in the physiological and social domains, signifies that individual organisms are striving for continuity while still surviving in variable immediate circumstances. Humans employ many cognitive and physiological resources to promote stability, predict outcomes, and achieve internal parameters necessary for supporting life processes. Allostasis helps to explain the effect of change on long-term physiological and psychological well-being and emphasizes regulatory flexibility rather than simple adjustments to a set-point change. Allostatis has shifted the emphasis from maintaining a particular balance (e.g., temperature control) to examining a range of balances that are possible in a changing environment (Sterling & Eyer, 1988). In this view there are multiple optimal states, depending on the circumstances of the individual. Information molecules are mediators that make possible these extraordinary adaptive capacities. Many of the same information molecules (e.g., corticotrophin-releasing hormone [CRH], oxytocin, vasopressin, angiotensin, prolactin; Power & Schulkin, 2009) are produced in the periphery (e.g., stomach, heart) and also in the brain. These information molecules serve as communicators in a loop between the brain, the body, and interactions with


Greta B. Raglan and Jay Schulkin

others or the context/environment. These systems create neurological and physical changes that support responses to external events (Schulkin, 2003; Sterling & Eyer, 1988). The interconnections of these molecular systems are indicative of the extensive integration of responses essential for adaptation to adversity. The coordination of these biological systems and the diverse effect they have on behavioral and social systems constitute the flexibility of functioning and of responses essential for maintaining positive outcomes by allowing the internal milieu to adjust to external influences. Responses that become overly rigid or that lose flexibility result in adverse psychological and/or physiological outcomes (Schulkin, 2003; Sterling & Eyer, 1988).

REGULATORY BREAKDOWN Chronic over-activation of regulatory systems, due to adversity or maladaptive hyperresponsivity, leads to increased vulnerability to pathophysiology and psychopathology (McEwen, 1998). Allostatic load occurs when a person’s body, well adapted to dealing with stress, becomes overwhelmed by adverse experiences. It can be useful to think of this regulatory system as a rubber band: the flexibility of the band allows it to be pulled in different directions to meet new needs but, when no longer necessary, the band can return to its original state. Allostatic load occurs when the “rubber band” is stretched too often or too far so that it loses its flexibility. This creates a change in the rubber band’s baseline state that can lead to a decreased ability to perform necessary functions and can eventually lead to breakage. While the term allostasis describes the ability to adjust to and recover from changes, allostatic load is the phenomenon that leads to the breakdown of that system. Allostatic load is the collective effect of long-term or severe stressors rather than a discretely defined event. Individual differences make people more or less susceptible to allostatic load, and its effects can result in psychological, physical, and social pathology with potentially lasting consequences (McEwen, 1998). Allostatic load can greatly reduce the ability to cope with future changes because of a decrease in the flexibility of established response patterns, leading to a repeated cycle of maladaptive responding and a loss of anticipatory abilities (McEwen & Wingfield, 2003). The effects of allostatic load have been particularly linked to over-activity in the hypothalamic pituitary adrenal (HPA) axis as well as to decreased reactivity in the HPA negative feedback loop (McEwen, 2002). People with increased levels of cortisol and CRH over extended periods of time are more likely to experience allostatic load and its related physical, social, and psychological effects (Chrousos & Gold, 1992; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008). These stress hormones are adaptive when individuals are adjusting to the immediate presentation of adversity. However, they have serious neuronal consequences such as cortical atrophy of the hippocampus and changes in the amygdala when exposure becomes chronic (McEwen, 2002). High levels of cortisol can also lead to a decrease in receptors for serotonin, triggering elevated CRH and an increased feeling of helplessness and depression (Charney, 2004; McEwen, 1998). Unremitting social distress, like other forms of stress, results in the accumulation of high levels of cortisol and in a concomitant decrease of social competence processes (Sapolksy, 1992), thereby increasing allostatic load (McEwen, 1998). The generally adaptive link between biological and social processes can thus lead to a cycle of devolution of functioning in both areas when these systems are impacted by stress. Under duress, the social system that usually reduces cortisol when it is no longer needed is now compromised and

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free ebooks ==> www.ebook777.com Introduction to Allostasis and Allostatic Load 47 continues to promote high levels of cortisol. This internal change results in bodily sensations of constant distress and in the inability to regain those external resources that might alleviate the experience. The response to stress and adversity within the neuroendocrine system is often the first sign of a stress response, yet neuroendocrine responses are often the result of feedback from social or physical cues related to a stressor, rather than the origin of the stress experience.

RESILIENCE The term resilience is usually applied to individuals who experience lasting stress or trauma but continue to be productive and healthy. Resilience describes a trajectory of responses to stress that do not include periods of significant ill-health or decline (Bonanno, 2004), and represent the “ideal” outcome of an allostatic system of regulation (McEwen, 2002). Resilience, like allostasis, is the ability to continue to function within normative boundaries while undergoing extreme changes and inconsistencies. In addition, a person’s ability to anticipate future, more stable circumstances may allow him/her to maintain relative stability in the face of dramatic changes. Apart from appearing in many psychological contexts, resilience shows many neurobiological expressions. We cannot do justice to all of them, but hope to highlight a few that will illustrate allostasis very well. Levels of cortisol following a traumatic event may play a role in a person’s ability to express resilience (McEwen, 1998). A number of mediators that effect cortisol include the brain-derived neurotrophic factor (BDNF) in the hippocampus (Karatsoreos & McEwen, 2011). Reduced BDNF in young rats exposed to prolonged stress has been linked to higher levels of corticosterone secretion (the cortisol equivalent in humans; Taliaz et al., 2011). These findings indicate that a reduction in BDNF in response to stress, particularly stress experienced at a young age, may reduce the expression of resilience. This and other studies may indicate that, although the connection between glucocorticoids and stress is undisputed, the relationship may not be direct. It is also apparent that the same systems that protect us from mortal peril play an important role in responses to stressors that do not pose immediate threats. Childhood trauma has been linked to neurobiological changes that encourage allostatic load and therefore diminished resilience. In animal studies, rats with a history of maltreatment showed signs of hyperresponsiveness to adversity (Grassi-Oliveira, Ashy, & Stein, 2008). Human studies demonstrate that individuals exposed to trauma at a young age show increased stress responses in the HPA axis when compared to those with no history of trauma (Davidson & McEwen, 2012; Heim et al., 2008). Such an individual is likely to experience increased levels of cortisol for an extended period of time, raising the likelihood of allostatic load and decreasing chances of resilience (Heim et al., 2008). Many studies also point to structural changes in the brain as a result of childhood trauma, most typically enlarged amygdala and decreased volume in areas of the prefrontal cortex (e.g., Davidson & McEwen, 2012). These early neurobiological changes may result in social changes that affect a person’s response to the environment in ways that also result in further decreased resilience. Adult chronic stress has been linked to multiple physiological changes that result in the disruption of stress regulation. Elliot, Ezra-Nevo, Regev, Neufeld-Cohen, and Chen (2010) found that stressed adult mice that displayed symptoms of defeat (e.g., social withdrawal) showed higher levels of demethylation and higher levels of CRH. This evidence supports the



hypothesis that demethylation and higher levels of CRH may lead to higher presentation of stress-induced psychopathology. Some neurochemical factors may encourage resilience and act as protective factors against allostatic load. Morgan et al. (2004) found that higher levels of dehydroepiandrosterone (DHEA) during military training were associated with better performance under stressful circumstances. It appears that higher levels of DHEA can counteract some of the deleterious effects of elevated cortisol and increase resilience in stress-inducing situations. Neuropeptide Y (NPY) seems to balance the effects of CRH in ways that may encourage more resilient responses to stressors (Rasmusson et al., 2000; Zukowska-Grojec et al., 1998). These and other factors are being explored for possible pharmacological interventions for people who experienced adversity (Charney, 2004). It is possible that by increasing neural plasticity through medical or psychotherapeutic means, for instance with DHEA or NPY, individuals in a state of allostatic load could experience recovery or that those at high risk might develop more adaptive pathways (Karatsoreos & McEwen, 2011). While a neurochemical understanding of resilience provides important information, allostatic theory highlights the interactions between the internal milieu and the external world. These neurochemical patterns are often the result of a lifetime of social interactions and the effects of an individual’s external environment. In addition, these internal factors inform social behaviors and modify the ways individuals relate to the world around them. It is the interplay between all of these factors that determines a person’s ability to anticipate and to react to adversity in an adaptive way.

SOCIAL INTERACTIONS That social contact and experiences have direct effects on physiological states and cognitive processes is an impressive testament to the importance of social context to human survival (Schulkin, 2003). Humans have evolved a “cognitive penchant” for considering the longterm implications of their behaviors toward others, such as the costs and benefits of social cooperation and social knowledge (e.g., Foley, 1996). Humans are also unique in the degree to which they engage in cooperative behaviors in order to achieve common ends. The ability to share common goals and to anticipate, account for, and consider others may be among the greatest human cognitive adaptations (Tomasello, Kruger, & Ratner, 1993). These social contacts establish the safeguards for anticipation of future duress and help determine whether individuals will experience resilience or allostatic load in the face of stressors. An abundance of evidence demonstrates the importance of interpersonal interactions and social support in reducing the impact of stress and substantially increasing neurobiological flexibility. Coan, Schaefer, and Davidson (2006) found that, amongst women exposed to the threat of shock, those who held their partner’s hand exhibited lower stress responses than those holding hands with a stranger or with no one. Strong social bonds and social support can prevent or reduce some maladaptive responses to life stressors. Davidson and McEwen (2012) identify several treatments that increase social skills, resulting in improved positive affect and changed brain functions associated with plasticity. These findings underscore the importance of the link between prosocial behavior and overall well-being. By increasing the levels of cortisol, allostatic load brings about devolution of social functioning (McEwen, 2002), reducing social meaning and social contact that are normally ameliorative (Huppert & Whittington, 2003). Group affiliation and the ability to attract

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free ebooks ==> www.ebook777.com Introduction to Allostasis and Allostatic Load 49 and use social support are key strengths in peoples’ abilities to cope with stress (Palombit, Seyfarth, & Cheney, 1997). Those individuals who have fewer social supports are more at risk for developing allostatic load in the face of multiple stressors (McEwen, 2002). While social structures differ across diverse cultures, they remain at the heart of human development and the ability to cope (Mead, 1964). Meaningful contacts in family and group structures are essential for mental health. Supportive social contact is not an absolute prophylactic but is ameliorative in combating disease and breakdown, along with increasing predictive abilities (Schulkin, 2011). These factors play a direct role in allostatic functioning and in responding adaptively in the face of crises. The individual’s cognitive state and social support have direct and important effects on the ability to cope with stressors and the ability to remain resilient in the face of changing circumstances.

FURTHER STUDY Resilience in the face of adversity has a major impact on individual well-being as well as on society as a whole. Individuals with diverse health conditions such as cardiovascular disease, HIV, depression, and PTSD have superior outcomes when they demonstrate resilience (Carver, 1998). These improved outcomes may lead to decreased medical costs and increased contributions to society at large. Viewing resilience as an allostatic process demonstrates more fully the social and biological underpinnings of resilience and of allostatic load. A deeper understanding of the integration between external and internal states can foster more comprehensive, targeted, and successful treatments (Logan & Barksdale, 2008). Concepts of allostasis enable the integration of allostasis into treatment plans for individuals who have experienced trauma or stress (Davidson & McEwen, 2012; Karatsoreos & McEwen, 2011). In fact, Fava, Guidi, Semprini, Tomba, and Sonino (2010) developed a system for identifying and classifying symptoms of allostatic load to help clinicians better identify and treat these symptoms. Fava et al. argue that such a focus will allow clinicians to treat the patient in a holistic approach and address the effects of adverse live events. Many psychological studies have focused on the characteristics of resilient individuals, but few have outlined therapeutic interventions that may be helpful to encourage resilience in those for whom it may not come naturally. A study by Coifman, Bonanno, Ray, and Gross (2007) found that practicing repressive coping behavior resulted in higher levels of resilience in individuals than other forms of coping. Another study found that a 10-session family program was helpful in promoting resilience in children of parents with depression (Riley et al., 2008). Studies of the Sanctuary Model of care have demonstrated that creating a community for the understanding of social skills and decision making can reduce the negative impact of traumatic childhood experiences (Bloom, 2007). By addressing the potential effects of adversity early in life, and possibly even in utero, interventions can teach healthy coping skills to children and reduce the future risk of allostatic load and functional impairment (Garner et al., 2012). Calls have been issued for the integration of positive health research into treatment and recovery. Singer and Ryff (2001) highlight the importance of understanding healing processes rather than focus on disease models. While an understanding of the origins of disease is key to treatment, a grasp of what prevents those same diseases from developing is equally important. This model stresses that a focus on those individuals who are able to avoid symptoms of allostatic load will reveal much about the nature of allostatic load.



CONCLUSION Allostasis provides a framework for understanding human adaptation to and anticipation of change. It is through the ability to adjust to an ever-changing environment, both internally through biochemical adjustments and externally through changes in social interactions, that individuals are able to thrive in the midst of adversity. Allostatic regulation is tied to the physiology of change and adaptation, a core feature of evolution and the structural foundation of internal regulatory systems. Underlying this adaptation are diverse neurochemical changes that both adjust to and anticipate changing circumstances. These neurochemicals (e.g., oxytocin, CRH, etc.) support the necessary physiological changes that are required for adaptation and also for acute coping (Schulkin, 2011). These same chemicals can be detrimental to overall health and well-being when overstimulated by prolonged acute stress or chronic exposure to a variety of stressful experiences. In addition to these important internal regulators of well-being, environment and social contexts exert major influences on our psychological and physical health and contribute to the feedback systems that direct reactions and anticipation of adverse conditions. Social contact is ameliorative in many cases of stress. Social isolation can create a chain of devolution of functioning (Singer & Ryff, 2001), as seen in decreased functioning and poor stress responses in a variety of species (Grippo et al., 2007). Allostasis differs from earlier conceptions of stress regulation represented by homeostasis in proposing anticipatory adaptation to ever-changing circumstances (McEwen & Wingfield, 2003; Schulkin, 2003). Many behaviors typical of daily life, particularly those that involve prosocial activities, are preparatory and involve the anticipation of future needs rather than merely reacting to present needs or the demands of present events. It is the concept of allostasis that takes into account this preparatory social nature (Sterling & Eyer, 1988) and that accounts for its effects on internal responsiveness to both external stressors and the internal milieu.

REFERENCES Bernard, C. (1957). Introduction to the study of experimental medicine (H. C. Greene, Trans.). London: Macmillan. (Original work published 1865) Bloom, S. L. (2007). The Sanctuary Model of trauma informed organizational change. The Source: The National Abandoned Infants Assistance Resource Center, 16, 12–16. Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–28. Cannon, W. B. (1929). Bodily changes in pain, hunger, fear and rage (2nd ed.). New York: Appleton. Cannon, W. B. (1932). The wisdom of the body. New York: Norton. Carver, C. S. (1998). Resilience and thriving: Issues, models, and linkages. Journal of Social Issues, 54, 245–266. Charney, D. S. (2004). Psychobiological mechanisms of resilience and vulnerability: Implications for successful adaptation to extreme stress. American Journal of Psychiatry, 161, 195–216. Chrousos, G. P., & Gold, P. W. (1992). The concepts of stress and stress system disorders. Journal of the American Medical Association, 267, 1244–1252. Coan, J. A., Schaefer, H. S., & Davidson, R. J. (2006). Lending a hand: Social regulation of the neural response to threat. Psychological Science, 17, 1032–1039. Coifman, K. G., Bonanno, G. A., Ray, R. D., & Gross, J. J. (2007). Does repressive coping promote resilience? Affective-autonomic response discrepancy during bereavement. Journal of Personality and Social Psychology, 92, 745–758.

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free ebooks ==> www.ebook777.com Introduction to Allostasis and Allostatic Load 51 Davidson, R. J., & McEwen, B. S. (2012). Social influences on neuroplasticity: Stress and interventions to promote well-being. Nature Neuroscience, 15, 689–695. Elliot, E., Ezra-Nevo, G., Regev, L., Neufeld-Cohen, A., & Chen, A. (2010). Resilience to social stress coincides with functional DNA methylation of the Crf gene in adult mice. Nature Neuroscience, 13, 1351–1353. Fava, G. A., Guidi, J., Semprini, F., Tomba, E., & Sonino, N. (2010). Clinical assessment of allostatic load and clinometric criteria. Psychotherapy and Psychosomatics, 79, 280–284. Foley, R. (1996). An evolutionary and chronological framework for human social behaviour. Proceedings of the British Academy, 88, 95–117. Garner, A. S., Shonkoff, J. P., Siegel, B. S., Dobbins, M. I., Earls, M. F, Garner, A. S., et al. (2012). Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science into lifelong health. Pediatrics, 129, e224–e231. Grassi-Oliveira, R., Ashy, M., & Stein, L. M. (2008). Psychobiology of childhood maltreatment: Effects of allostatic load? Revista Brasileira de psiquiatria, 30, 60–68. Grippo, A. J., Gerena, D., Huang, J., Kumar, N., Shah, M., Ughreja, R., et al. (2007). Social isolation induces behavioral and neuroendocrine disturbances relevant to depression in female and male prairie voles. Psychoneuroendocrinology, 32, 966–980. Heim, C., Newport, D. J., Mletzko, T., Miller, A. H., & Nemeroff, C. B. (2008). The link between childhood trauma and depression: Insights from HPA axis studies in humans. Psychoneuroendocrinology, 33, 693–710. Huppert, F. A., & Whittington, J. E. (2003). Evidence for the independence of positive and negative wellbeing: Implications for quality of life assessment. British Journal of Health Psychology, 8, 107–122. Karatsoreos, I. N., & McEwen, B. S. (2011). Psychobiological allostasis: Resistance, resilience and vulnerability. Trends in Cognitive Sciences, 15, 576–584. Logan, J. G., & Barksdale, D. J. (2008). Allostasis and allostatic load: Expanding the discourse on stress and cardiovascular disease. Journal of Clinical Nursing, 17, 201–208. McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338, 171–179. McEwen, B. S. (2002). Sex, stress and the hippocampus: Allostasis, allostatic load and the aging process. Neurobiology of Aging, 23, 921–939. McEwen, B. S., & Wingfield, J. C. (2003). The concept of allostasis in biology and medicine. Hormones and Behavior, 41, 2–15. Mead, G. H. (1964). On social psychology. Chicago: University of Chicago Press. Morgan, C. A., Southwick, S., Hazlett, G., Rasmusson, A., Hoyt, G., Zimolo, Z., et al. (2004). Relationships among plasma dehysropiandrosterone sulfate and cortisol levels, symptoms of dissociation and objective performance in humans exposed to acute stress. Archives of General Psychiatry, 61, 819–825. Palombit, R. A., Seyfarth, R. M., & Cheney, D. L. (1997). The adaptive value of “friendships” to female baboons: Experimental and observational evidence. Animal Behavior, 54, 599–614. Power, M. L., & Schulkin, J. (2009). Evolution of obesity. Baltimore: Johns Hopkins University Press. Rasmusson, A. M., Hauger, R. L., Morgan, C. A., III, Bremmer, J. D., Charney, D. S., & Southwick, S. M. (2000). Low baseline and yohimbine-stimulated plasma neuropeptide Y (NPY) levels in combat-related PTSD. Biological Psychiatry, 47, 526–539. Riley, A. W., Valdez, C. R., Barrueco, S., Mills, C., Beardslee, W., Sandler, I., et al. (2008). Development of a family-based program to reduce risk and promote resilience among families affected by maternal depression: Theoretical basis and program description. Clinical Child and Family Psychology Review, 11, 12–29. Sapolsky, R. M. (1992). Cortisol concentrations and the social significance of rank instability among wild baboons. Psychoneuroendocrinology, 17, 701–709. Schulkin, J. (2003). Rethinking homeostasis. Cambridge, MA: MIT Press. Schulkin, J. (2011). Social allostasis: Anticipatory regulation of the internal milieu. Frontiers in Evolutionary Neuroscience, 2, 1–15.



Singer, B. H., & Ryff, C. D. (2001). Positive health: Resilience, recovery, primary prevention, and health promotion. In B. H. Singer & C. D. Ryff (Eds.), New horizons in health: An integrative approach (pp. 45–62). Washington, DC: National Academy Press. Sterling, P., & Eyer, J. (1988). Allostasis: A new paradigm to explain arousal pathology. In S. Fisher & J. Reason (Eds.), Handbook of life stress, cognition, and health (pp. 629–651). New York: Wiley. Taliaz, D., Loya, A., Gersner, R., Haramati, S., Chen, A., & Zangen, A. (2011). Resilience to chronic stress is mediated by hippocampal brain-derived neurotrophic factor. Journal of Neuroscience, 31, 4475–4483. Tomasello, M., Kruger, A. C., & Ratner, H. H. (1993). Cultural learning. Behavioral and Brain Sciences, 16, 495–552. Zukowska-Grojec, Z., Karwatowska-Prokopczuk, E., Rose, W., Rone, J., Movafagh, S., Ji, H., et al. (1998). Neuropeptide Y: A novel angiogenic factor from the sympathetic nerves and endothelium. Circulation Research, 83, 187–195.

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Part B Resilience as Intrapersonal Process



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The Automatic Basis of Resilience Adaptive Regulation of Affect and Cognition Susanne Schwager and Klaus Rothermund

Automatic affective processing is the key to understanding psychological resilience. To convince the reader of this we start with a detective search for the basics of resilience. The definition of resilience is entirely complex. The term implies processes located within the person, ones that offer explanations for recovery from adversity. A closer look reveals the heart of resilience. It is the flexible regulation of motivation and action which involves affect and cognition. At the core of affect and cognition is the automatic regulation of selective attention and of affective processing that prepares the individual for motivational changes and that sets the stage for adaptive behaviors to threat and adversity. We support this process model of resilience with data in the second part of our chapter. First we will review recent research on the relationship between self-regulation and basic cognitive and affective mechanisms. Then we will connect these findings to studies that investigate coping and adaptation in real-life severe threats to psychological functioning and well-being. We conclude with future research needed to close existing gaps. We discuss potential implications of our analyses for an understanding of clinical phenomena and for designing interventions to overcome a lack of resilience.

CONCEPTUAL CLARIFICATIONS Defining and Identifying Resilience: Adverse Situations and the Role of the Person in Counteracting Them The definition of psychological resilience is a complex issue. To our mind, three major points are essential for the identification of resilience. First, the presence of an adverse situation has to be established. An adverse situation tends to interfere with some baseline psychological functioning, producing a change in emotional well-being, performance, and mental and/or physical health. The absence of any impairment in functioning cannot be attributed to resilience unless we have identified the presence of an adversity. A stressful or adverse situation typically consists of a discrepancy between a desired conception of reality that is specified by an individual’s goals, needs, motives, desires, and aspirations and the actual or anticipated situation confronting the person (Brandtstädter & Rothermund, 2002b; Carver & Scheier, 1998; Lazarus & Folkman, 1984; see Figure 5.1). Experiencing a deprivation of basic needs, difficulties in reaching important goals, or the loss of personal meaning and identity can give rise to anger, frustration, or helplessness that may result in impaired psychological and physical functions. Second, to be better off than others who are in a similar critical situation is not a sufficient condition for resilience. A person might have worse levels of functioning as a result of the


Susanne Schwager and Klaus Rothermund

person’s previous baseline level of functioning being lower than that of others. Making a comparison to a personal baseline (before the critical situation) is thus a crucial requirement for the establishment of an adverse situation’s effects on functioning. Furthermore, showing no impairment in a situation that has affected others might simply reflect the fact that the situation itself is less relevant and/or less adverse for that person. In such a case, stable levels of functioning do not indicate resilience. Third and most importantly, defining the recovery from a situation-induced impairment as a case of resilience logically presupposes that the cause of the recovery reflects a response to the adverse situation and/or its negative consequences and that this cause can be traced back to the person him- or herself. We would not apply terms like resilience or adaptation to describe a reinstatement of previous levels of functioning if external causes could be identified that fully explained the restoration of personal functioning, such as the termination of the critical situation, or an extraneous intervention like medical treatment.1 So for the identification of resilience it is indispensable to investigate the cause of the recovery and its underlying processes. Explaining Resilience: Trait Versus Process Models of Adaptive Responses to Stress The preceding discussion shows that psychological resilience is an intrinsically explanatory concept. Merely describing changes or differences between individuals in functioning following an adverse event cannot fully cover the meaning of the concept of psychological resilience. The upshot of our arguments is that, without knowing the cause of recovery from adversity, one cannot even describe this recovery as reflecting resilience. Research on psychological resilience thus has to focus on identifying the causes of recovery and on predicting differences in recovery from adversity (cf. Leipold & Greve, 2009). The simplest approach to explaining variance in the responses to stress and adversity has been a focus on stable interindividual differences in the ability to adapt to adversity. This is the basic personality trait conception of resilience (Block & Block, 1980). Such a perspective on resilience starts with the assumption that people can be characterized as being more or less resilient, regardless of the kind of adversity involved and the kind of psychological outcome that is considered. In the past decades this traditional account has been criticized (Leipold & Greve, 2009; Masten, 2001) and the definition of resilience was extended by several conceptual issues (extrapersonal components of resilience like family support, dynamics in resilience, external and internal expressions of recovery, domain-specificity; for an overview see Luthar, 2006). Even though resilience is now acknowledged to be a complex phenomenon, there is still a strong focus on interindividual differences in outcomes after encountering an adversity. Most research on resilience thus does not inform us about how the recovery from a stressful situation was brought about in resilient individuals or what prevented it in non-resilient individuals. Some more recent research tries to overcome this explanatory limitation of trait conceptions of resilience by assessing additional variables that can be used to predict resilience or to identify mediators of these effects (e.g., good peer relationships, need for connectedness). An assessment of predictors and mediators alone, however, does not provide us with a functional understanding of the processes and the mechanisms that constitute resilience. Coping models of resilience fill this explanatory gap (Leipold & Greve, 2009). Instead of assessing the frequency of resilient or non-resilient outcomes, models of coping focus on the different behavioral responses that become activated in situations of adversity. Taxonomies of

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free ebooks ==> www.ebook777.com The Automatic Basis of Resilience 57 coping strategies or behaviors can be derived from conceptual analyses of what constitutes a stressful situation and its consequences. Specifying the connection between stress and psychological impairments allows one to systematically distinguish between different types of coping processes, depending on how and at what point they target the stress–outcome relation. The stress–impairment connection also allows the development of hypotheses regarding the efficiency of adaptive processes during adversity. Our research is inspired by a classification of coping processes that distinguishes between assimilative and accommodative coping responses (Brandtstädter & Rothermund, 2002b). On the one hand, the individual can try to actively change or counteract an adverse situation in order to bring it in line with personal goals and aspirations. This form of coping is identified as “assimilative” coping. On the other hand, “accommodative” coping covers various processes that result in changing the personal evaluation of an adverse situation instead of changing the situation itself. Positively reappraising a negative situation or downgrading the personal importance of blocked goals will lead to more positive subjective evaluations of a situation, even without changing it. Active attempts to solve problems and to overcome situational difficulties have generally been considered highly adaptive forms of coping (Lazarus & Folkman, 1984). They are expected to relate positively to resilience. Mobilizing resources for effortful attempts to change or neutralize an adverse situation is clearly the most straightforward way to reestablish previous levels of functioning by terminating an adverse situation and any negative effects that might be connected with it. Emotion-focused coping, however, has often been seen as a maladaptive form of coping (Lazarus & Folkman, 1984). It was claimed that changing emotions targets only the symptoms rather than the causes of stress, leaving unchanged the adverse situation that produces impairments in psychological functioning. Recently these rigid positive and negative evaluations of problem- and emotion-focused forms of coping have come under increased scrutiny and challenge (Brandtstädter & Rothermund, 2002a, 2002b; Carver & Scheier, 1998). Active attempts at changing or counteracting negative situations may not always be adaptive and do not come without costs. Nor is there a guarantee that the investments one is prepared to make will ultimately lead to success. Then, wasting energy and time may even be more problematic when these resources are scarce and have to be divided among different life domains (Rothermund & Brandtstädter, 2003a). Furthermore, continued investment of ever more action resources in a problematic situation could prevent people from taking a neutral and distanced stance towards that situation and could block the development of more realistic views of the risks, benefits, and costs. Instead of promoting adaptation, doggedly pursuing a goal against all obstacles might conflict with rather than promote resilient recovery from an adverse event that cannot be easily changed or undone. Moreover, seeing accommodative coping only as reflecting intentional attempts at changing affective responses is inadequate. Such a direct route to changing emotions is not possible, nor does it capture the primary function of this form of coping. If emotions are taken to result from cognitive appraisals of a situation (Ellsworth & Scherer, 2003), a lasting and thorough change of emotions requires the development of a new view of a given situation (reappraisal). The primary function of such “emotion-focused” coping would adapt idealized conceptions of oneself and of one’s situation to a realistic assessment of one’s possibilities, opportunities, and dangers. If such an accommodation of beliefs and preferences leads to an acceptance of a formerly distressing situation, then the true cause of the adversity has been changed. Adversity does not consist in the purely objective situation but in its subjectively experienced implications regarding personal goals and personal identity.



Accommodating one’s preferences to given opportunities and constraints and accepting adverse situations are thus an indispensable part of resilience under particular circumstances, namely in situations that cannot be changed. The advantages and disadvantages of assimilative and accommodative coping processes reveal that neither of these processes is always the more adaptive one (Rothermund, 1998). Which type of coping process fosters resilience depends on features of the situation and of the person (Brandtstädter & Rothermund, 2002a, 2002b). Assimilation will be the dominant and most efficient response when the situation is modifiable, action resources are available, and the goals that are affected by the critical event also occupy a central position in an individual’s hierarchy of goals. On the other hand, accommodation will be the dominant and most efficient response when the situation is uncontrollable, action resources are scarce, and alternative goals can be substituted for goals affected by the critical event. Understanding Resilience: Automatic Self-Regulation of Motivation and Affect Early accounts restricted the notion of coping to controllable, strategic behaviors (Lazarus & Folkman, 1984). In our view, efficient coping cannot be understood adequately without recourse to basic mechanisms in automatic processing that help to adjust cognition, affect, and motivation to superordinate self-regulatory needs. At first glance it may seem difficult to see how effortful, resource-demanding attempts to change an adverse situation could be related to automatic mechanisms and processes. In order to see the connection, it may be helpful to recognize that the first response in meeting a serious obstacle to a goal may be to just let go of the threatened goal because the chances of achieving the goal in the near future may have dimmed quickly. The first requirement for any mobilization of resources for assimilative coping is a stabilization of motivational commitment to the goal in question. This is achieved by increasing the importance of a goal and by shielding the goal against competing alternatives (Shah, Friedman, & Kruglanski, 2002). Such a self-regulation of motivational commitment is adaptive in the long run because it allows us to successfully pursue important and challenging goals for which setbacks are highly likely during goal pursuit. An increase in the importance of a goal in response to obstacles, however, does not result directly from the insight that it might be good for me to stick to this goal. How, then, are we to explain the reactant increase in the importance of a threatened goal (Brehm, 1972), when rational deliberation and insight alone cannot increase the value of the threatened goal? Recent research has shown that automatic information processing mechanisms provide the basis for an increase in the importance of a threatened goal and thereby support the selfregulatory stabilization of motivational commitment in the face of adversity. For example, the threat to a goal (encountering temptations or difficulties during goal pursuit) leads to a preferred processing of goal-related information, whereas information that is unrelated to the goal becomes inhibited (Fishbach, Friedman, & Kruglanski, 2003). Such a focusing mechanism helps to stabilize goal pursuit in hard times and shields the goal against possible alternatives that could easily replace it in difficult times. Another mechanism that can support motivational stabilization is motivational-affective counter-regulation (Rothermund, 2003b; Rothermund, Voss, & Wentura, 2008). According to this principle, experiencing or anticipating negative outcomes during the pursuit of a goal should automatically increase the salience of positive information. Experiences of failure should thus sensitize the individual for the positive incentives to which the goal is linked. This should, in turn, increase the motivation to pursue this goal despite failure.2

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free ebooks ==> www.ebook777.com The Automatic Basis of Resilience 59 Similar arguments support the view that accommodative responses (e.g., emotional disengagement from a blocked goal, acceptance of an unchangeable situation) do not result from controlled behaviors that are based on rational deliberation. For example, knowing that the pursuit of a particular goal will be futile could result in the decision to refrain from further problem-focused coping. But this would not be sufficient to neutralize feelings of frustration, sadness, or helplessness that accompany the experience of ultimate failure. Goals and ambitions are endowed with stable emotional attachments that cannot be neutralized by a strategic decision (e.g., telling oneself that “It would be good for me not to care about this job anymore because I won’t get it anyhow” is not sufficient for losing interest in the job). The reason for this impossibility is that an intentional, strategic attempt at changing an appraisal of a situation (e.g., “I never really liked this job. I was afraid of the responsibilities and I always wanted to have more time for my family”) does not yield a convincing and acceptable view of the situation as long as you know that you have intentionally forged this appraisal. Reappraising a situation often involves a reorganization of goals and an adjustment of personal standards and aspiration levels to a given situation. Attempts at changing the evaluation of a situation are successful only if the resulting new appraisal is endorsed by the person as an adequate description of the situation that is in line with personal beliefs and preferences (Bennett, 1990; Koole & Rothermund, 2011). Such an endorsement of positive reappraisals requires changes in the cognitive accessibility of information that is relevant in evaluating the current situation. These changes are brought about by automatic cognitive-affective mechanisms that foster self-regulation by highlighting the positive aspects and benefits of a given situation (e.g., broadening the focus of attention that had been centered on the threatened goal during goal pursuit: Brandtstädter & Rothermund, 2002a; Reed & Antonova, 2007; Rothermund, 1998; counter-regulation in affective processing: Rothermund, 2011; Rothermund et al., 2008; Schwager & Rothermund, in press-a, in press-b).

AUTOMATIC AND STRATEGIC SELF-REGULATION: AN EXPANDED PROCESS MODEL OF RESILIENCE The preceding discussion shows that an explanation of resilience requires more than an investigation of controlled and effortful coping strategies and behaviors. In particular, assimilative (“problem-focused”) as well as accommodative (“emotion-focused”) coping cannot be understood without taking into account basic self-regulation mechanisms that operate in the domains of cognition, affect, and motivation. Based on these considerations, we have sketched an expanded process model of resilience (Figure 5.1). The model conceptualizes adversity as a discrepancy between desired and actual states of affairs. How we appraise discrepancies in terms of desirability, importance, and personal control will produce different outcomes in adaptation and psychological functioning. These outcomes can be used to assess the degree of initial impairment that results from the experience of an adverse situation. At the same time, detecting and appraising discrepancies also triggers a cascade of self-regulative processes. These operate in concert in order to change desired and/or actual states of affairs in such a way that the discrepancy is eventually neutralized and initial levels of functioning can be reestablished. The proposed model distinguishes between various types of self-regulatory processes (cognitive and affective mechanisms, reappraisal, motivational adjustment, coping behavior). We assume that automatic regulatory responses in the domains of affect and cognition are elicited first. By systematically changing the accessibility of relevant information, these



processes allow for a new assessment of the situation that provides the basis for a subsequent adjustment of motivation (stabilization of vs. disengagement from commitments, changes in goal importance). These motivational changes in turn prepare for and influence strategic decisions concerning coping behavior. In the case of successful self-regulation various process components will ultimately allow for a positive reappraisal of the initially adverse situation by changing the situation itself through active means, and by changing the personal evaluative standards against which this situation is compared. The change in psychological outcomes that is brought about by successful self-regulation then represents what we identify as resilience. Our summary model in Figure 5.1 provides a preliminary temporal sequence of which self-regulation processes are activated and how they influence each other. The model is mainly based on two theoretical approaches, the dual-process model of assimilative and accommodative coping (Brandtstädter & Rothermund, 2002b) and the counter-regulation model (Rothermund et al., 2008). The core idea common to both approaches is that motivational variables (outcome focus, perceived control, substitutability/centrality of a goal) determine the selection of a specific process out of a set of alternatives within a class of selfregulation processes. Selective Attention: Switching Between Open and Closed Modes of Information Processing Attention is selective. This selectivity influences the kind of information that enters the mind. What enters the mind in turn determines the appraisals we make and how we interpret a situation. A state of selective attention is set to enhance processing of goal-relevant information. By contrast, in a non-selective state irrelevant information is readily processed. At first glance the selective processing of goal-relevant information would seem to be the most promising way for successful self-regulation during adversities or for the attainment of

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Outcomes t1 Emotion Well-being Functioning/performance Health (mental/physical)

Desired Needs Goals Preferences Values Actual Aspirations Success/ failure Threat/ challenge Expectations

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Change = Resilience Self-Regulation

Basic cognitive and affective processes

Appraisal

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- Selective attention (focusing/opening, loosening/tightening, goal shielding/ Reappraisal distraction) - Affective processing (e.g. counter-regulation, positivity/negativity biases) - Reasoning (wishful thinking, problem focus)

Self-regulation of motivation Commitment (stabilization, disengagement) Goal importance (inrease, decrease) Resource mobilization Reactance/ Acceptance …

Outcomes t2 Emotion Well-being Functioning/performance Health (mental/physical)

Behavior - Problem-focused action (planning, effort) - Inhibition of action plans and habits - Reorientation (turning toward other goals and behaviors)

Desired

Actual

Motivational Focus Outcome focus

Perceived control

Motivational framing

Goal centrality, importance

Figure 5.1 A process model of resilience comprising automatic and strategic components of self-regulation in response to an adverse situation.

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free ebooks ==> www.ebook777.com The Automatic Basis of Resilience 61 a goal. Such a closed mode of information processing maintains a strong focus on the pursued goal by shielding the ongoing course of action from attractive alternatives, temptations, and competing action tendencies (Shah et al., 2002). In addition, disapproving thoughts and arguments against the goal are warded off, thereby maintaining goal commitment. Such goal shielding will be increased when goal attainment is threatened by emerging obstacles, adverse situations, or other discrepancies between desired and actual outcomes (Brehm, 1972; Fishbach et al., 2003). In general, a goal-focused mode of information processing is maintained until a goal has been reached. Goal achievement then suppresses the previous selective state of processing. However, experiences of failure or not reaching a goal typically prolong the selective focusing on goal-related content, a finding also known as the Zeigarnik effect (Zeigarnik, 1927; see also Rothermund, 2003a). This inertia of the goal-focusing mechanism explains the tendency to ruminate about problems and to persevere in the face of futile goal attainment and failure (Martin & Tesser, 1989). When the pursuit of a goal is extremely difficult and goal attainment becomes altogether unlikely, an amplified focus on goal-relevant information is no longer an adaptive way of self-regulation. It would simply be dysfunctional if blocked goals were shielded against competing alternatives for an infinite time and goal-relevant information was always processed preferentially while other information was neglected. The dual-process model integrates the open and focused modes of processing into a single theoretical framework. Perceived control, a moderator, switches between basic parameters of processing to create either an open or a closed mode of information processing (Brandtstädter & Rothermund, 2002a; Rothermund, 1998). When perceived control is high, a closed mode of processing is predicted, as it is most adaptive to self-regulation. Under this condition the influence of distracting stimuli is reduced to a minimum and goalsupportive information is preferentially processed. This boosts commitment to the pursuit of a goal despite obstacles and adversities. If perceived control is low and the achievement of a goal is permanently beyond one’s reach, self-regulation benefits from an open processing of information. The model predicts that, in a situation of low control, previously irrelevant or distracting information is no longer blocked but regains access to the cognitive system, leading to a withdrawal of attention from the current goal. An expanded attentional focus and enhanced responsiveness to distracting information increases access to information about alternative actions and goals. A reorientation to other alternatives can take place. Reappraisal of the pursued goal can occur more readily with increasing attention to negative features and rising doubts about the positive evaluation of a goal. Control as a moderator of attentional focus is supported by a number of studies. In one study, we (Brandstädter & Rothermund, 2002a) asked participants to work on a long series of unsolvable anagrams in the context of irrelevant distracting flanker stimuli. Incidental memory for the irrelevant stimuli dropped below baseline at the start of the series. This finding suggests that attention was focused on the goal of solving the anagrams and less on the irrelevant stimuli. The repeated encounter with unsolvable anagrams undermined perceived control over achieving the goal in the anagram task. During the second half of the series of unsolvable anagrams, the memory for irrelevant distractors increased, suggesting an open mode of information processing. Similar findings were obtained by Reed and Antonova (2007) and Rothermund (1998). The cueing effects of irrelevant external stimuli were stronger after exposure to uncontrollable outcomes in comparison to controllable ones. The effects of perceived control on the selectivity of information processing were also reported in animal studies on learned helplessness (Lee & Maier, 1988). Sensitivity to external stimuli was generally increased after encountering an uncontrollable situation, indicating



broad attentional processing of information. The fact that a relationship between perceived control and attentional focus is demonstrated even with animal subjects attests to the fundamental nature of these processes. Additional evidence for control as a moderator is found in studies on coping and selfregulation in real-life situations. In one study, we (Brandtstädter & Rothermund, 2002a; see also Rothermund, 2006) assessed the personal importance of goals related to identity (family-related, occupation-related, or health goals) as an indicator of focused versus open processes. Perceived discrepancies between reality and an individual’s goals predicted subsequent changes in the importance of goals depending on the experienced levels of control. If participants experienced high levels of control, the goals became more important when the perceived discrepancy between personal goals and reality was high. This reactant increase in the importance of the goal helps to maintain commitment to the goal in a situation of adversity and supports active pursuit of the goal. By contrast, when participants perceived low control over outcomes related to a goal, a large distance to a goal led to a subsequent reduction of the goal’s importance. This disengagement is important for effective self-regulation, as it prevents the continued investment of resources in a goal that seems unreachable. Such a decrease in the importance of a goal and the related opening up of information processing enable a reorientation if current attempts at goal achievement turn out to be futile. A control-dependent flexible regulation of goals and their importance during goal pursuit is a basic condition for well-being even in challenging circumstances involving critical life events, losses, and declines. Studies have revealed that these self-regulatory processes are reduced or even partly absent among depressed individuals. We have discussed the inverse relationship between goal distance and goal importance in the general population that is characteristic of an accommodative down-regulation of the importance of goals for uncontrollable goals. This effect, however, is absent for depressed individuals who show difficulties in downgrading the importance of blocked goals and disengaging from desired conceptions of themselves and their situation that exceed their personal capacities and potentials (Brandtstädter & Baltes-Götz, 1990). Depressed participants show deficits in basic self-regulation mechanisms that require the withdrawal of attention from goals after prolonged frustration and failure. This inability to disengage boosts the intensity of negative emotions after goalrelated failures and prevents a reorientation toward more promising goals. The ability to disengage from a specific goal after prolonged frustration of uncontrollable conditions also has important implications for an individual’s overall sense of control. Down-regulating the importance of a blocked goal has been shown to reduce the impact of a specific control belief on generalized control beliefs (Brandtstädter & Rothermund, 1994). If overall control reflects an individual’s perceived influence over the attainment of important outcomes, then downgrading the importance of unattainable goals prevents a spillover of specific experiences of helplessness onto superordinate control beliefs. A perceived lack of control fundamentally influences the emergence and maintenance of depression (Peterson, Maier, & Seligman, 1993). Accommodative adjustments of the importance of uncontrollable goals should thus also contribute to the prevention of depression. Low levels of depression are closely related to the ability to adjust the importance of specific goals in response to experiences of helplessness with respect to the particular goal (Brandtstädter & Rothermund, 1994). Such adjustment in goal significance exemplifies the importance of basic self-regulatory processes for adaptation and resilience. Studies investigating long-lasting emotional responses to negative outcomes also support the moderating role of control. If control is high (because negative outcomes are perceived as changeable or if they might be undone by some kind of further action) persons focus on

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free ebooks ==> www.ebook777.com The Automatic Basis of Resilience 63 negative outcomes and show stronger negative emotional responses (Gilbert & Ebert, 2002). Perceived control over outcomes thus appears to create a goal-focused mode of information processing that is accompanied by corresponding emotional responses, whereas the absence of control ultimately leads to a withdrawal of attention from the blocked goal. This reduces the emotional impact of negative outcomes and fosters disengagement and reorientation. The findings reviewed above show that perceived control plays an important role in the emergence of open vs. closed modes of processing that stabilize commitment to a goal or represent disengagement from a goal. These studies highlight the significance of such control-dependent adjustment for the importance of goals in the emergence of adaptive responses to failures and critical life events. What is lacking, however, is more direct evidence for the mediating role of attentional processes in adaptation to real-life stressors and adversities. We are not aware of research that has investigated how selective attention directly determines changes in commitment to goals and emotional adaptation to real-life stressors. This lack of evidence may be due to the fact that an assessment of attentional selectivity (breadth and focus of attention) would require response-time-based measures that are not available in real-life settings or in large-scale questionnaire studies. Given that attentional processes play such an important role for the emergence of adaptive or maladaptive responses to adversity, it seems worthwhile to think about ways to combine the disparate research paradigms in order to help clarify the underlying mechanisms of resilience. Affective Processing: Positivity and Negativity Biases Selective attention does not only refer to the breadth or the specific content of the information being processed. Another important aspect of selectivity is the valence of the processed information. Many theories of coping and self-regulation explicitly or implicitly assume that appraisals and reappraisals of critical situations are influenced by biases in affective processing, that is, by a selective orienting of attention toward either positive or negative information. Most situations of everyday life are ambiguous, neither exclusively positive nor exclusively negative. Those aspects of a situation that become salient influence our interpretations of that situation and in turn determine the affective, emotional, motivational, and behavioral responses to the situation. A flexible adjustment of valence biases toward either positive or negative stimuli is of vital importance for efficient self-regulation. In the following section we will consider two basic mechanisms that are essential for efficient regulation of affective processing in situations of adversity (Rothermund, 2011), (a) the control-dependency principle and (b) the counter-regulation principle. Control-Dependent Affective Processing: Problem Focus Versus Self-Enhancement The dual-process model of assimilative and accommodative coping holds that perceived control is essential for affective processing biases (Brandtstädter & Rothermund 2002b; Rothermund, 2006, 2011). The model posits that a perception of high control will lead to a preferred allocation of attention to negative aspects of the situation. Such a “problem focus” sensitizes attention for possible threats and dangers that might occur during the pursuit of a goal and fuels the motivation to avoid possible negative outcomes. The awareness of negative outcomes prevents the individual from staying in a state of passive daydreaming and spurs him or her on to pursue a goal tenaciously by assimilative coping (Oyserman & Markus, 1990). By contrast, low control is accompanied by a positive focus and a higher



awareness of self-assuring information that facilitates positive reappraisal of a situation previously seen as negative (“self-enhancement bias”). Positivity or negativity biases are assumed to occur automatically in a way that fosters adaptive responses to the respective situation, thereby promoting resilient adaptation. Numerous studies have supported a relationship between perceived control and the automatic tuning of affective processing of either positive or negative information. Self-serving biases that indicate a self-enhancing positivity bias are typically found in uncontrollable situations but not in controllable ones (Gilbert & Ebert, 2002). In a study by Rothermund, Bak, and Brandtstädter (2005), differential self-ascriptions were found for stable versus changeable personality traits or features (“avoiding demanding examiners” as a controllable versus “strong attachment to parents” as an uncontrollable trait). For stable traits or features that could not be modified by personal efforts, participants ascribed attributes to themselves that were presented as being desirable. This reflects a self-enhancement bias in the domain of uncontrollable attributes. In the same study, however, participants ascribed more negative than positive attributes to themselves if these attributes could be influenced or changed by personal efforts. This indicates a problem focus in the domain of controllable attributes. Further evidence regarding the role of control in automatic affective processing comes from experimental studies that investigate the processing of danger and threat (for a comprehensive review, see Rothermund, 2011). We investigated perceptual sensitivity for danger stimuli in a search task in which multiple stimuli were presented very briefly (Brandtstädter, Voss, & Rothermund, 2004). In the uncontrollable danger condition, a possible loss of points signaled by the danger stimulus could not be prevented by active attempts of the participant but was determined by chance. In the controllable danger condition, however, participants could avoid losing points by actively searching for the danger stimulus and by correctly identifying its spatial position in a subsequent task. Signal detection analyses revealed a reduced sensitivity (d’) for danger stimuli compared to neutral stimuli in the uncontrollable danger condition, indicating perceptual defense in the case of uncontrollable dangers. By contrast, perceptual sensitivity was increased for controllable danger stimuli. This indicated that attention was allocated to threatening information when that information was useful for the control of action and the selection of appropriate behaviors. Similar results were found in the literature on pain sensitivity. Higher perceptual thresholds were associated with uncontrollable aversive stimuli in comparison to aversive stimuli in the control condition (Maier, 1986). In another study (Rothermund, Brandtstädter, Meiniger, & Anton, 2002), changes in pain sensitivity were assessed in response to the application of painful stimuli that were either controllable or not: Pain duration either could be reduced by showing good performance in a task (Condition 1: controllable pain) or was independent of task performance (Condition 2: uncontrollable pain). A yoked control design guaranteed equal amounts of pain in the two conditions. Controllable pain led to an increase in global pain sensitivity (lower pain threshold). That is, perceived control over pain led to a focusing of attention on negative information when it provided an incentive for preventative action. By contrast, pain sensitivity decreased (higher threshold for heat stimuli) after experiencing uncontrollable pain, indicating that attention is withdrawn from aversive stimuli when avoidance of negative outcomes is experienced as uncontrollable. In sum, numerous studies and different research paradigms support the hypothesis that perception of control moderates affective processing biases in support of the dual-process model of assimilative and accommodative coping. These studies have demonstrated that perceived control over important outcomes increases the sensitivity for negative information (“problem focus”), whereas perceptions of low control tend to heighten the processing of

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free ebooks ==> www.ebook777.com The Automatic Basis of Resilience 65 positive information (“enhancement bias”). This facilitates adaptive responses to goal difficulties by promoting prevention motivation and tenacious persistence when the situation seems amenable to change, and by fostering the acceptance of situations that cannot be changed and preparing the individual for emotional detachment from unattainable goals. A large number of studies also support the major role that affective processing has in successfully coping with major negative life events. Shelley Taylor and colleagues have documented the adaptive functions of “positive illusions” during adversity (Taylor & Brown, 1988; see also Affleck & Tennen, 1996). Self-enhancing biases in the selection of information (benefit finding, focusing on positive aspects of one’s current situation and comparing them to more negative alternatives, positive reappraisal of negative situations) are positively related to psychological adjustment especially in situations perceived as uncontrollable (e.g., cancer, chronic pain, traumatization). A focus on positive aspects fosters acceptance of a difficult situation. This is essential for maintaining a sense of meaning in life that allows people to resume previous activities and to reestablish a normal way of living after experiencing severe losses (Luszczynska, Mohamed, & Schwarzer, 2005; McCracken & Eccleston, 2003). At the same time, the literature has treated realistic assessments as more adaptive in coping with daily hassles and critical life events (Colvin & Block, 1994; Zuckerman, Knee, Kieffer, Rawsthorne, & Bruce, 1996). Some researchers find a focus on negative information (e.g., fear of others, negative outcomes, possible failures) crucial for the maintenance of high levels of prevention motivation needed for the pursuit of goals and for coping (Oyserman & Markus, 1990). Again, these findings do not contradict the benefits of a positivity bias or of accommodative acceptance during uncontrollable losses and challenges. Instead, a negativity bias that allows individuals to focus on problems and possible failures should be seen as the most adaptive response in controllable situations that require active problem-focused coping. Few studies have systematically compared the prevalence and consequences of problemfocused versus acceptance-promoting coping in critical real-life situations that are either controllable or uncontrollable. We have, however, investigated compensatory efforts to ward off age-related functional losses at the transition from later adulthood to old age (Rothermund & Brandtstädter, 2003a). We have found that compensatory activities increased up to the age of 70, indicating a high sensitivity for actual or expected age-related declines. Age 75, however, represented a turning point. Engagement in compensatory efforts decreased sharply as the efficiency of behaviors in preventing functional losses declined (i.e., active compensatory efforts no longer provided efficient means to control important outcomes). Interestingly, this was accompanied by an increase in accommodative coping that promoted acceptance of the given, uncontrollable situation. Changes in evaluative standards (comparing oneself with same-age people rather than with younger adults) allowed even very old people to maintain a positive appraisal of their situation. Contentment with levels of personal functioning showed no decline across the entire age spectrum despite the sharp increase in perceived age-related functional losses after age 75. These findings illustrate nicely the proposed influence of perceived control on problem-focused coping (related to a negativity bias) versus self-enhancement (related to a positivity bias) in coping with adversity. We concede that integrating findings from the coping literature to basic research on affective processing biases is a speculative undertaking. We do not know of a single study that has investigated affective processing biases directly as a predictor of coping responses or adaptation in real-life situations of adversity. A fortiori, no study has investigated whether affective processing of perceived control is a mediator of coping and adaptation. Nevertheless, many of the coping processes that were investigated by the studies we reviewed earlier



are conceptually relevant to affective processing biases and highlight the need for empirical support of the proposed mediator model. Counter-Regulation in Affective Processing: Maintaining a Balanced Perspective The return to normal levels of functioning from impairments that resulted from the experiences of adverse situations is a core characteristic of psychological resilience. In our model of resilience (see Figure 5.1) self-regulation is proposed to counteract and eventually to neutralize emotional or functional deviations from normality. In this section, we will focus on a basic self-regulatory mechanism—affective-motivational counter-regulation—the very definition of which matches squarely this conception of resilience. Counter-regulation denotes a tendency to preferentially allocate attention to information that is opposite in valence to a currently dominating affective-motivational state (Rothermund et al., 2008). A positive state (anticipating or experiencing positive outcomes or emotions) will lead to an increase in the salience of negative stimuli. In a negative state (anticipating or experiencing negative outcomes or emotions) attention will be allocated preferentially to positive information. Affective-motivational counter-regulation can easily account for the typical limited duration of extreme emotional or functional reactions after critical events. This feature contributes to plausible explanations for resilient recovery from adversity.3 Making positive information more salient or accessible during a negative emotional-motivational state helps to prevent emotional escalation. And it is extremely useful in counteracting the initial negative situation and its implications. A positivity bias in situations of adversity can help in finding a way out of a problematic situation or help to identify opportunities for overcoming obstacles. In addition, counter-regulation supports accommodative forms of coping by highlighting positive aspects that are inherent in a negative situation. These may provide emotional relief or they may direct attention to alternative goals and incentives that could replace the currently blocked motivational orientation. In a series of experimental studies our lab investigated directly the incongruency bias in affective processing. We examined the effects of performance feedback (positive vs. negative) on affective processing biases with the help of speeded evaluation tasks (Rothermund, 2003b; Rothermund, Gast & Wentura, 2011; see also Derryberry, 1993). These studies showed that both negative and positive feedback led to an incongruency effect in the allocation of attention to affective stimuli. That is, faster responses for positive stimuli were observed after receiving negative feedback, whereas positive feedback was followed by faster responses to negative stimuli. Counter-regulation can also be evoked by the anticipation of positive and negative outcomes (Rothermund et al., 2008; Rothermund, Wentura, & Bak, 2001; Wentura, Voss, & Rothermund, 2009). In these studies, participants could either win or lose money, depending on their performance (response latencies and accuracies) during a larger block of trials. In blocks with a positive outcome focus, participants could gain but not lose money. In these blocks, automatic attention capture was stronger for negative compared to positive stimuli, indicating a negativity bias. The reversed pattern (i.e., a positivity bias) was obtained in blocks with a negative outcome focus where money could be lost rather than gained. Similar results were reported for other motivational focus manipulations (Schwager & Rothermund, in press-b). Counter-regulation might also explain findings in implicit emotion regulation (Koole & Rothermund, 2011). In a study on social exclusion (DeWall, Maner, & Rouby, 2009), the anticipation of social exclusion led to preferred attention allocation to positive social stimuli.

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free ebooks ==> www.ebook777.com The Automatic Basis of Resilience 67 The expectation of future belonging was followed by an increased attention to negative stimuli. In other studies counter-regulatory allocation of attention to stimuli of opposite valence was found after emotion induction via imagination or by watching positive or negative movie clips (Quirin, Bode, & Kuhl, 2011; Schwager & Rothermund, in press-a). Interestingly, even a state of disgust that was induced by having participants touch fake disgusting objects increased attention allocation to stimuli representing cleanliness (Vogt, Lozo, Koster, & De Houwer, 2011). Thus, there is an automatic tendency to focus on stimuli that are opposite in valence to the current emotional experiences. Although watching movies or merely imagining or simulating negative events should not be equated with experiencing these negative events in real life, these studies suggest that counter-regulatory processes are at work to implicitly regulate motivation and emotion in adversity. The importance of affective-motivational counter-regulation appears also in the context of relationship maintenance. For example, imagining a situation of relationship stress (e.g., the partner was supposed to be leaving for a year to study abroad) is followed by a global increase of trust toward others (Koranyi & Rothermund, 2012). The counter-regulation principle is evident in this affective processing bias. Studies on reactions to real-life events also support the neutralizing effect of affective counter-regulation mechanisms. Positive or negative life events impact emotional well-being only for a brief time. Emotions usually return to baseline levels quickly, or they may even be reversed in some cases (Solomon & Corbit, 1974; Taylor, 1991). This leveling off or reversal was observed not only for negative affect but also for positive states (Solomon & Corbit, 1974). Given this parallel finding, this amazing phenomenon cannot be explained away by appeals to “mood management” or intentional and active efforts to regulate emotions. Instead, automatic counter-regulation in the domain of affective processing biases may much better account for the spontaneous neutralization of emotional responses. We offer another example of counter-regulation in coping with real-life adversity in our study on the influence of daily hassles on emotional well-being (Rothermund & Meiniger, 2004). We replicated previous findings (Linville, 1987) where the impact of negative events on emotional well-being was attenuated in participants who possessed a large number of different self-aspects and thus had a complex representation of their self (with regard to social roles, relationships, activities, traits, goals, and attitudes). One intriguing result of our study may explain such a resilient response. For participants with a high self-complexity, high levels of stress were associated with a subsequent increase in the frequency of positive experiences (“uplifts”). One can easily imagine that counter-regulatory processes contributed to a higher salience of positive information, thus increasing the number of positive events that were recognized or remembered. This finding also points to an important requirement for efficient self-regulation, namely the possession of a variety of self-aspects. Such diversity might be necessary in order for counter-regulation to operate efficiently in coping processes involving reorientation and reinterpretation. Counter-regulation in affective processing might also contribute to the astonishing stability of well-being in old age (Greve & Staudinger, 2006; Rothermund & Brandtstädter, 2003b). This adaptive stability despite functional declines and losses in old age is a prime example of resilience and positive adaptation. Various studies have documented an association between emotional stability in old age and a positivity bias in affective processing (Mather & Carstensen, 2005). From the perspective of counter-regulation, such a positivity bias might actually be caused by the declines and losses that accompany aging as well as by a persistent focus on prevention among older people (Ebner, Freund, & Baltes, 2006). According to the principles of counter-regulation such a focus on negative outcomes should increase the salience of positive



information that can be used for “benefit finding” in situations of adversity (Affleck & Tennen, 1996), thereby counteracting the emotional consequences of accumulating losses. We have argued here that counter-regulation in affective processing is an important mechanism that can explain emotional stability in the face of losses and adversity. We have to acknowledge, however, that none of the studies investigating adaptation to real-life stressors assessed affective processing directly, rendering explanations of resilience in terms of affective counter-regulation still somewhat speculative. However, some hints can be found in the literature for the role of affective processing biases in implicit self-regulation of action and emotion. On the one hand, experimental studies revealed parallel effects of a social exclusion treatment on affective processing (positivity bias) and emotion (implicit positive affective responses), indicating that positive emotional responses might in fact be brought about by corresponding affective processing biases (DeWall et al., 2009). Further attesting to the causal role of affective processing in emotion and adaptation, recent studies in which attentional biases were modified by extensive experimental training reveal that a positivity bias in affective processing leads to subsequent corresponding changes in emotional well-being, self-esteem, and decision making (Mathews & MacLeod, 2002; Schwager & Rothermund, in press-b; Tran, Siemer, & Joormann, 2011). In conclusion, it is necessary and promising as well to connect these two different lines of research and to empirically show the missing link between affective processing biases, emotional wellbeing, and resilience.

LIMITS OF RESILIENCE Up to this point we have focused exclusively on the processes underlying successful adaptation to adversity and have assumed that these processes are at work in most cases. This is in accordance with recent conceptualizations of resilience as a normal phenomenon that is not limited to exceptional conditions but that reflects the default response to stressful situations (Greve & Staudinger, 2006; Masten, 2001). This view is in line with the assumption that a large number of self-regulation processes have their roots in automatically operating cognitive-affective mechanisms that reflect either natural properties of the human mind or highly overlearned and habitual processes. Our view would be naïve, were we to deny that people can fail to adapt to critical life events and suffer chronic impairments in psychological and health-related functioning. Instead of ruling out this possibility, process models of resilience provide an ideal starting point for identifying the causes for the lack of resilience. We propose that these models will ultimately trace difficulties in the recovery from adversity to deficits in self-regulation and/ or a malfunctioning of the underlying cognitive and affective mechanisms that normally set the stage for adaptation and resilience. Some psychopathologies constitute paradigmatic cases of non-resilience (depression, anxiety). These disorders are associated with deficits in emotion regulation. Research has repeatedly shown that depression and anxiety are characterized by rigid negativity or threat biases in affective processing (Mathews & MacLeod, 2005). Such lack of balanced and flexible affective processing suggests that the disorder may be a result of a breakdown in counter-regulation. The efficiency with which interventions counteract rigid negativity biases will point to the causal role of affective processing in these psychopathologies (Mathews & MacLeod, 2002). Another potential source for deficient self-regulation processes may be found in structural attributes of the self-concept or identity of an individual. As discussed previously, a rich and

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free ebooks ==> www.ebook777.com The Automatic Basis of Resilience 69 multifaceted self consisting of multiple attributes, goals, and social roles that a person possesses in different life domains may be crucial for efficient self-regulation (Linville, 1987; Rothermund & Meiniger, 2004). Many self-regulation processes require a shift of attention away from the problematic self-domain (from the attributes or goals that are most directly affected by a critical event) to a focus on other aspects of the self that are less affected. Processes such as reorientation, positive reappraisal, or flexible goal adjustment depend on the existence of other self-aspects that are sufficiently distinct from the most affected self-aspects. Unaffected self-aspects provide alternative views of the current situation and compensate for failures and losses of the affected self-aspect. The inability to direct attention away from an affected selfaspect (due to a lack of equally important alternatives) will then result in a rigid fixation on problematic aspects of the self, increasing the risk of rumination and of negative emotions, such as regret, anger, and anxiety.

SUMMARY AND CONCLUSIONS Process models of resilience provide us with a means to understand the phenomenon of resilience. Resilience is an intrinsically explanatory concept. We proposed that an understanding of the mediators of psychological recovery from adversity is a prerequisite for using the term resilience in the first place (cf. Leipold & Greve, 2009). Self-regulation aimed at either changing a problematic situation or adjusting the self to a given situation constitutes the core of resilience. In our model we have identified different types of self-regulation processes. These vary with regard to intentionality, resource-dependence, and automaticity. We have shown how self-regulation typically starts with changes in attention that affect the content and valence of information that is selected for processing. A systematic review of current laboratory studies on self-regulation and attention yielded evidence for the flexible configuration of cognitive and affective processing in accordance with superordinate motivational variables (control, outcome focus). Our attempts to integrate the findings from experimental laboratory studies with studies on adaptation in real-life situations revealed that many of the macro-phenomena reported in the literature on coping and resilience could be explained by basic attentional processes. However, current research continues to show a major gap between the two research traditions. Virtually no study on coping with real-life adversity has assessed attentional processes directly, leaving explanations of coping and resilience in terms of cognitive-affective microprocesses a highly speculative undertaking. Nevertheless, the literature on the processes of automatic self-regulation is growing rapidly and is yielding interesting and provocative results. Such a focus not only allows us to understand what is going on in successful self-regulation and resilience but also provides a theoretically informed view of the dysfunctional responses to stress and adversity that can be applied to the development of interventions to reestablish adaptive self-regulation.

ACKNOWLEDGMENTS Preparation of this chapter was funded by the German Research Foundation (grant RO 1272/2-3 to Klaus Rothermund). We want to express our thanks for a multitude of helpful comments and suggestions from Martha Kent and Werner Greve that helped us to substantially improve the quality of this chapter.



NOTES 1. These arguments do not rule out an ascription of resilience if mobilization of social support is due to activities or attributes of the person. Even stable structural features of a person’s environment (a caring grandmother, a large social network) can be counted as attributes of that person and thus can be subsumed as causes of resilience. 2. Of course, increases in the salience of positive information might also highlight possible alternatives to the current goal. As we will argue, counter-regulation might thus also play an important role not just for increasing the importance of a threatened goal but also for an accommodative reorienting to other, more promising endeavors if active goal pursuit is no longer possible. 3. Counter-regulation also has a preventive effect with regard to the emergence of adversities, because remaining sensitive for negative information when focusing on a current success or potential gain preserves vigilance also for potential threats and drawbacks. This protects against dangers and adversities. Although prevention is not part of the definition of resilience, it contributes to wellbeing by avoiding future adversities.

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free ebooks ==> www.ebook777.com The Automatic Basis of Resilience 71 Scherer, & H. H. Goldsmith (Eds.), Handbook of affective sciences (pp. 572–595). New York: Oxford University Press. Fishbach, A., Friedman, R. S., & Kruglanski, A. W. (2003). Leading us not unto temptation: Momentary allurements elicit overriding goal activation. Journal of Personality and Social Psychology, 84, 296–309. Gilbert, D. T., & Ebert, J. E. J. (2002). Decisions and revisions: The affective forecasting of changeable outcomes. Journal of Personality and Social Psychology, 82, 503–514. Greve, W., & Staudinger, U. (2006). Resilience in later adulthood and old age: Resources and potentials for successful aging. In D. Cicchetti & D. Cohen (Eds.), Developmental psychopathology: Vol. 3. Risk, disorder, and adaptation (2nd ed., pp. 796–840). Hoboken, NJ: Wiley. Koole, S., & Rothermund, K. (2011). “I feel better but I don’t know why”: The psychology of implicit emotion regulation. Cognition and Emotion, 25, 389–399. Koranyi, N., & Rothermund, K. (2012). Automatic coping mechanisms in committed relationships: Increased interpersonal trust as a response to threat. Journal of Experimental Social Psychology, 48, 180–185. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lee, R. K., & Maier, S. F. (1988). Inescapable shock and attention to internal versus external cues in a water discrimination escape task. Journal of Experimental Psychology: Animal Behavior Processes, 14, 302–310. Leipold, B., & Greve, W. (2009). Resilience: A conceptual bridge between coping and development. European Psychologist, 14, 40–50. Linville, P. W. (1987). Self-complexity as a cognitive buffer against stress-related illness and depression. Journal of Personality and Social Psychology, 52, 663–676. Luszczynska, A., Mohamed, N. E., & Schwarzer, R. (2005). Self-efficacy and social support predict benefit finding 12 months after cancer surgery: The mediating role of coping strategies. Psychology, Health and Medicine, 10, 365–375. Luthar, S. S. (2006). Resilience in development: A synthesis of research across five decades. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol. 3. Risk, disorder, and adaptation (2nd ed., pp. 739–795). Hoboken, NJ: Wiley. Maier, S. F. (1986). Stressor controllability and stress-induced analgesia. In D. D. Kelly (Ed.), Stressinduced analgesia (pp. 55–72). New York: New York Academy of Sciences. Martin, L. L., & Tesser, A. (1989). Toward a motivational and structural theory of ruminative thought. In J. S. Uleman & J. A. Bargh (Eds.), Unintended thought (pp. 306–326). New York: Guilford Press. Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227–238. Mather, M., & Carstensen, L. L. (2005). Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences, 9, 496–502. Mathews, A., & MacLeod, C. (2002). Induced processing biases have causal effects on anxiety. Cognition and Emotion, 16, 331–354. Mathews, A., & MacLeod, C. (2005). Cognitive vulnerability to emotional disorders. Annual Review of Clinical Psychology, 1, 167–195. McCracken, L. M., & Eccleston, C. (2003). Coping or acceptance: What to do about chronic pain? Pain, 105, 197–204. Oyserman, D., & Markus, H. R. (1990). Possible selves and delinquency. Journal of Personality and Social Psychology, 59, 112–125. Peterson, C., Maier, S. F., & Seligman, M. E. P. (1993). Learned helplessness: A theory for the age of control. New York: Oxford University Press. Quirin, M., Bode, R. C., & Kuhl, J. (2011). Recovering from negative events by boosting implicit positive affect. Cognition and Emotion, 25, 559–570. Reed, P., & Antonova, M. (2007). Interference with judgments of control and attentional shift as a result of prior exposure to controllable and uncontrollable feedback. Learning and Motivation, 38, 229–241.



Rothermund, K. (1998). Persistenz und Neuorientierung: Mechanismen der Aufrechterhaltung und Auflösung zielbezogener kognitiver Einstellungen. Retrieved from University of Trier Web site: http://ub-dok.uni-trier.de/diss/diss11/19990701/19990701.htm Rothermund, K. (2003a). Automatic vigilance for task-related information: Perseverance after failure and inhibition after success. Memory and Cognition, 31, 343–352. Rothermund, K. (2003b). Motivation and attention: Incongruent effects of feedback on the processing of valence. Emotion, 3, 223–238. Rothermund, K. (2006). Hanging on and letting go in the pursuit of health goals: Psychological mechanisms to cope with a regulatory dilemma. In D. de Ridder & J. de Wit (Eds.), Self-regulation in health-behavior (pp. 217–241). Chichester, UK: Wiley. Rothermund, K. (2011). Counter-regulation and control-dependency: Affective processing biases in the service of action regulation. Social Psychology, 42, 56–66. Rothermund, K., Bak, P., & Brandtstädter, J. (2005). Biases in self-evaluation: Moderating effects of attribute controllability. European Journal of Social Psychology, 35, 281–290. Rothermund, K., & Brandstädter, J. (2003a). Coping with deficits and losses in later life: From compensatory action to accommodation. Psychology and Aging, 18, 896–905. Rothermund, K., & Brandtstädter, J. (2003b). Depression in later life: Cross-sequential patterns and possible determinants. Psychology and Aging, 18, 80–90. Rothermund, K., Brandtstädter, J., Meiniger, C., & Anton, F. (2002). Nociceptive sensitivity and control: Hypo- and hyperalgesia under two different modes of coping. Experimental Psychology, 49, 57–66. Rothermund, K., Gast, A., & Wentura, D. (2011). Incongruency effects in affective processing: Automatic motivational counter-regulation or mismatch-induced salience? Cognition and Emotion, 25, 413–425. Rothermund, K., & Meiniger, C. (2004). Stress-buffering effects of self-complexity: Reduced affective spillover or self-regulatory processes? Self and Identity, 3, 263–281. Rothermund, K., Voss, A., & Wentura, D. (2008). Counter-regulation in affective attentional biases: A basic mechanism that warrants flexibility in emotion and motivation. Emotion, 8, 34–46. Rothermund, K., Wentura, D., & Bak, P. (2001). Automatic attention to stimuli signalling chances and dangers: Moderating effects of positive and negative goal and action contexts. Cognition and Emotion, 15, 231–248. Schwager, S., & Rothermund, K. (in press-a). Counter-regulation triggered by emotions: Positive/negative affective states elicit opposite valence biases in affective processing. Cognition and Emotion. Schwager, S., & Rothermund, K. (in press-b). Motivation and affective processing biases in risky decision making: A counter-regulation account. Journal of Economic Psychology. Shah, J. Y., Friedman, R., & Kruglanski, A. W. (2002). Forgetting all else: On the antecedents and consequences of goal shielding. Journal of Personality and Social Psychology, 83, 1261–1280. Solomon, R. L., & Corbit, J. D. (1974). An opponent-process theory of motivation: I. Temporal dynamics of affect. Psychological Review, 81, 119–145. Taylor, S. E. (1991). Asymmetrical effects of positive and negative events: The mobilization-minimization hypothesis. Psychological Bulletin, 110, 67–85. Taylor, S. E., & Brown, J. D. (1988). Illusion and well-being: A social psychological perspective on mental health. Psychological Bulletin, 103, 193–210. Tran, T., Siemer, M., & Joormann, J. (2011). Implicit interpretation biases affect emotional vulnerability: A training study. Cognition and Emotion, 25, 546–558. Vogt, J., Lozo, L., Koster, E. W., & De Houwer, J. (2011). On the role of goal relevance in emotional attention: Disgust evokes early attention to cleanliness. Cognition and Emotion, 25, 466–477. Wentura, D., Voss, A., & Rothermund, K. (2009). Playing TETRIS for science: Counter-regulatory affective processing in a motivationally “hot” context. Acta Psychologica, 131, 171–177. Zeigarnik, B. (1927). Das Behalten erledigter und unerledigter Handlungen. Psychologische Forschung, 9, 1–85. Zuckerman, M., Knee, C. R., Kieffer, S. C., Rawsthorne, L., & Bruce, L. M. (1996). Beliefs in realistic and unrealistic control: Assessment and implications. Journal of Personality, 64, 435–464.

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The Regulatory Power of Positive Emotions in Stress A Temporal-Functional Approach Christian E. Waugh

The word resilience is originally a metallurgy term that characterizes the ability of a metal to be stressed (e.g., bent or twisted) and then to rebound to its original form when that stress is no longer applied. As evidenced by this volume, the construct of resilience has become increasingly used by psychologists and psychiatrists to describe similar properties in people—the ability to withstand stress and to rebound to pre-stress levels of functioning when the stress is over. Although this conceptualization is not necessarily shared by all resilience investigators (e.g., Bonanno, 2004), it does illustrate one perspective that has pervaded research in resilience, as well as conceptions of resilience by lay people. Despite the usefulness of this “rebound from stress” conceptualization of resilience, it is becoming increasingly clear that this conceptualization is incomplete because it typically focuses on negative states and ignores one fundamental component of stressful experiences—positive emotions. One potentially counterintuitive pattern of findings in the stress literature is that, when under stress, people can experience both negative and positive emotions (Folkman, 1997). For example, Folkman (1997) found that, despite increased negative emotions, caregivers of people with AIDS were able to maintain a level of positive emotions that was hardly ever lower than their level of negative emotions and that was comparable to the positive emotions of the surrounding community. Positive emotions during stress are not just happy accidents, but are a critical component of resilience. Fredrickson, Tugade, Waugh, and Larkin (2003) measured trait levels of resilience in undergraduate students before the terrorist attacks on 9/11 and, after the attacks, assessed the students’ responses to the attacks. The investigators found that higher pre-attack trait resilience predicted fewer post-attack depressive symptoms and that this association was mediated by levels of positive emotions. Although high trait resilience also predicted slightly fewer negative emotions after the event, these few negative emotions did not mediate the association between resilience and fewer depressive symptoms, and resilience was more strongly associated with positive emotions (Fredrickson et al., 2003). The presence of positive emotions in resilient people does not necessarily coincide with fewer negative emotions. Indeed, research suggests that resilient people are characterized by the co-occurrence of positive and negative emotions in stressful situations (Folkman & Moskowitz, 2000; Ong, Bergeman, Bisconti, & Wallace, 2006), and that this cooccurrence may be due to the ability of resilient people to flexibly adapt their emotional responses to match the demands of the situation (Waugh, Thompson, & Gotlib, 2011; Westphal, Seivert, & Bonanno, 2010). Westphal et al. (2010) found that people who were better able to flexibly express both positive and negative emotions when instructed exhibited better adjustment over a two-year period. Waugh et al. (2011) found that this emotional flexibility in resilient people also occurred naturally and in response to rapidly changing events.


Christian E. Waugh

These findings that positive and negative emotions co-occur for resilient people during stressful situations support the “evaluative space” model that posits that positive and negative affect are independent systems and can be activated simultaneously (Cacioppo & Berntson, 1994). These findings also present the possibility that these states interact meaningfully to influence overall responses to stressful situations. Supporting this formulation, Ong et al. (2006) found that higher levels of positive emotions weakened the influence that daily experiences of stress had on subsequent negative emotions. Although these and other findings demonstrate that positive and negative emotions interact during stress, it is still not clear how they interact to influence stress responses. Understanding the precise mechanisms underlying their interaction could elucidate the difference between resilient and less resilient people, and potentially lead to more effective resilience training programs. In the remainder of this chapter, I examine the interaction of positive and negative emotions during stress in the hope of understanding the mechanisms by which resilient people use positive emotions to protect themselves from mental health problems. I begin by reviewing some influential theories on the interaction of positive and negative emotions. I then present a framework for understanding this interaction and end with important remaining questions.

THEORIES ON THE INTERACTION OF POSITIVE AND NEGATIVE EMOTIONS Dynamic Model of Affect Relationships One of the more influential theories on the interaction of positive and negative emotions is the dynamic model of affect relationships (DMA; Reich, Zautra, & Davis, 2003). The DMA was developed as a way to understand why positive and negative emotions are inversely related during times of stress, but become uncorrelated in times of little to no stress (Zautra, Reich, Davis, Potter, & Nicolson, 2000). The model posits that the varying uncertainty of stressful situations determines the degree of information processing required to cope with those situations. Highly stressful situations require a great deal of information processing, whereas the opposite is true for mildly stressful situations. Furthermore, the greater the degree of information processing that is needed to cope with a situation, the less processing there is left over for emotions. With less processing for emotions, it is difficult for complex variants of positive and negative emotions to occur at the same time, so they become inversely coupled. This bipolarity of positive and negative emotions in times of stress typically appears as a pattern of increased negative emotions and decreased positive emotions (Zautra et al., 2000). The reverse, however, can also occur (Reich & Zautra, 1981). Reich and Zautra (1981) gave college students a positive emotion induction and examined how it affected their levels of positive and negative emotions. They found that the positive emotion induction increased positive emotions for all students, but only decreased negative emotions for those students who had recently experienced heightened stress. According to the DMA theory, the nature of the interaction of positive and negative emotions is one of replacement. During times of stress, because of the limited emotional processing available, people feel either positive or negative emotions, and the feeling of one decreases the feeling of the other. This formulation is inconsistent, however, with the findings reported above that resilient people are able to maintain both positive and negative emotions during times of stress. Ong et al. (2006) directly tested the DMA theory and found that it only held for low resilient people—on highly stressful days, their reported

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free ebooks ==> www.ebook777.com The Regulatory Power of Positive Emotions in Stress 75 positive emotions were inversely related with their reported negative emotions. Inconsistent with the DMA theory, however, on highly stressful days, high resilient participants were able to maintain similar levels of positive emotions regardless of whether they were also feeling negative emotions. It may be that the DMA theory holds for only some people, but, if so, it does not fully explain how positive and negative emotions interact in resilient people to influence overall stress responses. Broaden-and-Build Theory of Positive Emotions Fredrickson’s broaden-and-build theory of positive emotions (Fredrickson, 1998) is also an information-processing theory of emotions, but, instead of focusing on how informationprocessing limitations influence emotions, as the DMA theory does, Fredrickson theorizes about how emotions influence information processing. Fredrickson suggests that at any given moment a person has available to him or her a repertoire of possible thoughts and actions. Similarly to the case with the DMA theory, stressful situations and their associated negative emotions can narrow that thought–action repertoire to focus on immediately salient and important behaviors to cope with the stressor. Departing from DMA theory, however, the broaden-and-build theory suggests that positive emotions broaden our thought–action repertoires, thereby making available to us a variety of possible thoughts and behaviors. For example, whereas people’s feelings of anger might narrow their attention to focus on the cause of the anger, people’s feelings of contentment might broaden their attention, allowing them to think about a variety of things, such as the surrounding landscape, clouds, or one’s partner. The broaden-and-build theory does not explicitly tackle the question of how positive and negative emotions might interact. However, the “build” part of the broaden-and-build theory may offer a starting point for how this theory might speak to this question. According to Fredrickson, the broadened thought–action repertoires that stem from positive emotions build psychological (e.g., optimism), physical (e.g., heart health), social (e.g., better relationships), and cognitive (e.g., creativity) resources that can be used to buffer the potential deleterious effects of stress. For example, excitement from one’s accomplishment might create the urge to have fun with friends, and the resulting relationships with these friends then serve as a crucial coping resource in times of stress. Because it was not developed explicitly as a theory about the interaction of positive and negative emotions, some unanswered questions remain. First of all, it is unclear whether negative emotions should be considered a deleterious effect of stress. On one hand, Fredrickson makes a point to note that negative emotions and their associated narrowing of attention are adaptive and useful, but on the other hand one can imagine that negative emotions can become maladaptive when they become overgeneralized and persistent. Further, the build portion of the broaden-and-build theory suggests that the beneficial effects of positive emotions occur before the stressor, which does not explain how positive and negative emotions interact when they occur concurrently during a stressor. Lastly, when positive and negative emotions are concurrent, it is unclear whether the resulting broadening and narrowing of thought–action repertoires replace each other, as in the DMA theory, or if there is some other type of interaction. Positive Affect as Meaningful Coping The final theory reviewed here deals perhaps most explicitly with how positive and negative emotions interact to influence responses to stress. Folkman and Moskowitz (2000) note


Christian E. Waugh

that, traditionally, coping strategies are thought to be successful if they reduce distress or negative emotions during stressful periods. They argue, however, that some coping strategies are successful because they are associated with increases in positive emotions during stressful periods. The unifying theme of these positive coping strategies is that they all involve making, changing, or finding meaning. For example, in studies of AIDS caregivers, increases in positive emotions throughout the study were associated with positive reappraisal and the cognitive strategy of reframing a situation in a positive light, as well as problem-focused coping, the attempt to directly deal with the problem causing the distress (Moskowitz, Folkman, Collette, & Vittinghoff, 1996). Beyond making or changing meaning about the stressful situation itself, Folkman and Moskowitz (2000) suggest that imbuing ordinary, unrelated events with positive meaning is also a successful coping strategy related to positive emotions. Folkman and Moskowitz (2000) present a compelling mediator—meaningful coping— for the association between positive and negative emotions. The meaningful coping strategies they describe in their formulation, however, are quite different in form and function. For example, although the three coping strategies presented above are associated with similar outcomes—more positive emotions during stress—the mechanisms underlying their interaction with negative emotions are quite different. Whereas positive reappraisal changes the meaning of the stressor itself (Gross, 1998), imbuing ordinary events with positive meaning does not necessarily change the meaning of the stressor. Resilient people tend to be flexible in their use of coping strategies (Cheng, 2001), suggesting that these different strategies may be more useful at certain phases or in response to certain elements of the stressful period. The nature of these relationships has yet to be unpacked. Summary I reviewed a sample of the more influential theories that ask the question of how positive and negative emotions might interact to influence responses to stress. This was not an exhaustive list of the theories on this topic, but instead represented the theories that helped me formulate my own ideas about the form and function of this interaction. The DMA theory illustrates the importance of the intensity of stress for shaping the association between positive and negative emotions. The broaden-and-build theory provides functional accounts of positive and negative emotions and introduces a specific avenue through which they may interact over time. Lastly, the positive affect as coping model most explicitly describes some of the coping strategies that underlie the interaction of positive and negative emotions during times of stress.

A TEMPORAL-FUNCTIONAL FRAMEWORK FOR THE INTERACTION OF POSITIVE AND NEGATIVE EMOTIONS In this section, I present my own framework for understanding the interaction of positive and negative emotions during times of stress. This framework rests on two premises. The first premise is that the nature of the interaction between positive and negative emotions depends largely on the phase of the stressor in which these emotions occur. Acute stressors consist of different phases, including, but not limited to, the anticipation of, engagement with, and recovery from that stressor (Waugh, Panage, Mendes, & Gotlib, 2010). Each of these phases (as well as an inter-stress period) is associated with a fairly different suite of psychological and physiological responses that require different coping strategies to manage

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free ebooks ==> www.ebook777.com The Regulatory Power of Positive Emotions in Stress 77 them. I suggest that positive and negative emotions, which are part of these response profiles, serve different functions depending on the phase of the stressor in which they occur. It follows then that these different functions produce different types of interactions. The second premise of this framework is that positive and negative emotions have independently adaptive functions that potentially interact with each other. That positive and negative emotions have independent functions is consistent with Cacioppo and Berntson’s (1994) evaluative space model. That these independent functions can both serve adaptive purposes is consistent with Fredrickson’s broaden-and-build theory (Fredrickson, 1998). Their independence leaves open the possibility that people can feel positive and negative emotions at roughly the same time, or at least within a small period of time, which is consistent with Folkman and Moskowitz’s (2000) theory, and that these independent states can and do interact to influence each other, which is consistent with DMA theory. Importantly, however, I posit that the independent adaptive functions of both emotional states need to be preserved when they interact in order for the interaction to be adaptive and to contribute to resilience. Before I unpack this framework, it is important to define what I mean by “stress.” For the purposes of this chapter, I distinguish between stressors, which are the discrete events that cause stress, and stress responses, which are the responses by the organism to those events (Selye, 1976). I also do not equate stress responses with negative emotions and do not use those terms interchangeably. Stressors can be both positive and negative events, and can elicit both positive and negative emotions. Because my framework emphasizes different phases in the stressor, I focus on acute, rather than chronic, stressors. Acute stressors are time-limited: they have a discrete and identifiable beginning and end, and they occur as a result of an initiating event. Acute stressors can also be sequenced together to form chronic intermittent stressors (e.g., job loss). These differ, however, from chronic stressors, which are ever-present, may or may not be initiated by a discrete event, and persist continuously (Elliott & Eisdorfer, 1982). Lastly, although I focus on discrete phases of acute stressors, my arguments do not rely on the assumption that a person experiences only one phase of one particular stressor at any given time. In fact, I believe that this framework is scalable; it applies both to superordinate stressors of potentially long duration (e.g., job loss) and to the associated shorter subordinate stressors (e.g., waiting in line at the unemployment office). Inter-Stressor Phase The inter-stressor phase is a period of time that occurs between discrete stressors and is defined by activities that are not directly related to a specific discrete stressor. Although chronic stress may be a backdrop during this period, any discrete stressors related to that chronic stressor are not. The notion of an inter-stressor phase is inherent in every study that uses a “baseline period” as a point of comparison to some “stress period.” Because the inter-stressor phase is not associated with a discrete problem to be solved, the functions of negative emotions during this period are limited. In this phase, people engage in strategies to proactively cope with potential stressors (Aspinwall & Taylor, 1997). These are strategies that are not necessarily connected to a specific stressor, but rather more generally used to prevent and/or recognize the occurrence of stressors. Negative emotions, such as those associated with worry, may help proactive coping efforts by allowing people to maintain a mild level of vigilance, which, in turn, aids in the recognition of potential stressors (Aspinwall, Sechrist, & Jones, 2005). For example, having chronic pain induces people to be vigilant for and avoid any potentially pain-inducing activity (Aldrich, Eccleston, & Crombez, 2000).


Christian E. Waugh

I argue that, although the vigilance provided by negative emotions can be useful, positive emotions are much more useful during the inter-stressor phase. Fredrickson’s broaden-andbuild theory suggests that during the inter-stressor period the function of positive emotions is to aid in the accumulation of resources (Fredrickson, 1998), which is an impactful proactive coping strategy because these resources can be used to cope with future stressors. For example, positive emotions build social resources, such as increased closeness with others (Waugh & Fredrickson, 2006), and social resources are critically important for both physical and mental health (Cohen & Wills, 1985). Positive emotions also build psychological resources. People induced to feel positive emotions via a meditation induction exhibited increased self-reports of optimism and purpose in life, and these psychological resources led to increased life satisfaction (Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008). Besides psychosocial resources, positive emotions also build physical resources that then aid in the coping of stressors. Daily reports of positive emotions over a nine-week period predicted increases in vagal tone—an index of the influence of the vagus nerve on the heart that is associated with social and psychological well-being (Kok & Fredrickson, 2010). During the inter-stressor phase, the disparate functions of positive and negative emotions suggest that there may be minimal interactions between them, supporting the assertion from the DMA theory that, during this phase, positive and negative emotions are relatively independent. I argue that, because the functions of positive emotions as “building” are more important during this phase than are the functions of negative emotions as “vigilant watchfulness,” resilient people should be characterized by a higher ratio of experienced positive to negative emotions. Fredrickson and Losada (2005) used nonlinear dynamics to model interand intra-individual emotion data to demonstrate that this indeed is the case—a positiveto-negative ratio of around 3:1 distinguished those who were resilient and flourishing from those who were not (Fredrickson & Losada, 2005). This model showed that flourishing decreased when the positive-to-negative ratio became too high, supporting my formulation that negative emotions are still adaptive and necessary, but only in small doses. Summary During the inter-stressor phase, negative emotions aid in the vigilant watchfulness for potential stressors, while positive emotions build social, psychological, and physical resources that can be used to cope with potential stressors. I argued that the functions associated with these emotional states are independent, and do not necessarily interact to influence responses to potential stressors. I further argued that these functions associated with positive emotions are relatively more important to coping with stress than the functions associated with negative emotions, which explains why resilient people tend to be characterized by a higher ratio of positive-to-negative emotions during this phase. Anticipation of a Stressor The next phase is the anticipation of a potential stressor. Often, but not always, people receive some cue that a stressor could occur in the future. Receiving this cue initiates the anticipation phase, which can endure for short periods of time, such as your boss telling you that they need to see you in their office, or long periods of time, as in being told that you are shipping out to a war zone in several months. The distinguishing characteristic of the anticipation phase is that people’s thoughts and feelings are directed toward a future stressor. Selye (1976) referred to the anticipation phase as the “alarm” stage because it is the

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free ebooks ==> www.ebook777.com The Regulatory Power of Positive Emotions in Stress 79 first moment that your body begins preparing for potential stressors. Indeed, the primary function of negative emotions during this phase is to prepare people physically (Selye, 1976), situationally (Aspinwall & Taylor, 1997), and emotionally (Shepperd, Findley-Klein, Kwavnick, Walker, & Perez, 2000) for the possible occurrence of that stressor. When stressors are controllable, negative emotions can motivate people to prepare for that stressor to mitigate the possible negative consequences of the stressor or even prevent the stressor from occurring. For example, Aspinwall et al. (2005) found that increased negative emotions when thinking about the potential consequences of the Y2K bug predicted the degree to which people prepared for the bug. When anticipating a stressor, I argue that the function of positive emotions is to shape the type and level of preparations being made so as to most appropriately and effectively cope with the stressor. Over-preparing for stressors is a waste of resources, and chronic overpreparing can harm mental health, as in the case of anxiety disorders. One adaptive function of positive emotions, then, is to ensure that negative emotions are only expressed to the degree that they induce the appropriate level of preparation for the stressor. Level of preparations is only one factor, however, in the effectiveness of a coping strategy. I also suggest that, by broadening people’s perspective and increasing their attention to context, positive emotions help guide people to use more effective coping strategies. When stressors are controllable, the level of preparation needed depends on the demands of the stressor. In those rare cases in which the stressor is imminent and very high levels of negative emotions are instrumental to the outcome of the stressor, it is important that positive emotions not distract people from attempting to solve the problem. In longitudinal studies of newlyweds, investigators found that overly biased positive appraisals—thinking that a negative event was more positive than it was—predicted more depressive symptoms when those negative events were judged to be severe (O’Mara, McNulty, & Karney, 2011). The investigators posited that people’s overly positive evaluations of severely negative events caused them to stop attempting to solve the problems associated with the negative events, which then became worse and caused greater levels of depression. On the other hand, when demands are very low, levels of preparation and thus negative emotions need to be low, and positive emotions can be beneficial by providing moments of levity and pleasant distraction. O’Mara, McNulty, and Karney (2011) showed that, when people were faced with mildly negative events, positive appraisals predicted fewer depressive symptoms. It is often the case that stressors require levels of preparation in between these two extremes. In those cases, resilient people are able to balance the negative emotions needed for preparing for the stressor with the positive emotions needed to prepare appropriately for the stressor (Tugade & Fredrickson, 2004). Positive emotions broaden people’s thought–action repertoire (Fredrickson, 1998), possibly allowing them to access a broader variety of possible coping strategies, which could promote the selection of the appropriate coping strategy for the situation. For example, Tugade and Fredrickson (2004) found that, when faced with an upcoming performance stressor, resilient people reported increased challenge appraisals and decreased threat appraisals of the upcoming stressor, suggesting that they felt that they had enough resources to meet the demands of the stressor (Tomaka, Blascovich, Kelsey, & Leitten, 1993). Resilience is also associated with dispositional optimism (Fredrickson et al., 2003), the tendency to have positive expectations about upcoming events. Optimism has been found to be associated with the increased use of adaptive approach-based coping strategies, decreased use of maladaptive avoidance-based coping strategies, and the ability to adjust coping strategies to match the demands of the stressor (Nes & Segerstrom, 2006).


Christian E. Waugh

When stressors are uncontrollable, there is little preparation that can be made for the stressor, so negative emotions may be minimally functional. However, there is mixed evidence for this formulation (Golub, Gilbert, & Wilson, 2009; Shepperd et al., 2000). Some investigators argue that, when stressors are uncontrollable, the function of negative emotions is to change the way people think about the potential stressor so as to mitigate potential emotional consequences. Shepperd et al. (2000) termed this “bracing for loss,” and demonstrated that people try to mitigate the aversive feelings associated with surprisingly negative stressors by preemptively feeling negative emotions before the stressor occurs. Golub et al. (2009) showed, however, that feeling negative emotions before a possible negative event does not actually translate into more positive emotions, or fewer negative emotions, when the event occurs. One possibility is that people may believe that feeling negative emotions about an upcoming stressor may attenuate their negative emotional responses if it occurs, but in reality this does not happen. More important than trying to attenuate future negative emotions may be for people to cope effectively with the uncontrollability of the stressor, which may be aided by positive emotions. For example, when faced with uncontrollable stressors, people’s level of optimism is associated with a greater likelihood of accepting the situation “as is” since nothing can be done—an effective emotion-based coping strategy for uncontrollable situations (Scheier, Weintraub, & Carver, 1986). Summary During the anticipation phase, the functions of negative and positive emotions depend on the type of stressor being anticipated. When stressors are controllable, negative emotions motivate people to prepare for those stressors, and positive emotions help by ensuring that the level of negative emotions and type of coping strategy match the demands of the stressor. When stressors are uncontrollable, I argued that negative emotions serve little preparatory purpose, whereas positive emotions may help people to use effective emotion-based coping strategies. Engagement With the Stressor In the engagement with the stressor phase, the stressor that was or was not anticipated finally occurs, for example when people go from anticipating the talk with their boss to actually talking with their boss, or from anticipating deployment to being in a firefight in that war zone. Like anticipation, engagement with a stressor requires demands of the person, but, unlike anticipation, those demands are being exacted as opposed to just being prepared for. Put another way, anticipation helps people prepare to solve a particular problem, and engagement is the act of solving that problem. Although it is a different phase from anticipation, engagement with the stressor shares much of the same qualities (Waugh et al., 2010). Controllability and intensity of the stressor are also important determinants of the types of coping strategies that people use when engaged with the stressor (Abramson, Seligman, & Teasdale, 1978). Thus, positive and negative emotions also share much of the same functions, but, instead of “preparing for” stressors, these functions serve to aid in “dealing with” stressors. Negative emotions that helped people prepare for stressors during the anticipation phase now help people deal with stressors by limiting their thought–action repertoires to those behaviors that have evolved to resolve the problem created by the stressor. For example, Tamir, Mitchell, and Gross

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free ebooks ==> www.ebook777.com The Regulatory Power of Positive Emotions in Stress 81 (2008) showed that feeling angry during a confrontational game aided in people’s performance during the game. As in the anticipation phase, it is critical for people to experience the appropriate levels of negative emotions when engaged with the stressor (Yerkes & Dodson, 1908). The Yerkes–Dodson (1908) law describes an inverse-U relationship between negative arousal and performance such that optimal performance is related to a medium level of arousal. I mentioned before the possible detrimental effects of overly high negative emotions and the role positive emotions play in tempering them, but overly low negative emotions may be equally detrimental. For example, some evidence suggests that depressed people are characterized by attenuated emotional reactivity to both negative and positive stimuli (Bylsma, Morris, & Rottenberg, 2008). This presents the intriguing, and as yet untested, possibility that, if positive emotions help keep negative emotions at a level appropriate to the stressor, then positive emotions may actually increase negative emotions in those moments where negative emotions are being under-expressed. Positive emotions, which during the anticipation phase help people select the most effective coping strategies, do much the same thing during engagement with the stressor (Moskowitz et al., 1996). This similarity may only hold, however, for those positive emotions that are relevant to the stressor (e.g., positively reappraising the stressor). One important difference between engagement with and anticipation of a stressor is the immediacy of the required coping strategies and problem solving. In the anticipation phase section I proposed that, when preparing for a relatively low-demand stressor, even if positive emotions are not related directly to the stressor they could still aid coping by providing levity and pleasant distractions. Distraction can be quite an effective coping strategy early in a stressor (Thiruchselvam, Blechert, Sheppes, Rydstrom, & Gross, 2011). When directly engaged with the stressor, however, these distractions produced by irrelevant positive emotions may be detrimental to coping. Positive emotions can decrease motivation to solve a problem because they serve as a cue that people have already done enough (Martin, Ward, Achee, & Wyer, 1993). Indeed, people will often choose to not feel positive emotions when engaged with a stressor, if they believe that those positive emotions will not help them deal with the stressor (Tamir et al., 2008). Summary When people are engaging with a stressor, positive and negative emotions serve similar functions to those served by positive and negative emotions when people are just anticipating the stressor. The primary difference may be the role of positive emotions that are not relevant to the stressor itself. When people are anticipating a stressor, these irrelevant positive emotions may aid coping by providing pleasant distractions. However, when people are engaged with a stressor, these distractions may be detrimental to trying to solve the problem caused by the stressor. Recovery From the Stressor The final phase is the recovery from the stressor. For the purposes of the current chapter, I define the start of recovery as the time at which the stressor places no more demands on the person. For example, recovery begins once you’ve left your boss’s office or after finishing the firefight. The defining characteristic of recovery is that the thoughts and behaviors during this phase are related to the stressor that just occurred.


Christian E. Waugh

Because the stressor no longer places any demands on the person, negative emotions have very limited functional value during recovery. The only functional value of negative emotions is perhaps to induce people to reflect on their experiences (Baumeister, Vohs, DeWall, & Zhang, 2007)—a form of post-stressor problem solving that can help people learn from those experiences. The danger of these potentially adaptive self-reflections, however, is that they can quickly turn into maladaptive ruminations. Rumination, the process of focusing on one’s emotions surrounding the stressor rather than reflecting on ways to learn from the stressor, is strongly associated with depression (Nolen-Hoeksema & Morrow, 1993). Positive emotions, on the other hand, have perhaps their strongest influence on the stress response during recovery. Positive emotions broaden thought–action repertoires (Fredrickson, 1998), which may aid recovery by ridding individuals of maladaptive ruminative thoughts, and allowing them to take a broader, more helpful perspective on the stressor. Reappraising the stressor in a positive light is one of the most powerful strategies for coping with stressors (Folkman & Moskowitz, 2000). Besides influencing stress-related cognitions, positive emotions also speed physiological recovery from stress (Fredrickson, Mancuso, Branigan, & Tugade, 2000), an important effect given the potentially deleterious consequences of prolonged physiological stress reactions (McEwen, 1998). The potent adaptive value of positive emotions is supported by findings that resilient people are generally more effective than non-resilient people at using positive emotions to recover from stress (Papa & Bonanno, 2008; Tugade & Fredrickson, 2004). For example, after anticipating a social threat (giving a speech), resilience was positively associated with faster cardiovascular recovery, an association that was mediated by positive emotions (Tugade & Fredrickson, 2004). In addition, Papa and Bonanno (2008) found that, after people had been induced with negative emotions, expressing positive emotions while monologuing about life events prospectively predicted lower distress several months later. Summary When the stressor is over and requires no more demands of the person, then negative emotions may be of limited usefulness other than in aiding self-reflected learning. Much more important during recovery are positive emotions, which rid people of maladaptive ruminative thoughts and speed physiological recovery.

CONCLUSIONS I have presented a temporal-functional framework for understanding how positive and negative emotions interact to influence responses to stressors. I argued that stressors have four distinct phases, each of which is associated with a distinct suite of positive and negative emotion-related functional responses. Negative emotions are primarily functional when trying to solve problems in the environment. As such, they are most useful when anticipating and then engaging with a controllable stressor. Positive emotions, on the other hand, have a multitude of functions that change depending on the phase of the stressor. During the anticipation of and engagement with a stressor, positive emotions influence the type of coping strategy people use by promoting problem-solving coping strategies for controllable stressors and acceptance strategies for uncontrollable stressors. They also help regulate negative emotions by keeping negative emotions to a level that matches the demands of the environment. Positive emotions are arguably most impactful, however, during the inter-stress and

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free ebooks ==> www.ebook777.com The Regulatory Power of Positive Emotions in Stress 83 recovery phases. During the inter-stress phase, positive emotions help people build social, physical, cognitive, and emotional resources that aid them in future stressors. After a stressor is over, positive emotions help people recover by ridding them of negative ruminative thoughts and speeding physiological recovery. Of course, there are several remaining questions. For example, I treated negative and positive emotions as broad classes of emotions. It will be important for future theory and research to consider how individual emotions within each of these classes impact stress responses. One glaring example is that recent research has shown that not all positive emotions broaden people’s thought–action repertoires. Positive emotions that are anticipatory and highly approach-related tend to narrow people’s thought–action repertoires to focus on the object of desire (Gable & Harmon-Jones, 2008). It is not clear, then, how these anticipatory positive emotions may impact coping strategies. Another remaining question that I only briefly touched upon is whether the manner in which positive and negative emotions occur within the context of the stressor alters their functional value. For example, given the impact of social support on stress, are socially generated positive emotions more powerful than non-social emotions in influencing stress responses? Also, given the primary role of problem solving for negative emotions, are irrelevant negative emotions as useful to stress responding as relevant ones? It is important for future investigations to address these and other remaining questions to provide a more complete understanding of the interaction of positive and negative emotions during stress. Despite these remaining questions, this framework provides a possible starting point not only for understanding the interaction of positive and negative emotions during stress, but also for understanding how resilient people are able to adapt well to stress and adversity. Understanding the mechanisms underlying resilience will help to provide possible targets for resilience-based interventions aimed at increasing resilience among those in our population who most desperately need it.

REFERENCES Abramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. (1978). Learned helplessness in humans: Critique and reformulation. Journal of Abnormal Psychology, 87, 49–74. Aldrich, S., Eccleston, C., & Crombez, G. (2000). Worrying about chronic pain: Vigilance to threat and misdirected problem solving. Behaviour Research and Therapy, 38, 457–470. 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, 357–388. Aspinwall, L. G., & Taylor, S. E. (1997). A stitch in time: Self-regulation and proactive coping. Psychological Bulletin, 121, 417–436. Baumeister, R. F., Vohs, K. D., DeWall, C. N., & Zhang, L. (2007). How emotion shapes behavior: Feedback, anticipation, and reflection, rather than direct causation. Personality and Social Psychology Review, 11, 167–203. Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–28. Bylsma, L. M., Morris, B. H., & Rottenberg, J. (2008). A meta-analysis of emotional reactivity in major depressive disorder. Clinical Psychology Review, 28, 676–691. Cacioppo, J. T., & Berntson, G. G. (1994). Relationship between attitudes and evaluative space: A critical review, with emphasis on the separability of positive and negative substrates. Psychological Bulletin, 115, 401–423. Cheng, C. (2001). Assessing coping flexibility in real-life and laboratory settings: A multimethod approach. Journal of Personality and Social Psychology, 80, 814–833.


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Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98(2), 310–357. Elliott, G. R., & Eisdorfer, C. (1982). Stress and human health. New York: Springer. Folkman, S. (1997). Positive psychological states and coping with severe stress. Social Science and Medicine, 45, 1207–1221. Folkman, S., & Moskowitz, J. T. (2000). Positive affect and the other side of coping. American Psychologist, 55, 647–654. Fredrickson, B. L. (1998). What good are positive emotions? Review of General Psychology, 2, 300–319. Fredrickson, B. L., Cohn, M. A., Coffey, K. A., Pek, J., & Finkel, S. M. (2008). Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources. Journal of Personality and Social Psychology, 95(5), 1045–1062. Fredrickson, B. L., & Losada, M. F. (2005). Positive affect and the complex dynamics of human flourishing. American Psychologist, 60, 678–686. Fredrickson, B. L., Mancuso, R. A., Branigan, C., & Tugade, M. M. (2000). The undoing effect of positive emotions. Motivation and Emotion, 24, 237–258. Fredrickson, B. L., Tugade, M. M., Waugh, C. E., & Larkin, G. R. (2003). What good are positive emotions in crisis? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001. Journal of Personality and Social Psychology, 84, 365–376. Gable, P. A., & Harmon-Jones, E. (2008). Approach-motivated positive affect reduces breadth of attention. Psychological Science, 19, 476–482. Golub, S. A., Gilbert, D. T., & Wilson, T. D. (2009). Anticipating one’s troubles: The costs and benefits of negative expectations. Emotion, 9, 277–281. Gross, J. J. (1998). Antecedent and response-focused emotion regulation: Divergent consequences for experience, expression, and physiology. Journal of Personality and Social Psychology, 74, 224–237. Kok, B. E., & Fredrickson, B. L. (2010). Upward spirals of the heart: Autonomic flexibility, as indexed by vagal tone, reciprocally and prospectively predicts positive emotions and social connectedness. Biological Psychology, 85, 432–436. Martin, L. L., Ward, D. W., Achee, J. W., & Wyer, R. S. (1993). Mood as input: People have to interpret the motivational implications of their moods. Journal of Personality and Social Psychology, 64, 317–326. McEwen, B. S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. Annals of the New York Academy of Sciences, 840, 33–44. Moskowitz, J. T., Folkman, S., Collette, L., & Vittinghoff, E. (1996). Coping and mood during AIDS-related caregiving and bereavement. Annals of Behavioral Medicine, 18, 49–57. Nes, L. S., & Segerstrom, S. C. (2006). Dispositional optimism and coping: A meta-analytic review. Personality and Social Psychology Review, 10, 235–251. Nolen-Hoeksema, S., & Morrow, J. (1993). Effects of rumination and distraction on naturally occurring depressed mood. Cognition and Emotion, 7, 561–570. O’Mara, E. M., McNulty, J. K., & Karney, B. R. (2011). Positively biased appraisals in everyday life: When do they benefit mental health and when do they harm it? Journal of Personality and Social Psychology, 101, 415–432. Ong, A. D., Bergeman, C. S., Bisconti, T. L., & Wallace, K. A. (2006). Psychological resilience, positive emotions, and successful adaptation to stress in later life. Journal of Personality and Social Psychology, 91, 730–749. Papa, A., & Bonanno, G. A. (2008). Smiling in the face of adversity: The interpersonal and intrapersonal functions of smiling. Emotion, 8, 1–12. Reich, J. W., & Zautra, A. J. (1981). Life events and personal causation: Some relationships with satisfaction and distress. Journal of Personality and Social Psychology, 41, 1002–1012. Reich, J. W., Zautra, A. J., & Davis, M. (2003). Dimensions of affect relationships: Models and their integrative implications. Review of General Psychology, 7, 66–83.

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free ebooks ==> www.ebook777.com The Regulatory Power of Positive Emotions in Stress 85 Scheier, M. F., Weintraub, J. K., & Carver, C. S. (1986). Coping with stress: Divergent strategies of optimists and pessimists. Journal of Personality and Social Psychology, 51, 1257–1264. Selye, H. (1976). Stress in health and disease. Boston, MA: Butterworth. Shepperd, J. A., Findley-Klein, C., Kwavnick, K. D., Walker, D., & Perez, S. (2000). Bracing for loss. Journal of Personality and Social Psychology, 78, 620–634. Tamir, M., Mitchell, C., & Gross, J. J. (2008). Hedonic and instrumental motives in anger regulation. Psychological Science, 19, 324–328. Thiruchselvam, R., Blechert, J., Sheppes, G., Rydstrom, A., & Gross, J. J. (2011). The temporal dynamics of emotion regulation: An EEG study of distraction and reappraisal. Biological Psychology, 87, 84–92. Tomaka, J., Blascovich, J., Kelsey, R. M., & Leitten, C. L. (1993). Subjective, physiological, and behavioral effects of threat and challenge appraisal. Journal of Personality and Social Psychology, 65, 248–260. Tugade, M. M., & Fredrickson, B. L. (2004). Resilient individuals use positive emotions to bounce back from negative emotional experiences. Journal of Personality and Social Psychology, 86, 320–333. Waugh, C. E., & Fredrickson, B. L. (2006). Nice to know you: Positive emotions, self–other overlap, and complex understanding in the formation of a new relationship. Journal of Positive Psychology, 1, 93–106. Waugh, C. E., Panage, S., Mendes, W. B., & Gotlib, I. H. (2010). Cardiovascular and affective recovery from anticipatory threat. Biological Psychology, 84, 169–175. Waugh, C. E., Thompson, R. J., & Gotlib, I. H. (2011). Flexible emotional responsiveness in trait resilience. Emotion, 11, 1059–1067. Westphal, M., Seivert, N. H., & Bonanno, G. A. (2010). Expressive flexibility. Emotion, 10, 92–100. Yerkes, R. M., & Dodson, J. D. (1908). The relation of strength of stimulus to rapidity of habit formation. Journal of Comparative Neurological Psychology, 18, 459–482. Zautra, A. J., Reich, J. W., Davis, M. C., Potter, P. T., & Nicolson, N. A. (2000). The role of stressful events in the relationship between positive and negative affect: Evidence from field and experimental studies. Journal of Personality, 68, 927–951.


Responding to Trauma and Loss An Emotion Regulation Perspective Matthew Tyler Boden, Madhur Kulkarni, Ashley Shurick, Marcel O. Bonn-Miller, and James J. Gross

Community- and population-based studies have found that, during their lifetimes, a majority of people will be exposed to at least one event which involves actual or threatened death, serious injury, or a threat of physical injury to self or significant others (e.g., Breslau et al., 1998). Although such events involve a marked disruption in everyday routines, individuals have a wide range of psychological and physical reactions to such events. In fact, such events are labeled by researchers as “potentially traumatic” to emphasize that not everyone experiences these aversive events as traumatic (Bonanno, 2004). For the sake of brevity, we will refer to these experiences as “trauma” and “loss” throughout this chapter. Importantly, individuals differ not only in their immediate responses to trauma and loss, but also in their longer-term responses and outcomes. Whereas some individuals develop significant symptoms of posttraumatic stress, depression, and related dysfunction, most individuals have relatively healthy reactions following such events and do not develop notable pathology (see Bonanno, 2004; also see Kessler, Chiu, Demler, Merikangas, & Walters, 2005). Many factors influence whether individuals who experience trauma or loss will experience positive or negative outcomes (Bonanno, 2004; Zoellner & Maercker, 2006). In this chapter, we argue that emotion regulation is one such factor, and describe a framework for understanding how one’s regulation of emotion in the immediate to long-term aftermath of trauma and loss can contribute to varying degrees of adaptation, and hence to positive or negative outcomes. First, we briefly review responses to trauma and loss. Second, we discuss emotion and emotion regulation. Third, we use basic affective science research to build a framework for understanding how emotion regulation contributes to varying degrees of adaptive emotional responding. Fourth, we apply this framework to trauma and loss. Finally, we consider wider implications for increasing recovery and resilience.

RESPONSES TO TRAUMA AND LOSS It is now clear that there are numerous psychological responses to trauma and loss. These responses can be distilled into four prototypical patterns (i.e., resilience, recovery, chronic, and delayed; Bonanno, 2004) that vary in terms of the intensity and duration of posttraumatic stress and/or depressive symptoms and related dysfunction. Posttraumatic stress symptoms are characterized by re-experiencing of the trauma (e.g., recurrent nightmares, flashbacks), hyperarousal (e.g., irritability or exaggerated startle response), avoidance of stimuli associated with the trauma, and emotional numbing, while depressive symptoms are characterized by dysphoria, diminished interest or pleasure in activities, feelings of

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free ebooks ==> www.ebook777.com Responding to Trauma and Loss 87

Disruptions in normal functioning Mild Moderate Severe

worthlessness or guilt, thoughts of death and suicidal ideation, and significantly increased or decreased appetite, weight, sleep problems, concentration, and psychomotor activity (American Psychiatric Association, 2000). Related dysfunction includes, but is not limited to, homelessness, financial loss, legal problems, occupational difficulties, problems in social relationships, physical health problems, and other psychiatric comorbidities (e.g., Cloitre, Miranda, Stovall-McClough, & Han, 2005; Dobie et al., 2004; Schnurr & Green, 2004; Schnurr, Lunney, Bovin, & Marx, 2009). As shown in Figure 7.1, “resilience” refers to an individual who experiences modest to no disruption in normal functioning and maintains relatively stable, healthy levels of psychological functioning following a traumatic event. The “recovery,” “chronic,” and “delayed” patterns are all characterized by the onset of sub-threshold to clinically significant posttraumatic stress and/or depressive symptoms and related dysfunction, and differ in terms of when the symptoms begin and how long they last. The “recovery” and “chronic” patterns can be characterized by immediate onset of pervasive symptoms and dysfunction of varying intensity. However, whereas the “recovery” pattern is characterized by a relatively rapid reduction in symptoms and return to normal functioning, the “chronic” pattern is characterized by symptoms and dysfunction of a long duration. The “delayed” pattern is characterized by a gradual increase in symptoms and dysfunction, which are likely to be chronic. Although distinguishing among these four patterns may give the impression of entirely distinct trajectories, we note that all individuals who experience symptoms following trauma and/or loss can develop clinically significant and chronic posttraumatic stress disorder (PTSD) and/or major depressive disorder (MDD). Likewise, all individuals who manifest symptoms have the potential to recover and experience positive outcomes. One such outcome is posttraumatic growth, which is conceptualized as the subjective experience of positive psychological change relative to an individual’s prior level of functioning as a result of experiencing a highly challenging life circumstance, and the learning that occurred through the struggle to cope with these events (see Linley & Joseph, 2004; Zoellner & Maercker, 2006). Posttraumatic growth can include positive changes such as growth and/or intimacy

Chronic Delayed

Recovery Resilience Event

1 year

2 years

Time Figure 7.1 Disruption in normal functioning across time following potentially traumatic events and interpersonal loss distilled into prototypical pathways. Adapted with permission from Bonanno (2004). Copyright 2005 by the American Psychological Association.


Boden, Kulkarni, Shurick, Bonn-Miller, and Gross

in relationships, greater sense of personal strength, recognition of new possibilities, and increased appreciation for life. In some cases, as people learn to manage the demands of trauma and loss, they may become more resilient to the impact of future traumas and losses (Linley & Joseph, 2004; Zoellner & Maercker, 2006). A pressing question in the study of responses to trauma and loss is what factors determine a person’s longer-term trajectory. Factors such as the type of event (e.g., combat exposure, sexual assault, death of a child), the age of exposure, and self-esteem have regularly been found to influence responses to trauma and loss (Bonanno, 2004; Friedman, Keane, & Resick, 2007; Linley & Joseph, 2004; Zoellner & Maercker, 2006). We propose that emotion regulation is one important additional factor that influences whether an individual is resilient to the effects of trauma and loss, recovers relatively quickly, or is chronically impaired by depression and/or posttraumatic stress symptoms and related dysfunction.

EMOTION AND EMOTION REGULATION Emotions are generally viewed as coordinated, biologically based responses to internal or external cues that are perceived as relevant to an organism’s needs, goals, or concerns (Scherer, Schorr, & Johnstone, 2001). To define emotions, many find it useful to consider three core features of a prototypical or commonly experienced emotion: (a) emotion antecedents, (b) emotion responses, and (c) the link between emotion antecedents and responses. Emotion antecedents are situations that are relevant to an individual’s present concerns, which may be expressed as goals, traits, attitudes, beliefs, and sensitivities to particular stimuli. Concerns predispose individuals to respond emotionally to particular situations as they are appraised in terms of a number of psychological dimensions (e.g., pleasantness, novelty; Scherer, 1999). Appraisals are the moment-by-moment evaluations of the personal significance of the situation (Scherer, 1999). Appraisals give rise to multifaceted, whole-body emotion responses, which involve loosely coupled changes in subjective experience, cognition (e.g., attention), behavior, and central and peripheral physiology (Mauss, Levenson, McCarter, Wilhelm, & Gross, 2005). These responses are mentally represented as subjective experience, or “feelings” (see Barrett, Ochsner, & Gross, 2007). They are often expressed as behavior via bodily responses involving motivation and motor systems (e.g., attacking a person who threatens you) that are supported by changes in central physiology (e.g., neuroendocrine changes) and peripheral physiology (e.g., increased blood flow to the limbs). These physiological changes immediately precede and follow the behavioral response and support the motor system responses associated with emotions. Emotion antecedents and responses are flexibly linked in a manner that allows for continual changes in emotional responses. In other words, emotional responses can be continually adapted to the specific requirements of a given situation as these requirements vary as a result of changes in (a) the situation itself or (b) the meaning of the situation in terms of the goals of the individual. It is in part because of the flexibility of links between emotion antecedents and responses that emotional responses are so often adaptive, and, when they are not, they may be regulated in various ways. Emotion regulation may involve initiating, increasing, or maintaining an emotion response (i.e., up-regulating) or stopping, decreasing, or avoiding an emotional response (i.e., down-regulating), depending on an individual’s goals and his or her ability to regulate

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free ebooks ==> www.ebook777.com Responding to Trauma and Loss 89 emotions in valued directions (Gross, 2007). Emotion regulation processes may target one domain of emotional responding (e.g., facial expression), while others (e.g., cardiovascular responding) may be left untouched. Additionally, emotion regulation processes may be more or less consciously initiated and controlled. In other words, emotion regulation processes vary in the extent to which they are purposely engaged to modulate emotions. We note that emotion regulation and coping are similar, but not redundant, constructs, and particular strategies (e.g., distraction) can be classified as both coping and emotion regulation strategies (Gross, 1998a). Therefore, much of the literature on stress and coping can be applied to understand emotion regulation, and vice versa. Many different strategies can be used to regulate emotions. One useful and empirically supported heuristic parses these strategies into five classes (Gross, 1998a). Each class consists of a set of related processes, all of which may be employed to influence emotions. Situation selection involves acting in ways that make it more or less likely that one will be in a situation in which one experiences particular emotions (e.g., avoiding driving after a traumatic motor vehicle accident to avoid trauma-related fear and panic). Should the situation be unavoidable, one may try to modify the situation by changing some aspect of it to lessen or increase the emotional response once in the situation (e.g., driving in a safer car). One may also attempt to direct one’s attention within a situation (i.e., attentional deployment) to regulate one’s emotions (e.g., listening to loud music or talking on the phone while in the car). Cognitive change refers to altering one’s appraisal (i.e., cognitive reappraisal) of the significance and meaning of an affective state, the eliciting situation, and/or the demands of the situation so as to change its emotional significance once the emotional response has begun (e.g., change the situational core meaning from “I am going to crash again” to “I will stay vigilant to prevent a car crash”). A fifth class of emotion regulation, response modulation, refers to directly influencing physiological, experiential, or behavioral responding after emotional responses have been initiated (e.g., suppressing the experience of fear as it occurs while driving).

EMOTION REGULATION AND ADAPTATION Emotion regulation that contributes to adaptive emotional responding serves as a core process that bolsters psychological health across a variety of life domains (e.g., social, vocational, residential; Gross, 2007), and prevents or decreases mental illness among vulnerable individuals. Alternatively, emotion regulation that contributes to maladaptive emotional responding decreases psychological health across a variety of life domains, and causes or maintains mental illness among vulnerable individuals (Werner & Gross, 2010). In this section, we describe an integrative framework in which emotion regulation is associated with greater or lesser adaptation depending on six proximal factors. As shown in Figure 7.2, these factors include (1) whether an emotion regulation strategy is used to modulate emotions, and (2) the type of strategy that is used, and whether the utilized strategy is a good match to (3) the emotion-eliciting situation and (4) the goals of the individual (i.e., context-sensitive), (5) well implemented (i.e., effective), and (6) flexibly applied over time and situation (i.e., flexible). Emotional responses are not always of a type, duration, and/or intensity to facilitate adaptive responses in a given situation. For example, a trauma-exposed individual may experience heightened perception of threats to trauma-related stimuli that are not actually dangerous in the current environment, which trigger rapid, exaggerated, and maladaptive


Boden, Kulkarni, Shurick, Bonn-Miller, and Gross Emotion regulation implemented Type of emotion regulation strategy

Context sensitive implementation -matches eliciting situation -matches individuals goals

Effectively implemented

Flexibly implemented

Figure 7.2 Factors influencing the adaptiveness of emotion regulation.

emotional responses (Pole, 2007). Therefore, emotional responses must sometimes be upor down-regulated to increase the likelihood of a context-appropriate emotional response (e.g., down-regulation of frustration when receiving a ticket for speeding from a police officer). The adaptive quality of emotion regulation will be influenced by the type of strategy that is employed. Some strategies may be effective in helping an individual to regulate emotions in a majority of contexts (e.g., acceptance), whereas others will be more limited. For example, regulating emotions by drinking alcohol may reduce short-term anxiety, but may hinder the achievement of long-term instrumental goals (e.g., sustained employment) when used repeatedly and excessively. A core underlying premise of our framework is that any emotion regulation strategy may be adaptive when effectively implemented in a context-sensitive and flexible manner. Thus, our framework is not consistent with the common view that particular emotion regulation strategies are adaptive or maladaptive independent of context. For example, although avoidant emotion regulation may be associated with maladaptive outcomes in some contexts, it is may also be quite beneficial in others (see next section for more detail). Because the benefits of a specific type of emotion regulation strategy will vary by context-dependent factors, the adaptiveness of a particular type of emotion regulation strategy is closely related to the extent to which the strategy is used in a context-sensitive manner. To be adaptive, emotion regulation must be sensitive to context in terms of situational demands. A nuanced approach will often be needed to adaptively respond to the situationspecific demands. For example, adaptive behavioral responses associated with the experience of frustration in response to criticism by a boss (e.g., thanking the boss for the excellent feedback) will likely vary from those in response to criticism by a romantic partner (e.g., asking for a more detailed explanation and time for discussion). The use of an emotion regulation strategy may be needed to help tailor the emotional response to situation-specific demands. However, not all emotion regulation strategies will be equally beneficial in this regard for all individuals in all situations. Following the previous example, suppression of emotional expression may be beneficial in terms of frustration associated with the boss’s criticism, whereas cognitive reappraisal (e.g., he/she loves me although he/she has these criticisms) may be beneficial in response to the frustration associated with the romantic partner’s criticism. Therefore, to adaptively tailor the emotional response to meet situationspecific demands, emotion regulation strategy choice must be context-sensitive. Additionally, whether a particular emotion regulation strategy is beneficial crucially depends on the goals of the individual engaging in emotion regulation (Werner & Gross,

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free ebooks ==> www.ebook777.com Responding to Trauma and Loss 91 2010). Theorists and researchers have traditionally considered the primary function of emotion regulation to be hedonic (i.e., emotions are regulated to increase/maintain positive affect and decrease/avoid negative affect). However, recent empirical research has shown that both positive and negative emotions can facilitate achievement of instrumental goals, and that people are willing to forgo immediate hedonic gains to pursue longer-term instrumental goals (e.g., gain and/or maintain relationships, employment, housing, physical/mental health; Tamir, 2009). Therefore, people regulate their emotions for both immediate hedonic and longer-term instrumental goals, and both hedonic and instrumental goal achievement can be facilitated through emotion regulation (Tamir, 2009). Situational demands will serve as constraints on whether and which hedonic and/or instrumental goals can be pursued in any given situation. For example, to adaptively respond to one’s critical boss for the purpose of maintaining employment, one might use an emotion regulation strategy that helps to reduce anger in a manner that allows for continued pleasant interactions (e.g., suppression) rather than one that merely reduces anger (e.g., avoidance). For a given individual, hedonic goals will be most salient in some situations, and instrumental goals will be most salient in others. In these instances, adaptive emotional responses will be associated with the choice of emotion regulation strategies that are likely to facilitate achievement of hedonic or instrumental goals, respectively. However, in many situations, it is likely that both hedonic and instrumental goals will be salient to some extent. Here, adaptive emotional responses will be associated with the choice of emotion regulation strategies that have the greatest likelihood of modulating emotions in order to meet instrumental goals while maintaining immediate hedonic equilibrium (Werner & Gross, 2010). For example, one may want to down-regulate anxiety while being interviewed for a job to reduce unpleasant sensations (i.e., hedonic goal) while also increasing the likelihood of being perceived as calm and thus obtaining the job (i.e., instrumental goal). Again, not all emotion regulation strategies will be equally beneficial in this regard for all individuals in all situations. Emotion regulation strategy choice must therefore be contextsensitive to tailor the emotional response to match the goals of the individual. Another factor that influences the extent to which emotion regulation contributes to adaptation is whether the implementation of a particular emotion regulation strategy is actually effective at tailoring the emotional response to situational demands and the goals of the individual, or, in other words, whether the emotion regulation strategy is effective at increasing, decreasing, avoiding, or maintaining an emotional response to match situation-specific demands and related hedonic and/or instrumental goals. Following our example of receiving criticism from a boss, suppression of emotional expression may be beneficial at reducing frustration for the purpose of keeping one’s job (i.e., instrumental goal), although it may not reduce unpleasant sensations (i.e., hedonic goal; Gross, 1998a). This may ultimately prove to be an example of adaptive emotion regulation use because situational demands have increased the salience of instrumental goals. The use of a particular emotion regulation strategy will contribute to less adaptive responses when it is not effective: (a) at tailoring the emotional response to match situational demands (e.g., one uses the strategy of emotional discharge, or yelling at one’s boss), (b) at helping the individual achieve either hedonic or instrumental goals (e.g., yelling at one’s boss makes one angrier while costing one the job), or (c) the costs to instrumental goals outweigh any benefit of hedonic goal achievement (e.g., one continually uses alcohol to effectively reduce anger and sadness, which hinders one’s ability to find a new job). To contribute to adaptive emotion responding, the choice of emotion regulation must be flexibly applied over time and across situations. Following the argument above, a given strategy that is effectively implemented in one situation may not be as effective in a similar



situation as a result of changes in situation-specific demands and in hedonic/instrumental goals. Even strategies that are effective in a particular situation may become less so as the situation and its demands evolve. Therefore, emotion regulation strategies must be implemented in a flexible manner that allows for continual updating to match evolving situational demands and hedonic/instrumental goals.

EMOTION REGULATION AND RESPONSE TO TRAUMA OR LOSS In this section, we apply our framework to describe how emotion regulation that is contextsensitive, effective, and flexible will facilitate positive outcomes (resilience, recovery, posttraumatic growth) following trauma and loss, whereas emotion regulation that is contextinsensitive, ineffective, and inflexible will hinder positive outcomes, and promote negative outcomes (posttraumatic stress/depressive symptoms and related dysfunction). For some individuals, the experience of trauma/loss will not contribute to changes in emotional responding. We posit that this is in part due to emotion regulation being optimally balanced to effectively and flexibly modulate emotions to manage long-standing emotional responding and instrumental goals. Therefore, changes to emotion regulation (e.g., increased use, flexibility) will not be needed to return to pre-trauma/loss functioning, which may have been more or less adaptive. However, increases in emotional disturbances (e.g., heightened perceptions of threat and emotional reactivity; Pole, 2007), which are a core feature of PTSD/MDD symptomatology, will occur in many individuals. These increases may be quite modest (i.e., resilience pathway; see Figure 7.1) to quite large, and may range from immediate to delayed onset and shorter to longer duration. Thus, these trauma/lossexposed individuals will need to increase their use of emotion regulation strategies to modulate emotions to return to pre-trauma/loss functioning. Furthermore, those who are able to choose emotion regulation strategies that are sensitive to situational demands and emotion regulation goals and effectively implement them will be more likely to experience recovery (i.e., recovery pathway). Individuals with chronic and high levels of posttraumatic stress/ depressive symptoms and related dysfunction (i.e., delayed and chronic pathways), will need to more effectively implement emotion regulation strategies in a context-sensitive and flexible manner to experience recovery. As the level of posttraumatic stress/depressive symptoms and related emotional disturbances increases following the experience of trauma/loss, so will the need to implement emotion regulation strategies, in an effective, flexible, and context-sensitive manner. This will facilitate a return to normal functioning. The greater the extent to which the emotional disturbance is pervasive and disruptive, and occurs in response to an over-inclusive range of stimuli, the greater an adaptive balance will be tilted in favor of hedonic goals. In these contexts, individuals may benefit from using emotion regulation strategies that effectively reduce or manage heightened emotional reactivity in a broad range of contexts. A large body of research documenting the substantial use of avoidance-oriented regulation strategies among trauma/loss-exposed populations (e.g., Hayes, Wilson, Gilford, Follette, & Strosahl, 1996) suggests that avoidance-oriented strategies may be useful in this regard. This hypothesis is further supported by basic research demonstrating that avoidance-oriented emotion regulation strategies are frequently chosen to regulate intense emotions (Sheppes, Scheibe, Suri, & Gross, 2011), and these strategies are particularly effective in doing so (Dan-Glauser & Gross, 2011; Sheppes & Gross, 2011). Thus, these strategies may be effective and contextually appropriate when hedonic relief is of paramount importance.

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free ebooks ==> www.ebook777.com Responding to Trauma and Loss 93 As emotional disturbances subside as a result of various factors (e.g., effective downregulation of anxiety, time since the trauma/loss), individuals who are able to flexibly implement emotion regulation strategies in a manner that effectively facilitates instrumental goals will likely experience greater adaptive emotional responding. The most important instrumental goal will be to process and integrate the experience of trauma/loss (e.g., learning that trauma-related cues are not a substantial threat in the current context). Here, emotion regulation strategies must be effective at reducing or managing emotional reactivity so that processing of the trauma/loss can occur with minimized disruption. Additional instrumental goals may range from those that were salient before the trauma/loss to newly posited instrumental goals that are salient because of the trauma/loss (e.g., physical healing). Therefore, emotion regulation strategies must be effective at helping an individual manage emotions associated with the pursuit of these instrumental goals (e.g., frustration) that facilitate a return to pre-trauma levels of functioning. As trauma/loss-exposed individuals may experience periodic increases of heightened emotional disturbances, they must also be able to flexibly switch between emotion regulation strategies that are optimized to achieve hedonic or instrumental goals. In this manner, recovery following trauma and loss will in part be achieved by using emotion regulation strategies that match situational demands while flexibly and effectively facilitating achievement of immediate hedonic goals and the pursuit of longer-term instrumental goals. Numerous studies have found that avoidant regulation strategies, in addition to cognitive reappraisal and acceptance, are associated with positive outcomes (resilience, reduced PTSD severity, increased posttraumatic growth) following trauma and loss (e.g., Bernstein, Tanay, & Vujanovic, 2011; Bonanno, Keltner, Holen, & Horowitz, 1995; Bonanno, Noll, Putnam, O’Neill, & Trickett, 2003; Eftekhari, Zoellner, & Vigil, 2009; Ehring & Quack, 2010; Park, Aldwin, Fenster, & Snyder, 2008; Thompson & Waltz, 2010; Vujanovic, Youngwirth, Johnson, & Zvolensky, 2009; also see Linley & Joseph, 2004; Zoellner & Maercker, 2006). Consistently with previous theorists (e.g., Bonanno et al., 2003), we posit that these strategies were flexibly matched to situational demands, and effectively reduced hedonic distress to allow for systematic and relaxed processing of the trauma and/or pursuit of instrumental goals when heightened emotional reactivity was acute and disruptive following the trauma/loss. Trauma/loss-exposed individuals who are unable or unwilling to use emotion regulation strategies in a context-sensitive, effective, and/or flexible manner will be more likely to experience paradoxical increases in emotional disturbances, as well as chronic posttraumatic stress/depressive symptoms and related dysfunction. These individuals may often use strategies that are ineffective at achieving emotion regulation goals, such as rumination (Clohessy & Ehlers, 1999; Ehlers, Mayou & Bryant, 1998). However, we posit that the inflexible and context-insensitive use of emotion regulation strategies is more problematic. Specifically, an adaptive balance between hedonic and instrumental goals is not maintained; the individual continually uses emotion regulation strategies to achieve hedonic relief (e.g., reduced sadness, despair, anxiety) at the expense of instrumental goals, the most important of which is the processing and integration of the trauma/loss. Owing to the extensive resources used to achieve hedonic goals, few resources are left to expend on secondary instrumental goals, which are needed to facilitate a return to pre-trauma levels of functioning. Although avoidance-oriented regulation strategies have been associated with positive outcomes following trauma/loss, cross-sectional, prospective, and experimental studies have further documented associations between these strategies and heightened levels of PTSD



symptom severity (e.g., Amir et al., 1997; Hepp, Moergeli, Buchi, Wittmann, & Schnyder, 2005; Jacobsen et al., 2002; Schnider, Elhai, & Gray, 2007). Additionally, avoidant coping has been found to amplify the positive, prospective relation between emotion reactivity (i.e., heart rate) to trauma-related cues and PTSD symptom severity among trauma-exposed individuals in the immediate aftermath of trauma (Pineles et al., 2011). Based on our framework, we posit that avoidance-oriented strategies may be beneficial when flexibly implemented in specific contexts (e.g., when experiencing high emotional reactivity). Avoidanceoriented strategies may not be useful when rigidly applied in a context-insensitive manner, as they may actually inhibit the processing of the trauma. Here, trauma/loss-related cues, which contribute to emotional disturbances, are avoided, and an individual remains sensitive to their impact. Furthermore, avoidance limits the ability of the individual to achieve other types of instrumental goals that would facilitate recovery, especially those that are salient because of the trauma/loss. This is because the pursuit of such goals would entail engagement with trauma/loss-related stimuli and, hence, increase emotional disturbances. Furthermore, avoidance-oriented strategies may directly maintain or increase symptoms through paradoxical processes. Here, a large body of research has demonstrated paradoxical increases in thoughts and emotions when an individual attempts to avoid or suppress them (e.g., Gross, 1998b; Wenzlaff & Wegner, 2000). If an individual does not have the ability to flexibly and effectively implement other types of emotion regulation strategies, he/she may continue to experience PTSD/MDD symptoms and dysfunction, potentially of a greater intensity or duration. Increased posttraumatic growth and resilience are likely to result from emotion regulation that regularly contributes to adaptive emotional responding following trauma and loss. This will occur via: (a) increases in confidence in the ability to manage the emotional demands of the current trauma/loss and future traumas and losses; and (b) strengthened belief in the ability to influence and learn from both pleasant and unpleasant emotions, and their causes and consequences (Benight & Bandura, 2004; Bonanno, 2004; Connor, 2006). These factors, along with increased actual ability to cope with and regulate emotions associated with trauma and loss, will promote posttraumatic growth and resilience to future traumas and losses.

IMPLICATIONS FOR INCREASING RECOVERY AND RESILIENCE Our framework suggests that improving adaptive emotional responding following trauma by targeting emotion regulation may enhance positive outcomes following trauma and loss. Emotion regulation may be effectively targeted in this manner through psychosocial interventions designed for this purpose. For example, a variety of existing treatments for PTSD actively target emotion regulation (e.g., cognitive processing therapy [CPT]; Resick & Schnicke, 1992; skills training in affective and interpersonal regulation [STAIR]; Cloitre, Koenen, Cohen, & Han, 2002). For example, cognitive-behavioral therapies attempt to reduce the use of avoidance-oriented regulation strategies through exposing participants to feared stimuli until habituation occurs, and increase the use of emotion regulation strategies such as cognitive restructuring (i.e., cognitive reappraisal; Hamblen, Schnurr, Rosenberg, & Eftekhari, 2009). While these therapies are effective in reducing PTSD symptoms and increasing recovery (Hembree & Foa, 2010), further benefits might be accrued by modifying therapies or developing new therapies to target emotion regulation in accordance with the premises of our framework.

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free ebooks ==> www.ebook777.com Responding to Trauma and Loss 95 Specifically, teaching patients when to use emotion regulation or to use one strategy (e.g., cognitive reappraisal) versus another (e.g., rumination) is not enough. Even typically adaptive emotion regulation strategies that are taught as part of “gold-standard” treatments for PTSD may not always be associated with reduced symptomatology (Boden, Bonn-Miller, Kashdan, Alvarez, & Gross, 2012). Here, it might be useful to teach patients how to choose emotion regulation strategies in a context-sensitive manner, and effectively and flexibly implement them. This would require patients to attend to and understand their emotional experiences (i.e., high emotional awareness), including salient hedonic and instrumental goals for which emotions are regulated. Patients would also need to increase their ability to choose emotion regulation strategies that are effective at facilitating achievement of these goals while maintaining a balance between them. For example, patients with PTSD often utilize strategies, such as avoidance and alcohol and drug use, to achieve immediate hedonic relief. Although such strategies may provide temporary hedonic relief, they do so at the expense of achievement of instrumental goals. Therefore, patients might be taught to identify salient instrumental goals and how such strategies hinder instrumental goal achievement. This might increase their willingness and ability to engage in empirically validated, but often distressing, procedures that directly reduce perceptions of threat and heightened emotional reactivity (e.g., systematic exposure to feared stimuli; Foa, Hembree, & Rothbaum, 2007). Additionally, they might be taught strategies that facilitate both hedonic and instrumental goal achievement (e.g., mindfulness-based strategies; Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011). Alternatively, one might target distal processes that directly influence the six factors that contribute to adaptive emotion regulation, and thus contribute to global improvements in emotion regulation. One such process is emotional awareness, which can be conceptualized as the extent to which people attend to and understand their emotions (Coffey, Berenbaum, & Kerns, 2003). Emotional awareness is crucial, because the optimal use of emotion regulation is dependent on accurate tracking of ongoing emotions (Barrett & Gross, 2001). A high level of emotional awareness provides information that has the potential to facilitate a person’s understanding of (1) when it would be beneficial to regulate emotions, (2) the type(s) of emotional regulation strategy that will be most (3) effective in matching nuanced (4) situational demands and (5) emotion regulation goals, and (6) when and how to flexibly modify emotion regulation, in the moment or otherwise, to increase its effectiveness (Barrett, & Gross, 2001). Thus, emotional awareness influences the proximal factors that determine the extent to which emotion regulation is adaptive, and through this amplifies the consequences of emotion regulation on responses to trauma and loss. These hypotheses are supported by theory and research demonstrating low levels of emotional awareness among individuals with PTSD and MDD (see Frewen, Dozios, Neufeld, & Lanius, 2008a; Luminet, Bagby, & Taylor, 2001), and inverse associations between emotional awareness posttraumatic stress and depressive symptom severity (e.g., Frewen, Dozios, Neufeld, & Lanius, 2008b; Honkalampi, Hintikka, Tanskanen, Lehtonen, & Viinamaki, 2000). Furthermore, a recent study conducted with trauma-exposed military veterans found that emotional clarity interacted with frequency of use of cognitive reappraisal to predict PTSD symptom severity and dispositional positive affect (Boden et al., 2012). Findings indicated that the combination of high levels of emotional clarity and frequent use of cognitive reappraisal were associated with (a) lower PTSD symptom severity, after accounting for positive affect and the extent to which emotions are attended to, and (b) greater positive affect, after accounting for PTSD symptom severity and attention to emotions. Lastly, we posit that treatments that teach patients how to use emotion regulation strategies in a context-sensitive, effective, and flexible manner may be modified to prevent



posttraumatic and depressive symptomatology and promote resilience in populations at high risk for future trauma (e.g., active duty military, police officers). Compared to the potentially significant costs of negative outcomes following trauma exposure, the resources required to implement such treatments as part of routine training would likely be minimal. Furthermore, such prevention strategies may increase mental health in these populations, more broadly (Werner & Gross, 2010).

CONCLUDING COMMENT Emotion regulation is increasingly recognized as a core process that influences mental health and illness in a variety of populations (Gross, 2007; Kring & Sloan, 2009). In this chapter, we have described a framework for understanding the key role of emotion regulation in influencing whether individuals experience negative or positive outcomes following trauma and loss. This framework has broad applicability as, unfortunately, a majority of people will experience trauma and loss during their lifetimes (e.g., Breslau et al., 1998). Clearly more work is needed to understand trauma and loss, and to prevent and mitigate negative outcomes and promote positive outcomes, as trauma and loss will always be an unpleasant aspect of human existence. We believe that the most important benefits of this framework will be realized in its application to guide prevention and treatment strategy development and implementation in a wide variety of contexts. As emotion regulation is increasingly recognized as a key intervention target (Kring & Sloan, 2009), we are optimistic that such work will impart broad and substantial benefits.

REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Amir, M., Kaplan, Z., Efroni, R., Levine, Y., Benjamin, J., & Kotler, M. (1997). Coping styles in posttraumatic stress disorder (PTSD) patients. Personality and Individual Differences, 23, 399–405. Barrett, L. F., & Gross, J. J. (2001). Emotion representation and regulation: A process model of emotional intelligence. In T. Mayne & G. Bonanno (Eds.), Emotion: Current issues and future directions (pp. 286–310). New York: Guilford Press. Barrett, L. F., Ochsner, K. N., & Gross, J. J. (2007). On the automaticity of emotion. In J. Bargh (Ed.), Social psychology and the unconscious: The automaticity of higher mental processes. New York: Psychology Press. Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behaviour Research and Therapy, 42, 1129–1148. Bernstein, A., Tanay, G., & Vujanovic, A. A. (2011). Concurrent relations between mindful attention and awareness and psychopathology among trauma-exposed adults: Preliminary evidence of transdiagnostic resilience. Journal of Cognitive Psychotherapy, 25, 99–113. Boden, M. T., Bonn-Miller, M. O., Kashdan, T. B., Alvarez, J., & Gross, J. J. (2012). The interactive effects of emotional clarity and cognitive reappraisal in posttraumatic stress disorder. Journal of Anxiety Disorders, 26, 233–238. Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–22. Bonanno, G. A., Keltner, D., Holen, A., & Horowitz, M. J. (1995). When avoiding unpleasant emotions might not be such a bad thing: Verbal–autonomic response dissociation and midlife conjugal bereavement. Journal of Personality and Social Psychology, 69, 975–989.

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free ebooks ==> www.ebook777.com Responding to Trauma and Loss 97 Bonanno, G. A., Noll, J. G., Putnam, F. W., O’Neill, M., & Trickett, P. (2003). Predicting the willingness to disclose childhood sexual abuse from measures of repressive coping and dissociative experiences. Child Maltreatment, 8, 1–17. Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. C., & Andreski, P. (1998). Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry, 55, 626–631. Clohessy, S., & Ehlers, A. (1999). PTSD symptoms, response to intrusive memories, and coping in ambulance service workers. British Journal of Clinical Psychology, 38, 251–265. Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 1067–1074. Cloitre, M., Miranda, R., Stovall-McClough, K. C., & Han, H. (2005). Beyond PTSD: Emotion regulation and interpersonal problems as predictors of functional impairment in survivors of childhood abuse. Behavior Therapy, 36, 119–124. Coffey, E., Berenbaum, H., & Kerns, J. G. (2003). The dimensions of emotional intelligence, alexithymia, and mood awareness: Associations with personality and performance on an emotional Stroop task. Cognition and Emotion, 17, 671–679. Connor, K. M. (2006). Assessment of resilience in the aftermath of trauma. Journal of Clinical Psychiatry, 67, 46–49. Dan-Glauser, E. S., & Gross, J. J. (2011). The temporal dynamics of two response-focused forms of emotion regulation: Experiential, expressive, and autonomic consequences. Psychophysiology, 48, 1309–1322. Dobie, D. J., Kivlahan, D. R., Maynard, C., Bush, K. R., Davis, T. M., & Bradley, K. A. (2004). Posttraumatic stress disorder in female veterans: Association with self-reported health problems and functional impairment. Archives of Internal Medicine, 164, 394–400. Eftekhari, A., Zoellner, L. A., & Vigil, S. A. (2009). Patterns of emotion regulation and psychopathology. Anxiety, Stress, and Coping, 22, 571–586. Ehlers, A., Mayou, R. A., & Bryant, B. (1998). Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. Journal of Abnormal Psychology, 107, 508–519. Ehring, T., & Quack, D. (2010). Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behavior Therapy, 41, 587–598. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Therapist guide. New York: Oxford University Press. Frewen, P. A., Dozios, D. J. A., Neufeld, R. W. J., & Lanius, R. A. (2008a). Meta-analysis of alexithymia in posttraumatic stress disorder. Journal of Traumatic Stres s, 21, 243–246. Frewen, P. A., Dozios, D. J. A., Neufeld, R. W. J., & Lanius, R. A. (2008b). Neural correlates of levels of emotional awareness during trauma script-imagery in posttraumatic stress disorder. Psychosomatic Medicine, 70, 27–31. Friedman, M. J., Keane, T. M., & Resick, P. A. (Eds.). (2007). Handbook of PTSD: Science and practice. New York: Guilford Press. Gross, J. J. (1998a). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2, 271–299. Gross, J. J. (1998b). Antecedent- and response-focused emotion regulation: Divergent consequences for experience, expression, and physiology. Journal of Personality and Social Psychology, 74, 224–237. Gross, J. J. (Ed.). (2007). Handbook of emotion regulation. New York: Guilford Press. Hamblen, J. L., Schnurr, P. P., Rosenberg, A., & Eftekhari, A. (2009). A guide to the literature on psychotherapy for PTSD. Psychiatric Annals, 39, 348–354. Hayes, S. C., Wilson, K. G., Gilford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders. Journal of Consulting and Clinical Psychology, 64, 1152–1168. Hembree, E. A., & Foa, E. B. (2010). Cognitive behavioral treatments for PTSD. In G. M. Rosen & B. C. Frueh (Eds.), Clinician’s guide to posttraumatic stress disorder. Hoboken, NJ: Wiley.



Hepp, U., Moergeli, H., Buchi, S., Wittmann, L., & Schnyder, U. (2005). Coping with serious accidental injury: A one-year follow-up study. Psychotherapy and Psychosomatics, 74, 379–386. Honkalampi, K., Hintikka, J., Tanskanen, A., Lehtonen, J., & Viinamaki, H. (2000). Depression is strongly associated with alexithymia in the general population. Journal of Psychosomatic Research, 48, 99–104. Jacobsen, P. B., Sadler, I. J., Booth-Jones, M., Soety, E., Weitzner, M. A., & Fields, K. K. (2002). Predictors of posttraumatic stress disorder symptomatology following bone marrow transplantation for cancer. Journal of Consulting and Clinical Psychology, 70, 235–240. Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617–627. Kring, A., & Sloan, D. M. (2009). Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment. New York: Guilford Press. Linley, P. A., & Joseph, S. (2004). Positive change following trauma and adversity: A review. Journal of Traumatic Stress, 17, 11–21. Luminet, O., Bagby, M. R., & Taylor, G. J. (2001). An evaluation of the absolute and relative stability of alexithymia in patients with major depression. Psychotherapy and Psychosomatics, 70, 254–260. Mauss, I. B., Levenson, R. W., McCarter, L., Wilhelm, F. H., & Gross, J. J. (2005). The tie that binds? Coherence among emotion experience, behavior, and autonomic physiology. Emotion, 5, 175–190. Park, C. L., Aldwin, C. M., Fenster, J. R., & Snyder, L. (2008). Coping with September 11th: Posttraumatic stress and post-traumatic growth in a national sample. American Journal of Orthopsychiatry, 78, 300–312. Pineles, S. L., Mostoufi, S. M., Ready, C. B., Street, A. E., Griffin, M. G., & Resick, P. A. (2011). Trauma reactivity, avoidant coping, and PTSD symptoms: A moderating relationship? Journal for Abnormal Psychology, 120, 240–246. Pole, N. (2007). The psychophysiology of posttraumatic stress disorder: A meta-analysis. Psychological Bulletin, 133, 725–746. Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault survivors. Journal of Consulting and Clinical Psychology, 60, 748–756. Scherer, K. R. (1999). Appraisal theories. In T. Dalgleish & M. Power (Eds.), Handbook of cognition and emotion (pp. 637–663). Chichester, UK: Wiley. Scherer, K. R., Schorr, A., & Johnstone, T. (Eds.). (2001). Appraisal processes in emotion: Theory, methods, research. London: London University Press. Schnider, K. R., Elhai, J. D., & Gray, M. J. (2007). Coping style use predicts posttraumatic stress and complicated grief symptom severity among college students reporting a traumatic loss. Journal of Counseling Psychology, 54, 344–350. Schnurr, P. P., & Green, B. L. (2004). Trauma and health: Physical health consequences of exposure to extreme stress. Washington, DC: American Psychological Association. Schnurr, P. P., Lunney, C. A., Bovin, M. J., & Marx, B. P. (2009). Posttraumatic stress disorder and quality of life: Extension of findings to veterans of the wars in Iraq and Afghanistan. Clinical Psychology Review, 29, 727–735. Sheppes, G., & Gross, J. J. (2011). Is timing everything? Temporal considerations in emotion regulation. Personality and Social Psychology Review, 15, 319–331. Sheppes, G., Scheibe, S., Suri, G., & Gross, J. J. (2011). Emotion regulation choice. Psychological Science, 22, 1391–1396. Tamir, M. (2009). What do people want to feel and why? Pleasure and utility in emotion regulation. Current Directions in Psychological Science, 18, 101–105. Thompson, B. L., & Waltz, J. (2010). Mindfulness and experiential avoidance as predictors of posttraumatic stress disorder avoidance symptom severity. Journal of Anxiety Disorders, 24, 409–415. Vujanovic, A. A., Niles, B., Pietrefesa, A., Schmertz, S. K., & Potter, C. M. (2011). Mindfulness in the treatment of posttraumatic stress disorder among military veterans. Professional Psychology: Research and Practice, 42, 24–31.

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free ebooks ==> www.ebook777.com Responding to Trauma and Loss 99 Vujanovic, A. A., Youngwirth, N. E., Johnson, K. A., & Zvolensky, M. J. (2009). Mindfulness-based acceptance and posttraumatic stress symptoms among trauma-exposed adults without Axis I psychopathology. Journal of Anxiety Disorders, 23, 297–303. Wenzlaff, R. M., & Wegner, D. M. (2000). Thought suppression. Annual Review of Psychology, 51, 59–91. Werner, K., & Gross, J. J. (2010). Emotion regulation and psychopathology: A conceptual framework. In A. Kring & D. Sloan (Eds.), Emotion regulation and psychopathology (pp. 13–37). New York: Guilford Press. Zoellner, T., & Maercker, A. (2006). Posttraumatic growth in clinical psychology: A critical review and introduction of a two component model. Clinical Psychology Review, 26, 626–653.


Music as an Agent of Resilience Donald A. Hodges

Demonstrating the role of music as an agent of resilience would be much easier if a CD accompanied this book. Since it does not, imagine, if you will, internal soundtracks to the following vignettes: • It is the early 1960s and hundreds of freedom fighters have joined Martin Luther King for a march on City Hall. Many have been bitten by guard dogs, battered by fire-hoses, clubbed by nightsticks, or thrown in jail. All of them have been disenfranchised simply by the color of their skin. As they link arms and begin to march, they lift their voices in that anthem of hope “We Shall Overcome.” • Earl is a 15-year-old high school sophomore, light of frame, and embarrassed by a stammer. Several older classmates have bullied and harassed him. At home in his basement, he takes out his frustrations and expresses his anger by playing his electric guitar along with songs like “Liar” by Megadeth blaring out of loudspeakers. • Family and friends have gathered at the funeral of a departed loved one. Expressions of grief and loss occur in the reading of scripture, the heartfelt eulogy, and hugs and handshakes; in addition, mourners share a personal and corporate affirmation of hopeful living in the congregational singing of the hymn “It Is Well With My Soul.”1 • Emily is an eight-year-old cancer patient. She has spent the bulk of her life in the hospital or in doctors’ offices fighting a losing battle. Her music therapist, Angie, meets with her regularly and together they listen to music, sing songs, and play instruments. Emily has even composed her own song to express her spirit of optimism and determination, in spite of all she is undergoing. With these sounds in your mind’s ears, consider that resilience “is best defined as an outcome of successful adaptation to adversity” (Zautra, Hall, & Murray, 2010, p. 4). As such, it encompasses rebounding (R) from an original stressful event, sustaining (S) that resilient response over time, and growing (G) into a new level of adaptation (Reich, Zautra, & Hall, 2011). Following the RSG model, resilience is seen not only as a response to a negative event, but also in the context of healthy, positive living. The purpose of this chapter is to explore the role of music in these processes.

ANECDOTAL EXAMPLES These opening stories represent only a few ways music can foster an attitude of resiliency. One means of conceptualizing the role of music is to explore how the actions of composing,

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free ebooks ==> www.ebook777.com Music as an Agent of Resilience 101 performing, and listening can contribute to resiliency. Following these largely anecdotal examples, we will turn to the research literature. Composing In Western classical music, there are numerous examples of the role musical composition may have played in enabling the composer to survive. Consider only two: Beethoven and Messiaen. In the summer of 1802, Ludwig van Beethoven was so overcome by his impending deafness that he wrote the famous Heiligenstadt Testament. In it he described a series of humiliating experiences over the previous six years based on his inability to hear, and then wrote that Such incidents drove me almost to despair; a little more of that and I would have ended my life—it was only my art that held me back. Ah, it seemed to me impossible to leave the world until I had brought forth all that I felt was within me. (Solomon, 1985, p. 117) French composer Olivier Messiaen was captured during World War II and placed in a prison camp, where he wrote the Quartet for the End of Time based on texts from the Book of Revelation (Rischin, 2003). In spite of his degraded circumstances, the work stands proof of the resiliency of the human spirit. In the more contemporary popular music realm, numerous artists wrote songs in response to the terrorists’ attacks on September 11, 2001. These included songs such as Alan Jackson’s “Where Were You (When the World Stopped Turning),” Toby Keith’s “Courtesy of the Red, White and Blue (The Angry American),” Mark McGuinn’s “More Beautiful Today,” Paul McCartney’s “Freedom,” and Neil Young’s “Let’s Roll,” and Bruce Springsteen’s album The Rising, among many others (Ritter & Daughtry, 2007). It is apparent that many are able to vent their frustrations through composing, such as one 13-year-old girl who stated, “When I am angry or everything seems like it is spinning out of control, I write a song. It calms me down and gets my feelings out” (Campbell, Connell, & Beegle, 2007, p. 228). Clearly, composing music is one way for people to find an outlet for overcoming struggles. Performing At 107 (in November 2010), Alice Herz-Sommer is the oldest Holocaust survivor. An avid pianist, still practicing three hours a day, she claims that “music has saved me from death in a concentration camp and my son was a famous cellist. When he died suddenly nine years ago, it was again music which helped me to come to terms with my grief” (Roe, 2010). Known as the Cellist of Sarajevo, Vedran Smajlovic´ played his cello every day in a rubble pile under the watchful eyes of snipers for 22 consecutive days to commemorate the 22 people killed by a bomb while waiting in line for bread during the Siege of Sarajevo (Sharrock, 2008). His selfless commitment to peace and human dignity inspired people all over the world. The powerful role that performing music can play in survival is exemplified in the life of Nathaniel Ayers. Ayers was an accomplished cellist studying at Juilliard when schizophrenia intervened and he ended up dropping out of school and living on the streets. The final phrase of the title of a book written about Ayers aptly captures the importance of performing in his life: The Soloist: A Lost Dream, an Unlikely Friendship, and the Redemptive Power of Music (Lopez, 2008). Though playing the cello certainly did not cure his schizophrenia, it


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was a vehicle for getting him off the streets and into a more stable lifestyle. Making music is perhaps the best way for Ayers to express himself and gives him a reason to live. Listening When Princess Diana died tragically, attendees at the funeral and millions of people around the world were comforted by Elton John’s song “Candle in the Wind” (Brown, Basil, & Bocarnea, 2003). Two thousand people attended the funeral (Kantrowitz, Pedersen, & McGuire, 1997), an estimated 2.5 billion watched on television (Blowen, 1997), and the recording of this song was the biggest and fastest selling single in U.S. and British history, selling 3.5 million copies in only one week (MTV News Online, 1997). Listening and performing music are linked via audio-motor systems in the brain (Zatorre, Chen, & Penhune, 2007). While this has most often been studied in performing musicians, music therapists can take advantage of this system to foster healing and recovery from injury. On January 8, 2011, Gabrielle Giffords, a member of the U.S. House of Representatives from Arizona, was severely injured by a gunshot to the head. During her extended recovery period, she learned to talk again by participating in music therapy sessions (Weintraub, 2011). The music therapist would sing songs that Giffords was familiar with and initially she would fill in just one word. For example, the therapist would sing, “Happy Birthday to...,” and Giffords would respond with “you” (Sohn, 2011). Through persistent hard work, Congresswoman Giffords was able to regain her speech by listening to and singing familiar songs.

RESEARCH EVIDENCE As convincing as these vignettes and anecdotal examples may be in substantiating the role of music as an agent of resilience, a wealth of research literature provides a more secure footing for this notion. Following the RSG model, research supports the role of music in enabling people to overcome a traumatic occurrence in their lives, it documents how people are able to use music to maintain a resilient response over time, and it underscores the role of music in enabling people to adapt to a new normal as they continue to lead happy and productive lives. The subsequent literature reviews are organized according to discipline—anthropology, sociology, biology, psychology, and the related disciplines of music therapy, music medicine, and music education. From Anthropology Anthropologists and ethnomusicologists, specially trained musicians who study world music, have documented many of the musical behaviors practiced around the globe. The first, and perhaps main, point is that there is abundant evidence to support the contention that all human societies, always and everywhere, engage in musical behaviors of some sort (Mithen, 2006). Music is so universal that no known cultures, past or present, exist(ed) without it. Beyond this generalized statement, there are numerous specific examples of how music contributes to resilience: • During the Diaspora and nearly 2,000 years of exile, Ashkenazi (primarily northern Europe) and Sephardi (Spain and the middle East) Jews kept their traditions and heritage alive, in part, through their music (Bahat, 1980).

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free ebooks ==> www.ebook777.com Music as an Agent of Resilience 103 • From time immemorial, music has strengthened warriors and sustained those left at home during wartime. Even today, the U.S. military spends enormous sums of money on music (Graham, 2004–2005). • Witch doctors, priests, shamans, and medicine men have incorporated music into healing rituals for thousands of years. Members of the !Kung tribe of the Kalahari desert sing and dance the Giraffe Dance for hours on end to achieve an emotional state called kia (Katz, 1982). The modern, Western concept of music medicine is discussed in a subsequent section. In sum, anthropologists and ethnomusicologists provide overwhelming evidence of the role of music in the lives of people and the resiliency they experience as a result of their experiences with and participation in music. From Sociology An important role music can play is to help individuals and societies develop personal (Hargreaves, Miell, & MacDonald, 2002) and corporate (Wade, 2009) identity. For example, a gay man might gain a stronger sense of gender identity by singing in an all-male chorus (Faulkner & Davidson, 2006), while citizens at large foster national identity through music (e.g., Germany: Applegate & Potter, 2002; Israel: Gilboa & Bodner, 2009; Nigeria: Omojola, 2009; and Russia: Daughtry, 2003). Social identity theory (SIT) includes music as a means of creating social identity. For example, the New Horizons International Music Association provides a means for adults over the age of 50 to have meaningful musical experiences. Coffman (2002) found that, while performing music is paramount, the fact that it takes place in a mutually supportive environment where friendships can develop is a much sought after bonus. The fact that Coffman’s article was published in the Journal of Aging and Identity suggests that these elder musicians also find their identity in these groups. To the extent that one’s personal and social identity is important in overcoming life’s stresses, both everyday and traumatic, music can make a significant contribution. The concert hall at the Center for Social Action through Music in Caracas, Venezuela rings with the music of Beethoven, Mozart, and Strauss performed by schoolchildren who come largely from shantytowns and the barrios (Vulliamy, 2007). Jose Antonio Abreu founded the National System of Youth and Children’s Orchestras of Venezuela, more commonly known as El Sistema, in 1975. During that time, hundreds of thousands of children have been saved from lives of poverty, crime, abuse, and drug addiction. According to Gustavo Dudamel, a graduate of El Sistema who now conducts the Los Angeles Philharmonic, music is a social savior. The motto of El Sistema is “to play and to fight,” which for these young musicians means “undertaking music as a collective experience which also involves individual effort; it entails a relentless pursuit of excellence and, above all, it means persevering until dreams become reality” (To play and to fight, n.d.). From Biology Neurologist Frank Wilson stated that we “have a biologic guarantee of musicianship” (1986). In the intervening 25 years, neuroscientists have collected abundant evidence to document this statement (Hodges, 2011). That is, we are musical in the same sense we are linguistic, mathematical, and so on. Not all of us are predisposed to be excellent performers, but nearly everyone can appreciate the music of the surrounding culture.


Donald A. Hodges

Musical circuits are widely diffuse, but locally specialized, neural networks, which include motor, cognitive, affective, and memory systems (Sergent, 1993). Another system, called the default mode network (DMN), is involved in autobiographical memory, imagining one’s future, and imagining the thoughts and feelings of others (theory of mind) (Spreng & Grady, 2010). New evidence suggests that musical experiences may tap into the DMN (Lloyd, 2011; Wilkins, Hodges, Laurienti, Steen, & Burdette, 2012). Perhaps, these connections help to explain why people all over the world use the power of music to overcome the stresses both of everyday living and of traumatic events. In addition to recent findings concerning music and the DMN, there is a considerable body of literature documenting bodily responses to music (Hodges, 2010). Psychophysiological responses include such measurable processes as heart rate, respiration rate, skin conductance, blood pressure, biochemical responses, temperature, muscular tension, facial expressions, chills (crying, lump in the throat, goose bumps, prickly feeling on the back of the neck or along the spine, etc.), blood volume, gastric motility, blood oxygen, pupillary and startle reflexes, and body movements such as foot tapping or head nodding. More recently, researchers have turned toward multivariate approaches, monitoring a cluster of psychophysiological responses to music, along with their connections to emotion. For example, investigators found relationships among self-rated emotion and psychophysiological measurements of zygomatic (smile) and corrugator (frown) muscle activity, heart rate, skin conductance, and finger temperature (Lundqvist, Carlsson, Hilmersson, & Juslin, 2009). Results indicated that listeners smiled more, had greater skin conductance and lower finger temperature, and expressed more happiness to happy music than to sad music. Thus, bodily and emotional responses are correlated. Of particular relevance for the issue of resilience are the effects of music on biochemistry, including such neurochemicals as beta-endorphins and cortisol.2 While space does not permit a full review, consider a few examples. Toyoshima, Fukui, and Kuda (2011) placed college students into one of four groups, based on their prior experience: piano playing (participants had a mean of 13.5 years’ experience), clay molding (12.7 years), calligraphy (15.7 years), and control (30 minutes of sitting quietly). Indicators of stress were cortisol, specifically endocrine secretion (salivary C that increases during periods of momentary stress), and scores on the State-Trait Anxiety Inventory (STAI-I). Cortisol decreased from pre- to posttest measures in all three creative activity groups, but not for the control group; cortisol decrease was significantly greater for the piano-playing group over clay molding and calligraphy. Posttest STAI-I scores indicated a significant decrease in anxiety for all three creative activities. Others have found similar results. Leardi and colleagues randomly assigned day surgery patients (N = 60) to one of three groups (Leardi et al., 2007). Group 1 listened to new age music before and during surgery, Group 2 to a choice from four different musical styles, and Group 3 to normal operating room sounds. They measured plasma levels of cortisol and natural killer lymphocytes before, during, and after surgery. Cortisol and natural killer cells decreased for both music groups and increased for the control group; the musical choice group had a significantly lower level of both biochemicals than the new age group. Likewise, another group of researchers found that cortisol decreased significantly more during music listening than during a control condition (Enk et al., 2008). As a result of findings such as these, more physicians are using music intentionally in a type of practice called music medicine, which is discussed subsequently. Further indications of the effects of music on ameliorating stress include participation in active music making. Researchers found that adults who participated in recreational music

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free ebooks ==> www.ebook777.com Music as an Agent of Resilience 105 making following a one-hour stress induction protocol had a reversal in 19 of 45 genetic stress hormone markers (Bittman et al., 2005). This was in contrast to those in the resting control group (6 out of 45 markers) or those in the ongoing stressor group (0 out of 45). These results confirmed findings from previous studies involving stress reduction in longterm care workers (Bittman, Bruhn, Stevens, Westengard, & Lynch, 2003) and nursing students (Bittman et al., 2004). From Psychology Although people engage in musical behaviors for many, many reasons, perhaps at the root of it all is how music makes people feel. Music psychologists have been divided between a perceived emotions or cognitivist position, where listeners can perceive emotions in the music without actually feeling that emotion, and an induced musical emotions or emotivist position, where listeners actually feel the emotion being expressed in the music (Kivy, 1990). There is considerable literature in support of both positions and, indeed, there is no reason why one cannot experience both, depending on the circumstances. Konecˇni (2005) posited an alternative to these views that he called the aesthetic trinity theory (ATT). The primary thrust of ATT is that music can elicit responses involving awe, being moved, and thrills. These are reactions that supersede or transcend specific emotions such as happy and sad. Regardless of the theoretical position one takes, there is considerable research literature dealing with the topic of musical emotions. Gabrielsson (2010) investigated the strongest reactions to music people could recall. In a content analysis of over 1,300 responses, he documented a wide variety of reactions, including many with relevance for the notion of resilience. These included reflections on the meaning of life and existence, transcendental and religious experiences, personal and social aspects such as insights into oneself or others, and self-actualization. While negative emotions can arise, the overwhelming majority of reported feelings were positive. An important factor about music emotions and resilience is that, while music can be useful in traumatic situations, many if not most people use music as a means of coping with everyday living as well. Furthermore, there is considerable evidence that using music to create or maintain a positive, healthy outlook on life is more frequent than its use to overcome a negative life event. Maslow (1970) found that music was one of the most common ways that people had peak experiences, a primary means of achieving self-actualization. Adolescents said that music-playing devices were among their most important possessions and that music helped them to have good days (Csikszentmihalyi & Rochberg-Halton, 1981). Fischman (1987) asked 75 adolescents to wear an electronic pager for three days. Participants indicated what they were doing and how they were feeling each time they were randomly contacted. Greg was a disaffected, rebellious youth; his reported emotions were overwhelmingly negative and, during his worst moments, he was experiencing music. Kathy, on the other hand, reported primarily positive emotions. She was happiest when she was playing her violin. Csikszentmihalyi & Hunter (2004) also used experience sampling methods (ESM) to examine happiness ratings among teenagers. They contacted 828 adolescents via an electronic pager randomly up to eight times per day for a week. In each instance, participants indicated what they were doing and with whom, and assessed their experiential state. Adolescents rated music among their three highest rated, happiest experiences. Finally, using ESM, researchers contacted 32 college students electronically seven times per day for two weeks as they maintained their regular daily routine (Juslin, Liljeström, Västfjäll, Barradas, & Silva, 2008). Researchers found that music occurred during 37 percent of


Donald A. Hodges

the responses and that calm–contentment and happiness–elation were the most frequently reported emotions during music episodes. Furthermore, participants experienced happiness–elation more frequently during music activities than non-music activities. Emotional self-regulation, the modification of intensity or valence of emotions, is an important coping mechanism. Saarikallio investigated the role of music in emotional selfregulation in children (2009), adolescents (2007), and adults (2011). She found that, among children from 3 to 8 years of age, music helped them calm down, to concentrate and stay interested, to express and enhance happiness, and to fantasize through mental imagery. Among adolescents, she found that mood improvement and mood control were primary, with girls using music for mood regulation more than boys and older teenagers more than younger ones. For adults, music played a significant role in emotional self-regulation throughout adulthood (from age 21 to 70). Across the lifespan, then, music can play an important function in regulating emotions in everyday life. From Music Therapy, Music Medicine, and Music Education Music Therapy and Music Medicine Music therapists are specially trained musicians who work with a wide array of client populations, including persons with mental health issues, developmental and learning disabilities, age-related conditions such as Alzheimer’s, substance abuse problems, brain injuries, physical disabilities, and acute or chronic pain. Music medicine is a field closely allied to music therapy. In this case, physicians and other healthcare professionals use music in numerous clinical applications, such as perioperative stress, surgery, anesthesia, acute and chronic pain management, intensive care, obstetrics, geriatrics, behavioral disorders, motor dysfunction, cancer care, and dentistry. The ideal situation is when music therapists and physicians work together for the benefit of the patients. Because of the breadth of the field, there is space for only a few examples. For example, two meta-analyses of studies on the efficacy of music therapy in pediatric healthcare reached similar conclusions that music was effective in these populations (Cassidy & Standley, 1995; Standley, 2002). Music therapy used with premature infants in neonatal intensive care units and their parents provided statistically significant and clinically important benefits, such as the reduction of stress, the promotion of developmental stimulation (e.g., increased oxygen saturation), bonding with parents, and improvement in neurologic, communication, and social development. In a review of 17 randomized control trials involving children from 1 to 18 years old, reviewers found qualified support for the effectiveness of music in pediatric healthcare, especially for children experiencing stressful life events or acute or chronic physical illness (Naylor, Kingsnorth, Lamont, McKeever, & Macarthur, 2011). In one randomized clinical trial, medical teams treated 83 pediatric oncology patients aged 4 to 7 in six different hospitals (Robb et al., 2008). Children who participated in active music engagement displayed a significantly greater number of coping-related behaviors than those who only listened to music or heard a taped narration of a children’s book. Similarly, children aged 4–13 receiving venipuncture were under duress. Patients who interacted with music therapists in the presence of their parents during the procedure experienced significantly less distress and pain compared to a group who only had their parents providing support during the procedure (Caprilli, Anastasi, Grotto, Abeti, & Messeri, 2007). See Hilliard (2008) for an additional discussion of the role of music with children and adolescents experiencing grief.

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free ebooks ==> www.ebook777.com Music as an Agent of Resilience 107 In relation to the other end of life, Heiderscheit, Chlan, and Donley (2011) described two case studies of critically ill patients who utilized a music listening intervention while receiving mechanical ventilatory support. These case studies were drawn from a larger randomized control trial involving five medical centers and 12 intensive care units (ICUs). Patients on mechanical ventilation (MV) often experience significant distress and anxiety. These researchers examined the effects of patient preferred music on their self-management of anxiety, in contrast to the usual treatments of intravenous sedatives, and assessed them daily with a version of the Spielberger State Anxiety Inventory and a visual analog scale for anxiety. David (50 years old) and Bob (71 years old) were both in the ICU receiving MV. A music therapist worked with each one to develop a personalized listening list. Although there was very little in the ICU experience the patients could control, they could control the music to which they listened. David utilized the music to help him manage the stress and anxiety he experienced during dialysis. He died before leaving the ICU. Bob likewise used his preferred music to cope with the stresses of his critical illness. Upon his discharge from the hospital, he remarked that music helped him survive this traumatic experience. The use of a personalized music listening intervention was effective in reducing stress and anxiety for both patients and for others in the study. Researchers randomly placed 54 patients with a left or right hemisphere middle cerebral artery stroke into one of three groups: a music group, a language group, or a control group (Särkämö et al., 2008). For two months the two experimental groups listened daily to self-selected music or audio books, while the control group received no listening protocol. Patients participated in a wide range of cognitive tests, mood and quality of life surveys at one week, three months, and six months following the stroke. Patients in the music group made significantly greater improvements in verbal memory and focused attention than patients in the other two groups. Furthermore, they were less depressed and confused. Another group of researchers randomly assigned adults (N = 79) with unipolar depression to two groups, one receiving standard care only and the other receiving standard care plus 20 bi-weekly individual music therapy sessions (Erkkilä et al., 2011). Those receiving music therapy plus standard care showed significantly greater improvement in depression and anxiety symptoms, and general functioning. In another study, 87 patients suffering from lumbar pain, fibromyalgia, inflammatory disease, or neurological disease received a music listening protocol along with standard treatment or standard treatment only (Guétin et al., 2012). Patients in the music listening group experienced significantly reduced pain, as well as reduced anxiety-depression, and consumption of medicine. These few, brief examples provide support for the notion that music therapy offers patients in a wide variety of settings a means of coping with their illnesses or disabilities. In general, active music making is more effective than passive listening, but it, too, offers considerable benefits. Music Education Although music educators do not routinely work with students experiencing the kind of traumatic stresses the clients of music therapists have, they do deal daily with students who are undergoing any number of stressful home and school circumstances. Even if they are only enduring normal growing pains, such as being teased for their physical appearance, children and adolescents are frequently in need of ways to relieve stress and anxiety. In one experiment, music education researchers who conducted a content analysis of essays written by 1,155 middle and high school students found that “just under half the references made


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to music’s therapeutic function were centered on the idea of ‘coping’ with the pressures of study, family, and the dynamics of friendship and social life” (Campbell et al., 2007, p. 228). “A large number of respondents reported that music helps them cope with the pain of loss or abuse” (p. 228). In commenting on the loss of both his parents when he was 10, a 14-yearold boy said that he and his sister relied heavily on music as a survival tactic. Another way that music educators enable students to survive and cope is through the inclusion of special needs children into music classrooms (Jellison, 2006). Jellison frames the basis of including special learners in regular music classrooms as a quality of life issue. Reviewing the extant literature, she found that disabled and non-disabled children had many similar skills and responses. Disabled children experience many of the same joys and pleasures through music as do non-disabled children, and the music classroom provides a positive and nurturing environment where both can enjoy it together.

CONCLUSION Music plays a critical role in enabling people of all ages to resist and overcome stress and trauma in a wide variety of settings and circumstances. Music is an enabling partner as those who have overcome trauma build a new life and sustain it over time. Finally, music is a core ingredient of healthy, positive living. While there is no intent to make the claim that music is the best means of bolstering resiliency in the human spirit, it is clear that music offers some distinctive benefits and advantages within the context of the RSG model of resilience. Music is: • Easily accessible, omnipresent, portable, and often free. The sheer ubiquity of music through radio, television, the movies, mp3 players, and the like provides everyone with instant access to any kind of desired musical experience. Portable devices allow people to take their music with them wherever they go. Many shops, stores, restaurants, medical offices, and so on have music playing in the background. Although one can certainly spend a great deal of money on tickets, recordings, or musical instruments, many people access music for free. • Richly diverse. Listeners can choose from numerous musical styles, with thousands upon thousands of choices within those styles. From grand opera to punk rock, there are musical styles to fit every taste and proclivity. • Flexible in meeting needs. The vast array of musical choices means that music can meet nearly any conceivable situation. There is appropriate music for seemingly trivial daily upsets, for life-altering traumas, and for everything in between. Research supports the notion that personal choice, that is, being able to engage in preferred music, is more effective than listening to whatever is provided or available. • Flexible in meeting personal circumstances. Age is no restrictor, as people can have meaningful musical experiences from birth until death. Level of cognitive functioning is not a barrier, as individuals from the lowest to the highest intelligence have meaningful musical experiences. Group size is not a limiter, as people can have meaningful musical experiences alone (even in silence with internal hearing) or within huge crowds. Neither age, race, religion, political affiliation, nor socio-economic status prohibit one from meaningful musical experiences. • Innate and trainable. Everyone has the potential to experience music at some level, and nearly everyone can improve musical skills through learning and experience. Through a

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free ebooks ==> www.ebook777.com Music as an Agent of Resilience 109 process called statistical learning—we learn many things through frequency of occurrence (Saffran, 2003)—everyone learns the music of the surrounding culture to some degree. Even those who profess they “can’t carry a tune in a bucket” or those with congenital amusia can understand and respond to music in the environment (e.g., television shows and movies). From the least to most talented, persons who make an effort to learn music are most often able to do so. • Passive and active. Listeners can enjoy music with little or no effort; it can even accompany another activity, whether pleasant (e.g., at a party) or unpleasant (e.g., while in the dentist’s chair or undergoing chemotherapy). Contrarily, many enjoy making music by singing in church choirs or jamming in a garage band. Anthropologist Alan Merriam (1964) captured all these attributes nicely when he said: The importance of music, as judged by the sheer ubiquity of its presence, is enormous.... There is probably no other human cultural activity which is so all-pervasive and which reaches into, shapes, and often controls so much of human behavior. (p. 218) The take-away message from this chapter, then, is that music plays a crucial role in enabling people to overcome, to persevere, and to live fulfilling lives. Whether one makes conscious decisions to engage in musical activities or simply encounters music as it happens to be in the environment, the central fact is that music serves powerfully and pleasurably as an agent of resiliency.

NOTES 1. The story behind the words of this great hymn are a monumental testimony to the resiliency of the human spirit. Horatio G. Spofford lost a fortune in the fire that consumed Chicago in 1871 (Morgan, 2003). Soon thereafter, his four-year-old son died of scarlet fever. Two years later, his wife and four daughters went ahead of him on a ship bound for Europe. The ship collided with another during the passage and 226 passengers drowned, including all of his daughters. His wife, among the 46 survivors, cabled “Saved alone.” En route to rejoin his wife, Spofford was apprised by the captain of the spot where his daughters had perished. He uttered the phrase, “It is well; the will of God be done.” He later based the words of the hymn on this idea. The music is by Philip Bliss. 2. A full list of the biochemicals that researchers have studied in terms of their responsiveness to music includes ACTH (adrenocorticotropic hormone), beta-endorphins, blood glucose, cortisol, dehydroepiandrosterone, dopamine, epinephrine, genetic stress hormone markers, growth hormone, interleukin-1, interleukin-6, interleukin-10, melatonin, mu-opiate receptor expression, natural killer cells, neutrophils and lymphocytes, norepinephrine, oxytocin, prolactin, secretory-immunoglobulin A (SigA), serotonin, testosterone, and T lymphocytes (CD4+, CD8+, and CD16+).

REFERENCES Applegate, C., & Potter, P. (2002). Music and German national identity. Chicago: University of Chicago Press. Bahat, A. (1980). The musical traditions of the oriental Jews. The World of Music, 2, 46–55. Bittman, B., Berk, L., Shannon, M., Sharaf, M., Westengard, J., Guegler, K., et al. (2005). Recreational music making modulates the human stress response: A preliminary individualized gene expression strategy. Medical Science Monitor, 11, BR31–40.


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Bittman, B., Bruhn, K., Stevens, C., Westengard, J., & Lynch, P. (2003). Recreational music-making: A cost-effective group interdisciplinary strategy for reducing burnout and improving mood states in long-term care workers. Advances in Mind–Body Medicine, 19, 4–15. Bittman, B., Snyder, C., Bruhn, K., Liebfreid, F., Stevens, C., Westengard, J., et al. (2004). Recreational music-making: An integrative group intervention for reducing burnout and improving mood states in first year associate degree nursing students: insights and economic impact. International Journal of Nursing Education Scholarship, 1, 1–29. Blowen, M. (1997, September 7). With grace and depth, ABC ruled. Boston Globe, p. A32. Brown, W., Basil, M., & Bocarnea, C. (2003). Social influence of an international celebrity: Responses to the death of Princess Diana. Journal of Communication, 53, 587–605. Campbell, P., Connell, C., & Beegle, A. (2007). Adolescents’ expressed meanings of music in and out of school. Journal of Research in Music Education, 55, 220–236. Caprilli, S., Anastasi, F., Grotto, R., Abeti, M., & Messeri, A. (2007). Interactive music as a treatment for pain and stress in children during venipuncture: A randomized prospective study. Journal of Developmental and Behavioral Pediatrics, 28, 399–403. Cassidy, J. W., & Standley, J. M. (1995). The effect of music listening on physiological responses of premature infants in the NICU. Journal of Music Therapy, 32, 208–227. Coffman, D. (2002). Banding together: New horizons in lifelong music making. Journal of Aging and Identity, 7, 133–143. Csikszentmihalyi, M., & Hunter, J. (2004). Happiness in everyday life: The uses of experience sampling. Journal of Happiness Studies, 4, 185–199. Csikszentmihalyi, M., & Rochberg-Halton, E. (1981). Object lessons. Psychology Today, 15, 78–85. Daughtry, J. (2003). Russia’s new anthem and the negotiation of national identity. Ethnomusicology, 47, 42–67. Enk, R., Franzke, P., Offermanns, K., Hohenadel, M., Boehlig, A., Nitsche, I., et al. (2008). Music and the immune system. International Journal of Psychophysiology, 69, 207–241. Erkkilä, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I., Termaniemi, M., et al. (2011). Individual music therapy for depression: Ramdomised controlled trial. British Journal of Psychiatry, 199, 132–139. Faulkner, R., & Davidson, J. (2006). Men in chorus: Collaboration and competition in homo-social vocal behaviour. Psychology of Music, 34, 219–237. Fischman, J. (1987). The ups and downs of teenage life. Psychology Today, 21, 56–57. Gabrielsson, A. (2010). Strong experiences with music. In P. Juslin & J. Sloboda (Eds.), Handbook of music and emotion (pp. 547–574). New York: Oxford University Press. Gilboa, A., & Bodner, E. (2009). What are your thoughts when the national anthem is playing? An empirical exploration. Psychology of Music, 37, 459–484. Graham, L. (2004–2005). Music in the military: It’s about influence. American Music Teacher, 54, 34–36. Guétin, S., Giniès, P., Siou, D., Picot, M.-C., Pommié, C., Guldner, E., et al. (2012). The effects of music intervention in the management of chronic pain. Clinical Journal of Pain, 28, 329–337. Hargreaves, D., Miell, D., & MacDonald, R. (2002). What are musical identities, and why are they important? In R. MacDonald, D. Hargreaves, & D. Miell (Eds.), Musical identities (pp. 1–20). New York: Oxford University Press. Heiderscheit, A., Chlan, L., & Donley, K. (2011). Instituting a music listening intervention for critically ill patients receiving mechanical ventilation: Exemplars from two patient cases. Music and Medicine, 3, 239–245. Hilliard, R. (2008). Music and grief work with children and adolescents. In C. Malchiodi (Ed.), Creative interventions with traumatized children (pp. 62–80). New York: Guilford Press. Hodges, D. (2010). Psychophysiological measures. In P. Juslin & J. Sloboda (Eds.), Handbook of music and emotion (pp. 279–312). New York: Oxford University Press. Hodges, D. (2011). Music in the human experience: An introduction to music psychology. New York: Routledge.

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free ebooks ==> www.ebook777.com Music as an Agent of Resilience 111 Jellison, J. (2006). Including everyone. In. G. McPherson (Ed.), The child as musician (pp. 256–272). New York: Oxford University Press. Juslin, P., Liljeström, S., Västfjäll, D., Barradas, G., & Silva, A. (2008). An experience sampling study of emotional reactions to music: Listener, music, and situation. Emotion, 8, 668–683. Kantrowitz, B., Pedersen, D., & McGuire, S. (1997, September 15). The day England cried. Newsweek, 80, 30–36. Katz, R. (1982). Boiling energy: Community healing among the Kalahari Kung. Cambridge, MA: Harvard University Press. Kivy, P. (1990). Music alone: Philosophical reflections on the purely musical experience. Ithaca, NY: Cornell University Press. Kone{chac}ni, V. (2005). The aesthetic trinity: Awe, being moved, thrills. Bulletin of Psychology and the Arts, 5, 27–44. Leardi, S., Pietroletti, R., Angeloni, G., Necozione, S., Ranalletta, G., & Del Gusto, B. (2007). Randomized clinical trial examining the effect of music therapy in stress response to day surgery. British Journal of Surgery, 94, 943–947. Lloyd, D. (2011). Music as mind. Frontiers in Psychology, 2, 1–9. Lopez, S. (2008). The soloist: A lost dream, an unlikely friendship, and the redemptive power of music. New York: Putnam. Lundqvist, L.-O., Carlsson, F., Hilmersson, P., & Juslin, P. (2009). Emotional responses to music: Experience, expression, and physiology. Psychology of Music, 37, 61–90. Maslow, A. (1970). Motivation and personality (2nd ed.). New York: Harper & Row. Merriam, A. (1964). The anthropology of music. Chicago: Northwestern University Press. Mithen, S. (2006). The singing Neanderthals: The origins of music, language, mind, and body. Cambridge, MA: Harvard University Press. Morgan, R. (2003). Then sings my soul. Nashville, TN: Thomas Nelson. MTV News Online. (1997, October 2). Elton “amazed” by the success of “Candle.” Retrieved from http://www.mtv.com/news/articles/1430664/19971002/john_elton.jhtml?paid=984 Naylor, K., Kingsnorth, S., Lamont, A., McKeever, P., & Macarthur, C. (2011). The effectiveness of music in pediatric healthcare: A systematic review of randomized controlled trials. Evidence-Based Complementary and Alternative Medicine, 2011, article 464759. Omojola, B. (2009). Politics, identity, and nostalgia in Nigerian music: A study of Victor Olaiya’s highlife. Ethnomusicology, 53, 249–276. Reich, J. W., Zautra, A. J., & Hall, J. S. (2011). Resilience science and practice: Current status and future directions. In M. Celinski & K. Gow (Eds.), Continuity versus creative response to challenge: The primacy of resilience and resourcefulness in life and therapy (pp. 33–50). Hauppauge, NY: Nova Publishers. Rischin, R. (2003). For the end of time: The story of the Messiaen Quartet. Ithaca, NY: Cornell University Press. Ritter, J., & Daughtry, J. (2007). Music in the post-9/11 world. New York: Routledge. Robb, S., Clair, A., Watanabe, M., Monahan, P., Azzouz, F., Stouffer, J., et al. (2008). Randomized controlled trial of the active music engagement (AME) intervention on children with cancer. Psycho-Oncology, 17, 699–708. Roe, M. (2010, November 25). Alice Herz-Sommer: Thanks to music I am still alive today. Retrieved from CzechFolks.com Saarikallio, S. (2007). Music as mood regulation in adolescence. Jyväskylä Studies in Humanities, 67, 1–46. Saarikallio, S. (2009). Emotional self-regulation through music in 3–8-year-old children. In J. Louhivuori, T. Eerola, S. Saarikallio, T. Himberg, & P.-S. Eerola (Eds.), Proceedings of the 7th Triennial Conference of European Society for the Cognitive Sciences of Music (pp. 459–462). Jyväskylä, Finland: European Society for the Cognitive Sciences of Music. Saarikallio, S. (2011). Music as emotional self-regulation throughout adulthood. Psychology of Music, 39, 307–327.


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Saffran, J. (2003). Musical learning and language development. Annals of the New York Academy of Sciences: The Neurosciences and Music (G. Avancini, C. Faienza, D. Minciacchi, L. Lopez, & M. Majno, Eds.), 999, 397–401. Särkämö, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikkonen, M., et al. (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain, 131, 866–876. Sergent, J. (1993). Mapping the musical brain. Human Brain Mapping, 1, 20–38. Sharrock, D. (2008, June 7). Cellist of Sarajevo, Vedran Smailovic, is wounded by words. The Sunday Times. Retrieved from http://entertainment.timesonline.co.uk/tol/arts_and_entertainment/ books/article4083037.ece Sohn, E. (2011, November 16). How music helped Gabrielle Giffords heal. Discovery News. Retrieved from http://news.discovery.com/human/gabrielle-giffords-photos-111116.html Solomon, M. (1985). Beethoven. New York: Schirmer Books. Spreng, R., & Grady, C. (2010). Patterns of brain activity supporting autobiographical memory, prospection, and theory of mind, and their relationship to the default mode network. Journal of Cognitive Neuroscience, 22, 1112–1123. Standley, J. (2002). A meta-analysis of the efficacy of music therapy for premature infants. Journal of Pediatric Nursing, 18, 107–113. To play and to fight. (n.d). Retrieved from http://www.fesnojiv.gob.ve/en/to-play-and-to-fight. html Toyoshima, K., Fukui, H., & Kuda, K. (2011). Piano playing reduces stress more than other creative arts activities. International Journal of Music Education, 29, 257–264. Vulliamy, E. (2007, July 29). Orchestral manoeuvres. The Observer. Retrieved from http://www. guardian.co.uk/music/2007/jul/29/classicalmusicandopera1 Wade, B. (2009). Thinking musically: Experiencing music, expressing culture (2nd ed.). New York: Oxford University Press. Weintraub, K. (2011, November29). Music therapy can help retrain an injured brain. USA Today. Retrieved from http://yourlife.usatoday.com/health/medical/treatments/story/2011-11-28/ Music-therapy-can-help-retrain-an-injured-brain/51446362/1 Wilkins, R. W., Hodges, D. A., Laurienti, P. J., Steen, M. R., & Burdette, J. H. (2012). Network science: A new method for investigating the complexity of musical experiences in the brain. Leonardo Transactions, 45, 282–283. Wilson, F. (1986). Tone deaf and all thumbs? New York: Vintage Books. Zatorre, R., Chen, J., & Penhune, V. (2007). When the brain plays music: Audio-motor interactions in music perception. Nature Reviews Neuroscience, 8, 547–558. Zautra, A. J., Hall, J. S., & Murray, K. E. (2010). Resilience: A new definition of health for people and communities. In J. W. Reich, A. J. Zautra, & J. S. Hall (Eds.), Handbook of adult resilience (pp. 3–34). New York: Guilford Press.

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Part C Resilience as Interpersonal Process



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Oxytocin and Attachment Facilitate a Shift From Seeking Novelty to Recognizing and Preferring Familiarity The Key to Increasing Resilience? Mattie Tops, Femke T. A. Buisman-Pijlman, and C. Sue Carter

Attachment can increase resilience in the face of stress and ward off addiction. We propose an underlying mechanism that is located in the interaction between oxytocinergic and dopaminergic systems. In the distinction between “wanting” and “liking,” it has been hypothesized that dopamine is involved in the “wanting” aspect of reactive reward processing. We propose that oxytocin and attachment play a main role in “liking” or stable appreciation. Ordinarily a reward increases the “liking” of the rewarding stimulus, while satiety decreases the “wanting” of that reward. However, continued drug use and stress will reduce liking and increase the wanting of drugs, even though the drug may no longer be pleasurable, and even though this addicted “wanting” state has no evolutionary benefit. By contrast, strong partner relationships show a progression from strong motivation to approaching and obtaining the partner (the “wanting” phase of being in love fueled by high levels of novelty) toward a steady high level of “liking” (attachment involving appreciation of familiarity). These parallel processes are relevant to resilience in that they may share a similar underlying mechanism. Oxytocin may be involved in shifting the balance between wanting and liking by facilitating consolidation of social information from reactive reward systems to “internal working models” that help to proactively select optimal actions for the future, thereby increasing resilience. Oxytocin may achieve its effects through dopaminergic, serotonergic, and endogenous opioid mechanisms.

INTRODUCTION: SHIFTING FROM REACTIVE CONTROL TO INTERNAL WORKING MODEL CONTROL INCREASES RESILIENCE The neuropeptide oxytocin is well known for its role in milk ejection during lactation, its role in the smooth muscle contraction of the uterus during parturition, in mother–infant bonding, and in parenting. More recently oxytocin has been implicated in adult affiliation and partner attachment (Carter, 1998; Feldman, 2012). Oxytocin is also thought to increase interpersonal trust, reduce stress responses, and protect against drug addiction and the negative effects of stress on health (Baskerville & Douglas, 2010; Carter, 1998; McGregor & Bowen, 2012; Smith & Wang, 2012). Although social attachment is a protective factor against stress and addiction, it is also degraded by chronic stress and drug abuse (reviewed by K. Young, Gobrogge, & Wang, 2011). In this chapter we will discuss evidence for a


Tops, Buisman-Pijlman, and Carter

theory in which oxytocin and attachment increase resilience by facilitating a neural shift from novelty processing (reactive reward seeking, fear responding, novelty seeking) to familiarity processing (recognition and appreciation of familiarity; see Figure 9.1). In Chapter 2 we proposed two systems that had evolved in the brain for the control of behavior in predictable and stable environments and control of behavior in unpredictable changing environments (Tops & Boksem, 2012; Tops, Boksem, Luu, & Tucker, 2010). Ventral corticolimbic control pathways (including the amygdala, inferior frontal gyrus or IFG, anterior insula, and areas in the anterior cingulate cortex) incorporate fast associative learning that is adaptive in low-predictable environments. This contrasts with dorsal control pathways (including posterior cingulate cortex, precuneus, posterior hippocampus, and dorsolateral prefrontal cortex) that are specialized for guiding behavior in a predictive and feed-forward fashion by internal models. In Chapter 2 we called these models context models; in the present chapter we will use the label internal working models to be consistent with the language of attachment theory (Bowlby, 1988). These internal working models are formed and kept stable by slow learning, a specialization that is adaptive in predictable environments. Internal working models are formed in long-term memory by the predictability of the environment or context. In low-predictable environments, effective internal models cannot be formed or used to control behavior in adaptive ways. Instead, ventral corticolimbic control guides behavior in reaction to momentary feedback from environmental stimuli. This reactive guidance by momentary environmental stimuli is associated with an attentional focus on stimuli that are urgent and close in time and space. Those stimuli can be positive (“I have to catch that reward that is in my reach before it gets away”) or negative (“I have to get away from that danger before it gets me, because I’m in its reach”). By contrast, the emotional experience of the internal working model is less immediate and overwhelming. It has a wider temporal focus that produces self-awareness and a sense of the past and the future. Moreover, the successful internal working models that are shaped and used in prospective control will tend to include representations of positive experiences and outcomes. This positive bias and the less intense emotions enable active coping through confronting both negative and positive affects. The biobehavioral programs associated with ventral and dorsal control systems have evolved because they are adaptive in certain environments and circumstances. Both the dorsal and the ventral programs are associated with talents and sources of resilience. However, while the reactive ventral programs are directly sensitive and responsive to both negative and positive environmental influences (including the social environment), the dorsal programs use internal working models and are, thus, less responsive to environmental influences. Because of this difference in responsivity, individuals who are biased towards dorsal control will generally do well and will not be distressed in most environments. On the other hand, individuals who are biased towards ventral control become distressed in many situations, including important ones. Shifting from ventral to dorsal control may be a mechanism that is involved in various processes that increase resilience (Figure 9.1). We propose that resilience can be increased in reactive persons by increasing their abilities to shift to internal working models and associated behavioral and physiological programs. The healthy brain is equipped with mechanisms to make this shift. Individuals often display such a shift during skill acquisition and performance learning. Resilience may be increased through similar learning mechanisms that can be applied to control behaviors and emotions in challenging environments. The literature on skill acquisition and performance learning shows that the shift from reactive control when a task is novel to control by an internal working model when that task has become familiar is potentially followed by one additional step

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free ebooks ==> www.ebook777.com Oxytocin and Attachment Facilitate a Shift 117 or shift: a shift toward automatic, routinized, habitual control (Figure 9.1). Although the shift to habitual control is part of a natural adaptive learning process, it may be less adaptive if behavior is controlled in a habitual or addictive fashion without sufficient self-reflective and predictive guidance by an internal working model. Resilience can be enhanced through the guidance by a model of action or performance and its context, without such guidance becoming an addictive habit. The shift that takes place during performance learning is a shift from reactive ventral to dorsal habitual control. It involves a shift in the activity of corticostriatal loops in which dopamine (DA) is an important modulator. Another neuromodulator, the neuropeptide and hormone oxytocin, is involved in attachment, in calming, and in trust. It is known that oxytocin derives many of its effects through interactions with DA systems (Baskerville & Douglas, 2010). In this chapter we will discuss the possibility that oxytocin and attachment increase resilience by facilitating a shift from ventral novelty seeking to dorsal familiarity processing in the corticostriatal loops.1 Evidence for this shift is provided by research on DA mechanisms of reward processing and by drug addiction. Instead of a shift toward familiarity and increased resilience, drug abuse and stress induce shifts toward habitual behavior.

THE SHIFT FROM NOVEL TO FAMILIAR In order to feel secure, an individual needs to feel that he can depend on resources and on other persons. Such a social and material environment is perceived as predictable. Familiarity with environments and persons is often associated with predictability. Even if they are not unequivocally pleasant, it is often possible to habituate and “get used to” familiar and predictable environments and people, even get attached to them (Pedersen, 2004). Bowlby (1988) thought that humans were motivated to maintain a dynamic balance between familiarity-preserving, stress-reducing behaviors (attachment to protective individuals and familiar home sites, retreat from the strange and the novel) and the antithetical exploratory and information-seeking behaviors. Moreover, the dependability during early experiences could function as a “secure base” from which the social environment could be explored. Both the secure base and the familiarized environment would be internalized as “internal working models” (Bowlby, 1988). Although predictability and appreciation of familiarity are aspects of stable attachment, in partner relationships a stable attachment develops from earlier stages of being “in love” involving sexual and/or romantic attraction, fueled by responsivity to reward and novelty. Here the development of attachment may involve a shift away from reactivity of rewards produced by novelty and a move toward the appreciation of familiarity. This is a change from a reward system triggered by external cues to a system responsive to internal cues. However, when social contexts are perceived as unpredictable, the individual will not develop feelings of security and familiarity with respect to those contexts. One reason why persons may experience problems with developing security in social contexts is that they have experienced inconsistent, unreliable, and unpredictable parental feedback. This could have produced ineffective internal models of the social context and resulted in a perception of social contexts as unpredictable. The lack of an internalized secure base and positive feedback could render perceptions of self-worth unstable and reactive to momentary feedback and social evaluation. This could be the case in insecure attachment as well as in social anxiety. Indeed, social anxiety is characterized by a lack of habituation to social contexts and by high reactivity to social feedback.



All species are adept at reading the larger world into which they are born. They can determine whether the environment is safe or predictable, in which moving slowly and carefully will pay off, or whether it is dangerous or unpredictable and it pays to grab what can be had. In studies of neighborhoods torn by gang violence where life expectancies are short, people make decisions that are consistent with such expectancies, as reflected in decisions about smoking, drinking, sex, and criminality (Kurzban, Dukes, & Weeden, 2010). People in such environments may pursue what is called a “fast life strategy” characterized by high novelty seeking and short-term rewards over long-term consequences. Attitudes regarding recreational drug use are better predictors of reproductive strategies or sexual attitudes than are abstract political commitments (Kurzban et al., 2010). It is unlikely that the novelty-seeking trait has evolved to predispose individuals to drug abuse. It may instead be an adaptive trait or life strategy, particularly for males in a low-predictable and risky environment (Del Giudice, 2009). Early psychosocial stress and insecure attachment lead to early predispositions to sense cues about risk in the environment and to switch development toward reproductive strategies favoring early reproduction and higher mating effort (Del Giudice, 2009). In human adult partner relationships there is tension between contrasting needs for novelty and predictability (Baxter, 1990). High novelty seeking has been associated with perceptions of risk in intimacy and low trust (Pilkington, 1988) and with infidelity, number of partners, and sexual risk taking (Hoyle, Fejfar, & Miller, 2000). Biological changes in adolescence promote novelty seeking, dislike of familiarity, and increase of risk taking: strategies that are adaptive in promoting independence from caregivers (Kelley, Schochet, & Landry, 2004). From the perspective of our model, trait novelty seeking and a fast life strategy may bias an individual toward ventral novelty processing and decrease the likelihood that stable attachments will be formed through the shift toward dorsal familiarity processing. The ventral-to-dorsal shift is hampered by attachment avoidance (Del Giudice, 2009) and social unpredictability. These interfere with the development of trust. The shifts involved in novelty–familiarity shifts and resilience are summarized in Figure 9.1. Ventral reactive control is initiated when stimuli or tasks are emotionally salient, unpredictable, or novel. By contrast, the dorsal internal working model guides behavior through information retrieved from memory. This is significant for familiarity. Stimuli and tasks retrieved from memory will have been experienced before and, therefore, will be more familiar. It follows that a shift from reactive toward internal working model control will involve a shift from novelty toward familiarity processing. Novelty and familiarity processing are thought to represent basic functions of the brain. These basic functions are recruited by many behaviors. For example, responding to a novel stressor or challenge involves initially

Novelty Reactive Ventral Manual In love, seeking Stress mobilization Drug exploration

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Routine Automatization Dorsal striatum Automatic Routine Habit Habit/compulsion

Dorsal Feed-forward Attachment Habituation, familiarization Resilience

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Figure 9.1 The novelty-to-familiarity-to-routine shift in stimulus processing and action control. Each horizontal line from left to right depicts stages that can follow each other during the process of learning. Oxytocin is suggested to increase resilience by favoring the middle familiarity stage, thereby protecting against undue reactive or habitual control.

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free ebooks ==> www.ebook777.com Oxytocin and Attachment Facilitate a Shift 119 the processing of novelty, which is followed by the activation of learning, which then allows familiarization and eventual habituation to the stressor. In the case of social attachments, the initial responses are first formed by the attraction of rewarding properties of an as-yet novel individual, which are then followed by feelings of attachment towards the familiarized individual. Attachment and familiarization reflect a shift toward an internal model-guided control that increases resilience and decreases reactivity. At the same time it also activates internal working models of social resources and rewards. This explains why attachment is associated with increased resilience in the face of stress, and decreased reactive responding to rewards (i.e., increased resistance against drug addiction) and to threat. We will focus next on the rewarding “warm glow” aspect of familiarity versus the reactive reward responding to novelty. We will show how attachment develops out of a dynamic shift from reward processing of novelty to the appreciation of familiarity. This is not to say that shared experiences of novelty, learning, and self-expanding activities are unimportant in attachment and couples relationships (Aron, A., Norman, Aron, E. N., & Lewandowski, 2002). In fact, such shared experiences may help to enhance and maintain close relationships because they repeat the process of the shift from novelty responding toward appreciation of familiarity that was instrumental in the initial development of attachment. We will also address aversive or fear responses to novelty, because such responses need to habituate in order for attachments to develop. Oxytocin has an important role in this habituation.

FROM NOVEL TO ROUTINE IN THE ASCENDING SPIRAL OF CORTICOSTRIATAL LOOPS During learning processes the transition from ventral reactive control to dorsal feed-forward control appears to be mediated by an ascending spiral in corticostriatal loops. In this section we briefly discuss the ascending spiral in corticolimbic loops, its primary neuromodulator DA, its involvement in performance or skill learning, and the behavioral effects of stress on the development of drug addiction. The ascending spiral in corticostriatal loops is illustrated in Figure 9.2. Cortex

Striatum Corticostriatal loops

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Dorsomedial Attachment

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Figure 9.2 Schematic representation of an ascending spiral that is formed between ventromedial (limbic), central/dorsomedial (associative), and dorsolateral (motor) striatal regions, via ventral and dorsal corticostriatal control pathways and via the midbrain dopamine (DA) cells (ventral tegmental area and substantia nigra, not shown here; see Figure 9.3B). Adapted from Tops and Boksem (2012).



We have provided a more detailed description and discussion of performance learning and the corticostriatal loops elsewhere (Tops, Luu, Boksem, & Tucker, Chapter 2, this volume; Tops & Boksem, 2012). In Chapter 2 we discussed skill learning and the shift in behavioral control from momentary stimuli of the present state (novelty processing) to control by predictable future states (familiarity processing), which turn into habitual control. This behavioral shift during learning appears to reflect a progressive involvement (via the corticostriatal loops) of ventral/limbic (the “ventral control pathway”), dorsal/associative (the “dorsal control pathway”), and dorsal/motor systems (Figure 9.2). DA is the primary neuromodulator in the striatum. The adaptive appetitive drive function of mesolimbic DA has been described as “wanting” (Berridge & Robinson, 2003) or “SEEKING” (Alcaro & Panksepp, 2011; Panksepp, 1998). In their review of DA function, Alcaro and Panksepp (2011) discuss the spiraling functional organization of the interconnections between striatal/basal ganglia areas and the mesolimbic DA system in which DA neurons act as intermediaries in a ventromedial–dorsolateral gradient that extends from the limbic to the associative and to the motor loop of these circuits (Figure 9.2). DA transmission mediates “wanting” in the limbic brain, but it may also promote passage in basal ganglia-thalamo-cortical circuits, to limbic, associative, and motor loops (Alcaro & Panksepp, 2011; Figure 9.2). In this way, limbic brain activation states are translated within the frontal cortex into higher-order intentional patterns aimed at exploring, seeking, and approaching new environmental reward opportunities. Or they are available for rapid utilization of learned cognitive and motor sequences that already have solidified goal-directed habit functions. Drugs that can lead to addiction activate the mesolimbic DA system. Drug addiction progresses from occasional recreational use, to impulsive use, and to habitual compulsive use. This correlates with a progression from reward-driven to habit-driven drug-seeking behavior. This behavioral progression also corresponds to the neuroanatomical progression from ventral striatal to dorsal striatal control over drug-seeking behavior. The result is a profound reorganization of the “wanting” urge around memories related to drug use and associated compulsive habits that persist in the face of significant adverse consequences (Alcaro & Panksepp, 2011). Koob and Volkow (2010) envision the development of a change in firing in mesolimbic DA neurons that begins with one administration of the drug, develops into long-term adaptations in the ventral striatum, and, via feedback loops, subsequently engages the dorsal striatum. Addiction also involves changes in cortically regulated cognitive and emotional processes that are associated with the overvaluing of drugs as rewards at the expense of the undervaluing of natural rewards. These changes reflect deficits in inhibitory control over the responses to drugs. An underperforming prefrontal system is widely believed to be crucial to the development of addiction (Koob & Volkow, 2010). Thus, drug addicts show a progression over time that reflects the shift from ventral to dorsal striatal control of behavior, a shift that is augmented by stress and underperformance of the prefrontal cortex. Stress is a powerful trigger for relapse to drug-taking behaviors, particularly psychostimulants. The gradual reorganization of reward and memory circuits that is brought about by chronic drug abuse may be crucial for the establishment of addiction (Koob & Volkow, 2010; Schwabe, Dickinson, & Wolf, 2011). Schwabe et al. (2011) review evidence for a switch from the internal working model that is goal-directed to habitual action that is prompted by stress and stress hormones. They identified a shift in processing from systems including dorsomedial striatum towards dorsolateral striatum. Acute stressors reinstate habitual responding to drug-related cues that then trigger relapse to addictive behavior. Prolonged or repeated stress (especially during adolescence), stress-related psychiatric disorders,

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free ebooks ==> www.ebook777.com Oxytocin and Attachment Facilitate a Shift 121 and histories of early abuse may accelerate the transition from voluntary to involuntary drug use and promote the development of addiction. Stress and stress hormones increase DA transmission (Piazza et al., 1996), suggesting that DA mechanisms may mediate the effects of stress on instrumental action. Prefrontal cortical functioning is significantly reduced in addiction. To overcome addiction, willpower and cognitive control processes are needed. These are brought about by the goal-directed systems. However, acute stress disrupts this goal-directed control, and the habit system takes over again (Schwabe et al., 2011). Acute stress may disrupt the neural systems underlying goal-directed behavior and promote reactivation of previously overlearned automatic behavior (habits).

OXYTOCIN, ATTACHMENT, AND RESILIENCE TO STRESS AND DRUG ADDICTION Research suggests that oxytocin and social attachment increase resilience and protect against addiction and the damaging consequences of stress to health. In this chapter we show how oxytocin and attachments increase resilience through facilitation of the dorsal guidance of behavior by internal working models that prevent stress and drugs from shifting activity in the corticostriatal loops toward dominance of less adaptive control. In Figure 9.3 we show how oxytocin and social attachment differ from stress and drug abuse in the way they restructure and facilitate shifts in the brain mechanism of Figure 9.2. We propose that modulation by oxytocin facilitates a shift from ventral striatal novelty processing towards dorsal striatal familiarity processing. This involves the formation of internal working models that include social relationships associated with them and perhaps some habits. The internal working models will decrease emotional reactivity and provide resources to fall back on for optimistic coping (Figure 9.3A). This shift follows the cortical path. By contrast, an important aspect of drug addiction and stress effects is the reduced functioning of cortical control. Instead of the cortical path, stress and drugs of abuse, such as psychostimulants, may increase the activation of the midbrain DA path (Figure 9.3B). Cortex

Ventral control pathway A

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resilience

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oxytocin

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drugs of abuse, stress

Substantia nigra VTA

B

Figure 9.3 Schematic depiction of how oxytocin and attachment may differ from drug abuse and stress effects in the way they restructure and facilitate shifts in the brain mechanisms (described in Figures 9.1 and 9.2). VTA = ventral tegmental area.



This pathway will not facilitate the formation of internal working models and social relations associated with them but will instead support the formation of drug-related habits. In addition, the failure to activate cortical controls in anxiety (perhaps because of the perceived unpredictability of the social or material environment) may prevent the formation of internal working models that would allow habituation and familiarization with the context.

OXYTOCIN AND ATTACHMENT: THE ASCENDING SPIRAL FROM NOVEL TO FAMILIAR As far as we know, the hypothesis that oxytocin and attachment induce a shift away from novelty responding in the ventral striatum and move toward stable attachment with a familiarized partner in the dorsal striatum has not been studied directly. Most studies have investigated the interaction between oxytocin and DA in the ventral striatum that facilitates the formation of pair bonds (Liu & Wang, 2003). However, human neuroimaging studies of attachment consistently show dorsal striatum (caudate nucleus) activation. Moreover, the first animal studies have recently reported that the three neuromodulators through which oxytocin exerts many of its effects induce a ventral to dorsal shift in corticostriatal processing. For two of those three neuromodulators this shift was found in the context of partner attachment formation, while the third one has also been implicated in attachment. The three neuromodulators were DA, endogenous opioids (morphine-like), and serotonin respectively (discussed in Tops et al., 2010). The evidence of DA involvement comes from studies on partner-preference learning in prairie voles, a much-studied species in investigations of monogamy and social affiliation. The monogamous prairie vole (Microtus ochrogaster) has proven to be an excellent model for neurobiological investigations of pair bonding (Carter, DeVries, & Getz, 1995). This species shows selective affiliation toward an established partner. A reliable behavioral index of pair bond formation in the prairie vole is the development of a preference for a familiar mate over a conspecific stranger, referred to as partner preference. Although partner preference is a prerequisite for pair bonding, this behavior alone does not entirely define a pair bond. A pair bond is only fully established when unfamiliar conspecifics, including potential mates, are aggressively rejected (Aragona et al., 2006; Carter et al., 1995). This selective aggression is the primary behavior responsible for the stable maintenance of a pair bond. Neurobiological changes support the dramatic behavioral transformation from affiliative approaches associated with partner-preference formation to avoidance and selective aggression toward unfamiliar conspecifics. Involved here are the opposing effects of DA in ventral versus dorsal striatal projections that depend on the stage of pair bond development (Aragona et al., 2006). Endogenous opioids mediate some of the effects of oxytocin on attachment. Recent evidence in prairie voles suggests that endogenous opioid receptors in the dorsal striatum are necessary for the formation of steady couples’ relationships (Burkett, Spiegel, Inoue, Murphy, & Young, 2011). Because the dorsal striatum is involved in the learning of goaldirected behaviors and habit formation, this suggests that brain circuits associated with habit and familiarity may be crucial in establishing stable social relationships (Furay & Neumaier, 2011). Burkett et al. (2011) also suggest that attachment formation involves a process that shifts processing from ventral to dorsal striatum (Figure 9.2).

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OXYTOCIN FACILITATES A SHIFT FROM NOVELTY TO FAMILIARITY PROCESSING As discussed above, there is indirect evidence that oxytocin facilitates a shift from ventral striatal novelty processing toward dorsal striatal familiarity processing. In this section we will discuss whether this general function provides a framework for understanding oxytocin functions in adult humans. At least three processes are required in order for stable attachment to develop: (1) There should be habituation to anxiety triggered by the novel social partner. Novel social environments and interaction partners may elicit some anxiety and initially may even be experienced as aversive. But, for attachments to develop, such defensive responses need to dissipate during familiarization. (2) Reactive reward responses or “wanting” elicited by novel social partners should give way to stable “liking” and preference for the attachment partner through consolidation in internal working models that will incorporate the individual’s reward history and prospective future goals and plans. (3) Reactive reward responses elicited by novel alternative social partners should give way to the derogation of attractive alternatives to the attachment partner. This may be the human equivalent of animal avoidance/selective aggression toward unfamiliar conspecifics. These three processes can be seen as involving a shift away from reactivity associated with novelty and a move toward familiarity processing, shown in Figure 9.4. We have discussed the role of oxytocin in shifting reactive reward responding to social partners toward stable liking and preference of the attachment partner. For a review of the sparse research of the role of oxytocin in human attachment we refer the reader to Feldman (2012). We will now discuss the role of oxytocin in the other two attachment processes involving habituation and derogation in the context of studies on the application of intranasal oxytocin and peripheral oxytocin in human adults. To fill in the gaps in human research, we will mention relevant animal studies. While there is debate about the delivery route of intranasal oxytocin or whether peripheral oxytocin reflects central activity, the human data on the relationship between oxytocin, prosocial interactions, and the stress response appear consistent in their findings and are supported by more direct evidence from animal models.

HABITUATION TO SOCIAL NOVELTY: THE FAMILIARIZATION– HABITUATION RESPONSE Oxytocin increases affiliative behavior and decreases anxiety in humans and animals (Bartz, Zaki, Bolger, & Ochsner, 2011; Neumann, 2008). It has been proposed that a unifying principal in oxytocin action in the brain may be to facilitate social encounters in novel environments and encounters with unfamiliar others that are achieved by reducing the associ-

Fear habituation “familiarization–habituation response”

Novel

Familiar

Reward Derogation of alternatives

Attachment

Figure 9.4 Sub-processes of attachment formation that involve a shift from novelty toward familiarity processing.



ated uneasiness and anxiety (Carter, 1998; McCarthy, 1995). Anxiolytic effects of oxytocin have been demonstrated in a variety of species. Neuroimaging studies show that oxytocin decreases responses to aversive stimuli in the reactive ventral avoidance system, such as in the amygdala (Bartz et al., 2011).2 Social support following intense psychological stress can promote the release of oxytocin while attenuating the physiological and behavioral stress response toward a subsequent stressor in pair-bonded female prairie voles (Smith & Wang, 2012). Social support attenuates the cortisol response, increases peripheral oxytocin (Grewen, Girdler, Amico, & Light, 2005), and increases calmness during psychosocial stress in humans. Intranasal oxytocin treatments can potentiate these calming effects (Heinrichs, Baumgartner, Kirschbaum, & Ehlert, 2003; Quirin, Kuhl, & Düsing, 2011). Finally, habituation of autonomic arousal predicted higher trust-related oxytocin release, a result that may reflect facilitation by oxytocin on habituation of autonomic arousal and distress responses (Kéri & Kiss, 2011; Kiss, Levy-Gigi, & Kéri, 2011). Recent studies of intranasal application of oxytocin and measures of peripheral levels of oxytocin demonstrated the involvement of oxytocin in interpersonal trust and cooperation (reviewed by Bartz et al., 2011; Campbell, 2010). During interaction with strangers, intranasal oxytocin reduces fear of being exploited and betrayed; and it increases trust. Trust may be a social-specific elaboration of more general mechanisms of habituation and familiarization. This function of oxytocin may be seen as having a role in social attachment processes, but also in stress coping and habituation processes. Recent findings show that stress selectively strengthens the memory of first impressions of others’ positive personality traits (Lass-Hennemann, Kuehl, Schulz, Oitzl, & Schachinger, 2011). Other results suggest that intranasal oxytocin may increase judgments of trustworthiness and of positive traits. Oxytocin is increased in response to stress. At the same time, intranasal oxytocin increases sensitivity to socially rewarding stimuli that signal that the social environment allows for increases in trust. In turn, higher trust predicts lower social stress responses (Takahashi et al., 2005). Indeed, in subjects who were ostracized or included during a virtual ball-tossing game, intranasal oxytocin increased the included participants’ desire to play again with the same participants (Alvares, Hickie, & Guastella, 2010). Intranasal oxytocin selectively increased recognition and memory for positive faces in comparison to neutral and angry faces (reviewed by Graustella & MacLeod, 2012). In women higher peripheral oxytocin levels related to perceiving faces as happier (Rubin et al., 2011). Intranasal oxytocin increased cooperation only when participants became familiar with their interaction partner or formed first impressions (Declerck, Boone, & Kiyonari, 2010), and when protagonists were described as trustworthy or were familiar (De Dreu et al., 2010; Mikolajczak et al., 2010). Similarly, mothers displayed higher oxytocin levels when familiarizing themselves with children than when interacting with their own children (Bick & Dozier, 2010). Together, these results suggest that oxytocin may increase sensitivity to signals of social safety and, in response to such signals, oxytocin facilitates the habituation of stress responses. In other words, oxytocin may facilitate “familiarization–habituation” responses to stress and social novelty.

DEROGATION OF SOCIAL ALTERNATIVES Human behavioral research shows that, in a way that is similar to the animal avoidance and selective aggression toward unfamiliar conspecifics, romantically involved participants implicitly derogate the attractiveness of alternative partners. In a neuroimaging study, the

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free ebooks ==> www.ebook777.com Oxytocin and Attachment Facilitate a Shift 125 successful derogation of attractive others corresponded with increased activation in the inferior frontal gyrus (IFG, an important ventral control area) and increased activation of posterior dorsomedial prefrontal cortex, but with decreased activation in the ventral striatum. In addition, activation in the right IFG correlated with participants’ level of relationship investment. These findings suggest that the right IFG may play a particularly important role in regulating the emotions that threaten the stability of a romantic relationship (Meyer, Berkman, Karremans, & Lieberman, 2011). This is consistent with the role of this brain area involved in untrustworthy judgments and antagonistic responding (lowering of trust) to unreciprocated cooperation (Rilling et al., 2012). The involvement of oxytocin in the derogation of unfamiliar alternate partners is supported only indirectly by a few intranasal oxytocin studies. Stronger effects of oxytocin on trust and cooperation were observed when protagonists were familiar rather than unfamiliar to the individual (reviewed by De Dreu et al., 2010; De Dreu, 2012). When the people to be trusted were anonymous strangers, the effects of oxytocin were statistically weak or absent. Declerck et al. (2010) found that, without prior positive interaction, oxytocin actually led to less cooperation than a placebo and appeared to increase distrust. Finally, De Dreu and colleagues found evidence that oxytocin increased the motivation for non-cooperation in interactions with rival groups, especially when the rival group represented a threat to the group to which the individual belonged (see De Dreu, 2012; De Dreu et al., 2010). In summary, although no direct evidence in humans regarding oxytocin effects on derogation of attachment partner alternatives is available, person derogation appears to involve the same brain mechanisms through which oxytocin regulates levels of trust. Moreover, oxytocin appears to have some defensive detrimental effects on trust and cooperation with unfamiliar strangers. Given the role of derogation of alternatives in the maintenance of attachment and the role of oxytocin in mate guarding (L. Young, Wang, & Insel, 1998), the regulation by oxytocin in the derogation of alternatives is a plausible hypothesis awaiting research in humans.

DISCUSSION We conclude by highlighting three processes that support resilience. The Power of Early Positive Experience Social experiences and the presence, nature, and quality of social attachments and interactions during early development and throughout life can greatly influence the susceptibility to drug abuse and the negative effects of stress. Indeed, perturbations in the social environment, particularly during early development, can increase the vulnerability to drug abuse later in life, while the development of strong social attachments, including parent–offspring and adult pair bonds, may protect against substance abuse (K. Young et al., 2011). The sensitivity of the oxytocin system, as well as steroid hormones and the related neuropeptide vasopressin, is thought to be altered by early social experiences on adult behavior (Cushing & Kramer, 2005). Furthermore, these systems interact with mesocorticolimbic DA to mediate social stress (Liu & Wang, 2003), and drug-related behaviors (K. Young et al., 2011). We suggest that positive early experiences facilitate the development of important internal working models that the individual can later fall back on to decrease emotional reactivity. Positive early experiences may also increase trust in internal model guided control that may



facilitate novelty-to-familiarity processing shifts which help in the development and maintenance of new internal working models and attachments. Finally, parenting tactics such as reasoning may stimulate the development of reasoning skills in the child that are essential for mental activities supporting efficient building and maintenance of internal working models, perspective taking, and reappraisal coping. Familiarization–Habituation Responses to a novel environment and novel cage-mates, particularly at the level of exploration and familiarization, are frequently studied in animals to investigate individual differences in stress responsivity, DA function, and novelty seeking (Cools & Gingras, 1998; Dellu, Piazza, Mayo, Le Moal, & Simon, 1996). Similar paradigms are used to study caregiver–child attachment security in humans (Strange Situation Procedure, Ainsworth & Bell, 1970). A familiarization–habituation coping response would be important in such a paradigm by both influencing initial exploration and novelty seeking and facilitating habituation through familiarization. The familiarization–habituation coping response may be crucial to resilience and health, because it prevents costly mobilization of physiological resources (stress responses) every time a particular benign social context is encountered anew. We think that the results of human and animal studies strongly suggest that oxytocin serves as a modulator of a familiarization–habituation coping response. There is as yet scarce support for oxytocin’s direct involvement in an additional behavioral coping step consisting of alliance formation (De Dreu et al., 2010) and stress-induced motivation to interact with familiar others, a “familiarization habituation alliance coping response” (Taylor et al., 2000). To summarize, novel social contexts activate stress systems that allow people to habituate to the context and become familiar with it, such that on subsequent occasions no stress response is triggered. Oxytocin responses to novel social contexts are involved in this habituation. If positive social signals are available, increased levels of oxytocin will increase trust in the novel context. This will carry over to subsequent occasions in this context and decrease stress responses, including oxytocin responses. Oxytocin initially increases reactivity to positive social stimuli, decreases reactivity to aversive stimuli, and generally increases social awareness (Bartz et al., 2011). Oxytocin also facilitates the consolidation of information from the reactive social reward systems into long-term memory and internal working models. The formation of those models allows for a shift from reactivity towards stable attachment, social habit formation, and appreciation of familiarity. The availability of internal working models provides resources and access to prospective and “common sense” control that prevents reactive responding and reactivation of habits. Consilience In this chapter we have applied our biobehavioral model of brain function to attachment and oxytocin functions. This has resulted in a theory that shows remarkable similarity with John Bowlby’s (1988) classical attachment theory, which was originally limited to caregiver–child attachment. We suggest that our present theory could be a neuroendocrinological update to attachment theory. An additional strength of our theory is that we have applied it to very different domains, such as positive affect, emotion regulation, willpower, mindfulness, and attentional focus (Chapter 2). We have related those domains to the broader processes of resilience. In developing our work, we find that we have embraced consilience. In consilience a theory or generalization is invented or proposed to account for one set of phenomena that

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free ebooks ==> www.ebook777.com Oxytocin and Attachment Facilitate a Shift 127 often account for others as well (Whewell, 1840; Wilson, 1998). Theoreticians, researchers, and other thinkers exhibit consilience when they integrate their knowledge by making internal working models that capture and explain an idea or natural phenomenon. Attachment- and affiliation-related internal working models are very important for human adaptation because they provide access to important resources, such as social support, internalized safe base, and self-esteem. The concept of consilience could be extended to the personal level. A personal consilient theory of internal working models could match different available resilience interventions with the person’s context, personal experience, and resources. Methods and pathways toward resilience could be designed for more efficient and durable effects. Each person could integrate those pathways and methods with personal experiences in a consilient internal working model. We think our theory provides a framework that may facilitate this integrative process.

NOTES 1. It is important to distinguish between novelty seeking and exploration of novel environments. Attachment does not make novelty seeking possible, but facilitates exploration, familiarization, and learning in novel environments. “Novelty seeking” is a much-investigated trait and behavior that refers to reactive responding and preference of novelty. As a trait it is associated with negative unpredictable environments, maladaptive behavior, and insecure attachment. In secure attachment, internalization of a secure base in internal working models makes exploration of novelty and confrontation of pleasant and unpleasant stimuli possible. In fact, exploration of novel environments is important for the construction and maintenance of internal working models. The reactive reward system seeks out novelty, the reactive avoidance system avoids novelty, and the internal working model-guided system appropriately explores novelty to incorporate it in internal models. 2. Although neuroimaging studies of male subjects showed that oxytocin decreased activation by negative stimuli in ventral system areas such as the amygdala, anterior insula, and IFG, recent studies of female subjects showed increased activation by negative stimuli in those areas (Domes et al., 2010; Lischke et al., 2012; Riem et al., 2011). Indeed, sex differences in the effects and functions of oxytocin are very likely (e.g., Taylor et al., 2000), if only for the fact that many effects of oxytocin depend on estrogen levels. For this reason, it is a shortcoming of the field that most human intranasal oxytocin studies have been performed on males and most studies of peripheral levels have been performed on females. One reason for sex differences in oxytocin functions may be that oxytocin functions in partner attachment and affiliation may have derived from oxytocin functions in mothering and mother–infant attachment (Carter, 1998; Feldman, 2012). Indeed, increased oxytocin-induced responding in reactive ventral system areas to unpleasant stimuli in women may reflect preparation and facilitation of mothering behavior, which should include sensitivity to signals of distress and danger (Tops, 2010).

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free ebooks ==> www.ebook777.com Oxytocin and Attachment Facilitate a Shift 129 Graustella, A. J., & MacLeod, C. (2012). A critical review of the influence of oxytocin nasal spray on social cognition in humans: Evidence and future directions. Hormones and Behavior, 61, 410–418. Grewen, K. M., Girdler, S. S., Amico, J., & Light, K. C. (2005). Effects of partner support on resting oxytocin, cortisol, norepinephrine, and blood pressure before and after warm partner contact. Psychosomatic Medicine, 67, 531–538. Heinrichs, M., Baumgartner, T., Kirschbaum, C., & Ehlert, U. (2003). Social support and oxytocin interact to suppress cortisol and subjective responses to psychological stress. Biological Psychiatry, 54, 1389–1398. Hoyle, R. H., Fejfar, M. C., & Miller, J. D. (2000). Personality and sexual risk taking: A quantitative review. Journal of Personality, 68, 1203–1231. Kelley, A. E., Schochet, T., & Landry, C. F. (2004). Risk taking and novelty seeking in adolescence: Introduction to part I. Annals of the New York Academy of Sciences, 1021, 27–32. Kéri, S., & Kiss, I. (2011). Oxytocin response in a trust game and habituation of arousal. Physiology and Behavior, 102, 221–224. Kiss, I., Levy-Gigi, E., & Kéri, S. (2011). CD 38 expression, attachment style and habituation of arousal in relation to trust-related oxytocin release. Biological Psychology, 88, 223–226. Koob, G. F., & Volkow, N. D. (2010). Neurocircuitry of addiction. Neuropsychopharmacology, 35, 217–238. Kurzban, R., Dukes, A., & Weeden, J. (2010). Sex, drugs and moral goals: Reproductive strategies and views about recreational drugs. Proceedings of the Royal Society B: Biological Sciences, 277, 3501–3508. Lass-Hennemann, J., Kuehl, L. K., Schulz, A., Oitzl, M. S., & Schachinger, H. (2011). Stress strengthens memory of first impressions of others’ positive personality traits. PLoS One, 6, e16389. Lischke, A., Gamer, M., Berger, C., Grossmann, A., Hauenstein, K., Heinrichs, M., et al. (2012). Oxytocin increases amygdala reactivity to threatening scenes in females. Psychoneuroendocrinology, 37, 1431–1438. Liu, Y., & Wang, Z. X. (2003). Nucleus accumbens oxytocin and dopamine interact to regulate pair bond formation in female prairie voles. Neuroscience, 121, 537–544. McCarthy, M. M. (1995). Estrogen modulation of oxytocin and its relation to behavior. Advances in Experimental Medicine and Biology, 395, 235–245. McGregor, I. S., & Bowen, M. T. (2012). Breaking the loop: Oxytocin as a potential treatment for drug addiction. Hormones and Behavior, 61, 331–339. Meyer, M. L., Berkman, E. T., Karremans, J. C., & Lieberman, M. D. (2011). Incidental regulation of attraction: The neural basis of the derogation of attractive alternatives in romantic relationships. Cognition and Emotion, 25, 490–505. Mikolajczak, M., Gross, J. J., Lane, A., Corneille, O., Timary, P. de, & Luminet, O. (2010). Oxytocin makes people trusting, not gullible. Psychological Science, 21, 1072–1074. Neumann, I. D. (2008). Brain oxytocin: A key regulator of emotional and social behaviours in both females and males. Journal of Neuroendocrinology, 20, 858–865. Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. New York: Oxford University Press. Pedersen, C. A. (2004). How love evolved from sex and gave birth to intelligence and human nature. Journal of Bioeconomics, 6, 39–63. Piazza, P. V., Rougé-Pont, F., Deroche, V., Maccari, S., Simon, H., & Le Moal, M. (1996). Glucocorticoids have state-dependent stimulant effects on the mesencephalic dopaminergic transmission. Proceedings of the National Academy of Sciences of the United States of America, 93, 8716–8720. Pilkington, C. J. (1988). Perceptions of risk in intimacy. Journal of Social and Personal Relationships, 5, 503–508. Quirin, M., Kuhl, J., & Düsing, R. (2011). Oxytocin buffers cortisol responses to stress in individuals with impaired emotion regulation abilities. Psychoneuroendocrinology, 36, 898–904. Riem, M. M., Bakermans-Kranenburg, M. J., Pieper, S., Tops, M., Boksem, M. A., Vermeiren, R. R.,



et al. (2011). Oxytocin modulates amygdala, insula and inferior frontal gyrus responses to infant crying: A randomized controlled trial. Biological Psychiatry, 70, 291–297. Rilling, J. K., Demarco, A. C., Hackett, P. D., Thompson, R., Ditzen, B., Patel, R., et al. (2012). Effects of intranasal oxytocin and vasopressin on cooperative behavior and associated brain activity in men. Psychoneuroendocrinology, 37, 447–461. Rubin, L. H., Carter, C. S., Drogos, L., Jamadar, R., Pournajafi-Nazarloo, H., Sweeney, J. A., et al. (2011). Sex-specific associations between peripheral oxytocin and emotion perception in schizophrenia. Schizophrenia Research, 130, 266–270. Schwabe, L., Dickinson, A., & Wolf, O. T. (2011). Stress, habits, and drug addiction: A psychoneuroendocrinological perspective. Experimental and Clinical Psychopharmacology, 19, 53–63. Smith, A. S., & Wang, Z. (2012). Salubrious effects of oxytocin on social stress-induced deficits. Hormones and Behavior, 61, 320–330. Takahashi, T., Ikeda, K., Ishikawa, M., Kitamura, N., Tsukasaki, T., Nakama, D., et al. (2005). Interpersonal trust and social stress-induced cortisol elevation. Neuroreport, 16, 197–199. Taylor, S. E., Klein, L. C., Lewis, B. P., Gruenewald, T. L., Gurung, R. A., & Updegraff, J. A. (2000). Biobehavioral responses to stress in females: Tend-and-befriend, not fight-or-flight. Psychological Review, 107, 411–429. Tops, M. (2010). Oxytocin: Envy or engagement in others? Biological Psychiatry, 67, e5–e6. Tops, M., & Boksem, M. A. S. (2012). “What’s that?” “What went wrong?” Positive and negative surprise and the rostral-ventral to caudal-dorsal functional gradient in the brain. Frontiers in Psychology, 3, 1–5. Tops, M., Boksem, M. A. S., Luu, P., & Tucker, D. M. (2010). Brain substrates of behavioral programs associated with self-regulation. Frontiers in Psychology, 1, 1–14. Whewell, W. (1840). Philosophy of the inductive sciences, founded upon their history. London: Parker. Wilson, E. O. (1998). Consilience: The unity of knowledge. New York: Knopf. Young, K. A., Gobrogge, K. L., & Wang, Z. (2011). The role of mesocorticolimbic dopamine in regulating interactions between drugs of abuse and social behavior. Neuroscience and Biobehavioral Reviews, 35, 498–515. Young, L. J., Wang, Z., & Insel, T. R. (1998). Neuroendocrine bases of monogamy. Trends in Neurosciences, 21, 71–75.

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free ebooks ==> www.ebook777.com 10 Social Touch and Resilience Mary H. Burleson and Mary C. Davis

Resilience is the process by which individuals adapt successfully to acute or chronic challenge and adversity (see Preface, this volume). Initially studied in developmental contexts, it is now a focus in adult psychology, where it vies with risk-based models to explain behavior and health-related outcomes. Resilience researchers ask “Why are most people able to overcome trauma or misfortune, even to thrive in their wake, whereas others are critically damaged by these experiences?” Some answers to this question suggest a powerful resiliencepromoting role for interpersonal relationships and social connection (Cacioppo, Reis, & Zautra, 2011). As noted by Berkman and colleagues, relationships influence well-being by providing opportunities for social integration and engagement, giving and receiving social support, influencing and being influenced by others, experiencing positive and negative social interactions, and feeling companionship or loneliness (Berkman, Glass, Brissette, & Seeman, 2000). Relationships also provide opportunities for interpersonal touch, particularly physical affection. A large body of evidence suggests that interpersonal touch influences both short- and long-term well-being. Social touch is critical in primate social relations (Dunbar, 2010) and normal human development (Field, 2010), and can communicate emotion, influence behavior, and alter physiological responding (Gallace & Spence, 2010). The sense of touch develops before any other, and therefore is the medium through which we first experience the external world. Our largest sensory organ is the skin, which has receptors that preferentially detect and transmit emotional and hedonic qualities of tactile input (McGlone, Vallbo, Olausson, Loken, & Wessberg, 2007). These neural fibers project to cortical areas that are critically involved in our ongoing sense of self (Craig, 2002). Furthermore, as a form of communication, interpersonal touch preceded language in evolutionary time (Dunbar, 1996). Perhaps most basically, touch between individuals is an indisputable signal of their physical presence (hence their accessibility to each other), and may signal availability of social support or other resilience resources. In this chapter, we examine the extant literature to ask whether some resilience-promoting benefits of close social relations in the face of trauma and stress are mediated through physical affection. Strength-based research on stress and trauma support a model in which resilience begins, unfolds behaviorally and physiologically, and reaches an eventual outcome. In this context, key indicators of resilience processes include the level of reactivity to, and the rapidity and completeness of recovery from, stress or trauma. Resilience resources are stable qualities of persons and environments that can contribute to recovery, in part by promoting resilience processes (i.e., reduced or shorter reactivity). Resilience resources include qualities within individuals (e.g., positive emotion, Fredrickson & Levenson, 1998), relationships (e.g., social connectedness, Rook, 1987), and sociocultural milieus (e.g., social mores that promote well-being).


Mary H. Burleson and Mary C. Davis

Given the significance of social touch in human well-being, it is especially important to address its contribution to resilience. In this chapter, we describe how positive interpersonal touch, exemplified by physical affection, promotes resilience at multiple levels by enhancing resilience resources and resilience processes, thereby promoting both mental and physical health. We discuss the roots of social touch, consider the biopsychosocial impacts of affectionate touch in early development, and note the importance of the meaning and context of touch as determinants of its effects.

SOCIAL TOUCH, RESILIENCE RESOURCES, AND RESILIENCE PROCESSES IN PRIMATES As primates, humans have a phylogenetic legacy of social touch via grooming, in which one or more animals tend to another’s skin and fur. For apes and many other primates, social grooming is a critically important behavior whose functions include social cohesion (Dunbar, 2010) and stress reduction (Goodall, 1986; de Waal, 1989). Social grooming reduces behavioral indicators of stress and anxiety and increases behavioral indicators of relaxation. Receiving grooming is associated with significantly lower heart rate (HR) compared with self-grooming or initiating grooming, and with HR decline following aggression (Boccia, Reite, & Laudenslager, 1989). Grooming also may buffer against immunosuppression from chronic social stress (Cohen, Kaplan, Cunnick, Manuck, & Rabin, 1992 ). These effects are likely mediated by endogenous opioid increases (reviewed in Dunbar, 2010). As humans differentiated from apes, the hygienic aspect of social grooming became less important—while, at the same time, humans’ increasingly complex and intense social relationships enhanced the scope and importance of tactile communication to facilitate bonding, maintain social cohesion, and reduce stress (Dunbar, 2010). As a category of behaviors among humans, interpersonal touch encompasses a wide range, from casual, even inadvertent, contact through handshakes and hugs to full body massage or sexual relations. This chapter focuses primarily on physical affection, defined by Gulledge and colleagues as “any touch intended to arouse feelings of love in the giver and/or the recipient” (Gulledge, Gulledge, & Stahmann, 2003, p. 234). To better focus discussion, we propose also that physical affection must be appropriate to the setting (thereby reducing potential embarrassment or social discomfort), must not interfere with goal-directed behavior (thereby reducing potential impatience), and must not be oriented toward immediate sexual gratification (thereby drawing a distinction between affection and sexual behavior). These criteria highlight the importance of context—cultural, social, and interpersonal—as well as individual perceptions of the meaning of the touch. Furthermore, because interpersonal touch can activate brain reward systems (see below), it must be hedonically positive or neutral (i.e., not aversive, as in a too-strong hug) to be fully effective. How Does Physical Affection Enhance Resilience Resources? Social Bonds in Infancy Multiple theoretical perspectives (e.g., attachment, ethology, social learning), along with conventional wisdom, suggest that infant and childhood experiences shape adult behavior and health. Empirical research with both humans and non-human animals strongly supports this notion, making it important to understand how early experiences foster or discour-

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free ebooks ==> www.ebook777.com Social Touch and Resilience 133 age later resilience. Nurturant touch is a crucial component of these experiences. Animal research has provided much information about its importance and the mechanisms underlying its effects. Harlow and colleagues demonstrated long ago that touch is more motivating to infant monkeys than food; ordinarily, primates spend their first weeks in constant physical contact with their mothers, and monkey infants deprived of touch do not develop normally either physically or socially (Harlow, Harlow, & Hansen, 1963; Sanchez, Ladd, & Plotsky, 2001). Maternal touch also is critical among rodents. Along with feeding, warming, and retrieving pups, rodent mothers typically lick and groom them extensively. The amount of maternal tactile stimulation received by pups influences multiple adult behavioral outcomes, including stress resilience and cognitive functioning, both of which are better in animals that receive more postnatal licking and grooming (Diorio & Meaney, 2007; Liu, Diorio, Day, Francis, & Meaney, 2000). Further, some effects of maternal absence can be reversed by stroking pups using a small brush (Diorio & Meaney, 2007), suggesting that specific tactile stimulation is required to regulate specific developmental processes (Hofer, 1994). Thus, data from both rodents and primates suggest strongly that early touch influences resilience by permanently altering physiological and behavioral stress reactivity and recovery. Recent studies suggest that these long-term effects of maternal touch on stress responses in animals occur through complex neuroendocrine and epigenetic processes. For example, Pedersen and Boccia (2002) reviewed studies describing how oxytocin, maternal touch, and stress responses are related. When lactating rats receive oxytocin antagonists, they lick their pups less. In adult brain areas where oxytocin reduces anxiety and hypothalamic-pituitaryadrenal (HPA) axis responses to stress (i.e., the amygdala and hypothalamus), oxytocin receptor density is positively related to amount of licking received during infancy (indicating higher expression of the oxytocin receptor gene, thereby enhancing regulation of stress responses, in more-licked pups). And, when female rat pups are given oxytocin or oxytocin antagonists, their own levels of maternal licking when they have pups are increased or decreased, respectively. Together, these studies suggest that maternal licking stimulates central oxytocin activity in female pups, which influences oxytocin receptor expression, thereby altering stress responses (and maternal behavior) over the long term. Via a similar mechanism, maternal behavior seems to permanently alter expression of the glucocorticoid receptor gene in relevant brain areas, and therefore the HPA axis response to stress (Diorio & Meaney, 2007). Although less is known about the underlying mechanisms, there is extensive evidence that touch is similarly essential for optimal growth and development of human infants, thereby promoting resilience in infancy and helping lay the foundation for lifelong mental and physical health. Although humans do not lick their newborns, they do engage in a predictable pattern of touching them, which may serve a similar purpose (Trevathan, 1981). Researchers have studied primarily two touch interventions in infancy: ventral skin-to-skin contact between mothers and newborns (ranging from placement of the infant on the mother as soon as the airways are cleared after birth to sessions of skin-to-skin contact days after delivery), and systematic gentle but firm massage of young infants. Touch appears to have immediate resilience-promoting effects on infant physiological processes. Ventral skin contact soon after birth fosters regulation of basic physiological processes such as temperature control and digestion (Winberg, 2005) and is associated with faster establishment of heart rate stability (Takahashi, Tamakoshi, Matsushima, & Kawabe, 2011). It also appears to promote lower levels of cortisol (Takahashi et al., 2011) and betaendorphin (Mooncey, Giannakoulopoulos, Glover, Acolet, & Modi, 1997), both of which



typically increase under stressful conditions. It improves breastfeeding outcomes (Moore, Anderson, Bergman, & Dowswell, 2012) and appears to promote faster weight gain (Anderson, 1991) in the first few months. Skin contact later in infancy can lower cortisol (Gitau, Modi, Giannakoulopoulos, Bond, & Glover, 2002) and reduce acute pain (Riddell et al., 2011). Infant massage also enhances health and well-being, at least for pre-term infants. Massaging these infants can decrease cortisol (Acolet et al., 1993) and increase vagal activity (Diego et al., 2006), which is associated in infants with effective environmental engagement (Bazhenova, Plonskaia, & Porges, 2001). Positive physical contact also can enhance long-term resilience resources. Both early skin contact and other warm touch during infancy boost subsequent attachment security, development of infants’ social agency, infant self-regulation, and mutuality and reciprocity in mother–child interactions (Bystrova et al., 2009). These findings are especially important for resilience because secure infant attachment predicts better psychosocial and physical health in childhood (Fearon, Bakermans-Kranenburg, Van IJzendoorn, Lapsley, & Roisman, 2010) and adulthood (Maunder & Hunter, 2001; Puig, Englund, Collins, & Simpson, 2013). Social Bonds in Adulthood Touch may be similarly important in the formation and maintenance of adult relationships. Among adults, a committed romantic partner benefits both mental (Simon, 2002) and physical (Burleson, Roberts, Vincelette, & Guan, 2012) health, but only if the relationship is good. Good romantic relationships provide affection, support, companionship, and most other important aspects of social connection. A committed romantic partner is often a secure attachment figure; both global attachment security and mental models of secure attachment within specific relationships are strongly linked to relationship satisfaction. As described below, attachment both fosters and is fostered by physical affection. Marital-type relationships afford abundant opportunities for physical affection, and relationship satisfaction is positively related to level of physical affection in marriages (Svetlik, Dooley, Weiner, Williamson, & Walters, 2005) and other romantic relationships. In a study of long-lasting marital-type relationships (average 30 years), physical affection was cited as crucial for enhancing psychological intimacy (Mackey, Diemer, & O’Brien, 2000). Because physical affection contributes in distinctive and important ways to positive affect and reward, co-regulation, and stress reduction (see below), it seems an ideal mediator of relationship influences on health. Thus, satisfying marital-type relationships may enhance mental and physical health at least partially through affectionate touch. Affection exchange theory (Floyd, 2006) proposes a fundamental need to give and receive affection, the fulfillment of which enhances romantic and platonic pair-bonding and confers psychological and physiological benefits. In one experiment that explicitly examined physical affection separately from other affectionate communication, increases in kissing led to lower perceived stress and higher relationship satisfaction (Floyd et al., 2009). Another study focused on the relation between childhood physical affection and current depression symptoms. Using a cross-sectional survey, Takeuchi et al. (2010) found self-reports of more childhood affection predicted fewer current depression symptoms. Far more is known about links between physical affection and physiological indicators. Not surprisingly, given the effects of social touch and affiliative reward on endogenous opiates, oxytocin, and autonomic nervous system responding (reviewed below), physical affection is associated generally with more favorable indicators, and multiple studies document direct relationships between touch with a relational partner and physical symptom reports

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free ebooks ==> www.ebook777.com Social Touch and Resilience 135 or cardiovascular, neuroendocrine, and/or immune system biomarkers. Physical contact in these studies included: neck and shoulder massage (Ditzen et al., 2007; Holt-Lunstad, Birmingham, & Light, 2008); kissing (Floyd et al., 2009; Kimata, 2003, 2006; Matsunaga et al., 2009); physical intimacy, either undefined (Stadler, Snyder, Horn, Shrout, & Bolger, 2012), or defined as holding hands, touching, hugging, kissing, or sexual interaction (Ditzen, Hoppmann, & Klumb, 2008); and nonverbal affection (Floyd et al., 2007). Pleasure and Reinforcement For species whose newborns require parental care to survive, behaviors that promote ongoing parental attention and support (i.e., attachment and caregiving behaviors such as proximity and physical contact) are inherently reinforcing for both parents and offspring (Bowlby, 1969). Although not all researchers agree, many argue that an attachment/caregiving neural system provides the underlying developmental framework for other affiliative behaviors later in life (see Depue & Morrone-Strupinsky, 2005). Indeed, Bartels and Zeki showed that, although they are not isomorphic, maternal and romantic love overlap in the brain, activating many of the same regions in striatum, insula, and cingulate cortex, and deactivating many of the same regions in prefrontal cortex (Bartels & Zeki, 2000, 2004). Social touch stimuli are especially potent activators of social reinforcement. For example, among female rats, contact with pups on the snout (e.g., when the dam investigates pups) or ventral surface (e.g., when pups attempt to nurse) induces both maternal behavior and a strong conditioned place preference associated with pups (Fleming, Korsmit, & Deller, 1994). On the other hand, visual, auditory, and olfactory stimuli from pups are insufficient to evoke either full maternal behavior or the associated powerful reinforcement. Many animals, particularly primates, find physical contact with conspecifics to be rewarding (see below). And, even when delivered by humans, gentle touch is an effective reinforcer for training dogs, cats, chimpanzees, and rhesus monkeys (reviewed in Taira & Rolls, 1996). Depue and Morrone-Strupinsky (2005) describe this underlying process of affiliative reward as “a core capacity to experience reward elicited by specific affiliative stimuli, especially those that involve both sexual touch and nonsexual soft, caressive tactile stimulation” (p. 374, italics added). This type of reward is consummatory rather than appetitive, and activates the “liking,” rather than the “wanting,” centers of the brain (Robinson & Berridge, 1993). Much research suggests that it is likely to be mediated significantly by endogenous opioid mechanisms (Depue & Morrone-Strupinsky, 2005). Another neuropeptide, oxytocin (and possibly the related neuropeptide vasopressin), appears also to play a critical role in affiliative reward processes and hence resilience (see Tops, Buisman-Pijlman, & Carter, Chapter 9, this volume). In humans and other animals, activity in oxytocin neurons is elicited by multiple kinds of social and sexual stimuli, most of which involve some kind of interpersonal touch (IsHak, Kahloon, & Fakhry, 2011). Researchers have proposed that oxytocin lowers the threshold for activating affiliative reward (Depue & Morrone-Strupinsky, 2005), influences social approach and withdrawal (Kemp & Guastella, 2011), and facilitates formation of affiliative memories (Winslow & Insel, 2004), all of which promote social bonds and thereby enhance resilience resources. Oxytocin administration can also enhance trust, reduce anxiety, and lower stress responses (MacDonald & MacDonald, 2010). Parallel to the central mechanisms discussed above, there are peripheral specializations for physical affection. Humans (and other mammals) possess somatosensory nerve fibers dedicated to detection of affiliative touch (Olausson et al., 2002). The rewarding emotional



properties of touch appear to be mediated by low-threshold slow-conducting fibers (C-tactile or CT fibers) that respond preferentially to slowly moving, low-intensity mechanical deformation of the skin surface such as caressing or stroking—or perhaps grooming (McGlone et al., 2007). CT fibers activate the posterior insula and orbitofrontal cortex, which integrate autonomic and sensory information into emotional percepts (Damasio, 1999). As such, they register hedonic value and likely contribute both to interoception (Craig, 2002) and to emotional, physiological, and behavioral responses during affiliative behavior (Olausson et al., 2002). Both insular cortex responses and ratings of touch pleasantness are lower among individuals with a low density of these fibers (Morrison et al., 2011). In addition, insular cortex response is modulated more strongly by touch from another person than by the same contact delivered using an object such as a padded stick (Kress, Minati, Ferraro, & Critchley, 2011), further supporting its role in affiliative touch. Associative Conditioning As noted above, positive touch activates primary reinforcement; it can therefore encourage particular responses. However, like all other sensory experiences, it is also a stimulus, and as such can be classically conditioned to elicit additional responses (Gallace & Spence, 2010). Depending on their nature, conditioned responses may either add to or detract from the reinforcing and relaxing qualities of the touch stimulus. For example, a positive feedback loop may develop in which physical affection triggers relaxation and parasympathetic activation, which are then further linked with the tactile sensations of affection through associative conditioning, thus increasing the ability of the tactile stimuli to elicit relaxation. The pleasure and relaxation that are naturally triggered by affiliative touch can also be conditioned to other stimuli, such as the affiliative partner, who then becomes a conditioned stimulus for pleasure and relaxation. This process likely contributes to the phenomenon of co-regulation, which is thought to be a primary pathway through which attachment relationships foster well-being (Sbarra & Hazan, 2008). In co-regulation, each partner serves as a primary regulator of the other’s ongoing physiological and psychological state. To the extent that these mutually regulated states are optimal for the context, co-regulation can enhance resilience, particularly through physical touch. How Does Physical Affection Influence Resilience Processes? Affectionate touch is central to establishing and maintaining strong long-term social bonds, but touch may also prove critical to promoting effective responding in the face of acute stress or trauma. Here we turn our attention to the potential influence of physical affection on resilience processes that mitigate the immediate effects of stress and its aftermath. Enhanced Positive Emotion Liking and loving are hedonically positive feelings. Because physical affection is an expression of liking or love, giving and receiving it are hedonically positive experiences. Lamm and Wiesmann (1997) found that the most frequently cited indication of liking or loving a person was the experience of positive mood when being with or thinking about that person, suggesting that the expression of liking or loving is likely to stimulate other positive emotions. In a daily diary study, the occurrence of physical affection on a given day predicted lower negative mood on the following day, and positive mood on a given day predicted physical

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free ebooks ==> www.ebook777.com Social Touch and Resilience 137 affection on the following day (Burleson, Trevathan, & Todd, 2007). Thus, although this idea has not been tested explicitly, one direct effect of giving or receiving physical affection is likely to be the stimulation of other positive emotions. In turn, positive emotion may encourage physical affection, resulting in a positive feedback loop that enhances both. In turn, positive emotion enhances recovery from stress (Fredrickson & Levenson, 1998). Touch as an Indicator of Presence Social baseline theory (Coan, 2008) suggests that humans (and other social species) are adapted to take for granted that other individuals of their species will be nearby. By merely being present, conspecifics lower both the perceived and the actual costs of interacting with the environment, by taking on some of the risk and burden of environmental engagement. These effects are stronger when the other individual(s) are allies or attachment figures. If social baseline theory is correct, physical affection should reduce stress responses, if only because it is proof of the immediate physical proximity of a trusted social partner, and thereby presumably reduces the perceived demands of the situation. Some available data shed light on this possibility. Using functional magnetic resonance imaging (fMRI), Coan, Schaefer, and Davidson (2006) monitored brain activation in married women who were anticipating receiving a mild electric shock. While they were holding hands with their husbands or with an unfamiliar male experimenter, neural activation in brain areas that are responsive to threat was lower, compared to when they were not holding hands with anyone. Even more interesting, wives’ marital quality ratings were negatively related to this threat-related brain activation, but only while holding their husbands’ hands, suggesting that the meaning of the physical contact was important. Another study found that holding a male partner’s hand led to lower pain ratings among women during moderate pain induced in a laboratory (Master et al., 2009). Stress Reduction The affiliative reward of physical affection is accompanied by physiological quiescence and behavioral calmness (Depue & Morrone-Strupinsky, 2005). This relaxation is partially mediated by vagal activation, which reduces HR and blood pressure (BP) and stimulates digestion. Central opioid release in affiliative reward also induces prefrontal inhibition of the HPA axis and the sympathetic branch of the autonomic nervous system (Sullivan & Gratton, 2002), both of which are strong contributors to peripheral stress responses, and the locus coeruleus, which typically regulates central arousal to optimize task performance (AstonJones & Cohen, 2005). It thus appears that, when it is appropriate to the context, physical affection has built-in hedonic and regulatory qualities that are incompatible with stress and negative emotions, and can thereby promote resilience in a very direct way. Such physiological benefits of affiliative touch are apparent in infants. The “still face” procedure, in which the caregiver is present but maintains a neutral facial expression and does not interact with the infant, typically elicits distress. However, Feldman, Singer, and Zagoory (2010) showed that, if actively touched by their caregivers during the still-face procedure, infants reacted with more smiling and less grimacing, less vagal withdrawal, less cortisol release, and faster cortisol recovery afterward. They concluded that touch attenuated stress reactivity by both “dampening the intensity of the response and increasing the system’s resilience following stress, two functions that play a central role in the organism’s adaptation to its environment” (p. 276). Infant nurturing behaviors appear also to reduce



acute stress responses in the nurturers. For example, mothers who held their infants for 10 minutes before a speech stressor had lower systolic BP during the stressor than those who did not (Light et al., 2000), and gentle massage of infants lowered cortisol levels in older volunteers (Field, Hernandez-Reif, Quintino, Schanberg, & Kuhn, 1998). Other researchers have studied relations between physiological indicators of stress and combinations of social interaction and physical affection among adults. For example, Grewen and colleagues used “warm partner contact” as a treatment condition in two studies. Warm partner contact comprised positive, relationship-focused verbal interaction (including talking about a subject that enhanced feelings of closeness to the partner and watching a five-minute romantic video) while maintaining physical contact (e.g., holding hands or sitting close to each other) for 10 minutes, followed by a full ventral hug lasting 20 seconds. The warm contact group had lower BP and HR responses to laboratory stressors (Grewen, Anderson, Girdler, & Light, 2003). These results suggest that physical affection promotes healthier stress responses; but, because the manipulation also included social interaction, the effects cannot be definitively attributed to physical affection. In an experiment addressing this issue, Ditzen et al. (2007) separately manipulated verbal social support and positive physical contact. Female participants received neck and shoulder massage or verbal support from their male partners, or waited alone, before performing laboratory stress tasks. Only those in the touch condition had lower cortisol and HR responses compared to the alone condition. Building on these results and on others from animal studies, other researchers have examined relationships among physical affection, oxytocin, and stress responses. For example, Ditzen et al. (2009) gave married or cohabiting couples an oxytocin nasal spray (which can enter the brain) or a placebo before a laboratory conflict interaction. Couples who received oxytocin behaved more positively and had smaller cortisol responses to the conflict. Similarly, couples with higher blood levels of oxytocin were more positive during a laboratory conflict interaction (Gouin et al., 2010). Oxytocin may also moderate more stable physiological processes not related to acute stress. For example, individuals with higher circulating oxytocin healed more quickly from experimentally created skin wounds (Gouin et al., 2010). Grewen and colleagues found that women’s blood levels of oxytocin were negatively related to BP, HR, and norepinephrine levels both at baseline (Light, Grewen, & Amico, 2005) and after warm partner contact (Grewen, Girdler, Amico, & Light, 2005). Blood oxytocin level partially mediated a relationship between reported typical frequency of spousal hugging and baseline blood pressure (Light et al., 2005). Further, Holt-Lunstad and colleagues found that an experimental manipulation to increase daily positive physical contact over four weeks increased salivary oxytocin compared to the control group (Holt-Lunstad et al., 2008). Single short-term touch interventions, however, may be insufficient to raise oxytocin—in one experiment where women in the treatment group received neck and shoulder massages from their husbands, peripheral oxytocin levels did not differ between the groups (Ditzen et al., 2007).

CONCLUDING COMMENTS In this chapter, we framed physical affection as a factor that not only contributes to the development and maintenance of stable resilience resources, including secure social bonds, but also initiates more resilient processes during stress, including more efficient biopsychosocial stress responses. Although affiliative touch has built-in effects, it is likely that these

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free ebooks ==> www.ebook777.com Social Touch and Resilience 139 effects can be augmented, diminished, or substantively altered, depending on its meaning, which is strongly influenced by cultural, situational, interpersonal, and individual characteristics. For example, attitudes toward and meanings of social touch appear to vary extensively both across and within cultures, as do norms regarding its frequency and appropriateness in different settings (Marler, Cox, Simmering, Bennett, & Fuller, 2011; McDaniel & Andersen, 1998). Dyadic characteristics are also important for the interpretation of touch. It is reasonable to speculate that relationship satisfaction and quality may influence both the frequency and the meaning of physical affection within a dyad, which in turn may influence its physiological effects. Indeed, Diamond (2001) proposed that participation in a secure long-term attachment might eventually “retune” patterns of physiological reactivity to enhance co-regulation and recovery from stress (see above). Finally, individual differences such as attachment style, attitudes about touch, and history of touch experience may also influence the effects of physical affection. For example, global attachment style has been related to preferences for and perceptions of physical contact, such that secure and ambivalent individuals were more comfortable with and preferred more interpersonal touch than avoidant individuals (Brennan, Wu, & Loev, 1998). The wealth of evidence gleaned from human and nonhuman animals to date has established the importance of affectionate touch for health and well-being throughout life. As is true in most fields of inquiry, the greater our base of knowledge, the more clearly we can see the myriad questions that remain to be answered. We hope that this perspective encourages future research using cutting-edge approaches to increase our understanding of this central and far-reaching domain of life.

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Burleson, M. H., Trevathan, W. R., & Todd, M. (2007). In the mood for love, or vice versa? Understanding the relations among physical affection, sexual activity, mood, and stress in the daily lives of mid-aged women. Archives of Sexual Behavior, 36, 357–368. Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A. S., Ransjo-Arvidson, A. B., Mukhamedrakhimov, R., et al. (2009). Early contact versus separation: Effects on mother–infant interaction one year later. Birth-Issues in Perinatal Care, 36, 97–109. Cacioppo, J. T., Reis, H. T., & Zautra, A. J. (2011). Social resilience: The value of social fitness with an application to the military. American Psychologist, 66, 43–51. Coan, J. A. (2008). Toward a neuroscience of attachment. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed., pp. 241–265). New York: Guilford Press. Coan, J. A., Schaefer, H. S., & Davidson, R. J. (2006). Lending a hand. Psychological Science, 17, 1032. Cohen, S., Kaplan, J. R., Cunnick, J. E., Manuck, S. B., & Rabin, B. S. (1992). Chronic social stress, affiliation, and cellular immune response in nonhuman primates. Psychological Science, 3, 301–304. Craig, A. D. (2002). How do you feel? Interoception: The sense of the physiological condition of the body. Nature Reviews Neuroscience, 3, 655–666. Damasio, A. R. (1999). The feeling of what happens: Body and emotion in the making of consciousness. Orlando, FL: Harcourt. Depue, R. A., & Morrone-Strupinsky, J. V. (2005). A neurobehavioral model of affiliative bonding: Implications for conceptualizing a human trait of affiliation. Behavioral and Brain Sciences, 28, 313–395. Diamond, L. M. (2001). Contributions of psychophysiology to research on adult attachment: Review and recommendations. Personality and Social Psychology Review, 5, 276–295. Diego, M. A., Field, T., Hernandez-Reif, M., Deeds, O., Ascencio, A., & Begert, G. (2006). Preterm infant massage elicits consistent increases in vagal activity and gastric motility that are associated with greater weight gain. Acta Pediatrica, 21, 1588–1591. Diorio, J., & Meaney, M. J. (2007). Maternal programming of defensive responses through sustained effects on gene expression. Journal of Psychiatry and Neuroscience, 32, 275–284. Ditzen, B., Hoppmann, C., & Klumb, P. (2008). Positive couple interactions and daily cortisol: On the stress-protecting role of intimacy. Psychosomatic Medicine, 70, 883. Ditzen, B., Neumann, I. D., Bodenmann, G., Dawans, B. von, Turner, R. A., Ehlert, U., et al. (2007). Effects of different kinds of couple interaction on cortisol and heart rate responses to stress in women. Psychoneuroendocrinology, 32, 565–574. Ditzen, B., Schaer, M., Gabriel, B., Bodenmann, G., Ehlert, U., & Heinrichs, M. (2009). Intranasal oxytocin increases positive communication and reduces cortisol levels during couple conflict. Biological Psychiatry, 65, 728–731. Dunbar, R. I. M. (1996). Grooming, gossip, and the evolution of language. London: Faber & Faber. Dunbar, R. I. M. (2010). The social role of touch in humans and primates: Behavioural function and neurobiological mechanisms. Neuroscience and Biobehavioral Reviews, 34, 260–268. Fearon, R. P., Bakermans-Kranenburg, M. J., Van IJzendoorn, M. H., Lapsley, A.-M., & Roisman, G. I. (2010). The significance of insecure attachment and disorganization in the development of children’s externalizing behavior: A meta-analytic study. Child Development, 81, 435–456. Feldman, R., Singer, M., & Zagoory, O. (2010). Touch attenuates infants’ physiological reactivity to stress. Developmental Science Journal, 13, 271–278. Field, T. M. (2010). Touch for socioemotional and physical well-being: A review. Developmental Review, 30, 367–383. Field, T. M., Hernandez-Reif, M., Quintino, O., Schanberg, S., & Kuhn, C. (1998). Elder retired volunteers benefit from giving massage therapy to infants. Journal of Applied Gerontology, 17, 229–239. Fleming, A. S., Korsmit, M., & Deller, M. (1994). Rat pups are potent reinforcers to the maternal animal: Effects of experience, parity, hormones, and dopamine function. Psychobiology, 22, 44–53.

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free ebooks ==> www.ebook777.com Social Touch and Resilience 141 Floyd, K. (2006). Communicating affection: Interpersonal behavior and social context. New York: Cambridge University Press. Floyd, K., Boren, J. P., Hannawa, A. F., Hesse, C., McEwan, B., & Veksler, A. E. (2009). Kissing in marital and cohabiting relationships: Effects on blood lipids, stress, and relationship satisfaction. Western Journal of Communication, 73, 113–133. Floyd, K., Mikkelson, A. C., Tafoya, M. A., Farinelli, L., La Valley, A. G., Judd, J., et al. (2007). Human affection exchange: XIV. Relational affection predicts resting heart rate and free cortisol secretion during acute stress. Behavioral Medicine, 32, 151–156. Fredrickson, B. L., & Levenson, R. W. (1998). Positive emotions speed recovery from the cardiovascular sequelae of negative emotions. Cognition and Emotion, 12, 191–220. Gallace, A., & Spence, C. (2010). The science of interpersonal touch: An overview. Neuroscience and Biobehavioral Reviews, 34, 246–259. Gitau, R., Modi, N., Giannakoulopoulos, X., Bond, C., & Glover, V. (2002). Acute effects of maternal skin-to-skin contact and massage on saliva cortisol in preterm babies. Journal of Reproductive and Infant Psychology, 20, 83–88. Goodall, J. (1986). The chimpanzees of Gombe. Cambridge, MA: Belknap Press. Gouin, J. P., Carter, C. S., Pournajafi-Nazarloo, H., Glaser, R., Malarkey, W. B., Loving, T. J., et al. (2010). Marital behavior, oxytocin, vasopressin, and wound healing. Psychoneuroendocrinology, 35, 1082–1090. Grewen, K. M., Anderson, B. J., Girdler, S. S., & Light, K. C. (2003). Warm partner contact is related to lower cardiovascular reactivity. Behavioral Medicine, 29, 123–130. Grewen, K. M., Girdler, S. S., Amico, J. A., & Light, K. C. (2005). Effects of partner support on resting oxytocin, cortisol, norepinephrine, and blood pressure before and after warm partner contact. Psychosomatic Medicine, 67, 531–538. Gulledge, A. K., Gulledge, M. H., & Stahmann, R. F. (2003). Romantic physical affection types and relationship satisfaction. American Journal of Family Therapy, 31, 233–242. Harlow, H. F., Harlow, M. K., & Hansen, E. W. (1963). The maternal affectional system of rhesus monkeys. In H. L. Rheingold (Ed.), Maternal behavior in mammals (pp. 254–281). New York: Wiley. Hofer, M. A. (1994). Early relationships as regulators of infant physiology and behavior. Acta Pediatrica, 83, 9–18. Holt-Lunstad, J., Birmingham, W., & Light, K. C. (2008). Influence of a “warm touch” support enhancement intervention among married couples on ambulatory blood pressure, oxytocin, alpha amylase, and cortisol. Psychosomatic Medicine, 70, 976–985. IsHak, W. W., Kahloon, M., & Fakhry, H. (2011). Oxytocin role in enhancing well-being: A literature review. Journal of Affective Disorders, 130, 1–9. Kemp, A. H., & Guastella, A. J. (2011). The role of oxytocin in human affect: A novel hypothesis. Current Directions in Psychological Science, 20, 222–231. Kimata, H. (2003). Kissing reduces allergic skin wheal responses and plasma neurotrophin levels. Physiology and Behavior, 80, 395–398. Kimata, H. (2006). Kissing selectively decreases allergen-specific IgE production in atopic patients. Journal of Psychosomatic Research, 60, 545–547. Kress, I. U., Minati, L., Ferraro, S., & Critchley, H. D. (2011). Direct skin-to-skin versus indirect touch modulates neural responses to stroking versus tapping. NeuroReport, 22, 646–651. Lamm, H., & Wiesmann, U. (1997). Subjective attributes of attraction: How people characterize their liking, their love, and their being in love. Personal Relationships, 4, 271–284. Light, K. C., Grewen, K. M., & Amico, J. A. (2005). More frequent partner hugs and higher oxytocin levels are linked to lower blood pressure and heart rate in premenopausal women. Biological Psychology, 69, 5–21. Light, K. C., Smith, T. E., Johns, J. M., Brownley, K. A., Hofheimer, J. A., & Amico, J. A. (2000). Oxytocin responsivity in mothers of infants: A preliminary study of relationships with blood pressure during laboratory stress and normal ambulatory activity. Health Psychology, 19, 560–567.



Liu, D., Diorio, J., Day, J. C., Francis, D. D., & Meaney, M. J. (2000). Maternal care, hippocampal synaptogenesis and cognitive development in rats. Nature Neuroscience, 3, 799–806. MacDonald, K., & MacDonald, T. M. (2010). The peptide that binds: A systematic review of oxytocin and its prosocial effects in humans. Harvard Review of Psychiatry, 18, 1–21. Mackey, R. A., Diemer, M. A., & O’Brien, B. A. (2000). Psychological intimacy in the lasting relationships of heterosexual and same-gender couples. Sex Roles, 43, 201–227. Marler, L. E., Cox, S. S., Simmering, M. J., Bennett, R. J., & Fuller, J. B. (2011). Exploring the role of touch and apologies in forgiveness of workplace offenses. Journal of Managerial Issues, 23, 144–163. Master, S. L., Eisenberger, N. I., Taylor, S. E., Naliboff, B. D., Shirinyan, D., & Lieberman, M. D. (2009). A picture’s worth: Partner photographs reduce experimentally induced pain. Psychological Science, 20, 1316–1318. Matsunaga, M., Sato, S., Isowa, T., Tsuboi, H., Konagaya, T., Kaneko, H., et al. (2009). Profiling of serum proteins influenced by warm partner contact in healthy couples. Neuroendocrinology Letters, 30, 227. Maunder, R. G., & Hunter, J. J. (2001). Attachment and psychosomatic medicine: Developmental contributions to stress and disease. Psychosomatic Medicine, 63, 556–567. McDaniel, E., & Andersen, P. A. (1998). International patterns of interpersonal tactile communication: A field study. Journal of Nonverbal Behavior, 22, 59–75. McGlone, F., Vallbo, A. B., Olausson, H., Loken, L. S., & Wessberg, J. (2007). Discriminative touch and emotional touch. Canadian Journal of Experimental Psychology, 61, 173–183. Mooncey, S., Giannakoulopoulos, X., Glover, V., Acolet, D., & Modi, N. (1997). The effect of mother–infant skin-to-skin contact on plasma cortisol and E-endorphin concentrations in preterm newborns. Infant Behavior and Development, 20, 553–557. Moore, E. R., Anderson, G. C., Bergman, N., & Dowswell, T. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, 2012, CD003519. Morrison, I., Loken, L. S., Minde, J., Wessberg, J., Perini, I., Nennesmo, I., et al. (2011). Reduced C-afferent fibre density affects perceived pleasantness and empathy for touch. Brain, 134, 1116–1126. Olausson, H. W., Lamarre, Y., Backlund, H., Morin, C., Wallin, B. G., Starck, G., et al. (2002). Unmyelinated tactile afferents signal touch and project to the insular cortex. Nature Neuroscience, 5, 900–904. Pedersen, C. A., & Boccia, M. L. (2002). Oxytocin links mothering received, mothering bestowed, and adult stress responses. Stress, 5, 259–267. Puig, J., Englund, M. M., Collins, W. A., & Simpson, J. A. (2013). Predicting adult physical illness from infant attachment: A prospective longitudinal study. Health Psychology, 32, 409–417. Riddell, R. R. P., Racine, N. M., Turcotte, K., Uman, L. S., Horton, R. E., Osmun, L. D., et al. (2011). Non-pharmacological management of infant and young child procedural pain. Cochrane Database of Systematic Reviews, 2011, CD006275. Robinson, T. E., & Berridge, K. C. (1993). The neural basis of drug craving: An incentive-sensitization theory of addiction. Brain Research: Brain Research Reviews, 18, 247–191. Rook, K. S. (1987). Social support versus companionship: Effects on life stress, loneliness, and evaluations by others. Journal of Personality and Social Psychology, 52, 1132–1147. Sanchez, M. M., Ladd, C. O., & Plotsky, P. M. (2001). Early adverse experience as a developmental risk factor for later psychopathology: Evidence from rodent and primate models. Development and Psychopathology, 13, 419–449. Sbarra, D. A., & Hazan, C. (2008). Coregulation, dysregulation, self-regulation: An integrative analysis and empirical agenda for understanding adult attachment, separation, loss, and recovery. Personality and Social Psychology Review, 12, 141. Simon, R. W. (2002). Revisiting the relationships among gender, marital status, and mental health. American Journal of Sociology, 107, 1065–1096.

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free ebooks ==> www.ebook777.com Social Touch and Resilience 143 Stadler, G., Snyder, K. A., Horn, A. B., Shrout, P. E., & Bolger, N. P. (2012). Close relationships and health in daily life: A review and empirical data on intimacy and somatic symptoms. Psychosomatic Medicine, 74, 398–409. Sullivan, R. M., & Gratton, A. (2002). Prefrontal cortical regulation of hypothalamic-pituitary-adrenal function in the rat and implications for psychopathology: Side matters. Psychoneuroendocrinology, 27, 99–114.7 Svetlik, D., Dooley, W. K., Weiner, M. F., Williamson, G. M., & Walters, A. S. (2005). Declines in satisfaction with physical intimacy predict caregiver perceptions of overall relationship loss: A study of elderly caregiving spousal dyads. Sexuality and Disability, 23, 65–79. Taira, K., & Rolls, E. T. (1996). Receiving grooming as a reinforcer for the monkey. Physiology and Behavior, 59, 1189–1192. Takahashi, Y., Tamakoshi, K., Matsushima, M., & Kawabe, T. (2011). Comparison of salivary cortisol, heart rate, and oxygen saturation between early skin-to-skin contact with different initiation and duration times in healthy, full-term infants. Early Human Development, 87, 151–157. Takeuchi, M. S., Miyaoka, H., Tomoda, A., Suzuki, M., Liu, Q., & Kitamura, T. (2010). The effect of interpersonal touch during childhood on adult attachment and depression: A neglected area of family and developmental psychology? Journal of Child and Family Studies, 19, 109–117. Trevathan, W. R. (1981). Maternal touch at first contact with the newborn infant. Developmental Psychobiology, 14, 549–558. Waal, F. de (1989). Chimpanzee politics. Baltimore: Johns Hopkins University Press. Winberg, J. (2005). Mother and newborn baby: Mutual regulation of physiology and behavior—A selective review. Developmental Psychobiology, 47, 217–229. Winslow, J. T., & Insel, T. R. (2004). Neuroendocrine basis of social recognition. Current Opinion in Neurobiology, 14, 248–253.

free ebooks ==> www.ebook777.com 11 Empathy and Resilience in a Connected World Grit Hein

The world breaks everyone, and afterward, some are strong at the broken places. Ernest Hemingway

This insightful observation of the great American writer summarizes what we all experience in our everyday lives. Our world is full of aversive events, but some people seem to be able to cope with “whatever comes their way,” whereas others respond to similar stressors with depression and despair. The question of what makes a person resilient in the aversive situations of life is intriguing and can be asked from different perspectives, as reflected in the chapters of this book. An important characteristic assigned to resilient individuals is social competence, because it is the basis for finding appropriate social support in times of challenge (Feder, Nestler, & Charney, 2009). One central aspect of social competence is the ability to generate appropriate emotional responses in social contexts, an ability that likely requires empathy. In this chapter, I will focus on empathy from a neuroscience perspective. The chapter first gives an overview of the definitions of empathy in different fields. I will next review the neural basis of empathic responses, its modulation, and the relation between empathy-related brain responses and actual social behavior. Finally, the chapter proposes a link between empathy and resilience to negative events.

WHAT IS EMPATHY? The term empathy is used in many different fields with a broad range of meanings. Often, even the definitions of empathy within one field are far from consistent. For example, social psychology has offered different definitions of empathy that depend on the focus of research. Some researchers provide rather broad definitions of empathy, as does Hoffman (1981, p. 44), who sees empathy as “an affective response appropriate to someone else’s situation rather than one’s own.” According to Hoffman, perceived distress in the other can elicit “empathic distress” or “sympathetic distress.” The latter is the basis for altruistic motivation that mainly aims to relieve one’s own distress. Note that other models of prosocial behavior predict that distress mainly results in withdrawal and not helping (e.g., Batson, 1991; see below), contradicting Hoffman’s assumption. Other influential definitions have emphasized the conceptual difference between empathy and sympathy (Eisenberg & Miller, 1987). Empathy is defined as “an affective state that stems from the apprehension of another’s emotional state or condition, and that is

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free ebooks ==> www.ebook777.com Empathy and Resilience in a Connected World 145 congruent with it” (Eisenberg & Miller, 1987, p. 91). Sympathy is defined as “an emotional response stemming from another’s emotional state or condition that is not identical to the other’s emotion, but consists of feelings of sorrow or concern for another’s welfare” (p. 92). Empathy in its pure form is not other-oriented. With further cognitive processing it can turn into sympathy, personal distress, or a combination of both (Eisenberg, 2000). Prosocial behavior is negatively correlated with personal distress, and positively associated with sympathy (Eisenberg & Miller, 1987). Sympathy can derive from empathy, but also from cognitive perspective taking. Yet another conceptual approach is offered by Batson and associates, who hold that perceiving a person in need can elicit either empathy, or “empathic concern,” or personal distress. Empathic concern is defined as an other-oriented response congruent with the perceived distress experienced by another person (Batson, Turk, Shaw, & Klein, 1995). It is elicited by adopting the other’s perspective and requires valuing the other’s welfare (Batson, Eklund, Chermok, Hoyt, & Ortiz, 2007). An impressive series of experiments demonstrated that empathic concern motivates helping behavior towards the person in need, even if it is costly for the helper (Batson, 1991). By contrast, personal distress is a self-centered stress response that does not motivate helping but rather withdrawal. For example, a person experiencing mainly distress when seeing a handicapped person struggling with entering the bus will take the back door in order to avoid the other in need of help. Definitions of empathy in clinical contexts stress the importance of “empathic accuracy” or that the empathic reaction resembles the other’s emotions as closely as possible (Rogers, 1959). At the same time, the empathizer needs to be fully aware that the empathic reaction represents the other’s emotional state and not the emotions of the empathizer. The focus of attention in clinical fields is the use of empathy as a therapeutic tool, and its concrete impact on the other in need, in this case the client. More recent work has also considered the cost for the empathizer (Maslach, 2003). One impressive example is the cost reflected in burnout, a complex of symptoms related to fatigue and depression that is often seen in caretakers. The distinction between empathy and personal distress proposed by social psychologists (Batson, 1991) raises the intriguing question of whether burnout stems from empathy or from a reaction that resembles personal distress (see Klimecki & Singer, 2012 for a similar point). The definition of empathy in social neuroscience focuses on yet other aspects. It is similar to the definitions of social psychology described above (Eisenberg & Miller, 1987), in that empathy is seen as an affective response that is congruent with the affective state of the other, but does not require other-oriented sympathy. Moreover, the empathizer needs to be aware that the felt emotions are induced by observing the other’s emotional state, and not by an event directly happening to the empathizer (for example, I am sad for a friend who is getting divorced, knowing that my sadness is related to her situation and independent from my own relationship). The emphasis on the affective quality of empathy distinguishes empathy from cognitive perspective taking, often referred to as “mentalizing” or “theory of mind.” Cognitive perspective taking connotes a person’s ability to cognitively represent the mental states of others, including their affective states, without necessarily becoming emotionally involved. By contrast, an empathic response always means an affective response that is derived from sharing the feelings of the other. The empathic sharing of the feeling of the other is not necessarily other-oriented in the sense of being concerned about the other’s welfare. This distinguishes empathy from sympathy. Empathizing with someone in need can trigger personal distress, which then leads to withdrawal or to sympathy that may result in a concern about the other’s welfare and thus increase the propensity to behave in a prosocial manner (see also Hein & Singer, 2008).


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HOW DO WE EMPATHIZE? Recent studies in social neuroscience have begun to localize brain regions that are activated when participants empathize with others. Most of these studies have focused on empathy for the pain of another person (for reviews see Hein & Singer, 2008; Lamm & Singer, 2010). To study empathy for pain, participants were presented with pictures of faces expressing pain (e.g., Lamm, Batson, & Decety, 2007; Saarela et al., 2007; Xu, Zuo, Wang, & Han, 2009) or body parts in painful positions (e.g., Cheng et al., 2007; Gu & Han, 2007; Lamm, Nusbaum, Meltzoff, & Decety, 2007). Other studies combined the observation of painful stimulation to others and the experience of self-pain (Hein, Silani, Preuschoff, Batson, & Singer, 2010; Singer et al., 2004; Singer et al., 2006). Here the participants inside the scanner experienced more or less painful shocks via an electrode attached to the back of their hands and observed a person sitting next to them in the scanning room in the same situation. Cues of different colors indicated to the participants both the painful/non-painful nature and the intensity of the stimulation to the other person. This setup allowed the localization of brain regions involved in the processing of first hand pain and brain regions associated with the processing of pain experienced by the other person. The results showed that observing how the other person received a painful shock activated the anterior insula (AI) and the anterior cingulate cortex (ACC), and often also the inferior frontal gyrus (IFG) (Figure 11.1). AI and ACC brain regions were also active when the participant experienced first hand pain, regions known to be involved in processing the affective aspect of the selfpain response. Specifying these results, Gu et al. (2010) suggested that AI might be the main region correlating with the empathic response.

Figure 11.1 Common activation (conjunction) for the picture-based and cue-based empathy paradigms. aMCC = anterior medial cingulate cortex; AI = anterior insular cortex; IFG = inferior frontal gyrus. Adapted from Lamm, Decety, & Singer (2011), with kind permission from C. Lamm.

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free ebooks ==> www.ebook777.com Empathy and Resilience in a Connected World 147 The results of studies using different paradigms such as faces with painful expressions and body parts in painful positions confirmed these main findings (Cheng et al., 2007; Saarela et al., 2007). However, a recent meta-analysis (Lamm et al., 2011) also showed differences in neural activations between empathy measured with “picture paradigms” (i.e., pictures of faces, etc.) and “cue paradigms” (i.e., cues indicating painful stimulation of self or of the other). In addition to AI and ACC, pictures of body parts in painful situations activated parts of the so-called “mirror neuron system,” the neural structures related to sensory-motor functions and action understanding (inferior parietal/ventral premotor cortices). By contrast, cues indicating the other’s pain activated areas associated with mentalizing or “theory of mind” (precuneus, ventral medial prefrontal cortex, superior temporal cortex, and temporoparietal junction). These findings suggest that there are different neural routes allowing for understanding and predicting others’ actions, feelings, and beliefs and that empathy is only one of them. The degree of interaction between these routes probably depends on the characteristics of the individual as well as on the task context and the information provided in a given situation (Lamm & Singer, 2010). More recent studies have extended the investigation of empathic brain responses to the domain of social pain (Masten, Morelli, & Eisenberger, 2011) and vicarious embarrassment (Krach et al., 2011). In Masten et al. (2011)’s study, participants in the fMRI scanner observed one person who was excluded by two others. Later on, participants could write emails to offer help or comfort to the excluded person. When seeing someone being excluded, participants who scored high on a trait empathy questionnaire displayed activation in AI and cingulate cortex, in addition to activations typically related to mentalizing (e.g., medial prefrontal cortex). Krach et al. (2011) presented participants with cartoons and descriptions of scenes depicting a protagonist in a possibly embarrassing situation. The results showed that the observation of vicarious embarrassment activated the AI and ACC, i.e., components of the affective pain matrix. In addition to physical pain and social pain, neuroscience studies have investigated empathic responses related to others’ experience of touch (Keysers et al., 2004; Schaefer, Heinze, & Rotte, 2012) and taste (Jabbi, Swart, & Keysers, 2007; Wicker et al., 2003). There is evidence that the observation of touch and the first hand experience of touch activate similar regions in the somatosensory cortex (Keysers et al., 2004; Schaefer et al., 2012). For example, in a study by Jabbi et al. (2007), participants watched video clips showing people sampling pleasant and unpleasant tastes, and then experienced the different tastes themselves. In line with the results of empathy for pain, Jabbi and colleagues found neural activation in AI cortex when people passively watched disgust in another person, and when they were disgusted themselves (see also Wicker et al., 2003). The studies summarized above have examined the neural correlates of empathy mainly in the domains of negative emotions such as pain, social exclusion, and disgust. So far there are only a few neuroscience studies that extend this focus to positive emotions such as sharing others’ happiness about winning money (Mobbs et al., 2009) or other positive events (e.g., winning a scholarship; Perry, Hendler, & Shamay-Tsoory, 2011). Perry and associates used vignettes to introduce a person matching the participant’s gender, and then presented sentences describing everyday-life positive or negative events happening to that person. Sharing the other’s distress was related to activations in the insula and regions related to “mentalizing,” such as superior temporal cortex and medial prefrontal cortex. Sharing the other’s joy revealed similar, but weaker, activations in these brain regions. In Mobbs et al. (2009)’s study, participants in the fMRI scanner witnessed similar or dissimilar others winning or losing money in a TV show. Seeing a similar other winning money correlated with increased


Grit Hein

activation in the nucleus accumbens, a brain region which was also activated when the participants won money themselves. Taken together, these studies suggest that empathy with the state of the other person is based on a simulation of his or her neural response by the brain of the empathizer, i.e., the activation of brain regions that are also active during the empathizer’s first hand experience of the positive or negative emotion.

WHICH FACTORS MODULATE EMPATHIC BRAIN RESPONSES? We know from our own experience that empathizing with the other’s state or situation is far from being automatic. Sometimes a strong empathic response is initiated immediately, whereas at other times we lack empathy or have to make a conscious effort to understand the feeling of the other. It can be challenging to measure such modulations of an empathic response merely based on self-report measures such as empathy scales or questionnaires. This is particularly true if the person experiences no empathy when, for example, witnessing the other’s misfortune. In many social contexts, such a lack or strong reduction of an empathic response is condemned. This fact is reflected in the social desirability effects that bias selfreports, resulting in an overestimation of the individual empathic response. Measuring a person’s empathy-related brain responses can be a valuable addition to self-report measures of empathy, since neural activation is known to be less biased by societal expectations and can even reflect unconscious processes. However, it is important to validate the functional meaning of the neural response with an external measure, as the same brain region can be activated in a variety of different situations. In the case of empathy research, this means that neural activation presumably related to empathy should correlate with a self-report measure of an empathic state or trait. Otherwise it is unclear whether the observed activation reflects empathy-related processes. Combining self-report measures of empathy and neuroimaging, a number of studies have shown large inter-individual variability in empathic brain responses. Such inter-individual differences in neural empathy responses were found to correlate with behavioral trait measures of empathy in empathy questionnaires such as the Empathic Concern Scale of the Interpersonal Reactivity Index (Davis, 1980), the Balanced Emotional Empathy Scale (Mehrabian & Epstein, 1972), and the Empathic Concern Scale (Batson, Early, & Salvarini, 1997). The higher subjects scored on these questionnaires, the higher their activation of empathy-related brain regions. Apart from inter-individual differences, a number of other factors modulate the strength of empathy-related brain activation (Hein & Singer, 2008). One such factor is the intensity of the stimulation or the displayed emotion. For example, it has been shown that empathy-related brain activation is stronger for faces showing acute pain than for faces showing chronic pain (Saarela et al., 2007). Faces of patients in acute pain expressed a more intense pain experience than faces of patients with chronic pain, suggesting that the intensity of the expressed motivation is an important factor for the strength of the empathic response. A second factor, the situational context, has also been found to modulate empathy. For example, empathic brain responses were reduced when participants were convinced that the other received pain as a therapeutic treatment and the therapy was successful rather than in vain (Lamm, Nusbaum, et al., 2007). Empathic brain responses are also modulated by where the empathizer directs his/her attention. Participants who observed pictures or cartoons of hands in painful situations showed stronger activation in AI and ACC when they focused on

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free ebooks ==> www.ebook777.com Empathy and Resilience in a Connected World 149 the intensity of the other’s pain as compared to when they were asked to count the number of hands, i.e., shifting attention away from the other’s pain (Gu & Han, 2007). A third factor, characteristics of the empathizer, also affects the strength of empathic brain responses. For example, Cheng and colleagues (2007) used animated pictures of needles being inserted in different body parts as a visual stimulus to compare empathic responses of physicians who practice acupuncture and those of naïve participants. The results revealed that physicians showed less empathy-related pain activity in AI, ACC, and regions of interest in the somatosensory cortex in comparison to the control group, indicating a reduction of empathic brain responses in empathizers who are frequently exposed to pain-inflicting situations. Another recent study reported differences in empathic brain responses to pictures showing suffering in humans and animals between omnivore, vegetarian, and vegan participants (Filippi et al., 2010). Likewise, alexithymia, characterized by difficulties in identifying and describing one’s own feelings and bodily sensations, correlates with modulation of empathic brain responses. Bird et al. (2010) measured neural responses to others’ pain in autistic participants and a control group. The results showed no difference in AI activation between the groups. However, there was a reduction of empathy-related brain activation in autistic participants scoring high on alexithymia, a trait that often accompanies autism. A final important factor for modulating empathic brain responses is related to the features of the empathy target. For example, men showed strong empathic brain responses if the recipient of the pain had behaved fairly towards them prior to the scanning session. In contrast, the brain responses were significantly weaker if the recipient of pain had behaved unfairly before (Singer et al., 2006). Empathic brain responses were also stronger for poor individuals than for those receiving a high monetary reward (Guo et al., 2011). Other studies have focused on the impact of group membership on neural empathy (Hein et al., 2010; Xu et al., 2009). One of these studies (Hein et al., 2010) investigated the empathy-related brain responses of soccer fans when observing pain in a fan of their favorite soccer team (ingroup member) or in a fan of the rival team (outgroup member) (see Figure 11.2). The results of the first part of the study showed a significant reduction of activation in AI when the suffering other was an outgroup member as compared to the ingroup member (Figure 11.2A). The activation in AI correlated with self-reported empathy on the Empathic Concern Scale (Batson et al., 1997). Moreover, participants who reported a particularly negative attitude towards the outgroup member displayed neural activation in the nucleus accumbens (NAcc), a brain region related to reward processing, when they saw the outgroup member suffering.

ARE EMPATHIC BRAIN RESPONSES LINKED TO PROSOCIAL BEHAVIOR? Based on the mounting evidence for brain regions involved in empathic reactions, recent neuroscientific studies have started to investigate the link between empathy-related brain activation and actual social behavior (Hein et al., 2010; Masten et al., 2011; Rameson, Morelli, & Lieberman, 2012). Influential models from social psychology propose that an empathic motivation increases the participants’ propensity to behave prosocially towards the other in need and, for example, to help at costs to the self (Batson, 1991; Eisenberg & Miller, 1987). In the second part of the study described above, Hein et al. (2010) tested the hypothesis that empathic brain responses predict individual differences in later prosocial behavior. They investigated whether the difference in empathy-related brain responses to


Grit Hein (a)

(b)

9

5 IG versus OG contrast in empathy session

Parameter estimates left AI in empathy session

3

2

1 –0.4

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Figure 11.2 Example for modulation of activation in anterior insular cortex (AI). A: The results revealed significantly stronger activation when seeing the ingroup (IG) member in pain as compared to the outgroup (OG) member. B: The individual differences in empathy-related brain activation when seeing the ingroup member and outgroup member in pain predicted individual differences in later helping behavior. The stronger the activation in AI for the ingroup member and not the outgroup member, the more likely was the person to help the ingroup member and not the outgroup member. Figure reprinted with permission from Hein et al. (2010).

the suffering of an ingroup and an outgroup member, elicited in the first part of the study, would predict differences in later helping behavior towards the members of the different social groups. Seeing either the ingroup member or the outgroup member receiving a painful shock, the participant in the scanner was to select one of three possible courses of action. One option was to help the ingroup or outgroup member by volunteering to receive half of that person’s pain himself, thus reducing the intensity of that person’s pain stimulation by half. Such helping behavior was costly for the participant because it resulted in a painful shock. The second option was to not help, but to watch a soccer video instead, while the other suffered pain. This option offered an attractive alternative to helping and distraction from watching the pain administration. The third option was to not help, but to watch the other person suffering pain. The behavioral results showed an ingroup bias in helping, with participants choosing the more costly helping decisions if the suffering other was an ingroup member. Interestingly, the extent to which a person favored the ingroup member was predicted by the individual difference in empathy-related brain activation in AI when seeing the ingroup member and the outgroup member in pain (as measured in the first part of the study). The stronger the difference in empathy-related AI activation in a direction favoring the ingroup member, the more likely the person was to help the ingroup member and not the outgroup member (Figure 11.2B). Moreover, activation in nucleus accumbens when observing the outgroup member suffering (found in the first part of the study) predicted a lack of helping towards the outgroup member. The stronger the activation of this reward-related region a person experienced when seeing the outgroup member suffering in the first part of the study, the less likely he was to help the outgroup member later on. Additional analysis (commonality analyses) tested the contribution of brain activations (AI, NAcc) and self-report measures

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free ebooks ==> www.ebook777.com Empathy and Resilience in a Connected World 151 (Empathic Concern Scale; Impression Scale, in Batson et al., 1988) to explaining variance in helping behavior towards the ingroup and the outgroup member. The results indicated that behavior towards a preferred other (ingroup member) is predicted equally well by brain measures and self-report, whereas brain measures explain additional variance when it comes to behavior towards a non-preferred other. Taken together, these results indicate that empathy-related brain responses are linked to actual social behavior and that the combination of brain measures and self-reports is beneficial for predicting actual behavior in socially sensitive situations. In a similar vein, other recent studies have investigated the association between brain responses when watching pictures of individuals in a sad situation and the tendency to help assessed in a diary study (Rameson et al., 2012), or the link between empathy for social pain and prosocial tendencies reflected in emails written to the victim (Masten et al., 2011). In line with the findings described above (Hein et al., 2010), the results showed a correlation between the extent of empathy-related brain activation and prosocial tendencies.

ARE EMPATHIC INDIVIDUALS MORE RESILIENT? One might intuitively assume a positive relationship between empathy and stress resilience. As outlined above, empathy is an important route for understanding the other and thus should be a crucial precondition for social competence, a main feature of resilient individuals (Feder et al., 2009). However, the empirical evidence is less clear cut. On the one hand, there is evidence that social competence including empathy increases stress resistance, for example reducing the likelihood of burnout (Harrison, 1983). Supporting this finding, the training of empathic skills was found to reduce clinicians’ burnout as compared to no training (Corcoran & Bryce, 1983). On the other hand, there are results indicating that empathizing with another person in a concrete situation is not likely to make the empathizer more resistant to the impact of aversive events (Loggia, Mogil, & Bushnell, 2008). Loggia and associates induced high empathy for an actor in one group, and low empathy in another group of participants, and compared their perception of self-pain. The results showed that the participants of the high-empathy group rated pain stimuli applied to themselves as more intense and unpleasant than participants of the low-empathy group. The individual differences in pain ratings correlated with a self-report measure of state empathy (a five-item questionnaire assessing the feelings of the participants after the experimental sessions). Here empathizing with the pain of the other person made the empathizer more sensitive toward aversive events. This is quite the opposite of what would be expected if empathy serves as a buffer against the negative consequences of stress-inducing events. Does the neuroscientific evidence reviewed above help to clarify the inconsistencies between studies promoting empathy as a resilience-enhancing factor and those suggesting the opposite? At a first glance, and when considering the relevant brain regions, the answer has to be no. For example, the AI and cingulate cortex, commonly activated in empathyfor-pain studies, are also activated in a variety of other situations related to the processing of negative uncertain events and conflict (Medford & Critchley, 2010; Shackman et al., 2011 for reviews). These findings suggest that empathizing with another person does not increase the resilience of the empathizer to negative events—it might make the negative experience even more salient, in line with the findings of Loggia et al. (2008). This interpretation would imply that empathy for others in need imposes high physiological costs on the empathizer. It becomes clearer why empathy-related brain responses are so readily modulated by


Grit Hein

a variety of different factors. If empathy is costly on the physiological and emotional level, it makes sense to restrict a strong empathic response to a “special” individual, i.e., a member of your own group or someone who is in massive pain. Contradicting the above assumption of the negative costs of empathy and its negative impact on resilience, the neuroscientific evidence reviewed earlier does show a positive correlation between empathy-related brain activation, for example in AI, and prosocial behavior. There is broad agreement that prosocial behavior stems from concern for the welfare of the other (Batson, 1991; Eisenberg & Miller, 1987), and not from personal distress. Concern for the other, or sympathy, is an other-centered response, whereas distress is a selfcentered stress response. The basic empathic reaction of the human brain can probably be transformed into both: sympathy that triggers prosocial behavior and personal distress that triggers withdrawal and increases sensitivity to the aversive event (Figure 11.3). The overall evidence from neuroscience and social psychology studies suggests that resilient individuals are individuals who are likely to transform an empathic response into sympathy and not distress (Figure 11.3). Sympathy for the other, or concern for the other’s welfare, does not induce self-centered negative arousal, but can serve as a buffer against negative emotions and their physiological correlates. Studies supporting this view have shown that the cultivation of sympathy or compassion by respective forms of meditation have beneficial effects on markers of immune functions (Davidson et al., 2003), reduce negative affect and stress (Chiesa & Serretti, 2009 for a review), and increase positive affect (Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008). Unfortunately, it is challenging to clearly disentangle the neural correlates of sympathy and personal distress. Based on the current evidence, we can only speculate as to which of these two “siblings of empathy,” sympathy or personal distress, is activated. In addition, it is conceivable that highly resilient persons are more likely to share the positive emotions of others, resulting in more positive affect in the self. Some of the studies reviewed earlier have suggested that the human brain is set up to simulate the joy of others by vicariously activating brain regions which are involved in the processing of reward to the self (Mobbs et al., 2009). The vicarious activation of reward-related brain regions when observing joyful others might provide a possible neural mechanism which accounts for the protective and resilience-enhancing impact of a stable social network, in particular positive family relations. Such a mechanism could explain why most of us find the abundant laughter

Empathy

Sympathy ·other-related • positive emotion • prosocial motivation

High resilience

Personal Distress • self-related • negative emotion • withdrawal

Low resilience

Figure 11.3 Schematic display of the relationship between empathy, sympathy, personal distress, and resilience.

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free ebooks ==> www.ebook777.com Empathy and Resilience in a Connected World 153 and happiness of children irresistible. They smile at us and show us their new toy and it is impossible not to smile back. It is an intriguing question for future studies whether empathic joy modulates the general reactivity towards stressful life events. In particular, future studies should investigate the intra-individual variability in the strength of the empathic joy reaction, and whether individual differences in empathic joy are related to differences in resilience to aversive events and everyday life stressors.

CONCLUSION The reviewed neuroscientific evidence suggests that the human brain is set up to share others’ emotional states and feelings and to empathize. Sharing the other’s emotional state is one efficient way to understand the other’s current feelings. It is commonly assumed that this ability is beneficial for an individual’s social competence, which serves to increase resilience against negative events. In this chapter I proposed that there is a positive relationship between empathy and resilience only if empathy is transformed into sympathy or concern for the wellbeing of the other. By contrast, a transformation of empathy into personal distress is a self-centered stress response that should weaken the individual’s resilience, since it could result in increased sensitivity towards aversive events. In addition, resilient individuals could be characterized by a stronger vicarious response to others’ joy. Future studies could test the link between individual resilience and individual measures of empathy, sympathy, personal distress, and empathic joy.

ACKNOWLEDGMENTS This work is supported by a Branco Weiss Fellowship from the Society in Science. I also gratefully acknowledge support from the Research Priority Program “Foundations of Human Social Behavior” at the University of Zurich.

REFERENCES Batson, C. D. (1991). The altruism question: Toward a social-psychological answer. Hillsdale, NJ: Erlbaum. Batson, C. D., Dyckk, J., Brandt, J., Batson, J., Powell, A., McMaster, M., & Griffitt, C. (1988). Five studies testing two new egoistic alternatives to the empathy-altruism hypothesis. Journal of Personality and Social Psychology, 55, 52–77. Batson, C., Early, S., & Salvarini, G. (1997). Perspective taking: Imagining how another feels versus imagining how you would feel. Personality and Social Psychology Bulletin, 23, 751. Batson, C. D., Eklund, J. H., Chermok, V. L., Hoyt, J. L., & Ortiz, B. G. (2007). An additional antecedent of empathic concern: Valuing the welfare of the person in need. Journal of Personality and Social Psychology, 93, 65–74. Batson, C., Turk, C., Shaw, L., & Klein, T. (1995). Information function of empathic emotion: Learning that we value the other’s welfare. Journal of Personality and Social Psychology, 68, 1042–1054. Bird, G., Silani, G., Brindley, R., White, S., Frith, U., & Singer, T. (2010). Empathic brain responses in insula are modulated by levels of alexithymia but not autism. Brain, 133, 1515–1525. Cheng, Y., Lin, C. P., Liu, H. L., Hsu, Y. Y., Lim, K. E., Hung, D., et al. (2007). Expertise modulates the perception of pain in others. Current Biology, 17, 1708–1713.


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Chiesa, A., & Serretti, A. (2009). Mindfulness-based stress reduction for stress management in healthy people: A review and meta-analysis. Journal of Alternative and Complementary Medicine, 15, 593–600. Corcoran, K. J., & Bryce, A. K. (1983). Intervention in the experience of burnout: Effects of skill development. Journal of Social Science Research, 7, 71–79. Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S. F., et al. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564–570. Davis, M. (1980). A multidimensional approach to individual differences in empathy. JSAS Catalogue of Selected Documents in Psychology, 10, 85. Eisenberg, N. (2000). Emotion, regulation, and moral development. Annual Review of Psychology, 51, 665–697. Eisenberg, N., & Miller, P. (1987). The relation of empathy to prosocial and related behaviors. Psychological Bulletin, 101, 91–119. Feder, A., Nestler, E. J., & Charney, D. S. (2009). Psychobiology and molecular genetics of resilience. Nature Reviews Neuroscience, 10, 446–457. Filippi, M., Riccitelli, G., Falini, A., Di, S. F., Vuilleumier, P., Comi, G., et al. (2010). The brain functional networks associated to human and animal suffering differ among omnivores, vegetarians and vegans. PLoS One, 5, e10847. Fredrickson, B. L., Cohn, M. A., Coffey, K. A., Pek, J., & Finkel, S. M. (2008). Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources. Journal of Personality and Social Psychology, 95, 1045–1062. Gu, X., & Han, S. (2007). Attention and reality constraints on the neural processes of empathy for pain. Neuroimage, 36, 256–267. Gu, X., Liu, X., Guise, K. G., Naidich, T. P., Hof, P. R., & Fan, J. (2010). Functional dissociation of the frontoinsular and anterior cingulate cortices in empathy for pain. Journal of Neuroscience, 30, 3739–3744. Guo, X., Zheng, L., Zhang, W., Zhu, L., Li, J., Wang, Q., et al. (2011). Empathic neural responses to others’ pain depend on monetary reward. Social Cognitive and Affective Neuroscience, 7, 535–541. Harrison, W. D. (1983). A social competence model of burnout. In B. A. Farber (Ed.), Stress and burnout in the human science professions (pp. 29–39). New York: Pergamon Press. Hein, G., Silani, G., Preuschoff, K., Batson, C. D., & Singer, T. (2010). Neural responses to ingroup and outgroup members’ suffering predict individual differences in costly helping. Neuron, 68, 149–160. Hein, G., & Singer, T. (2008). I feel how you feel but not always: The empathic brain and its modulation. Current Opinion in Neurobiology, 18, 153–158. Hoffman, M. L. (1981). The development of empathy. In J. P. Rushton & R. M. Sorrentino (Eds.), Altruism and helping behavior: Social, personality, and developmental perspectives (pp. 41–63). Hillsdale, NJ: Erlbaum. Jabbi, M., Swart, M., & Keysers, C. (2007). Empathy for positive and negative emotions in the gustatory cortex. Neuroimage, 34, 1744–1753. Keysers, C., Wicker, B., Gazzola, V., Anton, J. L., Fogassi, L., & Gallese, V. (2004). A touching sight: SII/PV activation during the observation and experience of touch. Neuron, 42, 335–346. Klimecki, O., & Singer, T. (2012). Empathic distress fatigue rather than compassion fatigue? Integrating findings from empathy research in psychology and social neuroscience. In B. Oakley, A. Knafo, G. Madhavan, & D. Wilson (Eds.), Pathological altruism (pp. 368–383). New York: Oxford University Press. Krach, S., Cohrs, J. C., Echeverria Loebell, N. C. de, Kircher, T., Sommer, J., Jansen, A., et al. (2011). Your flaws are my pain: Linking empathy to vicarious embarrassment. PLoS One, 6, e18675. Lamm, C., Batson, C. D., & Decety, J. (2007). The neural substrate of human empathy: Effects of perspective-taking and cognitive appraisal. Journal of Cognitive Neuroscience, 19, 42–58.

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free ebooks ==> www.ebook777.com Empathy and Resilience in a Connected World 155 Lamm, C., Decety, J., & Singer, T. (2011). Meta-analytic evidence for common and distinct neural networks associated with directly experienced pain and empathy for pain. Neuroimage, 54, 2492–2502. Lamm, C., Nusbaum, H. C., Meltzoff, A. N., & Decety, J. (2007). What are you feeling? Using functional magnetic resonance imaging to assess the modulation of sensory and affective responses during empathy for pain. PLoS One, 2, e1292. Lamm, C., & Singer, T. (2010). The role of anterior insular cortex in social emotions. Brain Structure and Function, 214, 579–591. Loggia, M. L., Mogil, J. S., & Bushnell, M. C. (2008). Empathy hurts: Compassion for another increases both sensory and affective components of pain perception. Pain, 136, 168–176. Maslach, C. (2003). Burnout: The cost of caring. Los Altos, CA: ISHK. Masten, C. L., Morelli, S. A., & Eisenberger, N. I. (2011). An fMRI investigation of empathy for “social pain” and subsequent prosocial behavior. Neuroimage, 55, 381–388. Medford, N., & Critchley, H. D. (2010). Conjoint activity of anterior insular and anterior cingulate cortex: Awareness and response. Brain Structure and Function, 214, 535–549. Mehrabian, A., & Epstein, N. (1972). A measure of emotional empathy. Journal of Personality, 40, 525–543. Mobbs, D., Yu, R., Meyer, M., Passamonti, L., Seymour, B., Calder, A. J., et al. (2009). A key role for similarity in vicarious reward. Science, 324, 900. Perry, D., Hendler, T., & Shamay-Tsoory, S. (2011). Can we share the joy of others? Empathic neural responses in distress versus joy. Social Cognitive and Affective Neuroscience, 7, 909–916. Rameson, L., Morelli, S., & Lieberman, M. (2012). The neural correlates of empathy: Experience, automaticity, and prosocial behavior. Journal of Cognitive Neuroscience, 24, 235–245. Rogers, C. (1959). A theory of therapy, personality, and interpersonal relationships as developed in the client-centered framework. In J. Koch (Ed.), Psychology: A study of a science: Vol. 3. Formulations of the person in the social context (pp. 184–256). New York: McGraw-Hill. Saarela, M. V., Hlushchuk, Y., Williams, A. C., Schurmann, M., Kalso, E., & Hari, R. (2007). The compassionate brain: Humans detect intensity of pain from another’s face. Cerebral Cortex, 17, 230–237. Schaefer, M., Heinze, H. J., & Rotte, M. (2012). Embodied empathy for tactile events: Interindividual differences and vicarious somatosensory responses during touch observation. Neuroimage, 60, 952–957. Shackman, A. J., Salomons, T. V., Slagter, H. A., Fox, A. S., Winter, J. J., & Davidson, R. J. (2011). The integration of negative affect, pain and cognitive control in the cingulate cortex. Nature Reviews Neuroscience, 12, 154–167. Singer, T., Seymour, B., O’Doherty, J., Kaube, H., Dolan, R. J., & Frith, C. D. (2004). Empathy for pain involves the affective but not sensory components of pain. Science, 303, 1157–1162. Singer, T., Seymour, B., O’Doherty, J. P., Stephan, K. E., Dolan, R. J., & Frith, C. D. (2006). Empathic neural responses are modulated by the perceived fairness of others. Nature, 439, 466–469. Wicker, B., Keysers, C., Plailly, J., Royet, J. P., Gallese, V., & Rizzolatti, G. (2003). Both of us disgusted in my insula: The common neural basis of seeing and feeling disgust. Neuron, 40, 655–664. Xu, X., Zuo, X., Wang, X., & Han, S. (2009). Do you feel my pain? Racial group membership modulates empathic neural responses. Journal of Neuroscience, 29, 8525–8529.

free ebooks ==> www.ebook777.com 12 An Attachment Perspective on Resilience to Stress and Trauma Mario Mikulincer and Phillip R. Shaver

Attachment theory has been one of the most useful contemporary conceptual frameworks for understanding emotion regulation and mental health. In his exposition of the theory, John Bowlby (1973, 1980, 1982) explained why the availability of caring, supportive relationship partners, beginning in infancy, is so important to developing a sense of safety and security. This sense supports effective distress management and facilitates psychological wellbeing during times of stress or crisis. In this chapter, we review research on attachmentrelated processes in adolescence and adulthood that has consistently shown that attachment security is a resilience resource in times of distress. We also review empirical studies that show how individual differences in attachment security and insecurity shape psychological and physiological reactions to attachment-related and attachment-unrelated stressful and traumatic events.

OVERVIEW OF ATTACHMENT THEORY Bowlby (1982) claimed that human beings are born with an innate psychobiological system (the attachment behavioral system) that motivates them to seek proximity to significant others (attachment figures) in times of need. Bowlby (1973) also outlined individual differences in attachment-system functioning. Interactions with attachment figures who are available in times of need, and who are sensitive and responsive to bids for proximity and support, promote a stable sense of security and result in positive mental representations of self and others. When these figures are not reliably available and supportive, however, proximity seeking fails to relieve distress, felt security is undermined, negative models of self and others are formed, and the likelihood of later emotional problems and maladjustment increases (Bowlby, 1973). When testing this theory in studies of adults, most researchers have focused on the organized pattern of relational expectations, emotions, and behavior that results from a history of interactions with one’s attachment figures—often called “attachment style” (Hazan & Shaver, 1987). Psychometric research (e.g., Brennan, Clark, & Shaver, 1998) has shown that attachment styles can be measured in terms of two independent dimensions: attachment anxiety and attachment-related avoidance. A person’s position on the attachment anxiety dimension indicates the degree to which he or she worries that a partner will not be responsive in times of need. Anxious individuals are afraid of being rejected or abandoned, partly because of their deeply rooted self-doubts and self-criticisms. A person’s position on the avoidance dimension indicates the extent to which he or she distrusts relationship partners’ goodwill and their capacity to help. Avoidant individuals defensively strive to maintain inde-

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free ebooks ==> www.ebook777.com An Attachment Perspective on Resilience 157 pendence and emotional distance from relationship partners. People who score low on both dimensions are said to be securely attached. A person’s location in this two-dimensional space can be measured with reliable and valid self-report scales (e.g., Brennan et al., 1998) and is associated in theoretically predictable ways with many aspects of psychological adjustment (see Mikulincer & Shaver, 2007a, for a review). Attachment styles begin to develop in interactions with primary caregivers during early childhood, as a large body of research has shown (see Cassidy & Shaver, 2008, for an anthology of reviews), but Bowlby (1988) claimed that relational experiences throughout life can move a person from one region to another in the anxiety-by-avoidance conceptual space. Moreover, although attachment style is often measured as a single global orientation toward close relationships, a person’s orientation to attachment is rooted in a complex cognitive and affective associative neural network that includes both secure and insecure episodic and semantic mental representations (Mikulincer & Shaver, 2007a). Indeed, a growing body of research shows that attachment style can change, subtly or dramatically, depending on current context and recent relational experiences (see Mikulincer & Shaver, 2007b, for a review). We (Mikulincer & Shaver, 2007a) proposed that a person’s location in the two-dimensional anxiety-by-avoidance space reflects both his or her sense of attachment security and the ways in which he or she deals with threats and stressors. People who score low on these two dimensions are generally secure, hold positive mental representations of self and others, and tend to employ constructive and effective affect-regulation strategies. Those who score high on either attachment anxiety or avoidance, or both (a condition called fearful avoidance, based on a seminal article by Bartholomew and Horowitz, 1991), suffer from attachment insecurities, self-related worries, and distrust of others’ goodwill and responsiveness in times of need. Moreover, such insecure people tend to use secondary attachment strategies that we, following Cassidy and Kobak (1988), conceptualize as the attachment system “hyperactivating” or “deactivating” to cope with threats, frustrations, rejections, and losses. People who score high on attachment anxiety rely on hyperactivating strategies—energetic attempts to achieve support and love combined with a lack of confidence that these resources will be provided and with feelings of anger and despair when they are not provided (Cassidy & Kobak, 1988). In contrast, people who score high on attachment-related avoidance tend to use deactivating strategies: trying not to seek proximity to others when threatened, denying vulnerability and needs for other people, and avoiding closeness and interdependence in relationships.

ATTACHMENT, EMOTION REGULATION, AND RESILIENCE According to attachment theory (Bowlby, 1982), the attachment system is automatically activated by external threats or internal sources of distress, and, when it functions appropriately, it leads to socially supported emotional stability. Recently, adult attachment researchers have designed experimental procedures to examine these regulatory properties of the attachment system. For example, in a series of laboratory experiments, Mikulincer, Gillath, and Shaver (2002) showed that mental representations of attachment figures (e.g., names of security-enhancing attachment figures) are automatically activated in a person’s mind when he or she is exposed to threatening stimuli, even unconsciously. Specifically, when a threatrelated word (e.g., “death”) was presented very briefly (i.e., subliminally) on a computer screen, participants were faster to detect the name of one of their attachment figures when it appeared on the screen and were slower to name the color in which such names were printed


Mario Mikulincer and Phillip R. Shaver

on the screen—an indication that the words had been automatically activated in memory (Mikulincer et al., 2002). In another set of studies of what we call “security priming,” Mikulincer, Hirschberger, Nachmias, and Gillath (2001) showed that activation of representations of security-enhancing attachment figures can automatically infuse a previously neutral stimulus with positive affect. For example, subliminal presentation of the names of people who were nominated by the participants as attachment figures, compared with others who were not nominated as attachment figures, led to greater liking of previously unfamiliar stimuli. Moreover, subliminal exposure to names of attachment figures eliminated the detrimental effects that threats otherwise had on liking for previously neutral stimuli. These effects of security priming on positive affect have been replicated in subsequent studies (see Mikulincer & Shaver, 2007b, for a review). Putting all of these findings together, we conclude that people automatically search for internal representations of security-enhancing attachment figures during times of stress, and mental activation of these representations produces positive emotions (e.g., relief, satisfaction, gratitude, love) that can facilitate effective coping and restore emotional equanimity. That is, actual or symbolic interactions with available and supportive attachment figures and the resulting sense of safety can be viewed as psychological resources for dealing with problems and adversities. Therefore, people who generally feel safe and protected can remain relatively unperturbed in times of stress, recover faster from episodes of distress, and experience longer periods of positive affectivity (Mikulincer & Shaver, 2007a). These beneficial effects of attachment security should be especially salient during exposure to natural or human-caused stressful and traumatic events, physical illnesses, and the death of loved ones. In such circumstances, a secure person’s mental cry for help should result in mobilization of internal representations of security-providing attachment figures and/or actual external sources of support. As a result, the secure person can maintain psychological well-being despite the external challenge, thereby making damage to mental health less likely when the stress or trauma subsides. Moreover, the secure person is likely to activate optimistic and hopeful representations of self and others, rely on constructive strategies of affect regulation, deal effectively with trauma, and restore emotional balance. In other words, the sense of attachment security should act, at least to some extent, as a protective shield against the formation of emotional problems following stressful and traumatic events. In contrast, disruptions in the sense of attachment security are viewed as risk factors for emotional problems and psychopathology. The early attachment experiences of insecure people (whether anxious, avoidant, or both) often involve unstable and inadequate distress regulation (Bowlby, 1973), which can interfere with the development of inner resources necessary for coping successfully with stressors. This impairment is particularly likely during prolonged, highly demanding stressful experiences that require active support-seeking and actual confrontation with a problem (Berant, Mikulincer, & Shaver, 2008). In such cases, anxious hyperactivating strategies can become extreme, damaging not only a person’s own mental health but that of key relationship partners. Moreover, avoidant defenses can collapse, resulting in a marked decline in psychological well-being. In subsequent sections of this chapter, we review studies of the association between attachment orientations and stress-related responses, in particular attachment-related variations in psychological and physiological reactions to (a) attachment-irrelevant stressful events, (b) attachment-related sources of distress (separation from, or loss of, a close relationship partner), (c) natural and human-caused life-threatening traumas, and (d) physical illnesses.

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ATTACHMENT AND RESPONSES TO STRESSFUL EVENTS In this section, we review studies that have examined attachment-style differences in the way people appraise, cope with, and emotionally and physiologically react to attachment-irrelevant stressful events (i.e., events that have no direct implications for one’s close relationships or attachment figures). These attachment-style differences have been examined in response to a wide variety of stressful events, such as combat training, transition to college, abortion, infertility, pregnancy, workload, financial problems, and job loss (see Mikulincer & Shaver, 2007a, for an extensive review). They have also been examined in studies that have not focused on a specific stressful event but have asked participants to report on any major stressors recently experienced (e.g., Holmberg, Lomore, Takacs, & Price, 2011). In addition, the link between attachment orientations and stress-related reactions has been examined in response to several laboratory-induced stressors, such as aversive noise (e.g., Quirin, Pruessner, & Kuhl, 2008), the Trier Social Stress Test (e.g., Smeets, 2010), and difficult cognitive tasks (e.g., Kidd, Hamer, & Steptoe, 2011). With regard to cognitive appraisal of stressful events, self-reports of attachment security have been found to be associated with distress-alleviating appraisals—that is, appraising challenges in less threatening ways and appraising oneself as being able to cope effectively. In contrast, attachment anxiety has been associated with distress-intensifying appraisals—appraising stressful events as threats rather than challenges and viewing one’s coping resources as deficient (see Mikulincer & Shaver, 2007a, for a review). For avoidant attachment, however, the findings are more complex. Whereas avoidant attachment is associated with appraising stressful events in more threatening terms, it is not associated with appraisals of coping resources (see Mikulincer & Shaver, 2007a, for a review). This dissociation might reflect avoidant individuals’ reluctance to recognize that they are vulnerable and weak and therefore need to rely on others for assistance and support (Mikulincer & Shaver, 2007a). With regard to differences in coping style and attachment, there is evidence that secure individuals are more likely than insecure ones to rely on constructive, problem-focused coping strategies (e.g., Raskin, Kummel, & Bannister, 1998). Findings also indicate that attachment insecurities are associated with less adaptive ways of coping. Whereas attachment anxiety is associated with emotion-focused coping, such as wishful thinking, selfblame, and distress-related mental rumination, avoidant attachment is associated with reliance on distancing strategies, such as stress denial, diversion of attention, and behavioral or cognitive disengagement (e.g., Holmberg et al., 2011). Moreover, these associations have been obtained in longitudinal studies (e.g., Zhang & Labouvie-Vief, 2004). For example, Zhang and Labouvie-Vief (2004) found that increases in attachment security over a 6-year period covaried with decreased use of distancing coping and increased use of constructive, flexible, and reality-oriented coping strategies. These findings fit well with the theoretical role of attachment security as a resilience resource that helps people maintain emotional balance. Several adult attachment studies have involved asking participants to report on their psychological distress or well-being during and following stressful events. Overall, findings indicate that attachment security is associated with lower levels of distress and higher levels of psychological well-being. In contrast, attachment insecurities—anxiety, avoidance, or both—are associated with self-reports of heightened distress and deteriorated well-being (e.g., Mikulincer & Florian, 1998). Moreover, some of the studies compared the emotional reactions of secure and insecure people undergoing stressful experiences with those of con-



trols, revealing that stressful events arouse distress mainly among insecurely attached people. For secure people, there is often no notable difference in emotion between neutral and stressful situations (e.g., Mikulincer & Florian, 1998). Recent studies have found that the attachment–distress link is reflected in physiological responses to stressful events. For example, two experiments (Diamond, Hicks, & OtterHenderson, 2006; Maunder, Lancee, Nolan, Hunter, & Tannenbaum, 2006) exposed participants to various laboratory stressors (e.g., recalling a stressful situation, performing demanding math tasks) and assessed signs of distress in the activity of the autonomic nervous system (heart rate, blood pressure, galvanic skin responses). Self-reports of avoidant attachment were associated with heightened physiological reactivity: decreased heart-rate variability, increased skin conductance, and heightened blood pressure. With regard to attachment anxiety, Maunder, Lancee, et al. (2006) found that attachment-anxious people’s responsiveness to stressors was manifested in higher levels of reported distress but not in heart-rate measures, perhaps suggesting that anxious people exaggerate their distress. In addition, four studies have assessed attachment-style differences in the activity of the hypothalamus-pituitary-adrenal (HPA) axis, which can be measured in terms of salivary cortisol levels during and following a laboratory-induced stressor. One study found that avoidant attachment was associated with increased levels of salivary cortisol (Kidd et al., 2011), one study (Quirin et al., 2008) found a positive association between attachment anxiety and heightened cortisol reactivity, and two studies found no significant association between attachment orientations and cortisol levels (Ditzen et al., 2008; Smeets, 2010). These inconsistencies might have been due, in part, to variations in the laboratory-induced stressors (e.g., aversive noise, the Trier Social Stress Test) and participants’ age (young adults, mid-life adults). More systematic research is needed to determine the presence or absence of a link between attachment insecurities and HPA dysregulation following stressful events. There is initial evidence that an association between attachment insecurities and psychological distress following stressful events can be observed in brain responses. Lemche et al. (2006) measured neural responses in healthy adult individuals to stressful and neutral primes using event-related functional magnetic resonance imaging (fMRI). They noted heightened responses in bilateral amygdalae during exposure to the stressful but not to the neutral prime. More importantly, more insecure people tended to react to stress with increased amygdala activity—a neural indication of distress arousal.

ATTACHMENT AND RESPONSES TO SEPARATION AND LOSS People differing in attachment orientations also differ in their reactions to attachment-related stressors, such as separation from a close relationship partner or the death of a spouse. These attachment-related threats, which were among Bowlby’s (1980) major concerns, are potent triggers of distress and regulatory strategies aimed at restoring emotional equanimity. Reactions to Separations and Relationship Breakups Several studies have shown that attachment orientations predict the intensity and duration of distress following a romantic relationship breakup (e.g., Sbarra, 2006; Sbarra & Emery, 2005), divorce (Birnbaum, Orr, Mikulincer, & Florian, 1997), wartime separations from marital partners (e.g., Medway, Davis, Cafferty, Chappell, & O’Hearn, 1995), and temporary separations from romantic partners (e.g., Diamond, Hicks, & Otter-Henderson, 2008).

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free ebooks ==> www.ebook777.com An Attachment Perspective on Resilience 161 In these studies, distress intensification was a common response of anxiously attached people, whereas attachment security was associated with faster emotional recovery and adjustment. For example, Sbarra (2006) collected daily emotion data for 4 weeks from young adults who had recently experienced a romantic relationship breakup, finding that attachment anxiety was associated with slower recovery from sadness and anger. In a 21-day diary study, Diamond et al. (2008) found that attachment anxiety was associated with difficulty sleeping, more severe physical symptoms, and higher levels of salivary cortisol during and following days of physical separation from a romantic partner brought about by work-related travel. Using fMRI to observe brain processes while recalling a painful separation, Gillath, Bunge, Shaver, Wendelken, and Mikulincer (2005) found that attachment anxiety was associated with higher activation of the left anterior temporal pole and left hippocampus, areas associated with the recall of sad thoughts, and lower activation of the orbitofrontal cortex, an area associated with emotional control. That is, anxious individuals seemed unable to control the reactivation of separation memories. For avoidant individuals, the findings depended on the nature of the separation. Avoidance was associated with higher levels of distress following divorce and wartime separations but lower levels of distress and greater relief following temporary separations from, or permanent breakups with, dating partners. It seems that avoidant people who can handle the distress of brief separations or the dissolution of casual bonds are less successful in dealing with major separations requiring reorganization of relational routines, goals, and plans. This fits with other evidence, including from experiments (e.g., Mikulincer, Dolev, & Shaver, 2004), that avoidant defenses collapse under pressure. There is also evidence that people differing in attachment orientations differ in the ways they cope with separation. For example, following divorce (Birnbaum et al., 1997) and temporary separations from a dating partner (Feeney, 1998), attachment-anxious individuals were more likely to rely on emotion-focused coping strategies, and avoidant individuals on distancing strategies. Similar coping strategies were noted by Davis, Shaver, and Vernon (2003) in a survey of more than 5,000 Internet respondents who described romantic relationship breakups. Avoidant respondents were less likely to seek support and more likely to cope with the breakup alone while avoiding new romantic involvements. Anxious respondents reacted with angry protests, heightened sexual attraction to the former partner, intense preoccupation with the lost partner, a damaged sense of identity, and interference with school and work activities. In addition, both anxious and avoidant individuals used alcohol and drugs as a means of coping with separation, which is not generally an effective coping strategy. Studies that induced thoughts about hypothetical or actual separations also provide important information about attachment-related differences in regulating the distress resulting from these thoughts. For example, using a thought suppression task, Fraley and Shaver (1997) showed that avoidant people were highly effective in suppressing separation-related thoughts. However, Mikulincer et al. (2004) found that avoidant people’s ability to suppress separation-related thoughts was disrupted when a cognitive load—remembering a seven-digit number—was added to the experimental task. We suspect that a similar interference occurs when a high emotional demand is imposed, as in the studies reviewed earlier that dealt with life-threatening traumatic events. Recently, Ehrenthal, Friederich, and Schauenburg (2011) found that avoidant attachment was associated with impaired blood pressure recovery following the recall of a painful separation, further emphasizing the fragility of avoidant defenses.



Reactions to the Death of a Close Relationship Partner Few studies have directly examined associations between attachment orientations and grief reactions following the death of a close relationship partner. However, what studies there are have consistently found that attachment anxiety is associated with complicated grief reactions (e.g., Fraley & Bonanno, 2004; Jerga, Shaver, & Wilkinson, 2011). For example, Field and Sundin (2001) found that anxious attachment, assessed 10 months after the death of a spouse, predicted higher levels of psychological distress 14, 25, and 60 months after the loss, and Fraley and Bonanno (2004) found that attachment anxiety assessed 4 months after the loss of a spouse predicted higher levels of anxiety, depression, grief, trauma-related symptoms, and alcohol consumption 18 months following the loss. With regard to avoidant attachment, studies have generally found no significant association between this attachment pattern and depression, grief, or distress following the death of a relationship partner (e.g., Field & Sundin, 2001; Fraley & Bonanno, 2004). However, Wayment and Vierthaler (2002) found that avoidance was associated with somatic symptom levels following the death of spouse. Recently, Jerga et al. (2011) found that avoidant attachment was positively associated with prolonged grief symptoms but not with typical or normative grief symptoms. That is, people who are generally avoidant in close relationships experience long-term difficulties adjusting to the death of a relationship partner, even though they do not necessarily experience more intense typical grief symptoms. Attachment and Responses to Traumatic Events There is extensive evidence that people differing in attachment orientations differ in their psychological reactions to traumatic events. One line of research has focused on the intensity of posttraumatic stress disorder (PTSD) symptoms following a traumatic event and found that self-reported attachment insecurities (anxiety, avoidance) are positively associated with these symptoms. This association has been replicated across different samples of adults, which include victims of childhood sexual or physical abuse (e.g., Sandberg, 2010), civilians living under life-endangering conditions (e.g., Besser & Neria, 2012), prisoners of war (e.g., Zakin, Solomon, & Neria, 2003), war veterans (e.g., Dekel, Solomon, Ginzburg, & Neria, 2004), Holocaust survivors (e.g., Cohen, Dekel, & Solomon, 2002), survivors of the 9/11 terror attacks (e.g., Fraley, Fazzari, Bonanno, & Dekel, 2006), security workers (e.g., Bogaerts, Kunst, & Winkel, 2009), and victims of interpersonal violence (e.g., Sandberg, Suess, & Heaton, 2010). For example, Fraley et al. (2006) found that both attachment anxiety and avoidance, as assessed by self-report scales administered 7 months after the 9/11 terror attacks, predicted more severe PTSD symptoms 11 months later. A second line of research has examined the extent to which a sense of attachment security can have healing effects on people suffering from PTSD and improve their response to treatment. For example, Forbes, Parslow, Fletcher, McHugh, and Creamer (2010) assessed the effectiveness of group-based treatment for combat-related PTSD and found that self-reports of attachment security predicted better treatment outcome and recovery from PTSD following treatment. In another psychotherapy outcome study, Muller and Rosenkranz (2009) found that increases in self-reports of attachment security during treatment in an inpatient program for adults with PTSD were associated with a reduction in PTSD symptoms after treatment. In two studies, Mikulincer, Shaver, and Horesh (2006) found direct evidence for the healing effects of attachment security. One study used a diary methodology and assessed Israelis’

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free ebooks ==> www.ebook777.com An Attachment Perspective on Resilience 163 daily psychological reactions during 21 days of the 2003 US–Iraq war. Findings indicated that global attachment insecurities (assessed with self-report measures before the war) were associated with more severe war-related PTSD across the 21-day period. However, contextual activation of the sense of attachment security (feelings of being loved, cared for, and accepted) on a given day reduced the severity of war-related PTSD symptoms that day and the next day. Moreover, contextual security augmentation weakened the link between dispositional attachment anxiety and PTSD. That is, the feeling of being supported by others on a given day reduced anxiously attached individuals’ PTSD symptoms. However, daily inductions of a sense of security did not reduce the detrimental effects of avoidant attachment on PTSD symptoms. It seems possible, therefore, that avoidant individuals’ deactivating strategies continue to operate even when actual or symbolic attachment figures are supportive. The second study focused on Palestinian terrorist attacks on Israeli cities and examined whether security priming in the lab can reduce implicit responses to trauma—that is, can affect the cognitive accessibility of trauma-related mental representations in a Stroop colornaming task (Mikulincer et al., 2006). Israeli undergraduates who had previously reported their attachment orientations completed a self-report scale tapping the severity of PTSD symptoms with regard to Palestinian terrorist attacks, and they were divided into two groups (PTSD, non-PTSD) according to the reported severity of their symptoms. On a later occasion they performed a Stroop color-naming task that included words connoting terror (e.g., Hamas, car-bomb) as well as negatively valenced words not related to terror and some emotionally neutral words. On each trial, participants were subliminally primed with an attachment-security word (the Hebrew word for “being loved”), a positively valenced but attachment-unrelated word (success), or a neutral word (hat). The results indicated that participants in the PTSD group took longer, on average, to name the colors in which terror-related words were presented (indicating greater mental availability of the words) than participants in the non-PTSD group. In addition, higher scores on attachment anxiety and avoidance scales were associated with longer color-naming latencies for terror words among people with PTSD symptoms. More important, contextual activation of attachment security had a healing effect on implicit PTSD responses. Specifically, subliminal priming of attachment-security representations lowered the color-naming latencies of terror-related words among people who suffered from PTSD symptoms, and this priming countered the effects of attachment anxiety on color-naming latencies. However, security priming failed to reduce the association between avoidant attachment and implicit PTSD responses. That is, the link between avoidance and longer color-naming responses for terror words was found even in the security priming condition, suggesting that avoidant people’s implicit PTSD vulnerability remained even in the presence of security primes. Overall, these findings support the hypothesis that mobilizing external or internal forms of security during traumatic and posttraumatic periods reduces the intensity of PTSD symptoms. The studies also show that at least some traumatized individuals respond favorably to actual support offered by familiar others in their immediate environment and to the contextual manipulation of their sense of attachment security.

ATTACHMENT-RELATED DIFFERENCES IN ADJUSTMENT TO PHYSICAL ILLNESS People differing in attachment orientations tend to differ in the way they appraise and cope with physical illnesses. For example, attachment anxiety is associated with higher threat



appraisals in response to chronic pain (Meredith, Strong, & Feeney, 2005) and lower perceived resources for coping with chronic pain (Meredith, Strong, & Feeney, 2006). Attachment anxiety has also been found to correlate with distress-exacerbating mental rumination in samples of fibromyalgia patients (Oliveira & Costa, 2009) and cancer patients (Cicero, Lo Coco, Gullo, & Lo Verso, 2009). In addition, diabetics scoring higher on avoidance relied more on cognitive distancing as coping strategies (Turan, Osar, Turan, Ilkova, & Damci, 2003) and those scoring higher on attachment anxiety relied less on task-oriented coping strategies (Bazzazian & Besharat, 2012). These attachment-related differences in ways of coping are manifested in the extent to which physically ill people can maintain psychological well-being and recover from psychological distress. Specifically, attachment insecurities, mainly of the anxious kind, are associated with heightened psychological distress among people suffering from physical illness (e.g., Bazzazian & Besharat, 2012; Vilchinsky et al., 2010). In a prospective 6-month study of ACS patients, Vilchinsky et al. (2010) found evidence for a buffering effect of security provided by one’s spouse: Attachment anxiety predicted heightened distress 6 months later only when spouses did not actively support the patient. This detrimental effect of attachment anxiety disappeared when spouses engaged in supportive actions, thereby providing a dyadic sense of security for the anxious patient. There is also evidence that attachment insecurities can interfere with the healing process. First, attachment insecurities interfere with the patient–physician relationship. For example, Ciechanowski et al. (2004) found, in a study of diabetic patients, that avoidant attachment was associated with poorer patient–physician communication. In addition, Maunder, Panzer, et al. (2006) found that insecure patients, whether anxious, avoidant, or both, had more troubled relationships with their physicians than did secure patients. Second, attachment insecurities interfere with adherence to medical regimens. For example, avoidant attachment among diabetics is associated with less faithful glucose monitoring and higher levels of HbA1c, a physiological indicator of poor glucose control (e.g., Bazzazian & Besharat, 2012). In addition, Ciechanowski et al. (2004) found that avoidant diabetics engaged in less exercise, maintained a poorer diet, and took their medication less regularly than their secure counterparts. These attachment-related interferences with self-care help to explain why attachment anxiety is linked with somatic symptoms (e.g., Kidd & Sheffield, 2005), troubled sleep (e.g., Carmichael & Reis, 2005), and more persistent physical pain (MacDonald & Kingsbury, 2006). Using data from the National Comorbidity Survey Replication, McWilliams and Bailey (2010) found that avoidant attachment was associated with chronic pain, whereas anxious attachment was associated with a wider range of health problems, including illnesses involving the cardiovascular system. Strikingly, attachment measures accounted for unique variance in health conditions beyond that accounted for by lifetime histories of depressive, anxiety, and alcohol- or substance-related disorders. Beyond interfering with adjustment to, and recovery from, physical illnesses, attachment insecurities play a role in the development of disorders by exacerbating physiological responses to stress (Maunder & Hunter, 2001). For example, avoidant attachment is associated with deficient immunity as manifested in lower natural killer cell cytotoxicity (Picardi et al., 2007) and heightened inflammatory responses to marriage-related stress as manifested in increased production of interleukin-6 (Gouin et al., 2009). In addition, Maunder, Lancee, Greenberg, Hunter, & Fernandes (2000) found higher avoidance scores among patients with ulcerative colitis (UC) who had no genetic marker for developing the disorder than among patients with a UC genetic marker. This implies that avoidant attachment is involved

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free ebooks ==> www.ebook777.com An Attachment Perspective on Resilience 165 in developing the disorder rather than being a mere consequence of the disorder, because it would be difficult to explain why genetically unexplained UC produced more avoidance than genetically caused UC. This conclusion is reinforced by studies showing that insecure attachment is more common in patients whose symptoms lacked an organic explanation than among patients with organically explicable physical symptoms (e.g., Ciechanowski, Katon, Russo, & Dwight-Johnson, 2002).

CONCLUDING REMARKS Although we have cited a large research literature showing that attachment security is a resilience resource that enhances and protects mental and physical health, we have barely scratched the surface. In recent years, researchers have shown that a person’s level of attachment security can be measurably increased by subliminal priming procedures, involvement in a relationship with a security-supporting partner, and participation in individual psychotherapy or residing in a supportive group home. Thus, at the same time that we take pride in having uncovered much of the mental and behavioral machinery associated with secure, anxious, and avoidant attachment, we are hopeful that research on adult attachment can be applied to increase resilience in the face of life’s unavoidable stresses and calamities, with resulting improvements in individual mental and physical health, and in the well-being of human communities.

REFERENCES Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a fourcategory model. Journal of Personality and Social Psychology, 61, 226–244. Bazzazian, S., & Besharat, M. A. (2012). An explanatory model of adjustment to type I diabetes based on attachment, coping, and self-regulation theories. Psychology, Health, and Medicine, 17, 47–58. Berant, E., Mikulincer, M., & Shaver, P. R. (2008). Mothers’ attachment style, their mental health, and their children’s emotional vulnerabilities: A seven-year study of children with congenital heart disease. Journal of Personality, 76, 31–66. Besser, A., & Neria, Y. (2012). When home isn’t a safe haven: Insecure attachment orientations, perceived social support, and PTSD symptoms among Israeli evacuees under missile threat. Psychological Trauma, 4, 34–46. Birnbaum, G. E., Orr, I., Mikulincer, M., & Florian, V. (1997). When marriage breaks up: Does attachment style contribute to coping and mental health? Journal of Social and Personal Relationships, 14, 643–654. Bogaerts, S., Kunst, M. J. J., & Winkel, F. W. (2009). Dismissive attachment and posttraumatic stress disorder among securely and insecurely attached Belgian security workers. Psychological Reports, 105, 889–899. Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation: Anxiety and anger. New York: Basic Books. Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. New York: Basic Books. Bowlby, J. (1982). Attachment and loss: Vol. 1. Attachment (2nd ed.). New York: Basic Books. Bowlby, J. (1988). A secure base: Parent–child attachment and healthy human development. New York: Basic Books. Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 46–76). New York: Guilford Press.



Carmichael, C. L., & Reis, H. T. (2005). Attachment, sleep quality, and depressed affect. Health Psychology, 24, 526–531. Cassidy, J., & Kobak, R. R. (1988). Avoidance and its relationship with other defensive processes. In J. Belsky & T. Nezworski (Eds.), Clinical implications of attachment (pp. 300–323). Hillsdale, NJ: Erlbaum. Cassidy, J., & Shaver, P. R. (Eds.). (2008). Handbook of attachment: Theory, research, and clinical applications (2nd ed.). New York: Guilford Press. Cicero, V., Lo Coco, G., Gullo, S., & Lo Verso, G. (2009). The role of attachment dimensions and perceived social support in predicting adjustment to cancer. Psycho-Oncology, 18, 1045–1052. Ciechanowski, P. S., Katon, W. J., Russo, J. E., & Dwight-Johnson, M. M. (2002). Association of attachment style to lifetime medically unexplained symptoms in patients with hepatitis C. Psychosomatics, 43, 206–212. Ciechanowski, P. S., Russo, J. E., Katon, W. J., Von-Korff, M., Ludman, E., Lin, E., et al. (2004). Influence of patient attachment style on self-care and outcomes in diabetes. Psychosomatic Medicine, 66, 720–728. Cohen, E., Dekel, R., & Solomon, Z. (2002). Long-term adjustment and the role of attachment among Holocaust child survivors. Personality and Individual Differences, 33, 299–310. Davis, D., Shaver, P. R., & Vernon, M. L. (2003). Physical, emotional, and behavioral reactions to breaking up: The roles of gender, age, emotional involvement, and attachment style. Personality and Social Psychology Bulletin, 29, 871–884. Dekel, R., Solomon, Z., Ginzburg, K., & Neria, Y. (2004). Long-term adjustment among Israeli war veterans: The role of attachment style. Anxiety, Stress, and Coping, 17, 141–152. Diamond, L. M., Hicks, A. M., & Otter-Henderson, K. A. (2006). Physiological evidence for repressive coping among avoidantly attached adults. Journal of Social and Personal Relationships, 23, 205–229. Diamond, L. M., Hicks, A. M., & Otter-Henderson, K. A. (2008). Every time you go away: Changes in affect, behavior, and physiology associated with travel-related separations from romantic partners. Journal of Personality and Social Psychology, 95, 385–403. Ditzen, B., Schmidt, S., Strauss, B., Nater, U. M., Ehlert, U., & Heinrichs, M. (2008). Adult attachment and social support interact to reduce psychological but not cortisol responses to stress. Journal of Psychosomatic Research, 64, 479–486. Ehrenthal, J. C., Friederich, H. C., & Schauenburg, H. (2011). Separation recall: Psychophysiological response-patterns in an attachment-related short-term stressor. Stress and Health, 27, 251–255. Feeney, J. A. (1998). Adult attachment and relationship-centered anxiety: Responses to physical and emotional distancing. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 189–219). New York: Guilford Press. Field, N. P., & Sundin, E. C. (2001). Attachment style in adjustment to conjugal bereavement. Journal of Social and Personal Relationships, 18, 347–361. Forbes, D., Parslow, R., Fletcher, S., McHugh, T., & Creamer, M. (2010). Attachment style in the prediction of recovery following group treatment of combat veterans with post-traumatic stress disorder. Journal of Nervous and Mental Disease, 198, 881–884. Fraley, R., & Bonanno, G. A. (2004). Attachment and loss: A test of three competing models on the association between attachment-related avoidance and adaptation to bereavement. Personality and Social Psychology Bulletin, 30, 878–890. Fraley, R. C., Fazzari, D. A., Bonanno, G. A., & Dekel, S. (2006). Attachment and psychological adaptation in high exposure survivors of the September 11th attack on the World Trade Center. Personality and Social Psychology Bulletin, 32, 538–551. Fraley, R. C., & Shaver, P. R. (1997). Adult attachment and the suppression of unwanted thoughts. Journal of Personality and Social Psychology, 73, 1080–1091. Gillath, O., Bunge, S. A., Shaver, P. R., Wendelken, C., & Mikulincer, M. (2005). Attachment-style differences in the ability to suppress negative thoughts: Exploring the neural correlates. Neuroimage, 28, 835–847.

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free ebooks ==> www.ebook777.com An Attachment Perspective on Resilience 167 Gouin, J. P., Glaser, R., Loving, T. J., Malarkey, W. B., Stowell, J., Houts, C., et al. (2009). Attachment avoidance predicts inflammatory responses to marital conflict. Brain, Behavior, and Immunity, 23, 898–904. Hazan, C., & Shaver, P. R. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52, 511–524. Holmberg, D., Lomore, C. D., Takacs, T. A., & Price, E. L. (2011). Adult attachment styles and stressor severity as moderators of the coping sequence. Personal Relationships, 18, 502–517. Jerga, C., Shaver, P. R., & Wilkinson, R. B. (2011). Attachment insecurities and identification of atrisk individuals following the death of a loved one. Journal of Social and Personal Relationships, 28, 891–914. Kidd, T., Hamer, M., & Steptoe, A. (2011). Examining the association between adult attachment style and cortisol responses to acute stress. Psychoneuroendocrinology, 36, 771–779. Kidd, T., & Sheffield, D. (2005). Attachment style and symptom reporting: Examining the mediating effects of anger and social support. British Journal of Health Psychology, 10, 531–541. Lemche, E., Giampietro, V. P., Surguladze, S. A., Amaro, E. J., Andrew, C. M., Williams, S. C., et al. (2006). Human attachment security is mediated by the amygdala: Evidence from combined fMRI and psychophysiological measures. Human Brain Mapping, 27, 623–635. MacDonald, G., & Kingsbury, R. (2006). Does physical pain augment anxious attachment? Journal of Social and Personal Relationships, 23, 291–304. Maunder, R. G., & Hunter, J. J. (2001). Attachment and psychosomatic medicine: Developmental contributions to stress and disease. Psychosomatic Medicine, 63, 556–567. Maunder, R. G., Lancee, W. J., Greenberg, G., Hunter, J. J., & Fernandes, B. (2000). Insecure attachment in a subgroup of ulcerative colitis defined by ANCA status. Digestive Diseases Science, 45, 2127–2132. Maunder, R. G., Lancee, W. J., Nolan, R. P., Hunter, J. J., & Tannenbaum, D. (2006). The relationship of attachment insecurity to subjective stress and autonomic function during standardized acute stress in healthy adults. Journal of Psychosomatic Research, 60, 283–290. Maunder, R. G., Panzer, A., Viljoen, M., Owen, J., Human, S., & Hunter, J. J. (2006). Physicians’ difficulty with emergency department patients is related to patients’ attachment style. Social Science and Medicine, 63, 552–562. McWilliams, L. A., & Bailey, S. J. (2010). Associations between adult attachment ratings and health conditions: Evidence from the National Comorbidity Survey Replication. Health Psychology, 29, 446–453. Medway, F. J., Davis, K. E., Cafferty, T. P., Chappell, K. D., & O’Hearn, R. E. (1995). Family disruption and adult attachment correlates of spouse and child reactions to separation and reunion due to Operation Desert Storm. Journal of Social and Clinical Psychology, 14, 97–118. Meredith, P. J., Strong, J., & Feeney, J. A. (2005). Evidence of a relationship between adult attachment variables and appraisals of chronic pain. Pain Research and Management, 10, 191–200. Meredith, P. J., Strong, J., & Feeney, J. A. (2006). Adult attachment, anxiety, and pain self-efficacy as predictors of pain intensity and disability. Pain, 123, 146–154. Mikulincer, M., Dolev, T., & Shaver, P. R. (2004). Attachment-related strategies during thoughtsuppression: Ironic rebounds and vulnerable self-representations. Journal of Personality and Social Psychology, 87, 940–956. Mikulincer, M., & Florian, V. (1998). The relationship between adult attachment styles and emotional and cognitive reactions to stressful events. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 143–165). New York: Guilford Press. Mikulincer, M., Gillath, O., & Shaver, P. R. (2002). Activation of the attachment system in adulthood: Threat-related primes increase the accessibility of mental representations of attachment figures. Journal of Personality and Social Psychology, 83, 881–895. Mikulincer, M., Hirschberger, G., Nachmias, O., & Gillath, O. (2001). The affective component of the secure base schema: Affective priming with representations of attachment security. Journal of Personality and Social Psychology, 81, 305–321.



Mikulincer, M., & Shaver, P. R. (2007a). Attachment in adulthood: Structure, dynamics, and change. New York: Guilford Press. Mikulincer, M., & Shaver, P. R. (2007b). Boosting attachment security to promote mental health, prosocial values, and inter-group tolerance. Psychological Inquiry, 18, 139–156. Mikulincer, M., Shaver, P. R., & Horesh, N. (2006). Attachment bases of emotion regulation and posttraumatic adjustment. In D. K. Snyder, J. A. Simpson, & J. N. Hughes (Eds.), Emotion regulation in families: Pathways to dysfunction and health (pp. 77–99). Washington, DC: American Psychological Association. Muller, R. T., & Rosenkranz, S. E. (2009). Attachment and treatment response among adults in inpatient treatment for posttraumatic stress disorder. Psychotherapy, 46, 82–96. Oliveira, P., & Costa, E. (2009). Interrelationships of adult attachment orientations, health status and worrying among fibromyalgia patients. Journal of Health Psychology, 14, 1184–1195. Picardi, A., Battisti, F., Tarsitani, L., Baldassari, M., Copertaro, A., Mocchegiani, E., et al. (2007). Attachment security and immunity in healthy women. Psychosomatic Medicine, 69, 40–46. Quirin, M., Pruessner, J. C., & Kuhl, J. (2008). HPA system regulation and adult attachment anxiety: Individual differences in reactive and awakening cortisol. Psychoneuroendocrinology, 33, 581–590. Raskin, P. M., Kummel, P., & Bannister, T. (1998). The relationship between coping styles, attachment, and career salience in partnered working women with children. Journal of Career Assessment, 6, 403–416. Sandberg, D. A. (2010). Adult attachment as a predictor of posttraumatic stress and dissociation. Journal of Trauma and Dissociation, 11, 293–307. Sandberg, D. A., Suess, E. A., & Heaton, J. L. (2010). Attachment anxiety as a mediator of the relationship between interpersonal trauma and posttraumatic symptomatology among college women. Journal of Interpersonal Violence, 25, 33–49. Sbarra, D. A. (2006). Predicting the onset of emotional recovery following nonmarital relationship dissolution: Survival analyses of sadness and anger. Personality and Social Psychology Bulletin, 32, 298–312. Sbarra, D. A., & Emery, R. E. (2005). The emotional sequelae of nonmarital relationship dissolution: Analysis of change and intraindividual variability over time. Personal Relationships, 12, 213–232. Smeets, T. (2010). Autonomic and hypothalamic-pituitary-adrenal stress resilience: Impact of cardiac vagal tone. Biological Psychology, 84, 290–295. Turan, B., Osar, Z., Turan, J. M., Ilkova, H., & Damci, T. (2003). Dismissing attachment and outcome in diabetes: The mediating role of coping. Journal of Social and Clinical Psychology, 22, 607–626. Vilchinsky, N., Haze-Filderman, L., Leibowitz, M., Reges, O., Khaskia, A., & Mosseri, M. (2010). Spousal support and cardiac patients’ distress: The moderating role of attachment orientation. Journal of Family Psychology, 24, 508–512. Wayment, H. A., & Vierthaler, J. (2002). Attachment style and bereavement reactions. Journal of Loss and Trauma, 7, 129–149. Zakin, G., Solomon, Z., & Neria, Y. (2003). Hardiness, attachment style, and long-term psychological distress among Israeli POWs and combat veterans. Personality and Individual Differences, 34, 819–829. Zhang, F., & Labouvie-Vief, G. (2004). Stability and fluctuation in adult attachment style over a 6-year period. Attachment and Human Development, 6, 419–437.

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free ebooks ==> www.ebook777.com 13 Using the Caregiver System Model to Explain the Resilience-Related Benefits Older Adults Derive From Volunteering Stephanie L. Brown and Morris A. Okun

Resilience can be conceptualized in several different ways. One view of resilience is that it represents the capacity, in the face of stressful and traumatic circumstances, (a) to bounce back and (b) to sustain oneself. In the present chapter, we focus on stress regulation and risk of mortality as markers of the bounce-back and sustainability components of resilience, respectively. Our central thesis is that providing support to another person (helping behavior), whatever its effect on the recipient, can promote the resilience-related resources of the helper (S. Brown & Brown, 2006). Providing assistance to another elevates the helper’s mood, improves relationship satisfaction, and relieves negative affective states such as sadness and distress (see Post, 2007). Brown and her colleagues have shown that helping behavior is associated with accelerated recovery from depressive symptoms among older adults experiencing spousal bereavement (S. Brown, Brown, House, & Smith, 2008) and with reduced risk of mortality (S. Brown, Nesse, Vinokur, & Smith, 2003), even among caregivers (S. Brown, Smith, et al., 2009). Okun and his colleagues showed that volunteering reduced the risk of mortality among older adults who have functional health limitations (Okun, August, Rook, & Newsom, 2010). Thus, helping behavior in general, and volunteering in particular, is a potential resilience resource for older adults facing stressors. However, researchers have not provided an integrative explanation for why volunteering enhances the resilience capability of older adults. To address this gap in the current chapter, we first quantify the benefit of volunteering on reducing the risk of mortality. Second, we present an overview of the caregiver system model of active help and stress regulation. Third, we use the caregiver system model to explain why volunteering enhances the resilience of older adults and under what circumstances it is likely to do so.

QUANTITATIVE SYNTHESIS We focused on the bivariate association between organizational volunteering and risk of mortality among adults 55 years and older. Organizational volunteering refers to an unpaid, voluntary activity that involves “taking actions within an institutional framework that potentially provides some service to one or more other people or to the community at large” (Piliavin & Siegl, 2007, p. 454). We located eight studies that estimated the association between volunteering and risk of mortality. For each study, we extracted an odds ratio (OR). The OR compared the odds of dying among volunteers with the odds of dying among non-volunteers. Values below 1 indicated that volunteering was associated with a reduced risk of dying, with values closer to 0 indicating the largest reduction in mortality risk associated with volunteering. For each odds ratio, we computed the 95% confidence interval. As can be seen in Figure 13.1, the ORs ranged from.29 to.66 and, for each study, the entire


Stephanie L. Brown and Morris A. Okun Odds ratio (95% CI) Odds ratio (95% CI)

Authors

Musick, Herzog, & House (1999) Harris & Thoresen (2005) Oman, Thoresen, & McMahon (1999) Okun, August, Rook, & Newsom (2010) Rogers (1996) Ayalon (2008) Lee, Cenzer, & Covinsky (2009) Luoh & Herzog (2002)

0.66 0.59 0.55 0.52 0.50 0.46 0.39 0.29

.00 l

.25 l

.50

l

.75

l

_

1.00 l

.47 to .93 .51 to .68 .43 to .69 .36 to .73 .38 to .66 .33 to .64 .33 to .46 .20 to .42 l .00

l .25

l .50

l .75

__ l 1.00

Figure 13.1 Plot of odds ratios from individual studies investigating the association between volunteering and mortality. 95% CI = 95% confidence interval.

95% confidence interval was below 1.0. Consistent with a previous review (Oman, 2007), volunteering was observed to be inversely related to mortality risk. Using the median OR of .51, we conclude that, without statistically controlling for other variables, volunteering was associated with a 49% reduction in the risk of mortality.

THE CAREGIVER SYSTEM MODEL OF ACTIVE HELP AND STRESS REGULATION The survival benefit of volunteering for the helper implies the existence of an underlying regulatory system (or set of interacting systems) that motivates helping behavior and has important physiological consequences for the body (S. Brown et al., 2003; S. Brown & Brown, 2006; S. Brown et al., 2008; S. Brown, Smith et al., 2009). We have recently hypothesized that helping behavior may be organized within a caregiving behavioral system,1 a suite of cognitions, emotions, and underlying neurophysiology that motivates active help (S. Brown, Brown, & Preston, 2012). Repeated activation of this system has been hypothesized to forge links between helping, modulation of the stress response, and health (Poulin, Brown, Dillard, & Smith, in press). With few exceptions (George & Solomon, 1999), theories of human caregiving systems have been uninformed by physiology and animal models that identify relevant neural circuitry. The utility of animal models for guiding research in psychology has been articulated recently by Cacioppo et al. (2007). Such models are particularly important for exploring links between volunteering and mortality because they provide neuroanatomical pathways for connecting helping behavior to physiological indicators of stress that plausibly influence health. Figure 13.2 shows the basic caregiving system model, grounded in what is known about maternal caregiving neural circuitry, including extensions to human helping behavior (S. Brown et al., 2012). Although we will not describe the underlying neural circuitry in detail here (see Numan, 2006, for a review), the circuit is under the influence of the medial preoptic area (MPOA) of the hypothalamus, which triggers motor programs for helping along two routes: (a) by increasing approach motivation (i.e., via the nucleus accumbens–ventral pallidum circuit) and (b) by decreasing the competing avoidance (stress) response (i.e., inhibition of the

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free ebooks ==> www.ebook777.com Using the Caregiver System Model to Explain the Benefits 171 CLOSE RELATIONSHIPS and USEFULNESS

PERCEIVED NEED (e.g., volunteer opportunity)

OTHER SOURCES OF MOTIVATION (e.g., norms, obligation)

ACTIVE, VOLUNTARY HELP

CAREGIVING MOTIVATION (e.g., compassion, positive emotions)

STRESS REGULATION (e.g., cortisol, DHEA, progesterone)

Figure 13.2 Caregiving system model of active help and stress regulation.

anterior hypothalamic nucleus and periaqueductal gray). Hormones that may increase the chance of activating the MPOA include oxytocin and progesterone, both of which have been shown to predict helping behavior and stress (S. Brown & Brown, 2006; S. Brown, Fredrickson, et al., 2009; Carter, 1998), The association of helping behavior with deactivation of the stress response and downstream effects on immune function is theorized to be part of the mechanism by which volunteering influences stress regulation and long-term physical health (S. Brown & Preston, 2012). Using the Caregiver System Model to Explain the Resilience-Related Benefits of Volunteering In applying the caregiving system model to understand the resilience-related benefits that older volunteers derive helping others, we posited four classes of mediating variables that may determine whether volunteering triggers activation of the caregiving system (see Figure 13.3). Perceived usefulness (e.g., sense of competence) and social relationships (e.g., social integration/support) are both thought to trigger the caregiving system, so we hypothesize that both will trigger positive emotions and compassionate, as opposed to reward-based, motives. Volunteering motivation is also hypothesized to be influenced by situational attributes such as the type of volunteer work. Compassionate helping triggered by volunteering is then expected to improve stress regulation and immune function, improve cognitive functioning, health, and well-being, and delay disease and death. The Directional Link From Volunteering to Perceived Usefulness and Sense of Competence One of the major motives given by older adults for volunteering is their desire to feel useful. Gruenewald, Karlamangla, Greendale, Singer, and Seeman (2007) demonstrated that, relative to older non-volunteers, older volunteers were 1.8 times more likely to frequently feel that they were useful to others. Piliavin and Siegl (2007) found that volunteering promoted a sense that one mattered and suggested that it led older people to feel that they had an important role in society. Volunteering in later life also has been shown to promote an agentic self-identity (Herzog, Franks, Markus, & Holmberg, 1998). Midlarsky and Kahana (1994) observed that, by helping others, older volunteers could increase their sense of competence. Because role occupancy declines with age (Van Willigen, 2000), perceived competence may be a particularly salient component of older adults’ leisure repertoires. In


Stephanie L. Brown and Morris A. Okun VOLUNTEERING SITUATION ATTRIBUTES Sponsor of volunteering Type of volunteer work Motivation appeal Recipient’s health and cognitive functioning

PERSON ATTRIBUTES Social connections Religiosity Health Education Social integration Support

Perceived usefulness Sense of competence

Positive emotions

Compassionate versus reward-based motives

Stress regulation

Well-being, cognitive functioning, and health

Postponement of disease and death

Figure 13.3 Using the caregiver system model to explain the resilience-related benefits of volunteering.

a rare true experimental field study, Midlarsky and Kahana (1994) found that an intervention designed to increase volunteering increased self-esteem among participants in a doseresponse fashion: i.e., greater hours volunteered led to higher levels of self-esteem. The Directional Link From Volunteering to Social Integration and Support Clearly, volunteering may expose the volunteer to social networks and can involve both giving and receiving social support. Data from surveys and an experiment show that volunteering is associated with more social connections (Harris & Thoresen, 2005; Midlarsky & Kahana, 1994; Oman, Thoresen, & McMahon, 1999). Furthermore, there is a robust association between social contact and physical health, rivaling the effect sizes of smoking, drinking, and exercise (House, Landis, & Umberson, 1988). Previous attempts to understand the health effects of social contact and social networks have focused on the presumed value of receiving social support from others. However, consistent with the foregoing discussion, increasing evidence is suggesting that providing social support to others may be more beneficial than receiving it (S. Brown et al., 2003). For example, S. Brown et al. (2003) found that providing emotional support to a spouse and instrumental support to one’s social network were each independently associated with a 30–60% reduction in mortality risk (for the giver) over the 5-year study period. These giving-related benefits could not be accounted for by measures of participants’ physical health, mental health, personality, other interpersonal variables, or support participants received from their spouse. In fact, support received actually increased participants’ mortality risk in some models, consistent with other studies that have shown harmful effects of receiving support (e.g., increased suicidal ideation; S. Brown & Vinokur, 2003). In an independent replication of the S. Brown et al. (2003) study, providing support but not receiving it predicted reduced morbidity (W. Brown,2 Consedine, & Magai, 2005).

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free ebooks ==> www.ebook777.com Using the Caregiver System Model to Explain the Benefits 173 Possible Moderators of the Links From Volunteering to Sense of Competence and Social Integration In this section, we speculate about how the relations between volunteering and sense of competence and social integration may vary with person and situation attributes. For example, assuming that the volunteer environment affords people with high levels of education opportunities to utilize their occupation-related expertise, it can be posited that the relation between volunteering and sense of competence increases as education increases. Indeed, in a study of individuals applying to volunteer in an ombudsman program, Keith (2003) found that education was positively related to interest in volunteering as a result of opportunities to use occupational skills. The relation between volunteering and social integration may increase with religiosity. In a study of adults living in retirement communities, Omoto and Schlehofer (2007) reported that religious individuals were more likely to volunteer through church-related activities than non-religious individuals, and, in turn, volunteering in church-related activities was positively related to life satisfaction. Involvement in volunteering via church-related activities is also likely to promote social integration (Omoto & Schlehofer, 2007). Among older volunteers, retirement communities (12% of volunteering) and political organizations (9% of volunteering) constitute two of the top 10 sponsors of volunteer services (Marriott Senior Living Services, 1991). Relative to politically sponsored volunteering, retirement community-sponsored volunteering may afford greater opportunity to foster social integration. Thus, it can be posited that the relation between volunteering and social integration is greater among volunteers who provide services for retirement communities as compared to political organizations. The Link From Perceived Usefulness and Sense of Competence to Positive Emotions A sense of perceived usefulness and competence can be considered personal resources that trigger, and are triggered by, positive emotions. Growing research in positive psychology notes the bi-directional influence between personal resources and positive emotions (Lyubomirsky, King, & Diener, 2005). Known as the broaden-and-build theory of positive emotions (Fredrickson, 2001), positive emotions are hypothesized to broaden the thought– action repertoire, which builds resources (e.g., maintaining a sense of mastery, social support), which, in turn, increase positive emotions. This bi-directional relationship causes an upward spiral in positive emotions, which have been shown to be predictive of better health (Doyle, Gentile, & Cohen, 2006) and longevity (Danner, Snowdon, & Friesen, 2001). Increases in positive emotions may also reflect activation of the caregiving system, because it relies on the neurotransmitter dopamine, a reward-based hormone (i.e., released in response to the anticipation of reward), to trigger approach behaviors involved in helping. Positive emotions may be especially sensitive to a feeling of usefulness because learned helplessness interferes with dopamine production (and therefore caregiving system activation) via increased activation of the habenula (Christoph, Leonzio, & Wilcox, 1986). The Link From Social Integration and Support to Positive Emotions Because social integration and support reflect social resources that are built by positive emotions (Fredrickson, 2001), we speculate that increases in these social resources also play a role in triggering positive emotions among volunteers. In addition to the rewarding prop-


Stephanie L. Brown and Morris A. Okun

erties of receiving social support from others, the provision of support has been shown to directly influence well-being, positive mood, and happiness (Post, 2007). For example, in a study, multiple sclerosis (MS) patients were taught coping flexibility, or received monthly phone calls from peer support volunteers, or themselves made monthly phone calls to peers with MS. The individuals who provided peer support exhibited the largest increases in quality of life. In other words, patients with MS who provided telephone support benefited more than MS patients who either received monthly phone calls or were taught coping flexibility (Schwartz & Sendor, 1999). A beneficial association of the provision of social support and positive emotions has also been shown among spousal caregivers of individuals with cognitive impairment (Poulin et al., 2010). In their study, Poulin and his colleagues used ecological momentary assessment with 73 caregivers, who reported on the amount of time they spent helping their spouse, their actual caretaking tasks, and their emotions. These reports were collected at 3-hour intervals during waking hours for a period of 7 days. The results of multi-level modeling indicated that active help was associated with increases in reports of positive emotions, especially for caregivers who felt interdependent with their spouse. Among caregivers who felt interdependent, active help was also protective against negative emotions. The association between providing social support and positive emotions may be explained in part by the role of the mesolimbic reward system in mediating acts of helping or charitable donation. In a neuroimaging study of charitable donation, for example, Moll et al. (2006) demonstrated that the act of donating to charity activated the same brain regions that are active when individuals receive monetary reward. In their study, the medial orbitofrontal– subgenual area of the anterior cingulate, which mediates emotional attachment and is part of the basis of the caregiving system model shown in Figure 13.2, also distinguished between donating to and opposing social causes. The Link From Social Integration and Support to Compassionate Versus Reward-Seeking Motives The foregoing discussion implies that routes mediating the beneficial effects of social support are linked with the act of giving as opposed to receiving support. Because of this, we speculate that “other-focused” motivational states may have more to do with the beneficial health and resilience effects of volunteering—relative to “self-focused” motivational states that compel individuals to deliberately seek support or resources from others. Indeed, the beneficial effects of volunteerism on mortality risk have been shown to differ as a function of underlying motivation. Among volunteers with “self-focused” reasons for volunteering, there was no benefit of volunteerism with respect to mortality risk (Konrath, Fuhrel-Forbis, Lou, & Brown, 2012). Tests of the link between compassion or empathy-based responding and physical health are just beginning to emerge. However, studies show that compassion is predictive of wellbeing (Sheldon & Cooper, 2008), and at least one study has demonstrated that compassion directed toward a spouse (communicating feelings of love and concern) predicted reduced mortality risk (S. Brown et al., 2003). A recent addition to this literature demonstrated that trait compassion increased the stress-buffering effects of receiving social support (Cosley, McCoy, Saslow, & Epel, 2010). We describe the association between compassion and stress regulation in more detail following the discussion below of how situational attributes of volunteering influence compassionate motives.

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free ebooks ==> www.ebook777.com Using the Caregiver System Model to Explain the Benefits 175 The Link From Situational Attributes to Compassionate Motives It is important to note that volunteers and non-volunteers differ markedly with respect to altruistic motivation to volunteer. Based on data from a national sample reported by Clary, Snyder, and Stukas (1996), it can be estimated that the average volunteer is located approximately seven standard deviations above the mean in the non-volunteer distribution of altruistic motivation to volunteer. This finding is consistent with the notion that volunteering, with its focus on helping others less fortunate than oneself, may activate and provide opportunities to act on compassionate motives. Altruistic motives for volunteering have been shown to vary with the sponsor (type of organization), type of volunteer job, the motivational appeal, and the recipient’s health. Controlling for other motives, volunteers serving in human services organizations exhibited greater altruistic motivation to volunteer than volunteers serving in other types of organizations (Clary et al., 1996). Among hospice volunteers, Black and Kovacs (1996) demonstrated that those engaged in direct patient care services rated altruistic motives for volunteering higher than those providing non-direct patient care services, whereas volunteers providing non-direct patient care services rated social motives for volunteering higher than volunteers engaged in direct patient care services. Taking a different tack, Millette and Gagne (2008) examined the relation between a composite measure of five job attributes (skill variety, task identity, task significance, autonomy, and feedback) and intrinsic motivation to volunteer. They found that volunteers who reported higher scores on the composite measure of job attributes also reported higher scores on intrinsic motivation to volunteer. Volunteer organizations provide a context in which volunteer efforts occur. For example, organizations can influence volunteer motivation through their expectations of the benefits that will accrue to volunteers. In a study of hospice volunteers, Omoto, Snyder, and Martino (2000) observed that volunteers who had higher expectations for the impact of volunteering on their feelings of giving back to others and their sense of being helpful to others reported higher compassionate motivation for volunteering. Houle, Sagarin, and Kaplan (2005) tested the hypothesis that tasks vary in the extent to which they satisfy motives for volunteering. In support of this hypothesis, they showed that two tasks—reading to the blind and making holiday greeting cards for residents of nursing homes—were rated by participants as more likely to satisfy altruistic motivation for volunteering than six other tasks such as typing letters and data entry. Satisfaction with volunteering is conceptualized to be a function of the match between the salience of an individual’s motives for volunteering and the opportunities afforded in the volunteer environment to meet these motives. For instance, for individuals high in altruistic motivation, volunteer satisfaction is maximized when they perceive that their volunteer service is enabling them to meet their humanitarian obligations (Stukas, Worth, Clary, & Snyder, 2009). Omoto and Snyder (2002) examined whether compassionate motivation for volunteering varied among individuals doing AIDS volunteer work as a function of membership in a community which was at risk for the disease. As expected, they found that ratings of compassionate motivation were higher among new gay volunteers relative to new non-gay volunteers. Implications for Stress Regulation Our model points to an intimate connection between the motivational states associated with the caregiving system and the requirement of regulating the helper’s stress. There are many



possible sources of helper stress antecedent to, concurrent with, or consequent to helping, including lost opportunities to help oneself, conflicts over whether to help, whom to help, and how much assistance to render, exposure to distress signals (e.g., cues for another individual’s pain, another’s suffering), and a whole host of perceived or actual threats to well-being, such as energy depletion, loss of status, illness, separation from family or friends, accidental injury, or even death. Of course, there are other possible sources of stress, many of which are not associated with helping behavior. Our model suggests that activation of the caregiving system modulates the volunteer’s stress response, whatever the source of stress may be. Mediating Neural Circuitry Based on studies conducted on mammalian social and maternal behavior (e.g., Numan, 2006), activation of the caregiving system triggers helping behavior in two ways. First, it activates an approach circuit that is coordinated by hypothalamic processes that triggers motor programs for helping behavior (i.e., via approach motivation of the nucleus accumbens– ventral pallidum circuit). Second, it interferes with avoidance motivation (the stress response) by down-regulating signals from the amygdala to the periaqueductal gray (PAG). The PAG is the command center for mobilizing resources associated with the fight-or-flight response. The fight-or-flight response, including the stress hormone cortisol, is thought to be harmful to health with prolonged exposure (Sapolsky, 1996). Effectively, whether helping behavior occurs is thought to depend on whether the signal strength in the MPOA is strong enough to compete successfully with the avoidance response. To the extent that these neural circuits underlie some types of helping in humans (i.e., when the caregiving system is engaged), then stress regulation becomes an essential prerequisite to helping behavior. Hormonal Mediators Ultimately the signal strength of the MPOA is determined by hormones that can prime the area. The MPOA has receptors for pregnancy hormones and oxytocin, which are thought to act on the MPOA in ways that bias the response to need in favor of helping behavior, as opposed to avoidance. Indeed, numerous studies demonstrate causal relationships between oxytocin and the onset of helping behavior (S. Brown & Brown, 2006), and between oxytocin and stress regulation (Carter, 1998). For example, oxytocin down-regulates HPA (stress) axis activity, and it is associated with restorative physiological processes such as cellular repair, storage of cell nutrients, and cell growth (Heaphy & Dutton, 2008). Progesterone, a hormone that declines rapidly with age (Genazzani et al., 1998) and with social isolation (Serra et al., 2003), may also underlie helping-induced stress-buffering. Progesterone has been shown to increase with social closeness in humans, and to be associated with helping behavior (S. Brown, Fredrickson, et al., 2009). Progesterone has also been shown to play a role in stress, and progesterone administration causes reductions in anxiety in humans and other animals via its metabolite, the hormone allopregnanolone (ALLO) (Soderpalm, Lindsey, Purdy, Hauger, & de Wit, 2004). In addition to its stress-reducing properties, progesterone may also confer neuroprotection (Liao et al., 2009). During times of elevated stress, cortisol is produced from progesterone and pregnenolone (Parker & Baxter, 1985), so elevated cortisol production may reduce overall levels of progesterone, consistent with studies indicating that, although progesterone and cortisol are positively correlated, social isolation decreases progesterone but increases cortisol (Serra et al., 2003).

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free ebooks ==> www.ebook777.com Using the Caregiver System Model to Explain the Benefits 177 The Role of Positive Emotions The model we have described thus far views help-related stress recovery in terms of compassionate motives and consequent inhibition of the stress response. However, our model is also compatible with the possibility that active help produces positive emotions in the helper, independent of (or in conjunction with) compassionate motives, which in turn regulates stress. Certainly, feedback from helping may also produce positive emotions in the helper, consistent with evidence indicating that helping elevates mood (Yinon & Landau, 1987). Indeed, positive emotions directly accelerate recovery from stress-induced cardiovascular arousal (Fredrickson, Mancuso, Branigan, & Tugade, 2000). Thus, there are sufficient empirical reasons for predicting that helping behavior regardless of the trigger (e.g., perceptions of target need, interdependence, normative concerns, sense of obligation) evokes positive emotions. By engendering positive affect, volunteering may decrease distress-related wear and tear on the body (i.e., allostatic load), which contributes to the onset of diseases via psychoneuroimmunological and psychoendocrinologic pathways (McEwen, 1998). Adverse Effects of Helping Behavior on Stress Regulation Although we emphasize stress-buffering effects of a caregiving system (e.g., helping based on compassionate motives), our model accommodates other scenarios, such as the possibility that obligatory (coerced) helping has adverse effects on stress regulation, and the possibility that grief associated with helping someone who is suffering has adverse effects on stress responding, consistent with evidence that links bereavement to worsened health, depression, and increased mortality risk (Vitaliano, Zhang, & Scanlan, 2003). In a systematic review of the spousal bereavement literature, Stroebe and Stroebe (2007) reported that nearly all well-controlled longitudinal studies suggest that there is a heightened mortality risk for bereaved individuals as well as increases in vulnerability to disease. In an effort to distinguish grief-related processes involved in helping a suffering spouse from potential benefits associated with active help, S. Brown, Smith, et al. (2009) examined the separate influences of these variables on mortality risk among caregivers. Using data from the Health and Retirement Study (HRS), S. Brown et al. (2008) demonstrated that hours spent helping a spouse were protective of a caregiver’s mortality risk, even after adjusting for baseline health and disability, socioeconomic status, demographics, and depression. The extent of spousal impairment, on the other hand, was positively related to mortality risk in the unadjusted model, consistent with the possibility that grief-related processes can be detrimental in the context of caregiving. Consequences of Stress Regulation for Well-Being, Cognitive Functioning, and Health A large literature attests to the harmful effects of stress on well-being and health (Schneiderman, Ironson, & Siegel, 2005). As described above, this association may be due to elevated levels of cortisol, which can be harmful with prolonged exposure (Sapolsky, 1996). A recent study examining the effect of exposure to stressful life events on mortality risk demonstrated that the effect of stress on health may be even more toxic than previously assumed (Poulin et al., in press). In their study, which used data from 423 married couples in the Changing Lives of Older Couples sample, the effect of exposure to stressful life events was found to interact with helping behavior to predict 5-year mortality risk. Results showed that



individuals who reported not helping others over the past year doubled their risk of mortality with each additional stressful life event encountered. Among those who reported helping someone in the past year, there was no harmful association of stressful life events and mortality risk. These findings could not be explained by main effects or interactive effects (with stress) of related variables such as received social support or social contact. Conceivably, hormones associated with close relationships and helping behavior improve health and well-being by reducing exposure to harmful levels of stress, and by being neuroprotective (progesterone) or promoting healthy immune regulation (oxytocin), as described above. In addition, low DHEA to cortisol ratios have been linked directly to morbidity and mortality. For example, low levels of DHEA predict obesity, diabetes, hypertension, coronary heart disease, HIV-related disease, cancer, and Alzheimer’s disease (McCraty, Barrios-Choplin, Rozman, Atkinson, & Watkins, 1998). Interestingly, DHEA levels have been shown to increase after exposure to a psychosocial intervention that requires participants to focus on their caring feelings for others (McCraty et al., 1998). The Link From Volunteering to Health and Cognitive Functioning Self-rated health and self-report measures of functional limitations have been shown to predict mortality (Idler & Benyamini, 1997; Wosinski, Johnson, & Stump, 1995). Several longitudinal studies (Luoh & Herzog, 2002; Omoto & Schlehofer, 2007; Piliavin & Siegl, 2007; Thoits & Hewitt, 2001; Van Willigen, 2000) have demonstrated that volunteering is associated with better health, although some researchers have also found that health is an antecedent of volunteering (Thoits & Hewitt, 2001). In a study employing a true experimental design, Fried et al. (2004) examined the benefits among older, mostly African American females of volunteering to help children in schools. Control group subjects were on a wait list to participate in the program. All participants were pretested and evaluated 8 months later. Whereas the percentage of control group participants who rated their strength very good or excellent declined by 16%, the percentage of intervention group participants who rated their strength as very good or excellent increased by 17%. Baseline levels and changes in cognitive functioning also have been linked to risk of mortality (McGuire, Ford, & Umed, 2006). In a more recent study, researchers targeted older adult volunteers in the Experience Corps program who were cognitively at risk (Carlson et al., 2009). The intervention group and the wait-listed control group were pretested using a selective attention task with recordings of neuroimaging data. Participants in the intervention group received training in general literacy support, library support, and conflict resolution via a multimodal activity program. Six months later all participants performed the same task and neuroimaging data were again collected. The neuroimaging data revealed that during task performance participants in the intervention group exhibited more cognitive activity in the left pre-frontal cortex and anterior cingulated cortex than participants in the control group. The behavioral data showed that the intervention group improved on the selective attention task but the control group did not. The Link From Volunteering to Positive Affect Danner et al. (2001) demonstrated that the amount of positive affect expressed in brief autobiographical statements made by nuns at the time of entry into the sisterhood predicted longevity. Several longitudinal studies (Omoto & Schlehofer, 2007; Piliavin & Siegl, 2007; Thoits & Hewitt, 2001; Van Willigen, 2000) have demonstrated that volunteering is associated with

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free ebooks ==> www.ebook777.com Using the Caregiver System Model to Explain the Benefits 179 higher subjective well-being, although the relation may be reciprocal (Thoits & Hewitt, 2001). One possibility is that volunteering fosters positive affect by reducing self-absorption.

CONCLUSION Providing opportunities for older adults to help others via volunteering can promote resources (e.g., positive emotions and cognitive functioning) that facilitate stress regulation, the bouncing-back component of resilience, and that foster longevity, the sustainability component of resilience. Insights gleaned from the present model of volunteering and related models of caregiving (e.g., S. Brown et al., 2012) could lead to the design of a new generation of psychosocial interventions that leverage the benefits of providing opportunities for prosocial behavior. The effectiveness of these interventions can be tested in a variety of health-related settings, across a variety of stressful and traumatic circumstances. One type of volunteering that is particularly intriguing in the context of stress and trauma involves peer assistance programs. For example, “expert” caregivers can volunteer to serve as mentors for novice caregivers. Our model suggests that caregivers who volunteer may be more resilient to stress than caregivers who do not seek out attempts to help others. A second type of volunteering that represents a provocative possibility is that, in certain instances, caregivers can boost the resilience of their care-recipients by affording them opportunities to provide help. For example, physically frail older adults can tutor children who need assistance with literacy-related skills, and mildly cognitively impaired care-recipients can help with volunteer projects such as beautifying parks. Finally, our model suggests the caveat that not all people will benefit equally from such programs. Individual differences in the types of motives evoked by engaging in prosocial behavior (e.g., feeling compassion for novice caregivers versus feeling better about oneself) are posited to alter the resilience-related consequences of volunteering. Furthermore, when highly stressed or strained in their respective roles, caregivers and care-recipients may not be favorably impacted by opportunities to volunteer.

NOTES 1. The “caregiving” system as used here is not specific to the context of providing care for an ill or disabled loved one. Rather, it is a behavioral system hypothesized to underlie the provision of care for any individual in need (Bowlby, 1969). 2. No relation.

REFERENCES References marked with a single asterisk indicate studies included in the quantitative synthesis. They are not cited in the body of the text itself. *Ayalon, L. (2008). Volunteering as a predictor of all-cause mortality: What aspects of volunteering really matter? International Psychogeriatrics, 20, 1–14. Black, B., & Kovacs, P. J. (1996). Direct care and nondirect care hospice volunteers: Motivations, acceptance, satisfaction, and length of service. Journal of Volunteer Administration, 14, 21–32. Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books.



Brown, S. L., & Brown, R. M. (2006). Selective investment theory: Recasting the functional significance of close relationships. Psychological Inquiry, 17, 1–29. Brown, S. L., Brown, R. M., House, J., & Smith, D. (2008). Coping with spousal loss: The potential buffering effects of self-reported helping behavior. Personality and Social Psychology Bulletin, 34, 849–861. Brown, S. L., Brown, R. M., & Preston, S. (2012). The human caregiving system: A neuroscience model of compassionate motivation and behavior. In S. Brown, R. Brown, & L. Penner (Eds.), Moving beyond self-interest: Perspectives from evolutionary biology, neuroscience, and the social sciences (pp. 75–88). New York: Oxford University Press. Brown, S. L., Fredrickson, B. L., Wirth, M., Poulin, M., Meirer, E., Heaphy, E., et al. (2009). Closeness increases salivary progesterone in humans. Hormones and Behavior, 56, 108–111. Brown, S. L., Nesse, R., Vinokur, A. D., & Smith, D. M. (2003). Providing social support may be more beneficial than receiving it: Results from a prospective study of mortality. Psychological Science, 14, 320–327. Brown, S., & Preston, S. (2012). Neuroscience mechanisms for links between prosocial behavior and physical health. Manuscript submitted for publication. Brown, S. L., Smith, D. M., Schulz, R., Kabeto, M., Ubel, P., Yee, J., et al. (2009). Caregiving and decreased mortality in a national sample of older adults. Psychological Science, 20, 488–494. Brown, S. L., & Vinokur, A. D. (2003). The inter-relations among poor health, depression, and loved ones’ messages of support and criticism as risk factors for suicide and suicide risk. American Journal of Community Psychology, 32, 131–141. Brown, W. M., Consedine, N. S., & Magai, C. (2005). Altruism relates to health in an ethnically diverse sample of older adults. Journals of Gerontology: Series B. Psychological Sciences and Social Sciences, 60B, 143–152. Cacioppo, J. T., Amaral, D. G., Blanchard, J. L., Cameron, J. L., Carter, C. S., Crews, D., et al. (2007). Social neuroscience: Progress and implications for mental health. Perspectives on Psychological Science, 2, 99–123. Carlson, M. C., Erickson, K. I., Kramer, A. F., Voss, M. W., Bolea, N., Mielke, M., et al. (2009). Evidence of neuroplasticity in at-risk older adults: The Experience Corps program. Journal of Gerontology: Medical Sciences, 64, 1275–1282. Carter, C. S. (1998). Neuroendocrine perspectives on social attachment and love. Psychoneuroendocrinology, 23, 779–818. Christoph, G., Leonzio, R., & Wilcox, K. (1986). Stimulation of the lateral habenula inhibits dopamine-containing neurons in the substantia nigra and the ventral tegmental area of the rat. Journal of Neuroscience, 6, 613–619. Clary, E. G., Snyder, M., & Stukas, A. A. (1996). Volunteers’ motivations: Findings from a national survey. Nonprofit and Voluntary Sector Quarterly, 25, 485–505. Cosley, B., McCoy, S., Saslow, L., & Epel, S. (2010). Is compassion for others stress buffering? Consequences of compassion and social support for physiological reactivity to stress. Journal of Experimental Social Psychology, 46, 816–823. Danner, D. D., Snowdon, D. A., & Friesen, W. V. (2001). Positive emotions in early life and longevity: Findings from the Nun Study. Journal of Personality and Social Psychology, 80, 804–813. Doyle, W. J., Gentile, D. A., & Cohen, S. (2006). Emotional style, nasal cytokines, and illness expression after experimental rhinovirus exposure. Brain, Behavior, and Immunity, 20, 175–181. Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-andbuild theory of positive emotions. American Psychologist, 56, 218–226. Fredrickson, B. L., Mancuso, R., Branigan, C., & Tugade, M. (2000). The undoing effect of positive emotions. Motivation and Emotion, 24, 237–258. Fried, L. P., Carlson, M. C., Freedman, M., Frick, K. D., Glass, T. A., Hill, J., et al. (2004). A social model for health promotion for an aging population: Initial evidence on the Experience Corps model. Journal of Urban Health, 81, 64–78. Genazzani, A. R., Petragalia, F., Bernardi, F., Casarosa, E., Salvestroni, C., Tonetti, A., et al. (1998). Circulating levels of allopregnanolone in humans: Gender, age, and endocrine influences. Journal of Clinical Endocrinology and Metabolism, 83, 2099–2103.

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free ebooks ==> www.ebook777.com Using the Caregiver System Model to Explain the Benefits 181 George, C., & Solomon, J. (1999). Attachment and caregiving: The caregiving behavioral system. In J. Cassidy and P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 649–670). New York: Guilford Press. Gruenewald, T. L., Karlamangla, A. S., Greendale, G. A., Singer, B. H., & Seeman, T. E. (2007). Feelings of usefulness to others, disability, and mortality in older adults: The MacArthur Study of Successful Aging. Journal of Gerontology: Psychological Sciences, 62B, 28–37. Harris, A. H., & Thoresen, C. E. (2005). Volunteering is associated with delayed mortality in older people: Analysis of the longitudinal study of aging. Journal of Health Psychology, 10, 739–752. Heaphy, E. D., & Dutton, J. E. (2008). Positive social interactions and the human body at work: Linking organizations and physiology. Academy of Management Review, 33, 137–163. Herzog, A. R., Franks, M. M., Markus, H. R., & Holmberg, D. (1998). Activities and well-being in older age: Effects of self-concept and educational attainment. Psychology and Aging, 13, 179–185. Houle, B. J., Sagarin, B. J., & Kaplan, M. F. (2005). A functional approach to volunteerism: Do volunteer motives predict task preference? Basic and Applied Social Psychology, 27, 337–344. House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health. Science, 241, 540–545. Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21–37. Keith, P. M. (2003). Interests and skills of volunteers in an ombudsman program: Opportunities for participation. International Journal of Aging and Human Development, 57, 1–20. Konrath, S., Fuhrel-Forbis, A., Lou, A., & Brown, S. (2012). Motives for volunteering are associated with mortality risk in older adults. Health Psychology, 31, 87–96. *Lee, S. J., Cenzer, I. S., & Covinsky, K. E. (2009). Volunteering and mortality in older Americans. Journal of the American Geriatrics Society, 57 (Suppl. 1), S14. Liao, G., Cheung, S., Galeano, J., Ji, A., Quin, Q., & Bi, X. (2009). Allopregnanolone treatment delays cholesterol accumulation and reduces autophagic/lysosomal dysfunction and inflammation in Npc1-/- mouse brain. Brain Research, 1270, 140–151. Luoh, M. C., & Herzog, A. R. (2002). Individual consequences of volunteer and paid work in old age: Health and mortality. Journal of Health and Social Behavior, 43, 490–509. Lyubomirsky, S., King, L., & Diener, E. (2005). The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin, 131, 803–855. Marriott Senior Living Services. (1991). Marriott Senior Volunteerism Study. Washington, DC: Author. McCraty, R., Barrios-Choplin, B., Rozman, D., Atkinson, M., & Watkins, A. D. (1998). The impact of a new emotional self-management program on stress, emotions, heart rate variability, DHEA, and cortisol. Integrative Physiological and Behavioral Science, 33, 151–170. McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338, 171–179. McGuire, L. C., Ford, E. S., & Umed, A. (2006). Cognitive functioning as a predictor of functional disability in later life. American Journal of Geriatric Psychiatry, 14, 36–42. Midlarsky, E., & Kahana, E. (1994). Altruism in later life. Thousand Oaks, CA: Sage. Millette, V., & Gagne, M. (2008). Designing volunteers’ tasks to maximize motivation, satisfaction, and performance: The impact of job characteristics on volunteer engagement. Motivation and Emotion, 32, 11–22. Moll, J., Krueger, F., Zahn, R., Pardini, M., Oliveira-Souza, R. de, & Grafman, J. (2006). Human fronto-mesolimbic networks guide decisions about charitable donation. Proceedings of the National Academy of Sciences, 103, 15623–15628. *Musick, M. A., Herzog, A. R., & House, J. S. (1999). Volunteering and mortality among older adults: Findings from a national sample. Journal of Gerontology, 54B, S173–S180. Numan, M. (2006). Hypothalamic neural circuits regulating maternal responsiveness toward infants. Behavioral Cognitive Neuroscience Review, 5, 163–190. Okun, M. A., August, K. J., Rook, K. S., & Newsom, J. T. (2010). Does volunteering moderate the relation between functional limitations and mortality? Social Science and Medicine, 71, 1662–1668.



Oman, D. (2007). Does volunteering foster physical health and longevity? In S. G. Post (Ed.), Altruism and health: Perspective from empirical research (pp. 15–32). New York: Oxford University Press. Oman, D., Thoresen, C., & McMahon, K. (1999). Volunteerism and mortality among the community-dwelling elderly. Journal of Health Psychology, 4, 301–316. Omoto, A. M., & Schlehofer, M. M. (2007). Volunteerism, religiousness, spirituality, and the health outcomes of older adults. In S. G. Post (Ed.), Altruism and health: Perspective from empirical research (pp. 399–409). New York: Oxford University Press. Omoto, A. M., & Snyder, M. (2002). Considerations of community: The context and processes of volunteerism. American Behavioral Scientist, 45, 846–867. Omoto, A. M., Snyder, M., & Martino, S. C. (2000). Volunteerism and the life course: Investigating age-related agendas for action. Basic and Applied Social Psychology, 22, 181–197. Parker, R. C., & Baxter, C. R. (1985), Divergence in adrenal steroid secretory pattern after thermal injury in adult patients. Journal of Trauma, 25, 508–510. Piliavin, J. A., & Siegl, E. (2007). Health benefits of volunteering in the Wisconsin Longitudinal Study. Journal of Health and Social Behavior, 48, 450–464. Post, S. G. (Ed.). (2007). Altruism and health: Perspectives from empirical research. New York: Oxford University Press. Poulin, M. J., Brown, S., Dillard, A., & Smith, D. (in press). Prosocial behavior buffers the association between stressful events and mortality: Evidence for the role of the caregiving system in health. American Journal of Public Health. Poulin, M. J., Brown, S. L., Ubel, P. A., Smith, D. M., Jankovic, A., & Langa, K. M. (2010). Does a helping hand mean a heavy heart? Helping behavior and well-being among spouse caregivers. Psychology and Aging, 25, 108–117. *Rogers, R. (1996). The effects of family composition, health, and social support linkages on mortality. Journal of Health and Social Behavior, 37, 328–329. Sapolsky, R. M. (1996). Stress, glucocorticoids, and damage to the nervous system: The current state of confusion. Stress: The International Journal on the Biology of Stress, 1, 1–19. Schneiderman, N., Ironson, G., & Siegel, S. D. (2005). Stress and health: Psychological, behavioral, and biological determinants. Annual Review of Clinical Psychology, 1, 607–628. Schwartz, C. E., & Sendor, M. (1999). Helping others helps oneself: Response shift effects in peer support. Social Science and Medicine, 48, 1563–1575. Serra, M., Pisu, M., Floris, I., Cara, V., Purdy, R., & Biggo, G. (2003). Social isolation-induced increase in the sensitivity of rats to the steroidogenic effect of ethanol. Journal of Neurochemistry, 85, 257–263. Sheldon, K. M., & Cooper, M. L. (2008). Goal striving within agentic and communal roles: Separate but functionally similar pathways to enhanced well-being. Journal of Personality, 76, 415–447. Soderpalm, A. H., Lindsey, S., Purdy, R., Hauger, R., & Wit, H. de. (2004). Administration of progesterone produces mild sedative-like effects in men and women. Psychoneuroendocrinology, 29, 339–354. Stroebe, M., & Stroebe, S. H. (2007). Health outcomes of bereavement. Lancet, 370, 1960–1973. Stukas, A. A., Worth, K. A., Clary, E. G., & Snyder, M. (2009). The matching of motivations to affordances in the volunteer environment: An index for assessing the impact of multiple matches on volunteer outcomes. Nonprofit and Voluntary Sector Quarterly, 38, 5–28. Thoits, P. A., & Hewitt, L. N. (2001). Volunteer work and well-being. Journal of Health and Social Behavior, 42, 115–131. Van Willigen, M. (2000). Differential benefits of volunteering across the life course. Journals of Gerontology: Series B. Psychological Sciences and Social Sciences, 55, S308–S318. Vitaliano, P. P., Zhang, J., & Scanlan, J. (2003). Is caregiving hazardous to one’s physical health? A meta-analysis. Psychological Bulletin, 129, 946–972. Wosinski, F. D., Johnson, R. L., & Stump, T. E. (1995). The risk of mortality among older adults over an eight-year period. The Gerontologist, 35, 150–161. Yinon, Y., & Landau, M. (1987). On the reinforcing value of helping behavior in a positive mood. Motivation and Emotion, 11, 83–93.

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Part D Resilience as Social Process



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free ebooks ==> www.ebook777.com 14 Resilience Is Social, After All Alex J. Zautra

Resilience rests, fundamentally, on relationships. Luthar (2006, p. 780)

On the news we have watched resilient people manage the most devastating tragedies, be these from the tsunami in Japan which wreaked havoc on whole communities, or the profound grief of a parent who has lost a child. The American media is quick to find us heroes of resiliency, consistent with their focus on the exceptional individual. The data, however, reveal that resilience is neither exceptional nor necessarily heroic. In response to trauma, people often display considerable capacity to adapt (Deci, 2000; Masten, 2001; Reich, 2006), and they do so not only through inner strength but also through social connections. This chapter provides a counterweight to the attention to personal characteristics by focusing instead on the value of social relations in shaping resilient responses to stressful events. First, some evidence that strong social connections promote resilient outcomes is provided. Second, two illustrative stories of trauma and recovery are presented to remind us that many people still are unable to build and maintain social connections. Third, a social intelligence framework is introduced to improve resilient capacities by helping individuals to engage more fully with their social world. Last, ways are discussed of how a community can help its citizens react in more resilient ways as they face a personal and/or community trauma.

DO STRONG SOCIAL CONNECTIONS PROMOTE RESILIENT OUTCOMES? Social connections play a critical role in mitigating the effects of life’s most stressful experiences (Cohen & Wills, 1985; Wolins & Wolins, 1993) across a range of stressful experiences. For instance, research on recovery following the death of a child show that the most important factor in the recovery process is support from friends (Greeff, Vansteenwegen, & Herbiest, 2011). People in high stress occupations also rely on social connections to blunt the impact of witnessing trauma. The ability of these individuals to talk freely, and without judgment, to their peers has been identified as the greatest predictor of preventing PTSD (Stephens, Long, & Miller, 1997). In a collective disaster, social support, ranging from tangible aid to emotional connection, is essential for people affected by events such as 9/11 and natural disasters such as


Alex J. Zautra

flooding (MacGeorge, 2004). One study of social support following a flood in Roanoke, Virginia showed that individuals suffered severe stress and psychological turmoil one week after the flood. However, the stress decreased sharply six weeks later. In the intervening weeks, perceived availability of social support was critical. It was especially important in terms of tangible support (aid in the forms of goods and services) and belongingness (a sense of embeddedness in a social network). Appraisal support (listening and giving advice and information) was the least important type of social support. It appears that concrete actions such as tangible aid or going to a movie with a friend were much more important than receiving advice when it came to recovering from this flood (Cook & Bickman, 1990). Recovery from domestic abuse is complicated because, by its very nature, it challenges core beliefs about the trustworthiness of close relationships (Goodkind, 2003; Werner-Wilson, Zimmerman, & Whalen, 2000). Victims of domestic abuse withdraw from people closest to them because of fear, shame, and feelings of helplessness. Also, friends and family simply do not know how to react to the plight of domestic abuse victims (Trotter & Allen, 2009). It should be noted that “distancing” may be helpful to domestic abuse victims, but only on a short term basis while they reorganize their lives. They must face their situation and their loneliness, and find a way to adapt that allows them to sustain their interests and values (Arokach, 2006). Consider the following narratives from two of the participants in our 5-year National Institute on Aging study of resilience in mid-life. Debbie and Joan both experienced physical abuse from their husbands, and both women were able to leave the relationship. However, as you will see, there are considerable differences in their recovery, sustainability, and growth from their abusive experiences. They also experienced dramatically different responses from their social networks that appear to distinguish the two women in how well they were able to adapt. Debbie’s Story For Debbie, domestic violence wasn’t a single event but a pattern of abuse throughout 22 years of her marriage. After her divorce, she “got a lot of counseling,” tried volunteering in domestic violence shelters, and joined a support group, but these efforts did not help. Family and friends did not help at all, she said. In fact, one of her closest friends, she learned later, was having an affair with her husband during her marriage. To get away from the stress of it all she moved away to Arizona, where she has lived for 6 years without making friends. People have tried to befriend her, but she is not able to connect, so she spends a lot of time alone. She recognizes that she “sabotages” relationships. “Got to get past that,” she says, in a tone of voice that is hopeless and sad, and without a confident plan to find her way forward. Joan’s Story Joan reported that she had 10 stitches in the back of her head to sew up a blow she received from her husband when she tried to put an end to an abusive 2-year marriage. The neighbors heard the assault and called the police, and a good friend drove her to the hospital. Joan reports she had PTSD following the experience, saying she did not function well during her 40s. Traumatized, unable to sleep, she worried that he would come back to kill her, even though he was out of her life. She hired a private investigator to find him and serve him with a civil suit as well as to make sure the criminal charges stuck. She was in graduate school at

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free ebooks ==> www.ebook777.com Resilience Is Social, After All 187 the time, but just could not get on the plane to go on job interviews after graduating, saying she just could not sustain her interests and career goals after that. Joan was very disappointed in her family’s response, and some of her friends got tired of hearing her in distress. However, group sessions with other survivors of domestic violence were very helpful. Her younger sister and three other close friends also were very supportive. The greatest gift they gave her, she said, was not being judgmental. Joan states she has learned a lot about herself because of that trauma. She is more aware of the people in her social network, and, if she had to do it all over again, she would be more effortful in reconnecting with the community, especially volunteering and helping others. Today, Joan is remarried, and is writing a book about what she learned so that she might help others recover from similar traumas. Debbie and Joan’s Current Social Connections Debbie self-reports on a questionnaire that the four people who now have the most impact in her life are her daughter, her son, her ex-husband, and her ex-boyfriend. She has contact with her daughter and son a few times a month, and neither are people she can go to for support. She talks to her ex-husband several times a month, and he causes her a great deal of stress. We do not know why she is in contact with him. Sadly, Debbie does not indicate she has a friend, confirming her narrative that she hasn’t made any friends since moving to Arizona 6 years ago. Her ex-boyfriend, whom she talks with once a month, appears to be her greatest source of support. Joan reports on a questionnaire that the four people who now have the most impact in her life are her husband, her two sisters, and a friend. She talks to one sister every day and the other sister a few times a month, but both sisters seem to cause Joan a lot of stress. Luckily, she talks to her friend once a week and indicates this friend is a good source of support. Joan rates her husband a 10/10 in terms of support if she needs it. When asked about their families in general, both Debbie and Joan describe family dynamics that make them feel tense and provoke feelings of conflict and anger. Both say that family members are critical of their behavior and take advantage of them. Based on this limited information, the difference in the two women is this: Joan has a supportive husband as well as a supportive friend. Debbie does not. Could these important social connections be why Joan eventually recovered and flourished after her traumatic experience? If so, what social capacity does Joan have that Debbie doesn’t? Why is Debbie unable to make the social connections she needs to be resilient?

SOME INDIVIDUALS ARE UNABLE TO BUILD AND MANAGE SOCIAL CONNECTIONS Debbie’s plight illustrates that this ability to connect with others is not realized for many people in our society. McPherson, Smith-Lovin, & Brashears (2006) found that an astonishing 25% of Americans report they have no one to talk to about important matters in their lives. Another 19% of Americans report they have only one such person. Social scientists have also examined the prevalence of a cardinal sign of social discontent: loneliness. Loneliness may be best described as the gnawing ache we feel when we find ourselves alone yet wanting social connection. The feeling of “loneliness,” much like “hunger,” is a built-in warning signal that alerts us to take action. Yet many do not heed this call to reach out and engage


Alex J. Zautra

with others. In fact, research evidence has shown that 15% to 30% of Americans feel lonely every day (Hawkley, 2010). There are many reasons people are unable and/or unwilling to make social connections. Temperament and personality certainly play a role. What many individuals lack is a clear perspective of the “self” in relationship to others; they do not understand the importance of relationships. Partly because of misplaced emphasis, but also because of past difficulties, many simply do not know how to develop relationships, nor do they understand the effort required to make and maintain relationships. Some of these problems begin early in life. A large body of evidence shows that children from harsh families are less likely than those from nurturing families to develop effective social competencies (Repetti, 2002). Early nurturing and supportive contacts are important for the development of social skills, especially those involving response to stress or threat. Our first experiences with relationships occur in family life as we, along with siblings and parents, learn to adapt to stressful changes in our lives (Walsh, 2003). Facing difficulties together early in life sets the stage for a stable success weathering the storms in adult life; not everyone has those kinds of formative experiences. However, even those who did not have to deal with childhood difficulties are often not prepared for the complexities involved in successfully managing their relationships, especially during traumatic experiences.

DEVELOPING SOCIAL CONNECTIONS AND ENGAGING IN THE SOCIAL WORLD CAN BE LEARNED What can be done to reverse the course of lives that appear destined to be disconnected? This question may be addressed directly with interventions that target the individual or more indirectly through programs built to enhance social cohesion in community life. The Resilience Solutions Group LLC is currently pilot-testing a training program in social intelligence (SI) that addresses some of the major challenges faced in social relations. The program is designed to help individuals 1) become more fully aware of and consciously attend to their social world, 2) learn how to develop and sustain meaningful social connections, and 3) enhance their capacity to be resilient in the face of adverse events. In the process of developing this program, we have identified a small cluster of key conceptual guidelines, summarized in Table 14.1 and discussed below. Later in this chapter, we address what needs to be done to further a community’s social intelligence. Other People Are Not Objects; They Are Also Human The first lesson in SI is recognizing the humanity of others. This understanding is undeniable in theory, but easily overlooked in practice. Seeing other people as also aware and capable, with thoughts, feelings, hopes, dreams, and anxieties, is a precondition for relationships. In cognitive science this is called having a “theory of mind” (Ybarra & Winkielman, 2012). We succeed socially not through manipulation of others as objects, although this may feel powerful in the immediate context. Rather we succeed simply by acknowledging that the other person is as real as we are. As Robert Wright (1999) puts it, social relations are not zero-sum games. Both people benefit from positive social connection, and such shared benefit is the primary goal of strong social relations.

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free ebooks ==> www.ebook777.com Resilience Is Social, After All 189 Table 14.1 Social Intelligence: Five Key Concepts 1. Other people are also human

2. We are wired to connect

3. We are relational beings

4. Our social brain governs our mind

5. Social relations take effort

Individual components

Community components

Awareness that others also have thoughts, feelings, intentions, and needs is fundamental to understanding one other and taking social intelligent action. Understanding another’s emotions is a built-in capacity that grows stronger with attention. Showing empathy and learning to listen without judgment facilitate close relations.

Realizing that even those of us from different backgrounds are also fully aware, sentient beings is fundamental to a community’s capacity for social cohesion.

We are in varying stages of awareness of the fundamental truth that we are defined by our relationships. The more we are able to follow this principle, the more we will be able to learn how to engage, contribute to, and be a part of our social world. Heuristics are cognitive short-cuts that can mislead us in our judgments of others. Confirmation bias and automaticity can be overridden with attention to the promise of strong relationships. To develop and sustain strong bonds, we need to stay aware of the needs and intentions of others. Those who are to become and stay close will reciprocate, making the effort worthwhile.

Understanding that we share similar responses to social pain with others in our social world, and also those from different communities, allows for the development of community-wide responses to assist others with adaptation to disconnection from family and friends, loss of loved ones, and social rejection. The “sense of community” is felt and lived, rather than managed as an abstract concept, once social relations, including our ties with neighbors and friends at work, are seen as a primary part of our identities. Engagement in perspective taking, and interruption of one’s own cultural stereotypes, false assumptions, and harsh judgments strengthen community bonds. Social wisdom is highest when we can identify how the diverse talents of community members contribute to the social intelligence of the group. Social intelligence complements and is consistent with larger values of the culture, but competing influences can lead community leaders to neglect these values. Attention to the principle that “We are, indeed, all in this together” requires putting aside more immediate interests that are quick fixes, to build on system strengths.

We Are Wired to Connect With Others Missing in most renderings of our social lives is an appreciation of the depth to which we are “wired” to connect. The field of social neuroscience offers surprising evidence of our relational selves. Gazzaniga (2011) summarizes some of this work, noting that there is no single site within the brain that controls social interactions. Instead there are separate but fluid interconnections throughout the brain that guide the development of relationships with others (Gazzaniga, 2011). In his book Social Intelligence, Daniel Goleman remarks: “The social brain represents the only biological system in our bodies that continually attunes us to, and in turn becomes influenced by, the internal state of people we’re with” (Goleman, 2006, p. 11). We are not alone: just separate in varying degrees of awareness of how we share consciousness with our fellow beings. We also have a biological signaling system that tells us when we have not sufficiently connected with others. When a person is rejected by others, the “social hurt” activates the same regions of the brain that would be activated if the person stubbed their toe, what we would normally call “real” hurt (Eisenberger & Lieberman, 2004). As it turns out, both hurts are just as “real” (Eisenberger, 2012). Acute


Alex J. Zautra

bouts of loneliness, as well as social pain from rejection, show physiological processes that motivate affiliative behaviors (DeWall, Deckman, Pond, & Bonser, 2011). Oxytocin and endogenous opioid peptides appear to play important roles in the regulation of this system (Depue & Morrone-Strupinsky, 2005). We can also boost that response by greater attention to direct solutions for the problem of social pain through building stronger social ties and more extensive social networks (Baumeister & Leary, 1995). We Are, by Definition, Relational Beings The implications of this point are more profound than most people realize. We often are willing to admit intellectually that we are “social” in the general sense, but we still hold on to the mistaken belief that we are also fully autonomous, with identities free of social influence. An understanding and embodiment of I–Thou relationships rather than I–It relationships was first described by existential philosopher Martin Buber in 1923 (Horwitz & Buber, 1988). People with the I–It perspective see the world in terms of objects and things, such that human beings (the “self” being the exception) are objects. The I–Thou world view takes as its fundamental premise that humans are not objects at all; instead their existence takes on form and shape based on their connections with one another. Their being is defined relationally, as part of one another—a unity of being, or non-separateness with a shared reality. This I–Thou world view is one of mutuality and reciprocity with others, of social connection, as opposed to the I–It view of separateness and detachment (Goleman, 2006). Once the I–Thou world view is embodied, emotional awareness, empathy, and perspective taking emerge naturally. It is less a matter of learning specific skills than one of grasping the fundamental insight that we are not meant to be separate from, but in relationship with, people who constitute our social worlds. Without that understanding, social-emotional intelligence is simply a tool for application to avoid or manipulate our social worlds, leaving us ill equipped to face the inevitable social conflicts that arise from I–It relations. Understanding Our Complex Brain Improves the Ability to Understand Our Behavior and Infer the Behavior of Others Why do we behave the way we do? What we know about how our brain functions can help us answer this question, if we are willing to admit to the evidence that our minds are bound by the rules of brain function. First, Neurological Processing Is Largely Unconscious The work of keeping the lights on applies to our emotional lives as well. We have established patterns of relating to others that, though not hard wired, are routinized to a large extent. Our perceptions are built up from prior experience and formed from expectation. We see what we expect to see, and we seek confirmation from the world for what we already know, processing information with “heuristics” (Kahneman, 2011). Sometimes that processing is erroneous and results in cognitive biases such as stereotyping and attribution errors. By accounting for bias when evaluating a situation or someone’s retelling of an event, we can make more accurate decisions, not so influenced by the mind’s confirmation-seeking expectancies (Kahneman, 2011).

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free ebooks ==> www.ebook777.com Resilience Is Social, After All 191 Second, Even When We Think We Are Making Choices, Our Brain Has Often Already Decided for Us This is currently being referred to in the neuroscience literature as the “6-second” delay. Neural activation actually occurs 6–10 seconds before our awareness of having made a decision (Soon, Brass, Heinze, & Haynes, 2008). Our choices, or at least our awareness of them, are after the fact, making our arguments framed to explain our actions primarily post hoc rationalizations (Gazzaniga, 2011). Third, Our Social Relationships Help Shape Our Brain Our brains are “plastic.” Every thought and every interaction with others changes the size and number of neurons in our brain. Both neuronal cell death and neurogenesis are ongoing throughout adult life, and social relationships are a major part of this story (Kolb & Whishaw, 1998). We impose order and stability in defense against uncertainty, yielding some truth to the shop-worn adage “The more things change, the more they stay the same.” Fourth, Our Brain Does Not Recognize the Difference Between Thinking and Feeling Former models of the brain made clear distinctions between the more evolved cognitive brain and its predecessor, the limbic or emotional brain. However, we now know that the “emotion” system extends into the medial prefrontal cortex, the insular cortex, the lower brainstem, and the spinal cord (Morgane, 2006). Thinking and feeling are intertwined, and the melding of the brain systems is becoming increasingly evident (Goleman, 2006). There just is little support for the belief that we think independently of our feelings. Forming and Maintaining Relationships Take Practice and Purposeful Effort When two people meet, each person makes a conscious or unconscious decision of whether they want to continue the relationship. If so, a small amount of effort is put into the relationship, by both sides, and “weak ties” are formed. If both parties want to continue putting in the effort, “strong ties” begin to form and will stay strong until one or both individuals stop their efforts. The ties then weaken and may disintegrate altogether. As simple as this may sound, many people do not understand this concept, nor do they understand their role in this lifecycle of relationships. Mutual benefits accrue from helping one another gauge the reality of a situation, as well as helping one another develop new ways of understanding traumatic situations (Tedeschi, 2004). The awareness needed includes “perspective taking” (Galinsky, Ku, & Wang, 2005), and “listening without judgment” to assure that the other person’s point of view is understood. The thoughtful interruption of one’s own behavior toward the other person, when it is biased as a result of one’s own past experience or cultural stereotypes, is needed to quell the widespread practice of disregarding others’ points of view after making biased assumptions about their intentions (Vangelisti & Young, 2000). Social isolation and rejection are painful, and those who find themselves as outcasts often bear some responsibility for their marginal social status. We each have patterns of relating to others, and we relive these patterns so readily that they often seem like automatic scripts. These “scripts” give us trouble if they are based on some very difficult life experiences in


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childhood or adult life leading us to lose trust and then to find reasons time and again to mistrust the people who care about us. We often seek automatically to fulfill our expectations about what we believe to be true about our relationships. If we have learned that our social world is a dangerous place, we will keep finding cause to be afraid. As David Brooks (2012) remarks in his column “The Machiavellian Temptation,” we are often told just to be aware of processes within us and devise strategies to manipulate ourselves (and others in the process) to be happier. However, SI is not primarily a question of social skills, of just being a clever social animal. Relational habits are ingrained and follow global principals such as “Trust no one,” “We must go along to get along,” or “It’s a jungle out there.” We need to reach for a larger belief to transform our way of thinking about relationships. To change, our brains need a plan to follow that is based on a greater, more profound principle, such as a desire to become more fully socially aware and intelligent in our relationships with others. Once we establish a foothold within such a plan, our brains will go to work re-shaping our social worlds, provided we keep the principle in mind.

WHAT CAN THE COMMUNITY DO TO HELP ITS CITIZENS REACT IN MORE RESILIENT WAYS AS THEY FACE PERSONAL AND/OR COMMUNITY TRAUMA? Individuals are embedded in their social worlds. Families come to mind as highly influential social units that were central influences in both of the stories recounted here. For Debbie, family ties were not supportive, her friends were a source of conflict, and the counseling programs were also not helpful to her. Joan reported both helpful and unhelpful interactions with family and friends. Trotter and Allen’s (2009) analysis of the narratives of survivors of domestic violence indicates that Debbie and Joan’s experiences are the norm. Only 22% of the women in their study reported network reactions that were solely beneficial. What are the qualities of a social network of family, friends, and community resources that would have helped Debbie and Joan more? We do not know the answer for them personally, but it is worth asking what communities can do to strengthen social connections in ways that help prevent failures of adaptation, and encourage resilient outcomes to abuse and other highly stressful life experiences. In Table 14.1, I summarize ways of extending the SI principles described above for individuals and applying them to community concerns. Communities Can Change to Promote Resilience The Carnegie Foundation offers a cogent analysis of problems and prospects for community responses to trauma and other stressful changes in an on-line handbook, Exploring Community Resilience in Times of Rapid Change (Wilding, 2011). There are three types of social capital defined in the Carnegie handbook: bonding, bridging, and linking capital (Sander, 2002). Communities differ in how easy it is for them to find ways to develop and sustain close relationships with others (bonding), connect socially to share experiences (bridging), and have ties across networks to people different from themselves (linking). These differences in social capital are stable manifestations of culture, but they are also modifiable by programs that expand opportunities for positive social interaction among community members (Zautra, Arewasikporn, & Davis, 2010). The Carnegie handbook (Wilding, 2011), for example, describes successful strength-based programs that focus on building stronger bonds and on bridging and linking diverse groups. One program from the Social Action for Health

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free ebooks ==> www.ebook777.com Resilience Is Social, After All 193 Project (http://www.safh.org.uk/safh_new/scripts/page/home.php) connects community members experiencing a stressful change with others who have had a similar experience. Of significance is the reliance on strengths within the community to build healthier social networks from the bottom up rather than the more common top-down approach of relying on professional caregivers. Okvat and Zautra (2011) highlight community gardening as another example of a resilience-building activity that promotes both social connection and ecological well-being (see also Tidball & Krasny, 2007). The quality of a community’s social development depends on its willingness to engage (Sander, 2002). People tend to gather with others who are like themselves, which can divide communities into exclusionary and antagonistic sub-groups (Galinsky & Moskowitz, 2000). Discomfort with diversity, if not overt antagonism toward those who are different, often leads citizens to “hunker down,” according to Putnam (2007), shutting off effective corridors to greater social connection among people. People experiencing personal traumas, like Debbie and Joan, may experience more doors closing than opening in those communities, with services available but delivered with prejudice and stigma attached. Resilience to both personal and community-wide traumas depends on social connections among and between diverse groups. Communities with a history of volunteerism, for example, weather crises better, because they have evolved a structure of trust and mutual selfhelp (Wilding, 2011). The death and destruction following Katrina have been attributed to the history of tensions between rich and poor leading to the absence of social connection between the wealthy and the impoverished citizens of New Orleans (McNamara, 2012). Cultural prohibitions can also stand in the way of needed changes in how people relate to one another. Successful adaptation to stressful change, whether due to personal trauma or widespread disaster, depends not only on the person’s social intelligence, but also on the community’s. Margaret Wheatley (2001) reminds us, “There is no power for change greater than a community discovering what it cares about.”

CONCLUSION Traumatic experiences can have lasting impacts. They can be sources of life-long disorders like PTSD; they can be both painful and uplifting; and they can be life-changing sources of growth. In the attempt to understand the underlying sources of resilient responding, the focus in the resilience literature has been on inner strengths, with a relative neglect of the social world: a fundamental attribution error (Jones & Harris, 1967). When we intentionally focus on one person’s behavior, what we are observing is only one part of an interaction between members of a group or between members of different groups. To fully understand resilience, we need to attend to context; see the person-in-situ, as Kurt Lewin advised, and develop ways to educate one another on the value of building, sustaining, and developing strong and weak social ties (Brug, 2006). Technology in the social sciences has advanced dramatically since Kurt Lewin’s time. Among the many advances has been the capacity for scientists to peer behind the eyes to observe neural activation. Our attention is drawn to images of brain activity that are in accord with and that even presage a person’s awareness of his/her choices on how to behave. The pull is thus even stronger to attribute human adaptive and maladaptive actions to what goes on inside. Gazzaniga (2011) reminds us, however, that most of our thoughts, emotions, and behaviors are relational; thoughts of a sense of responsibility or the feeling of freedom, for example, cannot be found by looking at the activities in a single brain. Rather


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it is the relationship between brains that matters. Human awareness is shared, feelings are forms of communication, our actions are imitated, and responses to our reactions to others’ behavior are shaped by social relations, past and present. To better understand resilience, I advise greater attention not just to advances that allow us to image individual brains, but also to a different set of new technologies that advance our social networking capacities. We have entered a new era that has expanded the reach of social connection, and intensified our awareness of the consequences of disconnection. We now have Internet devices that enhance our capacity to listen, reflect, and respond to one another, and alert us to our failures to relate. To capitalize on these advances, we need to keep in mind that we are social, after all. Our resilience depends on that.

ACKNOWLEDGMENTS This work is supported in part by a grant from the National Institute on Aging (R01 AG 026006, Alex Zautra [PI]). Eva Kenney Zautra of the Resilience Solutions Group LLC developed the social intelligence intervention described in this paper.

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free ebooks ==> www.ebook777.com Resilience Is Social, After All 195 Goleman, D. (2006). Social intelligence: The new science of human relationships. New York: Bantam. Goodkind, J. (2003). The impact of family and friends’ reactions on the well-being of women with abusive partners. Violence Against Women, 9, 347. Greeff, A. P., Vansteenwegen, A., & Herbiest, T. (2011). Indicators of family resilience after the death of a child. Omega: Journal of Death and Dying, 63, 343–358. Hawkley, L. L. C. (2010). Loneliness matters: A theoretical and empirical review of consequences and mechanisms. Annals of Behavioral Medicine, 40, 218–227. Horwitz, R., & Buber, M. (1988). Buber’s way to “I and thou”: The development of Martin Buber’s thought and his “religion as presence” lectures (American ed.). Philadelphia: Jewish Publication Society. Jones, E., & Harris, V. A. (1967). The attribution of attitude. Journal of Experimental Social Psychology, 3, 1–24. Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux. Kolb, B., & Whishaw, I. Q. (1998). Brain, behavior, and plasticity. Annual Review of Psychology, 49, 43–64. Luthar, S. S. (2006). Resilience in development: A synthesis of research across five decades. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Risk, disorder, and adaptation (pp. 740–795). New York: Wiley. MacGeorge, E. (2004). Stress, social support, and health among college students after September 11, 2001. Journal of College Student Development, 45, 655–670. Masten, A. S. (2001). Ordinary magic: Resilience processes in development. The American Psychologist, 56, 227–238. McNamara, J. (2012, March). Resilient homeland: Keep calm and carry on . Panel discussion at Defining Resilience Conference held by New America Foundation, Washington, DC. McPherson, M., Smith-Lovin, L., & Brashears, M. E. (2006). Social isolation in America: Changes in core discussion networks over two decades. American Sociological Review, 71, 353–375. Morgane, P. J. (2006). The limbic brain: Continuing resolution. Neuroscience and Biobehavioral Reviews, 30, 119–125. Okvat, H. A., & Zautra, A. J. (2011). Community gardening: A parsimonious path to individual, community, and environmental resilience. American Journal of Community Psychology, 47, 374–387. Putnam, R. D. (2007). E pluribus unum: Diversity and community in the twenty-first century. The 2006 Johan Skytte Prize Lecture. Scandinavian Political Studies, 30, 137–174. Reich, J. W. (2006). Three psychological principles of resilience in natural disasters. Disaster Prevention and Management, 15, 793–799. Repetti, R. L. (2002). Risky families: Family social environments and the mental and physical health of offspring. Psychological Bulletin, 128, 330–366. Sander, T. H. (2002). Social capital and new urbanism: Leading a civic horse to water. National Civic Review, 91, 213–221. Soon, C. S., Brass, M., Heinze, H. J., & Haynes, J. D. (2008). Unconscious determinants of free decisions in the human brain. Nature Neuroscience, 11, 543–545. Stephens, C., Long, N., & Miller, I. (1997). The impact of trauma and social support on posttraumatic stress disorder: A study of New Zealand police officers. Journal of Criminal Justice, 25, 303. Tedeschi, R. G. (2004). Posttraumatic growth: A new perspective on psychotraumatology. The Psychiatric Times, 21, 58. Tidball, K. G., & Krasny, M. E. (2007). From risk to resilience: What role for community greening and civic ecology in cities? In A. Wals (Ed.), Social learning toward a more sustainable world (pp. 149–164). Wageningen, Netherlands: Wageningen Academic Publishers. Trotter, J. L., & Allen, N. E. (2009). The good, the bad, and the ugly: Domestic violence survivors’ experiences with their informal social networks. American Journal of Community Psychology, 43, 221–231.


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Vangelisti, A. L., & Young, S. L. (2000). When words hurt: The effects of perceived intentionality on interpersonal relationships. Journal of Social and Personal Relationships, 17, 393–424. Walsh, F. (2003). Family resilience: A framework for clinical practice. Family Process, 42, 1–18. Werner-Wilson, R. J., Zimmerman, T. S., & Whalen, D. (2000). Resilient response to battering. Contemporary Family Therapy, 22, 161–188. Wheatley, M. (2001, March). Restoring hope to the future through critical education of leaders. In V. Shiksha, A Bulletin of Shikshantar. Udaipur, Rajasthan, India: People’s Institute for Rethinking Education and Development. Retrieved from http://margaretwheatley.com/articles/restoringhope.html Wilding, N. (2011). Exploring community resilience in times of rapid change. Dunfermline, UK: Fiery Spirits Community of Practice. Retrieved from http://www.carnegieuktrust.org.uk/carnegie/ media/sitemedia/Publications/ExploringCommunityResiliencedownload.pdf Wolins, S. J., & Wolins, S. (1993). The resilient self: How survivors of troubled families rise above adversity. New York: Villard. Wright, R. (1999). Nonzero: The logic of human destiny. New York: Pantheon. Ybarra, O., & Winkielman, P. (2012). On-line social interactions and executive functions. Frontiers of Human Neuroscience, 6, 75. Zautra, A. J., Arewasikporn, A., & Davis, M. C. (2010). Resilience: Promoting well-being through recovery, sustainability, and growth. Research in Human Development, 7, 221–238.

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free ebooks ==> www.ebook777.com 15 Developmental Social Factors as Promoters of Resilience in Childhood and Adolescence Bekh Bradley, Telsie A. Davis, Joanna Kaye, and Aliza Wingo

Despite the warranted attention to increased risk associated with exposure to adverse childhood experiences (ACEs), this is not the full picture. In fact, most individuals exposed to ACEs do not develop later health, mental health, and behavioral problems. Therefore, more research is needed on defining and understanding those developmental and social processes that promote lifespan resilience. This chapter focuses on empirical and theoretical knowledge related to developmental, social, and communal factors (e.g., positive parenting and community engagement) that benefit later resilience. These include proximal factors (e.g., family environment) and distal factors (e.g., neighborhood and community factors). Resilience needs to be understood in the context of human development. There may be sensitive developmental periods during which skills associated with resilience are best nurtured. Resilience-promoting interventions should be targeted to both the social context and the developmental stage of the at-risk individual. Much research has focused on child maltreatment and other ACEs that can impact negatively the course of development into adulthood. This research establishes a clear, significant, and positive correlation between dose of ACEs and adult psychological distress and disorders (Anda et al., 2006). Despite the warranted attention to increased risk associated with exposure to ACEs, it is important to note that this is not the full picture. Most individuals exposed to ACEs do not develop psychological problems. Approximately half of all Americans will experience a traumatic event, yet only approximately 5% to 10% will develop posttraumatic stress disorder (PTSD). Similarly, only a minority of individuals with a history of childhood sexual abuse demonstrated subsequent psychopathology. Adults with a history of childhood abuse and other adverse early life experiences often show successful functioning in life domains of education, employment, and other areas. Perhaps because of the “ordinariness” of resilience, this subject has not received as much research attention as has the subject of risk. These findings highlight the normalcy of a resilient developmental trajectory and underscore the need for further scientific examination of resilience in children and adolescents.

DEVELOPMENTAL SOCIAL MODELS OF RESILIENCE Resilience has been conceptualized as a normative, adaptive response system that allows individuals to successfully endure severe adversity. The literature provides varying definitions of resilience, ranging from those defining resilience based on the absence of psychopathology or other problems despite adversity to those defining resilience based on the presence of skillful and adaptive functioning despite adversity. Although most studies of resilience


Bradley, Davis, Kaye, and Wingo

use absence-based criteria, some research focuses on the presence of adaptive functioning in some domains even if there may be problematic functioning in others. This chapter focuses on empirical and theoretical knowledge related to developmental social factors (e.g., social competence, nurturing parenting, and neighborhood advantage) that contribute to later resilience. Resilience is expressed in interactions of intra- and interpersonal processes. These processes consist of factors that are consistent contributors to resilience across the lifespan, and others that are associated with resilience only in certain contexts and at specific times during development. The levels at which these processes influence resilience determine how we have organized our review of these factors. Thus, we explore four levels: (a) genetic predispositions and biology, (b) individual cognitive, emotional, and behavioral factors, (c) proximal relational and environmental factors, and (d) distal relational and environmental factors. Genetic Predispositions and Biology The contribution of gene by environment interaction to the prediction of risk and resilience following adverse events has found support in multiple studies. A number of studies of 5-HTTLPR gene suggest that short allele carriers (s/s or s/l genotypes) are at increased risk for depression in the context of exposure to environmental adversity compared to long allele homozygotes (l/l genotypes). Some research has also found that 5-HTTLPR genotype interacts with neighborhood factors to predict risk and resilience. A study of a hurricane exposed sample (Koenen et al., 2009) found that social environment variables modified the association between the 5-HTTLPR gene variations and risk of current PTSD such that the short allele of 5-HTTLPR was associated with decreased PTSD risk in low-risk environments but increased PTSD risk in high-risk environments. Our research program, the Grady Trauma Project (GTP), is focused on risk and resilience in a sample of traumatized, urban, low-income, predominately African American adults (Gillespie et al., 2009). Results identified several genetic variations related to the human stress response system that demonstrate an association with risk and resilience only when environmental influences such as childhood abuse exposure are taken into account. In a separate study of risk for adult depression in this population, variations of genetic polymorphisms within the CRH receptor (CRHR1) gene significantly interacted with childhood abuse exposure to predict higher levels of adult depressive symptoms (Bradley et al., 2008). Similarly, variations in FKBP5 genotype interacted with severity of child abuse to predict lower levels of adult PTSD symptoms (Binder et al., 2008). The genotype by childhood abuse interactions for both of these studies suggested an additive model for the interaction of genotype with childhood abuse. This means that, among those individuals who were exposed to high levels of childhood abuse, those with two “risk alleles” had the highest levels of depression or PTSD symptoms, while those with two “resilience alleles” had the lowest levels of depression or PTSD symptoms. Among individuals exposed to high levels of childhood abuse, those with one “risk allele” and one “resilience allele” had moderate levels of depression or PTSD symptoms. Research on gene by environment interactions associated with risk and resilience shows considerable variability, which has led to debate about the validity of these findings. Although no resolution to this debate has been achieved, some researchers account for the variations in outcomes by supporting the “differential sensitivity” theory, which suggests that those individuals who are most vulnerable in the face of exposure to adverse/traumatic experiences may also be the most resilient in response to exposure to enriching/positive environmental influences. For example, a study of risk and resilience for depression in a sample of young

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free ebooks ==> www.ebook777.com Developmental Social Factors as Promoters of Resilience 199 adults found that those with the “s/s” showed high levels of depression if they had been exposed to early life adversity or recent life stressors (S. Taylor, Eisenberger, Saxbe, Lehman, & Lieberman, 2006). However, they also found that “s/s” individuals showed the lowest levels of depression if they were raised in a supportive environment or exposed to recent positive events. This area of research highlights the importance of focusing on resilience-promoting factors when studying gene by environment interactions. Individual Cognitive, Emotional, and Behavioral Factors This section focuses on four individual-level factors that have received substantial empirical attention with respect to the development of resilience in childhood: (1) self-regulation, (2) emotion regulation, (3) psychological flexibility, and (4) social competence. Self-Regulation Self-regulation is a person’s ability to exert control over attention, emotion, thought, and behavior in the pursuit of personal goals that comply with broader social standards. Successful self-regulation in childhood predicted resilience in multiple domains. The ability to self-regulate is associated with a number of positive outcomes across multiple life domains. Lifespan studies of self-regulation show that delay of gratification in early childhood (e.g., delay eating one marshmallow in order to receive a second marshmallow) predicted positive psychological, behavioral, health, and economic outcomes across four decades (Casey et al., 2011). Successful self-regulation in childhood contributes to resilience in multiple domains of functioning. A study using a diverse sample (Gardner, Dishion, & Connell, 2008) found that, among youth who associated with peers who engaged in externalizing and antisocial behaviors, those with higher levels of self-regulation of attention and behavior were less likely to exhibit the behaviors of their peers. Similarly, incarcerated adolescents exposed to childhood family violence showed lower levels of internalizing and lower externalizing mental health problems if they had higher self-regulatory capacities as defined by a measure of executive functioning (Perkins, Cortina, Smith-Darden, & Graham-Bermann, 2012). Emotion Regulation Emotion regulation is a domain of self-regulation that refers to actions one takes to influence what, when, and how positive and negative emotions are experienced and expressed (Gross, 2007). In successful emotion regulation, individuals persist through difficulties, tolerate distress, display rule-governed conduct, and demonstrate norm-appropriate emotion in the context of negative stimuli. A community sample of third and fifth grade students showed that self-regulation moderated risk and adjustment, such that children with high positive emotions had better overall adaptive functioning despite exposure to multiple adversities (Lengua, 2002). In other research, both observational and biological measures of emotion regulation (i.e., left frontal electroencephalogram activity) successfully predicted resilient functioning in maltreated school-aged children (Curtis & Cicchetti, 2007). Psychological Flexibility The concept of psychological flexibility, defined as the ability to effectively modify thoughts, feelings, and behaviors in order to achieve a valued goal, reflects a synthesis of the research



on executive control, response modulation, and self-regulation within the field of positive psychology (Kashdan & Rottenberg, 2010). It is a dynamic process that includes: (1) adapting to changing circumstances, (2) engaging in perspective-taking and shifting perspectives, (3) adapting to unpredictable situational demands, (4) balancing and prioritizing competing needs across life domains, and (5) acting in ways consistent with deep-seated attitudes and values (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Kashdan & Rottenberg, 2010). A meta-analytic review of 32 studies using a self-report measure of psychological flexibility found that higher levels of psychological flexibility predicted better mental health outcomes, quality of life, and interpersonal functioning (Hayes et al., 2006). A longitudinal study of college students found that baseline ability to use flexibility in coping responses predicted better adjustment across the first two years of college (Bonanno, Papa, Lalande, Westphal, & Coifman, 2004). In a novel experimental design, high trait-resilient individuals exhibited more flexible emotional responses to a series of positive and negative emotional stimuli (Waugh, Thompson, & Gotlib, 2011). This research suggests that resilient adaptation requires cognitive, behavioral, and emotional agility as well as the ability to modify strategies based on changing situational demands. Social Competence Social competence is the ability to understand, connect with people, influence others, and form close relationships. Social competence during childhood enhances health and predicts better psychological and psychosocial functioning in adulthood. Social competence takes many forms and is expressed in a constellation of psychosocial and behavioral skills that are used to establish and retain mutually constructive relationships. Socially competent children are also more empathic and emotionally expressive, which attracts and engages other children, resulting in better peer relationships. Among youth, social competence has been linked to distress tolerance, and self-regulation of attention and behavior, and is positively correlated with successful academic performance. Another form of social competence is the ability to correctly infer the meanings of other people’s behavior in an interpersonal environment. A study of 143 psychiatric rehabilitation adult patients found that social inference ability moderated the relationship between childhood physical abuse and social functioning (Choi, Davidson, & Spaulding, 2011). Individuals with a more severe history of childhood physical abuse and higher levels of social inference ability displayed higher levels of social functioning as compared with those individuals who had a more severe history of childhood physical abuse and lower levels of social inference ability.

ENVIRONMENTAL CONTEXTS The resilience literature has long discussed the association between resilience and certain attributes of interpersonal relationships, as well as characteristics of the environments in which interpersonal transactions occur (Masten, 2001). These factors can be as immediate and concrete as the physical structures, landscape, and boundaries of the neighborhood in which individuals live, or can reflect community influences such as interpersonal connection, history, culture, identity, social and economic resources, and power. Environmental factors reviewed in this chapter are: (1) parenting style, (2) secure attachment, (3) family resources, (4) peer influence, (5) involvement in community and extracurricular activities, (6) racial socialization, and (7) socialized gender roles. The factors are organized accord-

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free ebooks ==> www.ebook777.com Developmental Social Factors as Promoters of Resilience 201 ing to whether they represent a direct influence on the social functioning of the individual, which we refer to as proximal factors, or an indirect influence, referred to as distal factors. Distal factors reflect higher-order social processes such as cultural values (e.g., individualistic vs. collectivistic), social privilege, and discrimination and marginalization. Proximal Environmental Factors Associated With Resilience Parenting Style Parenting style has been demonstrated to be a major conduit through which parents influence the trajectory of their child’s development. In general, parenting that is nurturing and democratic with authoritative traits (e.g., consistent limit-setting and monitoring) has been linked to greater achievement, and positive psychological and prosocial outcomes, such as improved academic functioning, self-control, and adherence to social rules. For example, data from a study using a nationally representative sample of 1,116 twin pairs and their families revealed that, even after controlling for heritability (twin status), maternal warmth protected children from the negative effects of being bullied (Bowes, Maughan, Caspi, Moffitt, & Arseneault, 2010). A growing body of research now recognizes the importance of considering broader social and cultural influences on parenting practices. A study comparing individualist cultures with collectivist cultures found that maternal authoritarianism was associated with maternal negative thoughts about children and lower child self-esteem in the individualist group but not the collectivist group (Rudy & Grusec, 2006). In an investigation of the use of non-abusive physical discipline, this form of punishment was associated with increased risk for externalizing behavioral problems in European American children, but was either not related to or associated with lower levels of externalizing behavioral problems in African American children (Deater-Deckard & Dodge, 1997; Lansford et al., 2005). One explanation given for these findings is that non-abusive physical discipline shows a weaker association with negative child outcomes in cultures/communities in which it is more normative as compared to those in which it is less normative (Deater-Deckard & Dodge, 1997; Lansford et al., 2005). Secure Attachment Children have the best chance for healthy development when raised in nurturing environments. The hallmark of these nurturing environments is a healthy attachment between children and caregivers that lays the foundation for lifelong secure attachment (Komro, Flay, & Biglan, 2011; Mikulincer & Shaver, 2012). One of the key tenets of attachment theory is that attachment relationships are resources for children in the face of stress or threat. A secure attachment relationship provides children with a sense of security and safety needed for developmentally appropriate exploration into new environments and the ability to regulate emotions and cope effectively in response to adversity (Mikulincer & Shaver, 2012). Not surprisingly, multiple sources of data point to a robust association between secure attachment and resilience in the face of ACEs. Individuals with secure attachment become less distressed in the face of threat or stress, recover more quickly from distress, and have higher levels of positive affect (Mikulincer & Shaver, 2012). A series of innovative studies examining the impact of “security priming” (e.g., displaying images of attachment figures and then asking people to recall memories of being supported by attachment figures) found that it



was associated with higher levels of positive mood in the face of threat, and increased compassion and altruism, and with decreased symptoms of mild PTSD (Mikulincer & Shaver, 2007). Similarly, a study found that attachment priming could mitigate neural responses to social exclusion (Karremans, Heslenfeld, van Dillen, & Van Lange, 2011). There is also research on “earned secure attachment” cases in which adults with insecure attachment styles are able to develop secure attachment styles. Research finds that earned attachment security is associated with higher levels of emotional support from non-parental attachment figures (Saunders, Jacobvitz, Zaccagnino, Beverung, & Hazen, 2011). Women with earned attachment security were more likely than insecurely attached women to develop secure attachments to their own infants. This finding points to lifespan interpersonal relationships as key contributors to resilience. Family Resources Both parental style and attachment security are important markers of social relationships with the capacity to confer resilience. However, these factors tend to focus on the mother– child relationship to the exclusion of other familial connections. The supportive role of fathers and siblings, broader family contexts, and multiple aspects of family functioning have been shown to be protective against the influence of a broad spectrum of ACEs on children’s later behavior. Both sibling warmth and positive home atmosphere are associated with positive emotional and behavioral adjustment in bullied children as compared to nonbullied children (Bowes et al., 2010). Findings show that, among lesbian, gay, bisexual, and transgender youths, family acceptance supports the development of mental and physical health. Support from extended family members can promote resilience, particularly for those in vulnerable, low-income, or violent urban environments. A study of low-income, African American families found that social support from an extended family mitigated problematic mother–adolescent relationships and adolescent internalizing and externalizing problems (R. Taylor, 2010). Extended family members and other non-parental adults (e.g., grandparents, teachers, coaches, and employers) also serve as “natural mentors” who provide guidance, encouragement, and support to youths and are a resilience resource particularly for “at-risk” youths (Greeson, Usher, & Grinstein-Weiss, 2010). Further exemplifying this point, youths in foster care who had “natural mentors” developed key skills in healthy conflict resolution, emotional self-regulation, independent living skills, and improved selfconcept (Ahrens et al., 2011). Peer Influence Although most of the research in this area has focused on the roles of peers in behavioral risk outcomes, peer group influence can exert a positive force on youth developmental course. Positive relationships with peers can be protective against risk-promoting environments. Findings show that, among youths exposed to parental violence, both peer communication and peer trust may reduce risk for depression and running away from home. Peer communication contributes to reduced risk for dropping out of high school. Peer acceptance has the potential to reduce the negative impact of parental rejection, while close friendships could buffer the impact of peer rejection or bullying, particularly for those youths who are already marginalized. Thus, peer groups can facilitate resilience or can stabilize deviant behavior and later problematic functioning.

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free ebooks ==> www.ebook777.com Developmental Social Factors as Promoters of Resilience 203 Involvement in Community and Extracurricular Activities Community and extracurricular activities involvement as a source of resilience has been an overlooked area of study. Research demonstrates that youths who are more engaged in organized, extracurricular activities, such as school clubs and sports, show overall better adjustment (Eccles & Barber, 1999; Fredricks & Eccles, 2006). A number of mechanisms may account for such involvement and resilience. These activities appear to provide children and adolescents with opportunities to practice positive coping skills, build healthy relationships, and develop self-efficacy and positive identity. A longitudinal study found that engagement in extracurricular activities was positively associated with educational status in young adulthood (Mahoney, Cairns, & Farmer, 2003). This study found a reciprocal relationship such that early adolescent social competence was associated with activity engagement, and activity participation was associated with increased interpersonal competence in later adolescence and young adulthood. Higher levels of participation in activities may be associated with less time spent with peers engaging in risk-promoting activities (Fredricks & Eccles, 2006). Among youths at risk for exposure to home or community violence, positive, structured extracurricular and community activities could decrease their risk of exposure to violence. Positive extracurricular involvement may also provide opportunities for positive growth and development. A qualitative study of resilience among males exposed to parental violence during childhood found that engagement in extracurricular activities including sports, afterschool activities, and personal hobbies provided a safe haven from violent environments and a positive distraction from a chaotic home environment (Gonzales, Chronister, Linville, & Knoble, 2012). Engagement in community and extracurricular activities may also have an impact on biological stress response systems. A study by McHale et al. (2012) found that engagement in clubs and sports was associated with lower daily cortisol levels among youths aged 10 to 18. Distal Environmental Factors Associated With Resilience Neighborhood Advantage and Community Cohesion Most research in the area of neighborhood and community influence has focused on the vulnerability of individuals who live in areas characterized by fragmented and disorganized social support systems (Johns et al., 2012; Koenen et al., 2009). However, more strength-based models of research have addressed neighborhood advantage and community cohesion. Most studies in this area find that, while level of neighborhood/community advantage does not directly increase the likelihood of resilient outcomes in the face of stress and trauma, neighborhood and community factors do contribute to resilient outcomes when combined with other resilience-promoting factors. This may reflect a synergistic combination of more proximal factors with neighborhood advantage. Many “proximal” factors associated with increased resilience (e.g., supportive family environment, authoritarian parenting practices, and prosocial peer groups) are more likely to be present when children are raised in neighborhoods with higher levels of advantage. For example, a study of lifespan resilience in a sample of men and women who had experienced childhood maltreatment (DuMont, Widom, & Czaja, 2007) found that the combination of household stability and neighborhood advantage contributed to increased resilience in adolescence. Another study of resilience in maltreated children found that children with parents who did not have substance use problems and who also lived in communities with lower levels of crime and higher



social cohesion were more likely to be resilient to the effects of maltreatment (Jaffee, Caspi, Moffitt, Polo-Tomas, & Taylor, 2007). Community cohesion is a characteristic of neighborhood advantage related to perceived trust and social bonds held within a community. Research suggests that, even in communities with high levels of concentrated disadvantage, community cohesion can serve as a buffer against risk. For example, research on perceived neighborhood disorder as a contributor to PTSD risk also showed that risk was mitigated by level of perceived community cohesion (Gapen et al., 2011). Similarly, data from the Detroit Neighborhood Health Study found that low neighborhood social cohesion was associated with increased risk for PTSD (Johns et al., 2012). Racial Socialization Experiences of racial discrimination are associated with increased risk for multiple physical and mental health problems, suggesting that factors such as racial socialization that could counter the impact of racial discrimination should be a major point of focus in resilience research. The core aspect of racial socialization is the transmission to children of knowledge, values, and beliefs about their race and ethnicity, including knowledge about racism and race-based discrimination, with the goals of developing a healthy racial identity and of successful negotiation of racism and other types of adversity (Hughes et al., 2006; Neblett, Terzian, & Harriott, 2010). A review by Hughes et al. (2006) identified four primary “types” of racial socialization: (1) cultural socialization or knowledge about, pride in, and promotion of race-related history and culture, (2) preparation for race-related bias and discrimination, (3) emphasis on equality between races, and (4) promotion of caution and mistrust in interaction with other races. Research on racial socialization shows that it is associated with positive outcomes in academic achievement, decreased risk for depression, positive self-concept, and increased overall well-being in children (Neblett et al., 2010). When cultural socialization practices are implemented, youths report stronger and more positive ethnic identities, better self-esteem in interactions with peers, better cognitive outcomes, and fewer behavioral and emotional problems. Among African American preschoolers, particularly boys, those with higher levels of racial socialization demonstrated better cognitive performance and fewer behavioral problems (Caughy, Nettles, O’Campo, & Lohrfink, 2006; Caughy, O’Campo, Randolph, & Nickerson, 2002). In a sample of African American college students, increased messages about pride and cultural legacy led to higher levels of racial socialization and were associated with better resilience in the face of discrimination (Brown, Parker-Dominguez, & Sorey, 2000). The interaction of racial socialization and neighborhood factors shows that living in an Africentric home, located in a neighborhood high in physical disorder and fear, as well as low in social cohesion, was linked to greater cognitive outcomes for boys. For girls, living in a home rich in African American culture in any type of neighborhood was associated with better cognitive outcomes (Caughy et al., 2006; Caughy et al., 2002). These findings point to the interaction of other social contextual factors in understanding the relationship between racial socialization and resilience. Socialized Gender Roles and Masculinity Gendered identity and gender role socialization contribute to resilience (Gray, Carter, & Levitt, 2012). Although youth whose behavior and appearance are not consistent with gendered social norms are at higher risk for problems such as anxiety and depression, many

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free ebooks ==> www.ebook777.com Developmental Social Factors as Promoters of Resilience 205 of the same factors that promote resilience in other contexts also contribute to resilience among gender non-conforming youth. Acceptance of gender non-conforming youth by peers positively influences their sense of self-worth. In addition, family and peer support is linked to reduced risk and promotion of resilience for gender non-conforming youths (Gray et al., 2012). In contrast to data focused on risk related to gender role non-adherence, other research highlights that the ability to develop a gender identity not rigidly constrained by stereotypes of masculinity and femininity is associated with resilience. For example, a study of resilience in male survivors of childhood sexual abuse (Kia-Keating, Sorsoli, & Grossman, 2010) found that increased risk often stemmed from rigid, stereotypic definitions of masculinity, while the ability to reconsider and renegotiate previously held standards of masculinity led to resilience in the wake of abuse. Similarly, a study of males exposed to parental violence (Gonzales et al., 2012) found that resilience was associated both with learning to challenge traditional definitions of masculinity and with adopting a more flexible, self-defined masculine identity. A related line of research points to the importance of often overlooked aspects of traditional masculinity in promoting resilience in males. This research, conducted with a sample of Mexican American males (Arciniega, Anderson, Tovar-Blank, & Tracey, 2008), points out that the concept of machismo has often been narrowly characterized. Often ignored, important aspects of machismo, referred to in this research as “caballerismo,” include nurturance, protection of family, wisdom, responsibility, spirituality, and emotional connectedness. Arciniega and colleagues found that, while the narrowly defined machismo was associated with increased risk for aggressive behaviors, the more broadly defined caballerismo was associated with increased life satisfaction and emotional connection (Arciniega et al., 2008). Thus, resilience-promoting interventions developed for boys and male adolescents may benefit from drawing from a more complete understanding of “traditional” masculinity and from encouraging male youth to develop less stereotypic and more flexible masculine identities.

CONCLUSION Exposures to ACEs represent a significant public health hazard for children, their families and communities, and society as a whole. ACE exposure is associated with increased risk for physical and mental health problems across the lifespan, and worthy of the robust empirical attention it has acquired. However, research focused on risk to the exclusion of a focus on resilience is short-sighted, given that most children exposed to ACEs demonstrate a number of strengths and can function successfully in multiple life domains. Children who demonstrate resilience are not exceptions but represent the norm. Thus, research on resilience could result in preventative interventions to mitigate the negative consequences of ACEs for more individuals. Models of risk stemming from ACEs incorporate multiple levels of risk factors, ranging from individual, biological, and family functions, to economic disparities and gender socialization. Our models of resilience must reflect these levels as well as the interactions among resilience-promoting factors. Data from GTP research suggest that, even in high levels of lifetime trauma exposure (Gillespie et al., 2009), multiple factors (e.g., relationships with supportive adults, community/extracurricular activities) may be associated with resilience. Even in the context of high trauma exposure and related high levels of neighborhood disorder, community cohesion is associated with resilience to PTSD symptoms (Gapen et al., 2011). Furthermore, factors that are associated with risk in one context may be associated with resilience in others contexts.



Resilience needs to be understood in the context of human development. There may be sensitive developmental periods when skills associated with resilience are best nurtured. Thus, resilience-promoting interventions should be targeted to both the social context and the developmental stage of the at-risk individual. In addition, interventions for children and their parents should take neighborhood factors and social cultural norms and values into account. It is our hope that a better understanding of the social and developmental factors associated with resilience will lead to new approaches that foster health promotion, and that youths will be healthy and thrive even in the face of ACEs.

REFERENCES Ahrens, K. R., DuBois, D. L., Garrison, M., Spencer, R., Richardson, L. P., & Lozano, P. (2011). Qualitative exploration of relationships with important non-parental adults in the lives of youth in foster care. Children and Youth Services Review, 33, 1012–1023. Anda, R. F., Felitti, V. J., Bremner, J., Walker, J. D., Whitfield, C. H., Perry, B. D., et al. (2006). The enduring effects of abuse and related adverse experiences in childhood. European Archives of Psychiatry and Clinical Neuroscience, 256, 174–186. Arciniega, G. M., Anderson, T. C., Tovar-Blank, Z. G., & Tracey, T. J. G. (2008). Toward a fuller conception of machismo: Development of a traditional Machismo and Caballerismo scale. Journal of Counseling Psychology, 55, 19–33. Binder, E. B., Bradley, R., Liu, W., Epstein, M. P., Deveau, T. C., Mercer, K. B., et al. (2008). Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults. Journal of the American Medical Association, 299, 1291–1305. Bonanno, G. A., Papa, A., Lalande, K., Westphal, M., & Coifman, K. (2004). The importance of being flexible. Psychological Science, 15, 482–487. Bowes, L., Maughan, B., Caspi, A., Moffitt, T. E., & Arseneault, L. (2010). Families promote emotional and behavioural resilience to bullying: Evidence of an environmental effect. Journal of Child Psychology and Psychiatry, 51, 809–817. Bradley, R., Binder, E. B., Epstein, M. P., Tang, Y., Nair, H. P., Liu, W., et al. (2008). Influence of child abuse on adult depression: Moderation by the corticotropin-releasing hormone receptor gene. Archives of General Psychiatry, 65, 190–200. Brown, K. E., Parker-Dominguez, T., & Sorey, M. (2000). Life stress, social support, and well-being among college-educated African American women. Journal of Ethnic and Cultural Diversity in Social Work, 9, 55–73. Casey, B. J., Somerville, L. H., Gotlib, I. H., Ayduk, O., Franklin, N. T., Askren, M. K., et al. (2011). Behavioral and neural correlates of delay of gratification 40 years later. Proceedings of the National Academy of Sciences, 108, 14998–15003. Caughy, M. O., Nettles, S. M., O’Campo, P. J., & Lohrfink, K. F. (2006). Neighborhood matters: Racial socialization of African American children. Child Development, 77, 1220–1236. Caughy, M. O., O’Campo, P. J., Randolph, S. M., & Nickerson, K. (2002). The influence of racial socialization practices on the cognitive and behavioral competence of African American preschoolers. Child Development, 73, 1611–1625. Choi, K. H., Davidson, C., & Spaulding, W. D. (2011). Social cognition moderates the influence of child physical abuse on inpatient psychiatric rehabilitation. Journal of Nervous and Mental Disease, 199, 465–470. Curtis, W. J., & Cicchetti, D. (2007). Emotion and resilience: A multilevel investigation of hemispheric electroencephalogram asymmetry and emotion regulation in maltreated and nonmaltreated children. Development and Psychopathology, 19, 811–840. Deater-Deckard, K., & Dodge, K. A. (1997). Externalizing behavior problems and discipline revisited: Nonlinear effects and variation by culture, context, and gender. Psychological Inquiry, 8, 161–175.

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free ebooks ==> www.ebook777.com Developmental Social Factors as Promoters of Resilience 207 DuMont, K. A., Widom, C. S., & Czaja, S. J. (2007). Predictors of resilience in abused and neglected children grown-up: The role of individual and neighborhood characteristics. Child Abuse and Neglect, 31, 255–274. Eccles, J. S., & Barber, B. L. (1999). Student council, volunteering, basketball, or marching band. Journal of Adolescent Research, 14, 10–43. Fredricks, J. A., & Eccles, J. S. (2006). Extracurricular involvement and adolescent adjustment: Impact of duration, number of activities, and breadth of participation. Applied Developmental Science, 10, 132–146. Gapen, M., Cross, D., Ortigo, K., Graham, A., Johnson, E., Evces, M., et al. (2011). Perceived neighborhood disorder, community cohesion, and PTSD symptoms among low-income African Americans in an urban health setting. American Journal of Orthopsychiatry, 81, 31–37. Gardner, T. W., Dishion, T. J., & Connell, A. M. (2008). Adolescent self-regulation as resilience: Resistance to antisocial behavior within the deviant peer context. Journal of Abnormal Child Psychology, 36, 273–284. Gillespie, C. F., Bradley, B., Mercer, K., Smith, A. K., Conneely, K., Gapen, M., et al. (2009). Trauma exposure and stress-related disorders in inner city primary care patients. General Hospital Psychiatry, 31, 505–514. Gonzales, G., Chronister, K. M., Linville, D., & Knoble, N. B. (2012). Experiencing parental violence: A qualitative examination of adult men’s resilience. Psychology of Violence, 2, 90–103. Gray, S. A., Carter, A. S., & Levitt, H. (2012). A critical review of assumptions about gender variant children in psychological research. Journal of Gay and Lesbian Mental Health, 16, 4–30. Greeson, J. K. P., Usher, L., & Grinstein-Weiss, M. (2010). One adult who is crazy about you: Can natural mentoring relationships increase assets among young adults with and without foster care experience? Children and Youth Services Review, 32, 565–577. Gross, J. J. (Ed.). (2007). Handbook of emotion regulation. New York: Guilford Press. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1–25. Hughes, D., Rodriguez, J., Smith, E. P., Johnson, D. J., Stevenson, H. C., & Spicer, P. (2006). Parents’ ethnic-racial socialization practices: A review of research and directions for future study. Developmental Psychology, 42, 747–770. Jaffee, S. R., Caspi, A., Moffitt, T. E., Polo-Tomas, M., & Taylor, A. (2007). Individual, family, and neighborhood factors distinguish resilient from non-resilient maltreated children: A cumulative stressors model. Child Abuse and Neglect, 31, 231–253. Johns, L. E., Aiello, A. E., Cheng, C., Galea, S., Koenen, K. C., & Uddin, M. (2012). Neighborhood social cohesion and posttraumatic stress disorder in a community-based sample: Findings from the Detroit Neighborhood Health Study. Social Psychiatry and Psychiatric Epidemiology, 47, 1899–1906. Karremans, J. C., Heslenfeld, D. J., Dillen, L. F. van, & Van Lange, P. A. M. (2011). Secure attachment partners attenuate neural responses to social exclusion: An fMRI investigation. International Journal of Psychophysiology, 81, 44–50. Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30, 865–878. Kia-Keating, M., Sorsoli, L., & Grossman, F. K. (2010). Relational challenges and recovery processes in male survivors of childhood sexual abuse. Journal of Interpersonal Violence, 25, 666–683. Koenen, K. C., Aiello, A. E., Bakshis, E., Amstadter, A. B., Ruggiero, K. J., Acierno, R., et al. (2009). Modification of the association between serotonin transporter genotype and risk of posttraumatic stress disorder in adults by county-level social environment. American Journal of Epidemiology, 169, 704–711. Komro, K. A., Flay, B. R., & Biglan, A. (2011). Creating nurturing environments: A science-based framework for promoting child health and development within high-poverty neighborhoods. Clinical Child and Family Psychology Review, 14, 111–134. Lansford, J. E., Chang, L., Dodge, K. A., Malone, P. S., Oburu, P., Palmérus, K., et al. (2005). Physical discipline and children’s adjustment: Cultural normativeness as a moderator. Child Development, 76, 1234–1246.



Lengua, L. J. (2002). The contribution of emotionality and self-regulation to the understanding of children’s response to multiple risk. Child Development, 73, 144–161. Mahoney, J. L., Cairns, B. D., & Farmer, T. W. (2003). Promoting interpersonal competence and educational success through extracurricular activity participation. Journal of Educational Psychology, 95, 409–418. Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227–238. McHale, S. M., Blocklin, M. K., Walter, K. N., Davis, K. D., Almeida, D. M., & Klein, L. C. (2012). The role of daily activities in youths’ stress physiology. Journal of Adolescent Health, 51, 623–628. Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. New York: Guilford Press. Mikulincer, M., & Shaver, P. R. (2012). An attachment perspective on psychopathology. World Psychiatry, 11, 11–15. Neblett, E. W., Terzian, M., & Harriott, V. (2010). From racial discrimination to substance use: The buffering effects of racial socialization. Child Development Perspectives, 4, 131–137. Perkins, S. C., Cortina, K. S., Smith-Darden, J. P., & Graham-Bermann, S. A. (2012). The mediating role of self-regulation between intrafamilial violence and mental health adjustment in incarcerated male adolescents. Journal of Interpersonal Violence, 27, 1199–1224. Rudy, D., & Grusec, J. E. (2006). Authoritarian parenting in individualist and collectivist groups: Associations with maternal emotion and cognition and children’s self-esteem. Journal of Family Psychology, 20, 68–78. Saunders, R., Jacobvitz, D., Zaccagnino, M., Beverung, L. M., & Hazen, N. (2011). Pathways to earned-security: The role of alternative support figures. Attachment and Human Development, 13, 403–420. Taylor, R. D. (2010). Risk and resilience in low-income African American families: Moderating effects of kinship social support. Cultural Diversity and Ethnic Minority Psychology, 16, 344–351. Taylor, S. E., Eisenberger, N. I., Saxbe, D., Lehman, B. J., & Lieberman, M. D. (2006). Neural responses to emotional stimuli are associated with childhood family stress. Biological Psychiatry, 60, 296–301. Waugh, C. E., Thompson, R. J., & Gotlib, I. H. (2011). Flexible emotional responsiveness in trait resilience. Emotion, 11, 1059–1067.

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Resilience Interventions

Part A Activating Interventions



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free ebooks ==> www.ebook777.com 16 Behavioral Activation as a Treatment for Depression Theory, Neurobiologic Effects, and Potential Linkages to Resilience Gabriel S. Dichter, Moria Smoski, Roselinde K. Henderson, and Sona Dimidjian Unipolar major depressive disorder (MDD) is a debilitating condition with a lifetime prevalence rate of 17% (Kessler et al., 1994). Recent epidemiological evidence indicates that MDD is the 4th leading cause of disease burden and the leading cause of disability-adjusted life years (Ustun, Ayuso-Mateos, Chatterji, Mathers, & Murray, 2004) and is associated with significant psychosocial and medical morbidity and mortality (Kovacs, 1996). MDD is characterized by a high rate of relapse, with approximately 40% of patients reporting relapse within 2 years (Solomon et al., 2000) and 85% within 15 years (Mueller et al., 1999). With each new episode of major depression, the likelihood of experiencing future episodes increases by 16% (Solomon et al., 2000). Given the chronic nature of MDD, a critical goal for treatment development is to target the core processes that make an individual vulnerable to depressive episodes and thus improve his/her resilience to future depression. Treatments for MDD include psychotherapy of various modalities and an array of psychopharmacologic agents. Clinical research data suggest that psychotherapy for MDD is effective, protects against relapse, and does not carry the same risks of side effects as comparably effective psychopharmacologic treatments. The most common empirically validated modalities of psychotherapy for MDD include cognitive therapy (CT), behavioral activation (BA) therapy, cognitive behavioral therapy (CBT), problem-solving therapy (PST), and interpersonal therapy (IPT) (Hollon, Thase, & Markowitz, 2002). Amongst outpatients with mild MDD, research suggests little difference in outcome differences among psychotherapy, psychopharmacological intervention, and placebo, though amongst outpatients with moderate to severe MDD both treatment approaches out-perform placebo (Guemes, Guillen, & Ballesteros, 2008). There is growing evidence that certain psychotherapies are as effective as psychopharmacologic treatments for acute, severe major depression (Guemes et al., 2008), and psychotherapy appears to have more enduring effects compared to psychopharmacologic antidepressants (Hollon et al., 2005). Despite the evidence that psychotherapy is an effective intervention for MDD, relatively little research has addressed whether certain psychotherapy modalities may be suited to target particular core symptoms of MDD. For example, anhedonia (the diminished capacity to experience pleasure in response to pleasurable stimuli) is a defining symptom of MDD according to both the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) and the International Classification of Diseases (World Health Organization, 1992). The centrality of anhedonia to MDD is corroborated by findings from the DSM-IV mood disorders field trial that found that 95% of MDD respondents endorsed anhedonia (Keller et al., 1995). Given this evidence, it is critical to investigate the effects of interventions that target reward processes on the core symptom of anhedonia. Specifically, BA is a therapy that targets


Dichter, Smoski, Henderson, and Dimidjian

such processes by encouraging activities that increase contact with a broad range of positive reinforcement, and BA has a strong evidence base in the treatment of depression and the promotion of resilience to future depressive relapse. Brief BA treatments have been shown to be efficacious in treating depression in both inpatient (Hopko, Lejuez, LePage, Hopko, & McNeil, 2003) and outpatient (Gawrysiak, Nicholas, & Hopko, 2009; Lejuez, Hopko, LePage, Hopko, & McNeil, 2001) settings. BA has been shown to perform as well as CBT (Jacobson, Dobson, Truax, & Assis, 1996) or better than CBT (Dimidjian et al., 2006) in treating depression. In addition, BA has been shown to demonstrate effects on relapse prevention. In a randomized clinical trial comparing BA treatment with CT, researchers showed that BA was as effective as CT in preventing relapse over the course of a 2-year follow-up period (Gortner, Gollan, Dobson, & Jacobson, 1998). Specifically, while 35% of patients who had received BA reported a relapse within the 2-year period, 46% of patients who received CT reported a relapse. A second clinical trial compared treatment outcome over a 2-year follow-up of patients who received BA, CT, or ongoing antidepressant medication (ADM), or who were withdrawn from ADM (Dobson et al., 2008). Patients who had received BA were 51% less likely to relapse to depression than patients who were withdrawn from ADM at the end of the first year of follow-up. At the end of the second year of followup, patients who received BA were 64% less likely to have a recurrence of depression than patients who were withdrawn from ADM. Although these effects reached the level of nonsignificant trends, they nonetheless suggest a pattern of superior posttreatment resiliency for patients who receive BA as compared with those who receive ADM.

WHAT ARE THE EFFECTS OF BEHAVIORAL ACTIVATION ON BRAIN FUNCTION? In addition to the dearth of research investigating the match between core features of MDD and specific therapies, little is known about the potential neurobiological mechanisms of action of various psychotherapy modalities. That is, do different psychotherapy modalities differentially affect brain function, and are therapies that target reward processes related to specific changes in brain functioning that reflect reduced anhedonia? Studies of the effects of psychotherapy for MDD are broadly consistent with the corticolimbic model of MDD in that these regions function abnormally in individuals with MDD and fronto-cortical and limbic regions change activation levels in response to MDD treatment (Kennedy et al., 2007). The majority of published studies, however, have addressed the effects of treatments, whether psychotherapy or medication, on MDD symptom severity broadly defined. To date, there have been few systematic investigations into the effects of targeted interventions on etiologically relevant brain regions. The framework of this chapter is that BA may be particularly effective not only at treating depression but at promoting resilience against future episodes of depression, and that studies of the effects of BA on regional brain activation may provide clues to potential neurobiological mechanisms of depression resilience. This framework is motivated by the fact that: (1) BA is designed to impact feelings of control and pleasure and to increase behavioral reinforcement; (2) MDD is characterized by both feeling of loss of control and diminished responsivity to pleasurable stimuli (anhedonia); and (3) fMRI is capable of measuring both the effects of MDD on the functioning of brain regions mediating cognitive control and reward processing and the effects of BA treatment on the functioning of these regions.

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AN OVERVIEW OF BEHAVIORAL ACTIVATION BA is rooted in the behavioral model of depression, which posits that decreased levels of positive reinforcement for active, healthy behaviors contribute to and maintain symptoms of depression (e.g., Lewinsohn & Shaffer, 1971). Stressful events that disrupt adaptive behavior and provoke sadness can decrease the likelihood and potency of daily rewards, weakening the learned association between adaptive behaviors and positive outcomes. Meanwhile, the tendency to avoid daily challenges may be reinforced, leading to temporary relief from stress but resulting in restricted behavior and increased depression symptoms over time. BA explicitly targets behavior change as the active ingredient of treatment, as patients learn to engage in active, adaptive behaviors and to identify the links of such increased activation with improved mood and functioning (Martell, Dimidjian, & Herman-Dunn, 2010). In addition, patients learn to inhibit habits of avoidance and withdrawal that limit their access to reward and contribute to depression over time. Research suggests that patients treated with BA experience not only acute response but also increased protection from relapse over time (Dobson et al., 2008). It is possible that this relapse prevention effect is produced by assisting individuals in creating lasting changes in life context and in learning to associate healthy action with improved mood. In BA, behavior change is accomplished through several core strategies, including (a) assessment and monitoring of behavior, and (b) structuring and scheduling of activation goals. Assessment consists of detailed monitoring of the patient’s daily behaviors and moods between sessions. Patients with depression are restricted in their range of behaviors, and therefore may have reduced access to reward or reinforcement as well as reduced pleasure when reinforcement occurs. Monitoring the relationship between activities and shifts in mood helps to identify adaptive behaviors that are associated with pleasure and mastery. These are the “antidepressant behaviors” that are targeted in future sessions and form the basis of activation goals. Monitoring also reveals those maladaptive behaviors that may temporarily allow the patient to avoid aversive contexts, but ultimately result in worse mood and poor problem solving. By identifying behavioral patterns, that is, the events that tend to trigger maladaptive behaviors and the negative consequences of those behaviors, the patient gains awareness of the situations in which he/she is most likely to fall into habits of avoidance. Assessment strongly informs the structuring of activation goals, a second core strategy in BA treatment. Activation goals are the set of behaviors that correspond to the patient’s values, and are likely to increase contact with reinforcement. The patient and clinician work together to select activation goals that are tailored to the unique needs of the patient, break those goals into manageable behaviors that can be accomplished between sessions, schedule each behavioral assignment with a concrete plan for responding to obstacles that could interfere with the assignment, and monitor the mood consequences of each behavior. Over the course of treatment, activation goals and monitoring are conducted together to track the behaviors that are most effective in improving the patient’s mood and daily functioning. Those behaviors become self-reinforcing as the link between action and mood improvement strengthens. A range of strategies to maximize compliance with activation assignments also is utilized, such as engagement of significant others, social accountability, and behavioral contracting. Ultimately, the patient learns to identify the specific behaviors that contribute to depression, as well as the specific antidepressant behaviors that improve mood and contribute to better daily functioning. This new learning forms the basis for the patient’s recovery from depression and long-term resiliency in the face of future stress.



EFFECTS OF BA ON BRAIN FUNCTION Our research team has conducted a series of NIMH-funded studies to investigate the effects of BA for depression on brain function (Dichter, Felder, Petty, et al., 2009; Dichter, Felder, & Smoski, 2009, 2010; Smoski et al., 2009). The overarching goal of these studies was to first assess brain areas that were differentially recruited in patients with depression by relevant cognitive-affective tasks, and then to investigate the effects of BA treatment on functioning of these brain regions. The study design was to scan outpatients with depression before and after an average of 11.4 (SD = 2.0) weekly sessions of BA treatment. Additional sessions (up to a total of 15 sessions; average of 1.4 additional sessions per participant) were subsequently offered to help patients consolidate therapeutic gains and transition to follow-up care, as necessary. Preliminary studies such as these require strict inclusion and exclusion criteria to maximize the internal validity of the constructs being examined. All participants received a structured clinical interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1996) to confirm diagnoses. Patients met DSM-IV criteria for a current episode of depression, no other current Axis I disorder other than dysthymia, and scored 15 or above on the Hamilton Rating Scale for Depression. Participants in the control group scored 6 or lower on the Hamilton Rating Scale for Depression, and did not meet criteria for a current Axis I disorder or current/lifetime episode of mood or anxiety disorder. Participant exclusion criteria for both groups included: 1) coexisting bipolar or psychotic disorder, 2) comorbid current Axis I diagnosis including substance dependence, 3) active suicidal ideation, 4) evidence of organicity, 5) estimated verbal IQ below 70, 6) magnetic resonance imaging contraindicated, 7) history of neurological injury or disease, 8) current use of psychoactive medications including antidepressants, and 9) pregnancy. Depressed and control groups did not differ in age, estimated IQ, smoking status, or gender distribution. We used a fully crossed Group × Time design in which depressed patients were scanned before and after BA treatment and control patients were scanned twice, separated by the same amount of time (about 100 days). The analytic approach was thus to first test for brain areas demonstrating significant Group × Time interaction effects. These clusters would reflect brain areas that changed activity in the depressed group significantly differently than in the control group, a more specific test of the effects of BA than simply assessing brain areas that changed activation as a result of BA. Clinically, depressed patients as a group responded well to BA: Hamilton Rating Scale for Depression scores changed from 23.8 (SD = 2.3) at Time 1 to 8.7 (SD = 9.4) at Time 2 (p <.003). Among the patients, 75% were classified as “responders,” and 83% were classified as “partial responders.” Group × Time tests yielded significant interaction effects in depressive symptoms, reflecting significant declines in the depressed patients group. Study I: The Effects of BA Treatment on Brain Regions Mediating Cognitive Control Engagement in goal-directed behavior, as reinforced in BA, requires cognitive control to break out of patterns of avoidance and instead move towards potentially rewarding contexts. Cognitive control, especially in affective contexts, is impaired in depression (Fales et al., 2008), and thus our first study examined the effects of BA on prefrontal brain regions known to mediate cognitive control. The focus on cognitive control was based on its mediation by the prefrontal cortex and the relevance of the prefrontal cortex to impaired goal-directed behaviors in depression. In

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nonclinical populations, responses to stimuli requiring cognitive control recruit prefrontal brain regions, including the dorsal anterior cingulate and the dorsolateral prefrontal cortex (Fichtenholtz et al., 2004). Depression is characterized by prefrontal dysfunction (Fales, Barch, Rundle, Mintun, Snyder, et al., 2008), and neuropsychological profiles of individuals with depression reveal poor performance in tasks that require cognitive control (Zakzanis, Leach, & Kaplan, 1998) and that depend on functional prefrontal integrity (Rogers et al., 2004). Individuals with depression also show greater amygdala activity in processing unpleasant stimuli (e.g., Surguladze et al., 2005). Further, amygdala hyper-responsivity to negatively valenced stimuli is evident in non-affected children of depressed parents (Monk et al., 2008), and antidepressant treatment appears to attenuate amygdala hyper-reactivity in depression (e.g., Fu et al., 2004). Importantly, depression is characterized by more intense reactions to sad events after the termination of sad stimuli (Peeters, Nicolson, Berkhof, Delespaul, & deVries, 2003), suggesting that the effects of amygdala hyperactivity to sad events may impact not only responses to sad stimuli per se, but events that follow such stimuli as well. In order to investigate the potential effects of limbic hyperactivity on prefrontal function in depression, we presented oddball target stimuli embedded within streams of sad images (Dichter, Felder, & Smoski, 2009) during the scan (see the top of Figure 16.1). We reasoned that, because depression is characterized by enhanced limbic responses to sad events and because activation of the limbic system, including the amygdala, is associated with concomitant negative activation in prefrontal brain regions, the depression group should show evidence of greater prefrontal recruitment to successfully respond to the target events that required cognitive control. Results confirmed the hypotheses (see the middle of Figure 16.1). The only prefrontal region characterized by relatively greater control group activation to targets embedded within neutral blocks was the left midfrontal gyrus. However, the depressed group demonstrated relatively greater activation to target events embedded within sad blocks in a number of prefrontal regions, including the mid-, inferior, and orbitofrontal gyrus and the anterior cingulate. We also assessed relations between regional brain activation and depressive symptom severity in the depressed group. There was a significant correlation between bilateral midfrontal activations in response to target events embedded within sad blocks and Beck Depression Inventory (BDI) scores. Given that the prefrontal cortex mediates goal-directed behaviors in the context of cognitive interference (e.g., Fichtenholtz et al., 2004), we interpreted these results to reflect that greater “cognitive effort” was required (Matsuo et al., 2007) to disengage from the sad images to respond to target events in the depressed group. In other words, it may be the case that responding to target events embedded within sad blocks required, in essence, greater cognitive control in the depressed group because of greater engagement with the task-irrelevant images. The same task was used to investigate changes in brain activation after an average of 11 weekly sessions of BA treatment (Dichter et al., 2010). Only a small handful of studies has investigated the effects of antidepressant treatment on the neural correlates of limbic and prefrontal dysfunction. Fales and colleagues (2009) reported that outpatients with depression demonstrated increased dorsolateral prefrontal cortex activity to fear stimuli after escitalopram treatment, and a number of studies have found that antidepressant treatment appears to attenuate limbic hyper-reactivity in depressed (Norbury, Mackay, Cowen, Goodwin, & Harmer, 2007). However, no study to date had evaluated the effects of antidepressant treatment on cognitive control in affective contexts in depression. Given that, at baseline, the



Figure 16.1 Effects of BA on cognitive control in affective contexts. Top:Schematic of the mixed block/event fMRI task. Participants saw alternating 30-second blocks of neutral or sad images with embedded target events requiring a speeded button press. Middle:Brain activation differences at baseline (i.e., before BA treatment). The right-sided sagittal view depicts differences between patients with MDD and nondepressed control participants at baseline to target events embedded within blocks of sad images. Depicted are areas with relatively greater activation in the nondepressed group, which included only a midfrontal gyrus cluster. The other areas depicted are areas with relatively greater activation in the MDD group, which include prefrontal clusters in the mid-, inferior, and orbitofrontal gyrus and the anterior cingulate. The coronal view depicts prefrontal activations to target events embedded within sad blocks that predicted Beck Depression Inventory scores in the MDD group, and the scatterplot depicts individual subject data for this relation. Adapted from Dichter, Felder, Petty, et al. (2009). Bottom:Brain activation patterns comparing MDD patients scanned before and after BA treatment and nondepressed controls scanned twice. The mid-sagittal view depicts a paracingulate gyrus cluster reflecting a significant Group (MDD, nondepressed) × Time (Time 1, Time 2) interaction. The bar graph depicts signal intensities in this cluster, and the scatterplot illustrates relations between change in BDI score (i.e., pretreatment–posttreatment) and pretreatment paracingulate gyrus activation in the MDD group. Adapted from Dichter, Felder, & Smoski (2010). Note:MFG: middle frontal gyrus; IFG: inferior frontal gyrus. Contrasts are thresholded at corrected Z>2.3. Error bars represent standard errors of the mean.

depressed group was characterized by relative prefrontal hyperactivation to targets embedded within sad blocks, we hypothesized that successful BA treatment would induce reductions in prefrontal cortical activations to these stimuli. Analyses of the effects of BA on accuracy and latency to target events revealed no significant effects. Similarly, patients were asked to rate the sad images presented during the task on the dimensions of Valence and Arousal, and these rating were not affected by BA treatment. In this regard, changes observed in patterns of brain activation did not recapitulate changes observed in task-related behavior or self-report. Brain imaging data revealed that a cluster within the paracingulate gyrus showed evidence of differential modulation after BA treatment (see the bottom of Figure 16.1) relative to change in activation in the control group. Simple effects tests revealed that the depressed group recruited this cluster to a significantly greater degree than did the control group at baseline. However, after treatment, this pattern was reversed, and the depressed group

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recruited this cluster to a lesser degree than did the control group. Further, the depressed group demonstrated a significant decrease in activation in this cluster after psychotherapy. Other areas that showed significant decreases in activation following psychotherapy included the right orbital frontal cortex, right frontal pole, left Heschl’s gyrus, left occipital pole, bilateral postcentral gyrus, bilateral precentral gyrus, left superior, left middle, and right inferior posterior temporal gyrus, and right anterior supramarginal gyrus. Finally, we assessed for brain regions whose pretreatment activity in the depressed group predicted the magnitude of change after BA treatment. Only the paracingulate gyrus cluster showed a significant relation, reflecting that individuals with greater changes in BDI scores (i.e., those with greater symptom reductions after BA treatment) were those with lower pretreatment signal intensities in this region. Decreased activation in the paracingulate gyrus after BA treatment is particularly interesting in light of the large literature demonstrating that metabolism in this region predicts depressed treatment response in an array of functional and metabolic imaging paradigms (Ressler & Mayberg, 2007). The finding of decreased right orbital frontal cortex activation may be conceptualized within the role of this region to mediate emotional evaluations (Wright et al., 2008) and known linkages between orbital frontal cortex dysfunction and depression in a number of contexts (Drevets, Price, & Furey, 2008). Finally, the right frontal pole is a mediator of executive control of cognitive operations and has been suggested to be a cognitive “gateway” that prioritizes information processing (Burgess, Dumontheil, & Gilbert, 2007). The fact that only the paracingulate gyrus predicted treatment response is consistent with the conceptualization that depression is associated with relatively greater prefrontal activation to targets embedded within sad blocks that reflects greater cognitive “effort” to disengage from sad stimuli: those with greater pretreatment signal intensity showed lesser symptom changes, whereas those with smaller pretreatment signal intensity showed greater symptom changes. Though the post hoc nature of these analyses warrants replication, these findings suggest that pretreatment paracingulate gyrus activation may be a predictor of BA response. Study II: The Effects of BA Treatment on Brain Regions Mediating Reward Processing We also evaluated the effects of BA on reward processing in the same cohort of depressed patients. The relevance of impaired reward circuitry function to depression reflects the centrality of anhedonia, the decreased response to pleasurable stimuli, to the diagnosis of depression. Anhedonia is also a central feature of a number of neurobiological theories of depression that posit that deficits in emotional and motivational responses to appetitive stimuli are core features of the disorder (Davidson, 1998), and the anhedonic endophenotype of depression is perhaps the most well supported (Hasler, Drevets, Manji, & Charney, 2004). Responses to rewards are mediated primarily by the ascending mesolimbic dopamine system, which is largely shared between humans and other animals (Berridge & Kringelbach, 2008). There are multiple constructs mediated by the mesolimbic system, and at least four such systems have been described in depth in numerous seminal reviews (e.g., Berridge & Kringelbach, 2008; Wise, 2008): (1) approach motivation, typically subsuming what is colloquially described as “wanting,” refers to processes that facilitate approach behaviors towards biologically relevant goals, and includes reward valuation, willingness to expend effort to obtain rewards, reward prediction, and reward-based decision making; (2) hedonic responses, including both consummatory behaviors and processes associated with regulation of such behaviors, are broadly referred to as “liking” or “pleasure” and describe core liking



reactions that may or may not influence future behavior; (3) reward learning, including reinforcement processes that shape the experience-dependent learning guiding future behaviors; and (4) habitual behaviors, reflecting those processes that were initiated based on reward feedback, but that persist in the absence of such feedback. The neurobiological bases of goal-directed behaviors are well understood in animal contexts (e.g., Berridge, Robinson, & Aldridge, 2009), and cognitive affective neuroscience techniques have facilitated the investigation of reward circuits in human clinical contexts (e.g., Haber & Knutson, 2010). Activity of dopamine neurons within mesolimbic pathways that project from the ventral tegmental area to the nucleus accumbens reinforces responses to both primary and secondary reinforcers (Wise, 1996). Reward information is processed via a limbic cortico-striatal-thalamic circuit that interdigitates with the mesolimbic dopamine pathway (Haber, 2003), with the nucleus accumbens serving as a dopamine-gated mediator for information passing from the limbic system to the cortex (Chau, Roth, & Green, 2004). This tract has been linked to primary rewards, secondary rewards (e.g., instrumental responding), and emotional processes, and is part of the limbic-striatal-pallidal circuit that is involved in motivated behavior (Swerdlow & Koob, 1987). The central node within the mesolimbic dopamine reward system is the nucleus accumbens within the ventral striatum that, along with the extended amygdala, mediates reward-based drive and motivation (McGinty, 1999). Of particular relevance to reward-based processes is the ventromedial shell of the nucleus accumbens (the core region regulates cognition and motor control) (Kalivas & Barnes, 1993) that serves as an interface between limbic and motor circuits, translating emotions into actions (Mogenson, Jones, & Yim, 1980). Reward system dysfunction in depression is well established (e.g., Hasler & Northoff, 2011). Behavioral studies have reliably found that individuals with depression show a blunted response to a range of rewarding stimuli (e.g., Pizzagalli, Iosifescu, Hallett, Ratner, & Fava, 2008). Reward learning has also been found to be impaired in depression (Robinson, Cools, Carlisi, Sahakian, & Drevets, 2012), and this impairment has been shown to be correlated with the severity of anhedonic symptoms (Liu et al., 2011). Additionally, the severity of major depressive disorder has been found to correlate highly with the magnitude of reward experienced after oral d-amphetamine, which increases dopamine availability (Tremblay, Naranjo, Cardenas, Herrmann, & Busto, 2002), and anhedonic symptoms in the general population predict rewarded effort-based decision making (Treadway, Buckholtz, Schwartzman, Lambert, & Zald, 2009). Functional neuroimaging studies in depression have consistently indicated hypoactivation in reward processing regions, including the dorsal and ventral striatum (e.g., Keedwell, Andrew, Williams, Brammer, & Phillips, 2005), as well as a host of other reward structures, including the medial prefrontal cortex, the pregenual and subgenual anterior cingulate, and the medial frontal gyrus (Keedwell et al., 2003). Reduced mesolimbic activity in depression has been demonstrated during reward anticipation and outcomes in both adults and children (e.g., Forbes et al., 2010), as well as during reward learning (Robinson et al., 2012). Altered reward network responsivity may also be characteristic of individuals with a history of depression but without significant current symptoms, suggesting that anhedonia may represent a trait marker of MDD vulnerability independent of current depression state (Alloy, Abramson, Raniere, & Dyller, 1999). Although studying patients with remitted depression is not sufficient to establish reward processing deficit as a trait marker of depression, given that the sequelae of past illness and treatments on brain function may not be conclusively ruled out, it is nevertheless a necessary initial step to identify this disease trait.

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To extend the research on reward processing in depression, we used a Wheel of Fortune task to assess the functional neural correlates of reward selection, reward anticipation, and reward feedback, with primary interest in the reward anticipation phase of the task (see the top left of Figure 16.2). This task has been shown to elicit activation in the striatum, a critical region mediating reward anticipation, during the reward anticipation phase (Ernst et al., 2004). Based on the centrality of anhedonic symptoms to MDD and evidence of relatively lower levels of response in mesolimbic dopamine regions to positive stimuli in depression (e.g., Keedwell et al., 2005), we hypothesized striatal hyporesponsivity in the depressed group during reward anticipation at the pretreatment scans. This is indeed what we found (see the top right of Figure 16.2; Smoski et al., 2009). Baseline scans revealed greater activation in regions of basal ganglia associated with reward prediction and learning from positive feedback, including the right caudate within the striatum, as well as the right hippocampus, a region critical for memory consolidation.

Figure 16.2 Effects of BA on reward processing. Top left: schematic of the reward processing task. A Wheel of Fortune task (Ernst et al., 2004) was used. On each trial, participants were first presented for 3 seconds with one of four different types of wheels and chose whether they thought that one portion or the other portion would be randomly selected (the size of each portion reflected the probability of being selected). Participants were told that if they made the correct choice, they would win the amount of money depicted under the wheel in the same color. Next, participants rated how sure they were of winning. This 3.5-second phase constituted the “reward anticipation” phase and was the primary phase of interest. Finally, in a 4-second screen, participants learned whether they had won or not and indicated how they felt using a pictorial rating scale. Top right: Brain activation differences at baseline (i.e., before BA treatment). The sagittal view depicts regions with greater activation in the control than the depressed group during the reward anticipation phase of the task. The crosshair highlights that the right caudate nucleus, a critical region in the brain’s reward processing network, showed relatively greater activation in the MDD group. Adapted from Smoski et al. (2009). Adapted from Dichter, Felder, Petty, et al. (2009). Bottom: Brain activation patterns during reward anticipation comparing MDD patients scanned before and after BA treatment and nondepressed controls scanned twice. The clusters reflect significant Group (MDD, nondepressed) × Time (Time 1, Time 2) interactions, and include the right caudate cluster highlighted by the crosshair. The bar graph illustrates that the MDD group showed significantly increased activation in this right caudate cluster after BA treatment. Note: Contrasts are thresholded at corrected Z>2.3. Error bars represent standard errors of the mean. Adapted from Dichter, Felder, Petty, et al. (2009).



The same task was used to investigate changes in brain activation after BA treatment (Dichter, Felder, Petty, et al., 2009). Despite a growing neuroimaging literature evaluating response to antidepressant interventions in MDD, far less research has examined functional neural responses after psychotherapy. Available data suggest that psychotherapy predicts metabolic changes in the cingulate and frontal cortices (e.g., Siegle, Carter, & Thase, 2006), basal ganglia (Martin, Martin, Rai, Richardson, & Royall, 2001), and hippocampus (Goldapple et al., 2004). Furthermore, a consistent pattern has emerged that antidepressant treatment response is predicted by pretreatment functioning of the anterior cingulate cortex (Kennedy et al., 2001). Critically, however, no published study had examined functional brain activation changes after antidepressant treatment (medication or psychotherapy) using tasks tapping reward processing. This omission is striking given that reward anticipation may represent the most valid method to assess treatments that putatively improve anhedonia (Willner, 1983). Because of linkages between animal models of depression, decreased reward seeking behaviors, and functioning of the striatum (e.g., Berridge & Robinson, 1998), we had particular interest in BA-induced changes in striatal functioning during reward anticipation. Specifically, we hypothesized that psychotherapy would cause decreased depressive symptoms accompanied by increased striatal functioning. Behavioral data once again revealed no significant effects on any task-related behaviors, including whether participants chose highor low-probability rewards during the reward selection phase of the task, how sure they were of winning on each trial, or self-reported affect after wins and non-wins. Analyses of brain imaging data revealed a significant Group (Depressed, Nondepressed) × Time (Time: Time 1, Time 2) interaction effect during reward anticipation in a number of clusters, including the right caudate, anterior cingulate gyrus, right middle and superior frontal gyri, right lingual gyrus, right lateral and superior-lateral occipital cortex, right posterior parahippocampal gyrus, left insular cortex, left precuneus, left subcallosal cortex, left posterior temporal fusiform cortex, and bilateral precentral gyrus and temporal poles. The finding of BA effects on activation in the right caudate after BA treatment represented the first report of psychotherapy-related increases in striatal activity during reward anticipation in depression. Psychotherapy-related increased striatal activity during reward anticipation is consistent with preclinical and clinical models of depression and anhedonia that implicate mesolimbic dysregulation in the pathophysiology of depression (e.g., Swerdlow & Koob, 1987) and is consistent with the conceptualization that the mechanism of action of BA is improved mesolimbic functioning. Pending replication of these findings, the implications of this research are that BA may be effective for normalization not only of functioning of brain systems that mediate responses to sad events, but also of functioning of those circuits that mediate approach motivation towards cues of pleasure and reward.

DOES BA PROMOTE RESILIENCE? BA is a therapy designed to promote active learning and goal-oriented behavior; the evidence reviewed here suggests that it is a targeted intervention that improves reward processing in the brain and the recruitment of goal-directed neural systems. However, a critical question for clinicians and neuroscientists alike is whether BA confers lasting benefit, and how BA may promote resilience on the broad level of learning and behavior change as well as on the mechanistic level of brain functioning.

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BA includes the core strategy of functional assessment, described above, providing the patient with daily life “data” that reveal personal triggers (e.g., stressors), habitual ways of responding to triggers, and the consequences of those behaviors. Essentially, this monitoring helps the patient become aware of personal patterns of adaptive and maladaptive behaviors. From this perspective of awareness, the patient is more likely to notice triggering events and therefore choose a behavioral response rather than falling into automatic habits. This ability to take a “bird’s-eye view” of life events and behavioral choices is a skill consolidated during BA treatment, but which can be applied long after treatment has terminated. The structuring and scheduling of activation goals in BA are also likely to be a key ingredient of lasting resilience. As the patient engages in activation goals, those behaviors cause greater contact with rewards, which increases the likelihood that such behaviors will be selected in the future. Notably, as the patient and clinician structure new and diverse activation goals, the patient builds a broader repertoire of “antidepressant behaviors,” thereby increasing the availability of rewards. The BA emphasis on activation is founded on basic principles of conditioning, in which reinforcement for active behaviors establishes strong learned associations between healthy action and positive emotions. These learned associations endure over time, and are further strengthened each time the patient engages in healthy behaviors that result in pleasure or mastery. Long after BA therapy has ended, the patient who responds to challenge or daily stress by pursuing active, antidepressant behavior will continue to show resilience in daily functioning and mood. In addition to improved awareness and learning that occurs within the patient, BA treatment may help the patient to change the context in which he/she lives. During BA, activation goals include approaching and solving problems, which may fundamentally change the environment of the patient and reduce the likelihood of aversive events. Additionally, as the patient expands his/her behavioral repertoire to embrace a wide range of healthy activities, the availability and likelihood of rewarding events are increased. Through these problemsolving and activation efforts, the patient may fundamentally change his/her environment context in ways that last beyond BA treatment.

INTERPRETIVE CHALLENGES An important challenge to studies aiming to delineate the potential neurobiological mechanisms of action of antidepressant treatment pertains to the interpretation of studies using measures of brain function to measure treatment effects. Intervention effects may not necessarily indicate a causal mechanism of disease manifestation or development. In other words, although a given intervention may change activation within a given brain network, atypical activation of that same network may not necessarily be etiologically relevant for a given disorder. However, non-etiologic factors may be relevant to treatment effects, given that there may be distinct neurobiologic factors that cause or maintain a psychiatric disorder, and observing theoretically predicted changes in brain function in response to treatment is information that may be added to a nomological network articulating a theory of causal pathways. Inferences of causality may be bolstered by sequentially demonstrating abnormal brain activation in patients relative to controls as well as normalization of brain activation following treatment (i.e., a discontinuation design). In disorders where full remission is possible, it is critical to establish normalization of brain activation patterns in individuals with a history of the disorders (i.e., trait effects) as well as in individuals at risk for the disorders



but currently asymptomatic (e.g., prodromal individuals or first-degree relatives of affected patients) (Tomarken, 1999). It is also critical to consider the effects of an intervention on symptoms versus the effects on patterns of brain activation. Neuroimaging clinical trials involve collection of both symptom and fMRI data, and researchers must consider scenarios where symptoms change in the absence of changes in brain function or brain function changes in the absence of changes in symptoms. It is imperative to specify prior to trial initiation whether clinical or neuroimaging measures are of primary interest. In contexts where clinical efficacy is of primary concern, neuroimaging measures may not be warranted. Thus, in most contexts fMRI intervention studies should examine the effects of interventions that have been previously established as effective in traditional clinical trials. This approach allows for a priori hypotheses concerning intervention effects on brain imaging metrics. Alternatively, in certain contexts brain imaging may be used in an experimental manner to test the effects of novel treatments. In this framework, fMRI tasks may be used to evaluate changes in neural activation or connectivity associated with changes in symptoms. fMRI may then be a useful tool to help develop treatments that are designed to target specific neural circuitry.

FUTURE DIRECTIONS An exciting prospect for the future clinical utility of brain imaging in psychiatry is the prospect of predicting which patients will respond to specific treatment modalities based on individual patterns of brain functioning. Initial results suggest that this may be possible, as multiple studies, including those reviewed in this chapter, suggest that the patient-specific effects of antidepressant treatment may be predicted by pretreatment measures of brain function (Siegle et al., 2006). Though the replicability of such a finding has yet to be established, such individualized matching of patients to specific treatments based on a single brain scan is clearly the holy grail of psychiatric brain imaging treatment-outcome research. Future research is needed to delineate linkages between laboratory measures of reward processing and real-life experiences of incentive motivation, positive affect, reward seeking, and risk-taking tendencies. The few studies that have evaluated potential relations between mesolimbic neural activity and subjectively experienced reward (Forbes et al., 2009) and motivation to work for rewards (Buhler et al., 2010) have yielded promising initial results suggesting the external validity of laboratory-based measures of reward processes, but research on the ecological validity of reward processing endophenotypic measures is needed. Additionally, the development of measures sensitive to reward system integrity and suitably sensitive to change for use in intervention studies is needed as well. Although self-report (e.g., Gard, Gard, Kring, & John, 2006) and behavioral (Treadway et al., 2009) measures of reward capacity have been developed, their prediction of neurobiologic function has proven to be limited. As suggested by Treadway and Zald (2010), an implication of clinical neurobiological research into reward system dysfunction may be the modification of diagnostic psychiatric interviews to frame and code questions to tap hedonic capacity and motivation towards certain classes of stimuli. Additionally, future research should clarify the ways in which BA may promote resilience to future stress, as well as the underlying mechanisms of such resilience. Longitudinal research that tracks formerly depressed individuals over time and incorporates assessment of daily wellness, behavior, and brain functioning would provide critical insight into processes of vulnerability and resilience in this population.

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ACKNOWLEDGMENTS Preparation of this chapter was supported by K23 MH081285 (Dichter), NIMH K23 MH087754 (Smoski), and NARSAD Young Investigator Awards to Dichter and Smoski.

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Ressler, K. J., & Mayberg, H. S. (2007). Targeting abnormal neural circuits in mood and anxiety disorders: From the laboratory to the clinic. Nature Neuroscience, 10, 1116–1124. Robinson, O. J., Cools, R., Carlisi, C. O., Sahakian, B. J., & Drevets, W. C. (2012). Ventral striatum response during reward and punishment reversal learning in unmedicated major depressive disorder. American Journal of Psychiatry, 169, 152–159. Rogers, M. A., Kasai, K., Koji, M., Fukuda, R., Iwanami, A., Nakagome, K., et al. (2004). Executive and prefrontal dysfunction in unipolar depression: A review of neuropsychological and imaging evidence. Neuroscience Research, 50, 1–11. Siegle, G. J., Carter, C. S., & Thase, M. E. (2006). Use of fMRI to predict recovery from unipolar depression with cognitive behavior therapy. American Journal of Psychiatry, 163, 735–738. Smoski, M. J., Felder, J., Bizzell, J., Green, S. R., Ernst, M., Lynch, T. R., et al. (2009). fMRI of alterations in reward selection, anticipation, and feedback in major depressive disorder. Journal of Affective Disorders, 118, 69–78. Solomon, D. A., Keller, M. B., Leon, A. C., Mueller, T. I., Lavori, P. W., Shea, M. T., et al. (2000). Multiple recurrences of major depressive disorder. American Journal of Psychiatry, 157, 229–233. Surguladze, S., Brammer, M. J., Keedwell, P., Giampietro, V., Young, A. W., Travis, M. J., et al. (2005). A differential pattern of neural response toward sad versus happy facial expressions in major depressive disorder. Biological Psychiatry, 57, 201–209. Swerdlow, N. R., & Koob, G. F. (1987). Dopamine, schizophrenia, mania, and depression: Toward a unified hypothesis of cortico-striato-pallido-thalamic function. Behavioral and Brain Sciences, 10, 197–245. Tomarken, A. J. (1999). Focus chapter: Methodological issues in psychophysiological research. In P. C. Kendall, J. N. Butcher, & G. N. Holmbeck (Eds.), Handbook of research methods in clinical psychology (2nd ed.). New York: Wiley. Treadway, M. T., Buckholtz, J. W., Schwartzman, A. N., Lambert, W. E., & Zald, D. H. (2009). Worth the “EEfRT”? The effort expenditure for rewards task as an objective measure of motivation and anhedonia. PLoS One, 4, e6598. Treadway, M. T., & Zald, D. H. (2010). Reconsidering anhedonia in depression: Lessons from translational neuroscience. Neuroscience and Biobehavioral Reviews, 35, 537–555. Tremblay, L. K., Naranjo, C. A., Cardenas, L., Herrmann, N., & Busto, U. E. (2002). Probing brain reward system function in major depressive disorder: Altered response to dextroamphetamine. Archives of General Psychiatry, 59, 409–416. Ustun, T. B., Ayuso-Mateos, J. L., Chatterji, S., Mathers, C., & Murray, C. J. (2004). Global burden of depressive disorders in the year 2000. British Journal of Psychiatry, 184, 386–392. Willner, P. (1983). Dopamine and depression: A review of recent evidence. III. The effects of antidepressant treatments. Brain Research, 287, 237–246. Wise, R. A. (1996). Addictive drugs and brain stimulation reward. Annual Review of Neuroscience, 19, 319–340. Wise, R. A. (2008). Dopamine and reward: The anhedonia hypothesis 30 years on. Neurotoxicity Research, 14, 169–183. World Health Organization. (1992). The ICD-10 classification of mental and behavioral diseases. Geneva: World Health Organization. Wright, P., Albarracin, D., Brown, R. D., Li, H., He, G., & Liu, Y. (2008). Dissociated responses in the amygdala and orbitofrontal cortex to bottom-up and top-down components of emotional evaluation. Neuroimage, 39, 894–902. Zakzanis, K. K., Leach, L., & Kaplan, E. (1998). On the nature and pattern of neurocognitive function in major depressive disorder. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 11, 111–119.

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free ebooks ==> www.ebook777.com 17 Resilience Training for Action and Agency to Stress and Trauma Becoming the Hero of Your Life Martha Kent and Mary C. Davis

THE HALLMARK OF RESILIENCE—GOOD SURVIVAL Human history is replete with naturalistic examples of extraordinarily good survival in extreme life-threatening situations. In this chapter, we draw on examples that come mainly from the destructive historical events of the past century, whose survivors described their experiences in autobiographies bearing witness to the deluge visited on them, their families, and their communities. The expression good survival was used both in the language of survivors themselves (e.g., Ginzburg, 1967, pp. 220–221) and in the terms experts used to describe survivors’ responses in clinical or historical reports (e.g., Terr, 1979). Among survivors themselves, the notion of good survival surfaced rarely and attracted little notice in surroundings where “goners” stood out. Good survival continues to escape our own awareness even today, aided by a language that provides a much richer means of expression for the experience of decline. We begin our chapter with examples of good survival, because science is as much a process of looking with fresh eyes, with a somewhat naïve unfettered curiosity, as it is of presenting evidence supporting or refuting hypotheses. We start with this state of undefined probing because this fosters a fresh way of looking and seeing that is not constrained by hypotheses. Nor will we be satisfied with ordinary terms that more suitably belong to the realm of folk psychology with which our language is so richly endowed. Rather than accept an ordinary language concept and its own direction of causality, we use the term resilience as a placeholder for what science may eventually discover about our responses to extreme threat. The goal of this chapter is to describe our understanding of resilience as an adaptive process to challenge, elaborate the key roles of action and agency in resilience, and highlight the neurobiological underpinnings of resilience supported by current neuroscience and imaging findings. We will present results from a randomized controlled clinical trial of a resiliencebuilding intervention to treat posttraumatic stress disorder (PTSD) and discuss the implications of a strength-based approach for the treatment of anxiety and affective disorders.

NATURALISTIC EXAMPLES OF RESILIENCE During the Great Purge of 1937 and the sweeping persecution and imprisonment of millions in the Gulag of the Soviet Union, Eugenia Ginzburg became one of the inmates for the next 18 years of her life. She spent the first year and a half in solitary confinement. During that time she chanted poetry she had learned in earlier years. As she chanted, she could sense the poets in her cell. She felt that with poetry she could survive any dungeon (Ginz-


Martha Kent and Mary C. Davis

burg, 1967, pp. 220–221). Marcella Leet recounted a similar episode described to her by a patient. During World War II the patient, as a young boy, played his violin whenever his city was bombed. He spoke of how he played his violin, heard the bombs, saw smoke and fire, and saw buildings collapse. He saw the destruction and continued to play (M. Leet, personal communication, 1984). George Ritchie served as a medic in an American unit assigned to attend to survivors of a liberated Nazi concentration camp near Wuppertal at the end of World War II. One of the survivors spoke several languages, was very helpful, and appeared fairly fit and in good spirits. The Americans thought he had spent only a few weeks in the camp. In fact, this survivor had seen his wife and five children executed before he himself was imprisoned in 1939. He had resolved not to hate anyone. In his legal practice, he had seen what hatred did to people. He resolved to love everyone and be helpful for the six years of his captivity. He had had the same rations and treatment as everybody else but had survived so well with the added compassion and caring (Ritchie, 1978). In 1965 Robert Shumaker became a prisoner of war (POW) in the infamous “Hanoi Hilton” prison in North Vietnam. In a televised documentary (This Emotional Life, 2010), Shumaker related how he built his dream house in his mind, counted the number of nails he used, and the feet of lumber he required. When he changed the location of a fireplace, he had to start his construction over again. He and fellow inmates devised a tapping code to communicate with each other and to teach and learn a number of subjects. He stated that he would not wish away his captivity, because he had discovered things about himself and his ability to survive. He had learned survival skills he would not have learned otherwise. He thought that, if he could survive captivity, he could survive anything. In 1976 a group of children were kidnapped in Chowchilla, California and locked in an underground vault of a cave. The roof of the vault started to collapse. One of the boys dug a way to the outside and to safety. Several months later, the psychiatrist Lenore Terr (1979) interviewed the children and found that all of them showed signs of stress except for the boy who had found a way out and had helped his classmates escape. Beyond the life-threatening situations surrounding each of them, what these individuals had in common was responses of approach and engagement with their surroundings in ways that kept them well. They also sought out and expressed human connections: the words of a poet, helping others, the tapping code of the prisoners in Hanoi. Of note is that their actions did not resemble a stress response. In the midst of unpredictable life-threatening circumstances, they exhibited goal-directed behavior requiring prolonged focused attention, actions that were incompatible with mortal danger. Thus, a third characteristic of extraordinary survival is an efficient stress response in which stress mechanisms rise quickly during threat and subside to baseline levels when the immediate danger has passed. These characteristics drawn from narratives of good survival are consistent with the findings of the large developmental literature on children growing up in adversity. The children’s positive outcomes are associated with a close relationship with one or more adults and self-efficacy or being effective in their environments, such as doing well in school. These two qualities are replicated in numerous studies with remarkable consistency (Luthar, 2006; Masten, Best, & Garmezy, 1990). The resilient children show characteristics that are similar to those of the adult survivors. Resilient responses are not usually the ones that first come to mind when considering lifethreatening experiences. In extreme situations, responses of traumatic distress are the effects we expect, even though traumatic stress is not the most common adaptation to extreme threat. So dominant are our commonly held expectations that stress has driven the direction

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free ebooks ==> www.ebook777.com Resilience Training for Action and Agency 229 of research for the past century. To be sure, this direction has been very productive, having amassed an extensive body of work on physiological mechanisms, neural circuits, brain plasticity, gene expression, and the emergence of a diagnostic category, posttraumatic stress disorder (PTSD). Proposed in 1980, PTSD represents the symptom triad of re-experience, numbing, avoidance of traumatic stress, and hypervigilance, described in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). What a contrast the emotional openness to the voice of a poem, the sound of a violin, or the tapping of code is in comparison to the PTSD symptoms of emotional numbing or avoidance and alienation from people! Resilience is everything that PTSD is not. These two response tendencies appear particularly polarized in these extremely threatening situations. Yet, whether a resilient or traumatic response, each behavioral constellation is supported by major neurobiological mechanisms in the service of approaching and engaging with what sustains life and withdrawing from or defending against threats to life. How, then, does approach/engagement sustain life under conditions of extreme threat?

RESILIENCE TRAINING FOR ACTION AND AGENCY: A MODEL What Are Actions and Agency? The broad response tendency of approach/engagement and withdrawal/defense has served as the basic framework for understanding adaptation to environmental challenges in numerous neurobiological, endocrine, corticolimbic, and biobehavioral models. These are summarized in Table 3.1 (see Kent, Chapter 3, this volume). The qualities of approach/engagement grew out of an intervention we developed to treat PTSD. At the outset we reviewed examples of survival in extreme situations and found resilient responding exemplified by interest, curiosity, appreciation, noticing beauty, and positive valuing. Another element was social relatedness expressed in empathy, helping, friendship, bonds, and love. In comparison, PTSD was characterized by re-experiencing of past trauma, avoidance of reminders, emotional numbing that includes estrangement from people, and physiological hypervigilance and hyperreactivity. These qualities along with characteristics treated in reviews of resilience and PTSD (e.g., Friedman, Keane, & Resick, 2007; Reich, Zautra, & Hall, 2010) are briefly summarized in Table 17.1. What accounts for the occurrence of a resilient versus a traumatic response to a life-threatening and unpredictable environment? The answer may lie outside of the environment. Prinz (Hommel, Müsseler, Aschersleben, & Prinz, 2001), Hommel (2010, 2013) and others have pursued a model in which behavior is a response not to stimuli of the environment but to stimuli that reside in the person’s own actions, namely in the goals or outcomes of the individual’s own actions. From this perspective, it is the goals or anticipated future outcomes rather than environmental stimuli that determine behavior. “Approach and avoidance are controlled by goals rather than stimuli,” as Eder and Hommel (in press) nicely put it. This ideomotor approach would place “ideomotor” action squarely at the center of any resilient responding and displace the prominent position held by the stimulus-driven, hedonic approach of seeking reward and avoiding harm. However, the ideomotor conception of action would transfer action to the inner realm where ideas move the body and engage the motor activities of arms and legs. To be sure, the ideas representing goals, intentions, and future plans would emerge from experience and learning about muscle movements and their



Table 17.1 Comparison of Resilience and Posttraumatic Stress Characteristics Resilience Environment: Environment is equally threatening and unpredictable

PTSD

Person acts on the environment Independent of environment Flexible detachment from environment

Environment acts on the person Hyperfocus on environment Environment has hold of person Stimulus bound

Proactive Engaged Actor/agent

Reactive Avoidant Object

Coping

Problem solving Flexible, choices Initiator, explorer

Helpless Rigid, no choices Repeats the past

Emotions

Emotion regulation Coherent Appropriate to situation Focused Full range of emotions

Emotion dysregulation Incoherent, disorganized Inappropriate to situation Hyperreactive Constricted emotions, numbing

Future

Prospective Plans for the future Goal-oriented Future possibilities Optimistic, hopeful

Retrospective, deterministic, preordained Re-experiencing of the past Reminders of the past Foreshortened future Pessimistic, hopeless

Social relatedness

Seek social relationships Friendships Good work and family roles

Avoid social relationships Isolates Problematic work and family roles

Cognitive functions

Focused attention Working memory Executive functions Biographical narrative

Impaired attention Impaired memory, flashbacks Impaired executive functions Impaired biographical narrative

Cortical functions

Medial prefrontal cortex (mPFC) Anterior cingulate cortex (ACC) Orbitofrontal cortex (OFC) Medial insula

Decreased activation of mPFC Decreased activation of ACC Decreased activation of OFC Hypo-hyperactive insula Hyperactive amygdale Hyperactive hippocampus

Endocrine functions

Oxytocin Dopamine Neuropeptide Y Allostasis (predictive)

Cortisol Norepinephrine Epinephrine Homeostasis (reactive)

Person functions: Action

sensory effects. These ideas would then be used to voluntarily achieve goals and future plans. We will take an intermediate route in which internal events correspond to external events. Mirror neurons hold the promise of such an intermediate place. In their review of mirror neurons, Rizzolatti and Sinigaglia (2010) define action as “goaldirected behavior.” They see action as multifaceted and encompassing intention, prediction, simulation, imitation, anticipation, and expectancy, among other features (Rizzolatti & Sinigaglia, 2010). Agency is “the cause or origin of an action” (Balconi, p. 3). It is most frequently considered to be an individual’s awareness that he/she is the actor, the person who is causing or generating an action. This conceptualization allows for the distinction between

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free ebooks ==> www.ebook777.com Resilience Training for Action and Agency 231 actions generated by the self and those generated by others. Agency includes awareness of goals, awareness of intentions to act, initiation of action, awareness of movement, and sense of mental effort, of control, and of authorship. According to Fogassi and Ferrari (2007), the “syntax” of action resembles the syntax of language. We propose that the central structure is the subject–verb–object relationship, identified in the grammar and syntax of most languages, in the structure of stories of heroes and villains enacting their plots, in countless variations in which the actor, action, and object find expression. This unity of actor–action–object is ubiquitous and is seen in the smooth daily interactions that make for easy social discourse. We propose that this order constitutes a basic form that provides a scaffolding or structure, a “grammar” of action, from which predictive processes of inference can be launched in the form of goals, intentions, or future plans. Serious disorganization of this action arrangement is to be found in pathological cases that particularly bring to the fore the fundamental structure underpinning action and agency. The Neurobiology of Action and Agency Advances in neuroscience over the past two decades have shed light on some of the neurobiological mechanisms supporting action and agency, considered crucial to resilient responses to threat. Action tendencies supporting survival are automatically activated by emotional states represented in cortical and subcortical circuits and nodes (Damasio, 1999; Panksepp, 1998). LeDoux, the pioneer of the brain fear circuit, calls for “active coping” as the approach to overcoming anxiety (LeDoux & Gorman, 2001). And the leading scientistclinician van der Kolk declares “effective action” central to overcoming the physical helplessness of PTSD (2006). The evolving neurobiological model of mirror neurons captures some of the essential features of action and agency. In brief, this model holds that select neurons, termed mirror neurons (MN), are activated not only by one’s own actions, but also by observing those same actions performed by others. MNs allow us to use our own experiences to simulate those of others and thereby understand or predict other people’s behavior. In the current discussion, we argue that MNs form the neurological structure of agency and action, such that the act, the actor, and the object or target of action are united during each act and each simulation or “mirroring” of that act. The MN model is particularly attractive in that it subsumes many features of action and of agency through simulation that allows recognition of the intentions of others, formulation of one’s own goals, and imitation learning, among others. Since the first discovery of MN 20 years ago (di Pellegrino, Fadiga, Fogassi, Gallese, & Rizzolatti, 1992; Rizzolatti, Fadiga, Gallese, & Fogassi, 1996), the very existence of mirror neurons has been questioned (Lingnau, Gesierich, & Caramazza, 2009) and reaffirmed (Mukamel, Ekstrom, Kaplan, Iacoboni, & Fried, 2010). Their ontogeny is contested in positions that range from nativist views of MN as genetically endowed (Rizzolatti & Sinigaglia, 2010), to MN resulting from Hebbian learning (Keysers & Perrett, 2004), to MN as associationist acquired capacities (Heyes, 2010), or a combination of the above: positions that were debated in the recent Mirror Neuron Forum (Gallese, Gernsbacher, Heyes, Hickok, & Iacoboni, 2011; Glenberg, 2011a). Mirror neurons serve various contested functions, the main one being the representation of action goals according to Gallese and colleagues (2011), or understanding the motor intentions and goals “from the inside” according to Rizzolatti & Sinigaglia (2010). Glenberg counters that “we need to know what goals are and how they are instantiated”



(Glenberg, 2011b, p. 409). Indeed, in the literature, “object-directed” action, goals, and intentions are used interchangeably, without acknowledging the inferences required to abstract a goal or intention from the object or target of an act. We propose to consider a less evident function of MNs, namely that they provide a basic structure for action and, thus, to social action and social life. We propose that action embodies the actor and the target or object being acted upon. The MN simulation allows for easy association and identification of an act with the actor and the object being acted upon. The action, actor, and object are further unified by such unconscious processes as readiness potential (Haggard & Libet, 2001) or “intention binding” (Frith, 2002) in which awareness of choosing to act comes after the onset of action, affordance or the enhanced possibilities of action through compatibilities of the environment and the actor (Grèzes & Decety, 2002) and perceptual anticipation in which the brain’s motor cortex is activated by perception of movement before the actual act of moving (Chaminade, Meary, Orliaguet, & Decety, 2001). Through intention binding, the sense of agency is brought about by the conscious awareness following an action, rather than preceding the action, that one is the owner of that action (Frith, 2002). A simple illustration comes from Libet’s well-known experiment in which individuals made the willed action of lifting a finger “whenever they felt the urge to do so.” The urge to move the finger occurred milliseconds after the first changes in brain activity (Libet, Gleason, Wright, & Pearl, 1983). That is, “action” in the brain’s motor cortex activation preceded the “action” of thinking to move the finger. “Affordance” also promotes the link between actor and action. The complementary enhancement of environment and actor occurs in various modalities, perception being perhaps the most common. Grèzes and Decety (2002) find that visual perception affords action in various studies, such as primes that are visually congruent with an object to be grasped (right-handed orientation for right-handed grasp) markedly reduce the reaction time for grasping, as do familiar objects, and so on. In a similar vein, the capacity for perceptual anticipation fosters the recognition of self as initiator of action. Chaminade and colleagues (2001) review the literature examining perceptual anticipation and note that the perception of human motion activates the cortical motor structures even before a movement is initiated by a subject. They see the cortical motor system as a “simulation network” of perceived action; and mirror neurons are a part that specializes in object-directed action. It should be noted that mirror neurons themselves contain a subclass, termed “canonical neurons,” that respond to the shapes of objects alone without accompaniment of action, such as neurons that are activated by shapes that require a closed hand grasp. Thus, there is a variety of unconscious processes that cortically “prepare” the actor for action and processes that support action because the environment is particularly compatible or “affords” action. The Actor–Action–Object in Mirror Neurons Accruing evidence suggests that MNs provide the neurobiological foundation for the actor–action–object associations that are central to good survival. One line of work has provided data consistent with the action–object link, suggesting that it is only when actions are directed at objects that MNs discharge in nonhuman primates (Ferrari, Gallese, Rizzolatti, & Fogassi, 2003). In humans, MNs discharge to transitive and intransitive actions (Rizzolatti & Craighero, 2004), demonstrating a cortical capacity to distinguish between actions that are directed at objects and those that are not. In a different study Umilta et al. (2001) found that MNs discharged when the object was hidden from the animal’s view, following an action sequence witnessed by the macaque. It should be noted that the prior presence

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free ebooks ==> www.ebook777.com Resilience Training for Action and Agency 233 of the object of action allowed for the inference of goal. It is an underlying frame that can be recalled and used to form inferences about goals and intentions, a view that is consistent with Gallese, Keysers, and Rizzolatti (2004). The conclusion we draw from Umilta et al.’s study is that inferences and goals require objects at which actions are directed. No objects, therefore no inferences and no goals. Without objects, the action would be one of objectless, meaningless motion. In a series of papers and studies, Fogassi and colleagues (Chersi, Ferrari, & Fogassi, 2011; Fogassi & Ferrari, 2007) propose that elements of intentional action are combined into a rule-based cortical system that resembles the syntax of language. Action chains are underpinned by neuronal chains. In their seminal study (Fogassi et al., 2005), they found that MNs actually responded not only to goals but to the end goal of an action sequence. MN distinguished between when the monkeys observed another monkey grasp food for eating versus grasping food for placing in a container near the mouth. These findings led Fogassi and colleagues to conclude that a rule-based cortical system combined with intentional action sequences that had “much in common with the syntactic structure of language” (Fogassi & Ferrari, 2007, p. 140). So far we have described action from the perspective of mirror neurons. We have done so because we find that actions show a coherence reflected in the actor–action–object order that is easily illustrated by the studies of mirror neurons, irrespective of ontological issues concerning whether mirror neurons are shaped by forms of learning or are genetically endowed. Moreover, actions are performed in relation to an entity being acted on. Mirror neurons as actor–action–object forms preserve this connection with acting on or interacting with an “object.” In addition, it is easy to imagine this basic elemental form of actor–action–object combine with other such forms, proliferate, and become larger structures of interaction chains. Last but not least, the actor–action–object form is one that is accessible to a lay public of clients and patients who have an ordinary language appreciation of what an actor is or what a person treated as an object is. Our treatment of action would be incomplete without a mention of other views of action, particularly the ideomotor approach of Prinz and Hommel noted earlier (e.g., Hommel et al., 2001) and the comparator or forward model pioneered by Wolpert, Doya, and Kawato (2003). These are important in raising awareness about the deeper nature of action impairments in PTSD that involve predictive and prospective action capacities. Although a fuller treatment is beyond the scope of this chapter, their roles in PTSD deficits will become clearer at a later point in the chapter. Posttraumatic Stress Disorder: A Disturbance of Action and Agency Instances of disturbed action frames can be found at the level of each of the elements of actor, action, and object, such as: when the actor is not him/herself but someone else, when the action is not the actor’s action, or when the person sees him/herself as an object of abuse long after the actual harmful incident has passed. In the “anarchic hand” (Marchetti & Della Sala, 1998), a hand moves of its own accord and without the patient intending to move it. The sight of an object alone will trigger the “anarchic hand” movement to pick up an object and proceed with actions the person has not intended. Utilization behavior (Lhermitte, Pillon, & Serdaru, 1985) is evident when patients operate and manipulate objects within their reach and field of vision that are inappropriate, and the patient is unaware of his/her inappropriate conduct. A related disorder is imitation behavior in which the patient imitates the gestures and behavior of the examiner (cf. Lhermitte et al., 1985). Both



disorders are attributed to inhibition failure by prefrontal cortical dysfunction. An abundance of psychiatric descriptions cover disturbances of agency. Examples are grandiose delusions of having a great talent, making an important contribution, or being a special person, such as a Christ in The Three Christs of Ypsilanti (Rokeach, 1963). Other examples are delusions of control in schizophrenia (DSM-IV-TR) where actions, thoughts, and speech are carried out by an external agent rather than willed by the person, such as in thought insertion, thought withdrawal, or being manipulated by outside agents. This misattribution of agency has been extensively studied (reviewed in Waters & Badcock, 2010) and the disturbance located in deficient motor prediction in which predicted sensations do not match the actual sensory feedback of action, a process described in terms of a central comparator or forward model (Synofzik, Their, Leube, Schlotterbeck, & Lindner, 2010). We propose that PTSD is fundamentally a disorder of action and agency. Each of the elements of actor–act–object is impaired in the daily functions of patients. The act: The acts in PTSD are often ones that were originally made during the traumatic event, such as a startle initially made in response to a bomb now made to the sound of a fire cracker, or the fear of the smell of gasoline at a gas station that was first experienced during an exploding Humvee. The act is a response made to an environment that no longer exists, such as seen in various expressions of avoidance of an old threat made to a thought, feelings, or place, or re-experiencing of past events in activities, images, dreams, or even re-enacting them. The object/target:The targets being responded to are reminders of the old life-threatening environment, such as an actual explosion of a Humvee, and the scraps of paper that hid the improvised explosive device. The actor/agent:The responses of the actor range from helplessness during freezing and the inability to make any response at all to hyperresponsivity seen in hypervigilance, exaggerated startle, or outbursts of anger, impaired regulation of emotion and of using emotions as guides to life, and impaired attention, memory, and thinking. The person is changed, has impaired faculties, is estranged from others, and has become the object of the forces of harm. He/she is no longer the actor/agent but has become an object being acted upon, and his/her doing is no longer action but reaction. The structure can be said to be one of the person as object who is reacting to threat. Responses to extreme threat activate the hypothalamic-pituitary-adrenal (HPA) axis and limbic areas that include the amygdala and medial prefrontal cortex (mPFC), and reduce activation of the prefrontal cortex (PFC) and Broca’s area, affecting a major location of mirror neurons directly in Broca’s area as well as the PFC, which controls parietal functions and the parietal lobule, the second main location of mirror neurons. The effects of traumatic stress responses are evident in impaired executive functions such as planning and foresight (Vasterling & Brewin, 2005), alexithymia (Frewen, Pain, Dozois, & Lanius, 2006), impaired social functions (Nietlisbach, Maercker, Rössler, & Haker, 2010), and impaired biographical narrative (Jelinek, Randjbar, Seifert, Keller, & Moritz, 2009). Experience-Dependent Simulation of Action and Agency: Foundation for Resilience Interventions Given the central role of agency and action to good survival, what kind of action should we be looking for in the intervention literature? Therapeutic approaches have not framed therapies in terms of agency and actions, but rather as insight (e.g., psychodynamic psychotherapy), or cognition (e.g., cognitive behavioral therapy), or conditioning processes (e.g., exposure). We developed an intervention to restore action and agency and to reinstate the actor as the originator of his/her actions, as proactive in responding to

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free ebooks ==> www.ebook777.com Resilience Training for Action and Agency 235 challenge. A parallel important goal was to develop a language and explanatory concepts that would be accessible to patients, in which they could recognize their lives and could move forward from their traumatic experiences. Recent therapeutic directions embrace agency-enhancing capacities in their approaches, including mindfulness training of attention (Siegel, 2007) and activation therapy in treating depression and PTSD (Dichter, Smoski, Henderson, & Dimidjian, Chapter 16, this volume), or skills training for childhood trauma (Hassija & Cloitre, Chapter 21, this volume). We add our efforts to this direction in developing an agency-building approach we have come to call “experience-dependent simulation.” The centrality of action has modified the focus and course of a number of fields, among them cognition, linguistics, and artificial intelligence (AI). In grounded cognition, thought and language are seen as fundamentally situated and embodied in action. The new AI has moved “from reactive to anticipatory cognitive embodied systems” (Pezzulo, 2007, p. 258) in which thinking is embodied and grounded in sensations and actions. We join cognitive robotics in this leap from reactivity to anticipatory adaptation. The central mechanism that allows this leap is simulation or the making and manipulation of internal models of action. In such a leap, anticipation and the future can emerge from more basic forms of interaction and proceed to complex abstract ones. Anticipation is widespread throughout most physiological functions and present not only in cognition but also in sensorimotor action (e.g., catching a ball). A great deal of behavior is not present-oriented and stimulus-driven, but is goal-directed and future-oriented (e.g., a future goal that directs action rather than the environment demanding a response). The making of complex inner models and the simulation of complex anticipation allow the disengagement from present sensorimotor cycles, the formulation of novel goals, and imagining alternative experiences, even alternative worlds. Our minds can create an internal model and substitute elements within that model. For example, during his time in the “Hanoi Hilton” as a prisoner during the Vietnam war, Robert Shumaker moved a chimney in his imaginary dream house, which required subsequent changes in the design of the house. Such representations can detach from the current sensorimotor cycle and be used instead of the actual environment, as exemplified by Shumaker’s dream house, imagined independently of the immediate threatening surroundings of the Hanoi prison. This capacity to anticipate and separate from current demands was critical for the preservation of autonomy, not only for Shumaker, but for Eugenia Ginzburg in her actual acts of chanting poetry, the boy playing his violin despite bombing, and the prisoner in a Nazi camp helping others. Anticipation can generate representations that are not completely determined by presentsensed stimuli but are derived from internal models. The sensations of the internal models are used to regulate present behavior. A wide range of sensory inputs activate similar cortical motor areas that are also activated by actual actions: imagined action (Decety & Grèzes, 2006; de Vries & Mulder, 2007), sounds associated with action (Ticini, Schütz-Bosbach, Weiss, Casile, & Waszak, 2012), language of action words (Hauk, Johnsrude, & Pulvermüller, 2004), and touch (Keysers et al., 2004)—all these sensory inputs activate similar cortical motor areas to those activated by actual actions. And they are accompanied by similar sensations, such as time taken to walk a distance, or heart rate (e.g., Decety & Grèzes, 2006). These physiological reenactments render inner model-making possible and powerful. These basic findings of simulation and anticipation from neuroscience and AI are helpful in formulating and describing our experience-dependent simulation intervention, which is aimed at transforming reactivity into anticipatory adaptation.



AN INTERVENTION FOR RESILIENCE TRAINING OF ACTION AND AGENCY It is easy to interact with an environment that is predictable. Adaptation is smooth. What we do has an effect on our situation. However, the survivors in our examples could do little to change their unpredictable threatening situations. Eugenia Ginzburg could not change her imprisonment. The boy playing his violin could not change the bombing of his city. Nevertheless, survivors could take charge of how they responded to those circumstances. Their responses were anticipatory and goal-directed, allowed disengagement from immediate stress-inducing stimuli of the environment, and allowed for predictive sensations of approach/engagement and social relatedness. They were autonomous agents with qualities that we want for our patients. To that end, we developed a resilience training program in which participants would learn to restore agency in situations where they had not had such responses, in essence to return to traumatic experiences with responses that were as flexible as the anticipatory, goal-directed, and prospective responses of survivors like Eugenia Ginzburg or Robert Shumaker. Imaging support for such flexibility is provided by the work of Simmons et al. (2012) with Navy SEALs, chosen as subjects because they excel in high pressure situations. This imaging study showed increased activation of middle insula and bilateral PFC during anticipation of a shift in the valence of stimuli (such as positive to negative or vice versa). The SEALs showed increased activation when the environmental context was about to change, thus allowing preparation for threat. In another study on anticipation, Simmons, Strigo, Matthews, Paulus, and Stein (2009) found that participants with PTSD showed cortical insular activation only to negative stimuli, thus responding to anxiety before the threat occurred. The SEALs had learned to control anticipatory responses in a threatening situation at a physiological and cortical level. It is at this point that it might be useful to point out and underscore what is lost in PTSD and what it is that the SEALs have that allows them to function effectively in extreme threat. The difference is goal-directed, voluntary, intentional behavior, a forward model that anticipates the future with effective responses. The ideomotor theory is a predictive model of action. So is the forward or comparator model. Neither one has much to offer when the stimuli to be responded to are not the perceived effects or consequences of the individual’s own actions but are the life-threatening demands of the environment about to take the person’s life, to which he/she needs to respond and do so without experience, learning, and time for the formation of goals, intentions, and voluntary decisions. It is just in the most current research that the mechanisms of intentional action and reactive responding are being investigated. “One action system or two?,” Hughes, Schütz-Bosbach, and Waszak (2011) ask with regard to the cortical mechanisms involved in voluntary versus stimulus-driven actions. And their question does not even take affect or threat into account. Also of note is the earlier work of Astor-Jack and Haggard (2005) on intention and reactivity, and Herwig and Prinz’s (2007) paper investigating two modes of sensory integration representing intention-based and stimulus-based action. Most relevant are dysfunctions in predictive models identified in psychiatric conditions, such as in the forward model in sense of agency of obsessive-compulsive disorder (Gentsch, Schütz-Bosbach, Endrass, & Kathmann, 2011), or in sensory prediction in delusional ideation (Teufel, Kingdon, Ingram, Wolpert, & Fletcher, 2010). It is this level of sensory prediction that may well constitute the deepest and most basic level of impairment in PTSD. Our method of simulation and repeated practice introduces the patient to prospective, predictive experiences in the context of old threat or trauma that could, thereby, modify the

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free ebooks ==> www.ebook777.com Resilience Training for Action and Agency 237 re-experience of threat itself at a neurobiologically deep level that includes the insula and its interoception of interior bodily homeostatic changes. The neural pathways involved in embodied covert simulation and implicit anticipation, which includes bodily anticipation as a forward model, are summarized in detail by Svensson, Morse, and Ziemke (2009). In order to restore action, agency, and flexible affective anticipation, we developed a systematic approach that encouraged participants to take experiences of approach/engagement and social relatedness into past traumatic episodes in ways that could dissipate their distress, as illustrated in Figure 17.1. The resilience training program embraced four steps, which asked participants to: set traumatic experiences aside and identify one “cherishing” experience, identify and reexperience past approach/engagement/relatedness experiences from earlier times, use past experiences in a simulation to transform trauma, and imagine and design a future with agency.

Predictable environment

Predictable environment Positive experiences

Predictable environment Negative experiences

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Figure 17.1 Transforming trauma through the simulation of action and agency in approach/engagement and withdrawal/defense.



• Step 1. At the outset the immediate need is to engage a calming response that will allow participants to do the work of the program. They are asked to set traumatic experiences aside and find an episode from childhood and early adult years in which they are cherished and loved or they cherish and love someone or something else. They are to turn to this episode when stressed during the course of the intervention, rather than remain in their stressful state. According to Mikulincer, Shaver, and Horesh (2006), secure attachment restores feelings of safety even during high threat conditions, reduces vulnerability to PTSD, and helps heal trauma when mobilized symbolically. • Step 2. Participants identify approach/engagement and social relatedness experiences from childhood and early adulthood. These early experiences are formative in shaping brain development and emotional brain circuits. For the participant, these experiences are not novel but already have biological expression that facilitate their use and expansion. Memory is not a perfect reproduction of the past but a construction made of bits and pieces of it (Schacter, Norman, & Koutstaal, 1998). Participants have an opportunity to find relevant fragments of the past and form coherent themes and episodes. • Step 3. Participants use approach/engagement and social relatedness episodes to return to traumatic events. An example is the Vietnam era veteran who returns to a battle scene in his narrative with the activity and sensations of holding his first frog in his hands when he was 5 years old. The battle scene now feels like the wiggling magical creature in his hands, and his sensations move back and forth between the frog in his hands and an exploding grenade. Or the veteran returns to a scene in Baghdad as the boy fixing his toys and selling them on the sidewalk in Cleveland. The veteran is asked to describe the sensations of the Cleveland sidewalk sale in Baghdad, the humid air of Ohio now in Baghdad. In this sensory interweaving, the bombing in the Baghdad market takes on a different feel and perspective. Here the constructive view of memory is particularly relevant; the past is remembered in order to construct the future. According to Schacter and Addis (2007), the primary role of the episodic memory system may not be in recall but rather in future thinking, and the main function of episodic information is mainly for simulating possible future scenarios, outcomes, and needs. Schacter’s understanding of memory is very compatible with our experience-dependent simulation, with the difference that our simulation focuses mainly on sensations and treats episodes as the vehicles that carry sensations. We use sensory memory of approach/engagement to help patients become unstuck from the sensations of their traumatic past and thereby help in transforming a reactive view of the future into sensations of agency. • Step 4. Participants are asked to design a good life, a life with agency. Participants are asked to take the approach/engagement and social relatedness episodes they discovered and apply them to possible future challenging experiences. They are asked to design a future with their own goals and interests and how to achieve these. It is the approach/ engagement and social relatedness experiences that are so essential for flexible anticipatory proactive adaptation with the capacity to transform reactivity. The result is a new, more resilient, and integrated narrative that the participant has made of his/her life. We call the activities in Steps 3 and 4 experience-dependent simulation because the simulations are drawn directly from participants’ personal experiences. Studies on simulation find that people simulate in concrete form and create highly specific settings and behaviors that match social reality and bring in information about social life. Interdependent actions resemble real actions (Taylor & Schneider, 1989). A major benefit here is the evocation of actions and emotional states that can counter stress and trauma and restore agency and

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free ebooks ==> www.ebook777.com Resilience Training for Action and Agency 239 proactive emotions. Changes in affect, in symptoms, and in cognition happen concurrently with these change from object to agent, from past to the future. A detailed manual covered the above steps in four modules, which are described in Table 17.2. We tested whether the intervention would not only relieve symptoms but also improve positive emotional health and well-being and executive cognitive functions for individuals with PTSD by conducting a randomized clinical trial (Kent, Davis, Stark, & Stewart, 2011). The study sample consisted of 39 veterans with PTSD who had experienced trauma from a wide range of traumatic events, including childhood abuse and combat. Veterans were assigned to either the resilience treatment or a wait-list control condition, and assessed both before the treatment started and immediately following the end of the 12-week intervention period. The findings, summarized in Figure 17.2, were striking. The veterans assigned to the intervention group showed large improvements in their PTSD and depression symptoms, on the same order of magnitude as other established treatments for PTSD like exposure therapy. In fact, we found that the proportion of individuals in the severe range for PTSD decreased from 70% at pre-intervention to 30% at post-intervention for the treatment group. Likewise, the proportion of severely depressed intervention group members decreased from 40% at pre-intervention to 10% at post-intervention. In contrast, the control group remained unchanged in PTSD symptom severity, and showed some worsening in depressive symptoms, with an increase in the proportion of severely depressed individuals from 42.1% at preintervention to 63.2% at post-intervention. But, at least as important as the improvements in symptoms, the individuals who experienced the resilience treatment also showed large gains in positive emotional health and substantial gains in their cognitive health, including improved memory and executive function. The wait-list group, on the other hand, declined in well-being and showed no changes in cognitive health. Table 17.2 A Modular Program for Resilience Training of Action and Agency Introduction

Module I

Module II

Module III

Module IV

The body sense. The brain registers states of stress and calm in body states. This introduction serves to improve awareness of bodily states of calm, energy, and strength in body map exercises. Trauma is first experienced in the body, is physiologically maintained, and needs to leave bodily states. Approach/engagement proactive orientation. It covers experiences of interest, curiosity appreciation, noticing beauty. It is reinstated by re-experiencing past episodes of childhood and early adulthood, times that are formative. Participants are asked to describe each episode, indicate where in the body the respective qualities (of interest, curiosity, etc.) are, and what sensations accompany each episode, with reference to the five senses (vision, hearing, smell, touch, taste). They are to make a visual representation (method and materials of their choosing, e.g., collages, sculptures, etc.). Brain and endocrine functions are briefly reviewed with neuroscience examples. Social relatedness. It covers experiences of empathy, helping, caring for, affiliation, friendship, bonds, love. Participants are asked to re-experience past affiliative episodes by describing them, making the body connection, and describing the sensations that accompany each episode (vision, hearing, smell, touch, taste). They are asked to make a visual representation (method and materials of their choosing, e.g., collages, photo album, etc.). Brain/endocrine functions are reviewed with neuroscience examples. Trauma/stress resolution. It integrates the re-established approach and relatedness experiences covered in Modules I and II with the recall of traumatic and stressful life events that are now transformed in Module III. Stressful experiences are revisited in a graded manner with practiced approach/engagement or social relatedness experiences. Again, participants are asked to describe this resilience-based return to trauma, make the body connection, and describe the sensations that accompany each resolution with the five senses. They are asked to make a visual representation. Brain/endocrine changes are briefly illustrated with examples. The future with agency. It asks the question “What is a good life?” It explores a view of the future that participants can look forward to rather than one they dread.


Martha Kent and Mary C. Davis 1.2

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We were especially encouraged because our attrition rate was only 8%, indicating that almost all individuals were able to stay engaged in treatment. It is worth noting that some of the most widely used treatments that focus immediately on exposure to trauma-related stimuli report high attrition rates, approaching as much as 40% in the treatment groups (e.g., Schnurr, 2007). As we hoped, the resilience approach incorporating experience-dependent mental simulation seemed to help the veterans feel more capable of managing the distress associated with revisiting their traumas, and it may prove to be more effective than other treatments at preventing dropouts. Only a head-to-head trial comparing the resilience intervention with other treatment approaches, though, can answer this question. Nevertheless, all told, the findings are promising, and suggest that an experience-dependent simulation approach may have broad applicability to not only PTSD but also other conditions characterized by loss of approach/engagement, social connection, and agency. Depending on the type and severity of the disorder, the manualized program may be adapted to extend from 12 to 14 weeks and is conducted in a small-group format. The sessions cover the key steps described above. Future efforts will examine the utility of adaptations of the intervention to treat outpatient PTSD, depression, mixed Axis I groups, inpatient and outpatient addiction, sexual assault, and chronic illnesses including chronic pain and fibromyalgia.

CONCLUSION Agency makes humans “unique in their power to shape their life circumstances” (Bandura, 2006). Through agency, “People are not simply acted upon; instead, they interact with, influence, and cognitively transcend their immediate environments” (Cikara, Eberhardt, & Fiske, 2010, p. 540). Restoring the diminished capacities of action and agency reclaims a strength that not only ameliorates anxiety and other symptoms but brings with it a

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free ebooks ==> www.ebook777.com Resilience Training for Action and Agency 241 prospective future and goal-directed orientation, an action structure that is not merely reactive but is proactive, generative, and transformative of the individual and his/her life. Instead of defining this approach as a therapy, it may be more accurately described as a rehabilitation that restores and strengthens a capacity with which we are naturally endowed. In their recent review of the neurobiology of resilience, Russo and colleagues conclude that “it should be possible to induce natural mechanisms of resilience” (Russo, Murrough, Han, Charney, & Nestler, 2012, p. 1482). Our intervention has attempted to develop and test such a natural mechanism of resilience. Moreover, this direction is already underway with such treatment approaches as mindfulness (Siegel, 2007), skills building (Hassija & Cloitre, Chapter 21, this volume), activation therapy (Dichter, Smoski, Henderson, & Dimidjian, Chapter 16, this volume), acceptance and commitment (Hayes, 2004), and other approaches, some of which are represented in this volume. It is a restoration that allows us not only to regain balance and homeostasis, but to direct the weaving of the fabric of our lives. Joy and woe are woven fine, A clothing for the soul divine. Under every grief and pine Runs a joy with silken twine. William Blake

ACKNOWLEDGMENTS This work is partly supported by the Phoenix VA Health Care System and the Institute for Mental Health Research for contributions by Martha Kent. The contents of this chapter do not represent the views of the Department of Veterans Affairs or of the U.S. Government. The contents represent the positions of the authors, Martha Kent and Mary C. Davis. We thank Arthur M. Glenberg for his helpful review of this chapter.

REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Astor-Jack, T., & Haggard, P. (2005). Intention and reactivity. In G. W. Humphreys & M. J. Riddoch (Eds.), Attention in action: Advances from cognitive neuroscience (p. 109). New York: Psychology Press. Balconi, M. (2010). Neuropsychology of the sense of agency: From consciousness to action. Berlin: Springer. Bandura, A. (2006). Toward a psychology of human agency. Perspectives on Psychological Science, 1, 164–180. Chaminade, T., Meary, D., Orliaguet, J.-P., & Decety, J. (2001). Is perceptual anticipation a motor simulation? A PET study. Neuroreport, 12, 3669–3674. Chersi, F., Ferrari, P. F., & Fogassi, L. (2011). Neuronal chains for actions in the parietal lobe: A computational model. PloS One, 6, e27652. Cikara, M., Eberhardt, J. L., & Fiske, T. (2010). From agents to objects: Sexist attitudes and neural responses to sexualized targets. Journal of Cognitive Neuroscience, 23, 540–551. Damasio, A. R. (1999). The feeling of what happens: Body and emotion in the making of consciousness. New York: Harcourt Brace.



Decety, J., & Grèzes, J. (2006). The power of simulation: Imagining one’s own and other’s behavior. Brain Research, 1079, 4–14. Eder, A. B., & Hommel, B. (in press). Anticipatory control of approach and avoidance: An ideomotor approach. Emotion Review. Ferrari, P. F., Gallese, V., Rizzolatti, G., & Fogassi, L. (2003). Mirror neurons responding to the observation of ingestive and communicative mouth actions in the monkey ventral premotor cortex. European Journal of Neuroscience, 17, 1703–1714. Fogassi, L., & Ferrari, P. F. (2007). Mirror neurons and the evolution of embodied language. Current Directions in Psychological Science, 16, 136–141. Fogassi, L., Ferrari, P. F., Gesierich, B., Rozzi, S., Chersi, F., & Rizzolatti, G. (2005). Parietal lobe: From action organization to intention understanding. Science, 308, 662–666. Frewen, P. A., Pain, C., Dozois, D. J., & Lanius, R. A. (2006). Alexithymia in PTSD: Psychometric and fMRI studies. Annals of the New York Academy of Sciences, 1071, 397–400. Friedman, M. J., Keane, T. M., & Resick, P. A. (Eds.). (2007). Handbook of PTSD: Science and practice. New York: Guilford Press. Frith, C. (2002). Attention to action and awareness of other minds. Consciousness and Cognition, 11, 481–487. Gallese, V., Gernsbacher, M. A., Heyes, C., Hickok, G., & Iacoboni M. (2011). Mirror neuron forum. Perspectives on Psychological Science, 6, 369–407. Gallese, V., Keysers, C., & Rizzolatti, G. (2004). A unifying view of the basis of social cognition. Trends in Cognitive Sciences, 8, 396–403. Gentsch, A., Schütz-Bosbach, S., Endrass, T., & Kathmann, N. (2011). Dysfunctional forward model mechanisms and aberrant sense of agency in obsessive-compulsive disorder. Biological Psychiatry, 71, 652–659. Ginzburg, E. S. (1967). Journey into the whirlwind (P. Stevenson & M. Hayward, Trans.). New York: Harcourt Brace Jovanovich. Glenberg, A. M. (2011a). Introduction to the mirror neuron forum. Perspectives on Psychological Science, 6, 363–368. Glenberg, A. M. (2011b). Positions in the mirror are closer than they appear. Perspectives on Psychological Science, 6, 408–410. Grèzes, J., & Decety, J. (2002). Does visual perception of object afford action? Evidence from a neuroimaging study. Neuropsychologia, 40, 212–222. Haggard, P., & Libet, B. W. (2001). Conscious intention and brain activity. Journal of Consciousness Studies, 8, 47–63. Hauk, O., Johnsrude, I., & Pulvermüller, F. (2004). Somatotopic representation of action words in human motor and premotor cortex. Neuron, 41, 301–307. Hayes, S. C. (2004). Acceptance and commitment therapy and the new behavior therapies. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 1–29). New York: Guilford Press. Herwig, A., & Prinz, W. (2007). Two modes of sensorimotor integration in intention-based and stimulus-based actions. Quarterly Journal of Experimental Psychology, 60, 1540–1554. Heyes, C. (2010). Where do mirror neurons come from? Neuroscience and Behavioral Reviews, 34, 575–583. Hommel, B. (2010). Grounding attention in action control: The intentional control of selection. In B. J. Bruya (Ed.), Effortless attention: A new perspective in the cognitive science of attention and action (pp. 121–140). Cambridge, MA: MIT Press. Hommel, B. (2013). Ideomotor action control: On the perceptual grounding of voluntary actions and agents. In W. Prinz, M. Beisert, & A. Herwig (Eds.), Action science: Foundations of an emerging discipline (pp. 113–136). Cambridge, MA: MIT Press. Hommel, B., Müsseler, J., Aschersleben, G., & Prinz, W. (2001). The theory of event coding (TEC): A framework for perception and action planning. Behavioral and Brain Sciences, 24, 849–878.

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free ebooks ==> www.ebook777.com Resilience Training for Action and Agency 243 Hughes, G., Schütz-Bosbach, S., & Waszak, F. (2011). One action system or two? Evidence for common central preparatory mechanisms in voluntary and stimulus-driven action. Journal of Neuroscience, 31, 16692–16699. Jelinek, L., Randjbar, S., Seifert, D., Keller, M., & Moritz, S. (2009). The organization of autobiographical and nonautobiographical memory in posttraumatic stress disorder (PTSD). Journal of Abnormal Psychology, 118, 288–298. Kent, M., Davis, M. C., Stark, S. L., & Stewart, L. A. (2011). A resilience-oriented treatment for posttraumatic stress disorder: Results of a preliminary randomized clinical trial. Journal of Traumatic Stress, 24, 591–595. Keysers, C., & Perrett, D. I. (2004). Demystifying social cognition: A Hebbian perspective. Trends in Cognitive Science, 8, 501–507. Keysers, C., Wicker, B., Gazzola, V., Anton, J. L., Fogassi, L., & Gallese, V. (2004). A touching sight: SII/PV activation during the observation and experience of touch. Neuron, 42, 335–346. Kolk, B. van der (2006). Psychobiology of posttraumatic stress disorder: A decade of progress. Annals of the New York Academy of Sciences, 1071, 277–293. LeDoux, J. E., & Gorman, J. M. (2001). A call to action: Overcoming anxiety through active coping. American Journal of Psychiatry, 158, 1953–1955. Lhermitte, F., Pillon, B., & Serdaru, M. (1985). Human autonomy and the frontal lobes: Part I. Imitation and utilization behavior: A neuropsychological study of 75 patients. Annals of Neurology, 19, 326–334. Libet, B., Gleason, C. A., Wright, E. W., & Pearl, D. K. (1983). Time of conscious intention to act in relation to onset of cerebral activity (readiness potential): The unconscious initiation of a freely voluntary act. Brain, 106, 623–642. Lingnau, A., Gesierich, B., & Caramazza, A. (2009). Asymmetric fMRI adaptation reveals no evidence for mirror neurons in humans. Proceedings of the National Academy of Sciences, 106, 9925–9930. Luthar, S. S. (2006). Resilience in development: A synthesis of research across five decades. In D. J. Cohen & D. Cicchetti (Eds.), Developmental psychopathology (2nd ed., pp. 739–795). Hoboken, NJ: Wiley. Marchetti, C., & Della Sala, S. (1998). Disentangling the alien and anarchic hand. Cognitive Neuropsychiatry, 3, 191–207. Masten, A., Best, K. M., & Garmezy, N. (1990). Resilience and development: Contributions from the study of children who overcame adversity. Developmental and Psychopathology, 2, 425–444. Mikulincer, M., Shaver, P. R., & Horesh, N. (2006). Attachment bases of emotion regulation and posttraumatic adjustment. In D. K. Snyder, J. A. Simpson, & J. N. Hughes (Eds.), Emotion regulation in couples and families: Pathways to dysfunction and health (pp. 77–99). Washington, DC: American Psychological Association. Mukamel, R., Ekstrom, A. D., Kaplan, J., Iacoboni, M., & Fried, I. (2010). Single-neuron responses in humans during execution and observation of action. Current Biology, 20, 750–756. Nietlisbach, G., Maercker, A., Rössler, W., & Haker, H. (2010). Are empathic abilities impaired in posttraumatic stress disorder? Psychological Reports, 106, 832–844. Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. New York: Oxford University Press. Pellegrino, G. di, Fadiga, L., Fogassi, L., Gallese, V., & Rizzolatti, G. (1992). Understanding motor events: A neurophysiological study. Experimental Brain Research, 91, 176–180. Pezzulo, G. (2007). Anticipation and future-oriented capabilities in natural and artificial cognition. In M. Lungarella, F. Iida, J. Bongard, & R. Pfeifer (Eds.), 50 years of artificial intelligence: Essays dedicated to the 50th anniversary of artificial intelligence (pp. 257–270). Berlin: Springer. Reich, J. W., Zautra, A. J., & Hall, J. S. (Eds.). (2010). Handbook of adult resilience. New York: Guilford Press. Ritchie, G. G. & Sherrill, E. (1978). Return from tomorrow. Grand Rapids, MI: Baker Book House. Rizzolatti, G., & Craighero, L. (2004). The mirror-neuron system. Annual Review of Neuroscience, 27, 169–192.



Rizzolatti, G., Fadiga, L., Gallese, V., & Fogassi, L. (1996). Premotor cortex and the recognition of motor actions. Cognitive Brain Research, 3, 131–141. Rizzolatti, G., & Sinigaglia, C. (2010). The functional role of the parieto-frontal mirror circuit: Interpretations and misinterpretations. Nature Reviews Neuroscience, 11, 264–274. Rokeach, M. (1963). The three Christs of Ypsilanti. New York: Knopf. Russo, S. J., Murrough, J. W., Han, M.-H., Charney, D. S., & Nestler, E. J. (2012). Neurobiology of resilience. Nature Neuroscience, 15, 1475–1484. Schacter, D. L., & Addis, D. R. (2007). The cognitive neuroscience of constructive memory: Remembering the past and imagining the future. Philosophical Transactions of the Royal Society B, 362, 773–786. Schacter, D. L., Norman, K. A., & Koutstaal, W. (1998). The cognitive neuroscience of constructive memory. Annual Review of Psychology, 49, 289–318. Schnurr, P. P. (2007). The rocks and hard places in psychotherapy outcome research. Journal of Traumatic Stress, 20, 779–792. Siegel, D. J. (2007). The mindful brain: Reflection and attunement in the cultivation of well-being. New York: W. W. Norton. Simmons, A. N., Fitzpatrick, S., Strigo, I. A., Potterat, E. G., Johnson, D. C., Matthews, S. C., et al. (2012). Altered insula activation in anticipation of changing emotional states: Neural mechanisms underlying cognitive flexibility in Special Operations Forces personnel. NeuroReport, 23, 234–239. Simmons, A., Strigo, I. A., Matthews, S. C., Paulus, M. P., & Stein, M. B. (2009). Initial evidence of a failure to activate right anterior insula during affect set-shifting in PTSD. Psychosomatic Medicine, 71, 373–377. Svensson, H., Morse, A. F., & Ziemke, T. (2009). Neural pathways of embodied simulation. In G. Pezzulo, M. V. Butz, O. Sigaud, & G. Baldassarre (Eds.), Anticipatory behavior in adaptive learning systems (LNAI 5499, pp. 95–114). Berlin: Springer. Synofzik, M., Their, P., Leube, D. T., Schlotterbeck, P., & Lindner, A. (2010). Misattributions of agency in schizophrenia are based on imprecise predictions about the sensory consequences of one’s actions. Brain, 133 (Pt. 1), 262–271. Taylor, S. E., & Schneider, S. K. (1989). Coping and the simulation of events. Social Cognition, 7, 174–194. Terr, L. C. (1979). Children of Chowchilla: A study of psychic trauma. The Psychoanalytic Study of the Child, 34, 547–623. Teufel, C., Kingdon, A., Ingram, J. N., Wolpert, D. M., & Fletcher, P. C. (2010). Deficits in sensory prediction are related to delusional ideation in healthy individuals. Neuropsychologia, 48, 4169–4172. This Emotional Life (Series). (2010). PBS. Ticini, L. F., Schütz-Bosbach, S., Weiss, C., Casile, A., & Waszak, F. (2012). When sounds become actions: Higher-order representation of newly learnt action sounds in the human motor system. Journal of Cognitive Neuroscience, 24, 464–474. Umilta, M. A., Kohler, E., Gallese, V., Fogassi, L., Fadiga, L., Keysers, C., et al. (2001). I know what you are doing: A neurophysiological study. Neuron, 31, 155–165. Vasterling, J. J., & Brewin, C. R. (Eds.). (2005). Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives. New York: Guilford Press. Vries, S. de, & Mulder, T. (2007). Motor imagery and stroke rehabilitation: A critical discussion. Journal of Rehabilitation Medicine, 39, 5–13. Waters, F. A. V., & Badcock, J. C. (2010). First-rank symptoms in schizophrenia: Reexamining mechanisms of self-recognition. Schizophrenia Bulletin, 36, 510–517. Wolpert, D. M., Doya, K., & Kawato, M. (2003). A unifying computational framework for motor control and social interaction. Philosophical Transactions of the Royal Society B, 358, 593–602.

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Part B Intrapersonal Interventions



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free ebooks ==> www.ebook777.com 18 Different Strokes Empathy, Individual Characteristics, and Helping Alicia J. Hofelich and Stephanie D. Preston

As the chapters in this book attest, there is wide individual variation in the ways that people respond to personal life struggles, ranging from denial to a complete loss of emotional control, to the type of resilience to which we all strive—where we actively participate in our strife and emerge stronger, having learned and perhaps even benefited from the experience. Despite a respected and growing segment of psychological and health research on resilience and its less desirable counterparts (e.g., Davydov, Stewart, Ritchie, & Chaudieu, 2010; Epel, McEwen, & Ickovics, 1998), very little research has examined how an individual’s response to life stress can influence helping responses from people around him/her. There is a significant body of research on individual differences in the empathic response but most of this research uses narrative, confederate, or fictional needy targets that were designed to be sympathetic (e.g., see Batson et al., 1997; Eisenberg & Faber, 1990; Graziano, Habashi, Sheese, & Tobin, 2007). For this reason, we know very little about how different responses to need can produce diverging empathic responses to them. We are particularly interested in whether people who need help (hereafter, “targets”) elicit different emotional and prosocial responses in those observing them (hereafter, “observers”). Such interactive effects between targets and observers are not pedantic complexities. We are daily surrounded by people in need, including the homeless in our town, hungry children on television, distressed students in our office, and overwhelmed parents on our block. We may feel a twinge of their suffering and sometimes offer support—a dollar, a donation, a few reassuring words—but many potential targets do not elicit these responses. People are extremely selective when choosing whom to help, sometimes even derogating the need of those whom they choose not to help. Understanding these interactive complexities is key not only to our ability to better predict who will be helped and when, but also to resolving theoretical disputes in the academic literature on empathy. The research summarized in this chapter was designed to test a specific and debated aspect of the perception–action model (PAM; Preston & de Waal, 2002)—the importance of shared experience in empathy. We demonstrate that people display need in different ways and, because targets are processed through observers’ own, experience-dependent representations, this influences observer responses in predictable ways. We first describe the PAM in a little greater detail and introduce the different displays of emotion found in real hospital patient targets. We then describe a series of studies that predicted the response of observers to the resilient versus distraught patients, on the basis of the observers’ own experience and knowledge.


Alicia J. Hofelich and Stephanie D. Preston

THE PERCEPTION–ACTION MODEL Many lay definitions of empathy highlight the importance of shared experience, requiring that an empathic observer previously experience a similar situation to the target, having “walked a mile in his/her shoes.” This is consistent with many neuroscientific theories of empathy, which assume that our ability to understand the target’s emotion relies upon the observer’s own representations for experiencing that state. People can “feel into” or experience the emotions of targets because the brain naturally maps the motor movements and emotions of others onto the observer’s own neural representations for performing those movements or experiencing those emotions (e.g., Decety & Jackson, 2004; Preston & Hofelich, 2012; Preston & de Waal, 2002). A specific and underappreciated aspect of the PAM (Preston & de Waal, 2002) is that the perception of a target’s emotion spontaneously activates not only “mirror neurons” for specific affective states (e.g., Rizzolatti & Craighero, 2004), but also distributed, dynamic neural representations for the complete situation, including conceptual knowledge, motor and sensory information, memories, emotions, and physiological responses associated with the emotion, situation, or target (Preston & Hofelich, 2012). Thus, the empathic response is not just a knee-jerk imitative response, as it is sometimes caricatured, but a complex implicit integration of the situation through the lens of the observer’s own relevant cognitive and emotional knowledge structures. This perception–action design, in an inherently distributed neural system, provides a way not only to abstractly understand, but also to obtain first-person information about the feelings of others, which can produce resonant feelings and helping under certain conditions (e.g., when the need is salient and familiar and the observer can help; Preston & Hofelich, 2012). Representations Are Shaped by Experience Because each person has unique experiences and interactions with the world, the key personal representations of emotion that mediate empathy differ across people, reflecting their unique histories and influencing their ability to empathize. For example, someone who passes a begging homeless man daily may disregard him as a nuisance, while someone who encounters begging for the first time may feel alarmed or concerned. In general, the richer the observer’s representations for the target’s state, the better able the observer is to understand and empathize with the target; however, experience can also produce projection when the observer and target appraise the same situation differently (e.g., Hodges, Johnsen, & Scott, 2002). For example, someone who previously lived on the street may offer more tailored assistance to the homeless man, but may also offer the wrong kind of help, for example if he/she was solicitous while on the street he/she could offend the target, who prefers to feel independent. Evidence for experience-dependent modulation in empathy has been found at many levels. In the motor domain, even automatic neural mirroring depends upon correlated experiences of executing and observing actions (e.g., Heyes, 2001). In empathy, familiarity and similarity are among the strongest predictors of empathic concern and prosocial behavior (Barnett, Tetreault, Esper, & Bristow, 1986; Batson et al., 1996; Cialdini, Brown, Lewis, & Luce, 1997; Hodges & Wegner, 1997). However, people with similar experiences, such as divorce or childbirth, do not always better understand a target even when they feel more sympathetic or make the target feel understood (Hodges, Kiel, Kramer, Veach, & Villanueva, 2010). Thus, the content of an observer’s representations, including their appraisals

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and interpretations of an event, is what is important for predicting empathy, rather than the presence or absence of a similar experience. Thus, the nature of the neural mechanism for instantiating empathy, in which observers employ personal representations of experiences to observe and understand others, naturally produces both the positive, shared emotional experience known as empathy, and also critical mismatches that can produce key empathic failures.

THE CURRENT RESEARCH In order to study individual differences in empathy, we chose to use a wide range of real targets of need, who experience and display their stressful experiences in naturally differing ways. This is in contrast to the majority of empathy studies, which examined empathy with single prototypical targets (e.g., Batson, Eklund, Chermok, Hoyt, & Ortiz, 2007; Graziano et al., 2007) or a few fictional scenarios (e.g., Batson et al., 2007; Eisenberg & Fabes, 1990). Such paradigms served well to isolate specific situational or personality factors that influence empathy and to prove that empathically motivated help exists (cf. Batson & Shaw, 1991). But these procedures also mask important interactions between the experience of the observer and the display of the target which abound in real-world situations and need to be examined. Hospital Patients Express Their Need in Divergent Ways Our research began with the videotaping of quality-of-life interviews of 14 real patients who were hospitalized for serious chronic or terminal illness (Preston, Hofelich, & Stansfield, 2012). The original intent was to generate videos of real, uniformly sympathetic targets. However, upon watching the videos it was clear that the patients responded very differently to their fairly similar health challenges. Some cried throughout most of the interview, others said little and exhibited only fleeting emotions, and still others laughed and joked with the interviewer even when describing real struggle and even death. To systematically capture these patient displays and their effects on observers, a set of participant observers initially watched the videotaped interviews and rated each on a range of emotions that they observed in the target and felt in themselves (using similar procedures in prior empathy studies, e.g., Batson et al., 1997). To focus the study on the emotional content, the videos were all edited to remove references to their specific illness or prognosis so that observers were unaware of these factors. Even in this relatively small patient sample, distinct “types” of patients could be classified using cluster analysis of the observer ratings of the patients’ emotions. Five maximally differentiated types were identified, and each differed significantly on at least one of the main emotion display factors (distress, softheartedness, humor; see Figure 18.1). Distraught patients (n = 3) were upset and distressed, often breaking into tears. Resilient patients (n = 4) were positive and upbeat, but also discussed struggles. Sanguine patients (n = 3) were less emotional than distraught or resilient targets, did not discuss major problems, and tended to make jokes. A single patient was reticent, giving only single-word responses like “fine” or “none” and not overtly expressing emotion. Wistful patients (n = 3) appeared slowed by their illnesses, and talked about fears of dying, but were not overtly distressed like distraught targets. These varying emotional displays also elicited different responses from the participant observers (based on the factor-analyzed ratings of the



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observers’ felt emotion using the four top factors: personal distress, empathic concern, happiness, and horror). For example, distraught patients elicited the most personal distress and horror in observers and, while they were perceived as the most sick, they received comparable levels of help to the resilient patients, who were perceived as less sick but were the most liked. The reticent patient was disliked more than the others and received less empathy and help than all other types (Preston et al., 2012). Because of our initial PAM perspective, we were most interested in whether we could predict the observer responses to different patient types on the basis of observers’ emotional experiences or traits. Very few participants offered the most help to the unliked reticent patient, but the extent to which participants helped him was predicted by individual differences in self-reported ability to take the perspective of others (from the Interpersonal Reactivity Index; Davis, 1980), perhaps compensating for this laconic man’s subtle emotional cues. Participants were fairly split between offering the most help to the distraught versus the resilient patients, which was interesting, as everyone agreed that the distraught needed more help and were sicker. This suggests that some people prefer to offer aid to those who are easier to be around or perhaps could benefit more from the aid. In our subsequent study, we investigated whether individual variation in the content of observers’ own representations of distress could predict the preference for distraught over resilient patients. Prosocial Responses Can Be Predicted by Observer Female–Sadness Associations Sadness often occurs in situations of need and was salient in our real-world patient targets. However, even as a signal of need, sadness and distress produce variable responses in others, demonstrated by the fact that equal numbers of observers preferred to help the less sick-seeming and happy resilient patients. Cultural differences abound in beliefs about the expression of sadness. For example, Americans were surprised to see Russian president-elect Vladimir Putin shedding a tear, which is considered appropriate and even expected from

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stoic men in Russia (Rath, 2012). In general, Americans appear to believe that overt sadness is more permissible and common for females (e.g., Barrett, Robin, Pietromonaco, & Eyssell, 1998) and openly discourage such displays in even very young males (Brody & Hall, 2000). As most of the distraught and resilient patients were female, our next study tried to predict the preferential response to distraught over resilient women from participants’ individual associations between sadness and gender (Hofelich & Preston, 2012b). The logic was that people who had stronger female–sadness associations would believe that such displays were more permissible and, thus, offer more relative aid to distraught targets. In Study 1, the strength of each participant’s female–sadness association (contrasted against male–anger) was measured through a modified Implicit Associations Test (IAT; Greenwald, McGhee, & Schwartz, 1998). In this IAT, the key comparison is the response time (RT) to categorize words when response mappings are compatible with the predicted association (“female” and “sadness” are mapped onto one button; “male” and “anger” are mapped onto the other) compared to when they are incompatible (“female” and “anger” on one button; “male” and “sadness” on the other). A second replication study (Hofelich & Preston, 2012b), Study 2, employed a modified priming task (e.g., Dijksterhuis, Aarts, Bargh, & van Knippenberg, 2000) to separately measure the association between females and sadness without the male–anger association and to rule out alternative hypotheses. In both experiments, the measure of the individual’s female–sadness association was followed by observation of the interviews with female distraught and resilient patients. Participants indicated how much self-reported practical and emotional support and actual money they wanted to give to each patient, with the key measure being whether stronger female–sadness associations predicted greater relative offers to distraught over resilient patients. Both the IAT and female–sadness priming tasks positively predicted preferential donations to distraught over resilient female patients. Participants with the strongest female–sadness associations gave the most to the upset, distraught female patients, as predicted, which was not better explained by their non-affective female stereotypes. Participants with stronger female–sadness associations also perceived the distraught patients to be sicker, in line with the view that these observers decoded the distraught displays as more genuine signals of need. These results can be viewed as evidence in favor of the PAM, because the female– sadness associations are assumed to be part of the dynamic, conceptual knowledge structures that are spontaneously activated when observing distressed females, which then influences how we frame their behavior as sympathetic (Hofelich & Preston, 2012a; Preston & Hofelich, 2012; Preston & de Waal, 2002). Prosocial Responses Can Be Predicted by Observer Experiences With Sadness Another way to test the influence of person-specific representations on the preference for distraught over resilient targets was to find people with deeper or more frequent personal experiences with distress. We chose to study the effects of experiences with depression; while the presenting symptoms of depression can differ across individuals (e.g., undereating/overeating, not sleeping/sleeping too much), intense negative mood is a consistent and core attribute of all depression cases. Despite being one of the most common mental illnesses, it is not clear yet how depression affects empathy. Studies on the effects of maternal depression suggest it may impair a child’s development of empathy (e.g., Jones, Field, & Davalos, 2000), while other studies suggest depression may affect only personal distress and not empathic concern and perspective taking (O’Connor, Berry, Weiss, & Gilbert, 2002). Furthermore, some studies even suggest that high trait empathy can increase the chances



of developing depressive symptoms in response to distressing life events (Gawronski & Privette, 1997). Pilot data in our lab found that women with depression responded with more empathic concern to the distraught patients and with less to the reticent patient than nondepressed controls. Depressed women also perceived more differences across distraught patients than controls, producing two smaller clusters of distraught patients from their emotion ratings, rather than one larger group, suggesting that the depressed participants may have had richer representations of distress that allowed them to see finer-grained distinctions among these patients. To try to replicate this result in a larger sample, a second study was performed (Hofelich, Preston, & Kross, 2012) that compared participants with and without a past history of depression, who also varied on a continuous measure of current depressive symptoms (Beck Depression Inventory, BDI-II; Beck, Steer, & Carbin, 1988). Participants again watched the 14 patient videos, rated the emotions of the patients and their own emotional responses, and indicated how much help they would offer each patient. The 14 patients were again clustered into subtypes from the participant ratings of emotion observed in the patients (as in Preston et al., 2012 and the pilot data). Again, those with a past depression experience perceived greater distinctions among the distraught targets than controls, suggesting richer, more differentiated representations of distress in those participants. This time, however, previously depressed participants did not offer more help specifically to distraught patients, but offered more help across all patient types when they felt more similar to them (using their ratings of perceived similarity in emotional and life experiences), which control participants did not do. It turns out that many of the previously depressed participants did not actually feel similar to the distraught patients; perhaps they endured their own illness in a way that was more akin to that of one of the other types and, thus, perceived similarity was a more sensitive measure of the degree to which their internal representations for the state overlapped. Current depressive symptoms had an unexpected but sensible effect on observers. Those with more current symptoms on the BDI felt less empathic concern and gave less emotional and practical support to distraught patients. Mediation analysis suggested that they offered less help because they perceived distraught patients as needing less than the nondepressed participants did. Perhaps the negative self-focus associated with feeling depressed induces a competing focus upon one’s own feelings and needs that prevented them from attending to and sympathizing with the distraught targets. To follow up on the nature of this effect, an additional study tried to replicate this effect after inducing sadness in nondepressed participants. While the mood induction was successful, sad participants did not exhibit reduced empathy or helping for distraught targets; rather, they seemed to feel less empathy overall (to both resilient and distraught patients) and even gave slightly less to resilient patients. These results suggested that the decreased giving to distraught targets associated with current depression was due not simply to a current negative mood state, but likely to other features of clinical depression that more deeply influence motivation and perception (e.g., self-focus, anhedonia, negative bias).

CONCLUSION Despite an abundance of need in the world, failures of empathy are not uncommon and may trace in part to the fact that observers do not all perceive potential targets as needing or deserving help. This chapter presented work in our lab examining predicted but previ-

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ously unstudied interactions between the way that people display their need and observers’ perception of them and subsequent motivation to help. Together, this work demonstrates that people with different internal representations for emotional states, which are derived from their own personal experiences with the world, differ in their empathic responses in predictable (and sometimes unexpected) ways. What differentiates this work from much of the empathy literature is the use of varying, naturally occurring targets of need, combined with assessments of how observers’ internal affective representations influence the prosocial response to them. All of the targets were real hospital patients displaying natural, unstaged reactions to questions about their experience with illness. These ecological stimuli cannot be perfectly controlled (e.g., all distraught patients happened to be females), but they importantly permit us to examine how need is actually displayed in the real world, which likely has profound consequences on whether and how people choose to help. Recent work has compared responses to multiple targets designed to vary on a few dimensions, such as the congruence of their situation and emotional response (e.g., Szczurek, 2012), the type of pain they are experiencing (e.g., Bruneau, Dufour, & Saxe, 2012), or their general expressivity (Zaki, Bolger, & Ochsner, 2008), mostly using fictional targets, vignettes, or short descriptions (with the exception of Zaki et al., 2008) and examining common differences in observers such as their trait empathy or expressivity (e.g., Zaki et al., 2008). However, observers clearly have varying temperaments, personal experiences, associations, and representations about the world. Even the commonly held belief that women are associated with sadness varied tremendously in strength across our sample, with some even having the reverse associations (Hofelich & Preston, 2012b). Rather than seeing these differences as noise, we used them to predict the prosocial response while testing a popular but debated theoretical tenet of empathy—that it should be affected by observers’ personal experiences. Future work is needed to follow up on these studies, for example by comparing responses to these patients in observers from cultures where large negative displays of emotion are preferred or disdained. We also want to better understand what it is about feeling depressed that makes others’ plight seem less problematic and motivating. Particularly relevant to this volume, it would be good to also observe in the real world, if distraught or resilient patients are treated differently in the hospital, or by friends and family, in ways that impact their care or recovery. As we strive for resilience in the face of our own life struggles, how do we impact the way others perceive our situation and need? Does it change the way we perceive another’s distress? Only by probing complex interactions between the people who need help and the people who observe them can we fully understand when empathy thrives and fails.

REFERENCES Barnett, M. A., Tetreault, P. A., Esper, J. A., & Bristow, A. R. (1986). Similarity and empathy: The experience of rape. Journal of Social Psychology, 126, 47–50. Barrett, L. F., Robin, L., Pietromonaco, P. R., & Eyssell, K. M. (1998). Are women the “more emotional” sex? Evidence from emotional experiences in social context. Cognition and Emotion, 12, 555–579. Batson, C. D., Eklund, J. H., Chermok, V. L., Hoyt, J. L., & Ortiz, B. G. (2007). An additional antecedent of empathic concern: Valuing the welfare of the person in need. Journal of Personality and Social Psychology, 93, 65–74.



Batson, C. D., Sager, K., Garst, E., Kang, M., Rubchinsky, K., & Dawson, K. (1997). Is empathy-induced helping due to self-other merging? Journal of Personality and Social Psychology, 73, 495–509. Batson, C. D., & Shaw, L. L. (1991). Evidence for altruism: Toward a pluralism of prosocial motives. Psychological Inquiry, 2, 107–122. Batson, C. D., Sympson, S. C., Hindman, J. L., Decruz, P., Todd, R. M., Weeks, J. L., et al. (1996). “I’ve been there, too”: Effect on empathy of prior experience with a need. Personality and Social Psychology Bulletin, 22, 474–482. Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77–100. Brody, L. R., & Hall, J. A. (2000). Gender, emotion, and expression. In M. Lewis & J. M. HavilandJones (Eds.), Handbook of emotions (2nd ed., pp. 338–348). New York: Guilford Press. Bruneau, E. G., Dufour, N., & Saxe, R. (2012). Social cognition in members of conflict groups: Behavioural and neural responses in Arabs, Israelis and South Americans to each other’s misfortunes. Philosophical Transactions of the Royal Society B: Biological Sciences, 367, 717–730. Cialdini, R. B., Brown, S. L., Lewis, B. P., & Luce, C. (1997). Reinterpreting the empathy–altruism relationship: When one into one equals oneness. Journal of Personality and Social Psychology, 73, 481–494. Davis, M. (1980). A multidimensional approach to individual differences in empathy. JSAS Catalogue of Selected Documents in Psychology, 10, 85. Davydov, D. M., Stewart, R., Ritchie, K., & Chaudieu, I. (2010). Resilience and mental health. Clinical Psychology Review, 30, 479–495. Decety, J., & Jackson, P. L. (2004). The functional architecture of human empathy. Behavioral and Cognitive Neuroscience Reviews, 3, 71–100. Dijksterhuis, A., Aarts, H., Bargh, J. A., & Knippenberg, A. van (2000). On the relation between associative strength and automatic behavior. Journal of Experimental Social Psychology, 36, 531–544. Eisenberg, N., & Fabes, R. A. (1990). Empathy: Conceptualization, measurement, and relation to prosocial behavior. Motivation and Emotion, 14, 131–149. Epel, E. S., McEwen, B. S., & Ickovics, J. R. (1998). Embodying psychological thriving: Physical thriving in response to stress. Journal of Social Issues, 54, 301–322. Gawronski, I., & Privette, G. (1997). Empathy and reactive depression. Psychological Reports, 80, 1043–1049. Graziano, W. G., Habashi, M. M., Sheese, B. E., & Tobin, R. M. (2007). Agreeableness, empathy, and helping: A person × situation perspective. Journal of Personality and Social Psychology, 93, 583–599. Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. K. (1998). Measuring individual differences in implicit cognition: The implicit association test. Journal of Personality and Social Psychology, 74, 1464–1480. Heyes, C. (2001). Causes and consequences of imitation. Trends in Cognitive Sciences, 5, 253–261. Hodges, S. D., Johnsen, A. T., & Scott, N. A. (2002). You’re like me, no matter what you say: Self projection in self-other comparisons. Psychologica Belgica, 42, 107–112. Hodges, S. D., Kiel, K. J., Kramer, A. D. I., Veach, D., & Villanueva, B. R. (2010). Giving birth to empathy: The effects of similar experience on empathic accuracy, empathic concern, and perceived empathy. Personality and Social Psychology Bulletin, 36, 398–409. Hodges, S. D., & Wegner, D. M. (1997). Automatic and controlled empathy. In W. Ickes (Ed.), Empathic accuracy (pp. 311–340). New York: Guilford Press. Hofelich, A. J., & Preston, S. D. (2012a). The meaning in empathy: Distinguishing conceptual encoding from facial mimicry, trait empathy, and attention to emotion. Cognition and Emotion, 26, 119–128. Hofelich, A. J., & Preston, S. D. (2012b). Need in the eye of the observer: Implicit emotion associations predict the prosocial response. Manuscript submitted for publication.

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Hofelich, A. J., Preston, S. D., & Kross, E. (2012). The specificity of shared experience: Diverging effects of past versus current depression on empathy for another’s distress. Manuscript in preparation. Jones, N. A., Field, T., & Davalos, M. (2000). Right frontal EEG asymmetry and lack of empathy in preschool children of depressed mothers. Child Psychiatry and Human Development, 30, 189–204. O’Connor, L. E., Berry, J. W., Weiss, J., & Gilbert, P. (2002). Guilt, fear, submission, and empathy in depression. Journal of Affective Disorders, 71, 19–27. Preston, S. D., & Hofelich, A. J. (2012). The many faces of empathy: Parsing empathic phenomena through a proximate, dynamic-systems view of representing the other in the self. Emotion Review, 4, 24–35. Preston, S. D., Hofelich, A. J., & Stansfield, R. B. (2012). The ethology of empathy: Emotions displayed and elicited by real targets of need. Manuscript under review. Preston, S. D., & de Waal, F. B. M. (2002). Empathy: Its ultimate and proximate bases. The Behavioral and Brain Sciences, 25, 1–71. Rath, A. (2012, March 5). The meaning of Putin’s tears. PRI’s The World. Rizzolatti, G., & Craighero, L. (2004). The mirror-neuron system. Annual Review of Neuroscience, 27, 169–192. Szczurek, L. (2012). The stranger effect: Reactions to violators of emotional norms. Paper for Society for Personality and Social Psychology Annual Meeting, San Diego, CA. Zaki, J., Bolger, N., & Ochsner, K. (2008). The interpersonal nature of empathic accuracy. Psychological Science, 19, 399–404.

free ebooks ==> www.ebook777.com 19 Forgiveness Interventions and the Promotion of Resilience Following Interpersonal Stress and Trauma Nathaniel G. Wade, Jeritt R. Tucker, and Marilyn A. Cornish Many people experience some form of interpersonal stress and trauma in their lives. These traumatic events often lead to sustained posttraumatic emotional states that can overwhelm affect regulation capacities (Briere, Hodges, & Godbout, 2010). There are various strategies people use to cope with such posttraumatic emotions, many of which may not lead to successful outcomes. One strategy is to blame oneself for the interpersonal offense (JanoffBulman, 1979). Another is to blame an external party for the transgression (Lazarus, 1991). While these reactions may confer initial benefits to victims (e.g., control, setting appropriate boundaries, etc.), when these reactions are perpetuated victims of interpersonal trauma often continue down paths toward outcomes including psychological symptoms, physical health problems, and relational problems (Gordon, Burton, & Porter, 2004; Worthington & Scherer, 2004; Znoj, 2011). An alternative outcome of interpersonal trauma is forgiveness. In cases of interpersonal trauma, forgiveness may be a highly resilient response that leads down a path toward more beneficial secondary (long-term) outcomes (for a review see Worthington, 2005).

DEFINITIONS OF RESILIENCY AND FORGIVENESS Zautra, Hall, and Murray (2010) broadly define resilience as “an outcome of successful adaptation to adversity” (p. 4). Resiliency necessarily implies exposure to an adverse event or threat and includes two major definitions: recovery and sustainability (Zautra et al., 2010). Recovery is a gradual return to pre-event levels of functioning. Sustainability is the capacity to quickly regain equilibrium following a potentially traumatic event with little to no disruption in functioning (Bonanno, 2004). Whereas some researchers suggest that resilience is different from recovery (e.g., Bonanno, 2004), others suggest that recovery should be considered a domain of resiliency (e.g., Luthar, Cicchetti, & Becker, 2000). Based on this latter definition, resilience is not a single spectrum with risk factors at one end and protective factors on the other. Instead, people can be motivated by both the need to defend against harm (recovery) and the need to move toward goals (sustainability). We conceptualize forgiveness as a prosocially motivated reduction of negative emotions and an increase in positive emotions toward an offender following an interpersonal trauma (Worthington & Wade, 1999). We argue that the promotion of forgiveness after interpersonal transgressions can result in recovery from trauma, and that the promotion of forgivingness (i.e., the disposition to forgive) can result in sustained growth responses in the face of potentially traumatic events. Thus, interventions to promote forgiveness are one promising method of encouraging resilient responses in those affected by interpersonal trauma.

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MODEL TO UNDERSTAND FORGIVENESS-RELATED PSYCHOLOGICAL RESPONSES TO TRAUMA Although there is much conceptual overlap between the resiliency and forgiveness literatures, there is little work combining the two. In the absence of such literature, the present chapter is organized around a conceptual model relating forgiveness to nonresilient and resilient response patterns. This model, illustrated in Figure 19.1, is based on two core principles: (a) emotion and its regulation are central to understanding the diverse responses to trauma (Briere et al., 2010; Lazarus & Folkman, 1984), and (b) forgiveness is an emotion-focused coping effort following interpersonal stress (Worthington & Scherer, 2004; Worthington & Wade, 1999). Understanding the responses to interpersonal trauma provides one avenue for understanding forgiveness as a potentially resilient response. Figure 19.1 provides the theoretical temporal relationships among the forgiveness-related variables that we review in this chapter. Some of these are hypothesized to be causally related (e.g., secondary outcomes such as embitterment are thought to cause long-term outcomes such as relationship difficulties); others are expected to be related only through other mediating variables (e.g., unforgiveness does not cause forgiveness, but does come prior to it and may give way to forgiveness as a result of variables that are not included in the model, such as an offender’s apology). We use the text to differentiate

Event

Emotional reactions Self-Deprecating Emotions (e.g., Shame, Sadness, Powerlessness)

Primary outcomes

Secondary outcomes

Characterological Self-blame

PseudoForgiveness

Interpersonal Trauma

• Premature reconciliation • Poor boundaries • Relationship problems • Psychological symptoms

Embitterment

• Depression • Hostility • Physical health problems

Forgiveness

• Healthy boundaries • Resolution of the past • Effective reconciliation • Resiliency

Self-Protective Emotions (e.g., Anger, Indignation, Vengefulness)

Long-term outcomes

Unforgiveness

Figure 19.1. Theoretical model of the temporal unfolding of forgiveness-related responses and outcomes to interpersonal trauma. Note: Solid arrows indicate the theoretical temporal flow of forgiveness-related experiences following interpersonal trauma. These arrows may or may not indicate causation (e.g., secondary outcomes are theorized to cause long-term outcomes; however, unforgiveness is not theorized to cause forgiveness, but is seen as occurring before forgiveness). Dashed arrows indicate places where intervention can keep secondary outcomes from developing into long-term problems.


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between the two. Finally, we highlight areas where interventions might be used to prevent negative long-term outcomes from developing. Traumatic Event Our model is based on the assumption that an interpersonal trauma has occurred and that the individual perceives it as a hurtful or offensive action. Berry, Worthington, Parrott, O’Connor, and Wade (2001) have conceptualized unforgiveness and forgiveness as occurring in response to perceived interpersonal transgressions such as betrayals, offenses, and wrongs. This is consistent with definitions of resilience, which necessarily imply exposure to some adverse event or threat. Trauma Broadly speaking, trauma involves exposure to a non-normative event that disrupts one’s self-concept and, at least temporarily, overwhelms one’s ability to cope (Briere & Scott, 2006). The DSM-IV-TR defines trauma as directly experiencing or witnessing a threat to one’s physical integrity (American Psychiatric Association, 2000), although this definition may be limited. Many events can overwhelm one’s internal resources even if injury or a threat to one’s life is not imminent (Briere & Scott, 2006). For example, the death of a loved one can be quite disruptive and possibly traumatic, even if there is no perceived threat of injury or death to oneself. Interpersonal Trauma As a subset of both the larger classes of trauma and interpersonal transgressions, interpersonal trauma can be defined as traumatic acts of sexual, physical, or psychological violence perpetrated against a person by others. Interpersonal trauma may be viewed by victims as more intentional, malignant, and intrusive than other forms of trauma (Briere et al., 2010), and thus has been associated with more negative outcomes (Briere & Scott, 2006). Traumatic events of an interpersonal nature, as opposed to other forms of trauma, may result in negative emotional reactions that increase more drastically over time (Amstadter & Vernon, 2008). Accordingly, research suggests that psychological responses to interpersonal trauma may result as people attempt to cope with posttraumatic emotions that might otherwise overwhelm internal affect regulation capacities (Briere et al., 2010). Initial Emotional Responses to Trauma We have organized potential initial reactions to interpersonal trauma into two broad categories, self-deprecating and self-protective emotions. This distinction is based on evolutionary theories of emotion, which differentiate between shame as a feeling associated with defeat and anger as a feeling associated with counterattack and survival (Gilbert, 1997). It is also consistent with emotion theory, which posits a distinction between inward-focused and outward-focused negative emotions. Inward-focused negative emotions are often reflections of internal attributions of responsibility, whereas outward-focused negative emotions occur when individuals assess others to be responsible for a perceived injustice (Barclay, Skarlicki, & Pugh, 2005). Although these are not the only ways in which an individual might respond

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to an interpersonal trauma, they include the primary, initial emotional responses that are related to the forgiveness process. Self-Deprecating Emotions The first category of responses is self-deprecating emotional reactions. These include shame, guilt, sadness, worthlessness, and powerlessness. They are emotional reactions that motivate people to respond in ways that do not necessarily protect the self, but instead help people cope with the event by reducing its stressfulness or perceived consequences, or by mitigating the trauma in the moment (Janoff-Bulman, 1979). For example, responding to physical abuse in a self-deprecating, submissive, or passive way can help to mitigate the violence in the moment and allow the victim to feel responsible for, and thus in control of, the event. Although self-blame can be an adaptive response to trauma if it accurately reflects one’s behavioral contribution to the event, it frequently involves blame of some unmodifiable aspect of oneself (Littleton, Magee, & Axsom, 2007). These responses come at a psychological cost to the victim beyond the impact associated with the interpersonal trauma. Such costs include the emotional pain associated with shame and worthlessness as well as the perpetuation of cycles of retraumatization (Janoff-Bulman, 1979). These responses begin a path related to forgiveness that is unique from the path for those responding in more obviously self-protective ways (see Figure 19.1). Self-Protective Emotions The category of self-protective responses includes emotions that motivate individuals to protect themselves. These include responses such as anger, outrage, indignation, and vengefulness. These emotional responses typically motivate people to seek revenge against or avoid offenders (McCullough et al., 1998), to set boundaries that keep the person from harming them again, or to respond with aggression or even violence (Lazarus, 1991). Although feeling angry when appropriate may be an indication of self-respect and a concern for one’s rights and dignity (Lamb, 2002), role-socialization and unequal distributions of power between victim and offender may make it exceedingly difficult or dangerous for some victims to express anger. Women often have particular difficulty expressing self-protective emotions as a result of cultural socialization to suppress anger and resentment (Becker, 1997). Additionally, when a victim is without power to exert direct control over the situation, as is the case when systemic inequalities are present, attempts to protect the self may activate systems of oppression and discrimination against the victim. It is thus important that, in seeking to foster forgiveness, we not overlook the roles of power and privilege in both one’s ability to feel angry and the appropriateness of such anger in all contexts. Still, in working through anger, we argue that empowerment is possible. Feeling appropriate outrage and replacing those feelings with more positive emotions toward the offender is itself an expression of power, the power of forgiveness. Primary Forgiveness-Related Outcomes to Trauma Depending on the initial emotional responses to trauma, one of two forgiveness-related primary outcomes is likely to occur. Those who respond with self-deprecating emotions will likely experience self-blame, whereas those who respond with self-protective emotions will likely transition to an experience of unforgiveness.



Self-Blame Self-deprecating emotional reactions of shame, sadness, and worthlessness are more likely to lead to responses of self-blame. Control theory asserts that, because one cannot have control over the wealth of possible environmental events, people can gain a sense of control over environmental stressors by attributing the cause of events to the people involved (Walster, 1966). In the case of interpersonal trauma, in which the cause of the trauma is another, selfattributions may be a means for victims to feel they have power over the recurrence of the trauma and regain a sense of control of their lives. Self-blame is not an uncommon response of those who have been victims of interpersonal trauma (Littleton et al., 2007). Subtypes of self-blame have been described as either characterological or behavioral (JanoffBulman, 1979). Janoff-Bulman describes characterological self-blame as the process of blaming core attributes of the self for something that has occurred. Characterological self-blame is a self-deprecating form of self-blame that attributes hurtful events to something wrong with oneself. It has been related to poorer outcomes following traumatic events, such as greater psychological distress, depression (Janoff-Bulman, 1979), and maladaptive coping (e.g., using drugs or alcohol; Filipas & Ullman, 2006). Behavioral self-blame, in contrast, is self-blame that focuses on one’s behaviors that may have contributed to the events. This form of selfblame is theoretically more adaptive, in that it provides a sense of control and a target that is changeable. Behavioral self-blame has been associated with better outcomes in some studies (Startup, Makgekgenene, & Webster, 2007) but not others (Frazier, Tashiro, Berman, Steger, & Long, 2004). With this distinction in mind, the type of self-blame we are describing in the model is more akin to Janoff-Bulman’s (1979) self-deprecating characterological self-blame. Unforgiveness In contrast, for those responding with the self-protective emotions of anger or outrage, a typical outcome is unforgiveness. Unforgiveness is a complex emotional state consisting of feelings of resentment, hatred, bitterness, and/or vengefulness. Unforgiveness develops over time from initial reactions of anger and develops into a “cold” emotional state, often through the process of ruminating about the event (Worthington & Wade, 1999, p. 386). In previous research, unforgiveness for a specific offense has been measured by the degree to which victims are motivated toward desires of revenge against and avoidance of the offender (McCullough et al., 1998). Secondary Forgiveness-Related Outcomes to Trauma These primary forgiveness-related outcomes, self-blame and unforgiveness, give way to important and unique secondary outcomes. Pseudo-forgiveness is likely to follow from selfblame. In contrast, embitterment and true forgiveness are two distinct outcomes that can follow from unforgiveness. Pseudo-Forgiveness Self-blame by definition cannot lead to genuine forgiveness, which will be described below. Instead, self-blame is likely to lead to pseudo-forgiveness. Pseudo-forgiveness is an outcome that cuts short the experiences of both unforgiveness and forgiveness. Victims of trauma who engage in pseudo-forgiveness do not experience either the anger and potential

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empowerment of unforgiveness or the freedom and peace associated with forgiveness. Instead, they experience a false forgiveness that tends to condone, excuse, pardon, or minimize the traumatic experience. This pseudo-forgiveness does not hold the perpetrator accountable and does not embrace the healthy aspects of anger, rage, or bitterness that result when acknowledging a true offense. Victims who engage in pseudo-forgiveness often deprecate themselves and take on blame and responsibility that should be directed elsewhere. As a result, they may stay connected to people who hurt them but avoid establishing healthy boundaries, setting themselves up for future hurt and victimization. Pseudo-forgiveness has negative interpersonal and psychological consequences, as discussed in the final step of the model. Embitterment In contrast, the primary outcome of unforgiveness has two likely secondary forgivenessrelated outcomes. The first is embitterment. Embitterment is primarily an emotional state consisting of hatred, resentment, and feelings of being treated unfairly or unjustly that might also include hopelessness and helplessness (Linden, Rotter, Baumann, & Lieberei, 2007). Emotionally, embitterment is not much different than unforgiveness. The one distinction that we make in our model is that embitterment is the perpetuation and solidification of unforgiveness. As such, embitterment has a more global quality, in which the anger and resentment generalize from the specifics of the traumatic event to the broader experiences of the person. Instead of just feeling resentful about the specific event, the individual takes on a more resentful disposition. Embitterment also has the element of hopelessness that is not central to unforgiveness. This hopelessness may develop over time as a result of seeing no positive change or no justice or revenge. The bitterness remains because it has not been dealt with or dissipated in some way (Linden et al., 2007). Forgiveness Another potential secondary outcome to unforgiveness is forgiveness. Forgiveness involves both a reduction of negative emotions and an increase in positive emotions toward the offender (Worthington & Wade, 1999). Many definitions of forgiveness have been offered. For example, Enright and the Human Development Study Group (1991) defined forgiveness as “the overcoming of negative affect and judgment toward the offender... by endeavoring to view the offender with compassion, benevolence, and love while recognizing that [the offender] abandoned the right to them” (p. 126). Similarly, Wade, Bailey, and Shaffer (2005) defined forgiveness as the process of “replacing the bitter, angry feelings of vengefulness often resulting from a hurt with positive feelings of goodwill toward the offender” (p. 634). In forgiveness, individuals acknowledge that a significant transgression has occurred and they place an appropriate level of responsibility on the offender. Rather than holding onto the negative feelings of unforgiveness associated with this acknowledgement, however, those who forgive release those negative feelings, and replace them with positive feelings toward the offender (Worthington & Scherer, 2004; Worthington & Wade, 1999). These positive feelings might involve compassion toward the offender or empathy that comes from perspective taking. Following an interpersonal trauma, positive affect does not necessarily increase as a function of decreasing affect; the two processes are seen as independent (Wade & Worthington, 2003). However, if only negative feelings specifically



about the offense and offender are reduced and nothing positive is increased, then forgiveness has not occurred. We might call such a state tolerance or indifference or forgetting, but not forgiveness. Instead, forgiveness is a special case following an interpersonal hurt where a person experiences a reduction in negative feelings and an increase in positive feelings (e.g., empathy, compassion, love). Even in cases of extreme interpersonal trauma (e.g., murder), forgiveness can still involve an increase in positive reactions, such as pity that someone could be so disturbed as to carry out such terrible actions (Wade, Johnson, & Meyer, 2008). Importantly, with true forgiveness the transformation of emotional responses to the offender occurs without giving up appropriate boundaries that provide emotional and/or physical safety from hurtful people (Wade et al., 2005). Forgiveness occurs at an intrapersonal, rather than an interpersonal, level. Therefore, although the intrapersonal process of forgiveness can lead to later reconciliation with one’s offender, such reconciliation is considered distinct from forgiveness. Someone who experiences interpersonal trauma may forgive the offending person but make the decision to cut off contact with that person to prevent further hurt or victimization (Wade et al., 2008). In addition, because forgiveness is internal rather than interpersonal, individuals whose offenders are no longer living can still work toward and achieve forgiveness. Long-Term Forgiveness-Related Outcomes to Trauma The final part of our model describes the potential long-term outcomes to trauma and the way people respond to it. These long-term outcomes are likely to be in proportion to the degree, severity, and frequency of pseudo-forgiveness, embitterment, and forgiveness. On one side, those who respond more frequently to interpersonal hurts and trauma with embitterment are more likely to experience most or all of these long-term outcomes than someone who has developed embitterment based on one event. On the other, persons who respond more frequently to interpersonal trauma with forgiveness can be said to exhibit forgivingness, or the disposition to forgive others across time and situations, and are more likely to experience the positive outcomes associated with forgiveness (Berry, Worthington, O’Connor, Parrott, & Wade, 2005). Outcomes of Pseudo-Forgiveness The potential long-term outcomes associated with pseudo-forgiveness include relationship problems, chronically poor boundaries with others, psychological distress, posttraumatic stress symptoms, and greater susceptibility to revictimization. The process by which pseudo-forgiveness develops encourages these outcomes. By directing blame and anger at oneself for a traumatic event, victims are less likely to stand up for themselves, hold perpetrators accountable, and have strong boundaries against future hurts. Thus, people are more likely to hurt them in the future. In addition, without appropriate, self-protective boundaries, these individuals are more likely to experience poorer relationship quality and greater psychological distress. Although very little research exists on pseudo-forgiveness, one study of 121 women residents of domestic violence shelters may be instructive. In that study, Gordon and colleagues (2004) found that “forgiveness” of abuse by a partner was related to the intent to return. Although this research might indicate that forgiveness is related to returning to an abusive relationship, we would argue that more likely Gordon and colleagues (2004) were assessing pseudo-forgiveness. Their assessment of forgiveness included statements that

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could be true of either forgiveness or pseudo-forgiveness (e.g., “reporting that they were more forgiving, less bitter and resentful,... more willing... to put the abuse behind them” (p. 336). For example, participants who agreed with the statement that they were not bitter or resentful could have been experiencing either true forgiveness or pseudo-forgiveness; both processes would lead to a report of minimal bitterness. True forgiveness would reduce bitterness as the victim came to terms with the event, processed the negative feelings and reactions, and developed more positive feelings toward the offender (e.g., compassion, love). In pseudo-forgiveness the victim experiences very little anger or bitterness in the first place, circumventing those emotions by condoning, excusing, or otherwise minimizing the offense. Although it is impossible to know the true experience of participants in Gordon and colleagues’ study, we would argue that, to the degree that the victims were willing to make excuses for the offender, see themselves as culpable, and return to the relationship without explicit and strong boundaries against further violence, they were experiencing pseudo-forgiveness rather than true forgiveness. Outcomes of Embitterment The long-term outcomes of embitterment also are not positive. Research directly related to embitterment indicates that those who harbor grudges and bitterness report greater psychological disturbance. In a comparison of adults in an inpatient hospital setting, those diagnosed with embitterment reported greater symptom distress (e.g., greater paranoia, depression, and hostility; Linden et al., 2007). In addition, embittered patients reported more intrusive thoughts about, hyperarousal related to, and avoidance of the traumatic event compared to control patients (Linden et al., 2007). Other research on embitterment shows that greater degrees of embitterment are related to paranoid ideation, hopelessness, and hostility (Znoj, 2011). In general, the longer an individual stays embittered, the more dramatic and psychologically (and perhaps physically) debilitating the long-term outcomes will be. Outcomes of Forgiveness The potential long-term outcomes related to forgiveness are generally more positive and demonstrate that forgiveness may be a resilient response to interpersonal trauma. Based on our definition of forgiveness, we theorize that several beneficial long-term outcomes could result. For example, owing to internal resolution of anger and bitterness, we expect people who have forgiven to have greater emotional well-being and to be able to recall the traumatic event without a strong or overwhelming emotional or physiological response. In addition, those who have forgiven should experience greater relationship satisfaction both in general and with the person whom they forgave (if they choose to maintain a relationship with that person). Longer-term outcomes might also include better physical health, particularly lower blood pressure and fewer chronic illnesses that are typically associated with stress. These beneficial outcomes have been supported in the empirical literature on forgiveness. Related to emotional well-being, increased forgiveness of a transgression has been associated with decreased anger, depression, anxiety, revenge motivations, and rumination about the offense, as well as increased self-esteem, environmental mastery, and the ability to find meaning after suffering (Lin, Mack, Enright, Krahn, & Baskin, 2004; Reed & Enright, 2006; Wade & Meyer, 2009). Forgiveness has also been shown to be related to positive physical health outcomes. For example, Witvliet, Ludwig, and Bauer (2001) found that, when recalling and imagining a person they had forgiven, participants had lower mean arterial



pressure, heart rate, and skin conductance than when thinking about a person for whom they were unforgiving. In an examination of the association between forgiveness and health in a national sample, a relationship was found between greater trait forgivingness (i.e., the disposition to forgive) and fewer health symptoms among the elderly (Toussaint, Williams, Musick, & Everson, 2001). This suggests that consistent forgiveness over time may have positive physical health implications or that forgiveness is a health-protective factor among those vulnerable to declining health (i.e., the elderly). Taken together, these outcomes demonstrate that forgiveness can indeed be understood as a resilient response to interpersonal trauma. Summary of the Model One way of understanding responses to traumatic events in terms of forgiveness is to see the typical responses and the potential short- and long-term outcomes of these responses. We believe that forgiveness comes from a place of strength and power that is typically marked by strong feelings of initial anger, outrage, or indignation. “Forgiveness” that comes as a response that is associated with characterological self-blame, shame, and low self-regard is pseudo-forgiveness. We theorize that both pseudo-forgiveness and embitterment will lead to primarily negative outcomes in the long term, whereas true forgiveness will lead to more positive outcomes. Following an interpersonal hurt, one of the most resilient outcomes might be forgiveness. As a result, helping people who have been traumatized by others might include assisting them with the forgiveness process. There is now a substantial research literature on interventions designed to explicitly promote forgiveness. We review that literature below.

PSYCHOLOGICAL INTERVENTIONS TO PROMOTE FORGIVENESS Of the responses to interpersonal, traumatic events outlined in our model, the most resilient response is forgiving the hurt. However, true forgiveness as we have described is not an easy process. Some people have trouble allowing themselves to experience anger and resentment, even following severe offenses, and instead move toward pseudo-forgiveness. Others can become angry and resentful quickly, but struggle to move beyond those feelings. Such people might continue to punish the offending person or stay stuck in their embitterment. With the potential benefit and difficulty of the forgiveness process in mind, several clinical researchers have developed and tested interventions to promote forgiveness. Overview of Interventions to Promote Forgiveness Although clinically oriented discussions of forgiveness periodically emerged in the scholarly literature (e.g., Close, 1970), it was not until the 1990s that clinical researchers began to create and empirically examine interventions specifically designed to promote forgiveness. The two pioneers in this area are Robert Enright and Everett Worthington. Enright and his research group (e.g., Enright, 2001) created an intervention that evolves over four phases: Uncovering (negative reactions about the event), Decision (to work toward forgiveness for a specific event), Work (including understanding the offender and accepting the pain of the offense), and Discovery (of unanticipated positive outcomes). Each of the phases has several steps associated with them that help the client move from a place of hurt,

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anger, or even denial about the offense to a place of peace and resolution. This model has been expanded over time and described for a clinical audience (e.g., Enright, 2001). Worthington and his research group have also developed an intervention to promote forgiveness (e.g., Worthington, 2001). In their model, clients experience a five-step program called REACH. Each letter represents one of the five steps of the program. “R” is recalling the hurt, wherein clients focus on the traumatic event and discuss their experiences, feelings, and thoughts associated with the event. “E” is building empathy for the offender. After clients have explored their reactions to the hurt, they are encouraged to develop appropriate empathy for the offender, based on seeing the offender as a whole person, not just a perpetrator. “A” stands for altruistic gift. In this step, clients work toward understanding forgiveness as an altruistic gift and deciding whether they want to give such a gift to the offender. “C” is for committing to forgiveness, wherein clients acknowledge the progress they have made toward forgiveness. Finally, “H” stands for holding onto forgiveness. In this step, clients work on skills and strategies to keep from relapsing into the anger and bitterness and to maintain their forgiveness. Other clinical researchers have also created programs to help people promote forgiveness, although these methods have not been tested as frequently nor disseminated as widely as Enright’s and Worthington’s. Other interventions include Rye’s model (e.g., Rye & Pargament, 2002), which combines elements from Enright’s and Worthington’s models, with interventions specific to offenses among romantic partners. Luskin’s (2002) model incorporates cognitive-behavioral theory and techniques with relaxation training and meditation. Most forgiveness intervention strategies, however, include three primary steps: (a) discussing the hurt and exploring emotions associated with the event, (b) increasing understanding and empathy for the perpetrator, and (c) making a personal commitment to the forgiveness process (Wade & Worthington, 2005). Effectiveness of Interventions to Promote Forgiveness The intervention strategies mentioned above have all been tested empirically and found to be generally effective for promoting forgiveness. Wade, Hoyt, Kidwell, and Worthington (2012) meta-analyzed and summarized the efficacy data on existing forgiveness interventions. The meta-analysis included 57 unique studies of forgiveness interventions in individual, couples, and group modalities. Overall, the forgiveness interventions were more effective for promoting forgiveness than no treatments and alternative treatments (e.g., social skills building, relaxation). Amount of time intervening and severity of the interpersonal offense significantly moderated intervention efficacy. Greater time and greater severity were associated with greater changes in forgiveness from pre- to post-treatment. Although the meta-analysis included forgiveness interventions for a wide range of offenses from mild to more severe, there are several specific intervention studies that might more directly address interpersonal trauma. One such study examined the efficacy of the Enright intervention with 12 adult women who had been sexually abused as children (Freedman & Enright, 1996). Compared to participants on the waiting list, those in the treatment condition reported significantly more increases in forgiveness and decreases in depression and anxiety. A similar study examined the Enright program with 20 women who had been emotionally abused in romantic relationships (Reed & Enright, 2006). Compared with a typical treatment for survivors of emotional abuse, the Enright intervention resulted in significantly more forgiveness and fewer symptoms of posttraumatic stress, depression, and anxiety. These studies indicate that interventions can be effectively applied to promote forgiveness even for some of the most traumatic interpersonal injuries.



Tailoring Interventions to Promote Forgiveness Based on our model (see Figure 19.1), those responding in self-deprecating versus selfprotective ways will have different needs and different paths to genuine forgiveness. This means that different interventions might be necessary for different people depending on their reactions. For those already responding in angry and vengeful ways, an intervention might target managing and resolving feelings of anger and helping people to avoid embitterment. For example, some who have been traumatized experience waves of intense rage and desires for revenge that can feel overwhelming. Interventions can be used to help such individuals recognize such waves (e.g., identifying emotional, physical, and situational cues) and minimize the impact on their daily functioning (e.g., responding with a relaxation or meditation exercise). Ultimately, such individuals would likely benefit from explorations that help to promote empathy for the person who hurt them. By developing an understanding of the background and situations that may have led the offending person to hurt them, many people are able to manage their rage and move toward resolving their bitterness. In contrast, interventions designed to help people develop empathy for their offenders may not be indicated for those with more self-deprecating responses. Those who respond more from self-blame may be identifying too much with their offenders already. In such situations, developing empathy may only intensify their feelings of shame and self-condemnation and encourage them to excuse or minimize the offense against them. Instead, our model would suggest that such individuals should be given time and assistance in developing their anger, outrage, and indignation. They should be encouraged to see these emotions as positive, self-protective responses and given the tools and support to experience and act upon those feelings.

INTEGRATING RESILIENCY WITH INTERVENTIONS TO PROMOTE FORGIVENESS Resilience is a frequent response to traumatic events. In fact, resiliency may be the most common response to trauma, with estimates of a resilient trajectory following trauma ranging from 35% to 65% (Bonanno, Westphal, & Mancini, 2011). Forgiveness interventions can be built on this knowledge. One way is to offer forgiveness interventions that interface with the natural proclivity toward resilience most individuals demonstrate. Reich (2006) offers three core principles that are important in this regard: control, coherence, and connectedness. Control refers to regaining a sense of personal control after a traumatic event. Forgiveness interventions may help enhance the experience of control and empowerment. The decision to forgive, even when a victim of interpersonal trauma has the right to remain angry at his/her transgressor, represents a position of inner strength and self-determination. This decision is a step toward greater personal freedom and control over one’s emotional, relational, and psychological well-being. Coherence refers to the epistemological need for people to find meaning and direction in their lives following trauma (Reich, 2006). Forgiveness may well be a meaning-focused coping technique, as it is a method of modifying one’s appraisal of the meaning of situations to be more consistent with one’s goals (be they relationship satisfaction, psychological well-being, or physical health; Worthington & Scherer, 2004). Connectedness refers to the need to seek out others for informational, instrumental, and emotional support following trauma (Reich, 2006). Forgiveness, although it does not

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necessitate a renewed relationship with transgressors, often precedes reconciliation and can enable offended individuals to build new relationships. Although forgiveness interventions may serve to address all three of these components, we offer that forgiveness is primarily an emotion-focused coping effort. Forgiveness is linked with positive and prosocial emotions (e.g., empathic concern, perspective taking) and negatively correlated with negative interpersonal emotions (e.g., hostility, fear; Berry et al., 2005). Additionally, forgiveness reduces rumination and negative emotions and cognitions surrounding the interpersonal trauma (Berry et al., 2005). Forgiveness allows a victim of interpersonal trauma to “let go” of the offense and thereby experience psychological freedom. Forgiveness may thus be one way for victims of interpersonal trauma to cope with triggered and sustained posttraumatic emotions that might otherwise overwhelm internal affect regulation capacities.

SUMMARY AND CONCLUSION One alternative to self-blame or hostility in coping with posttraumatic emotions following interpersonal trauma is forgiving. Increased forgiveness of a transgression has been associated with numerous emotional and psychological benefits. Thus interventions designed to promote forgiveness after interpersonal transgressions are indicated to enhance recovery and sustained growth in the face of potentially traumatic interpersonal events. Forgiveness interventions, when framed as growth-oriented mechanisms to enhance control, coherence, connectedness, and emotional regulation following interpersonal trauma, can prevent persons from traveling down paths that solidify self-deprecating emotions or lead to prolonged embitterment and interpersonal dissatisfaction. Although not universal prophylactics, forgiveness interventions can help people recover from and promote intrapersonal growth in the face of otherwise psychologically overwhelming events.

REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Amstadter, A., & Vernon, L. (2008). Emotional reactions during and after trauma: A comparison of trauma types. Journal of Aggression, Maltreatment and Trauma, 16, 391–408. Barclay, L., Skarlicki, D., & Pugh, S. (2005). Exploring the role of emotions in injustice perceptions and retaliation. Journal of Applied Psychology, 90, 629–643. Becker, D. (1997). Through the looking glass. Boulder, CO: Westview Press. Berry, J. W., Worthington, E. L., Jr., O’Connor, L. E., Parrott, L., III, & Wade, N. G. (2005). Forgivingness, vengeful rumination, and affective traits. Journal of Personality, 73, 183–225. Berry, J. W., Worthington, E. L., Jr., Parrott, L., III, O’Connor, L. E., & Wade, N. G. (2001). Dispositional forgivingness: Development and construct validity of the Transgression Narrative Test of Forgiveness (TNTF). Personality and Social Psychology Bulletin, 27, 1277–1290. Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–28. Bonanno, G. A., Westphal, M., & Mancini, A. D. (2011). Resilience to loss and potential trauma. Annual Review of Clinical Psychology, 7, 511–535. Briere, J., Hodges, M., & Godbout, N. (2010). Traumatic stress, affect dysregulation, and dysfunctional avoidance: A structural equation model. Journal of Traumatic Stress, 23, 767–774.



Briere, J., & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage Publications. Close, H. (1970). Forgiveness and responsibility: A case study. Pastoral Psychology, 21, 19–25. Enright, R. D. (2001). Forgiveness is a choice: A step-by-step process for resolving anger and restoring hope. Washington, DC: American Psychological Association. Enright, R. D., & the Human Development Study Group. (1991). The moral development of forgiveness. In W. Kurtines & J. Gerwirtz (Eds.), Handbook of moral behavior and development (Vol. 1, pp. 123–152). Hillsdale, NJ: Erlbaum. Filipas, H. H., & Ullman, S. E. (2006). Child sexual abuse, coping responses, self-blame, posttraumatic stress disorder, and adult sexual revictimization. Journal of Interpersonal Violence, 21, 652–672. Frazier, P., Tashiro, T., Berman, M., Steger, M., & Long, J. (2004). Correlates of levels and patterns of positive life changes following sexual assault. Journal of Consulting and Clinical Psychology, 72, 19–30. Freedman, S. R., & Enright, R. D. (1996). Forgiveness as an intervention goal with incest survivors. Journal of Consulting and Clinical Psychology, 64, 983–992. Gilbert, P. (1997). The evolution of social attractiveness and its role in shame, humiliation, guilt and therapy. British Journal of Medical Psychology, 70, 113–147. Gordon, K. C., Burton, S., & Porter, L. (2004). Predicting the intentions of women in domestic violence shelters to return to partners: Does forgiveness play a role? Journal of Family Psychology, 18, 331–338. Janoff-Bulman, R. (1979). Characterological versus behavioral self-blame: Inquiries into depression and rape. Journal of Personality and Social Psychology, 37, 1798–1809. Lamb, S. (2002). Women, abuse, and forgiveness: A special case. In S. Lamb & J. G. Murphy (Eds.), Before forgiving: Cautionary views on forgiveness in therapy (pp. 155–171). New York: Oxford University Press. Lazarus, R. S. (1991). Emotion and adaptation. New York: Oxford University Press. Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lin, W.-F., Mack, D., Enright, R. D., Krahn, D., & Baskin, T. W. (2004). Effects of forgiveness therapy on anger, mood, and vulnerability to substance use among inpatient substance-dependent clients. Journal of Consulting and Clinical Psychology, 72, 1114–1121. Linden, M., Rotter, M., Baumann, K., & Lieberei, B. (2007). Posttraumatic embitterment disorder: Definition, evidence, diagnosis, treatment. Ashland, OH: Hogrefe & Huber. Littleton, H. L., Magee, K. T., & Axsom, D. (2007). A meta-analysis of self-attributions following three types of trauma: Sexual victimization, illness, and injury. Journal of Applied Social Psychology, 37, 515–538. Luskin, F. (2002). Forgive for good. New York: HarperCollins. Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543–562. McCullough, M. E., Rachal, K. C., Sandage, S. J., Worthington, E. L., Jr., Brown, S. W., & Hight, T. L. (1998). Interpersonal forgiving in close relationships II: Theoretical elaboration and measurement. Journal of Personality and Social Psychology, 75, 1586–1603. Reed, G. L., & Enright, R. D. (2006). The effects of forgiveness on depression, anxiety, and posttraumatic stress for women after spousal emotional abuse. Journal of Consulting and Clinical Psychology, 74, 920–929. Reich, J. (2006). Three psychological principles of resilience in natural disasters. Disaster Prevention and Management, 15, 793–798. Rye, M. S., & Pargament, K. I. (2002). Forgiveness and romantic relationships in college: Can it heal the wounded heart? Journal of Clinical Psychology, 58, 419–441. Startup, M., Makgekgenene, L., & Webster, R. (2007). The role of self-blame for trauma as assessed by the Posttraumatic Cognitions Inventory (PTCI): A self-protective cognition? Behaviour Research and Therapy, 45, 395–403. Toussaint, L. L., Williams, D. R., Musick, M. A., & Everson, S. A. (2001). Forgiveness and health: Age

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differences in a U.S. probability sample. Journal of Adult Development (Special issue on spirituality and adult development), 4, 249–257. Wade, N. G., Bailey, D., & Shaffer, P. (2005). Helping clients heal: Does forgiveness make a difference? Professional Psychology: Research and Practice, 36, 634–641. Wade, N. G., Hoyt, W., Kidwell, J. E., & Worthington, E. L., Jr. (2012). Meta-analysis of explicit forgiveness interventions: Main effects and moderators. Unpublished manuscript, Iowa State University, Ames. Wade, N. G., Johnson, C. V., & Meyer, J. E. (2008). Understanding concerns about interventions to promote forgiveness: A review of the literature. Psychotherapy: Theory, Research, Practice, Training, 45, 88–102. Wade, N. G., & Meyer, J. E. (2009). Comparison of brief group interventions to promote forgiveness: A pilot outcome study. International Journal of Group Psychotherapy, 59, 199–220. Wade, N. G., & Worthington, E. L., Jr. (2003). Overcoming interpersonal offenses: Is forgiveness the only way to deal with unforgiveness? Journal of Counseling and Development, 81, 343–353. Wade, N. G., & Worthington, E. L., Jr. (2005). In search of a common core: A content analysis of interventions to promote forgiveness. Psychotherapy: Theory, Research, Practice, Training, 42, 160–177. Walster, E. (1966). Assignment of responsibility for an accident. Journal of Personality and Social Psychology, 3, 73–79. Witvliet, C. V. O., Ludwig, T. E., & Bauer, D. J. (2001). Granting forgiveness or harboring grudges: Implications for emotion, physiology, and health. Psychological Science, 121, 117–123. Worthington, E. L., Jr. (2001). Five steps to forgiveness: The art and science of forgiving. New York: Crown House. Worthington, E. L., Jr. (Ed.). (2005). Handbook of forgiveness. New York: Brunner/Routledge. Worthington, E. L., Jr., & Scherer, M. (2004). Forgiveness is an emotion-focused coping strategy that can reduce health risks and promote health resilience: Theory, review, and hypotheses. Psychology and Health, 19, 385–405. Worthington, E. L., Jr., & Wade, N. G. (1999). The psychology of unforgiveness and forgiveness and the implications for clinical practice. Journal of Social and Clinical Psychology, 18, 385–418. Zautra, A., Hall, J., & Murray, K. (2010). Resilience: A new definition of health for people and communities. In J. W. Reich, A. J. Zautra, & J. S. Hall (Eds.), Handbook of adult resilience (pp. 3–35). New York: Guilford Press. Znoj, H. (2011). Embitterment: A larger perspective on a forgotten emotion. In M. Linden & A. Maercker (Eds.), Embitterment: Societal, psychological, and clinical perspectives (pp. 5–16). New York: Springer.

free ebooks ==> www.ebook777.com 20 Resilience Interventions With a Focus on Meaning and Values Crystal L. Park and Jeanne M. Slattery

Those who have a “why” to live can bear almost any “how.” Friedrich Nietzsche

While many people experience at least transient symptoms following a significant stressor, problems are not inevitable, nor even typical. For example, the percentage of people diagnosed with posttraumatic stress disorder (PTSD) following a wide range of traumas is surprisingly low (Bonanno, 2004). In fact, despite adversity, most people are happy most of the time (Dunkel Schetter & Dolbier, 2011). Like Nietzsche, we believe that a significant factor predicting resilience is having a sense of meaning that helps people transcend difficult times (Frankl, 1959/2006). In the following pages we present a model of meaning making to use as a framework to describe interventions increasing a positive sense of meaning and coherent values, thus facilitating resilience. Consistent with a long tradition in the developmental sciences, primarily studies of children who thrived despite disadvantage and adversity, we define resilience as a longitudinal trend or trajectory of continued favorable functioning in the face of an event or trauma that increases risk of a drop in functioning (Bonanno, 2004; Bonanno, Moskowitz, Papa, & Folkman, 2005). Further, resilience following stressors or trauma stems from possessing a set of skills or behaviors leading to positive outcomes in work, interpersonal relationships, and psychological functioning (or the absence of negative outcomes). Resilience may vary across stressors, such that someone who is resilient when experiencing chronic pain may have difficulty with some kinds of psychological stressors and vice versa (Sturgeon & Zautra, 2010). Further, when predicting an individual’s resilience, one should consider vulnerabilities as well as resilience factors (Sturgeon & Zautra, 2010). This process view of resilience is a useful framework for identifying interventions causally related to increased resilience (rather than only markers associated with resilience). In this chapter, we examine two types of interventions: primary interventions, which promote strength prior to trauma exposure, and curtail stress responses when people subsequently experience a trauma; and secondary interventions, which target people who have already experienced a stressor, focusing on helping them respond with more adaptive thoughts, emotions, and behaviors.

MEANING-MAKING MODEL The meaning-making model posits two levels of meaning, global and appraised, guiding perceptions and actions and resulting from experiences (Park, 2010; see Figure 20.1).

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Figure 20.1 Resilience and the meaning-making model.

Stressful Event

Appraised Event Meaning Causal Attributions Primary Appraisals (threat, loss, challenge) Secondary Appraisals (sense one can cope effectively)

Meaning Making: The Focus of Secondary Resilience Interventions

No Distress

Discrepant?

No

Yes Distress

Meaning Making Reappraisal Acceptance

Global Meaning: The Focus of Primary Resilience Interventions Beliefs Goals (desired ends or states) and Values (guidelines for achieving goals) Sense of Life as Purposeful

Meanings Made Changes in Appraised Meaning of Stressor Changes in Global Meaning Stress-Related Growth



Crystal L. Park and Jeanne M. Slattery

Global meaning is the framework through which people structure their experiences and assign meanings to specific experiences. Global meaning has three aspects: beliefs, goals and values, and feelings (Park, 2010). Global beliefs are the broad assumptions that people make regarding themselves, others, and the universe. Values refer to the principles that people use to guide how they live, as well as how they attempt to achieve their goals. Global goals are high-level ideals, states, or objects that provide people’s motivation or purpose for living, choice of goals, standards for judging behavior, and basis for self-esteem. Global meaning has a significant cognitive component, but it also has an important affective one: the subjective sense of life as meaningful. This sense is derived, in part, from seeing one’s actions as oriented toward desired future goals and making adequate progress toward achieving them (McGregor & Little, 1998). Global meaning influences individuals’ interpretations of both ordinary encounters and highly stressful events (appraised meaning). When people appraise a trauma as violating their global meaning, they may lose a sense of control and have a sense that the world is incomprehensible; they may feel helpless and hopeless about the future. The meaningmaking model posits that the level of distress a person experiences derives from the extent of discrepancy between one’s global beliefs and goals, on the one hand, and appraised meaning of the event, on the other (Park, 2010). This distress initiates an attempt to restore coherence among aspects of global meaning and the appraised meaning (Park, Edmondson, & Mills, 2010). Some people are able to see the world and maintain meaning in the face of what would be perceived as a meaning violation by someone else, and thus they do not experience stress. For example, they may recognize that life is characterized by both good and bad, up and down— but believe that life goes on and that they will recover. As a result, they are more likely to be resilient in the face of situations that might be life shattering for someone else, which is what we call primary resilience. On the other hand, some people hold rigid and inflexible views about people, life, and the world (e.g., bad things do not happen to good people), and thus perceive a trauma as violating their worldview and experience distress. Following a disruption or violation in global meaning, many people engage in meaning making, which involves coming to see or understand a situation in a different way and/or reconsidering their global beliefs and goals so as to regain consistency among them (Park, 2010). When an event’s appraised meaning is discrepant from global meaning, people typically attempt to assimilate the event’s occurrence into their global meaning by changing its appraisal; however, people may also accommodate events by changing their global meaning to incorporate it. Meaning making reduces the sense of discrepancy between appraised and global meanings and restores a sense that the world is comprehensible and life is worthwhile. We refer to this restoration of previous functioning through meaning making as secondary resilience. Many outcomes, or meanings made, can result from meaning making, including changed appraisals of a stressful event (e.g., viewing the event as less aversive), changes made in one’s global meaning system (e.g., viewing the world as less controllable), or stressrelated growth (e.g., experiencing increased appreciation for life, stronger connections with family and friends, or greater awareness of one’s strengths). Some interventions promoting resilience prevent or reduce negative outcomes following a future loss or trauma (primary resilience interventions). These interventions target thinking strategies (and thus ultimately meanings made), and views of self and the world. Others, implemented following a trauma (secondary resilience interventions), help restore a sense of meaning so that people can live with greater hopefulness, optimism, and feelings of agency, purpose, and connectedness (Adler, 2012).

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PRIMARY RESILIENCE STEMMING FROM MEANING AND VALUES In general, meaning-related primary resilience interventions attempt to increase levels of generally adaptive global meaning (i.e., beliefs, goals, and sense of meaning and purpose in life), enabling individuals to withstand greater stress by promoting a more authentic and existentially aware life. Rather than focusing on bringing people back up to baseline following trauma, primary resilience interventions are conducted outside the context of trauma and target people regardless of trauma exposure, with the goal of boosting resilience to subsequent exposures. Although the people may experience problems following a stressor, loss in functioning will be mitigated—shorter in duration or lower in level of distress (Carver, 1998). Resources Related to Primary Resilience In general, resilient people hold more flexible worldviews (Teasdale et al., 2001), are engaged with rather than alienated from society (Grossman & Tierney, 1998; Hahn, Leavitt, & Aaron, 1994; O’Donnell et al., 2002), and are hardy (Bonanno, 2004; Britt, Adler, & Bartone, 2001). They are more optimistic (Grote & Bledsoe, 2007; Quale & Schanke, 2010; Schok, Kleber, & Lensvelt-Mulders, 2010), have higher levels of inspiration (Thrash, Elliot, Maruskin, & Cassidy, 2010), make more positive appraisals about themselves and the world (Grossman & Tierney, 1998; Park, 2005), perceive a higher sense of control (Schok et al., 2010), maintain a more positive self-image (Bonanno, 2004; Schok et al., 2010), are more likely to persist and achieve (Wilson & Linville, 1985), and hold more positive social norms (Botvin & Griffin, 2004). Religion may protect some people from posttraumatic stress symptoms (PTSS) (e.g., Park & Slattery, in press); however, because of the poor quality of most of the research addressing this issue, it remains premature to draw conclusions. Better definitions of spirituality and religiousness are needed, and studies must be conducted prospectively, assessing spiritual resources prior to traumatic encounters. Mindfulness is an active, open attention on the present, where thoughts and feelings are observed from a distance, without judging. It seems to be a good candidate for increasing resiliency, although the research is still preliminary. One study found that firefighters with higher levels of mindfulness reported lower levels of depression, PTSD symptoms, physical symptoms, and alcohol abuse (Smith et al., 2011). Further, mindfulness was more strongly related to positive outcomes than were other resilience resources (i.e., social support, optimism, and personal mastery). Relative to these three resources, mindfulness focuses more on intrapersonal resources than interpersonal ones, the present rather than the future, and acceptance rather than control. This study was correlational in nature and assessed only current relationships between resilience resources and outcomes rather than assessing the role of mindfulness prospectively; therefore, causal direction is unclear, and it is possible that these findings may be attributable to other, unassessed variables. In a prospective study, teaching mindfulness to early teenage boys did not significantly increase well-being and resilience, although boys who practiced more outside of class reported greater mindfulness and well-being (Huppert & Johnson, 2010). Rees (2011), in his review of the field, reported that mindfulness had a significant and positive impact on a number of variables related to resiliency among military troops, although concluded that transcendental meditation had both more published research and more support in headto-head comparisons.



Having a sense of meaningfulness and purpose is another important resiliency resource. For example, in a longitudinal study, veterans of the Bosnian war who perceived their work as meaningful were more likely to report benefits of their deployment, and were especially likely to do so when they had more exposure to damages caused by the war, presumably because they were able to perceive how their work helped the populace (Britt et al., 2001). Veterans who have a sense of commitment and perceive events as challenges and under their control are also more likely to perceive their work as meaningful and to perceive benefits stemming from their deployment (Britt et al., 2001). Positive outcomes were not related to dispositional hardiness per se, but the ability to perceive their work as meaningful. People who maintain a positive self-image by pursuing success, distorting appraisals of events to make them reflect better on the self, or drawing positive reactions from others, experience greater well-being when exposed to subsequent stressful events (Bonanno, 2004). Self-enhancing activities can be adaptive and promote effective coping, and have been observed among people who prematurely lost a spouse, among Bosnian civilians exposed to urban combat and, more recently, among college students (Bonanno, Field, Kovacevic, & Kaltman, 2002; Gupta & Bonanno, 2010). These effects can be complicated and vary with the measure of resiliency used; for example, self-enhancement was related to resilience following the 9/11 terrorist attack on the World Trade Center when defined as low levels of PTSD at 7 and 18 months post-attack, but self-enhancement was also related to negative outcomes, including lower assessments of honesty at the second follow-up (Bonanno, Rennicke, & Dekel, 2005). Further, self-enhancement strategies were associated with positive affect at 7 months only when the person was exposed to low levels of danger, as “even selfenhancers may have difficulties generating positive affect while discussing [extreme] events” (Bonanno, Rennicke, et al., 2005, p. 994). Optimism is closely related to resilience, as demonstrated in studies conducted in diverse settings. Pregnant women’s levels of optimism predicted fewer depressive symptoms 6 months and 12 months postpartum, and buffered their response to financial, spousal, and physical stress during pregnancy (Grote & Bledsoe, 2007). Similarly, lowincome women who were optimistic reported a greater sense of control, fewer stressors, and fewer depressive symptoms (Grote, Bledsoe, Larkin, Lemay, & Brown, 2007). People in a rehabilitation setting with spinal cord injuries identified as resilient were significantly more optimistic than people identified as distressed (Quale & Schanke, 2010). Dutch veterans who were more optimistic, perceived greater control, and had higher levels of self-esteem saw their military service as comprehensible, reported more personal significance, and had lower levels of distrust, perceptions of threat, cognitive intrusions, and avoidance, as well as greater reported benefits and growth (Schok et al., 2010). Optimism may be helpful in several ways, including decreasing maladaptive coping and disengagement, while promoting positive coping strategies such as acceptance and positive reframing (Antoni, Carver, & Lechner, 2009). Optimism can also help people prepare for difficult situations, as people recognize both positive and negative outcomes and prepare for them, implement effective problem solving, and identify appropriate social support (Davis & Asliturk, 2011). One of the difficulties in understanding primary resilience is identifying which factors are causal, as many purported causal factors are interrelated. For example, among people with chronic pain, optimism may lead to making healthy lifestyle choices, while acceptance has been related to lower levels of pain catastrophizing, better functioning in a wide number of domains, and improved quality of life (Sturgeon & Zautra, 2010). Conversely, changes in

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free ebooks ==> www.ebook777.com Resilience Interventions With a Focus on Meaning 275 mood and behavior can lead to changes in meaning. For example, experimental studies have shown that manipulating positive and negative affect can change people’s perceptions that their lives are meaningful (King, Hicks, Krull, & Del Gaiso, 2006). Interventions to Bolster Resilience Resources Several multidimensional resilience intervention programs have demonstrated efficacy in increasing resilience, problem solving, self-esteem, and positive affect with a variety of different populations (e.g., Dolbier, Jaggars, & Steinhardt, 2010; Sood, Prasad, Schroeder, & Varkey, 2011; Steinhardt & Dolbier, 2008). Perhaps the most famous study of resilience, the Comprehensive Soldier Fitness program, is currently being studied longitudinally (Lester, McBride, Bliese, & Adler, 2011), while other attempts by the military to increase resilience have already demonstrated some success (A. Adler, Bliese, McGurk, Hoge, & Castro, 2009). One multimodal intervention emphasizing challenging dysfunctional thinking found that participants receiving the resilience intervention reported more stress-related growth, improved ability to relate to others, greater personal strength, and increased spirituality relative to wait-listed controls (Dolbier et al., 2010). Changes in “self-leadership” (i.e., the ability to listen to, nurture, comfort, and negotiate among aspects of the self) were positively correlated with stress-related growth, although changes in hopeful coping, social support, and avoidant coping were not. Initial findings regarding the effectiveness of the Penn Resiliency Program (PRP), a 12-week cognitive-behavioral and social skills intervention for older children and young teens, were promising, showing decreased depressive symptoms one year after participating in the intervention; however, later reports on this program have been less favorable (Brunwasser, Gillham, & Kim, 2009). In their meta-analysis, Brunwasser et al. concluded that PRP was more effective for some populations than others, treatment effects were typically small, and the monetary cost per case of prevented depression was high. They suggested that future research should examine whether PRP reduces subclinical distress or depression, delays depressive symptoms, increases awareness of symptoms, strengthens their relationships, or improves parental well-being and parental practices, and particularly examine outcomes for longer periods of time post-intervention. On the other hand, Big Brother/Big Sister programs have been effective when tested in controlled studies: these youths did better academically, had better relationships with their parents, were less likely to be abusing drugs and alcohol, were less likely to have hit someone, performed better in school, and had attended school more regularly (Grossman & Tierney, 1998; Rhodes, Grossman, & Resch, 2000). Why these differences? These children were more likely to trust their parents, and white Little Brothers reported better communication with adults and stronger social acceptance. This suggests positive outcomes are related to children and teens feeling less alienated and more connected to their parents, and believing that the world is a safer place (Grossman & Tierney, 1998; Rhodes et al., 2000). Yoga seems to be a promising resilience-building intervention. For example, one study found that teens who received 11 weeks of yoga sessions rather than regular physical education classes experienced greater reported anger control and less fatigue/inertia (Khalsa, Hickey-Schultz, Cohen, Steiner, & Cope, 2012). Relative to wait-listed controls, university employees receiving a 6-week yoga intervention reported significantly greater feelings of composure, clear-mindedness, elation, energy, confidence, confidence under stress, and



life purpose satisfaction (Hartfiel, Havenhand, Khalsa, Clarke, & Krayer, 2011). Although people receiving yoga interventions report significant positive effects, it is not clear whether these effects are maintained across time. In sum, programs directly focused on meaning have demonstrated some promising findings in terms of better well-being expected to translate into resilience in the face of a subsequent potentially stressful encounter. However, much more research is needed to examine whether resilience can be taught. This would require long-term follow-ups of these interventions to examine outcomes following stress exposures. Further, some resources thought to promote resilience have not been examined empirically. For example, although we expect that gratitude, values congruence, and inspiration are related to greater resilience, we were unable to identify interventions that demonstrated building these to increase primary resilience.

SECONDARY RESILIENCE INTERVENTIONS BASED ON MEANING AND VALUES Secondary resilience meaning interventions are those used following exposure to specific traumatic or highly stressful events, directed towards helping people cope adaptively with and make meaning from specific stressful encounters that have already occurred. In general, these interventions promote healing of global meaning violations by helping people develop a narrative that brings appraised and global meaning together and restores a sense of meaning and purpose. They also help people identify areas of positive change and growth following the stressor or trauma and through their coping efforts. These interventions do not simply remove the tension or discrepancy between global and appraised meanings, but also help people respond to that tension with action, growth, and greater meaning rather than only distress and apathy. Recounting or Restorying Stressful Experiences Recounting or restorying is probably the most widely used meaning-focused approach to secondary resilience or recovery, despite continued controversy over its value and potential for harm for people with milder, more “normal” symptoms following a trauma (A. Adler et al., 2009; Bonanno, 2004). Nonetheless, most researchers and clinicians contend that people who have been exposed to multiple traumas or who have developed symptoms of PTSD should recount the trauma—sometimes on multiple occasions—and that, as a result, events will lose their power and associated negative affect (A. Adler et al., 2009). Currently, the most widely used empirically supported clinical approaches to recovery from trauma exposure and PTSD are cognitive processing therapy (CPT) and prolonged exposure therapy (PET). Both approaches involve making meaning through restorying (e.g., changing how one views oneself and the world as well as the traumatic situation). CPT directly attempts to correct distorted thinking by helping people question the factual basis of their dysfunctional thoughts. This approach produces long-lasting adaptive thinking processes and more positive global meaning. Similarly, PET produces persistent positive shifts in how individuals think about themselves and the world (see Beck, Jacobs-Lentz, McNiff, Olsen, & Clapp, in press, for a review). Similar positive findings have been reported when people recount their story in expressive writing studies (Neimeyer, Pennebaker, & van Dyke, 2009). In fact, Pals and McAdams (2004) concluded that posttraumatic growth was

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free ebooks ==> www.ebook777.com Resilience Interventions With a Focus on Meaning 277 related, in part, to people’s improved ability to openly acknowledge and examine violations of global meaning created by the trauma. Further, the type of stories people tell about trauma is predictive of the outcomes experienced (McAdams, Reynolds, Lewis, Patton, & Bowman, 2001; Pals & McAdams, 2004). People who do well post-trauma acknowledge that the trauma shook up their life, yet are able to tell a coherent and positive story about the trauma that makes sense of themselves and life, and search for benefits from that trauma. They are able to tell redemption stories, where negative events are transformed or redeemed with positive outcomes (e.g., “As a result, I am now wiser, more compassionate, know who my friends are ...”). On the other hand, people with more negative outcomes tell contamination stories, where life tends to start well, but then is ruined, contaminated, or undermined by events. They perceive the world as bad and unfair, recognize little control, and expect these conditions will continue into the future. Certainly being able to tell a coherent and positive story is useful; however, any narrative that is narrow, rigid, and limiting is likely to become problematic at some point, thus interfering with resilient responses (Teasdale et al., 2001). More resilient people tend to avoid extreme and absolutist ways of perceiving events. Neimeyer and his colleagues (2009) suggest that complicated grief occurs when a “crisis in meaning” deprives a person “of a significant past, a comprehensible present and a purposeful future” (p. 457). Further, friends and family often encourage people to move on and get over their difficult perceptions and emotions rather than making sense of them. Telling their story allows people to move “into” rather than “on from” complicated grief by meaningfully assimilating trauma into their life narrative. Pennebaker and others have reported that an inability to make sense of loss is related to a range of negative psychological and health-related outcomes (e.g., Pennebaker, Kiecolt-Glaser, & Glaser, 1988). Accordingly, studies have found that having participants write their deepest thoughts and feelings about a stressful experience for 20–30 minutes per day over 3 to 4 days can lead to decreased pain and medication use, fewer depressive symptoms, improved immune system functioning, fewer side effects of treatment for breast cancer, higher grades, and acquiring a new job faster after being laid off (see Neimeyer et al., 2009, for a review). The greatest improvements in health were associated with narratives with more positive-emotion words and moderate use of negative-emotion words; people using either very few or many negative-emotion words had poorer health outcomes (Pennebaker, Mayne, & Francis, 1997). Similarly, people using an increased number of causal and insight words over the course of the writing had better health outcomes. Another kind of meaning-making intervention following a loss or trauma involves explicitly helping clients make positive reappraisals and engage in benefit finding (Sears, Stanton, & Danoff-Burg, 2003). For example, the U.S. Army has attempted to implement this type of meaning making in two programs for returning soldiers, battlemind debriefing and battlemind training, with the notion that being able to understand and explain post-deployment “symptoms” and behaviors as functional and previously purposeful can be useful. In these programs, troops acknowledge and normalize combat-related behaviors and reactions, reframing post-deployment “symptoms” as combat-related strengths that may be inappropriately applied after returning home (A. Adler et al., 2009). For example, tactical awareness, a strength during combat, may cause hypervigilance and sleep problems at home. Rather than blaming themselves for and ruminating on symptoms, veterans are encouraged to adapt their combat-related behavioral and cognitive skills and strengths to home situations, thus developing a coherent and positive explanation of post-combat behaviors. Interestingly, while battlemind debriefing and battlemind training were as effective as stress management for



troops with low trauma exposure, they were more effective than stress management for troops with high exposure to trauma, who presumably had more to gain from such interventions (A. Adler et al., 2009). Spiritual Interventions Spirituality and religiosity appear to be important resiliency resources worthy of further investigation. People who were resilient following a variety of stressors were less angry with God and experienced less spiritual struggle (Exline, 2002), and had a stronger sense of purpose in life—or at least were able to maintain a sense of purpose relative to the stressor or trauma (Britt et al., 2001). Resilient caregivers tended to use positive religious coping and avoid negative religious coping (Pearce, 2005). Religious and spiritual resources, like other sources of meaning, sometimes predict higher levels of distress in the short term, presumably because trauma and loss can cause greater disruptions in positive religious worldviews (e.g., Park, 2005, 2010). For example, a traumatic experience may be appraised as highly inconsistent with beliefs in a loving and benevolent God (Park, 2005). In general, however, spirituality may promote better adjustment, as spiritual resources can help people make more benign reappraisals of trauma and loss and decrease distress in the longer term. Existential concerns regarding control, identity, relationships, and meaning are frequently raised by illness and loss (Cole & Pargament, 1999). Spiritual issues are often embedded in these existential questions, and spirituality may be a resource promoting healing. Pargament and his colleagues have developed several interventions that help people draw on spirituality as a resource for recovery. Interventions have been designed for living with HIV (Pargament, 2007), cancer (Cole & Pargament, 1999), bereavement (Pargament, 2007), and sexual abuse (Murray-Swank & Pargament, 2005). These multimodal interventions incorporate tools with established efficacy. Early data suggest they are useful with these populations, although more rigorous trials are necessary. Chan, Chan, and Siv Man (2006) have developed an approach for dealing with trauma and illnesses consistent with Eastern values and teachings. Although not yet tested, it also seems promising. Other Meaning-Making Interventions A variety of other meaning-focused interventions have been developed to promote resilience. Like restorying, the meaning-making intervention (MMi) explicitly focuses on bringing together global and situational meaning, but also encourages people to find meaning or a sense of purpose, and evaluate goals and priorities. MMi is a relatively brief intervention that has so far focused on helping cancer survivors make sense of their cancer experience. MMi has shown some preliminary efficacy in breast and colorectal cancer patients (Lee, Cohen, Edgar, Laizner, & Gagnon, 2006). Benefit finding has not been studied systematically as an intervention, but seems worth studying as such. It has been well studied as an outcome, however, and in a range of studies people who are resilient—or become more resilient following an intervention—report an increased ability to find benefits post-trauma. For example, more resilient bereaved parents can make sense of their child’s death (e.g., the death was God’s will), and find benefits from the trauma or loss (e.g., increased empathy or compassion, helping others who have experienced such a loss) (Lichtenthal, Currier, Neimeyer, & Keesee, 2010).

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SUGGESTIONS FOR FUTURE RESEARCH Considerable research suggests that resilience is a common, perhaps even a modal, response to trauma and loss (A. Adler et al., 2009; Bonanno, 2004; Quale & Schanke, 2010), yet a number of questions remain about the role of meaning in this resiliency. When and under what conditions can resilience best be developed? Further, some of this research has focused only on perceptions of benefits rather than some more objective measure (e.g., Britt et al., 2001). Most research on resilience is cross-sectional and retrospective rather than longitudinal; it is unclear whether resources promoting resilience were present before the fact. Some researchers have suggested that resilience can be developed in interventions that are cost-effective (Sood et al., 2011), while others have questioned the cost-effectiveness of interventions that are applied to broad populations (Brunwasser et al., 2009). Furthermore, follow-ups for most resilience interventions have been very brief, often one month or less after completing a program (Dolbier et al., 2010; Hartfiel et al., 2011; Sood et al., 2011), although others have been as long as three years (Gillham et al., 2007). It remains unclear whether increased resiliency can be maintained without booster sessions. Is childhood a sensitive period for developing resiliency? To what degree can it be increased in adults? The military’s recent focus on building primary resilience is an interesting test of these questions. Although some work has demonstrated resilience longitudinally (Britt et al., 2001; Sood et al., 2011), much work on this issue is more speculative and crosssectional in nature, making causality difficult to identify. Most interventions have been multifaceted, affecting a wide range of resilience-related factors (Dolbier et al., 2010; Gillham et al., 2007; Lester et al., 2011; Sood et al., 2011). This research has led to successful intervention programs, but limits our ability to identify the specific factors leading to the increased resilience and their mechanisms. Although it is plausible that many primary resilience interventions are effective as a result of changed self-narratives, most programs have not tested this hypothesis. Big Brothers/Big Sisters programs are an important exception, as they have begun to identify some mediators and exclude others, although findings have been mixed across studies (Grossman & Tierney, 1998; Rhodes et al., 2000). Further, we may want to consider when and in what ways people are resilient following a stressor or trauma, as people can be resilient in some ways, yet not others (Bonanno, Rennicke, et al., 2005). Research on psychotherapy outcomes has long asked when and with whom treatment is effective; these questions are just now being asked for resilience interventions. Although primary resilience interventions may be useful for a wide range of people, secondary resilience interventions seem most useful for people at greatest risk, and may be harmful for people at low risk (Bonanno, 2004). We still need to identify variables predicting when interventions may be most useful and effective. Finally, culture may influence the degree to which a resiliency intervention is effective, but this question is still largely unexplored. To what degree—and how—does culture influence what we see as acceptable narratives (Pals & McAdams, 2004)? Which traumas are seen as unsurvivable? For example, Quale and Schanke (2010) reported resilience trajectories among their sample of people with sport-related injuries (spinal cord injuries or multiple traumas), while the two people in their study injured in the course of an assault followed a distress trajectory (i.e., continued depression and anxiety). Which narratives and forms of meaning about trauma and loss do individual cultures accept, promote, and use successfully? Answers to these questions await future research.



REFERENCES Adler, A. B., Bliese, P. D., McGurk, D., Hoge, C. W., & Castro, C. A. (2009). Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: Randomization by platoon. Journal of Consulting and Clinical Psychology, 77, 928–940. Adler, J. M. (2012). Living into the story: Agency and coherence in a longitudinal study of narrative identity development and mental health over the course of psychotherapy. Journal of Personality and Social Psychology, 102, 367–389. Antoni, M. H., Carver, C. S., & Lechner, S. C. (2009). Enhancing positive adaptation: Example intervention during treatment for breast cancer. In C. L. Park, S. C. Lechner, M. H. Antoni, & A. L Stanton (Eds.), Medical illness and positive life change: Can crisis lead to personal transformation? (pp. 197–214). Washington, DC: American Psychological Association. Beck, J. G., Jacobs-Lentz, J., McNiff, J., Olsen, S. A., & Clapp, J. D. (in press). Understanding posttrauma cognitions and beliefs. In L. Zoellner and N. C. Feeny (Eds.), Facilitating resilience and recovery following traumatic events. New York: Guilford Press. Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–28. Bonanno, G. A., Field, N. P., Kovacevic, A., & Kaltman, S. (2002). Self-enhancement as a buffer against extreme adversity: Civil war in Bosnia and traumatic loss in the United States. Personality and Social Psychology Bulletin, 28, 184–196. Bonanno, G. A., Moskowitz, J. T., Papa, A., & Folkman, S. (2005). Resilience to loss in bereaved spouses, bereaved parents, and bereaved gay men. Journal of Personality and Social Psychology, 88, 827–843. Bonanno, G. A., Rennicke, C., & Dekel, S. (2005). Self-enhancement among high-exposure survivors of the September 11th terrorist attack: Resilience or social maladjustment? Journal of Personality and Social Psychology, 88, 984–998. Botvin, G. J., & Griffin, K. W. (2004). Life skills training: Empirical findings and future directions. Journal of Primary Prevention, 25, 211–232. Britt, T. W., Adler, A. B., & Bartone, P. T. (2001). Deriving benefits from stressful events: The role of engagement in meaningful work and hardiness. Journal of Occupational Health Psychology, 6, 53–63. Brunwasser, S. M., Gillham, J. E., & Kim, E. S. (2009). A meta-analytic review of the Penn Resiliency Program’s effect on depressive symptoms. Journal of Consulting and Clinical Psychology, 77, 1042–1054. Carver, C. S. (1998). Resilience and thriving: Issues, models, and linkages. Journal of Social Issues, 54, 245–266. Chan, C. W., Chan, T. Y., & Siv Man, N. (2006). The Strength-Focused and Meaning-Oriented Approach to Resilience and Transformation (SMART): A body–mind–spirit approach to trauma management. Social Work in Health Care, 43, 9–36. Cole, B., & Pargament, K. I. (1999). Re-creating your life: A spiritual/psychotherapeutic intervention for people diagnosed with cancer. Psycho-Oncology, 8, 395–407. Davis, C. G., & Asliturk, E. (2011). Toward a positive psychology of coping with anticipated events. Canadian Psychology/Psychologie Canadienne, 52, 101–110. Dolbier, C. L., Jaggars, S. E., & Steinhardt, M. A. (2010). Stress-related growth: Pre-intervention correlates and change following a resilience intervention. Stress and Health, 26, 135–147. Dunkel Schetter, C., & Dolbier, C. (2011). Resilience in the context of chronic stress and health in adults. Social and Personality Psychology Compass, 5, 634–652. Exline, J. J. (2002). Stumbling blocks on the religious road: Fractured relationships, nagging vices, and the inner struggle to believe. Psychological Inquiry, 13, 182–189. Frankl, V. E. (2006). Man’s search for meaning. Boston: Beacon Press. (Original work published 1959) Gillham, J. E., Reivich, K. J., Freres, D. R., Chaplin, T. M., Shatté, A. J., Samuels, B., et al. (2007). School-based prevention of depressive symptoms: A randomized controlled study of the effective-

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free ebooks ==> www.ebook777.com Resilience Interventions With a Focus on Meaning 281 ness and specificity of the Penn Resiliency Program. Journal of Consulting and Clinical Psychology, 75, 9–19. Grossman, J., & Tierney, J. P. (1998). Does mentoring work? An impact study of the Big Brothers Big Sisters program. Evaluation Review, 22, 403–426. Grote, N. K., & Bledsoe, S. E. (2007). Predicting postpartum depressive symptoms in new mothers: The role of optimism and stress frequency during pregnancy. Health and Social Work, 32, 107–118. Grote, N. K., Bledsoe, S. E., Larkin, J., Lemay, E. P., & Brown, C. (2007). Stress exposure and depression in disadvantaged women: The protective effects of optimism and perceived control. Social Work Research, 31, 19–33. Gupta, S., & Bonanno, G. A. (2010). Trait self-enhancement as a buffer against potentially traumatic events: A prospective study. Psychological Trauma: Theory, Research, Practice, and Policy, 2, 83–92. Hahn, A., Leavitt, T., & Aaron, P. (1994). Evaluation of the Quantum Opportunities Program: Did the program work? Waltham, MA: Brandeis University, Heller Graduate School. Hartfiel, N., Havenhand, J., Khalsa, S. B., Clarke, G., & Krayer, A. (2011). The effectiveness of yoga for the improvement of well-being and resilience to stress in the workplace. Scandinavian Journal of Work, Environment and Health, 37, 70–76. Huppert, F. A., & Johnson, D. M. (2010). A controlled trial of mindfulness training in schools: The importance of practice for an impact on well-being. Journal of Positive Psychology, 5, 264–274. Khalsa, S. S., Hickey-Schultz, L., Cohen, D., Steiner, N., & Cope, S. (2012). Evaluation of the mental health benefits of yoga in a secondary school: A preliminary randomized controlled trial. Journal of Behavioral Health Services and Research, 39, 80–90. King, L. A., Hicks, J. A., Krull, J. L., & Del Gaiso, A. K. (2006). Positive affect and the experience of meaning in life. Journal of Personality and Social Psychology, 90, 179–196. Lee, V. S., Cohen, R., Edgar, L., Laizner, A. M., & Gagnon, A. J. (2006). Meaning-making intervention during breast or colorectal cancer treatment improves self-esteem, optimism, and self-efficacy. Social Science and Medicine, 62, 3133–3145. Lester, P. B., McBride, S., Bliese, P. D., & Adler, A. B. (2011). Bringing science to bear: An empirical assessment of the Comprehensive Soldier Fitness program. American Psychologist, 66, 77–81. Lichtenthal, W. G., Currier, J. M., Neimeyer, R. A., & Keesee, N. J. (2010). Sense and significance: A mixed methods examination of meaning making after the loss of one’s child. Journal of Clinical Psychology, 66, 791–812. McAdams, D. P., Reynolds, J., Lewis, M. L., Patton, A., & Bowman, P. J. (2001). When bad things turn good and good things turn bad: Sequences of redemption and contamination in life narrative, and their relation to psychosocial adaptation in midlife adults and in students. Personality and Social Psychology Bulletin, 27, 472–483. McGregor, I., & Little, B. R. (1998). Personal projects, happiness, and meaning: On doing well and being yourself. Journal of Personality and Social Psychology, 74, 494–512. Murray-Swank, N. A., & Pargament, K. I. (2005). God, where are you? Evaluating a spiritually-integrated intervention for sexual abuse. Mental Health, Religion and Culture, 8, 191–203. Neimeyer, R. A., Pennebaker, J. W., & Dyke, J. G. van (2009). Narrative medicine: Writing through bereavement. In H. M. Chochinov & W. Breitbart (Eds.), Handbook of psychiatry in palliative medicine (2nd ed., pp. 454–469). New York: Oxford University Press. O’Donnell, L., Stueve, A., O’Donnell, C., Duran, R., San Doval, A., Wilson, R., et al. (2002). Longterm reductions in sexual initiation and sexual activity among urban middle schoolers in the reach for health service learning program. Journal of Adolescent Health, 31, 93–100. Pals, J. L., & McAdams, D. P. (2004). The transformed self: A narrative understanding of posttraumatic growth. Psychological Inquiry, 15, 65–69. Pargament, K. I. (2007). Spiritually integrated psychotherapy. New York: Guilford Press. Park, C. L. (2005). Religion as a meaning-making framework in coping with life stress. Journal of Social Issues, 61, 707–729.



Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136, 257–301. Park, C. L., Edmondson, D., & Mills, M. A. (2010). Religious worldviews and stressful encounters: Reciprocal influence from a meaning-making perspective. In T. Miller (Ed.), Handbook of stressful transitions across the lifespan (pp. 485–502). New York: Springer. Park, C. L., & Slattery, J. M. (in press). Religion, spirituality, and mental health. In R. F. Paloutzian & C. L. Park (Eds.), Handbook of the psychology of religion and spirituality (2nd ed.). New York: Guilford Press. Pearce, M. (2005). A critical review of the forms and value of religious coping among informal caregivers. Journal of Religion and Health, 44, 81–118. Pennebaker, J. W., Kiecolt-Glaser, J. K., & Glaser, R. (1988). Disclosure of traumas and immune function: Health implications for psychotherapy. Journal of Consulting and Clinical Psychology, 56, 239–245. Pennebaker, J. W., Mayne, T. J., & Francis, M. E. (1997). Linguistic predictors of adaptive bereavement. Journal of Personality and Social Psychology, 72, 863–871. Quale, A. J., & Schanke, A.-K. (2010). Resilience in the face of coping with a severe physical injury: A study of trajectories of adjustment in a rehabilitation setting. Rehabilitation Psychology, 55, 12–22. Rees, B. (2011). Overview of outcome data of potential meditation training for soldier resilience. Military Medicine, 176, 1232–1242. Rhodes, J. E., Grossman, J. B., & Resch, N. L. (2000). Agents of change: Pathways through which mentoring relationships influence adolescents’ academic adjustment. Child Development, 71, 1662–1671. Schok, M., Kleber, R., & Lensvelt-Mulders, G. (2010). A model of resilience and meaning after military deployment: Personal resources in making sense of war and peacekeeping experiences. Aging and Mental Health, 14, 328–338. Sears, S. R., Stanton, A. L., & Danoff-Burg, S. (2003). The Yellow Brick Road and the Emerald City: Benefit finding, positive reappraisal coping and posttraumatic growth in women with early-stage breast cancer. Health Psychology, 22, 487–497. Smith, B. W., Ortiz, J. A., Steffen, L. E., Tooley, E. M., Wiggins, K. T., Yeater, E. A., et al. (2011). Mindfulness is associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems in urban firefighters. Journal of Consulting and Clinical Psychology, 79, 613–617. Sood, A., Prasad, K., Schroeder, D., & Varkey, P. (2011). Stress management and resilience training among Department of Medicine faculty: A pilot randomized clinical trial. Journal of General Internal Medicine, 26, 858–861. Steinhardt, M. A., & Dolbier, C. L. (2008). Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symptomatology. Journal of American College Health, 56, 445–453. Sturgeon, J. A., & Zautra, A. J. (2010). Resilience: A new paradigm for adaptation to chronic pain. Current Pain and Headache Reports, 14, 105–112. Teasdale, J. D., Scott, J., Moore, R. G., Hayhurst, H., Pope, M., & Paykel, E. S. (2001). How does cognitive therapy prevent relapse in residual depression? Evidence from a controlled trial. Journal of Consulting and Clinical Psychology, 69, 347–357. Thrash, T. M., Elliot, A. J., Maruskin, L. A., & Cassidy, S. E. (2010). Inspiration and the promotion of well-being: Tests of causality and mediation. Journal of Personality and Social Psychology, 98, 488–506. Wilson, T. D., & Linville, P. W. (1985). Improving the performance of college freshmen with attributional techniques. Journal of Personality and Social Psychology, 49, 287–293.

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Part C Interpersonal Interventions



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free ebooks ==> www.ebook777.com 21 The Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Model A Treatment Approach to Promote Resilience Christina M. Hassija and Marylene Cloitre Epidemiological studies have demonstrated for some time that exposure to trauma is pervasive (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), that the most damaging traumatic events are interpersonal (Charuvastra & Cloitre, 2008), and that trauma survivors are likely to experience multiple events or live in chronically stressful environments (Kessler, 2000). Interests in the development of treatment approaches have expanded beyond the resolution of psychopathology to approaches that train skills in order to provide protection against future traumatizing effects of adverse events. Trauma research has joined the “Third Wave” in the evolution of psychotherapies that are as concerned with resolving symptoms as building strengths. An important task for trauma research is the development of psychological interventions that foster capacities that reduce trauma-related distress and bolster resilience. The present chapter defines resilience, outlines potential targets for intervention in trauma treatment, and identifies psychotherapeutic approaches that foster resilient adaptations. Particular attention is paid to the benefits of integrating techniques that enhance self-efficacy, emotion regulation, and interpersonal effectiveness. Skills Training in Affective and Interpersonal Regulation (STAIR) followed by Narrative Story Telling (NST) is presented as an example of a resilience-building treatment that promotes the acquisition and/or strengthening of emotional and interpersonal capacities. We review evidence supporting the efficacy of the STAIR narrative model as a treatment for posttraumatic stress disorder (PTSD) and other co-occurring trauma sequelae and discuss its potential to promote resilience among trauma survivors.

FACTORS ASSOCIATED WITH PSYCHOLOGICAL RESILIENCE FOLLOWING TRAUMA Mental health consequences commonly associated with trauma exposure include PTSD and other affective, anxiety, and substance use disorders (Kessler et al., 1995; Pietrzak, Goldstein, Southwick, & Grant, 2011). Despite high rates of lifetime trauma exposure within the general population (i.e., 50–60%), resilience appears to be the normative adaptation, with only a minority of trauma-exposed individuals going on to develop PTSD (7.8%; Kessler et al., 1995). Increasingly, attention has focused on identifying factors associated with psychological resilience following trauma exposure. Resilience can be understood as the ability to successfully adapt to and cope with challenging situations (Agaibi & Wilson, 2005). It has been characterized as a set of interrelated psychological and biological factors that confer protection against psychopathology following stress (Hoge, Austin, & Pollack, 2006).


Christina M. Hassija and Marylene Cloitre

Self-Efficacy Much of the PTSD literature has emphasized the protective qualities of particular aspects of an individual’s personality and his/her characteristic pattern of responding to stress (for recent reviews see Agaibi & Wilson, 2005; Hoge et al., 2006), such as internal locus of control and increased sense of self-efficacy. Internal locus of control refers to an individual’s sense that he/she can influence life’s circumstances (Hoge et al., 2006). In a related vein, self-efficacy within a trauma context can be thought of as an individual’s perceived ability to cope with the demands of the environment following a traumatic event (Benight & Bandura, 2004). Locus of control and self-efficacy beliefs may influence the extent to which individuals perceive they have control over their environment and their emotional reactions post-trauma. Possessing and maintaining self-efficacy beliefs may enable trauma survivors to mobilize and sustain adaptive coping efforts. Among sexual trauma survivors, developing and maintaining control/efficacy beliefs is associated with increased ability to distinguish between safe and risky situations, reduced perceptions of vulnerability, and greater resistance to future coercive assaults (Ozer & Bandura, 1990; Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007). Internal locus and high sense of coping efficacy may foster strategies designed to modify threatening and hazardous environments. Although research on locus of control and self-efficacy emerged from studies of personality, they have enriched the concepts and language with which to consider aspects of trauma and resilience. Psychological trauma is defined as the experience of an overwhelming adverse event that exceeds the individual’s capacity to cope. This formulation of psychological trauma can be viewed as including the loss of self-efficacy and competency. Accordingly, many trauma therapies include interventions which aim to rehabilitate directly or indirectly the individual’s sense of mastery and competency. For example, interventions that guide the patient to emotionally engage with a traumatic memory and reappraise its meaning are experiential exercises for reclaiming a sense of self-efficacy. A refrain that is sometimes used to guide this work is “You own the memory; the memory does not own you.” Restoration or enhancement of self-efficacy can also proceed by identifying examples of competencies in day-to-day life, strengthening skills relevant to the recovery from trauma, or achieving valued goals. Trauma creates irrevocable change in the individual and sometimes his/her personal environment. Thus, self-efficacy, as construed in the larger context of resilience, reflects a general confidence in the ability to manage change, adapt to circumstances, and find meaning in the change. Emotion Regulation The ability to adequately modulate intense emotions is a critical element of optimal recovery. Up-regulation of positive feelings is as important as down-regulation of negative feelings in the recovery process (Coifman & Bonanno, 2007). A threatening event activates stress mechanism for rapid action and survival. The natural course of recovery follows with the reduction of arousal, reappraisal of the experience, return to an emotional equilibrium, and restoration of a sense of safety. For some, significant disturbances in emotional states persist, as reflected in continued reactivity to traumatic reminders, difficulty reducing arousal, and inability to return to a state of emotional equilibrium. The strengthening of emotion regulation capacities reduces PTSD symptoms (Cloitre et al., 2010), suggesting that early interventions post-trauma may help to resolve traumatic symptoms before they evolve into a full-blown disorder.

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free ebooks ==> www.ebook777.com The STAIR Narrative Model 287 Emotion regulation is a multifaceted capacity that contributes to: the restoration of functional capacity following trauma exposure (Cloitre, Miranda, Stovall-McClough, & Han, 2005); overall positive, effective functioning in day-to-day life (Gross & Muñoz, 1995); and the development of supportive relationships, goal-directed activity, and role functioning. Emotion regulation engages attention, perception, cognition, and behavior in processes that direct emotions in ways that are adaptive to our goals. Emotion regulation includes self-soothing activities that reduce negative emotional states, as well as activities that increase positive emotion to facilitate appropriate action. Emotion regulation consists of a variety of interrelated skills. It requires awareness and appropriate expression of what one is feeling, the assessment of whether associated action tendencies promote or retard one’s goals, and the capacity to sustain or modify the feeling depending on whether it facilitates or hinders goal attainment. Inherent in this conceptualization is the idea that adaptive emotional regulation requires flexibility but also control. Emotion regulation is a critical ingredient of resilience, as it supports adaptive and sustained functioning under varying circumstances, particularly those that are unexpected or adverse. We wish to highlight one aspect of emotion regulation, the role of positive emotions and their potential for strengthening resilience (Folkman & Moskowitz, 2000). Experiences of positive emotions, such as pleasure or mastery, are thought to expand thought–action repertoires, thereby broadening the range of cognitions and behaviors and increasing physical, intellectual, and social resources (see Fredrickson’s broaden-and-build theory of positive emotions, 2001). An enhanced capacity to experience positive emotion may foster resilience and reduce the distress of stressful experiences (e.g., Cohn, Fredrickson, Brown, Mikels, & Conway, 2009). Consistent with this notion is the risk that the absence of positive emotions may pose in recovery following trauma. A recent study examined “real-time” emotional experiences during the weeks after a traumatic injury that required a visit to a hospital emergency room. Results showed that a subset of those who developed PTSD were characterized by very low levels of both positive and negative emotion, suggesting that low positive emotion played a critical role in predicting PTSD following a traumatic event (Carlson, Field, Ruzek, & Spain, 2008). Social Bonds Another critical resource that supports resilience is the presence of social bonds. Several studies have found that both psychological and physical health are strongly influenced by the presence of friendships and social networks (Cohen & Wills, 1985; Kiecolt-Glaser, Gouin, & Hantsoo, 2010; Uchino, 2004). Individuals who are socially engaged report greater life satisfaction, have improved physical health, and live longer (Barger, Donoho, & Wayment, 2009; Holt-Lunstad, Smith, & Layton, 2010; Uchino, 2004). Strong perceptions of interpersonal resources may buffer against the development of PTSD and facilitate recovery. One meta-analysis examined the impact of 14 separate risk factors for PTSD and found that social support showed the strongest effect size (Brewin, Andrews, & Valentine, 2000). Insufficient social support may have significant negative effects on the psychological status of trauma-exposed individuals. Additionally, a prospective 14-year study identified social support as a risk and protective factor (Koenen, Stellman, Stellman, & Sommer, 2003). Vietnam veterans with PTSD who demonstrated greater community involvement were more likely to show remission of their PTSD over the course of the study, while those who reported increased perceptions of negative community attitudes at homecoming were more likely to have a chronic course. The results suggest the doublesided and powerful nature of social bonds in influencing outcomes post-trauma.



Emotion Regulation and Social Bonds Emotion regulation is typically described in reference to the individual person (i.e., his/ her capacities). However, social bonds and emotion regulation are integrally related in a dynamic and reciprocal fashion. Emotion regulation is necessary in every interaction and social situation. In order to create and sustain relationships, awareness of and response to the other person’s feelings are necessary. Further, significant others often serve as “emotion regulators” in times of need. The emotion regulatory function of a wide variety of relationships has been demonstrated in social bonds, beginning with the first social bond between parent and child and extending to those that emerge in later life (see Charuvastra & Cloitre, 2008). A defining aspect of emotion regulation is the capacity to be aware of and modulate one’s own feelings. An additional dimension in the social context is the awareness of the feelings and reactions of others. Emotion regulation within the social context includes skills related to communicating feelings, recognizing and responding to the feelings of others, and modulating the expression of feelings sensitively to the social context. Limited awareness of others’ feelings has been demonstrated to have a negative impact on social functioning and ability to access social support (Wei, Vogel, Ku, & Zakalik, 2005). The mechanisms by which this happens warrant further investigation. One can easily imagine that difficulties in monitoring the feelings of others or the social context may lead to conversations that are inappropriate, ineffective, or hurtful and that the sustained expression of negativity may wear out the goodwill of even the best of friends. Conversely, the influence of emotion regulation capacities on overall well-being, on social networks, and on social adjustment was recently investigated in a series of studies by Bonanno and colleagues (see Coifman & Bonanno, 2009). Among college students, greater flexibility in upward or downward regulation of both positive and negative emotional expression relative to social demands was associated with improved posttrauma adjustment following 9/11 (Bonanno, 2004). Similarly, the capacity to experience positive affect shortly after 9/11 was predictive of size and strength of social networks two years later (Papa & Bonanno, 2008). Additionally, among young adults with a history of childhood sexual abuse, greater capacity to provide emotional expression “in synch” with the content of their conversation was associated with improved social adjustment, while dyssynchronous emotional expression was associated with declining social adjustment over time (Coifman & Bonanno, 2009). These results indicate the importance of supporting or strengthening socially sensitive emotional expression and modulation in individuals exposed to trauma. Flexibility in Expectations and Behaviors The ability to think about and approach situations in a flexible and adaptive manner has been associated with improved psychological adjustment (Fresco, Williams, & Nugent, 2006; Palm & Follette, 2011). The extent to which an individual is able to generate alternative ways of viewing the self, the world, and others may be an important determinant of effective coping. Similarly, individuals who are able to flexibly respond and adapt in the context of an interpersonal interaction may be more successful accessing support from their network. Interpersonal flexibility has been associated with greater positive perceptions of emotional and tangible support (Xia et al., 2012). Hence, being able to modify one’s expectations and goals consistent with the social context may lead to greater success and more positive experiences with social support.

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free ebooks ==> www.ebook777.com The STAIR Narrative Model 289 Reliance on others for support is likely to be more effective if expectations are consistent with the available resources and personality of the friend. For example, some friends easily acknowledge pain and suffering, while others are better at creating fun and engaging in positive experiences. Flexibility in matching one’s requests and expectations to the specific aptitudes of particular social networks is likely to increase mutual satisfaction in the relationship and support its maintenance. Interpersonal flexibility also includes adjusting expectations to the characteristics of the relationship. Expectations within one’s relationship to a spouse, colleague, or one’s own child differ according to these characteristics. Actions and reactions are contingent on the differences in power and level of intimacy unique to a particular relationship. Confusion or rigidity about relationships is likely to lead to mutual dissatisfaction and disappointment, and may result in conflict or loss of the relationship. In summary, we propose that resilience is enhanced by building or restoring various emotional, personal, and interpersonal qualities. These include a sense of self-efficacy or competency and emotion regulation capacities, including awareness and responsiveness to the emotions of others, as well as flexibility in regard to expectations about oneself and others.

INTERVENTION APPROACHES THAT PROMOTE RESILIENCE Although there are a number of efficacious treatments for PTSD, few interventions have attempted to address the larger objective of cultivating resilience among trauma survivors. Traditional treatments advanced for PTSD are primarily based on behavioral approaches that emphasize reducing the conditioned fear responses to trauma-related stimuli (Foa, Keane, & Friedman, 2004). Experimental studies derived from the principles of fear learning and fear extinction using both animals and humans suggest that disturbances in the neural circuitry of fear regulation are associated with PTSD (Phelps & LeDoux, 2005; Shin, Rauch, & Pitman, 2006). The extinction of trauma-associated fear is seen as the mechanism of change commonly attributed to the success of trauma memory processing. Emerging affective neuroscience recognizes that emotions rarely exist in a pure form, but rather are experienced in a social context (Charuvastra & Cloitre, 2010). Consideration of the positive influence of self-efficacy, emotion regulation, and social bonds on trauma recovery allows us to expand treatment models of PTSD and include interventions that strengthen these resources in clinically meaningful ways. Emotion regulation disturbances create vulnerability to pathological affective states, while improvement in emotional awareness, modulation, and expression can promote recovery and protect against future adversities (Charuvastra & Cloitre, 2008). Absent or deteriorated social bonds create risk for PTSD and other emotional problems, while improvement in relational functioning can promote recovery and resilience. Sense of self-efficacy arises from the development of these skills, as well as from a reappraisal of the meaning of the trauma (Cloitre, Cohen, & Koenen, 2006). Below we describe a treatment that has extended traditional trauma therapy by including skills training in emotion regulation and relational engagement consistent with the above conceptualization. STAIR/NST STAIR/NST is an evidence-based PTSD treatment with proven effectiveness in not only reducing PTSD symptomatology, but also increasing psychological and behavioral characteristics that contribute to resilience. While conventional trauma interventions



have received considerable empirical support for their efficacy in alleviating PTSD symptoms (e.g., Foa et al., 2004), these interventions were not designed to target specifically common co-occurring impaired emotion regulation and interpersonal functioning. STAIR/NST is a sequential, phase-based treatment that goes beyond traditional fearbased approaches. It incorporates interventions that address emotion regulation and social difficulties and highlights their roles in improving functioning in day-to-day and overall quality of life. STAIR/NST consists of two modules completed in sequence (see Table 21.1). The STAIR phase addresses and builds skills in emotion regulation and interpersonal functioning, while NST involves the exploration of trauma memories with the aim of reducing PTSD symptoms. STAIR The treatment goals of STAIR include: (a) enhancing emotional awareness, (b) strengthening emotion regulation capacities, (c) identifying and changing maladaptive interpersonal patterns, and (d) increasing interpersonal flexibility. In concert with the skills training, the therapist provides support and positive feedback to the client with the implicit goal of fostering self-efficacy and interpersonal effectiveness. Table 21.1 Elements of the STAIR Narrative Model STAIR Session 1: Introduction to treatment Session 2: Identification and labeling of feelings Session 3: Emotion regulation Session 4: Distress tolerance

Session 5: Identification of problematic relationship patterns Session 6: Alternative interpersonal schemas Session 7: Assertiveness and sense of agency Session 8: Interpersonal flexibility

Psychoeducation on PTSD and the role of emotion regulation and relationships as resources for effective living. Psychoeducation on the functional value of emotions; introducing ways to identify feelings; practicing self-monitoring of feelings and related cognitions and behaviors. Introducing and practicing emotion regulation skills via body-based, cognitive and social-behavioral exercises. Emphasis on engaging in pleasurable activities. Continued practice of emotion regulation skills. Psychoeducation on acceptance of feelings and distress tolerance. Identifying a valued goal, and assessing pros and cons. Creating plans to achieve approach behaviors using emotion regulation skills. Psychoeducation on interpersonal schemas and relationship between affect and interpersonal problems. Exploration of relationship patterns. Identifying desired goals in troubling interpersonal situations. Creating new expectations about self and other (new schema); practicing role play emphasizing conformity of feelings and behavior with goals. Focusing on problems with assertive behaviors. Identifying desired goals in troubling interpersonal situations. Creating new expectations about self and other (new schema); practicing role play emphasizing conformity of feelings and behavior with goals. Psychoeducation on flexibility in relationships; conducting role plays of requiring flexibility.

NST Session 9: Introduction to narrative work Sessions 10–16

Rationale for imaginal exposure to traumatic memories. Bolstering self-regulation; appraisal of trauma-generated schema with newly evolving schemas from STAIR. Continuing NST; practicing of emotion regulation and interpersonal exercises as relevant. Trauma reappraisal: positive sense of self, enhancing self-efficacy.

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free ebooks ==> www.ebook777.com The STAIR Narrative Model 291

Identifying and Expressing Feeling States (Sessions 1–2) The first sessions of STAIR focus on learning to identify, discriminate, elicit, and monitor emotions. Trauma survivors with stress-related conditions often experience difficulties understanding and labeling their feelings. Some may describe feeling extremely angry or anxious, but are unable to identify the trigger or label painful underlying feeling states, such as sadness, guilt, or shame, while others may describe persistent feelings of numbness with little understanding of its causes. Accordingly, clients are taught to identify their feelings and corresponding triggers, thoughts, and current mood-regulation strategies. This information is elicited through in-session dialogue and tracked on self-monitoring forms. An experiential aspect of the intervention arising from the therapist’s response is that disclosure of negative feelings can be met with recognition and acceptance by another person. The goals of these exercises are for the client to develop ease in identifying and describing his/her feelings and to learn to expect an accepting response.

Emotional Regulation Skills (Sessions 3–4) Clients next learn effective coping strategies for extreme emotions. Clients are guided in identifying strengths and weaknesses in current coping. Emotion regulation strategies within three channels of experience are systematically identified: bodily experience, cognitions, and behaviors, with an emphasis on engaging in activities leading to increased socialization. Psychoeducation about the value of positive experiences is introduced, pleasurable activities are scheduled, and coping strategies that best suit the client’s temperament and needs are selected for development and strengthening. Clients are encouraged to confront distressing situations and emotions, particularly in the case of valued goals. Improvement in emotion regulation skills and practice in approach-related behaviors strengthen a sense of efficacy for difficult emotions, thoughts, and situations, and broaden existing behavioral coping repertoires.

Expanding the Interpersonal Social Repertoire (Sessions 5–8) The remaining STAIR sessions focus on identifying and revising maladaptive interpersonal patterns, characterized as “interpersonal schemas.” Interpersonal schemas are identified through the analysis of recent interpersonal experiences. They are core beliefs about oneself and expectations about how others will respond. For example, past experiences may lead someone to develop schemas such as “If I make my needs known, others will not care” (example from a person who had experienced neglect) or “If I show my feelings, I make myself and others vulnerable” (example from a combat veteran). Schemas serve an adaptive function in that they allow an individual to act according to realistic expected outcomes. However, they may become maladaptive when generalized across social contexts. The individual who has left the abusive home or the soldier who has returned home may automatically apply a trauma-generated schema to a new or different social circumstance that may inadvertently elicit the expected response from others, creating a vicious cycle of maladaptive relational dynamics. The person who has experienced neglect has learned not to make her needs known. This leads to a lack of responses from others, thereby reinforcing her experience of being uncared for and the validity of her negative schema. The soldier comes home and holds back on his feelings. Without the routines of active duty to manage them, he eventually explodes and assaults his wife, reinforcing his schema that feelings are dangerous.



The rigid application of negative interpersonal expectations hinders opportunities to recognize people who do not fit the schema and limits exploring alternative, more beneficial ways of relating to others. The interpersonal sessions involve identifying and modifying a maladaptive schema and exploring alternative schemas. An alternative schema is generated from the client’s desired interpersonal goals (“I want people to know more about me” or “I want to be close to my wife”) and its specification (“If I disclose my problems, people will be interested and will try to help”). Implementation of alternate schemas is supported by emotion regulation exercises related to interpersonal goals and is repeated by role plays. The importance of flexibility in interpersonal relationships and the need for varied forms of communication sensitive to situations are emphasized. NST NST focuses on working through the traumatic memories. The telling of the trauma and associated feelings in a narrative form with a beginning, middle, and end, is accomplished in an emotionally engaged but regulated way. In telling the story, the person as narrator: (a) learns to regulate the flow of emotion, (b) experiences directed, contained, and goal-oriented emotional expression, and (c) strengthens meta-cognitive functioning and self-awareness capacities by being both a part of the story and its narrator. NST has shown continuing gains in emotion regulation (Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004), suggesting that successful narrative work, in and of itself, may be an emotion regulation exercise. Continued improvement in emotion regulation during NST may be the result of practicing emotion regulation skills as they apply to day-to-day problems and the implementation of alternative interpersonal schemas. Distinctions are made between old schemas, based in past traumatic experiences, and new, alternative schemas that emerge from the STAIR work. The therapist and client explore the past meaning of the traumatic experience and reappraise its meaning in the present, in light of new information gleaned from therapy work. Reappraisals often involve the recognition that the chronic fear belongs to an event in the past and that changes resulting from the trauma (e.g., loss of sense of worth and capacity to relate well to others) can be purposefully reworked and transformed in the present.

THE ROLE OF THE THERAPEUTIC RELATIONSHIP IN STAIR/NST It may be useful to see the process of therapy as involving the creation of a social bond between the therapist and client. PTSD is almost inevitably associated with broken or distressed social bonds, as a result of the nature of the trauma itself (e.g., sexual assault, combat), the social repercussions of certain kinds of traumas (e.g., blaming, stigmatizing responses), or weakened social networks (e.g., disaster victims). Consequently, the therapeutic alliance is particularly relevant in PTSD treatment. The therapeutic relationship can provide clients with a corrective relationship experience, thereby enhancing interpersonal self-efficacy and capacities for flexible responding in relational contexts. The therapeutic process in STAIR/NST involves creation of an environment that cultivates new learning regarding emotion regulation and social skills. This process echoes the exchanges of the first bond (therapist as caregiver) and, accordingly, is likely to flourish when the therapist endows the process with characteristics of that bond, namely availability as a “safe haven,” and expressions of support, confidence, and admiration. A relational role

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free ebooks ==> www.ebook777.com The STAIR Narrative Model 293 as a supportive external “emotion regulator” is emphasized, which is similar to the types of relationships that exist and can be expected within a larger social network. While these processes are not made explicit to the client in the course of therapy, they may provide “corrective emotional experiences” that create the outlines of healthy and positive schemas that can be applied to other relationships.

EMPIRICAL SUPPORT OF STAIR/NST The efficacy of STAIR/NST was evaluated in two studies of adult survivors of childhood trauma, one study of survivors of mass violence (9/11), and a fourth study of a sample of inpatients dually diagnosed with PTSD and schizo-affective disorders. Results support the utility of STAIR/NST for improved emotional and social functioning in ways that foster resiliency and positive adaptation. Cloitre, Koenen, Cohen, and Han (2002) evaluated the efficacy of STAIR/NST delivered over the course of 16 weeks in a sample of 58 women with childhood abuse-related PTSD. In comparison to wait-list controls, STAIR/NST intervention participants demonstrated significant improvements in affect regulation, interpersonal skills, and PTSD symptoms. Furthermore, gains were maintained at 3- and 9-month follow-up periods. At 9 months post-treatment, significant improvements were observed in measures of interpersonal problems, social support, and family, work, and social functioning. The STAIR phase produced improvements in negative mood regulation and anger expression, but not PTSD symptoms. Therapeutic alliance and improvement in negative mood regulation predicted participants’ responses to the NST phase of treatment. Thus, the role of the therapist and skills training component may enhance the modulation of negative emotions during exposure of the second phase. Overall, treatment outcomes demonstrated significant improvements in interpersonal skills, role functioning, and social support. A second investigation evaluated a flexible application of STAIR/NST in the treatment of 9/11 World Trade Center terrorist attack survivors (Levitt, Malta, Martin, Davis, & Cloitre, 2007). Clinicians were allowed to skip or repeat protocol sessions based on their relevance to the patients’ symptom presentation and deficits and end treatment prior to completing the entire protocol if satisfactory improvement had occurred. Therapists could also incorporate non-protocol sessions to address a current life stressor that warranted clinical attention. Length of treatment varied from 12 to 25 sessions. Results showed significant improvements on measures of psychological distress and social and emotional functioning in participants who received the flexibly administered treatment. STAIR/NST produced large effect sizes on measures of PTSD and depression symptoms and medium to medium-small effect sizes on measures of interpersonal problems, alcohol and drug use, social support, and functional impairment. Most noteworthy, treatment reduced the reported use of coping strategies reliant on alcohol and drug use and increased the utilization of social support. Hence, emotional and interpersonal skills training can foster adaptive coping and may confer protection towards future challenges. STAIR/NST appears to be effective in reducing distress when delivered flexibly, suggesting a potential for tailored treatments to a wide range of trauma populations and clinical settings. Most recently, Cloitre and colleagues (2010) conducted a randomized controlled trial of STAIR/NST among 104 women with childhood trauma-related PTSD. STAIR/NST was compared to two control conditions: supportive counseling followed by exposure and



skills training followed by supportive counseling. Results indicated that STAIR/NST participants were more likely to achieve sustained and full remission of PTSD in comparison to the two control conditions, and they demonstrate greater emotion regulation and sustained improvement in anger expression than did support/exposure participants. Of note is the finding that the benefits of STAIR/NST emerged primarily at 3- and 6-month follow-up assessments. Participants in the STAIR/NST intervention group evidenced greater improvements in emotion regulation, perceptions of social support, and interpersonal problems than participants in the control conditions. STAIR/NST was also associated with fewer cases of worsening PTSD. It appears that the continuing improvements post-treatment may have resulted from the cumulative and complementary benefits of each treatment component. Since patients confront day-to-day challenges in the context of interpersonal situations and other life stressors, successful exposure may reduce the reactivity to “traumatic reminders” and similar events, while skills training may aid successful approach of stressful situations. STAIR has also demonstrated efficacy as a group-based intervention for chronically hospitalized complex trauma survivors. Trappler and Newville (2007) examined the efficacy of STAIR in a sample of 24 inpatients with co-morbid PTSD and schizophrenia. Compared to a supportive therapy control group, patients who underwent STAIR showed significant improvement on measures of psychotic and PTSD symptoms. Specifically, patients who received STAIR evidenced greater reductions in positive symptoms, emotional withdrawal, tension, depressed mood, unusual thought content, blunted affect, and excitement, as well as reduced PTSD intrusion and avoidance symptoms. To summarize, STAIR/NST appears to be an efficacious treatment intervention for multiple aspects of trauma-related distress and for social and emotional impairments. STAIR/ NST alleviates symptoms of PTSD associated with early childhood and mass violence trauma, fosters continued improvement in mood regulation, and improves interpersonal functioning after treatment has ended (Cloitre et al., 2002; Cloitre et al., 2010). We suspect that the benefits of STAIR/NST may be due to: (1) enhanced abilities to effectively manage future stressful situations and emotional difficulties and (2) the continued development and use of social support resources.

FUTURE DIRECTIONS There are a number of fruitful avenues for future research within the area of resiliencebuilding interventions for PTSD. Most importantly, other, non-traditional psychotherapy treatments for trauma-related distress may enrich our understanding of resilience-based approaches for PTSD. These therapies may not include any processing of trauma memories, the “gold standard” treatment for PTSD. It remains to be seen how effective they are relative to established trauma-focused therapies or to multi-component therapies, such as STAIR/NST. Contemporary contextual behavioral interventions, such as behavioral activation (Martell, Addis, & Jacobson, 2001), acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 1999), and dialectic behavioral therapy (Linehan, 1993), may provide a useful framework within which improved mood and emotion regulation capabilities can be developed and implemented. These approaches have reduced high-distress behaviors, such as suicidal ideation, as well as parasuicidal and suicidal acts of self-harm (e.g., Becker & Zayfert, 2001). Since positive social support is among the best predictors of resiliency and recovery from

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free ebooks ==> www.ebook777.com The STAIR Narrative Model 295 PTSD, interpersonal therapies are likely useful treatment candidates for improving social functioning and community integration. Although multi-component trauma interventions, such as STAIR/NST, can produce improvements in areas associated with resilience, such as emotion regulation and interpersonal effectiveness, the extent to which such interventions produce clinical improvement above and beyond traditional PTSD treatments remains unclear. Findings from Cloitre and colleagues’ (2010) dismantling study suggest that greater long term benefits are associated with a combined skills training plus exposure-based intervention as compared to an exposure plus supportive counseling condition. However, future research is necessary to determine the effects of these treatments among trauma populations. In addition, research efforts aimed at identifying particular trauma populations or patient characteristics, which might dictate the incorporation of skills training approaches, would be valuable. Research is needed to identify mechanisms of action related to resilience. Examining how perceptions of self-efficacy, behavioral and interpersonal flexibility, and other regulation abilities account for symptom reduction would be useful. Similarly, identifying the most suitable targets for intervention and resilience promotion among trauma-exposed populations could move trauma treatment forward. Such assessments could include realtime behavioral assessments or measures of physiological reactivity. Longitudinal investigations of skills-based trauma interventions would shed light on the extent to which treatment gains are sustained and improve preventative trauma treatment and access resilience capacities. Lastly, the addition of fMRI technology can be utilized to explore the underlying neurocircuitry related to the modulation of fear and related emotions, as well as the roles that social stimuli and social context have in these processes. An fMRI study of STAIR/NST (Brown et al., 2011) examined brain activation patterns in response to an anticipatory fear task before and after treatment among a small group of women with PTSD related to childhood sexual abuse (n = 7). Results indicate that responders (n = 4), defined as those with 30% or more reduction in CAPS PTSD scores, exhibited less recruitment of the amygdala during the anticipatory fear task than nonresponders (n = 3), suggesting that treatment responders exhibited less sensitivity to threatening stimuli before and after treatment. Treatment responders also displayed increased recruitment of the ventromedial prefrontal cortex, specifically in the subgenual anterior cingulate, a region believed to be involved in the modulation of fear. These sites are known to be critically involved in the emotion regulation processes that rely on attention and executive functioning, suggesting that a positive outcome was related to changes in emotion regulation processes, consistent with the strategies employed during STAIR/NST. These results, along with others (e.g., Linden, 2006), suggest that psychotherapy changes the brain and provide insight into the underlying mechanisms of psychotherapy on a neurobiological level. In sum, emerging research suggests that personal, behavioral, and interpersonal factors may be associated with resilience following trauma exposure. Specifically, internal locus and self-efficacy beliefs, effective behavioral coping and emotion modulation, and improved interpersonal functioning may promote adaptive stress responding. Enhancing mood regulation and interpersonal relationship functioning may be useful targets for resiliency-building treatment interventions for trauma. STAIR/NST may be an effective strength-based intervention that enhances emotion regulation and interpersonal capacities. Future research should be directed towards the continued elucidation of factors associated with adaptive responding following trauma exposure to guide the development of psychotherapeutic interventions that promote resilience.



ACKNOWLEDGMENTS The writing of this manuscript was supported by the VA Advanced Fellowship Program in Mental Illness Research and Treatment, VA Office of Academic Affiliations.

DISCLAIMER The views and opinions of the authors expressed herein do not necessarily reflect those of the Department of Veterans Affairs.

REFERENCES Agaibi, C. E., & Wilson, J. P. (2005). Trauma, PTSD, and resilience: A review of the literature. Trauma, Violence, and Abuse, 6, 195–216. Barger, S. D., Donoho, C. J., & Wayment, H. A. (2009). The relative contributions of race/ethnicity, socioeconomic status, health, and social relationships to life satisfaction in the United States. Quality of Life Research, 18, 179–189. Becker, C. B., & Zayfert, C. (2001). Integrating DBT-based techniques and concepts to facilitate exposure treatment for PTSD. Cognitive and Behavioral Practice, 8, 107–122. Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behaviour Research and Therapy, 42, 1129–1148. Bonanno, G. A. (2004). Loss, trauma and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–29. Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748–766. Brown, A. D., Root, J. C., Cloitre, M., Perez, D., Teuscher, O., Pan, H., et al. (2011). Changes in fear reactivity in response to STAIR/NST: A preliminary analysis. Symposium at the annual conference of the International Society for Traumatic Stress Studies, Baltimore. Carlson, E. B., Field, N., Ruzek, J., & Spain, D. (2008). Individual differences in the phenomenology of PTSD over time. Presentation at the annual meeting of the International Society for Traumatic Stress Studies, Chicago. Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301–328. Charuvastra, A., & Cloitre, M. (2010). Emotions and emotion regulation in the process of trauma recovery: Implications for the treatment of post-traumatic stress disorder. In R. A. Lanius, E. Vermetten, & G. Pain (Eds.), The impact of early life trauma on health and disease: The hidden epidemic (pp. 278–285). New York: Cambridge University Press. Cloitre, M., Cohen, L. R., & Koenen, K. C. (2006). Treating survivors of childhood abuse: Psychotherapy for the interrupted life. New York: Guilford Press. Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to child abuse. Journal of Consulting and Clinical Psychology, 70, 1067–1074. Cloitre, M., Miranda, R., Stovall-McClough, K. C., & Han, H. (2005). Beyond PTSD: Emotion regulation and interpersonal problems as predictors of functional impairment in survivors of childhood abuse. Behavior Therapy, 36, 119–124. Cloitre, M., Stovall-McClough, C., Miranda, R., & Chemtob, C. M. (2004). Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72, 411–416.

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free ebooks ==> www.ebook777.com The STAIR Narrative Model 297 Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L., et al. (2010). Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry, 167, 915–924. Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310–357. Cohn, M. A., Fredrickson, B. L., Brown, S. L., Mikels, J. A., & Conway, A. M. (2009). Happiness unpacked: Positive emotions increase life satisfaction by building resilience. Emotion, 9, 361–368. Coifman, K. G., & Bonanno, G. A. (2007). Emotion context sensitivity in adaptation and recovery. In A. M. Kring & D. M. Sloan (Eds.), Emotion regulation and psychotherapy: A transdiagnostic approach to etiology and treatment. New York: Guilford Press. Coifman, K. G., & Bonanno, G. A. (2009). Emotion context sensitivity in adaptation and recovery. In A. Kring & D. M. Sloan (Eds.), Emotion regulation and psychotherapy (pp. 157–173). New York: Guilford Press. Foa, E. B., Keane, T. M., & Friedman, M. J. (2004). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press. Folkman, S., & Moskowitz, J. T. (2000). Positive affect and the other side of coping. American Psychologist, 55, 647–654. Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-andbuild theory of positive emotions. American Psychologist, 56, 218–226. Fresco, D. M., Williams, N. L., & Nugent, N. R. (2006). Association of explanatory flexibility and coping flexibility to each other and to depression and anxiety. Cognitive Therapy and Research, 30, 201–210. Gross, J. J., & Muñoz, R. F. (1995). Emotion regulation and mental health. Clinical Psychology: Science and Practice, 2, 151–164. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hoge, E. A., Austin, E. D., & Pollack, M. H. (2006). Resilience: Research evidence and conceptual considerations for posttraumatic stress disorder. Depression and Anxiety, 24, 139–152. Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk: A metaanalytic review. PLoS Medicine, 7, e1000316. Kessler, R. (2000). Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry, 61 (Suppl. 5), 4–12. Kessler, R., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. Kiecolt-Glaser, J. K., Gouin, J., & Hantsoo, L. (2010). Close relationships, inflammation, and health. Neuroscience and Biobehavioral Reviews, 35, 33–38. Koenen, K. C., Stellman, J. M., Stellman, S. D., & Sommer, J. F. (2003). Risk factors for course of posttraumatic stress disorder among Vietnam veterans: A 14-year follow-up of American legionnaires. Journal of Consulting and Clinical Psychology, 71, 980–986. Levitt, J. T., Malta, L. S., Martin, A., Davis, L., & Cloitre, M. (2007). The flexible application of a manualized treatment for PTSD symptoms and functional impairment related to the 9/11 World Trade Center attack. Behaviour Research and Therapy, 45, 1419–1433. Linden, D. E. J. (2006). How psychotherapy changes the brain—The contribution of functional neuroimaging. Molecular Psychiatry, 11, 528–538. Linehan, M. M. (1993). Cognitive-behavioral treatment for borderline personality disorder. New York: Guilford Press. Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York: Norton. Ozer, E. M., & Bandura, A. (1990). Mechanisms governing empowerment effects: A self-efficacy analysis. Journal of Personality and Social Psychology, 58, 472–486. Palm, K. M., & Follette, V. M. (2011). The roles of cognitive flexibility and experiential avoidance in



explaining psychological distress in survivors of interpersonal victimization. Journal of Psychopathology and Behavioral Assessment, 33, 79–86. Papa, A., & Bonanno, G. A. (2008). Smiling in the face of adversity: The interpersonal and intrapersonal functions of smiling. Emotion, 8, 1–12. Phelps, E. A., & LeDoux, J. E. (2005). Contributions of the amygdala to emotion processing: From animal models to human behavior. Neuron, 48, 175–187. Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25, 456–465. Shin, L. M., Rauch, S. L., & Pitman, R. K. (2006). Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Annals of the New York Academy of Sciences, 1071, 67–79. Trappler, B., & Newville, H. (2007). Trauma healing via cognitive behavior therapy in chronically hospitalized patients. Psychiatric Quarterly, 78, 317–325. Uchino, B. N. (2004). Social support and physical health: Understanding the health consequences of our relationships. New Haven, CT: Yale University Press. Walsh, K., Blaustein, M., Knight, W. G., Spinazzola, J., & Kolk, B. A. van der. (2007). Resiliency factors in the relation between childhood sexual abuse and adulthood sexual assault in college-age women. Journal of Child Sexual Abuse, 16, 1–17. Wei, M., Vogel, D. L., Ku, T., & Zakalik, R. A. (2005). Adult attachment, affect regulation, negative mood, and interpersonal problems: The mediating roles of emotional reactivity and emotional cutoff. Journal of Counseling Psychology, 52, 14–24. Xia, L., Liu, J., Ding, C., Hollon, S. D., Shao, B., & Zhang, Q. (2012). The relation of self-supporting personality, enacted social support, and perceived social support. Personality and Individual Differences, 52, 156–160.

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free ebooks ==> www.ebook777.com 22 Promoting Resilience After Trauma Clinical Stimulation of the Oxytocin System Jessie L. Frijling, Mirjam van Zuiden, Saskia B. J. Koch, Laura Nawijn, Dick J. Veltman, and Miranda Olff Traumatic experiences that threaten a person’s life or physical integrity and evoke a response of fear, helplessness, or horror are a common phenomenon. In the Netherlands, approximately 80% of people experience a potentially traumatic event at least once during their lives. Of these, approximately 10% develop psychological symptoms that meet the criteria for posttraumatic stress disorder (PTSD) (de Vries & Olff, 2009). PTSD is characterized by symptoms of re-experiencing the traumatic event, avoiding reminders of the event, hyperarousal, and emotional deficits such as emotional numbing (American Psychiatric Association, 2000). Present evidence-based early interventions for PTSD treat this condition after symptoms have developed (Veterans Health Administration, Department of Defense [VA/ DoD], 2010). A practice that would apply therapeutic intervention at an earlier stage in order to prevent the onset or the aggravation of PTSD symptoms would be greatly desirable. At the present time some early interventions appear to be effective (e.g., Zohar, Sonnino, Juven-Wetzler, & Cohen, 2009). However, these have not been tested sufficiently to meet evidence-based criteria. The ability to distinguish resilient from vulnerable trauma-exposed individuals may be important for the development of novel interventions to prevent PTSD. Modifiable risk factors may be identified and targeted for early interventions. Among the strongest and most consistently found predictors of PTSD is a lack of perceived social support post-trauma. In addition, inadequately regulated stress and fear responses seem to underlie the development of PTSD. These risk factors for PTSD may be suitable targets for early interventions. Oxytocin (OT) is a mammalian neuropeptide that supports social bonds and affiliation and that regulates stress and fear responses. In this chapter, we will discuss evidence that stimulation of the OT system is a promising clinical approach to promote resilience posttrauma by regulating stress and fear responses and improving feelings of social support.

PROCESSES INVOLVED IN THE DEVELOPMENT OF PTSD: SOCIAL SUPPORT AND STRESS AND FEAR RESPONSES Social Support and the Development of PTSD Studies have established that a subjective lack of social support following trauma is a strong predictor of the development of PTSD. A lack of social support can result from either the presence of negative social interactions or the absence of positive social reactions. Both have been found to be associated with increased risk for the development of PTSD (Robinaugh et al., 2011). In addition, findings suggest that childhood trauma and its associated insecure


Frijling, van Zuiden, Koch, Nawijn, Veltman, and Olff

attachment are related to increased risk for PTSD and the ability to benefit from social bonds (Charuvastra & Cloitre, 2008). Increasing social support at an early phase following trauma may change an adverse course into a more resilient trajectory (Olff, 2012). Stress and Fear Responses and the Development of PTSD Since Walter Cannon’s fight–flight formulation, a century of research on stress and fear has established that psychological stress results in the activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis. The activity levels of these systems usually return to baseline levels after the stressor has disappeared. However, functioning of these systems may be dysregulated during and after traumatic experiences, as demonstrated in the extensive literature since the establishment of the PTSD diagnosis in 1980 (Pole, 2007; van Zuiden, Kavelaars, Geuze, Olff, & Heijnen, 2013). Prospective studies have assessed sympathetic, parasympathetic, and HPA axis changes at an early phase after trauma and the subsequent development of PTSD symptoms. These studies showed that high heart rate (e.g., Coronas et al., 2011), lower heart rate variability (e.g., Shaikh al Arab et al., 2012), and low cortisol levels (for review see van Zuiden et al., 2013) were predictive of the development of PTSD in adults, although these findings have not been consistent. Studies have also considered pre-trauma vulnerability factors that are associated with the development of PTSD. Pre-existing high startle responses to threat (e.g., Pole et al., 2009) predicted PTSD symptoms following a traumatic experience. In addition, pre-trauma measures of HPA axis functioning and amygdala reactivity have been associated with increased PTSD risk post-deployment in military personnel (for a review see van Zuiden et al., 2013). Thus, studies of stress and fear mechanisms involved in PTSD development have shown alterations in these systems in vulnerable individuals exposed to trauma. These alterations may represent insufficient stress and fear regulation in the face of a traumatic experience. Resilience to PTSD could be promoted by improving adaptive regulation of stress and fear responses during the early phase following exposure to trauma. Links Between Social Support, Stress, and Fear Responses The presence or absence of social support modulates stress and fear in a number of studies. The presence of a familiar supportive person attenuated heart rate responses while experiencing a psychosocial stressor (i.e., a public speech task) compared to the presence of a stranger or no one present (e.g., Lepore, Allen, & Evans, 1993). Men who perceived instrumental and emotional support from their partners showed diminished cortisol responses to a psychosocial stressor compared to controls who did not receive support (Kirschbaum, Klauer, Filipp, & Hellhammer, 1995). In women with metastatic breast cancer, those with a greater perceived quality of social support had lower diurnal salivary cortisol levels (Turner-Cobb, Sephton, Koopman, Blake-Mortimer, & Spiegel, 2000). Consistent with these findings, a neuroimaging study demonstrated that handholding diminished brain activity in areas related to threat processing (Coan, Schaefer, & Davidson, 2006). The magnitude of this decrease depended on the quality of the relationship with the handholder. Early social experience may alter fear and stress responses later in life. For example, human studies showed that adverse social interactions during development, such as maltreatment and interpersonal adversity, were associated with adult altered cortisol and heart rate responses to stressors (Lovallo, Farag, Sorocco, Cohoon, & Vincent, 2012).

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free ebooks ==> www.ebook777.com Promoting Resilience After Trauma 301

STIMULATING THE OXYTOCIN SYSTEM TO PREVENT PTSD The neuropeptide OT is widely distributed in the brain (Gautvik et al., 1996). As a hormone, endogenous OT is released into the bloodstream, where it acts as a smooth muscle contractor involved in childbirth and lactation. The past few decades have seen a burgeoning of research on the role of OT in social behavior. In pioneering studies in the monogamous prairie vole, OT facilitated pair-bonding and partner preference (Carter, Williams, Witt, & Insel, 1992). In human studies, OT is involved in mother–infant bonding (Galbally, Lewis, van IJzendoorn, & Permezel, 2011) and other forms of parental behavior (Feldman, Gordon, & Zagoory-Sharon, 2011). OT is released during safe social contact, such as vocal socialization of a mother to her child (Seltzer, Ziegler, & Pollak, 2010) and during massage (e.g., Rapaport, Schettler, & Bresee, 2012). In studies of the novel application of intranasal OT, results showed that OT facilitates trust and prosocial behavior (for a review see van IJzendoorn & Bakermans-Kranenburg, 2012). By attenuating HPA axis (Altemus, Deuster, Galliven, Carter, & Gold, 1995) and sympathetic activity (Light et al., 2004), OT demonstrated a significant role in modulating physiological stress. Findings showed that in humans intranasal OT decreased HPA axis responsivity (Heinrichs, Baumgartner, Kirschbaum, & Ehlert, 2003) and increased parasympathetic responsivity (Norman et al., 2011). Intranasal OT also dampened amygdala activity (e.g., Domes et al., 2007) and enhanced functional connectivity between the amygdala and the prefrontal cortex (Sripada et al., 2012), thereby indicating that intranasal OT may increase fear regulation. Owing to the observed effects of OT on social behavior and on stress and fear responses, OT activity appears to serve important neurobiological underpinnings of the effects of social support on the reactivity of stress and fear (Uvnäs Moberg, 1998). Based on these welldocumented findings, we propose that the stimulation of OT will have a preventive role in the development of PTSD (Figure 22.1).

Social support Intervention

Safe Social Contact

TRAUMA

Intranasal Oxytocin

Oxytocin Activity

Increased risk: Stress and Fear Regulation of Stress and Fear Social Support Resilient: Adaptive Recovery Recovery Pattern

No PTSD

Outcome Time

Figure 22.1. Schematic overview of the hypothesized effects of oxytocin stimulation on the prevention of PTSD.



Figure 22.1 shows how stimulation of the OT system following trauma will target risk factors associated with PTSD: inadequate regulation of stress and fear responses, and the lack of perceived social support. There are two ways to stimulate the OT system: intranasal OT administration and the provision of safe social contact (social support intervention). Both methods of stimulating OT should affect endogenous OT activity, and are predicted to result in the regulation of stress and fear responses. Improved regulation of stress and fear is expected to turn an adverse course into a more resilient recovery, which may result in preventing the development of PTSD. The effectiveness of intranasal OT in preventing PTSD is being studied in an ongoing randomized controlled trial (RCT) in our center in Amsterdam. Two studies have examined the acute effects of intranasal OT in patients who have already developed PTSD. Pitman, Orr, and Lasko (1993) reported on the effects of intranasal OT on sympathetic reactivity in PTSD patients. In this study, intranasal OT, arginine vasopressin (a neuropeptide very similar to OT in structure), or placebo were administered to veterans with and without PTSD. Results showed that sympathetic reactivity to personal combat imagery was lower in both groups after OT administration compared to intranasal placebo or arginine vasopressin (Pitman et al., 1993). The second study was a pilot report on a single administration of OT administered to patients with PTSD. Eighteen patients with PTSD were treated with both intranasal OT and placebo in a within-subject design. Fifty minutes after the administration of OT, findings showed lowered anxiety, tension, restlessness, and irritability, as well as improved mood and the desire for social interaction. These were associated with a small reduction of acute PTSD symptoms compared to intranasal placebo (Yatzkar & Klein, 2010). Comparable findings were obtained in a rodent study. Central OT administration immediately or 7 days after a severe stressor was associated with reduced PTSD-like behavior in rats 1 week after administration in comparison to the control condition (Cohen et al., 2010). Interestingly, central OT administration in mice prior to fear conditioning subsequently facilitated fear extinction (Toth, Neumann, & Slattery, 2012). These findings support the development of OT stimulation treatments for the prevention of PTSD.

OXYTOCIN STIMULATION TREATMENT APPROACHES Intranasal Oxytocin Treatment There is good evidence that intranasal OT administration stimulates the endogenous OT system. Administration of intranasal OT results in increased peripheral OT levels that last for a considerable length of time (for at least 7 hours), an effect attributed to a feed-forward cascade that increases endogenous OT release following intranasal OT administration (van IJzendoorn, Bhandari, van der Veen, Grewen, & Bakermans-Kranenburg, 2012). There are no established guidelines yet on the dose and duration of intranasal OT application for optimal effects. The doses most commonly used in clinical OT studies are 24 and 40 international units (IU). However, little is known about the differential effects of these doses (E. MacDonald et al., 2011). The longest reported time period of continued use of intranasal OT in an RCT was 13 weeks in patients with chronic constipation, in whom it was hypothesized that OT’s smooth muscle contracting properties would decrease abdominal symptoms (Ohlsson et al., 2005). In a report on the effects of intranasal OT on sexual functioning, OT was administered for several months and continued stable benefits without

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free ebooks ==> www.ebook777.com Promoting Resilience After Trauma 303 discernible adverse effects being reported (K. MacDonald & Feifel, 2012). A review showed that short-term use (up to three weeks) of daily or twice-daily intranasal OT up to 40 IU produced minimal side-effects, both in healthy individuals and in psychiatric patients. In addition, groups receiving OT or placebo did not differ in number and severity of sideeffects (E. MacDonald et al., 2011). Increasing Social Support Novel interventions aimed at increasing social support are currently being tested for their effectiveness in preventing PTSD. For example, psychological first aid (PFA) was created as an evidence-informed early intervention in the acute aftermath of disasters. PFA provides a guideline for professionals or volunteers who aid individuals after a traumatic event and who want to offer both psychological and material support. Based on the observation that a perceived lack of social support is a strong predictor of PTSD, providing acute social support and connecting individuals with their loved ones is an important part of this intervention (National Child Traumatic Stress Network and National Center for PTSD, 2005). However, no studies on the effectiveness of PFA in preventing PTSD have appeared in the literature. We propose that the aim of a preventative social support intervention should be twofold: to provide acute safe social contact and to promote the use of the available social support from one’s own environment. The provision of safe social contact by the professional provides a general non-threatening social environment, creates social support, and increases endogenous OT activity, as supported by studies on safe social context and increased peripheral OT levels. Furthermore, creating awareness of specific personal needs with regard to social support as well as exploring means for meeting those needs may result in new resilient coping skills. These may lead to more effective supportive social contexts and to the building of more stable positive social supports. Significant others of those individuals exposed to trauma may be part of an intervention. In such a dyadic social support intervention, the aim should be to strengthen already existing supportive behaviors and to explore ways of meeting common supportive needs. One limitation of social support stimulating interventions is that they may apply only to those who have an available social network. However, in trauma-exposed individuals who experience a lack of support and do not have supportive ties, the therapist may explore other avenues of support, including victim self-help groups, Internet connections, or the company of pets. The latter have shown beneficial effects induced by OT activity (Beetz, Uvnäs Moberg, Julius, & Kotrschal, 2012). A social support intervention should ideally consist of two or three sessions and should be easy to administer. This will allow different professionals working in mental health care settings to follow a simple protocol in providing the intervention. Finally, a combination of the two methods to stimulate OT activity may also be used. In order to enhance receptiveness to a psychological intervention, intranasal OT could be administered prior to a session (Olff, Langeland, Witteveen, & Denys, 2010). Pre-session OT may result in increased OT release as a result of a positive feedback mechanism (van IJzendoorn et al., 2012), and increased readiness to engage socially, and promote a trusting relationship with the therapist, which may make the intervention more effective.



METHODOLOGICAL CONSIDERATIONS IN OT STIMULATION APPROACHES Target Populations In order to effectively prevent the development of PTSD, the intervention should be aimed at recently traumatized individuals. It should be noted that various traumas do not come to the immediate attention of health care professionals and not all trauma-exposed individuals will be readily identified for early interventions. Survivors of traffic accidents requiring medical attention and individuals at high risk for exposure to trauma (i.e., military personnel, police, etc.) have most often been treated in early intervention studies. Survivors of disasters are also relatively easy to identify for early intervention. Early interventions require clear selection procedures. Since the majority of individuals exposed to trauma will actually not develop PTSD, only those with increased risk for PTSD should receive the intervention. The identification and selection of individuals at increased risk for PTSD should be based on established information on vulnerability and resilience factors. At this stage, known biological risk factors cannot be used in the identification of individuals at risk, since optimal cutoffs and the timing of assessments have not been reliably and validly established. In addition, these measures are not easy to obtain. An alternative is the use of validated surveys to distinguish high-risk from low-risk trauma-exposed individuals. These surveys assess self-reported risk factors at pre-trauma, peri-trauma, and post-trauma stages. One drawback is that questionnaires may be influenced by purposeful or unintentional distortion in comparison to biological measures. An optimal future approach may combine both biological and psychological measures in risk assessments. With regard to intranasal OT, contraindications should be considered prior to treatment. Pregnant or breast-feeding individuals exposed to trauma cannot receive intranasal OT, since OT may cause uterine contractions and breast milk secretion (E. MacDonald et al., 2011). Timing An optimal time for the prevention of PTSD stipulates that intervention occur within the first 6 hours post-trauma, the so-called “golden hours.” These 6 hours are important in the consolidation of traumatic memory (Zohar et al., 2009). The same research group investigated effects of central OT administration either 1 hour or 1 week after severe stress exposure in rats. At both time points OT reduced PTSD-like behavior in comparison to control vehicle-treated animals (Cohen, 2011; Cohen et al., 2010). This finding implies that OT stimulating interventions may still be effective in reducing PTSD-like behavior after the golden hours have passed, thereby providing broader opportunities to treat trauma-exposed individuals. So far we have discussed preventive interventions to be administered post-trauma. In theory, preventative measures could also be applied pre-trauma to populations at high risk of exposure to trauma, such as military personnel or police employees. In these populations OT would have to be administered frequently for a prolonged period of time, since the time of trauma exposure is often unexpected. However, health effects of prolonged OT administration would have to be thoroughly investigated beforehand.

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free ebooks ==> www.ebook777.com Promoting Resilience After Trauma 305 Context and Individual Factors Important considerations when implementing intranasal OT in a clinical application are the effects OT administration has on contextual and interindividual factors (Bartz, Zaki, Bolger, & Ochsner, 2011). Clinical studies using intranasal OT and/or social support should evaluate the influence of these factors in their subgroups before any of these interventions can become general practice. Effects of OT reveal a variety of sex differences. For example, neuroimaging studies show that OT administration in females increased amygdala activation to emotional faces (Domes et al., 2010). By contrast, men show decreased amygdala activation after intranasal OT (Domes et al., 2007). In addition, salivary alpha-amylase levels (a measure of sympathetic activity) decreased in women during couple conflict conditions after OT administration, whereas alpha-amylase levels increased in men (Ditzen et al., in press). It is possible that similar sexually dimorphic effects may be observed in the effects of a social support intervention. Other interindividual factors complicate the effects of OT further. De Dreu and colleagues (2010) observed that, following intranasal OT, participants donated more money only to their in-group members. By contrast, out-group members received less money (De Dreu et al., 2010). Several studies showed that OT’s prosocial effects acted mainly through in-group favoritism (van IJzendoorn & Bakermans-Kranenburg, 2012). These findings may have implications for the application of intranasal administration of OT to trauma-exposed individuals in relation to their personal in-group and out-group perceptions. Consideration should also be given to the influence of attachment on the effectiveness of interventions that stimulate OT. In a study on perceptions of maternal closeness, the authors observed that less anxiously attached individuals remembered their mothers as more caring after OT administration, whereas those who were more anxiously attached remembered their mothers as less caring after intranasal OT (Bartz, Zaki, Ochsner, et al., 2010). In other studies intranasal OT was effective for those individuals who could gain with regard to social functioning. Intranasal OT improved empathetic accuracy only in individuals with poorer social-cognitive performance in comparison to those with better social-cognitive performance (Bartz, Zaki, Bolger, et al., 2010). Intranasal OT attenuated cortisol levels only in those with low emotion regulation abilities, but not in individuals with high emotion regulation abilities (Quirin, Kuhl, & Dusing, 2011). Similar findings were observed in men who experienced early parental separation, while men without early parental separation did not exhibit diminished basal cortisol levels after intranasal OT administration (Meinlschmidt & Heim, 2007). It has been proposed that OT increases the salience of social cues. Salience depends on interpersonal and contextual factors (Bartz et al., 2011). This may explain the selective effects of intranasal OT administration. Therefore, when studying the effects of OT stimulating interventions post-trauma, individual characteristics and social perceptions of traumaexposed individuals should be assessed, in order to identify those factors that account for the interventions’ effectiveness.

CONCLUSIONS The development of PTSD is associated with a lack of perceived social support and with inadequate regulation of stress and fear responses. The current review shows that these risk factors may be modifiable and that they may be suitable targets for early intervention to



prevent the development of PTSD in individuals exposed to trauma. Interestingly, social behavior and the functioning of HPA axis, sympathetic, parasympathetic, and cortico-limbic fear mechanisms are closely interconnected and are all influenced by OT. OT can be administered intranasally and is safe to use. In addition, OT release may be stimulated endogenously by the provision of safe social contact, such as therapeutic social support settings. A promising area of research is the effectiveness of OT stimulating interventions, applied in the aftermath of a traumatic event prior to the development of the full-blown constellation of PTSD symptoms. In this context, attention needs to be paid to contextual and interindividual influences on the effects of OT. The timing of the intervention and dose of OT stimulation should be assessed to establish maximal efficacy. In conclusion, we propose that OT stimulating interventions administered early after trauma are a promising treatment approach and are easily applied in order to restore an adaptive resilient response in individuals with PTSD.

REFERENCES Altemus, M., Deuster, P. A., Galliven, E., Carter, C. S., & Gold, P. W. (1995). Suppression of hypothalamic-pituitary-adrenal axis responses to stress in lactating women. Journal of Clinical Endocrinology and Metabolism, 80, 2954–2959. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Bartz, J. A., Zaki, J., Bolger, N., Hollander, E., Ludwig, N. N., Kolevzon, A., et al. (2010). Oxytocin selectively improves empathic accuracy. Psychological Science, 21, 1426–1428. Bartz, J. A., Zaki, J., Bolger, N., & Ochsner, K. N. (2011). Social effects of oxytocin in humans: Context and person matter. Trends in Cognitive Sciences, 15, 301–309. Bartz, J. A., Zaki, J., Ochsner, K. N., Bolger, N., Kolevzon, A., Ludwig, N., et al. (2010). Effects of oxytocin on recollections of maternal care and closeness. Proceedings of the National Academy of Sciences, 107, 21371–21375. Beetz, A., Uvnäs Moberg, K., Julius, H., & Kotrschal, K. (2012). Psychosocial and psychophysiological effects of human–animal interactions: The possible role of oxytocin. Frontiers in Psychology, 3, 1–16. Carter, C. S., Williams, J. R., Witt, D. M., & Insel, T. R. (1992). Oxytocin and social bonding. Annals of the New York Academy of Sciences, 652, 204–211. Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301–328. Coan, J. A., Schaefer, H. S., & Davidson, R. J. (2006). Lending a hand: Social regulation of the neural response to threat. Psychological Sciences, 17, 1032–1039. Cohen, H. (2011). High dose hydrocortisone immediately after trauma may alter the trajectory of PTSD: Interplay between clinical and animal studies. European Neuropsychopharmacology, 21, 796–809. Cohen, H., Kaplan, Z., Kozlovsky, N., Gidron, Y., Matar, M. A., & Zohar, J. (2010). Hippocampal microinfusion of oxytocin attenuates the behavioural response to stress by means of dynamic interplay with the glucocorticoid-catecholamine responses. Journal of Neuroendocrinology, 22, 889–904. Coronas, R., Gallardo, O., Moreno, M. J., Suarez, D., Garcia-Pares, G., & Menchon, J. M. (2011). Heart rate measured in the acute aftermath of trauma can predict post-traumatic stress disorder: A prospective study in motor vehicle accident survivors. European Psychiatry, 26, 508–512. De Dreu, C. K., Greer, L. L., Handgraaf, M. J., Shalvi, S., Van Kleef, G. A., Baas, M., et al. (2010). The neuropeptide oxytocin regulates parochial altruism in intergroup conflict among humans. Science, 328, 1408–1411.

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free ebooks ==> www.ebook777.com Promoting Resilience After Trauma 307 Ditzen, B., Nater, U. M., Schaer, M., La, M. R., Bodenmann, G., Ehlert, U., et al. (in press). Sex-specific effects of intranasal oxytocin on autonomic nervous system and emotional responses to couple conflict. Social Cognitive and Affective Neuroscience. Domes, G., Heinrichs, M., Glascher, J., Buchel, C., Braus, D. F., & Herpertz, S. C. (2007). Oxytocin attenuates amygdala responses to emotional faces regardless of valence. Biological Psychiatry, 62, 1187–1190. Domes, G., Lischke, A., Berger, C., Grossmann, A., Hauenstein, K., Heinrichs, M., et al. (2010). Effects of intranasal oxytocin on emotional face processing in women. Psychoneuroendocrinology, 35, 83–93. Feldman, R., Gordon, I., & Zagoory-Sharon, O. (2011). Maternal and paternal plasma, salivary, and urinary oxytocin and parent–infant synchrony: Considering stress and affiliation components of human bonding. Developmental Sciences, 14, 752–761. Galbally, M., Lewis, A. J., IJzendoorn, M. van, & Permezel, M. (2011). The role of oxytocin in mother– infant relations: A systematic review of human studies. Harvard Review of Psychiatry, 19, 1–14. Gautvik, K. M., Lecea, L. de, Gautvik, V. T., Danielson, P. E., Tranque, P., Dopazo, A., et al. (1996). Overview of the most prevalent hypothalamus-specific mRNAs, as identified by directional tag PCR subtraction. Proceedings of the National Academy of Sciences, 93, 8733–8738. Heinrichs, M., Baumgartner, T., Kirschbaum, C., & Ehlert, U. (2003). Social support and oxytocin interact to suppress cortisol and subjective responses to psychosocial stress. Biological Psychiatry, 54, 1389–1398. IJzendoorn, M. H. van, & Bakermans-Kranenburg, M. J. (2012 A sniff of trust: Meta-analysis of the effects of intranasal oxytocin administration on face recognition, trust to in-group, and trust to out-group. Psychoneuroendocrinology, 37, 438–443. IJzendoorn, M. H. van, Bhandari, R., Veen, R. van der, Grewen, K., & Bakermans-Kranenburg, M. J. (2012). Elevated salivary levels of oxytocin persist more than seven hours after intranasal administration. Frontiers in Neuroscience, 6, 1–6. Kirschbaum, C., Klauer, T., Filipp, S. H., & Hellhammer, D. H. (1995). Sex-specific effects of social support on cortisol and subjective responses to acute psychological stress. Psychosomatic Medicine, 57, 23–31. Lepore, S. J., Allen, K. A., & Evans, G. W. (1993). Social support lowers cardiovascular reactivity to an acute stressor. Psychosomatic Medicine, 55, 518–524. Light, K. C., Grewen, K. M., Amico, J. A., Boccia, M., Brownley, K. A., & Johns, J. M. (2004). Deficits in plasma oxytocin responses and increased negative affect, stress, and blood pressure in mothers with cocaine exposure during pregnancy. Addictive Behaviors, 29, 1541–1564. Lovallo, W. R., Farag, N. H., Sorocco, K. H., Cohoon, A. J., & Vincent, A. S. (2012). Lifetime adversity leads to blunted stress axis reactivity: Studies from the Oklahoma Family Health Patterns Project. Biological Psychiatry, 71, 344–349. MacDonald, E., Dadds, M. R., Brennan, J. L., Williams, K., Levy, F., & Cauchi, A. J. (2011). A review of safety, side-effects and subjective reactions to intranasal oxytocin in human research. Psychoneuroendocrinology, 36, 1114–1126. MacDonald, K., & Feifel, D. (2012). Dramatic improvement in sexual function induced by intranasal oxytocin. Journal of Sexual Medicine, 9, 1407–1410. Meinlschmidt, G., & Heim, C. (2007). Sensitivity to intranasal oxytocin in adult men with early parental separation. Biological Psychiatry, 61, 1109–1111. National Child Traumatic Stress Network and National Center for PTSD (2005). Psychological first aid: A field operations guide. Medical Reserve Corps field operations guide. Norman, G. J., Cacioppo, J. T., Morris, J. S., Malarkey, W. B., Berntson, G. G., & DeVries, A. C. (2011). Oxytocin increases autonomic cardiac control: Moderation by loneliness. Biological Psychology, 86, 174–180. Ohlsson, B., Truedsson, M., Bengtsson, M., Torstenson, R., Sjolund, K., Bjornsson, E. S., et al. (2005). Effects of long-term treatment with oxytocin in chronic constipation: A double blind, placebo-controlled pilot trial. Neurogastroenterology and Motility, 17, 697–704.



Olff, M. (2012). Bonding after trauma: On the role of social support and the oxytocin system in traumatic stress. European Journal of Psychotraumatology, 3, 1–11. Olff, M., Langeland, W., Witteveen, A., & Denys, D. (2010). A psychobiological rationale for oxytocin in the treatment of posttraumatic stress disorder. CNS Spectrums, 15, 522–530. Pitman, R. K., Orr, S. P., & Lasko, N. B. (1993). Effects of intranasal vasopressin and oxytocin on physiologic responding during personal combat imagery in Vietnam veterans with posttraumatic stress disorder. Psychiatry Research, 48, 107–117. Pole, N. (2007). The psychophysiology of posttraumatic stress disorder: A meta-analysis. Psychological Bulletin, 133, 725–746. Pole, N., Neylan, T. C., Otte, C., Henn-Hasse, C., Metzler, T. J., & Marmar, C. R. (2009). Prospective prediction of posttraumatic stress disorder symptoms using fear potentiated auditory startle responses. Biological Psychiatry, 65, 235–240. Quirin, M., Kuhl, J., & Dusing, R. (2011). Oxytocin buffers cortisol responses to stress in individuals with impaired emotion regulation abilities. Psychoneuroendocrinology, 36, 898–904. Rapaport, M. H., Schettler, P., & Bresee, C. (2012). A preliminary study of the effects of repeated massage on hypothalamic-pituitary-adrenal and immune function in healthy individuals: A study of mechanisms of action and dosage. Journal of Alternative and Complementary Medicine, 18, 789–797. Robinaugh, D. J., Marques, L., Traeger, L. N., Marks, E. H., Sung, S. C., Gayle, B. J., et al. (2011). Understanding the relationship of perceived social support to post-trauma cognitions and posttraumatic stress disorder. Journal of Anxiety Disorders, 25, 1072–1078. Seltzer, L. J., Ziegler, T. E., & Pollak, S. D. (2010). Social vocalizations can release oxytocin in humans. Proceedings of the Royal Society B: Biological Sciences, 277, 2661–2666. Shaikh al Arab, A., Guédon-Moreau, L., Ducrocq, F., Molenda, S., Duhem, S., Salleron, J., et al. (2012). Temporal analysis of heart rate variability as a predictor of post traumatic stress disorder in road traffic accidents survivors. Journal of Psychiatric Research, 46, 790–796. Sripada, C. S., Phan, K. L., Labuschagne, I., Welsh, R., Nathan, P. J., & Wood, A. G. (2012). Oxytocin enhances resting-state connectivity between amygdala and medial frontal cortex. International Journal of Neuropsychopharmacology, 30, 1–6. Toth, I., Neumann, I. D., & Slattery, D. A. (2012). Central administration of oxytocin receptor ligands affects cued fear extinction in rats and mice in a timepoint-dependent manner. Psychopharmacology (Berlin), 223, 149–158. Turner-Cobb, J. M., Sephton, S. E., Koopman, C., Blake-Mortimer, J., & Spiegel, D. (2000). Social support and salivary cortisol in women with metastatic breast cancer. Psychosomatic Medicine, 62, 337–345. Uvnäs Moberg, K. (1998). Oxytocin may mediate the benefits of positive social interaction and emotions. Psychoneuroendocrinology, 23, 819–835. Veterans Health Administration, Department of Defense (VA/DoD) (2010). Clinical practice guideline for management of posttraumatic stress (version 2.0, draft). Retrieved from http://www. onlinecpg.com/review/ptsd/ptsd-reviewdraft.pdf Vries, G. J. de, & Olff, M. (2009). The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands. Journal of Traumatic Stress, 22, 259–267. Yatzkar, U., & Klein, E. (2010). P.3.026 intranasal oxytocin in patients with post traumatic stress disorder: A single dose, pilot double blind crossover study. European Neuropsychopharmacology, 20, S84. Zohar, J., Sonnino, R., Juven-Wetzler, A., & Cohen, H. (2009). Can posttraumatic stress disorder be prevented? CNS Spectrums, 14, 44–51. Zuiden, M. van, Kavelaars, A., Geuze, E., Olff, M., & Heijnen, C. J. (2013). Predicting PTSD: Preexisting vulnerabilities in glucocorticoid-signaling and implications for preventive interventions. Brain, Behavior and Immunity, 30, 12–21.

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5–HTTLPR gene 198 Abramson, L.Y. 80, 218 Abreu, J.A. 103 acceptance and commitment therapy (ACT) 36, 40, 294–5 accommodative coping (emotion-focused coping) 57–8, 59, 63, 267 action-agency training xvi, 36, 40, 227–44 activation goals 213, 221 active coping 24–5, 37 actor–action–object 231, 232–4 acute stressors 77–82 adaptation: emotion regulation and 89–92; to threat xiv, 33–43 adaptive regulation xiv, 55–72 addiction 7, 26; oxytocin, attachment and resilience to xv, 115–30 Adler, A.B. 275–9 adverse childhood experiences (ACEs) xvii, 197–206 adverse situation 55, 59 aesthetic trinity theory (ATT) 105 affect, laws of 10 affection exchange theory 134 affective-motivational counter-regulation xiv, 58–9, 60, 66–8 affective networks xiii, 3–14 affective processing 63–8 affluence 40–1 affordance 232 African Americans 204 age-related functional losses 65 agency 231, 233, 234, 236 see action-agency training AIDS caregivers 73, 76 allostatis xiv, 33, 35, 37, 44–52 allostatic load xiv, 35, 37, 46–7, 48–9 altruistic motivation to volunteer 175 amygdala 16, 35, 38–9, 215, 300, 301; hyperactivity 215 anarchic hand 233 anger 257, 258, 259, 266; RAGE network 5–11

anhedonia 211–12; effects of Behavior Activation (BA) treatment on brain regions mediating reward processing 217–20 anterior cingulate cortex (ACC) 146–7, 174 anterior insula (AI) 25–7, 146–7 anthropology 102–3 anticipation 45, 78, 81, 232, 235, 236 anticipation phase 78–80, 81 antidepressant behaviors 213, 221 antidepressant medication 8–9, 211, 212 anxiety 68; attachment anxiety 156–7; music and reducing 107 appraisals 88, 159 appraised meaning 270–2 approach, reactive 22, 23–4 approach/engagement xiv, xvi, 33–43, 80, 228, 229; resilience training for action and agency 236–40 approach motivation 217 ascending spiral 20, 119–22 Aspinwall, L.G. 22–5, 77, 79 assessment 213, 221 assimilative coping (problem-focused coping) 57–8, 59, 63–6 associative conditioning 136 Astor-Jack, T. 236 attachment 305; affective networks and 6; emotion regulation xv, 156–68; secure 156– 7, 201–2; shift from seeking novelty to preferring familiarity xv, 115–30 attachment anxiety 156–7 attachment-irrelevant stressful events 159–60 attachment style 139, 156–7 attention: attentional scope 21–2; deployment of 89; selective 60–3 attention-deficit/hyperactivity disorder (ADHD) 26 automatic self-regulation xiv, 55–72 autonomic nervous system (ANS) 34–7 aversive/unpredictable environment 36, 40 avoidance: attachment-related 156–7; reactive 22, 23–4


Index

avoidance-oriented emotion regulation 92, 93–4 Ayers, N. 101–2 Balleine, B.W. 19, 20 Bandura, A.B. 94, 240, 286 Bartholomew, K. 157 Bartz, J.A. 123–4, 126, 305 Batson, C.D. 144–6, 148–51, 247–9 battlemind training/debriefing 277–8 Baumeister, R.F. 27, 82, 190 Beck, A.T. 36, 215–6, 252 Beethoven, L. van 101 behavioral activation (BA) 36, 40, 294–5; effects on brain function 212–20, 221–2; treatments for depression xvi, 211–26 behavioral model of depression 213 behavioral self-blame 260 beliefs 271, 272 benefit finding 277–8, 278 Bennett, J. 59 bereavement 162, 177 Bernard, C. 44–5 Berridge, K.C. 7, 120, 135, 217–8, 220 Bewernick, B.H. 9 Big Brother/Big Sister programs 275, 279 biobehavioral programs xiii-xiv, 15–32, 35, 40 biochemistry, music and 104–5 biology: developmental social model of resilience 198–9; and music 103–5 Bisconti, T.L. 23–4, 73 Black, B. 175 blame 256; see also self-blame Bloom, S.L. 49 Bonanno, G.A. 23, 47, 49, 73, 82, 85–8, 93–4, 162, 200, 256, 266, 269, 273–4, 276, 279, 286, 288 bonding capital 192 bottom-up 4 boundaries 257, 262 Bowlby, J. xv, 6, 19, 116–7, 126, 135, 155–60, 179 bracing for loss 80 Bradburn, M. 39 brain-derived neurotrophic factor (BDNF) 9, 47 brain function: action and agency 230, 231–3; adaptation to threat 35, 38–9; affective networks xiii, 3–14; effects of behavioral activation 212–20, 221–2; empathy 146– 51; helping behavior 176; response to music 103–4; and social connections 189, 190–1; STAIR/NST 295 Breslau, N. 86 Brewin, C.R. 254, 287 bridging capital 192 Briere, J. 256, 257, 258

broaden-and-build theory of positive emotions 22, 75, 76, 77, 78, 173 Brooks, D. 192 Buber, M. 190 Buckner, R.L. 18 Burgdorf, J. 8, 9 Burkett, J.P. 122 C-tactile (CT) fibers 136 caballerismo 205 Cacioppo, J.T. 24–5, 74, 77, 131, 170 ‘Candle in the Wind’ (John) 102 Cannon, W.B. 33–5, 37, 45, 300 canonical neurons 232 CARE network 5–11 caregiver system model xv, 170–5; resiliencerelated benefits of volunteering 171–5 Carnegie Foundation 192 Carter, C.S. xii, xiii, xv, 35, 38, 115, 122, 124, 127, 135, 171, 176, 204, 220, 301 Carver, C.S. 22, 24, 49, 55, 57, 80, 273–4 Casey, B.J. 26, 199 Cassidy, J. 106, 157 cause of recovery 56 Chaminade, T. 232 characterological self-blame 257, 260 Charney, D.S. 46, 48, 148, 217, 241 Charuvastra, A. 285, 288–9, 300 Chan, C.W. 278 cherishing experience 237–9 childhood abuse-related PTSD 293–4 childhood experiences: adverse xvi, 197–208; and the ability to make social connections 188; positive 125–6 children: music education 107–8; music therapy 106; see also infants Chowchilla child kidnapping and cave collapse 34, 228 chronic response to trauma and loss 86–7, 92 chronic stressors 77 Chrousos, G.P. 46 Chiechanowski, P.S. 164, 165 Clay, E.G. 175 closed information processing 60–3 Coan, J.A. 48, 137, 300 cognition 3, 4, 191; cognitive change 89; expanded process model 59–69 cognitive-behavioral therapy (CBT) 94, 211, 212 cognitive functions 230; effects of Behavior Activation (BA) treatment 214–17; helping behavior and stress regulation 177–8 cognitive perspective taking 145 cognitive processing theory (CPT) 276 cognitive therapy (CT) 211, 212 Cohen, S. 78, 132, 173, 185, 287 coherence 266–7

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free ebooks ==> www.ebook777.com Index Coifman, K.G. 23, 49, 200, 286, 288 color-naming task 163 community: involvement in community activities 203; social intelligence 189, 192–3 community cohesion 204 comparator or forward model 233, 234, 236 compassionate motives 171, 172, 174–5 competence, sense of 171, 172, 173 complicated grief 277 composition, musical 101 Comprehensive Soldier Fitness program 275 concentration camps 101, 228 conditioning 221; associative 136 conduct disorder 26 connectedness 266–7 consilience 126–7 contamination stories 277 context see environment/context context model control xiv, 15–32, 35, 40; shift from reactive control to 19–28, 29; see also internal working models control 266–7; biobehavioral programs xiiixiv, 15–32, 35, 40; internal locus of 286; perceived 61–5 control-dependent affective processing 63–6 control theory 260 controllable attributes 64 cool versus hot control 25–7 coping 230; active 24–5, 37; attachment security and 159; coping models of resilience 56–8; emotion-focused 57–8, 59, 63, 267; meaningful 75–6, 77; passive 37; problem-focused 57–8, 59, 63–6; regressive 49 co-regulation 136 cortical functions 230 corticostriatial loops, ascending spiral in 20, 119–22 corticotrophin-releasing hormone (CRH) 45, 46, 47–8 cortisol 46–7, 48, 104, 176; attachment and 160 counter-regulation xiv, 58–9, 60, 66–8 Craig, A.D. 25, 131, 136 critically ill patients 107 Csikszentmihalyi, M. 105 Damasio, A.R. 136, 231 danger stimuli 64 Danner, D.D. 178 Darwin, C. 3, 39 Davidson, R.J. 28, 35, 39, 47, 48, 137, 152, 217 deactivating strategies 157 Decety, J. 146, 232, 235, 248 Deci, E.L. 185 De Dreus, C.K. 124, 125, 126, 305

311

deep brain stimulation (DBS) 5; antidepressant therapies 9–10 default mode network (DMN) 18, 104 defense see withdrawal/defense dehydroepiandrosterone (DHEA) 48, 178 delay of gratification 26 delayed response 86–7, 92 Del Guidice, M. 27, 118 demethylation 47–8 depression 68; affective neuroscience 6–10; Behavior Activation (BA) as a treatment for xvi, 211–26; Deep Brain Stimulation (DBS) antidepressant therapies 9–10; and empathy 251–2; music and 107; self-regulation 62; shortcomings of past approaches to 8–9; see also major depressive disorder (MDD) depressive symptoms 86–7, 92, 95–6 Depue, R.A. 135, 137, 190 derogation of social alternatives 123, 124–5 Derryberry, D. 21, 22, 66 developmental social factors xvi, 197–208 DeWall, C.N. 27, 66, 68, 82, 190, dialectic behavioral therapy 294–5 Diamond, L.M. 139, 160–1 Diana, Princess of Wales 102 dichotomous models 33–41 differential sensitivity theory 198–9 Dimidjian, S. xii, xiii, xvi, 8, 36, 40, 212, 213, 235, 241 Diori, J. 133 directional drive 17 disabled children 108 disgust 147 distal environmental factors 200–1, 203–5 distraction 79, 81 distraught patients 249–52 distress 145, 152, 249–50; attachment security and 159–60 Ditzen, B. 135, 138, 160, 305 domestic violence 186–7, 192; pseudo-forgiveness 262–3 Donley, K. 107 dopamine xv, 7, 20, 117, 120–1, 122, 173, 217 dorsal corticolimbic pathways xiv, 15–32, 40, 116–23 Drevets, W.C. 25, 217–8, drug addiction see addiction dual-process model 57–8, 60, 61, 63 Dudamel, G. 103 Dunbar, R.I.M. 131–2 dynamic model of affect (DMA) 23, 40, 74–5, 76, 77 earned attachment security 202 education 173


Index

effectiveness: of emotion regulation 91–2; forgiveness interventions 265 efficient stress response xvi, 228–9 effort, and social relations 189, 191–2 Eisenberg, N. 144, 145, 149, 152, 247, 249 Eisenberg, N.I. 147, 189, 199 Elliot, E. 47, 273 Ellsworth, P.C. 57 embitterment 257, 260, 261, 264; long-term outcomes 262, 263 emotion antecedents 88 emotion-focused coping 57–8, 59, 63, 267 emotion regulation xv, 20, 25–8, 199, 286–8, 289; attachment, resilience and 157–8; music and 106; and response to trauma or loss xiv, 86–99; and social bonds 288; STAIR/ NST 290, 291, 292 emotion theory 258 emotional awareness 95, 290, 291 emotional disturbances 92–3 emotional primes 4–11; functions of 6 emotions 191, 230; dichotomous models 35, 39–40; and emotion regulation 88–9; emotional responses to trauma 257, 258–9, 260, 266; emotional well-being 263; primary process xiii, 3–14; thinking and feeling 191 empathic concern 145 empathizer characteristics 149 empathy xv, 144–55; forgiveness interventions 265, 266; individual characteristics and helping xvii, 247–55 empathy recipient 149 endocrine 230 endogenous opioids 122 engagement/approach see approach/engagement engagement phase 80–1 Engelman, M. 37 enhancement bias 63–6 Enright, R.D. 261, 263–5 environment/context 230; aversive/ unpredictable 36, 40; contextual factors and oxytocin (OT) stimulation 305; developmental social factors and resilience 200–5; empathic brain responses 148–9; extremely adverse environments 34, 227–8, 235, 236 ethnomusicology 102–3 Etkin, A. 25 evaluative space model 74, 77 evolutionary theories of emotion 258 excessive reward disorders 40–1 expanded process model 59–69 expectations, flexibility in 288–9, 290, 291–2 experience: childhood experiences see childhood experiences; representations shaped by 248–9; shared and empathy xvii, 247–55

experience-dependent simulation 234–41 experience sampling methods (ESM) 105–6 extracurricular activities 203 extremely adverse environments 34, 227–8, 235, 236 Fales, C.L. 214, 215 familiarity 248–9; shift from novelty seeking to familiarity preferring xv, 115–30 familiarization–habituation response 123–4, 126 family resources 202 fast life strategy 118 Fava, G.A. 49, 218 fear: FEAR network 5–11; stimulation of the oxytocin (OT) system and the fear response xvii, 299–308 female–sadness associations 250–1, 253 Field, T.M. 131, 138, 151 fight–flight 37 Fichtenholtz, H.M. 215 Fishbach, A. 58, 61 flexibility, psychological 199–200, 288–9, 290, 291–2 Foa, E.B. 36, 94–5, 289–90 focused attention meditation 28 Föster, J. 21, 23 Fogassi, L. 231–3 Folkman, S. 24, 55, 57–8, 73, 75–7, 82, 257, 269, 287 forgiveness xvii, 256–69; interventions to promote 264–7; model for forgiveness-related responses to trauma 257–64; true forgiveness as secondary outcome 257, 260, 261–2, 263–4 Enright forgiveness intervention program 264–5 long-term forgiveness-related outcomes 257, 262–4 primary forgiveness-related outcomes 257, 259–60 secondary forgiveness-related outcomes 257, 260–2 tailoring of forgiveness interventions 266 forward or comparator model 233, 234, 236 Fraley, R. 161–2 Fredrickson, B.L. 21–2, 73, 75, 77–9, 82, 131, 137, 152, 171, 173, 176–7, 287 Frewen, P.A. 95, 234 Fried, L.P. 178 Friedman, R.S. 21, 23, 58 Frith, C. 232 functional magnetic resonance imaging (fMRI) 222, 295; effects of Behavioral Activation (BA) on brain function 214–20 future 230; designing a good life with agency 237–8

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free ebooks ==> www.ebook777.com Index Gable, P.W. 21–2, 83 Gabrielsson, A. 105 Gallese, V. 231–3 Garcia, R. 35, 38 Garner, A.S. 49 Gazzaniga, M. 189, 191, 193 gender role socialization 204–5 general adaptation syndrome (GAS) 37 genetic predispositions 198–9 Giffords, G. 102 Ginzburg, E. 34, 227, 235–6 Glenberg, A.M. 231–2 global meaning 270–2 GLYX-13 8 goal-relevant information processing 60–3 goals 271, 272; activation goals 213, 221; emotion regulation and 90–2, 93, 94, 95; ideomotor theory 229–30 ‘golden hours’ 304 Goleman, D. 189, 190–1 Goodall, J. 132 good survival 227–9 Gordon, K.C. 256, 262–3 Grady Trauma Project (GTP) 198 Grassi-Oliviera, R. 47 Greve, W. 56, 67–9 Grewen, K.M. 124, 138, 302 Grèzes, J. 232, 235 grief 23, 162, 177; complicated 277; PANIC/ GRIEF network 5–11 grooming 132 group membership 305; empathy and 149–51 growth, posttraumatic 87–8, 94 Gruenewald, T.L. 171 Guemus, I. 211 Gulag 34, 227 Haber, S.N. 7, 20, 218 habitual behaviors 218 habitual (routinized) control 116–17, 118, 119–21, 126 Haggard, P. 232, 236 Hamblen, J.L. 94 Hamilton Rating Scale for Depression 214 ‘Hanoi Hilton’ prison 34, 228, 235 Harlow, H.F. 133 Hasler, D. 217–8 Hayes, S.C. 36, 40, 92, 200, 241, 294 healing rituals 103 health: adjustment to physical illness 163–5; helping behavior and stress regulation 177–8; responses to trauma 257, 263–4 hedonic goals 91–2, 93, 95 hedonic responses 217–18 Heiderscheit, A. 107 Heiligenstadt Testament (Beethoven) 101

313

Heim, C. 46–7, 305 Heimer, L. 5 Heinrichs, M. 38, 124, 301 helping behavior 144, 145; empathic brain responses and 149–51, 152; empathy, individual characteristics and xvii, 247–55; resilience-related benefits from volunteering xv, 169–82 Herman, J.P. 38 Herz-Sommer, A. 101 Heyes, C. 231, 248 hippocampus 35, 38–9 Hoffman, M.L. 144 Hollon, S.D. 211 Holocaust, 34, 101 homeostasis 33, 35, 37; allostasis and 44–6 Hommel, B. 229, 233 hormones 176 hot control 25–7 Houle, B.J. 175 Hughes, G. 236 humanity of others 188, 189 humor 249–50 Huppert, F.A. 48, 273 hyperactivating strategies 157, 158 hypothalamic-pituitary-adrenal (HPA) axis 35, 37, 38, 46, 47, 160, 234, 300, 301 I-Thou world view 190 identity 103; multiple self-aspects 67, 68–9 ideomotor theory 229–30, 233, 236 illness, physical 163–5 imitation behavior 233–4 implicit associations test (IAT) 251 incongruency bias 66 individual factors: empathy, helping and xvii, 247–55; oxytocin (OT) stimulation 305 induced musical emotions (emotivist) position 105 infants: social bonds 132–4; ‘still face’ procedure 137; touch and 137–8; see also childhood experiences, children inferior frontal gyrus (IFG) 18, 25–7 information molecules 45–6 information processing 58; switching between open and closed modes 60–3 Interpersonal Reactivity Index 248 Interpersonal Therapy (ITP) 211 instrumental goals 91–2, 93, 94, 95 insulin-like growth factor 1 9 intensive care units (ICUs) 107 intention binding 232 interaction of positive and negative emotions 73–85; temporal-functional framework 76–83; theories 74–6 internal locus of control 286 internal models of action 235


Index

internal working models 115–30; see also context model control interpersonal flexibility 288–9, 290, 291 interpersonal process xii, xiii, xv interpersonal schemas 290, 291–2 interpersonal stress and trauma xvii, 256–69 inter-stressor phase 77–8 intranasal oxytocin 124, 125, 301, 302, 302–3, 304, 305 intrapersonal process xii, xiii, xiv-xv inward-focused negative emotions 258 ‘It Is Well With My Soul’ 100, 109 Janoff-Bulman, R. 256, 259, 260 Jellison, J. 108 Jewish exiles 102 John, Elton. 102 joy 147–8, 152–3 juvenile play 8–9 Kahneman, D. 190 Katrina, Hurricane 193 Keren, G. 33 Kessler, R.C. 86, 211, 235, 285 Keysers, C. xii, 147, 231, 233, 235 King, A. 96 King, M.L. 100 Knutson, B. 5, 7, 218 Koenen, K.C. 94, 198, 203, 287, 289, 293 Koob, G.F. 120, 218, 220 Koolhaas, J.M. 37 Krach, S. 147 !Kung tribe of the Kalahari desert 103 Larsen, J.T. 24, 25 laws of affect 10 Lazarus, R.S. 55, 57–8, 256–7, 259 Leardi, S. 104 learning systems 19–20 LeDoux, J. 35, 231, 289 Lee, R.K. 61 Leet, M. 228 Leipold, B. 56, 69 Levine, P. 27 Levitt, J.T. 293 Lewin, K. 193 Libet, B. 232 liking 217–18; shifting the balance between wanting and xv, 115–30 Linden, M. 261, 263 Linehan, M.M. 294 linking capital 192 Linley, P.A. 87, 88, 93 Linville, P.W. 67, 69, 273 listening to music 102 Liu, Y. 122, 125 Loggia, M.L. 151

loneliness 187–8 loss: attachment and responses to 160–3; emotion regulation and response to 92–6; responses to trauma and 86–8 Luskin, F. 265 LUST network 5–11 Luthar, S.S. xii, 34, 40–1, 56, 185, 228, 256 Lutz, A. 28 machismo 205 major depressive disorder (MDD) 87, 95, 211; behavioral activation as treatment xvi, 211– 26; see also depression Manna, A. 28 marital-type relationships 134 Martell, C.R. 213, 294 masculinity 205 Maslow, A. 105 Masten, A.S. xii, 34, 137, 185, 200, 228 Masten, C.L. 56, 147, 149, 151 maternal touch 133–4 Mather, M. 67 Mathews, A. 68 Mauder, R.G. 164 Mayberg, H.S. 9, 217 McAdams, D.P. 276–7, 279 McEwen, B.S. 8–9, 34–5, 37, 46–50, 82, 177, 247 Mead, G.H. 49 meaning, interventions with a focus on xvii, 270–82 meaning-making intervention (MMi) 278 meaning-making model 270–2 meaningful coping 75–6, 77 meaningfulness 274 Meaney, M.J. 133 mechanical ventilation 107 medial prefrontal cortex (mPFC) 39 medial preoptic area (MPOA) of the hypothalamus 170–1, 176 meditation 20, 27–8 memory 238, 240 Merriam, A. 101 mesolimbic neural activity 217–20, 222 Messiaen, O. 101 Metcalfe, J. 26 Midlarsky, E. 171, 172 Millett, V. 175 mindfulness 273 mindfulness meditation 20, 27–8 mindfulness therapies 36, 40 mirror neurons 230–3, 248; actor–action–object in 232–3 Moll, J. 174 monitoring 213, 221 Morgan, C.A. 48 mortality, volunteering and risk of 169–70, 172

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free ebooks ==> www.ebook777.com Index Moskowitz, J.T. 24, 73, 75–6, 77, 81–2, 193, 270, 287 motivation: automatic self-regulation of 58–9; expanded process model 59–69; for volunteering 171, 172, 174–5 multiple sclerosis 174 music xiv-xv, 100–12, 228 music education 107–8 music medicine 103, 104, 106–7 music therapy 102, 106–7 Narrative Story Telling (NST) xvii, 285–98 natural killer lymphocytes 104 natural mentors 202 Navy SEALs 236 need, expression of and observers’ motivation to help 247–55 negative emotions/affect 11, 12, 39–40; and attentional scope 21–2; independence or bipolarity of positive affect and 22, 23–4; interaction with positive emotions 73–85 negativity biases 63–8 neighborhood advantage 203–4 Neimeyer, R.A. 276–8 nested BrainMind hierarchies 3, 4 neurobiological expressions of resilience 47–8 neuroendocrine models 35, 37–8 neurons: canonical 232; mirror 230–3; social connections and 191 neuropeptide Y (NPY) 48 New Horizons International Music Association 103 Nicolson, N. 23, 39, 74 non-abusive physical discipline 201 novelty seeking, shift to familiarity preferring from xv, 115–30 obesity 40–1 Ochsner, K.N. 25, 88, 123, 253, 305 older adults: affective processing 65, 67–8; resilience-related benefits from volunteering xv, 169–82 Omoto, A.M. 173, 175, 178 O’Mara, E.M. 79 Ong, A.D. 73, 74–5 open information processing 60–3 open monitoring meditation 20, 27–8 optimism 22, 79, 80, 274 organizational volunteering 169–70 Orr, S.P. 302 Osgood, C. 39 outward-focused negative emotions 258 oxytocin (OT) 35, 38, 171, 176; clinical stimulation of the OT system xvii, 299–308; shifting the balance between wanting and liking xv, 115–30; and touch 133, 135, 138 Oyserman, D. 63, 65

315

Palombit, R.A. 49 pain 23, 146–7; sensitivity 64 PANIC/GRIEF network 5–11 Panksepp, J. 35, 37–8 paracingulate gyrus 216–17 paradoxical processes 94 parasympathetic nervous system (PNS) 35, 300, 301 parenting style 201 Pargament, K.I. 278 partner preference 122 passive coping 37 patients: individual differences in and empathy 249–52, 253; patient–physician relationship 164 Pedersen, C.A. 117, 133 peer assistance programs 179 peer influence 202 Penn Resiliency Program (PRP) 275 Pennebaker, J.W. 276–7 perceived control: affective processing biases 63–5; information processing 61–3 perceived emotions (cognitivist) position 105 perceived resources 24–5, 27 perceived usefulness 171, 172, 173 perception–action model (PAM) 247–9, 251 performing music 101–2 personal distress see distress personality trait conception of resilience 56 personalized music listening intervention 107 Peterson, C. 62 Phillips, M.L. 25–6, 218 physical affection xv, 131–43 physical health see health physician–patient relationship 164 physiology: physical affection and physiological indicators 134–5, 138; physiological models of adaptations to threat 34–7; responses to music 104; responses to stress Piliavin, J.A. 169, 171, 178 Pitman, R.K. 289, 302 PLAY network 5–11 pleasure, touch and 135–6 Pole, N. 90, 92, 300 polyvagal theory 35, 37 Porges, S.W. 35, 37 positive early experiences 125–6 positive emotions/affect 11, 12, 39–40, 287; and attentional scope 21–2; broadenand-build theory 22, 75, 76, 77, 78, 173; empathy and 147–8, 152–3; enhanced by touch 136–7; enhancement 20, 21–5; forgiveness and 261–2; independence or bipolarity of negative affect and 22, 23–4; as meaningful coping 75–6, 77; regulatory power in stress xiv, 73–85; volunteering and 171, 173–4, 177, 178–9


Index

positivity biases 63–8 posttraumatic growth 87–8, 94 posttraumatic stress disorder (PTSD) 87, 197, 285, 287; attachment and 162–3; comparison of resilience and 228–30; disturbance of action and agency 233–4; emotion regulation 92, 93–4, 95–6; prevention by stimulation of the oxytocin (OT) system xvii, 299–308; processes involved in the development of 299–300; resilience training of action and agency 236–40; STAIR/NST 289–95; symptoms 86 power 259 prairie voles 122 predictable environment 16, 18, 116, 237 predictive control 35 prefrontal cortex (PFC) 27, 35, 38–9, 214–17 preparation, levels of 79 presence, touch as an indicator of 137 Preussner, J.S. 35, 39 primal emotions scale 11 primary process emotional structure xiii, 3–14 primary resilience interventions 270, 271, 272; with a focus on meaning and values 273–6, 277, 279 primates 132–8 Prinz, W. 229, 233, 236 problem-focused coping 57–8, 59, 63–6 progesterone 171, 176 prolonged exposure therapy (PET) 276 prosocial behavior see helping behavior proximal environmental factors 200–1, 201–3 pseudo-forgiveness 257, 260–1, 264; long-term outcomes 262–3 psychological first aid 303 psychological flexibility 199–200, 288–9, 290, 291–2 psychology 105–6 Putin, V. 250 Putnam, R.D. 193 quality-of-life interviews 249–50 Quartet for the End of Time (Messiaen) 101 Quirin, M. 67, 124, 159–60, 305 racial socialization 204 RAGE network 5–11; see also anger REACH program (Recall, Empathy, Altruism, Committing, Holding on) 265 reactive behavioral control xiii-xiv, 15–32, 35, 40; shifting from reactive to context model control 19–28, 29, 115–23 rebound, behavioral 27 Rebounding, Sustaining, Growing (RSG) model 100 recounting stressful experiences 276–8

recovery 256; cause of 56; response to trauma and loss 86–7, 92, 94–6 recovery phase 81–2 redemption stories 277 Reed, P. 59, 61 Rees, B. 273 reflection 82 regressive coping 49 Reich, J. 23, 33, 35, 39–40, 74, 100, 184, 229, 266 reinforcement, touch and 135–6 related dysfunction response 86–7 relational beings 189, 190 relationships: breakups 160–1; problems with 257, 262 religion 173, 273, 278 representations, shaped by experience 248–9 Resick, P.A. 88, 94, 229 resilience alleles 198 resilience resources 131; social touch, resilience processes and 132–9 Resilience Solutions Group 188 resilience training for action and agency xvi, 36, 40, 227–44 resilient patients 249–52 resilient responses 86–7, 228–30, emotion regulation 92, 94–6 resources: family 202; perceived 24–5, 27; related to primary resilience 273–6; resilience 131, 132–9 response modulation 89 responses to stress/trauma/loss 86–8; attachment and 159–65; efficient stress response xvi, 228–9; emotion regulation and 92–6; forgiveness-related 257–64; good survival 227–9; resilience compared with traumatic responses 228–30; social support and development of PTSD 299–300 restorying 276–8 reticent patients 249–52 reward learning 218 reward processing 217–20, 222 reward-seeking motives 171, 172, 174 right caudate 219, 220 risk alleles 198 Ritchie, G. 228 Rizzolatti, G. 120, 135, 217, 218, 220, 230–3, 248 Robinson, O.J. 218 romantic relationships 134–5, 160–1 routinized (habitual) control 116–17, 118, 119–21, 126 Rubia, K. 26 rumination 82, 93 Rye, M.S. 265 Saarikallio, S. 106

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free ebooks ==> www.ebook777.com Index sad images block task 215–17 sadness 250–2, 253 safe social contact 301, 302, 303, 305 Sanctuary Model of care 49 sanguine patients 249–52 Sapolsky, R.M. 35, 46, 176, 177 Sarajevo, Siege of 101 Särkämö, T. 107 Sbarra, D.A. 136, 160–1 Schacter, K.L. 238 schemas, interpersonal 290, 291–2 Scheier, M.F. 55, 57, 80 Scherer, K.R. 57, 88, 256–7, 261, 266 schizophrenia 294 Schmeichel, B.J. 27 Schneirla, T. 39 Schnurr, P.P. 87, 94, 240 Schultz, W. 7, 35 Schwabe, L. 120–1 scripts 191–2 SEALs 236 secondary process 3, 4, 6 secondary resilience interventions 270, 271, 272; with a focus on meaning and values 276–8, 279 secure attachment 156–7, 201–2 security priming 157–8, 163, 201–2 SEEKING network 5–11, 35, 37–8 Segal, Z.V. 36, 40 selective attention 60–3 self-blame 256, 257, 259, 260, 266 self-deprecating emotions 257, 259, 260, 266 self-efficacy 286, 289 self-enhancement 63–6, 274 self-protective emotions 257, 259, 260, 266 self-reflection 18 self-regulation 27, 199; automatic xiv, 55–72; expanded process model 59–69 Selye, H. 34–5, 37, 77–9 sense of life as meaningful 271, 272 separation, responses to 161–2 serotonin 122 sex differences 305 Shah, J.Y. 58, 61 shame 258 shared experience xvii, 247–55 Shepperd, J.A. 80 short allele carriers (s/s or s/l genotypes) 198–9 Shumaker, R. 34, 228, 235 similarity 248–9 Simmons, A.N. 236 simulation, experience-dependent 234–41 Singer, B.H. 49, 50 Singer, T. 137, 145–8, 149 Sistema, El 103 situation modification 89 situation selection 89

317

situation-specific demands 90, 91–2 situational attributes 171, 175 Skills Training in Affective and Interpersonal Regulation with Narrative Story Telling (STAIR/NST) xvii, 36, 40, 285–98 skin contact 133–4 Smoski, M.J. xii, xiii, xvi, 8, 36, 40, 214–6, 219, 223, 235, 241 Smajlovic´, V. 101 Social Action for Health Project 192–3 social baseline theory 137 social bonds see social connections/bonds social capital 192 social competence 144, 151, 200 social connections/bonds xvi, 185–96, 228; action-agency training 236–40; in adulthood 134–5; comparison of resilience and PTSD 229, 230; emotion regulation and 288; good survival xvi, 228–9; inability to build and manage 187–8; in infancy 132– 4; learnability of developing 188–92; strong and resilient outcomes 185–7; therapeutic relationship in STAIR/NST 292–3 warm partner contact 138 social exclusion 147 social identity theory (SIT) 103 social inference ability 200 social intelligence (SI) 188–93 social integration 171, 172, 173–4 social pain 147, 189–90 social process xii, xiii, xv-xvi social relatedness see social connections/bonds social support 185–6; allostasis and 48–9; clinical stimulation of the oxytocin system xvii, 299–308; and the development of PTSD 299–300; intervention 301, 302, 303, 305; volunteering and 172, 173–4 social touch xv, 131–43 socialization: gender role 204–5; racial 204 sociology 103 softheartedness 249–50 Solomon, R.L. 67 Solomon, D.A. 211 spirituality 273, 278 spouse: attachment and death of 162; spousal caregiving 174, 177 Sterling, P. 34, 35, 37, 45, 46, 50 ‘still face’ procedure 137 strategic self-regulation 59–68 stress: interpersonal and forgiveness xvii, 256–69; oxytocin, attachment and resilience to xv, 115–30; recounting stressful experiences 276–8; regulation and volunteering 175–9; regulatory power of positive emotions xiv, 73–85; responses to see responses to stress/trauma/loss; touch and reduction of 137–8


Index

stressors 76–82 striatum 218, 219–20 stroke patients 107 survival, good 227–9 survival circuits xiii, 3–14 sustainability 256 sympathetic nervous system 300, 302 sympathy 144–5, 152 Tamir, M. 80, 81, 91 target populations 304 Taylor, S.E. 65, 67, 77, 79, 95, 126–7, 199, 120, 238 technology 193–4 temporal-functional framework for interaction of positive and negative emotions 76–83 Terr, L. 228 terrorist attacks: 9/11 101, 163, 293 tertiary process 3, 4 Thayer, R.E. 17 theory of mind 188 therapeutic relationship 292–3 thought, and emotion 191 thought–action repertoires 80–1, 82, 83, 173 threat, adaptations to xiv, 33–43 timing 304 Tomasello, M. 48 Toomey, B. 8 touch xv, 131–43 Toyoshima, K. 104 training, action-agency xvi, 36, 40, 227–44 trauma 258; attachment and responses to 162–3; factors associated with psychological resilience following 285–9; interpersonal and forgiveness xvii, 256–69; PTSD see posttraumatic stress disorder; responses to see responses to stress/trauma/loss; return to and transformation of 237–9 Trier Social Stress Test 159, 160 Trotter, J.L. 186, 192 Tugade, M.M. 73, 79, 82, 177 ulcerative colitis (UC) 164–5 Umilta, M.A. 232 unconscious processing 190 unforgiveness 257, 259, 260, 261

unpredictable environment 16, 18, 116, 237 usefulness, perceived 171, 172, 173 utilization behavior 233–4 Uvnäs Moberg, K. 35, 38, 301, 303 Vogt, J. 67 values, focus on xvii, 270–82 ventral corticolimbic pathways xiii-xiv, 15–32, 40, 116–23 ventral skin-to-skin contact 133–4 ventral vagus 35, 37 vigilance 77–8 violin-playing boy 228, 235, 236 volunteering xv, 169–82 Waal, de F. 132, 247–8, 251 wanting 217; shifting the balance between liking and xv, 115–30 war 103, 162–3, 228 war veterans 274 Waugh, C.E. 72 ‘We Shall Overcome’ 100 well-being 177–8, 263 Wheel of Fortune task 219–20 Wilding, N. 192–3 willpower 25–7 wired to connect 189–90 wistful patients 249–52 withdrawal/defense xiv, 33–43 Witvliet, C.V.O. 263 Wöhr, M. 9 World War II 228 Worthington, E. 265–8, 260–2, 264–6 Wright, R. 188 Yatzkar, U. 302 Yerkes–Dodson law 81 yoga 275–6 Zatorre, R. 22, 102 Zaki, J. 122, 123, 162, 253, 305 Zautra, A.J. 39–40, 74, 100, 131, 229, 256, 270, 274 Zeigarnik, B. 61 Zoellner, T. 87, 88 Zuiden, van M. 300

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