Summary book Capita Selecta in

Clinical Psychology

Book: captia selecta in clinical psychology

Chapter 18: psychopharmacology
There are many good reasons to provide at least an overview of psychopharmacology here.:
- Effective professional interactions between psychologists and prescribing physicians
threatening the same patient
- The possibility of being proactive in collaborating with a physician to compose an ideal
treatment package for patients that may consist of drug treatment and parallel psychological
supports.
- Better understanding of the patients full medical status in order to complete meaningful
assessments.
- Better understanding of potential somantic and psychological symptoms that can arise from
medication effects and medication side effects.
The language of pharmacology: important concepts
When it comes to prescription drugs there is considerable opportunity for confusion because each
drug company created trade names for its drugs. In order to provide a standard or shared language,
the science of pharmacology uses a terminology of its own that associates on specific name with one
specific drug type: we refer to these terms as generic names.
It become quickly apparent that the use of generic terms also allows a systematic approach to the
development of names that can help recognize which type of drug we are talking about.
To retain transparency and assure patient safety, the medical-pharmaceutical world has created a
reference book, referred to as the compendium of pharmaceuticals and specialties (CPS). The CPS
provides a listing of trade names that can then be matched with generic names and also allows the
reverse, namely, to look up a generic drug name and identify which company offers this product
under what trade name. For each drug listed in the CPS, there is also information about the chemical
itself, typical dosages, the intended effect, and known side effects. Another helpful feature,
especially in emergency situations, is the beginning section of the CPS, where a very large number of
prescription drugs are displayed visually so that the reader can take a given medication and, judging
simply by its size, color, shape, and whatever is inscribed on a pill, can determine which drug and
dosage it is without having to ask the patient or the prescribing physician.
Types of psychopharmacological medication and areas of application
A crude, but useful, approach to classifying psychoactive street drugs is to block them into a) upper
(drugs that increase arousal and alertness) and b) downers (drugs that decrease excessive arousal
and produce calm). Prescription drugs, however, have more complex mechanisms and do not fit will
into this simple classification scheme. In terms of drug actions, there is some overlap between street
drugs and prescriptions drugs.
What does apply to all drugs (illicit and prescription) is that increasing dosage also increased toxicity
and ultimately the probability of death. Some uppers and many hypnotic sedatives have very high
addiction potential and should be taken only for well-defined, short periods of time, prescribed by a
physician who closely follows the patient.
The relevant main areas of psychological, psychiatric, and general medical practice applications and
the corresponding use of drugs that can be broadly called psychopharmacological agents are:
- Pain
- Anxiety
- Depression
- Bipolar disorder

Schizophrenia
Post-traumatic stress disorder
Smoking cessation
Weight loss

The nature of possible relationships between pharmacological medication and psychological

interventions can be seen as fitting into one of these four categories:
1. Pharmacological medication is recognized as a highly effective and necessary first line
treatment. However, despite the fact that medication is needed and effective for these
conditions, there also is consistent evidence that the addition of psychological support and
behavioural training can further enhance the benefits of many first-line drug treatments.
2. Both psychological and drug treatments are recognized as effective, and either one can be an
appropriate first-line treatment.
3. There is evidence that psychological treatment is a superior choice to medication and should
be considered as a first option.
4. A fourth possible option is to plan from the outset to integrate medication and psychological
therapy.
Another important area where clinical psychology is connected to pharmacological treatment is
frequently via the problem of poor adherence.
How the arrival of the internet has changed clinical practice
With the advent of the internet, patients themselves have developed a great deal of savvy about
medical conditions, diagnose, and possible interventions. It is therefore more and more frequent that
patients approach either their physician or clinical psychologist with very specific ideas on what
disease they have and what treatment they should be getting for it. More and more patients know of
effective psychological treatments and will try to sway their physicians to try a psychological
intervention over a drug treatment. Not surprisingly, the patients physician will not always agree
with the patient, and good communication and bedside manner on part of the professional is needed
to resolve a possible impasse.
While it may be tempting for a clinical psychologist to side with the patient and prefer psychotherapy
over a drug, it is not only a major lack of professional courtesy but actually a safety requirement that
the psychologist communicates with the patients physician so that a proper flow of communication
between all three parties can occur and that a coherent treatment plan can be implemented.
Given that patients have grown more cognizant of treatment options, they often try to reduce their
medication intake because they:
- Dislike medication dependence and dont accept the implicit role of chronic patient
- Notice unpleasant side effects
- Are aware that long-term drug use can negatively affect their liver or lead to dependency
- Learn from reports of scientific advances in the popular press that particular drugs are not as
effective as initially believed.
Should psychologist have drug prescription privileges?
The profession itself is split over the issue, with one group arguing that a combination treatment of
medication and psychological support is often best and that patients are not well served by having
two different practitioners providing these two forms of treatment in parallel. This is a reasonable
argument., the other side takes a more philosophical stance and posits that the very values and
beliefs that characterize the practice of clinical psychology are the emphasis on emotion, thought
and behaviour and an attempt to gradually empower patients to look after themselves. Many
psychologists see medications as a quick fix that just manages, instead of cures, symptoms.

Chapter 8 Clinical forensic psychology

Clinical forensic psychology
As clinical psychology and forensic psychology have advanced as separate professions, the area of
overlap between them has increased. Having both forensic training and the clinical skills needed to
assess and treat clearly facilitates dealing with criminal offenders who are also disordered, often in
prison context.
The forensic implications of impulsive disorders are unlikely to be understood by a magistrates court
regarding a shoplifting offence, but an expert in this field with forensic training can place the offence
in its pathological context and arrive at the appropriate degree of mitigation.
Abnormal offender are a hybrid offender who provides many challenges for health and justice
systems which assume clients that are singly disordered or offenders.
The abnormal offender
Within clinical forensic psychology and criminology there is a strong connection between criminal
deviance and mental abnormality, sometimes referred to as the mad-bad debate.
Increasing levels of some crimes among the psychiatric population. The reason for this may lie in the
progression towards only having the most dangerous, criminally recidivist or unstable patients
admitted to hospital, with those less at risk and therefore less likely to offend being supported in the
community.
The types of disorder associated with serious crimes are more easily identified, as these are the
disorders most readily accepted as mitigation in court. The hallucinations, delusions and paranoid
ideation in schizophrenia have led sufferers to harm others, though self-harm is also a frequent
outcome. Schizophrenic individuals form 1 per cent of the population but are responsible for about 5
per cent of homicides.
In mood disorders symptoms of depression can lead to one-side suicide pacts, in which the sufferer
sees only a bleak future in a threatening world for those close to them, their way out being to kill
their loved ones then themselves. In the bipolar form of the disorder, symptoms of mania can lead to
reckless acts of irresponsibility or even paranoid reactions, as in schizophrenia.
Substance abuse has a close association with pretty crime. In the case of alcohol rates of crime
among alcoholics are very high, varying between 40 and 80 per cent.
Mental retardation is associated with crime, in that many in the criminal population then to be below
average in their IG, especially those acting as accomplices.
Although rare, the lack of empathy and people-reading skills in autism and Asperger syndrome can
lead to callous acts by sufferers, who do not always react to the distress of others. Thus mental
illness has a definite but inconsistent relationship with crime, which is specifically evident but may be
masked if generalized across both crimes and disorders.
Theoretical links between crime and abnormality are also pertinent to the mad-bad debate identified
abouve, simply stated, if criminality is determined by a disorder, then this would favour the label
mad, with the attendant possibility of an insanity plea. However, if the offender were acting under
his or her unimpaired free will, then the verdict would be bad, with nu such claim to insanity as
mitigation. This principle underlies the mens rea (clear mind).

Here the interface between clinical forensic psychology and law is vitally important, as rational views
of culpability in the mentally ill population must incorporate the fact that , in most cases, mentally ill
individuals can distinguish right from wrong.
Narcissistic personality disorder, a very rare disorder in which judgements of right and wrong are not
lost. Courts tend to have to follow the advice of clinical forensic expert witnesses in such cases and it
may transpire that the common sense of the courts discretion is lost as mental disorder has the
potential to outweigh mens rea.
A number of psychological approaches to crime assume that some abnormality predisposes
individuals to crime in the first place.
These include factors such as: a personality type based on physiological differences; the XYY sexchromosome abnormality; genetic predispositions to crime; maternal deprivation; abnormalities of
brain structure and function; and disorders such as attention deficit hyperactivity disorder, linked to
crime due to stimulus seeking and disruption of education.
Clinical correlates of crime: constitutional and psychological factors
Theoretical approaches to explaining the causes of criminal behaviour in individuals have
traditionally been produced under the heading of criminology or criminal psychology, supplemented
by consideration of criminogenic environmental factors and societal forces from the various
sociological schools of thought.
However, forensic psychologist have increasingly carried out research on prison populations, and
grand theories of criminality have tended to give way to a more pragmatic approach in which the
forensic psychologist play a prominent role.
There are assumptions regarding the individual causes of crime built into the legal system. For
example, children and young persons act assumes that young criminals are victims rather than
inherently bad and that delinquency is a cry for help.
Biological causes of crime: the enigma of the constitutional criminal
Biological positivism focuses on only objective empirical evidence in the biological sphere.
Older biological approaches to crime
Cesare Lombrosoo was one of the first to apply anything approaching a scientific method to the
study of criminality.
His focus on physical features linked him to the dubious school of phrenology founded by Gall, a
pseudoscience that inferred traits from the shape and size of the skull.
Lombroso studies and categorized racial types, bringing him uncomfortably close to the racial
anthropology movement with its social policy influences. This association also muddied the positivist
aim of impartial scientific objectivity.
Lombroso found that his criminal population to have more atavistic or evolutionarily primitive
features than his controls. Thus for Lombroso criminals were not fully phylogenetically developed.
Lombroso later added other factors to his anthropometric approach, such as contact with
degenerates and poor education, revising his earlier premise to that of only one-third of criminals
being born bad.
Kretschemere introduced the concept of body build indicating personality types. Sheldon applied this
approach to crime by considering the basic three somatypes in terms of temperament, then
extrapolating this to criminality:

1. The ectomorph was thin and frail, and being a quiet introvert was thus not predisposed to
crime.
2. The endomorph shape implied soft, rotund body and a relaxed, sociable personality, who
would be less likely to turn criminal.
3. The mesomorph refers to an athletic and muscular body build and was considered by
Sheldon the most likely of the somatypes to be criminal.
Sheldon could reasonably assume that body type was largely a product of genetic inheritance and
that the body type could be linked to criminality via personality.
Glueck and Glueck (1905; 1956) attempted to support the criminality of the mesomorph, but their
initial findings did not stand up to further scrutiny; however, they added psychological and
situational factors, which did weaken the criticism of overprediction of mesomorphic criminicals.
Thus early biological positivist approaches tended to pioneer the scientific method in crime research
but were remarkably weak in establishing cause and affect relations with the factors on which they
focused.
Chromosomal abnormalities are usually non-inherited abnormalities in the structures containing the
DNA sequences that form genes. The twenty-third pair of chromosomes are sex influencing. There
are a number of abnormal formations of the sex chromosomes. One viable abnormality is the XYY
male resulting from non-disjunction.
The main established characteristics associated with the XYY abnormality were tallness, mental
retardation or immaturity and mild acne. Mental retardation rather than aggression would account
for a higher proportion of them ending up in institutions. It has been speculated that their tallness
and other features may make them more likely to be accused, charged and sentenced, due to
perceived threat or difference in appearance.
Eysenck: personality and crime
One of the major figures in the area of biological positivism was Han Eysenck, who re-oriented his
1947 trait theory of personality towards a biologically based theory of the criminal personality. The
three independent dimensions of personality are:
1. Extraversion introversion
2. Neuroticism stability
3. Psychoticism normality. High scores are claimed by Eysenck to be criminal, psychopathic,
alcoholic of schizophrenic.
Eysencks approach to crime causation places his work in at least three camps: that of biological
positivism, a personality-based psychological approach and also control theory. The latter approach
theorises that everyone could be a criminal but some factor restrains the majority; in the case of
Eysenck, this factor is socialization or the development of a conscience, and those failing to develop
this restraint are more likely to become criminal. He also used learning theory in his approach, and
later in the development of his explanation of crime he incorporated many approaches, Eysenck
initially produces two dimensions of personality but later added a third, with all individuals being
located at some point along each of these orthogonal continua.
Neurotic introvert: a melancholic or moody and anxious type, prone to mental disorders.
Neurotic extravert: a choleric or restless and aggressive type, prone to criminality
Stable introvert: a phlegmatic or peaceful, controlled and reliable type.
Stable extravert: a sanguine or optimistic, outgoing and responsive type.

Eysenck draws the conclusion that extraverts would also be poor at learning more complex forms of
behaviours.
Extraverts may not find punishment aversive, and may find that aggression provides needed
stimulation. Thus anti-social behaviour may not be inhibited by fear of punishment. Eysenck develops
this argument further to include such anti-socialisation influences as biosocial interaction between
parents and poor learning mechanisms.
Eysenck modified this approach by dividing extraversion into the components of impulsiveness and
sociability, with impulsiveness identifying the criminal trait.
Eysencks theory depends on a consistent personality that is, individuals acting the same way in
different situations and does not acknowledge situationalist arguments that personality may
change with context. Eysenck makes no allowance for labeling of an individual having an effect on
the likelihood of reconviciont, or the idea that a persons manner or appearance can influence
judgements and reactions of others.
Other psychological approaches to crime
Early psychodynamic approaches to crime
Aichhorn focused on genetics and early emotional relationships in explaining latent delinquency.
Here a lack of socialization due to a failure of the reality principle results in a weak superego, leaving
a latent form of the pleasure principle guiding behaviour.
The main criminogenic theory to emanate from the psychodynamic school of thought was John
Bowlbys concept of maternal deprivation, which also relied heavily on ethology and evolutionary
psychology. This theory of disrupted emotional attachment and development.
Bowlby described the majority as having an affectionless character, also referred to as affectionless
psychopathy, and in addition to having a criminal incluniation they were unable to form close
personal relationships.
Studies of the factors influencing the development of criminality have lent some support to the idea
of separation from mothers leading to delinquency and maternal rejection interacting with biological
factors predicting later violence.
Learning criminality
Learning theory is a major source of explanation for behaviour but has had relatively little impact on
explaining criminality and, until recently, applied only weakly to modifying such behaviour.
Drawing on operant conditioning, Skinner considered that behaviour operated in an environment to
produce criminal change, which is reinforcing to that particular individual.
Rotter (1954) initiated the concept of social earning, which was applied experimentally by Albert
Bandura as vicarious learning, or learning by observing the consequences of others behaviour. This is
basically a cognitive form of operant conditioning. Social learning theory has been combined with
control theory in explaining why some people commit crimes and not others.
Cognitive explanations of crime have examined the thinking styles of criminals, often identifying
these as being more impulsive and concrete in their patterns.
Control theories of crime
The assumptions of control theories of crime are that everyone has the potential to be criminal but
that the factor identifying a particular control theory approach is what restrains the majority who do

not commit crimes. The main approaches considered from a psychological viewpoint concern moral
development and morality restraining criminal inclinations. Jean Piagets three stages of moral
development pre-moral; authoritarian; and negotiability and consensus were not specifically
applied to crime, but a similar structure by Kohlberg (1964) has been applied to criminal behaviour.
In this, a lack of moral control disinhibits criminal behaviour progressively as moral development
continues from childhood through adolescence.
Kohlbergs stages were considered to be linear and fixed in order of development, with each stage
being a prerequisite for its successor.
Twenty-first-century approaches to crime causation: biological positivism revisited
Raine (1997) makes the point that, just as social variables can protect those who are biologically
vulnerable to crime, so those socially vulnerable to crime may escape due to protective biological
variables. This consideration of both biological and social-environmental factors in the explanation of
individual differences in the propensity for crime not only differentiates modern biological theorists
from their more biased predecessors but also coincides with a sharp acceleration in the accuracy and
detailed knowledge of crime-related biological processes.
Attention deficit hyperactivity disorder (ADHD)
Hyperactive children, who would now be diagnosed with attention deficit hyperactivity disorder,
were later found to be involved in more anti-social and criminal activity than non-hyperactive
children.
Brain area function and criminality
Raine, Buchsbaum and La Casse (1997), using positron emission tomography (PET), reported that
impulsive murders of strangers showed low activity in brain areas controlling planning, strategies,
impulsive behaviour, reading and mathematic. Raine and Yang (2006) summarise the brain areas
structurally or functionally impaired in anti-social or criminal behaviour as including dorsal and
ventral regions of the prefrontal cortex, amygdale, hippocampus, angular gyrus and anterior.
Raine et al. consider these biological underpinnings to concurrent anti-social behaviour to be a
greater predictor of criminal potential than social factors.
The interaction effect on anti-social outcomes is as much as double that of the sum of the
component influences of biology and environment.
Criminal profiling
The pathological nature of the crimes committed by disordered, psychopathic and sexual offenders,
and the tendency to repeat them, have made such offenders special targets for the police and other
specialist agencies.
One increasingly used resource is that of the psychologist, especially the clinical forensic psychologist
in the role of psychological profiler or criminal profiler, or crime action profiler.
Of the differing approaches adopted by those carrying out the role of profiler, that of the clinical
forensic profiler tends to be a marginally more successful approach, as a result of most of the cases
amenable to profiling involving disordered offenders.
Offender profiling has come to supplement the work of crime scene analysis and investigating
officers.

Profiling has been described as an educated attempt to provide investigative agencies with specific
information as to the type of individual who would have committed a certain crime, which more than
hints at this process being an art rather than a science.
Overwiew: USA to Europe
One of the distinctions made by the FBI that has been supported over time is that of the organized
versus disorganized murder.
Using characteristics provided by profilers, investigating officers could cut down the search area and
number of suspects for a specific crime dramatically. Profiling has also been useful in cases of serious
assault, hostage taking, letter threats, abduction of children and violent offences that show
characteristics of psychopathology in the perpetrator.
The profiling process
The FBI considered the process of profiling a crime to be the four-stage process:
1. Data ssimilation
2. Crime classification
3. Crime reconstruction
4. Profile generation
Uk profilers tend to add two more important stage to the list: that of police investigation leading to
the apprehension of a suspect; and also the interviewing and successful prosecution of the offender.
The organized murder has characteristics such as evidence of planning, control, use of restraint and
removal or hiding of any evidence, whilst the disorganized murder scene is where evidence and
victim may be left at the somewhat random primary scene with sign of impulsiveness and sudden
violence.
An organized murderer would be expected to be of good IQ, be socially, sexually and occupationally
competent, lie with a partner, have transport, follow crime coverage and take steps to evade
discovery ,whereas the disorganized murderer should show the reverse of these characteristics:
living alone, being less competent and often living near the crime scene without transport.
David canter in the UK came from an environmental psychology background to a position of
authority in the area of offender profiling, which he prefers to term investigative psychology.
He has focused on a number of aspects of offender behaviour, amongst which are the following:
- Interpersonal narratives: are the way in which the offender interacts with other factors. In
this there is interpersonal coherence, in that the relationship with the victim tends to reflect
the offenders relationships in the rest of their life.
- Spatial patterns: refer to the areas within which an offender feels safe, usually because they
are familiar.
- Crime careers: develop as an offender refines their behaviour over a number of repeat
offences, in which they may become more confident of less liable to leave evidence.
- Forensic awareness: is where an offender learns to cover up evidence and discovers what
enables them to evade capture or conviction.
He has adapted facet theory and a form of multidimensional scaling called smallest space analysis to
the explanation of the interrelationships between aspects of various crimes.
A critical evaluation of profiling
The successfulness of offender profiling is usually thought of in terms of their work leading directly to
the capture of the actual offender.

Profiling use in the UK, found that clinical approaches were the most useful form of profiling but that
profiling only led to the identification of the offender in 3 per cent of the cases in which it was used.
However, profiling was deemed to be useful in around 16 per cent of such cases and a substantial
number of UK police forces thought having a profiler involved to be of value in various ways.
The targets of profilers are often those difficult offenders who pose considerable risk to the public
and the greatest challenge to police and the justice system
Challenging issues in forensic psychopathology
Some forms of criminal activity and groups of offenders lie within the overlap between clinical and
forensic psychology.
The more we know about these criminals, the more we realize how difficult they are to deal with in
the given legal and medical frameworks at our disposal. The following examples of stalking, sex
offenders and psychopathic or DSPD offenders may seem to be discrete categories of criminals, but
there are overlaps between each and all of these.
Stalking
Stalking in a clinical forensic context refers to a pattern of behaviour that involves the repeated
significant harassment of one individual by one or more other people. Counter to public perceptions,
the majority of stalkers do not kill or seriously injure their victims.
Stalkers are primary examples of systems abusers in that they break the rules that victims and others
abide by giving them a functional advantage.
Definitions of stalking
Stalkers are very controlling, emotionally abusive and usually have psychiatric and/or criminal
histories. They are manipulative serial bullies, motivated by anger and control rather than sex or
love, to inflict psychiatric injury on their victims. Around 79 per cent of stalkers are male, who are on
average more intelligent and older than other criminals.
Canter (1994) refers to the consistency of interactional style of those who offend against others, and
this is true of stalkers who, although single, will often have a history of failed and disturbed
relationships.
Types of stalker
Having a typology for stalkers can lead to more effective interventions to prevent harm without
wasting resources.
- Rejected stalker: the rejected stalker is the most common type. In this case, the victim is an
ex-intimate and the stalker purports to seek reconciliation, though this may turn to revenge
over their rejection. They deny the relationship has ended whilst seeking a perpetuation of
what has usually been a poor relationship. The rejected type is often sane but angry, showing
depending characteristics, poor social skills and interpersonal inadequacy. They are normally
responsive to treatment and legal sanction, but may resort to physical attack more often
than the other types of stalker with the exception of the predatory type.
- Intimacy seeker; the intimacy seeker is often deluded or otherwise disordered, but even if
pathology is not apparent, they will still engage in a one-sided fictional relationship with a
particular stranger. Their solitary real lives are usually lonely and devoid of intimacy, and as a
result their understanding of intimacy may be drawn from fiction and lack reality testing. This
category will include the historical erotomanic or de Clerambault type and, although rare,
may gain disproportionate publicity and sometimes infamy as celebrity stalkers.

They interpret rejection or almost any response from the victim as affirmation of mutual
affection.
The intimacy seeker tends to be faithful to one victim, but their fictional relationship may not
always be of the romantic type and could be parental. If the delusion is responsive to
medication, the behaviour may diminish, leaving the intimacy seeker more amenable to skills
training.
Incompetent suitors: the incompetent suitor is deficient in interpersonal skills and
particularly in courtship skills, but still wants a relationship or at least some approximation to
their understanding of a relationship. They may vary from the socially isolated with schizoid
or autistic-like traits to the arrogant, insensitive and overconfident, but all will lack effective
intimacy skills and be indifferent to the preferences of their victim. The incompetent suitors
pursuit tends to be very brief and they are easily dissuaded from this by sanctions. However,
they are serial stalkers and rapid recidivists, moving on to a new victim with the minimum of
respite. Their poor skills provide a target for intervention, and training can be a successful
treatment approach for their stalking behaviour.
Resentful stalkers: this group deliberately frighten their victims, exerting power and control
by utilizing more extreme tactics such as sending wreaths or some form of offensive material
to their victims address, and may involve the victims work colleagues, family or friends.
The resentful types are often resentful against authority in general and tend to see
themselves as victims rather than perpetrators. They are suspicious of therapy, but it is
useful in addressing their paranoid traits and sometimes comorbid disorders such as
depression and substance abuse.
Predatory stalker: this is the most dangerous but fortunately a rare form of stalker. The
predatory stalker pursues in preparation for attack, usually sexual assault or even homicide,
without alerting their victim. These are stranger stalkers driven by power and control, who
derive pleasure from the secretive, voyeuristic observation and planning of their assault.
They are dangerous, almost always male, and their sexual intent is deviant and predatory.
They are usually lacking in sexual skills, confidence and experience.

Victims of stalking
The vast majority of victims are ordinary people, who rapidly find their lives dominated by
pathological pursuit, suffering privately without the public interest given to their celebrity
counterparts. There are evident risk factors for becoming a victim of stalking such as being female,
professional ,educated, single and in the age group 18-30.
Victims are likely to have a prior history of reported domestic violence, which may outlive the
relationship.
75 per cent of known victims of stalking are female.
Violence is found to be greater for female victims and in cases where there has been a prior
relationship with the victim. However, most victims find the persistent threats and intrusive
behaviour of their stalkers far more damaging to their health, occupation, and social and personal
relationships than physical assault.
Victims suffered high levels of anxiety, insomnia and other symptoms with over a third having met
the criteria for post-traumatic stress disorder.
Stalking of professionals
Professionals prone to being victims of stalking can be anyone in public eye, but those in one-to-one
contact with clients are more at risk: for example, GPs, psychiatrists, counselors, lawyers, therapists
and even dentists are all at an increased risk from all types of stalkers.

This vulnerability also applies to those in the media where pseudo-intimate relationships occur, as
they become a familiar face that appears to speak directly to those prone to talk, such as intimacy
seekers.
Stalkers of professionals will mistake attention or concern for affection, perceive the professional
relationships as personal and treat professional duty as a form of interpersonal commitment.
Forms of contact
Forms of contact by stalkers vary from daily letters and perhaps 200 phone calls a day (and night), to
receiving a mutilated animal by post or having pornographic material delivered to the victims work
colleagues.
A victims sense of control of these situation is greatly challenged when the stalker involves their
spouse, family, friends and employer by fabricating information, or by direct threat to these key
people in the victims life.
Stalking by letter is common, but anonymous letters are rare in stalking.
Cyberstalking
Victims are particularly disturbed by having detail of their daily movements related back to them by
their stalker via constant emails, SMS or instant messaging.
The gender ratio of stalking victims is similar to that of terrestrial stalking with it affecting around 4-5
times more women than men
Thus victims of cyberstalking can be subject to intense psychological stress and public denigration
that cannot be simply dismissed as less harmful or even equivalent to terrestrial stalking, as in many
cases the effects can be much worse.
Activities often referred to as cyberaggression, such as flaming, mail bombing or spamming, and
ultimately identity thefts, have become the tools of cyberstalkers.
Help for victims: stalking legislation
General advice to potential victims tends to oppose their natural reactions, including bringing in the
police as soon as viable to avert future stalking, keeping all evidence of harassment and documenting
incidents.
Victims of stalking most frequently turn to family and friend for help, and tend only to involve the
police where crimes are overt. The police are increasingly more sympathetic and less suspicious of
complaints of harassment and may rapidly give a verbal warning to the other party, which can be
effective in many milder cases.
Clinical aspects of stalkers and their management
Many stalkers also have DSM-IV-TR personality disorders.
In particular, cluster b personality disorders, including anti-social personality disorder and
psychopathic personalities, are associated with predatory stalking. Narcissistic personality disorder is
rare, but more common in stalkers who pursue famous or high-standing victims, and schizoid
personality or autistic spectrum traits can characterize some of the incompetent suitor types of
stalker, who have poor social skills and may display an indifference to the feelings of their victims.
Morbid jealousy often co-occurs with paranoid personality and is also a feature shared with a
number of stalkers, particularly rejected ex-intimates. Dependent personality disorder is common

amongst rejected talkers, but it can also occur amongst some longsuffering victims, who may be
over-tolerant of harassment.
Treating mood disorders amongst stalkers can reduce their harassing behaviour and improve their
receptiveness to further interventions.
Clinical approaches to stalkers will often take place during detention in prison with a strong emphasis
on risk assessment and careful evaluation of the outcomes of interventions, as stalking is an
extremely persistent behaviour.
Selective serotonin reuptake inhibitors (SSRIs) can be used with a number of stalkers.
For the clinical forensic psychologists, the use of cognitive behavioural therapy (CBT) is an important
intervention that can erode aspects in the thinking and behaviour of stalkers that precipitate and
sustain their behaviour.
Sex offenders
Sexual offences tend to fall into three overlapping areas: rape and sexual assault; pedophilic
offences; and other paraphilic offences.
As almost all cases of paraphilic activity can also be defined as criminal acts by legal systems.
Sex offenders in general and pedophilic offenders in particular are often considered distinct from
other criminals by the justice system, and are demonized by both media and public.
In clinical terms, the paraphilias are a subgroup of the sexual disorders, and although they may be
distinct in legal terms, the disorder groups are related in terms of therapy and ultimately risk
assessment. In reoffending terms, it may be as important to encourage acceptable sexual desire and
skills as it is to reduce paraphilic or offending behaviour.
Sexual offences
A central issue in defining offences is that of consent, or the extent to which the intentions and
actions of the perpetrator are unwanted and unsolicited by the victim.
It has been suggested that consent should not be part of the definition of sexual offences, in order to
avoid the focus on the victims contribution to a case and to concentrate on the offender.
Rape is the non-consenting penetration of vagina, anus or mouth, or in the case of statutory rape,
penetration of a child under the age of consent. Rape tend to stigmatise both offender and victim,
which is often used to dissuade victims from pursuing their case and can intimidate those who are
accused but innocent.
The relationship between victim and offender is important in some typologies, such as the degree of
attempted intimacy with the victim or so-call unselfishness.
Some rapists show a lack of self-esteem and a need to assert their dominance via sexual assault and
have often limited sexual skills or the ability to relate to females as a route to sexual experience. Such
a deficit in skills and esteem can be addressed by cognitive behavioural therapy and training.
In clinical terms, pedophilia is a form of paraphilia in which the inappropriate target for sexual
gratification is a sexually immature child, and in contrast to the context-specific prosecution of other
paraphilias, pedophilic acts to tend to be universally criminalized.

Pedophilic offences are most commonly non-contact offences involving child pornography, exposure
or pedophilic voyeurism. Pedophilic penile penetration is relatively infrequent and pedophilic
offences by strangers are far less frequent than offences within families, which is often counter to
public perception.
Issues in the management of sex offenders
The management of sex offenders involves their initial assessment, treatment, risk assessment and
subsequent monitoring in the community.
All convicted sex offenders in many countries are placed on sex offender registers, from which police
have access to information such as home address and what offences has been committed, and they
also enable police to monitor how many offenders are in their area.
Although treatment should theoretically be a top priority for this group of disordered offenders,
public protection from offending risk tends to take priority.
Psychopathy, DSPSD and public protection
Cluster B personality disorders are often seen as aggravating rather than mitigating in a defendant,
and are considered more important in a forensic than a clinical setting. Some personality disorders
have their symptoms defined in almost the same terms as criminal behaviour. Primarily, this refers to
anti-social personality disorder, but arguably psychopathy belongs with this nosological grouping.
The problem posed by the psychopathic offender and those now described as having DSPD could be
considered the heartland of clinical forensic psychology.
Psychopathy and its relationship to DSPD
All psychopathic individuals can also be diagnosed with anti-social personality disorder but less than
an estimated third of APD individuals could be classified as psychopathic.
APD criteria include persistent behaviours that are adult versions of conduct disorder, such as
offending, impulsiveness and disregard for others, the truth, finances or future plans. A DSM
diagnosis of APD usually requires conduct disorder to be diagnosed before the age of 15.
About half of adolescents with conduct disorder go on to be diagnosed as APD, with most of the
others shedding such behaviour with maturity. Around 80 per cent of convicted criminals could be
diagnosed as APD, given that the behavioural criteria include offending behaviours.
The psychopath differs from the ordinary offender or most individuals with APD, in their greater
potential for harm.
Over 90 per cent of sexual and serial killers are diagnosed as psychopaths.
Psychopathic individuals have a lack of empathy or conscience that often makes them more able in
such areas as business, the military or politics, though they are usually less than successful due to
recklessness. Individuals with APD commit most crimes, but psychopaths account for a
disproportionate excess of these crimes due to their lifetime traits and consequent recidivism.
Psychopathy is controversial as a disorder, as the sufferer rarely suffers, only those near to them, and
although they have good contact with reality, they have little insight into the concept that there is
something wrong with them or their behaviour.

They do not wish to change their behaviour and gain pleasure from exploiting and manipulating.
Thus, psychopathic individuals are not simply resistant to therapy; they will also manipulate the
therapeutic relationship to their advantage and even subvert the treatment programmes of fellow
inmates.
At the end of the twentieth century, the term DSPD was adopted in the UK to represent not only
those individuals in high security or special hospitals but also those serious offenders with
personality disorders in prison.
DSPD is not a true diagnosis but more a result of government policy and to some extent was
intended to displace the term psychopathy.
Risk and public protection
One job of the clinical forensic psychologist is to predict the reoffending risk or dangerousness of
offenders with psychopathy or DSPD, as risk assessment need to be carried out for anyone with
persistent mental health or offending problems due for discharge or resettlement into the
community
Where treatment and rehabilitation are limited but their condition raises their risk to others,
detention becomes a purely preventative measure and the primary aim of reform gives way to public
protection.

Chapter 12 Stress and illness moderators

Indirectly factors affect outcome via their influence upon cognitive and behavioural responses to
stressful demands placed on us these efforts are known as coping.
This chapter focuses on the indirect routers, ie how different personalities, beliefs and emotions
influence the stress-illness relationship, either directly, or via an effect on cognitive and behavioural
coping responses.
Coping defined
Transactional model, according to this model, psychological stress results from an unfavourable
person-environment fit: in other words when there is a perceived mismatch between demands and
resources as perceived by an individual in a specific situation. Individuals are required to alter either
the stressor or how they interpret it in order to make it appear more favourable. This effort is called
coping.
Coping involves a constellation of cognitions and behaviour that arise from the primary and
secondary appraisals of events, and the emotions attached to them. Coping is anything a person does
to reduce the impact of a perceived or actual stressor, and because appraisals elicit emotions, coping
can operate to either alter or reduce the negative emotions or it can directly target the objective
stressor.
The goal of coping is to try to achieve adaptation, and it is consequently a dynamic, learned and
purposeful process.
Coping can be cognitive or behavioural, active or passive, with many different, often overlapping,
terms being used in the coping literature.
Problem-focused coping (problem-solving function): instrumental coping efforts (cognitive and/or
behavioural)directed at the stressor in order to either reduce the demands of it or increase ones
resources. Strategies include: planning how to change the seeking practical or informational support
in order to alter the stressor; confronting the source of stress; or showing restraint.
Emotion-focused coping (emotion-regular function): mainly, but not solely, cognitive coping efforts
directed at managing the emotional response to the stressor: for example, positively reappraising
the stressor in order to see it in a more positive light; acceptance; seeking emotional support;
venting anger; praying.
Attentional/approach, monitoring, vigilant, active: concerned with attending to the source of stress
and trying to deal with the problem by, for example, seeking information about it, or making active
cognitive or behavioural efforts to manage the stressor
Avoidant, blunting, passive: concerned with avoiding or minimishing the treat of the stressor;
sometimes emotion-focused, sometimes involves avoiding the actual situation: for example,
distraction by thinking of pleasant thoughts or distraction by engaging in other activities to keep
ones mind off the stressor; disengagement through substance use.
Coping styles or strategies
Coping styles are generally considered as unrelated to the specific context or stressor stimulus;
instead, they are trait-like forms of coping that people have a tendency to adopt when facing a
potentially difficult situation.
One example of a coping style dimension is that of monitoring versus blunting.

Monitoring reflects an approach style of coping, where threat-relevant information is sought out and
processed, for example asking about treatments and side-effects, or seeking information about
forthcoming exam content.
Blunting reflects a general tendency to avoid or distract oneself from threat-relevant information.
Coping strategies derive from an approach that considers stress and coping as a dynamic process that
varies according to context, event and the persons resources, mood and so on.
What is adaptive coping?
Lazaruss model of coping suggests that it is hard to predict which coping strategies will be effective
in which situations, as both problem-focused and emotion-focused strategies are interdependent
and work together to create the overall coping response in any situation
The role of appraisal and reappraisal of coping efforts: modifications are made depending on
whether previous coping efforts are thought to have been successful or not.
Generally, it is considered that problem-focused or attentional coping is more likely to be adaptive
when there is something that can be done to alter or control the stressor event.
When facing life-changing surgery for example, or on receipt of a diagnosis of a life-threatening
illness, emotion-focused coping may be more adaptive if, in such events, the individuals has little
control over the event or if their resources to deal with it are low.
In relation to coping and adaptation, emotions can have adaptive coping functions rather than
disruptive functions.
Coping responses of fighting spirit and helplessness differentially associated with either active,
problem-focused or passive, avoidant coping behaviour. (a style of coping that involves emotional
regulation by avoiding confrontation with a stressful situation. Analogous to emotion-focused
coping.)
Meaning-focused coping: coping strategies which draw on a persons values and beliefs and
encompasses goal revision, reordering priorities and focusing on strengths in order to obtain
personal and possibly existential meaning within a negative and stressful situation. Meaning-focused
coping is thought to regulate the experience of positive emotion.
Coping goals
Coping intentions or goals are likely to influence the coping strategies employed in any given
situation and their likely success.
The reason for selecting one or more strategy to deal with a perceived stressor is related to past
experience with that coping response, but more importantly it is related to the anticipated outcomes
of that coping response, ie coping is a purposeful or motivational process. The general purpose or
goal of coping, ie to manage a situation so as to make it less distressing, brings with it an inherent
need to maintain good relations with others.
Stress, personality and illness
Personality can be defined as the dynamic organization within the individual of those psychophysical
systems that determine his characteristic behaviour and thought. This definition reflects a trait
approach to personality, which considers a persons personality profile in terms of stable and
enduring dimensions such as sensitivity, conscientiousness or neuroticism.

Big five theory which conceptualizes and assesses personality using five dimensions:
- Agreeableness, ie cooperative
- Conscientiousness, ie responsible
- Extroversion, ie sociable
- Neuroticism, ie tense, anxious
- Openness, ie imaginative, open to new experiences.
Each of these factors has been considered as a set of traits that enable both individuals and groups to
adapt to demands of life, and many associations between these relatively stable personality traits,
stress, coping and health outcomes have been reported.
Personality traits provide a helpful means for us to typify behaviour patterns, with clusters of traits
often providing typologies.
There are various possible models of association between personality variables and health and illness
that have differing degrees of directness:
- Personality may promote unhealthy behaviour predictive of disease, thereby having an
indirect effect on disease risk
- General aspects of personality may influence the manner in which an individual appraises or
copes with stress or illness events, thereby having an indirect effect on illness progression or
outcomes.
- Personality may simply be predictive of disease onset.
- Specific clusters of personality traits may predispose to specific illness.
Neuroticism and negative affectivity
Neuroticism is considered a trait which is relatively unchangeable and is a broad dimension
characterized by the tendency to experience negative emotions and to exhibit associated beliefs and
behaviours. Individuals high on neuroticism often display anxious beliefs and behaviour
disproportionate to the situation.
In terms of responding to events appraised as stressful, research has suggested that neurotic
individuals employ more different types of coping strategies and that these tend to be maladaptive
and emotion-focused coping strategies
Conscientiousness and the other big five traits
Conscientiousness, defined as being of a responsible and dependable character, following social
norms, having foresight, being persistent and self-disciplined, has shown a consistent relationship to
positive health outcomes, including longevity.
In responding to stress, those high in conscientiousness have been shown to use problem-focused
coping and their characteristic persistence is considered beneficial to self-regulatory efforts such as
when trying to control ones response to stress.
It has also been suggested that while extraversion and neuroticism are more closely associated with
emotional well-being (eg happiness), conscientiousness is more closely aligned to cognitive and
evaluative aspects of well-being (eg satisfaction).
Agreeableness is generally considered adaptive in terms of flexible coping response to stressors, and
extraversion has been found to be positive in some regards, ego appraisal, active coping, and
emotional well-being, but less so in relation to exposure to health-risk behaviours, given their
tendency to seek stimulation.

Optimism
One protective resource is that of dispositional optimism, dispositional optimists are predisposed
towards believing that desired outcomes are possible, and that this motivates optimistic individuals
to cope more effectively and persistently with stress or illness events, thus reducing their risk of
negative outcomes.
Pessimism, on the other hand, is a generalized negative outlook associated with denial and
distancing responses to stress.
Another construct related to dispositional optimism is that of unrealistic optimism, ie the view that
unpleasant events are more likely to happen to others than to oneself, and that pleasant events are
more likely to happen to oneself than to others.
This way of thinking may operate as an emotional buffer against the recognition or acceptance of
possible negative outcomes, ie it may protect people from a depressing reality.
Hardiness
Hardiness can be considered more perhaps as a belief system than part of personality, given that it
was defined as an aspect of a person arising from having experienced rich, varied and rewarding
experiences in childhood, and manifest in feelings of:
- Commitment: a persons sense of purpose or involvement in events, activities and with
people in their lives
- Control: a persons belief that they can influence events in their lives.
- Challenge: a persons tendency to view change as a normal aspect of life and as something
that can be positive.
Rather than exerting a direct effect on health, it is thought that by possessing each of these
characteristics, a hardy person would be buffered against the experience of stress, thus enabling
them to remain healthy.
Hardiness has more effect in situations of high stress than in situations of low stress, ie a buffering
effects.
Type A behaviour and personality
Type A behaviour (TAB) is a multidimensional concept combining action and emotion and is manifest
in individuals showing the following:
- Competitiveness
- Time-urgent behaviour
- Easily annoyed/arousal hostility and anger
- Impatience
- Achievement-oriented behaviour
- A vigorous speech pattern
Type b behaviour pattern is the converse of type a, ie relaxed with little aggressive drive.
Type A respond more quickly and in a stronger emotional manner to stress, and that they exhibit a
greater need for control than non-type a individuals. These features of Type A may actually increase
the persons likelihood of encountering with others and result in the individual experiencing a more
stressful environment.
Hostility and anger
Hostility emerged as an important predictor of illness from various large-scale studies.

First, hostile individuals have been found to engage in health-risk behaviour which may itself be risk
factors for illnesses such as heart disease.
Secondly, hostile individuals have been found to have a lower capacity to benefit from psychosocial
resources or interpersonal support and thus they are less buffered against the negative effects of
stressful or challenging events. This has been termed a psychosocial vulnerability hypothesis,
whereby hostility is considered to be a moderator of the relationship between stressful
environmental characteristics and health problems.
Thirdly, experimental studies have shown that hostile individuals are generally more stress-reactive
than non-hostile individuals. Reduced buffers plus a tendency to greater stress reactivity among
hostile individuals makes them vulnerable to coronary heart disease, and even acute events such as
heart attack.
Finally, investigations of the pathways through which hostility affected health status have highlighted
one of its core features trait anger.
Type C personality
Type c personality has the following characteristics:
- Cooperative and appeasing
- Compliant and passive
- Stoic
- Unassertive and self-sacrificing
- Tendency to inhibit or repress negative emotions particularly anger.
Type c personality: a cluster of personality characteristics manifested in stoic, passive and nonemotionally expressive coping responses. Thought to be associated with an elevated cancer risk.
Type D personality
Type D personality considered to be detrimental to cardiovascular disease prognosis and outcomes.
This personality type is best described as a distressed personality, with individuals scoring highly on
negative affectivity (NA) and social inhibition (SI). Type D individuals therefore are thought to
experience negative emotions but inhibit them while also avoiding social contact. There is evidence
that these characteristics associated with increased mortality following a heart attack or other
cardiac event.
Type d personality: a personality type characterized by high negative affectivity and social inhibition
Cardiac event: generic term for a variety of end points of coronary heart disease, including a
myocardial infarction, angina and cardiac arrest.
Stress and cognitions
Perceived control
Early work on the construct of control considered it to be a personality trait. Locus of control is a
generalized belief that would influence behaviour as greater reinforcements (eg rewarding
outcomes) were expected when responsibility for events was placed internally rather than externally.
Furthermore, internal locus of control beliefs would only predict behaviour in situations where the
rewards/outcomes where valued. LoC therefore refers to the trait-lie expectation that personal
actions will be effective in controlling or mastering the environment, with individuals falling on the
side of either internality or externality.
An internal individual would take responsibility for what happens to them.
An external individual would be more likely to believe that outside forces or chance circumstances
control their lives, and both success and failures would be likely to be attributed to luck or change.

It is considered that internal individuals have more efficient cognitive systems and that they expend
energy on obtaining information that will enable them to influence events of personal importance. In
other words, internally oriented individuals would engage in more problem-focused coping efforts
when faced with personal or social stressors.
The multidimensional health locus of control scale assesses the extent to which a person believes
that they themselves, external factors or powerful others are responsible for their health and health
outcomes.
The beneficial effects of perceived-control beliefs, as assessed at baseline were significantly
predictive of long-term physical recovery, but not emotional recovery in terms of reduced distress.
The importance of this type of findings is that control beliefs can be modified with simple or more
intensive intervention.
Various types of control have been described:
- Behavioural: the belief that one can perform behaviours likely to reduce the negative impact
of a stressor, eg using controlled breathing techniques prior to and during a painful dental
procedure.
- Cognitive: the belief that one has certain thought processes or strategies available that
would reduce the negative impact of a stressor, eg distracting oneself from surgical pain by
focusing on pleasant thoughts of a forthcoming holiday.
- Decisional: having the opportunity to choose between options, eg having a local anaesthetic
prior to a tooth extraction
- Informational: having the opportunity to find out about the stressor; ie the what, why, when,
where, likely outcomes, possibilities, etc. information allows preparation.
- Retrospective: attributions of cause or control of an event made after it happens: ie.
Searching for the meaning of an event can give some sense of order in life.
Each of these types of control can reduce the stressfulness of an event by altering the appraisal a
person makes of the stressor, by reducing emotional arousal or by influencing the coping responses
adopted.
Self-efficacy and perceived locus of control are the two main control concepts used in health
psychology, and they could be considered as spanning different phases of the coping process; for
example, locus of control is an appraisal of the extent to which an individual believes they can control
outcomes, whereas self-efficacy addresses appraisal of the resources and skills an individual believes
they can use in order to achieve desired outcomes. Also related to control beliefs are causal
attributions: where a person attributed the cause of an event, feeling or action to themselves, to
others, to change or to some other causal agent.
Hope
Hope was defined as a positive motivational state that is based on an interactively sense of
successful a) agency (goal-directed energy) and b) pathways (planning to meet goals).
Stress and emotions
Depression and anxiety
The role of depression in increasing the incidence/ likelihood of disease experience is controversial
and depends on the disease concerned.
Significant association between depression and CHD outcomes.
A significant association between depressed mood and mortality from heart attack has also been
reported.

Depressed mood may reflect an underlying state of negative affectivity. Cardiovascular disease
outcomes can be partially explained by high NA scores combined with social inhibition (type D
personality).
When considering pathways by which depression may affect health outcomes, there are, as with
personality, various possible routes.
First, depression and anxiety have been shown to influence the appraisals that individuals make
when facing stressful events, thus influencing the coping actions a person engages in.
The second route is also indirect, ie. Via a persons behaviour. Depression is seen to reduce the
likelihood of healthy behaviour or cessation of unhealthy behaviour.
Thirdly, there may be physiological pathways through which depression exerts its effects. Pointing to
this, individuals with elevated depressive symptoms but without a history of coronary disease were
twice as likely as their non-depressed counterparts to have carotid plaques (a significant risk factor
for CHD), and this association also controlled for baseline risk factors.
Finally, depression may also interfere with a persons ability to seek, or benefit from, social support
and supportive interactions.
Emotional disclosure
One possible moderator of coping receiving increased attentions in recent years is that of emotional
disclosure the opposite of emotional suppression, or repressive coping, commonly found to be
detrimental to health (type c personality)
Disclosure of emotional experiences is not to be confused with work on expressed emotion (EE, the
disclosure of emotional experiences as a means of reducing stress; often achieved by describing the
experience in writing, can include the venting of negative as well as positive emotion) which, has
been associated with poorer prognosis among psychiatric populations and is showing contradictory
findings among the physically ill. It is thought that venting negative emotion may maintain the
emotion by virtue of increasing the attention paid to it; it can also interfere with the potential to
receive social support.
Social support and stress
Evidence exists that people who have strong networks of social support are healthier and live longer
than the socially isolated
Definition, types and functions of social support
Social support can be actual (Received support) or perceived.
Social support is generally considered in terms of two interacting components- its structure (ie type
of support, size of networks) and the function(s) they serve.
A lack of intergration, also referred to as social isolation, is a recognized risk factor for poor wellbeing.
Social support is considered within lazaruss stress and coping framework as a resource variable that
when perceived as being available will affect how individuals appraise and respond to, ie cope with,
events. Individuals who perceive support levels as high are likely to appraise events as less stressful
than individuals who do not perceive they have any support.

Social support and mortality

Early support, with almost a twofold increased risk of mortality for both men and women with fewest
social ties, even when health status and self-reported health-risk behaviour were controlled for.
Social isolation was associated with heart disease mortality among middle-aged men followed up for
ten years.
Socio-economic and cultural factors can shape the extent to which individuals can access social
networks which facilitate support provision and receipt.
Social support and disease
Evidence of a relationship between life stress and health status has pointed to social support as a
moderator.
It has been suggested that social relationships are particularly important in diseases where physical
dependence on others, and decreased social activity resulting from the disease, are present.
How does social support influence health status?
There is ample evidence that social support effectively reduces distress during times of stress, and
furthermore the lack of social support during times of need can itself be very stressful, particularly
for people with high needs for social support but insufficient opportunities to obtain it.
Two broad theories as to how social support might operate have been proposed:
1. Direct effects hypothesis: social support is beneficial regardless of the amount of stress
people experience, and a lack of social support is detrimental to health even in the absence
of stress
2. Buffering hypothesis: social support protects the person against negative effects of high
stress. Social support acts as a buffer by either a)influencing the persons cognitive appraisals
of a situation so they perceive their resources as being greater to meet threat; or b)
modifying the persons coping response to a stressor after it has been appraised as stressful.
Gender and cultural influences on seeking support
Gender is considered to be a robust predictor of the use of social support, with many empirical
studies finding that females have a greater tendency both to seek and provide social support, and as
a result tend to report larger social networks than males.
There are consistent findings that cultural differences exist in the norms of support-seeking
behaviour and in the perceptions of available support.
People in the more collectivistic cultures may be relatively more cautious about bringing personal
problems to the attention of others for the purpose of enlisting their help because they share the
cultural assumption that individuals should not burden their social networks and that others share
the same sense of social obligation.
Can social support be bad for you?
There are some instances where high levels of social support can be detrimental.
Over-caring can cause the care recipient to become overly dependent on the carer and overly passive
in terms of their own recovery.

Chapter 14: the impact of illness on quality of life

Illness and quality of life
In order to reduce morbidity and premature mortality, there is a need to address more global
outcomes of health-care treatment and services, such as patient well being.
It is important to evaluate the individuals perceptions of how the treatment or intervention has
influenced their illness experience and their general psychosocial functioning. Quality of life (QoL)
research has become a major area of multidisciplinary research for a variety of reasons. One likely
reason is that because technological advanced in medicine can effectively treat conditions that in
previous generations people would have died from.
A consequence of this is growing acceptance of the importance of knowing about and understanding
the psychosocial as well as the clinical outcomes of treatments or interventions.
Furthermore, patients may derive great benefit from certain treatments or interventions in terms of
enhanced quality of life, even though these same treatments or interventions may not extend
survival or quantity of life.
What is quality of life?
In general terms, quality of life (QoL) can be referred to as an individuals evaluation of their overall
life experience (their situation, experiences, states and perceptions) at a given time (global quality of
life), with the term health-related QoL emerging to refer to evaluations of this life experience and
how it is affected by symptoms, disease, accidents or treatments, and also by health policy. A healthrelated quality of life (HRQoL) is therefore associated with optimal levels of mental, physical, role
(e.g. work, parent, carer) and social functioning, including relationships, and perceptions of health,
fitness, life satisfaction and well-being. It should also include some assessment of the patients level
of satisfaction with treatment, outcome and health status and with future prospects.
According to the World Health Organization Quality of Life (WHOQoL), QoL is a persons perceptions
of their position in life in relation to their cultural context and the value systems of that context in
relation to their own goals, standards and expectations. Quality of life is considered to be a broad
concept affected by an individuals physical and mental health, level of independence, quality of
social relationships, social integration and, added subsequently, their personal, religious and spiritual
beliefs.
QoL grouped into one of six domains:
1. Physical health
2. Psychological
3. Level of independence
4. Social relationships
5. Relation to environment
6. Spirituality, religion and personal beliefs.
Most of the QoL measures available to researchers or clinicians address the multiple dimensions
described above, and certainly if you asked someone nowadays what their quality of life was, their
answer would reflect many differing aspects of life.
Certainly one of the aims of assessing QoL is to ascertain the impact of disease on an individuals
functioning.
What influences quality of life?
Many factors influence QoL including:
- Demographics
- treatment
- The condition itself
- psychosocial factors

Age and quality of life

Age has been shown to influence the aspects of life considered to be important to people.
Given that QoL judgements are made by assessing present lifestyle relative to ones expectations, a
fruitful avenue of work might therefore examine whether children with chronic disease modify their
future life expectations as a result of QoL being compromised in their childhood.
Post-traumatic growth: following a traumatic event, including serious illness, a person may
experience positive psychological change, e.g. increased life appreciation, improved relations to self
and others, new life values and priorities.
Qualitative methods: concerned with describing the experience, beliefs and behaviour of a particular
group of people.
Socio-economic variables including parental income, education an occupational status, type of
housing and extent of childs extracurricular activities significantly explained QoL whereas health
status did not/
It may be that age is less important than life stage: i.e. the impact of a disabling illness on QoL might
vary according to whether or not it occurs at a time in life when a person is still professionally or
reproductively active.
The goal of healthy ageing approaches is to minimize dependency, which, in turn, it is hoped, will
reduce the costs to society of health-care provision for an increasingly ageing population.
The broadest model of understanding of what it meant to have aged successfully was most predictive
of a person reporting they had a good quality of life, or not a not good one. This broad lay model
encompassed biomedical (function), broader biomedical (e.g. roles and function), social functioning
(social networks and support), and psychological resources (e.g. self-efficacy, optimism, coping)
models, but added in socio-economic (income, capital) and environmental (safety, services, access)
factors.
Illness type appears less important than the level of any resultant physical disability, most likely
because physical disability challenges many of these other important domains a persons social,
emotional, cognitive, economic, social and environmental functioning.
While a key global aim of interventions to enhance QoL, regardless of disease type, is the
improvement and maintance of physical and role functioning, in old age as at all ages QoL continues
to be multidimensional.
One explanation for why some people with chronic illness report higher than expected, can perhaps
by found in studies of adaption which suggest that when a situation is clear-cut and understood to be
a permanent feature of ones life, adaptation is easier and better than when one beliefs their
circumstances may change.
Culture and quality of life
Culture influences many factors relevant to quality of life judgments, such as response to pain,
attitudes towards and use of traditional versus Western medicines and treatments, concepts of
dependency, and the culture of communication.
The role of culture and the underlying values and beliefs about health, illness and QoL must
therefore be considered in terms of their influence on self-reported QoL.

Aspects of the illness and quality of life

There is a reasonably strong body of evidence showing that physical illness has an impact on a
persons reported QoL.
Severity of illness is not inevitably or consistently associated with lower health-related QoL, and
disease-specific relationships need to be explored.
It is quite common for QoL not to be predicted by objectively determined severity of illness and
associated symptoms. Furthermore, among carers, it has also been shown that the severity of
symptoms or disability of the cared-for does not inevitably reduce carer QoL.
Aspects of treatment and quality of life
Treatment itself also influences QoL.
Psychosocial influences on quality of life
Among physically healthy populations, the presence of anxiety symptoms or disorder has been
associated with poor QoL. Among those with physical illness, emotional responses have also been
shown to impact upon quality of life.
Depression is the strongest predictor.
Pain affects a broad range of psychosocial functioning.
Findings highlight that several factors need to be taken into account when attempting to establish
what predicts QoL: the presence or absence of pain; the presence or absence of depressed mood;
levels of social support, ethnicity and other background stressors that may be happening
independently of the disease process under study.
There is no one coping strategy that is inherently better than another, and coping will change over
time and place depending on the demands and resources available to the person.
Perceived social support is generally considered important to personal well-being, and many positive
relationships between perceived social support, coping and adjustment to chronic disease have been
reported.
Measuring quality of life
Several main reasons have been suggested as to why QoL assessment is a useful clinical practice.
These include:
- Measure to inform: to increase understanding about the multidimensional impact of illness
and factors that moderate impact, in order to a) inform interventions and best practice, and
b) inform patients about treatment outcomes or possible side-effects in order that they are
mentally prepared for them, or so that supportive resources can be put in place.
- Measure to evaluate alternative: QoL measures may be used as a form of clinical audit to
identify which interventions have the best outcomes for the patient, but also often in
relation to costs
- Measure to promote communication
Whatever the motive for assessing QoL, a major issue faced by researchers or clinicians is which
instrument or method of assessment to use.
All its possible component parts, e.g. physical, emotional and social functioning, should be seen as
separate any of these determinant will influence changes in QoL.
Generic versus specific QoL measures.
A question remains as to whether to adopt a generic, or global, measure of QoL which assesses
concepts relevant to all illness groups or to adopt a measure specific to the illness being studied.

Generic measures, while allowing for comparison between different illness groups, often fail to
address some of the unique QoL issues for that illness.
Disease-specific measures therefore have added value, but they do not allow for the same amount
of between-illness comparability.
Individualized QoL measures
Another option available to health researchers is to take an individualized approach to assessing QoL.
Such approaches abandon the dimensions of many generic and disease-specific instruments and
allow respondents to choose the dimensions and concerns relevant and of value to them.
While individualized methods of assessment acknowledge the subjectivity of QoL, such methods are
time consuming and relatively complex processes that critics suggest may exclude their use in certain
populations.
Practicality of measures
Where assessment circumstances allow, most studies use multiple measures and, as well as assessing
generic and/or illness-specific multidimensional QoL, will generally also include unidimensional
outcome measures such as assessments of mood, pain or disability that address only one specific
aspect of QoL. There is a natural limit to how many questionnaires can be inflicted on an ill individual,
and it is important for researchers to be sensitive to this. A good research tool may not be an
appropriate tool to administer in a clinical setting.
Response shift
Some authors have found individuals with limiting illness to rate their QoL higher than do healthy
people.
Researchers have begun to consider the idea that illness can bring about changes that create what is
described as a response shift: changes in subjective reports that may result from a reprioritization of
life expectations or recalibration of internal standards so that the construct being assessed is
reconceptualised.
Qualitative findings have commonly pointed to changes in life expectations, meanings, goals and
priorities following diagnosis or during illness and therefore we should not be surprised to find that
such shifts in perspective affects how questionnaire items are interpreted and scored at different
time points.
Two final factors that warrant consideration in the development of new measures or in the choice
made from existing instruments is that of participant age and culture.
-

Cultural differences are likely to affect statistical findings and thus the conclusions drawn
from the data.
Age: many studies using parents to complete questionnaires on behalf of their children. This
is known as proxy measurement. Parents reported that more problems where faced by their
children than the children themselves reported. Healthy children, by contrast, have been
reported to show less agreement with their parents regarding their physical status than they
do in other domains.

Chapter 15 The impact of illness on patients and their families

Illness, emotions, and adjustment
The impact of illness
Illness present individuals with many challenges and issues that change over time, depending upon
the illness, the treatment, the individuals cognitive, behavioural and emotional responses, and the
social and cultural context in which the illness occurs.
Individuals facing illness are considered as having to deal with:
1. Uncertaintly: this is a period in which the individual tries to understand the meaning and
severity of the first symptoms.
2. Disruption: this occurs when it becomes evident to the individual that they have a significant
illness. At this time, they experience a crisis characterized by intense stress and a high level
of dependence on health professionals and/or other people who are emotionally close to the
individual.
3. Striving for recovery: this period is typified by the individual attempting to gain some form of
control over their illness by means of active coping
4. Restoration of well-being: in this phase, the individual achieves a new emotional equilibrium
based on an acceptance of the illness and its consequences.
In relation to cancer, a similar series of stage of response to diagnosis has been proposed:
1. Initial response: can include a range of responses, including disbelief, denial and shock.
2. Dysphoria: this phase may last one-two weeks and involves individuals gradually coming to
terms with the reality of their diagnosis.
3. Adaptations: this period may last for weeks, or months, and involves the person adapting
more positively to their diagnosis and developing long-term coping strategies in order to
maintain equilibrium.
Although these models propose a stage adaptive process, not all individuals will move through the
stages smoothly and achieve emotional equilibrium or a stage of acceptance and adaptation. It is
likely that elements from different stages may co-occur.
models of adjustment
adaptation from a medical viewpoint will consider pathology, symptom reduction or physical
adjustment; from a psychological viewpoint it may well consider emotional will-being or lack of
distress, cognitive adaptation or psychiatric morbidity; and from a biopsychosocial perspective
adaptation is likely to consider pathology, emotions, cognitions and coping responses, and also the
nature and extent of social adjustment or functioning.
The biopsychosocial approach best fits the chronic disease experience, given evidence of the critical
role of personal characteristics, appraisals, mood, and coping responses in predicting symptoms
experience and disease outcomes.
A psychological model of adjustment argued that the process of adjustment to threatening events
centre around three themes:
- Searching for meaning in the experience
- Attempting to gain a sense of control or mastery over the experience
- Making efforts to restore self-esteem
This is known as a cognitive adaptational model in that, following a stressful event, a person is
motivated to face the challenges and be proactive in finding ways to deal with them in order to
restore equilibrium in ones life.

Finding meanings implies a degree of acceptance of the situation, but not to the extent that it
produces passivity, but rather to the extent that it promotes adjustments being made that enable life
to carry on.
Negative emotional reactions to illness
Reactions to diagnosis
Most studies find that reactions to cancer diagnosis are frequently catastrophic and highly emotional,
with some individuals describing themselves quite literally as fighting for their life.
Emotional reactions to illness
For those living with diabetes, emotional distress is prevalent, a 14 per cent prevalence of
generalized anxiety disorder among those with diabetes, and a lot have depression.
In terms of living with a disease for which a certain degree of stigma is still attached, studies of those
with HIV infections and AIDS point to even higher levels of distress. Perhaps unique to those with HIV
infection, the presence of what have been identified as punishment beliefs, have been associated
with relatively high levels of depression and relatively low self-esteem.
Heart disease and heart attack, it has been estimated that one-third or more of sufferers will
experience levels of depression above cut-offs indicating clinical disorder. Depression and anxiety
often persists for up to a year following hospital discharge.
Finally, in relation to cancer, the overall prevalence rates of emotional distress have been reported as
high as 70 per cent, with both depression and anxiety considered to be present in the majority of
patients at some point.
As well as or often tied op with distress, chronic illness can also bring about a sense of loss of self to
the sufferer, a condition exacerbated by the necessity of living a restricted life due to symptoms, or
by social isolation due to physical limitations or fears of others response to their new state.
Emotional reactions to treatment and hospitalization
When ill and needing hospital treatment, not everyone will willingly submit themselves to hospital
care and take on the sick role and the depersonalization and loss of control that can often
accompany entering large institutions such as our hospitals.
Pre-surgical anxiety in both adults and children is high and has been shown to influence post-surgical
outcomes and where treatments are repeated and ongoing, patients report feelings of anticipatory
anxiety and anticipatory nausea (i.e. feeling worried and unwell just at the thought of entering
hospital for the treatments)
At all stages of treatment, health professional communication is key to whether a patient feels
informed, cared for, and able to make choices about their treatment that address their needs and
their goals.
Reactions at the end of treatment
In the immediate period following treatment, patients and their families may experience a degree of
emotional ambivalence: on the one hand, the treatment and any side-effects have stopped, but on
the other hand, a sense of vulnerability and of being abandoned can result from decreased contact
with the health professional staff, with whom relationships have inevitably built up during treatment.
A transition from curative to palliative treatment, if the former is unsuccessful, can be extremely
distressing for patients, if they understand this transition.

the effect of negative emotional reactions to illness

unfortunately, the presence of depression and anxiety can impede engagement in treatment or
rehabilitation efforts. Depressed people, for example, are less likely to attend cardiac rehabilitation
classes than non-depressed ones. Depression and anxiety have also been shown to impede
behavioural change.
Depression also exerts a significant influence on whether such patients resume pre-illness
functioning, particularly in terms of return to work and social activities, and this may in part be due
to the symptoms inflation commonly witnessed among depressed people. It is clear therefore that
depressive illness is a significant cause of morbidity and disability.
Positive responses to illness
There is consistent evidence that positive dispositional characteristics and positive appraisals can
influence outcomes either directly or indirectly, and that illness itself can bring about positive
changes.
Positive appraisals
Having a positive or optimistic outlook has been consistently associated either directly with positive
outcomes, or indirectly via effects on coping responses thought to be more adaptive.
Positive emotions
The key benefits of maintaining positive emotions:
- The promotion of psychological resilience and more effective problem solving
- The dispelling of negative emotions
- The triggering of an upward spiral of positive feelings
However, maintaining positive emotions form only part of a persons response to illness: the coping
strategies that a person adopts to help them to cope with the disease and its consequences are also
important in determining illness outcomes.
Finding benefit and post-traumatic growth
A growing number of studies are reporting that those facing significant health or life stressors often
report gains from their experience. Commonly referred to as benefit finding.
Five domains of positive change as a result of stress or trauma have generally been identified:
1. Enhanced personal relationships
2. Greater appreciation for life
3. A sense of increased personal strength
4. Greater spirituality
5. A valued change in life priorities and goals
Benefit-finding can be considered as a potential predictor of outcomes, such as improved mood,
better adjustment or QoL, but it has also been considered by some as an outcome in its own right.
The experiencing of benefits is influenced by personal characteristics and psychosocial resources,
including coping responses.
Individuals with high social support resources exhibited greater benefit-finding regardless of whether
acceptance coping (accepting the reality of a situation and that it cannot easily be changed) or social
comparison (the process by which a person or group of people compare themselves with others)
coping was used, whereas the beneficial effect of self-efficacy appeared to be mediated by coping.

Coping with illness

As with stress, there needs to be a distinction between acute illness events and chronic illnesses, as
these present the individual with the different set of challenges. The accepted cut-off for becoming
chronic tends to be where an illness and it symptoms or effects last for greater than six months, or
where there may be no potential for cure.
Three processes that resulted from the crisis of illness:
1. Cognitive appraisal: the individual appraises the implications of the illness for their lives
2. Adaptive tasks: the individual is required to perform illness-specific tasks such as dealing with
symptoms, and general tasks such as preserving emotional balance, or relationships with
others
3. Coping skills: the individual engages in coping strategies defined as either appraisal- focused
(e.g. denial or minimizing, positive reappraisal, mental preparation/planning); problemfocused (e.g. information and support-seeking, taking direct action to deal with a problem,
identifying alternative goals and rewards); and emotion-focused (e.g. mood regulation,
emotional discharge such as venting anger, or passive and resigned acceptance)
Coping by denial or avoidance
A common initial response to diagnosis or illness onset is either conscious or unconscious denial of its
occurrence. Denial appears to be adaptive in the short term as it enables the individual to minimize
any threat and cope with the distress felt. In the longer term, however, denial and the related
strategy of avoidance tend to interfere with active coping efforts and are associated with increased
long-term distress.
Problem-focused and acceptance coping
Generally speaking, after the initial period following illness onset of diagnosis has passed, problemfocused coping, such as making use of social support resources or planning how to deal with the
problems faced, and acceptance coping are associated with more positive adaptation.
A prospective relationship existed between problem-focused coping and improved health outcomes,
suggesting that effort directed to changeable aspects of the situation resulted in improved health
outcomes.
People engage in all sorts of coping efforts and do not generally use strategies defined as only
emotion-focused, only problem-focused or only avoidant. This I because situations are generally
dynamic and multidimensional, and therefore responses also need to be dynamic and
multidimensional
The coping responses of people facing illness are therefore individual and influenced by many
factors, including cultural and ethnic variables.
Crisis theory assumes that individuals cope out of a motivation to restore equilibrium and normality
to their lives. One of the key resources that most individuals have to aid in that process is that of
family support.
Illness: a family affair
People do not get ill in a vacuum: their illness exists within their immediate personal context and
within their larger social network and culture. Not surprisingly, many of the wide-ranging effects of
illness on the sufferer described earlier in this chapter can also be experienced by those closest to
the ill person.

Family system
The families of people who develop an illness also need to adapt to changes that an illness brings.
The diagnosis of serious illness and subsequent tests and/or treatment can have a significant impact
on family coping and on their levels of certainty for the future, and life goals.
Stress in the family is a pressure that can disrupt or change the family system, and they also
suggested stages in a continuum of adaption:
1. Stage of resistance: where family members try to deny or avoid the reality of what has
happened.
2. Stage of restructuring: where family members begin to acknowledge reality and start to
reorganize their lives around the notion of a changed family.
3. Stage of consolidation: where newly adopted roles may have to become permanent.
Relevant to this continuum of adaptation are the tree integrated dimensions of family system
functioning: cohesion, adaptability and communication. That families who were balanced on these
dimensions showed better adaptation to life stressors, including illness.
Three specific factors within parental coping strategies were identified:
1. Coping by maintaining and focusing on family life and the relationships therein
2. Coping by trying to maintain well-being through the use of social relationships
3. Coping by having relationships with medical staff and parents of other ill children
Caring
While family members are generally involved in providing support to a family member if they
become ill, some also become that persons primary (main) caregiver: i.e. they are required to
provide assistance above and beyond that which is normal for their role.
Caregiver confidence in the recovery of their spouse following a stroke was a significant predictor of
both patient self-efficacy beliefs and patient recovery from activity limitations two months later.
Addressing caregiver issues is therefore crucial to both patient and caregiver outcomes.
Supportive relationships
Benefits of social support include:
- Increased adherence to treatment and self-care
- Less distress/better emotional adjustment and coping with stressful events
- Better physiological functioning
- Reduced mortality or increased survival
Helpful and unhelpful caring
There are common caring actions that are perceived as helpful, such as practical assistance and
expressions of love, concern and understanding, and relative consistency in terms of actions
considered to be unhelpful. For example minimizing the situation, being unrealistically cheerful,
underestimating the illness effects on the patient, or being critical or overdemanding.
Unhelpful actions appear to have a more strongly negative effect on well-being than helpful actions
have a positive effect.
Consequences of caring
Providing regular care in the context of illness in a loved one has been seen more often as a threat to
well-being, possibly because of the emotional bonds that exist or because familial carers do more
than just provide active help on occasion, and instead are immersed in the role 24 hours a day.
Caregiver burden: the objective and subjective costs of caring to the caregiver

Emotional impact of caring

Research has suggested that up to three-quarters of caregivers for someone with chronic illness or
disability experience clinically significant distress, a level significantly higher than that found in agematched controls.
Findings suggest that caring becomes more stressful when it is judged as going beyond the call of
duty, and thus identifying caregiver role expectations and in fact their perceived spousal obligations
is important.
Physical effects of caring
Australian women aged from 70 to 75 did not find a significant difference in physical health between
the 10 percent identified as caregivers and the majority of the elderly sample. However, the
caregivers did differ significantly in terms of their emotional well-being and perceived stress levels,
supporting the reasonably consistent findings as to the emotional impact of caring.
Immunological effects of caring
The nature, intensity, duration and frequency of stressor events have been found to influence the
nature and extent of immune change in a dynamic manner, in part dependent on the state of the
immune system at the time the stressor event occurs. There is a large body of evidence that points to
immunosuppressant effects of long-term caring.
Positive aspects of the caring role
Caring may be appraised as an intrusion on personal lifeplans, but may also be appraised as positive,
to the extent that it provides affirmation of valued aspects of the self.
However, this did vary depending on the care recipients level of impairment, with care recipients
who had greater impairment generally having caregivers who reported more hassles.
Influences on caring outcomes
Features of the illness or of the cared-for
The illness of behavioural features of the care recipients have important but complex influences on
caregiver outcome.
Among caregivers of stroke survivors, while the severity of stroke impairment during the acute phase
predicted their future expectancies, it was their appraisals of the consequences of the illness and of
their coping resources that predicted their psychological well-being. Subjective appraisals of the
situation made by the caregiver therefore differ from objective features of the illness, such as
disability, in the extent to which they determine caregiver outcomes.
Older caregivers were less burdened.
An increase in negative characteristics of the care recipient predicted caregiver depression, whereas
a decrease in their positive characteristic predicted caregiver perceived burden.
The influence of caregiver characteristics and responses
Personality
- Characteristics had direct effects on caregiver mental health, as well as indirect effects via
their influence on perceived stress, and on the perceptions and appraisals of the care
recipients level of impairment

Caregiver appraisals
- The underlying source of caregiver distress or strain appears to result from subjective
appraisals of an imbalance between the demands of caring and the resources perceived to
be available to the caregiver.
- Resistance factors include intrapersonal factors such as personality and motivation, socioecological factors such as the caregivers family environment and support resources, and
stress-processing factors, which include an individuals cognitive appraisals of a situation and
their coping responses.
Use of social support
- Using social support as a coping strategy has emerged as an important predictor of caregiver
outcomes
- Perceived social support, or the lack of it, also played a central role in the stress process
model prediction QoL or burden in caregiving for a family member.
Protective buffering
- Other caregiver behaviour, such as that made in response to the patients situation, may also
influence their emotional well-being; for example, spousal caregivers have been found to
inhibit, deny or conceal negative information, thoughts ore feelings, and yield to partners, in
order to protect their partners, although in doing so they may increase their own distress
and even that of the patient partner.
The relationship between caregiver and patient
Active helping of a spouse predicted greater positive affect in caregivers when illness status,
functional impairment and being on call was controlled for, but particularly where there was a
perceived interdependence with their spouse, i.e. where the caregivers agreed with statements such
as I need my spouse as much as he or she need me. Helping and being on call generally predicted
negative affect where interdependence was low. Such findings show that interdependence may
buffer any negative effects of helping behaviours in patient-carer dyads but also highlight that not all
aspects of the caring role are negative. What is becoming increasingly clear is that, as well as the
nature of the caregiver-patient relationship, the quality of the relationship between these individuals
influences the outcomes of caring for both parties.
Relationship quality
- Understanding the nature and processes in dyadic relationships is beneficial to our
understanding of adjustment to illness.
- The quality of a relationship can moderate the effects of individual coping
- Relationship quality is also likely to interact with motivations to commence and to continue
to provide care.
Couple identity
- Another aspect that may mediate the stress of caregiving for a spouse is that of couple
identity, whereby the relationship takes on its own identity, rather than being seen as two
separate individuals.
Dyadic perceptions, shared and discrepant beliefs
It cannot be assumed that family caregivers and those they care fro will exhibit similar beliefs and
responses.
Caregivers often perceive that they are giving more than the patients feel they are receiving, which
has inevitable consequences for caregiver distress.

The most negative perceptions and conflicting perceptions emerged in relation to perceptions of
control/cure, with shared positive perceptions more evident in relation to the identity, timeline and
consequences dimensions. Dyads with shared positive perceptions fared better in terms of lower
disability, fewer sexual functioning difficulties, less health-related distress, greater vitality and better
global adjustment than dyads with negative or conflicting perceptions

Chapter 16 Pain
The experience of pain
Types of pain
Medical definitions have categorized various types of pain, including:
- Acute pain: despite most peoples experience of acute pain as lasting only a few minutes,
acute pain is defined as pain lasting less than three to six months. Some episodes of acute
pain, usually involving some form of injury, may occur only once, and generally the pain
disappears once the damaged tissue has healed.
- Chronic pain: this is pain that continues for more than three to six months. Chronic pain
generally begins with an episode of acute pain that fails to improve over time. In this
category, there are two broad types of pain: 1) pain with an identifiable cause such as
rheumatoid arthritis or a back injury, and 2) pain with no identifiable cause (85% of back pain
has no physical cause).
Chronic pain can be divided into two types:
o Chronic benign pain: in which long-term pain is experienced to a similar degree over
time.
o Chronic progressive pain: here, the pain becomes progressively worse over time due
to the progression of a disease such as rheumatoid arthritis.
Another way of thinking about types of pain is to think about the nature of the pain. Here, three
dimensions of experience are frequently used:
1. The type of pain
2. The severity of pain
3. The pattern of pain
The prevalence of pain
18 per cent of a large community sample reported some degree of chronic pain and 5 per cent
reported sufficient pain to interfere extremely with activity.
Pain is a primary reason for visiting a doctor. 40 per cent of primary care visits were the result of
pain; 21 per cent of their sample who attended their doctor with a primary symptom of pain had
experienced pain for more than six months, and 80 per cent reported limited physical function as a
consequence of their pain.
The most common areas of pain were in the lower back, abdomen and head.
The cost of pain is not only physical and psychological, but also economic.
Living with pain
Pain can have a profound effect on an affected individual and those close to them, so much as that
many people with chronic pain organize their day around their pain.
Levels of depression are high among people with chronic pain.
A further factor that may influence how people respond to pain comes from their interactions with
their social environment. Pain brings a number of costs it may also bring a number of benefits to
both the person in pain and those around them.
Three kinds of gain or reward associated with pain:
1. Primary (intrapersonal) gain: occurs when expressions of pain results in the cessation or
reduction of an aversive consequence for example, someone taking over a household
chore that causes pain;
2. Secondary (interpersonal) gain: occurs when pain behaviour results in a positive outcome,
such as expressions of sympathy or care;

3. Tertiary gain: involves feelings of pleasure or satisfaction that someone other than the
individual in pain may experience when they help them.
The various reward systems can lead to considerable problems. If an individual in pain experiences
an environment in which their expressions of pain are rewarded by outcomes that they desire and
that those around them gain satisfaction from providing, this may result in them doing less and less
to help themselves, leading to increasing inactivity, muscle stiffness and wastage, which exacerbate
any problems they may have.
Brena and chapman described the so-called five Ds that may result from such an environment:
1. Dramatisation of complaints
2. Disuse through inactivity
3. Drug misuse as a result of over-medication in response to pain behaviour
4. Dependency on others due to learned helplessness and impaired use of personal coping skills
5. Disability due to inactivity.
Biological models of pain
The simplest biological theory of pain is that there are pain receptors in the skin and elsewhere in the
body that when activated transmit information to a centre in the brain that processes pain-related
information. Once activated, this pain centre produces the sensory experience of pain. This type of
theory, known as a specificity theory.
Theories have one common tenet: that the sensation of pain is a direct representation of the degree
of physical damage or sensation sustained by the individual.
Unfortunately, it can easily be shown to be wrong.
Three sets of evidence have been used to challenge these simple biological theories of pain:
1. Pain in the absence of pain receptors
o The most dramatic example of this phenomenon is known as phantom limb pain,
which involves sensations, sometimes extremely painful, that feel located in a
patients missing limb following amputation.
2. Pain receptors that do not transmit pain
o Individual with CUIP (person who dont feel pain) appear to have intact pain
pathways, so they present the opposite problem to that posed by phantom limbs: a
failure to perceive pain in the presence of an apparently intact pain pathways.
3. The influence of psychological factors on the experience of pain
o A number of psychological factors have been found to influence the experience of
pain. Three of the key ones are:
1. Mood: anxiety and depression reduce pain tolerance and increase the reporting
of pain. Mood influences the perception of pain and pain influences mood.
2. Attention: focusing on pain increases the experience of pain
A number of theoretical models have elaborated on the role of attention in
the experience of, and response to, pain. Motivational account of bias toward
pain-related stimuli. This suggested we have an evolutionary bias towards
automatically attending to pain, at the expense of paying attention to other
goals.
A similar model was proposed by Eccleston and Crombez who identified
three basic responses to pain. First, the presence of pain initiates escape
behaviours. Secondly, pain demands and captures attention. Thirdly, the ability
of pain to capture attention and interrupt other on-going activities is influenced
by a number of characteristics of the pain: its intensity, novelty, and any emotion
such as fear that it may be associated with.

3. Cognitions: expectations of increases or reductions in pain can be self-fulfilling

Mood may influence pain by influencing our thoughts about the nature and
consequences of any pain. The types of thought that may influence the pain
experience include:
Attributions concerning the cause of pain
Beliefs about the ability to tolerate pain
Beliefs about the ability to control pain
Expectations of pain relief the placebo effect.
Expectation of pain relief: the placebo response
One of the most fascinating phenomena associated with pain is known as the placebo response..
Two key mechanisms through which the placebo effect is assumed to have its effect have been
posited. The first involves a classical conditioned response, which has been implicated in immune
and respiratory responses. A second process, particularly relevant to pain, involves our expectations
of pain or pain relief. We experience a reduction in pain because we expect a reduction in pain.
Negative expectations can lead to increases in pain the nocebo response.
A psychobiological theory of pain
The evidence considered previously suggests that two sets of processes are involved in the
experience of pain: one involving sensory information from the site of the painful stimulation, the
other involving emotional and cognitive processes.
The gate control theory of pain takes both processes into account and is generally recognized as the
best theoretical account of the experience of pain we now have.
Gate control theory of pain: a theory of pain developed by Melzack and Wall in which a gate is used
as a metaphor for the chemicals, including endorphins, that mitigate the experience of pain.
The essence of their gate control theory of pain is that the degree of pain we experience is the result
of two sets of processes:
1. Pain receptors in the skin and organs transmit information about physical damage to a series
of gates in the spinal column. Within the gates, these nerves link to other nerves along the
spinal column that transmit information up to pain centres in the brain.
2. At the same time as we experience physical damage, we also experience related cognitions
and emotions fear, alarm, and so on. This information results in the activation of nerve
fibres taking information from the brain down the spinal column to the gate at which the
incoming pain signals enter the spinal column.
The degree of pain we experience is a result of differing levels of activation in these two systems.
Pain sensations are transmitted from the site of an injury to the spinal gate by nerves known as
nociceptors, three types of which have been identified:
- A delta fibres (types I and II):
o Respond to light touch, mechanical and thermal stimuli; carry information about
brief sharp pain;
o Very strong noxious stimuli related to potential or actual damage to tissues; the
experience is short-lasting.
- C polymodal fibres:
o Slow conducting; carry information about dull, throbbing, pain which is
experienced for a longer period than that from the A delta fibres.

A second set of nerves, known as A beta fibres, also transmit tactile information, particularly related
to gentle touch.
Activation of A beta fibres to touch and gentle stimuli can close to pain gate.
The A and C fibres transmit information to areas in the spinal cord known as the substaniagelatinosa.
Nerve impulses here trigger the release of a chemical known as substance P. This, in turn, activated
nerve fibres known as T fibres, which transmit the sensation of pain to the brain:
- Information from A fibres is taken to the thalamus and on to the cortex, where the individual
can plan and initiate action to remove them from the source of the pain.
- Information from the C fibres follows a pathway to the limbic system, hypothalamus and
autonomic nervous system. Activity within the limbic system adds an emotional content,
such as fear or alarm, to the experience of pain. The hypothalamus controls activity within
the autonomic nervous system, which allows us to respond quickly to remove ourselves from
harm.
The results of this neural activity are transmitted down the spinal column through nerve pathways
known as reticulospinal fibres to the spinal gate mechanism. These may trigger the release of a
variety of chemicals into the soup of chemicals in the substantiagelatinosa, the most important of
which are naturally occurring opiate-like substance called endorphins. These close the gate and
moderate the degree of pain experienced. Activity in this system is mediated by a number of factors,
each of which influences the release of endorphins. These include:
- Focusing on the pain: worrying, or catastrophising, reduces the amount of endorphins
released and opens the gate.
- Emotional and cognitive factors: feeling optimistic and unconcerned about the meaning of
the pain increases endorphin release and closes the gate anxiety, worry, anger or
depression opens the gate.
- Physical factors: relaxation increases endorphin release and lessens the experience of pain.
Future understanding of pain: the neuromatrix
Despite the success of the gate theory of pain, it has still struggled to account for one important type
of pain phantom limb pain.
Melzack has developed a more complex theory of the mechanisms of pain that attempts to explain
this mysterious phenomenon. His model has three key assumptions:
1. The same neural processes that are involved in pain perception in the intact body are
involved in pain perception in the phantom limb.
2. All the quality that we normally feel from the body, including pain, can be felt in the absence
of inputs from the body.
3. The body is perceived as a unity and is identified as the self, distinct from other people and
the surrounding world.
Melzack contended that the anatomical substrate of the body-self is a large, widespread network of
neurons linking the thalamus, cortex and limbic system in the brain. He termed this system the
neuromatrix. We process and integrate pain-related information within the neuromatrix. Related
information about a pain experience combine to form a neurosignature or network of information
about the nature and emotional reaction to a pain stimulus. Neurosignatures have two components:
1. The body-self matrix: processes and integrates incoming sensory and emotional information.
2. The action neuromatrix: develops behavioural responses in response to these networks.
Helping people to cope with pain

The first-line treatment for acute pain is generally some form of pharmacological treatment varying
in strength from aspirin to some form of opium derivative such as pethidine. Psychological
interventions generally form a second-level intervention.
Measuring pain
The simplest measure of pain involves the use of a simple linear visual analogue or numerical rating
scales typically varying from a score of 0, registering no pain, to 100, rating the most pain you could
imagine.
Another simple approach involves patients rating their pain on a series of adjective denoting
increasing pain: mild, distressing, excruciating, and so on.
The McGill pain questionnaire provides a multidimensional understanding of the nature of the pain
that an individual is experiencing. In its various forms, it measures:
- The type of pain
- The emotional response to the pain
- The intensity of the pain
- The timing of pain
Treating acute pain
A number of approaches have been used to help people to cope with acute pain. Any procedures
used need to be relatively easy to learn and use. Accordingly, most approaches to acute pain control
have focused on:
1. Increasing control: patient-controlled anaesthesia
The experience of pain following trauma or surgical operations can be made worse by
patients fears that they cannot control their pain.
Patient-controlled analgesia: using this method, the patient control how much analgesic drug
they receive through an intravenous drip albeit with some controls built into the delivery
system so they cannot exceed a specified dosage. It is assumed that because patients can control
the timing of their pain relief, they will be less anxious about the control of their pain, be more
satisfied with their analgesia and use less analgesic.
2. Teaching coping skills
a. Distraction: given the apparent simplicity of teaching distraction techniques, these
would seem to be sensible strategies to teach patients who are in acute pain or who
have to undergo painful procedures. The procedure seems to work.
b. Relaxation: a second relatively simple approach that can be taught to patients is the use
of relaxation. This involves teaching people to relax the muscles throughout their body,
particularly those close to the site of the pain. This has a number of advantages.
First, it can be used to reduce any muscular tension that can contribute to the
experience of pain. Secondly, because relaxation instruction may explicitly involve
thinking about pleasant images or at least images inconsistent with the painful situation,
it may act as a form of distraction. The concentration involved in relaxing may also
distract from pain sensations. Finally, there is evidence that relaxation promotes
endorphin release and thus has a direct impact on the pain experience.
3. Hypnosis: hypnosis is a procedure during which a health professional suggests that a patient
experience changes in sensations, perception, thoughts or behaviour. Although there are many
different hypnotic inductions, most include suggestions for relaxation, calmness and well-being.
Treating chronic pain
Transcutaneous electrical nerve stimulation (TENS)

Based on the electrical stimulation of A beta fibres in order to compete with the pain signals of painrelated nerves and stimulate C fibres to result in endorphin release: Transcutaneous electrical nerve
stimulation (TENS).
Relaxation and biofeedback
Relaxation can be used to relax the whole body or to relax specific muscle groups such as those on
the forehead or back, which contribute to headaches and back pain, respectively.
Biofeedback: technique of using monitoring devices to provide information regarding an autonomic
bodily function, such as heart rate or blood pressure. Used in an attempt to gain some voluntary
control over that function.
- Electromyographic (EMG): measures the small amount of electrical current in the muscles
- Galvanic skin response (GSR): measures general tension in the body by measuring subtle
changes in the moisture typically of the hand.
- Thermal biofeedback: based on a theory that warming the skin can reduce the pain of
headaches.
As relaxation is both simpler and cheaper to implement, this should perhaps be the first-line
treatment rather than biofeedback.
An alternative strategy has been to combine relaxation with antidepressant medication.
Behavioural interventions
Behavioural interventions are based on operant conditioning processes.
Operant theory states that pain behaviour may be established and controlled not only by the
experience of pain but also by how others respond to expressions of pain.
The aim of behavioural interventions is to reduce disability by changing the environmental
contingencies that influence pain behaviour to remove the individual from any reinforcement of
their pain behaviour. Non-pain related, adaptive behaviour is reinforced. The methods used include:
- Reinforcement of adaptive behaviour such as appropriate levels of exercise
- Withdrawal of attention or other rewards that were previous responses to pain behaviour.
- Providing analgesic medication at set times rather than in response to behaviour
Cognitive-behavioural interventions
Behavioural programmes may indirectly change pain-related cognitions, and these changes may
contribute to any improvements that patients make. Cognitive-behavioural approaches tackle these
issues more directly. They focus on the cognitions mediating our emotional and behavioural
responses to pain. Cognitions are seen as central to our experience of pain, and our reactions to it.
The goals of cognitive-behavioural therapy for pain are threefold:
1. To help patients alter their beliefs that their problems are unmanageable.
2. To help patients identify the relationship between their thoughts, emotions and behaviour,
and in particular how catastrophic or other negatively biased thoughts can lead to increased
perceptions of pain, emotional distress and psychosocial difficulties
3. To provide patients with strategies to manage their pain, emotional distress and psychosocial
difficulties, and in particular to help them to develop effective and adaptive ways of thinking,
feeling and behaving.
Two types of cognitive intervention. The first is known as self-instruction training. In this, patients are
taught to change the commentary in their head at times of worry or concern about their pain or
activities to a more positive commentary.

A more complex cognitive process involves trying to identify the thoughts that are driving any
emotional distress or inhibiting behaviour and challenging them. This involves treating them not as
truths but as hypotheses, and challenging the hypotheses by looking for contrary evidence.
Cognitive-behavioural treatment proved more effective than not treatment on measure of reported
pain, mood, cognitive coping and appraisals, behavioural activity and social engagement. They
proved more effective than pharmacological, educational and occupational therapy interventions on
measures of reported pain, cognitive coping and appraisal, and in reducing the frequency of painrelated behaviour. Perhaps surprisingly, however, cognitive-behavioural interventions were no more
effective than the others in reducing negative, fearful or catastrophic thoughts.
Mindfulness-based interventions
As mindfulness-based interventions are becoming increasingly used in mental health settings, so are
they in physical health setting and with some effect.
It seems the intervention did not change perceptions of pain, but did help participant cope more
effectively with it.

Chapter 4 resilience (veerkracht)

Resilience refers to humans amazing ability to bounce back and even thrive in the face of serious life
challenges. Research suggests that resilience is a widely shared human capacity that many people
may not know they possess until confronted with trauma or crisis.
What is resilience?
Developmental perspectives
Definitions of resilience share a common core of meaning, focusing on good outcomes following
significant life challenges. Such challenges have the potential to derail normal development and
undercut healthy functioning.
It is important to recognize that descriptions of resilient responses or resilient individuals are
judgment calls. Two factors are involved. For a judgment of resilience to be made, a person must first
face a significant threat or risk that has the potential to produce negative outcomes.
Without a demonstrated risk, there is no resilience.
The second part of resilience requires judgment of a favorable or good outcome. The standards for
judging outcomes may be defined by the normative expectations of society for the age of situation of
the individual
Finally, some researchers have also defined resilience as an absence of problem behaviours or
psychopathology following adversity. Children of alcoholic, mentally ill, or abusive parents may be
judged resilient if they dont develop substance abuse problems, suffer mental illness, become
abusive parents themselves, or show symptoms of poor adjustment.
Resilient responses to adversity are common across the life span.
As in childhood, resilient responses to challenge are quite common across the life span
phenomenon called ordinary magic.
The foundations of resilience include psychological resources such as a flexible self-concept that
permit people to change key features of their self-definition in response to changing circumstances, a
sense of autonomy and self-direction, and environmental mastery and competence. Social resources
are also important to resilience.
Clinical perspectives
Clinical investigations have examined how people cope with more specific life challenges occurring
within a shorter frame of time.
Recovery and resilience represent two distinct patterns of response.
Recovery, judged by mental health criteria, involves a period of clinically significant symptoms lasting
at least 6 months. This period is followed by a much longer time frame of several years, during which
the individual gradually returns to the level of mental health that existed before the trauma or loss.
Resilience, on the other hand, involves short-term disturbances in a persons normal functioning
lasting only for a period of weeks. This disturbance is followed by a return to relatively stable and
generally healthy functioning. Resilience is characterized by bouncing back from negative
experiences within a relatively short period of time. The concept of resilience highlights the strength
of the individual and his or her coping resources. Recovery begins with more severe reactions and
takes considerably more time before the person returns pre-event levels of function. The concept of
recovery highlights individual vulnerability and coping resources that have been overwhelmed.

chronic and delayed patterns of response to trauma are characterized by enduring or delayed
disruptions, respectively.
Resilience is both a common and a healthy response to loss and trauma
Resilience research
Sources of resilience
Resilience is best characterized as ordinary magic. Resilience in the face of challenge is quite common
and does not arise from superhuman effort or abilities.
The dangers of blaming the victim
Studies of resilience must not be taken to mean that people are personally responsible for the level
of distress they experience following and adverse life event.
Some of the protective factors involved in resilience are within the person in his or her abilities,
personality, and coping skills. However, it is critical that we avoid the potential dangers of assuming
that people who suffer more severe reactions to adversity and need help to recover are somehow
responsible for their difficulties.
Blaming a victim for her or his own distress can impede recovery by adding an additional source of
stress, and by reducing the social support a person needs to recover.
It is important to note that the traits and abilities associated with resilience are part of most peoples
psychological makeup. They are not highly unusual or rare. It is also important to recognize that
whatever traits contribute to resilience, together they comprise only one component. To regard
resilience as primarily dependent on the inner strength of the individual would be both misleading
and incomplete.
Masten and Reed have described three general categories of protective factors: those within the
child, within the family, and within the community.
Sources of resilience in children
Protective factors within the child include:
- Good intellectual and problem-solving abilities
- An easy-going temperament and a personality that can adapt to change
- A positive self-image and personal effectiveness
- An optimistic outlook
- Ability to regulate and control emotions and impulses
- Individual talent that are valued by the individual and by his or her culture
- A healthy sense of humor
Protective factors within the family include:
- Close relationships with parents or other primary caregivers
- Warm and supporting parenting that provides clear expectations and rules
- An emotionally positive family with minimal conflict between parents
A structured and organized home environment
- Parents who are involved in their childs education
- Parents who have adequate financial resources.
Protective factors within the community include:
- Going to a good school
- Involvement in social organizations within the school and community

Living in a neighborhood of involved and caring people who address problems and promote
community spirit
Living in a safe neighborhood
Easy availability of competent and responsive emergency, public health and social services.

Resilience, according to Masten, has more to do with the health of these protective systems than
with the specific nature of the adversity faced.
Mastens concept of ordinary magic summarizes two aspects of resilience research. First, it points to
the finding that many people show resilient response to significant life challenges. Secondly, it points
to a lack of extraordinariness in the sources of resilience.
Focus on research: resilience among disadvantaged youth
Self-regulation was the most powerful predictor of resilience in this study. Self-regulation refers to a
persons ability to guide and direct behaviour toward desirable goals over time and across varying
situations.
Self-regulation is particularly important in coping with stressful life situations.
Cognitive and emotional self-regulation skills
Buckner and his colleagues found that resilient youths, compared to non-resilient youths, scored
significantly higher on measures of cognitive and emotional self-regulation. Cognitive self-regulation
serves an executive function in directing action and solving problems
Emotional self-regulation is equally important to resilient living. Emotional self-regulation refers to
the ability to keep your cool in tough situations.
Developing self-regulation abilities
The degree of parental monitoring also differentiated resilient from non-resilient youth.
Monitoring probably contributed to childrens awareness that they were cared for and valued,
thereby perhaps contributing to their own sense of worth and their development of self-regulation
skills.
Sources of resilience in adulthood and later life
Many of the factors that contribute to resilient responses in childhood also contribute to adult
resilience.
The six dimensions presented below describe psychological well-being
1. Self-acceptance: self-acceptance defines a person who has a positive attitude toward himself
or herself and accepts all the varied aspects of self, including both strengths and weaknesses.
2. Personal growth: personal growth refers to a persons feelings of continued development
and effectiveness, and an openness to new experiences and challenges
3. Purpose of life: purpose in life means that you have goals and beliefs that give direction to
your life.
4. Environmental mastery: mastery refers to a feeling of competence and the ability to manage
the complex environment of todays fast-placed life.
5. Autonomy: autonomous people are comfortable with self-direction, taking initiative, and
working independently.
6. Positive relations with others: people who have positive relations have warm, satisfying, and
trusting interactions with others and are capable of empathy and intimacy.

Research has shown that these factors are predictive of resilient responses in the face of adversity,
and in successful aging and the maintenance of good mental health
Successful aging
Recent studies focusing on the process of aging support the operation of basic adaptive and
protective systems that provide strength and resilience as people enter the final stages of life.
One recent theory called socioemotional selectivity theory helps explain how age-related changes
can be the basis of a more satisfying, pleasurable, and hassle-free life, and for stronger social
support.
Carstensen argues that peoples perception of how much time they have left in life exerts a powerful
influence over the goals they choose to pursue. Aged individuals tend to perceive time as limited
because most of their lives lie behind them.
According to socioemotional selectivity theory, as people realize they have fewer years remaining in
their lives, they begin to shift their energy and attention away from activities and goals related to the
future and come to focus more on the present. This transition involves a shift in emphasis, from
knowledge-related social goals that prepare a person for the future, to emotion-related social goal
that maintain and enhance ones present life situation.
The age-related changes described by the socioemotional selectivity theory can be seen as adaptive
responses that create resources for resilience as one faces the inevitable challenges of aging.
Growth through trauma
A growing body of empirical literature reveals that many people find meaningful life lessons, a
renewed appreciation for life, and increased feelings of personal strength as a result of traumatic
experiences.
Positive outcomes arising from traumatic experiences have been referred to as posttraumatic growth
(PTG).
Negative effects of trauma
Posttraumatic stress disorder (PTSD) symptoms include repeated reliving of the traumatic event in
memory, and intrusive thoughts and feelings associated with the event.
Janoff-Bulman argues that the psychological toll of trauma occurs, in large part, because traumatic
events shatter peoples basic assumptions about themselves and the world they lie in. She described
three basic assumptions that are challenged by trauma: 1) the belief in personal invulnerability; 2)
the perception of the world as meaningful and comprehensible; 3) the view of ourselves in a positive
light.
The first assumption refers to the belief that it cant happen to me. After victimization occurs,
people know something bad can happen to them and they spend considerable time and energy
worrying that trauma may occur again.
The second assumption, that life is meaningful and comprehensible, may also be contradicted by a
traumatic experience. After trauma, a persons life may seem chaotic and confusing. Victims
frequently ask themselves, why me? Or what did I do to deserve this?.
The third assumption, concerning positive self-image, may undergo a similar transformation.
Research shows that peoples sense of personal worth and self-esteem is often deflated and
undermined by trauma.

Positive effects of trauma

The general explanation for PTG is that challenged beliefs and assumptions about life can provide a
basis and a opportunity for personal growth. Over time, people may learn deeper lessons about
themselves and about life.
Explanations for growth through trauma
Frankl argued that a will to meaning was a basic motivating force in peoples lives. He thought that
people need an overarching sense of purpose, meaning, and direction to sustain them through lifes
journey.
When traumatic experiences shatter or disrupt these goals and purposes, life may be perceived as
meaningless. Under such conditions, people are highly motivated to restore a sense of meaning and
purpose to their lives. Such circumstances present opportunities for personal growth as people
develop and commit themselves to new goals, ambitions, and purposes that re-establish their sense
of meaning and direction.
How do people create growth and find meaning out of trauma and suffering? Meaning-making refers
to an active process of reappraisal and revision of how an event might be interpreted or what it
might signify.
Researchers have focused on two forms of meaning-making following tragedy: making sense of the
event, and finding benefits or positive outcomes.
Sense-making refers to making the event comprehensible in terms of beliefs about how the world
operates.
The second form of meaning-making is called benefit-finding. This involves finding benefits or
positive outcomes in trauma and loss.
Reported benefits typically fall within the three categories described earlier: perceptions of the self
as stronger, closer relationship, and greater clarity concerning what is truly important in life.
Focus on research: in their own words- making sense of loss
Making sense of loss contributed to less distress only if it occurred during the first year after the loss.
Benefit-finding was associated with longer-term adjustment to loss.

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