Week 3
Millions23
Week3.docxInstructions
Multigenerational communities are being built all around the United States. Even Jimmy Buffett has created one in Florida. With such a hectic life, many people yearn for a return to a simpler way of living, where there is very little mental stress and health and well-being are promoted through community gardens, art, cultural activities, and physical health. For an example, review the information on Serenbe, a multigenerational community near Atlanta, Georgia, located in this week’s resources.
After reviewing this week’s resources, conduct further research on other multigenerational communities that promote positive emotions, diversity, a sense of community, inclusion and thriving. How do they attract LGBTQ families or minorities? What kind of activities, resources, worship centers, etc. would be attractive? Be sure to conduct additional research for scholarly articles in the library as well. These articles could be related to these types of communities or how diversity is celebrated in any structure, organized community.
Develop an annotated bibliography with your research results. Incorporate at least 10 peer-reviewed studies from the last 5 years, unless they are historical or seminal. After each annotation, indicate how the study might inform the proposal for your Signature Assignment.
Following your annotated bibliography, include a paragraph that details the primary role of the community and why that type of community appeals to you for the final project. Remember, for the Signature Assignment, you will draft a proposal for developers who build vibrant communities for multigenerational groups. Think about the type of vision you have for this community after reviewing the Serenbe Community and conducting your research for this assignment.
Length: Annotated Bibliography plus paragraph for the Signature Assignment, but not including title and reference pages
References: Include a minimum of 10 scholarly resources
Your assignment should demonstrate thoughtful consideration of the ideas and concepts presented in the course by providing new thoughts and insights relating directly to this topic. Your response should reflect scholarly writing and current APA standards where appropriate. Be sure to adhere to Northcentral University's Academic Integrity Policy.
Upload your document and click the Submit to Dropbox button.
Due Date
May 28, 2023 11:59 PM
All The Readings Needed
https://www.mindsetworks.com/Science/Default
https://www.mindsetworks.com/Science/Impact
Whereas the vast majority of researchers have centered on understanding the role emotions play in pathology, dysfunction, and disorder (Ong, Bergeman, Bisconti & Wallace, 2006), positive psychologists have focused on how emotions and protective factors contribute to the flourishing of individuals and societies (Seligman & Csikszentmihalyi, 2000). Rejecting the deficit-based models underlining normative analyses, behavioral problems and mental illness, this relatively new branch of psychology has demonstrated interest in understanding how individuals respond successfully to adversity, trauma and tragedy. Through the exploration of “what works,” “what is right,” and “how people manage to improve their lives” (Sheldon & King, 2001, p. 216), positive psychologists contribute to our existing knowledge regarding how positive emotions help us adapt during times of stress. Within the wide range of adaptive human characteristics explored in their studies, the psychological concept of resilience has received significant attention that has translated into an impressive and extensive body of scholarly literature (Luthar, 2006; Masten, 2001). As a result of their strong contribution in the area of psychological resilience, positive psychologists claim that their empirical findings have effectively brought to light the developmental strengths and resourcefulness of their participants (Aspinwall & Staudinger, 2003; Keyes & Haidt, 2003; Peterson & Seligman, 2004; Seligman, Reivich, Jaycox, & Gillham, 2007). Pursuing their claim further, we have found numerous positive psychology studies reporting on the resilience of a variety of populations including trauma victims (Bonanno, 2008; White, Driver, & Warren, 2008), college students (Mak, Ng, & Wong, 2011), the military (Cornum, Matthews, & Seligman, 2011; Reivich et al., 2011), Jews and Arabs (Hobfoll et al., 2009), injury patients at rehabilitation clinics (Quale, & Schanke, 2010), men (Hammer & Good, 2010), and many more. However, some critics have pointed out that this far-reaching literature on resilience has failed to include the voices of nonheterosexual families (Meyer, 2003; Torres, 2011). Further, the focus in positive psychology has remained on individuals, not on families. Because nonheterosexual families face unique challenges that heterosexual families do not (e.g., heterosexism and sexual prejudice), it would be inappropriate to assume that positive psychology literature on resilience, which has mainly focused on heterosexual individuals, helps advance our understanding regarding the systemic strengths that enable thriving in overlooked lesbian, gay, bisexual, transgender, or queer (LGBTQ) families.
Addressing overlooked LGBTQ and systemic factors in positive psychology, this article draws on family resilience literature and LGBTQ literature to theorize a systemic positive psychology framework for working with nonheterosexual families. Hoping to help practitioners understand, elicit, and amplify the systemic strengths that enable thriving in LGBTQ families, we developed the LGBTQ relationally based positive psychology framework. This framework integrates positive psychology’s strengths-based perspective with the systemic orientation of Walsh’s (1996) family resilience framework along with the cultural considerations proposed by LGBTQ family literature. We theorize that the LGBTQ relationally based positive psychology framework takes into consideration the sociopolitical adversities impacting nonheterosexual families and sensitizes psychologists, including those working in organized care settings, to the systemic interactions of same-sex loving relationships. Our framework proposes that understanding the systemic interactions of LGBTQ families as well as the sociocultural and political context in which those interactions take place, can help practitioners improve the quality of health care services delivered and can help offer clients a valuable treatment experience. Practitioners working in organized care settings often need to collaborate with clients who feel unheard and misunderstood by health professionals. According to researchers, working with the larger family system can help offer clients support and can assist practitioners in the development of a treatment plan that promotes family involvement as clients work through noncritical or critical situations (de Jong & Schout, 2011). Unlike traditional approaches used in public mental health that often center on the individual, our framework is driven by the entire family system. In this article, we hope to encourage practitioners to explore the resources and strengths that have enabled LGBTQ families to overcome stressors including heterosexism, sexual prejudice, and institutional discrimination, among others. In a post-Defense of Marriage Act (1996) world in which federal health care benefits have been extended to same-sex married couples, their children, and stepchildren, organized care settings will likely notice an increase in the demand for public mental health services from nonheterosexual families (Respect for Marriage Act, 2013). With that in mind, health professionals interested in increasing customer satisfaction and building an affirming practice for LGBTQ families, should consider incorporating the LGBTQ relationally based positive psychology framework into their clinical practice. Our resilience framework promotes an inclusive definition of “family” and encourages practitioners working in public service settings to create a warm therapeutic environment that celebrates same-sex loving relationships. Our framework utilizes a culturally sensitive approach that may help clients who have had negative experiences with organized care settings and their staff in the past, feel connected, valued, and supported.
Literature Review
Although lesbians and gay men report relatively high utilization rates for counseling and psychotherapy services (Liddle, 1997), research “addressing the care of LGBT populations in the public sector appears to be nonexistent” (Hellman & Drescher, 2005, p. 16). In addition, recent studies demonstrated that both rural and urban providers in the public sector lack adequate training and competency on LGBTQ issues (Warren & Smalley, 2014). Researchers argue that there is an absence of coordinated funding opportunities in the public sector to support research and practice on LGBTQ mental health issues (Hellman & Drescher, 2005). According to Semp (2011), the limited research on public mental health services for the LGBTQ population suggests that professionals working in the public sector often ignore their clients’ sexuality. In addition, studies suggested clients receiving public mental health services reported feeling uncomfortable disclosing their sexual orientation, even when they believe their sexuality is relevant to their mental health concerns (Semp, 2011). With the former in mind, many psychologists have recognized the need for culturally sensitive psychological services to help the LGBTQ community. Maylon (1982) asserted the necessity for gay affirmative therapy, an approach which “represented a special range of psychological knowledge which challenges the traditional view that homosexual desire and fixed homosexual orientations are pathological” (p. 69). His approach encouraged the development of literature highlighting gay affirmative practice (GAP) within the fields of psychology and social work (Appleby & Anastas, 1998; Crisp, 2007; Crisp, 2006; Davies & Neal, 1996, 2000; Hunter & Hickerson, 2003; Hunter, Shannon, Knox, & Martin, 1998; Neal & Davies, 2000; Tozer & McClanahan, 1999; Van Den Bergh & Crisp, 2004). Several scholars have discussed guidelines for practicing GAP such as abiding by one’s professional code of ethics, not assuming the client is heterosexual, becoming attentive and mindful to different “coming out” stories, and practicing awareness of our own heteronormative and gender normative assumptions, among others (Appleby & Anastas, 1998; Hunter et al., 1998). Likewise, Davies and Neal (1996, 2000; Neal & Davies, 2000) declared that a gay affirmative approach does not require a distinct set of skills and techniques, it simply requires treating LGBTQ individuals with respect, fairness, compassion, and as having value. Altogether, the premises of GAP demonstrate a commitment to counteracting the effects of homophobia and heterosexism by calling practitioners to surpass a neutral position by “celebrating and advocating the validity of lesbian, gay, and bisexual persons and their relationships” (Tozer & McClanahan, 1999, p.736). Although psychologists have contributed research on the positive aspects of LGBTQ identity within the past decade (Horne, Puckett, Apter, & Levitt, 2014), there is an undeniable dearth in literature highlighting a strengths-based framework for working with LGBTQ families seeking psychological services.
Some researchers have recognized the urgency for practitioners to sustain a strengths-based perspective when working with the LGBTQ population (Appleby & Anastas, 1998; Butler, 2004; Crisp, 2007; Van, Wells, & Boes, 2000). For example, Crisp (2007) and Butler (2004) suggest practitioners help sexual minorities draw upon their assets and strengths to assist them in overcoming their presenting concerns. Nevertheless, this literature is limited to the field of social work, in turn, restricting the generalizability of its implications to psychological services delivered in organized care settings. Thus, it remains that few resources are available to assist psychologists providing managed care, in their application of strengths-based approaches to help nonheterosexual families succeed. Strengths-based approaches are especially important, given that LGBTQ clients are often portrayed in the literature as wounded individuals whose victimization has produced deficits in their mental and physical health, academic achievement and identity development (Espelage & Swearer, 2008; Russell & Richards, 2003). Torres (2011) argued this deficit view has evolved because resiliency research is dominated by heterosexist ways of knowing that neglect “the lives, voices, and developmental successes of same-sex attracted individuals” (p. 12). Scholars argue that although earlier research in counseling psychology has explored the intersection of strengths and culture, positive psychology researchers have been slow in their contributions of LGBTQ research (Lopez et al., 2002). Although positive psychologists have strong convictions to help at-risk populations overcome life’s obstacles, our review found few research studies conducted by positive psychologists looking into the protective factors that help nonheterosexual families remain hopeful, optimistic and confident in the midst of difficult challenges. The question, “What makes life worth living for nonheterosexual families?” is rarely addressed by positive psychologists.
Clearly, positive psychologists are devoted to building a social science that promotes families that allow children and communities to flourish (Positive Psychology Center, 2007). Considering the invisibility of sexual minority topics in their research, what is still far from clear is whether positive psychology’s definition of “family” is inclusive of nonheterosexual families. This review points to a gap in resiliency research that rarely addresses how nonheterosexual families engage in creative behaviors and cognitive flexibility to facilitate their life pursuits. Practitioners working in organized care settings should be cautious not to overlook the culture-specific stressors faced by LGBTQ families as this may compromise the therapeutic process and therapeutic outcome. We encourage practitioners providing public mental health services to ask their LGBTQ clients the question, “What has helped your family succeed in the midst of difficult challenges?” We believe that the answer to this question may help LGBTQ families arrive at systemic solutions to their problems. Practitioners interested in exploring the underlying resiliencies and resources that have helped their LGBTQ clients and their families succeed in the face of hardship, may find our framework to be a helpful resource.
Positive Psychology Research on Resilience
Resilience is an adaptive and dynamic quality found among all humans that enables them to cope and thrive despite adversity (Garmezy & Rutter, 1983; Luthar & Wong, 2003; Masten, 2001). In the field of positive psychology, two camps have emerged that view human strengths differently. One camp proposes that strengths are universal and culture-free (Peterson & Seligman, 2004; Seligman & Csikszentmihalyi, 2000), and the other proposes that strengths are manifested differently depending on the sociocultural context (Constantine & Sue, 2006; Snyder & Lopez, 2007). The Oxford Handbook of Positive Psychology (Lopez & Snyder, 2011) contains a number of research studies conducted by the first and second camps. No culture-embedded models (the second camp) presented in this handbook addressed the resilient qualities presented by LGBTQ families. In contrast, a chapter titled “Positive Psychology and LGBTQ Populations” (Horne et al., 2014) in the book Perspectives on the Intersection of Multiculturalism and Positive Psychology by Pedrotti and Edwards (2014) offers a review of positive psychology research on the strengths of LGBTQ individuals, relationships, and families. Their review suggested that LGBTQ people have “considerable strengths in terms of self-definition, self-determination, perspective-taking, community building, and creating family networks and communities” (p. 199). Our framework integrates some of the most prominent research conducted by positive psychologists on the theory of learned optimism, the broaden-and-build theory, and literature on the positive identity in LGBTQ individuals, and captures how practitioners in the public sector can help LGBT families utilize their systemic strengths, assets, and resources to boost their resilience. The following section reviews the theory of learned optimism, the broaden-and-build theory, and literature on LGBTQ positive identity.
Seligman’s Model
Seligman’s culture-free perspective on resilience suggests that there are 24 personal strengths and universal attributes that can be found across cultures (Peterson & Seligman, 2004; Snyder & Lopez, 2007). His empirical work on resilience (2006) has led to a focus on teaching applied strategies designed to help all people from all cultures challenge adversity. He and his colleagues maintain that psychology can “transcend particular cultures and politics and approach universality” (Seligman & Csikszentmihalyi, 2000, p. 5). Seligman’s (2006) theory of learned optimism proposed that people could learn how to become optimistic if they are taught how to challenge negative self-talk. Seligman and others theorize that resilience is a protective factor that can be learned from experts in the field of positive psychology, including those providing public mental health services. They contend that individuals who master these techniques are more apt to rise above debilitating pessimism and depression. Focusing on the factors identified by Masten and Reed (2002) (e.g., optimism, problem solving, self-efficacy, self-regulation, emotional awareness, flexibility, empathy, and strong relationships), Reivich and colleagues (2011) promote the use of the Penn Resiliency Program, which trains individuals to effectively challenge their unhelpful thoughts using cognitive–behavioral principles. Contrary to Peterson and Seligman’s (2004) understanding that strengths are universal, members of the second camp argue that cultural norms construct what is considered to be “strength,” “weakness,” “the good life,” and the “good person” (Pedrotti, Edwards, & Lopez, 2009, p. 49). They propose that overlooking culturally specific strengths is problematic. Even more problematic is overlooking the inner strengths of historically “overpathologized populations” (Lopez & Snyder, 2011, p. 172).
Our framework proposes that Seligman’s research appears to be culture bound in its efforts to teach individuals, including nonheterosexual family members, strategies that have not been significantly studied or proposed to be effective with a large LGBTQ sample. Seligman’s emphasis on “teaching” and his position on strengths-promotion suggest that positive psychologists can, through innovative strategies, inform clients about stress reduction. Nevertheless, stigma, discrimination and violence against LGBTQ families create additional stresses beyond what are typically experienced by heterosexual families (Herek, 2009, 2010). The cognitive–behavioral principles found in Seligman’s resilience model are proposed as potentially helpful to all individuals and across all cultures. Yet it remains to be demonstrated that they be useful when working with families in general and nonheterosexual family systems in particular.
The Broaden-and-Build Theory
Barbara Fredrickson (2000), a positive psychologist, introduced the broaden-and-build theory of resilience. Fredrickson (2001) claimed that when people are exposed to negative experiences (e.g., failure) they tend to narrow their focus onto the problem. When this narrowing of focus occurs, they are unable to access their full cognitive potential. Conversely, when people are exposed to positive emotions (e.g., joy, curiosity, hope and contentment), it strengthens their cognitive associations, broadens their attention and empowers them to implement creative and positive solutions to their problems. Her theory proposes that resilient individuals, more than the general population, possess creative and flexible problem solving skills that help them practice the benefits of positive emotions to their advantage. She suggests that discovering positive meaning within adversity is one way that resilient individuals demonstrate their strength. Given that this theory finds a relationship between discovering positive meaning within adversity and being resilient, we pose these questions—“Are LGBTQ individuals resilient because they somehow find positive meaning in the context of traumatic experiences such as hate crimes, bias crimes and bullying?” Or, “Are LGBTQ individuals able to bounce back because they are forced to adjust to their existing environment in order to survive?” Or, “Are both valid propositions?” Fredrickson’s findings highlight the importance of building positive emotional experiences into people’s everyday lives; however, her theory is unable to account for how LGBTQ families manage to move forward while simultaneously experiencing negative emotions within the discriminatory context in which they are situated. John Chambers Christopher (2011) argues that positive psychology models such as Fredrickson’s require a move beyond objectivism and relativism and a move toward a framework that understands that reality is socially constructed across and within cultures. A move toward a culturally embedded positive psychology framework that addresses how families with multiple salient identities (e.g.- racial minority nonheterosexual families, nonheterosexual binational families, lesbian-headed families) manage to experience positive emotions while coping with threatening environments. We propose that the use of a culturally embedded positive psychology is imperative in the public sector, as practitioners work to understand how nonheterosexual families, including LGBTQ families of color, mobilize their protective systems while navigating their multiple identities across cultures.
Research on the Positive Identity of LGBTQ Individuals
Although Fredrickson (2000) has addressed positive meaning as a sign of resilience in the broaden-and-build theory, some researchers are further narrowing the existing gap in positive psychology literature on LGBTQ mental health by investigating the lives and identities of nonheterosexuals. In 2008, a positive psychology online survey found that over 500 gay and lesbian participants considered the following to be positive aspects of having a nonheterosexual lifestyle: belonging to a community, creating families of choice, forging strong connections with others, serving as positive role models, developing empathy and compassion, living authentically and honestly, gaining personal insight and sense of self, being involved in social justice and activism, being free from gender-specific roles, exploring sexuality and relationships, and enjoying egalitarian relationships (lesbian participants only; Riggle, Whitman, Olson, Rostosky, & Strong, 2008). Other studies in which LGBTQ mental health and positive psychology converged included topics like the development of a positive self-identity and self-worth among “rural lesbian youth” (Cohn & Hastings, 2010), the positive aspects of a bisexual self-identification (Rostosky, Riggle, Pascale-Hague, & McCants, 2010), and the resiliency factors reported by LGB individuals in response to anti-LGB political campaigns and legislation (Russell & Richards, 2003). Butler (2004) posits that sexual minorities possess exceptional resiliency and specific strengths that help them overcome these obstacles. She asserts that LGBTQ individuals develop coping skills through the process of accepting their sexual identity and through the coming out process. Additionally, sexual minorities gradually experience less stigma, greater flexibility, and are able to better manage social perception because of the difficulties they so often face (Butler, 2004). Although these studies did take into consideration contextual factors specific to gays, lesbians and bisexuals, they primarily focused on individuals’ perceptions of their growth-fostering connections rather than on the systemic interactions that protected their families from crisis or breakdown. Whereas the former research centered on understanding individuals’ perceptions of their growth-fostering connections, our family driven framework, focuses on the systemic interactions that help LGBTQ families thrive.
Christopher and Hickinbottom (2008) suggest that the current paucity of literature that takes into account systemic factors has resulted from positive psychologists’ focus on the Western concept of “self.” Hence, positive psychologists subscribe to an individualistic framework and “insulate themselves from reflecting critically on their work” (p. 563) as it relates to systemic, cultural, and other diversity factors. We find that Walsh’s (1996) family resilience framework may offer a way to integrate these factors. Her resiliency framework focuses on healthy family functioning and offers a relevant and systemic alternative to research focused solely on the stressors that nonheterosexual individuals endure.
By and large, resilience as a mechanism to thrive in the face of adversity has undeniable prominence in positive psychology literature. Given the problems sexual minorities contend with on a day to day basis, strengths-based approaches that emphasize resilience have the potential to be beneficial to LGBTQ individuals’ well-being. Although there is great acceptance for LGBTQ individuals and relationships in some sectors of society, considerable amounts of inequality, discrimination, heterosexism, and homophobia continue to impact nonheterosexual families receiving services in organized care settings. To better serve LGBTQ families seeking psychological services in the public sector, an approach that looks at resilience within a systemic family context is imperative. One distinct attempt at highlighting the importance of resilience from a systemic perspective is found in Walsh’s (1996) relationally based family resilience framework. In the following section, we will describe Walsh’s framework in detail.
Resilience Focused on Systems: A Much Needed Source in Positive Psychology
Walsh’s (1996) relationally based family resilience framework maintains that stressful events impact the entire family and create a ripple effect on everyone’s relationships. Family resilience theory goes beyond current positive psychologists’ research by focusing its attention on the family. Walsh’s theory proposes that family members already have the necessary tools to reduce their distress and to strengthen their relationships with others. Moreover, this framework openly challenges the myth that the standard North American family (White, intact nuclear family headed by father) is healthier than any other family constellation (Smith, 1993), and openly welcomes diverse family arrangements. Walsh (2003) argues that we need to move beyond the “myth of the self-reliant nuclear family household by expanding attention to the multiple relationships and powerful connections” that exist in today’s world (p. 47). Recently Walsh (2011) conceptualized the notion of “family” as a social construction with multiple meanings, relational patterns and unique caring bonds. In short, her framework focuses on (a) family strengths under stress, (b) multiple realities for diverse families, (c) the sociocultural context in which people are situated, (d) the belief that families have the resources to recover and grow from adversity, and (e) the understanding that what helps boost resilience are the family processes that nurture caring, safe, and committed relationships.
Regardless of family configuration (e.g.-heterosexual, nonheterosexual, single-parent headed family, multigenerational etc.), family resilience can be defined as a collectivistic phenomenon that grows and develops with each challenge allowing families to balance stress and demands (Patterson, 2002). Research suggests that in spite of stress and demands, LGBT parents often demonstrate low rates of parenting stress and high parenting efficacy (Horne et al., 2014). According to family resiliency theorists, that is because family relationships are strengthened when participants view environmental adversity as a kind of collaborative challenge that can be met by the family system (Walsh, 1998). Researchers have found support for this theory of family resilience in studies that indicate that when families employ various capabilities and protective factors, they are best suited to meet life’s demands and successfully manage risks and stressors (Power et al., 2010; Walsh, 1998). On the other hand, if environmental stressors overwhelm the family’s capabilities and resources, crises or breakdowns may occur. In other words, family systems whose resources and capabilities become depleted are at risk of being overwhelmed by breakdown and hardship. In this light, family resilience theorists advise that families build collaborative support systems that enhance family resources to successfully meet life’s inevitable challenges. Above all, because family systems are uniquely different, each family system can overcome adversity by using its own set of tools and strategies.
In the following section we propose a framework that brings together (a) positive psychology literature on the theory of learned optimism, the broaden-and-build theory, as well as literature on the positive identity in LGBTQ individuals; (b) Walsh’s family resilience framework; (c) and nonheterosexual family resilience literature. This LGBTQ relationally based positive psychology framework takes into consideration the sociopolitical adversities impacting nonheterosexual families and sensitizes psychologists, including those working in organized care settings, to the interactions of same-sex loving relationships. We propose that our framework captures the complexity of the psychological health needs of LGBTQ families seeking services in organized care settings.
LGBTQ Relationally Based Positive Psychology
We theorize an LGBTQ relationally based positive psychology framework that facilitates the support, motivation and empowerment of nonheterosexual families. Our framework seeks to explore the question, “How do nonheterosexual families manage to protect their relationships and their children from hardship while simultaneously battling stress and adversity?” We want to shed light on a population that has remained almost invisible in the positive psychology literature. LGBTQ relationally based positive psychology posits that LGBTQ families have multiple identities including ethnic, cultural, religious, political and professional identities. By challenging the heterosexist cultural standards that continue to exist in psychological research and practice today, we propose a systemic positive psychology framework for understanding resilience in LGBTQ families. Specifically, we address the areas of learned optimism, emphasizing systemic interactions, and building on positive emotions as positive psychology research suggests these factors are particularly essential to enable thriving and boosting resilience. Additionally, we discuss the opportunities provided by shifting to a strengths-based perspective in exploring the resources that build resilience and help nonheterosexual families remain hopeful, optimistic and confident in the midst of difficult challenges.
Learned Optimism to Boost Resilience in LGBTQ Families
Psychologists working from our framework must move beyond traditional ideas that the definition of family is linked to a predictable life path that involves the ability to procreate. It is unhelpful to hold heterosexual parenthood as the standard (Kitzinger & Wilkinson, 2004). Instead, psychologists should try to understand how each unique LGBTQ couple organizes, perceives and constructs their own definition of family (Kranz & Daniluk, 2006). Although researchers propose that care, commitment, devotion, love, and the ability to provide for and nurture a child determines parent competency, some critics of same-sex headed-households continue to believe that sexual orientation is crucial in parenting (Negy & McKinney, 2006). Not surprisingly, LGBTQ couples are often confronted with insecurities about their own legitimacy as parents. Resilient nonheterosexual families who dare to challenge sexual prejudice and heterosexism must learn how to effectively dispute negative self-talk that mitigates thriving. Seligman’s (2006) theory of learned optimism proposes that people can learn how to become optimistic if they dispute negative self-talk when faced with discrimination. Alternative self-talk should promote the idea that healthy relationships and effective parenting are not determined by sexual orientation, but are rather associated with homes where family members receive love, stability, safety, care, and respect. Examples of alternative self-talk that challenge misinformed and oppressive social attitudes include, “Sexual stigma and prejudice are the problem, not our family” or “Bullying children for having LGBTQ parents is the problem, not our family.” Practitioners must challenge LGBTQ parents’ fears and anxieties by exploring what it is about each family member’s character strengths and about their relational strengths as a couple that are evidence of their competency and readiness for parenting and partnership.
Emphasizing Systemic Interactions as the Key to Overcoming Adversity
Researchers indicate that building supportive relationships in different contexts and with members of the straight and LGBTQ communities (e.g., neighborhoods and schools) helps nonheterosexual families adapt to significant crises in a society that privileges heterosexual couples. Thus, we propose that practitioners should explore the following relational interactions: (a) healthy interactions within nonheterosexual couples, (b) between parents and their children, (c) between LGBTQ families and their support networks (extended families or families of choice), (d) and between LGBTQ families and the larger community. These interactions are highlighted with the understanding that when families overcome adversity in a multisystemic fashion, opportunities are created where families can define what it means for them to be a family strengthened by resilience and other resources. Open communication about present or expected crisis situations facilitates authentic family relationships in an environment of mutual support. Promoting a family’s resilient qualities should revolve around the following questions: “How do the members in your family draw strength from one another considering the barriers and obstacles encountered along the way?” and “What are the mechanisms that nonheterosexual headed households employ to provide emotional support to their children during times of stress?” Practitioners should consider talking to clients about the large number of “community resources, public programs, community institutions, as well as societal norms and values” that can help build resiliency (Connolly, 2006, p. 149). For example, one researcher has indicated that lesbian mothers who are active in the gay community, who enroll their children in schools with LGBTQ curricula and increase their children’s contact with children who have similar family stories, help protect their children against sexual prejudice and help strengthen their resilience (Bos, Gartrell, Peyser, & van Balen, 2008). Thus, practitioners should emphasize the importance of understanding social networks and intimate alliances as valuable resources that offer resilient families support in times of stress.
Helping LGBT Families Build on Positive Emotions
Fredrickson’s (2001) broaden-and-build positive psychology theory does not account for how LGBTQ families manage to move forward while simultaneously experiencing negative emotions within the discriminatory context in which they are situated. Although many LGBTQ families constantly experience negative emotions as a result of oppression, their families continue to display resilience by using their coping arsenals and adapting to new challenges. According to Walsh (1998), resilient families are able to weather troubled times because resilience is about being able to struggle well. She contends that regular interactions with environmental stressors could, in fact, create productive and protective qualities for the family system and each of its members. According to researchers Kranz and Daniluk (2006), same-sex parents enter into parenthood only when they feel that their relationships are financially and emotionally secure and when both partners feel fully committed to parenting because they are aware of the oppressive context. In other words, resilient LGBTQ families who prepare for possible stressors to come by establishing concrete goals designed to help endure troubled times, may feel empowered to continue building on their previous successes. With the former in mind, our framework subscribes to Fredrickson’s proposition that positive emotions help generate new ideas and solutions that enlarge our thought-action repertoire. However, we suggest that although nonheterosexual families are frequently exposed to negative experiences created by forces outside of their control, instead of narrowing their focus on problems, family members find purpose in the positive meaning of their family interactions. We propose the idea that nonheterosexual families may simultaneously experience negative emotions related to the sociopolitical forces oppressing them and positive emotions related to their systemic interactions. As Connolly (2006) best put it, nonheterosexual families create a “united front” and engage in processes of mutuality that help them survive external stressors together (p. 151). Although it is important for practitioners to validate the struggles and stressors that nonheterosexual families are constantly battling, it is imperative that they explore the purpose and objective behind fighting the battle. We speculate that many nonheterosexual families choose to battle sexual prejudice and discrimination because they find positive meaning and purpose in their everyday interactions with family members.
A Shift From Deficit Based to Strengths Based
This framework embraces a strengths-based perspective that emphasizes exploring the resources that nonheterosexual families possess as opposed to what has been absent in their lives. For instance, helping family members shift their focus from antigay comments often found in the media, to focus on the loving statements friends and family members share with them about their family, may help empower families to develop positive emotion, strength and resiliency. To further their understandings of resilience within LGBTQ families, practitioners must tap into how same-sex couples manage to mobilize resources in response to risks or threats to selves or families. Encouraging the telling of parents’ “coming out” stories or narratives of triumph may help underline the strengths and resources available to family members. For example, Short (2007) found that lesbian mothers used several strategies and shared efforts to deal with homophobia themselves, including having a deep understanding of heterosexism, studying the literature on family studies, participating in the LGBTQ community, and carefully selecting the schools their children attended. Because our framework acknowledges that realities are socially constructed, practitioners are encouraged to explore the unique resources that each family uses to remain resilient. Exploring how children manage to thrive, in spite of their experience of homophobic stigmatization in the form of sexual prejudice against their parents, is also important. Researchers have found that in response to oppression, gay and lesbian families develop flexibility in gender roles, an appreciation for diversity, a strong sense of self, empathy about what it is like to be in the minority group, and develop egalitarian relationships that lead to increased satisfaction in family life (Martin, 1993). With these factors in mind, asking questions that explore how couples are able to engage in creative, nurturing healthy family relationships, helps LGBTQ families become aware of the coping skills and unique strategies already being employed that help them live with pride.
Conclusion
There is a dearth of research addressing the care of LGBTQ populations in organized care settings. Hoping to find a culturally sensitive and strengths-based framework that would assist practitioners in their practice with LGBTQ families, we turned to vast resiliency literature including the theories recently proposed by positive psychologists. We reviewed resilience research on nonheterosexual families, and found it inchoate. Although positive psychologists have contributed to our understandings of how positive emotions and flexible cognition enhance resiliency, their research has failed to help practitioners understand how nonheterosexual families manage to remain resilient in a society ruled by heterosexist principles. In other words, positive psychologists’ research has not addressed the relational resources and interactions that help nonheterosexual families overcome adversity. We propose that positive psychology currently does not have a comprehensive resilience framework that addresses the unique experiences of LGBTQ families and the complexity of their psychological needs. Because such a framework has yet to be developed, we theorized the LGBTQ relationally based positive psychology framework. This framework is mindful of the heteronormative context that often structures organized care settings and encourages practitioners in the public sector to have conversations with their LGBTQ clients that revolve around the strengths, resources, and capabilities of their family support system and their same-sex loving relationships.
We would encourage positive psychology researchers to direct their research efforts toward nonheterosexual family members. In particular, we think a focus on a systemic understanding of these families’ resilience will be particularly helpful. Our LGBTQ relationally based positive psychology framework may be a starting point for this research. We think our framework may be uniquely suitable for nonheterosexual families because it considers how family members collaborate together to overcome the sociocultural and political factors that impact their family system. Our framework will be particularly helpful in the public health sector now that the Supreme Court’s repeal of the Defense of Marriage Act (1996) has extended federal health care benefits to same-sex married couples, their children, and stepchildren. With an increase in the demand for public mental health services from nonheterosexual families, our framework may serve as a helpful resource to access.
References
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Health Anxiety, Cognitive Coping, and Emotion Regulation:
A Latent Variable Approach
Stefanie M. Görgen & Wolfgang Hiller & Michael Witthöft
Published online: 24 February 2013
# International Society of Behavioral Medicine 2013
Abstract
Background Health anxiety, the fear or conviction of suffering from a severe disorder, represents a dimensional and
multifactorial construct consisting of cognitive, behavioral,
affective, and perceptual components. It has recently been
proposed that dysfunctional emotion regulation strategies
contribute to health anxiety, but the empirical evidence for
this claim is sparse.
Purpose The current research was aimed at broadly exploring and clarifying possible relationships between dimensions of health anxiety and cognitive coping and emotion
regulation strategies.
Method In two studies with non-clinical samples (nstudy 1=
172; nstudy 2=242), health anxiety, cognitive coping, and emotion regulation strategies were assessed using multidimensional
self-report measures. Functional (e.g., reappraisal) and dysfunctional (e.g., rumination) cognitive coping and emotion
regulation strategies were differentiated.
Results Using structural equation modeling, the results of
Study 1 revealed significant and consistent associations
between the dimensions of health anxiety and dysfunctional
coping and emotion regulation strategies. Study 2 replicated
and extended the main findings of Study 1 by demonstrating
that the associations between health anxiety and strategies of
coping and emotion regulation were independent of the
current level of depressive symptoms.
Conclusion Health anxiety was found to be associated with
dysfunctional coping and emotion regulation strategies (e.g.,
suppression). The positive associations between behavioral
dimensions of health anxiety (e.g., seeking reassurance) and
dysfunctional coping strategies may suggest that behavioral
dimensions of health anxiety serve as a compensatory strategy to overcome difficulties in cognitive coping.
Keywords Catastrophizing . Coping . Emotion regulation .
Health anxiety . Hypochondriasis . Rumination
Introduction
Health anxiety and hypochondriasis are characterized by the
fear or conviction of having a serious disease in the absence
of confirmatory medical findings [1]. This fear or conviction
is typically stimulated and maintained by minor bodily
sensations (e.g., headache) that are interpreted in a catastrophic manner (e.g., having a brain tumor) [1]. Recent
studies demonstrated that not only hypochondriasis but also
sub-threshold variants of elevated health anxiety that are
quite prevalent in the general population (about 6 %) are
associated with clinically relevant impairment and distress
[2]. This finding is also in line with recent taxometric studies
demonstrating that health anxiety actually represents a dimensional construct with the most severe case of hypochondriasis only differing quantitatively but not qualitatively
from less severe states of health anxiety [3, 4]. Besides high
levels of distress and functional impairment, health anxiety
is particularly associated with high health care usage [5].
Gaining a better understanding of the etiology and pathogenesis of health anxiety appears pivotal to promote ways to
effectively treat this condition.
Because clinical observations suggest that health anxiety is
often exacerbated in situations marked by high stress and
elevated emotional arousal, health anxiety might be associated
with deficits or maladaptive strategies of cognitive coping or
S. M. Görgen (*) : W. Hiller : M. Witthöft
Department of Clinical Psychology and Psychotherapy,
University of Mainz, Wallstraße 3,
55122 Mainz, Germany
e-mail: [email protected]
Int.J. Behav. Med. (2014) 21:364–374
DOI 10.1007/s12529-013-9297-y
emotion regulation in terms of effectively terminating negative affective states. Interestingly, the crucial role of emotion
regulation deficits has so far mainly been investigated in the
realm of anxiety and mood disorders [6–8]. A recent review
summarized the pivotal role of alterations in emotion regulation strategies in the development and maintenance of anxiety
disorders [9]. Emotion regulation strategies may modulate the
immediate behavioral, physiological, and cognitive consequences of the fear response during re-encounters with the
conditioned stimuli. In the long term, the inflexible, habitual
use of dysfunctional emotion regulation strategies (e.g., expressive suppression) may result in functional impairments
that are associated with anxiety disorders. These postulated
processes of (dysfunctional) emotion regulation might not
only be relevant to states of anxiety and dysphoria but also
to health anxiety and hypochondriasis because contrary to the
current controversial classification of hypochondriasis among
the somatoform disorders [10, 11], it has been suggested that
pathological health anxiety is actually more closely related to
the spectrum of anxiety disorders [12, 13].
Up until now, only two studies have explicitly focused on
the role of emotion regulation strategies in hypochondriasis
and health anxiety [14, 15]. Fergus and Valentiner [14] found
in a sample of students (N=503; Mage=19.1, SDage=2.3 years;
68 % female) that the regulation strategies cognitive avoidance (β=.09) and reappraisal (β=−.11) are significant predictors of disease convictions. Marcus et al. [15] investigated
the relationship between health anxiety and the regulation
strategies of rumination and catastrophizing. In this study (N=
198 students; Mage=21.1, SDage=4.1 years; 76 % female), a
significant correlation (r=.24) between rumination and health
anxiety was found. This association did not only result from the
shared variance with negative affectivity because rumination
was also directly related to health anxiety. The results also
showed that catastrophizing ambiguous bodily symptoms
(e.g., to interpret headache as a sign of a brain tumor) is directly
associated with health anxiety (r=.19).
However, no previous study has yet considered the
multidimensional model of health anxiety underlying
cognitive-behavioral interventions with affective, cognitive,
behavioral, and physiological aspects [16]. Marcus et al.
[15] operationalized health anxiety with only one general
score, and Fergus and Valentiner [14] distinguished the two
dimensions: disease phobia and disease conviction. Additionally, the two prior studies examined only a small number
of emotion regulation strategies. So, the present studies were
designed to focus on this multidimensionality of health
anxiety and on different coping and emotion regulation
strategies, which might play a relevant role in health anxiety.
Regarding their consequences on emotional (e.g., dysfunctional emotion regulation resulting in increased negative affect
[17, 18]) or cognitive processes (e.g., dysfunctional emotion
regulation associated with reduced memory performance
[19]), the regulation strategies can be divided into maladaptive
coping or emotion regulation strategies (e.g., rumination,
catastrophizing, self-blame, other-blame, and suppression)
and adaptive coping or emotion regulation strategies (e.g.,
acceptance, positive refocusing, refocusing on planning, putting into perspective, and reappraisal) [20, 21]. Adaptive strategies (e.g., reappraisal and acceptance) showed mostly no or
weak (negative) and inconsistent associations to psychological
problems compared to maladaptive strategies (e.g., rumination
and suppression) [22, 23]. Accordingly, we expected no significant associations between adaptive cognitive coping and
emotion regulation strategies and the affective, behavioral,
cognitive, and perceptual dimension of health anxiety.
In contrast, there are several empirical findings and clinical observations suggesting that associations between maladaptive regulation strategies and the four dimensions of
health anxiety are rather likely: Clinical observations have
shown that people with elevated health anxiety or hypochondriasis are repetitively and excessively preoccupied
with illness worries or/and illness convictions, bodily symptoms, and the need for social support [1, 16]. So, we assumed positive correlations between rumination and all four
dimensions of health anxiety (see hypotheses in Fig. 1).
Because a recent study showed a relationship between
safety behaviors (including social support) and increased
health anxiety, probably due to catastrophizing fostered by
safety-related behaviors [24], we hypothesized that not only
the catastrophic interpretation of bodily symptoms [15] but
also catastrophizing in general the tendency to interpret an
experience as particularly terrible [20] would be positively
related to the affective, cognitive, behavioral, and perceptual
components of health anxiety.
Two further maladaptive strategies, self-blame and blaming
others, are also related to negative affect [25]. In particular,
blaming yourself for an event or experience is positively
correlated to anxiety and stress [25]. We therefore assumed
that self-blame and other-blame are particularly associated
with the affective dimension of health anxiety. Because the
cognitive component of health anxiety also includes discrepancies between one's own illness convictions and the reactions
of other people [26], we hypothesized that other-blame is
positively related to the cognitive dimension.
An additional maladaptive strategy, emotional suppression,
refers to the inhibition of ongoing emotion-expressive behavior such as facial expression [27]. While suppression could
reduce the external signs of emotional states [27, 28], Gross
and John [21] found a positive relationship between the habitual use of expressive suppression and the experience of
negative emotions. In line with this, the counterproductive
effect of suppression on anxiety was demonstrated in experimental studies with non-clinical [18, 29] and clinical samples
[30]. We therefore expected a positive correlation between
expressive suppression and the affective dimension of health
Int.J. Behav. Med. (2014) 21:364–374 365
anxiety. Emotional suppression probably results in a discrepancy between inner feelings and outer expression and possible
reactions of other people. Suppression is therefore probably
positively related to the cognitive dimension of health anxiety
as well. Whereas Gross and John [21] also found that individuals who habitually use suppression have less social
support, people with hypochondriacal concerns tend to seek
social support and medical reassurance [31]. For that reason,
we expected a negative relationship between suppression and
the behavioral dimension of health anxiety.
In general, we expected positive relationships between
maladaptive coping and emotion regulation strategies and
dimensions of health anxiety (our detailed hypotheses are
summarized in Fig. 1). Because various coping and emotion
regulation strategies are strongly related to depression [8,
32] and also health anxiety shows substantial overlap with
depression [33], significant associations between cognitive
coping and emotion regulation strategies and health anxiety
could also result from the shared variance with depression.
However, we assumed that the hypothesized relations
should not only result from this shared variance (i.e., significant correlations should be observable, even when statistically controlling for the levels of depression; Study 2).
Study 1 was designed to test the outlined hypotheses regarding significant associations between maladaptive coping and emotion regulation strategies and health anxiety.
Study 2 aimed at replicating and extending the findings of
Study 1 by statistically controlling for individual differences
in depressive symptoms and by testing a possible mediating
influence of depressive symptoms.
Study 1
Method
Participants and Procedure
In Study 1, a total of 172 participants (122 women; Mage=
26.23 years, SDage=10.01 years) completed self-report measures on health anxiety and cognitive coping and emotion
regulation strategies in an internet-administered test version.
The participants were recruited at a German university and
in online communities. A flyer about the study or an e-mail
included the link to the online survey.
Measures
The Multidimensional Inventory of Hypochondriacal Traits
(MIHT) The MIHT is a 31-item questionnaire for the dimensional assessment of health anxiety in the general population [26, 34]. The MIHT consists of the following four
subscales: the affective subscale, including illness worries; the
cognitive scale, which assesses illness convictions (that are not
shared by others) and hypochondriacal alienation as a consequence; the behavioral subscale, which measures the tendency
to seek social support; and the perceptual subscale, which
focuses on bodily sensations [26, 34] and is closely related to
the concept of somatosensory amplification [35]. Subjects are
asked to “read each statement carefully” and to “use the following scale to rate each statement”: 1=“strongly disagree” to
5=“strongly agree” [36]. The internal consistencies of the
MIHTc
ERQb
CERQa
MIHT-affective
(e.g., ‘I worry a lot about
my health.’)
MIHT-behavioral
(e.g., ‘I turn to others for
support when I do not
feel well.‘)
MIHT-cognitive
(e.g., ‘People seem unconvinced that my symptoms
are signs of illness.‘)
MIHT-perceptual
(e.g., ‘I am aware of
physical sensations.‘)
Rumination
(e.g., ‘I dwell upon the feelings
the situation has evoked
in me.’)
Catastrophizing
(e.g., ‘I continually think how
horrible the situation
has been.’)
Self-blame
(e.g., ‘I feel that I am the
one to blame for it.’)
Other-blame
(e.g., ‘I feel that others are
to blame for it.’)
suppression
(e.g., ‘I control my emotions
by not expressing them.‘)
+
+
+
+
+
+
+
+
+
+
+
+
+
-
Fig. 1 The predicted positive
(+) and negative (−)
associations between
maladaptive coping and
emotion regulation strategies
and the four dimensions of
health anxiety (with sample
items in parentheses). The used
self-reports are (a) CERQ=
Cognitive Emotion Regulation
Questionnaire, (b) ERQ=
Emotion Regulation
Questionnaire, and (c) MIHT=
Multidimensional Inventory of
Hypochondriacal Traits
366 Int.J. Behav. Med. (2014) 21:364–374
subscales range from α=.75 to α=.89. Evidence for convergent validity has been provided through correlations with other
established measures of health anxiety and discriminant validity through relationships with general assessments of psychopathology [34]. In these studies, the model fits for the MIHT
were χ2
=609.68 (df=426, p<.01), CFI=.92, TLI=.92, and
RMSEA=.05 (Study 1) and χ2
=659.48 (df=426, p<.01),
CFI=.95, TLI=.95, and RMSEA=.05 (Study 2).
Cognitive Emotion Regulation Questionnaire (CERQ) The
CERQ assesses cognitive coping strategies used after
experiencing negative life events (“By the following questions you are asked to indicate what you generally think,
when you experience negative or unpleasant events.”) [20,
37]. This 36-item questionnaire consists of nine subscales:
self-blame (e.g., “I feel that I am the one who is responsible
for what has happened”), blaming others (e.g., “I feel that
basically the cause lies with others”), acceptance (e.g., “I
think that I must learn to live with it”), refocus on planning
(e.g., “I think about how I can best cope with the situation”),
positive refocusing (e.g., “I think of nicer things than what I
have experienced”), rumination (e.g., “I am preoccupied with
what I think and feel about what I have experienced”), positive
reappraisal (e.g., “I think that the situation also has its positive
sides”), putting into perspective (e.g., “I think that other people
go through much worse experiences”), and catastrophizing
(e.g., “I often think that what I have experienced is the worst
that can happen to a person”) [20, 37]. The CERQ uses a fivepoint scale (1=“almost never” to 5=“almost always”). Internal
consistencies range from α=.75 to α=.87 and the test–retest
correlation (1-year follow-up) from r=.48 to r=.65 [32]. In a
German adaptation [37], Cronbach's α coefficients were
α≥.73, except for the subscales acceptance (α=.60) and
rumination (α=.66). The test–retest correlations (7-month
follow-up) were found to be acceptable to good, with values
ranging between r=.48 (positive refocusing) and r=.84
(catastrophizing) [37]. In our studies, the model fits for the
CERQ were χ2
=906.83 (df=524, p<.01), CFI=.88,
TLI=.86, and RMSEA=.07 (Study 1) and χ2
=1,028.54
(df=556, p<.01), CFI=.93, TLI=.91, and RMSEA=.06
(Study 2).
Emotion Regulation Questionnaire (ERQ) Because the
CERQ does not include any suppression scale, we additionally used the ERQ [21, 38]. This questionnaire is a widely
used self-report measure of individual differences in suppression (four items; e.g., “I control my emotions by not
expressing them”) and reappraisal (six items; e.g., “I control
my emotions by changing the way I think about the situation
I'm in”) [21, 38]. The habitual use of both emotion regulation strategies (“We would like to ask you some questions
about your emotional life, in particular, how you control
[that is, regulate and manage] your emotions....”) was
measured on a seven-point scale (1=“strongly disagree” to
7=“strongly agree”). Cronbach's α coefficients range from
α=.75 to α=.82 for reappraisal and from α=.68 to α=.76
for suppression [21]. In the current studies, the model fits for
the ERQ were χ2
= 119.23 (df=34, p<.01), CFI=.93,
TLI=.91, and RMSEA=.12 (Study 1) and χ2
=183.08 (df=
34, p<.01), CFI=.93, TLI=.91, and RMSEA=.14 (Study 2).
Statistical Analyses
The hypotheses regarding the associations between cognitive coping and emotion regulation strategies and health
anxiety dimensions were examined by using a structural
equation modeling (SEM) approach. The advantage of the
SEM approach is that the latent structures of constructs are
explicitly modeled and critically evaluated according to
goodness of fit indices, and that relations between latent
variables represent true score correlations that are independent of measurement error. The separate measurement
models for the factors of the MIHT, ERQ, and CERQ were
specified using the suggested structures in the original literature [20, 21, 26, 34]. Afterwards, we analyzed the standardized latent variable correlations between the dimensions
of health anxiety (MIHT), dysfunctional and functional
cognitive coping strategies (CERQ), and the ERQ dimensions reappraisal and suppression.
The analyses were performed using Mplus version 6 [39].
Mplus makes it possible to examine confirmatory models
with categorical indicators modeled by a two-parameter
normal-ogive IRT model and uses an integrated and generalized approach for measurement and structural models with
latent variables [40]. The analyses of the measurement
models were conducted with the robust mean and variance
adjusted weighted least squares (WLSMV) procedure,
which is insensitive to non-normal distributions. Because
the WLSMV procedure is based on the tetrachoric correlation matrix and tetrachoric correlations have been observed
to be biased with low cell frequencies [41], we collapsed
rarely used response categories to obtain response frequencies of at least 5 % in each cell. The χ2 test is sensitive to the
sample size and the complexity of the model. Therefore, we
used other descriptive fit measures for the evaluation of the
model fit (e.g., [42]). As an absolute fit index, we chose the
RMSEA (root mean square error of approximation). The
CFI (comparative fit index) and the TLI (Tucker–Lewis
index) are reported as incremental fit indices. It has been
recommended [43] that the RMSEA should be smaller than
.08 or .05 to indicate an acceptable or good fit. For the CFI
and TLI, values greater than .95 can be considered as an
adequate fit and values greater than .97 as a good fit.
However, some researchers regard these cutoffs for the
CFI and TLI as very restrictive. Particularly in trait research,
Int.J. Behav. Med. (2014) 21:364–374 367
models with CFI values ≥.90 might be considered as
acceptable [42].
Results
Means, standard deviations, and Cronbach's α coefficients
of the four dimensions of health anxiety and the coping and
emotion regulation strategies are shown in Table 1.
Model 1: Dimensions of Health Anxiety and Dysfunctional
Cognitive Coping Strategies
The first model included the MIHT dimensions of health
anxiety (affective, cognitive, behavioral, and perceptual) as
well as the dysfunctional coping strategies of the CERQ
(self-blame, rumination, catastrophizing, and other-blame).
The fit indices (χ2
=1,266.15, df=1,004, p<.01; CFI=.92,
TLI=.92, RMSEA=.04) indicated that the model is an acceptable to good representation of the data. The latent variable correlations between dimensions of health anxiety and
dysfunctional coping strategies (CERQ) are presented in
Table 2. As expected, the dimensions of health anxiety were
positively related to rumination and catastrophizing. The
strongest correlation (r=.47) was observed between affective
health anxiety and rumination. Only the relationship between
catastrophizing and the perceptual dimension of health anxiety was unexpectedly negative. The results showed, as
expected, positive correlations between self-blame and the
affective dimension of health anxiety, while other-blame was
positively associated with the affective and cognitive dimension of health anxiety.
Model 2: Dimensions of Health Anxiety and Functional
Cognitive Coping Strategies
In Model 2, we tested the hypothesis that there are no
associations between functional coping strategies of the
CERQ (acceptance, positive refocusing, refocusing on planning, positive reappraisal, and putting into perspective) and
dimensions of health anxiety (MIHT). The corresponding
model fit was acceptable to good (χ2
=1,400.83, df=1,137,
p<.01; CFI=.92, TLI=.91, RMSEA=.04). Only a few significant correlations were observed. Positive refocusing was
positively related to the behavioral factor of health anxiety,
and refocusing on planning was positively associated with
the affective and perceptual dimensions of health anxiety.
The strategy of positive reappraisal was positively correlated
with the perceptual dimension of health anxiety.
Table 1 Means (M), standard
deviations (SD), and Cronbach's
α of the dimensions of health
anxiety and the measured coping
and emotion regulation strategies for Studies 1 and 2
MIHT Multidimensional Inventory of Hypochondriacal Traits,
CERQ Cognitive Emotion Regulation Questionnaire, ERQ
Emotion Regulation Questionnaire, PHQ-9 depression scale of
the Patient Health Questionnaire
Measures (possible range) Study 1 (n=172) Study 2 (n=242)
M SD α M SD α
Health anxiety dimensions
MIHT
Affective (7–35) 19.42 5.04 .79 16.17 5.56 .83
Behavioral (8–40) 24.26 5.22 .83 22.94 5.77 .80
Cognitive (7–35) 16.59 4.91 .85 12.90 5.53 .89
Perceptual (9–45) 28.81 4.64 .78 26.65 6.29 .83
Cognitive coping
CERQ (each subscale, 4–20)
Self-blame 10.00 3.16 .74 9.69 3.13 .74
Acceptance 11.80 3.16 .75 12.42 3.38 .76
Rumination 10.44 3.56 .77 9.85 3.39 .72
Positive refocusing 10.02 2.93 .75 10.15 3.64 .85
Refocusing on planning 11.83 2.80 .60 11.59 3.41 .73
Positive reappraisal 12.65 3.34 .78 12.51 3.93 .85
Putting into perspective 12.15 3.62 .80 12.56 3.88 .82
Catastrophizing 7.57 3.40 .81 6.84 2.89 .76
Other-blame 6.70 2.41 .82 6.45 2.30 .80
Emotion regulation
ERQ
Reappraisal (6–42) 4.39 0.99 .79 4.67 1.04 .80
Expressive suppression (4–28) 3.49 1.13 .71 3.40 1.21 .74
Depression
PHQ-9 (0–27) 5.31 4.33 .84
368 Int.J. Behav. Med. (2014) 21:364–374
Model 3: Dimensions of Health Anxiety, Reappraisal,
and Expressive Suppression
In Model 3, we tested associations between the dimensions
of health anxiety (MIHT) and the two emotion regulation
strategies of the ERQ: suppression and reappraisal. Again,
the model fit was acceptable (χ2
=1,028.31, df=762, p<.01;
CFI=.91, TLI=.90, RMSEA=.05). In account with our
hypotheses, a greater habitual use of expressive suppression
was associated with a lower extent of the behavioral dimension and a greater extent of the cognitive dimension of health
anxiety. The emotion regulation strategy of reappraisal was
only positively related to the perceptual scale of the MIHT.
Discussion
Study 1 confirmed our hypotheses regarding the relations
between cognitive coping and emotion regulation strategies
and health anxiety (except the links between catastrophizing
and perceptual health anxiety and between suppression and
affective health anxiety). Thereby, our results replicate and
extend the findings of Marcus et al. [15]. While Marcus et
al. [15] only used a total score of health anxiety, in the
present data, more detailed associations were detected between different dimensions of health anxiety on the one hand,
and rumination and catastrophizing on the other: Whereas
rumination was generally positively associated with all four
dimensions of health anxiety, the strategies of catastrophizing
and blaming others were positively associated with the first
three dimensions of health anxiety, but negatively or unrelated
to the perceptual dimension, reflecting the somatosensory
amplification construct [44]. This might suggest that the latter
two strategies serve as “externalizing” strategies that turn
one's attention away from bodily signals, as measured by the
perceptual factor. Furthermore, in contrast to the study of
Marcus et al. [15], we did not only examine catastrophizing
of bodily sensations, but rather catastrophizing in a more
general manner.
Probably, the use of these cognitive coping strategies,
which we consider as dysfunctional, appears subjectively
meaningful and beneficial. Especially via rumination, people
attempt to understand the causes and consequences of events
in order to avert further risks and disasters. However, in fact,
rumination mostly appears dysfunctional. The thoughts remain abstract and maintain the preoccupation with problems
because usually there is neither adequate problem solving nor
emotional processing [45]. In the context of health anxiety,
this self-focused and abstract rumination may play an important role because the strong self-focusing might increase the
selective attention on bodily sensations (which is empirically
mirrored in the positive association between rumination and
the perceptual dimension of health anxiety), and the abstractness of thoughts could result in a deficit of alternatives to
explain the experienced bodily symptoms.
The positive associations between the dimensions of health
anxiety and the coping strategy of other-blame are worth a
closer look: Blaming someone else clearly represents a form
of external attribution. While internal factors are often considered as abnormal and pathological, external factors tend to be
evaluated as normalizing [46]. For people with elevated health
anxiety, blaming others may be beneficial at least in the short
run because the external attribution has an alleviative effect on
negative thoughts. However, blaming someone else can contribute to troubled social relations and the difficult physician–
patient relationships that are often reported in the context of
health anxiety [47]. The meaningful correlations between selfblame and health anxiety (particularly, affective health anxiety) fit well with previous studies on the relationship between
self-blame and psychopathology, in particular anxiety and
depression symptoms [25, 32].
In line with previous studies (e.g., [22, 23]), functional
strategies showed no or fewer relations to psychological
Table 2 Standardized latent variable correlations between dimensions of
health anxiety and coping and emotion regulation strategies in Study 1
Health anxiety dimensions (MIHT)
Affective Behavioral Cognitive Perceptual
Dysfunctional strategies (CERQ)
Self-blame .41** .04 .20* −.07
Rumination .47** .37** .23** .28**
Catastrophizing .34** .22* .24** −.17*
Other-blame .37** .34** .25** −.01
Functional strategies (CERQ)
Acceptance <.01 −.07 −.02 .07
Positive refocusing <.01 .19* −.14 .06
Refocusing on
planning
.19* .05 −.04 .36**
Positive reappraisal −.02 .04 −.12 .31**
Putting into
perspective
.01 .15 −.12 −.01
ERQ dimensions
Reappraisal −.06 .10 −.07 .22*
Expressive
suppression
.07 −.44** .27** −.02
Model 1: dimensions of health anxiety and dysfunctional coping strategies, χ2 =1,266.15, df=1,004, p<.01; CFI=.92, TLI=.92, RMSEA=.04.
Model 2: dimensions of health anxiety and functional coping strategies,
χ2 =1,400.83, df=1,137, p<.01; CFI=.92, TLI=.91, RMSEA=.04 (item
20 of the subscale acceptance was excluded because it had a low factor
loading of less than .03). Model 3: dimensions of health anxiety,
reappraisal and expressive suppression, χ2 =1,028.31, df=762, p<.01;
CFI=.91, TLI=.90, RMSEA=.05
MIHT Multidimensional Inventory of Hypochondriacal Traits, CERQ
Cognitive Emotion Regulation Questionnaire, ERQ Emotion Regulation Questionnaire
*p<.05; **p<.01
Int.J. Behav. Med. (2014) 21:364–374 369
problems. However, we found a few unexpectedly positive
links, especially between reappraisal and the CERQ subscale
refocusing on planning and the perceptual dimension of health
anxiety. Possibly, paying attention to the body results in more
information about the own well-being, which might, particularly in our relatively young and healthy sample, facilitate the
revaluation or coping with an event or emotion. Nevertheless,
in general, our study confirmed previous results that the use of
dysfunctional emotion regulation strategies has greater importance in psychological disorders than the absence of functional
strategies [48]. However, a recent study showed that functional strategies are negatively related to psychological problems,
when there are higher values for dysfunctional strategies [49].
This indicates that adaptive strategies could be compensatory
under certain circumstances (e.g., particular high levels of
rumination).
Regarding suppression, as expected, the more people suppress their emotions, the less they tend to seek social support.
This negative link between expressive suppression and the
behavioral dimension of health anxiety is in accord with the
findings of Gross and John [21], showing that the habitual use
of expressive suppression is negatively associated with social
support and close relationships, and positively with the avoidance of attachments. Consistent with our hypothesis, we found
a positive link between expressive suppression and the cognitive dimension of health anxiety. However, we found no
meaningful correlation between expressive suppression and
the affective dimension. The behavioral and cognitive dimensions, like expressive suppression, may possibly refer to behavioral responses to the environment, while the affective and
perceptual dimensions rather involve an inner engagement
because these dimensions focus on worries and selective
attention to bodily sensations.
A major shortcoming of Study 1 is that no measure of
negative affect or depressive psychopathology was included.
We are therefore unable to demonstrate that the associations
between dysfunctional cognitive coping and emotion regulation strategies and dimensions of health anxiety did not only
result from the shared variance with negative affect or depressive psychopathology. This problem was addressed in Study 2.
Study 2
The aims of the second study were to replicate the findings of
Study 1 and to prove a possible influence of depressive symptoms on the documented associations by statistically controlling for individual levels of depression. First, we tested model
fits and associations with depression as a covariate. Additionally, we used latent mediation analysis to test direct and indirect
effects from cognitive coping and emotion regulation to health
anxiety. Because we only observed few and weak associations
between adaptive coping and emotion regulation strategies and
health anxiety in Study 1, the second study exclusively focused
on the dysfunctional cognitive coping strategies of the CERQ
and the two ERQ dimensions of reappraisal and expressive
suppression.
Method
Participants and Procedure
In Study 2, a total of 242 participants (169 women; Mage=
28.82 years, SDage=12.07 years) completed self-report measures, of whom 116 participants (94 women; Mage=
29.90 years, SDage=14.10 years) used a pencil-and-paper
test version and 126 (75 women; Mage=27.76 years, SDage=
9.63 years) an internet-administered version. The participants were mainly students at German universities who were
recruited at the university campus and received course
credits for their participation (paper-and-pencil sample) or
were reached by mailing lists of their psychology departments (internet-administered version). Because a lot of research [50–52] showed that it is legitimate to summarize
data from internet and paper-and-pencil samples, we merged
these data for our calculations.
Measures
As in Study 1, dimensions of health anxiety were assessed
with the MIHT. The CERQ and ERQ were used to measure
cognitive coping and emotion regulation strategies.
The depression scale of the Patient Health Questionnaire
(PHQ-9) [53] was used to measure the severity of common
depressive symptoms based on DSM-IV. The nine items are
rated with four categories (0=“not at all” to 3=“nearly every
day”) and have a good internal consistency of α=.89 [54].
In this study, the model fit for the PHQ-9 was χ2
=66.20 (df=
27, p<.001), CFI=.97, TLI=.95, and RMSEA=.08.
Statistical Analyses
In addition to the described analyses in Study 1, we statistically controlled the hypothesized relationships for the individual levels of depression (depression as a covariate) and
conducted mediation analyses by specifying depression as a
mediator between dysfunctional coping and emotion regulation and health anxiety. To test direct and indirect effects
from coping and emotion regulation to health anxiety, we
used path analysis in Mplus [39]. In this procedure, significant indirect effects indicate significant mediators. Common used tests (e.g., the Sobel test) focus on products of
coefficients and rely on normal distribution assumption.
However, because the products are often not normally distributed, MacKinnon et al. [55] recommended using the
bias-corrected bootstrap method. Based on 10,000 bootstrap
370 Int.J. Behav. Med. (2014) 21:364–374
samples (as recommended by Mallinckrodt et al. [56]), we
evaluated the indirect effects using 95 % confidence intervals
(CIs). The path analyses were computed with each of the
(dysfunctional) regulation strategies and each of the health
anxiety dimensions (e.g., testing, whether catastrophizing has
a direct or/and an indirect effect on the cognitive dimension of
health anxiety).
Results
Table 1 presents the means, standard deviations, and
Cronbach's α coefficients for all measures.
Model 1: Dimensions of Health Anxiety and Dysfunctional
Cognitive Coping Strategies
In Model 1, we tested the assumed associations between the
dimensions of health anxiety (MIHT) and dysfunctional
cognitive coping strategies (CERQ). The fit of the model
containing the four dimensions of health anxiety and the
four dysfunctional coping strategies was good to excellent
(χ2
=1,247.58, df=1,002, p<.01; CFI=.96, TLI=.95,
RMSEA=.03). When statistically controlling for individual
levels of depression (by regressing the latent coping variables and latent health anxiety dimensions on depression),
the fit indices remained unaltered (χ2
=1,278.95, df=1,041,
p<.01; CFI=.96, TLI=.95, RMSEA=.03), indicating a very
good model fit. The latent variable correlations between
health anxiety and dysfunctional coping strategies, including
the corresponding correlations after adding the level of depression as a covariate in parentheses, are presented in
Table 3.
As expected and in line with the findings of Study 1,
health anxiety was moderately positively related to rumination and catastrophizing. Even when statistically controlling
for the level of depression, most of the correlations remained
unaltered in their strengths. Regarding the cognitive coping
strategies of other-blame and self-blame, we found significant relationships between other-blame and affective as well
as cognitive health anxiety, but failed to find a significant
correlation between self-blame and affective health anxiety.
Model 2: Dimensions of Health Anxiety, Reappraisal,
and Expressive Suppression
In Model 2, we examined the anticipated associations between health anxiety and the emotion regulation strategies
of the ERQ, reappraisal and expressive suppression (χ2
=
1,139.45, df=762, p<.01; CFI=.94, TLI=.93, RMSEA=.05).
Controlling for the individual level of depression (as outlined
in Model 1) hardly changed the model fit (χ2
=1,142.40, df=
797, p<.01; CFI=.94, TLI=.93, RMSEA=.04). As expected
and in accord with Study 1, we found a negative association
between expressive suppression and the behavioral dimension
of health anxiety, and a positive link between expressive
suppression and the cognitive dimension. These correlations
remained stable and almost unaltered in their size after controlling for depression.
Mediation Analysis
To test the assumption that dysfunctional coping and emotion regulation is not only indirectly associated with health
anxiety via depression, we evaluated the significance of
Table 3 Standardized latent variable correlations between dimensions of health anxiety and coping and emotion regulation strategies in Study 2
(corresponding correlations after adding the level of depression as a covariate in parentheses)
Health anxiety dimensions (MIHT)
Affective Behavioral Cognitive Perceptual
Dysfunctional strategies (CERQ)
Self-blame .14 (.00) .11 (.07) −.06 (−.25**) .05 (.03)
Rumination .27** (.22**) .36** (.35**) .08 (−.04) .35** (.36**)
Catastrophizing .36** (.31**) .26** (.25*) .27** (.15) .08 (.07)
Other-blame .22** (.19*) .19* (.18) .31** (.29**) .15 (.15)
ERQ dimensions
Reappraisal .02 (.05) −.04 (−.03) −.07 (−.04) .20** (.21**)
Expressive suppression .18* (.14) −.35** (−.38**) .39** (.35**) −.07 (−.09)
Model 1: dimensions of health anxiety and dysfunctional coping strategies, χ2 =1,247.58, df=1,002, p<.01; CFI=.96, TLI=.95, RMSEA=.03
[item 28 (self-blame) and item 30 (rumination) were allowed to load on the factor “catastrophizing”]. Model 2: dimensions of health anxiety,
reappraisal, and expressive suppression, χ2 =1139.45, df=762, p<.01; CFI=.94, TLI=.93, RMSEA=.05
MIHT Multidimensional Inventory of Hypochondriacal Traits, CERQ Cognitive Emotion Regulation Questionnaire, ERQ Emotion Regulation
Questionnaire
*p<.05; **p<.01
Int.J. Behav. Med. (2014) 21:364–374 371
indirect and direct effects using mediation analyses. Merely
for the cognitive MIHT scale, mediation analyses (with depression as a mediator) revealed significant indirect effects for
the catastrophizing scale of the CERQ (βstandardized=.19,
p<.001, 95 % CI=.09–.29) and for the suppression scale
of the ERQ (βstandardized=.07, p<.05, 95 % CI=.01–.13),1
indicating a significant mediating mechanism via depression
for these scales. In contrast, only direct effects without indirect
effects were observed for the relations between the affective
MIHT scale and the cognitive coping strategies catastrophizing
(βstandardized=.33, p<.01), rumination (βstandardized=.23, p<.05),
and other-blame (βstandardized=.18, p<.05). For the behavioral
MIHT scale, analyses revealed significant direct effects for
catastrophizing (βstandardized=.28, p<.05), for rumination
(βstandardized=.40, p<.01), and for suppression (βstandardized=
−.42, p<.01). Furthermore, we found significant direct
effects between the cognitive MIHT scale and other-blame
(βstandardized=.26, p<.01) and between the perceptual MIHT
scale and rumination (βstandardized=.39, p<.01).
Discussion
The results of Study 2 replicated the main findings of
Study 1. By statistically controlling for individual levels
of depression and by testing mediation models, Study 2
confirmed the hypothesis that the associations between
different dysfunctional coping and emotion regulation
strategies and dimensions of health anxiety did not only
result from the shared variance with depression. Our
findings are in line with the results presented by Marcus
et al. [15], demonstrating that dysfunctional regulation
strategies (e.g., rumination and catastrophizing) are not
only indirectly (via negative affect) but also directly
related to health anxiety. Noteworthy is the correlation
between self-blame and the cognitive dimension of health
anxiety because the direct effect is negative in direction,
indicating that the more self-accusations people report,
the fewer illness convictions they have. Probably, selfblaming might result in realizing more alternative explanations for, e.g., minor bodily symptoms (e.g., physical
strain, body checking, or catastrophic beliefs).
General Discussion
The clinical and empirical observation that health anxiety
and hypochondriasis co-occur with elevated states of negative affectivity suggests that dysfunctional coping and emotion regulation strategies might play a crucial role in the
etiology and maintenance of health anxiety and hypochondriasis. The primary aim of the two studies was to test the
assumed links between various coping and emotion regulation strategies and different dimensions of health anxiety.
In summary, the present results confirm substantial links
between dysfunctional coping and emotion regulation strategies, especially rumination, catastrophizing, and otherblame and affective, cognitive, and behavioral dimensions
of health anxiety. While expressive suppression was negatively related to the behavioral dimension, we found positive
association between expressive suppression and the cognitive dimension of health anxiety, suggesting that the habitual
suppression of one's affective states seems to be related to
illness conviction and hypochondriacal alienation.
Because the behavioral dimension of health anxiety (e.g.,
the tendency to seek social support and medical reassurance)
is one of the crucial components in cognitive-behavioral
models of health anxiety and hypochondriasis (e.g., [16,
57]) and plays an important role in the maintenance of
health anxiety, the associations between this dimension
and coping strategies are worth a closer look. Both, Study
1 and Study 2, found medium-sized positive associations
between rumination and the behavioral subscale of the
MIHT (independent of the level of depression; mediation
analysis showed only a direct effect; Study 2). Although the
current cross-sectional design precludes definite causal interpretations, behavioral dimensions of health anxiety might
serve to counteract ruminative tendencies. However, the
positive nature of the associations suggests that this strategy
is not successful in lowering illness worries. Such an interpretation of the association between rumination and behavioral dimensions of health anxiety is in line with Selby's
emotional cascade theory [58], which states that ruminative
thoughts increase negative affect and promote dysregulated
behavioral responses in order to overcome negative affective states, at least in the short run.
Compared to other studies in the general population and
in college students [20, 21, 26, 34], we found similar descriptive statistics of the measurements (see Table 1). Based
on this, the findings were assumed to be valid for the general
population. In future studies, it appears fruitful to further
examine the association between multiple dimensions of
health anxiety and coping and emotion regulation strategies
in patients with full-blown hypochondriasis. If the reported
associations prove true in patient samples, therapeutic approaches focusing on coping and emotion regulation strategies might be promising add-ons to existing successful
cognitive-behavioral treatment approaches.
Limitations and Future Directions
It has to be acknowledged that in some cases, the fit indices
did not indicate very good fits of the models (e.g., in case of
1 Additionally, we found a direct effect (βstandardized=.32, p<.001)
indicating a partial mediation.
372 Int.J. Behav. Med. (2014) 21:364–374
the measurement models for the CERQ and the ERQ). However the RMSEA, one of the best-performing and most-used
fit indices [42, 59, 60], was good to very good in most of the
models (except for the ERQ model). Lower CFI values (<.95)
may also result from an unfavorable proportion of the number
of observations and the number of manifest variables within
the model [61]. Furthermore, a critical CFI value of .95,
indicating a good model fit [43], is difficult to achieve in trait
models and is presumably too restrictive [42].
The question of the etiological relevance of cognitive
coping and emotion regulation—i.e., whether dysfunctional
coping and emotion regulation strategies result in the
development of health anxiety and especially in dysfunctional behavior (e.g., excessive reassurance seeking) or vice
versa—remains unanswered because the cross-sectional design of the present studies precludes conclusions about
causality. Because neither Study 1 nor Study 2 included
measures of trait anxiety, anxiety sensitivity, or negative
affectivity, it is also not possible to determine how specific
the reported associations between facets of health anxiety
and strategies of coping and emotion regulation are. A
further limitation concerns the exclusive use of selfreports. So, it would also be interesting to assess the links
between coping and emotion regulation strategies and
health anxiety by objective measures.
Stroke is a leading cause of death and disability. Various forms of positive psychological health (e.g., emotional vitality) are associated with lower risk for heart disease. However, it is unclear whether positive psychological health may also be beneficial for stroke risk. The purpose of the present study was to examine prospectively the association between emotional vitality and incident stroke in a nationally representative sample of 6,019 participants in the first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Methods: Emotional vitality was assessed via self-report at study baseline in 1971–1975. Stroke cases were identified from hospital/nursing home discharge reports and death certificates. Multivariate Cox proportional hazards regression models were used to estimate hazard ratios and 95% confidence intervals of incident stroke associated with a 1 SD increase in emotional vitality scores. Models were adjusted for traditional cardiovascular disease risk factors and subsequently for psychological distress. Results: Higher emotional vitality was associated with lower risk of incident stroke over a mean of 16.29 (SD = 4.75) years of follow-up (hazard ratio = 0.89; 95% confidence interval: 0.81, 0.99). Findings persisted when controlling for traditional cardiovascular disease risk factors and psychological distress. Conclusions: Higher levels of emotional vitality were prospectively associated with lower stroke risk in a representative sample of the U.S. population. Associations were independent of psychological distress. Results point to the potential importance of positive psychological functioning for cardiovascular health and for stroke prevention. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Method
Sample and Study Design
National Health and Nutrition Examination Survey (NHANES I; 1971–1975) collected data on a representative sample of the U.S. civilian population, aged 1–74 years. The baseline assessment, conducted on the full cohort, included an in-person structured interview, physical examination, and blood draw. A representative subsample of noninstitutionalized adults aged 25–74 years (n = 6,913) (Engel, Murphy, Maurer, & Collins, 1978) also had a more comprehensive medical examination and completed the General Well-Being Schedule (GWB). In total, 2,644 members of this detailed subsample completed the Center for Epidemiologic Studies of Depression (CESD) scale (Radloff, 1977). Follow-up studies, conducted in 1982, 1987, and 1992, included an interview with the respondent or proxy (for decedents), obtainment of overnight hospital/nursing home stay records, and tracking participants via the National Death Registry and death certificates. Details of the NHEFS study design and sampling methods are published elsewhere (Cohen et al., 1987; Cox et al., 1992). Present analyses included members of the detailed subsample traced at one or more follow-ups. Participants were excluded if they had a history of stroke (n = 118) or heart disease (n = 347) at baseline. Participants with missing or unknown values for one or more variables (n = 429) were also excluded. The final analytic sample included 6,019 participants.
Incident Stroke
Stroke events were identified through hospital/nursing home discharge reports and death certificates. A stroke event was defined by International Classification of Diseases, Ninth Revision (ICD-9) codes 431–434.9, 436, and 437–437.1 listed on a hospital/nursing home discharge report or if identified as a cause of death on the death certificate (World Health Organization, 1977).
Emotional Vitality
Emotional vitality is defined as “a sense of positive energy, the ability to effectively regulate emotions and behavior, and positive well-being” (Kubzansky & Thurston, 2007;, p. 1393). The validity and reliability of the emotional vitality construct (Richman et al., 2005) and details about the development of the scale used in this study (Kubzansky & Thurston, 2007) have been previously published. Briefly, an emotional vitality score was derived from two items on each of the vitality, positive well-being, and emotional self-control subscales of the GWB administered at baseline. The six individual response items were summed to create an emotional vitality score, with higher values indicating higher levels of emotional vitality. The emotional vitality measure in the present analytic sample had high internal consistency reliability (α = .79). Prior studies have reported this, and similar measures of the same construct are correlated in the expected direction with related constructs, providing support for construct validity. For example, in this sample, lower levels of emotional vitality are associated with taking medication for psychological problems and less likely to have reported having had a nervous breakdown (Kubzansky & Thurston, 2007). Other work has demonstrated this construct is negatively correlated with depression, anger, and negative affect and positively correlated with optimism, mastery, and positive affect (Richman, Kubzansky, Maselko, Ackerson, & Bauer, 2009).
Covariates
Age and race/ethnicity (White, non-White) were obtained from updated/corrected values from the 1982 interview. All other covariates were obtained from the baseline NHANES I examination. Sex, education (<high school, high school, some college, or college degree), marital status (married or not married), blood pressure (BP) medication use in the past 6 months, doctor-diagnosed history of diabetes, recreational physical activity (low, moderate, or high), alcohol use (none, ≤2 drinks per week, or >2 drinks per week), and cigarette smoking (current or never/former) were obtained via self-report. Seated BP, height (m), and weight (kg) were measured and used to derive body mass index (BMI; kg/m2). Total serum cholesterol was obtained from the blood draw. Depressive symptoms were assessed with the CESD administered at baseline. Only a subset of the detailed sample was given the CESD, so multiple imputation was used to impute missing values. The correlation between CESD and emotional vitality scores in this sample was r = −0.42. Reported psychotropic medication use also provided a measure of psychological distress.
Analytic Plan
Hazard ratios (HRs) and 95% confidence intervals (CIs) of incident stroke associated with emotional vitality were estimated using multivariate Cox proportional hazards models. Follow-up time was calculated as time from baseline interview to stroke event date, nonstroke death date, or last date known alive. Models were adjusted for standard cardiovascular disease risk factors (age, sex, race/ethnicity, education, marital status, systolic BP, diastolic BP, BP medication use, cholesterol, diabetes, BMI, physical activity, smoking, and alcohol use) and subsequently for psychological distress (CESD and psychotropic medications). Additional analyses excluded the first 3 years of follow-up to evaluate the likelihood that prodromal symptoms of stroke might influence emotional vitality. Analyses were conducted using SAS, Version 9.3 (SAS Institute, Cary, NC).
Results
Baseline characteristics of the sample are presented in Table 1. A total of 419 incident stroke cases were identified over a mean follow-up period of 16.29 (SD = 4.75) years. After adjustment for standard cardiovascular disease risk factors, higher emotional vitality scores were significantly associated with lower risk of stroke (HR = 0.89; 95% CI = 0.81, 0.99). Associations between emotional vitality and stroke persisted when additionally adjusting for psychological distress (HR = 0.88; 95% CI = 0.80, 0.98). Results were similar when considering emotional vitality scores categorically, with the highest tertile having significantly lower risk for stroke compared with the lowest tertile when adjusting for age and sex (HR = 0.77; 95% CI = 0.60, 0.99; Figure 1). These associations were slightly attenuated in fully adjusted models (data not shown).
hea-34-10-1043-tbl1a.gifBaseline Characteristics of Sample (n = 6,019)
hea-34-10-1043-fig1a.gifFigure 1. Estimated survival function of relations between emotional vitality and incident stroke.
To further ensure that higher levels of emotional vitality did not simply represent less negative affect, in separate models, we excluded individuals with CESD scores ≥16 (i.e., cutoff for clinical depression), those who reported taking psychotropic medications, or those without CESD scores. Results persisted in these models (data not shown). Results from analyses excluding the first 3 years of follow-up were largely unchanged to those presented earlier.
Discussion
This study is the first to examine the association between emotional vitality and incident stroke. Higher levels of emotional vitality were prospectively associated with lower risk of incident stroke. Associations were maintained over and above standard cardiovascular disease risk factors and psychological distress. These findings suggest that increased awareness and assessment of positive emotional functioning may contribute to more effective cardiovascular disease prevention among the general population.
Few studies have examined positive psychological functioning in relation to stroke. In the present investigation, higher levels of emotional vitality were associated with a lower risk of incident stroke among a representative sample of the U.S. population, with every 1 SD increase in emotional vitality associated with an 11% decrease in stroke risk. These findings are consistent with Ostir, Markides, Peek, and Goodwin (2001), who reported an association between positive affect and stroke risk in older adults, and with previous work demonstrating a protective effect of positive psychological health for heart disease (Boehm & Kubzansky, 2012).
The mechanisms whereby emotional vitality and positive psychological functioning may be protective for stroke are likely multifactorial. Individuals with better psychological health may engage in other health-enhancing behaviors that are associated with lower stroke risk. However, in the present analyses, results were maintained even after controlling for a number of relevant health behaviors. These findings suggest emotional vitality could also be related to other factors, including better adherence to medical therapy, better social functioning, higher quality relationships, or more psychological resources. Emotional vitality could also influence restorative behaviors and biological processes not measured in this study (e.g., sleep, immune function, autonomic nervous system function, and antioxidants) but reported to be associated with positive psychological factors in prior work (Boehm & Kubzansky, 2012).
The study had several limitations but also notable strengths. Limitations include the fact that the baseline history of stroke and coronary heart disease was self-reported, possible bias may have occurred due to excluding individuals lost to follow-up or with missing data, and inaccurate diagnoses on discharge reports/death certificates could result in misclassification of incident stroke cases or fail to capture silent strokes (although such misclassification would likely bias results toward the null). Furthermore, the observational design of our study does not allow for determination of a causal effect of emotional vitality on stroke risk, and these findings should be replicated in a more recent cohort because data for the current study were collected over a 22-year period ending in 1992. However, this study had numerous strengths, such as being able to adjust for previously identified stroke risk factors, including psychological distress, and having stroke events confirmed by medical records/death certificates. Furthermore, we examined the relationship in a nationally representative sample of the U.S. population followed up to 22 years.
In conclusion, higher levels of emotional vitality were prospectively associated with a lower risk for incident stroke in a representative sample of the U.S. population. Our findings suggest that additional research in this area is warranted and may also point to the potential value in screening and early intervention for positive psychological health. Accumulating evidence suggests that positive psychotherapeutic techniques are effective in enhancing positive psychological functioning (Seligman, Rashid, & Parks, 2006) and may warrant examination in relation to cardiovascular health. Thus, greater focus on screening and interventions for increasing positive psychological functioning could have benefits not only for mental health but also for cardiovascular health.
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It would appear that flourishing following a distressing experience is more closely
associated with active engagement than with denial or psychological erasure. The
distress of a traumatic event can be met with approach-oriented coping, such as
addressing the situation and managing emotions, or with avoidance-oriented coping
such as denial or the use of drugs and alcohol which suppress them. There is ample
evidence that the former is more likely to lead to resolution and the latter to
continuing difficulties ([12] pp. 117–135). Jean Piaget’s concepts of assimilation
and accommodation [30] can be applied as a way of understanding this. In the
course of observing children’s development Piaget developed the view that a
psychological or behavioural repertoire could respond to newly encountered
contingencies by assimilating them into the range of contingencies already covered
by existing capabilities; an apple is a spherical object just like a ball, and so it is
something to roll and play with, or by accommodating to new information by
acquiring new repertoires of understanding and behaviour; an apple may be just like
a ball in some ways but when you put it into your mouth and chew something nice
comes out, and mother treats these particular balls in a different way from others, so
there might be something to be gained by developing a new line on spherical
objects. Psychological development has occurred. Traumatic experiences are, by
definition challenges to pre-existing assumptions. Suddenly driving is no longer a
relatively safe and mundane activity but one that can include painful and life
threatening accidents. A secure future is abruptly undermined by the discovery of
cancer. The world is literally turned upside down in the course of a shipwreck and
140 Health Care Anal (2016) 24:133–147
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the survivor experiences the agonies of those who do not survive. A cherished
pregnancy comes to naught in the course of a miscarriage, or perhaps even worse, a
stillbirth. All these and others challenge assumptions and demand a response. The
experience is inevitably unpleasant and one reaction might be to deny its validity
and press on regardless but that is unrealistic. The traumatic event has occurred and
one person’s denial cannot speak for others. There may be undeniable consequences
such as a broken limb or even a permanent disability. The reality of trauma is
inescapable and an event which has touched others, altered perceptions of what the
world is or resulted in clearly apparent disability cannot be assimilated into preexisting routines of perception and behaviour. Routines of perception and behaviour
have to change in order to accommodate the new. Growth occurs and life embarks
upon a new course. If it doesn’t, the consequences of changed relationships, altered
evaluations of safety and security and/or the effects of injury act as constraints upon
the continuation of status quo ante.
