Summary of Capita Selecta in Clinical Psychology by Wessel and Aan het Rot - 1st edition

What is psychopharmacology? - Chapter 18

Even though psychoactive drugs are mostly prescribed by family physicians and other types of specialists, but not by psychiatrists, it can be beneficial for the patient if the psychiatrist and the prescribing physician interact. This can lead to a better treatment of the patient. The medication of a patient can also influence their cognitive abilities, thus it makes sense to check both the physical status of a patient (for example by a physician) as well as to check the mental status (for example by a psychiatrist).

The Language of Pharmacology

Psychoactive drugs may be confused by the layman due to trade names; the names each drug company gives their drugs. The term generic name refers to the association of one specific name with one specific type of drug. This means that the one type of drug with the same generic name can have several trade names. For example the generic drug methylphenidate is sold under many trade names, such as Ritalin, Methylin and Concerta. This results from several drug companies producing the same kind of drugs. The Compendium of Pharmaceuticals and Specialties (CPS) serves as a reference book for trade names and generic names. It is updated annually and can help find the right medication as well as to find the purpose of different types of medication.

There are certain concepts important for understanding underlying principles of how prescription drugs work. Toxicity refers to the harmful effects of taking a too high amount of a certain drug. Side effects are troublesome and unintended symptoms produced by the drug that can differ from patient to patient. These are mostly predictable and relatively harmless. Adverse effects are unintended effects by drugs that can become seriously harmful, such as liver failure or damage to a child in the womb. The term tolerance refers to the fact that if medication is taken over a long period of time the body becomes accustomed to the dosage. Thus a higher dosage is needed to achieve the same effect. Half-life refers to the point in time at which the drug has approximately reached the middle of the time period in which it is effective, since the effects of drugs mostly have a limited duration. When stopping the medication of a patient, this is usually done with gradual decreases in dosage to reduce withdrawal effects. When patients take several types of medication (and possibly illicit drugs as well) the effects of the drugs can potentiate and synergize, leading to stronger or unplanned outcomes. Patients can become dependent on a drug after long periods of time, because their bodies start to rely on the drugs presence. This can be especially dangerous if the body can normally produce these chemicals itself, but becomes dependent on the drug to provide them instead.

Psychoactive drugs (including psychoactive street drugs such as MDMA and LSD) can be classified roughly into uppers and downers. Uppers increase arousal and alertness, while downers decrease arousal and lead to relaxation of the patient. These classifications work better for street drugs than for prescription drugs, because these are usually much more complex. It can be generally said for all drugs that a higher dosage leads to a higher toxicity and thus carries higher risk factors than lower dosages. Many drugs are also potentially highly addictive, making the decision of prescribing them a difficult matter. In medical practice, the most commonly used drugs are called psychopharmacological agents.

The main areas of psychopharmacological agents:

• Analgesics (drugs used against pain)

• Anxiolytics (drugs used against anxiety)

• Antidepressants (drugs used against depression)

• Lithium derivatives (drugs used against bipolar disorder)

• Major tranquilizers or antipsychotics (drugs used against schizophrenia)

• Affect-modulating drugs (drugs used against post-traumatic stress disorder)

• Stimulants like amphetamines (drugs used against weight loss)

Pharmacological medication and psychological interventions both have benefits of their own. Often a combination of both yields better results than just one of the two on its own. This depends on the type of problem. For example schizophrenia, bipolar disorder, acute pain, ADHD, and others are best treated by pharmacological medication, even though the addition of psychological therapy can increase its benefits. On the other hand problems such as phobias, post-traumatic stress disorder, and bulimia are better treated with psychological methods than with medication. However, the addition of a drug treatment can produce some kinds of benefits as well. In cases such as depression it makes sense to administer drugs to produce a short-term benefit, while also administering a therapy to produce long-term benefits. There are many different views about the ideal treatment for most disorders. Thus decisions about treatment should ideally be based on empirical evidence.

How the Internet changed Clinical Practice

Nowadays the internet allows patients to access a lot of medical information. Patients grow more skeptical of medical treatments, with many people demanding psychological treatments from their doctors. Furthermore, patients often try reducing their drug intake. This may be due to a higher awareness for possible dependence on their medication, side effects, and negative long-term effects (such as liver problems). Patients also become more knowledgeable of the fact that medication is not necessarily a cure, for example by reports in the press highlighting the uncertainties of efficiency of certain drugs.

Drug Prescription

Clinical psychologists are forbidden to prescribe drugs in most countries, even though they can diagnose clients. Medical associations doubt the effectiveness and safety of letting clinical psychologists prescribe medications. However, tests show that trained clinical psychologists, if allowed to prescribe medication, do this very well. Additionally, clinical psychologists may actually be able to add benefits through a more thorough knowledge of other treatment options, in comparisons with physicians. Despite this, medical associations are still blocking attempts to allow clinical psychologists to prescribe medication. This may be problematic when a patient receives two lines of treatment without sufficient agreement between the two: One medication treatment by a physician and one psychological treatment by a psychiatrist. Often the type of treatment is determined by affordability, with drugs often being cheaper than therapy (and also more likely being covered by health insurance).

What is forensic psychology? - Chapter 8

Clinical Forensic Psychology

Clinical forensic psychology deals with criminal actions and criminals themselves. It focuses on disordered criminal offenders, often in the context of prisons. Many criminals with disorders, such as stalkers and sex offenders, are recidivists. This means that they are often resistant to treatment. A lot of work in the area of clinical forensic psychology focuses on the abnormal offender, a term used to describe disordered criminal offenders. This may be for example someone who sends anonymous missives – unwanted letters sent by an anonymous individual over years. This connection between criminal behaviors and mental abnormalities is referred to as the mad-bad debate.

Many aspects influence the judgment of criminality or pathology, males are for example judged more often as “bad”, while women are judged more often as “mad”. Studies did not find a very high difference between the crime rates of the general population and the crime rates of mentally disordered populations, even though there seem to be increased rates of some crimes in the mentally disordered populations. The most easily identified disorders usually include hallucinations and delusions related to serious crimes. These symptoms can lead people to harm themselves or others. Take for example that five percent of homicides are committed by schizophrenic people, who just make up one percent of the population. Mood disorders or depression can cause individuals to form one-sided suicide pacts, with the affected individual seeing only a negative future, which can cause them to kill themselves or their loved ones. Affective disorders can cause people to commit irresponsible and thoughtless acts. The relationship between psychosis, typically schizophrenia, and violence is proven. Increased crime rates are also shown among people with mental retardation. Another factor involved in crime is substance abuse. High rates of crime are related to alcoholism, with 40 to 80 percent of alcoholics committing criminal acts.

Legal Situation

Many courts work under the mens rea criterion. This means that to be fully punishable, crimes had to be committed by the free will of the offender. Otherwise, if the offender was influenced by a disorder, he may plea insanity. It is important to realize that under many mental illness conditions individuals can still recognize right and wrong. The twinkie defense argument is an example of that, with the offender claiming that him shooting San Francisco´s mayor was the result of high blood pressure (hyperglycemia) after eating a big amount of candy. It is seen that some abnormalities may predispose people to commit crimes. This is also supported by society preferring the view that criminals are distinct from the rest of the population, instead of anyone possibly committing crime without being influenced to do so.

Biological Causes of Crime

There are many approaches to the biological causes of crime. An early approach was biological positivism, which carries the view that criminal behavior results from defects within an individual. Criminals are seen as being inherently prone to commit crime, and thus biologically different from the rest of the population. This view ignores societal and environmental reasons for criminal behavior. Cesare Lombrose (19^th century) was one of the first studying criminality with a scientific approach. He unfortunately did this by categorizing racial types, which sparked a lot of criticism. Furthermore, he also studied differences between the heads of prisoners and of non-prisoners, concluding that criminals have a more evolutionarily primitive appearance. All in all, these results were not reproducible, and have been criticized in many ways.

In 1942 Sheldon related the idea that physical body stature indicates personality, and applied it to crime, since both are partially genetically inherited. He argued that the thin ectomorph build indicated a quiet introvert not being predisposed to criminal activity. The soft endomorph build is supposed to indicate a calm, sociable personality unlikely to behave criminally. The athletic and muscular mesomorph build was supposed to be most likely to act criminal. This view was challenged by a lot of people, for example due to the overprediction of mesomorphic individuals being criminals.

Some chromosomal abnormalities can also predispose one for criminal behavior. One such abnormality is the XYY male, a male individual having two Y chromosomes, also called a “supermale” by laymen. There is a far higher prevalence of XYY males in prisons than one would expect based on their prevalence in the general population. XYY males are assumed to be more aggressive and more criminal than the normal average male. They may also be treated different by the justice system than normal individuals, due to a perceived threat due to their appearance. XYY males tend to be tall, mentally retarded, and physically build in a way that may cause others to perceive them as a threat. Criminal offenders also tend to have higher level of testosterone than normal individuals. Genetic research also implies that criminality may be in part biologically determined, even though there are also environmental influences.

Eysenck and the Relationship between Personality and Crime

Hans Eysenck developed three dimensions of personality, which are thought to be biologically based. The first dimension is extraversion-introversion, with extraverts being internally under-stimulated and searching for stimulation, and introverts being internally well stimulated, thus seeking only little external stimulation. The second dimension is neuroticism-stability, with neurotic individuals being anxious and/or nervous due to an over-reacting autonomic nervous system. The third dimension is psychoticism-normality, with people scoring high being judged as criminal, psychopathic or schizophrenic. Eysenck´s approach is based on biological positivism (see earlier), a personality-based psychological approach and control theory. Control theory refers to the idea that everyone could be a criminal, but some factors control the majority to not commit crimes. These factors are seen to be socialization or the development of a conscience. Still, it is shown that people often act in ways they are aware of being wrong. Eysenck originally proposed four different personality types, based on the dimensions of extraversion-introversion and neuroticism-stability:

• Neurotic introvert: A personality type characterized by melancholy, moodiness and anxiety, seen as predisposed for mental disorders.

• Neurotic extravert: A personality type characterized by choleric, restlessness and aggression, seen as predisposed for criminality.

• Stable introvert: A personality type characterized by calmness, seen as having a controlled and dependable personality.

• Stable extravert: A personality type characterized by optimism, seen as having an outgoing and open personality.

The Yerkes-Dodson principle proposes that extraverts need higher levels of stimulation to preserve an ideal level of arousal. Eysenck speculated that this can lead to extraverts not fearing punishment, and using aggression to attain needed stimulation. Eysenck´s approach acknowledges some environmental influence, even though its focus is on individuals being genetically predisposed for crime. Still, Eysenck´s theory ignores situationalism, the notion that personality can differ among contexts, and overpredicts criminality.

Other Psychological Approaches to Crime

Many of the first psychological approaches to crime relied on the psychodynamic approach and Freud´s psychosexual stages. Early theories focus on genetics and relationships in childhood and infancy to explain delinquent behavior. John Bowlby developed the concept of maternal deprivation. This concept suggests that being separated for a long period time from one´s main caregiver during the first five years of life can lead to delinquency as well as forming an affectionless psychopathy, with individuals not being able to form close personal relationships. These effects are not thought to be irreversible, and may be countered for example by an initial secure relationship, preparing the child for being separated, and general emotional involvement by the main caregiver. This emotional involvement seems to be more influential than physical involvement.

There are some theoretical approaches about the influence of learning on criminality. Skinner´s theory of operant conditioning emphasizes the reinforcement of criminal behavior. Reinforcement can occur through materialistic outcomes, such as money gained through theft, as well as through avoidance of undesirable outcomes, such as avoiding drug withdrawal. Bandura´s theory of social learning – learning via modeling/observing the behavior of others and their consequences (also called vicarious learning) – was combined with control theory to explain why only some people act in criminal ways, while others are inhibited by cognitive moral processes. Cognitive explanations propose that the thinking style of criminals differ from the thinking styles of the general population, often being more impulsive, concrete, irresponsible, and less capable of empathy. Differential association theory by Sutherland states that criminal behavior is learned through relationships with other criminal people in one´s close groups. Thus, people may learn to see crime as an acceptable way to live one´s life through by peers with that opinion.

Modern Approaches to Crime Causation

Nowadays biological and social-environmental factors both are used to explain the emergence of criminal behavior. As an example attention deficit hyperactivity disorder (ADHD) in children is linked to later anti-social behavior and criminal activity, as well as to conduct disorder in adolescence. Medications such as methylphenidate (Ritalin), anti-depressants, and SSRIs improve the condition of ADHD as well as improving self-esteem, cognition and social functioning. Thus an early intervention may help to avoid anti-social behavior later in life. There are also several brain structures involved in anti-social or criminal actions. The areas that may be impaired in these cases include the prefrontal cortex, amygdale, hippocampus, angular gyrus, and the anterior. These impairments are also linked to people becoming career criminals, a term that refers to people engaging in a life (“career”) of criminal activity. These influences can on the one hand foster the outcomes of anti-social or violent behavior, and on the other hand protect one from these outcomes. This supports the notion of genetic influences on anti-social behavior, even though it seems like the biggest influence on whether someone develops anti-social behavior is the interaction between biological and environmental influences. Some of the biological influences can result for example in a low heart rate, which indicates a lack of fear response. They can also lead to the children of anti-social parents eliciting negative parenting behavior from adopting parents. Protective factors include a high autonomic arousal, which seems to reduce the impact of an anti-social environment. All these factors lead to predictions of criminal risk based on biological factors becoming more precise as scientific understanding of these factors becomes more detailed. It seems as if this growing predictive validity could lead to dilemmas of prophylactic detention or compulsory treatment, which are problematic from a moral viewpoint.

Criminal Profiling

Special agencies often deal with crimes of a pathological nature, with the offenders tending to repeat their crimes, such as sexual offenses. Clinical forensic psychologists often work as psychological profilers or criminal profilers in these agencies. A lot of the cases where a profiler is consulted involve disordered offenders. Profiling is used to add information that crime scene analysis and investigating officers may not find. Offenders become more and more forensically aware, meaning they try to leave no physical evidence like DNA. This causes many investigations to be more dependent on profilers than they used to. The FBI conducted interviews with many criminals to reveal characteristic types of criminals, such as differentiating between organized and disorganized murders, which are assumed to have different murderer characteristics. The idea behind this is to infer characteristics of the offender from the crime scene. Furthermore, some special agencies such as the FBI and UK agencies created databases where details of the crime can be entered into, and that then provide likely offender details.

The Profiling Process

The FBI developed a four-stage process for profiling:

• Data assimilation: Collect all the relevant information, without collecting too much irrelevant information that could complicate the investigation.

• Crime classification: Decide what kind of crime was committed, such as deciding whether the crime was organized or disorganized.

• Crime reconstruction: The detail and sequence of action is investigated from several viewpoints, the goal of which is to find the overall modus operandi.

• Profile generation: Assimilation of all the collected information into several hypotheses about the offender.

In the UK there is also a big focus on the profiler advising on interview techniques once the offender is caught. The distinction of an organized versus an unorganized crime is a very important one, with organized crimes providing some evidence of planning, control, and removal of evidence. An unorganized crime tends to show signs of impulsiveness and abrupt violence. Past classifications of criminals allows the inference of characteristics of the offender from the crime scene, such as offenders leaving an organized crime scene tending to be intelligent, socially competent, being mobile, and keeping in touch with media coverage. One of the entrepreneurs of offender profiling, David Canter, proposed a number of facets of offender behavior. These include interpersonal narratives, meaning how the offender interacts with factors, such as their relationship to the victim. Spatial patterns consider the spaces in which an offender has a feeling of safety, normally because these locations are familiar to the offender. Crime careers refer to the tendency of an offender who commits several crimes to “optimize” their criminal behavior over the course of several offences. Forensic awareness refers to an offender learning to cover up a crime scene in order to evade capture. Canter also shaped facet theory and a type of multidimensional scaling by the name of smallest space analysis to group factors that probably co-occur with a specific individual, linking the aspects of several crimes together.

Critical Evaluation of Profiling

There are several constraints regarding the reliability of criminal profiling. Some critics argue that profiling is more of an art than an empirical science. This is more the case for the UK than for the USA, since in comparison criminal profilers in the UK tend to use a more intuitive approach, while profilers in the USA tend to use a more empirical approach. Early successes of criminal profiling were very limited, and even though the discipline became far more sophisticated, this problem still persists. An additional reason is the fact that criminal profilers are mostly consulted in cases where there is very little or no evidence and “standard” investigation techniques do not yield any results. These crimes are generally very difficult to solve, which could explain why criminal profiling is judged to be helpful only in a rather small proportion of cases. Generally there is a higher success of criminal profiling if the offender is highly disturbed and the crime itself was of sexual nature. There are different approaches to criminal profiling, with profilers in the UK relying more on intuitive methods, and profilers in the USA relying more on empirical methods. One drawback resulting from the use of criminal profiling is that once a criminal profile is created, there is a danger of relying too heavily on this profile and disregarding other evidence.

Challenging Issues in Forensic Psychology

With our increasing knowledge in these areas, the overlap between clinical psychology and forensic psychology becomes more and more problematic. Many criminal offenders are difficult to deal with in terms of legal and medical aspects, such as when criminal activity is caused or influenced by psychopathology. We are going to consider examples of stalkers, sexual offenders, and psychopathic individuals.

Stalking

Stalking refers to behaviors by one or more individuals that repeatedly and unwanted by the victim harass an individual. Even though stalking often is not violent, many intense serial crimes started with stalking. Also, many people who are being stalked would prefer an assault over the constant fears caused by the stalking. Stalking is rather common, according to the British Crime Survey approximately 2.9 percent of the population being stalked in one year. Public perception sees stalkers often as lonely individuals who have fallen in love with their victim and won´t accept their refusal. In reality though stalkers are mostly male, controlling, emotionally offensive, and tend to have a psychiatric and/or criminal past (around 50 percent of stalkers have a criminal record). Even though there is a high prevalence of male individuals among stalkers, this ratio is comparable to other crimes. There seems to be a consistency of interactional style, with stalkers tending to have a past of unsuccessful and disturbed relationships. Having classifications of stalkers can be advantageous for preventing harm. Still, early typologies were weak in this aspect, even though they added knowledge as well. Those early typologies e.g. classified the class of erotomanic stalkers, which are typically female and live in the delusion that their victim loves them and started the relationship, even if they are clearly rejected by their victim.

A modern, useful typology of stalking was proposed by Mullen, Pathe and Purcell, who sorted stalkers into five categories:

• The rejected stalker is most common. The victim normally is an ex-intimate whom the stalker attempts to reconcile with. This tends to turn into seeking revenge over rejection from the victim. These stalkers are normally mentally sound but angry. They also tend to lack social skills and may be quite easily provoked to act violent, for example when meeting the victim with a new partner. This kind of stalking can often be reduced by treatment and sanctions.

• The intimacy seeker often is deluded and/or disordered. These kinds of stalkers often make up a fantasy one-sided relationship with their victim. A subtype of this is the erotomanic stalker, as mentioned earlier. Intimacy seekers misinterpret any reaction by their victim, even clear rejection, as affirmation. Intimacy seekers tend to live lonely lives lacking intimacy. These kinds of delusions may in some cases be medication-induced.

• The incompetent suitor lacks social skills and romantic skills, but strongly desires a relationship. These individuals lack intimacy skills and are unresponsive to the wishes of their victims. These people may have a disorder or personality traits such as being overconfident and arrogant. They are not as strongly attached to their victim as other types of stalkers, and can be rather easily stopped from stalking through sanctions. Instead of continuing to stalk their victims after being sanctioned, they often tend to stalk a new victim. Treatment is possible by training their social skills.

• The resentful stalker tries to evoke strong fears in their victim, resulting from the stalkers perception of being humiliated by their victim and wanting to “get back” at them. These individuals exert power and control by means of extreme actions. This may be through sending offensive or scary material to the victim or people in contact with the victim, ranging from sending threats to the victim to trying to denounce the victim in front of friends and colleagues, which heavily increases the victim´s amount of psychological stress.

• The predatory stalker is the most dangerous and (fortunately) most rare type of stalker. The predatory stalker is almost exclusively male and sexually motivated. These individuals stalk their victims in order to be able to plan and carry out an assault on the victim, being motivated by dominance and control. They typically lack intimacy skills, are unconfident and inexperienced.

Given that the types of stalkers differ strongly, it takes different approaches to deal with them.

Victims of Stalking

Victims of stalking often are ordinary people, but the media most often only reports cases of famous victims (giving the impression that victims are mostly famous). Victims are likely (but not necessarily) female, young, educated, and single. Violence is more likely if the stalker and the victim had a prior relationship, resulting possibly from a sense of ownership over the victim. Many cases of stalking are not reported (around half of them). Still, the psychological harm done by threats, stalking, and intrusion is often judged by the victims as more severe than actual physical assault. Stalking often has a giant impact on the life of the victim, resulting in drastic lifestyle changes such as focusing way more on one´s security and becoming more isolated. Many victims of stalking even change jobs and their homes to escape the stalker, which often does not help against an overly motivated stalker. Especially the victims´ fears and their increasing isolation lead to a loss of social capital (such as family and friends) in a situation where the victims would need their support most, leaving the victim even more vulnerable than before. Being stalked often results in anxiety, insomnia, and other symptoms related to post-traumatic stress disorder (PTSD).

In many cases professionals are the victims of stalking. This can be any individual in the public eye. The highest risk exists for professionals who have a one-to-one connection with the client. This can be for example therapists, counselors, doctors, and healthcare professionals. What’s more, individuals in the media are also at a high risk of being stalked, often due to pseudo-intimate relationships, in which the stalkers think the individual (for example a news anchor) is speaking directly with them. They imagine a relationship with the victim, especially if the stalker is an intimacy seeker. Another problem especially for mental healthcare providers is that they are often over-tolerant to illicit behavior, ascribing it to the disorders of the patient. This, in combination with e.g. therapists often seeing their client as the only vulnerable party in the client-helper relationships, can create an ideal setting for a stalker.

Means of Stalking

Stalking can involve a variety of forms. The stalker can personally follow his/her victim as well as confront the victim by means such as breaking into their house, damaging their car, and generally causing damage to their property. Other typical ways of stalking involve sending letters and making phone calls to the victim. One of the most unsettling things for the victims is their families, friends and/or colleagues being targeted or threatened by the stalker. Particularly distressing for the victim is also stalking by proxy, which refers to the involvement of third parties into the stalker´s activities. This can cause the victim to falsely believe the whole world being against them, which may be emotionally or economically disastrous, especially if this involves the personal network of the victim.

Due to the internet becoming more and more widely accessible, cyberstalking becomes more of a problem. Cyberstalking can cause intense psychological stress, which can even exceed the stress from terrestrial stalking, for example through providing the victim with details of their every action via emails, text messages or other means. The anonymity provided by the internet can decrease inhibitions of the stalker even further, fostering sadism and increasing the possible scale of stalking activity, such as denouncing a victim to a big amount of people at once. Cyberstalking includes for example cyberaggression, such as spamming the victim with hateful email, and identity theft, such as setting up a fake website in the name of the victim. Because cyberstalking does not have local boundaries, the stalker can often be from another country than the victim, making legislation and prosecution extremely difficult.

Anti-Stalking Legislation

Legislation against stalking is relatively new, also due to the non-physical aspect of the harassment. Victims should generally alert police as early as possible, not respond to the stalker (in order to not reinforce the stalker´s behavior), and keep all evidence of harassment. Especially the last point is in reality often difficult, because victims tend to get rid of “reminders” of their stalkers. Depending on the type of stalker legal sanctions may be rather ineffective, for example for the erotomanic stalker. Stalkers may also use legal processes to further their aims, for example by bankrupting their victims over the process or extending their relationship with the victim over the course of the trial. Sometimes legal procedures may even serve as stalking by proxy, such as when counter-suing the victim (suing the victim for example for defamation).

Clinical Conditions of Stalkers

A lot of stalkers have personality disorders, mostly those from the cluster “B” personality disorders from the DSM, which include anti-social and psychopathic disorders. For example the incompetent suitor type of stalker is often related to schizophrenia or autism. Some stalkers also have a paranoid personality combined with morbid jealousy. Many stalkers also have a dependent personality, as well as suffering from delusions. For those stalkers that have clinical problems, there are possible treatments. Unfortunately, these treatments often only become possible once the stalker is in prison. Treatment options include medication such as selective serotonin reuptake inhibitors (SSRIs), which reduce symptoms of depression as well as of aggressive disorders. Another possible treatment is cognitive behavioral therapy (CBT), which may change the ways of thinking and behavior that cause and maintain the stalker´s behavior. CBT may also help the stalker realize that he/she uses the stalking relationship as a substitute for a real, proper relationship, thus also damaging his/her own life.

Sex Offenders

There are three broad dimensions of sexual offences: (1) Rape and sexual assault, (2) pedophile offences, and (3) further paraphilic offences. Sexual offences are generally defined by each country´s legal system, which can lead to way different definitions of sexual offences among different countries or cultures, such as homosexuality being an illegal sexual offence in some countries. A lot of victims do not report the incidents to authorities, leaving the offender free and prone to repeat his deeds, while the victim tends to be left alone with their pain. This is for example caused by many victims being reluctant to report the incidents, also due to fear of embarrassment and stigmatization, leading to a high dark figure percentage of sexual offences that are never reported.

Treatment of sexual offenders is very important, so that they do not carry out offences once they are no longer imprisoned. Offences are generally defined by whether the sexual contact was consensual or not. This is often difficult to determine if there was a pre-existing relationship between the offender and the victim. Statutory rape refers to the special case of sexual offences towards a person below the age of consent. Rape often includes a cooling-off period between offences, hostility, control, involvement with the victim, and even theft. Hazelwood and others elaborated a typology of rapists with four different types:

• Power reassurance type: Seeks for confirmation of masculinity and sexual ability. These rapists normally do not act violent and often even try to find pseudo-unselfish ways of establishing a relationship with the victim, such as begging for forgiveness.

• Power-assertive type: Convinced of their sexual ability, lures their victim by being charming and persuading, until their behavior changes to aggression and violence. These rapists are selfish, experienced, and intelligent, and often actually harm the victim physically.

• Anger-retaliatory type: Transfers his anger, typically towards another person, towards the victim. Attacks are rapid and selfish, spending their anger in an outburst of extreme aggression.

• Anger-excitement type: Rare and selfish type of rapist who plans his offence thoroughly and is encouraged by the misery of his victim, often leading to strong brutality and even homicide.

Some rapists have an external locus of control, meaning that they ascribe the causes of their offences to something beyond their control. There are three general treatment options for sexual offenders: (1) Cognitive programs focused on changing styles of thought and increasing empathy in the rapist, (2) Behavioral techniques and physical measures focus on the reorientation of an offender´s reactions, and (3) Medical interventions, such as reduction of hormone levels or eventually castration. These techniques have been combined into sex offender treatment programs (SOTP), which are mainly focused on cognitive behavioral techniques because they seem to be the most effective. Still, these treatments have no high overall effect, but every small positive change in sexual offenders is seen as helpful.

Managing sexual offenders includes an evaluation, treatment, risk evaluation, and continuous supervision. In many countries there are registers for sex offenders, which for example the police can access. There is generally a focus on public protection, rather than on treatment of the offenders. An example of this is the Sex Offender Risk Management Approach (SORMA), which emphasizes practical surveillance of offenders and exchange of information among several agencies. Reporting on sexual offences, especially cases of pedophilic offences, seems to increase newspaper sales, which leads to a high prevalence of “naming and shaming” of sexual offenders. This public denunciation of sex offenders can lead to attacks on them, but also on treated offenders or offenders´ innocent families. It can also lead to offenders trying to avoid registration, or increasing their efforts to not be caught, such as by killing their victims and removing evidence.

Psychopathy and DSPD

Dangerous and severe personality disorder (DSPD) is a subcategory of psychopathic disorder. Especially important in court are cluster “B” personality disorders, which are seen as more dangerous than other disorders. These cluster “B” disorders include anti-social personality disorders and psychopathy, the latter of which is unfortunately not listed in the DSM. Furthermore, all psychopaths also have an anti-social personality disorder (APD), but only around one third of people with APD can be considered psychopathic. APD includes continuous offending, impulsiveness and a general disrespect for rules. Often APD develops from conduct disorder in adolescence. Due to their nature of lacking emotions and remorse as well as tending to offend without any aim psychopaths pose a greater potential for harm than individuals with APD. For example around 90 percent of sexual and serial killers are found to be psychopaths. The lack of empathy and conscience in psychopathic individuals makes them often rather successful in business, military settings, or politics. They are often seen as untreatable because they show “moral insanity”, do not learn from experience, and manipulate any treatment. There are some useful measures of psychopathy such as the PCL-R and PCL-SV, which are psychopathy checklists used for determining the risk of offending. Due to the legal complications this poses, the term DSPD was politically motivated and includes all those personality disorders that suggest a risk for others, including psychopathy and APD.

Risk assessment of psychopathic or DSPD individuals is of great interest to the public and is often done by clinical forensic psychologists. Especially the early detection of psychopaths is important, but also carries problems. The UK Mental Health Acts up to 1983 required all psychopathic individuals to be detained compulsory. This poses a problem known as Scull´s dilemma: Releasing psychopaths carries an unbearable risk for the public, but detaining them even though they haven´t committed a crime yet and are untreatable is also problematic. Still, for example in the UK 2006 Mental Health Bill, public safety is generally regarded as more important than patients’ rights. In many countries, a mental health review tribunal monitors the risk of forensic and other patient´s release, as well as overseeing risk and treatment conformity in the society. Special legal procedures deal with these disturbed individuals, such as the UK Multi-Agency Public Protection Arrangement (MAPPA), which establishes an inter-agency cooperation and arrangement aimed at evaluation, monitoring, and managing violent and sexual offenders in the UK.

What are moderators for stress and illness? - Chapter 12

Coping

Stress can be seen as an objective experience as well as a subjective one, with several factors moderating the impact of stress on the individual. Sometimes, stress can even be helpful, for example when moderate stress increases performance. One of the factors moderating the impact of stress is coping. Coping refers to any action by a person aimed at reducing the effect of a stressor. Coping is generally seen to serve several functions: it can weaken the impact of damaging external circumstances and it can help one to tolerate negative occurrences or at least adjust to them. Furthermore coping can help one to keep up a positive self-image, as well as reducing emotional stress and preserving a satisfying connection to one´s environment or other people. Coping can happen cognitively or behaviorally, as well as actively or passively.

There are two main classifications of coping among literature. On the one hand it is distinguished between problem-focused coping, which refers to mostly cognitive efforts aimed at reducing the stressor´s impact, such as changing the source of stress, and emotion-focused coping, which refers to cognitive efforts aimed at reducing the emotional reaction toward the stressor, such as seeking emotional support. On the other hand it is distinguished from approach-oriented coping, which refers to focusing on the source of the stress, such as by searching information about it, and avoidant coping, which refers to the avoidance of the stressor, such as distracting oneself from thinking about the stressor. Throughout the field many subscales of coping were created, such as Endler´s three coping dimensions of (1) emotion-orientation, (2) task-orientation, and (3) avoidance orientation.

Coping Styles and Coping Strategies

It is often differentiated between coping styles and coping strategies. Coping style refers to trait-like ways of coping that people tend to use when confronted with a stressful situation, while coping strategy refers to a range of different options and strategies used to actually cope with a stressor. People often use a combination of different coping strategies. It was, for example, found that people who had a heart attack tend to use a combination of passive coping, such as accepting the situation and re-evaluating it in a positive light, and problem-focused active coping, such as adjusting their lifestyle, at the same time. People differ in their flexibility of using different coping strategies. The interdependence of problem-focused coping and emotion-focused coping make it very difficult to predict the effectiveness of each strategy. The use of one strategy influences the use of another strategy, due to coping efforts being constantly evaluated and being adjusted if considered unsuccessful.

Coping is also contextual, depending on the external situation as well as on one´s locus of control. Problem-focused coping for example only makes sense when one can actually change the situation, otherwise it can be counterproductive. Another influential coping response, especially in patients suffering from severe illnesses, is the so called fighting spirit, referring to a mentality of wanting to beat the disease, or acting in a helpless/hopeless manner. The latter is related to negative life outcomes, such as a higher probability of death from potentially lethal diseases. Coping goals and styles are influenced by many factors, such as previous experience with that specific coping reaction, anticipated outcomes, and the protection of one´s self-esteem. People not only differ in their coping strategies due to different coping styles, but also because they have different coping goals.

Stress, Personality and Illness

Personality is often seen as a relatively stable set of dispositions within one individual. The Big Five theory includes (1) agreeableness, (2) conscientiousness, (3) extroversion, (4) neuroticism, and (5) openness to experience. Personality is linked to health in various ways, mostly by influencing health and risk of diseases indirectly. It can influence one´s proneness to unhealthy behaviors such as drinking or smoking, it can influence one´s ways of coping and appraisal of stressful events, and there are certain personality types that seem to be prone to certain diseases.

Neuroticism is related to anxiety and un-proportional reactions towards stressors. Neurotic individuals are biased to view events negatively, and tend to use maladaptive and emotion-focused coping strategies. Neuroticism is linked to the trait of negative affectivity (NA), which is a major factor in the relationship between stress and health. Individuals high on NA generally have a pessimistic outlook, tend to have a low baseline mood, and have a low self-concept. NA is also related to lower perceived health, no matter how healthy the individual objectively is. Due to this it is uncertain whether neuroticism is linked to lower health only due to self-reported lower health, or due to actual factors. One actual factor that was found is that N/NA seems to add to immune suppression.

Conscientiousness on the other hand is generally linked to positive health outcomes and protective actions, such as positive health behaviors (for example regularly going to the doctor). Conscientious individuals act more anticipatory and self-disciplined. Furthermore, high conscientiousness is related to more problem-focused coping approaches as well as more self-regulation, such as restraining oneself from unhealthy behaviors. All in all, it is often argued that conscientiousness refers more to the cognitive than the emotional features of well-being, such as satisfaction and positive evaluation. Agreeableness and extraversion are also both linked to positive health outcomes, agreeableness by being linked to more flexible coping, and extraversion by being linked to some positive outcomes such as positive appraisals. Still, extraversion also carries health risks by fostering stimulation-seeking behavior, which may be unhealthy (such as drug use).

Other Personality-Related Influences on Health

Optimism is another influence on health. Dispositional optimism refers to a trait-like resource, having a general positive attitude end expecting positive outcomes. Dispositional optimism may foster the belief of wanted outcomes being possible, thus motivating individuals high on dispositional optimism to cope better with negative events, and to use more problem-focused coping strategies. This can diminish the risk of unfavorable outcomes. Dispositional optimists tend to have an external locus of control for uncontrollable stresses, which may be beneficial for their emotional well-being. Optimistic individuals tend to cope more actively and have a less negative state of mind or depression than less optimistic individuals. Unrealistic optimism, such as viewing hope in the face of a disease where there is no chance of actually becoming better, can be beneficial in unchangeable situations. Thus an individual with unrealistic optimism and a lethal disease may have better emotional well-being than a more realistic individual.

Related to optimism is also the concept of self-efficacy, which refers to the strength of one´s belief in one´s abilities to reach one´s goals. Self-efficacy is more helpful than unrealistic optimism in cases of negative situations that are still somewhat controllable by the individual (such as restraining oneself from eating sugar as a diabetic). There is also a bundle of characteristics buffering one against the experience and effects of stress. These characteristics are summarized as hardiness. Hardiness seems to be more of a belief system than a trait, consisting of three different feelings: (1) A feeling of commitment, referring to one´s sense of involvement in events, causing one to see stressors as meaningful and fascinating; (2) a feeling of control, referring to one´s sense of the influenceability of events, causing one to think that it is possible to change stressful events; and (3) a feeling of challenge, referring to the view of change being something normal and positive, causing one to see a stressor as a chance for growth instead of a threat. Hardiness exerts more of a buffering effect in situations with high stress levels than in situations with low stress levels. Non-hardiness also seems to be related to neuroticism.

Personality Types Prone to Illness

As mentioned earlier, there are certain personality types prone to certain illnesses. One of these patterns of behavior and personality has been named Type A behavior (TAB). TAB is believed to be linked to coronary heart disease and its outcomes. It includes behaviors and emotions, such as competitiveness, being easily stressed or annoyed, being prone to hostility and anger, being impatient and being achievement-oriented. This is quite the opposite from the relaxed and peaceful Type B behavior. The proneness of TAB individuals to coronary heart disease and its outcomes may be fostered by their tendency to respond quicker and stronger to stressors than type B individuals, as well as showing greater physiological reactivity. This may also lead to TAB individuals perceiving many situations as more stressful. Stress and the resulting physiological reactivity are highly related to various diseases, this for example explaining the link between TAB and coronary heart disease.

Hostility is also an especially important predictor of illness. Individuals high in hostility tend to engage in behaviors carrying health-risks, with anger being related to raised levels of alcohol and nicotine intake. They also profit less from social support, thus being less protected from the harmful influences of stressful or negative events. The term psychosocial vulnerability hypothesis refers to the suggestion of hostility moderating the connection between stressful life events and health problems. Moreover, individuals high in hostility also tend to be more reactive to stress in general. This in combination with a lower “buffer” due to less influence from social support makes hostile individuals prone to coronary heart disease. One of the components of hostility is trait anger, which refers to the predispositional anger levels of individuals. High levels of trait anger are linked to high blood pressure and hypertension, both conditions also fostering illness.

Other personality types have been proposed to explain proneness to certain illnesses. One such type has been labeled the Type C personality, which was supposed to be prone to developing cancer. The Type C personality is characterized by being harmonious, passive, detached, and an inclination to suppress negative emotional responses. Even though research about the Type C personality found a link between a passive and helpless style of coping and inadequate illness diagnosis, it was also found that Type C personality, other than expected, is not a good predictor of cancer. Type C personality is characterized by negative affectivity (NA) and social inhibition (SI), the latter of which being defined as a pattern of avoidance-behaviors regarding social interactions due to the fear of rejection or disapproval. Due to the combination of NA and SI, type C individuals are thought to have negative emotions while not being able to cope with them well, due to them not using social support. SI is also related to a high reactivity of blood pressure to stressful situations.

Another type of personality is the Type D personality, which is thought to be disadvantageous for the prognosis of cardiovascular diseases and their outcomes (known as cardiac events), thus being for example proven to be related to a higher likelihood of death after a cardiac event.

Stress and Cognitions

An important influence on health and health outcomes is the perception of control within an individual. The term locus of control refers to one´s tendency to ascribe the responsibility for events and results to either oneself (internal locus of control) or to external factors such as other people, chance, or external forces (external locus of control). One´s locus of control also influences one´s behavior, for example is it more likely that someone with an internal locus of control takes the initiative to change a situation than that someone with an external locus of control does this, just because of their expectations of whether they can actually change something or not. It is proposed that individuals with an internal locus of control are cognitively more efficient in regard to information that allows them to influence events. Thus, individuals with an internal locus of control tend to use more problem-focused coping. It is for example found that individuals with an internal locus of control have beneficial effects on physical recovery. On the other hand, an internal locus of control can be counterproductive in situations where those beliefs are unrealistic, such as when one becomes frustrated because he believes he can change his situation, but has a terminal illness that cannot be influenced.

Locus of control can be specific to certain categories, and even when one cannot influence some categories, retaining an internal locus of control for some other categories can still be beneficial. These five categories are:

• Behavioral control refers to the assumption that one is capable of performing behaviors that may decrease the negative influence of a stressor.

• Cognitive control refers to the assumption that one is cognitively capable of dealing with the negative influence of a stressor, for example by engaging in self-distraction.

• Decisional control refers to the assumption that one has the possibility to make his/her own decisions.

• Informational control refers to the assumption that one has the possibility to gain more information about the stressor in order to be then better able to deal with it.

• Retrospective control refers to the attribution of control after an event has happened.

The ideas of perceived locus of control and self-efficacy are the major concepts of control in health psychology. Relevant in this matter is also the concept of causal attributions, referring to one´s attribution of the cause of a situation, emotion or behavior to oneself, to other people, or to other causal powers such as faith, chance, or destiny. One potential problem with an internal locus of control in the face of negative events is self-blame, which can almost be seen as a trait. People who blame themselves for their problems they are clearly not directly responsible for (for example thinking: “It is something unchangeable about me that let me develop this tumor”) tend to have poorer health outcomes, with self-blame being related to negative feelings and depression. It seems that one´s locus of control is also influenced by one´s social class, with people from the middle and upper class tending to have a more internal locus of control. An internal locus of control in individuals from low-income groups also seems to diminish the effect of low income on physical and psychological outcomes.

An increasing amount of research is focused on positive psychology. Positive psychology tries to determine the components of a healthy and happy life, which is seen as an important addition to all the knowledge that has been collected about negative influences such as illnesses or maladaptive patterns. One component of positive psychology is the concept of hope. Hope is hard to define, with the most major definitions focusing on the belief that one can set, prepare and attain goals. This view is extended by the inclusion of a need for motivation and the necessary pathways in order to achieve goals. Hope seems to be based on appraisal, similar to stress, and involves a perception of meaning and relevance. This can result in hope sometimes having faith-like features.

Stress and Emotions

Another influence on health seems to be of an emotional nature. Especially depression seems to increase the likelihood of certain diseases, such as breast cancer, especially among the elderly. Research also indicates a link between depression and the outcomes of coronary heart disease (CHD), where depression and anxiety both seem to be important predictors for CHD. Furthermore, there is also a significant relationship between depression and the likelihood of mortality from a heart attack. Overall, it seems as if depression is a better predictor of death than are the severity of damage to the heart or previously having had a heart attack. It has been speculated that a depressed state of mind may indicate a condition of negative affectivity. This, as mentioned earlier, is related for example to more negative CHD outcomes.

Depression may also affect health outcomes in several other ways. It may have an impact on one´s appraisals of potential stressors and thus change one´s coping behavior. As shown earlier, the coping styles are a strong influence on health. Depression can also influence health by reducing healthy behavior such as decreasing the frequency of one´s visits to the doctor. Moreover, depression is also suggested to influence health via physiological pathways; depressed individuals are for example more than twice as likely on average as non-depressed individuals to have carotid plaques, which are conditions that increase one´s risk of CHD. Also, depression can have a negative impact on one´s health outcomes by impeding one´s ability to seek social support. Thus, generally it can be said that depression seems to influence health in several, mostly indirect, ways.

Another influence on the relation between emotions, stress, and health is emotional disclosure. The term emotional disclosure refers to sharing one´s feelings with someone else or just writing about them, such as in the form of a diary. This is shown to reduce stress and thus have long-term advantages, for example for immune functioning and the healing of wounds. Closely related to emotional disclosure is the concept of expressed emotion, which refers to expressing one´s positive or negative emotions with the goal to reduce stress. Expressing and possibly discussing negative emotions is thought to potentially have negative effects, by keeping one´s attention focused on the negative emotion as well as by possibly damaging one´s net of social support. The way one expresses these emotions has a strong impact on whether outcomes of sharing these emotions are positive or negative. Congestive heart failure is a condition in which the heart fails to pump blood efficiently and this condition has been linked to couples suffereing from poor marital quality and increased distress.

Social Support and Stress

It has been shown that strong networks of social support increase both health and longevity. Social support can be split into actual support and perceived support. It seems as if perceived support is more predictive of health outcomes than is actual support. This makes sense since perceived support influences one´s ways of appraising and coping with stressful events, with a strong perceived network serving as a “buffer” against stress. Social support can be split into its structure (such as type of the network and size of the network) and into its function (such as providing one with information). Social support networks can be of an instrumental, emotional and/or informal nature, each serving distinct functions. Individuals who do not have social networks and are socially isolated are at a risk of poor well-being.

Influences of Social Support on Health

Social support benefits health in several ways. Research shows that low levels of social support are related to higher levels of mortality, for example through strokes, cancer or heart disease. Social support also seems to moderate the association between stressors and health outcomes. It seems to be especially influential in the face of diseases that cause one to be physically dependent on others. Two theories have been suggested about how social support is beneficial for one´s health. The first theory is called the direct effects hypothesis. It states that social support directly influences health, for example by means of providing a feeling of belonging and an increase in self-esteem. This is thought to result in a positive perspective on life as well as in the adaption of healthier life styles. The direct effects hypothesis also proposes that social support, through the means of positive appraisals and emotions, can physiologically reduce blood pressure reactivity. The second theory is called the buffering hypothesis. It states that social support is protecting one against the effects of huge stress. It is thought to do so by two processes: Social support on the one hand influences one´s cognitive appraisals of the severity of a stressor as well as of one´s own resources and it on the other hand influences one´s coping responses, such that coping does not occur alone but in a social setting.

There are several lines of evidence for the direct effects hypothesis. It is shown that social support promotes healthy behaviors, such as regularly going to the doctor. It is speculated that this may happen through social support fostering one´s self-efficacy beliefs, such as telling a former alcoholic that he can manage to stay abstinent. It is also shown that social support has direct physiological influences. It has been shown to reduce stress reactivity and enhance immune reactions. It has also been shown to change hormone levels, such as by lowering cortisol levels, which is beneficial because cortisol down-regulates the immune system. There is also evidence for the buffering hypothesis. It has been shown that the sole perception of social support being accessible, regardless of actual social support, is related to more optimistic outcome expectancies as well as more optimistic judgments of control over the situation. These judgments of control are also related to being more likely to seek the help of one´s social support networks as a way of proactive coping.

Seeking and Providing Social Support

Whether someone actually seeks social support or not is influenced by several factors. One of these factors seems to be gender. Females tend to be way more likely than males to seek or give social support, which also results in females tending to have bigger social support networks. Men tend to be less likely to provide social support, with for example male partners in a relationship relying on their female partner for social support, but their female partner relying mostly on other female friends and relatives for social support. Another influence on the seeking of social support seems to be culture. It has been found that especially in Asian collectivist cultures individuals are far less likely to seek social support from others. This is speculated as being attributable to the fact that in collectivist cultures it is perceived as unfriendly to trouble one´s social network with one´s problems. Implicit support has a way higher value and influence in these cultures than explicit support.

Finally, it has to be mentioned that social support can also have negative consequences. Practical help with frequent tasks may lead to poor adaptation by means of operant conditioning. A high amount of help may also lead the recipient to develop a strong dependence on the helper, as well as becoming more passive in his/her way of coping.

What is the relationship between illness and the quality of life? - Chapter 14

Illness and Quality of Life

As people all over the world grow older than they used to even 50 years ago, there are new challenges emerging in how to deal with this elderly part of the population. One important focus lies on patient´s subjective well-being, also called quality of life. Quality of life refers to one´s subjective judgment about one´s life in general at a specific time. In the past there was a big emphasis on how physical health influences quality of life, but now the opinion that physical impairments are more of a potential influence upon quality of life than a determinant of quality of life itself is most common. Quality of life seems to be influenced mainly by six broad domains: (1) Physical health (e.g. illness, disease, energy); (2) psychological factors (e.g. self-efficacy beliefs, self-esteem, positive and negative affect); (3) level of independence (e.g. voluntary activities, mobility); (4) social relationships (e.g. social support networks, sexual activity); (5) relation to the environment (e.g. safety, finances); and (6) beliefs and religion. Physical impairments alone can be buffered by these other domains from having a strong impact on one´s quality of life, but if problems in several of these domains accumulate, one´s quality of life may suffer. Quality of life is also influenced by one´s demographics such as age and culture; one´s condition itself, one´s treatment method, as well as one´s psychosocial factors.

Demographic Influences on Quality of Life

The first demographic factor on quality of life is age. Different physical health problems have a different impact at different ages. Generally it seems like the effects of an impaired quality of life, such as lowered self-esteem and lower self-efficacy beliefs, can accumulate over life. Thus for example a child with a serious illness may become more and more depressed over the years due to social isolation resulting from the non-participation in social activities due to the illness. But serious illnesses can also have the contrary effect, especially with adolescents. This phenomenon is called post-traumatic growth and refers to the experience of positive psychological change after a serious illness, such as a higher appreciation for life and new priorities. Furthermore, the “life stage” in which the individual finds himself is an important contributor to the perceived impact of a condition on quality of life. A physical condition that makes one unable to work may be perceived as worse by a 25 year old than by a 65 year old. Moreover, independence is more influential on quality of life for old people than for young people. Other important life domains for the elderly are physical health and social activity and relationships. Quality of life is impaired, especially in elderly people, when one has health problems that interfere with daily life. Physical impairments may challenge many other domains as well, such as by restricting social activities due to immobility. But physical health does not necessarily have to determine one´s quality of life. Some people with chronic illnesses may have “normal” levels of quality of life, because adapting to their condition may be easier when the impairment is seen as permanent and unalterable.

Another demographic factor on quality of life is culture. Culture can influence one´s reactions to pain, one´s attitudes towards medicine, and one´s ideas of dependency and communication. The meaning of health and disease are also influenced by culture. It was for example found that Chinese cancer patients highlight their family support more than western patients.

Illness-Related Influences on Quality of Life

Another influence on quality of life are illnesses themselves. Physical illnesses have the potential to influence quality of life. Some aspects of the illness matter more than others, with pain and disability being very influential on perceived quality of life. Still, the severity of an illness is not necessarily related to lower health-related quality of life. Neurological illnesses, such as Parkinson´s disease, can also diminish quality of life by disrupting other quality of life domains. It may for example impair physical functioning and one´s social relationships, thus impairing quality of life directly and indirectly. This shows once again that quality of life is not an objective measure, but depends on many subjective factors.

Quality of life judgments are also influenced by the treatment one receives. It has for example been shown that children being subjected to thorough treatment have a lower quality of life than those who don´t receive that treatment. Not much research has yet been done on the impact of treatment on quality of life, but it has for example been found that cancer patients receiving bone marrow transplantations after having done chemotherapy report a lower quality of life than those who receive solely chemotherapy. Treatments and caregiving are especially influential on quality of life for people close to death. It seems as if older people tend to not fear death itself, but rather be afraid of dying in pain or dying undignified and without self-control.

This also brings up the ethically difficult question of whether terminally ill people should be assisted in dying quickly instead of senselessly suffering for prolonged periods of time. Many countries have laws against active euthanasia, which is a kind of assisted suicide. But it is quite common in medical practice to do passive euthanasia, which refers to not treating a dying person. In many countries people can determine under which conditions they do not want medical help, thus setting the stage for passive euthanasia.

Psychosocial Influences on Quality of Life

Psychosocial factors also influence one´s perceived quality of life. For patients with physical impairments their quality of life is also partially determined by their emotional responses towards their illness. Anxiety and depression are both found to be related to poor quality of life. This has implications especially for illnesses that cause strong pain, because pain is strongly associated with depressed mood and negative affect. For example AIDS patients experiencing pain experience more distress and depressive symptoms than AIDS patients not experiencing pain. Pain was also found to affect a wide range of psychosocial functioning, such as impairing one´s emotional or social functioning. Race also seems to be related to quality of life and as well to distress, with patients that were not white on average reporting lower quality of life and higher distress than white patients. Why this is the case is not certain, but it was hypothesized to be due to different levels of socioeconomic status or different levels of life stress. It is generally seen that the main predictors of quality of life with patients that have illnesses are pain, a depressed state of mind, social support, and one´s ethnicity. Even though some short-term effects of social support on quality of life have been shown, its long-term effects on quality of life are not clear and have actually been challenged by some studies.

Another influence on one´s quality of life is brought on by one´s goals. The self-regulation theory by Scheier and Carver describes the course of goal attainment despite big disturbances such as severe illness. If one´s personal goal attainment is disturbed by chronic disease and its outcomes this is very likely to influence one´s perceived quality of life. One´s appraisals also influence one´s quality of life, such as appraisals of events, of one´s goals attainability, and of one´s resources. Disturbance of subjectively important goals has a far bigger impact on quality of life than that of less important goals. Quality of life could for example be strongly impaired by the perception that one´s ability to fulfill duties, to have fun and to care for important others is impeded. Goals also indirectly affect quality of life outcomes by changing the meaning someone attached to their disease, which influences subjective well-being as well as adjustment to the situation. As understanding for quality of life grows, it seems that the goals and priorities of each individual have to be taken into consideration in order to determine his level of quality of life.

Why Measure Quality of Life?

There are several reasons why measuring quality of life makes sense in a clinical setting. The first reason is that measurement allows for better information, on the one hand better information about best interventions, on the other hand better information provided to the patients, allowing them to psychologically prepare for the interventions in advance. Informing patients and their relatives about the different quality of life outcomes of different treatments can also help them to make more sophisticated choices about treatments. The second reason why measuring quality of life in a clinical setting makes sense is that it allows for the better evaluation of alternatives. It can help in the decision-making process for choosing the “best” alternative. Determining what may be considered the “best” alternative can depend on a variety of factors, such as expected quality of life, price of the treatment, and expected length of life after the treatment. A third reason for measuring quality of life is that it can promote communication. Assessing quality of life may cause doctors to assess areas they otherwise would not have assessed, such as the patient´s satisfaction with treatment, their interactions with friends and family, and the patient´s sexual functioning. This in turn may lead many doctors to consider a more holistic picture of what impact a treatment actually has on a patient. After considering why to measure quality of life in a clinical setting, the next emerging question is how to measure it. On the one hand quality of life may be judged based on its outcomes, but on the other hand it is influenced by one´s perceptions and appraisals of several factors, such as physical or emotional functioning.

How to Measure Quality of Life

A question in place is whether to measure quality of life in a generic/global way or in a specific way. Generic measures of quality of life assess concepts important for the quality of life with all illnesses, while specific measures of quality of life assess concepts explicitly related to the illness in question. Examples of generic measures are the Medical Outcome Study Short Form 36, short SF36, and the Nottingham Health Profile, short NHP, which are both used frequently in a clinical setting. There are also specific measures for many different diseases such as cancer, Parkinson´s, asthma, and so forth. Both types of assessment carry different benefits and risks. While generic measures may fail to assess factors that are unique in determining quality of life for certain illnesses, specific measures on the other hand do not allow for a good comparison between illnesses in regard to quality of life.

There are also individualized measures of quality of life. These measures typically ask patients to choose the aspects and matters that are most important to them, and then assess them on basis of these dimensions. Individualized measures may for example ask patients about the five most valuable areas in their life and ask them afterwards to rate themselves on these five areas. Another common technique is the Q-sort technique, which asks patients to sort determinants of quality of life according to one´s priorities. It was generally found with individualized measures that younger patients rate independence as more important than older patients, while older patients on the other hand rate satisfied family-life, good relationships, and support as more important than younger patients do. It is also possible that a readjustment after the onset of an illness may change one´s priorities, such as judging one´s health as less important after one accepted the fact that one´s health is impaired. In general it can be said that individualized measures consume a lot of time and are very complex, even though there are some emerging computer-based systems that are supposed to make the development and administration of individualized measures easier.

When choosing a measure of quality of life, one has to be aware of several constraints. It is important to realize that many measures are helpful in a research setting, but not in a clinical setting. Measures that take a long time to administer or consist of many items are problematic to administer in clinical settings to very ill patients. Certain illnesses also make the assessment of quality of life difficult, such as patients that suffered a stroke often having deficits communicating. Due to the variety of measures it is often also very difficult to compare the results of different studies, even in a solely research-based setting.

Changes in Perceived Quality of Life

It has often been found that some patients with a limiting disease report higher levels of quality of life than healthy people. This on the one hand underlines the subjectivity of quality of life, but it also fostered further research. One explanation of this phenomenon is called response shift, and refers to subjective reports of quality of life changing over time. This change may result from the patient changing the priorities of his life expectations or an adjustment of one´s internal standards. This is thought to change the patient´s perception of the measured construct, thus also changing his response to it. It was also found in what is called a “then test” that patients retrospectively judge one´s quality of life at the time of illness-onset as worse than patients actually judged it at that time, fostering the perception that one´s quality of life improved since then. The response shift may also be facilitated by one changing one´s anticipation of life outcomes, one´s meanings, one´s goals and one´s priorities during the course of the illness. It was also found that the quality of life ratings of patients are often made in comparison to others, even though it is not fully clear yet in which way this influences the measurements.

Other Influences on Health-Related Quality of Life

Another influence on health-related quality of life is culture. Since most assessments on quality of life were developed in English, the translations of these measurements may have been inadequate and thus distort the quality of life result. Different cultures have also differing experiences with diseases, such as a way higher death rate due to AIDS in Africa than in Europe, which may affect one´s illness expectations and one´s quality of life expectations. Different cultures also deal differently with specific diseases, such as it being common that in Asian cultures a disease is communicated with one´s family, but not with one´s friends, which can also influence disease and quality of life outcomes.

Age also influences health-related quality of life. This is most obvious in the case of ill children. Children often do not understand abstract assessment questions, such as questions about feelings. Age-related cognitive restraints may make understanding of concepts such as quality of life difficult for them. Due to this, a common measure is proxy measurement, which in children refers to a third party, mostly their parents, answering the assessment questions for their children. This is problematic on the one hand because it goes against the idea that quality of life is subjective and is rather based on observable behaviors, and on the other hand because it has been shown that perceptions of a child´s quality of life differ strongly between its parents and its treating physician. These discrepancies may influence the caregiving behavior of parents, as well as causing them to doubt the usefulness of the treatment and thus possibly not adhering to important aspects of the treatment.

What is the impact of illness? - Chapter 15

Stages of the Course of an Illness

Illnesses introduce various new challenges to an individual that change with the course of the illness. There are several stage models that propose which topics individuals with illnesses have to deal with. The generic model of emotional and coping responses by Morse and Johnson proposes the following stages:

• Uncertainty: A phase characterized by an individual´s effort to comprehend the implications and severity of early symptoms.

• Disruption: A phase characterized by an individual realizing he may be facing a significant illness. This realization is accompanied by high levels of distress and feelings of dependence on others.

• Striving for recovery: A phase characterized by the patient trying to gain control over the situation, for example through engaging in active coping.

• Restoration of well-being: A phase where the individual start accepting the illness and its implications and reaches a state of emotional balance.

A prominent stage model of illness regards the response of an individual to their diagnosis. This model includes the following stages:

1. Initial response: A phase defined by a variety of reactions, such as doubt, refusal and shock. Information processing is clouded, and the individual may act very defensive.

2. Dysphoria: A phase defined by the individual slowly accepting the reality of their diagnosis, typically lasting one to two weeks. This phase is often accompanied by great distress and accompanying symptoms such as restlessness, concentration problems, and anxiety. Throughout this phase, hope and positive beliefs may emerge and challenge one´s distressing patterns of thought.

3. Adaptation: A phase defined by the patient slowly adapting in a positive way to the diagnosis. Patients also develop lasting coping strategies in order to sustain their developed emotional balance.

Still, these staged approaches have also been criticized, especially because individuals do not strictly proceed through these stages. Symptoms of several stages may co-occur, or patients may move back and forth between some stages.

Adaption to an Illness

Adapting to an illness means different things from different perspectives. A medical perspective on adaption is likely to focus on pathology, reducing the symptoms, as well as physical arrangement. Biopsychosocial perspectives may also include one´s social functioning, emotions, and one´s understanding of the illness. Taylor proposed a psychological cognitive model of adaption, which includes three main topics: (1) Seeking meaning in the occurrence of the illness, (2) trying to win some sense of control over the illness, and (3) attempting to bring back one´s self-esteem. Stanton suggested several other concepts of adjustment to continuous illness, including preserving one´s functionality, having low negative mood, and not having psychological disorders. From a psychological perspective adaption is a dynamic process, including cognitive processes in order to challenge the situation. Taylor also suggested that the feelings of finding meaning, regaining a sense of control and improving self-esteem may be illusionary, even though they have real implications for the adjustment of the patient.

Negative Emotional Reactions to Illness

It is quite common for many different diagnoses and conditions to be accompanied by negative emotional responses. In particular, reactions after being diagnosed with cancer are often disastrous and extremely emotional. After being diagnosed with cancer many people, around 50 percent of those being diagnosed, develop depression. Fortunately, these rates of depression sink over the years following the diagnosis.

Having a chronic disease is related to high levels of emotional distress. This may often result in high levels of anxiety and depression, from “moderate” diseases such as diabetes to diseases such as HIV or cancer. Diseases with a certain stigma, such as AIDS, carry very high levels of distress and depression, which is also hypothesized to be due to internalization of these stigmata. Even after surviving a possibly terminal illness, the uncertainty of possible recurrence or other outcomes can lead to higher levels of anxiety. Further distress and anxiety may be added through feeling like “losing oneself”, referring to the feeling of one´s life being heavily restricted and one´s roles being lost. Feeling like a burden to others, which may be strengthened through negative comments by others, may also add emotional distress. The processes of keeping one´s former idea of self and of accepting the loss of some control foster one´s adjustment to the situation.

Negative Emotional Reactions to Hospitalization

Not all people who need hospitalized medical care are willing to betake oneself to hospitalization. They are often reluctant to take on the role of being sick, and the depersonalization and the giving up of control related to hospitalization. Many fears are associated with medical treatment, especially in relation to treatments that constrain or involve physical suffering. Anxiety prior to surgery is often high, and can actually affect the outcomes of the treatment. Anxiety may even lead people to withdraw from the treatment, leaving them prone to even worse health outcomes. Over the course of a treatment, especially when it is a long-term treatment, there are phases that are more commonly associated with anxiety than others, such as when waiting for test results or when a new treatment is introduced. Even when having an increased risk for a certain disease some people reject treatment. This is considered to be likely due to the individual being not well informed and seeing the treatment as not as effective as it actually is. It is often seen that these reluctances can be reduced by better communication from the side of health care professionals.

Negative Emotional Reactions after End of Treatment

Once a patient has finished treatment, an emotional ambivalence is quite common. On the one hand the patient is happy because treatment is over, as well as possible side effects, but on the other hand the patient may also feel unhappy because they may have feelings of being vulnerable and being abandoned. These negative feelings can result from the reduced contact with medical professionals. Another cause of distress may be the reduced social support from friends and family after a treatment is successfully over, leaving one to possible feel exposed and “missing something”. These feelings of distress do not have to occur though, and may be strongly reduced through a good management of one´s expectations. If treatment is not successful or there are changes to palliative treatment, meaning a treatment not any more focused on curing the illness but simply relieving pain, extreme distress is common. Even though not too many dying people are depressed (around one quarter of dying people), high levels of anxiety are very common. Being certain that one is going to die can cause existential crisis, fear of pain or fear of losing one´s dignity. Kubler-Ross proposed a stage-model of the approach of death. After a deadly diagnosis one is shocked and may experience feelings of numbness. This is followed by a stage of denying the reality of the diagnosis, as well as possibly feeling isolated. In this stage patients may have high anger and even blame others for their illness. Finally, one may reach a stage of accepting the terminality of the illness, even though this stage does not necessarily have to be reached by all individuals.

Influences of Negative Emotions on Outcomes

Negative emotional reactions to illness can have several implications. Being depressed or anxious can interfere with one´s commitment to treatment or recovery efforts. Depressed people tend to be less likely to visit rehabilitation classes. Being depressed or anxious also hinder necessary changes of behavior, such as anxiety being associated with worse control of blood glucose levels in diabetics. Depression and anxiety is also related to counterproductive behaviors, such as HIV-positive individuals still engaging in unprotected sex. Depressed individuals also retain less functioning, especially in aspects of social activities and work, which may be partially due to an inflation of symptoms in depressed individuals. This may also be one of the reasons why depression is considered a significant cause of disease and disability.

Positive Responses to Illness

Much less focus in research was directed on positive responses to illness than on negative responses to illness. Some new research was directed on the impact of being religious on illness. Religious coping was found to possibly reduce distress and improve adaption. But it can also be harmful, depending on whether one views god as good and supportive or as punishing.

A positive/optimistic outlook is related to more positive outcomes such as reduced pain and more adaptive coping. Positive emotions also have several beneficial effects. They boost psychological resilience and foster a more productive way of problem solving. Positive emotions also influence a patient and their outcomes by eliminating negative feelings. A higher baseline level of positive affect is also related to superior functional recovery.

Many people report finding benefits in their stressful and ill situation. This benefit-finding is also referred to as post-traumatic growth, which refers to experiencing positive psychological adjustments resulting from struggling with stressing life situations. This positive change can be: (1) Improved relationships; (2) higher appreciation of being alive; (3) the feeling of boosted personal strength; (4) a sense of higher spirituality; and/or (5) a positive change in one´s priorities and goals. Finding benefits through one´s condition has positive long-term effects and results in a better long-term adjustment of the patient. Benefit-finding is relatively common and for example reported by around 60 percent of heart attack patients, who find a change towards closer relationships and living a healthier lifestyle. This benefit-finding partially explain why some ill individuals report a higher quality of life than many healthy individuals. Due to the better adjustment related to benefit-finding, finding benefits in one´s situations can be considered a good predictor of positive outcomes. Internal resources such as self-efficacy and external resources such as social support both influence and help to predict benefit-finding. The impact of external resources on benefit-finding is way less influenced by one´s means of coping than the impact of internal resources, which seems to be stronger mediated by means of coping such as acceptance coping (which refers to acceptance of one´s situation and its unalterable nature) and social comparison coping (which refers to comparing one´s situation to the situation of others).

Coping with Illness

Experiencing a severe illness may come to many people as a crisis, with changes in identity, location, roles and duties, and one´s social support. There are no coping strategies uniquely related to dealing with illness, and the coping strategies related to stress and to illness are quite similar. Furthermore, coping strategies differ between dealing with acute illnesses or chronic illnesses, similar to stress. Moos and Schaefer proposed three processes resulting from the illness-related crisis:

• Cognitive appraisal: Refers to judging the meaning of one´s illness for one´s life.

• Adaptive tasks: Refers to one performing tasks specific to the illness. This can include handling one´s symptoms and pain, preserving some level of control over the illness, establishing a good level of communication with health professionals, getting ready for an insecure future, maintaining one´s level of self-esteem and self-image, and generally dealing with all the changes resulting from the illness.

• Coping skills: Refers to one´s engagement in coping strategies. These can, as with stress, be problem-focused, emotion-focused, or appraisal-focused (see chapter 8).

After receiving a distressing illness diagnosis, many people engage in denial coping or avoidance coping. This may have short-term benefits by reducing distress and one´s sense of threat, but is also related in the long run to more distress and harm. Avoidant coping with an illness seems to be related to higher levels of depression, as well as to a stronger maladjustment.

In contrast to that, there seems to be a strong relationship between engaging in problem-focused coping and engaging in acceptance coping and a more positive adjustment of the patient. It was found that the most common coping strategy in a hospital setting is acceptance-focused coping, closely followed by problem-focused coping. These two coping strategies are related to lower degrees of distress and higher levels of positive mood than was found with emotion-focused coping and avoidance-coping. The engagement in actually changing aspects of one´s situation related to problem-focused coping are also related to better health outcomes, thus apparently being an efficient way to diminish the impact of the problems arising from one´s illness. It has to be mentioned that people rarely engage in only one coping strategy, but rather use a combination of different strategies. It seems that the use of coping strategies changes over the course of longer illnesses, with for example patients with cancer often switching over the course of their illness from initial active coping and problem-focused coping to passive and avoidant coping strategies. As public knowledge of diseases grows, partially caused by better accessibility of information via the internet, common coping strategies also change. It was found for example that HIV-positive patients nowadays engage in more self-controlling coping and acceptance coping than they did even twenty years ago. Two forms of coping seem to be especially effective in HIV-positive patients, with direct action coping (concentrating on changing one´s situation) and positive reappraisal coping (trying to find something good in the situation) both being related to higher levels of positive affect and increased levels of physical health. Which coping strategy one engages in is highly individual and depends on many different aspects, such as culture and ethnicity.

Illness: A Family Affair

People´s illness happens in a setting of personal relationships, social networks, and culture. Close relatives or friends of the ill individual may actually experience similar effects as the ill person himself does. The family of an ill individual also has to adapt to the illness and its implications. Distress, e.g. caused by a severe illness of a family-member, can cause changes in the family system. McCubbin and Patterson suggested a stage model of family adaptation to the illness of a family member:

• Resistance stage: In this stage family members tend to reject or avoid the existence of the problem.

• Restructuring stage: In this stage family members accept the reality of the situation, and start reorganizing their lives based on the new circumstances.

• Consolidation stage: Stage that emerges when the situation changes from possible being only temporary to being permanent, e.g. through chronic illness. Family members may have to permanently exert their new roles, and changes in thinking for example about life and health may occur.

There are three dimensions that determine the functioning of a family system: Cohesion, adaptability, and communication. Families that are balanced on these three dimensions seem to adapt better to life stressors such as severe illnesses of a family member. The model shown above also shows what was mentioned earlier as well: avoidance coping may be adaptive, but only shortly after the diagnosis, not if continued for a longer period of time. One interesting effect shown by studies of parental coping with illness of their child was that mothers tend to show higher levels of distress than fathers, even though both seem to maintain their distress even after a successful treatment, due to fear of recurring of the illness.

Caring

Family members that are involved with their family may become caregivers when one of their closer relatives becomes ill. This may include activities that go beyond a “normal” role of providing assistance, such as helping the ill individual to bathe or get dressed. Approximately 60 percent of people have to take on the role of a caregiver over the course of their life. Most people receiving care are older individuals over the age of 65. Even though caregiving through relatives saves the medical system billions, the needs of care-givers often have low priority. Even though it was found that training informal caregivers provides many benefits for them as well as for the patients, such training is barely ever offered. Support networks are very influential on patient well-being, because they are mostly responsible for long-term care and heavily influence post-treatment psychosocial outcomes. The quality and function of one´s social support networks exert several benefits. They can cause heightened devotion to treatment, can buffer distress and increase the patient´s emotional adjustment, can lead to better functioning and ultimately also to increased survival.

Caring can obviously have helpful effects, but in some situations caring can also be unhelpful. Helpful caring behaviors include for example practical help and expressions of love, compassion, and understanding towards the patient. Unhelpful caring behaviors include for example downplaying the severity of the situation, expressing unrealistic optimism, being critical or overly demanding towards the patient. Other types of unhelpful behavior include being insensitive, acting disengaging, and/or blaming the patient. Unhelpful caring behavior can have severe implications for the patient, such as higher levels of negative affect or even the development of depression. Helpful caring behavior can also be over-done, resulting in the patient being “rewarded” for their sickness, which can cause higher levels of sickness symptoms due to the principles of operant conditioning. Feelings of being over-protected may also result in decreased self-esteem and motivation, as well as increased depression of the patients. An interesting study found that gender seems to influence helpful or unhelpful caring behavior, with women being more sensible to changing needs of the patients than men, which can result in better support.

Negative Consequences of Caring on the Caregiver

Even though generally providing care to others is related to better caregiver well-being, providing care to a sick loved one tends to be a threat to the caregiver´s well-being. This may be due to the involved emotional bonds as well as due to caregiving in a family setting being a 24-hours-a-day job instead of being constrained to specific times. The term caregiver burden refers to the price of caring to the caregiver, no matter if subjective or objective. Providing care to a relative with a chronic illness is related to very high levels of distress, which often constrains the caregiver´s physical health and life-satisfaction, resulting in far higher levels of depression than in non-caregivers. Providing care also becomes more stressful when appraised as going beyond one´s responsibility. Being extrinsically instead of intrinsically motivated to provide care also has strong negative effects on caregiver´s well-being. Sometimes teenagers have to take on the role of a caregiver, for example for their sick parents. That has strong negative effects on the teenagers, for example by constraining them academically and socially. Providing long-term care also reduces the immune system functioning due to stronger and more frequent levels of distress. This effect is stronger for older caregivers than for younger caregivers.

Positive Consequences of Caring on the Caregiver

But caregiving does not only have negative implications for the caregiver. Having a caring role can also have positive implications. Caring can be appraised positively, for example in terms of affirming aspects of oneself one ascribes high value to. Providing care to a close relative, for example one´s spouse, can cause one to feel closer to the care-recipient. Thus, good caregiving can actually bring the caregiver and the care-recipient closer together and improve their relationship. The level of impairment of the patient is also influential in terms of whether the relationship has more positive aspects or more hassles, with negative effects on caregiver´s well-being emerging when the hassles outweigh the positive aspects of the caregiving relationship.

Influences on Caring Outcomes

Features of the illness or the behavior of patients have complex influences on outcomes of their caregivers. Critical and troublesome behaviors cause way higher levels of distress in the caregiver than for example higher levels of disability or physical deterioration. The experienced levels of stress by the caregiver depend on changes in the patient´s well-being. Negative tendencies and characteristics of the patient, such as being aggressive or overly demanding, are associated with higher risks of depression in the caregiver. It seems that younger caregivers feel easier burdened and are thus at a higher risk of dangerous levels of distress. Shifts in objective and subjective factors, such as health of the patient or changes in the caregiver´s social contacts related to their caregiving, can influence outcomes of the caregiver. It is important to note that a reduction in patient´s positive characteristics increases the perceived caregiver burden, while a growth of patient´s negative characteristics increase the risk of caregiver depression.

Influences of Caregiver´s Characteristics on Caring Outcomes

Characteristics of the caregiver also influence how they are affected by giving care to someone. Personality is a first factor, with one´s optimism and neuroticism levels exerting direct influences on the mental health of the caregiver, as well as indirectly influencing the caregiver´s stress levels. Another factor is the way the caregiver appraises the situation. If the caregiver perceives an inequality between the demands of providing care and the perceived resources the caregiver has, high levels of distress can emerge. So-called resistance factors are seen to buffer stress and include the caregiver´s motivation, his/her socioeconomic status, and his/her cognitive appraisals and coping reactions. Beneficial cognitive appraisals can include seeing the stressors as harmless, using approach coping, and having a high level of perceived social support. Studies show that a caregiver´s quality of life can be best predicted by his/her perception of being burdened and his/her perception of mastery. It was also found that a caregiver´s perception of caregiving satisfaction is not related to the caregiver´s quality of life. Also influential to the caregiver´s outcomes are the caregiver´s use of his/her social support as a means of coping. The perceived availability of social support also influences the caregiver´s levels of distress. Another influence on patient´s as well as caregiver´s distress is the so-called protective buffering, which refers to the caregiver suppressing and/or rejecting negative information in order to protect oneself as well as the patient. A high use of protective buffering can significantly increase the patient´s distress and can put constraints on the satisfaction within the patient-caregiver relationship.

Influence of Caregiver-Patient Relationship

The type of relationship the caregiver has to the care-recipient also influences the impact of providing care on the outcomes of the caregiver. It has been found that negative changes in the health of the caregiver are lower if the caregiver is the spouse of the patient, as well as negative changes in health being lower for female caregivers than for male caregivers. It has also been found that older caregivers are less likely to be negatively affected by providing care than are younger caregivers. The higher the patient´s and spousal caregiver´s feelings of interdependence, the lower the caregiver´s level of negative affect. These findings emphasize the effect that the quality of the relationship between the caregiver and the patient has on the outcomes of caregiving for both parties. It has also been shown that even though stronger feelings of control in both the caregiver and the patient are related to less distress, when these parties are low in perceived control they profit more from supportive behavior of the other party. Especially when the relationship between the caregiver and the patient is a spousal relationship, adjustment of both partners is interdependent. In these cases, the sickness can cause the stress of one partner to spill over onto the other partner. Thus the quality of the relationship directly and indirectly influences the outcomes and distress levels of both partners. In a spousal caring relationship the quality of the relationship influences the effectiveness of both parties´ coping. It was found that patients that engage in maladaptive coping (e.g. avoidant coping) experience less distress if they are in a strong positive relationship than if they aren´t. It also seems that negative effects of the illness on both caregiver and patient are buffered if the spousal relationship between them includes a sense of shared identity.

Differences in the beliefs and perceptions of the caregiver and the patient (known as dyadic perceptions) can cause distress on both sides. It seems to be common that caregivers judge their contributions as higher than the patient does. This can cause high levels of distress in the caregiver. It seems that the involvement of the patient in his treatment depends more on the attribution of a spousal caregiver about the causes of the illness than on the attribution of the patient himself/herself. If the caregiver and the patient differ strongly in their attributions of the cause of the illness (e.g. the spouse attributing the illness to bad habits of the patients, but the patient attributing the illness to external circumstances), their relationship may experience further struggles and distress, as well as worse outcomes for both parties. When the caregiving spouse minimizes (“down-plays”) or maximizes the implication of the illness in relation to how the patient perceives them, negative consequences are likely to emerge.

What is pain? - Chapter 16

The Experience of Pain

Pain is a functional experience, alerting us of possible harm to our body. Pain can often cause reflexes, such as pulling the hand away from a hot stove. Pain is also indirectly functional, because we normally only seek medical assistance once we perceive some kind of pain, such as with the onset of an illness. Thus pain is important for survival, and those who do not experience pain (for example in individuals who have a congenital universal insensitivity to pain (CUIP)) are at higher risk of experiencing problems, because they do not notice these early warning signs. Long-term pain though is often damaging and poses many problems to an individual. It is even possible to experience pain in parts of the body that one no longer has, a phenomenon called phantom limb pain.

Types of Pain

There are several categories of pain:

1. Acute pain is defined as pain that lasts for less than three to six months. This can include stomach pain, pain at childbirth, and other temporary types of pain. Acute pain can also be repeating, such as in people experiencing migraines.

2. Chronic pain is defined as pain that lasts for longer than three to six months. It normally starts with an experience of acute pain, which does not improve over time. Chronic pain can either have an identifiable cause or an unidentifiable cause. Chronic pain is distinguished into:

• Chronic benign pain which is defined as long-term pain that stays at the same degree over time, such as back pain.

• Chronic progressive pain which is defined as long-term pain that continuously becomes worse over time due to the advancement of the disease, such as osteoarthritis.

Pain is also generally evaluated on three aspects: (1) The type of pain, such as stabbing, throbbing, or sharp pain; (2) the severity of pain, from a mild irritation to torturous pain; and (3) the pattern of pain, such as continuous pain or brief flashes of pain.

Prevalence of Pain

Chronic pain is quite common, with an estimated amount of one fifth of the population experiencing chronic pain. Several risk factors for experiencing chronic pain have been identified, including being old, being divorced or separated, and having a job with a high amount of physical strain. Still, even a surprisingly high amount of teenagers (around 10 percent) already report chronic back pain, probably caused by being seated too much and carrying heavy bags on only one shoulder. Pain is also the major cause of people visiting a doctor. Experiencing pain does not only do physical and psychological harm, but can also harm the individual economically, with high direct costs of pain (such as medication) as well as high indirect costs of pain (such as missing days at work). Chronic pain can severely constrain one´s life, such as heavily restricting one´s physical, social, and even work activities. Chronic pain can indirectly damage one´s relationships, for example when friends pull back from the individual because he often has to cancel activities due to his condition. Partially due to these factors it is not surprising that chronic pain is linked to a high risk of depression. On the other hand depressed individuals more likely to perceive pain, thus pain and depression may reciprocally increase each other. The influence pain exerts on one´s social life can also have some “benefits”.

Three types of potential benefits/gains of pain have been proposed:

• Primary (intrapersonal) gains refer to direct benefits of the expression of pain. This is mostly a cutback of unsympathetic consequences, such as someone else doing one´s duties.

• Secondary (interpersonal) gains refer to situations in which pain behavior causes a positive outcome, such as someone else expressing compassion or care for the ill person.

• Tertiary gains refer mostly to emotional benefits of other people. This can be for example someone who helps the ill individual feeling good about himself/herself and experiencing feelings of gratification for helping someone else.

These gains can actually be harmful in some situations. They can cause the ill individual to become more and more inactive, and giving up more and more tasks to willing helpers. Higher levels of inactivity in ill individuals are related to the worsening of symptoms such as muscle stiffness. These patterns of behavior can also result in learned helplessness, higher dependency on others, and higher levels of disability. If one´s social support is “good”, these problems should not occur, because the ill individual is more likely to be encouraged to engage in activities that prevent a worsening of one´s situation.

Biological Models of Pain

Simple theories of pain have been around for centuries. One of the earliest theories is called specific theory and goes back to ideas of Epicurus and Descartes. This theory refers to the idea that pain receptors in all parts of the body transfer information to pain-related brain centers, which then create the sensory experience of pain. This theory and extensions of it were popular up until the middle of the 20^th century when it became clear that these theories don´t hold. There are three main lines of evidence speaking against these theories, the first being the possibility of experiencing pain in the absence of pain receptors (such as in the case of phantom limb pain). The second is the fact that some pain receptors actually may not transmit pain, such as in the condition of CUIP, which was mentioned earlier. The interesting thing about CUIP is also that pain pathways seem to be intact, but the individual still does not experience it. The third line of evidence is the fact that experiencing pain is also influenced by psychological aspects. These psychological factors include three major influences:

• Influence of mood: Negative mood states and traits both influence the perception of pain. Having an improved mood also reduces one´s perceived pain, while being in a negative mood increases one´s perceived pain. Negative mood states or mood disorders such as anxiety and depression also increase one´s perceived level of pain. It also seems as if pain and mood are reciprocally related. Having for example chronic pain is related to higher levels of anxiety and depression, while having higher levels of anxiety and depression also increase one´s pain. Thus depression may be a predictor of some aspects of pain, while pain may be a predictor of some aspects of depression.

• Influence of attention: Focusing one´s attention on the pain stimuli or at the pain itself increases the perceived severity of the pain. Focusing one´s attention on other things decreases the perceived pain. This can be seen for example in wounded soldiers, who keep on fighting on the battlefield even they in other conditions would already have collapsed, because their attention is entirely directed at other situational factors. Thus, distracting oneself from pain is beneficial for the perceived severity of the pain. A bias in one´s attention may also be the cause for some people developing chronic pain out of acute pain, by causing the person to react to their pain with fear of more pain, thus focusing way more attention on any possible pain stimuli and becoming over-sensitive to these pain sensations. Humans may also be evolutionarily biased to focus on pain sensations, thus paying less attention to other things.

• Influence of cognition: One´s anticipations of changes in one´s pain levels can act as self-fulfilling prophecies, such as those changes shown through the placebo effect. One´s beliefs can also change one´s perceived pain, for example through beliefs about being able to tolerate or control pain causing an actual relief of pain. They also influence one´s behavior, with people who have high feelings of control of their pain engaging in more active behavior. It also makes a difference what cause one attributes the pain to. It was found that if patients attribute pain to a mild disease, they require only a weak painkiller to ease the pain, while when they attribute the exact same pain to cancer they require a strong opiate painkiller to relieve the pain. One´s expectations of pain are highly influential, with people being most constricted when the experienced pain exceeded the expected pain. People who engage in catastrophizing (which refers to ascribing the pain to something being seriously wrong) have significantly worse health outcomes.

The Placebo Effect

The placebo effect is an amazing cognitive phenomenon related to pain. Even if people are told that they are being administered a pill with no effect on their pain whatsoever, and the pill indeed does not have any biochemical effects, many people will still experience a pain relief. Generally receiving anything that seems like a treatment is beneficial for one´s perceived level of pain whether it has any actual benefits or not. Injections of salt water in patients with nerve-related pain cause around 50 percent reduction in reported levels of pain in most patients. The placebo effect does not only work for pain, but also is beneficial in cases of inflammation, can increase the speed of wound healing, can increase immune reactions, and so forth. For these reasons new medications are no longer compared against a control-group without any treatment, but rather against a control-group that receives a placebo treatment. Two major mechanisms have been proposed that are assumed to cause the placebo effect:

1. Classical conditioned responses, which are involved in responses of immune functioning and respiratory functioning.

2. Expectations of pain or pain relief, with changes of the experienced pain being due to our expectation of these changes. This is for example reflected in placebos becoming less effective if they are used over longer periods of time, where one´s expectations about the effectiveness may gradually decrease, thus also exerting fewer effects on the perceived pain.

A Psychobiological Theory of Pain

As shown before, two types of methods are involved in experiencing pain: on the one hand sensory information from the location of the pain stimulus, on the other hand emotional and cognitive mechanisms that influence the pain perception. Both are included in Melzack´s and Wall´s gate control theory that involves chemicals such as endorphins reducing the perceived pain intensity. “Gates” in the spinal column are considered to mediate the strength of pain perception. How widely open these “gates” are depends on two factors: (1) The transmission of pain sensation from pain receptors to the brain, and (2) the top-down influence of emotions and cognitions, such as fear and attention. For example the pain-easing effects of distracting oneself from the pain are thought to “close” these gates a little bit, thus allowing less pain sensation to reach the brain and diminishing the intensity of the perceived pain.

Nociceptors are the nerves that conduct the pain sensations from the location of the injury to the spinal gate. There are three types of nociceptors that transfer pain information at different speeds. Type I and type II delta fibers transmit short-lasting, sharp pain sensations. C polymodal fibers transmit slow, dull, and long-term/chronic pain sensations. An interesting observation is that another type of fiber that transmits gentle touch information, called A beta fiber, competes with the nociceptor fibers at the spinal column. This explains why for example rubbing an injury decreases the perceived amount of pain, because the rubbing sensation competes with the pain sensation. Information from the A fibers is taken to the thalamus (area of the brain important for linking the hindbrain and midbrain to higher processing centers) and the cortex, where one can plan actions to reduce the pain. Information from the C fibers is taken to the limbic system (the so called emotional computer of the brain), which contributes to emotional reactions to the pain such as fear. Information from C fibers is also taken to the hypothalamus and the autonomic nervous system, which grants one the ability to respond quickly to the pain sensation. These neural activities are sent from the brain down the spinal column through nerve pathways, and can trigger the release of several chemicals, including endorphins. Endorphins are opiate-like chemicals that “close” the gate and thus reduce the degree of experienced pain. The release of endorphins is influenced by several factors, such as whether one focuses on the pain (decreases endorphin-release) or not, one´s emotional and cognitive factors (with optimism increasing endorphin release and depression and anxiety decreasing it, thus opening the gate), and one´s physical factors (with relaxation increasing endorphin release and closing the gate).

Future Understandings of Pain: The Neuromatrix

Even though gate theory is widely accepted, it does not explain the sensation of phantom limb pain, because it relies of the presence of A and C fibers. Trying to account for this, the theory of a neuromatrix was formed. The neuromatrix is supposed to be an extensive neural network that links the thalamus, the cortex, and the limbic system and that represents the “body self”. It processes pain-related information and forms an integrated neurosignature from this information, including nature of the pain and emotional reactions to a pain stimulus. It seems as if the neuromatrix expects that limbs can move, even when these limbs have been amputated, and thus sends more and more messages to the limb when it gives no response. In phantom limb pain these messages sent to the muscles become so many that they are perceived as pain.

Measuring Pain

Before pain can be treated, it has to be measured. This can be done in a scale format, assessing pain as a whole. Due to its multidimensional nature it makes sense to measure pain in terms of its type, one´s emotional response, as well as the intensity and timing of the pain. It is also possible to assess pain via one´s pain behaviors, such as vocalizations, motor behavior, or functional limitations.

Treating Acute Pain

The three most common approaches to treating acute pain include increasing the patient´s sense of control, teaching coping skills, and hypnosis. Increasing the patient´s sense of control can reduce anxiety, and is achieved for example by patient-controlled analgesia (PCA), where patients can control the amount of analgesic drugs that are administered to them. Teaching coping skills includes the training of distraction techniques and relaxation. Relaxation is beneficial due to several reasons. It decreases muscle tension that possibly adds to the pain experience. Relaxation often involves positive thoughts or positive imagery, which can distract one from the pain sensation. Relaxation is also involved in the release of endorphins, thus also indirectly decreasing the pain sensation. Relaxation is also indirectly beneficial by reducing levels of distress. The third common approach to acute pain is treatment by hypnosis. In hypnosis a health specialist suggests experiencing changes in perceptions, sensations, cognitions, and behavior. The most commonly induced states by means of hypnosis include relaxation, well-being, and calmness. Contrary to popular skepticism hypnosis has been proven to be beneficial in conditions of pain. It helps to reduce pain as well as anxiety, and even supports a better physical recovery. It seems as if the imagination of one´s wounds healing quicker actually causes them to do so. These effects are even found when one is not hypnotized by someone else, but engages in self-hypnosis.

Treating Chronic Pain

A prominent method for treating of chronic pain is the transcutaneous electrical nerve stimulation (TENS) that relies on electrical stimulation of A beta fibers in order for the stimulation to compete with pain signals, as well as electrical stimulation of C fibers to cause a release of endorphins. Even though TENS is widely used in medical settings, its effectiveness has not yet been reliably proven.

Relaxation is also useful for chronic pain, because tension in certain muscles contributes to chronic pain such as headache or back pain. Because many people have difficulty relaxing the exact muscles that contribute to their chronic pain, the method of biofeedback is often used in order to gain some voluntary control over the relaxation of these muscles. Biofeedback is a technique that monitors one´s autonomic bodily function, and providing feedback about these functions is beneficial to train relaxing more specific muscle groups and one´s general physiological responses. There are several biofeedback techniques, such as electromyographic biofeedback (EMG), thermal biofeedback or galvanic skin response (GSR). The use of biofeedback has proven especially beneficial in the treatment of chronic headaches. Methods of relaxation are also often combined with the administration of antidepressants. Antidepressants also help with relieving pain, even though it is not fully clear yet why.

Another line of treatment for chronic pain is behavioral intervention. These interventions are aimed at reducing maladaptive pain behavior through non-reinforcement and increasing non-pain-related, adaptive behavior through reinforcement. Pain behavior can be anything from wincing, lying down, or even avoiding social contacts. Attempts are made to extinguish these behaviors, which not only requires the help of health professionals, but also of other social contacts of the patient. It is for example much more beneficial to engage in exercise when having back pain than to engage in pain behavior such as avoiding any physical work. These methods are very effective for treatment outcomes, for example in the treatment of back pain.

One more common approach to treating chronic pain is a cognitive-behavioral intervention. Cognitive-behavioral interventions also implement the ideas of behavioral intervention, but add the aspect of also focusing on one´s cognitions that mediate one´s emotional and behavioral reactions to pain. It thus also focuses on the variables that mediate the openness of the gate in gate theory. Cognitive-behavioral treatments have three major goals:

• Changing the patient´s beliefs that they cannot manage their problems. The patient is guided towards becoming better at problem solving and away from feeling not able to deal with the pain.

• Helping the patient to realize how their cognitions (thinking, emotions, and behavior) influence their pain. A focus lies on the realization that catastrophic thoughts or other negative cognitions increase one´s pain, one´s distress and other psychosocial difficulties.

• Providing the patient with methods to deal with their pain, their distress and other difficulties. This goal is mainly focused on developing adaptive and efficient ways to think, feel, and behave.

Cognitive-behavioral treatment can either happen individually or in a group setting. Changes in cognitions are achieved in several stages. First, patients are helped in identifying maladaptive thoughts that may increase their pain. Once this is accomplished, they are supported in changing these patterns of thought towards more adaptive ones. This can be done in one of two ways. The first is called self-instruction training, and aims at changing their negative thoughts about their pain towards more positive ones, for example by pre-rehearsing certain thoughts in the intervention session. The second way is more complex, and aims at identifying thoughts that cause distress or restrict behavior and then challenging these thoughts. This is normally done by looking for evidence disproving one´s previous beliefs and thoughts. Cognitive-behavioral treatment also often includes the practice of relaxation techniques. A patient´s cognitive change during therapy predicts later pain outcomes.

A final common approach for treating chronic pain is the mindfulness-based intervention. This type of intervention aims less at changing the perception of pain, but rather at helping the patients to cope more effectively with their pain. Mindfulness-based interventions seem to increase the perceived intensity of pain for some conditions (such as neck pain or arthritis), but not for others (such as migraine or fibromyalgia).

What is resilience? - Chapter 4

Defining Resilience from a Developmental Viewpoint

From a developmental perspective, resilience refers to the sustainment, recovery, or enhancement of mental or physical health after being exposed to a challenging or threatening situation. Resilience from a developmental perspective cannot be defined completely objectively, but requires a judgment. First, the judgment has to be made that one was subject to a powerful threat that could potentially produce negative outcomes, such as growing up in poverty or in an abusive home. Second, the judgment has to be made that positive outcomes emerged, for example by comparing the outcome to a norm. Resilience is also sometimes referred to as an absence of problematic behaviors or psychopathologic results following catastrophic situations. Resilience to adverse situations seems to be natural throughout life, such as in difficult situations like divorce, illness, or losing a loved person. Masten coined the phenomenon that resilience seems to be common throughout one´s lifetime as “ordinary magic”. Resilience is based on many interacting factors. A flexible self-concept, that can be adjusted to changes, is influential, as well as having a feeling of autonomy and self-direction. Other influences on one´s resilience include situational mastery and one´s social resources, including close, high-quality relationships. The developmental approach to resilience is mostly focused on children and their long-term adjustment to unfavorable circumstances.

Defining Resilience from a Clinical Viewpoint

A clinical perspective on resilience is less focused on long-term influences, but more on short-term responses to particular events such as losses or trauma. Resilience from a clinical perspective refers to adults being able to still psychologically and physically function on a rather constant and healthy level after being subjected to a single potentially disturbing situation, such as losing a loved person or being exposed to severe violence. Two patterns of reaction to loss and trauma have been recognized: Resilience being a short-term reaction of returning to a normal level after a disturbance in few weeks on the one hand, and recovery being a long-term response of slowly returning to one´s former state of mental health on the other hand. Resilience depends on the emotional stability and the coping resources of an individual. If one actually has to rely on recovery instead of resilience, one´s coping resources have been overwhelmed and the individual has been strongly vulnerable to the disturbance. Clinical psychologists often underestimate the influence of resilience, possibly because these more resilient individuals do not feel the need to visit a psychologist over their problems, because they feel like they can cope with it themselves. It seems that resilient responses to even severely disturbing life events are more common than thought, and are not maladaptive, contrary to the quite popular belief that individuals who do not suffer prolonged periods of distress and grief following a loss are not “normal” and possibly even pathological. Instead, they just seem to be more resilient.

Resilience Research

Research into the domain of resilience was sparked by the discovery that many children that suffer from unfavorable situations still develop in a normal and healthy manner. This was first noted for children that had a background of being exposed to influences such as war, deficiency, and violence. Despite the expectancy of becoming troubled adults, many of these children turned out to become fully functional, healthy adults. Being resilient to negative life changes was also found in old individuals that suffer from illnesses, losses, and physical and mental declines, but still maintain a high level of subjective well-being. It seems that resilience is not reserved for extremely tough and emotionally strong individuals, even though there also are some individuals that suffer heavily from adverse life events, and need a long time as well as much support in order to recover.

Blaming the Victim

Even though some protective components against the impact of a disturbing event lie within an individual, such as abilities, personality, and coping skills, other factors determining the impact of the event are external. One thing seems to be especially damaging for people who suffer comparably strong emotional reactions: Blaming the victim. This refers to other people assuming that the individual´s high level of distress is partially his/her own fault, and for example telling them to “get over it”. Accusing a victim to be partly liable for their distress adds a further source of distress, thus quite probably impeding the victim´s recovery. Blaming someone for not having sufficient protective factors to deal with the impact of a situation is counterproductive and unfair.

Protective Factors Involved in Children´s Resilience

Some protective factors come from within individuals, while other protective factors stem from an individual´s environment. The trait explanation attributes resilience to traits such as ego-resilience, hardiness, willpower, self-enhancement, and optimism. But solely attributing resilience to these factors allows for blaming to victim as being “weak”. These factors are mostly involved in coping effectively, but seem to be not the only influence on the impact of adverse events. External factors also play a role, as was shown by research focusing on protective factors against adverse life events in children. Three domains of protective factors for children have been found:

• Protective factors within children, such as:

  • Good intellect

  • Being easy-going and being able to adapt to change

  • Humor, optimism and a positive self-image

  • Being able to control one´s emotions and desires

• Protective factors within families, such as:

  • Close, warm and caring relationships with family-members

  • Structured home setting with little conflict

  • Parents concerned about the child´s education and with decent financial capacities

• Protective factors within communities, such as:

  • Living in a safe community with attentive and involved people

  • Easily accessible emergency, health and social services

  • Visiting a good school, being socially involved in the community

It seems that the amount of one´s protective resources mediates the amount of adversity one can withstand. Internal factors are involved in this, but they only explain part of why some people are more resilient to adversity than others.

Resilience in Children from an Impoverished Environment

It seems that children from a poor environment also tend to have fewer external protective resources not only in the family, but also in the community. Children from an impoverished home are more likely to be exposed to negative behavior such as violence, drug use, and other criminal behavior. They are also at a higher risk to grow up in a community with a lack of health services and social services and tend to go to a bad school. Still, many poor children don´t commit felonies themselves and manage to grow up as well adjusted people. This likelihood of good outcomes in the face of adverse situations is even higher for children that grow up in a poor, but caring and stable family. It furthermore seems that children from an impoverished environment that are not resilient to adversity have suffered a significantly higher number of negative life events and have a high level of chronic stress, while resilient children from an impoverished environment that also face serious threats and stress do so at a lower frequency and with lower severity. Resilient children in a poor environment also tend to be more intelligent and have a better self-image than non-resilient children. It was also found that resilient youths tend to have way higher self-regulation skills, such as being able to control one´s thoughts, attention, emotions, and behavior. Self-regulation is also associated with the ability to use more adaptive coping strategies. Cognitive and emotional self-regulation skills seem to be especially important when growing up in a poor environment. Cognitive self-regulation skills are for example related to thoughtfully making plans and carrying them out step by step. Emotional self-regulation skills are for example related to not expressing one´s negative emotions too strongly, such as inhibiting oneself from destroying things out of anger or insulting other people, thus being a skill that is very important in maintaining positive relationships with other people.

Resilience in Adulthood

Almost all protective factors involved in the resilience of children are also influential for adult´s resilience. Six further dimensions have been identified that also influence the resilience of an adult are: (1) Self-acceptance (having positive beliefs about oneself); (2) personal growth (a perception of continuous development); (3) purpose in life (having a sense of direction in one´s life due to one´s goals and beliefs); (4) environmental mastery (feeling competent to manage one´s environment); (5) autonomy; and (6) positive relations with others.

These protective factors are also important for successful aging. Old age is associated with a higher risk of adversity, such as losing loved ones or suffering from illnesses. Still, many old people preserve their levels of subjective well-being. Socioemotional selectivity theory suggests that as people grow older and start to perceive their time as limited, they change the focus of their goals and attention from being future-oriented to being more oriented towards the present. People tend to change from pursuing knowledge-related social goals to the pursuit of emotion-related social goals when they grow old. Instead of focusing on future gains, people focus on emotional satisfaction and try to engage only in the things that are important to them, such as their relationships with family members. This decreasing emphasis on the future seems to help the elderly to better regulate their emotions when dealing with losses or conflicts. Older people also tend to adjust their social networks to being smaller, but of higher quality.

Negative Effects of Trauma

Traumatic events, such as the loss of a loved one, catastrophic fires, or surviving a possibly deadly illness, can have life-changing effects for an individual. These situations induce strong emotional reactions such as shock, anxiety, fear, and depression. Experiencing a traumatic situation can demolish one´s basic assumptions. Three basic beliefs tend to be challenged by trauma: The belief that one is invulnerable and certain events are not going to happen to oneself; the belief that the world is a fair, meaningful and comprehendible place; and the view of oneself in a positive light (e.g. view of one having control, power, and autonomy).

Positive Effects of Trauma

Traumatic events can also have positive effects on an individual. The term posttraumatic growth refers to positive outcomes emerging from traumatic experiences. These positive outcomes result from an enhanced understanding of oneself, one´s relationships and of life due to the challenged beliefs and assumptions. These changed beliefs can result in closer ties to one´s family, an increased perception of one´s personal strength and confidence, a greater appreciation of life, and generally adjusting one´s priorities in life. Traumatic events challenge the perception of one´s life being meaningful. In order to create growth out of a traumatic event, people have to engage in meaning-making in order to regain some sense of meaning in their life. Creating a sense of meaning depends on two processes:

• Sense-making: The process of trying to understand the traumatic event in the framework of one´s understanding of how the world operates, such as interpreting the death of a young person in the sense of death being inevitable or in the sense of the death being part of “God´s plan”.

• Benefit-finding: The process of discovering benefits or positive outcomes in traumatic events. Losing a loved one may for example result in one realizing the fragility of life and thus engaging more in one´s close relationships. People often change their behavior in positive ways after a traumatic event due to not taking things for granted any more.