finding, and test the relationship between benefit-finding and adjustment outcomes. ... KEY WORDS: benefit-finding; interpersonal relationships; rheumatoid ...
C 2005) Journal of Behavioral Medicine, Vol. 28, No. 1, February 2005 ( DOI: 10.1007/s10865-005-2720-3
Benefit-Finding Among Patients with Rheumatoid Arthritis: Positive Effects on Interpersonal Relationships Sharon Danoff-Burg1,3 and Tracey A. Revenson2 Accepted for publication: March 12, 2004
This longitudinal study of patients with rheumatoid arthritis used mixed methods to identify and describe the positive effects of illness on relationships, examine correlates of benefitfinding, and test the relationship between benefit-finding and adjustment outcomes. When asked about interpersonal benefits of their illness, 71.3% of the respondents described interpersonal benefits, whereas 16.2% reported another type of benefit, and 12.5% reported no benefits. The most frequently described benefit was appreciation of support received from loved ones. Less pain, lower psychological distress, and perceiving fewer social constraints were related to finding interpersonal benefits in the illness experience. Interpersonal benefitfinding predicted lower levels of disability at a 12-month follow-up. Findings are discussed with regard to conceptual issues, methodological recommendations, and implications for interventions. KEY WORDS: benefit-finding; interpersonal relationships; rheumatoid arthritis; chronic illness.
A growing body of research suggests that positive psychological responses to illness, such as finding benefits in the experience, are associated with enhanced emotional, health-related, and immunologic outcomes (Kiecolt-Glaser et al., 2002). A number of studies provide evidence that people faced with physical illness not only have high levels of positive affect, but also report personal growth that arose out of the illness experience. In a study of married couples coping with one partner’s rheumatic disease (Revenson, 2003), even the most psychologically distressed couples reported high levels of personal growth because of the illness. Similarly, victims of heart attacks have reported that their illness created greater selfinsight and positively altered their values and priorities (Affleck et al., 1987). Understanding the environmental, interpersonal, and personal dynamics of individuals with chronic illnesses who find meaning
in their experience (e.g., Park, in press), remain resilient (O’Leary and Ickovics, 1995), or adjust well to chronic illness (Stanton and Revenson, in press) may enhance our ability to specify protective factors and design psychological interventions. Finding Benefits in Serious Illness Benefit-finding, defined as identification of benefit from adversity (Tennen and Affleck, 2002), manifests itself in various ways, including awareness of deepened interpersonal relationships, an enhanced sense of spirituality and life purpose, and an overall increased appreciation for life. Finding something beneficial or meaningful in a traumatic experience increases sense of mastery and may allow people who have suffered adversity to cognitively process negative experiences in a smoother manner (Lepore, 2001). As Affleck and Tennen (1996) have written, “adversity can lose some of its harshness through cognitive adaptations—including finding the good in bad events—which can restore comforting views of ourselves, other people, and the world” (p. 900).
1 Department
of Psychology, University at Albany, State University of New York, Albany, New York. 2 Social-Personality Psychology, The Graduate Center, City University of New York, New York, New York. 3 To whom correspondence should be addressed; e-mail: sdb@ albany.edu
91 C 2005 Springer Science+Business Media, Inc. 0160-7715/05/0200-0091/0
92 A number of studies have shown that individuals who are confronted with serious illnesses are able to find benefits in their ordeal, which often include positive changes in their personal relationships (e.g., Lepore and Eton, 2000; Stanton et al., 2002). Collins and colleagues (1990) interviewed 55 patients with various types of cancers who had been diagnosed or sustained a recurrence within the past 3 years. They reported changes in personal relationships, activities, and priorities that were primarily positive, although their perceptions of the self and the future were less so. Katz et al. (2001) found that patients with cancer or systemic lupus erythematosus (SLE) also perceived benefits from their illness, including a deeper appreciation of life, greater levels of compassion, and more willingness to express their feelings. Sears et al. (2003) reported that 83% of participants reported at least one benefit from their experience with breast cancer, with nearly half (46%) identifying improvement in relating to others as a benefit, which was approximately four times the frequency of any other type of benefit reported. Although no comprehensive review specific to chronic illness is available, Tennen and Affleck (2002) reviewed the literature on the association between benefit-finding and adjustment to adversity, including studies of life-threatening illness, bereavement, and natural disaster. Fourteen of 20 cross-sectional studies revealed an association of benefit-finding and better adjustment. In many cases, medical patients able to construe benefits from their experience with the illness show improved mood and quality of life (e.g., Carver et al., 1993; Curbow et al., 1993; Katz et al., 2001). In a study of individuals with multiple sclerosis, Mohr et al. (1999) factor analyzed responses to interviews assessing how the illness had affected patients’ lives. Benefit-finding was related to the coping strategies of seeking support and positive reappraisal of the illness experience, although it was related to reduced emotional distress only in some areas (i.e., tension-anxiety and anger, but not depression). Cordova and colleagues (2001) conducted a controlled comparison study of breast cancer survivors’ posttraumatic growth using the Posttraumatic Growth Inventory (Tedeschi and Calhoun, 1996). Participants were assessed on depression, well-being, and posttraumatic growth 24 months following completion of initial medical treatment and compared with a group of healthy women matched on age and education. Although the two groups did not differ in depressive symptoms or well-being, the breast can-
Danoff-Burg and Revenson cer patients reported greater personal growth, particularly with regard to relationships, spirituality, and appreciation of life. Several longitudinal studies have found significant associations between benefit-finding and health among individuals with chronic or acute physical illness. Affleck et al. (1987) found that benefit-finding following a first heart attack predicted better cardiac health and a lower rate of subsequent infarction 8 years later, controlling for age, socioeconomic status, and severity of the initial heart attack. Bower et al. (1998) found that among HIV-seropositive men who were mourning the death of a loved one, discovering meaning in the experience predicted less rapid decline in CD4 T lymphocyte levels 2–3 years later and lower rates of AIDS-related mortality over a 4–9-year follow-up period. The relation between finding positive meaning and CD4 decline and mortality was not explained by HIV-related symptoms, health behaviors, or depression. Stanton et al. (2002) found that breast cancer patients randomly assigned to write on four occasions about positive thoughts and feelings regarding their experience with cancer had significantly fewer medical appointments for cancer-related morbidities 3 months later, compared to controls assigned to write about the facts of their breast cancer experience.
Benefit-Finding Among Patients with Rheumatic Disease While the literature on psychological aspects of rheumatic disease has examined extensively many of the negative factors associated with chronic illness, such as depression and pain, few investigations have illuminated the more positive effects that patients may experience. Zautra et al. (2001) found that the presence of positive affect reduced the size of the relationship between pain and negative affect among fibromyalgia, osteoarthritis, and rheumatoid arthritis (RA) patients. In a study of women with RA, SLE, osteoporosis, or multiple sclerosis, Gordon et al. (2002) found an association between strong religious beliefs and successful coping with chronic illness. We identified four published studies of benefit appraisals among adults with rheumatic disease, three conducted by the same investigators. In an early study (Affleck et al., 1988), RA patients were asked to describe any benefits that had come from their illness. The majority cited at least one benefit,
Benefit-Finding Among Patients With RA the most frequent of which fell into the categories of positive personality changes, increased empathy, and improved relationships. In a daily process study of 54 patients with RA (Tennen et al., 1992), patients who perceived more benefits (measured by five questionnaire items rated on a 6-point scale) reported fewer subsequent days during which their activities were limited due to severe pain. In another study, Tennen and Affleck (1999; also see Affleck and Tennen, 1996) collected daily process data from 89 women with fibromyalgia, having patients rate on 30 consecutive evenings the extent to which they had reminded themselves of illness-related benefits that day. Patients who reminded themselves of benefits more frequently were more likely to experience positive mood, independent of pain intensity. Katz et al. (2001) examined benefit-finding among 31 patients with SLE (as well as 56 patients with cancer) by administering a questionnaire that included a 15-item scale assessing benefit-finding. The benefit-finding scale correlated positively with selfreported outcomes of vigor and activity, and negatively with pain and emotional distress. Given the cross-sectional design of the study, the authors acknowledged that it was unclear whether benefitfinding led to reduced suffering or whether suffering led to reduced benefit-finding. The most frequently endorsed benefits were appreciating life more and becoming more compassionate toward others. Overall, patients reported twice as much benefit-finding than demoralizing effects and deteriorated relationships, although cancer patients reported more benefits than SLE patients. With the exception of the earliest study by Affleck and colleagues (1988), which utilized both qualitative and quantitative methods, studies of benefit-finding in patients with rheumatic disease have used quantitative, closed-ended measures of benefit-finding. Certainly, these investigations have yielded useful information, but the administration of single-item ratings assessing benefit-finding or scales that instruct respondents to endorse the extent to which they have experienced particular benefits most likely capture only a narrow range of benefits experienced by patients. For example, the study of individuals with RA conducted by Tennen et al. (1992) included only five benefit items (e.g., “Dealing with my pain has made me a stronger person”; “My pain has helped me to find new faith”), all of which focused specifically on pain, and none of which mentioned the common theme of strengthened interpersonal relationships.
93 Closed-ended questions may mask the complexity of the process of construing benefits from illness. In previous research on coping with RA (DanoffBurg et al., 2000) we demonstrated that patients do not always understand questionnaire items in the manner intended by researchers. Particularly with regard to cognitive processes (as opposed to behavioral efforts, which are more conceptually concrete), we found mismatch between researcher-derived definitions of coping strategies and RA patients’ interpretations of coping checklist items. In new areas of inquiry, qualitative methods are especially useful in framing research questions and providing a way to “get inside” patients’ experiences of chronic illness. As such, they are likely to be productive in furthering our understanding of benefit-finding. In light of this, the present study used both qualitative and quantitative approaches to investigate the content, correlates, and consequences of benefit-finding among adults with RA.
Interpersonal Benefit-Finding A wealth of research over the past two decades has shown that the quality of interpersonal relationships is an important predictor of adjustment to illness (e.g., Lepore, 2001; Sarason et al. 2001; Schmaling and Sher, 2000). The present study was grounded within the interpersonal arena because of the central role that interpersonal relationships play in adaptation to chronic illnesses, RA in particular (Danoff-Burg et al., 2004; Danoff-Burg and Revenson, 2000; Manne and Zautra, 1989; Revenson et al., 1991; Revenson and Danoff-Burg, 2000; Zautra et al., 1994), and also because changes in relating to others was the most common benefit (Sears et al., 2003) or among the most common benefits (Affleck et al., 1988) cited in previous qualitative research. We expected that despite the pain and disability associated with RA, the majority of participants would report that their illness experience had positively affected their interpersonal relationships. The nature of interpersonal benefits has not been specified in previous studies, so a goal of the present study was to identify and describe these benefits. Another goal of the present study was to identify factors distinguishing patients with the ability to find illness-related, interpersonal benefits from patients unable to find such benefits. Whereas most studies of benefit-finding among individuals with physical illness have been cross-sectional, we tested whether
94 finding interpersonal benefits could predict adjustment outcomes over time. Specifically, we hypothesized that individuals who reported that RA had affected their relationships in positive ways would have lower levels of depressive symptoms, pain, and functional disability 1 year later, compared with patients who were unable to identify any positive ways that RA had affected their relationships. Finally, we were interested in the relationship between interpersonal benefit-finding and other interpersonal processes known to affect adaptation to illness. Previous studies have documented the influence of social constraints, defined as the perception of network members as unreceptive to efforts to discuss stressful or traumatic events (Lepore et al., 1996), on adjustment to RA (Danoff-Burg et al., 2004), cardiac problems (Fritz, 2000), and breast, prostate, and colon cancer (Cordova et al., 2001; Lepore, 2001). Persons who perceive that others are unreceptive to hearing about their experiences have less opportunity to process their thoughts and feelings in a social context and show poorer adjustment than those who view their social networks as more receptive; in contrast, the opportunity to discuss personal stress or trauma in a supportive, uncritical social environment allows individuals to find positive meaning in their experience, which in turn may lead to improved adjustment (Lepore, 2001). We tested such a mediation process in this study: We expected that lower levels of perceived social constraints would be associated with the ability to describe positive effects of the illness on relationships, which would in turn predict better adjustment.
METHOD Sample and Procedures Participants were recruited through the patient registry of a metropolitan hospital that specializes in orthopedic and rheumatic disorders. To ensure an adequate number of male participants, additional referrals for male patients were requested from rheumatologists in the metropolitan area not affiliated with the hospital. Eligible patients received a personalized letter from their rheumatologist inviting them to participate and were asked to return a postcard to the investigators indicating whether they were interested in learning more about the study. Fifty-two percent of these postcards were re-
Danoff-Burg and Revenson turned with an affirmative response. Of these patients, 74.9% (N = 158) completed a questionnaire through the mail (Time 1). Participants received payment of $10.00. Of the patients in the Time 1 sample, 78.5% (N = 124) completed a follow-up questionnaire through the mail 1 year later (Time 2). Analyses were conducted to determine whether patients who completed the follow-up questionnaire differed on any study variables from patients who participated in only the first wave of data collection. Two differences were found with regard to demographic characteristics; patients who completed both questionnaires were more likely to be White, χ2 (1, N = 155) = 10.47, p = .001, and to have more education, χ2 (4, N = 156) = 12.03, p = .02. Within the questionnaire administered at Time 1, participants were asked to respond to an open-ended question inquiring about “positive effects that having RA has had on your relationships with others.” Fourteen percent of the patients (N = 22) did not provide a response to this openended question. These patients were excluded from subsequent analyses, because it was impossible to interpret whether failure to respond was due to the content or the format of the open-ended question. These patients did not differ with regard to gender, age, time since diagnosis, race, income, occupation, education, or marital status from patients who did provide a response to the question. The sample of patients who responded to the benefit-finding question consisted of 111 women and 25 men, reflecting the higher prevalence of RA (2.5:1) among women. Average age was 58 years (SD = 14.05), and average length of time since diagnosis was 16 years (SD = 11.69). Fifty-four percent of respondents were married or in a maritaltype relationship, and one quarter of respondents were members of an ethnic minority group. With regard to socioeconomic status, slightly over half (53.3%) had attended college, graduate, or professional school, and the median household income was between $30,000 and 50,000. Only 30.2% of the sample was employed. The remainder was retired (30.9%), unemployed due to disability (25.7%), homemakers (10.3%), or “other” (2.9%). Measures Functional disability, psychological distress, and pain were measured at both time points.
Benefit-Finding Among Patients With RA Benefit-finding, social constraints, and demographic (e.g., age) and disease-related information (e.g., length of time since diagnosis) were assessed at Time 1 only. Functional disability was measured with a modified version of the Stanford Health Assessment Questionnaire (HAQ; Pincus et al., 1983), which assesses ability to perform eight activities of daily living (e.g., dressing, reaching). Items are rated on a scale from 1 (able to do without any difficulty) to 4 (unable to do). Pincus et al. (1983) reported that the modified HAQ provides data comparable to that obtained by the full HAQ (Fries et al., 1982). Coefficient alpha was .92. at both Time 1 and 2. Psychological distress was measured with the Hopkins Symptom Checklist-25 (HSCL-25; Derogatis et al., 1974). This 25-item measure, which has been used internationally to detect psychological distress (Sandanger et al., 1998), instructs respondents to indicate the extent to which symptoms (e.g., “feeling hopeless about the future”) bothered them during the past month. Items are rated on a scale ranging from 1 (not at all) to 4 (extremely). To determine whether somatic symptoms associated with RA might artificially inflate HSCL-25 scores (Blalock et al., 1989), 11 items measuring potentially overlapping symptoms of RA and depression (e.g., “feeling everything is an effort”) were removed from the HSCL-25. The correlation of this shortened scale with the full measure was .96 at Time 1 and .97 at Time 2. Therefore, we concluded that the standardized 25-item measure was appropriate for use with this sample, so the full version of the scale was used in subsequent statistical analyses (α = .93 at Time 1 and .95 at Time 2). Pain was measured with a 100-mm visual analog scale, with endpoint anchors of “no pain” and “pain as bad as it can be.” Self-report visual analog scales have been established as valid and reliable and are widely used in pain research (Price, 1988). Social constraints were measured with eight illness-specific items based on the work of Lepore et al. (1996). Sample items are “I’d like to talk more about my experience with RA, but others don’t seem to want to hear” and “Others around me seem to feel awkward when talking about RA.” The response format ranges from 1 (strongly disagree) to 5 (strongly agree). Internal consistency reliability (α = .68) was lower than that found in other studies, but this is likely due to the lower number of items.
95 RESULTS First we describe the nature of interpersonal benefits using the patients’ own words. We then use discriminant analysis to examine the differences between people with RA who found interpersonal benefits to those who did not. Finally, we test whether the ability to find interpersonal benefits mediates relations between perceived social constraints and adjustment outcomes. The Nature of Interpersonal Benefit-Finding In order to identify major concepts or themes, two researchers trained in qualitative research techniques examined subsamples of participants’ responses to the open-ended benefit-finding question. Identified themes were refined through an iterative process, resulting in eight content categories. Using these categories, all text responses (N = 136) were coded by two independent raters. Each response received a single code; if multiple themes were apparent, raters assigned a code based on the theme judged to be most prominent within the text response. Kappa was .91, indicating a high degree of inter-rater reliability. Six of the content categories reflected interpersonal themes: Appreciation of Support from Loved Ones (35.3%), Increased Compassion/Empathy (19.9%), Educating Others (7.4%), Discovered the Kindness of Strangers (4.4%), Improved Relationships with Health Professionals and Patients (2.9%), and Learned to Accept Help (1.5%). Although participants were instructed to report interpersonal benefits, 22 participants (16.2% of those who answered the question) described other types of benefits instead. Because their responses centered on a common theme that was identified as New Outlook on Life or Self, we created a seventh category. As hypothesized, a minority of participants (12.5%) indicated that they had experienced no benefits from their illness. These patients’ data, constituting an eighth category, were included in subsequent analyses comparing those who reported that they were able to find benefits in their experience to those who reported that they could not. Of all the benefits described that were interpersonal in content, 40.3% represented expressions of appreciation of support from loved ones. As one man stated, “The only thing that I could say that is positive about dealing with RA is that you get to
96 see the devotion and dedication of your loved ones. They have been closer and closer to me and very much concerned of my daily well-being.” Whereas some patients referred to close relationships in general, such as in the previous example, others referred to specific relationships that improved following the onset of their illness. Many patients, for example, described relationships with spouses: “I knew my husband was wonderful before I was diagnosed with RA but the illness has shown me how great he really is. He always says, ‘I’m married to you for sickness and health.’ He never once has complained about working so hard at work and in the house and he takes wonderful care of me.” Another woman disclosed similar feelings more bluntly: “RA was the test that let me know my boyfriend loved me.” These responses are interesting in light of the broader literature on social support and rheumatic disease. Social support can function as a doubleedged sword (Revenson et al., 1991), as it can be either protective or detrimental to mental and physical health, depending on whether the support offered is perceived by the potential recipient as either helpful or unhelpful. Although patients with RA are likely to experience supportive and nonsupportive interactions with the same individuals in their social networks (Revenson et al., 1991), many participants in the present study appeared skilled at appraising the support offered to them as beneficial. For example, assistance from others that could have been viewed as a negative reminder of physical disability and a concomitant lack of independence was instead viewed as a sign of positive, caring relationships: “My entire family all volunteer to do things for me while in their company. They will not allow me to carry packages, lift objects or strain myself in any way. I look upon this as love!” Approximately one-fifth of the benefits described in the present study reflected the belief that having RA resulted in increased personal empathy or compassion toward others. Often this was discussed in reference specifically to other individuals with physical problems. For instance, a middle-aged man wrote, “The most singular positive effect from RA is the heightening of my awareness of people with disabilities. I am very sympathetic and empathetic to disabled individuals.” Other patients, however, expressed the view that their illness made them more empathetic or compassionate in general: “As a result of RA, coping with everyday pain and stress has caused me to be a caring person.” These findings are similar to those of Affleck et al. (1988), who found
Danoff-Burg and Revenson that nearly a third of RA patients cited increased empathy as a benefit of their illness. Interactions with health care providers can have profound influences on patients’ psychological adaptation to illness. Several patients noted the benefits of developing positive relationships with health professionals. One woman enthused, “Since I’ve been treated for RA my associations with the medical personnel at my hospital have been terrific! Wonderful people.” Other patients focused not on their associations with health professionals, but on their interactions with other patients. For instance, a woman in her mid-60s commented, “I met many wonderful friends. We were able to be of great support for each other and my friendships remain after 15 years.” In contrast to those who focused on the benefits of receiving support from others with RA, some respondents emphasized the satisfaction they derived from being able to educate other individuals. An elderly woman wrote of the benefit she perceived in serving as a resource for other patients: “I talk and listen to them and encourage them to go to the doctor to get medicine for their pain. . . . I also encourage them to get rest and to learn how to do their daily activities correctly.” The theme of educating others also was revealed in the responses of patients who felt it important to model successful coping with illness. For instance, a man in his 70s explained that by never missing a day of work he had “tried to set an example of not giving in to an affliction.” Complementing this theme of gaining satisfaction from helping others was the theme of learning to accept help. A few patients wrote explicitly about how accepting help was not an easy process: “I guess in some ways, RA has at times enabled me to experience being helped and cared for by my husband— lifting heavy grocery bags, opening tight jars, etc. It is difficult, though, for me to think of myself as dependent on anyone or as ‘disabled’ even to a mild degree.” This response illustrates the struggle experienced by many individuals with chronic illness as they attempt to balance their need to receive support from others with their desire to maintain independence. Indeed, living with the prospect of severe disability and future dependence on others to carry out activities of daily living may cause patients with RA to become particularly sensitive to interpersonal stress (Zautra et al., 1994). Our data suggest that at least a small number of patients are able to transcend conflicting feelings regarding the need for help by reframing their acceptance of assistance as an indicator of personal growth.
Benefit-Finding Among Patients With RA
97
Table I. Intercorrelations Among Study Variables Variable
1
2
3
1. Interpersonal benefit-finding 2. Age 3. Gender 4. Years since diagnosis 5. Social constraints 6. Time 1 disability 7. Time 1 distress 8. Time 1 pain 9. Time 2 disability 10. Time 2 distress 11. Time 2 pain
— −.03 .08 .08 −.33∗∗ −.17∗ −.19∗ −.22∗ −.27∗∗ −.17 −.26∗∗
— −.15 .16 −.23∗ .11 −.23∗∗ −.06 .07 −.15 −.15
— .05 .02 .13 .08 .05 .12 .06 .19
4
— −.05 .35∗∗ −.03 .15 .40∗∗ −.09 .13
5
6
7
8
9
— .19∗ .45∗∗ .23∗ .22∗ .37∗∗ .14
— .42∗∗ .59∗∗ .85∗∗ .37∗∗ .52∗∗
— .36∗∗ .36∗∗ .79∗∗ .45∗∗
— .50∗∗ .28∗∗ .57∗∗
— .47∗∗ .60∗∗
10
— .48∗∗
Note. Interpersonal benefit-finding coded (0 = reported no benefits or noninterpersonal benefits; 1 = reported interpersonal benefits). ∗ p < .05. ∗∗ p < .01.
Related to the theme of accepting help was the benefit experienced by some patients of discovering (with apologies to Tennessee Williams) the kindness of strangers. Several patients wrote responses similar to the following: “The positive effect that RA has had on my life is that I find that people in general are genuinely caring and helpful. Total strangers will hold doors open, let me through (a house door, car doors, etc.), give up seats on buses, help me up on a bus if necessary. People are attentive.” The perspective of another patient on this topic, however, was mixed: “Strangers are sometimes kinder to me because of RA, but on the other hand, everybody in the supermarket seems to be impatient (or to think it’s funny) when I can’t get the money out of my wallet.” Some of the benefits described were coded as not interpersonal in content, despite the fact that the question asked specifically about interpersonal benefits. These responses tended to reflect a new perspective on life or about the self, a common theme in studies of posttraumatic growth. For example, a man in his 50s explained, “I think RA made me realize I am not invincible—throughout my earlier years I enjoyed very good health and I took it for granted. Now I look at life as a gift and try not to take all the things around me for granted.” Predictors of Interpersonal Benefit-Finding We conducted a discriminant function analysis to determine which patient and situational characteristics distinguished those who found interpersonal benefits in their illness experience from those who did not. Based on the literature concerning psychological adaptation to chronic illness in general
(Stanton and Revenson, in press) and RA in particular (Keefe et al., 2002), we included seven variables that reflected different contexts of psychological adaptation (Ickovics et al., 2001; Revenson, 1990, 2003): the sociodemographic context (age, gender), the medical context (years since diagnosis, functional disability, pain), the situational context (psychological distress), and the interpersonal context (social constraints). In the discriminant analysis we tested whether this set of variables could distinguish the 97 patients who reported interpersonal benefits from the 39 patients who did not, i.e., those who reported no benefits (n = 17) or who reported benefits that were not interpersonal in content (n = 22).4 Intercorrelations among the study variables are displayed in Table I. Table II lists the variables entered into the discriminant analysis, mean differences between the two groups, and the standardized discriminant function coefficients for the seven Time 1 variables entered into the equation. The overall Wilks’ lambda was significant, = .79, χ2 (7, N = 110) = 24.80, p = .001, with a canonical correlation of .46. Univariate F tests were significant for three of the seven predictors: social constraints, pain, and psychological distress. Lower pain, lower psychological distress, and perceiving fewer social constraints 4 The
discriminant function analysis, as well as subsequent regression analyses, were also conducted after excluding the 22 participants who reported benefits that were not interpersonal in content. Results were similar to findings from the full data set, and therefore only the latter are reported. The discriminant function analysis, as well as subsequent regression analyses, were also conducted after excluding the 22 participants who reported benefits that were not interpersonal in content. Results were similar to findings from the full data set, and therefore only the latter are reported.
98
Danoff-Burg and Revenson Table II. Means, Standard Deviations, Analyses of Variance (ANOVA), and Standardized Discriminant Function Coefficients for Time 1 Variables Interpersonal benefits
No interpersonal benefits
Variable
M
SD
M
SD
ANOVA F
Age Gender Years since diagnosis Social constraints Pain Functional disability Psychological distress
56.32 .81 15.50 16.83 27.84 13.40 42.43
14.27 .39 10.54 5.12 23.90 4.93 12.38
57.23 .69 13.81 21.59 39.48 14.97 48.17
14.54 .47 11.91 4.56 24.46 5.39 14.34
.09 1.96 .51 19.53∗∗ 5.01∗ 2.06 4.22∗
Standardized coefficient .260 −.324 −.169 .859 .368 .073 .002
Note. Gender dummy coded (0 = male; 1 = female). ∗ p < .05; ∗∗ p < .001.
were all related to finding interpersonal benefits in the illness experience. Using the discriminant function, 71.8% of the individuals in the sample were correctly classified as to whether they found interpersonal benefits or not.
Does Interpersonal Benefit-Finding Predict Adjustment? Multiple regression analyses were performed to examine whether the ability to identify interpersonal benefits would predict better adjustment 1 year later. Three separate analyses were conducted with each of the Time 2 adjustment variables (pain, functional disability, and psychological distress) as criterion variables. The relevant Time 1 adjustment variable was entered into the equation on the first step, and the dummy-coded predictor variable (reported interpersonal benefits or did not report interpersonal benefits) was entered on the second step. The only significant result was for functional disability, F (2, 104) = 139.39, p < .001, indicating that patients who saw interpersonal benefits in their illness had improved physical functioning 12 months later compared with patients who did not report interpersonal benefits (β = −.11, p = .04).
Does Interpersonal Benefit-Finding Explain Relations Between Social Constraints and Adjustment? We expected that lower levels of perceived social constraints would be associated with the ability to describe positive effects of the illness on relationships, which would in turn predict better adjustment. And, as described in the discriminant analysis, per-
ceiving fewer social constraints was related to finding interpersonal benefits in the illness experience. Following the method described by Kenny et al. (1998), we used linear regression to test for mediating effects of interpersonal benefit-finding on the relation between social constraints and adjustment. To establish mediation, three conditions must be met. First, the predictor variable must predict the criterion variable. Next, the predictor variable must predict the potential mediator. Finally, the mediator must predict the criterion variable when the predictor variable is controlled statistically. Complete mediation is established if the association between the predictor and the criterion disappears when controlling the mediator. Partial mediation is established if the mediator is significantly related to the criterion when the predictor is controlled, but the relation between the predictor and the criterion when controlling the mediator does not go to zero. We ran three separate regression analyses in which the criterion variable was Time 2 adjustment (functional disability, psychological distress, or pain). The relevant Time 1 adjustment variable was entered into the equation first, followed by the predictor variable of social constraints on the next step. In no case did social constraints predict Time 2 adjustment above and beyond Time 1 adjustment. Indeed, the high correlation between social constraints and each of the Time 1 adjustment variables coupled with the stability of the adjustment variables over time (see Table I) rendered it unlikely that residualized analyses would produce significant outcomes. We therefore conducted the analyses described above without controlling for baseline adjustment. Social constraints were significantly related to the Time 2 outcomes of functional disability and psychological distress, but not pain (see Table I). The hypothesized mediation model was supported only
Benefit-Finding Among Patients With RA when functional disability was the criterion variable: When interpersonal benefit-finding (the mediator) and social constraints (the predictor) were entered into the equation simultaneously, social constraints no longer predicted functional disability (β = .14, p = .18), whereas the association between interpersonal benefit-finding and functional disability was significant (β = −.25, p = .02). DISCUSSION The findings of this study contribute to a growing positive psychology literature (Seligman and Csikszentmihalyi, 2000; Snyder and Lopez, 2002) that recognizes that health is not merely the absence of pathology. New studies have documented often surprising perceived benefits arising from adverse life experiences as divergent as HIV/AIDS (Siegel and Schrimshaw, 2000) and child sexual abuse (McMillen et al., 1995). Although often studied with regard to life-threatening illnesses such as cancer or HIV/AIDS, the phenomenon of benefit-finding also is worth understanding as applied to nonfatal illnesses that deeply affect quality of life. The present study focused on appraisals of benefits resulting from RA, a chronic illness that has detrimental effects on both physical activity and role functioning (DeVellis et al., 1997). Building on previous studies documenting the centrality of interpersonal relationships to the adjustment of people with RA (e.g., Revenson et al., 1991; Zautra et al., 1994), the present study focused on interpersonal benefits. As expected, the majority of respondents (71.3%) were able to describe interpersonal benefits resulting from their illness when asked, and another 16.2% described other types of benefits. Only 12.5% of respondents failed to find any benefits. The participants’ own words revealed rich information about the diverse positive effects that a painful and often disabling illness may have on interpersonal relationships. The open-ended format of the interpersonal benefit-finding question allowed themes to emerge that have not been prominent in previous studies. Most notably, although “appreciation of support from loved ones” (i.e., family members and friends) was the most common theme, many individuals reported positive effects of the illness on less intimate relationships. For example, some participants described deriving a sense of meaning through educating others, such as support group members or coworkers, about RA. This finding suggests the need for research examining the benefits for patients
99 with rheumatic disease of actively providing support to others (Peterson et al., 1993). Other participants expressed satisfaction with their relationships with people they had met at hospitals or support groups. Interactions with medical professionals can have profound influences on patients’ psychological adaptation to illness, and therefore it is important to include health care providers when studying positive and negative aspects of social support (Coyne and Fiske, 1992; Lanza et al., 1995). Other participants disclosed their feelings, both positive and negative, about strangers’ reactions to their illness. Overall, the experiences of the participants in this study underscore the need for research on both intimate and less close relationships in adaptation to chronic illness (e.g., Shumaker and Brownell, 1984).
Long-Term Benefits of Benefit-Finding A critical question that only rarely has been examined empirically among people coping with chronic illness is whether benefit-finding predicts mental and physical health outcomes over time. Most of the studies that have examined the relation of benefit-finding to health outcomes have been crosssectional. In the present study, the ability to find interpersonal benefits resulting from illness predicted lower levels of functional disability 1 year later, even when initial disability level was statistically controlled. Future research should address whether these effects continue over a longer time period, and whether improvements in functioning lead to increases in perceived interpersonal benefits. Additional research also is needed to understand why interpersonal benefit-finding did not predict long-term psychological distress in the present sample. Nor did it predict pain, although pain fluctuates among individuals with RA and therefore may be difficult to predict without the use of more frequent assessment methods such as daily diaries (Keefe et al., 1997; Tennen et al., 1992). We had thought that the unexpected lack of a significant relationship between interpersonal benefit-finding and psychological distress might be attributable to high stability in psychological distress across assessment points. However, the stability coefficient for functional disability—the significant outcome variable— was .85, while the stability coefficients for distress and pain were lower (r’s = .79 and .57). Similarly, minimal change over time in mean adjustment scores has been found in other longitudinal studies
100 of people with RA (Gardiner et al., 1993; Smedstad et al., 1995). We had expected that people with lower levels of constraints in their social environment would describe positive effects of the illness on relationships, which would in turn predict better adjustment. Although perceived social constraints were not significantly related to changes in adjustment 1 year later when baseline levels of adjustment were controlled, nonresidualized outcome analyses indicated that level of social constraints predicted psychological distress and functional disability 12 months later. Furthermore, the association between constraints and disability was mediated by whether patients reported interpersonal benefits. Lepore (2001) theorized that people facing chronic illness who perceive that others are willing to help and support them are likely to experience enhancement in feelings of selfworth, sense of control, and cognitive adaptations such as the ability to find benefits in the experience. Indeed, the ability to perceive one’s relationships as strengthened following adversity may contribute to the satisfaction of a fundamental human need to maintain social bonds (Baumeister and Leary, 1995). In contrast, patients who lack a supportive social network in which to discuss personal difficulties may be less likely to make sense of their experience or gain control of their negative emotions (Lepore, 2001). Findings of the current study suggest that the poorer adjustment of these individuals may manifest itself in the domain of physical as well as psychological functioning.
Danoff-Burg and Revenson benefits clearly reflects cognitive reappraisal. It remains for future studies to examine the conceptual overlap of interpersonal benefit-finding with seeking social support (a coping strategy) and to determine whether it is stable over time and stressors, indicating a personality disposition versus a situational coping response. There are other constructs related to yet distinct from benefit-finding to which researchers must devote attention, in order to determine which constructs best predict which outcomes for which individuals. Sears et al. (2003) found that among women with early-stage breast cancer, positive reappraisal coping but not benefit-finding predicted positive mood, better perceived physical health, and posttraumatic growth at a 12-month follow-up. In a prospective study of adults with a family member in hospice care, Davis et al. (1998) demonstrated that making sense of the loss and finding benefit in the experience played independent roles at different points in time during the adjustment process. Additional longitudinal studies are needed to elucidate temporal relations between benefit-finding and different aspects of psychological and physical functioning, as well as potential mechanisms mediating these associations. In particular, the possible relation of benefitfinding to decreased sympathetic activation and immune modulation requires further study (e.g., Bower et al., 1998). If benefit-finding is found to predict positive outcomes in specific patient groups, then interventions targeting patients’ benefit appraisals could be developed. This crucial issue will be discussed in greater detail at the conclusion of this article.
Conceptual Issues The present study raises anew Tennen and Affleck’s (1999, 2002) important conceptual conundrum of whether benefit-finding is best seen as a cognitive reappraisal process, a dispositional trait, a reflection of growth, a rationalization of temperament, or a coping strategy. This study could not test all of these alternative conceptualizations. Nonetheless, our data provide numerous examples of benefitfinding as a cognitive reappraisal process. For example, some patients had conflicting feelings regarding their need for assistance with physically challenging tasks but were able to move beyond their negative feelings by interpreting their ability to accept help from others as a sign of personal growth. Others had learned to view tangible assistance from others as expressions of love rather than reminders of unwanted dependence on others. Thus, finding interpersonal
Asking About Benefits: A Comment on Methodology As with any psychological study, how one phrases questions about benefit-finding will affect the nature of the data and thus one’s conclusions and interpretations. Given the nascent status of the study of benefit-finding and posttraumatic growth, we believe it important to comment on methodology, although this comment is not unique to the present study. In the present study we asked participants to think of any interpersonal benefits that may have resulted from having RA. Other studies have asked similar open-ended questions, but about benefits of any type (e.g., Sears et al., 2003), whereas other researchers have provided closed-ended scales (e.g., Park et al., 1996) or the equivalent of checklists
Benefit-Finding Among Patients With RA of benefits (e.g., Katz et al., 2001). Asking participants in our study to focus on a particular conceptual domain—interpersonal relationships— circumscribed the range of response to the phenomenon we were interested in, but also may have confused some individuals. An appreciable number of participants (13.9%) left the question blank; does this mean that they did not find benefits or that they could not think of any in the interpersonal realm? Some respondents seemed to ignore the specificity of the open-ended question and write about other personal benefits. It is unclear whether this subgroup of patients connected such benefits to their interpersonal relationships in an implicit way that was not intuited by the researchers coding their responses, or whether they were aware that they were providing information that differed from what had been requested. If the latter is correct, we do not know whether patients answered in this manner because they felt that their illness had not affected their relationships in any positive ways, or whether they had in fact experienced interpersonal benefits but preferred instead to write about other types of benefits that they perceived as more salient. Based on previous findings (e.g., Davis et al., 1998; Sears et al., 2003), there might have been a higher percentage of benefits reported in this study if the question on benefit-finding had been phrased more broadly rather than specifying interpersonal benefits. Similarly, we do not know whether patients who left the question blank did so because they had not experienced interpersonal benefits as a result or their illness, or whether they did so for other reasons, such as not wanting to provide a written response to a question with an open-ended format. Some participants responded to the open-ended question by writing that they had experienced no benefits, but there were too few to conduct analyses comparing these individuals with those who answered the question affirmatively. Nor was the number of people within each category large enough to allow reliable comparisons among those who reported different types of benefits (e.g., interpersonal benefits vs. noninterpersonal benefits). Although the overall percentage of respondents finding benefits was similar to that found in other studies of chronic illness, some of the category percentages differed from previous research. For example, Katz et al. (2001) found that over 80% of SLE patients reported becoming more compassionate toward others, yet we found that only 20% of the sample described this type of interpersonal benefit. The
101 difference in these percentages is most likely due to differences in methodology rather than in type of illness; compared with the open-ended format used in the present study and in the study by Affleck and colleagues (1988), Katz et al. (2001) used a closed-ended questionnaire that made each benefit salient and easily endorsed.
Implications for Interventions A question that raises interesting implications for researchers and clinicians alike is whether benefit-finding may actually reflect a denial process in which appraising a negative situation as positive is indicative of a maladaptive distortion of reality. Affleck and Tennen (1996) considered this question and concluded that the extant literature does not support the notion that finding benefits in adverse experiences comes at the cost of denying the reality of their negative effects. Nonetheless, health care professionals must be aware of the possibility that particular individuals might focus on positive aspects of their situation in order to defend against painful emotions or mask the severity of their illness and its consequences, which could be associated with maladaptive consequences in the long run. For this reason we have concerns about self-help interventions that convey to patients with chronic illnesses messages such as “You can’t afford the luxury of a negative thought” (John-Roger and McWilliams, 1991). Consideration of the appropriateness of interventions promoting “the tyranny of positive thinking” (Holland and Lewis, 2000, p. 14) among medical patients leads us to the question of whether benefit-finding is only effective when self-generated or whether it should be facilitated externally. For example, is it possible for family members, friends, or health care providers to actively encourage this process in patients without being perceived as obtrusive or insensitive? Tennen and Affleck (1999) cautioned, “directed, imposed, or suggested benefits will almost surely fail to achieve their desired goal” (p. 298). Recently, investigators have begun to examine this assertion empirically. New experimental research with breast cancer patients (Stanton et al., 2002) and healthy college students (King and Miner, 2000) shows that directed benefit-finding can lead to positive health outcomes. It is important to note, however, that the efficacy of such benefit-finding interventions actually may result from producing a balanced evaluation of both the positive and negative
102 aspects of stressful or traumatic experiences rather than a uniform focus on the positive (Stanton et al., 2002). Even if for most patients there exists a “bright side” of having an illness in terms of its impact on their relationships and other aspects of life, further study is needed to understand how and when individuals can attain this perspective.
ACKNOWLEDGMENTS This research was supported by a Postdoctoral Award from the Arthritis Foundation to Sharon Danoff-Burg. Portions of this research were presented at the annual meeting of the American Psychological Association, August 2001, San Francisco. We are grateful to Stephen A. Paget and Allan Gibofsky for help with referrals. We also thank Katy Tai for assistance with the patient registry and John D. Agee and Kathleen M. Maloney for assistance with data coding. Finally, we thank Stephen J. Lepore for his comments on an earlier draft of this article.
REFERENCES Affleck, G., Pfeiffer, C., Tennen, H., and Fifield, J. (1988). Social support and psychological adjustment to rheumatoid arthritis: Quantitative and qualitative findings. Arthritis Care Res 1: 71– 77. Affleck, G., and Tennen, H. (1996). Construing benefits from adversity: Adaptational significance and dispositional underpinnings. J. Pers. 64: 899–922. Affleck, G., Tennen, H., Croog, S., and Levine, S. (1987). Causal attribution, perceived benefits, and morbidity after a heart attack: An 8-year study. J. Consult. Clin. Psychol. 55: 29–35. Baumeister, R. F., and Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychol. Bull. 117: 497–529. Blalock, S. J., DeVellis, R. F., Brown, G. K., and Wallston, K. A. (1989). Validity of the Center for Epidemiological Studies Depression Scale in arthritis populations. Arthritis Rheum. 32: 991–997. Bower, J. E., Kemeny, M. E., Taylor, S. E., and Fahey, J. L. (1998). Cognitive processing, discovery of meaning, CD 4 decline, and AIDS-related mortality among bereaved HIVseropositive men. J. Consult. Clin. Psychol. 66: 979–986. Carver, C. S., Pozo, C., Harris, S. D., Noriega, V., Scheier, M. F., Robinson, D. S., Ketcham, A. S., Moffat, F. L., Jr., and Clark, K. C. (1993). How coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. J. Pers. Soc. Psychol. 65: 375–390. Collins, R. L., Taylor, S. E., and Skokan, L. A. (1990). A better world or a shattered vision? Changes in life perspectives following victimization. Soc. Cogn. 8: 263–285. Cordova, M. J., Cunningham, L. L., Carlson, C. R., and Andrykowski, M. A. (2001). Posttraumatic growth following breast cancer: A controlled comparison study. Health Psychol. 20: 176–185.
Danoff-Burg and Revenson Coyne, J. C., and Fiske, V. (1992). Couples coping with chronic and catastrophic illness. In Akamatsu, T. J., Stephens, M. A. P., Hobfoll, S. E., and Crowther, J. (Eds.), Family Health Psychology, Hemisphere, Washington, DC, pp. 129–149. Curbow, B., Somerfield, R., Baker, F., Wingard, J. R., and Legro, M. W. (1993). Personal changes, dispositional optimism, and psychological adjustment to bone marrow transplant. J. Behav. Med. 16: 423–443. Danoff-Burg, S., Ayala, J., and Revenson, T. A. (2000). Researcher knows best? Toward a closer match between the concept and measurement of coping. J. Health Psychol. 5: 183– 194. Danoff-Burg, S., and Revenson, T. A. (2000). Rheumatic illness and relationships: Coping as a joint venture. In Schmaling, K. B., and Sher, T. G. (Eds.), The Psychology of Couples and Illness, American Psychological Association, Washington, DC, pp. 105–133. Danoff-Burg, S., Revenson, T. A., Trudeau, K. J., and Paget, S. A. (2004). Unmitigated communion, social constraints, and psychological distress among women with rheumatoid arthritis. J. Pers. 72: 29–46. Davis, C. G., Nolen-Hoeksema, S., and Larson, J. (1998). Making sense of loss and benefiting from the experience: Two construals of meaning. J. Pers. Soc. Psychol. 75: 561–574. Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., and Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behav. Sci. 19: 1–15. DeVellis, B. M., Revenson, T. A., and Blalock, S. J. (1997). Rheumatic disease and women’s health. In Gallant, S. J., Keita, G. P., and Royak-Schaler, R. (Eds.), Health Care for Women: Psychological, Social, and Behavioral Influences, American Psychological Association, Washington, DC, pp. 333–347. Fries, J., Spitz, P., and Young, D. (1982). The dimensions of health outcomes: The Health Assessment Questionnaire, disability, and pain scales. J. Rheumatol. 9: 789–793. Fritz, H. L. (2000). Gender-linked personality traits predict mental health and functional status following a first coronary event. Health Psychol. 19: 420–428. Gardiner, P. V., Sykes, H. R., Hassey, G. A., and Walker, D. J. (1993). An evaluation of the Health Assessment Questionnaire in long-term longitudinal follow-up of disability in rheumatoid arthritis. Br. J. Rheumatol. 32: 724– 728. Gordon, P., Feldman, D., Crose, R., Schoen, E., Griffing, G., and Shankar, J. (2002). The role of religious beliefs in coping with chronic illness. Couns. Values 46: 162–174. Holland, J. C., and Lewis, S. (2000). The Human Side of Cancer: Living With Hope, Coping With Uncertainty, HarperCollins, New York. Ickovics, J. R., Thayaparan, B., and Ethier, K. A. (2001). Women and AIDS: A contextual analysis. In Baum, A., Revenson, T. A., and Singer, J. E. (Eds.), Handbook of Health Psychology, Erlbaum, Mahwah, NJ, pp. 817–839. John-Roger, and McWilliams, P. (1991). You Can’t Afford the Luxury of a Negative Thought, Prelude, Los Angeles. Katz, R. C., Flasher, L., Cacciapaglia, H., and Nelson, S. (2001). The psychosocial impact of cancer and lupus: A crossvalidation study that extends the generality of “benefitfinding” in patients with chronic disease. J. Behav. Med. 24: 561–571. Keefe, F. J., Affleck, G., Lefebvre, J. C., Starr, K., Caldwell, D. S., and Tennen, H. (1997). Pain coping strategies and coping efficacy in rheumatoid arthritis: A daily process analysis. Pain 69: 35–42. Keefe, F. J., Smith, S. J., Buffington, A. L. H., Gibson, J., Studts, J. L., and Caldwell, D. S. (2002). Recent advances and future directions in the biopsychosocial assessment and treatment of arthritis. J. Consult. Clin. Psychol. 70: 640–655.
Benefit-Finding Among Patients With RA Kenny, D. A., Kashy, D. A., and Bolger, N. (1998). Data analysis in social psychology. In Gilbert, D., Fiske, S., and Lindzey, G. (Eds.), The Handbook of Social Psychology, 4th ed., Vol. 1, McGraw-Hill, Boston, pp. 233–265. Kiecolt-Glaser, J. K., McGuire, L., Robles, T. F., and Glaser, R. (2002). Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Ann. Rev. Psychol. 53: 83– 107. King, L. A., and Miner, K. N. (2000). Writing about the perceived benefits of traumatic events: Implications for physical health. Pers. Soc. Psychol. Bull. 26: 220–230. Lanza, A. F., Cameron, A. E., and Revenson, T. A. (1995). Helpful and unhelpful support among individuals with rheumatic diseases. Psychol. Health 10: 449–462. Lepore, S. J. (2001). A social-cognitive processing model of emotional adjustment to cancer. In Andersen, B. (Ed.), Psychosocial Interventions for Cancer, American Psychological Association, Washington, DC, pp. 99–118. Lepore, S. J., and Eton, D. T. (2000). Response shifts in prostate cancer patients: An evaluation of suppressor and buffer models. In Schwartz, C., and Sprangers, M. (Eds.), Adaptations to Changing Health: Response Shift in Quality-of-Life Research, American Psychological Association, Washington, DC, pp. 37–51. Lepore, S. J., Silver, R. C., Wortman, C. B., and Wayment, H. A. (1996). Social constraints, intrusive thoughts, and depressive symptoms among bereaved mothers. J. Pers. Soc. Psychol. 70: 271–282. Manne, S., and Zautra, A. (1989). Spouse criticism and support: Their association with coping and psychological adjustment among women with rheumatoid arthritis. J. Pers. Soc. Psychol. 56: 608–617. McMillen, J. C., Zuravin, S., and Rideout, G. (1995). Perceived benefit from child abuse. J. Consult. Clin. Psychol. 63: 1037– 1043. Mohr, D. C., Dick, L. P., Russo, D., Pinn, J., Boudewyn, A. C., Likosky, W., and Goodkin, D. E. (1999). The psychosocial impact of multiple sclerosis: Exploring the patient’s perspective. Health Psychol. 18: 376–382. O’Leary, V. E., and Ickovics, J. R. (1995). Resilience and thriving in response to challenge: An opportunity for a paradigm shift in women’s health. Womens Health: Res. Gender Behav. Policy 1: 121–142. Park, C. L. (2004). The notion of stress-related growth: Problems and prospects. Psychol. Inq. 15: 69–76. Park, C. L., Cohen, L., and Murch, R. (1996). Assessment and prediction of stress-related growth. J. Pers. 64: 71–105. Peterson, M. G., Horton, R., Engelhard, E., Lockshin, M. D., and Abramson, T. (1993). Effect of counselor training on skills development and psychosocial status of volunteers with systemic lupus erythematosus. Arthritis Care Res. 6: 38–44. Pincus, T., Summey, J. A., Soraci, S. A., Wallston, K. A., and Hummon, N. P. (1983). Assessment of patient satisfaction in activities of daily living using a Modified Stanford Health Assessment Questionnaire. Arthritis Rheum. 26: 1346–1353. Price, D. D. (1988). Psychological and Neural Mechanisms of Pain, Raven, New York. Revenson, T. A. (1990). All other things are not equal: An ecological perspective on the relation between personality and disease. In Friedman, H. S. (Ed.), Personality and Disease, Wiley, New York, pp. 65–94. Revenson, T. A. (2003). Scenes from a marriage: Examining support, coping, and gender within the context of chronic illness. In Suls, J., and Wallston, K. (Eds.), Social Psychological Foundations of Health and Illness, Blackwell, Oxford, England, pp. 530–559. Revenson, T. A., and Danoff-Burg, S. (2000). Arthritis. In Kazdin, A. E. (Ed.), Encyclopedia of Psychology, Vol. 1, American
103 Psychological Association, Washington, DC, pp. 240– 242. Revenson, T. A., Schiaffino, K. M., Majerovitz, S. D., and Gibofsky, A. (1991). Social support as a double-edged sword: The relation of positive and problematic support to depression among rheumatoid arthritis patients. Soc. Sci. Med. 7: 807–813. Sandanger, I., Moum, T., Ingebrigtsen, G., Dalgard, O. S., Sorensen, T., and Bruusgaard, D. (1998). Concordance between symptom screening and diagnostic procedure: The Hopkins Symptom Checklist-25 and the Composite International Diagnostic Interview I. Soc. Psychiatry Psychiatr. Epidemiol. 33: 345–354. Sarason, B. R., Sarason, I. G., and Gurung, R. A. R. (2001). Close personal relationships and health outcomes: A key to the role of social support. In Sarason, B. R., and Duck, S. (Eds.), Personal Relationships: Implications for Clinical and Community Psychology, Wiley, Chichester, England, pp. 15– 41. Schmaling, K. B., and Sher, T. G. (Eds.). (2000). The Psychology of Couples and Illness, American Psychological Association, Washington, DC. Sears, S. R., Stanton, A. L., and Danoff-Burg, S. (2003). The Yellow Brick Road and the Emerald City: Benefit-finding, positive reappraisal coping, and posttraumatic growth in women with early-stage breast cancer. Health Psychol. 5: 487–497. Seligman, M. E. P., and Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist 55: 5–14. Shumaker, S., and Brownell, A. (1984). Toward a theory of social support: Closing conceptual gaps. J. Soc. Issues 40: 11–36. Siegel, K., and Schrimshaw, E. W. (2000). Perceiving benefits in adversity: Stress-related growth in women living with HIV/AIDS. Soc. Sci. Med. 51: 1543–1554. Smedstad, L. M., Kvien, T. K., Moum, T., and Vaglum, P. (1995). Life events, psychosocial factors, and demographic variables in early rheumatoid arthritis: Relations to one-year changes in functional disability. J. Rheumatol. 22: 2218–2225. Snyder, C. R., and Lopez, S. (Eds.). (2002). Handbook of Positive Psychology, Oxford, New York. Stanton, A., and Revenson, T. A. (in press). Adaptation to chronic illness. In Friedman, H. S., and Silver, R. C. (Eds.), The Oxford Handbook of Health Psychology, Oxford University Press, New York. Stanton, A. L., Danoff-Burg, S., Sworowski, L. A., Collins, C. A., Branstetter, A., Rodriguez-Hanley, A., Kirk, S. B., and Austenfeld, J. A. (2002). Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients. J. Clin. Oncol. 20: 4160–4168. Tedeschi, R. G., and Calhoun, L. G. (1996). The posttraumatic growth inventory: Measuring the positive legacy of trauma. J. Trauma. Stress 9: 455–471. Tennen, H., and Affleck, G. (1999). Finding benefits in adversity. In Snyder, C. R. (Ed.), Coping: The Psychology of What Works, Oxford, New York, pp. 279–304. Tennen, H., and Affleck, G. (2002). Benefit-finding and benefitreminding. In Snyder, C. R., and Lopez, S. (Eds.), Handbook of Positive Psychology, Oxford, New York, pp. 584–597. Tennen, H., Affleck, G., Urrows, S., Higgins, P., and Mendola, R. (1992). Perceiving control, construing benefits, and daily processes in rheumatoid arthritis. Can. J. Behav. Sci. 24: 186–203. Zautra, A. J., Burleson, M. H., Matt, K. S., Roth, S., and Burrows, L. (1994). Interpersonal stress, depression, and disease activity in rheumatoid arthritis and osteoarthritis patients. Health Psychol. 13: 139–148. Zautra, A. J., Smith, B., Affleck, G., and Tennen, H. (2001). Examinations of chronic pain and affect relationships: Applications of a dynamic model of affect. J. Consult. Clin. Psychol. 69: 785–796.
