PSYCHOLOGY OF RELATIONSHIPS

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PSYCHOLOGY OF RELATIONSHIPS

EMMA CUYLER
AND
MICHAEL ACKHART
EDITORS

Nova Science Publishers, Inc.

New York
Copyright © 2009 by Nova Science Publishers, Inc.

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LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

Cuyler, Emma.
Psychology of relationships / Emma Cuyler and Michael Ackhart.
p. cm.
ISBN 978-1-60741-931-0 (E-Book)
1. Interpersonal relations. I. Ackhart, Michael. II. Title.
HM1106.C89 2009
302.3'4--dc22
2008039628

Published by Nova Science Publishers, Inc.Ô New York

 CONTENTS

Preface ix
Chapter 1 Communicating Empathies in Interpersonal Relationships 1
Grace Anderson and Howard Giles
Chapter 2 Interpersonal Representations: Their Structure, Content, and Nature 35
Shanhong Luo
Chapter 3 Generalized Anxiety Disorder and Interpersonal Relationships:
The Case For a Systemic Intervention 65
Danielle Black, Amanda Uliaszek, Alison Lewis and
Richard Zinbarg
Chapter 4 Another Kind of “Interpersonal” Relationship: Humans, Companion
Animals, and Attachment Theory 87
Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster
Chapter 5 The Role of Oxytocin in the Pathophysiology of Attachment 111
Marazziti Donatella, Catena Dell’Osso Mari,
Consoli Giorgio and Baroni Stefano
Chapter 6 Identity Exploration and Commitment Associations with Gender
Differences in Emerging Adults’ Romantic Relationship Intimacy 131
H. Durell Johnson, Kristen A. Loff, George Bell, Evelyn Brady,
Erin A. Grogan, Elizabeth Yale, Robert J. Foley and
Trishia A. Pilosi
Chapter 7 Development of an Interview for Assessing Relationship Quality:
Preliminary Support for Reliability, Convergent and Divergent
Validity, and Incremental Utility 149
Erika Lawrence, Robin A. Barry, Rebecca L. Brock,
Amie Langer, Eunyoe Ro, Mali Bunde, Emily Fazio,
Lorin Mulryan,Sara Hunt, Lisa Madsen and Sandra Dzankovic
vi Contents

Chapter 8 Assessing Relationship Quality: Development of an Interview and

Implications for Couple Assessment and Intervention 173
Erika Lawrence, Rebecca L. Brock, Robin A. Barry, Amie Langer
and Mali Bunde
Chapter 9 The Tendency to Forgive in Premarital Couples: Reciprocating the
Partner or Reproducing Parental Dispositions? 191
F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate and
Camillo Regalia
Chapter 10 Is the Serotonergic System Altered in Romantic Love? A Literature
Review and Research Suggestions 213
Sandra J. E. Langeslag
Chapter 11 Update on Pheromone Research 219
Donatella Marazziti, Irene Masala, Stefano Baroni,
Michela Picchetti, Antonello Veltri and
Mario Catena Dell’Osso
Chapter 12 Normal and Obsessional Jealousy: An Italian Study 229
Donatella Marazziti, Marina Carlini, Francesca Golia,
Stefano Baroni, Giorgio Consoli and Mario Catena Dell’Osso
Chapter 13 Jealousy, Serotonin and Subthreshold Psychopathology 237
Donatella Marazziti, Francesca Golia, Marina Carlini,
Stefano Baroni, Irene Masala, Mario Catena Dell’Osso,
and Giorgio Consoli
Chapter 14 Advances in Dyadic and Social Network Analyses for Longitudinal
Data: Developmental Implications and Applications 245
William J.Burk,Danielle Popp, and Brett Laursen
Chapter 15 Mother-Infant Interaction in Cultural Context: A Study of
Nicaraguan and Italian Families 259
Ughetta Moscardino, Sabrina Bonichini
and Cristina Valduga
Chapter 16 “It’s Saturday…I’m Going out with My Friends”: Spending Time
Together in Adolescent Stories 281
Emanuela Rabaglietti and Silvia Ciairano
Chapter 17 Prevention of the Negative Effects of Marital Conflict:
A Child-Oriented Program 303
Patricia M. Mitchell, Kathleen P. McCoy, E. Mark Cummings,
W. Brad Faircloth and Jennifer S. Cummings
Chapter 18 Mother-Infant Bonds: The Effects of Maternal Depression on the
Maternal-Child Relationship 319
Deana B. Davalos, Alana M. Campbell and Amanda L. Pala
 Contents vii

Chapter 19 Social Networks and Psychosocial Functioning among Children and

Adolescents Coping with Sickle Cell Disease: An Overview of
Barriers, Considerations, and Best Practices 339
Rebecca H. Foster, HaNa Kim, Robbie Casper, Alma Morgan,
Wanda Brice and Marilyn Stern
Chapter 20 Parenting and Children’s Involvement in Bullying at School 365
Ken Rigby
Chapter 21 Neurobiology of Social Bonding 369
Donatella Marazziti, Alessandro Del Debbio, Isabella Roncaglia,
Carolina Bianchi and Liliana Dell’Osso
Chapter 22 Cooperative and Non-cooperative Behavior in Pairs of Children:
The Reciprocal Effects of Social Interaction in the Ongoing
Construction of a Play Sequence 381
Emanuela Rabaglietti, Fabrizia Giannotta, and Silvia Ciairano
Chapter 23 Social Relationships and Physical Health: Are We Better or Worse
off because of Our Relationships? 399
Julianne Holt-Lunstad and Briahna Bushman
Chapter 24 Living in Discrepant Worlds: Exploring the Cultural Context of
Sexuality among Turkish and Moroccan male Adolescents 417
Barbara C. Schouten and Chana van der Velden
Chapter 25 HIV/AIDS Prevention on Mexican Adolescents: The Synthesis of
two Theories Considering the Interpersonal, Individual, and
Psychological Influences 437
Raquel A. Benavides-Torres, Georgina M. Núñez Rocha,
Esther C. Gallegos Cabriales, Claude Bonazzo,
Yolanda Flores-Peña, Francisco R. Guzmán Facudo, and
Karla Selene López García
Chapter 26 Adolescents with Cancer: Adjustment and Supportive Care Needs 451
Luisa M. Massimo
Chapter 27 The Quality of Caring Relationships 461
Tineke A. Abma, Barth Oeseburg, Guy A. M. Widdershoven
and Marian Verkerk
Chapter 28 An Attachment-Based Pathways Model Depicting the Psychology
of Therapeutic Relationships 471
Geoff Goodman
Chapter 29 A Study of the Relationship between Self-conscious Affects,
Coping Styles, and Depressive Reaction after a Negative
Life Event 493
Masayo Uji, Toshinori Kitamura and Toshiaki Nagata
viii Contents

Chapter 30 The Neuropsychology of Passionate Love 519

Elaine Hatfield and Richard L. Rapson
Index 545
 PREFACE

This book describes the various aspects of interpersonal relationships, which can be
defined as the interactions between one group and another. How people represent their
interpersonal relationships based on past experiences is explored, as well as the three main
aspects of interpersonal representations- structure, content, and nature. Conflictive social
interpersonal relationships and how they influence mental health are explored in this chapter,
as well as the different coping styles people have. In addition, the various dimensions of
empathy and how they relate to interpersonal relationships are reviewed and incorporated into
a unified source of reference for future research.
The role of the nonapeptide called oxytocin in the pathophysiology of attachment is
described as well as the possible involvement of oxytocin in the onset of mental disorders.
Differences in romantic relationship intimacy, resulting from identity exploration are
discussed, as well as the differences in commitment based on gender. In addition, the
correlation(s) between relationship adjustment, satisfaction, and quality are reviewed based
on the Relationship Quality Interview (RQI), which assesses relationship quality across five
dimensions, including trust, inter-partner support, quality of intimacy, respect, and
communication. Furthermore, the association between social relationships and physical health
is examined.
The tendency to forgive in premarital couples is examined as well as the reasons behind
forgiveness-possibly deriving from parental model behavior or reciprocation of the partner's
behavior. In addition, a review of studies is done on the relationship between serotonin levels
and romantic love, as well as how the thoughts of infatuated individuals mirror those who
suffer from obsessive-compulsive disorder. Furthermore, generalized anxiety disorder
(GAD), one of the more common anxiety disorders, is discussed and how it affects
occupational, interpersonal and family functioning, as well as the different treatments for
GAD.
This book presents the most up-to-date information on pheromone research, including
how pheromones may influence reproductive endocrinology and have a positive effect on
one's mood. In addition, the differences between normal and obsessional jealousy is explored,
as well as the role that neurotransmitters may play in the expression of jealousy.
The neurobiological correlates of attachment in both animals and humans is examined,
including infant-mother attachment, mother-infant attachment, adult-adult pair bonding
formation, and human bonding. Human-pet relationships and their importance in the field of
human psychology animal are also explained in this book. Furthermore, the relationships
x Emma Cuyler and Michael Ackhart

between cooperative and non-cooperative or competitive behavior in pairs of children in the

ongoing process of interaction is reviewed. The social networking and psychosocial
functioning among children and adolescents coping, in particular, with sickle cell disease is
examined in this book, as well as the best practices for treatment. Furthermore, studies done
on the adjustment and supportive care for adolescents that are dealing with high-risk diseases
such as cancer are discussed.
This book explores the major public health issue of HIV/AIDS in Mexican adolescents
and Turkish and Moroccan male adolescents in the Netherlands. Three types of influences are
discussed, including interpersonal influences, individual influences, and psychosocial
influences.
Finally, this book explores the psychology of therapist-patient relationships as well as the
relationships between patients or disabled persons and professionals. The ways in which
conflictive social interpersonal relationships may influence mental health is also discussed.
Chapter 1 - Empathy is a concept that has been widely researched across the social
sciences and, more importantly, is commonly used outside of academe as a method “to open-
up the channel of communication with the other” (Wikipedia, 2006). Although commonly
employed colloquially, empathy is challenging to define explicitly and, hence, this chapter
begins with some conceptual wood-clearing. Prior definitions reflect the specific contexts in
which empathy was measured and studied. For instance, a study measuring empathy as a
response to media defines empathy differently than a study that examines empathy as an
interpersonal communication construct – and these definitions are not mutually exclusive or
disparate. Instead, different definitions are a result of the various dimensions of empathy that
researchers choose to highlight as a function of the particular empirical study’s focus. For this
reason, many individuals may find empathy easier to enact than to describe its meaning in
words.
This chapter will examine the major definitional variations of empathy that have
developed in research on interpersonal relationships, comparing and contrasting their
implications. For instance, one major difference is whether empathy is a stable trait or a
changing state; this definitional difference can lead to very different methods of research. An
attempt is made to accomplish a more global definition of empathy by discussing the distinct
ways in which it has been examined in the past, such as in terms of communicative
competence, personal distress, and nonverbal expressions, and incorporating the many
dimensions of empathy into a unified source of reference for future research. In so doing, this
chapter will discuss how one individual may feel and express empathy and how that empathy
may or may not be perceived as such by its recipients. The psychological origins of empathy
will be identified and questions regarding motives underlying empathy will be raised,
including whether it can be used as a form of impression management during social
interactions.
Empathy has been recognized as an important component of health communication.
Research has shown that an empathic person holds more positive attitudes towards healthy
behaviors regarding smoking and alcohol consumption (Kalliopuska, 1992). Moreover, an
effective health campaign will evoke empathy among its target audience because it evokes
greater cognitive and affective processing of the campaign message (Campbell & Babrow,
2004). Empathic communication with people with disabilities (particularly those inflicted by
cancer) will be a continuous example used to help us understand the multidimensional
implications of empathic communication. Empathy can ease tensions that may occur during
 Preface xi

this form of interaction and suggestions of appropriate empathic communication will be

offered. Finally, a new communication model of the process of empathy will be introduced.
Chapter 2 - How people represent their interpersonal relationships based on past
experiences has great impact on their subsequent interactions with others. This chapter
reviews previous theories and presents new propositions regarding three important aspects of
interpersonal representations (IRs)—their structure, content, and nature. Specifically, the
structure of IRs can be viewed as a three-level hierarchical organization, with general
representations at the highest level, domain-specific representations at the midlevel, and
relationship-specific representations at the lowest level. The content of IRs can be divided
into three distinct yet interrelated components: self representations, other representations,
and relationship representations. With regard to the nature, IRs can be conceptualized as
consisting of accurate perceptions, systematic biases, and random errors.
Chapter 3 - Generalized anxiety disorder (GAD), one of the more common anxiety
disorders, is associated with significant impairment in occupational, interpersonal and family
functioning. There is growing consensus that there is a need to improve the effectiveness of
treatments for GAD given that even the most positive findings suggest that only 50% of
patients treated with cognitive-behavior therapy (CBT) and/or medications experience what
might be considered to be a cure. Whereas established treatments for GAD are individual
modalities, there is evidence from several lines of research suggesting current treatments for
that systemic therapy has promise to augment the effectiveness of therapy for GAD. These
lines of research include (a) evidence that elevated marital dissatisfaction is associated with
GAD; (b) evidence that marital and family problems are associated with other anxiety
disorders including panic disorder with agoraphobia and obsessive compulsive disorder and
are associated with poor outcome in the treatment of these other anxiety disorders; (c)
evidence that marital and family problems are associated with major depression - another
psychiatric condition closely related to GAD – and poor outcome in the treatment of major
depression; (d) preliminary evidence that marital functioning and interpersonal problems
predict outcome in the treatment of GAD; and (e) evidence that at least some forms of
couples therapy are effective treatments for major depression and panic disorder with
agoraphobia.
Chapter 4 - Human-companion animal relationships provide an important but largely
unexplored component of the human experience. Research examining these interspecies
relationships may elucidate the depth and meaning of these relationships as well as provide
unique insights into the fundamental nature of human psychology. Human-animal
relationships offer a distinctive testing ground because pet choice is unilateral, whereas
human friendships and romantic partner choices are mutual, and individuals may have
reduced fear of rejection or evaluation from a pet than from a human relationship partner.
This chapter reviews and applies to human-pet relationships key elements of attachment
theory, including caregiving, exploration, the malleability of attachment styles, and the role of
attachment anxiety and avoidance in choosing relationship partners. Potential future research
directions using relationships theories in companion animal contexts is also covered.
Chapter 5 - Oxytocin is a nonapeptide synthesized in the paraventricular and supraoptic
nuclei of the hypothalamus. Although OT-like substances are present in all vertebrates,
oxytocin has been identified only in mammals where it seems to be fundamental in the onset
of typical mammalian behaviors, including labour and lactation. In the present chapter, the
physiological role of oxytocin in the regulation of different functions and behaviors will be
xii Emma Cuyler and Michael Ackhart

addressed: several data, mainly coming from animal models, have highlighted the role of this
neuropeptide in the formation of caregiver-infant attachment, pair-bonding and, more
generally, in linking social signals with cognition, behaviours and reward. In addition, recent
evidences have demonstrated alterations of oxytocin system in several human
neuropsychiatric disorders, leading to the hypothesis of a possible involvement of oxytocin in
the onset of mental disorders. In this frame, the psychopathological implication of the
disregulation of the oxytocin system and the possible use of oxytocin or its analogues and/or
antagonists in the treatment of psychiatric disorders will be discussed.
Chapter 6 - Emerging adulthood is considered a time when intimacy becomes an integral
aspect of romantic relationships, and Arnett (2000) argues intimacy in emerging adults’
romantic relationships results from identity explorations. Previous research, however,
suggests emerging adults’ romantic intimacy is associated not only with identity exploration,
but also with identity commitments and gender. In an attempt to examine the theorized
relationships among identity exploration, identity commitment, gender, and perceived
romantic intimacy, the current study examined identity and romantic intimacy responses from
a sample of 271 emerging adults (183 females, mean age = 19.22 years; and 88 males (mean
age = 19.29 years). Findings indicated 1) both identity exploration and commitment predict
emerging adults’ romantic relationship intimacy, 2) gender differences in romantic
relationships differ according to emerging adults’ identity status, and 3) identity status
differences in romantic relationship intimacy differs for emerging adult males and females.
The current study’s test of Arnett’s (2000) hypothesis regarding identity exploration and
romantic relationship intimacy development did not fully support his theorized association.
Rather, findings suggest differences in emerging adults’ romantic intimacy are associated
with their gender and identity commitments as well as identity exploration. As a result,
Arnett’s (2000) proposal that identity exploration during emerging adulthood is a necessary
precursor for intimate romantic relationships may not completely describe the association
between identity and intimacy that emerges during this period, and this association may be
more complex than originally theorized. Results are discussed in terms of understanding the
moderating association of gender on identity exploration and commitment differences in
emerging adults’ reports of romantic relationship intimacy.
Chapter 7 - Historically, relationship satisfaction and adjustment have been the target
outcome variables for almost all couple research and therapies. In contrast, far less attention
has been paid to the assessment of relationship quality. The first section of the chapter
reviews the long-standing debate regarding – and clarify the distinctions among – relationship
adjustment, satisfaction, and quality. Also discussed is the need for an empirically-supported,
psychometrically strong measure of relationship quality. The second section presents the
Relationship Quality Interview (RQI), a semi-structured, behaviorally anchored, individual
interview that yields objectively coded ratings from the interviews. It was designed to assess
relationship quality across five dimensions: (a) trust, closeness, and emotional intimacy; (b)
inter-partner support; (c) quality of the sexual relationship; (c) respect, power, and control;
and (e) communication and conflict management. The third section provides preliminary
evidence of the reliability and validity of the interview. Across two samples, the RQI
demonstrated strong reliability (internal consistency, inter-rater agreement, agreement across
interviewers based on two members of the same couple, correlations among the scales)
convergent validity (correlations between RQI scales and self-report questionnaires assessing
similar relationship dimensions), and divergent validity (correlations between RQI scales and
 Preface xiii

behavioral observations of related constructs, global measures of marital satisfaction, and

individual difference measures of related constructs). A brief discussion of broader clinical
issues relevant to couple assessment and prevention efforts concludes the chapter.
Chapter 8 - Historically, relationship satisfaction and adjustment have been the target
outcome variables for almost all couple research and therapies. In contrast, far less attention
has been paid to the assessment of relationship quality. In the first section of the chapter is a
review of the long-standing debate regarding -- and clarify the distinctions among --
relationship adjustment, satisfaction, and quality. Also discussed is the need for an
empirically-supported, psychometrically strong measure of relationship quality. In the second
section, the multidimensional nature of relationship quality, and review prior research
relevant to each dimension. An introduction on the Relationship Quality Interview (RQI), a
semi-structured, behaviorally anchored, individual interview that yields objectively coded
ratings is covered. The RQI was designed to assess relationship quality across five
dimensions: (a) trust, closeness, and emotional intimacy; (b) inter-partner support; (c) quality
of the sexual relationship; (c) respect, power, and control; and (e) communication and conflict
management. In the third section, preliminary evidence of the reliability and validity of the
interview is provided. Across samples of dating and married couples, were examined
reliability, convergent and divergent validity, and incremental validity of the RQI. A broader
clinical issues relevant to couple assessment and intervention efforts is discussed in the fourth
section.
Chapter 9 - Although the tendency to forgive the partner has been shown to enhance
personal and relational well-being, little is known about how this tendency originates. One
possibility is that the tendency to forgive the partner develops as a function of the forgiveness
exchanges people experience within their romantic relationships, thereby leading them to
become more and more similar to the partner in their proneness to forgive. Another possible
explanation is that social experiences people were exposed to within their own family of
origin has led them to gradually internalize parental models and to become more and more
similar to their parents in their willingness to forgive. These associations may be particularly
evident during emerging adulthood, when engaged couples have to balance their family
heritage and the forming of their new couple.
The present work aimed at providing initial evidence in support of these hypotheses by
investigating in a sample of premarital couples (N=165) and their parents the extent to which
young adults’ tendency to forgive the partner was similar to the partner’s tendency to forgive
them as well as to their mothers’ and fathers’ tendency to forgive one another. Dyads were
the units of analysis and stereotype accuracy was controlled. Results indicate that young
adults’ disposition to forgive the partner is similar to that of their partner and of their parents.
Gender moderated these associations, as females were more similar to their parents than were
males in their disposition to forgive.
The findings are consistent with the idea that premarital couples, even though strongly
involved in defining their own couple identity, are nonetheless affected by the forgiveness
models to which they are exposed within their family of origin.
Chapter 10 - Infatuated individuals think about their beloved a lot. The notions that these
frequent thoughts resemble the obsessions of obsessive-compulsive disorder (OCD) patients
and that those patients benefit from serotonin reuptake inhibitors (SSRIs), have led to the
hypothesis that romantic love is associated with reduced central serotonin levels. In this
chapter, the literature on this topic is reviewed and suggestions for future research are made.
xiv Emma Cuyler and Michael Ackhart

Previous studies have shown that romantic love is associated with lower blood serotonin
levels and with lower serotonin transporter densities, the latter of which has also been
observed in OCD patients. Further, SSRIs have been found to decrease feelings of romantic
love and the serotonin 2 receptor gene has been associated with the love trait ‘mania’, which
is a possessive and dependent form of love. Given that serotonin 2 receptors in the prefrontal
cortex have also been implicated in impulsive aggression, this suggests that stalking behavior
may be associated with these receptors. In short, the serotonergic system appears to be altered
in romantic love indeed. Future research is needed to identify what parts of the serotonergic
system, such as which serotonergic projections, brain areas, transmission stages and receptor
types, are affected in romantic love and in what way they are altered. Furthermore,
challenging the serotonergic system would be useful in determining the causal relationship
between central serotonin levels and feelings of romantic love. In addition, future research
should specifically investigate the different aspects of romantic love, such as state, trait,
requited and unrequited love and its development in time.
Chapter 11 - Pheromones are volatile compounds secreted into the environment (in
sweat, urine) by one individual of a species and perceived by another individual of the same
species, in which they trigger a behavioral response or physiological change. Besides insects,
pheromones have been described in several invertebrate and vertebrate animals; moreover,
they have been shown to modulate mating preferences, timing of weaning, learning ability to
distinguish poisoning from not-poisoning food, social recognition and level of stress.
Several studies suggest that pheromones might play an important role also in mammals,
as it has been demonstrated that they can use chemical signals for mate attraction, territorial
marking, dominance and probably other functions yet to be identified, amongst which,
perhaps, some social behaviors.
In humans, several studies have indicated that pheromones may influence reproductive
endocrinology and have a positive effect on mood. Menstrual synchrony amongst women
sharing the same environment is a long-recognized phenomenon related to pheromones
produced in the armpits; these substances are not perceived as having any particolar odour,
but nonetheless can influence the lenght of the mestrual cycle through the interference with
different hormones. The aim of the present paper is to review the latest data on pheromones
with a specific focus on humans and future developments.
Chapter 12 - Background: Jealousy is a complex emotion spanning from normality to
pathology. The present study aimed to define the boundaries between normal and obsessional
jealousy by utilizing a specific self-report questionnaire.
Methods: The so-called “Questionnaire of Affective Relationships (QAR)” was
administered to 400 university students of both sexes, as well as to 14 outpatients affected by
obsessive-compulsive disorder (OCD). The total scores and the responses to each of the 30
items were analyzed and compared.
Results: Two hundred and forty-five (approximately 61 %) of the questionnaires given to
the students were returned. Statistical analyses revealed that the OCD patients had higher total
scores than the healthy students. Moreover, it is possible to identify an intermediate group of
subjects, consisting of 10 % of the total, who exhibited thoughts of jealousy regarding their
partner, but to a lesser degree than the OCD patients. These were labeled as “healthy jealous
subjects” because no other psychopathological trait could be observed. in addition, significant
intergroup differences in single items were observed.
 Preface xv

Conclusion: The present study showed that in the population of university students, 10 %
of the subjects, although normal, had excessive jealous thoughts regarding their partner. In
fact, this clearly distinguishes these subjects from the OCD patients and from the healthy
subjects with no jealousy concerns by means of the specific questionnaire developed by us.
Probably, they represent a subgroup of jealous , albeit normal, subjects.
Chapter 13 - Background: Different studies have suggested that some neurotransmitters
may play a role in the expression of jealousy. This study utilized the specific binding of 3H-
paroxetine (3H-Par) as a peripheral tool to explore the serotonergic system in platelets of
healthy subjects with and without jealousy concerns.
Methods: Twenty-one subjects with thoughts of jealousy and 21 subjects without
jealousy concerns, as revealed by their score at a specific questionnaire (“Questionnaire of
Affective Relationships”, QAR), were included in the study. Subjects in the first group were
administered a battery of self-report instruments designed to detect the presence of
subthreshold psychopathology. The binding of 3H-Par was carried according to a standardized
protocol.
Results: The results showed a reduced density of 3H-Par binding in the “jealous” subjects,
as compared with the “non-jealous” subjects. In addition, most of the subjects of the first
group had one or moresubthreshold psychopathological conditions.
Conclusion: In conclusion, jealousy may be considered an expression of subtle forms of
psychopathology, and may provoke an alteration of the serotonergic system, as reflected by
the lower density of the platelet serotonin transporter.
Chapter 14 - Interdependence, a central feature of close relationships, presents
contemporary scholars with theoretical and statistical challenges. Dyadic and social network
analytic techniques have recently been formulated that offer several advantages over previous
statistical methods by accounting for various forms of interdependence for longitudinal data
collected from both relationship partners. Two of these methods are described: the Actor-
Partner Interdependence Model (APIM: Kenny, Kashy, & Cook, 2006) and actor-based
models of network-behavioral dynamics (Snijders, Steglich, & Schweinberger, 2007). The
APIM partitions variance into estimates of behavioral stability of both dyad members (actor
effects), and interpersonal influence (partner effects), while adjusting for initial behavioral
similarity between partners. The actor-based models describe dyadic relationships as
embedded within a multitude of interconnected dyadic relationships (i.e., social networks).
These dynamic models utilize computer simulations to partition variance into parameters that
ascribe similarity based on network, dyadic and individual behavioral attributes. To illustrate
the applicability of both methods, empirical examples from recent work using these models
techniques are described.
Chapter 15 - Although a common goal for parents is to promote their children’s
successful development in a respective society, there is considerable cross-cultural variation
in the beliefs parents hold about children, families, and themselves as parents. Previous
research suggests that in traditional rural areas across the world, parents highly appreciate
interrelatedness in their conceptions of relationships and competence, whereas in urban
settings of Western industrialized societies, parents seem to promote independent parent–
child relationships from early on. The main purpose of this study is to compare conceptions of
parenting and mother-infant interactions in two cultural contexts that may be expected to hold
different beliefs about parent-child relationships: Nicaraguan farmer families and middle-
class Italian families. Fifty-six mothers from central Nicaragua (n = 26) and northern Italy (n
xvi Emma Cuyler and Michael Ackhart

= 30) and their infants aged 0-14 months participated in the study. Mothers were interviewed
regarding their childrearing beliefs and behaviors, and were videotaped interacting with their
infants during a free play session. Maternal responses were qualitatively analyzed using a
thematic approach; maternal behaviors were coded into one of the following categories: social
play, object play, motor stimulation, verbal stimulation, and face-to-face interaction. Findings
indicated that: 1) Nicaraguan mothers emphasized interdependence and connectedness to
other people in their socialization goals, whereas Italian mothers placed greater focus on
childrearing strategies consistent with a more individualistic orientation; 2) Nicaraguan
mothers exhibited a higher overall frequency of behaviors related to motor stimulation and
face-to-face interaction, whereas Italian mothers were more likely to engage in social play,
object play, and to emit a greater overall number of verbal behaviors towards their infants
during the free-play session. The results suggest that parents’ conceptions of childcare reflect
culturally regulated norms and customs that are instantiated in parental behavior and
contribute to the structuring of parent-child interactions from the earliest months of life, thus
shaping developmental pathways of infants and children. Implications for theory on the
psychology of relationships as well as for clinical practice are discussed.
Chapter 16 - During adolescence, peer relationships and friendships are relevant contexts
for cognitive and social development [Bukowski, Newcomb and Hartup, 1996] and for future
adult adjustment [Hartup and Stevens, 1999]. It is also known that people, and particularly
adolescents, by way of narration and autobiographic construction, can define and attribute
meaning to their self and their relationships with others. Bruner and colleagues [Amsterdam
and Bruner, 2000; Bruner, 2002] pointed out that individuals construct stories to attribute
meaning and order to daily life events. By narrating one’s own story it is possible to organise
episodic memory, to shape the recollection of events, and to build reality [Smorti and
Pagnucci, 2003]. Specifically in friendship relationships, narrative autobiographic
experiences represent specific interpretative modalities used by adolescents to give meaning
to the self and the others within these relationships.
In this study, which is based on adolescent narrations, adolescent leisure-time behaviour
in the company of friends, specifically on Saturday afternoons was explored. This study is
also interested in identifying the self markers [Bruner, 1986; 1997], by which adolescents
perceive themselves and others, and attribute meaning to their own experiences. Finally,
investigating the relationship between the Self markers and some indicators of well-being
(e.g. positive self-perception and expectations of success), social self-efficacy, adulthood (e.g.
value of autonomy), and discomfort (e.g. feelings and sense of alienation).
Participants included thirty adolescents (11 girls and 19 boys) aged 14 to 20 years (M=
15.8; D.S.= 1.4) attending two different types of high school (43% lyceum, 57% technical and
vocational) in the northwest of Italy. The adolescents were asked to write a essay on the
subject: “It’s Saturday…I’m going out with my friends”.
The essays were analysed using thematic analysis of content as well as Bruner’s [1986;
1997] system of self markers. The following profiles summarise the findings. Most of the
adolescents go out on Saturday and they have fun, talk, share convivial activities and
sometimes also illegal activities (particularly boys) with their friends. Adolescents use
frequently especially the Self markers of Agency (97%), Commitment (87%), Coherence
(80%) and Social references (83%). Girls use the subjective aspects of Self markers, such as
Qualia and Evaluation on the bases of expectations, more frequently than boys. Older
adolescents use Agency and Resources more frequently than younger adolescents. Finally,
 Preface xvii

Resources and Evaluation are related to positive self-perception and Social references is
linked to Social self efficacy. This study has some limitations, such as the limited number of
participants and the specificity of the essay, which make it impossible to generalise these
findings to adolescent social life. Nevertheless, the findings can contribute to a better
understanding of the meaning that peers and friends assume in adolescence.
Chapter 17 - A psycho-educational program for advancing children’s coping skills and
reactions to marital conflict was evaluated. Families with a child between the ages of 4 and 8
were randomly assigned to one of three groups: 1) parent program only; 2) parent and child
program; or 3) self-study (control group). Parents in the parent-only and parent-child groups
received the same psycho-educational program. Only children in the parent-child group
received the child program which consisted of four visits in which children learned about
marital conflict and family relationships; were taught about emotions and different levels of
emotions; and were given tools for coping with conflict that would help them react in optimal
ways for their development. Analyses suggested the promise of a child program for older
children (ages 6-8) with regard to improved emotional security about marital conflict.
However, consistent with other research, simply educating children about coping with marital
conflict had minimal effects on outcomes associated with conflict between the parents.
Chapter 18 - The mother infant bond has long been recognized as being crucial in
multiple areas of infant development. The value that is placed on this relationship is
recognized across the world and across groups of varying socioeconomic status. The
multitudes of variables that are thought to be influenced by the mother infant relationship are
impressive, even staggering. Research suggests that, depending on the level of bonding or
lack thereof, infants may suffer outcomes as severe as irreversible neuropsychological deficits
or development of long-standing psychopathology. However, others have argued that the
effects are likely much more subtle, but certainly still important. During the last two decades
there has been an increase in research focusing on the effects of maternal depression on the
mother infant bond. Research in this field has apparently developed out of; a recognition of a
relatively higher prevalence of postpartum maternal depression than once believed and
recurring observations of differences in mother/infant relationships or infant behavior
associated with maternal postpartum depression. The infant behaviors that have been
implicated as resulting from this theoretically compromised mother infant relationship have
included slight, transient effects on sociability and affective sharing to results suggesting
significant increases in irritability, cognitive delays, behavioral problems, and difficulties
with attachment, among others. Longitudinal data suggest that while some problems appear to
resolve relatively quickly, there are some characteristics that endure long after infancy.
Specifically, some researchers have argued that children and even adolescents who
experienced problems bonding with their depressed mothers are at significantly greater risk of
experiencing a variety of psychological symptoms, including depression, anxiety, and
problems with addiction. Again, this view is controversial and others in the field link these
increased risks to other factors such as low socioeconomic status or marital discord. While
there appears to be consensus among most researchers in recognizing that there are likely
effects of postpartum depression on mother infant bonding that affect early development,
there is little consensus regarding the specific details of these effects. This review will
systematically analyze research focusing on the effects of postpartum depression on the
mother infant bond and those variables that are believed to be affected from potential
difficulties in this bond.
xviii Emma Cuyler and Michael Ackhart

Chapter 19 - Over 70,000 individuals in the United States are diagnosed with sickle cell
disease, yet relatively little attention has been paid to this group when compared to those
diagnosed with other chronic illnesses such as asthma, cystic fibrosis, diabetes, or cancer.
Like most major chronic illnesses, sickle cell disease influences familial and social
relationships in numerous and ever-changing ways. Advances in sickle cell disease treatments
and improved survival rates have resulted in dramatic shifts in relationship networks and
psychosocial adaption for each child diagnosed. Several primary areas of concern have been
identified for children and families facing sickle cell disease such as disruptions to
educational and socialization processes, sudden changes in medical conditions including the
persistent threat of pain crises, existential anxieties about death, the wide range of emotions
that are often present in managing with the various stages of the disease and treatment, the
overarching developmental trajectory of the child, and coping with having a serious illness or
caring for a child with a serious illness. Literature has cited and research continues to find
evidence of challenges faced by these children and adolescents including ways in which
family functioning, social acceptance by peers, interactions with siblings, parenting style used
in the home, and daily anxieties and pressures can play integrated roles in shaping life-long
relationships and overall quality of life. Because sickle cell disease predominantly affects
minority groups within the United States, families and medical professionals also must
consider the cultural needs of each patient in order to promote best practices for treatment and
the development of sustained, healthy relationships. While these noted challenges tend to be
constant foci for all concerned with caring for and working to develop optimal relationships
among individuals diagnosed with sickle cell disease, many individuals and families coping
with a sickle cell disease diagnosis seem to function quite well when adaptive coping and
supportive networks are present and persistent. This chapter will investigate how the many
relationships that exist within the social context of a child’s world are impacted by sickle cell
disease. An overview will be provided examining dynamics between parents, the children
diagnosed with sickle cell disease, and their peers and siblings in terms of the challenges
faced and the relationship strengths displayed. Cultural influences and means of improving
life-long relationships will be explored. Lastly, currently implemented interventions
promoting positive relationships will be discussed as well as future directions for research and
intervention studies.
Chapter 20 - Research into bullying amomg children has suggested that parents can play
an important role in reducing the risk of their children becoming involved in bully/victim
problems at achool .and can take steps to enable their children to cope more effectively
(Smith and Myron-Wilson, 1998; Stelios, 2008; Rigby 2008). At the same time, it should be
acknowledged that parental influence is limited by such factors as their child’s genetic
endowment (Ball et al., 2008) peer pressure at school and unpredictable life events. (Harris,
1998).
What parents can do to reduce the risk or impact of bullying on children can be
considered under these headings:
1) Early childhood parenting
2) Parenting style with older children
3) Parents promoting skills that are helpful in reducing the risk of
4) Parents assisting children who are being bullied at school
5) Parents providing emotional and social support when children are bullied
 Preface xix

Chapter 21 - Social bonding development is fundamental for several animals, particularly

for humans who are the most immature at birth, for its relevant impact upon survival and
reproduction. Several neural and endocrine factors, most of which are still largely unknown,
may modulate reproductive behaviors, mother-infant attachment and adult-adult bonding.
Consequently, the aimed to review the neurobiological correlates of attachment in both
animals and humans. MEDLINE and Pub-Med (1970-2008) databases were searched for
English language articles using the keywords attachment, neuropeptides, neurotrophins, pair
bonding, social behavior. Papers were reviewed that addressed the following aspects of
attachment neurobiology: 1) Infant-mother attachment; 2) Mother-infant attachment; 3)
Adult-adult pair bonding formation; 4) Human bonding. Oxytocin and vasopressin, two
neurohypophyseal peptides, are known to be involved in the attachment process. Oxytocin is
supposed to facilitate a rapid conditioned association to maternal odor cues, while linking
environmental cues to the infant's memory of the mother. While oxytocin plays a role in the
onset of maternal behavior in rats, vasopressin seems to influence paternal behavior in praire
voles. Parental behavior development requires also gonadal steroids action. In adults,
oxytocin and vasopressin may contribute to pair bonding process by modulating the
neuroendocrine response, behaviors and emotions associated to preference formation and pair
bonding. Recently, even neurotrophins have been suggested to play a role in social bonding.
In conclusion, although the neurobiological basis of social attachment is mainly based on
animal data, preliminary findings suggest that the same mechanisms may occur also in
humans and would involve multi-sensory processing, complex motor responses and cognitive
functions, such as attention, memory, recognition and motivation. The few data available in
humans are intriguing and seem to open even more exciting perspectives to the treatment of a
broad range of neuropsychiatric disorders.
Chapter 22 – It is known that some social interactions begin and end cooperatively, while
others start aggressively and end up even more so. It is also known that in some social
interactions one of the partners might initially behave either cooperatively or competitively
and aggressively towards the other partner, who may respond with the opposite type of
behavior. However, over time, as the relationship evolves, behavioral patterns may change as
each partner adapts to the behavior of the other.
As social interactions evolve over time, it is possible to identify two phases: first, a
reciprocal exploration phase, and second, an adjustment phase. Investigating very short term
social interaction sequences of about ten minutes, concluded that these two phases last about
five minutes each.
The present study investigates the relationships between cooperative and non-cooperative
or competitive behavior in pairs of children in the ongoing process of interaction during a ten-
minute play sequence. To reach the goal, it was necessary to first divide the time of the play
sequence (10’) in two phases and looked at the differences between the first and second phase
(5’ each). Second, divide the pairs of children in three groups: i) initially high in cooperation;
ii) initially high in competition; iii) initially high in both. Third, look at the outcomes using
both linear and logistic regression analyses. Hypothesised that: a) initially prevalent
cooperative behavior is more likely to end in cooperation; b) initially prevalent competitive
behavior is more likely to end in competition; c) initially mixed social interactions (both
cooperative and competitive) are more likely to end in abandonment of the interaction and
doing nothing.
xx Emma Cuyler and Michael Ackhart

The sample is composed of 125 pairs of children. 69% (N=86) of the pairs were
composed of same-sex children, while the remaining 31% (N=39) were mixed. The
individuals within each pair were the same age. 35% of the pairs (N =44) were eight years
old, 38% (N =48) were ten years old, and 27% (N=33) were twelve years old. The
cooperative and competitive behavior of both the partners were observed.. The task was to
finish a puzzle in ten minutes.
The findings confirmed only the first two hypotheses. It was found that initially mixed
situations were also more likely to end in cooperation. These findings underline the
importance of intervention programs aimed at promoting social and cooperative skills in
children to avoid starting negative social cycles or patterns.
Chapter 23 - When asked, “What is necessary for your happiness?” or “What is it that
makes your life meaningful?” most people mention before anything else-- satisfying close
relationships with family, friends, or romantic partners. Relationships with others form a
pervasive role in our everyday lives and are generally regarded as emotionally satisfying.
Although it may not be surprising that social relationships are associated psychological
benefits, there is also evidence to suggest that these relationships have beneficial effects on
physical health and/or the lack of meaningful relationships may be detrimental. In fact,
reviews of the literature indicate that a lack of meaningful relationships is associated with
increased risk for morbidity and mortality from a variety of causes. Importantly, both the
quantity and quality of social relationship can affect health and mortality. Overall, research
suggests that having more and better quality relationships is associated with beneficial effects
on health, while fewer and negative relationships are associated with detrimental effects on
health. Therefore, a complete understanding of health-related consequences of social
relationships requires simultaneous consideration of both the negative and the positive aspects
of social experience.
In this chapter, the health consequences of social relationships will be examined. This
chapter will proceed by first, reviewing definitions of social support; second, a brief review of
the substantial body of evidence that has linked social relationships with health benefits will
be provided; third, the chapter will also include a brief review of the evidence showing the
negative side of relationships (e.g., negativity and conflict within relationships is associated
with negative health outcomes); and finally, the bulk of the chapter will focus on a relatively
newer line of research that examines relationships that are characterized by both positive and
negative aspects (ambivalent relationships).
Because research has examined the positive and negative aspects of relationships
separately, less is known about relationships that are not entirely positive or negative-but a
mix of both negative and positive feelings. The remainder of this chapter will (1) define
ambivalent relationships and provide theoretical and empirical justification for examination of
ambivalent relationships; (2) summarize evidence linking ambivalent relationships to both
mental and physical health outcomes; (3) provide evidence regarding maintenance of
ambivalent relationships; and (4) propose future research. Thus, this chapter will summarize
empirical research on the health impact of social relationships characterized by mixed-
feelings (ambivalence). This data on ambivalent relationships will be presented in the context
of the larger literature on social relationships and physical health and highlight the need for
new directions in social relationships research.
Chapter 24 - A high percentage of Turkish and Moroccan male adolescents in the
Netherlands is sexually active. At the same time, they frequently engage in risky sexual
 Preface xxi

behavior, which makes them vulnerable to HIV/STDs infection. To be able to design

culturally appropriate health promoting interventions, more knowledge about the factors that
influence their sexual behavior is needed. Therefore, this paper reports on a qualitative study
that aims to increase our understanding of the influences on Turkish and Moroccan adolescent
male sexuality within a broader interest in HIV/STD prevention. Seven focus groups with 29
Moroccan and 20 Turkish boys, aged between 14 and 18 years, were conducted. Analysis of
the data highlighted several factors that may hinder condom use, such as lack of knowledge,
lack of perceived risk, peer norms, lack of parent-adolescent communication about sexuality,
and lack of self-efficacy toward buying condoms. Results also show some significant
differences between the Turkish and Moroccan adolescents. Turkish adolescents are more
conservative toward sexuality, they stick more strongly to cultural traditions and they have
less knowledge about HIV/STDs than Moroccan adolescents. Moroccan adolescents
experiment more frequently with sex. Therefore, they may be at higher risk of getting infected
with HIV/STDs. The findings of this study provide a fertile starting point for designing
culturally appropriate and effective health education programs in the field of safe sex
promotion for ethnic minority adolescents.
Chapter 25 - In Mexico, HIV/AIDS is a complex public health issue that carries
significant psychosocial, socio-political, and economic repercussions. Adolescence is a period
of development that not only encompasses physical and social changes, but also
psychological. Adolescents engaging in unprotected sexual activities during this stage of
development are at risk of contracting HIV infections. This paper posits that the Theory of
Planned behavior has shown to be helpful in guiding research in HIV/AIDS prevention, but
remains limited in the inclusion of ecological influences. Hence, this limitation is addressed
using the Ecodevelopmental Theory. Therefore, this paper aims to develop a model based on
the Theory of Planned Behavior and the Ecodevelopmental Theory that will explain
HIV/AIDS prevention within the context of Mexican adolescents using concepts from both
theories and the empirical evidence available. Three types of influences were identified
during the process of theory synthesis: a) Interpersonal influences from the microsystem were
parent communication about sex and peer influences; b) Individual influences included
HIV/AIDS knowledge, gender (female), and age; and c) psychosocial influences consisted of
perceived behavioral control for sexual health behaviors, subjective norms (gender roles),
positive HIV attitudes, and sexual intentions. Results provide insight into the complex
dynamics of the synthesis of the two aforementioned theories with respect to HIV/AIDS
prevention. Communication about sex is positively related to sexual health behaviors for
HIV/AIDS prevention, being female, and knowledge about HIV/AIDS. Peer influence is
negatively correlated with sexual behaviors for HIV/AIDS prevention. It is unclear the
relationship of HIV/AIDS knowledge and sexual behaviors and being female. Gender
(female) is positively correlated with sexual behaviors and perceived behavioral control, but
its relationship is unclear with subjective norms. Age is positively correlated with subjective
norms, but negatively correlated with sexual health behaviors. Perceived behavioral control
and positive attitudes are positively correlated to intentions and sexual health behaviors. In
the case of subjective norms, it was positively correlated with intentions, but not with sexual
behaviors. Finally, high intentions to use condoms influence sexual health behaviors. The
final model allows for a better understanding of the connections among concepts related to
sexual health behaviors in HIV/AIDS prevention. Future research is recommended regarding
the unknown associations between gender, knowledge, subjective norms, and attitudes for
xxii Emma Cuyler and Michael Ackhart

future implementation of preventions programs against this fatal disease in the Mexican
Adolescents.
Chapter 26 - Adolescence is a difficult in-between age, even in good health, and any kind
of illness can alter this situation. Living with a high risk disease for several years during
adolescence requires the activation of psychological defense mechanisms, cognitive
functions, perception, acceptance, memory, communication, judgment, and emotions, which
taken together mean good coping. The successful evolution of the coping process ultimately
leads to good quality of life and adaptation. Over the last few years, physicians and clinical
psychologists have endeavored to provide a good psychosocial status to their patients,
especially those with cancer and those undergoing painful and distressing treatments.
This study chose to use the "narrative" approach with sick adolescents, since it would
appear to be the most suitable in individual encounters. There is often the need to overcome
an important barrier through a friendly approach. Narrative medicine, more than others, lends
itself to the intimate knowledge of the person being examined. Listening and talking through
a patient/doctor alliance are the first steps towards true psychological healing. Over the last
few years this sort of dialogue with adolescent patients was chosen, since they turn to us both
seeking the physicians who know them well and a space where they can talk openly. The
narrative approach requires time, willingness and an appropriate setting. In addition, the
supportive care needs of these youngsters with cancer are often brought up in these
encounters and this suggests the extent to which these needs may remain unmet. The dialogue
that takes place following the “narrative” approach allows us to obtain detailed personal
information and insight into the values and abilities of each subject. Undoubtedly, some
psychosocial disorders can be prevented. Nowadays, pediatricians, supported by
psychologists and other specialists, can create an alliance with the parents and the sick
adolescents in order to adequately face pitfalls that may become the source of disorders in
their physical, cognitive, emotional and behavioral development, and especially with regards
to post-traumatic stress. Four different situations of adolescents who were either suffering
from or who were cured of cancer are reported in detail in this chapter, including information
concerning their need for understanding, discrepancy in appearance and insight, crisis in
quality of life and the identity process.
Chapter 27 - In healthcare, relationships between patients or disabled persons and
professionals are at least co-constitutive for the quality of care. Many patients complain about
the contacts and communication with caregivers and other professionals. From a care-ethical
perspective a good patient-professional relationship requires a process of negotiation and
shared understanding about mutual normative expectations. Mismatches between these
expectations will lead to misunderstandings or conflicts. If caregivers listen to the narratives
of identity of patients, and engage in a deliberative dialogue, they will better be able to attune
their care to the needs of patients. This is illustrated with the stories of three women with
Multiple Sclerosis. Their narratives of identity differ from the narratives that caregivers and
others use to understand and identify them. Since identities give rise to normative
expectations in all three cases there is a conflict between what the women expect of their
caregivers and vice-versa. These stories show that the quality of care, defined as doing the
right thing, at the right time, in the right way, for the right person, is dependent on the quality
of caring relationships.
Chapter 28 - Throughout the history of psychotherapy, clinical theoreticians have evoked
various metaphors to depict the therapist-patient relationship. With the advent of attachment
 Preface xxiii

theory and other advances in developmental psychology in the 1950s and 1960s, a new
therapeutic metaphor was born: the caregiver-infant attachment relationship. This metaphor
has yielded a number of insights into the process of psychotherapy and the nature of the
interactions in which the therapist and patient engage. The first objective of this article is to
illuminate both the advantages and disadvantages of using this metaphor to depict the
psychology of therapeutic relationships. One distinction between this metaphor and the
therapeutic relationship is the state of development of mental structures in the infant versus
the patient. Whereas the caregiver is behaving in response to the infant’s emotional cues not
contextualized by an interactional history of expectations to guide these cues, the patient
enters into a therapeutic relationship with a complex and intricate interactional history of
expectations. This asynchrony between the caregiver-infant attachment relationship and the
therapist-patient relationship requires the therapist to behave in sometimes
noncomplementary ways to challenge and interpret these transferential patterns rather than
simply responding to emotional cues, as a caregiver would do. These interactional
expectations, typically organized around definable patterns of behavior in the therapeutic
relationship, are “often neither conscious and verbalizable nor repressed in the dynamic
sense”, and thus pose challenges to traditional psychotherapy models that rely exclusively on
symbolization to produce therapeutic change. This new understanding of therapeutic change
forces therapists to focus more intensively on their own attitudes and behaviors vis-à-vis the
patient as the quintessential instruments of change. Various aspects of the therapeutic
relationship, in addition to verbalized interpretations of repressed conflict, have thus come
under increased scrutiny. I present an attachment-based pathways model for understanding
the interrelations among three relationship-based concepts used in contemporary
psychotherapies: working alliance, patient attachment and therapist caregiving, and
transference and countertransference. Thus, the second objective of this article is to sensitize
therapists and psychotherapy process researchers to the structure and functioning of these
interrelated concepts to increase therapeutic effectiveness.
Chapter 29 - This study aimed to explore how the affects that result from conflictive
social interpersonal relationships influence mental health, as well as to investigate how
specific coping styles mediate between these affects and mental health.
The Test of Self-Conscious Affect-3 assesses six self-conscious affects, namely guilt-
proneness, shame-proneness, externalization, detachment, alpha pride, and beta pride. In this
study, selected for analysis were the four affects that originated from negative evaluations of
the presented scenarios (guilt-proneness, shame-proneness, externalization, and detachment).
This study used the Coping Inventory for Stressful Situations for estimating coping style,
specifically task-oriented coping, emotion-oriented coping, and avoidance-oriented coping.
A structural equation model that makes it possible to explore the causal relationship
between self-conscious affects, coping styles, and mental health, was chosen as a statistical
technique. Among the 394 Japanese university students who agreed to participate in this
study, 298 experienced moderate to severe stressful negative life events during the four-
month study. Of those 298 respondents, 268 completed every item of the TOSCA-3, the
CISS, and the Self-rating Depressive Scale. These 268 were subjected to a structural equation
model.
Among the four affect categories which occur under stressful situations, only shame-
proneness directly contributed to a depressive reaction, whereas the other three (guilt-
proneness, externalization, and detachment) did not. Individuals with shame-proneness tended
xxiv Emma Cuyler and Michael Ackhart

towards an emotional-oriented coping style, but this inhibited task-oriented coping. Guilt-
proneness induced task-oriented coping and avoidance-oriented coping. Externalization
induced task-oriented coping and emotion-oriented coping. Detachment gave rise only to
avoidance-oriented coping. Interestingly, among the three coping styles, only task-oriented
coping induced a depressive reaction, whereas emotion-oriented coping and avoidance-
oriented coping did not.
These results were discussed primarily from the psychological perspective but also look
briefly at how they might be applied to a clinical setting within psychiatry.
Chapter 30 - Throughout history, artists, poets, and writers have been interested in the
nature of passionate love, sexual desire, and sexual behavior. In the 1960s, social
psychologists and sexologists began the systematic investigation of these complex
phenomena. Yet, only recently have neuroscientists and biochemists begun to explore these
complex phenomena.
In this entry will review what these distinguished theorists and researchers have learned
about these processes.
In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 1

COMMUNICATING EMPATHIES IN
INTERPERSONAL RELATIONSHIPS

Grace Anderson* and Howard Giles

Department of Communication
University of California, Santa Barbara, California 93106, USA

ABSTRACT
Empathy is a concept that has been widely researched across the social sciences and,
more importantly, is commonly used outside of academe as a method “to open-up the
channel of communication with the other” (Wikipedia, 2006). Although commonly
employed colloquially, empathy is challenging to define explicitly and, hence, we shall
need to begin this chapter with some conceptual wood-clearing. Prior definitions reflect
the specific contexts in which empathy was measured and studied. For instance, a study
measuring empathy as a response to media defines empathy differently than a study that
examines empathy as an interpersonal communication construct – and these definitions
are not mutually exclusive or disparate. Instead, different definitions are a result of the
various dimensions of empathy that researchers choose to highlight as a function of the
particular empirical study’s focus. For this reason, many individuals may find empathy
easier to enact than to describe its meaning in words.
This chapter will examine the major definitional variations of empathy that have
developed in research on interpersonal relationships, comparing and contrasting their
implications. For instance, one major difference is whether empathy is a stable trait or a
changing state; this definitional difference can lead to very different methods of research.
We seek to accomplish a more global definition of empathy by discussing the distinct
ways in which it has been examined in the past, such as in terms of communicative
competence, personal distress, and nonverbal expressions, and incorporating the many
dimensions of empathy into a unified source of reference for future research. In so doing,
we will discuss how one individual may feel and express empathy and how that empathy
may or may not be perceived as such by its recipients. The psychological origins of
empathy will be identified and questions regarding motives underlying empathy will be

*
Contact: Grace L. Anderson. Department of Communication, University of California, Santa Barbara, Santa
Barbara, CA 93106-4020, USA. gracea@umail.ucsb.edu; Fax: 805-893-7102
2 Grace Anderson and Howard Giles

raised, including whether it can be used as a form of impression management during

social interactions.
Empathy has been recognized as an important component of health communication.
Research has shown that an empathic person holds more positive attitudes towards
healthy behaviors regarding smoking and alcohol consumption (Kalliopuska, 1992).
Moreover, an effective health campaign will evoke empathy among its target audience
because it evokes greater cognitive and affective processing of the campaign message
(Campbell & Babrow, 2004). Empathic communication with people with disabilities
(particularly those inflicted by cancer) will be a continuous example used to help us
understand the multidimensional implications of empathic communication. Empathy can
ease tensions that may occur during this form of interaction and suggestions of
appropriate empathic communication will be offered. Finally, a new communication
model of the process of empathy will be introduced.

HOW IS EMPATHY CONCEPTUALIZED?

Empathy has been recognized as a multidimensional concept, consisting of both cognitive
and emotional components (Duan & Hill, 1996). Researchers consider the cognitive
component to be characterized as the ability to take another’s perspective in a social
encounter (Coke, Batson, & McDavis, 1978; Smith, 2006; Smither, 1977; Wilson & Cantor,
1985). Yet, this distinct form of perspective-taking requires the individual to imagine what
the other person is experiencing rather than what the individual him/herself would experience
under similar circumstances (Batson, Early, & Salvarani, 1997; Jackson, Brunet, Meltzoff, &
Decety, 2006).
Bennett (1979) distinguished between the perspective-taking of the self and other by
contrasting sympathy and empathy. More specifically, sympathy involves a form of
perspective-taking based upon the notion that all individuals perceive a common reality and,
therefore, react to stimuli in a similar manner. As a result, an individual will take another’s
perspective by envisioning how him/herself will react to circumstances in a uniform reality.
Conversely, empathy is based upon the assumption that all individuals experience different
realities. As a result, perspective-taking must incorporate the possibility that another
individual may react differently to similar circumstances.
Ritter (1979) found this differentiation between sympathy and empathy apparent during
the maturation of adolescents. More specifically, younger adolescents engage in more
generalized perspective-taking strategies, failing to differentiate between the needs of others
and the needs of themselves. In comparison, older adolescents engage in more complex
perspective-taking because they “simply have a greater range of interpersonal constructs
available, particularly those relevant to understanding others’ psychological characteristics,
upon which to base communication strategies” (Ritter, 1979, p. 50). Listener-adapted
communication was exhibited by older adolescents as a result of their increased
communicative strategy repertoire. As a consequence of their interpersonal experience, older
adolescents have a greater ability to understand the specific perspective of another.
In sum, perspective-taking gives the empathizer knowledge regarding another
individual’s affective state, but the communicator must develop an understanding of others’
psyche through accumulated life experiences. The empathizer can understand how others may
feel and possibly identify the causes for their emotions. Consequently, this has been labeled
 Communicating Empathies in Interpersonal Relationships 3

cognitive empathy. Yet, empathy entails an intimate form of communication that goes beyond
cognitive understanding and an empathizer can adopt the emotions of others in order to
vicariously feel their sentiments (Smith, 2006; Smither, 1977; Warner, 1997). This second
dimension of empathy has been labeled emotional empathy.
As an illustration, imagine an empathic person communicating with a young investment
banker who smokes cigarettes and has just been diagnosed with lung cancer. Cognitive
empathy allows the empathizer to take the specific perspective of the investment banker.
Although smoking may be the direct cause of the investment banker’s cancer diagnosis, an
empathizer would also realize that such a stressful job with long hours may have driven the
banker to use nicotine as a stimulant in order to increase job productivity. As a result, the
banker is not directly to blame for his cancer diagnosis and an empathizer realizes that a
number of complex factors - in addition to smoking - may have contributed to the presence of
cancer in the body. In addition, empathy is emotional because the empathizer also shares in
the emotions of the investment banker. The empathizer would be able to vicariously feel the
stress of the investment banker’s career and his subsequent anguish because the banker’s
future is threatened by a potentially fatal illness. It is the sharing of emotions that makes
empathy a unique concept.
In order to share an affective state with another individual, some scholars assert that the
empathizer must suspend his/her own emotions in order to better feel the emotions of another
individual. On the other hand, the empathizer should refrain from complete integration of
identity with the other individual (Greenberg & Elliott, 1997; Vanaerschot, 1997; Warner,
1997). In this respect, the empathizer is aware of the other’s emotions yet, retains his/her
distinct identity from the other individual. For example, when empathizing with a jealous
individual “one does not become jealous himself but merely experiences what it must be like
[for the other individual] to feel jealously” (Smither, 1977, p. 257). This identity distinction
can help the empathizer validate the other individual’s emotions in relation to his/her own
experiences (Bohart & Greenberg, 1997). This disagreement may not have to be resolved
immediately. Instead, individuals can possess different forms of empathy depending upon the
degree to which they retain a distinct identity. In other words, there is a spectrum of identity
suspension. The empathizer can experience complete emotional contagion with another
communicator or understand the other communicator’s emotion without intensely
experiencing the specific emotions him/herself. This may vary as a function of
communication context, the communicator’s ability to take the other’s perspective, and/or
distracting communicative noise. But as yet, this phenomenon needs empirical examination.
Some researchers have clarified the debate over identity suspension by further
subdividing emotional empathy into emotional contagion and empathic concern (Stiff,
Dillard, Somera, Kim, & Sleight, 1988). The former occurs when the empathizer adopts the
affective state of the other individual, as discussed previously. The latter can be characterized
as a general concern and regard for the welfare of others. Empathizers who experience
empathic concern will exhibit prosocial behaviors, such as helping and communicative
responsiveness, because they are motivated by a concern for the other’s welfare. However,
empathizers who also experience emotional contagion will vicariously feel the other’s distress
and become less communicatively responsive. They are egotistically motivated to reduce their
own unpleasant feelings instead of comforting the distressed other. Taken together, empathic
concern is positively associated with emotional contagion such that empathizers must first
feel concerned for the other’s welfare in order to vicariously feel the other’s emotions. These
4 Grace Anderson and Howard Giles

findings suggest that empathizers should suspend their identities from complete integration
with the other individual in order to behave altruistically. But, complete identity suspension
during empathy may deny the empathizer the more visceral experiences of empathy which
may be more intrinsically and extrinsically rewarding (for an intercultural perspective on
empathy, see Arnett & Nakagawa, 1983; Broome, 1991; & DeTurk, 2001).
Empathy, therefore, has been conceptualized as a multidimensional concept that consists
of two forms of empathy with corresponding functions. Cognitive empathy describes the
perspective-taking function that enables the empathizer to understand and anticipate the
thoughts, reactions, urges of the recipient of empathic communication. This allows the
empathizer to best tailor a message specifically towards the recipient and consequently
communicate a message that empathically incorporates the recipient’s specific needs. The
second form of empathy is emotional empathy. This form of empathy serves the function of
emotional sharing where the empathizer can feel the emotions of the other individual. This
function validates another’s emotions because they are justified by an empathizer who
legitimately feels similar emotions as result of their communicative interaction. When
combined, the two functions of empathy leads the recipient of empathic communication to
feel increased perceived support and personal control as a consequence of such an interactive
experience (Williams, Giles, Coupland, Dalby, & Manasse, 1990).
Future research could illuminate exactly how such a communicative context is created
and maintained by the empathizer. Ritter (1979) found that the general ability to take
another’s perspective develops as an individual matures and gains life experiences to become
knowledgeable about the possible perspectives of another (see section below for further
elaboration). It would be interesting to discover which immediate contextual circumstances
alter this perspective-taking ability. What is the degree to which perspective-taking ability can
be weakened by contextual noise? Additionally, empirical analysis could study the degree to
which individuals suspend their identity when sharing emotions during empathic
communication with another individual. Which kind of empathizer retains a distinct identity
when sharing in the emotions of another individual? Is there a difference between these
empathizers and other empathizers that completely integrate their identities with other
individuals when sharing in their emotions? This could be related to the attributions the
empathizer assigns to the other individual and his/her distress. For instance, an empathizer
may empathize with a speaker who has acquired lung cancer. However, the empathizer does
not fully integrate his/her identity with the other when sharing the in the other’s emotions,
because the empathizer feels that the other is partially to blame for contracting lung cancer as
a result of heavy smoking. The degree to which a communicator suspends his/her own
identity when sharing in another’s emotions may be a way in which communicators can vary
the degree of empathy they communicate. In the next section, we will discuss variation in
empathic communication in more depth and related methodological considerations.

EMPATHY: TRAIT VERSUS STATE

Variation in empathy is most pronounced when it is defined as an emotional state. In this
case, an individual’s empathy fluctuates as a function of differing social interactions and their
level of respect for and affiliation with another (Duan & Hill, 1996). For instance, a single
 Communicating Empathies in Interpersonal Relationships 5

individual can experience varying degrees of empathy, depending upon how the context
evokes empathy. Conversely, empathy can be considered similar to a personality trait
whereby empathy is tantamount to a stable ability that an individual develops through
maturation (Smither, 1977; Wilson & Cantor, 1985). In this case, trait empathy varies from
individual to individual as some have greater capacity to empathize compared to others. The
investigation of trait empathy would lend itself well to a between-subjects design where
personality differences between individuals could be observed. On the other hand,
investigation of state empathy lends itself to a within-subjects design where changes in
empathy could be observed within the individual as context changes.
Methodological difference between state empathy and trait empathy can be demonstrated
by considering the degree of identity suspension during emotional empathy. For instance, one
individual may experience complete emotional contagion while other empathizers may
maintain a distinct identity. In this way, there are inter-individual differences of identity
suspension during emotional empathy (Duan & Hill, 1996). Imagine a young child in day care
who observes another child start to cry and, as a result, the initial child offers his/her security
blanket as solace. However, observing another peer in distress proves to be too overwhelming
and this child starts to cry as well. In comparison, an older adolescent may have a better sense
of personal identity and, consequently, suspends his/her identity during empathic
communication. This exemplifies that emotional contagion differs between individuals as a
function of developmental ability.
In addition, one individual may experience varying degrees of identity suspension during
emotional empathy. In this case, empathy is a fluctuating state where a single individual may
experience different forms of empathy over a relatively short period of time (Duan & Hill,
1996). For instance, picture a female teenager waiting by the telephone for a call from her
love interest. Her little brother approaches her seeking attention because he has cut his finger
while playing and wants comfort. The sister acknowledges her brother’s hurt finger, covers it
with a Band-Aid and tells him to play with more caution. The telephone rings and the
teenager excitedly greets her love interest on the other end, but swoons when the love interest
informs her that he has injured himself during a touch football game. Her response over the
telephone is emotional and she feels weak at the knees. The same individual has exhibited
fluctuating state empathy as a consequence of a change in context. In this case, a change of
interactants during empathic communication causes the individual’s state empathy to vary.
It is important to remember that each empathizer exhibits both trait empathy and state
empathy, as in Figure 1. Each individual has a general empathic ability (trait empathy) that is
a function of their life experiences and cognitive complexity. Yet each individual experiences
variations of empathy (state empathy) that fluctuates around their general empathic ability
level (trait empathy) as a consequence of context and other temporary situational variables
(Duan & Hill, 1996). Individuals’ state empathy fluctuates around their general ability level
of trait empathy.
6 Grace Anderson and Howard Giles

Figure 1. Model exhibiting the inter-individual differences of trait empathy in addition to the intra-
individual and inter-individual differences of state empathy.

As above, it may be useful to measure trait empathy with a between-subjects design and
state empathy with a within-subjects design, but this may not always be the case. Sometimes
it may be useful to measure state empathy with a between-subjects design when the frequency
of and size of fluctuations around each individual’s trait empathy differs between individuals.
For example, some individuals may experience more rapid fluctuations of state empathy in
comparison to others and/or they may experience greater extremes of empathy as their state
empathy fluctuates dramatically from their general trait empathy level. This may be the case
when an individual is more behaviorally sensitive to contextual cues and, consequently,
experiences greater fluctuations of state empathy more frequently than other individuals who
may be better able to ignore contextual distractions or communicative noise. In this manner,
state empathy varies on an inter- as well as intra-individual basis. Additionally, trait empathy
may be measured with a within-subjects design if one were interested in investigating how
life-altering events may influence an individual’s general empathy level overall. For instance,
experiencing the death of a loved one may boost an individual’s trait empathy to a higher
level by gaining the experiential knowledge of that event so that perspective-taking is easier
to enact when empathizing with others also experiencing devastating life events.
In sum, the difference between state empathy and trait empathy lies in the manner in
which empathy is conceptualized. Research that treats empathy as a state is concerned with
the manner in which individuals empathically respond to specific stimuli that evoke empathy.
In this way, state empathy is usually considered an outcome variable where individuals react
to contextual cues. On the other hand, research examining trait empathy focuses on the
maturational or experiential differences between individuals and how this affects their stable
empathic patterns. In this case, trait empathy is generally treated as a pre-existing variable
where individuals respond to particular stimuli as a function of their previous experiences and
maturity.
 Communicating Empathies in Interpersonal Relationships 7

A DEVELOPMENTAL PERSPECTIVE ON EMPATHY

A developmental perspective on empathy considers it an artifact of an individual’s
maturity. Empathy is developed as one gains life experiences with which to use as cognitive
reference tools when taking the other’s perspective during communicative interactions. In
other words, an empathic individual must first understand his/her own identity to use as a
reference with which to compare to another’s identity (Smither, 1977). In fact, the
components of empathy may be evolutionary in nature. Perspective-taking may have evolved
as a result of a complex social environment in which individuals must predict the behaviors of
others in order to manipulate social circumstances to their advantage. In addition, emotional
sharing may have evolved in order for individuals to facilitate group cohesion, such as kin
and sexual selections (Smith, 2006).
Not only is empathy a construct that has evolved with the growth of general society, but
empathy and perspective-taking, in particular, are skills that develop as one matures (Ritter,
1979). Wilson and Cantor (1985) measured the self-reports and physiological responses of
children of differing ages to television programming and found that younger children became
less emotionally aroused by a television character’s fear than older children who experienced
the same treatment. Wilson and Cantor believe that the lack of empathy exhibited by the
younger children did not result from a failure to recognize the nature of the character’s
emotion, but a failure to take the character’s perspective when compared to older children.
Conflicting research, however, suggests that children as young as preschoolers exhibit
affective perspective-taking towards each other in the sense that they infer each others’
feelings in a non-egocentric manner and engage in cognitive perspective-taking (Denham,
1986). In addition, there is evidence that perspective-taking abilities can be fostered among
relatively young children by allowing them to work cooperatively together. Bridgeman (1981)
found that fifth grade students when learning in a cooperative peer-initiated classroom
environment engaged in increased role-taking when compared to fifth grade students in a
more formal teacher-centered classroom and other innovative classroom environments. She
concludes that role-taking is critical to the development of a child’s conscious self as
described by George Herbert Mead. An individual’s identity can only be conceived in relation
to others. The important conclusion to be drawn from this contrary evidence of younger
children regards the peer interactivity of these methodological designs. Young children are
able to relate to other children of similar age in a manner that best fosters an environment for
the acquisition of empathic skills. It seems as though interactions among young peers
stimulates empathic behaviors at an earlier age than would unfettered maturation. In addition,
this peer interactivity has been found to increase empathy among older children (fourth and
fifth graders) with below age norm performance on empathy, in the absence of explicit
training (Silvern et. al., 1979). It would seem that peers can teach each other empathic
behaviors in the place of trained professionals when another peer needs to be caught-up to an
age-appropriate empathic skill level.
Empirical research that takes a developmental perspective on empathy tends to treat
empathy as a stable trait of research participants. Less research has been conducted that
measures empathy as a fluctuating dispositional state. Yet, dispositional state empathy
suggests that “empathic disposition can be trained” and, therefore, raises important empirical
questions for future research (Greif & Hogan, 1973, p. 284). This implies that state empathy
8 Grace Anderson and Howard Giles

and trait empathy are not mutually exclusive. Over time, state empathy can become less
variable and more stable with the recurrence of a certain context and emotional state and,
accordingly, more closely resemble trait empathy. As a certain form of state empathy
becomes engrained into an individual’s normal behavioral patterns, this particular form of
empathy becomes trait empathy.
Previous research has examined this process by measuring children’s state empathy as a
function of the common environment of television viewing. Zillmann and Cantor (1977)
measured children’s dispositional reactions to a television character’s emotions. This study,
however, did not fully support empathy as the impetus for the children’s reaction to the
television character. Instead, these researchers found state empathy to be a partial mediator in
the relationship between a television show and children’s reactions to the programming.
When the television character behaved benevolently and neutrally, the children’s affective
responses conformed to the character’s emotional reaction. When the benevolent character
expressed triumph, the children also responded with triumph. Alternatively, when the
character behaved malevolently the children’s affective responses were discordant with the
character’s emotional reaction. When the malevolent character expressed triumph, the
children may express disappointment. In this case, the children could not have behaved
empathically because they would have conformed to the malevolent character’s emotions as
well. Instead, Zillmann and Cantor concluded that children’s affective reactions conformed
when they held positive sentiments towards the television character and exhibited discordant
affective reactions when they had negative sentiments towards the television character. This
is also known as the affective-dispositional rationale.
This study demonstrates that state empathy has precursors during interpersonal
interactions. In this case, children only exhibit state empathy when positive sentiment is felt
for the target individual. This behavior will be cultivated as these children mature and
continue to view television as a common pastime. State empathy towards well-liked
characters becomes less variable and more established as a trait form of empathy. In addition,
this empathic reaction to television characters may also become a reaction to target
individuals in reality according to the cultivation hypothesis.
More specifically, there may be precursors to empathy towards people with disabilities
and the disease of cancer. Will the affective-dispositional rationale be supported among
research subjects empathizing with a target individual diagnosed with cancer? This implies
that individuals would only express empathy towards another with cancer if the individual
harbors positive sentiment towards the latter. This requires that the two individuals have a
personal relationship where positive sentiment has been developed and harbored between
them. Consequently, the affective-dispositional rationale may only be a fragment of the entire
picture because empathy can be expressed between individuals who do not have a close
personal relationship with each other.
What if a personal relationship has not developed? An important factor to consider would
be the attributions an individual assigns without much personal knowledge about the
interactant. For example, different attributions are typically assigned to individuals with lung
cancer when compared to individuals with leukemia. Individuals may assign blame and
believe that an adult with lung cancer caused this infliction to occur to him/herself when
compared to an individual with a type of cancer that is less preventable, such as leukemia.
This train of thought is supported by previous research where it was found that “cancer
patients held less firm convictions about causative factors in the etiology of cancer than did
 Communicating Empathies in Interpersonal Relationships 9

non-cancer patients” (Linn et al., 1982, p. 838). The researchers suggest that cancer patients
are not necessarily avoiding reality, instead they are more aware of the complexities of the
disease and its multitude of possible causes. Individuals without cancer, however, are not so
acutely aware of the disease and its causes and, consequently, use heuristics in order to assign
attributions to the cancer patient. The assignment of attributions is not contingent upon a
personal relationship between the individuals. In addition, the assignment of attributions is
more commonplace during everyday communication and may serve as a more universal and
explanatory precursor to the expression of empathy towards individuals with cancer. The
predictive influence of attributions can be investigated by measuring empathic reactions to
individuals with diverse forms of cancer diagnoses. Different cancer diagnoses may affect the
empathic reactions individuals with cancer receive from others because attributions influence
this relationship.

FROM WHERE DOES EMPATHY COME?

Aside from the precursors and the communicative context, empathy is an innately human
response to observing another human in distress. This section takes a step back in order to
best examine the fundamental derivation of empathy. The field of psychoanalysis considers
the origins of empathy to arise from human identity itself. More specifically, individuals each
possess a dual identity that consists of an articulate self and an organic self. The articulate self
is an individual’s responsible agent with values, goals, and intentions. This is an individual’s
conscious identity that is manifested when the individual refers to him/herself as ‘I’. In
contrast, the human identity also consists of an organic self, where the interdependence of
bodily functions allows for the existence of the articulate self to exist and function (Barrett-
Lennard, 1997).
The most fundamental form of empathy is ‘self empathy’ and this occurs when an
individual’s organic self and articulate self are in equilibrium. This can be conceived as a
form of inner listening where the needs of the organic self are realized by the articulate self
(Barrett-Lennard, 1997). Self-empathy can be conceptualized as the articulate self’s
recognition of the organic self’s limitations. For instance, an individual may consciously
desire to attend a university but may experience health limitations resulting from cancer and
the corresponding treatment. The equilibrium of the articulate self with the organic can be
represented by the individual’s recognition of the specific implications that cancer will have
on his/her academic performance. This equilibrium may be maintained over time if the
individual enrolled in a university with a large medical facility where he/she would have more
immediately convenient access to treatment.
The internal empathic process has been documented in the form of a magnetic resonance
imaging experiment (Jackson, Brunet, Meltzoff, & Decety, 2006). Researchers found that
respondents activated different portions of their brains when imagining themselves in pain
compared to imagining another individual in pain. More specifically, brain activation was
restricted to the affective components such as the anterior cingulate cortex, the insula, and the
right temporo-parietal region associated with perspective-taking tasks when the research
subject was asked to imagine another individual in pain. In comparison, further activation was
detected when the research participant was asked to imagine him/herself in pain. The sites of
10 Grace Anderson and Howard Giles

the brain already activated by imagining another in pain were accompanied by further
activation of the medial prefrontal cortex and the neural circuit, which has been associated
with self-identification.
The researchers associated the overlapped difference in brain activation to Batson’s
(1983) distinction between empathy and personal distress. Empathy may be represented by
the perspective-taking and affective activation of the brain when the research subject
imagines another in pain. However, the greater activation when research subjects imagining
themselves in pain may be an indication of the egocentric characteristic of personal distress.
“Focusing on our own thoughts and feelings reduces empathy, whereas focusing on those of
distressed Others increases empathy” (Jackson et al., 2006, p. 759). These researchers further
speculate that experiencing another’s pain to the same degree as one experiences his/her own
pain would result in over-arousal of empathy where every individual’s distress would become
distressing to the observer as well.
The fact that there is not a complete overlap in brain activity between the self and other
conditions suggests support for the above distinction between the articulate and the organic
self. The brain activity stimulated by imagining another individual in pain may be an
indication of the activation of the articulate self. The research subject is consciously
processing the pain of another individual as an outside observer. In comparison, the increased
brain activity stimulated by imagining oneself in pain may represent the simultaneous
activation of the articulate and the organic self. The research subject can imagine exactly how
the pain would feel him/herself through the organic self. In addition, research subjects use
their articulate selves to imagine how they would appear to others observing their pain.
Problems arise for the individual when the organic and articulate self internally conflict.
For example, people with invisible inflictions, such as many forms of cancer in early stages,
may appear to be healthy externally, yet are ailing internally. In other words, the organic self
is unhealthy, however, the articulate self may seem healthy to other individuals because a
person with cancer may function and communicatively appear as a healthy individual. In fact,
some people in the early stages of cancer may strive to keep their cancer diagnosis concealed
during casual interactions and may experience anxiety as a result. In this manner, a person
with cancer is motivated to avoid being labeled as disabled and unhealthy (Harwood &
Sparks, 2003; Matthews & Harrington, 2000).
Matthews and Harrington (2000) believe, however, that people with cancer may be
susceptible to feelings of shame during communicative encounters because these people are
aware that they are externally representing a healthy person when they are not internally
healthy. In other words, the person with cancer is consciously withholding information
regarding their diagnoses during interpersonal interactions in order to maintain group
membership in a dominant social group of healthy people. In this respect, shame may increase
because there is potential for a negative discovery of the cancer diagnosis. More specifically,
shame may increase with time when a person harbors a clandestine cancer diagnosis during
relationships with others. Additionally, shame may dramatically amplify when this furtive
diagnosis is abruptly discovered by another. In this case, shame can be considered an outcome
of a discord between the articulate and organic self when one is not self-empathic.
Although empathy is typically considered a behavior that requires the interaction of two
or more individuals, the origins of empathy arise from the identity and the self. At the most
basic level, an individual empathizes with him/herself when the individual strikes a
compromise between his/her organic self and articulate self. This form of intrapersonal
 Communicating Empathies in Interpersonal Relationships 11

empathy gives the individual a balanced identity and the foundation with which to feel and
express empathy with others in the interpersonal setting.

FELT AND PERCEIVED EMPATHIES

Just as there may be inconsistencies between a single individual’s organic and articulate
selves, there can be inconsistencies where some may try to communicate empathy, yet the
recipient does not interpret their communication as such. Braithwaite and Eckstein (2003)
have documented such empathic discrepancies by interviewing people with disabilities
regarding their management of instrumental help from other individuals. For instance, a
person with a disability may want and/or need assistance, yet the manner in which the
assistance is offered and enacted may not respect the needs of the disabled person. The
individual’s initial motivation may have been empathic, yet the recipient of the assistance will
not likely interpret the help as empathic because it was unwanted or conducted in an
inappropriate manner. This suggests that an individual with a disability may seek or need a
form of empathy that a healthy individual is unable to enact as a result of a lack of awareness
or an inappropriate perspective.
Previous research supports this claim by finding that observers’ judgments of individuals’
illnesses are more highly correlated with the actual severity of illness when compared to
individuals’ self-rating of their illnesses. Brissette, Leventhal, and Leventhal (2003)
conducted a 9-year longitudinal study and attributed the observers’ greater accuracy of illness
severity to their reliance on objective manifestations of illness, such as appearance and visible
symptoms. In comparison, the individual with the illness harbors more hopeful judgments
about themselves stemming from their positive affect and optimism which can cause them to
underestimate their own illness severity. This divergence in judgments may be the root of the
discrepancy between the observer’s perceived empathy and how that empathy is interpreted
by the person with the illness. An observer may empathically offer unwanted assistance
because the noticeable symptoms of the illness are compelling to the observer. However, the
person with the illness may be too optimistic to believe that such help is necessary and,
therefore, the offer of assistance is not perceived as empathic.
Not unrelatedly, Williams et al. (1990) argue that the motivation to seek support and or
provide support is a consequence of an individual’s personal goals. Accordingly, an
inconsistency between an individual’s communicated empathy and how that empathy is
perceived by the recipient can be a consequence of conflicting goals. For instance, individuals
may express empathic support in order to communicate their altruism. Yet, the recipient of
the empathic communication may wish to remain autonomous and not desire support or the
manner in which the empathic support was offered violated the recipient’s autonomy.
Consistent with the development perspective, empathy may take practice in order to
accurately and affectively share in another’s emotions. To facilitate this form of empathy, the
empathizer must learn to distinguish the appropriate cues. More specifically, the
communicator must perceive and recognize behaviors of the other individual that reveals their
internal emotional state. This recognition includes gestures that are intentionally enacted to
communicate an internal emotional state and natural expressions which are non-intentional
symptoms of the individual’s internal emotional turmoil (Smither, 1977). In this case, a
12 Grace Anderson and Howard Giles

discrepancy between felt empathy and perceived empathy would occur if the empathizer does
not effectively recognize these emotional manifestations or if the individual seeking empathy
does not effectively communicate their emotional gestures to the empathizer. At the very
least, both individuals need to recognize the importance of communicating internal emotional
states.
In order to avoid a discrepancy between felt and perceived empathy, observers should
first be confident that they are taking the perspective of the specific target of their empathic
efforts. Many times someone with a disability prefers to seek assistance from acquaintances
and friends in order to ensure that his/her perspective is in mind (Braithwaite & Eckstein,
2003). However, even family members of cancer patients experience difficulties in this regard
(Lobchuk & Vorauer, 2003). This suggests that family members need to be consciously
reminded to refrain from taking their own self-oriented viewpoint and take the cancer
patient’s instead. Once accomplished, however, the assistance will appeal to the needs of the
ill individual, not to the philanthropic needs of the observer.
Family members’ difficulty with empathizing and visualizing the needs of another family
member diagnosed with cancer may stem from unawareness. The health consequences of
cancer and chemotherapy are experiences that many people have not encountered and this
may make empathy difficult to effectively enact. Family members of a person with cancer can
overcome this difficulty by first acknowledging that the cancer experience is different that
their own healthy experiences. This will combat the family members’ tendency to consider
their own self-oriented viewpoint as similar to the viewpoint of the individual diagnosed with
cancer. In addition, it will help the healthy family member to harbor a more appropriate
estimation of the specific perspective of the person with cancer.
The second component of empathy, affective contagion, may be difficult as well for
family members. They have not likely experienced the emotions and sensations associated
with cancer and chemotherapy and, therefore, cannot fully comprehend the discomfort and
pain associated with the condition of the actual diagnosis. In this case, it is important to listen
attentively to the individual’s requests for help and accomplish exactly what was requested
(Braithwaite & Eckstein, 2003). A common mistake family members make when assisting a
cancer patient is to foresee and predict assisting duties that the cancer patient may need in the
future. For example, family members may commonly help loved ones with cancer by
assisting them to the restroom when they are too weak. These family members may believe
that they can further assist their loved ones by purchasing and placing a chamber pot next to
the bed in order to eliminate the trek to the restroom and the need for assistance. Yet, this
chamber pot may represent a loss of autonomy and control for people with cancer. The loved
ones with cancer may feel ashamed by the negative associations of the chamber pot and regret
asking for assistance from family members. Healthy family members do not always have the
specific knowledge regarding the emotions associated with a cancer diagnosis to make such
assumptions.
Many times people with a disability prefer to ask for assistance before being offered
assistance in order to maintain control of their daily routine. In addition, general offers of
assistance may be better received than specific suggestions of assistance (Braithwaite &
Eckstein, 2003). For example, “May I help you?” is a better offer of assistance than “Do you
need help opening the cabinet door?”. The increased specificity of the second offer of
assistance may make the person’s disability overly salient. In this way, the observer’s
empathy is drawing too much attention towards the individual’s inability to open the cabinet
 Communicating Empathies in Interpersonal Relationships 13

door instead of the individual’s personal identity (Merrigan, 2000). Empathy should be
exclusively directed towards target individuals’ emotional state instead of characteristics of
the target individuals, such as their disabilities or general health conditions.
General messages of assistance are better than specific messages because the individual
without the disability does not likely have sufficient knowledge to make specific assumptions
about the emotional state of the individual with a disability. Hence, the individual without a
disability must become comfortable with the emotional uncertainty involved in an interaction
with an individual with a disability. The latter will reduce this uncertainty for the individual
without the disability by asking for assistance when it is desired and needed. In this case, the
individual without the disability can exhibit empathy by recognizing that the perspective of
the individual with the disability may be too different for the individual without the disability
to accurately imagine on his/her own. “If incompetence, paradoxically, is necessary along the
road to competent, enmeshed intercultural relationships [between disabled culture and non-
disabled culture], perhaps short-term, local risks in each individual interaction are exchanged
for long-term attitudinal change and development” (Merrigan, 2000, p. 233).
The Communication Predicament of Disability Model displays communication between
cultures and may lend insight to this discussion (Ryan, Bajorek, Beaman, & Anas, 2005).
This model is cyclical and describes how non-disabled individuals allow stereotypes to dictate
the manner in which they address disabled individuals. The cyclical characteristic of this
model demonstrates how stereotypes can be continuously confirmed and stray further and
further from reality. In this case, an individual may express empathy in an inappropriate
manner because it is stemming from a faulty stereotype that has been internalized. The
solution to this predicament empowers the people with disabilities by suggesting that they
exhibit selective assertiveness. In this manner, the stereotype may be weakened and the
individual with the disability is not labeled as a constant dissenter.
Interestingly, experienced empathy discrepancy does not always occur on an
interpersonal level. This discrepancy is observable during intrapersonal communication as
well. Loewenstein (2005) labels these discrepancies as hot-cold empathy gaps. He believes
that individuals can misjudge their own behaviors and tendencies across different affective
states. Individuals who are in affectively ‘cold’ states - or are not affectively aroused - will
fail to recognize how they will behave when they become affectively aroused or when they
are in a ‘hot’ state. For example, an individual who has a benign cancer tumor may wish to
undergo surgery in order to remove the tumor. Yet, this individual may regret this decision
when he/she is experiencing anxiety directly before the surgery. Conversely, individuals who
are experiencing affectively ‘hot’ states may underestimate the influence of their emotional
state and overestimate the resolution of their decision. For instance, individuals who have just
been diagnosed with life-threatening cancer may feel especially vulnerable and choose to
undergo aggressive chemotherapy treatment. Yet, these individuals may come to regret this
decision when the side-effects of chemotherapy dramatically reduce their quality of life. In
order to combat the effects of hot-cold empathy gaps, individuals must exhibit a presence of
mind where individuals may feel affectively hot or cold, yet are able to foresee their emotions
when the affective state has changed.
To summarize, individuals exhibit helping behaviors stemming from empathic altruism
even when the needs of the other are different from the needs of the empathizer (Denham,
1986; Litvack-Miller, McDougall, & Romney, 1997). Empathy springing from good
intentions may fall short and not be interpreted reciprocally as empathic by the receiver. This
14 Grace Anderson and Howard Giles

problem can be combated by accurate perspective-taking and emotional awareness of the

other’s affective state. However, accuracy becomes increasingly difficult when the other
individual is experiencing something that empathizers have not experienced themselves, such
as cancer and corresponding treatments. In this case, the empathizer must tolerate a level of
uncertainty during the preliminary stages of the interaction or relationship in order to allow
the other individual to seek the specific empathy or assistance that is truly needed. A
“conservative” form of empathic communication is more appropriate when unsure of the
correct application of empathy during unfamiliar social encounters.

EMPATHY AS AN IMPRESSION MANAGEMENT TOOL

Can a person strategically communicate empathy without actually feeling it? In others
words, can an individual express a manufactured or even deceitful version of empathy in
order to favorably manipulate an interpersonal relationship? There is evidence that people
may avoid feeling empathy when they anticipate that they will be asked to help - and when
such helping could be considered costly for the empathizer (Shaw, Batson, & Todd, 1994).
But what if the communicator still wants to be perceived as empathic in order to maintain a
positive social identity? This is a circumstance where an individual intends to maintain a
division between experienced empathy and expressed empathy in order to communicate a
form of so-called Machiavellian empathy. This section will discuss how empathy can be used
for impression management when the communicators vary in the degree to which they enact
perspective-taking and emotional contagion, respectively.
Smith (2006) believes that the answer lies in the very conceptualization of empathy.
More specifically, all individuals may not have the capacity to enact both components of
empathy, perspective-taking and affective sharing. An individual may possess greater
perspective-taking abilities and lack the affective ability to share in another’s emotions. This
kind of individual may be a skilled manipulator of social circumstances because these
individuals will not become overwhelmed with the emotions of others around them. A lack of
sensitivity to others’ affective states combined with a skilled sense of others’ perspectives
will give these individuals the capacity to manipulate social relationships to their advantage.
Yet, this individual’s Machiavellian empathy may incur personal costs, such as social
isolation, because others may become aware that they are being manipulated or, intuitively,
sense that this manipulator is not sincere.
There is evidence that this egocentrism is common because taking another’s perspective
does not automatically lead to empathic behaviors. After considering the other’s perspective,
individuals will have less egotistic judgments concerning resource allocation and fairness
(Epley, Caruso, & Bazerman, 2006). However, these judgments of fairness are not reflected
in the behaviors of these individuals. Egotistic or self serving behaviors did not reduce as a
consequence as taking the other’s perspective. In this manner, an individual may engage in
perspective-taking of the other and realize the fair and just manner in which to treat the other,
yet still behave egotistically in order to gain an advantage over another or accomplish a
personal goal (as above, see Stiff et al., 1988).
On the other hand, Smith (2006) contends that an individual may easily share in another’s
emotions, yet neglect to take that person’s perspective. These individuals are likely to be
 Communicating Empathies in Interpersonal Relationships 15

easily influenced by empathic emotion and this affective contagion will cause them to have a
fluctuating sense of self. In addition, such individuals will neglect to imagine how others
perceive their behavior and, therefore, lack the ability to purposely tailor communicative
messages. This type of empathic ability, consisting of low perspective-taking and high
affective sensitivity, may lend the individual to being susceptible to Machiavellian empathy
because they would be captive to the emotional surges of an interpersonal encounter.
However, to lack the ability of affective sensitivity or perspective-taking is an extreme
condition that would not frequently manifest itself in many individuals. It is more likely that
individuals possess both components of empathy and, instead, exhibit moderate fluctuations
in both perspective-taking and affective sensitivity in order to adhere to social expectations,
as shown in Figures 2 and 3. “One could be empathic (i.e., enter the other’s frame of
reference) but then use one’s sense of the other’s experience to manipulate the person”
(Mahrer, 1997, p. 168). For example, an individual may momentarily engage in increased
perspective-taking in order to gain the approval of another communicator. Or an individual
may feign emotional contagion in order to emphasize similarity and affective connection with
another. This discussion re-conceptualizes empathy to have a looser definition whereby
individuals differentially engage in perspective-taking or emotional contagion for an
egocentric advantage during interpersonal relationships. In this manner, empathic
communication can differ in degree and intensity such that only the “purest” form of empathy
can be communicated when both perspective-taking and emotional contagion are
authentically enacted.

Figure 2. Diagram of empathy and impression management.

16 Grace Anderson and Howard Giles

Figure 3a. The components of empathy and an individual’s ability to manage another’s impressions of
him/herself.

Figure 3b. The components of empathy and an individual’s susceptibility to impression management
from another.

Again, the distinction between state and trait empathy is an important one. The individual
who lacks the ability to take another’s perspective or share in another’s emotions will exhibit
a different form of trait empathy than another who possesses both components of empathy.
Conversely, individuals’ who have the capacity to change their perspective-taking and
affective sharing abilities in order to match social appropriateness exhibit a fluctuating state
empathy that changes within the individual according to specific contexts. Either way,
empathy, without compassion, can be dangerously manipulative - and empathy without
perspective-taking can be foolhardy (Bohart & Greenberg, 1997).
It would be interesting to study variations in perspective-taking and affective sharing
abilities using the theoretical framework of communication accommodation theory.
 Communicating Empathies in Interpersonal Relationships 17

Following this, individuals would vary the empathy that they express to another in order to
explicitly communicate their intergroup attitudes (Gallois, Ogay, & Giles, 2005; Giles,
Coupland, & Coupland, 1991; Hecht, Jackson, & Pitts, 2005). For example, communicators
that wish to distinguish themselves from a member of an outgroup might underaccommodate
their speech style when interacting with them. In terms of empathy, these communicators
would take the other’s perspective only to determine their outgroup status, yet neglect to
communicate any emotional response that they may or may not feel as a consequence of
interacting with the other individual. In other words, the communicators are intentionally
withholding their emotional empathy in order to make group boundaries explicit and
seemingly impermeable during the interaction.
On the other hand, communicators can use empathy to linguistically converge towards
another in order to reduce intergroup dissimilarity and soften the emphasis of group
boundaries with communication accommodation. In this case, communicators would take the
other’s perspective more intensely in order to determine the individual’s group membership
and better tailor a message towards the listener. In addition, these communicators would
emphasize that they are sharing in the emotions of the other and consequently verbally
accentuate emotional similarity. Future research that supports this approach would imply that
empathy can be used as an impression management tool during interpersonal interactions
when individuals behave vis-à-vis their intergroup beliefs (see Harwood & Giles, 2005).

OPERATIONALIZATIONS OF EMPATHY
Empathy may seem difficult to measure, yet previous researchers have already belabored
the arduous task of creating operational measures that capture the multidimensional nature of
it. Valid and reliable measurement tools, such as the Hogan Empathy Scale (EM) and the
Mehrabian and Epstein Questionnaire Measure of Emotional Empathy (QMEE), have been
developed and they measure two distinct aspects of empathy (Chlopan, McCain, Carbonell, &
Hagen, 1985; Duan & Hill, 1996). Although some research has found both measures to be
reliable and valid, the QMEE seems to be measuring vicarious emotional arousal and,
possibly, an individual’s general tendency to become emotionally aroused in various contexts.
Alternatively, EM more closely measures the perspective-taking component of empathy
(Hogan, 1969). But some have questioned its validity because EM has been found to be
multidimensional at both the first- and second-order factor levels, suggesting that EM’s
subscales are more informative than its composite score (Dillard & Hunter, 1989). “Taken
together, these two scales, the QMEE and Hogan’s EM scale measure empathy as the ability
(a) to become emotionally aroused to the distress of another and (b) to take the other person’s
point of view, in order to have true empathy” (Chlopan et. al., 1985, p. 650).
In fact, Davis (1983) has integrated these components of empathy into one scale entitled
the Interpersonal Reactivity Scale (IRI). “Rather than treating empathy as a single unipolar
construct (i.e., as either cognitive or emotional), the rationale underlying the IRI is that
empathy can best be considered as a set of constructs, related in that they all concern
responsivity to others but are also clearly discriminable from each other” (Davis, 1983, p.
113). More specifically, the IRI consists of four subscales that each measure perspective-
taking, empathic concern, fantasy, and personal distress. The perspective-taking and empathic
18 Grace Anderson and Howard Giles

concern subscales attempt to measure the components of empathy previously discussed.

However, Davis also considered fantasy tendencies and personal distress as additional
components. Davis’ fantasy subscale measures an individual’s ability to imagine the feelings
of fictitious characters in books and movies, for example. Fantasy tendencies are expected to
have a positive relationship to an individual’s emotionality. The personal distress subscale
measures the egocentric feelings of personal anxiety during interpersonal interactions. The
association between empathy and personal distress will be discussed in greater detail in an
ensuring section.
Davis found a positive correlation between the perspective-taking and the empathic
concern subscales which support the previous discussion indicating that perspective-taking
and affective contagion are important components of empathy (Coke et al., 1978). In addition,
Davis found that the perspective-taking subscale was highly correlated with the EM and the
fantasy tendencies and empathic concern subscales were highly correlated with the QMEE.
This confirms the claims made by Chlopan et al. regarding the distinct measurements of the
EM and the QMEE. In sum, the EM measures the perspective-taking component of empathy
and the QMEE measures vicarious emotional arousal in various contexts.
In general, the fantasy subscale resembles the empathic concern subscale in that both
subscales have a relationship with emotional reactivity and selfless concern. However when
compared to the empathic concern scale, the fantasy subscale has a weaker relationship with
other-oriented sensitivity and a stronger relationship with verbal intelligence measures
(Davis, 1983). Other-oriented sensitivity is integral to the concept of empathy and its weak
relationship with the fantasy subscale may indicate that an empathic individual with fantasy
tendencies has trouble tailoring a message that incorporates another individual’s specific
needs. Overall, research has shown that an individual with fantasy tendencies will react
emotionally to another in distress and have selfless concern for the other individual; however
this concern may not be communicated with other-oriented sensitivity. In other words, the
receiver of the empathic communication may not interpret the message as empathic because it
was communicated in an inappropriate manner. The fantasy aspect of empathy has been the
target of intriguing investigations in media communication where fantasy involvement (i.e.,
perspective-taking of fictional characters) has led to some interesting reactions to film
(Tamborini, Salomonson, & Bahk, 1993; Tamborini, Stiff, & Heidel, 1990).
Davis’ personal distress subscale was important because it exhibited a negative
correlation with the EM. This indicates that individuals with high personal distress will be
less able to take another’s perspective and, therefore, less likely to feel empathy. In other
words, personal distress is an opposite reaction to another in distress and a reaction that is
separate and distinct from empathy. This is consistent with the research conducted by Batson,
O’Quin, Fultz, and Vanderplas, (1983) where a distinction was invoked between empathy and
personal distress as separate reactions to the same stimulus of viewing another individual’s
suffering. Personal distress is an egocentric reaction to another’s distress because individuals
are focused on their own negative feelings as a consequence of the other’s distress. Empathy,
on the other hand, is an altruistic reaction in the sense that the individual’s focus is on the
other’s distress. Taken as a whole, these correlations further confirm that researchers are
sharpening empathy measures towards increased validity.
Smither (1977) offers the researcher a word of caution regarding the measurement of
empathy. ‘Pseudo-empathy’ must be controlled for during measurement. More specifically,
‘pseudo-empathy’ is an individual’s normative reactions to another in order to adhere to
 Communicating Empathies in Interpersonal Relationships 19

implicit social expectations. “The concern here is an important one: empathy is a response to
the particular feeling-states of another individual, and cannot be a response to a generalized-
other or to the situation itself” (emphasis in text; p. 258). In order to prevent the
measurement of ‘pseudo-empathy,’ the individual or research participant must have
information regarding the specific emotions and relational context in which the individual is
embedded. Many times individuals respond to a situation in a generic manner because they
prefer to be careful and cautious during interpersonal interactions or because they have
experienced similar situations in the past. It is important for future research to have poignant
stimuli that actually evoke empathy instead of a cautious normative response. Another way to
combat the measurement of ‘pseudo-empathy’ would be to confront research participants
with unfamiliar situations and individuals during experimental treatments. Consequently,
research participants would be forced to specifically scrutinize the current research condition
because they do not have a similar past experience to rely upon.
However, Duan and Hill (1996) call for a dramatic change in the manner by which
empathy is measured. They believe the previous measures of empathy do not adequately
evaluate intra-individual fluctuations of empathy (state empathy) and, instead, suggest that an
indirect measurement of empathy is superior. These researchers believe a better calculation of
the perspective-taking function of empathy would be to measure the attributions that
empathizers assign to the behaviors of recipients in addition to the attributions recipients
assign to their own behaviors. Empathy has occurred when both the empathizer and the
recipient identify the same attributions for the recipient’s behavior. “The validity of the
method can be theoretically inferred, because the accuracy of the match [of assigned
attributions] should reflect the degree to which one person is taking another’s perspective”
(Duan & Hill, 1996, p. 267). Similarly, the emotional contagion function of empathy can be
measured by the degree of match between the empathizer’s and the recipient’s emotions or
affective state. In sum, the unit of analysis when measuring the perspective-taking component
of empathy is attribution congruence and the unit of analysis when measuring the emotional
contagion component of empathy is affective congruence.
Duan and Hill’s second-order manner of assessing empathy has the benefit of using the
empathic recipient’s perspective and emotions as the comparison baseline to which an
empathizer must conform in order to exhibit a true form of empathy. In other words, this is a
subjective measure of empathy that is more adaptable to personal and contextual differences.
This is to be compared to objective measures where an individual’s empathy is compared to a
pure and superior form of empathy that independently exists outside of the particular
interaction. However, Duan and Hill’s measurement of empathy was intended for counseling
psychology and psychotherapy and, consequently, has methodological drawbacks when their
conclusions are applied to the empirical context of social science. In order for a match of
perspectives and emotions to occur, both an empathizer and a recipient of empathy must be
present in a controlled environment in order for researchers to measure their congruence. This
limits the measurement of empathy to the experimental setting with at least two interacting
research participants. This rules out the measurement of empathy in response to media forms,
for example, and limits the possibility of surveys and content analyses of empathic content.
In fact, different methods of empathy measurement result in varying associations between
empathy and prosocial behavior. For instance, positive associations between empathy and
prosocial behavior are strongest when empathy is measured with physiological indices (i.e.
heart rate), when similarity is experimentally manipulated, and by self-report measures during
20 Grace Anderson and Howard Giles

experimental situations (Eisenberg & Miller, 1987). Interestingly, picture/story procedures

measuring empathy among children were not associated with prosocial behavior. This
suggests that some methods can better detect altruistic behavior associated with empathic
communication than others.
A global construct such as empathy needs an amalgamated analysis in order to accurately
measure the multidimensional nature of the variable during empirical research. Although
pitfalls such as pseudo-empathy have been identified, there are subtle ways to combat these
pitfalls during the empirical process that reduce the chances of measuring normative
responses instead of empathy. In addition to the methods of measurement identified above,
the strength of empirical research investigating empathy lies in the treatment stimuli that in
fact evoke empathy from research participants.

RELATED CONSTRUCTS
Empathy is an important construct to measure empirically because it primarily leads to
positive behaviors, such as assistance and helping behaviors towards others in distress.
However, it is important to make a distinction between empathy and other reactions
individuals have when observing another in distress. The relationship between empathy and
personal distress confirmed by Batson et al. (1983) is one of many findings that purport
empathy and personal distress to result in distinct motivations to help another individual.
More specifically, empathy motivates an individual to help another out of altruistic desire. On
the other hand, personal distress leads to an egocentric form of helping behavior where
individuals will help another in order to calm down their own state of mind (Batson, Fultz, &
Schoenrade, 1987; Batson et al., 1983; Coke et al., 1978). In sum, both empathy and personal
distress can be reactions to the same stimulus of witnessing another individual experiencing
distress. However, empathy and personal distress are distinct reactions because they trigger
divergent motivations to help.
Unfortunately, empathic altruistic desires to help diminish as the cost of helping the other
individual increases (Batson et al., 1983). For instance, the treatment of cancer can be
financially costly especially when considered at an aggregate level where hospital
administrators have to consider the costs and rewards of treating a number of cancer patients
without health coverage. On a case-by-case basis, administrators empathize with each cancer
patient and their families and are altruistically motivated to help. However, the costs
dramatically accrue when all cancer patients without health coverage are considered on a
budgetary basis. In this case, the financial costs increase hospital administrators’ personal
distress and egotistic concern for their job security because it is their responsibility to adhere
to a manageable budget. This egotistic desire will eventually override an empathic
administrator’s altruistic motivation to help. The altruistic alternative would sacrifice
resources at the cost of the collective good. Hospital funds would be allocated to a few
individuals and less total resources would be available for general upkeep of the hospital
facilities that would benefit all patients indiscriminately.
There is evidence documenting how egotistic and altruistic allocations of resources
change as a consequence of empathy. Individuals’ are primarily motivated to benefit oneself
and secondarily motivated to allocate resources that benefit their social group as a whole
 Communicating Empathies in Interpersonal Relationships 21

(Batson et al., 1995). But if individuals feel empathy for a particular other, then they are
motivated to benefit the other individual even when it costs the group, as a whole.
Interestingly, there are times when the altruistic motivations of empathy may conflict with the
collective good. An egotistic motivation to help oneself and one’s social group can lead to
greater long-term self-benefit because resource allocation to the collective good would
solidify a positive social standing for oneself within the social group and would benefit the
group in relation to other groups also competing for resources in a society. In this case, an
altruistic motivation to help a particular other at the expense of the group would not lead to
long-term self benefit. Perhaps this illustrates why empathy is so intriguing to examine.
Empathic communication is a common human behavior of altruism that paradoxically occurs
at the expense of the collective good and long-term self-benefit.
Perhaps the two distinct forms of motivation produced by empathy and personal distress
are the cause of ambiguous empirical results concerning attitudes and stereotypes about
individuals diagnosed with cancer. For instance, Gray and Rodrigue (2001) found that young
adolescents with high trait empathy had stronger desire to participate in academic, social and
general activities with a hypothetical new peer with cancer. In fact, this stronger desire
remained when empathic young adolescents considered participating in activities with a
healthy hypothetical new peer. This indicates an absence of a cancer stigma. And all
adolescents (empathic and non-empathic) intended to exhibit positive behaviors towards the
peer with cancer when compared to a hypothetical peer without cancer. These encouraging
results may have been a result of the researchers’ ability to successfully evoke an altruistic
desire to help and, subsequently, measure empathy towards a peer with cancer.
Conversely, Sherman, Smith, and Cooper (1982-83) found that individuals had less
positive affect towards contact with a cancer patient when compared to contact with a patient
with a broken leg. More specifically, positive affect increased with the patients’ attractiveness
and decreased when the individuals perceived the patient to be in greater pain. In this case,
the researchers may have evoked personal distress among their research respondents.
Interacting with an unattractive patient in great pain may be personally distressing.
These findings have unfortunate implications. Cancer patients who may, arguably, be
considered less attractive under certain conditions tend to be individuals who have undergone
intense chemotherapy and have consequently experienced hair and weight loss. These
individuals also tend to be in great pain from the treatment itself in addition to an aggressive
form of cancer. This is a ripe opportunity for empathy to be expressed in order to quell cancer
patients’ physical and emotional distress. However, Sherman et al. has shown that empathy is
not healthy individuals’ common reaction under these circumstances. In fact, this finding
remains consistent with Gray and Rodrigue because their research participants were asked to
imagine a hypothetical peer with cancer. These research participants were children who
probably would not imagine a new peer who is unattractive and in constant pain. It can be
suggested that Gray and Rodrigue would have encountered different results if their research
participants were actually confronted with a new peer who was observably experiencing pain
and other physical indications of an aggressive cancer diagnosis. As above, the empathizer
experiences increased emotional contagion and vicariously feels the distress of the peer, the
empathizer is more likely to become communicatively unresponsive in order to reduce one’s
own distress (Stiff et al., 1988).
Future research is needed in order to specifically identify aspects of the cancer experience
that evoke empathy among healthy observers instead of personal distress. Or which
22 Grace Anderson and Howard Giles

individuals tend to express empathy more often towards others with cancer? Can increased
contact cultivate empathy towards individuals-with-cancer and reduce personal distress?
Increased contact could help a healthy individual realize and appreciate another individual’s
distinct personality and how a cancer diagnosis inhibits the other’s persona (Pettigrew &
Tropp, 2000; Wright, Broday, & Aron, 2005). This would imply that individuals who have
had a relative with cancer or experienced cancer themselves would be more likely to express
empathy in this context. Medical personnel of oncology may also express increased empathy
according to this contact hypothesis, however their increased knowledge about treatment and
medical practice may be a covariate. A common aim for future research could be focused on
discovering the aspects of the cancer experience that bring out the best responses in healthy
observers in addition to individuals-with-cancer.
Another construct related to empathy is communication competence (Greif & Hogan,
1973; Ritter, 1979). Wiemann (1977) considered competent communicators as empathic,
affiliative, supportive, relaxed while interacting, and able to adapt their behavior according to
the specifics of the interaction and between interactions. Individuals have greater competence
as they possess more of these qualities and the degree to which they exhibit these qualities.
Redmond (1985) found the concepts of communication competence and empathy very closely
related (r = .98). Communication competence and empathy may be composed of the same set
of skills and behaviors. In fact, Redmond believes that such a strong correlation may
methodologically hinder effective research and indicate that the concept of empathy is being
treated too globally. It is possible that one factor, empathy/the competent communication of
empathy, is being measured twice when researchers treat empathy and communicator
competence as separate and distinct concepts. Empathy may be an internal skill and
communication competence may be the behavioral manifestation of empathy. It may be
possible for an individual to feel empathy yet not be able to effectively communicative his/her
empathic state. This internal empathy, unfortunately, would not be recognized as empathy
because it was not effectively communicated.
This is consistent with Redmond’s findings because research subjects were required to
take the third person perspective and assess empathy and communicative competence as an
outsider to an auditory interaction. Research participants listened to an auditory interaction
and, accordingly, did not have visual cues and personal knowledge regarding the
communicator’s internal affective state. These research participants will not be able to detect
the communicator’s empathy unless it is competently verbalized. Any empathy that was
detected by research participants was detected only because the communicator was
competently able to express empathy. Therefore, the strong correlation between empathy and
communication competence existed because auditory manifestations of communicator
competence were required in order for research participants to perceive the presence of
empathy in the target individual during the auditory interaction. In sum, empathy has to be
competently communicated in order for another individual to recognize it as empathy.
Thompson (1981) found that children with handicaps had lower communication
competence in that they were less able to adapt their communication towards the listener. In
addition, children without handicaps were less able to adapt their communication toward
children with handicaps as well. This effect persisted even when children with and without
handicaps shared classes together. The authors find these results an indication that children
with handicaps are not receiving empathic communication from their peers and, therefore, not
able to model empathic communication themselves because they are not being exposed to it.
 Communicating Empathies in Interpersonal Relationships 23

However, another possibility could be a circumstance where the children are experiencing a
form of intergroup conflict and children with and without handicaps are each avoiding any
consideration of the other’s perspective. Either way, empathic communication can often be
problematic between children with and without handicaps. According to communication
accommodation theory, this behavioral pattern can be considered reciprocal
underaccommodation where handicapped and non-handicapped children are maintaining a
division between social groups within the classroom. Although there are other factors
influencing the communicative competence of handicapped children, this discussion implies
that the environment in which children communicate with disabled children is already
unstable and not naturally fostering reciprocal empathic communication.
Interestingly, however, siblings of children with cancer experience fewer difficulties in
psychological adjustment when they also experience high empathy (Labay & Walco, 2004).
Empathy may help them emotionally reconcile discrepancies in family resources that are
focused away from the siblings. Conversely, siblings who are less empathic and less able to
understand others’ emotional states may have difficulty communicating their needs and act
impulsively. It would seem that the empathizer has increased communicative competence
during the distress following cancer diagnoses in the family. Empathy was also found to be
correlated with age, further suggesting that empathy is a developmental ability that may
develop in tandem with communicative competence during maturation.
Can nonverbal cues effectively communicate empathy? Recently, researchers have
focused on the combination of person-centered messages and nonverbal immediacy cues in
comforting messages (Jones, 2004, 2005; Jones & Burleson, 1997, 2003; Jones & Guerrero,
2001; Jones & Wirtz, 2006). Comforting messages could be considered a way for individuals
to express their empathy and altruistic desire to help another individual. Person-centered
comforting messages validate and acknowledge another individual’s specific emotional
distress and Jones (2004) found that individuals who receive person-centered messages feel
reduced emotional distress and perceive the communicator of person-centered messages as
supportive and caring. On the other hand, nonverbal immediacy conveys liking, interpersonal
warmth and connection, and stimulates psychological arousal which helps the individual to
recognize the prior emotions of warmth, liking and connectedness. In addition, Jones found
that individuals who communicate nonverbal immediacy are perceived as more competent
communicators. It would seem that communicators who express nonverbal immediacy and
person-centered supportive messages are more competent communicators of empathic
warmth and connection.
However, Jones and Guerrero (2001) maintain that nonverbal immediacy and person-
centeredness facilitate different functions during the emotional support process and may be
distinct concepts. Nonverbal immediacy communicates a warm and open context for
comforting, but person-centeredness incorporates explicit statements which encourages
disclosure of distressing emotions. Consequently, person-centered comforting messages
overtly provide an opportunity for emotional distress to be verbalized and allows for the
reappraisal of these emotions in an interpersonal context.
Jones and Wirtz (2006) further suggest that the comforting process consists of a
reappraisal of distressing emotions which can lead to emotional improvement. In other words,
emotional reappraisal was a mediating variable between person-centeredness and affective
improvement. Individuals who use person-centered messages in order to comfort distressed
individuals will explicitly encourage other individuals to verbalize their feelings. This
24 Grace Anderson and Howard Giles

verbalization will help determine the cause of distress and spur other sense-making cognitive
reappraisals that will eventually reduce the initial distress. However, reappraisal was found to
be only a partial moderator because there was a direct decrease in emotional distress resulting
from person-centered comforting messages. More specifically, an individual’s emotional
distress will reduce simply as a result of another individual validating and acknowledging
his/her distress with person-centered comforting messages, as in Figure 4.
In sum, person-centered comforting messages communicate empathy in two ways. First,
an individual is acknowledging another’s distress by tailoring a message towards the
particular distress of the other individual. Second, person-centered messages explicitly allow
the distressed individual to verbalize emotional distress and commence a reappraisal process
towards distress reduction (Bohart & Greenberg, 1997; Jones & Wirtz, 2007; Warner, 1997).
Both functions of person-centered messages manifest a unique form of perspective-taking
required of the empathizer. An individual can take another’s perspective by simply
acknowledging the other individual’s emotional distress. On the other hand, the reappraisal
process can be considered a more dynamic form of perspective-taking where each individual
shares his/her perspective regarding the emotional distress of one individual and, thus,
negotiate a more balanced interpretation of the distressing emotions. In this manner, a mutual
perspective of all members of the interaction is achieved and this leads to emotional distress
reduction.
There are a number of constructs related to empathy as the latter is not an isolated
orthogonal entity. Instead, empathic communication is part of a process where another’s
distress is recognized by an individual and that individual’s empathic response may or may
not be competently communicated. However, the presence of empathy in the individual’s
psyche can trigger an altruistic motivation to help another individual in distress which can be
manifested by the comforting behaviors of nonverbal immediacy and person-centered
messages.

Figure 4. Model of outcomes resulting from comforting behaviors.

 Communicating Empathies in Interpersonal Relationships 25

In further examining the process of empathic communication, the following came to

mind. What circumstances or events in everyday life commonly trigger individuals’ egotistic
motivation of personal distress to override their empathic altruistic motivation to help
another? What strategies can individuals use to combat personal distress and restrain egotistic
motivation in order to uphold an altruistic desire to help in the face of adversity or personal
hardship? Are there other helping behaviors that better manifest an empathic individual’s
altruistic desire to help? Is there a way to measure empathy that an individual legitimately
harbors, yet is not able to competently communicate? These questions only seek to further
illuminate an empathic process that has been diligently documented by previous research.

OUTCOMES OF EMPATHY
As just discussed, messages of empathy and their underlying altruistic motivations to
help can be manifest by comforting behaviors such as nonverbal immediacy and person-
centered messages. In many respects, the emotional distress reduction resulting from the
reappraisal process spurred by person-centered messages can be considered an outcome of
empathic communication. This is supported by cancer research where supportive
conversations consisting of the mutual sharing of personal cancer experiences lead to greater
perceptions of effective helping among interactants (Pistrang, Solomons, & Barker, 1999). In
this case, the self-disclosure regarding cancer was more positively evaluated when empathy
was first communicated during the relationship. Consequently, one positive outcome of
empathy is the perceived emotional assistance resulting from the mutual sharing of
experiences.
Other, more global, outcomes of empathy have been explored as well. For instance,
international conflicts may be resolved through the proper enactment of collective empathy
(Nadler, 2003; Nadler & Liviatan, 2004, 2006; Nadler & Saguy, 2005). Researchers have
analyzed the international conflict between the Palestinians and the Israelis to discover the
role of empathy in the achievement of conflict resolution. They have found that empathy
leads towards conflict resolution only when the conflicting parties maintain a preliminary
level of trust. If trust is not present between the conflicting parties, expressions of empathy
may sometimes lead to increased conflict. In this case, an expression of empathy is perceived
as an empty offer of reconciliation and possibly perceived as intentionally deceptive. In this
manner, trust has been found to moderate the relationship between empathy and conflict
resolution. Trust can be engendered when the opposing groups participate in successive
interactions towards a common goal that fulfills the needs of all groups involved. The
researchers use social identity theory for support by asserting that groups engaging in
collective action will embrace a larger group identity that overrides their separate identities
and lead to cooperative interaction. Likewise, trust may be an important moderator during
interpersonal conflict and two individuals in disagreement can engender trust by working
towards a common goal. Over time, trust will develop once cooperative interaction becomes
more frequent.
Similar intergroup conflict can be observed between healthy individuals and individuals-
with-cancer. Individuals may avoid others who have been diagnosed with cancer or
individuals may exhibit overly intrusive behaviors that can strain the interpersonal
26 Grace Anderson and Howard Giles

relationship (Flanagan & Holmes, 2000). Moreover, this conflict may lack trust. Cancer is a
disease that can remain invisible to an observer some days and, yet, produce noticeable
symptoms other days. Healthy individuals may harbor doubts about the severity of the disease
when the observable signs of the illness are ambiguous (Matthews & Harrington, 2000).
These doubts may spring from a wishful desire for the cancer diagnosis of their friend or
family member to be bogus. In order for empathy to reconcile the strained relationship, trust
must be re-established. Trust may be restored by educating healthy individuals about the
fluctuating symptoms of cancer, especially if this education is collectively achieved through a
partnership between the healthy individual and the individual-with-cancer. If these
individuals collectively work towards the goal of cancer education together, they both will
have increased knowledge in addition to a larger shared identity between them. Increased
trust will further increase the likelihood of a positive relationship between empathy and
conflict resolution.
These possible outcomes demonstrate that the effects of empathic communication
resonate from the interpersonal to the international level. However, it is important to
remember that positive outcomes from empathy will only occur when empathy is
communicated in the context of a trusting relationship.

A MODEL OF INTERPERSONAL AND INTERGROUP EMPATHY

AS A COMMUNICATIVE PROCESS

The empirical findings discussed in the previous sections have been mapped-out into a
model in order to display the process of empathic communication. For simplicity, this model
of empathy displays the communication between an empathizer and a receiver. The
communicator has just witnessed or become aware that another individual is experiencing
some form of distress and, consequently, this communicator feels personal distress and/or the
beginnings of empathy: perspective-taking and emotional contagion, as in Figure 5.
Picture this model as a set of three concentric circles that start at the upper left-hand
section of the model and each circle represents a different process related to empathy. As
depicted, two processes commence when communicators observe another in distress. These
communicators can experience personal distress themselves as a result of witnessing another
endure a painful experience or emotional turmoil. The outmost circle represents the process of
personal distress where egotistic motivation compels communicators to reduce their own
distress by comforting the other individual. This particular process is represented by personal
distress appearing twice on the processional model in order to reflect both the empathizer’s
and the recipient’s distress. The empathic process is represented by the next concentric circle
where individuals can respond to others’ distress by taking their perspective and sharing in
their emotions because empathizers have an altruistic desire to help the other individuals.
Lastly, the innermost circle represents the process of conflict resolution where empathy is
fundamental to the resolution of conflict between two parties. Empathy is integral to the two
inner circles and consequently there is overlap of the empathic process and the process of
conflict resolution.
 Communicating Empathies in Interpersonal Relationships 27

Figure 5. Empathic communication process model.

Parsimony notwithstanding at this stage of model development, there are a number of

possible additions and potential changes to this model that future research can implement.
One improvement entails the identification of specific helping behaviors individuals enact
when exhibiting empathy. The current dialog box signifying ‘helping behaviors’ is perhaps
generic and needs elaboration in future theorizing. It would be interesting to assess whether
individuals experiencing personal distress resort to different helping behaviors as a
consequence of their egotistic motivation to help in comparison to the altruistically motivated
helping behavior commonly chosen by individuals who exhibit empathy. Any differences
would have direct implications for the empathy as a communicative process model. Instead of
one ‘helping behaviors’ dialog box, personal distress and empathy would have relationships
with two separate ‘helping behaviors’ dialog boxes, each representing the differing helping
behaviors that personally distressed individuals and empathic individuals typically enact.
Additionally, it would be interesting to discover if helping behavior springing from personal
distress results in as much emotional improvement in the target individual as helping behavior
exhibited by an empathic individual.
28 Grace Anderson and Howard Giles

EPILOGUE
Empathy’s multidimensional nature has been reflected by the diverse manner in which it
has been examined in previous research in addition to this present analysis. Although a
mainly interpersonal construct, historically, empathy research has been expanded to embrace
the dynamics of media communication, intergroup, and intrapersonal communication.
However, empathy has not been explicitly examined in organizational settings. Boggs and
Giles (1999) scrutinize the communication accommodation that occurs in the workplace as a
consequence of gender social groups. Could the observed accommodative patterns be a
corollary of empathy (or lack thereof) in the workplace? Can an empathic workplace be
intentionally fostered?
In addition, empathy research has yet to investigate the effect of intercultural differences.
Duan and Hill (1996) report that collectivistic values are positively related to dispositional
empathy. However, they question whether this tendency would remain when an individual
with collectivistic values is confronted with another’s distress about a decidedly
individualistic issue. Other questions regarding empathy in collectivistic cultures remain. For
instance, will empathy communicated in a collectivistic culture be more broadly directed to
the family of the distressed individual? How does empathy change when comparing cultures
that typically communicate with high vs. low contexts? More specifically, is empathy more
likely to be implicitly communicated in a high context culture when compared to a low
context culture?
Overall, research has focused on the role of the empathizer as opposed to the receiver of
empathic communication. However, the research which incorporates empathy into the context
of disability and cancer better focuses the attention on the receiver of empathic
communication. The experience of a cancer diagnosis and treatment is embedded within the
social relationships of people with cancer which contributes to their social identity (Harwood
& Sparks, 2003; Sparks & Harwood, 2008). This highlights the importance of social
relationships when facing the health threat of cancer. Yet, empirical findings indicate that
friends and family have difficulty taking the perspective of the person-with-cancer. In
consideration, friends and family members should recognize that the cancer experience may
be beyond their perspective-taking abilities. Although this can be psychologically
uncomfortable as a result of uncertainty, empathy can be best expressed by its availability. It
might be helpful to allow people with cancer to ask for assistance and emotional support
when needed and in the manner that they desire. The cancer experience changes as a
consequence of different stages from diagnosis to chemotherapy to remission and social
relationships of support need to adapt accordingly (Sparks & Harwood, 2008). Fortunately,
empathy is a common reaction when observing another in distress and contributes to
comforting behaviors in addition to a variety of other prosocial behaviors (Litvack-Miller,
McDougall, & Romney, 1997). It can be the manner in which empathy is expressed during
sensitive communicative interactions that heightens or dampens its positive effect on the
social relationship.
Needless to say, there is an array of other viable theories we could have fruitfully invoked
(e.g. uncertainty reduction theory) however, space and parsimony precludes such a luxury.
For instance, the dual identity proposed as the origin of empathy in this chapter may be
similar to the dual identity proposed by the theory of Symbolic Interactionism. Do the
 Communicating Empathies in Interpersonal Relationships 29

articulate self and the organic self correspond with the ‘I’ and the ‘me’? In addition, social
identity theory has been used to examine the intergroup relationships between individuals-
with-cancer and other social groups (Harwood, & Sparks, 2003). It would be interesting to
further study how empathy may change intergroup communication. Does empathy change the
manner in which group identity is achieved and maintained via social comparison? Can
empathy soften the perceived boundaries between social groups? Moreover, communication
accommodation theory (as above) may explain the linguistic manifestations of empathic
intergroup interaction. Do the linguistic strategies of communication accommodation theory
provide a better framework with which to examine empathic communication? Can a
communicator linguistically diverge from another while still expressing empathy; or is
empathy solely a form of communication convergence?
Almost finally and returning to our starting point, empathy still deserves more conceptual
scrutiny. More specifically, empathy has been regarded as an individual’s response to
observing another experiencing distress. This implies that empathy only occurs when an
individual observes another’s negative emotion(s). However, empathy can be a response to
another’s positive emotion(s) such as a wedding engagement, a pregnancy announcement,
graduation, etc. It would be interesting to discover if there is a difference between positive
emotions and negative emotions in the manner in which empathy is elicited. Duan and Hill
(1996) believe that “empathizing with someone with positive emotions can be emotionally
rewarding and empathizing with someone with negative emotions can be morally rewarding”
(p. 268). Future research could empirically explore this assumption in order to determine if
empathizers responding to another’s positive emotions experience a different empathic
process than communicators responding to another’s negative emotions. Empathic
communication in response to another’s positive emotions is outside of the framework of this
chapter, yet it is an important manner in which empathy can vary and, therefore, an area in
need of further development
A global concept such as empathy requires a global method of examination. However,
analysis of such a ubiquitous concept is needed in order to better understand interpersonal
relationships. Previous research has met this demand and has proven to be both enlightening
and enigmatic. Most importantly, empathy is not simply a reification of academia, but a
concept pragmatically used by the general population in a fairly reliable manner (Hogan,
1969).

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 2

INTERPERSONAL REPRESENTATIONS:
THEIR STRUCTURE, CONTENT, AND NATURE

Shanhong Luo*
Department of Psychology, University of North Carolina at Wilmington,
North Carolina, USA

ABSTRACT
How people represent their interpersonal relationships based on past experiences has
great impact on their subsequent interactions with others. This chapter reviews previous
theories and presents new propositions regarding three important aspects of interpersonal
representations (IRs)—their structure, content, and nature. Specifically, the structure of
IRs can be viewed as a three-level hierarchical organization, with general representations
at the highest level, domain-specific representations at the midlevel, and relationship-
specific representations at the lowest level. The content of IRs can be divided into three
distinct yet interrelated components: self representations, other representations, and
relationship representations. With regard to the nature, IRs can be conceptualized as
consisting of accurate perceptions, systematic biases, and random errors.

Keywords: Interpersonal representations, working models, relational schema, general

representations, domain-specific representations, relationship-specific representations,
self representations, other representations, relationship representations, accuracy, bias

One of the most important ideas in the area of close relationships is that individuals’ past
relationship experiences exert powerful influences on their subsequent interactions with
others. It has been theorized that the mechanism by which past experiences influence current
behaviors is through internal representations. That is, people internalize repeated experiences
and develop mental representations that capture regularities in patterns of the self in relation

*
Correspondence should be sent to Shanhong Luo, Department of Psychology, Social Behavioral Science Building,
University of North Carolina at Wilmington, Wilmington, NC, 28403. Email: luos@uncw.edu.
36 Shanhong Luo

to others; these interpersonal representations guide how people process, interpret, and respond
to incoming information (see Bowlby, 1973, 1980; Baldwin, 1992; Safran, 1990a, 1990b).
Given the central role these representations play in interpersonal behaviors, it is of particular
importance to understand three key aspects of interpersonal representations (IRs)—their
structure, content, and nature.
Over the past two decades, researchers have made great strides in understanding the
structure and content of IRs. However, little attention has been given to the nature of IRs until
recently. This chapter has two primary goals. The first goal is to provide an integration of
theoretical propositions and a review of empirical evidence regarding the structure and the
content of IRs. The second goal is to introduce a conceptualization to help understand the
nature of IRs. More specifically, I discuss the following three propositions: First, with regard
to structure, IRs are hypothesized to be organized in a hierarchical fashion, including general
representations at the highest level, domain-specific representations at the midlevel, and
relationship-specific representations at the lowest level. Second, with regard to content, IRs
can be thought of as having three distinct yet interrelated components: representations of the
self, others, and the relationship between the two. Finally, with regard to the nature of IRs, it
is suggested that IRs can be conceptualized as consisting of accurate perceptions, systematic
biases, and random errors.
In discussions of these propositions, I draw heavily on attachment literature, particularly
theory and research regarding internal working models, because working models of
attachment are central elements of IRs. However, I also review theories and empirical work in
other fields that are not necessarily within the attachment framework, such as relational
schema theory and person perception research. The term “interpersonal representations” is
selected because of its broad applicability and inclusiveness.

THE STRUCTURE OF INTERPERSONAL REPRESENTATIONS

General and Specific Representations

Typically individuals are involved in more than one relationship. For example, most
people have relationships with parents, romantic partners, friends, colleagues, and etc.
Consequently, it is likely that individuals do not hold a single set of representations but have a
family of representations. Early attachment theorists have suggested that internal working
models should include both overarching, general representations and more contextualized
representations that correspond to specific relationships (Bowlby, 1973, 1980; Bretherton,
1985; Main, Kaplan, & Cassidy, 1985). This idea of multiple representations has been widely
accepted by relationship researchers (e.g., Baldwin, 1992; Collins & Read, 1994;
Pietromonaco & Feldman Barrett, 2000; Shaver, Collins, & Clark, 1996).
The hypothesis of multiple representations has received little empirical examination until
recently. Several studies have been designed to explicitly test this hypothesis (e.g., Baldwin,
Keelan, Fehr, Enns, & Koh-Rangarajoo, 1996; Cozzarelli, Hoekstra, & Bylsma, 2000;
Klohnen, Weller, Luo, & 2005; Pierce & Lydon, 2001; Ross & Spinner, 2001). These studies
show that individuals indeed hold both general representations as well as specific
representations that correspond to different types of relationships. Moreover, specific
 Interpersonal Representations: Their Structure, Content, and Nature 37

representations tend to be positively associated with each other, suggesting that individuals
tend to hold similar models across different relationships. However, the size of these
correlations ranged only from small to moderate (Furman et al., 2002; Pierce & Lydon, 2001;
Ross & Spinner, 2001; Klohnen et al., 2005), indicating that representations that correspond
to various relationships are not identical. General representations are also positively
associated with specific representations; once again these associations tend to have modest
magnitude, suggesting that general representations are not simply a composite of specific
representations (Pierce & Lydon, 2001; Cozzarelli et al., 2000; Klohnen et al., 2005). Overall,
these findings show that individuals have distinct, yet interrelated representations for different
relationships, and that these specific representations are also linked to general representations.

A Hierarchical Model of Interpersonal Representations

To date, research designed to test the structure of representations has typically assessed
IRs on two levels—general and specific representations. However, it is important to
differentiate between two types of specific representations that differ in their level of
abstractness. Specifically, adults are not only involved in many different types of
relationships (e.g., parental, friendships, romantic relationships), but within each type of
relationship they also typically interact with many different individuals. Therefore it is very
likely that in addition to holding the more general representations corresponding to each type
of relationship, individuals also hold distinct, concrete representations for each person whom
they are interacting with.
Consistent with these ideas, Collins and colleagues suggested that the structure of IRs can
be conceptualized as a three-level hierarchical organization (Collins & Read, 1994; Collins,
Guichard, Ford, & Feeney, 2004). Figure 1 provides a hypothetical example of this hierarchy.
General representations, the most abstract representations, are at the top of the hierarchy. At
the midlevel are domain-specific representations—representations corresponding to different
types of relationships, such as relationships with parents, romantic partners, and friends.
Relationship-specific representations are at the lowest level of the hierarchy. These are the
most concrete representations corresponding to specific individuals, such as mother and
father, previous and current romantic partners, and different friends. Due to space limitation,
Figure 1 only provides two examples of specific individuals under each type of relationship.
However, it is very likely that several different persons are nested within each type of
relationship in real life.
Overall, Fletcher, & Friesen (2003) has tested the validity of this hierarchical
conceptualization of interpersonal representations. The researchers took a confirmatory factor
analysis (CFA) approach to examine the hierarchical structure of attachment working models.
They assessed working models at both domain-specific level (i.e., how people view
themselves and others in different types of relationships including familial, friendship, and
romantic relationships) and relationship-specific level (i.e., how people view themselves and
specific others in each relationship, for example, relationship with one’s mother and father,
specific friends, and current romantic partner). CFA results from both sets of data showed that
the manifest indicators at the relationship-specific level could be modeled as forming domain-
based latent variables, which in turn formed one overarching, second-order latent factor. This
higher-order factor can be thought of as representing individuals’ most general attachment
Figure 1. A hypothetical example of the hierarchical model of interpersonal representations. Note. Ptn1 = partner 1. Ptn 2 = partner 2. Frd 1 = friend 1. Frd 2 =
friend 2.
 Interpersonal Representations: Their Structure, Content, and Nature 39

representations. These findings suggest that manifest indicators of relationship-specific

representations measured for different relationships can be successfully modeled as forming a
hierarchical structure similar to the model in Figure 1. A limitation of this research was that it
treated domain-specific and general representations as latent factors which in theory cannot
be directly assessed. However, the studies reviewed earlier have shown that individuals do
have access to these more generalized representations (e.g., Baldwin et al., 1996; Klohnen et
al., 2005). It thus will be important for future research to examine the proposed three-level
hierarchical model more directly by assessing all three levels of the hierarchy (rather than
treating the more general levels as latent factors) and modeling all of the levels
simultaneously.

Implications of a Hierarchical Organization of Interpersonal

Representations

Differential Predictive Power of General and Specific Representations

General and specific representations are likely to have differential power when it comes
to prediction of intra- and interpersonal functioning. For example, representations at the
higher levels of the hierarchy should be stronger predictors of broader constructs such as
general well-being and psychological adjustment, whereas representations at the lower levels
should be better predictors of narrower outcomes such as quality of specific relationships.
Several studies provide evidence that general and specific representations are differentially
associated with different outcomes (Cozarelli et al., 2000; Crowell, Fraley, & Shaver, 1999;
Klohnen et al., 2005; Pierce & Lydon, 2001). For example, Klohnen et al. (2005) found that
general attachment models were the strongest and most reliable predictors of personal well-
being variables such as emotional stability, self-esteem, and ego-resiliency, whereas domain-
specific models best predicted relationship outcomes (e.g., satisfaction, conflict, closeness)
within different types of relationships. Although these studies did not investigate the
predictive validity of relationship-specific representations, it is expected that relationship-
specific representations should be the best predictor of quality of relationships with specific
individuals.

Which Lower-level Representations are Most Important to Higher-level Ones?

Given that individuals hold multiple sets of specific representations, it is important to test
which specific representations make the most contributions to the more abstract
representations. It is likely that representations of the most important relationships (such as
relationships with significant others) at a lower level will have the strongest influence on
representations at the next higher-level of abstraction. In Figure 1, this proposition is
illustrated by showing the links between the most influential representations and next higher-
level representations in bold. Klohnen et al. (2005) provide some support for this proposition.
In a sample of college students, they found that romantic partner and friend models made the
strongest and independent contributions to the prediction of general models than models of
mother and father. This pattern of results is consistent with the proposal that most young
adults have shifted their focus from parents to peers as their primary source of fulfillment of
their attachment needs (see Fraley & Davis, 1997; Trinke & Bartholomew, 1997).
40 Shanhong Luo

A related proposition is that the relative importance of lower-level representations to

higher-level representations may change over time. Children may base their general
representations primarily on their relationship experiences with their major caregivers,
usually their parents. As individuals reach adulthood, peers, particularly romantic partners,
play an increasingly important role in individuals’ lives. Klohnen et al. (2005) found that the
longer individuals had been involved in their romantic relationships, the more strongly their
romantic attachment models were predictive of their general attachment models. As
individuals take on new roles and responsibilities (e.g., moving away from parents, getting
married, starting a career, having children, taking care of aging parents), the relative
importance of representations of each relationship type as well as of each person may change
drastically. Thus, it is extremely important that researchers who pursue these types of
questions to take a developmental perspective and examine how lower-level representations
contribute to higher-level representations at different life stages.

What Is Adaptive, More Consistent or More Variable Representations?

Given that individuals hold fairly distinct representations under different relationship
contexts (e.g., La Guardia et al., 2000), it is important to examine whether some people show
greater variation in their representations across relationships than others. If individual
differences in variability do exist, what implications does this have for psychological well-
being and relationship functioning? Klohnen and Weller (2006) assessed working models that
participants held for the self in relation to romantic partners, friends, their father, and their
mother. They indexed working model variability by computing the standard deviation of the
ratings across the four relationships for each participant; that is, each participant obtained a
variability index that indicated how much his or her self-representations varied across the four
relationships. They indeed found substantial individual differences in the variability of
working models. Moreover, differences in variability were systematically associated with
attachment security. Specifically, more insecure individuals tended to hold more variable
working models than more securely attached individuals. Individuals who held more variable
working models were also lower in self-esteem, less emotionally stable and ego-resilient, and
had lower self-concept clarity. With regard to relationship outcomes, variability was
associated with less adaptive relationship functioning, including lower satisfaction, less
involvement, and more conflict. Most importantly, this pattern of results held when
attachment insecurity was controlled, suggesting that variability had negative consequences
for intra- and interpersonal functioning above and beyond effects due to attachment
insecurity.
These findings are quite consistent with self-concept differentiation theory, which
suggests that variability of internal self representations across roles may indicate a
maladaptive fragmentation of the self (Donahue, Robins, Roberts, & John, 1993). The
findings go against attachment researchers’ idea that having a singular, rigid representation of
self in different relationships is likely to be maladaptive given that different relationship
partners will, in fact, behave differently and therefore should be interacted with differently
(e.g., Linville, 1987; Pierce & Lydon, 2001). However, given the lack of research on
variability of representations across relationships, it is important to test the robustness of
these findings and to examine the causal direction of these effects as well as the underlying
processes.
 Interpersonal Representations: Their Structure, Content, and Nature 41

Accuracy of Representations Varying in Specificity

Specificity of representations is likely to play a role in the extent to which these
representations are accurate and biased. Neff and Karney (2002, 2005) reasoned that for more
specific representations, it should be relatively easy to find objective standards to evaluate the
accuracy of these representations and thus more difficult to hold biased perceptions that have
little basis in reality. As representations become more general and abstract, fewer objective
standards exist, making it more necessary and more likely to develop biases. It is predicted
that more general representations are likely to be more biased and less accurate, whereas the
opposite should be true for more specific representations. It is important to note that this
proposed pattern should also hold for representations that are within the same level of the
hierarchy but differ in their extent of abstractness. For example, perceiving a partner as
“loving” is more global than perceiving him or her as “taking care of me when I’m sick.”
Global partner perceptions are likely to be less accurate than perceptions of the partner’s
specific attributes (Neff & Karney, 2005).

THE CONTENT OF INTERPERSONAL REPRESENTATIONS

Because IRs develop on the basis of repeated interactions primarily within dyadic
relationships, the content of these representations should involve representations of the self, of
others, and of the relationship between the self and others.1 As Figure 1 shows,
representations at every level of the hierarchy are hypothesized to have all of these three
components. Specifically, at the lowest, relationship-specific level, people hold
representations of themselves and each specific interaction partner, and representations of the
relationship between themselves and the partner. At the domain-specific level, they hold a
more generalized representations of the self and others involved in each type of relationship,
and representations of every type of relationship. At the highest level, individuals hold the
most general representations of the self, others, and relationships. Thus, IRs are not only
vertically connected within the hierarchy (i.e., across different levels), but also horizontally
connected (i.e., across representations of the self, others, and relationships).

Representations of the Self and Others

Relationship researchers have long-standing interests in mental representations of the self

and others. Attachment theory, one of the classical theories in relationship literature, suggests

1
Different authors have conceptualized content of interpersonal representations from slightly different perspectives.
Some researchers think of content components in terms of the target of representation (Pietromonaco &
Feldman Barrett, 2000); that is, the content of IRs includes how people represent about the self (e.g., am I
lovable?) and about others (e.g., are others trustworthy?). Other researchers conceptualize the content of
representations from a more cognitive perspective (Collins & Read, 1994; Collins et al., 2004); that is, the
content of IRs is likely to include several different types of cognitions such as memories, beliefs and
expectations, goals and needs, plans and action tendencies. Each of these two conceptualizations has their own
merits and is not mutually exclusive. I chose to take the “target” approach because the focus of the entire
article is on schema-like representations that are abstracted from past experiences and are consciously
accessible. It seems most appropriate to think of the content of these representations as including self
representations, other representations, and relationship representations.
42 Shanhong Luo

that individuals develop internal working models of self and other on the basis of repeated
interactions with primary attachment figures. Whereas models of self capture the generalized
beliefs about how acceptable and worthwhile the self is, models of others capture the
generalized beliefs about how available and responsive others are (e.g., Bowlby, 1973;
Bartholomew & Horowitz, 1991; Hazan & Shaver, 1987; Pietromonaco & Feldman Barrett,
2000). Models of self and others can be viewed as representations of self and others at the
general level.
According to relational schema theory (Baldwin, 1992), self schemas and other schemas
are two of the three key elements of relational schemas. Baldwin (1992) defined self schemas
and other schemas as “generalizations about the self and others in specific relational contexts
that are used to guide the processing of social information.” (pp. 468) Self and other schemas
thus are highly contextualized constructs and quite similar to relationship-specific
representations of the self and others in the three-level hierarchical model.
The current conceptualization of IRs is able to integrate the essence of both working
models of attachment and relational schemas and expand it into a broader framework. In
particular, I propose that the content of self representations should not limit to the worthiness
of the self; similarly, the content of other representations should not restrict to the availability
and responsiveness of others. Both self and other representations should contain multiple
dimensions including the more intrapersonal (e.g., competent, worrying) and the more
interpersonal dimensions (e.g., sociable, distant). I will illustrate this point further below.

Are Self Representations and Other Representations Independent or Interdependent?

Because IRs develop on the basis of repeated interactions between the self and others,
self representations and other representations are likely to be related to each other. According
to Bowlby’s (1973) original attachment theory, children’s models of self and models of others
are hypothesized to be mutually confirming. For example, a child with a consistently rejecting
mother may come to think of the self as worthless and of others as undependable. This
interdependence between self and other representations should also hold for adults. For
example, a person with loving and responsive romantic partner may perceive the self as
lovable and of the partner as trustworthy.
More recently several authors have argued that individuals who are involved in close
relationships are motivated to represent the self and close others in a collective rather than in
an individualistic manner (e.g., Agnew, Van Lange, Rusbult, & Langston, 1998; Aron, Aron,
Tudor, & Nelson, 1991; Cross, Morris, & Gore, 2002). Empirical research provides strong
evidence for this hypothesis. For example, individuals tend to perceive their romantic partners
and their close friends as being similar to themselves even though there is little actual
similarity between them (Kenny & Acitelli, 2001; Klohnen & Luo, 2006; Watson, Hubbard,
& Wiese, 2000b; Murray, Holmes, Bellavia, Griffin, & Dolderman, 2002; Cross et al., 2002);
they also tend to show greater spontaneous usage of plural pronouns (e.g., we, us, ours,
Agnew et al., 1998) and have more difficulty differentiating between characteristics of the
self and of close others (Aron et al., 1991); finally, individuals view partners’ successes as
shared glories rather than threats to self-esteem as the classical social comparison theory
would expect (Gardner, Gabriel, & Hochschild, 2002; Beach et al., 1998). These findings
suggest that representations of the self and of others are highly interdependent rather than
independent.
 Interpersonal Representations: Their Structure, Content, and Nature 43

However, attachment studies tend to show that self models and other models are largely
independent of each other (e.g., Cozzarelli et al., 2000; Griffin & Bartholomew, 1994; Pierce
& Lydon, 2001). How do we reconcile this seeming inconsistency? I argue that the
independence between self models and other models based on attachment research should not
be interpreted as evidence for the relation between representations of self and others, because
(1) these studies actually only measured self representations and did not explicitly measure
individuals’ representations of others (i.e., they did not ask participants to rate how they view
others); (2) essentially these studies assessed two dimensions of self representations—a more
intrapersonal dimension (which was named “self model”) captures a sense of competence and
confidence, whereas the other dimension is more interpersonal in nature (which was named
“other model”) and captures how individuals perceive themselves in relation to others (e.g.,
do individuals perceive themselves as trusting and loving, or cold and distant?) (e.g., Griffin
& Bartholomew, 1994). The interpersonal dimension (i.e., other model) is expected to be
relatively independent from the intrapersonal dimension (i.e., self model) because they
capture quite different domains of self representations. In other words, the finding that self
and other models tend to be independent only reflects the association between the two
dimensions—the intrapersonal dimension and the interpersonal dimension, rather than the
true association between self- and other representations. In order to test whether self- and
other representations are truly interdependent, particularly whether this interdependence holds
at more general levels as most evidence for the interdependence has been obtained from
studies of relationship-specific representations, future research will need to independently
assess these two representations and systematically test their associations.

Individual Differences in Self and Other Representations

Important individual differences seem to underlie representations of the self and others.
Attachment researchers have theorized that individuals with different attachment styles are
likely to hold systematically different models of self and other: Whereas primarily secure
individuals have positive beliefs about the self and others, fearful individuals are typically
characterized by low self-worth and negative expectations about others. Dismissing
individuals tend to hold negative models of others and highly positive models of the self,
whereas preoccupied individuals show the opposite pattern—they have negative beliefs about
the self and positive models of others (see Bartholomew & Horowitz, 1991; Griffin &
Bartholomew, 1994).
Pietromonaco and Feldman Barrett (2000) provided a comprehensive review regarding
the evidence for these hypothesized patterns associated with different attachment styles. They
concluded that whereas there is robust evidence for the theoretically predicted patterns of
models of self, evidence is less consistent for models of others. Part of the inconsistency
observed for other models is likely to be due to the fact that some studies examined self and
other representations in general terms (e.g., Collins & Read, 1990; Hazan & Shaver, 1987),
whereas others tested them in specific relationships (e.g., Pietromonaco & Feldman Barrett,
1997). Since every specific interaction partner is different from each other, accordingly, one’s
representations of others should show reasonable variability. In general, most previous studies
have only examined individual differences on either general representations or a specific type
of representations and thus failed to take into consideration the fact that individuals hold
multiple representations at different levels. Thus, it will be important for future research to
clarify (1) for each level in the hierarchy of IRs, how different individuals represent the self
44 Shanhong Luo

and others and (2) to what extent these individual differences in self representations and other
representations hold across different levels of abstractness.

Importance of Self and Other Representations to Relationship Functioning

Self- and other representations have strong associations with relationship satisfaction.
Previous research has shown that individuals who perceive themselves as low in self-esteem,
highly neurotic, or insecurely attached tend to be less satisfied with their relationship; their
relationships also tend to be less stable (e.g., Karney & Bradbury, 1995; Murray, Holmes, &
Griffin, 2000; Campbell, Simpson, Boldry, & Kashy, 2005; Watson, Hubbard, & Wiese,
2000a). Individuals tend to be happier in their relationships if they perceive their partner as
more extraverted, agreeable, conscientious, and less neurotic, and if they view their partner as
less avoidant and anxious (e.g., Kosek, 1996; Watson et al., 2000a; Watson et al., 2004).
Watson et al. (2000a, 2004) used both individuals’ self-ratings and partner-ratings on a range
of individual difference domains (e.g., Big Five, affectivity) to predict relationship
satisfaction in dating and married samples. Their findings showed that in spite of their
interdependence, self and other ratings made independent, substantial contributions to the
prediction of relationship satisfaction. However, partner ratings tended to contribute more
than self ratings did, suggesting that self and partner representations may play different roles
in relationship maintenance and that partner representations may be the more proximal
predictors of relationship satisfaction than self representations.

Relationship Representations

In their interactions with others, individuals form representations of many aspects of their
interpersonal experiences. Self- and other representations are two subsets of these
representations. In addition to holding representations of the self and others, individuals may
also develop representations of the relationship between themselves and others. Relationship
representations can be conceptualized as organized knowledge, perceptions, and evaluations
of the relationship between the self and others. The content of relationship representations
may include perceptions of various aspects of the relationship such as relationship closeness,
mutual trust, control in relationship, optimism about future of relationship, severity of
relationship conflict, and quality of communication.
To date, there has been sporadic discussion about relationship representations in the
relationship literature. For example, attachment theorists propose that internal working
models have two primary components—models of the self and models of others. Although
some authors have suggested that working models may also include models of the
relationship between the self and others (e.g., Pietromonaco & Feldman Barrett, 2000), there
is no systematic conceptualization of relationship representations as a unique component of
working models. Other theorists tend to focus on representations of specific interactions or
events between the self and others rather than on representations of the relationship between
the two (Baldwin, 1992; Stern, 1985; Mitchell, 1988; Safran, 1990a, 1990b). For instance, in
addition to proposing that self schemas and other schemas are important components of
relational schema, Baldwin (1992) defined a third component, interpersonal scripts, as
schemas for the typical “if-then” interaction sequences between self and other in a particular
situation. Example interpersonal scripts are “if I come home late, my girlfriend will suspect
 Interpersonal Representations: Their Structure, Content, and Nature 45

that I am with some other girl and will complain for hours.” Because interpersonal scripts are
schemas of “if-then” interaction sequences between the self and specific others, whereas
relationship representations are expected to consist of generalized expectations regarding the
relationship between the self and others, interpersonal scripts can be thought of as forming the
basis of relationship representations.
It is very important for researchers to start to consider relationship representations as a
unique component of IRs and as an equally important component as self- and other
representations. Although relationship representations are likely to be closely associated with
representations of self and others, they may contain unique perceptions of the relationship and
reflect the interactive nature of the relationship that is not likely to be fully captured by self
and other representations. Thus including relationship representations in the study of IRs
should greatly improve our understanding of IRs.
Empirical research regarding relationship representations is scarce. However, some initial
findings shed important light on the link between relationship representations and self
representations. Helgeson (1994) found that positive self-beliefs and positive relationship
beliefs showed differential predictive power to general psychological wellbeing (i.e., anxiety,
depression, hostility) and relationship outcomes (i.e., breakup or not, adjustment to physical
separation, adjustment to breakup). More specifically, positive self-beliefs were associated
with better wellbeing but not with relationship outcomes, whereas relationship beliefs
predicted all three relationship outcomes. Fowers, Lydons, and Montel (1996) tested whether
positive illusions about marriage are primarily outgrowths of the self-enhancing illusions or
an integral part of a satisfaction maintenance mechanism. Their results supported that positive
illusions about marriage are more closely associated with marriage quality than with self-
enhancement tendencies. Finally, Endo, Heine and Lehman (2000) found that relationship-
serving biases were largely unrelated to self-esteem and self-serving biases. Overall, it seems
that relationship representations are quite distinct from self representations and may serve
very different functions. As Van Lange and Rusbult (1995) pointed out, “compared to self-
enhancement processes, relationship enhancement may be more complex… and may be
multifaceted.” However, these pioneering studies have focused on one particular aspect of
relationship representations—enhancement perceptions and have only examined the links
between relationship representations and self representations. It thus will be important to test
(1) how relationship representations and other representations are associated and (2) whether
these two components independently predict relationship outcomes.

THE NATURE OF INTERPERSONAL REPRESENTATIONS

To date, theorizing about the nature of IRs has been limited to the notion that IRs are
internalized, general beliefs about the self in relation to others that develop from past
interpersonal experiences. For example, attachment theorists have suggested that working
models include general beliefs about self and others (e.g., Bowlby, 1973; Collins & Read,
1994). According to Baldwin’s (1992) conceptualization, relational schemas primarily consist
of generalizations about self and other as well as expectations of behavior sequences involved
in their interactions. However, what is exactly the nature of these “general beliefs” about self,
others, and the relationship? These theories did not provide further hypotheses. One important
46 Shanhong Luo

purpose of this chapter is to provide a useful conceptualization of the nature of IRs. Although
IRs are likely to include other components such as past memories and future goals (see
Collins & Read, 1994; Collins et al., 2004), the focus here is on the nature of “working”
representations that are expected to have the most direct and powerful influence on
individuals’ current thoughts, feelings, and behaviors. In particular, I focus on consciously
accessible representations that can be assessed by self-report methods.
One way to conceptualize the nature of IRs is to think from the perspective of accuracy
and inaccuracy of these representations. Individuals are able to obtain reasonable accuracy
when they are motivated to be accurate and have sufficient cognitive resources to do so (see
Gagne & Lydon, 2004). At the same time, representations may be systematically biased in
one way or another due to cognitive (e.g., Watson et al., 2000b) and motivational factors
(e.g., Klohnen & Luo, 2006; Murray, Holmes, & Griffin, 1996a; Murray et al., 2002). Finally,
random perceptual errors occur due to temporary, situational factors (see Funder, 1995;
Murray et al., 1996a). Therefore, the nature of IRs should necessarily reflect reality to some
degree and should also contain misperceptions. Some misperceptions are systematic biases
and some are purely erroneous perceptions (see Figure 2). Accordingly, it is useful to
conceptualize IRs as a composite of accurate perceptions, systematic biases, and random
errors (see Klohnen & Luo, 2006; Murray et al., 1996a). This three-component
conceptualization can be readily incorporated in the proposed hierarchical model of IRs. We
can think of the three components as being nested within self, other, and relationship
representations at each level of the hierarchy. That is, general, domain-specific, and
relationship-specific representations of self, others, and relationships, should all contain
accurate perceptions, systematic biases, and random errors.

Interpersonal Accurate Inaccurate

Representations = Perceptions + Perceptions

Systematic Random
Biases Errors

Figure 2. A conceptualization of the nature of interpersonal representations.

In the following sections of the article, my focus is on the systematic components of

representations—accurate and biased perceptions since these two components are expected to
have systematic and most meaningful influences on personal and relational outcomes. I first
discuss the methodological approaches to studying accuracy and bias, followed by a review of
research regarding accuracy and bias in representations of the self, the partner and the
relationship in the romantic context. I choose to focus on accuracy and bias in romantic
representations because romantic relationship is usually the most influential relationship in
adulthood and thus romantic representations should have the greatest impact on individuals’
intra- and interpersonal functioning.
 Interpersonal Representations: Their Structure, Content, and Nature 47

Approaches to Conceptualizing and Measuring Accuracy and Bias

There are two major approaches to conceptualizing and assessing accuracy and bias: the
logical impossibility approach and the accuracy benchmark approach (see Funder, 1995;
Taylor & Brown, 1988).

The Logical Impossibility Approach

This approach has been widely used to examine social comparison processes. In a typical
paradigm of this approach, participants are asked to rate themselves relative to average others.
Results show the majority rate desirable attributes as more descriptive of themselves than of
average others (the “above-average effect”) and undesirable attributes as less descriptive of
themselves than of the average others (the “below-average effect”) (e.g., Brown, 1986;
Kruger, 1999). Because most attributes have a statistically normal distribution, it is logically
impossible for the majority to be truly better than the average; that is, some people must be
exaggerating. This self-serving tendency is considered to be a bias. The “better than average
effect” is seen not only in self perceptions, but also in perceptions of one’s close others,
including romantic partners (e.g., Murray & Holmes, 1997), friends (e.g., Brown, 1986; Suls,
Lemos, & Stuart, 2002), and family members (e.g., Endo et al., 2000). Although this
approach clearly shows that some people in the population must be biased, it does not allow
us to pinpoint who are biased and to what extent these individuals are biased.

The Accuracy Benchmark Approach

Researchers who take this approach first need to define an accuracy benchmark, which
then allows them to show to what extent individuals’ perceptions deviate from that
benchmark. Any systematic differences between individuals’ perceptions and the accuracy
benchmark are then considered a bias. This approach is popular among psychologists who are
interested in self perceptions and other perceptions. The basic assumption behind this
approach is that individuals’ perceptions contain both accurate perceptions and biases, and it
is possible to separate accurate perceptions and biases as long as there is an accuracy
benchmark. However, unlike object perception, for which we are able to find some objective
criteria to judge whether the perceptions are accurate or not, there is no perfect “objective
truth” or accuracy benchmark in person perception. In fact, various accuracy benchmarks
have been used and justified depending on the particular research purposes (e.g., Funder,
1995).
In the study of intimates’ perceptions, one possible accuracy benchmark is ratings
provided by an outside observer of the couple, for example, a common friend to both partners.
Self-friend agreement on ratings of the same attributes is then considered as an index of
accuracy. If intimates’ ratings significantly and systematically deviate from the ratings made
by outsiders, the deviations are considered as indicators of perceptual bias (e.g., John &
Robins, 1994; Murray, Holmes, Dolderman, & Griffin, 2000). Self-ratings provided by the
partners can be another accuracy benchmark for individuals’ perceptions of their partners.
Deviations in participants’ partner perceptions from the partners’ self-perceptions are then be
considered as evidence of bias (e.g., Murray et al., 1996a, 1996b; Kenny & Acitelli, 2001;
Klohnen & Luo, 2006; Watson et al., 2000b; see Gagne & Lydon, 2004 for a more detailed
review).
48 Shanhong Luo

Accuracy and Bias in Self Representations

Overall, people seem to hold fairly accurate self representations because (1) there is
substantial agreement between participants’ self ratings and their partner’s ratings of them
(e.g., Klohnen & Luo, 2006; Watson et al., 2000b; Murray et al., 1996a), (2) the agreement
between participants’ self-ratings and friends’ ratings of them is reasonable (e.g., John &
Robins, 1994; Murray et al., 2000), and (3) self-evaluations of performance show
considerable convergence with evaluations from unacquainted peers and observers (John &
Robins, 1994). Despite this accuracy, there is also robust evidence that individuals’ self
representations are biased. Taylor and Brown (1988) published an influential review of the
enhancement bias in self-concepts. They suggest that self-enhancement biases are a rule
rather than an exception and that these biases can be observed in three domains: (a) overly
positive views of the self, (b) exaggerated perceptions of personal control, (c) unrealistic
optimism about one’s future.
How do romantic relationships influence individuals’ self representations? Important
changes in self views seem to take place when people start to have romantic feelings for
somebody. Aron, Paris and Aron (1995) followed their participants five times over 10 weeks
and found that those who had just fallen in love during this period showed significant self-
concept changes: participants discovered new aspects of self, and their self-efficacy and self-
esteem increased. These findings indicate that falling in love has a powerful, positive
influence modifying self representations. However, because the researchers only obtained
self-report measures of the representations, it is not clear to what extent the changes in self-
concepts reported by those who fell in love would be evident to outside observers; that is, we
are not sure how accurate these changes are. We also do not know whether these changes in
self representations are permanent. For example, would individuals lose the changes in self-
concepts when they do not have feelings for the person any more? Would they show negative
changes in self representations when they experience relationship break-ups? Longitudinal
studies following individuals throughout their relationships are needed to answer these
questions.
Research on dating and married couples suggests that people in relationships may rely on
their partners’ feedback to construct their self views. Murray et al. (1996b) followed dating
individuals over a year and found that partners’ initial perceptions of participants were a
significant predictor of participants’ self-perceptions one year later when participants’ initial
self perceptions were controlled. This finding suggests that intimates tend to incorporate
partners’ perceptions into their self views. Drigotas and his colleagues (Drigotas, 2002;
Drigotas, Rusbult, Wieselquist, & Whitton, 1999) found that the more individuals believed
that their partner perceive them in line with what they ideally would like to become, the more
individuals indeed became so over time. It seems that partners’ perceptual confirmation of
individuals’ ideal self motivates them to move further toward their ideal self, thus bringing
their actual self representations closer to their ideal self over time. In summary, romantic
partners’ feedback plays an important role in shaping individuals’ self representations.
 Interpersonal Representations: Their Structure, Content, and Nature 49

Accuracy and Bias in Romantic Partner Representations

Partner representations have been extensively studied in the past decade. Overall,
research suggests that there is substantial accuracy in individuals’ partner representations. For
instance, individuals’ ratings of their partners show moderate agreement with partners’ self-
ratings (Kenny & Acitelli, 2001; Klohnen & Luo, 2006; Klohnen & Mendelsohn, 1998;
Watson, et al., 2000b; Murray et al., 1996a, 1996b). Individuals also share considerable
agreement with their friends regarding perceptions of their partners (Murray et al., 2000).
Finally, married and dating couples are relatively accurate in inferring each other’s ongoing
thoughts and feelings (Thomas, Fletcher, & Lange, 1997; Thomas & Fletcher, 2003). On the
other hand, as the old saying “beauty is in the eyes of the beholder” illustrates, partners’
perceptions of each other are nevertheless biased even though they are able to perceive their
partners fairly accurately. In order to test how people form perceptions of their partners,
researchers have examined possible ways by which individuals’ perceptions of their partners
systematically deviate from the partners’ self-perceptions.

Perceiving Actual Partner as Being Similar to One’s Ideal Partner

Everybody has his or her own ideas about what their ideal partner is like. However, in
real life very few people end up with a partner who fits their ideal images perfectly. Rather
than being constrained by the less-than-perfect reality of what partners are actually like,
individuals may be motivated to view their partners in an idealized fashion. For example,
research has consistently shown that individuals perceive their partner as being similar to
their ideal partner standards to a degree that goes beyond the actual resemblance between
their partner’s self-ratings and their ideal partner images (Murray et al., 1996a, 1996b). More
importantly, individuals tend to be happier and stay longer in their relationships when they
perceive partners close to their own ideal partner images (Fletcher, Simpson, & Thomas,
2000; Fletcher, Simpson, Thomas, & Giles, 1999). Therefore, distorting partner perceptions
in the direction of one’s ideal partner images may have beneficial rather than detrimental
effects.

Perceiving the Partner as Being Similar to One’s Ideal Self

The motivation that underlies this process is similar to the previous one. Individuals seek
in partners what they value in themselves and what they ideally want to be but are not able to
achieve; in short, individuals are motivated to fulfill their own “ideal self” in their partners
(Klohnen & Mendelsohn, 1998; Klohnen & Luo, 2003). However, because people do not
always secure a partner who resembles their ideal self, they might bias their partner
perceptions toward their ideal self. There is empirical evidence for this hypothesized
perceptual pattern. At the initial attraction stage, the more similar the potential partner is
perceived to be to one’s ideal self, the more attractive the partner appears to be (Klohnen &
Luo, 2003; LaPrelle, Hoyle, Insko, & Bernthal, 1990). Dating and married individuals tend to
perceive their partners as being more similar to their ideal selves than they actually are
(Murstein, 1971; Klohnen & Mendelsohn, 1998). It seems that people wish to be with
somebody who has the potential to fulfill their ideal self and are motivated to perceive their
current partners in line with their ideal selves.
50 Shanhong Luo

Perceiving the Partner in An Overly Positive Way

Individuals may also be motivated to simply perceive their partner in a generally positive
light or in a socially desirable way—not necessarily in line with their ideal self or ideal
partner images. There are good reasons for people to do so because positive biases allow them
to maintain their conviction that their partner is the “right” one and that their relationship is
worth keeping, particularly when the relationship is threatened by feelings of doubt and
uncertainty (Murray, 1999). Indeed, recent research provides robust evidence for positive
biases in partner perceptions. Research taking the logical impossibility paradigm has well
documented the “(partner) better than average effect” among dating and married individuals;
that is, the majority of individuals believe their own partners are more virtuous than average
or typical partners (e.g., Murray & Holmes, 1997; Endo et al., 2000) and better than their
friends’ partners (e.g., Murray et al., 2000). Research based on the accuracy benchmark
approach also shows that intimates tend to perceive their partners more positively than the
partners view themselves or their friends perceive the partner (e.g., Murray et al., 1996a,
1996b, 2000). Moreover, individuals who hold these positive biases tend to be happier and
their relationships are more likely to persist over time (e.g., Murray et al., 1996a, 1996b;
Rusbult, Van Lange, Wildschut, Yovetich, & Verette, 2000).

Perceiving the Partner as Being Similar to One’s Actual Self

From a motivational perspective, it is psychologically rewarding to perceive partners
similar to the self because the perceived similarity may validate one’s self views, increase
familiarity between intimates, and result in fewer disagreements and conflicts (Aron et al.,
1991; Klohnen & Luo, 2003; Murray et al., 2002). In fact, the more individuals perceive a
potential partner as similar to themselves, the more attracted they are to him or her (Klohnen
& Luo, 2003). People in dating and married relationships also exaggerate the similarity
between themselves and their partner on a variety of dimensions such as interpersonal
qualities, values, and feelings (Murray et al., 2002; Kenny & Acitelli, 2001), general
personality and affectivity (Klohnen & Luo, 2006; Watson et al., 2000b), adaptive and non-
adaptive personality characteristics (Ready, Clark, Watson, & Westerhouse, 2000), and
attachment dimensions (Klohnen & Luo, 2006; Ruvolo & Fabin, 1999). It is important to note
that different labels have been applied to this general phenomenon, including “egocentrism”
(Murray et al., 2002), “similarity bias” (Klohnen & Luo, 2006), “assumed similarity”
(Watson et al., 2000b), “self-based heuristic” (Ready et al., 2000), and “social projection”
(Ruvolo & Fabin, 1999). Irrespective of the label, the underlying idea is the same—intimates
tend to perceive more similarity between themselves and their partners than their actual
similarity. Furthermore, this similarity bias is positively associated with feelings of being
understood and relationship satisfaction (Klohnen & Luo, 2006; Murray et al., 2002).
In summary, individuals’ partner representations include both accurate and biased
perceptions. There appears to be several processes leading to biases in partner
representations: perceiving partners as similar to one’s actual self, ideal self, ideal partner, as
well as perceiving partners in an overly positive way. There is at least one other process in
partner perceptions—perceiving partners as highly secure in terms of attachment (Klohnen &
Luo, 2003). It is likely that these processes may be partly overlapping, or that one or several
of these processes may be more influential than others. So far no study has investigated all of
these processes in the same context. Klohnen and Luo (2003) examined three processes in
participants’ perceptions of hypothetical dating partners: perceiving the partner as similar to
 Interpersonal Representations: Their Structure, Content, and Nature 51

(a) participants’ actual self, (b) their ideal self, and (c) the secure attachment prototype.
Results showed that the effect of perceptual security on attraction to the partner was
subsumed by the effect of perceptual ideal self similarity. However, both actual and ideal self
similarity made significant and independent contributions to the prediction of attraction.
Future research should examine all of these processes simultaneously to determine which of
these processes has the strongest influence on partner representations, and to what extent
these processes make independent contributions to attraction and subsequent relationship
development.

Accuracy and Bias in Romantic Relationship Representations

Although relationship representations have received less attention compared to self- and
partner representations, several studies have shown that accuracy and bias coexist in romantic
relationship representations. Evidence for accuracy in relationship representations mainly
comes from two types of research: First, representations are considered accurate if dyadic
partners’ ratings of the relationship are correlated. For example, couples’ perceptions of
improvement in their relationship, optimism about the relationship, perceptions of joint
control over events in the relationship were moderately correlated (Murray & Holmes, 1997;
Spretcher, 1999). Second, individuals’ thoughts and feelings about their relationship (e.g.,
their self-reported love, satisfaction, commitment, and closeness) are valid predictors of the
future status of their relationships (see Gagne & Lydon, 2004 for a review). Individuals’
predictions of their own relationship length are also moderately correlated with how long
their relationships last six months later (MacDonald & Ross, 1999). On the other hand, recent
research also shows robust evidence for relationship enhancement bias. Parallel to Taylor and
Brown’s (1988) typology of self enhancement bias, relationship enhancement bias can be
categorized into three domains: perceived superiority of one’s own relationships, exaggerated
control over relationships, and unrealistic optimism about the relationship development.

Perceived Superiority of One’s Own Relationships

Individuals take it for granted that their own relationships are much better than those of
others. For example, intimates perceive the quality of their own relationships or marriages as
better than that of average others’ in terms of closeness, mutual understanding,
supportiveness, happiness, and the importance of the relationship (Endo et al, 2000; Fowers,
Lyons, Montel, & Shaked, 2001). Individuals also tend to rate their relationships as better
than those of their friends (Helgeson, 1994; Van Lange & Rusbult, 1995; Rusbult et al., 2000;
Agnew, Loving, & Drigotas, 2001; Martz et al., 1998). Compared to outside observers, such
as friends, intimates egocentrically view their own relationships more positively (MacDonald
& Ross, 1999; Murray et al., 2000).

Exaggerated Control Over One’s Own Relationships

Murray and Holmes (1997) asked dating and married individuals to rate the amount of
joint control they possessed over positive and negative events within their relationships; that
is, their ability to increase the probability of good outcomes and decrease the probability of
bad outcomes. Results showed that participants believed that they had much more control
52 Shanhong Luo

than other couples had. Using a similar procedure, Martz et al. (1998) found that intimates
also believed that they had better control over their relationships than their friends had.

Unrealistic Optimism about Romantic Relationship Development

People tend to egocentrically believe their relationships are getting better over time.
Sprecher (1999) conducted a longitudinal study that followed couples over four years. When
asked to make a global comparison between their current relationship quality and the
relationship quality measured last time, participants believed that their relationships were
becoming more enjoyable and satisfactory. However, their actual ratings of relationship
satisfaction obtained each time showed that their satisfaction, in fact, decreased over time.
Another longitudinal study conducted by Karney and Frye (2002) corroborated this finding.
They followed newlyweds over 10 years and found that intimates’ actual ratings of marital
satisfaction were getting lower as time went by; however, when thinking in retrospective,
they believed that their relationships were becoming better. Individuals also tend to
overestimate how long their own relationships will last, whereas their roommates, friends and
parents make more accurate predictions (Drigotas et al., 1999; MacDonald & Ross, 1999).
When it comes to prediction of the likelihood of divorce, the majority of married respondents
believed that they were unlikely to divorce, while the national divorce rate is nearly 50%
(e.g., Fowers et al., 2001; Heaton & Albright, 1991).
In summary, partners tend to show reasonable agreement with each other in their views
and predictions of the relationship. On the other hand, they egocentrically believe that their
own relationships are better than others, that they have more control over their own
relationships, and that their relationships are becoming better. These relationship-
enhancement biases are associated with better concurrent relationship outcomes, such as
greater satisfaction and less conflict; these biases are also associated with greater relationship
stability (Murray & Holmes, 1997). Given that representations of the self, partners, and
relationships all contain enhancement biases, one important next step is to examine the how
self-, partner-, and relationship-enhancement biases are related to each other and whether
these biases play independent roles in relational functioning.

Revisiting Several Key Questions about Accuracy and Bias

Over the last decade, an increasing number of researchers have become interested in
accuracy and bias in perceptions of romantic partners (Gagne & Lydon, 2004; Kenny &
Acitelli, 2001; Klohnen & Luo, 2006, 2005b; Klohnen & Mendelsohn, 1998; Murray et al.,
1996a, 1996b, 2002; Neff & Karney, 2002, 2005). However, theorizing and research on this
topic to date are quite limited because (1) most research and theory have primarily been
concerned with understanding “when and how people are accurate as well as when and how
they are mistaken” (pp. 652, Funder, 1995) rather than systematically considering accuracy
and bias in the same context, and (2) previous research has not vigorously related accuracy
and bias to other variables such as individual differences and relationship outcomes. I hope
that conceptualizing the nature of IRs as containing accurate and biased perceptions (as well
as random errors) will provide helpful insights for addressing the following questions about
accuracy and bias.
 Interpersonal Representations: Their Structure, Content, and Nature 53

How Should We Conceptualize the Relation between Accuracy and Bias?

The above review of romantic representations provides robust evidence that accuracy and
bias coexist in representations people hold about themselves, their partners, and their
relationships. In fact, this has become a consensus among relationship researchers (Gagne &
Lydon, 2004; Kenny & Acitelli, 2001; Klohnen & Luo, 2006; Neff & Karney, 2002, 2005).
However, little research has examined how being accurate is associated with being biased. A
common, naïve assumption is that accuracy and bias are mutually exclusive; that is, the more
accurate one’s perceptions are, the less biased these perceptions must be. Klohnen and Luo
(2006) explicitly proposed that accuracy and bias do not have to be inversely associated.
Because IRs are conceptualized to consist of accurate perceptions, systematic biases, and
random errors, it is possible that when one of the three components changes, it does not
necessarily translate into direct, one-to-one change in the other components. The association
between perceptual accuracy and bias is likely to depend on the specific context in which
these perceptions develop, such as the nature of the relationship and the degree of
acquaintanceship. In the context of committed romantic relationships, Klohnen and Luo
(2006) reasoned that accuracy and bias in partner perceptions are independent because the
motivational factors that are likely to foster accuracy and those likely to foster biases are quite
distinct in nature. Indeed, their results showed that accuracy was unrelated to the similarity or
positivity bias.
It is interesting to reflect on what these findings really mean. They suggest that knowing
how accurate a person’s perceptions of his partner are, does not necessarily inform us about
how biased he is—he may be very biased, moderately biased, or not at all biased. These
findings thus fundamentally challenge the common assumption that greater accuracy in our
perceptions of others must necessarily entail becoming less biased. I hope that this new
perspective will stimulate more research on the nature of the association between accuracy
and bias. For example, it will be important to examine how type of relationship and
acquaintanceship may moderate the relation between accuracy and bias (see Klohnen & Luo,
2006).

Is Everybody Equally Accurate and Biased?

Although on average, individuals tend to be both accurate and biased when perceiving
their partners, there appears to be considerable variability in the degree to which they are
accurate and biased. Luo and Klohnen (2006) found that more ego-resilient and more securely
attached individuals tend to show greater accuracy, similarity bias, and positivity bias in
partner perceptions. Murray et al. (1996a, 1996b) showed that individuals with more positive
self-views tend to see their partners more consistent with their ideals, whereas those who have
more negative self-views engage in less idealization of their partners. John and Robins (1994)
found that there was substantial variation in the extent to which individuals enhance their self
evaluations; in particular, people whose self-evaluations were the most unrealistically positive
tended to be narcissistic. It appears that individuals’ tendency to be accurate and biased are at
least in part a function of who they are (see also Gagne & Lydon, 2004). However, the
processes underlying the link between individual differences and perceptual accuracy or bias
have not been fully explored.
54 Shanhong Luo

Which is More Adaptive: Accuracy or Bias?

Another interesting question is to what extent accuracy and bias in IRs are beneficial.
There has been a long debate regarding whether accuracy or positive bias is more adaptive.
Some researchers argue that positivity or enhancement bias is adaptive (e.g., Endo et al.,
2000; Martz et al., 1998; Murray et al., 1996a, 1996b; Murray & Holmes, 1997; Taylor &
Brown, 1986), whereas others argue that accurate perceptions are beneficial (Colvin, Block,
& Funder, 1995; Kobak & Hazan, 1991; Swann, Hixon, & De La Ronde, 1992; Swann, De
La Ronde, & Hixon, 1994). It is suggested that these seemingly contradictory perspectives
may both be true to some extent and can be reconciled if we conceptualize the relationship
between accuracy and bias not as mutually exclusive but as relatively independent. Based on
this conceptualization, it is possible for accuracy and bias to both have adaptive effects.
Klohnen and Luo (2006) provided the most direct evidence for this proposition. They
created an accuracy index and a positivity index for each individual in their newlywed
sample; results suggested that accuracy and positivity bias contributed independently to the
prediction of marital satisfaction. Neff and Karney (2005) also found that accuracy and
positivity bias can operate simultaneously at different levels: Although most newlyweds
enhanced their partners at the level of global perceptions, those who held more accurate
perceptions of partners’ specific qualities were more supportive and less likely to divorce.
Finally, Katz and her colleagues (Katz & Joiner, 2002; Katz, Anderson, & Beach, 1997)
found that the association between positivity bias and relationship satisfaction was
curvilinear, indicating that even though people tend to idealize their partners, their
perceptions are also constrained by reality; perceptions that are too positive and have no basis
in reality tend to have negative effects on relationships. These results consistently show that
both accurate perceptions and positive bias are important to relationships.
With regard to the adaptive value of similarity bias, researchers have found that similarity
bias is associated with better marital satisfaction (Murray et al., 2002). More importantly,
Klohnen and Luo (2006) showed that accuracy and similarity bias made independent
contributions to the prediction of satisfaction. In summary, these findings suggest that both
accuracy and bias are beneficial and important to a happy, satisfactory relationship or
marriage. It is likely that a combination of moderate accuracy and bias may be most adaptive
for relationship functioning; that is, accuracy without bias or bias without accuracy can both
have negative implications for relationships (see also Gagne & Lydon, 2004; Neff & Karney,
2005).

FURTHER CONSIDERATIONS
The primary aim of this chapter was to review, discuss, and propose theories and research
relevant to how people represent their interpersonal relationships based on past experiences,
with a particular emphasis on romantic contexts. Specifically, I have discussed three
important aspects of IRs: their structure, content, and nature. Although the discussion has
mainly focused on these aspects of IRs, I would like to draw attention to several additional
questions that are broader in scope.
 Interpersonal Representations: Their Structure, Content, and Nature 55

Do Interpersonal Representations Contain Both Implicit and Explicit

Components?

I have been mainly discussing consciously accessible (i.e., explicit) representations that
can be obtained from self-report measures. However, IRs are likely to include more than just
explicit components. Research on attitudes, self-esteem, and stereotypes suggests that these
psychological processes contain both implicit and explicit components that independently
influence perceptions, judgments and behaviors (for a review see Greenwald & Banaji, 1995).
Recent empirical evidence suggests that personality also includes implicit and explicit
components (Asendorpf, Banse, & Mucke, 2002). Although little direct evidence indicates
that IRs contain both explicit and implicit components, relationship researchers have reflected
on this possibility. For example, attachment theorists have suggested that conscious and
unconscious working models may be inconsistent and that the more conscious side may serve
self-defensive functions (Bowlby, 1980; Collins & Read, 1994; Collins et al., 2004;
Mikulincer, 1995; Pietromonaco & Feldman Barrett, 2000; Simpson & Rholes, 2002). In
particular, Bartholomew (1997) elaborated on this issue in light of the observation that
dismissing individuals tend to hold positive self models and that preoccupied individuals tend
to hold positive other models when assessed with explicit measures. She noted that at some
unconscious level dismissing individuals may feel negatively about themselves, yet they
manage to maintain a positive self-image as a way to defend a “fragile” sense of self.
Similarly, preoccupied individuals may unconsciously hold negative models of others, and
their conscious positive other models are a defense against the fact that their significant others
are at times unavailable and unsupportive.
In order to get a comprehensive understanding of IRs, it is extremely important for
researchers to use more implicit measures (e.g., the Implicit Association Test) in addition to
explicit measures to examine representations that are less masked by conscious self-defense
or self-presentation motives. Specific questions to be addressed include: (1) Are there
systematic discrepancies between responses obtained from explicit and implicit measures of
IRs? (2) If there are systematic discrepancies, does the nature of these discrepancies differ
across individuals? (3) How do explicit and implicit representations jointly influence the
processing of information? (4) Are explicit and implicit representations differentially
associated with personal and relationship well-being?

How Do Interpersonal Representations Influence Perceptions, Feelings, and

Behaviors?

The main purpose of this chapter is to review theories and research regarding the more
static aspects of IRs—their structure, content, and nature. However, one of the most important
tasks that relationship researchers face is to understand the dynamic aspects of IRs—how
representations affect individuals’ perceptions, feelings, and behaviors. Social cognition
research has provided important insights in this regard. Representations can be largely
categorized into two types in terms of their accessibility. Most frequently used representations
become chronically accessible and they influence information processing in an automatic
manner, whereas representations that are less accessible can be temporarily activated (e.g.,
56 Shanhong Luo

Bargh, Bond, Lombardi, & Tota, 1986); which specific representations that are activated and
used to guide perceptions and behaviors will likely depend on the extent to which it applies to
the specific situation (see Higgins, & Brendl, 1995).
IRs, just like other mental representations, include both chronically and temporarily
accessible representations. Different individuals are likely to hold different chronically
accessible representations that have automatic and systematic influence on their perceptions,
feelings, and behaviors. For example, individuals with low self-esteem may hold chronic
negative self representations that may lead them to perceive others’ positive feedback as
sarcastic. With chronic positive other representations, securely attached individuals may
interpret their partner’s absence as temporary and unintentional. For individuals who hold
chronic negative relationship representations, they may be hesitant to get involved in
committed relationships because they believe that relationships are difficult and frustrating.
Research designed to examine temporarily accessible IRs is still at its earliest stage;
however, initial findings shed important light on how these representations are activated and
applied to subsequent information processing. For example, Mikulincer, Gillath, and Shaver
(2002) found that subliminal priming of threat led to increased accessibility of representations
of attachment figures, suggesting that situation plays an important role in the activation of
representations. Baldwin, Carrell, and Lopez (1990) found that participants gave less positive
self-evaluations after the subliminal presentation of a disapproving significant other, whereas
subliminally priming a disapproving non-significant other did not have any effect.
Mikulincer, Hirschberger, Nachmias, and Gillath (2001) subliminally primed attachment-
secure representations or non-attachment representations and found that the primed secure
representations led to more positive reactions to neutral stimuli than non-attachment priming
did. Pierce and Lydon (2001b) showed that subliminal activation of positive interpersonal
expectations increased reports of seeking emotional support and decreased the use of self-
denigrating coping, whereas activation of negative interpersonal expectations decreased
experiences of positive affect and tended to impede constructive coping.
In summary, it seems that both chronic accessible and temporarily activated
representations strongly influence the processing of incoming information. Given that social
cognition research has shown that chronically and temporarily accessible representations have
additive influences on social perception (Bargh et al., 1986), it will be useful for relationship
researchers to explore the nature of the joint influence of these two types of representations in
relationship contexts—whether their effects are independent, overlapping, or interactive.

Stability and Change in Interpersonal Representations

Most theorists acknowledge that IRs are quite stable over time but also changeable when
life circumstances change (e.g., Bowlby, 1969; Pietromonaco, Laurenceau, & Feldman
Barrett, 2003). Indeed, previous research has provided robust evidence that individuals’
representations of themselves and others are remarkably stable over time (e.g., Kirkpatrick &
Hazan, 1994; Klohnen & Bera, 1998; Murray et al., 1996b; Scharfe & Bartholomew, 1994).
In spite of this high stability, IRs also show interesting changes over time in response to new
experiences. For example, when individuals fall in love with somebody, their self concepts
are expanded and their self-esteem increases (Aron et al., 1995). Dating and married
individuals come to adopt partners’ perceptions of them into their self representations
 Interpersonal Representations: Their Structure, Content, and Nature 57

(Murray et al., 1996b; Drigotas et al., 1999). They also tend to represent the self and close
others as a unit over time (e.g., Aron et al., 1991; Agnew et al., 1998). The marital
intervention literature suggests that it is possible and useful to induce changes in people’s
representations of the self, the spouse, and the relationship; these changes provide alternatives
to maladaptive representations (see Pietromonaco et al., 2003 for a review).
To date, research investigating the question of representational stability has primarily
focused on individuals who are involved in well-established relationships. Only a few studies
have examined IRs at earliest stages of relationship development (Aron et al., 1995; Fletcher
et al., 2000). Even less research has been conducted to examine how individuals represent
themselves, their ex-partners, and previous relationships after the relationship has dissolved
(but see Felmlee, 2001 for an exception). Given that individuals tend to hold “positive
illusions” for themselves, their partner, and their romantic relationship while they are
involved in an ongoing relationship, would they become more objective or more negatively
biased after they break up with their partner? It is very important to examine IRs throughout
the entire course of relationship development, including initial crush or attraction,
consolidation, and dissolution. This type of longitudinal research is extremely valuable
because they not only inform us regarding the stability of IRs, but also help to address
questions regarding the direction of causality between representations and relationship
outcomes, for example, do positive partner representations lead to attraction or does attraction
to someone make people biased?

CONCLUSIONS
A good understanding of how people represent themselves in relation to others is of
enormous importance to relationship research because what we think about ourselves, others,
and our relationship is likely to greatly influence how we attend to new information and how
we interpret new facts; moreover, our representations guide what we feel and how we act in
relationships. The structure, content, and nature are the three most fundamental aspects of
these representations. Understanding these aspects of IRs as well as of the links between IRs
and individuals’ feelings and behaviors in relationships also has important practical
implications because such knowledge helps us design interventions that will hopefully
promote healthy relationship patterns and prevent maladaptive ones from developing in the
first place. The study of IRs is therefore both theoretically rich and practically valuable. It
nicely bridges social cognition and relationship research, and cuts across different areas of
psychology, including social, personality, developmental, and clinical psychology. This
challenging work will likely require creative methodologies that combine techniques typically
employed by social psychologists (e.g., priming, response latencies) and research designs
typically used by relationship researchers (e.g., dyadic design, longitudinal studies). As an
effort to accomplish this goal, this chapter provides an extensive review and discussion of
theories and research regarding the structure, content, and nature of IRs. I hope that this
chapter will provide a useful beginning of a more comprehensive theoretical framework that
can help shape future research on IRs.
58 Shanhong Luo

ACKNOWLEDGEMENT
The author wishes to thank Eva Klohnen for her helpful comments on earlier drafts of
this chapter.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 3

GENERALIZED ANXIETY DISORDER AND

INTERPERSONAL RELATIONSHIPS:
THE CASE FOR A SYSTEMIC INTERVENTION

Danielle Black
The Family Institute at Northwestern University, Evanston, Illinois 60201, USA
Amanda Uliaszek, Alison Lewis
Northwestern University, Evanston, Illinois 60208, USA
Richard Zinbarg
Northwestern University, Evanston, Illinois 60208, USA
The Family Institute at Northwestern University, Evanston, Illinois 60201, USA

ABSTRACT
Generalized anxiety disorder (GAD), one of the more common anxiety disorders, is
associated with significant impairment in occupational, interpersonal and family
functioning. There is growing consensus that we need to improve the effectiveness of our
treatments for GAD given that even the most positive findings suggest that only 50% of
patients treated with cognitive-behavior therapy (CBT) and/or medications experience
what might be considered to be a cure. Whereas established treatments for GAD are
individual modalities, there is evidence from several lines of research suggesting current
treatments for that systemic therapy has promise to augment the effectiveness of therapy
for GAD. These lines of research include (a) evidence that elevated marital
dissatisfaction is associated with GAD; (b) evidence that marital and family problems are
associated with other anxiety disorders including panic disorder with agoraphobia and
obsessive compulsive disorder and are associated with poor outcome in the treatment of
these other anxiety disorders; (c) evidence that marital and family problems are
associated with major depression - another psychiatric condition closely related to GAD –
and poor outcome in the treatment of major depression; (d) preliminary evidence that
marital functioning and interpersonal problems predict outcome in the treatment of GAD;
and (e) evidence that at least some forms of couples therapy are effective treatments for
major depression and panic disorder with agoraphobia.
66 Danielle Black, Amanda Uliaszek, Alison Lewis et al.

INTRODUCTION
Generalized Anxiety Disorder (GAD) is an impairing psychological problem in which an
individual experiences worry and anxiety over a number of different things most of the day,
nearly every day, for a period of at least six months (DSM-IV-TR, 2000). In order to meet
diagnostic criteria for GAD, worries must be accompanied by a number of physical and
psychological symptoms including restlessness, muscle tension, sleeplessness, difficulty
concentrating, frequent fatigue, and irritability. Subjective distress over symptoms is often
quite severe, with feelings of loss of control over worry serving as another diagnostic
criterion (DSM-IV-TR, 2000).
GAD is very common; epidemiological results from the National Cormorbidity Survey
(NCS) found lifetime prevalence rates of GAD to be nearly seven percent for females and
four percent for males (Kessler et al., 1994). Further, according to this study, more than three
percent of the population suffers from GAD within any given year. The more recent National
Comorbidity Survey Replication found very similar prevalence rates (Kessler, Berglund,
Demler, Jin, et al., 2005; Kessler, Chiu, Demler & Walters, 2005). Within the NCS,
regardless of whether lifetime or one year prevalence rates were examined, among suffers of
GAD, women outnumbered men by a rate of two to one (Wittchen, Zhao, Kessler, & Eaton,
1994).
GAD typically begins early in life and has a relatively chronic course. Fifty percent of
cases report onset by age 18 and 75 percent report onset by age 26 (Campbell, Brown &
Grisham, 2003). Further, in DSM-IV, the former diagnosis of Overanxious Disorder (OAD)
in children was subsumed under GAD. According to Albano, Chorpita, and Barlow (2003),
data collected using DSM-III and DSM-III-R diagnoses, suggest that GAD may typically
begin in childhood between 10.8 and 13.4 years of age. Among patients with GAD, rates of
full remission are low (Kessler, Keller, & Wittchen, 2001). Although epidemiological studies
have not yet looked at the longitudinal course of this disorder in a non-treatment seeking
population, based on comparisons of point prevalence rates and lifetime prevalence rates in
these studies, researchers have estimated that 40 to 60 percent of individuals with a lifetime
history of GAD are experiencing an episode at any given point (Kessler, Keller, & Wittchen,
2001). This suggests that individuals with a history of GAD are symptomatic for much of
their lifetimes and that the course of GAD is relatively chronic. Symptoms of this disorder
appear to wax and wane, getting worse during times of stress (DSM-IV-TR, 2000).
Research indicates that GAD has considerable costs, both for individuals who suffer from
this disorder and for society as a whole. GAD can severely impair physical, psychological,
and social functioning as well as quality of life (e.g. Ninan, 2001; Roy-Byrne & Katon, 1997;
Wittchen, Carter, Pfister, Montgomery, & Kessler, 2000). Within the National Commorbidity
Survey, individuals with GAD were 2.5 times more likely than others to report high levels of
social impairment and 3.5 times more likely to report high levels of work impairment
(Wittchen, 2002).
Studies suggest that GAD has a significant financial impact, with the primary costs
relating to nonpsychiatric healthcare expenses. GAD is the most common anxiety disorder in
primary care medical settings and primary care physicians often order expensive tests to try to
find end-organ dysfunction rather than diagnosing GAD (Ninan, 2001; Wittchen, 2002).
Patients with GAD report a two-fold higher average number of visits to primary care
 Generalized Anxiety Disorder and Interpersonal Relationships 67

physicians than individuals with depression and significantly more visits to non-mental health
doctors even after entering the presence of physical illness as a covariate (Wittchen, 2002).
Workplace costs are also significant (Ninan, 2001; Wittchen, 2002). In one study, 34 percent
of individuals who experienced pure GAD within a 12-month period year and 48 percent of
individuals who experience GAD and comorbid depression exhibited reductions of ten
percent or more in work productivity over the course of a month (Wittchen, 2002).

LIMITATIONS IN THE EFFECTIVENESS OF

CURRENT TREATMENTS FOR GAD
To date, two types of treatments for GAD, pharmacotherapy and Cognitive Behavioral
Therapy (CBT), have received extensive empirical support. However, there is reason to
believe that both of these forms of treatment are limited in their effectiveness. Many
individuals with GAD do not show any improvement following treatment, and among those
who do improve, a number remain symptomatic (Borkovic & Whisman, 1996; Gould, Otto,
Pollack, & Yap, 1997).
Medications that are commonly used to treat GAD include benzodiazepines, azapirones,
tricyclic anti-depressents, selective-serotonin reuptake inhibitors, and serotonin
norepinephrine reuptake inhibitors (Wittchen, 2002). A recent meta-analysis suggested that
pharmacotherapy is superior to placebo in producing short-term reductions in symptoms of
generalized anxiety disorder (Mitte, Noack, Steil, & Hautzinger, 2005).
Empirically supported CBT packages for GAD target the physiological, cognitive, and
behavioral components of this disorder using a number of different techniques. Techniques
utilized in CBT for GAD include psychoeducation, relaxation training, cognitive
restructuring, worry imagery exposure, in-vivo situational exposure, and time management
(e.g., Brown, O’Leary, & Barlow, 1994; Craske & Barlow, 2005Craske, Barlow & O’Leary,
1992; Zinbarg, Craske & Barlow, 19932006). Chambless and Gillis (1993) meta-analyzed 9
trials of CBT for GAD and reported that the mean effect size for CBT compared with either
wait-list, pill placebo or nondirective therapy was 1.54. This mean effect size was
significantly greater than zero, indicating that CBT is an effective treatment for GAD. Gould,
Otto, Pollack and Yap (1997) reported a more modest mean effect size of .70 on symptoms of
anxiety based on 22 trials of CBT for GAD. However, this more modest effect size was still
significantly greater than zero, again indicating that CBT is an effective treatment for GAD.
In addition, Gould et al. found that CBT was just as effective as pharmacotherapy for
symptoms of anxiety and was significantly more effective than pharmacotherapy for
symptoms of depression that commonly co-occur with GAD.
Looking at the clinical significance of these treatments, however, paints a more sobering
picture. Borkovec & Whisman’s (1996) meta-analysis of CBT trials examined the percentage
of patients in these studies who were classified as high on end state (HES) functioning at
post-treatment, defining HES as falling within the normal range of scores on the majority of
outcome measures given at the end of each study. They reported an average HES figure of 50
percent. Though pharmacotherapy trials have tended not to report HES statistics, given that
CBT produces at least as large an effect size as medications on symptoms of anxiety in GAD
68 Danielle Black, Amanda Uliaszek, Alison Lewis et al.

trials (Gould, Otto, Pollack, & Yap, 1997), it seems reasonable to assume that medications
produce no more impressive outcomes than CBT for GAD in terms of HES.
Borkovec, Newman, Pincus and Lytle (2002) attempted to improve on the effectiveness
of CBT for GAD in several ways, increasing therapy time by 50 percent and refining
previously included treatment components. Despite these modifications, HES rates of
treatment effectiveness were comparable to rates found in previous studies, leading Borkovec
and colleagues to conclude that other methods are needed to improve upon the results
produced by CBT techniques. Within this study, higher levels of interpersonal difficulties as
measured by the Inventory of Interpersonal Problems–Circumplex Scales (Alden, Wiggins &
Pincus, 1990; Horowitz, Alden, Wiggins & Pincus, 2000) at both pre- and post-treatment,
were associated with poorer outcome at 6 month follow-up. Hence, one potential method for
improving treatment efficacy would be to incorporate treatment components targeting patient
interpersonal functioning.
Preliminary results from the current trial just being completed by the Borkovec
laboratory, in which individual interpersonal therapy techniques were added to their CBT
package, have yielded a post-treatment effect size that is 17.5% to 78.8% larger than the post-
treatment effect sizes from their previous trials of pure CBT packages (Borkovec &
Sharpless, 2003). Clearly, these preliminary results are promising. At the same time, it is
important to consider that for most people marriage is the relationship that is the greatest
source of both social support (e.g., Argyle, 1999; Argyle & Furnham, 1983; Denoff, 1982;)
and conflict (e.g., Argyle, 1999; Argyle & Furnham, 1983; Whisman, Sheldon & Goering,
2000). Thus, couples therapy may also have promise in the treatment of GAD. Indded, As we
discuss below, there are several indirect lines of evidence that suggest that couples therapy
may be at least as promising an interpersonal therapy as individual interpersonal therapy to
add to the CBT package for GAD patients with partners. We begin by reviewing the evidence
on GAD and problematic interpersonal functioning in general. We then proceed to focus more
specifically on difficulties in marital and family functioning in GAD and disorders closely
related to GAD.

GAD AND PROBLEMATIC INTERPERSONAL STYLES

Several studies have shown that people with GAD experience significant interpersonal
problems with peers, family, and romantic partners (Borkovec, Newman, Pincus, & Lytle,
2002; Whisman et al., 2000). Perhaps not surprisingly, therefore, the content of worry
experienced by people with GAD is often interpersonal in nature (Breitholtz, Johansson, &
Ost, 1995; Roemer, Molina, & Borkevec, 1997). More specifically, people with GAD appear
to exhibit interpersonal styles that may impact their experience of interpersonal problems and
worry. Using the Inventory of Interpersonal Problems (IIP; Horowitz, Alden, Wiggins, &
Pincus, 2000), several studies have found that GAD is related to specific problematic
interpersonal styles, specifically behaviors associated with being overly nurturant,
nonassertive, overly accommodating, self-sacrificing, and intrusive/needy (Crits-Christoph,
Gibbons, Narducci, Schamberger, & Gallop, 2005; Eng & Heimberg, 2006).
There is also evidence that people with GAD have perceptual biases during interpersonal
interactions which impact their interpersonal problems and experiences. Studies on
 Generalized Anxiety Disorder and Interpersonal Relationships 69

information processing have shown that people with high anxiety (as opposed to normal
controls or people with depression) show an attentional bias toward social threat cues, which
depressed and normal controls tended to direct their attention away from the same threatening
stimuli (MacLeod, Matthews, & Tata, 1986; Mathews & MacLeod, 1985; Mogg, Matthews,
& Eysenck, 1992). GAD is also associated with a greater vigilance and orientation toward
threatening faces (Bradley, Mogg, White, Groom, & de Bono, 1999;; Mogg, Millar, &
Bradley, 2000). One study also found adolescent’s perception of parental rejection, over-
control, and attachment was correlated with adolescent GAD, with perceived parental
rejection and alienation uniquely predicting GAD (Hale, Engels, & Meeus, 2006).
Some research has speculated that people with GAD lack awareness of their negative
interpersonal impact on others (Erikson & Newman, 2007; Newman, Castonguay, Borkevec,
& Molnar, 2004). Research has examined both overestimation of negative impact or
catastrophizing bias (a belief that the GAD participant had a much more negative impact on
the confederate than the confederate believed) and underestimation of negative impact or
naivety bias (a lack of awareness on the part of the GAD participant concerning their negative
impact as perceived by the confederate). In a study where those with GAD and control
participants interacted with a confederate in a self-disclosure task, results showed that GAD
was associated with a greater discrepancy between how the participant believed they
impacted confederates and how the confederates actually reported feeling (Erikson &
Newman, 2007). This finding was most pronounced in the Hostile-Submissive domain of
interpersonal impact. This domain refers to a sense that one’s partner feels inadequate and
nervous in the interaction, which exerts an interpersonal “pull” for one to put the other at ease
or otherwise contain their discomfort. This behavioral style is therefore submissive in its
unassertive aspects and hostile in the passive sense of expecting ridicule and coldly
withdrawing from full social engagement. This study also found a U-shaped relationship
between the amount of worry and degree of discrepancy in estimation in the Hostile-
Submissive area. In other words, high worry was associated with both over- and under-
estimating the degree of hostility-submissiveness, illustrating both a catastrophizing and
naivety bias. Those demonstrating the naivety bias (those who underestimated their impact on
others) were the least liked by the confederates, possibly because they were unable to read
social cues concerning their interpersonal behaviors (Erikson & Newman, 2007).
For patients with GAD, problematic interpersonal styles tend to change in the more
desirable direction over the course of therapy (Borkevec et al., 2002; Crits-Christoph et al.,
2005). Crits-Christoph and colleagues (2005) found a significant change in social avoidance,
nonassertive, exploitable, overly nurturant, and intrusive interpersonal styles, as well as a
change in a total score of all problematic styles combined. Borkevec and colleagues (2002)
also found a change in all IIP categories from pre- to post-treatment.

MARITAL FUNCTIONING AND GAD

There are several lines of evidence to suggest that GAD is associated with poor marital
functioning. McLeod (1994) investigated marital distress and GAD among couples in which
one member had a diagnosis of GAD (wives with GAD only and husband with GAD only) as
well as couples in which both members had GAD. Wives with GAD reported significantly
70 Danielle Black, Amanda Uliaszek, Alison Lewis et al.

higher levels of marital distress than wives without GAD. However, husbands with GAD did
not significantly differ on their report of marital distress compared to husbands without GAD.
Couples who both had GAD did not report significantly higher levels of marital distress than
couples with only one spouse diagnosed with GAD. Whisman (1999) replicated these results
in a randomized national sample. That is, GAD was significantly associated with marital
distress for woman but not for men with GAD. Whisman et al. (2000) extended this finding
by examining nine diagnoses and found that the strongest diagnostic correlate of marital
dissatisfaction was GAD. However, this study did not replicate the findings with regard to
gender; gender did not moderate the relationship between GAD and marital distress. This
study also compared the relationship between GAD and dissatisfaction among different social
relationship including spouse, relatives, and friends. Individuals suffering with GAD reported
significantly more dissatisfaction with their marital relationship compared with their
dissatisfaction with other social relationships such as relatives and friends. In the most recent
national sample investigating the relationship between GAD and marital distress, marital
distress was significantly associated with elevated risk of GAD (Whisman, 2007). Among all
of the anxiety disorders, marital distress had the strongest association with GAD. Further,
GAD had one of the strongest associations with marital distress than any other psychiatric
disorder excluding bi-polar disorder and alcohol dependence. Finally, gender did not
moderate the relationship between GAD and marital distress.
Overall, the association between marital distress and GAD is robust across several large
national samples. Further, GAD appears to have a higher association with marital distress
compared to other psychiatric disorders across these studies. Marital distress is one of the
most robust predictors of divorce (see Bradbury & Karney, 1995 for a review). The previous
research suggests GAD should also be associated with a higher risk for divorce. Only one
study has investigated this association. In a national random survey, GAD was associated
with a significantly elevated risk of divorce for both men and woman (Kessler, Walters, &
Forthofer, 1998). Men with GAD had a higher risk of divorcing than men with any other
disorder excluding mania. For women, GAD was significantly associated with an elevated
risk for divorce; however, the odds ratio for elevated risk of divorce was equal to or lower
than most of the other psychiatric disorders. Interestingly, whereas GAD is associated with an
elevated risk of divorce, one study has shown that GAD is also associated with a higher
likelihood of entering into marriage or a marriage-like relationship (Yoon & Zinbarg, 2007).
Negative marital interaction appears to be one of the main factors that contribute to
increased marital distress and divorce (see Karney and Bradbury, 1995; Weis & Heyman,
1990 for reviews). Thus, the previous evidence from the GAD marital functioning research
would indicate GAD most likely would be associated with negative marital interaction. Only
one study, conducted by our laboratory, has investigated the observed marital interaction of
GAD couples (Zinbarg, Lee & Yoon, 2007). However, this study did not compare observed
marital interaction between GAD, normal controls, and other psychiatric disorders but rather
studied associations between marital interaction and treatment outcome within a GAD
sample. We have since recruited a normal control sample and are currently working on
analyses comparing the GAD couples and the normal control couples. By extension of the
previous marital interaction research with normal and distressed couples, we expect GAD
couples to have higher levels of negative marital interaction compared to other psychiatric
diagnoses and normal controls. Given that GAD shares core features in common with the
other anxiety disorders and depression (e.g., Zinbarg & Barlow, 1996; Kendler, Gardner,
 Generalized Anxiety Disorder and Interpersonal Relationships 71

Gatz, & Pederson, 2007; Krueger, Caspi, Moffitt, Silva, & McGee, 1996), we next turn to the
evidence regarding associations of marital and family functioning with anxiety disorders
other than GAD and with depression.

MARITAL AND FAMILY FUNCTIONING AND

ANXIETY DISORDERS OTHER THAN GAD
Dysfunctional family functioning (e.g., marital and extended family members) relates to
anxiety disorders other than GAD. The majority of research between family functioning
focuses on Panic Disorder with Agoraphobia (PDA). A growing number of studies focus on
the relationship between dysfunctional family functioning and Post Traumatic Stress Disorder
(PTSD). Finally, there exist a small number of studies investigating the relationship between
family functioning and Obsessive Compulsive Disorder (OCD) and Social Anxiety Disorder
(SAD).
PDA is sometimes associated with dysfunctional marital functioning. Bryne, Carr, and
Clark (2004) reviewed 24 studies investigating the relationship between marital distress and
PDA. Ten of these studies investigated the relationship between marital distress and PDA
retrospectively. The majority of these studies (n = 9) found an association between marital
distress and PDA (Fry, 1962; Goldstein and Chambless,
1978; Goodstein and Swift, 1977; Holmes, 1982; Kleiner & Marshall, 1987; Quadrio,
1984; Roberts, 1964; Symonds, 1971; Webster, 1953). Only one study did not find a
significant relationship between marital distress and PDA. However, retrospective studies
have many methodological flaws such as response biases. Fourteen studies investigated the
relationship between marital distress and PDA prospectively (Arrindell & Emmelkamp, 1986;
Buglass et al., 1977; Emmelkamp et al., 1992; Fisher and Wilson, 1985; Friedman, 1990;
Hafner, 1977a, 1983; Hand and Lamontagne, 1976; Kleiner et al., 1987; Lange and van Dyck,
1992; McLeod, 1994; Markowitz et al., 1989; Massion et al., 1993; Torpy and Measey,
1974). In six studies, PDA was significantly associated with marital distress. In seven of the
prospective studies, marital distress was not significantly associated with PDA (Arrindell &
Emmelkamp, 1986; Buglass et al., 1977; Emmelkamp et al., 1992; Fisher and Wilson, 1985;
Friedman, 1990; Hafner, 1977a; Lange and van Dyck, 1992). Finally, one study (Massion et
al., 1993) found that couples in which one member had PDA reported similar levels of marital
distress compared to couples in which member had GAD. Thus, whereas the association
between PDA and marital distress may not be as strong when measured prospectively as
when assessed retrospectively, the prospective studies do converge with the retrospective
ones in demonstrating that PDA is associated with marital distress.
There is a growing body of research investigating the relationship between family
functioning and PTSD. In a series of studies, PTSD has been significantly associated with
marital distress (Forbes, et al, 2003; Whisman, 1999; Whisman, 2007). In one national study,
PTSD was even found to be more highly associated with martial distress than any other
psychiatric disorder (Whisman, 1999). Further, across different PTSD populations (e.g.,
veterans, POWs, etc.), individuals with PTSD, compared to their non affected counterparts
(those experiencing the same trauma without PTSD), reported higher levels of marital distress
(Carroll, Rueger, Foy, & Donahoe, 1985; Cook et al., 2004; Dekel & Solomon, 2006).
72 Danielle Black, Amanda Uliaszek, Alison Lewis et al.

PTSD has been linked to other forms of marital dysfunction such as marital violence and
divorce. PTSD symptoms are significantly associated with the use of physical aggression with
intimate partners (O’Donnell et al., 2006; Hughes, 2007) and an elevated risk for divorce
(Kessler, Walters, & Forthofer, 1998). Individuals with PTSD have higher rates of divorce
and marital violence compared to their counterparts without PTSD. Men diagnosed with
PTSD, compared with men without PTSD, are more likely to be physically aggressive toward
their relationship partners (Carroll, Rueger, Foy, & Donahoe, 1985; Sherman, Fred, Jackson,
Lyons, & Han, 2006) and are twice as likely to divorce and three times as likely to experience
multiple divorces (Jordan et al., 1992).
Less is known about the relationship between marital functioning and OCD. For example,
whereas Whisman (1999, 2000, 2007) investigated the relationship between several
psychiatric diagnoses and marital distress, OCD was not included in any of these three
studies. Similarly, Kessler, Walters, and Forthofer (1998) investigated the likelihood of
divorce associated with several different psychiatric diagnoses; however, OCD was not
included in the study. To date, only one small sample study has investigated the relationship
between marital distress and OCD symptoms (Riggs, Hiss, & Foa, 1992). This study did not
find a significant relationship between OCD symptoms and marital distress.
Little is also known with regards to social phobia and marital functioning. Whisman
(1999) found a significant relationship between social phobia and marital distress and this
relationship was replicated in a separate national sample by Whisman (2007). It should be
noted, however, that once the presence of other psychiatric diagnoses were entered as
covariates in Whisman (1999), social phobia was no longer significantly correlated with
marital distress. Further, social phobia is not related to an increased risk of divorce (Kessler,
Walters, & Forthofer, 1998).

MARITAL AND FAMILY FUNCTIONING AND MAJOR DEPRESSION

Several lines of empirical research support a close link between GAD and major
depressive disorder (MDD). First, GAD and MDD co-occur at a rate greater than what would
be expected by chance (Kessler, Nelson, McGonagle, Liu, Schwartz, & Blazer, 1996;
Mineka, Watson, & Clark, 1998). Second, similar phenotypic patterns have emerged
suggesting that GAD is more closely related to MDD than to other anxiety disorders (e.g.,
Zinbarg and Barlow, 1996). Third, GAD and MDD have a genetic correlation of 1.0,
indicating that they are not genetically distinguishable from one another (Kendler, Gardner,
Gatz, & Pederson, 2007; Kendler, 1996, Kendler, Neale, Kessler, Heath, & Eaves, 1992).
Fourth, according to personality studies, GAD and MDD share the common vulnerability trait
of neuroticism or negative emotionality (Krueger, Caspi, Moffitt, Silva, & McGee, 1996;
Barlow & Campbell, 2000; Watson, Gamez, & Simms, 2005). Therefore, the literature on
marital and family functioning in MDD might be relevant to similar topics in GAD.
Epidemiological research indicates the MDD is significantly related to not getting along
with one’s spouse and not having any close friends (Whisman, Sheldon, & Goering, 2000).
Other studies have documented elevated rates of insecure adult romantic attachment in
depressed patients and their partners, with the likelihood of insecure attachment in partners
covarying with the chronicity of the patient’s depressive symptoms (e.g., Roberts, Gotlib &
 Generalized Anxiety Disorder and Interpersonal Relationships 73

Kassel, 1996; Whiffen, Kallos-Lilly & MacDonald, 2001; Whisman & McGarvey, 1995).
Several lines of research offer an explanation for the interpersonal difficulties found in those
with MDD. One literature review summarized four major areas of interactional problems
among depressed dyads (Beach, Sandeen & O'Leary, 1990). First, depressed patients engage
in more “depressive” behaviors with their spouses than do non-depressed spouses and these
behaviors suppress spousal aggression (Beach & Nelson, 1989; Biglan, et al., 1985, 1989;
Hops et al., 1987; Nelson & Beach, 1990). Second, depressed and discordant couples
experience low levels of relationship cohesion, even when compared to discordant,
nondepressed dyads (Beach et al., 1988; Monroe, Bromet, Connell, & Steiner, 1986). Third,
the interactions of depressed persons and their spouses lack symmetry, such that depressed
individuals are more likely to be passive and let decision making be done for them. Fourth,
even though they suppress the expression of hostility, depressed discordant dyads are likely to
reciprocate negative partner behavior when it occurs (Biglan, et al., 1985).
Another possible explanation for the interpersonal problems found in those with MDD
concerns reassurance seeking behavior (e.g., Joiner & Metalsky, 1995, 2001; Joiner &
Schmidt, 1998; Potthoff, Holahan & Joiner, 1995). This research has been done in the context
of peer/roommate relationships, as well as with married and dating couples. Findings suggest
that reassurance seeking predicts negative attitudes and contagious depression in partners, as
well as depression in response to partner devaluation (e.g., Benazon, 2000; Katz, Beach &
Joiner, 1998, 1999). While some studies have reported that reassurance seeking is specific to
depression, at least two analyses have supported a link between anxiety and reassurance
seeking (e.g., Joiner, 1994; Joiner, Katz and Lew, 1999).
In addition to the problematic interpersonal styles evidenced by people with MDD, there
is also growing evidence that depressed individuals play a role in generating interpersonal
stressors in their lives (e.g., Hammen, 1991; Hammen, Davila, Brown, Ellicott, & Gitlin,
1992; Uliaszek, Zinbarg, Mineka, Craske, & Griffith, 2008). Research has shown that
depressed women subsequently experience more dependent (i.e., at least party due to the
woman’s behavior), interpersonal stressful life events compared with others, but not on
stressful life events that were judged to be independent or outside the woman’s control. The
types of interpersonal stress experienced included marital problems (including divorce or
separation) and social dysfunction.

MARITAL AND FAMILY FUNCTIONING AND PREDICTION OF

TREATMENT RESPONSE IN DEPRESSION AND ANXIETY DISORDERS
OTHER THAN GAD

Marital, familial, and peer interpersonal difficulties have relevance for response to
treatment of depression. There is a large body of research on expressed emotion (EE) and
treatment response in depression. EE is conceptualized as consisting of three factors: criticism
and hostility, emotional overinvolvement (EOI), and positivity (Chambless, Steketee, Bryan,
Aiken, & Hooley, 1999). The evidence suggests that the expression of hostility toward the
depressed patient by family members (most of whom are spouses) and patient perceived
criticism predict poor treatment response (e.g., Addis & Jacobson, 1996; Hooley & Teasdale,
1989; Rounsaville, Weissman, Prusoff & Herceg-Baron, 1979). It is also noteworthy that the
74 Danielle Black, Amanda Uliaszek, Alison Lewis et al.

severity of expressions of hostility toward the patient correlates with the chronicity of the
symptoms among depressed patients (Hayhurst, Cooper, Paykel, Vearnals & Ramana, 1997).
Dysfunctional family interactions also influence response to treatment for a variety of
anxiety disorders. EE has been linked to treatment outcome across a variety of anxiety
disorders. Peter and Hand (1998) found that higher criticism expressed by a spouse toward
the patient with PDA predicted better long – term outcome in CBT for PDA. However,
Tarrier, Sommerfield and Pilgrim (1999) found that greater levels of relative hostility
expressed toward the patient predicted poorer treatment outcome in PTSD patients treated
with either cognitive therapy or imaginal exposure therapy for PTSD. Although these results
seem contradictory, other researchers have found differential relationships between the
different facets of the EE construct and treatment outcome for anxiety disorders. In a sample
of OCD and PDA patient completing CBT, Chambless and Steketee (1999) found that greater
levels of hostility expressed toward the patient by relatives predicted higher rates of dropout
and poorer treatment outcome. On the other hand, they also found that higher rates of non-
hostile criticism predicted better treatment outcome. Fogler, Tompson, Stektee, and Hofmann
(2007) investigated the impact of EE on treatment outcome for social phobia. These
researchers found lower levels of perceived criticism were associated with a greater
likelihood of treatment dropout; whereas, hostile EE and emotional overinvolvement were not
associated with treatment dropout.

INTERPERSONAL PREDICTORS OF GAD TREATMENT RESPONSE

Results from studies utilizing the IIP have found that interpersonal problems can predict
of the patient’s response to treatment. One GAD treatment study found that greater
interpersonal problems (as assessed by the IIP) predicted worse outcome at 6-month follow-
up (Borkevec et al., 2002). Another study demonstrated that being overly nurturant was
associated with less change in anxiety and worry symptomatology at post-treatment (Crits-
Christoph et al., 2005). Overall, improvement in interpersonal problems, especially of the
overly nurturant variety, was associated with improvement in symptomatology (Crits-
Christoph et al., 2005).
The results of a study examined interpersonal interactions between GAD patients and
their partners also suggests that interpersonal problems are predictors of treatment response
just as the IIP studies do (Zinbarg, Lee, & Yoon, 2007). This study found that partner
hostility when discussing the GAD patients’ worries predicted worse functioning at the end of
treatment. Non-hostile criticism by the partner during the worry discussion predicted better
end-state functioning.

EFFICACY OF COUPLES THERAPY FOR DEPRESSION

ND ANXIETY DISORDERS OTHER THAN GAD

The efficacy of couples therapy for GAD has yet to be investigated. Several studies have
investigated the efficacy of couples therapy or spouse assisted therapy for depression and
 Generalized Anxiety Disorder and Interpersonal Relationships 75

other anxiety disorders. For the reasons discussed above, these studies may have relevance for
GAD and so we review them below.
Given the dyadic problems of many depressed individuals and the effects of marital
functioning on treatment response in depression, it should perhaps not be surprising that
several studies have tested the efficacy of couples therapy for depression. Across these
studies, couples therapy improved both depressive symptoms and marital functioning.
Jacobson et al. (1991) randomly assigned married women diagnosed with depression to
Behavioral Marital Therapy (BMT), individual cognitive therapy (CT), or a treatment
combining BMT and CT. BMT was as effective as the other conditions at reducing depressive
symptoms, but only BMT significantly improved marital distress. Beach and O’Leary (1992)
replicated and extended these findings in a sample of distressed couples in which the wife
was depressed. The couples were randomized to three different conditions: BMT, CT, or a 15
week waiting list condition. BMT and CT both significantly reduced depressive symptoms.
Similarly to the Jacbson et al. (1991) study, only BMT provided significant improvements in
marital distress. These previous studies focused on depressed wives. Emanuels-Zuurveen and
Emmelkamp (1996) extended and replicated these previous findings by including depressed
husband and depressed wives in their sample. Couples were randomly assigned to either
individual cognitive/behavioral therapy or communication-focused marital therapy. In both
conditions depressive symptomotology improved post treatment; however, only the marital
therapy condition exhibited significant reductions in marital distress. Finally, Foley et al.
(1989) extended these findings using a different theoretical intervention than CBT. Depressed
patients (including men and woman) were randomized to either individual interpersonal
psychotherapy (IPT) or a couple format version of IPT. Similar to past findings, both
conditions improved depression, but only the couple IPT intervention improved marital
functioning. Overall, these studies provide evidence that couples therapy is an efficacious
treatment for depression. Further, couples treatment has the extra benefit of improving marital
functioning; whereas, individual treatment only reduces depressive symptoms.
Several treatment outcome studies have investigated the efficacy of involving
relationship partners in the treatment of Agoraphobia. Interventions involving partners in the
treatment of Agoraphobia differ in the focus of treatment. These interventions can be divided
into two main foci. One group of interventions target the patient’s avoidance through partner
assisted exposure therapy. The second group target relationship functioning through
interpersonal skills training for both the patient and partner. Daiuto, Baucom, Epstein and
Dutton (1998) conducted a meta analysis that distinguished outcomes based on these two
types of interventions. The first set of analyses compared individual exposure therapy to
partner assisted exposure therapy. Across six treatment outcome studies, individual exposure
therapy, if anything, outperformed partner assisted exposure therapy; however, the two types
of treatment were not significantly different from one another. The second group of analyses
compared interventions targeting couple functioning to interventions targeting general
interpersonal problems. Interventions targeting couple functioning led to significantly better
outcomes at follow-up than exposure alone. In contrast, interventions targeting general
interpersonal problems led to significantly worse outcomes at both post-treatment and follow-
up than exposure alone. Thus, it appears that including the partner in treatment is most
effective when interventions are included that are aimed at the partners’ interaction patterns.
Indeed, some forms of involving the partner in treatment (i.e., partner-assisted exposure) may
even be counter-productive.
76 Danielle Black, Amanda Uliaszek, Alison Lewis et al.

Despite the large body of literature establishing a relationship between PTSD and marital
functioning and the fact that several treatment developers have developed clinical
interventions for PTSD incorporating couple therapy (e.g., Johnson, 2002), there exists only
one randomized clinical trial of family therapy for PTSD.. Monson et al. (2004) investigated a
Cognitive –Behavioral Couples’ treatment for PTSD. The PTSD patients improved
significantly on PTSD symptoms from pre-test to post-test; however, this study did not
include a control sample. Thus, it is difficult to attribute the results to the intervention. Glynn
et al. (1999) conducted the first randomized clinical control trial of couples therapy with a
PTSD population. Veterans and a family member were randomly assigned to three different
conditions: waiting list, 18 sessions of twice-weekly exposure therapy, or 18 sessions of
twice-weekly exposure therapy followed by 16 sessions of behavioral family therapy (BFT).
Both active treatments performed better than the wait-list control group. However, BFT was
not significantly different than individual exposure therapy at reducing PTSD symptoms.
Despite evidence showing that family functioning may influence OCD response to
treatment and the fact that some therapists have developed systemic treatments for OCD (e.g.,
MacFarlene, 2001), there has yet to be a randomized clinical trial investigating the efficacy of
family or couple therapy for OCD. Some research has investigated family therapy for children
suffering from social phobia (e.g., Barrett, Dadds, & Rapee, 1996); however, an empirical
evaluation of a systemic intervention for adults has not yet been investigated.

CONCLUSION
GAD is not only common but is also associated with significant impairment in
occupational, interpersonal and family functioning. Unfortunately, there is also growing
consensus that our current treatments for GAD are not effective enough and we need to
improve them. Whereas established treatments for GAD are individual modalities, we have
reviewed evidence from several lines of research suggesting current treatments for that
systemic therapy has promise to augment the effectiveness of therapy for GAD. One of the
important lessons from the literature on the inclusion of the patient’s partner in the treatment
of PDA, is that one needs to choose one’s intervention targets carefully when including a
family member in treatment as some forms of couples interventions so appear to augment the
effectiveness of CBT for PDA whereas others show a trend toward worse outcomes compared
with individual CBT (Daiuto, Baucom, Epstein & Dutton, 1998). We are currently beginning
a study designed to assist in the process of selecting systemic targets. One aim of this study is
to replicate the findings from Zinbarg, Lee & Yoon (2007) showing that pre-treatment levels
of partner hostility predict worse response to individual CBT whereas pre-treatment levels of
partner non-hostile criticism predicts better treatment response. A second aim of this study is
to extend our earlier findings by testing whether similar patterns hold for interactions with
other relatives for those patients with GAD who are not married or in a marriage-like
relationship as well as testing whether these systemic variables predict treatment response
above and beyond the effects of potential third-variables such as chronicity of GAD, axis II
pathology in the patient, and axis I or axis II pathology in the partner/relative. If our earlier
results are replicated and found to be not entirely attributable to plausible third-variables, it
 Generalized Anxiety Disorder and Interpersonal Relationships 77

would suggest that systemic interventions designed to reduce hostility and increase non-
hostile criticism would hold great promise for increasing the efficacy of treatment for GAD.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 4

ANOTHER KIND OF “INTERPERSONAL”

RELATIONSHIP: HUMANS, COMPANION ANIMALS,
AND ATTACHMENT THEORY

Jeffrey D. Green, Maureen A. Mathews

Virginia Commonwealth University, USA
Craig A. Foster
United States Air Force Academy, USA

ABSTRACT
Human-companion animal relationships provide a important but largely unexplored
component of the human experience. Research examining these interspecies relationships
may elucidate the depth and meaning of these relationships as well as provide unique
insights into the fundamental nature of human psychology. Human-animal relationships
offer a distinctive testing ground because pet choice is unilateral, whereas human
friendships and romantic partner choices are mutual, and individuals may have reduced
fear of rejection or evaluation from a pet than from a human relationship partner. We
review and apply to human-pet relationships key elements of attachment theory,
including caregiving, exploration, the malleability of attachment styles, and the role of
attachment anxiety and avoidance in choosing relationship partners. We also discuss
potential future research directions using relationships theories in companion animal
contexts.

Human beings are social creatures, and as such have a fundamental need to belong
(Baumeister & Tice, 1990; Leary, Tambor, Terdal, & Downs, 1995). We seek the security,
support, and comfort of friends and family. It is therefore not surprising that the field of close
relationships has been a central and burgeoning area within psychology. However, most close
relationships theory and research overlooks the important fact that “interpersonal” needs can
be met without other people per se. Individuals commonly attach themselves to objects,
concepts, and abstractions to serve attachment and belonging functions. One particularly
88 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

prevalent and compelling type of attachment involves the one that humans have with non-
human animals.
Individuals go to great lengths to form or maintain social connection. Gardner, Pickett,
and Knowles (2005) proposed that individuals use one-sided (“parasocial”) attachments to
maintain belongingness when necessary. In two recent studies, Knowles and Gardner (2008)
found that writing about or viewing a picture of one’s favorite TV character (i.e., characters
from the NBC show “Friends”) buffered individuals from the negative emotional
consequences of social rejection. Similarly, researchers have studied God as a “substitute
attachment figure” (e.g., Kirkpatrick, 1998), including possible psychological and physical
health benefits of feeling interdependent with a deity. Connection to nature in general also
may foster a sense of belongingness. Frantz, Winter, and Mayer (2008) found that individuals
who felt a strong connection to nature reported a higher sense of belongingness as a result of
interaction with the natural world and were psychologically shielded from the effects of social
rejection. If individuals feel a connection to and appear to benefit from a relationship with
intangible or invisible characters, it stands to reason that significant benefits may accrue from
relationships with animal companions.
Though relationships with some animals (e.g., fish) may be relatively parasocial or one-
sided, relationships with other common pets, such as cats and dogs, clearly provide
companionship, physical contact, and comfort. Human-animal relationships are profoundly
important ones, and pets frequently are treated as family members. Though the influence of
pets on human well-being has been investigated, little theoretically based work has been
conducted to fully explicate the psychology of these relationships. Human-animal
relationships are different from interpersonal relationships in many ways. Unique
characteristics of the human-animal relationship (e.g., ability of humans to unilaterally choose
their animal companions, reduced fear of evaluation by animal companions) provide an
opportunity to examine human psychology in contexts unavailable to traditional human-
human relationships. That is, a closer investigation of human relationships with animals may
extend our understanding of human cognition, emotion, and behavior.
In this chapter, we provide a selective review of some research on human-animal
relationships to demonstrate that these relationships have a significant impact on the human
experience. At the same time, we argue that researchers have just scratched the surface of this
potentially rich field and should investigate human-animal relationships using available
interpersonal relationship theories and methods. Our review will draw primarily upon the
important theory of attachment (Bowlby, 1969) as one example of an appropriate theory to
extend to human-animal relationships. Finally, we propose ways in which human-animal
relationships can be used to both examine and extend traditional psychological theory, and
suggest new avenues of research in order to advance our understanding of human-animal
relationships. We begin by providing some background on the evolution of the most common
pets (i.e., cats and dogs) as an intial basis for explaining the prevalence and depth of human-
animal relationships.
 Another Kind of “Interpersonal” Relationship 89

CO-EVOLUTION OF HUMANS AND ANIMALS

The dog-human relationship is arguably the closest we humans can ever get to establishing a
dialogue with another sentient life-form, so it is not surprising that people tend to emerge from
such encounters with a special sense of affinity with ‘man’s best friend.’ James Serpell
(1995), p. 2

Companion animals vary widely from fish to birds to several species of mammals, but
canine-human relationships have a particularly long evolutionary history. Descended from the
grey wolf (Vila et al., 1997), modern domestic dogs (Canis familiaris) were the first animals
that humans domesticated at the end of the last Ice Age, approximately 15,000 years ago
(Serpell, 1995). One account suggests that this domestication accompanied the hunting shift
to early archery; domesticated dogs facilitated successful hunting by helping track herds and
subdue wounded prey (Serpell, 1995). However, a more radical view by Schleidt and Shalter
(2003) argues that humans and wolves, both omnivores and both relatively cooperative,
group-oriented species, started following herds in Eurasia around the same time, and thus co-
evolved as joint partners in obtaining food. In either case, it is notable that humans
domesticated dogs before domesticating the animals that have provided them with their most
common sources of animal protein (e.g., cattle, goats, pigs), animals whose domestication
requires less nomadic living.
Whether through domestication or co-evolution, the long history of dogs living with
humans has led dogs to understand verbal and non-verbal communication from humans.
Scientific views about the abilities of non-human animals to use language and, more broadly,
engage in symbolic thought, have ebbed and flowed in recent decades, but the latest research
suggests that humans have underestimated the abilities of canines and other animals such as
orangutans, parrots, and dolphins (Morell, 2008). Some dogs have learned to understand
hundreds of words, and recent research suggests that they may engage in other types of
symbolic cognition such as connecting an object to its two-dimensional picture (Morell,
2008). A series of studies (Hare, Brown, Williamson, & Tomasello, 2002), found that dogs
were superior to chimpanzees (our closest existing relative biologically) and wolves in
reading nonverbal human cues. In these studies, humans pointed to, tapped, or gazed at the
location of hidden food; even puppies (but not wolf pups) were relatively successful at
decoding these human behaviors, suggesting that this ability is not the result of learning but
the result of the evolution of dogs living with humans. Thus, it appears that dogs are able to
communicate with humans on a level that even humans’ closest relatives (i.e., chimpanzees)
cannot.
The domesticated cat (Felis catus) also has a storied history with human beings. The
modern-day house cat descends from Felis silvestris lybica in the Far East. The development
of agriculture is thought to have spurred the relationship between cats and humans; cats
eradicated vermin from grain storage, and humans, in return, provided basic shelter and food
(Driscoll et al., 2007). A recent archeological excursion uncovered 9,500 year-old cat remains
buried with human remains on the island of Cyprus (Vigne, Guilaine, Debue, Haye, &
Gérard, 2004). In addition, the ancient Egyptian culture had a high reverence toward cats, and
even had gods (e.g., Bastet) that took feline form. Cats were considered to be intelligent but
mysterious, and thus were treated with wonder and respect.
90 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

SIGNIFICANCE OF ANIMAL COMPANIONS TO HUMANS

The rich history between humans and dogs or cats helps to explain the lavish
interdependence that can occur between humans and animals today. The American Pet
Products Manufacturers Association (APPMA) reports in the 2007-2008 National Pet Owners
Survey that 63% of U.S. households include a pet. It is estimated that in 2008, the total U.S.
expenditures within the pet industry will exceed $43.3 billion, nearly double the 1998 figure.
It may be the case that more people own pets, but it is also appears that individuals are
spending increasing amounts of time and money on their pets. Many types of brand-name or
luxury pet products and services have been developed and marketed in recent years, including
products analogous to those for humans. Companies such as Paul Mitchell and Omaha Steaks
are marketing new designer pet products, such as dog shampoo and gourmet steak dog treats
(APPMA, 2007), and massage, acupuncture, and yoga for pets are now readily available.
Many hotel chains have adopted increasingly pet-friendly policies, and insurance companies
offer accident and life insurance for pets. As of 2007, 39 states allow for the establishment of
trusts to take care of pets in case of the owner’s or guardian’s death (Bennett, 2007). Some
owners also spend vast sums of money on ceremonies to celebrate milestones such as pet
birthdays and pet weddings, complete with wedding outfits, cakes, and (human) officiants.
State courts have recognized that animals represent far more than mere possessions. In two
notable cases, owners have been awarded upwards of $30,000 when their pets were deemed
to have been killed wrongfully (Tanick, 1998).
In short, pets are ubiquitous. Individuals go to great lengths to care for them, and
illustrate their deep attachment by traveling with them, celebrating milestones with them, and
(as we will revisit later) mourning their loss. Psychologists appear to have underestimated the
similarities to interpersonal relationships, but they also largely have ignored characteristics of
human-animal relationships that are unique. Such characteristics may provide new insights
into human psychology.

HUMAN-ANIMAL RELATIONSHIPS AND PSYCHOLOGICAL INQUIRY

Unique facets of the human-animal relationship might provide elegant and compelling
tests of traditional psychological theory. We will summarize a few ways in which the
development and maintenance of interpersonal relationships differs from human-animal
relationships.

Risk of Rejection

One critical issue is that the decision to acquire an animal companion can be a unilateral
choice, whereas the choice of a romantic partner or friend is almost inevitably a mutual one.
This issue is most clearly revealed in unrequited love, where a suitor experiences love for
someone who does not love in return (Baumeister, Wotman, & Stillwell, 1993). Although
interpersonal rejection commonly is associated with romantic relationships, social exclusion
also occurs between friends and acquaintances and has powerful psychological consequences,
 Another Kind of “Interpersonal” Relationship 91

including aggressive and self-defeating behaviors (Twenge, Baumeister, Tice, & Stucke,
2001; Twenge, Catanese, & Baumeister, 2002). Some individuals may hesitate to initiate
friendship or romantic relationships due to fear of rejection, but when it comes to
relationships with animals, individuals experience virtually no risk of partner rejection.

Fear of Evaluation

A related aspect of human-animal relationships is the reduced fear of evaluation.

According to George Eliot, “we long for an affection altogether ignorant of our faults. Heaven
has accorded this to us in the uncritical canine attachment.” There are many implications for
this reduced fear of evaluation by an animal companion. For example, owning a pet could be
particularly beneficial for the socially anxious. Social anxiety is the distress felt when one
perceives that she will be negatively evaluated by another person (Fenigstein, Scheier, &
Buss, 1975; Leary, 1983), and is associated with hypersensitivity to social situations and
presenting oneself as non-confrontational (Schlenker & Leary, 1985). Social anxiety,
loneliness, and feeling that one has poor social skills often co-occur (Bruch, Kaflowitz, &
Pearl, 1988; Solano & Koester, 1989). Companion animals may provide the socially anxious
with relatively non-evaluative and therefore non-threatening social interaction experiences
both at relationship initiation and during relationship maintenance. The socially anxious
person’s fears of possessing poor social skills are unlikely to be activated in interactions with
animals. The presence of an animal companion may reduce feelings of loneliness in some
circumstances (e.g., Banks & Banks, 2005, but see Gilbey, McNicholas, & Collis, 2007).
Having a pet may even increase one’s confidence in social interactions with other people,
including but not limited to opportunities to meet likeminded individuals via one’s pet (such
as behavioral training classes or pet playdates), situations that also may be relatively less
threatening since the focus often is on the animals.

Choice and the Selection of Partner Characteristics

Humans have an unprecedented amount of choice in choosing whether to obtain a pet and
the corresponding nature of that animal companion. The process of selecting pets may be
limited by individuals’ living arrangements or finances. Nevertheless, the choice of a pet is a
relatively unconstrained, particularly when compared to mutually negotiated human
relationships. Mail-order brides notwithstanding, one cannot simply unilaterally choose to
enter into a romantic relationship, but one can wake up intending to initiate a relationship
with a pet, go to a shelter or pet store, and begin a close relationship that very day.
Moreover, individuals can choose the species that they prefer based on the amount of
care required, and can even choose the specific characteristics they desire in an animal
companion. In fact, some animals, particularly different breeds of dog, have been bred
selectively to possess certain temperaments and characteristics. Thus, animals generally are
more predictable than humans (Leary et al., 1994). Animals (even cats) do not plot how to put
their best paw forward, selectively disclose information, or engage in outright deception in
order to be viewed more favorably. A relationship with a pet is “what you see is what you
get” relative to the unpredictability of a human relationship.
92 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

In summary, companion animals offer qualitatively different types of supportive

relationships, especially compared to romantic relationships, by providing a great deal of
choice in a relatively non-evaluative context. We revisit these and other aspects of human-
animal relationships in the context of attachment theory.

ATTACHMENT THEORY AND THE HUMAN-ANIMAL RELATIONSHIP

Introduction to Attachment Theory

Attachment theory describes interlocking behavioral systems centered on the formation

of close interpersonal bonds. Bowlby (1969; 1980) asserted that the attachment system
evolved due to prolonged helplessness on the part of human offspring. Behaviors such as the
crying of infants serve to maintain or increase proximity between infant and caregiver. Infants
and children use their caregivers as a safe haven, where they can seek refuge and support
when afraid. Caregivers also serve as a secure base from which children can explore their
environments. Ainsworth and colleagues (e.g., Ainsworth, Blehar, Waters, & Wall, 1978)
employed the “Strange Situation,” a laboratory procedure in which children and caregivers
experience separation and reunion, to systematically test some of the tenets of Bowlby’s
theory. They identified specific ways in which children reacted to the reappearance of their
mother, which led to theory and research on different attachment styles.
Ainsworth and colleagues (1978) found three primary attachment styles based on her
Strange Situation research: secure, anxious-ambivalent, and avoidant. A secure style
presumably develops when the caregiver is consistently responsive and affectionate. Secure
individuals are comfortable with closeness, and approach relationships with confidence and
trust. An anxious-ambivalent style presumably develops when the caregiver is inconsistently
responsive. The unpredictability leads anxious-ambivalent individuals to be more uncertain of
and preoccupied with the status of their relationships. An avoidant attachment style
presumably develops when the caregiver is cool and emotionally unresponsive. Avoidant
individuals tend to be more emotionally distant, reluctant to express physical expression or
emotional need, and more independent.
In recent decades, social psychologists have appropriated the attachment framework to
explore issues of intimacy, support seeking, caregiving, and emotion regulation in adult
relationships, particularly romantic relationships. Hazan and Shaver (1987) led this expansion
of attachment theory, and adapted and validated the secure, anxious-ambivalent, and avoidant
styles for adult romantic relationships. Bartholomew and Horowitz (1991) provided a revised
but complementary framework by conceptualizing attachment as two dimensions on a
positive-negative continuum: view of self and view of others, yielding four different styles. A
positive view of both self and others corresponds to Hazan and Shaver’s secure attachment. A
negative view of self and positive view of others corresponds to Hazan and Shaver’s anxious
ambivalent attachment, which Bartholomew and Horowitz refer to as preoccupied. The Hazan
and Shaver avoidant category describes a negative view of others, but Bartholomew and
Horowitz characterize a positive view of self and negative view of others as dismissing-
avoidant and a negative view of self and negative view of others as fearful-avoidant.
 Another Kind of “Interpersonal” Relationship 93

Subsequent research has proposed moving beyond a typology or style approach, instead
characterizing attachment along two dimensions: attachment avoidance and attachment
anxiety (Fraley & Waller, 1998). However, the four Bartholomew and Horowitz styles have
heuristic value when considered as mapping avoidance and anxiety in two-dimensional space
(e.g., low avoidance and high anxiety corresponds to preoccupied attachment; high avoidance
and low anxiety corresponds to dismissing-avoidant attachment).

Attachment to Pets

The emotional depth of the human-companion animal bond suggests that attachment
theory can be applied to human-animal relationships. Many researchers agree with this
informal view (Beck & Madresh, 2008). Moreover, humans frequently treat companion
animals similarly to children or domestic partners; attachment theory has demonstrated that it
is versatile enough to apply both to parent-child and romantic relationships. However, we
mention a few important caveats. First, the word attachment is commonly used by researchers
when they are referring to general bonding with animals but does not necessarily refer to
Bowlby’s attachment theory in particular (Crawford, Worsham, & Swineheart, 2006). Several
scales purportedly measure human attachment to pets, but are not based on attachment theory
(e.g., the Lexington Attachment to Pets Scale; Johnson, Garrity, & Stallones, 1992). Second,
human-pet relationships are inherently unequal: the animal is dependent on its human
companion for virtually all of its major needs. (However, it is worth noting that this power
differential is characteristic of many interpersonal relationships, from parent-child to
supervisor-worker to romantic relationships, where one member of the dyad possesses more
control in the relationship.) Third, some debate exists over the quality of attachment to
animals. For example, Endenburg (1995) conducted a large survey study in the Netherlands
and described the attachment relationships assessed between humans and their animals as
“weak,” though the strongest attachments were felt to dogs and cats relative to other animals.
Indeed, many animals are owned for work-related reasons (e.g., herding) or are otherwise
seen as instrumental (e.g., for protection of the home); owners do not necessarily feel
psychologically attached to such animals. Put another way, some pet owners consider their
pet merely to be their property, whereas others consider their pet to be a valued member of
the family deserving of the rights and privileges as such (Carlisle-Frank & Frank, 2006).
Fourth and most important, much of the recent research involving attachment theory and
human-animal relationships is theoretically or methodologically problematic. Researchers
need to develop or adapt (Beck & Madresh, 2008) more valid measures of attachment to pets
and study a wider variety of pet-related behaviors and cognitions. Much of the extant human-
pet work is correlational, bringing into question some of the conclusions that may be drawn.
Experimental methods often are challenging (e.g., it is difficult to randomly assign people to
be cat owners or dog owners), but are essential for advancing our understanding of these
relationships. In addition, the research has been limited because its focus primarily has been
the influence of pets on humans, rather than the psychology of the human-animal relationship
more broadly. An enhanced application of traditional interpersonal relationships theory and
methods to the companion animal arena can demonstrate the significance of these
relationships and use these unique relationships to further understand people. In short, this
research area would benefit from a superior integration of established theory and
94 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

methodology. Nevertheless, researchers have begun to explore this profoundly important

component of human relationships.

Can Humans be Attached to Animals? What Defines an “Attachment”?

Bowlby (1969) hypothesized that the attachment system is activated automatically by

threatening situations. Recent research has found that peers (i.e., close friends and romantic
partners) replace parents as serving the functions of safe haven (to whom do you turn when
you feel vulnerable?), proximity maintenance (with whom do you want to spend time?), and
secure base (whom do you count on to support you when you really need it?), and that
separation from close others, particularly romantic partners, is both subjectively distressing
(e.g., Fraley & Shaver, 1998) and physiologically arousing (Fraley & Shaver, 1997). These
functions may be identified in cognition, emotion, physiology, and behavior (Hazan, Gur-
Yaish, & Campa, 2006). The attachment process appears to take time to develop, and these
behavioral systems may be transferred from parent to romantic partner or best friend in
progressive stages (i.e., proximity seeking followed by safe haven and then secure base;
Fraley & Davis, 1997). It takes about six or seven months for infants to direct the various
attachment behaviors to a particular caregiver (Ainsworth, Bell, & Stayton, 1973; Bowlby,
1969). Adults appear to take months or years to transfer these systems to their romantic
partner (Hazan & Zeifman, 1994). Most types of strong attachment bonds are marked by high
degrees of physical contact, though the type of contact varies according to relationship type
(e.g., sexuality for romantic partners). In short, attachment relationships are qualitatively
different from the relationships between acquaintances and are marked by a particular pattern
of cognition, emotion, and behavior.
How might one assess the degree to which humans are attached to animals? The tools of
cognitive-social psychologists might be harnessed to test attachment to animals. In a series of
lab studies, Mikulincer, Gillath, and Shaver (2002) subliminally primed threat and found that
the names of attachment figures were more accessible. Participants first provided several lists
of names, including individuals who served attachment functions for them, individuals they
were close to but who were not attachment figures, and acquaintances. Participants were
presented with a string of letters that was either a word or not, and tasked with deciding as
quickly as possible whether the string of letters was a word. Prior to the presentation of the
letter string, participants were subliminally exposed to either a threat word (failure,
separation) or neutral word (hat). Individuals were quicker to recognize the names of
attachment figures after the threat word but not after the neutral word; this difference was not
significant for the names of other close persons, acquaintances, unknown persons, or
nonwords.
This research also revealed differences in individual attachment style. Those high in
anxiety showed heightened accessibility of the names of attachment figures even without the
subliminal threat word prime, and individuals high in avoidance appeared to inhibit the
activation of attachment figure names when the threat prime word was separation. This is
consistent with other research (e.g., Simpson, Rholes, & Nelligan, 1992); these investigators
brought couples into the lab and told the female member of the couple that she was going to
experience an anxiety-provoking experimental procedure, showing her a room filled with
psychophysiological equipment. Unbeknownst to them, the couples were filmed while
 Another Kind of “Interpersonal” Relationship 95

waiting for this ostensible procedure, and their caregiving and support-seeking behaviors
were observed and coded. Securely attached women, relative to anxious or avoidant women,
were more likely to seek support and reassurance from their romantic partner when facing a
stressful situation.
The paradigm developed by Mikulincer and colleagues (2002) could be modified to test
whether individuals form attachment bonds to their pets. Although the variety and
distinctiveness of pet names may need to be accounted for, adding pet names to the lists of
names provided by participants and engaging in the same lexical decision task would assess
whether this heightened accessibility exists for close pets. We suggest that a significant
percentage of individuals, those who report a longer and closer relationship with their pets,
will identify their pets’ names more quickly when exposed to a subliminal threat.
The method employed by Simpson and colleagues (1992) also could be applied to pets,
by observing how individuals seek support from their pets during stressful and non-stressful
situations (also see following discussion of Allen, Blascovich, Tomaka, & Kelsey, 1991).
More broadly, research in the lab or in the field could assess the extent to which individuals
perceive their pets as serving proximity maintenance, safe haven, and secure base functions.
For example, individual preferences for animal companions when under stress, either in a
diary-type study or manipulated directly in the lab, could be investigated. Presumably, these
functions, though different in their manifestations from human relationships, should be
present in many human-animal relationships. Like human relationships, human-animal
companion relationships likely take months or years to develop, and the proximity seeking,
safe haven, and secure base functions likely transfer at different stages as they do from
parents to peers. Examining individuals who lack a primary human attachment (e.g., single
adults living alone but with a pet) would be a particularly interesting test of these processes.
The strong attachment that many humans form with their companion animals is revealed
in the bereavement that humans endure after losing their non-human friends (Hunt & Padilla,
2006). The significance of losing an animal companion has been characterized as
“disenfranchised,” meaning that the depth of this loss is underestimated and social support
often is lacking (Stewart, Thrush, & Paulus, 1989), but scholars have observed a significant
animal-related bereavement process. Over half of participants in one study reported believing
in an afterlife for their deceased pet (Davis, Irwin, Richardson, & O’Brien-Malone, 2003).
One researcher has developed a social work bereavement model based on traditional human
grief therapy, but specifically designed for animal loss (Turner, 2003). Attachment theory
should be harnessed to further research pertaining to pet bereavement; reactions to the death
of a spouse as well as the death of a pet proceed through similar stages as the distress of
separation from an attachment figure: protest, despair, and detachment (Parks, 1972). In short,
some evidence for the viability of the notion that humans may be as attached to their pets as
they are to humans is manifest in similar and profound emotional reaction to their loss.

Safe Haven, Caregiving, and Support Seeking

Many safe haven and secure base functions of the attachment system may be subsumed
under the notion of caregiving (Feeney & Collins, 2006); a caregiver provides felt security.
Caregivers typically regulate their behavior in response to the needs and expressions of
infants. Cries of hunger and cries of pain elicit different responses by parents to restore
96 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

closeness and meet the infant’s needs. However, attachment style differences exist regarding
how effectively the caregiver notices and interprets the needs of the infant, and the extent to
which the caregiver appropriately regulates behavior.
More distressing events elicit a stronger desire to restore proximity to an attachment
figure (e.g., people often seek physical contact with a romantic partner or parent when
distressed or ill). Unfortunately, individuals often give the type of support that they
themselves have received (e.g., abused individuals often are insensitive to the needs of
others). Avoidant individuals are more likely to use indirect support-seeking strategies, which
often lead to unhelpful forms of support (Collins & Feeney, 2004). Avoidant men overall
provide less support and are more insensitive to their partners’ needs, failing to regulate the
amount of support given as a function of distress that the partner feels. There is some
evidence that the more stressful the situation, the less support provided by avoidant men to
their partners, the opposite of the pattern typically desired by their partners (Simpson et al.,
1992). Avoidant individuals are less likely to provide the physical proximity and contact that
their distressed partners desire. Research on the relationship between avoidant individuals and
their animal companions could further reveal the dimensions and causes of this pattern of
support giving. Do avoidant individuals turn to their pets when stressed? Are they more likely
to engage in physical contact with animals but not human romantic partners in such
circumstances? Do they provide comfort to their distressed animal companions better than
they do to their distressed human companions?
Anxious individuals provide less effective support and exhibit more compulsive or
overinvolved caregiving (Kunce & Shaver, 1994). That is, the care they offer may be more
focused on their own needs (and their perceptions of non-fulfillment) and not well
coordinated with their partners’ preferences. We suspect that compulsive caregiving by
anxious individuals extends to treatment of pets. This may lead to animals that are unruly and
poorly trained. We also suspect that patterns of support-seeking directed at pets might differ
from the pattern directed at humans by anxious individuals.
Feeney and Collins (2006) took attachment-related support-seeking and caregiving
research a step further by investigating motivations for caregiving. Avoidant caregivers are
more likely to help their partners for selfish reasons, such as feeling a sense of obligation or
assuming that the help will be reciprocated later. Anxious caregivers show a mixture of these
motivations and more selfless motivations, including concern for their partners and intrinsic
enjoyment of helping their loved ones. Secure individuals appear to be motivated more by
love and concern for their partners. Thus, these different motivations suggest reasons why
insecurely attached (i.e., avoidant or anxious) individuals provide less effective support or
more compulsive support. The motivations for caregiving potentially could be assessed even
more powerfully by comparing motivations for the selection of different animals as pets, such
as by modifying Kunce and Shaver’s (1994) adult caregiving questionnaire. Such research
also would have implications for animal welfare (e.g., if there is a link between owner
attachment style and pets that are overfed or more likely to develop separation anxiety).
 Another Kind of “Interpersonal” Relationship 97

Secure Base and Exploration

Exploration is a fundamental need that is active when the attachment system is quiescent.
Bowlby (1969, 1988) discussed the notion of the secure base as a central one in attachment
theory. Infants and children use their primary caregivers as launching pads from which to
explore. As they get older, children typically operate in ever-increasing orbits around their
caregivers. The attachment and exploration systems are connected because exploration
potentially exposes explorers to dangers as they increase distance from caregivers. When the
threat of danger is perceived, the attachment system is activated and individuals seek to re-
establish greater proximity to attachment figures.
Research on exploration and especially the concept of the secure base have been virtually
ignored by researchers. One of the few direct investigations of the secure base found that
when individuals felt that they had a reliable secure base in their partners (i.e., their partners
were sensitive to their needs when they were stressed), they felt that their goals were more
attainable and had higher goal-related self-efficacy (Feeney, 2003).
Mikulincer (1997) found that curiosity or information search, a cognitive precursor to
exploration, was greater for secure individuals relative to avoidant individuals, and that secure
individuals also had reduced need for cognitive closure relative to anxious and avoidant
individuals. Hazan and Shaver (1990) operationalized exploration as orientation to work, and
found that secure individuals were more confident about work, enjoyed work for its own sake,
and were not preoccupied by fears of failure. Anxious individuals, in contrast, feared negative
evaluation and appeared to be motivated to gain the approval of others. Avoidant individuals
often used work to replace social interactions.
Elliot and Reis (2003) identified a link between attachment and exploration-related
motivation, specifically effectance motivation—the desire to have successful interactions with
one’s environment. Effectance motivation, and the desire for exploration in general, should be
a default motivation unless other motives temporarily establish primacy (e.g., individuals who
believe that their safety is threatened will cease exploring their environment). Anxiously
attached individuals, for example, may therefore have chronic interference with exploration-
based motivation because they feel threatened (Elliot & Reis, 2003; White, 1959). Elliot and
Reis found that secure attachment was associated with a high need for achievement (and a
low fear of failure) in academic settings. Security also was associated with more approach
goals (how can I get better at this?) than avoidance goals (how do I prevent failing?).
Green and Campbell (2000) developed an index to measure exploration in the social (e.g.,
meet new people), intellectual (e.g., visit a modern art museum), and environmental (e.g.,
travel overseas) domains, and found that attachment avoidance and anxiety both were
negatively correlated with exploration. That is, less anxiety and greater comfort with
closeness correlated with the desire to engage in activities such as joining a new social group,
visiting a strange place, or thinking about unusual ideas. A second study activated one of the
three attachment relational schemas (cf. Baldwin, 1992; Baldwin, Carrel, & Lopez, 1990) to
assess experimentally the link between attachment and adult exploration. Individuals were
primed with a secure, anxious, or avoidant relational schema via an ostensible sentence
memorization task in which key words in the sentences related to attachment constructs (e.g.,
dependence, unpredictability, trust, disclosure, uncertainty). Individuals primed with one of
the two insecure styles were less interested in exploration and expressed reduced preference
98 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

for novel stimuli (e.g., unusual Escher prints such as a dragon biting its own tail) relative to
those primed with the secure style.
Future research could investigate how couples affect each other’s exploration. Perhaps
securely attached couples foster more exploration as each partner serves as a secure base for
the other from which to try new activities. In a similar vein, animal companions might
provide the emotional resources (i.e., the secure base) for an individual to engage in greater
social or environmental exploration, or even change an owner’s dispositional levels of anxiety
or avoidance, preparing him or her for more secure human relationships. Perhaps simply
having a pet might open the door to pet-related activities that facilitate the development of
human relationships (e.g., volunteering at the ASPCA, online chats with fellow cat lovers).
On the other hand, some types of exploration might be inhibited by the attachment to an
animal companion. For example, Mikulincer (1997) found that avoidant individuals read
more about consumer products (i.e., acted more curious) when that choice competed with
social interaction. That is, avoidant individuals may choose a less threatening relationship
with a pet over a human relationship. In addition to possible moderation by attachment
anxiety or avoidance, the type of animal companion or the quality of the human-animal
relationship might moderate this relationship. In short, examining exploration from the
perspective of pet-human relationships may provide valuable insights about human
attachments and exploration in various domains.

Pet Choice and Attachment Style

A great deal of social psychological theory has addressed how individuals choose their
friends and romantic partners, and these concepts may be applied to research on choosing
pets. Attachment theory provides a particularly fascinating approach to this issue. Research
suggests that the pairing of individuals according to attachment style is not random. Some
research has found that individuals are most attracted to those who share their attachment
style (Frazier, Byer, Fischer, Wright, & DeBord, 1996). However, these preferences may not
become reality. Kirkpatrick and Davis (1994) found no avoidant-avoidant or anxious-anxious
pairs in a sample of 354 heterosexual dating couples. They also found that couples composed
of an avoidant man and an anxious woman were fairly stable over three years, in spite of the
fact that these relationships were relatively unhappy. It may be that individuals find
themselves with partners who confirm their (often negative) attachment-related expectations
(e.g., an avoidant man expects his partner to be clingy and demanding, which characterizes
anxious-ambivalence).
What is the relevance of this research for human-animal pairings? First, do humans view
different pets along attachment-related dimensions? We have obtained suggestive evidence
that they do. We asked individuals to provide open-ended descriptions of dogs and cats, and
used content analysis to examine the attachment-related words. Dogs were described with
more security-related words, whereas cats were described with more avoidance-related words.
(These results were not qualified by individual levels of avoidance and anxiety—similar
perceptions of cats and dogs existed for everyone.) These findings were replicated when we
adapted the Experiences in Close Relationships (ECR-R) scales (Fraley, Waller, & Brennan,
2000; Sibley, Fischer, & Liu, 2005), the most commonly used and validated measure of
attachment avoidance and anxiety, to dogs and cats separately. That is, we asked individuals
 Another Kind of “Interpersonal” Relationship 99

to imagine owning a particular animal and to report how they would feel in the context of a
relationship with that animal (“it is easy for me to be affectionate with my dog”).
If dogs and cats are perceived to vary along attachment-related dimensions, does their
desirability as pets depend in part on the level of avoidance or anxiety of potential owners?
We collected some preliminary data on this question as well. Not surprisingly, the more
avoidant individuals reported themselves to be, the less interested they were in owning a pet.
The more anxious individuals reported themselves to be, the more interested they were in
wanting to own a pet. However, findings for specific animals varied somewhat: anxiety was
positively correlated with wanting to own a cat, but not correlated with wanting to own a dog.
Our tentative conclusion is therefore consistent with the Kirkpatrick and Davis (1994)
findings and their interpretation of attachment pairing: individuals may end up choosing a pet
that confirms their expectations (e.g., an anxious person is more likely to choose a cat, who is
perceived to be relatively avoidant). More direct research is needed to assess if attachment
avoidance and anxiety predict the type of pet that individuals actually choose.

Do Attachment Styles Change?

Another fascinating theoretical question involves the malleability of attachment styles or

dimensions. Attachment usually is conceptualized as a stable individual difference developed
during childhood as a result of the pattern of behavior by one’s primary caregiver. Reports of
the stability of attachment styles have varied widely in the literature, but the best conclusion
at this time is that these styles are only moderately stable over the long-term (Fraley, 2002).
Individuals likely have different attachment styles with different individuals (Kamenov &
Jelic, 2005). Put another way, individuals have schemas or working models of different
attachment styles in memory. Even though there likely is a primary (or chronically activated)
style, the other styles can be activated under different circumstances or in different
relationships (Green & Campbell, 2000). For example, one may feel securely attached to
many friends, but feel anxious when considering a particular friend who rarely returns calls.
Attachment stability is affected by the beginning or ending of a romantic relationship
(Kirkpatrick & Hazan, 1994) and non-romantic relationships (i.e., those with family members
and friends) tend to be more secure than romantic relationships (Kamenov & Jelic, 2005).
When we directly compared individuals’ attachment anxiety and avoidance (as assessed
by the ECR-R) with their reports on the same measure adapted for different animals, we
found that individuals reported significantly more attachment security to dogs than to people
(with cats falling in between). Similar results of strongly felt security associated with pets
were recently reported by Beck and Madresh (2008), supporting our previous contention that
human-pet relationships are characterized by reduced evaluation concerns. Research shows
that experiences with family members, friends, and romantic partners may buffer and possibly
even alter attachment anxiety and avoidance; however, whether pets may help individuals
change on attachment dimensions (i.e., become less avoidant or less anxious) is a currently
unaddressed but fascinating question. That is, will the felt security from a long-term
relationship with a pet change one’s predominant attachment style from an insecure to a
secure one? If so, how might that affect the individual’s human relationships? In summary,
attachment anxiety and avoidance can be measured at the general level or at the partner-
specific level. Relationships with many animals may be associated with less anxiety than
100 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

relationships with humans. Future research should investigate whether pet-human

relationships affect more general attachment orientations, and thus possibly affect future
human relationships.
More broadly, research on both humans and animals as third parties to dyadic
relationships is needed (Green, Burnette, & Davis, 2008), because third parties can
profoundly influence those relationships. This area is woefully underresearched, in part due to
methodological and statistical challenges. Balance theory (Heider, 1958) provides a
particularly useful framework for investigating the role of third parties in dyadic
relationships. Being overly attached to one’s pet (one’s first love?) may have deleterious
consequences for a romantic relationship if the partner feels he or she is competing against
the pet. Stammbach and Turner (1999) found that attachment to cats correlated negatively
with the number of close others who provided social support. On the other hand, as
mentioned previously, pets may provide a secure base or buffer for some individuals, or
provide a training ground for learning caregiving and support-seeking, leading to better
human relationships longer-term.

COMPANION ANIMALS AND HEALTH

Physical Contact, Ownership, and Health

Attachment theory can also be seen in the considerable literature (of which we discuss
only representative examples) investigating the influence of animals on human well-being.
Such research generally has found that companion animals improve physical and mental well-
being for human owners (Crawford, Worsham, & Swinehart, 2006). Proximity to a variety of
pets (e.g., watching aquarium fish; Katcher, Segal, & Beck, 1984) or petting an animal (even
snakes, Eddy, 1996) can reduce blood pressure or heart rate, although the evidence is
somewhat mixed. Other work has confirmed that touching pets can attenuate cardiovascular
responses (Vormbrock & Grossberg, 1988), but some research has found no significant
benefits or even come to the opposite conclusion (i.e., raised physiological markers in the
presence of an animal). However, some of these studies have used unfamiliar animals,
highlighting the differences between the potential calming presence of any animal and the
unique bond with one’s own animal.
The attachment system is activated under stressful conditions, so attachment-related
concerns will be more pronounced in stressful situations than in non-stressful situations.
Though they did not assess attachment style, which may have qualified their results, Allen
and colleagues (1991) had female dog owners perform a stressful mental arithmetic task in
the lab as well as at home. Autonomic responses (e.g., skin conductance, pulse rate) were
assessed on both occasions. Participants completed the task at home either alone (only the
experimenter present), with their dog present (but no touching of the pet occurred), or with a
close friend. Compared to the alone condition, participants had significantly less
physiological reactivity when their pets were present, but more reactivity when their friends
were present. Participants apparently were concerned about being evaluated by their friends
even though the friends intended to be supportive; participants tried to perform the arithmetic
tasks more quickly but made more errors when their friends were present. The dogs in this
 Another Kind of “Interpersonal” Relationship 101

case appear to have provided non-evaluative social support, consistent with our previous
assumptions.
These more controlled experiments are complemented by research focusing on the
influence of animals on longer-term physical and psychological health. Research confirms
that companion animals usually provide health benefits, though this evidence is also
sometimes conflicting (for reviews see Podberscek, Paul, & Serpell, 2000; Wilson & Turner,
1998). For example, a longitudinal study demonstrated that individuals who had recently
acquired pets, as opposed to non-pet owners, showed significant decreases in the number of
subsequent physician visits (Headey & Grabka, 2007). Researchers found lower rates of
depression among humans highly attached to their pets (Garrity et al., 1989). The limitations
of correlational research are particularly noteworthy in these situations. It is possible that the
presence of a pet reduces depressive symptoms, but it is also possible that non-depressed
individuals are more likely to seek out a pet for companionship, and that additional variables
may moderate this association.

Special Populations

Much of the companion animal and health research has focused on special populations
such as the elderly, likely due to potential increases in loneliness and health-related issues
associated with this demographic group (Siegel, 1990; Tucker, Friedman, Tsai, & Martin,
1995). Elderly animal owners, relative to non-owners, showed less deterioration in general
health (Raina, Waltner-Toews, Bonnett, Woodward, & Abernathy, 1999), engaged in
healthier behaviors such as exercise and diet (Dembrecki & Anderson, 1996), and had
significantly fewer visits to the doctor (Siegel, 1990). However, the influence of companion
animals on elderly health has not been entirely consistent (Parslow, Jorm, Christensen,
Rodgers, & Jacomb, 2005; Siegel, 1990) likely due to the considerable methodological
challenges associated with studying pet ownership in this population (Pachana, Ford,
Andrew, & Dobson, 2005).
Another special population that has received attention is individuals recovering from
serious illness. For example, dog ownership (but not cat ownership) was associated with a
higher survival rate from heart episodes over one year (Friedman & Thomas, 1995). A
parallel study examined the role of pet ownership in lung transplant recipients (Irani, Mahler,
Goetzmann, Russi, & Boehler, 2005). Lung transplant recipients who owned pets showed
subsequently greater quality of life but no significant physical health differences when
compared to lung-transplant recipients who did not own pets. The absence of any significant
health differences is compelling when considering that health centers sometimes warn against
pets because of the possibility for zoonotic disease transmission. At least in this intriguing
study, any physical health-related risks associated with having pets appear to be negligible or
offset by the psychological boosts associated with owning a pet.
The influence of pets on human health dovetails nicely with growing utilization of
animals in pet-facilitated therapy. Pet-facilitated therapy (PFT) refers to the use of animals as
catalysts in several forms of therapeutic intervention (Brodie & Biley, 1999; Hines &
Fredrickson, 1998). “Therapy” in this context may carry some degree of ambiguity; it often is
unclear whether PFTs are tied to a specific therapeutic goal or the more general goals of
personal development and well-being. To illustrate the former, Levinson (1969), in a seminal
102 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

paper, had his dog (described as a co-therapist) attend therapy sessions with child psychiatric
patients and found that withdrawn children often opened up after interacting with the dog. To
illustrate more general well-being or skill goals, pets have been used to facilitate reading
development in children: the presence of a pet helped children increase their reading skill and
their confidence in reading (Philips, 2006). The most common applications of PFT involve
elderly populations who frequently lack social support (Hooker, Freeman & Stewart, 2002) or
children and adults with clinical or related disorders. For example, PFT has been utilized for
hospitalized children (Kaminski, Pellino, & Wish, 2002), autistic children (Prothmann et al.,
2005; Redefer & Goodman, 1989), children with eating and anxiety disorders (Prothmann et
al., 2005), and adult incarcerated felons (Moneymaker & Strimple, 1991). The fact that
animals can assist in the recovery or increased well-being of individuals with a variety of
physical or psychological problems provides further evidence that the human-animal bond
can be a close and vital one.

Explanations for Health Benefits: Direct and Indirect Effects

Several explanations have been proffered for why animals confer health benefits to their
human companions. One obvious direct effect involves the affection that individuals receive
from pets and the fact that individuals can affiliate with pets during stressful times (Collis &
McNicholas, 1998). In addition, some researchers have investigated the idea that animals
provide humans with greater meaning or purpose because they are responsible for the care of
their pets (e.g., Collis & McNicholas, 1998). One indirect explanation for the association
between pet ownership and health is that companion animals can increase social support by
facilitating interactions between humans (e.g., Chinner & Dalziel, 1991). Another indirect
explanation is that pet owners may exhibit increased physical activity, such as dog owners
going for walks more often than non-dog owners.

Connections to Attachment Theory

Much less work has approached these questions from an attachment theory (or other
theoretical) perspective. Indirectly related to attachment theory and its emphasis on close
emotional bonds, unmarried dog owners who reported feeling close to their pet had fewer
doctor visits than unmarried dog owners who reported not feeling close to their pet, as well as
fewer doctor visits than unmarried non-owners (Headey, 1999). Colby and Sherman (2002)
incorporated attachment style directly into an examination of pet visitation and subjective
well-being in an institutionalized elderly population. They demonstrated that attachment
styles play an important role in the effectiveness of pet visitation; whereas individuals with
secure or anxious/ambivalent attachment styles responded positively to dog visitation, those
with avoidant attachment styles responded negatively. This pattern is consistent with research
on humans. Carpenter and Kirkpatrick (1996) found the following attachment style
differences regarding stress and physiological reactivity: Securely attached women did not
show different reactivity to a psychological stressor when alone than when with their
romantic partner, but avoidant women showed higher blood pressure when their partner was
with them compared to when they were by themselves. As queried previously, do avoidant
 Another Kind of “Interpersonal” Relationship 103

individuals inhibit contact with pets when highly stressed, or is the lack of evaluation going to
make them just as likely to turn to a pet, rather than a human, for comfort?
In summary, the majority of research suggests that companion animals provide physical
and psychological health benefits. Nevertheless, researchers should continue to incorporate
attachment theory and other relationship theories and methods to investigate the connection
between animals and health.

SUMMARY
One of the most popular textbooks on the psychology of interpersonal relations
(Berscheid & Regan, 2005) includes a section on “relationships with companion animals.”
This brief synopsis includes wonderful anecdotes about the bonds between individuals and
animals as well as examples in which an animal beloved by one person increases the stress
felt by that person’s spouse. However, no scientific research is cited, which emphasizes (a)
the poor integration of the human-animal relationship into the broader notion of
“interpersonal relationships” and (b) the opportunity for additional research. We hope that our
selective review of the relevant literature helps spur researchers to venture into these largely
uncharted waters, so that future textbooks on relationships have a surfeit of sources from
which to draw. We have touched on only a few of the myriad applications to both human and
animal welfare.
Bowlby’s attachment theory and his insights about human emotional bonds were in part
inspired by research on animals, including the Harlow studies (e.g., Harlow, 1958) of rhesus
monkey babies who attached to artificial cloth mothers that did not provide milk over wire
mothers that provided milk (highlighting the importance of physical touch in an emotional
bond), as well as animal imprinting studies that demonstrated the tendency of many baby
animals such as goslings to follow the first animal they see after they are born or hatched.
Therefore, it is gratifying to see that attachment theory may come full circle and be fruitfully
applied to relationships between humans and their animal companions. We deliberately
focused on this one theoretical perspective, but other theories of human relationships also
may be applied to relationships between humans and animal companions. For example,
interdependence theory (Kelley & Thibaut, 1978; Rusbult & Arriaga, 2000) may help to
illuminate issues of power and dependence and the variety of interdependent situations in
which humans and animals find themselves enmeshed.
As psychologists and pet owners, we are excited about what the future holds for research
on human-animal relationships. These close relationships are worthy of study in their right,
but we also are confident that a theoretically and methodologically rigorous approach to
studying them will expand our understanding of interpersonal human bonds.

ACKNOWLEDGEMENTS
We thank Jeni Burnette, Jennifer Clarke, and Jody Davis and for their constructive
feedback on earlier drafts. We also thank our beloved pets Indy, Maggie, Mini, Durango,
Jupiter, and Emily for their inspiration and support during this project. Correspondence
104 Jeffrey D. Green, Maureen A. Mathews and Craig A. Foster

concerning this article should be addressed to Jeffrey D. Green, Department of Psychology,

Virginia Commonwealth University, 806 West Franklin Street, P. O. Box 842018, Richmond,
Virginia 23284-2018; E-mail: jdgreen@vcu.edu

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Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 5

THE ROLE OF OXYTOCIN

IN THE PATHOPHYSIOLOGY OF ATTACHMENT

Marazziti Donatella1,*, Catena Dell’Osso Mari2,

Consoli Giorgio1, and Baroni Stefano1
1
Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie,
University of Pisa, Italy
2
Dipartimento di Psicologia, University of Florence, Italy

ABSTRACT
Oxytocin is a nonapeptide synthesized in the paraventricular and supraoptic nuclei of
the hypothalamus. Although OT-like substances are present in all vertebrates, oxytocin
has been identified only in mammals where it seems to be fundamental in the onset of
typical mammalian behaviors, including labour and lactation. In the present chapter, the
physiological role of oxytocin in the regulation of different functions and behaviors will
be addressed: several data, mainly coming from animal models, have highlighted the role
of this neuropeptide in the formation of caregiver-infant attachment, pair-bonding and,
more generally, in linking social signals with cognition, behaviours and reward. In
addition, recent evidences have demonstrated alterations of oxytocin system in several
human neuropsychiatric disorders, leading to the hypothesis of a possible involvement of
oxytocin in the onset of mental disorders. In this frame, the psychopathological
implication of the disregulation of the oxytocin system and the possible use of oxytocin
or its analogues and/or antagonists in the treatment of psychiatric disorders will be
discussed.

*
Author to whom correspondence and reprint requests should be sent: Dr. Donatella Marazziti. Dipartimento di
Psichiatria, Neurobiologia, Farmacologia e Biotecnologie, University of Pisa, via Roma, 67, I-56100 Pisa,
Italy; Telephone: +39 050 835412; Fax: +39 050 21581; E-mail address: dmarazzi@psico.med.unipi.it
112 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

INTRODUCTION
The first evidence of the existence of a neural pathway from the supraoptic (SON)
nucleus of the hypothalamus to the posterior pituitary dates back to the end of the 19th
century [1]. Subsequently, Scharrer (1928) discovered, in the fish hypothalamus, the
existence of neurons which could secrete substances via exocytosis of cytoplasmic vesicles,
the so-called “glandular cells” [2]. Two decades later, oxytocin (OT) was isolated in pituitary
extracts and became the first peptide hormone to have its amino acid sequence identified and
to be synthesized in its active form [3].
This chapter aimed to provide a comprehensive review of the OT system and of its role in
the formation of social bonds, as well as its possible involvement in the onset of
psychopathology.

SYNTHESIS AND LOCALIZATION

OT is a small peptide characterized by a six amino acid ring and a three amino acid tail. It
differ from vasopressin (AVP) in terms of two amino acids: Ile vs Phe at position 3 and Leu
vs Arg at position 8, respectively. The presence at the position 8 of the chain of a neutral
amino acid enables OT to bind to its receptors [4]. All vertebrates possess at least a OT-like
and a AVP-like peptide, while suggesting the existence of two evolutionary molecular
lineages: the isotocin-mesotocin-OT line, implicated in reproductive functions, and the
vasotocin-vasopressin line, involved in the water homeostasis. On the contrary, OT and AVP
have been found only in mammals and probably have developed in parallel with typical
mammalian behaviors, such as uterine contraction during labour and milk ejection essential
for lactation.
Magnocellular neurons of the SON and paraventricular (PVN) nuclei of the
hypothalamus OT and AVP are the major source of OT [5]. OT and AVP are assembled as
precursors which are subsequently processed in the neurosecretory vesicles. The largest
precursor of OT is preprooxytocin, that comprises three components: a signal sequence of
about 16–30 amino acid residues at the neuropeptide terminal, the neuropeptide sequence and
the space parts [6]. During the intravescicular post-translational processing, OT precursor
undergoes sequential proteolytic cleavage and other enzimatic modifications, such as
glycosylation, phosphorylation, acetylation and amidation, that lead to the three final
products: OT, neurophysin and a carboxy-terminal glycoprotein. Once synthetized, OT is
targeted along the axon to the posterior pituitary [7] where each axon produces several nerve
terminals that constitute about 50% of the total volume of the neural lobe. At this level OT
and its transporting proteins may be released into the blood, so that they can stimulate their
receptors located in distant target organs, such as mammary gland and kidney. Several other
biologically active substances, including AVP, neuropeptide Y, tyrosine hydroxylase,
dynorphin, thyrotropin-releasing hormone, atrial natriuretic factor, galanin and nitric oxide
(NO) synthase, are co-released with OT, even if the reciprocal effects between them and OT
are still unknown [8, 9].
Oxytonergic magnocellular projections do not reach only the posterior pituitary, but also
terminate in the arcuate nucleus, the lateral septum, the medial amygdaloid nucleus and the
 Development of an Interview for Assessing Relationship Quality 113

median eminence [10]. In the magnocellular SON and PVN nuclei, OT is also locally released
from dendrites and can act as self-neuromodulators: the somatodendritic release occurs in
response to several stimuli, including suckling, parturition, dehydration, hemorrhage, fever,
physical restraint, pain, mating and territorial marking behaviors, administration of hypertonic
solutions or pharmacological challenges [11].
OT, through the hypothalamic-pituitary portal vascular system, can also reach the
adenohypophysis where it seems to be involved in the regulation of the release of different
adenohypophysial hormones, including prolactin, adrenocorticotropic hormone (ACTH) and
gonadotropins. OT is supposed to act as a prolactin-releasing factor but only when the
dopamine levels are low, like during periods of dopamine withdrawal that characterize the
onset of prolactin secretion. Moreover, since pituitary OT receptor gene expression is
restricted to lactotrophs and increases at the end of gestation [12], it seems that OT function
as a prolactin-releasing factor only around the end of gestation.
OT may play a role in the endocrine response to stress: in rats, OT seems to potentiate the
release of ACTH induced by CRH. In fact, if CRH is responsible for the immediate secretion
of ACTH following an acute stress, when CRH levels begin to decrease during prolonged
stress, the persistent level of OT in the median eminence seems to be related to the delayed
ACTH response and the generation of ACTH pulsatile secretory bursts [13]. However data
are controversial: in humans, OT infusion inhibited the plasma ACTH responses to CRH, and
suckling and breast stimulation increased and decreased, respectively, plasma OT and ACTH
levels; these evidences would indicate an inhibitory influence of OT on ACTH secretion.
OT has also been demonstrated to stimulate LH release: an advancement of the LH surge
with earlier ovulation has been described after OT administration to proestrous rats. However,
the physiological relationships between OT and LH has yet to be clarified [14].
OT is also released from neurons localized in the dorsal-caudal part of PVN and called
parvicellular given their smaller size, as compared with that of the magnocellular neurons.
Their axons are part of the descending tract directed to the sympathetic centers of the spinal
cord and to the parasympathetic caudal autonomic centers, such as the dorsal motor nucleus
of the nervus vagus and the nucleus of tractus solitarii [15, 16]. A peripheral synthesis of OT
has also been demonstrated in placenta, uterus, corpus luteum, amnion, testis and heart.

OXYTOCIN RECEPTORS
There is a single population of OT receptors which can be found in the brain and
peripheral organs. They belong to the class I of G protein-coupled receptor family and are
coupled to phospholipase C-beta which, once activated, leads to the generation of 1,2-diacyl-
glycerol and inositol trisphosphate. The final increase of intracellular Ca2+ may trigger several
cellular events, such as smooth cell contraction, changes of cellular excitability, modifications
of gene trascription and protein synthesis [17].
The brain distribution of OT receptors show a large interspecies variability. In rats, OT
binding sites have been found in the olfactory system, basal ganglia, thalamus, lymbic system
(bed nucleus of the stria terminalis, central amygdaloid nucleus, ventral subiculum),
hypothalamus (ventromedial nucleus), brain stem and spinal cord. In the rabbit, no receptors
have been detected in the ventral subiculum of the hippocampus or in the hypothalamic
114 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

ventromedial nucleus. In human brain, they are mainly distributed in the pars compacta of
substantia nigra and globus pallidus, areas which have been linked to attachment, as well as in
the anterior cingulate and medial insula [18]. Conversely, OT binding sites were absent in
hippocampus, amygdala, entorinal cortex and olfactory bulb. Theoretically, the different
distribution of OT receptors in the brain of individuals belonging to different species might be
related to the variety of functions potentially regulating by them. The density and distribution
of OT receptors in the brain also varies across development and can be influenced by steroids,
such as estrogen, progesterone, androgens and glucocorticoids.
At peripheral level they have been demonstrated to be localized in kidney, heart, thymus,
pancreas and adipocytes. These receptors are stimulated by the OT released into the blood by
the neurohypophisis and carry on several important physiological function.

SOCIAL ATTACHMENT AND OXYTOCIN

Most of the data on the neurobiological mechanisms that subtend the formation of social
bonds came from animal models. In fact, the methods of science (invasive, rigorously
controlled) are difficult to apply to personal experiences associated with social attachment in
humans. Neuropeptides, particularly OT, seem to play a critical role in the initiation and
maintenance of complex social behaviors [19-21]. They would act trough the inhibition of
defensive behaviours associated with fear and anxiety and trough the promotion of positive
social behaviours which may lead to social bonds formation.
The most relevant data on this issue will be reviewed, according to Harlow’s
classification of social bonds (parental attachment, infant attachment, pair attachment) [22].
The hormonal effects of specific physiological states, which are known to encourage positive
social behaviours, will also be reported.

Parental Attachment

The most stable and long-lasting form of social bond is maternal attachment, which is
critical for the survival of mammals. Most of the data on the biochemical and neurobiological
mechanisms that subtend maternal bonding came from precocial ungulates, especially sheep,
who develop selective filial attachment. In fact, as in humans, in these animals maternal
attachment is usually developed only towards the ewe’s own lamb. The hormones regulating
birth and lactation have been implicated in the genesis of caregiver – infant attachment [23,
24]. OT, the mammalian hormone with the predominant role in both birth and lactation, has
been obviously considered the main candidate for the onset of caregiver – infant attachment
and about 30 years ago was proposed as the hormone of the mother love [25, 26]. Vaginal
stimulation and sukling may lead to maternal bonding trough a release of OT and endogenous
opioids [24]. In sheep, it has been demonstrated that OT injection can lead ewes to get
attached to unfamiliar lamb, while OT antagonists may block the maternal bond formation
[27].
Rats represent another ideal subject for studying the maternal care: nulliparous female
rats do not show any interest in infants until the parturition, when a drastic change in
 Development of an Interview for Assessing Relationship Quality 115

motivation occurs and typical maternal behaviours became established [28]. OT injection in
the lateral ventricles of nulliparous ovariectomized rats may induce maternal behaviors [29],
while the central injection of OT antagonists or lesions of OT-producing magnocellular
neurons in the hypothalamus inhibit the onset of maternal behaviors. These data, coupled with
the fact that, once a female has become maternal, OT antagonists have no effect, might
indicate that OT is foundamental for the onset, but not for the maintenance of maternal
attachment [30]. In humans, little is known on the influence of OT in maternal behaviors: in a
old study it was reported that breast-feeding within 1 h of birth, when OT levels are high,
could contribute to a long-lasting mother-infant bond with beneficial effects on the
development of the child [31].
Although the neurobiological mechanisms underlying OT-related onset of maternal
behaviors are still unclear, the increase of OT receptors in the bed nucleus of the stria
terminalis and the ventromedial nucleus of the hypothalamus, that occurs just before
parturition, may represent crucial steps of this process [32].

Infant Attachment

Infant attachment has been often studied on the basis of behavioural and hormonal
changes associated to the separation from the attachment figure. In primates, the attachment
object represent the safe and secure base which can protect the infant from threats and
provide him with food. During the early development, the mother-infant interaction and the
early social experiences may produce long-lasting changes in the brain of the infant with
profound behavioural and emotional effects throughout the whole life.
OT seems to be critical in the genesis of infant attachment: infants are exposed to the
high levels of maternal OT during both labor and lactation. In animals, infants do not develop
preferences for the mother if they are pretreated with OT antagonists, while OT
administration was demonstrated to facilitate a rapid conditioned association to maternal odor
cues [33]. Therefore, the increased blood levels of this hormone may induce positive social
interactions, including the formation of social bonds and of their memories, as well as of
selective infant–parent attachments. OT administration reduces the separation response of the
rat pups, consistently with the role of this peptide in either attachment or separation response
[34, 35]. Interestingly, OT receptors have been found in the developing brain with a transient
but marked “overproduction” (as compared to the adult) in the limbic areas in the first two
postnatal weeks [36, 37]. In addition, OT receptors are present in the reward circuit that
includes the nucleus accumbens, the cortex, the talamus and the pallidus, and which, during
infant development, has been implicated in the regulation of that sense of ssafety and
protection which makes social and parental interactions highly rewarding.
OT is considered to be one of the potential candidates involved in the transduction of
early experiences (birth process, breast-feeding and other aspects of parent-infant
interactions) into physio- (patho-) logical changes, including brain growth, later stress
reactivity and ovarian disorders [38].
In humans, the deprivation of the normal parental cares has been recently shown to
produce long-lasting changes in the sensitivity to OT during adulthood [39] and to alter the
development of children’s OT and AVP systems, which interfere with the comforting effects
that typically emerge between children and familial adults who take care of them; in fact, OT
116 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

and AVP levels are increased by socially pleasant experiences, including comforting touches
and smells [40].

Adult Pair Bonds

A natural animal model for studying the neurobiological substrates of pair bond
formation is provided by the prairie voles, small arvicoline rodents that live in pairs and
develop adult heterosexual pair bonds that resemble those of humans [41]. In fact, the prairie
vole, that are usually found in multigenerational family, shows the classic features of
monogamy: a breeding pair lives in the same nest and territory, males, too, take care of
infants and intruders of either sex are refused [42]. On the contrary, montane voles are not
monogamous and live in isolated conditions showing little interest in social contact. The two
species show a different neural distribution of OT receptors: the prairie voles show OT
receptors in the nucleus accumbens and prelimbic cortex, brain regions associated with the
reward system, while suggesting that OT might have reinforcing properties. In the montane
voles the OT receptors are mainly distributed in the lateral septum and seem to be responsible
for the effects of OT on self-grooming behavior observed only in this species. Similar
differences in receptor distribution have also been observed in pine and meadow voles which
are characterized by different social organization (i.e., monogamous versus non-
monogamous) [43].
In prairie voles, period of non-sexual cohabitation can lead to pair bond formation,
however, if mating is allowed, they are developed more quikly [44]; mating is known to lead
to a release of OT which, therefore, has been hypothesized to be involved in pair bonding
[21]. The hypothesis of the involvement of OT in pair bonding seemed to be confirmed by the
evidence that, in female prairie voles, central OT treatments increase social contact and
facilitate partner preference formation which, on the contrary, seem to be inhibited by the use
of OT antagonists [45, 46]. In any case, OT seems to produce different effects in male and
female prairie voles: central OT administration in females, but not in males, facilitates the
development of a partner preference in the absence of mating [34]. However, the role of OT
in males remain unclear, possibly because males are more dependent on AVP.
In humans, OT administration seem to increase the trust towards the others, possibly
through the involvement of the amygdala, the main component of the circuit of fear and social
cognition which highly expresses OT receptors [47]. OT seem to be able to modulate some
functions of human amygdala: a neuroimaging study (functional magnetic resonance) showed
that OT reduced significantly the activation of amygdala and its coupling to brain regions
implicated in autonomic and behavioral responses to fear [48]. The property of OT to
facilitate the formation of social bonds has been related to the improvement of the inference
of the affective mental state of the other subjects, which, in turn, would lead to a reduction of
the ambiguity experienced during a social interaction with subsequent decreases of anxiety
levels [49]. This theory is in line with the previous result of a reduction of the autonomic
response to aversive pictures after OT treatment [50]. OT administration, however, did not
affect self-report scales of psychological state regarding anxiety and mood [51]; it seems that
the presence of a social interaction is necessary to elicit the OT effect, since it would become
evident only in the social context, but not when subjects rate themselves in isolation.
Moreover, it has been demonstrated that the decrease of amigdala activation after OT
 Development of an Interview for Assessing Relationship Quality 117

administration was more significant for social stimuli, such as faces, than for non social ones,
suggesting that different neural systems may mediate social and non-social fear [51].
A critical requirement for the formation of pair bonds is the ability to identify
conspecifics [52]. OT seem to be involved in social learning and recognition, the so-called
social memory. In fact, OT knock-out mices are not able to recognize previously encountered
conspecifics and do not show any attachment behaviour; however, central OT administration
before the first contact can restore normal attachment behaviors [53]. Therfore, OT seems to
be involved in acquisition rather than in consolidation of social bonds and, in rats, OT can
lead to the onset of partner preference [54].
The likelihood of a social encounter is also important for pair bond formation: for
example, anxiety and novelty avoidance may reduce the likelihood of approaching a
conspecific. While OT has been demonstrated to decrease anxiety-like behaviors, AVP seems
to increase them [55]. The opposite effects on behaviors produced by OT and AVP may be
explained by the need of a gender-specific modulation of different behaviors. Although OT
influences sexual behaviors and social interactions in both males and females, the onset of
maternal behaviors is fundamental in females [16] and require the inhibition of novelty
avoidance, the suppression of prior social avoidance learning and a decrease of aggression.
On the contrary, AVP promotes behavioral modifications leading to the establishment of
territories and dominance hierarchies characteristic of male social behavior.

Sexual Behavior and Attachment

There is a strong relationship between neuropeptides and sexual behaviour. In those

species that form heterosexual pair bonds, such as prairie voles, sexual contacts are followed
by the formation of stable bonds [42]. In humans, plasma OT levels increase during sexual
arousal and are significantly higher during orgasm than at baseline in both males and females
[20, 21]. Moreover, the level of muscular contractions during orgasm has been positively
related to OT plasma levels [56], suggesting that some OT effects may depend on its ability to
stimulate smooth muscles contraction in the genital area. In addition, intranasal OT
administration seems to enhance the sexual arousal and orgasm intensity: interestingly, a
woman who had used a synthetic OT spray, experienced an increased sexual desire associated
with intense vaginal transudate [57, 58]. Overall, during sexual arousal OT seems to act
peripherally on reproductive organs and activates the sexual functions in both women and
men. Beyond its peripheral effects on reproductive organs, OT might also sensitize the
neurons responsible for the cognitive feelings of orgasm, while representing a physiological
substrate for both sexual behavior and performances. In men, AVP concentrations increased
significantly during arousal and returned to basal levels at the time of ejaculation, while
plasma OT rose about five-fold during ejaculation and returned to basal concentrations within
about 30 minutes [59].

Stress and Attachment

It is well known that threatening situations might strengthen and facilitate the onset of
social bonds [60]. In prairie voles, stress and corticosterone injection have been demonstrated
118 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

to facilitate pair bond formation. The underlying hypothesized mechanism is that

glucocorticoids modulate social bonds by influencing synthesis and release of OT and/or OT
receptors [61]. OT may be released from the pituitary gland in response to different stressful
stimuli, such as pain, conditioned fear and exposure to novel environments [62].
In rats, the acute exposure to immobilization stress resulted in increased OT-mRNA
levels, while both forced swimming and shaker stress provoked a raise of central and plasma
OT concentrations. OT would facilitate the activation of the hypothalamic-pituitary-adrenal
axis by increasing the glucocorticoid release. Along this line, it is supposed that the stress-
induced central release of OT can ameliorate some stress-related disorders, such as depression
and anxiety: in mice and in rats, OT showed anxiolytic properties in estrogen-treated females
possibly mediated by its influence on dopaminergic neurotransmission in the limbic areas.
Since stress and anxiety impair maternal caretaking, a reduced stress responsiveness
during lactation appear to be adaptive for both mother and infant. In line with these
observations, lactating women showed reduced hormonal responses to exercise stress, as
compared with postpartum women who bottle-feed their infants [63]. Furthermore, women
with panic disorder have been demonstrated to experience, during lactation, a reduction of
their anxiety symptoms [64].

OXYTOCIN AND NEUROPSYCHIATRIC DISORDERS

Only a few data exist on a possible involvement of OT in the pathophysiology of
neuropsychiatric disorders. Although most of them should be considered as suggestions,
nevertheless they are intriguing and would indicate the need of further research in this
promising area.

Depression

Since OT has been shown to decrease stress response and anxiety levels, to modulate
cognitive functions and promote positive social relationships, some symptoms of depression,
including social withdrawal, cognitive impairment, appetite modifications and stress
reactivity [65], have been related to alteration of the OT system [66]. In a postmortem study,
increased density of AVP- and OT-expressing neurons was detected in the PVN nucleus of
depressed patients [67]; on the contrary, no difference in OT levels was found in
cerebrospinal fluid (CSF) of depressed patients and control subjects [68]. As far as OT
plasma levels, although in a first study decreased levels of the neuropetide have been reported
in depressed patients [69], no difference in a larger group of patients, as compared with
healthy subjects was also found [70]. More recently, a negative correlation correlation was
found between plasma OT and symptoms of depression and anxiety in 25 patients affected by
major depression [71]. The OT abnormalities reported in depression, although requiring
further support, may be linked to the dysregulation of the HPA axis reported in this condition,
together with the multiple neurotransmitters and modulators acting at this level.
 Development of an Interview for Assessing Relationship Quality 119

Anxiety Disorders

Obsessive-compulsive disorder (OCD) is characterized by obsessions and/or

compulsions. OT may influence physiological activities, including memory acquisition,
maintenance and retrieval, as well as grooming, maternal and sexual behaviors, which may be
related to some OCD features. OT receptors have been identified in some brain areas, which
have also been implicated in the pathophysiology of OCD [72-75]. In animals, the central OT
injection produce a significant increase of grooming behavior [76, 77] which is considered a
model of compulsions, as cleaning behaviors are prototypical symptoms in OCD patients [78,
79] and parallel the OT-induced grooming behaviors observed in animals [80]. The
hypothesis of an involvement of the OT system in the pathophysiology of OCD is supported
by the evidence that pregnancy and the postpartum period are characterized by an increased
risk for the onset of contamination obsessions [81-84]. It is possible that a subgroup of
women are vulnerable to the induction or exacerbation of OCD after the exposure to the
elevated OT levels, such as those occurring during the pregnancy [85, 86]. Moreover,
increased OT levels in the CSF of adults with OCD and Tourette’syndrome, as compared
with healthy control subjects, have been reported and they seem to correlate with the current
severity of OCD [87]. The attempts to administer OT to OCD patients led to controversial
results [88-92], so that further data are necessary to understand the potentiality of OT or its
analogues as antiobsessional treatment.
OT seems to have anxiolytic properties. In mothers, OT levels have been demonstrated to
positively relate with a reduction of the incidence of stress and anxiety disorders [63];
pregnancy, a period characterized by increased OT levels, seems to be protective for some
anxiety disorders, including panic disorder. OT, which is released during stress, seems to be
an important modulator of anxiety and fear response, with a final reduction of anxiety [93-
95]. Dysfunctions of the amygdala, which is implicated in the biological response to danger
signals in social interaction, have been reported in anxiety disorders; however, it is known
that amygdala activity is modulated by OT, since its intranasal administration reduce
amygdala activation and its coupling to the brain regions involved in the autonomic and
behavioral response to fear [48]. Recently, a downregulation of OT receptors has been related
to the pathophysiology of social anxiety disorder that might explain the cognitive
misappraisals typical of the patients affected by this condition [48].
In patients with post-traumatic stress disorder (PTSD), the intranasal OT administration
was able to decrease the memory retrieval and conditioned response [50]. In fact, OT
attenuates memory consolidation and retrieval, facilitates the extinctions of an activated
avoidance response and attenuates passive avoidance behavior [96, 97]. Alterations of the OT
system following severe early stress and trauma may interfere with the normal brain
devolpment while increasing the subsequent risk of developing PTSD and, more in general,
any kind of psychopathology [98].

Eating Disorders

OT and AVP, which have been demonstrated to influence feeding behavior [99], have
been eating disorders where inconclusive results have been reported [100-103]. The serum
activity of the prolyl endopeptidase (PEP), an enzyme that cleavages many active
120 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

neuropeptides, such as OT, AVP, thyrotropin releasing hormone, substance P, bradykinin,

neurotensin and angiotensin [104], was decreased in both bulimic and anorectic patients
[105]. The CSF OT levels were found to be low in restricting anorectic partients [103], but,
since they tend to normalize after weight restoration, they were interpreted as secondary to
malnutrition and abnormalities in fluid balance [105, 106]. Autoantibodies against OT were
reported in both anorexia and bulimia nervosa and seem to indicate that immune dysfunctions
may also be involved in the pathophysiology of these disorders [107].

Addiction

A crucial drug-sensitive component of the reward circuit, which is enhanced by abuse

drugs, is represented by the mesolimbic dopaminergic system which is under the modulatory
control of several neurotransmitters and hormones [108]. OT could be involved in the
development of tolerance and dependence towards abuse substances including opiates and
cocaine [109]. Given that adaptation and learning are likely to be implicated in the neural
events leading to drug tolerance and dependence [110], OT is supposed to modulate
dopamine in the reward circuit.
In mice, OT seems to inhibit the onset of tolerance to morphine [111] and to attenuate the
symptoms of morphine withdrawal [109]. OT attenuated also the cocaine-induced
hyperactivity and inhibited the behavioral tolerance to the effect of this drug, while
facilitating the development of behavioral sensitization [112-114]. As far as ethanol is
concerned, OT was shown to inhibit the development of tolerance to ethanol in mice [115];
acute alcohol administration inhibits OT secretions [116], while its chronic use stimulates it
[117]. It has also been hypothesized that OT might be involved in the cognitive dysfunctions
observed in alcoholics [117, 118].

Schizophrenia

Only a few data are available on the relationship between OT system and psychoses. OT
levels were increased in schizophrenic patients, as compared with healthy controls,
particularly in those taking neuroleptics [119]. In addition, in the brain of untreated
schizophrenic patients, a morphometric evaluation of neurophysin-immunoreactivity
suggested the presence of alterated OT function [120].

Autism and Related Disorders

OT and AVP seem to be implicated in social skills [19-21, 121, 122] and abnormalities of
their neural pathways may underlie several aspects of autism, such as repetitive behaviors,
cognitive and social deficits, early onset, and genetic loading [123, 124]. The central
regulation and expression of OT and AVP may help to explain the higher prevalence of the
disorder in male subjects: in fact, centrally active AVP has been related to increased
vigilance, anxiety, arousal and activation, while OT seems to have opposite effects including
reduced anxiety, relaxation, growth and restoration. Therfore, higher activity of AVP, due to
 Development of an Interview for Assessing Relationship Quality 121

an increased exposure to androgens, might contribute to the male vulnerability to autism,

while OT, which is estrogen-dependent and is higher in female subjects, especially during
early development, may be a protective factor [125].
There are only a few data on the relationships between OT and autism: plasma OT levels
have been reported to be decreased in 29 autistic children, as compared with healthy control
subjects, and to negatively relate to the reported scores on social and developmental measures
[126]. Moreover, in the blood of autistic children, an altered, extended form of OT, which is
normally detected only during the fetal life, has been found at higher levels than in normal
subjects [127]; this fetal form less active than the adult OT and may interfere with the
functioning of the OT system. In addition, it has been suggested that the OT receptor gene
may be an excellent candidate for the susceptibility to autism [123, 128-130]: two specific
nucleotide polymorphisms of OT receptors, rs2254298 and rs53576, seem to characterized
autistic subjects in a Chinese Han population [131]; this association has been replicated in a
Caucasian sample of United States but only for the rs2254298 polymorphism [132]. Another
association study has recently confirmed that specific haplotypes in the OT receptor gene may
confer the risk to develop autism [133].

Prader-Willy Syndrome

The Prader Willy syndrome (PWS) is a genetic disorder characterized by mental

retardation, hypogonadism, short stature and distinctive dysmorphic features. A 42%
reduction of OT-expressing neurons was described, post-mortem, in the PVN nucleus of PWS
subjects, as compared with healthy controls [134]. Similarly to what described in OCD
patients, increased OT CSF levels have been found in PWS subjects [81].

CONCLUSION
OT and the OT system are currently attracting an increasing interest and have become
one of the main topics of several research lines. Several data, mainly coming from animals,
suggest that OT plays a major role in the modulation of a broad range of functions and of
complex behaviours including its role in the formation of caregiver-infant attachment, pair-
bonding and, more generally, in linking social signals with cognition, behaviours and reward.
Recently OT has been implicated in the pathophysiology of different neuropsychiatric
disorders, even if data are scattered and the abnormalities described in patients are quite
meagre and, therefore, should be considered preliminary.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 6

IDENTITY EXPLORATION AND COMMITMENT

ASSOCIATIONS WITH GENDER DIFFERENCES IN
EMERGING ADULTS’
ROMANTIC RELATIONSHIP INTIMACY

H. Durell Johnson*, Kristen A. Loff, George Bell, Evelyn Brady,

Erin A. Grogan, Elizabeth Yale,
Robert J. Foley, and Trishia A. Pilosi
Pennsylvania State University, Pennsylvania, USA

ABSTRACT
Emerging adulthood is considered a time when intimacy becomes an integral aspect
of romantic relationships, and Arnett (2000) argues intimacy in emerging adults’
romantic relationships results from identity explorations. Previous research, however,
suggests emerging adults’ romantic intimacy is associated not only with identity
exploration, but also with identity commitments and gender. In an attempt to examine the
theorized relationships among identity exploration, identity commitment, gender, and
perceived romantic intimacy, the current study examined identity and romantic intimacy
responses from a sample of 271 emerging adults (183 females, mean age = 19.22 years;
and 88 males (mean age = 19.29 years). Findings indicated 1) both identity exploration
and commitment predict emerging adults’ romantic relationship intimacy, 2) gender
differences in romantic relationships differ according to emerging adults’ identity status,
and 3) identity status differences in romantic relationship intimacy differs for emerging
adult males and females. The current study’s test of Arnett’s (2000) hypothesis regarding
identity exploration and romantic relationship intimacy development did not fully support
his theorized association. Rather, findings suggest differences in emerging adults’
romantic intimacy are associated with their gender and identity commitments as well as

*
Correspondence concerning this article should be addressed to H. Durell Johnson, Human Development and
Family Studies, Pennsylvania State University, 120 Ridge View Drive, Dunmore, PA 18512-1699, Phone:
570-963-2672, Fax: 570-963-2535, E-mail: hdj2@psu.edu
132 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

identity exploration. As a result, Arnett’s (2000) proposal that identity exploration during
emerging adulthood is a necessary precursor for intimate romantic relationships may not
completely describe the association between identity and intimacy that emerges during
this period, and this association may be more complex than originally theorized. Results
are discussed in terms of understanding the moderating association of gender on identity
exploration and commitment differences in emerging adults’ reports of romantic
relationship intimacy.

INTRODUCTION
Early romantic relationships act as a “training ground” for social development by
allowing adolescents to experiment with intimacy and sexual activity within a secure context
(Davies & Windle, 2000; Furman & Shaffer, 2003), and this secure context is beneficial to
the members of the relationship. For example, involvement in a romantic relationship
increases one’s status within the peer group (Furman & Simon, 1999; Miller & Benson, 1999;
Davies & Windle, 2000) and serves as an additional friendship context (Furman & Shaffer,
2003). Further, the secure context of romantic relationships provides both members with a
feeling of connectedness to the other member as well as a sense of companionship. The
connectedness and companionship associated with romantic relationships are associated with
increased positive affect (Furman & Shaffer, 2003; Joyner & Udry, 2000), increased positive
self-concept (Davies & Windle, 2000; Brendgen, Vitaro, Doyle, Markiewicz, & Bukowski,
2002), and lower levels of loneliness and anxiety (Collins & Sroufe, 1999; Davies & Windle,
2000). Higher levels of self-esteem are associated with adolescent feeling of being understood
and cared for within their romantic relationship (Collins & Sroufe, 1999). By providing
companionship that is beneficial for its members (Furman & Simon, 1999; Miller & Benson,
1999), involvement in romantic relationships can lead to positive social adjustment (Brengden
et al., 2002; Davies & Windle, 2000).
The transition to intimate romantic relationships is considered a normative developmental
process. However, individuals vary in their capacity for developing and maintaining these
relationships. One factor associated with the capacity for developing intimate romantic
relationships is each member’s personal identity development. Previous research suggests that
identity and intimacy progress concurrently during adolescence and emerging adulthood
(Craig-Bray, Adams, Dobson, 1988; Dyk & Adams, 1987; Franz & White, 1985; Mellor,
1989; Paul & White, 1990). According to Erikson (1968), it is possible to share oneself with
another through the formation of intimate relationships after the development of identity.
Before the formation of identity, however, the person is not able to share and commit a self
that is not fully differentiated and not fully understood. Sullivan (1953), however, states that
the development of intimacy and emotional closeness is an important milestone for the
development of identity during adolescence.
Research supports the association between identity and intimacy formation as well as
similar patterns of identity development during later periods of adolescence for males and
females (Schiedel & Marcia, 1985). Although males and females display similar patterns of
identity development, research by Schiedel and Marcia (1985) indicates that 1) females
generally score higher than males in relationship intimacy when identity development is low
and 2) females typically report higher levels of intimacy when compared to males with
 Development of an Interview for Assessing Relationship Quality 133

similar identity characteristics. These findings suggest that males and females take different
pathways towards intimacy development, and intimacy is contingent upon identity for males
but not for females. By adolescence, boys focus on developing an independent identity. In
contrast, females organize and develop the self in the context of important relationships which
serves as the basis of their identity process (Gilligan, 1982; Josselson, 1987; Patterson,
Sochting, & Marcia, 1992; Surrey, 1991). Therefore, “identity and intimacy issues may be
merged for females” (Dyk & Adams, 1990, p. 93), and “identity [development] precedes the
emergence of … intimacy for males” (Dyk & Adams, 1987, p. 232). As a result, female
reports of relationship intimacy may not be as strongly related to their identity development
as are male reports of relationship intimacy, and this pattern of intimacy and identity
development is likely to continue until adulthood (Josselson, 1987).
Although Erikson (1968) and Sullivan (1953) appear to argue contradictory roles of
intimacy and identity in development, both agree that the later period of adolescence is
characterized by the development and integration of intimacy and identity. Establishing
emotional closeness is important for relationship development and assists in establishing a
safe context (i.e., a close relationship) for identity exploration (Mclean & Thorne, 2003).
Further, commitment to an interpersonal identity is associated with higher intimacy for
females than males in same- as well as opposite-sexed relationships (Craig-Bray et al., 1988).
Possessing a more advanced identity status promotes the development of emotional closeness
and intimacy in adolescent friendships which further promotes identity development. As a
result, individuals with “more advanced identity statuses are typically in more advanced
intimacy statuses” (Dyk & Adams, 1987, p.232).

INTIMACY AND IDENTITY ASSOCIATIONS

DURING EMERGING ADULTHOOD

Despite the established association between intimacy and identity in the literature, the
relationship between these constructs during emerging adulthood is not as well known
(Montgomery, 2005). New theories of adolescent and adult development (i.e., Arnett, 2000)
have proposed that identity exploration is a process characteristic of late adolescent and adult
development, and exploration seen during early and middle adolescence is not associated with
identity development. Only in late adolescence and young adulthood does one see the
examination and exploration processes necessary for identity achievement. According to
Arnett’s (2000) conceptualization of emerging adulthood (i.e., 18 to roughly 25 years of age),
identity exploration during this period involves “trying out various life possibilities and
gradually moving toward making enduring decisions”, and emerging adulthood is “the period
that offers the most opportunity for identity explorations of romantic relationships” (p. 473).
Further, emerging adults who engage in identity exploration increasingly focus on long-term
factors in their romantic relationships than emerging adults who have not engaged in identity
exploration or have limited explorations. As a result, emerging adults’ decisions regarding
their romantic relationships increasingly focus on relationship intimacy as they engage in
identity explorations (Arnett, 2000; Nelson & Barry, 2005).
Arnett’s (2000) argument regarding identity exploration as a component of romantic
relationship intimacy development is supported by previous research (e.g., Dyk & Adams,
134 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

1987, 1990). However, he proposes identity exploration as leading to romantic intimacy

commitments. In his description of emerging adults’ romantic intimacy development, Arnett
(2000) implies that emerging adults who engage in identity explorations develop more
intimate romantic relations than individuals not exploring their identity. Although identity
exploration may lead to identity commitments, identity commitment is not considered an end
result of identity exploration (Waterman, 1993, 1999). Rather, Marcia (1980) and Bilsker and
Marcia (1991) state that identity commitment and exploration are separate but interrelated
processes of identity development. As a result, 1) emerging adults can commit to intimacy
beliefs without exploring these beliefs, 2) emerging adults can explore intimacy beliefs
without making a commitment, or 3) emerging adults can neither explore nor commit to
intimacy beliefs. Rather than viewing identity exploration as the primary process to intimacy
commitments and viewing identity commitment as an end result of identity exploration, the
joint role of identity commitment and exploration may serve as a better predictor of emerging
adults’ romantic relationship intimacy.
Research examining the joint role of identity commitment and exploration associations
with relationship intimacy suggests identity commitment (separate from identity exploration)
predicts relationships intimacy. For example, findings by Loff, Bell, Grogan, Foley, Pilosi,
and Johnson (2005) and Loff and Johnson (2006) indicate that individuals characterized as
having made identity commitments have more intimate romantic relationships than those
characterized as having not made identity commitments regardless of their reported identity
explorations. Further, Meeus, Iedema, Helsen, and Vollebergh (1999) state that individuals
may find decisions made without exploration an “acceptable end-point of identity
development” because identity exploration is not a necessarily needed component of
“progressive development” (p. 429). Waterman (1993) also argues that individuals who have
made commitments without exploring these commitments may be as satisfied with their life
choices as those who have explored their commitments, and these decisions should not be
disrupted unless they interfere with one’s ability to function effectively.
An additional limitation concerning Arnett’s (2000) argued association between identity
exploration and romantic intimacy concerns gender differences in identity and intimacy
development. Several researchers (i.e., Markstrom & Kalmanir, 2001) propose that males and
females take different identity pathways towards developing relationship closeness and
intimacy. According to Dyk and Adams (1987, 1990) and Surrey (1991), female identity and
intimacy development may unfold simultaneously while male identity development may
precede intimacy development. As a result, females who have made identity commitments
may report higher levels of intimacy than females who have not made commitments,
regardless of their explorations. Males, however, who have not made commitments or who
have made commitments without exploration may not report intimacy levels as high as those
males who have both explored and committed to their identity decisions.
Although identity exploration may serve as a precursor for more advanced intimacy
development in romantic relationships, previous research 1) does not suggest identity
exploration as the definitive pathway to more intimate relationships and 2) suggests the
identity – intimacy association possibly differs for males and females. To test Arnett’s (2000)
proposed association between identity exploration and romantic intimacy in relation to these
previous findings, the associations among gender, identity status, and perceived romantic
relationship intimacy were examined in the current study. First, results were hypothesized to
indicate significant identity status differences in romantic relationship intimacy for female
 Development of an Interview for Assessing Relationship Quality 135

and male participants. As previously stated, female relationship intimacy often coincides with
their identity development. As a result, females low in identity exploration and commitment
were expected to report the lowest levels of romantic relationship intimacy. Females high in
identity commitment, however, were expected to report higher levels of intimacy than
females who had not reported identity commitments. Further, males typically do not report
high levels of relationship intimacy until they have resolved identity-related issues. Therefore,
males high in both identity exploration and commitment were expected to report higher
intimacy levels than males low in identity commitment and/or exploration. Second, results
were hypothesized to indicate significant gender differences in intimacy across identity
statuses. Because females generally report more intimate relationships than males regardless
of identity status, female participants were hypothesized to report higher levels of romantic
relationship intimacy than males regardless of identity status.

METHOD

Participants

A total of 437 emerging adults from a commuter campus of a large Northeastern

university were recruited to participate in the current study. Given the focus on emerging
adults who were “exploring” romantic relationships, only unengaged and unmarried
participants were included in the current study. Based on this criteria, the preliminary sample
consisted of 292 participants (93 males, mean age = 19.27 years; Range = 18 to 21 years, and
199 females, mean age = 19.17 years; Range = 18 to 21 years). Examination of missing data
resulted in two additional participants being removed from the study. Analysis of the
remaining participants indicated a final sample of 88 males (mean age = 19.29 years; Range =
18 to 21 years), and 183 females (mean age = 19.22 years; Range = 18 to 21 years). The final
sample did not significantly different in age from participants not reporting a romantic
relationship, t (271) = < -1, p = .49. In order to reduce potential selection and response bias
associated with recruiting from introductory social science classes, requests for participation
were directed to the general student body through the posting of fliers on campus and
speaking to undergraduate courses across disciplines. Participants were given a small gift and
course extra-credit for their participation.

Demographic and Relationship Description Measures

Personal data (i.e., age and gender) were obtained from each participant. Participants
were then asked to think of their romantic partner, report on the length of time they have
known their friend (years and months), and indicate the average amount of time per day that
they typically spent with that person (hours and minutes).
136 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

Table 1. Participant Identity Status Distribution

Diffuse Foreclosed Moratorium Achieved

Females 32 51 56 44
Males 26 28 23 11

Identity Status Measure

The Ego Identity Process Questionnaire (EIPQ: Balistreri, Busch-Rossnagel, &

Geisinger, 1995) was used to assess participant perceptions of their current identity process
characteristics. The EIPQ is a 32-item scale that measures dimensions of commitment (e.g., “I
have definitely decided on the occupation I want to pursue.”) and exploration (e.g., “I have
considered adopting different kinds of religious beliefs.”) on a six point scale that ranges from
1 - Strongly disagree to 6 - Strongly agree. Commitment and exploration responses are
measured on eight different areas of identity development (e.g., Occupation, Religion,
Politics, Values, Family, Friendship, Dating, and Sex-Roles). Reliability of the overall
commitment and exploration scales was α = .81 and .79, respectively. Using median split
procedures (Mdn = 61.00 for commitment and Mdn = 64.00 for exploration), individuals were
categorized as either high or low in identity commitment and exploration. Identity
commitment and exploration categories were then combined to categorize individuals
according to a specific identity status: diffuse (low commitment and exploration), foreclosed
(high commitment and low exploration), moratorium (low commitment and high
exploration), or achieved (high commitment and exploration). Frequencies for each identity
category are presented in Table 1.

Romantic Relationship Intimacy Measures

General Friendship Intimacy

General same- and cross-sex friendship intimacy was assessed using the intimacy
component subscale of Triangular Love Scale Sternberg (1997). The intimacy component
sub-scale is a 15-item scale that measures perceived closeness in relationships (e.g., “I am
able to count on ____________ in times of need.”). Responses are measured according to a
nine point Likert scale ranging from 1 – Not at all to 9 – Extremely. Scale reliability in the
current study was α = .91.

Intimacy Intensity and Frequency

The Miller Social Intimacy Scale (MSIS) is a 17-item scale that measures dimensions of
intimacy frequency and intensity (Miller & Lefcourt, 1982). Six questions are used to assess
intimacy frequency (e.g., “How often do you show your friend affection.”), and responses are
recorded on a ten point scale that ranges from 1- Very rarely to 10 – Almost always. Eleven
questions are used to assess intimacy intensity (e.g., “How close do you feel to your friend
most of the time.”), and responses are recorded on a ten point scale ranging from 1 – Not
 Development of an Interview for Assessing Relationship Quality 137

much to 10 – A great deal. Reliability of the overall frequency and intensity scales was α =
.83 and .84.

Positive and Negative Intimacy

The positive intimacy subscale of the Personal Assessment of Intimacy in Relationship-
Modified inventory (PAIR-M; Theriault, 1998) was used to assess participant perceptions of
their capacity for closeness. The positive intimacy subscale consists of 5-items that measure
participant perceptions of positive intimacy behaviors. (e.g., “I can tell my feelings to my
friend.”) and 7-items that measure negative intimacy (“I have the tendency to neglect my
romantic partner’s needs.”). Responses to the PAIR-M are recorded on a five point Likert
scale that ranges from 1 – Very rarely to 5 – Very often. Scale reliabilities in the current study
were α = .83 for positive intimacy and α = .79 for negative intimacy.

Relationship Closeness
The Inclusion of Other in the Self (IOS) Scale developed by Aron, Aron, and Smollar
(1992) was used to measure participant perceptions of relationship closeness. The IOS Scale
consists of two circles that signify the participant and a designated other (e.g., same-sex
friend). Participants were asked to choose one of the seven sets of circles, ranging from no
overlap between the two circles (scored as 1 - Not a close relationship) to nearly complete
overlap between the two circles (scored as 7 - Very close relationship) that best describes the
closeness of the relationship. The IOS shows good convergent validity with other measures in
the current study measuring relationship closeness (See Table 1), and reliability measures of
the IOS Scale as reported by Aron et al. (1992) show satisfactory measurement test-retest
reliability for friendships, α = .92.

Relationship Commitment
Commitment level in participant friendships was measured using the commitment
subscale from the Rusbult Investment Model Scale (Rusbult, Drigotas, & Verette, 1994). This
seven-item Likert-scale assesses four domains of personal relationships. Each item in the
commitment scale asked the participant to indicate such features as the strength of
commitment, stability, and the likely duration of a specified relationship on a scale from 1 -
Not very; quite short to 5- Completely committed/Very long duration. Rusbult et al. (1994)
report commitment subscale reliabilities of α =.91 to .95. Scale reliability in the current study
was α = .81.

Data Collection Procedures

Data used in the current study were part of larger study examining interpersonal and
intrapersonal factors associated with college students’ friendship and romantic relationship
intimacy. Data collection occurred during a one and a half-hour session. Participants were
informed by the researchers that the study was examining relationship intimacy and
closeness. Participants were then administered one of a series of booklets asking them to
report their demographic information and to think of either a same-sex friend, cross-sex friend
or romantic partner. Participants were then asked to read the instructions very carefully before
138 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

beginning, and instructed to describe the length of time they have know their friend and the
amount of time spent with the friend daily, as well as the intimacy and emotional closeness
experienced with their same-sex or cross-sex friend. Questionnaires were collected after
participants completed the first friendship description, and participants were administered the
identity questionnaire (as well as several others not used in the current study). After
completing the identity measurements, participants were then administered a second booklet
asking them to describe another of their relationships (depending upon which relationship was
described previously) and report on the same relationship characteristics. On completion of
the second relationship booklet, participants were administered a series of questionnaires that
assessed social adjustment. Finally, participants were administered the final relationship
questionnaire and requested to follow the same instructions. Once participants completed the
third relationship rating, they were debriefed and compensated for participating.

Table 2. Participant Demographics, Relationship Demographics, Identity Component,

and Romantic Relationship Intimacy Correlations

1 2 3 4 5 6 7 8 9 10 11 12
1. Gender --- -.25** -.17** -.12* -.11 .02 -.19** -.10 -.15* .20** -.40** -.25**
Identity
Components
2. Exploration --- -.15 -.01 -.07 -.20** -.11 -.12* -.07 -.14* -.03 -.06
3. Commitment --- .11 .17** .12* .39** .36** .37** -.47** .27** .31**
Relationship
Demographics
4. Months
Known --- .18** .18** .14* .17** .11 -.02 .18** .02
5. Minutes
Spent w/ Daily --- .08 .13* .12 .18** -.07 .27** .19**
Intimacy
Measures
6. Closeness --- .61** .40** .39** -.19** .42** .33**
7. General
Intimacy --- .59** .65** -.45** .60** .63**
8. Commitment --- .46** -.43** .27** .31**
9. Positive
Intimacy --- -.49** .49** .53**
10. Negative
Intimacy --- -.37** -.40-**
11. Intimacy
Frequency --- .66**
12. Intimacy
Intensity ---
Note: Spearman’s Rho presented for Gender correlations (-1 = Female and 1 = Male).
*p < .05. **p < .01.

RESULTS

Data Transformations and Preliminary Correlation Analysis

Prior to testing the hypothesized associations between gender, identity status, and
romantic relationship intimacy, identity and intimacy scores were transformed to standardized
 Development of an Interview for Assessing Relationship Quality 139

Z-scores. In addition, correlations were conducted to examine relationships 1) among

predictor variables, 2) between relationship descriptive variables (i.e., minutes spent with
daily and months known) and friendship intimacy variables, and 3) among intimacy
measures. As shown in Table 2, correlations among predictor variables (i.e., gender and
identity status) indicated females reported higher levels of identity exploration and
commitment than did males. The pattern of correlations indicates differential reporting of the
predictor variables according to participants’ gender. Examination of relationship descriptive
variables and romantic relationship intimacy variable correlations indicated the number of
months participants have known their romantic partner was significantly associated with each
intimacy measure except positive intimacy, negative intimacy, and intimacy intensity.
Further, the number of minutes participants spent daily with their romantic partner was
positively associated general intimacy, positive intimacy, intimacy intensity, and intimacy
frequency (see Table 2). Given the consistent correlation patterns, both the number of months
participants have known their friend and the amount of time spent with their friend daily were
used as covairates when examining the gender, identity, and intimacy associations. Finally, as
shown in Table 2, examination of intimacy correlations indicated significant correlations
among all measures and supports the use of multivariate analysis of variance in the
examination of the hypothesized intimacy differences.

Examination of Proposed Intimacy Differences

Multivariate analysis of covariance (MANCOVA) was conducted to examine differences

in romantic relationship intimacy. Because the number of months participants have known
their romantic partner and the amount of time participants spend weekly with their romantic
partner was correlated with the intimacy measures (see Table 2), both relationship descriptive
variables were used as covariates. A 2 (Gender) X 4 (Identity Status) MANCOVA failed to
indicate either months know, Wilk’s λ= .93, F(7, 255) = 2.10, p = .06, or minutes spent with
daily Wilk’s λ= .95, F(7, 255) = 1.97, p = .07, as significant covariates of intimacy reports. As
a result, the relationship demographic variables were dropped from further analysis, and a 2
(Gender) X 4 (Identity Status) multivariate analysis of variance (MANOVA) was used to test
the proposed hypotheses.
The 2 (Gender) X 4 (Identity Status) MANOVA indicated a significant Gender X Identity
Status interaction associated with reports of romantic relationship intimacy, Wilk’s λ= .73,
F(21, 744) = 4.00, p < .001. Examination of the interaction’s identity status simple-effects
indicated significant gender differences for participants classified as diffuse, Wilk’s λ= .46,
F(7, 50) = 8.25, p < .001, foreclosed, Wilk’s λ= .49, F(7, 71) = 10.37, p < .001, moratorium,
Wilk’s λ= .65, F(7, 73) = 5.61, p < .001, or achieved, Wilk’s λ= .65, F(7, 47) = 3.59, p < .01.
Further, gender simple-effects indicated significant identity status differences for females,
Wilk’s λ= .42, F(21, 503) = 8.34, p < .001, and males, Wilk’s λ= .54, F(21, 225) = 2.51, p <
.001.

Identity Status Simple-effects Multiple Comparisons

As shown in Table 3, Tukey’s-b examination of gender differences across identity
statuses revealed diffuse females reported higher levels of romantic relationship intimacy than
males except on reports of closeness and negative intimacy. Foreclosed females reported
140 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

higher levels of intimacy than males except on reports of negative intimacy. Moratorium
females differed from moratorium males on reports of negative intimacy and intimacy
frequency. Achieved females differed from achieved males on reports of closeness and
commitment. No other significant differences were indicated between moratorium and
achieved females and males.

Table 3. Gender and Identity Status Differences in Romantic Relationship Intimacy

Identity Status
Intimacy Variable Diffuse Foreclosed Moratorium Achieved
Closeness
Female .08a .48b -.51c .12a
Male -.04 -.03 -.04 .42
General Intimacy
Female -.33a .76b -.69c .33a
Male -.64a -.40a -.16a .55b
Commitment
Female .03a .69b -.67c .21a
Male -.41a -.08a -.40a .79b
Positive Intimacy
Female .29a .56b -.51c .32a
Male -.69a .02a -.58a .32b
Negative Intimacy
Female .40a -.57b .11a -.36b
Male .67a -.12b .69a -.38b
Intimacy Frequency
Female .23a .86b -.26c .38a
Male -.62a -.82a -.65a .24b
Intimacy Intensity
Female .13a .69b -.41c .45a
a
Male -.55a -.39a -.66 .79b
Note: Intimacy variable row means with different superscripts significantly different, p < .05. Intimacy
variable column means in bold significantly different, p < .05.

Female Identity Status Differences

As shown in Table 3, Tukey’s-b examination of female intimacy scores indicated several
identity status differences. First, foreclosed females reported higher levels of closeness,
general intimacy, commitment, positive intimacy, intimacy frequency, and intimacy intensity
than did achieved, moratorium, and diffuse females. Further, achieved and diffuse females
reported higher scores on each of these intimacy measures than did moratorium females.
Achieved and diffuse females did not differ on their reports of these measures. Second,
foreclosed and achieved females did not differ in their reports of negative intimacy and
 Development of an Interview for Assessing Relationship Quality 141

reported lower levels of negative intimacy than did diffuse and moratorium females. Diffuse
and moratorium females did not differ in their reports of negative intimacy.

Male Identity Status Differences

Tukey’s-b examination of male identity status differences revealed achieved males
reported more intimate romantic relationships than did diffuse, foreclosed, and moratorium
males across each intimacy measure except negative intimacy and closeness. Achieved and
foreclosed males reported lower levels of negative intimacy than did diffuse and moratorium
males, and no significant differences were indicated for romantic relationship closeness (see
Table 3).

CONCLUSION
As previously stated, Arnett (2000) argues emerging adults’ identity explorations allow
them to make long-term commitments regarding intimacy decisions in their romantic
relationships. Although identity exploration is often considered an integral part of identity
development, theorist and researchers do not necessarily view exploration as a necessary
process when making identity commitments (Meeus et al., 1999; Waterman, 1993). Further,
Arnett’s (2000) argument stating identity exploration is a distinct and necessary process for
intimacy development during emerging adulthood minimizes the role of identity commitment
and gender in the formation of romantic relationship intimacy. As evidenced in the current
study, identity exploration explained certain specific differences in emerging adult intimacy
reports. However, several instances are evident where identity exploration was not an
effective predictor of intimacy. As a result, the proposal that identity explorations occurring
during emerging adulthood are necessary for intimacy development may not apply equally to
all emerging adults. The conceptualization of the identity exploration and intimacy
relationship during emerging adulthood fails to recognize the differential approach to
relationship intimacy taken by females and males. Because the identity development process
varies for each individual and does not follow one developmental sequence (Grotevant,
1986), Arnett’s (2000) theoretical position concerning qualitative differences in the identity
process during adolescence and adulthood overlooks the importance of gender and identity
commitments associated with exploration when attempting to explain emerging adults’
capacity for romantic relationship intimacy.
The current study’s test of Arnett’s (2000) hypothesis regarding identity exploration and
romantic relationship intimacy development did not fully support his theorized association.
Rather, findings indicate 1) both identity exploration and commitment predict emerging
adults’ romantic relationship intimacy, 2) gender differences in romantic relationships differ
according to emerging adults’ identity status, and 3) identity status differences in romantic
relationship intimacy differs for emerging adult males and females. As a result, Arnett’s
(2000) proposal that identity exploration during emerging adulthood is a necessary precursor
for intimate romantic relationships may not completely describe the association between
identity and intimacy that emerges during this period, and this association may be more
complex than originally theorized.
142 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

Gender Differences in Romantic Relationship Intimacy across Identity

Statuses

As mentioned previously, research indicates females report more intimate relationships

than males. Results, however, qualify this finding in that gender differences in intimacy are
moderated by emerging adults’ identity status. Gender comparison of emerging adults who
reported low exploration scores and either low or high commitment scores (i.e., diffuse and
foreclosed identity statuses) indicated females reported more romantic intimacy than did
males. Although gender differences were evident for moratorium and achieved emerging
adults, the number of variables in which females and males differed was relatively small
when compared to genders differences for diffuse and foreclosed emerging adults. This
finding was not expected, and it possibly provides further insight into previously reported
gender differences in relationship intimacy, as well as provides support for Arnett’s (2000)
argument concerning the association between identity exploration and romantic intimacy.
Adolescents have generally not engaged in identity explorations concerning romantic
intimacy (Arnett, 2000). Although male and female adolescents are similar in their identity
explorations and romantic intimacy, females report closer and more intimate relationships
than males (Clark-Lempers, Lempers, & Ho, 1991; Fischer, Munsch, & Greene, 1996;
Johnson, 2005). Findings from the current study suggest similar gender differences in
romantic intimacy reports for emerging adults who report low levels of identity exploration.
Emerging adults who reported low levels of identity explorations reported romantic intimacy
patterns similar to that of adolescents. Romantic intimacy differences present during
adolescence likely continue into emerging adulthood for those individuals who have not
engaged in identity exploration. However, this difference in emerging adults’ intimacy reports
appears to decrease as males and females begin their identity explorations.

Female and Male Identity Status Differences in Romantic Relationship

Intimacy

The current study’s general pattern of findings does not fully support Arnett’s (2000)
position regarding the association between emerging adults’ identity exploration and romantic
relationship intimacy. Findings do, however, suggest that Arnett’s proposal may describe
male experiences of romantic intimacy. In the current study, males who were classified as
achieved (i.e., reported high levels of exploration and commitment) reported higher levels
intimacy than did males classified as diffuse, foreclosed, or moratorium (and lower levels of
identity exploration and/or commitment). These findings support the notion that increased
romantic intimacy and relationship commitment emerges out of explored identity
commitments. Further, this finding supports previous research examining the association
between identity and intimacy that suggests 1) males place a greater importance on identity
relative to intimacy (Surrey, 1991), and 2) males are likely to develop intimate relationships
as identity issues are resolved through exploration and commitment (Dyk & Adams, 1990).
As a result, associations suggest emerging adult males may be more committed to their
romantic relationships and view these relationships as more intimate after identity
commitments are made through exploration. Further the identity status difference evident in
 Development of an Interview for Assessing Relationship Quality 143

male reports of intimacy does provide support for Arnett’s (2000) argument that emerging
adult identity explorations are necessary for the formation of intimate romantic relationships.
Associations between male emerging adults’ identity and intimacy reports support
Arnett’s (2000) theory regarding identity exploration and romantic intimacy. However,
responses from female emerging adults suggest a very different set of associations between
identity and intimacy. Females who reported high levels of identity commitment and low
levels of exploration reported more intimate romantic relationships than did females with
other identity commitment and exploration patterns (Females who reported low levels of
commitment and high levels of exploration reported the lowest levels of relationship
intimacy.). As stated previously, Arnett (2000) argues that explored identities are a necessary
component of romantic relationship intimacy. However, Erikson (1968) states that individuals
with formed identities are more likely to form and maintain intimate romantic relationships
relative to those without an established identity. Based on the current findings, it is possible
the commitment to an identity (regardless of exploring these identity decisions) constitutes an
established identity for emerging adult females. For example, one can be satisfied with their
identity beliefs without having explored these beliefs (Waterman, 1993). Further, Patterson et
al. (1992) state that previous studies examining female identity patterns suggest foreclosed
females “looked more similar to those in identity achievement” (p. 18). As a result, females
who have made identity commitments but are not currently questioning or exploring these
decisions may have clear romantic relationship expectations that are associated with an
increased focus on the formation, maintenance, and development of romantic relationships.
Further, these relationship expectations and increased relationship focus likely lead to more
committed, intimate, and emotionally close romantic relationships relative to females with
different identity patterns.
A second pattern of findings somewhat contradictory to Arnett’s argument regarding the
necessity of identity exploration concerns the similar intimacy reports of identity diffuse (i.e.,
low commitment and exploration) and achieved (i.e. high commitment and exploration)
females. Although these two groups did not report the same intimacy levels as foreclosed
females, previous research, suggests achieved females would have more intimate
relationships than diffuse females. The higher than expected intimacy levels can possibly be
explained by the interpersonal approach taken by females who have not explored or
committed to a set of identity beliefs. Muuss (1996) argues that females who are low in
identity exploration and commitment may become “overly receptive” to their relationship
experiences (p. 63). These females may become “distracted by the pleasures” of the
relationship (Waterman, 1993; p. 153) which leads to the perceptions of a committed and
intimate romantic relationship. However, as evidenced by the higher negative intimacy score
for diffuse females, diffuse females appear to view their romantic relationships more
negatively than achieved and foreclosed females. As a result, the similar romantic relationship
intimacy scores between diffuse and achieved females indicated in the current study is likely
qualitatively different despite the quantitative similarities and warrants further investigation.
Arnett (2000) argues identity exploration during emerging adulthood is a necessary
precursor for the development of romantic intimacy. The position that identity exploration is
isolated to late adolescence and young adulthood is misrepresentative of the identity process
must be interpreted with caution. Identity development is a fluid process that does not
necessarily begin or end in any specific developmental stage, and previous research shows
identity exploration is not limited to one developmental trajectory or developmental period.
144 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

As a result, identity research that follows the theory that identity exploration is a specific late
adolescent and young adult process will overlook the importance of the superficial and
transient decisions made during early adolescence that provide the foundation for later
identity explorations. Although previous findings provide moderate support for this position,
the current study indicates identity commitment associations with romantic relationship
intimacy as well as gender differences in the relationship among identity commitment,
exploration, and romantic relationships intimacy. Use of a college sample possibly limits
generalization of the current study. However, findings may provide a better understanding of
the identity process associated with romantic intimacy development for male and female
emerging adults by indicating that identity exploration is only a part of the larger process that
leads to the development of intimate romantic relationships.

AUTHOR NOTES
H. Durell Johnson, Kristen A. Loff, George Bell, Evelyn Brady, Erin A. Grogan,
Elizabeth Yale, Robert J. Foley, and Trishia A. Pilosi, Department of Human Development
and Family Studies, Penn State Worthington Scranton. Elizabeth Yale and George Bell are
currently pursuing graduate degrees at Marywood University, Scranton, PA.
Portions of this research were funded by the Pennsylvania State University Matthew’s
Research Award and Research Development Grant awarded to the first author and the
Pennsylvania State University’s Undergraduate Research Grant awarded to Kristen A. Loff,
George Bell, Erin A. Grogan, Robert J. Foley, and Trishia A. Pilosi. Portions of this study
were presented at the 2005 Annual Meting of the Society for Research on Identity Formation,
Miami, FL and the 2007 Biennial Meeting of the Society for Research on Adolescence,
Boston, MA.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 7

DEVELOPMENT OF AN INTERVIEW
FOR ASSESSING RELATIONSHIP QUALITY:
PRELIMINARY SUPPORT FOR RELIABILITY,
CONVERGENT AND DIVERGENT VALIDITY, AND
INCREMENTAL UTILITY

Erika Lawrence, Robin A. Barry, Rebecca L. Brock,

Amie Langer, Eunyoe Ro
University of Iowa, Iowa City, Iowa, USA
Mali Bunde
CIGNA Behavioral Health Care, Minnesota, USA
Emily Fazio
University of Denver, Denver, Colorado, USA
Lorin Mulryan
University of Loyola,Chicago, Illinois, USA
Sara Hunt
Utah State University, Logan, Utah, USA
Lisa Madsen
Emory University, Atlanta, Georgia, USA
Sandra Dzankovic
Des Moines University, Des Moines, Iowa, USA

ABSTRACT
Historically, relationship satisfaction and adjustment have been the target outcome
variables for almost all couple research and therapies. In contrast, far less attention have
been paid to the assessment of relationship quality. In the first section of our paper, we
150 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

review the long-standing debate regarding – and clarify the distinctions among –
relationship adjustment, satisfaction, and quality. We also discuss the need for an
empirically-supported, psychometrically strong measure of relationship quality. In the
second section, we present the Relationship Quality Interview (RQI), a semi-structured,
behaviorally anchored, individual interview that yields objectively coded ratings from the
interviews. It was designed to assess relationship quality across five dimensions: (a) trust,
closeness, and emotional intimacy; (b) inter-partner support; (c) quality of the sexual
relationship; (c) respect, power, and control; and (e) communication and conflict
management. In the third section, we provide preliminary evidence of the reliability and
validity of the interview. Across two samples, the RQI demonstrated strong reliability
(internal consistency, inter-rater agreement, agreement across interviewers based on two
members of the same couple, correlations among the scales) convergent validity
(correlations between RQI scales and self-report questionnaires assessing similar
relationship dimensions), and divergent validity (correlations between RQI scales and
behavioral observations of related constructs, global measures of marital satisfaction, and
individual difference measures of related constructs). We conclude with a brief
discussion of broader clinical issues relevant to couple assessment and prevention efforts.

INTRODUCTION
Historically, relationship satisfaction and adjustment have been the target outcome
variables for almost all couple research and therapies. In contrast, far less attention have been
paid to the assessment of relationship quality. In the first section of our paper, we review the
long-standing debate regarding – and clarify the distinctions among – relationship adjustment,
satisfaction, and quality. We also discuss the need for an empirically-supported,
psychometrically strong measure of relationship quality. In the second section, we present the
Relationship Quality Interview (RQI), a semi-structured, behaviorally anchored, individual
interview that yields objectively coded ratings from the interviews. It was designed to assess
relationship quality across five dimensions: (a) trust, closeness, and emotional intimacy; (b)
inter-partner support; (c) quality of the sexual relationship; (c) respect, power, and control;
and (e) communication and conflict management. We describe the development of the
interview, our justification for the dimensions of relationship quality included, and the micro-
analytic and macro-analytic coding systems we developed.
In the third section, we provide preliminary evidence of the reliability and validity of the
interview. Our goal is for the RQI to be used as an assessment tool prior to the
implementation of prevention programs with young couples. Therefore, we administered the
RQI to 101 newlywed couples 91 dating individuals. To assess reliability, we analyzed
internal consistency, inter-rater agreement, agreement across interviewers based on two
members of the same couple, and correlations among the scales. To examine convergent
validity, we analyzed correlations between RQI scales and self-report questionnaires
assessing similar relationship dimensions. To examine divergent validity, we computed
correlations between RQI scales and: (a) behavioral observations of related constructs, (b)
global measures of relationship satisfaction, and (c) individual difference measures of related
constructs.
In the fourth section, we discuss broader clinical issues relevant to couple assessment and
prevention efforts. First, we discuss the importance of standardizing empirically-supported
couple assessments, and review ongoing efforts to achieve this goal. Second, we make
 Development of an Interview for Assessing Relationship Quality 151

specific recommendations for enhancing couple prevention programs. Third, we discuss the
possible utility of interviews as motivational tools to increase participation in prevention
programs among couples at high risk for longitudinal distress and dissolution, and review
ongoing efforts to achieve this goal.

SECTION 1: RELATIONSHIP SATISFACTION,

ADJUSTMENT, AND QUALITY
For as long as relationship satisfaction has been assessed, there has also been
considerable confusion and controversy over the differences among the terms relationship
satisfaction, relationship adjustment, and relationship quality (See Snyder, Heyman, &
Haynes, 2005, and Heyman, Sayers, and Bellack, 1994 for detailed discussions of these
issues.) Relationship satisfaction refers to global sentiment or happiness as a unitary
construct. Relationship adjustment is broader in scope, and includes a consideration of dyadic
processes such as conflict management skills and relationship outcomes such as satisfaction.
Relationship quality refers to dyadic processes alone, such as the quality of a couple’s conflict
management skills, supportive transactions, sexual relations, or emotional intimacy.
Additionally, several terms have been used to describe low satisfaction or adjustment,
including relationship discord, dissatisfaction, distress, and dysfunction. Low relationship
satisfaction is also distinguished from dissolution, which refers to separation or divorce.
Over the last 60 years, relationship satisfaction and adjustment have been the target
outcome variables for almost all couple research and therapies. They have been assessed via
epidemiological research, treatment outcome research, and basic close relationships research.
They are the field’s measures of whether couples are happy and whether our couple therapies
are working. Relationship satisfaction and adjustment are strongly associated with the 50%
divorce rate in the U.S., individual distress (e.g., depression, anxiety, and alcohol abuse),
physical health, and children’s well-being.
Far less attention has been paid to the assessment of relationship quality. Some
dimensions of relationship quality have received a lot of attention, such as communication
and conflict management processes. Others have received almost no attention, such as
emotional intimacy and balance of decision-making and interpersonal control within a couple.
Still others have received attention in other disciplines but have not been integrated into
couple research or couple therapy, such as investigations of the quality of a couple’s sexual
relationship.
Among the measures that do exist for assessing relationship quality, several conceptual
and methodological limitations hinder their utility. First, these measures are typically specific
to one dimension such as conflict management skills, rather than capturing the
multidimensional construct of relationship quality. Second, existing measures of relationship
quality are often confounded with measures of satisfaction or adjustment. Specifically, these
measures include items that tap into both relational processes and satisfaction. The purpose of
this study is to introduce and provide preliminary evidence for a new instrument designed to
assess relationship quality as a multidimensional phenomenon.
Historically, relationship satisfaction and adjustment have been assessed by administering
questionnaires to partners and then calculating sum scores based on their responses. Scores
152 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

are typically placed on a continuum from low to high satisfaction. Starting in the 1950s,
relationship adjustment was assessed with omnibus measures in which partners evaluated
multiple aspects of their relationships, such as the amount of disagreement across different
areas of conflict, global evaluations of the relationship, and frequency of sexual relations. The
Marital Adjustment Test (MAT; Locke & Wallace, 1959) and Dyadic Adjustment Scale
(DAS; Spanier, 1976) are two widely used measures of dyadic adjustment. In the 1980s,
researchers and clinicians also began assessing relationship satisfaction with shorter,
unidimensional measures of global sentiment toward one’s relationship. The Quality of
Marriage Index (QMI; Norton, 1983) and Kansas Marital Satisfaction Scale (KMS; Schumm
et al., 1986) are widely used measures of global relationship satisfaction. Researchers and
clinicians also began to assess relationship satisfaction using a semantic differential approach,
a way of quantifying partners’ evaluations of their relationships by having them rate their
perceptions on scales between two opposite adjectives (e.g., satisfied to dissatisfied, good to
bad; Osgood, Suci, & Tannenbaum, 1957; Huston & Vangelisti, 1991). Since the mid-1990s,
there has been a move toward assessing relationship satisfaction and adjustment with
multidimensional approaches. For example, the Positive and Negative Quality in Marriage
Scale (PANQIMS; Fincham & Linfield, 1997), on which partners evaluate the positive and
negative qualities of their partner and relationship, yields scores for two distinct aspects of
relationship satisfaction. Other measures collapse these two domains, making it impossible to
determine whether it is lack of positive or high levels of negative evaluation that reduces
relationship happiness. In contrast, the PANQIMS allows partners to be categorized as happy
(high positive and low negative), distressed (low positive and high negative), ambivalent
(high on both positive and negative), or indifferent (low on both positive and negative). The
Marital Satisfaction Inventory (MSI-R; Snyder & Aikman, 1999) is a multidimensional
measure of relationship adjustment that differentiates among levels and sources of distress.
Dimensions include assessments of family of origin conflict, sexual satisfaction, and
problem-solving communication strategies. Three other multidimensional inventories have
been used in the last decade or two (PREPARE, Olsen, Fournier, & Druckman, 1996;
FOCCUS, Markey & Micheletto, 1997; RELATE, Busby, Holman, & Taniguchi, 2001). Each
of these inventories provide scores on dimensions such as realistic relationship expectations,
effective communication, emotional health, exposure to negative family-of-origin
experiences, and personal stress management (Larson, Newell, Topham, & Nichols, 2002).
Thus, like the MSI-R, these measures are multidimensional in nature, yet they capture a
variety of factors that may influence dyadic functioning and were not intended to measure
relationship quality specifically.
Couple researchers and clinicians have long used self-report questionnaires to quantify
dyadic processes in basic research and to guide interventions. Unfortunately, self-report
questionnaires are vulnerable to biases including social desirability (Godoy et al., 2008;
Kluemper, 2008), depressed mood and depressive cognitions (e.g., Cohen, Towbest, &
Flocco, 1988; Raselli & Broderick, 2007), memory biases in retrospective reports (Karney &
Frye, 2002), and cognitive dissonance (e.g., newlyweds may be more likely to present couple
processes in a positive light because they have just gotten married and do not want to consider
the possibility that their marriage already has difficulties; McNulty, O’Mara, & Karney, 2008;
Miller, Niehuis, & Huston, 2006). Behavioral observation tasks were developed to deal with
these problems, and our ability to understand couple processes across domains became much
stronger. However, observational methods are costly and time-consuming, and as such are
 Development of an Interview for Assessing Relationship Quality 153

less likely to be widely adopted by clinicians in the near future. Moreover, although
standardized, psychometrically sound interaction protocols exist to assess couples’
transactions with established coding systems, there is no network at present that can readily
and conveniently code these interactions and provide results in a timely manner. In sum,
although an important methodological development in couple research methodology,
behavioral observation tasks are not going to become a standardized assessment tool for
couple therapists.
In addition to self-report questionnaires and behavioral observation tasks, clinical
interviews are often used to gather reliable and valid information during an assessment.
Outside of the close relationships literature, The Structured Clinical Interview for the
Diagnostic Statistical Manual (DSM-IV; First et al., 1995) is a standardized interview for
assessing Axis I disorders. The Adult Attachment Interview (AAI; George, Kaplan, & Main,
1985) is routinely used by researchers studying attachment processes. There is also emerging
interest in developing semi-structured interviews to assess relationship satisfaction and
quality. There are several advantages to using clinical interviews rather than behavioral
observation data in couple research. First, clinical interviews allow the objective coder to
consider partners’ perceptions when evaluating the relationship; however, the biases of self
report are still omitted (e.g., Morrison & Hunt, 1996). Second, interviews allow for a more
global perception of dyadic processes as opposed to behavioral observation data that provide
a snapshot of a particular type of interaction. Third, once an interviewer is trained to
reliability, administering and coding clinical interviews is typically faster and less expensive
than coding behavioral observation data. Fourth, clinical interviews are more likely to be
embraced by clinicians compared to behavioral observation methods, affording us the
opportunities to move toward standardization of couple assessments and bridge the gap
between couple researchers and clinicians.
There have been isolated efforts to develop and validate structured interviews for couple
research and therapy. For example, the Structured Diagnostic Interview for Marital Distress
and Partner Aggression (Heyman et al., 2001) allows researchers and clinicians to reliably
and validly diagnose couples in terms of relationship distress and physical aggression. The
content of the interview is similar to that of the Dyadic Adjustment Scale (Spanier, 1976) and
the Conflict Tactics Scales (Straus et al., 1996), and the format is similar to that of the SCID.
However, no interview exists to assess the construct of relationship quality. The purpose of
the present study was to develop a semi-structured interview to assess relationship quality and
to provide preliminary support of its reliability and validity.

SECTION 2: THE RELATIONSHIP

QUALITY INTERVIEW AND DIMENSIONS OF RELATIONSHIP QUALITY
The Relationship Quality Interview (RQI) was designed to provide an interview-based
approach to quantifying important dimensions of relationship quality. It is a multidimensional
interview to assess relationship quality across five key relationship domains, including
emotional intimacy, inter-partner support, sexual relations, inter-partner respect and control,
and communication and conflict management. We use objective interviewer ratings of couple
functioning on each domain based on semi-structured, behaviorally anchored, individual
154 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

interviews with both partners to control for the possibility that self-reports of relationship
functioning might be influenced by factors such as global relationship satisfaction, depression
or social desirability. The use of objective ratings also allowed us to control for the possibility
that couples married only 3-6 months might experience cognitive dissonance when discussing
potential weaknesses or problems in their relationships, which might influence their self-
reports of the quality of their relationship.

Domains of Relationship Quality

Our aim in the present study was to be comprehensive in our examination of dimensions
of relationship quality that would influence the longitudinal course of relationship satisfaction
and stability. As such, after an exhaustive review of the close relationships literature across
multiple disciplines (e.g., social and clinical psychology, communication studies, family
studies, sociology), we identified five dimensions of relationship quality as potential risk or
protective factors. Communication and conflict management was operationalized as
comprising frequency and length of arguments, verbal, psychological and physical aggression
during arguments, withdrawal during arguments, emotions and behaviors before, during and
after arguments, and conflict resolution strategies. In accord with Cutrona and colleagues’
work (e.g., Cutrona, Russell, & Gardner, 2005), inter-partner support was operationalized as
comprising four types of support when one partner has had a bad day, is feeling down, or has
a problem: emotional support (talking and listening to each other, holding hands, hugging,
letting partner know s/he understands), direct or indirect tangible support (direct support:
when one’s partner helps to solve the problem or make the situation better; indirect support:
providing time or resources so that one’s partner is better able to solve the problem him- or
herself, e.g., providing childcare), informational support (giving advice, providing partner
with information, helping partner think about a problem in a new way), and esteem support
(expressing confidence in one’s ability to handle things, telling partner s/he is not at fault for
a problem). Match between types of support desired and types of support provided, and
whether support is offered in a positive or negative manner, were also assessed. Level of
dyadic emotional closeness and intimacy was operationalized as comprising emotional
closeness (an overall mutual sense of closeness, warmth, affection, and interdependence),
quality of the couple’s friendship, and demonstrations of love and affection (quantity and
quality of love and affection expressed in the relationship, including verbal and physical
expressions of love). Sensuality and sexuality was operationalized as comprising the quality
of the sexual relationship (frequency of sexual activity, symmetry in initiation of sexual
activity, satisfaction, negative emotions, sexual difficulties, concerns) and sensuality
(touching, hugging, cuddling, massage, the extent to which sensuality exists separate from
sexual activity in the relationship). Respect and control was operationalized as comprising
mutual acknowledgement of competence and independence; acceptance and positive regard
for the other even when one disagrees with him or her, a/symmetry in decision-making across
a variety of areas, partners’ satisfaction with that division of responsibilities, and a couple’s
ability to negotiate control across a variety of areas (e.g., scheduling one’s own day,
controlling money).
The overwhelming majority of research in the close relationships field has been focused
on the quality of a couple’s ability to solve problems and conflicts. Theories of intimate
 Development of an Interview for Assessing Relationship Quality 155

relationships and of the determinants of relationship outcomes (e.g., Christensen &

Walczynski, 1997; Gottman, Swanson, & Murray, 1999), a great deal of the empirical
research on intimate relationships, most observational research on intimate relationships,
reviews on dyadic interactions (e.g., Karney & Bradbury, 1995; Weiss & Heyman, 1997), and
most existing psychological interventions for couple distress (e.g., Behavioral Marital
Therapy; Jacobson & Holtzworth-Munroe, 1986; Prevention and Relationship Enhancement
Program; Floyd, Markman, Kelly, Blumberg, & Stanley, 1995) have targeted relationship
conflict. Within the last decade or so, there has been a tremendous increase in attention to the
role of spousal support as an adaptive dyadic skill (e.g., Gable, Gonzaga, & Strachman, 2006;
Neff & Karney, 2005; Pasch & Bradbury, 1998). Other researchers have focused specifically
on emotional intimacy (e.g., Barnes & Sternberg, 1997; Barry, Lawrence, & Langer, in press;
Cordova, Gee, & Warren, 2005; Laurenceau et al., 2005), the quality of a couple’s sexual
relationship (e.g., Henderson-King & Veroff, 1994; LoPiccolo, Heiman, Hogan, & Roberts,
1985), and respect and control (e.g., Gray-Little & Burks, 1983; Ehrensaft, Langhinrichsen-
Rohling, Heyman, & Lawrence, 1999; Huston, 1983; Whisman & Jacobson, 1990). We know
of only one study in which multiple dimensions of relationship quality were examined
(Schramm, Marshall, Harris, & Lee, 2005). (See Lawrence et al., in press for a detailed
review of the literature relevant to our decisions to include each of these five dimensions of
relationship quality.)
In sum, the existing literature suggests that there are multiple aspects of relationship
quality. However, when relationship quality is examined, researchers typically examine only
one or two domains of dyadic processes per sample, which presumably grossly
underestimates the complexity of relationship quality. Moreover, many of these studies did
not statistically examine sex differences in relationship quality, which may lead to an
incomplete, skewed, or inaccurate conceptualization of intimate relationships and,
consequently, to interventions that are limited in their effectiveness. This literature has also
suffered from methodological limitations, including measurement issues such as the use of
self-report measures of relational behaviors which may be influenced by social desirability
and cognitive dissonance (particularly among newlyweds), shared method variance,
retrospective data, heterogeneous samples and cross-sectional designs.
By developing the RQI, we sought to begin to overcome these limitations and provide a
novel way to assess the dimensions of relationship quality. Our goal was to develop a semi-
structured interview that can be administered individually to partners to assess their
relationship quality or functioning across multiple relationship domains and yield objective
ratings. The goal of the RQI is to serve as an assessment tool prior to disseminating
intervention programs for couples.

The Relationship Quality Inventory (RQI)

The RQI is a 60-minute semi-structured interview yielding objective ratings of the quality
of couples’ relationships across five dimensions. Partners are administered the interview
individually. After obtaining information on relationship history, participants are asked to
describe the quality of their relationship across five dimensions over the past six months;
Open ended questions – followed by a series of closed ended questions – are asked to allow
novel contextual information to be obtained. During the spouse’s description of each
156 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

dimension of relationship quality, the interviewers probe using detailed behavioral indicators
and exemplars of each area to establish veridicality of report (see Prescott et al., 2000).
Answers are coded into nominal or ordinal categories; responses also guide decisions about
which subsequent questions are asked. Thus, the interview is branch-structured to facilitate
conditional questions.
Broad dimensions and specific items originally were selected following a
multidisciplinary review of the close relationships literature. Following the compilation of a
pool of potential domain-specific items, a team of six psychology pre-doctoral and doctoral
students specializing in couple relationships sorted the pool into the domain categories. Items
were deleted if there was less than 80% agreement among raters on their dimension
classification. To get at the domain of Emotional Closeness and Intimacy, items were
included that aimed to measure a couple’s ability to create mutual emotional closeness and
intimacy in their relationship. Sample items include “How close do you feel to your partner?”
and “Are there any specific personal (i.e., non-relationship) topics that either of you avoid
talking about with the other?” Items in the Support section of the interview measured the
level of support provided in the relationship, the type of support (emotional, tangible, etc),
whether the support is given in a variety of situations and the mutuality of the support in the
couple. Sample items include “Does your partner try to support you by spending a lot of time
talking with you when you have a problem?” and “Can your partner tell when you are feeling
down or need support, even if you don’t say anything?” In the section on the domain of
Sensuality and Quality of the Sexual Relationship, items were included that asked about the
frequency of sexual and sensual behaviors, the partner’s satisfaction, negative emotions, and
difficulties in this area. Examples of items include “How satisfied are you with your sexual
relationship?” and “Do you engage in sensual behaviors together, such as touching, cuddling,
hugging or massage?” Items in the Respect and Control domain ask about dyadic decision-
making across a variety of topics, and the balance of control in the relationship. Sample items
include “Does one of you tend to make most of the decisions in your relationship?” and “How
is money managed in your relationship?” Items included to assess the domain of
Communication and Conflict Management looked at negative affect in the relationship,
verbal, psychological, and physical aggression, and conflict resolution strategies. Sample
items include “Do you feel comfortable expressing your own opinions during a discussion
with your partner?” and “Do either of you ever threaten to leave the relationship during an
argument?”
Interviewers independently rated the relationship on each domain using five-point scales.
Ratings may range from 1-5 and scores of .5 (e.g., 3.5) are permissible. For example, in the
domain of Spousal Support, a rating of 1 indicates that the couple “blames, challenges, gives
advice when not requested; neither partner gives much/any support, or amount of support is
extremely skewed in favor of one partner over the other.” A rating of 3 is assigned if “some
support is provided, but skewed in favor of one partner over the other or provided in only
certain situations. Variety of support is limited.” A rating of 5 indicates “a high level and
quality of support from both partners; large variety of types of support spanning a variety of
situations.” Interviewers made objective ratings to eliminate the possibility that associations
between poor functioning in a key domain and other factors (e.g., marital distress) were due
to reporting biases. All interviews were audio-taped, and inter-rater reliability was assessed
using a random sample of 20% of the interviews. Coders were considered to be in agreement
if two independent raters were within .5 on the 5-point scale.
 Development of an Interview for Assessing Relationship Quality 157

SECTION 3: PRELIMINARY EVIDENCE FOR THE RELIABILITY AND

VALIDITY OF THE RELATIONSHIP QUALITY INVENTORY (RQI)
In this section we provide preliminary evidence for the reliability and validity of the RQI
in our target populations of young relationships – dating and newlywed couples. First, we
assessed reliability, convergent validity, and divergent validity. Second, we examined the
generalizability of the RQI across dating and marital relationships and across men and
women. Third, we examined the utility of the RQI to assess risk of relationship distress over
and above existing self-report measures and behavioral observation methods.

Samples Recruited to Assess Reliability and Validity of the RQI

Sample 1 comprised 101 married couples recruited through marriage license records from
suburban communities and small towns in Iowa. Couples dated an average of 48 months (SD
= 27.79) prior to marriage and 77% of them cohabited. Average estimated annual joint
income of couples was between $30,001- $40,000. Husbands’ average age was 25.91 (SD =
3.09) and their modal years of education were 14 years. Wives’ average age was 24.5 (SD =
3.46) and their modal years of education were also 14 years. For 15% of the couples, at least
one member of the couple identified him or herself as a member of an ethnic minority group.
(The proportion of non-Caucasian individuals in Iowa is 9%; US Census, 2007.)
Sample 2 comprised 91 individuals in heterosexual romantic relationships lasting at least
two months. Participants were enrolled in an introductory psychology course at The
University of Iowa. They ranged in age from 18 to 27 (M = 18.27 years, SD = 1.03 years) and
were predominantly Caucasian/Non-Hispanic (96.7%). Most participants defined their
relationships as “seriously dating” (96%). Only 1.1% were cohabiting, and relationship
duration ranged from 2 months to 5 years (M = 17.16 months, SD = 13.26).
Objective codes for all five RQI scales are presented in Table 1. On a 1-5 scale,
interviewers’ mean ratings ranged from 3.35 to 4.20 across all five RQI scales. On average,
couples’ relationship quality in these five domains was good to very good, which would be
expected in samples of dating or newlywed couples. Moreover, scores on all domains yielded
normal distributions, suggesting that there was adequate range in relationship quality across
participants in each of the five domains.

Reliability Analyses

To assess reliability of the RQI, we analyzed inter-rater reliability, agreement of

interviewers’ scores across husbands’ and wives’ interviews, and correlations among RQI
scales; see Table 1 for all of the results.
158 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

Table 1. Descriptives and Reliability Analyses

Descriptives and Agreement across Intraclass Correlations

Husband and Wife Interviews
Marital Sample Dating Marital Sample Dating
Sample Sample
RQI Scales Husbands Wives t(102) Mean Husbands Wives ICC
Mean Mean (SD) ICC ICC
(SD) (SD)
Trust, Closeness 4.13 4.20 1.06 3.40 .82 .71 .82
& Emotional (.53) (.39) (.65)
Intimacy
Inter-partner 3.97 (.49) 3.94 -.41 3.63 .78 .88 .87
Support (.50) (.50)

Sexual Relations 3.92 (.65) 3.87 -.79 3.36 .94 .76 .77
(.64) (.66)

Respect, 3.97 (.55) 4.01 .51 3.36 .82 .84 .91

Acceptance, (.47) (.69)
Decision-Making
& Control
Communication & 3.69 (.75) 3.78 1.17 3.35 .93 .84 .92
Conflict (.67) (.83)
Management

Inter-Rater Reliability
To assess inter-rater reliability, 20% of the audio-taped interviews were randomly
assigned to a second coder. Intra-class correlations were computed by averaging across
correlations for each pair of objective codes. Correlations were above .70 across all five RQI
scales for husbands’ and wives’ interviews in the marital sample and for participants in the
dating sample. See Table 1 for all intra-class correlations.

Agreement Based on Husband versus Wife Interviews

Cross-spouse correlations on RQI ratings were low to moderate in magnitude (rs ranged
from .25 to .54), suggesting that husbands and wives were providing somewhat different (but
related) information and perspectives on their relationship functioning. Even though ratings
were objective and generated based on behavioral indicators of relationship functioning,
spouses may be giving at least somewhat different behavioral indicators, which then guide
those objective ratings. However, the magnitude of the majority of the inter-spousal
associations suggested the potential utility of aggregating across RQI ratings based on
husbands’ and wives’ interviews to create a more reliable rating for each domain. Moreover,
the t-tests revealed that ratings based on husbands’ and wives’ individual interviews were not
significantly different (ts(100) ranged from .51 to 1.17, all ns).
 Development of an Interview for Assessing Relationship Quality 159

Correlations among RQI Scales

It was important to first determine that the RQI scales were sufficiently interrelated to
justify conceptualizing them as components of a higher-order measure of relationship quality.
Within-subject correlations across RQI scales are presented in Table 2. Pairs of RQI scales
within wives and within husbands in the marital sample correlated .38 to .65. In the dating
sample, pairs of RQI scales correlated .24 to .63. This level of inter-correlation is appropriate
for sub-factors of a more general construct (Clark & Watson, 1995) and indicates that the
different scales are moderately inter-correlated but not redundant. There was one exception to
this pattern, however. Inter-partner Support and Respect and Control were strongly correlated
within subjects in the marital sample, with correlations of .65 and .70 for husbands and wives,
respectively.

Convergent/Divergent Validity Analyses

To assess convergent/divergent validity, we examined the extent to which RQI interview

scales correlated with data on these same dyadic processes collected via self-report
questionnaires and behavioral observations. Self-report measures included: (a) the Problem
Solving Communication (PSC) and Affective Communication (AFC) subscales from The
Marital Satisfaction Inventory-Revised (MSI-R; Snyder & Aikman, 1999) to measure
negative communication and conflict management patterns, and (b) a modified version of The
Support in Intimate Relationships Rating Scale (SIRRS; Dehle et al., 2001; see Barry et al.,
2008 for details and psychometric properties of the revised SIRRS) to assess perceptions of
support amount from one’s partner and support adequacy. Behavioral observation indices of
relationship quality included: (a) an inter-partner support interaction task and the Social
Support Interaction Coding System (SSICS; Pasch, Harris, Sullivan, & Bradbury, 2002), a
coding system that assesses the behaviors exchanged by partners during a supportive
discussion, and (b) a problem-solving interaction task and the Specific Affect Coding System
– Revised (SPAFF-R; Gottman McCoy, & Coan, 1996), designed to measure positive and
negative affect expressed during a problem-solving discussion.

Correlations between RQI Subscales and Self-report Measures of Related Constructs

First we examined the correlations between the RQI subscales and self-report measures
of relationship function in the relevant domains. Thus the constructs were somewhat related
and the methods of assessment differed (objective interview versus self-report
questionnaires). For the Emotional Closeness and Intimacy subscale we used the Affective
Communication subscale of the Marital Status Inventory-Revised. For the Inter-partner
Support subscale we used the adequacy scale from the Support in Intimate Relationships
Rating Scale. For the Communication and Conflict Management subscale we used the
Problem-Solving Communication scale of the MSI-R. (Self-report measures of the quality of
the sexual relationship and of respect and control were not available in the present sample to
compare to the RQI Sexual Relations and Respect and Control subscales, respectively.) As
shown in Table 3, the RQI scales were weakly to moderately correlated with the self-report
questionnaires. Correlations ranged from .24 to .56 in the marital sample, and from .03 to .23
in the dating sample.
 Table 2. Correlations among RQI Scales

Marital Sample
Dating Sample
Husbands

Trust & Respect & Comm. & Trust & Respect & Comm. &
Wives Support Sex Support Sex
Closeness Control Conflict Closeness Control Conflict
Trust & Closeness .32** .56** .38** .54** .49** ----- .59**** .65**** .46****
.56****
Inter-partner Support
.59** .27** .51** .65** .44** ----- ----- .25* .38**** .24*
Sexual Relations
.49** .52** .54** .38** .44** ----- ----- ----- .35** .26****
Respect & Control
.52** .70** .47** .25** .54** ----- ----- ----- ----- .63**
Communication &
.46** .57** .40** .63** .51** ----- ----- ----- ----- -----
Conflict Mgmt.
 Development of an Interview for Assessing Relationship Quality 161

Table 3. Convergent and Divergent Validity Analyses

Range of Correlations with Correlations with Questionnaires of Correlations with Correlations with Global Correlations with Individual
other RQI Scales Similar Relationship Constructs a Behavioral Data of Relationship Satisfaction c Differences in Similar
Similar Constructs Constructs d
b

Marital Dating Marital Dating Marital Marital Dating Marital Dating

Husb. Wife Husb. Wife Husb. Wife Husb. Wife Husb. Wife
Trust & .38-.56 .48-.59 .56-.65 .37** .42** -.23* ----- ----- .41** .41** .09 -(.07- -(.20- -(.05-.07)
Closeness .29**) .22)
Support .44-.65 .52-.70 .24-.56 .28** .24* .03 .18+ -.05 .46** .39** .002 ----- ----- -----
Sexual .38-.51 .40-.52 .25-.56 ----- ----- ----- ----- ----- .35** .37** -.05 ----- ----- -----
Relations
Respect .38-.65 .47-.70 .35-.65 ----- ----- ----- -.17+ -.05 .43** .39** -.01 -(.19- -(.004- -.08-.12
& Control .34**) .12)
Comm. & .44-.54 .40-.63 .24-.63 .56**** .44**** -.08 .25** .14+ .36** .38** .22* -(.34- -(.26- -(.08-.12)
Conflict .51)*** .31)*
a
Self-report questionnaires of similar constructs for each RQI scale were: for Trust and Closeness, the AFC Scale of the MSI-R; for Support, the Adequacy
scale of the SIRRS; for Communication and Conflict, the PSC Scale of the MSI-R. Of note, the Trust and Closeness RQI scale was also compared to the
Intimacy and Passion Scales from the Sternberg Love, Passion, and Intimacy Scale, and the pattern of correlations remained the same (rs = -.01 and .02,
respectively).
b
Behavioral observation data of similar constructs for each RQI scale were: for Support, the Social Support Interaction Task and the SSICS; for Respect and
Control, the Problem-Solving Interaction Task and the Contempt, Disgust, Domineering, and Belligerence codes from the SPAFF-R; for Communication
and Conflict, the Problem-Solving Interaction Task and the remaining 12 positive and negative affect codes from the SPAFF-R. Of note, SPAFF data were
analyzed multiple ways using to examine correlations with Communication and Conflict Management, and the pattern of results remained the same.
c
The Quality of Marriage Index (QMI) was analyzed for all correlations with global relationship satisfaction. Of note, in the sample of dating couples, this
pattern of findings was replicated using the Perceived Relationship Quality Components (PRQC); rs ranged from .00 to .13.
d
Self-report questionnaires of individual differences were identical in both samples unless otherwise noted here. Measures of individual differences in similar
constructs for each RQI scale were: for Trust and Closeness, the SNAP Detachment and Mistrust Scales, the Relationship Scales Questionnaires (in the
marital sample), and the ECR-R Avoidance Scale (in the dating sample); for Respect and Control, the SNAP Manipulativeness Scale and the Hostility
Scale from the Buss-Perry Aggression Questionnaire; for Communication and Conflict Management, the SNAP Negative Temperament Scale and the
Anger Scale from the Buss-Perry Aggression Questionnaire.
162 Development of an Interview for Assessing Relationship Quality

Correlations between RQI Subscales and Behavioral Observations of Related

Constructs
Next we examined the correlations between the RQI subscales and behavioral
observations of measures of relationship functioning in the relevant domains. (Behavioral
observation data were only available in the marital sample.) Thus the constructs were related
but the methods of assessment differed (objective interview versus behavioral observations of
couple functioning). For the Inter-partner Support subscale we used behavioral observations
from two support interaction tasks that were later coded via the Social Support Interaction
Coding system. For the Communication and Conflict Management subscale we used
behavioral observations from two problem-solving interaction tasks that were later coded via
the Specific Affect Coding System – Revised. As shown in Table 2, conclusions about
marital processes yielded based on the RQI did not correlate with data collected via
behavioral observations of these marital processes. Correlations ranged from .05 to .25.

Divergent Validity Analyses

To assess divergent validity, we examined the associations between RQI subscales and
measures of individual differences in related constructs. For example, we examined
associations between the Emotional Closeness and Intimacy domain to measures of
detachment and mistrust as personality traits, and to avoidant attachment as an attachment
style. We measured individual differences by administering: (a) the Negative Temperament,
Detachment, Mistrust, and Manipulativeness scales from The Schedule for Nonadaptive and
Adaptive Personality - 2nd Edition (SNAP-2; Clark, Simms, Wu, & Casillas, in press); (b) the
Anger and Hostility Scales from The Buss-Perry Aggression Questionnaire (Buss & Perry,
1992); and the Relationship Scales Questionnaire (RSQ; Griffin & Bartholomew, 1994) and
the Experiences in Close Relationships – Revised scale (ECR-R; Fraley, Waller, & Brennan,
2000). We also assessed divergent validity by examining the associations between RQI
subscales and a global measure of relationship satisfaction, The Quality of Marriage Index
(QMI; Norton, 1983), to determine whether our purported assessment of domain-specific
relationship quality was distinct from global relationship satisfaction.
Three aspects of discriminant validity were considered. First, Campbell and Fiske (1959)
state that a good convergent/discriminant validity pattern exists when matched variables
correlate more highly with each other than with any other variable. Thus we examined
whether the inter-correlations among RQI scales were higher than the correlations between
RQI scales and measures of similar constructs via different methods. Second, the associations
between the RQI scales and related traits were examined to determine whether RQI subscale
scores discriminated between functioning within one’s marriage on a given domain and
individual differences in interpersonal functioning on that domain across relationships. Third,
we examined associations between RQI scales and a measure of global marital satisfaction to
determine whether the RQI is simply assessing global marital satisfaction rather than
relationship quality across multiple domains. Results are presented in Table 3.
 Development of an Interview for Assessing Relationship Quality 163

Campbell and Fiske’s Test of Convergent/divergent Validity

We examined whether the inter-correlations among RQI scales were higher than the
correlations between RQI scales and measures of similar constructs via different methods.
Results are presented in Table 3. In general, this target pattern was clearly obtained for all
five RQI scales in both samples. For each RQI scale, the correlations with other RQI scales
(convergent validity) were generally larger than correlations with questionnaire or behavioral
observation data. This support was evident for husbands and wives, and across marital and
dating participants. Three of the four RQI Scales – Emotional Closeness and Intimacy, Inter-
partner Support, and Respect and Control – clearly meet the Campbell and Fiske test for
excellent convergent and discriminant validity at the scale level. In contrast, there is mixed
but generally strong evidence regarding the RQI Communication and Conflict Management
Scales. The scale does meet Campbell and Fiske’s criteria when compared to self-report
questionnaires in the dating sample and when compared to behavioral observation data in the
marital sample. Moreover, the RQI Communication and Conflict Management Scale is only
moderately correlated with the corresponding self-report questionnaire. However, this
moderate correlation is similar to the moderate correlations between the RQI Communication
and Conflict Management scale and the other RQI scales (which range from .40 to .63); thus,
it does meet the Campbell and Fiske criteria in that regard.

Correlations between RQI Subscales and Relevant Traits

Zero-order correlations between the RQI subscales and trait-level constructs related to
each domain assessed were examined. (Trait questionnaires to measure sexual relations across
relationships and global social support were not available in the present samples to compare
to the RQI Sexual Relations and Inter-Partner Support subscales, respectively.) For the
Emotional Closeness and Intimacy subscale we used the (a) SNAP Detachment scale, (b)
SNAP Mistrust scale, and (c) ECR-R Attachment Avoidance scale. All of the associations
relevant to the Emotional Closeness and Intimacy subscale were small across husbands and
wives and across dating and marital participants (rs ranged from .05 to .29). These findings
support our contention that the RQI Emotional Closeness and Intimacy subscale is not simply
measuring individual differences such as global detachment or mistrust as personality traits or
an avoidant attachment style but rather measures a construct that is specific to the intimate
relationship.
For the Respect and Control subscale we used the SNAP Manipulation scale and the AQ
Hostility Scale. All of the associations were small across husbands and wives and across
dating and married participants (rs ranged from .004 to .34). Therefore, the Respect and
Control subscale is not simply measuring individual differences such as manipulative or
hostile personality traits but rather measures a construct that is specific to the intimate
relationship.
For the Communication and Conflict Management subscale we used (a) the Anger Scale
from the Buss-Perry Anger Questionnaire and (b) the SNAP Negative Temperament scale.
With one exception, the correlations were small, with rs ranging from .08 to .34. (The
correlation between this scale and Negative Temperament for husbands was moderate (.51),
although this association was small among wives and dating participants. Thus, the quality of
a couple’s communication and conflict management strategies is clearly distinct from both
trait anger and global negative temperament; however, for husbands, quality of conflict
management is also clearly related to husband negative temperament.
164 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

Correlations between RQI Subscales and Global Relationship Satisfaction

Correlations between ratings of domain-specific relationship quality and global
relationship satisfaction were low to moderate for husbands and wives (rs ranged from .35 to
.46) and low for dating participants (rs ranged from .002 to .22), indicating that the domain-
specific assessments of relationship quality did not simply represent indicators of an
underlying latent variable of marital satisfaction. Moreover, the associations between
relationship quality and satisfaction are clearly stronger for married couples compared to
dating couples, which we expected given the longer duration and stronger commitment of
married couples.

Incremental Validity Analyses

We examined the utility of the RQI to assess risk of relationship distress over and above
existing self-report measures and behavioral observation methods. In addition to our
assertions that a clinical interview will be more user-friendly for clinicians and that the
interview provides a better measure of the constructs of interest (compared to existing self-
report questionnaires and behavioral observational data), we also expected the RQI scales to
predict global relationship satisfaction over and above these existing measures. We examined
the incremental utility of each RQI scale when predicting cross-sectional and longitudinal
(three-year) satisfaction for men and women.
In the marital sample, we examined the extent to which each RQI scale provided
incremental predictive validity in accounting for global marital satisfaction. For four of the
five RQI scales – Emotional Closeness and Intimacy, Inter-partner Support, Respect and
Control, and Communication and Conflict – we analyzed the incremental predictive power of
the RQI scale over and above self-report questionnaires of these marital processes and, when
available, behavioral observation data of these marital processes. We did not have any self-
report questionnaire data for the quality of the couple’s sexual relations. Incremental validity
was examined when predicting both concurrent and longitudinal marital satisfaction. Results
for all regression analyses are presented in Table 4.

Cross-sectional Analyses
In the marital sample, three of the four RQI scales – Emotional Closeness and Intimacy,
Inter-partner Support, and Respect and Control – demonstrated incremental predictive power.
Interestingly, in the dating sample, only the RQI Communication and Conflict Management
scale demonstrated incremental predictive power. The RQI Emotional Closeness and
Intimacy Scale predicted concurrent marital satisfaction for husbands and wives over and
above our self-report measure of this construct (Affective Communication Scale of the MSI-
R; Snyder & Aikman). The RQI Inter-Partner Support Scale predicted concurrent marital
satisfaction for husbands and wives over and above both our self-report measure (SIRRS;
Dehle et al.) and our behavioral observation data (SS interaction task coded via the SSICS
coding system; Pasch et al.). The RQI Respect and Control Scale predicted concurrent marital
satisfaction for husbands – but not for wives – over and above both our self-report measure
(Problem-Solving Communication Scale of the MSI-R; Snyder & Aikman) and our
behavioral observation data (problem-solving interaction task coded for belligerence,
 Development of an Interview for Assessing Relationship Quality 165

dominance, contempt, and disgust via the SPAFF coding system; Gottman et al.). The RQI
Communication and Conflict Management Scale predicted concurrent relationship
satisfaction for dating participants (but not for husbands or wives) over and over and above
our self-report measure (Problem-Solving Communication Scale of the MSI-R; Snyder &
Aikman). Thus, the RQI appears to provide incremental utility to explaining global marital
satisfaction compared to existing self-report questionnaires and behavioral observation data
for Emotional Closeness and Intimacy, Inter-partner Support, and Respect and Control, but
not for Communication and Conflict Management.

Table 4. Incremental Predictive Validity

Predicting Time 1 Relationship Satisfaction Predicting Time 4 Satisfaction

Marital Sample Dating Marital Sample
Sample
Husbands Wives Husbands Wives

b (SE) / b (SE) / b (SE) / b (SE) / b (SE) /

Adjusted R2 Adjusted R2 Adjusted R2 Δ Adjusted R2 Δ Adjusted R2
Δ Δ Δ
MSI-R: AFC Scale 1.29**** 1.07**** -1.59**** 1.02** (.33) .45+ (.28)
(.19) (.13) (.24)
RQI Trust & 1.46* (.72) / 1.91* (.98) / -.26**** (.43) 3.02* (1.21) / .15 (1.95)
Closeness .02* .02* / .33 .06* /.00
SIRRS Adequacy .12+ (.05) .14 *** (.04) .28 (.09) ** .08 (.07) .09 + (.05)
Scale
RQI Support Scale 3.20**** 2.72** (.92) / -.01 (.48) / .09 .42 (1.28) / 1.21 (1.19) /
(.87) / .22 .26 .001 .04
SIRRS Adequacy .14** (.05) .07 (.05) ----- .10 (.09) .07 (.06)
Scale
SSICS Support Codes .01 (.02) -.02 (.03) ----- .03 (.04) -.02 (.03)
RQI Support Scale 1 .82+ (1.07) 3.30** ----- .91 (2.05) / 1.28 (1.39) /
/ .192 (1.12) / .15 .02 .002
MSI-R: PSC Scale -.63**** -.72**** -.65**** -.30 (.17)+ -.39* (.19)
(.09) (.09)
SPAFF Behaviors a -.00 (.02) .01 (.02) ----- -.02 (.03) .03 (.03)
RQI Respect & 1.51* (.69) / 1.45* (.74) / -.04/.41 2.47* (1.23) / 1.13 (1.43) /
Control .03* .02* .04* .02
MSI-R: PSC Scale 1.05**** 1.04**** -.91 (.12) .19 (.27) .34 (.21)
(.15) (.14) ****
SPAFF Behaviors b .001 (.003) .001 (.003) ----- .003 (.005) -.001 (.004)
RQI -.09 (.60) / .70 (.60) / .46 .64* (.30) / 1.40 (1.10) / 1.14 (.92) /
Commun./Conflict .41 .41* .03 .04
a
SPAFF behaviors: Disgust, Contempt, Domineering, Belligerence.
b
All other positive and negative SPAFF codes. Of note, SPAFF data were analyzed multiple ways to
examine corr.s with Commun. & Conflict. Pattern of results remained the same.
+
p < .10; * p < .05; ** p < .01; *** p < .001; **** p < .0001.
166 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

Longitudinal Analyses
Next we examined the incremental predictive utility of these same RQI scales when
predicting longitudinal marital satisfaction – at three years of marriage. Two of the four RQI
scales – Emotional Closeness and Intimacy and Respect and Control – demonstrated
incremental utility in predicting husbands – but not wives – longitudinal marital satisfaction.
The RQI Emotional Closeness and Intimacy Scale predicted husbands’ longitudinal marital
satisfaction over and above our self-report measure of this construct (Affective
Communication Scale of the MSI-R; Snyder & Aikman). The RQI Respect and Control Scale
also predicted husbands’ longitudinal marital satisfaction over and over and above both our
self-report measure (Problem-Solving Communication Scale of the MSI-R; Snyder &
Aikman) and our behavioral observation data (problem-solving interaction task coded for
belligerence, dominance, contempt, and disgust via the SPAFF coding system; Gottman et
al.). The RQI Inter-partner Support Scale and Communication and Conflict Scales did not
incrementally predict longitudinal marital satisfaction for either husbands or wives over and
above our self-report measure or our behavioral observation data Thus, the RQI appears to
provide incremental utility to explaining husbands’ – but not wives’ – longitudinal global
marital satisfaction compared to existing self-report questionnaires and behavioral
observation data for Emotional Closeness and Intimacy and Respect and Control, but not for
Inter-partner Support or Communication and Conflict Management.

Conclusion

The RQI demonstrated strong reliability, with inter-rater agreement consistently above .7,
no significant differences among interviewer ratings based on whether the male or female
partner was interviewed in a given couple. Correlations among RQI subscales ranged from .2
to .6 (with one exception), supporting our contention that the subscales are best
conceptualized as related dimensions of the underlying construct of relationship quality, yet
these subscales capture conceptually distinct (albeit related) dimensions of relationship
quality. The RQI also demonstrated good convergent validity, with correlations ranging from
.2 to .6 between the subscales and self-report measures of related relationship constructs
(emotional intimacy, communication and conflict management, inter-partner support).
Divergent validity was assessed four ways. First, correlations between RQI scales and
behavioral observations of related constructs were weak, ranging from .05 to .25, supporting
our contention that the RQI captures markedly distinct constructs from what is captured via
behavioral observation interaction tasks. Second, correlations between RQI scales and
measure of global relationship satisfaction were weak, ranging from .002 to .46, supporting
our contention that the RQI is not simply a measure of global relationship satisfaction. Third,
correlations between RQI subscales and individual difference measures of related constructs
(e.g., avoidant attachment, mistrust, detachment, negative temperament, hostility) were weak,
ranging from .004 to .3 (with one exception at .5), supporting our contention that the RQI
scales capture constructs that are unique to one’s current intimate relationship rather than
being indicative of individual differences that might be present across multiple types of
relationships (e.g., friends, acquaintances, co-workers). Fourth, convergent validity analyses
generally yielded stronger correlations then divergent validity analyses, lending partial
support to the Campbell-Fiske (1959) test of construct validity.
 Development of an Interview for Assessing Relationship Quality 167

SECTION 4: CLINICAL IMPLICATIONS OF THE RQI FOR

COUPLE ASSESSMENT AND PREVENTION EFFORTS
In this section we discuss clinical implications at two levels. First, we discuss the
generalizability of the RQI itself based on the data presented in Section 3. Second, we discuss
the broader clinical implications of the RQI for improving couple assessment and prevention
efforts.

Generalizability of the RQI

We examined the generalizability of the RQI in two ways. First we examined its
generalizability across men and women. The RQI yielded strong psychometric data for men
and women. Second, we found that the RQI demonstrated reliability, validity, and incremental
utility across dating and marital relationships. As the proportion of couples who cohabit
and/or date for many years prior to marriage increases, greater attention is being given to the
study of pre-marital relationships (e.g., Brown & Booth, 1996; Stanley, Rhoades, &
Markman, 2006). Additionally, it has been suggested that patterns that develop early in
relationships (i.e., even before marriage) are important for individual and dyadic outcomes
(Cutrona et al., 2005). Thus, patterns of relationship quality that emerge during courtship
likely impact individual and relationship functioning. Despite this potential importance, little
work has addressed whether relationship quality functions similarly in dating and marital
relationships. As expected, the pattern of findings was stronger in the analyses of the marital
sample compared to the dating sample. The longer duration and stronger commitment of the
married participants would presumably lead to greater utility of the RQI in such a sample.
The next step is to examine the psychometric properties of the RQI in distressed samples of
couples, such as in a sample of couples seeking couple therapy. We would expect the pattern
of results to be similar, if not stronger, to that found with the marital sample. More generally,
as the intimate relationship becomes more solidified and more central to one’s life, we would
expect the RQI to have greater utility and for the interview to demonstrate stronger
convergent and divergent validity when administered.
There are several ways in which the generalizability of the RQI can be expanded in future
research. First, although the RQI was developed as an assessment tool for young couples and
to be administered in accord with prevention programs, it seems just as likely that it could be
used as part of a standardized assessment protocol for treatment-seeking and/or distressed
couples and to guide treatment for those couples. Before we can recommend that the RQI be
used in this way, we must first assess the reliability and validity of the RQI in distressed,
established, and/or treatment-seeking couples. Second, the reliability and validity of the RQI
should be examined with same-sex couples and couples at other stages of their relationships
(e.g., cohabiting couples, engaged couples, couples experiencing the transition to
parenthood). Finally, other dimensions of relationship quality might be worth incorporated
into the RQI, such as fun and leisure time and quality of the couple’s friendship.
168 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

Implications for Couple Assessment and Prevention Efforts

There are several implications of the present study for couple assessment and intervention
efforts. First, the RQI is intended to be used as part of a standardized assessment battery for
couple interventions. For example, it can be administered to couples and then incorporated
into a feedback session in which relationship strengths/protective factors and relationship risk
factors/ vulnerabilities are emphasized. By quantifying relative strengths and weaknesses
across multiple dimensions of a relationship, feedback may be more palatable to couples.
Second, the RQI might function as a motivational tool to get couples to participate in
couple prevention programs or treatments. Cordova and colleagues (Cordova et al., 2005;
Gee, Scott, Castellani, & Cordova, 2002) developed an indicated intervention program called
the Marriage Checkup based on the principles of motivational interviewing. As they describe,
prior to dissolution, it is likely that couples that become severely distressed first pass through
an at-risk stage in which they experience early symptoms of marital deterioration but have not
yet suffered irreversible damage to their marriage. It is during this at risk stage when couples
might benefit most from early intervention. To date, they have found evidence for the
attractiveness, tolerability, efficacy, and mechanisms of change produced by this interview, as
well as its ability to predict marital satisfaction two years later. In line with this important
work, it is possible that the RQI could be modified and tested as a motivational interview for
at risk couples as well.
Third, because the RQI can be used to identify domains of strength and weakness in
couples’ relationships, it might be useful as a tool to identify at risk couples. To date, studies
of leading preventive interventions have not fared well at recruiting couples at risk for
adverse marital outcomes. Published samples have been disproportionately Caucasian, well
educated, and middle class (see Carroll & Doherty, 2003, for a review). However, divorce
rates are markedly higher among African American couples (70% vs. 47% in Caucasian
couples), among couples who did not finish high school (60% vs. 36% for college graduates),
and among couples who start marriage with children (rates are twice as high as couples who
marry without children; Raley & Bumpass, 2003). Despite their omission from prevention
programs, couples in these high-risk populations report high levels of interest in participating
in these interventions (Johnson et al., 2002). In sum, relationship enhancing interventions
appear to have failed to test their programs in the populations at greatest risk for distress and
divorce. Administering the RQI prior to implementing a prevention program might allow at
risk couples to be identified, while simultaneously being used as a motivational tool to
encourage these at risk couples to participate in these prevention interventions.
Fourth, intervention programs can be better tailored to the needs of specific couples,
rather than implementing a one-size fits all approach. For example, a couple’s RQI may
indicate strong quality of communication and conflict management skills but poor quality of
inter-partner support. In this case, intervention techniques specific to improving the quality of
support in that relationship is more appropriate and intervention techniques targeting conflict
management skills are unnecessary. This approach seems more beneficial for treating couples
and more cost-effective from a health care perspective.
 Development of an Interview for Assessing Relationship Quality 169

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 8

ASSESSING RELATIONSHIP QUALITY:

DEVELOPMENT OF AN INTERVIEW AND
IMPLICATIONS FOR COUPLE ASSESSMENT AND
INTERVENTION

Erika Lawrence, Rebecca L. Brock, Robin A. Barry, Amie Langer

University of Iowa, Iowa City, Iowa, USA
Mali Bunde
CIGNA Health Solutions, Eden Prairie, Minnesota, USA

ABSTRACT
Historically, relationship satisfaction and adjustment have been the target outcome
variables for almost all couple research and therapies. In contrast, far less attention has
been paid to the assessment of relationship quality. In the first section of our paper, we
review the long-standing debate regarding -- and clarify the distinctions among --
relationship adjustment, satisfaction, and quality. We also discuss the need for an
empirically-supported, psychometrically strong measure of relationship quality. In the
second section, we discuss the multidimensional nature of relationship quality, and
review prior research relevant to each dimension. We also introduce the Relationship
Quality Interview (RQI), a semi-structured, behaviorally anchored, individual interview
that yields objectively coded ratings. The RQI was designed to assess relationship quality
across five dimensions: (a) trust, closeness, and emotional intimacy; (b) inter-partner
support; (c) quality of the sexual relationship; (c) respect, power, and control; and (e)
communication and conflict management. In the third section, we provide preliminary
evidence of the reliability and validity of the interview. Across samples of dating and
married couples, we examined reliability, convergent and divergent validity, and
incremental validity of the RQI. In the fourth section, we discuss broader clinical issues
relevant to couple assessment and intervention efforts.
174 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

INTRODUCTION
Historically, relationship satisfaction and adjustment have been the target outcome
variables for almost all couple research and therapies. In contrast, far less attention has been
paid to the assessment of relationship quality. In the first section of our paper, we review the
long-standing debate regarding -- and clarify the distinctions among -- relationship
adjustment, satisfaction, and quality. We also discuss the need for an empirically-supported,
psychometrically strong measure of relationship quality. In the second section, we introduce
the Relationship Quality Interview (RQI), a semi-structured, behaviorally anchored,
individual interview that yields objectively coded ratings. It was designed to assess
relationship quality across five dimensions: (a) trust, closeness, and emotional intimacy; (b)
inter-partner support; (c) quality of the sexual relationship; (c) respect, power, and control;
and (e) communication and conflict management. We describe the development of the
interview, our justification for the dimensions of relationship quality included, and the coding
system employed.
In the third section, we provide preliminary evidence of the reliability and validity of the
interview. Our goal is for the RQI to be used as an assessment tool prior to the
implementation of prevention programs with young couples. Therefore, we administered the
RQI to 101 newlywed couples and 91 dating individuals. To assess reliability, we analyzed
internal consistency, inter-rater agreement, agreement across interviewers based on two
members of the same couple, and correlations among the scales. To examine convergent
validity, we analyzed correlations between RQI scales and self-report questionnaires
assessing similar relationship dimensions. To examine divergent validity, we computed
correlations between RQI scales and (a) behavioral observations of related constructs, (b)
global measures of relationship satisfaction, and (c) individual difference measures of related
constructs. We also examined the incremental utility of the RQI to explain cross-sectional and
longitudinal relationship satisfaction over and above existing measures of these same
dimensions of relationship quality.
In the fourth section, we discuss broader clinical issues relevant to couple assessment and
prevention efforts. First, we discuss the importance of identifying a standardized couple
assessment strategy, and review ongoing efforts to achieve this goal. Second, we make
specific recommendations for enhancing couple prevention programs. Third, we discuss the
possible utility of interviews as motivational tools to increase participation in prevention
programs among couples at high risk for longitudinal distress and dissolution, and review
ongoing efforts to achieve this goal.

SECTION 1: RELATIONSHIP SATISFACTION,

ADJUSTMENT, AND QUALITY
Over the last 60 years, relationship satisfaction and adjustment have been the target
outcome variables for almost all couple research and therapies. Nevertheless, there has also
been considerable debate over the differences among the terms relationship satisfaction,
relationship adjustment, and relationship quality. Relationship satisfaction refers to global
sentiment or happiness as a unitary construct. Relationship adjustment is broader in scope,
 Assessing Relationship Quality 175

and includes a consideration of dyadic processes such as conflict management skills and
relationship outcomes such as satisfaction. Relationship quality refers to dyadic processes
alone, such as the quality of a couple’s conflict management skills, supportive transactions,
sexual relations, or emotional intimacy (Lawrence, Barry, Brock, & Langer, in press; see
Snyder, Heyman, & Haynes, 2005, and Heyman, Sayers, and Bellack, 1994 for detailed
discussions of these issues). In this section, we provide a brief overview of the ways in which
relationship adjustment, satisfaction, and quality have been assessed to date, followed by a
discussion of the strengths and weaknesses of different methods of relationship assessment
(e.g., self-report questionnaires vs. clinical interviews).

Assessments of Relationship Adjustment, Satisfaction and Quality

Relationship adjustment is typically assessed with omnibus measures in which partners

evaluate multiple aspects of their relationships, such as the amount of disagreement across
different areas of conflict, global evaluations of the relationship, and frequency of sexual
relations (cf. Dyadic Adjustment Scale, Spanier, 1976; Marital Adjustment Test, Locke &
Wallace, 1959). Others have employed multidimensional approaches that distinguish among
sources of distress. For example, dimensions of the Marital Satisfaction Inventory (MSI-R;
Snyder & Aikman, 1999) include family of origin conflict, sexual satisfaction, and problem-
solving communication. Other questionnaires include dimensions such as relationship
expectations, emotional health, and personal stress management, as well as communication
strategies and family of origin conflict (FOCCUS, Markey & Micheletto, 1997; Larson,
Newell, Topham, & Nichols, 2002: PREPARE, Olsen, Fournier, & Druckman, 1996;
RELATE, Busby, Holman, & Taniguchi, 2001). We contend that the multidimensional nature
of these questionnaires represents an improvement over the omnibus measures that yield a
single aggregated score for marital adjustment. However, the dimensions included in these
newer questionnaires seem to confound predictors of dyadic functioning (e.g., family of
origin conflict) with assessment of dyadic functioning (e.g., problem-solving communication)
and, in some cases, with individual functioning (e.g., emotional health).
Relationship satisfaction is often assessed with shorter, unidimensional measures of
global sentiment toward one’s relationship (e.g., Kansas Marital Satisfaction Scale, Schumm
et al., 1986; Quality of Marriage Index, Norton, 1983). Others have employed a semantic
differential approach, a way of quantifying partners’ evaluations of their relationships by
having them rate their perceptions on scales between two opposite adjectives (e.g., satisfied to
dissatisfied, good to bad; Huston & Vangelisti, 1991; Osgood, Suci, & Tannenbaum, 1957).
Still others have developed multidimensional approaches. For example, on the Positive and
Negative Quality in Marriage Scale (PANQIMS; Fincham & Linfield, 1997), partners
evaluate the positive and negative qualities of their partner and relationship, and are
subsequently categorized as happy (high positive and low negative), distressed (low positive
and high negative), ambivalent (high on both positive and negative), or indifferent (low on
both positive and negative).
In contrast to the wealth of attention paid to assessing relationship satisfaction and
adjustment, far less attention has been paid to the assessment of relationship quality. Some
dimensions of relationship quality have received a lot of attention, such as communication
and conflict management processes. Others have received almost no attention, such as
176 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

emotional intimacy or decision-making/interpersonal control processes. Still others have

received attention in other disciplines but have not been integrated into couple research or
therapy, such as investigations of the quality of a couple’s sexual relationship.
Among the measures designed to assess relationship quality, several conceptual and
methodological limitations hinder their utility. First, these measures are typically specific to
one dimension such as conflict management, rather than capturing the multidimensional
nature of relationship quality. Second, existing measures of relationship quality are often
confounded with the constructs of satisfaction or adjustment. Specifically, these measures
include items that tap into both relational processes and satisfaction.

Method of Assessment: Questionnaires, Behavioral Observations, and

Clinical Interviews

Couple researchers and clinicians have long used self-report questionnaires to quantify
dyadic processes in basic research and to guide couple interventions. Unfortunately, self-
report questionnaires are vulnerable to biases including social desirability (Godoy et al., 2008;
Kluemper, 2008), depressed mood and depressive cognitions (e.g., Cohen, Towbest, &
Flocco, 1988; Raselli & Broderick, 2007), memory biases in retrospective reports (Karney &
Frye, 2002), and cognitive dissonance (e.g., newlyweds may be more likely to present couple
processes in a positive light because they have just gotten married and do not want to consider
the possibility that their marriage already has difficulties; McNulty, O’Mara, & Karney, 2008;
Miller, Niehuis, & Huston, 2006). Behavioral observation tasks were developed to deal with
these problems, and our ability to understand couple processes across domains improved.
However, observational methods are costly and time-consuming, and as such are less likely to
be widely adopted by clinicians in the near future. Moreover, although standardized,
psychometrically sound interaction protocols exist to assess couples’ transactions with
established coding systems, there is no network at present that can readily and conveniently
code these interactions and provide results in a timely manner. In sum, although an important
methodological development in couple research methodology, behavioral observation tasks
are unlikely to become standardized assessment tools for couple therapists.
In addition to self-report questionnaires and behavioral observation tasks, clinical
interviews are often used to gather information during an assessment. Outside of the close
relationships field, The Structured Clinical Interview for the Diagnostic Statistical Manual
(SCID; First et al., 1995), a standardized interview for assessing Axis I DSM disorders, is
often used. The Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985) is also
routinely used by researchers studying attachment processes.
There are several advantages to employing clinical interviews rather than behavioral
observation data in couple research. First, clinical interviews allow the objective coder to
consider partners’ perceptions when evaluating the relationship; however, the biases of self-
report are still omitted (e.g., Morrison & Hunt, 1996). Second, interviews allow for a more
global perception of dyadic processes as opposed to behavioral observation data that provide
a snapshot of a particular type of interaction. Third, once an interviewer is trained to
reliability, administering and coding clinical interviews is typically faster and less expensive
than coding behavioral observation data. Fourth, clinical interviews are more likely to be
embraced by clinicians compared to behavioral observation methods. This latter advantage
 Assessing Relationship Quality 177

could have important implications for the future of couple assessment and intervention,
including helping to facilitate a move toward the standardization of couple assessments, and
bridging the gap between couple researchers and clinicians. (See Section 4 of this chapter for
a detailed discussion of clinical implications.)
There have been isolated efforts to develop and validate structured interviews for couple
research and therapy. For example, the Structured Diagnostic Interview for Marital Distress
and Partner Aggression (Heyman et al., 2001) allows researchers and clinicians to reliably
and validly diagnose couples in terms of relationship distress and physical aggression. The
content of the interview is similar to that of the Dyadic Adjustment Scale (Spanier, 1976) and
the Conflict Tactics Scales (Straus et al., 1996), and the format is similar to that of the SCID.
However, no interview exists to assess the construct of relationship quality. Therefore, as we
describe in the next section, we sought to develop an interview-based approach to quantifying
important dimensions of relationship quality.

SECTION 2: DIMENSIONS OF RELATIONSHIP QUALITY

AND THE RELATIONSHIP QUALITY INTERVIEW

As we began to develop our interview, we sought to be comprehensive in our

examination of the dimensions of relationship quality that would influence the longitudinal
course of relationship satisfaction and stability. Therefore, we first conducted an exhaustive
review of the close relationships literature across multiple disciplines (e.g., social and clinical
psychology, communication studies, family studies, sociology). In this section, we summarize
our review and describe how it guided the development of the interview.

Dimensions of Relationship Quality

The overwhelming majority of research in the close relationships field has been focused
on the quality of a couple’s ability to solve problems and conflicts. Theories of intimate
relationships and of the determinants of relationship outcomes (e.g., Christensen &
Walczynski, 1997; Gottman, Swanson, & Murray, 1999), a great deal of the empirical
research on intimate relationships, most observational research on intimate relationships,
reviews on dyadic interactions (e.g., Karney & Bradbury, 1995; Weiss & Heyman, 1997), and
most existing psychological interventions for couple distress (e.g., Behavioral Marital
Therapy; Jacobson & Holtzworth-Munroe, 1986; Prevention and Relationship Enhancement
Program; Floyd, Markman, Kelly, Blumberg, & Stanley, 1995) have targeted relationship
conflict. Within the last decade or so, there has been a tremendous increase in attention to the
role of partner support as an adaptive dyadic skill (e.g., Gable, Gonzaga, & Strachman, 2006;
Neff & Karney, 2005; Pasch & Bradbury, 1998). Other researchers have focused specifically
on emotional intimacy (e.g., Barnes & Sternberg, 1997; Barry, Lawrence, & Langer, 2008;
Cordova, Gee, & Warren, 2005; Laurenceau et al., 2005), the quality of a couple’s sexual
relationship (e.g., Henderson-King & Veroff, 1994; LoPiccolo, Heiman, Hogan, & Roberts,
1985), and respect or control (e.g., Gray-Little & Burks, 1983; Ehrensaft, Langhinrichsen-
178 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

Rohling, Heyman, & Lawrence, 1999; Huston, 1983; Whisman & Jacobson, 1990). (See
Lawrence et al., 2008 for a detailed review of the literature.)
Across these studies of relationship quality, researchers typically examine only one or
two domains of dyadic processes per sample, which presumably grossly underestimates the
complexity of relationship quality. Moreover, many of these studies did not statistically
examine sex differences in relationship quality, which may lead to an incomplete, skewed, or
inaccurate conceptualization of intimate relationships and, consequently, to interventions that
are limited in their effectiveness. This literature has also suffered from methodological
limitations, including measurement issues (such as the use of self-report measures of
relational behaviors that may be influenced by social desirability and cognitive dissonance,
particularly among couples in new relationships), shared method variance, retrospective data,
heterogeneous samples and cross-sectional designs. Consequently, we sought to begin to
overcome these limitations and provide a novel way to assess the dimensions of relationship
quality.

Dimensions of Relationship Quality Included in the Relationship Quality

Interview (RQI)

Based on our review, we identified five dimensions of relationship quality: (1)

communication and conflict management, (2) inter-partner support, (3) emotional closeness
and intimacy, (4) quality of the sexual relationship, and (5) respect, power, and control. We
operationalized communication and conflict management as comprising frequency and length
of arguments, verbal, psychological and physical aggression during arguments, withdrawal
during arguments, emotions experienced and behaviors expressed before, during and after
arguments, and conflict resolution strategies. In accord with Cutrona and colleagues’ work
(e.g., Cutrona, Russell, & Gardner, 2005), inter-partner support was operationalized as
comprising four types of support when one partner has had a bad day, is feeling down, or has
a problem: emotional support (talking and listening to each other, holding hands, hugging,
letting one’s partner know s/he understands), direct or indirect tangible support (direct
support: helping one’s partner solve the problem or make the situation better; indirect
support: providing time or resources so that one’s partner is better able to solve the problem
him- or herself, e.g., providing childcare), informational support (giving advice, providing
one’s partner with information, helping one’s partner think about a problem in a new way),
and esteem support (expressing confidence in the partner’s ability to handle things, telling
one’s partner s/he is not to blame for a problem). Match between types of support desired and
types of support provided, and the extent to which support is offered in a positive or negative
manner, are also assessed. Emotional closeness and intimacy was operationalized as
comprising emotional closeness (an overall mutual sense of closeness, warmth, affection, and
interdependence), quality of the couple’s friendship, and demonstrations of love and affection
(quantity and quality of love and affection expressed in the relationship, including verbal and
physical expressions of love). We operationalized quality of the sexual relationship as
comprising the quality of the sexual relationship (frequency of sexual activity, symmetry in
initiation of sexual activity, satisfaction, negative emotions, sexual difficulties, concerns) and
sensuality (touching, hugging, cuddling, massage, the extent to which sensuality exists
separate from sexual activity in the relationship). Finally, respect, power, and control was
 Assessing Relationship Quality 179

operationalized as comprising mutual acknowledgement of competence and independence;

acceptance and positive regard for the other even when one disagrees with him or her,
a/symmetry in decision-making across a variety of areas, partners’ satisfaction with that
division of responsibility, and a couple’s ability to negotiate control across a variety of areas
(e.g., scheduling one’s own day, controlling money).

The Relationship Quality Interview (RQI)

Once we converged upon and operationalized our dimensions of relationship quality, we

generated a pool of potential items. A team of six psychology pre-doctoral and doctoral
students specializing in couple relationships sorted the items into the different relationship
categories. Items were deleted if there was less than 80% agreement among raters on their
classification. Next we conducted three pilot studies in which we administered the interview
to dating, cohabiting, and married couples; the RQI was revised after each pilot study. The
final version of the RQI is described herein.
The RQI is a 60-minute semi-structured interview administered indvidually to each
partner. After obtaining information on relationship history, participants are asked to describe
the quality of their relationship across the five different dimensions over the past six months.
Open-ended questions -- followed by a series of closed-ended questions -- are asked to allow
novel contextual information to be obtained. During the individual’s description of each
dimension of relationship quality, the interviewers probe using detailed behavioral indicators
and exemplars of each area. Participants’ responses also guide decisions about which
subsequent questions are asked. Interviewers independently rate the relationship on each
domain. Ratings may range from 1-5 and scores of .5 (e.g., 3.5) are permissible.
We use objective interviewer ratings to control for the possibility that self-reports of
relationship functioning might be influenced by factors such as global relationship
satisfaction, depression or social desirability. The use of objective ratings also allows us to
control for the possibility that couples in the early stages of a relationship (e.g., dating for
only a few months, newly married) might experience cognitive dissonance when discussing
potential weaknesses or problems in their relationships, which might influence their self-
reports of the quality of their relationship.

SECTION 3: RELIABILITY AND VALIDITY OF

THE RELATIONSHIP QUALITY INTERVIEW (RQI)

In this section we provide preliminary evidence for the reliability and validity of the RQI
in dating and newlywed couples. First, we assessed reliability, convergent validity, and
divergent validity. Second, we examined the generalizability of the RQI across dating and
marital relationships and across men and women. Third, we examined the utility of the RQI to
assess risk of relationship distress over and above existing self-report measures and
behavioral observation methods. (Please see Lawrence et al., 2008 for a detailed presentation
of these analyses.)
180 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

Samples Recruited to Assess Reliability and Validity of the RQI

Sample 1 comprised 101 married couples recruited through marriage license records from
suburban communities and small towns in Iowa. Couples dated an average of 48 months (SD
= 27.79) prior to marriage and 77% of them cohabited. Average estimated annual joint
income of couples was between $30,001- $40,000. Husbands’ average age was 25.91 (SD =
3.09) and their modal years of education were 14 years. Wives’ average age was 24.5 (SD =
3.46) and their modal years of education were also 14 years. For 15% of the couples, at least
one member of the couple identified him or herself as a member of an ethnic minority group.
Sample 2 comprised 91 individuals in heterosexual romantic relationships lasting at least
two months. Participants were enrolled in an introductory psychology course at The
University of Iowa. They ranged in age from 18 to 27 (M = 18.27 years, SD = 1.03 years) and
were predominantly Caucasian/Non-Hispanic (96.7%). Most participants defined their
relationships as “seriously dating” (96%). Only 1.1% were cohabiting, and relationship
duration ranged from 2 months to 5 years (M = 17.16 months, SD = 13.26).
On a 1-5 scale, interviewers’ mean ratings ranged from 3.35 to 4.20 across the two
samples and across all five RQI scales. On average, couples’ relationship quality ranged from
“good” to “very good,” as expected in samples of dating or newlywed couples. Moreover,
scores on all domains yielded normal distributions, suggesting that there was adequate range
in relationship quality across participants in each of the five domains.

Reliability Analyses

We examined the reliability of the RQI in three ways. First, to assess inter-rater
reliability, 20% of the audio-taped interviews were randomly assigned to a second coder.
Intra-class correlations were above .70 across all five RQI scales for husbands’ and wives’
interviews in the marital sample and for participants in the dating sample. Second, we
examined whether interviewers’ ratings on the RQI scales differed as a function of whether
the interviewer was speaking to the husband or the wife of a given couple. There were no
significant differences among interviewer ratings based on whether the male or female partner
was interviewed (ts(100) ranged from .51 to 1.17, all ns). Third, we examined within-subject
associations among RQI scales. Correlations among RQI subscales ranged from .25 to .65,
supporting our contention that the subscales are best conceptualized as related dimensions of
the underlying construct of relationship quality, yet these subscales capture conceptually
distinct (albeit related) dimensions of relationship quality. (There was one exception to this
pattern: in the marital sample, Inter-Partner Support and Respect, Power, and Control were
strongly correlated, with correlations of .65 and .70 for husbands and wives, respectively.)

Agreement with Self-Report Questionnaires and Behavioral Observations

We examined the extent to which RQI interview scales correlated with existing measures
-- self-report questionnaires and behavioral observations -- of these same relationship
dimensions. We expected correlations between RQI scales and self-report questionnaires, and
between RQI scales and behaviorally observed data, to generally be low for two reasons.
 Assessing Relationship Quality 181

First, our assertion is that the RQI interview provides a more valid measure of relationship
quality in each of the assessed domains. Thus we did not operationalize our constructs in the
same way as they were operationalized in the existing measures. Second, the RQI is the first
interview of relationship quality. Therefore, we cannot examine convergent validity of the
RQI by comparing it to an existing interview. Instead we are comparing RQI scales to
measures of similar constructs assessed with different methods. This method variance is
expected to generate lower correlations than if our method was the same but our constructs
differed.
First we examined the correlations between the RQI subscales and self-report measures
of relationship quality in the relevant domains. Self-report measures included: (a) the Problem
Solving Communication (PSC) and Affective Communication (AFC) subscales from The
Marital Satisfaction Inventory-Revised (MSI-R; Snyder & Aikman, 1999) to measure
negative communication and conflict management patterns, and (b) a modified version of The
Support in Intimate Relationships Rating Scale (SIRRS; Dehle et al., 2001) to assess
perceptions of support amount from one’s partner and support adequacy (see Barry et al., in
press for details and psychometric properties of the revised SIRRS). The RQI scales were
weakly to moderately correlated with the self-report questionnaires. Correlations ranged from
.24 to .56 in the marital sample, and from .03 to .23 in the dating sample.
Next we examined the correlations between the RQI subscales and behavioral
observations of relationship quality in the relevant domains. (Behavioral observation data
were only available in the marital sample.) Behavioral observation indices of relationship
quality included: (a) an inter-partner support interaction task and the Social Support
Interaction Coding System (SSICS; Pasch, Harris, Sullivan, & Bradbury, 2002), a system that
assesses the behaviors exchanged by partners during a supportive discussion, and (b) a
problem-solving interaction task and the Specific Affect Coding System – Revised (SPAFF-
R; Gottman McCoy, & Coan, 1996), designed to measure positive and negative affect
expressed during a problem-solving discussion. Correlations between RQI scales and
behavioral observations of related constructs were weak, ranging from .05 to .25, supporting
our contention that the RQI captures markedly distinct constructs from what is captured via
behavioral observation interaction tasks.

Discriminant Validity

Three aspects of discriminant validity were considered. First, Campbell and Fiske (1959)
stated that a good convergent/discriminant validity pattern exists when matched variables
correlate more highly with each other than with any other variable. Thus we examined
whether the inter-correlations among RQI scales were higher than the correlations between
RQI scales and measures of similar constructs collected via different methods. In general, this
target pattern was clearly obtained for all five RQI scales in both samples. For each RQI
scale, the correlations with other RQI scales (convergent validity) were generally larger than
correlations with questionnaire or behavioral observation data. This support was evident for
husbands and wives, and across marital and dating participants. Three of the four RQI Scales
– Emotional Closeness and Intimacy, Inter-Partner Support, and Respect, Power, and Control
– clearly met the Campbell and Fiske test for excellent convergent and discriminant validity.
In contrast, there was mixed but generally strong evidence regarding the RQI Communication
182 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

and Conflict Management Scale. The scale did not meet Campbell and Fiske’s criteria when
compared to self-report questionnaires in the dating sample, nor when compared to behavioral
observation data in the marital sample. Moreover, the RQI Communication and Conflict
Management Scale was only moderately correlated with the corresponding self-report
questionnaires. However, this moderate correlation was similar to the moderate correlations
between the RQI Communication and Conflict Management scale and the other RQI scales
(which range from .40 to .63); thus, it does meet the Campbell and Fiske criteria in that
regard.
Second, we examined associations between RQI scales and a measure of global
relationship satisfaction (Quality of Marriage Index; Norton, 1983) to determine whether the
RQI simply captures satisfaction rather than relationship quality across multiple domains.
Correlations were low to moderate for husbands and wives (rs ranged from .35 to .46) and
low for dating participants (rs ranged from .002 to .22), supporting our contention that the
RQI is not simply a measure of global relationship satisfaction.
Third, the associations between the RQI scales and related traits were examined to
determine whether RQI scores discriminated between (a) functioning within one’s
relationship on a given dimension and (b) individual differences in interpersonal functioning
across relationships. For example, we compared the Emotional Closeness and Intimacy scale
to measures of global detachment, mistrust, and avoidant attachment. We measured individual
differences by administering: (a) the Negative Temperament, Detachment, Mistrust, and
Manipulativeness scales from The Schedule for Nonadaptive and Adaptive Personality - 2nd
Edition (SNAP-2; Clark, Simms, Wu, & Casillas, in press); (b) the Anger and Hostility Scales
from The Buss-Perry Aggression Questionnaire (Buss & Perry, 1992); and the Relationship
Scales Questionnaire (RSQ; Griffin & Bartholomew, 1994) and the Experiences in Close
Relationships – Revised scale (ECR-R; Fraley, Waller, & Brennan, 2000). Correlations
between RQI subscales and individual difference measures of related constructs (e.g.,
avoidant attachment, mistrust, detachment, negative temperament, hostility) were weak,
ranging from .004 to .3 (with one exception at .5), supporting our contention that the RQI
scales capture constructs that are unique to one’s current intimate relationship rather than
being indicative of individual differences that might be present across multiple types of
relationships (e.g., friends, acquaintances, co-workers).

Incremental Validity Analyses

Finally, we gathered preliminary evidence for the utility of the RQI to assess risk of
relationship distress over and above existing self-report measures and behavioral observation
methods. In addition to our assertions that (a) a clinical interview will be more user-friendly
for clinicians, and (b) our interview provides a better measure of the constructs of interest
(compared to existing self-report questionnaires and behavioral observational data), we also
expected the RQI scales to predict global relationship satisfaction over and above these
existing measures. We examined the incremental utility of each RQI scale when predicting
cross-sectional and longitudinal (three-year) satisfaction for men and women.
First we examined the incremental utility of the RQI in explaining cross-sectional
relationship satisfaction. In the marital sample, three of the four RQI scales – Emotional
Closeness and Intimacy, Inter-partner Support, and Respect, Power, and Control –
 Assessing Relationship Quality 183

demonstrated incremental explanatory power (bs > 1.44, ps < .05). In the dating sample, two
scales -- Emotional Closeness and Intimacy, and Communication and Conflict Management --
demonstrated incremental predictive power (bs > .25, ps < .05). Next we examined the RQI’s
incremental utility in predicting longitudinal (3-year) relationship satisfaction in the marital
sample. Two of the four RQI scales – Emotional Closeness and Intimacy and Respect, Power,
and Control – demonstrated incremental utility in predicting husbands’ – but not wives’ –
longitudinal marital satisfaction (bs > 2.46, ps < .05).

SECTION 4: CLINICAL IMPLICATIONS OF THE RQI FOR COUPLE

ASSESSMENT AND PREVENTION EFFORTS
In this section we discuss clinical implications at two levels. First, we discuss the
generalizability of the RQI itself based on the data presented in Section 3. Second, we discuss
the broader clinical implications of the RQI for improving couple assessment and prevention
efforts.

Generalizability of the RQI

We examined the generalizability of the RQI in two ways. First we examined its
generalizability across men and women. The RQI yielded strong psychometric data for men
and women. Second, we found that the RQI demonstrated reliability, validity, and incremental
utility across dating and marital relationships. As the proportion of couples who cohabit
and/or date for many years prior to marriage increases, greater attention is being given to the
study of pre-marital relationships (e.g., Brown & Booth, 1996; Stanley, Rhoades, &
Markman, 2006). Additionally, it has been suggested that patterns that develop early in
relationships (i.e., even before marriage) are important for individual and dyadic outcomes
(Cutrona et al., 2005). Thus, patterns of relationship quality that emerge during courtship
likely impact individual and relationship functioning. Despite this potential importance, little
work has addressed whether relationship quality functions similarly in dating and marital
relationships. As expected, the pattern of findings was stronger in the analyses of the marital
sample compared to the dating sample. The longer duration and stronger commitment of the
married participants would presumably lead to greater utility of the RQI in such a sample.
The next step is to examine the psychometric properties of the RQI in distressed samples of
couples, such as in a sample of couples seeking therapy. We would expect the pattern of
results to be similar, if not stronger, to those found in the marital sample. More generally, as
the intimate relationship becomes more solidified and more central to one’s life, we would
expect the RQI to have greater utility and for the interview to demonstrate stronger
convergent and divergent validity when administered.
There are several ways in which the generalizability of the RQI can be expanded in future
research. First, although the RQI was developed as an assessment tool for young couples and
to be administered in accord with prevention programs, it seems just as likely that it could be
used as part of a standardized assessment protocol for treatment-seeking and/or distressed
couples and to guide treatment for those couples. Before we can recommend that the RQI be
184 Erika Lawrence, Robin A. Barry, Rebecca L. Brock et al.

used in this way, we must first assess the reliability and validity of the RQI in distressed,
established, and/or treatment-seeking couples. Second, the reliability and validity of the RQI
should be examined with same-sex couples and couples at other stages of their relationships
(e.g., cohabiting couples, engaged couples, couples experiencing the transition to
parenthood). Finally, other dimensions of relationship quality might be worth incorporating
more fully into the RQI, such as fun and leisure time and quality of the couple’s friendship.

Implications for Couple Assessment and Prevention Efforts

There are several implications of the RQI for couple assessment and intervention efforts.
First, the RQI is intended to be used as part of a standardized assessment battery for couple
interventions. For example, it can be administered to couples and then incorporated into a
feedback session in which relationship strengths/protective factors and relationship risk
factors/vulnerabilities are emphasized. By quantifying relative strengths and weaknesses
across multiple dimensions of a relationship, feedback may be more palatable to couples.
Second, the RQI might function as a motivational tool to increase couples’ participation
in prevention programs or treatments. Cordova and colleagues (Cordova et al., 2005; Gee,
Scott, Castellani, & Cordova, 2002) developed an indicated intervention program called the
Marriage Checkup based on the principles of motivational interviewing. As they describe,
prior to dissolution, it is likely that couples that become severely distressed first pass through
an at-risk stage in which they experience early symptoms of marital deterioration but have not
yet suffered irreversible damage to their marriage. It is during this at risk stage that couples
might benefit most from early intervention. To date, they have found evidence for the
attractiveness, tolerability, efficacy, and mechanisms of change produced by the Marriage
Checkup, as well as its ability to predict marital satisfaction two years later. In line with this
important work, it is possible that the RQI could be modified and tested as a motivational
interview for at risk couples as well.
Third, because the RQI can be used to identify domains of strength and weakness in
couples’ relationships, it might be useful as a tool to identify at risk couples for prevention
programs. To date, studies of leading preventive interventions have not fared well at
recruiting couples at risk for adverse marital outcomes. Published samples have been
disproportionately Caucasian, well educated, and middle class (see Carroll & Doherty, 2003,
for a review). However, divorce rates are markedly higher among African American couples
(70% vs. 47% in Caucasian couples), among couples who do not finish high school (60% vs.
36% for college graduates), and among couples who start marriage with children (rates of
divorce are twice as high as couples who marry without children; Raley & Bumpass, 2003).
Despite their omission from prevention programs, couples in these high-risk populations
report high levels of interest in participating in these interventions (Johnson et al., 2002). In
sum, relationship enhancing interventions appear to have failed to test their programs in the
populations at greatest risk for distress and divorce. Administering the RQI prior to
implementing a prevention program might allow at risk couples to be identified, while
simultaneously being used as a motivational tool to encourage these at risk couples to
participate in these prevention interventions.
Fourth, intervention programs can be better tailored to the needs of specific couples,
rather than implementing a “one size fits all” approach. For example, a couple’s RQI data
 Assessing Relationship Quality 185

may indicate strong quality of communication and conflict management skills but poor
quality of inter-partner support. In this case, intervention techniques specific to improving the
quality of support in that relationship would presumably be more appropriate, whereas
intervention techniques targeting conflict management skills would be unnecessary. This
approach seems more beneficial for treating couples and more cost-effective from a health
care perspective.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 9

THE TENDENCY TO FORGIVE IN PREMARITAL

COUPLES: RECIPROCATING THE PARTNER OR
REPRODUCING PARENTAL DISPOSITIONS?

F. Giorgia Paleari
University of Bergamo, Italy
Silvia Donato, Raffaella Iafrate and Camillo Regalia
Catholic University of Milan, Italy

ABSTRACT
Although the tendency to forgive the partner has been shown to enhance personal
and relational well-being, little is known about how this tendency originates. One
possibility is that the tendency to forgive the partner develops as a function of the
forgiveness exchanges people experience within their romantic relationships, thereby
leading them to become more and more similar to the partner in their proneness to
forgive. Another possible explanation is that social experiences people were exposed to
within their own family of origin has led them to gradually internalize parental models
and to become more and more similar to their parents in their willingness to forgive.
These associations may be particularly evident during emerging adulthood, when
engaged couples have to balance their family heritage and the forming of their new
couple.
The present work aimed at providing initial evidence in support of these hypotheses
by investigating in a sample of premarital couples (N=165) and their parents the extent to
which young adults’ tendency to forgive the partner was similar to the partner’s tendency
to forgive them as well as to their mothers’ and fathers’ tendency to forgive one another.
Dyads were the units of analysis and stereotype accuracy was controlled. Results indicate
that young adults’ disposition to forgive the partner is similar to that of their partner and
of their parents. Gender moderated these associations, as females were more similar to
their parents than were males in their disposition to forgive.
The findings are consistent with the idea that premarital couples, even though
strongly involved in defining their own couple identity, are nonetheless affected by the
forgiveness models to which they are exposed within their family of origin.
192 F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate et al.

INTRODUCTION
Within the literature on close relationships, a body of evidence attests that forgiving a
romantic partner has potential benefits for the well-being of the relationship and of the victim.
In particular, there is evidence that in community couples forgiving the partner reduces
psychological aggression, enhances intimacy and commitment in the relationship, promotes
constructive communication, and has a positive influence on marital quality over time (Eaton
& Struthers, 2006; Fincham & Beach, 2002, 2007; Paleari, Regalia & Fincham, 2005; Tsang,
McCullough, & Fincham, 2006). Forgiveness toward the partner has also proven to enhance
the victim’s overall mental and physical health (Berry & Worthington, 2001; Karremans, Van
Lange, Ouwerkerk, & Kluwer, 2003; see also, Bono, McCullough, & Root, 2008), thereby
helping the individual to maintain and restore a valuable close relationship, crucial to the
victim’s human need of connectedness.
Considering the great amount of attention that has been devoted to partner forgiveness as
a predictor of relational and personal well-being, surprisingly little is known about how the
tendency to forgive the partner originates. The purpose of the present research is to fill this
gap in the literature, focusing particularly on the degree to which the tendency to forgive
emerges from an individual’s relationship with an intimate partner and from his or her
experiences in the family of origin.
The tendency to forgive the partner can be defined as a general propensity to overcome
avoidant, resentful or revengeful reactions (i.e., thoughts, feelings, intentions, and behaviors),
and to develop benevolent and conciliatory ones, when facing the partner’s offences (e.g.,
Fincham, Hall, & Beach, 2005; Rye, Loiacono, Folck, Olszewski, Heim, & Madia, 2001;
McCullough, Pargament, & Thoresen, 2000). Empirical support for this notion has been
found by studies showing that the tendency to forgive the partner entails two correlated
dimensions, a positive one, reflecting benevolent and conciliatory dispositions, and a negative
one, involving resentful, vengeful, and/or avoidant inclinations (Fincham & Beach, 2002).
Evidence of one single factor underlying the two dimensions has also recently been found
(Maio, Thomas, Fincham, & Carnelley, 2008). The tendency to forgive the partner is more
general than specific acts of forgiveness as it is assumed to be stable across multiple offences
occurring within a romantic relationship. At the same time the tendency to forgive the partner
is more specific than “forgivingness” (Berry, Worthington, Parrott, O’Connor, & Wade,
2001). Forgivingness is understood as the global disposition to forgive across multiple
offences occurring in a variety of relationships and interpersonal situations, thus serving as a
basis for more specific responses of forgiveness (Roberts, 1995), whereas the tendency to
forgive the partner is linked more tightly to the particular history with the romantic partner
(see also McCullough & Witvliet, 2002; Kachadourian, Fincham, & Davila, 2004).
The tendency to forgive the partner and “forgivingness” have been shown to be related to
personality dimensions such as trait empathy, emotional stability and agreeableness
(McCullough & Witvliet, 2002; Mullet, Neto, & Rivière, 2005; Maio et al., 2008) which are
known to be influenced by genetic factors (Tsuang, Eaves, Nir, Jerskey, & Lyons, 2005; Flint,
2004). This finding is sometimes used to support the argument that the tendency to forgive
may have a biological root, which explains its relative stability across situations.
Despite these possible genetic influences, the tendency to forgive the partner is likely to
be affected by relationships experienced within one’s social network. In particular we
 The Tendency to Forgive in Premarital Couples 193

maintain that two types of social experiences will be linked to one’s tendency to forgive the
partner, namely those shared with the partner himself/herself and those shared within one’s
own family of origin. This association may be particularly evident during “emerging
adulthood” (Arnett, 2000), a distinct developmental period corresponding to the third decade
of life (i.e., ages 20 to 30). During this period dating relationships are generally transformed
into more serious romantic relationships (Furman, 2002) and engaged couples, more then ever
before, have to acknowledge and balance the different heritage partners received from their
families and the forming of their new couple (Cigoli & Scabini, 2006).
A first possibility is that the tendency to forgive the partner emerges from partners’
shared experiences with one another, and especially from their forgiveness transactions, with
each partner sometimes in the role of offender and other times in the role of victim (Hoyt et
al., 2005). The norm of reciprocity suggests that the partner’s typical forgiving or unforgiving
responses to one’s own relational transgressions are likely to be important determinants of
one’s propensity to forgive future partner offences. Studies on negative reciprocity (e.g.,
Capaldi, Kim, & Shott, 2007; Cordova, Jacobson, Gottman, Rushe, & Cox, 1993)
demonstrate that this norm may be particularly strong in couple relationships. In other words,
given that partners’ interdependence is the defining feature of close relationships (Kelley et
al., 1983), one’s willingness to forgive the partner is likely to be progressively modulated as a
function of the disposition to forgive that the partner shows in the context of ongoing
interactions. In this regard, a study by Hoyt and colleagues (2005) found tentative evidence
indicating that the propensity to forgive the partner tends to be reciprocated in long term
married couples. This evidence suggests that over time an individual’s proneness to forgive
the partner may become similar to the partner’s.
Another possible explanation for the development of the tendency to forgive the partner
involves social experiences within one’s own family of origin. The disposition to forgive the
partner may be transmitted across generations not only because of its potential heritable
component, but also because of the parents’ role in socialization, a process that clearly
continues throughout emerging adulthood (Arnett, 2007). According to Grusec (2002),
parental socialization involves three specific goals - a) the development of self-regulation of
emotion, thinking, and behavior¸ b) the acquisition of a culture’s standards, attitudes, and
values, and c) the development of role-taking skills, strategies for resolving conflicts, and
ways of viewing relationships - all of which are closely linked to forgiveness. Forgiveness has
been judged of critical importance in strengthening self-regulatory processes through
empowering powerless victims (e.g., Ahmed & Braithwaite, 2006) and has been repeatedly
conceptualized and empirically examined as a crucial strategy to effectively cope with
interpersonal and intergroup conflicts and to restore social relationships (e.g., Fincham,
Beach, & Davila, 2004; Hoyt et al., 2005; Roe, 2007). Furthermore, given the high moral
value that many religions place on it, forgiveness is viewed as a moral virtue and as a human
strength across many cultures (e.g., Friesen & Fletcher, 2007; Rye et al., 2000). Thus, for a
variety of reasons, parents may include forgiveness in their socialization practices.
The transmission of values and behavioral patterns across generations has often been
described in terms of internalization, a process whereby parental and societal values and
behaviors are gradually integrated into the child’s self system, resulting in intergenerational
similarity. As reviewed by Zentner and Renaud (2007), internalization concepts can be found
within different theoretical approaches such as symbolic interactionism (Cooley, 1902; Mead,
1934), psychoanalysis (Freud, 1923/1961; Sandler & Rosenblatt, 1962; Meissner, 1981), and
194 F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate et al.

social learning (Aronfreed, 1968; Bandura, 1971). Even though parent-child similarity (or
congruence) does not necessarily imply internalization, in the traditional sense of accurately
perceiving parents’ positions and behaviors and integrating them into a coherent sense of self
(Grusec & Goodnow, 1994; Zentner & Renaud, 2007), verifying the existence of such a
similarity is undoubtedly the first step to examine whether internalization actually occurs
across generations.
Extant research provides evidence that parents and children are similar across a wide
range of domains, including attitudes (e.g., Cashmore & Goodnow, 1985), values (e.g., Knafo
& Schwartz, in press), ideal selves (Zentner & Renaud, 2007), perfectionism (Soenens et al.,
2005) and empathy (Soenens, Duriez, Vansteenkiste, & Goossens, 2007). Research based on
married offspring also indicates that parent and children are similar in the risk of marital
instability (Amato & DeBoer, 2001), in their level of marital conflict, intimacy and
individuation (Harvey, Curry, & Bray, 1991; Story, Karney, Lawrence & Bradbury, 2004).
To our knowledge, only two studies provide data relevant to the hypothesis that the
tendency to forgive is transmitted across generations. These studies, by Mullet and
colleagues, show that parents and their adult children tend to be similar both in the
conceptualization of forgiveness (Mullet, Girard, & Bakshi, 2004) and in the tendency to
grant it (Mullet, Rivière, & Munoz Sastre, 2006). In particular, by distinguishing between
different dimensions underlying “forgivingness,” Mullet and colleagues found that mother’s
tendency to be resentful as well as fathers’ tendency to avenge or to grant forgiveness
depending on contingent circumstances were linked to their children’s corresponding
dispositions.
Our main goal in the present study was to provide further evidence on forgiveness
similarity across generations and across partners, by investigating the extent to which
premarital engaged adult children’s tendency to forgive the partner was congruent a) with
their parents’ tendency to forgive one another, thereby suggesting a possible internalization
process by the children, and b) with their romantic partners’ tendency to forgive them,
thereby indicating reciprocity within the premarital couple. We focused on adult children
prior to marriage because, as previously observed, they were living a life transition during
which they have to balance their family heritage and the forming of their new couple. A
significant degree of similarity in the tendency to forgive the partner was expected both
across offspring and their parents and across partners. In fact, although premarital partners are
still influenced by the culture they inherited from their family of origin, during this period
they are deeply involved in defining their couple identity as a separate entity from their
familial belonging (Aquilino, 1997; Crespi & Sabatelli, 1997; Cigoli & Scabini, 2006). Along
with these considerations, in this particular phase of the family life cycle, we can hypothesise
a greater similarity to the partner’s tendency to forgive than to the parents’ ones.
A secondary goal was to verify whether intergenerational similarity in the tendency to
forgive the partner was moderated by child and parent gender, and by children’s perception of
parents as positive models for their lives. A substantial literature suggests that child and
parent gender may affect the degree of intergenerational similarity. Compared to males,
females tend to develop values, aspirations, behaviors and relationship outcomes more similar
to their parents’ ones (e.g., Caspi & Elder, 1998; Zentner & Renaud, 2007), probably because
they spend more time in close proximity to their family than males do and are more accurate
perceivers of parental positions, owing to their higher ability in adopting others’ points of
view (e.g., Cotterell, 1993; Eisenberg, Carlo, Murphy, & van Court, 1995; Eisenberg, Miller,
 The Tendency to Forgive in Premarital Couples 195

Shell, McNalley, & Shea, 1991). Moreover, children are more likely to be similar to their
mothers than to their fathers, because mothers, by virtue of spending more time with children
and having more intimate relationships with them, tend to have more opportunities to share
with them their ideals, attitudes and feelings (e.g., Harach & Kuczynski, 2005). Consistent
with these gender patterns, we assumed that the parent-child similarity would be higher for
female children than for male ones and for mothers than for fathers. Furthermore, there are
reasons to suppose that intergenerational similarity would increase the extent to which
children hold a positive view of parents and of what they have transmitted to them. For
example, research on racial attitudes demonstrated that racial attitudes parents are willing to
express influence their children’s implicit prejudice, depending on children’s level of
identification with their parents (Sinclair, Dunn, & Lowery, 2005). Similarly, maternal
gender-role beliefs and attitudes are stronger predictors of daughters’ beliefs and attitudes
when daughters identify with their mothers (Steele & Barling, 1996).
To address the above questions we decided to adopt a dyad-centered or idiographic
approach when evaluating similarity (see Luo & Klohnen, 2005; Kenny, Kashy, & Cook,
2006). Much research on partners and parent-child similarity has taken a variable-centered or
nomothetic approach, focusing on variables as the unit of analysis. This approach assesses
similarity by computing a correlation between the members of a dyad’s scores on the same
domain across all dyads in a particular sample (e.g., between mothers’ and children’s scores
on the tendency to forgive across all mother-child dyads). This correlation reflects the degree
to which members of a dyad tend to be similar in a given sample, but it does not tell us the
extent to which any specific dyad is similar or not. Conversely, the dyad-centered approach
computes a profile similarity index for every dyad in the sample by correlating each member
of a dyad’s scores across all items on a given domain. Thus, the profile similarity index is a
characteristic of each dyad, not of the whole sample. Adopting the dyad-centered approach
allowed us to treat the profile similarity index as a variable in itself, for example to examine
whether it differs across child gender or types of dyads considered (i.e., mother-child, father-
child, and partner-child) or whether it is related to other variables (e.g., children’s perception
of parents as models). More importantly, adopting the dyad-centered approach allowed us to
control for the so-called stereotype accuracy 1. Members of a dyad might appear to be similar
in their tendency to forgive the partner not only because they are really similar to each other
but also because they respond stereotypically, matching the profile of responses of other
people in the same cultural group (e.g., Cronbach, 1955; Kenny & Acitelly, 1994). In other
words, because both members of a dyad are part of a larger group, in which some responses
to forgiveness issues are more typical or normative than others, as a result of shared cultural
values, social desirability, and social biases (e.g., Klohnen & Mendelsohn, 1998), their
responses are expected to be similar not only because of their own relationship but also
because of this stereotype effect. For example, given that forgiveness is an highly desirable
value for the Catholic church, which is strongly rooted within the Italian society, people who
give stereotypic responses may tend to say that they are forgiving in their relationship.
According to Kenny and colleagues (Kenny et al., 2006; Kenny & Acitelli, 1994), stereotype
accuracy needs to be removed to uncover the degree of unique similarity between the dyad
members. As Kenny and colleagues pointed out, however, both stereotype accuracy and

1
This concept has been referred to also as “stereotype” (Cronbach, 1955; and Kenrick and Funder,1988) and as
“stereotype effect” (Kenny and Acitelly,1994).
196 F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate et al.

uniqueness are sources of dyadic similarity, though they refer to two different aspects of it.
As for the purpose of our study, the absence of a unique similarity might not mean the
absence of reciprocation or internalization, but a different mechanism through which these
processes may take place, namely through partners’ socialization of the broader forgiveness
culture in which their relationships are embedded. Moreover, because fathers, mothers and
children may hold different views about forgiveness-related issues, we can expect different
stereotype effects for these three different groups (Kenny & Acitelli, 1994). Relying upon
these considerations, we also verified whether forgiveness responses in the present sample
were affected by one single or by multiple stereotype effects and whether controlling for them
substantially altered any of the findings related to similarity. With this respect, we expected
that, when controlling for stereotype accuracy, the level of similarity across partners and
across generations would be still significant, but substantially reduced. On the one hand, we
had theoretical reasons to expect that across partners and generations the similarity in the
tendency to forgive would not be simply an artefact of stereotype accuracy. On the other
hand, previous evidence suggests that controlling for stereotype effects could substantially
reduce the level of similarity (see for example Deal, Halverson, & Wampler, 1999). Owing to
the lack of literature on the issue, we were not able to predict whether the strength of this
expected reduction in similarity would be different in mother-child, father-child, and partner-
child dyads nor whether and how controlling for stereotype accuracy would alter any of the
postulated moderating effects of parent/child gender and of child’s perceptions of parents
upon similarity.
In sum, our review of the existing literature has led us to investigate the following
hypotheses.

Hypothesis 1: There is a significant similarity in the tendency to forgive the partner

between engaged young adult partners and between these partners and
their parents. This similarity remains significant, even though reduced,
when controlling for stereotype accuracy.
Hypothesis 2: Similarity between engaged partners is higher than similarity between
partners and their parents.
Hypothesis 3: Mother-child similarity is higher than father-child similarity.
Hypothesis 4: Parent-daughter similarity is higher than parent-son similarity.
Hypothesis 5: Parent-child similarity is positively related to children’s views of parents
as models for their life. Specifically, children are more similar to their
parents in the tendency to forgive the partner when they perceive parents
as positive models for their lives.

We also examined whether forgiveness responses were affected by one single or by

multiple stereotype effects and whether corrections for it/them would affect the different
types of similarity or would change any of the moderating effects described from hypothesis 2
to hypothesis 5.
 The Tendency to Forgive in Premarital Couples 197

METHOD

Participants

One hundred and sixty-five premarital heterosexual couples and their parents living in the
North of Italy participated in the study. Specifically in 135 couples both of the woman’s
parents completed their questionnaires (overall 540 participants); in 106 couples both of the
man’s parents completed their questionnaires (overall 424 participants) and in 76 couples
both parental couples filled in the materials.
Among the engaged partners, the average duration of the relationship was 6 years (SD =
3.6). Women’s mean age was 29 (SD = 3.7) and men’s age was 31 (SD = 4.3). Thirty-four
percent of the couples were cohabiting; among non-cohabiting partners 60.5% of women and
54.9% of men were living with their parents. The form of household was not significantly
related to any of the investigated variables. Although a few offspring ended their formal
education with elementary school (6.7% of the women, 15.3% of the men), most reached a
terminal high school degree (49.1% women, 60.2% of the men) or a college or university
degree (44.2% women, 24.5% men). As for household income, 21% of women and 13.5% of
men earned below 1.500 € per month, 61% of women and 64% of men earned between 1.500
and 3.000 €, 13.5% of women and 19% of men earned between 3.000 € and 5.000 €, 4.5% of
women and 3.5% of men earned over 5.000 €.
Among the parents, the average duration of the marriage was 33.3 years (SD = 5.2).
Mothers’ mean age was 57 (SD = 6.7) and fathers’ mean age was 60 (SD = 6.8). Parents’
number of children ranged from 1 to 7 (M = 2, SD = 0.8). Twenty-seven point seven percent
of mothers and 25.4% of fathers reached up to elementary school, 65.7% of mothers and
68.2% of fathers reached up to high school degree, and 4.6% of mothers and 6.4% of fathers
reached college or university degree. As for household income, 26.5% of parents earned
below 1.500 € per month, 55.3% of parents earned between 1.500 and 3.000 €, 15.7% of
parents earned between 3.000 € and 5.000 €, and 2.5% of parents earned over 5.000 €.
More than the 95% of subjects defined themselves as affiliated with the Catholic Church.
However, their degree of religiousness was modestly related to their tendency to forgive
(r<|.32|).

Procedure

Engaged couples were recruited through advertising in premarital courses. Partners were
asked to involve their parents in the study whenever possible. Couples were given a packet of
questionnaires that included six separate and distinct versions (one for each partner in the
premarital couple and one for each partner in their parents’ couples), together with
instructions to complete the questionnaires independently.
Subjects were not paid for their completion of questionnaires, as it is not usual in Italy to
pay participants when taking part in this kind of research.
Engaged couples were included in the present study (67% of the overall couples we got
in contact with) when at least one partner returned both his/her parents’ questionnaires .
198 F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate et al.

Measures

In addition to providing demographic information, all participants completed measures

assessing their tendency to forgive the partner. Children also filled in items evaluating their
parents’ educational role.

Tendency to Forgive the Partner

The tendency to forgive the partner when hurt or wronged by him/her was assessed using
a modified version of the Marital Offence-Specific Forgiveness Scale (MOFS; Paleari,
Regalia, & Fincham, submitted). The MOFS is a 10-item psychometrically robust measure
assessing forgiveness toward the partner for a specific offence. In order to make the scale
consistent with our goal of assessing dispositional forgiveness items were modified so that
they referred to relationship transgressions in general rather than to a single transgression (for
example, “Since my partner behaved this way, I have been less willing to talk to her/him”
became “When my partner hurts me, I am less willing to talk to her/him for quite a while”
and “Although she/he hurt me, I definitely put what happened aside so that we could resume
our relationship” became “When my partner hurts me, I quickly put it aside so that we can
resume our relationship”). Items were rated on a 6-point Likert-type scale (1= never,
6=always). Four items reflected the tendency to be benevolent and conciliatory toward the
partner, four items referred to the tendency to be resentful and to avenge, and the final two
items reflect the tendency to avoid the partner. An exploratory factor analysis on these items
(factor extraction method: Principal Factors Analysis; rotation method: Direct Oblimin)
identified two factors: Unforgiveness, defined by avoidant and resentful items, and
Benevolence. All the items had factor loadings greater than |.30|. Unforgiveness explained
more than 25% of variance in children’s, mothers’ and fathers’ data, while Benevolence
explained more than 20% of variance in children’s, mothers’ and fathers’ data. The
correlations between the two subscales ranged from -.38 to -.60. The existence of two
correlated dimensions of forgiveness is in line with previous studies on the tendency to
forgive the partner as well as on offence-specific and trait forgiveness (Fincham & Beach,
2002; Mullet et al., 2006; Paleari et al., 2005). Both factors were satisfactory reliable in
children, mothers and fathers (alpha ≥. 80 and .78 for Unforgiveness and Benevolence,
respectively).

Parents as Models
Children’s perceptions of each parent as a positive model for their lives was evaluated
using two items: “Do you think your mother/father has conveyed positive things to you?” and
“Do you think your mother/father has been a positive model for your life?”). Respondents
expressed their opinions on each of the two items using a 4-point scale (1= not at all, 2=a
little, 3=somewhat, 4=very much). The two items were averaged into a “Mother/Father as a
model” index (alpha ≥.66 for mothers and .68 for fathers).
 The Tendency to Forgive in Premarital Couples 199

RESULTS

Data Analytic Strategy

All analyses were conducted separately on the 135 couples in which both of the woman’s
parents completed their questionnaires and on the 106 couples in which both of the man’s
parents completed their questionnaires, with the exception of the analysis verifying the child
gender moderation hypothesis. In this case the analyses were performed on the 76 couples in
which both the woman’s and the man’s parents returned complete questionnaires.

Mean Differences on Forgiveness Dimensions

Prior to hypothesis testing, we assessed whether Benevolence and Unforgiveness means

differed across different roles (young adult child, mother, father, and partner) using the
general linear model (GLM) general factorial procedure with repeated measures (see Table1).
Generally participants expressed a high proneness to be benevolent and not avoidant nor
resentful toward their partners. This could be a consequence of the great value granted to
forgiveness by Catholic tradition, deeply embedded in the Italian society. Replicating
previous studies on Italian samples (e.g., Fincham et al., 2002), on average mothers were less
benevolent than fathers and than engaged men, both when they were their sons or their
daughter’s partners. Engaged men’s mothers were also more unforgiving than their husbands,
their sons, and their son’s partners.
Engaged women’s partners were less unforgiving than women themselves and both
women’s parents.

Table 1. Means, Standard Deviations, and Role Differences for Major Study Variables

Benevolence Unforgiveness
M (SD) M (SD)
Engaged Women 4.51ab (1.02) 2.59b (.84)
their Partner 4.73a (1.03) 2.34a (.85)
their Mother 4.28b (1.11) 2.85b (1.00)
their Father 4.62a (1.09) 2.63b (.99)
GLM F(3,402) =5.54, p = .001 F(3,402) =9.07, p = .000
Engaged Men 4.81a (1.06) 2.37b (.87)
their Partner 4.46b (1.06) 2.53b (.85)
their Mother 4.41b (1.12) 2.97a (1.01)
their Father 4.66a (1.06) 2.60b (.97)
GLM F(3,315) =3.44, p = .017 F(3.315) =3.44, p = .017
Note: N=135 for women’s sample and 106 for men’s one.
200 F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate et al.

Profile Similarity Indexes and Stereotype Adjustment

We computed profile similarity indexes via intraclass correlations for each dyad type
(child-mother, child-father, and child-partner). Intraclass correlations evaluate the size of
similarity between the two members of a dyad by taking into account both the overall mean
(level), the variability (spread) and the pattern of differences, or ups and down (shape), of the
two members’ responses across forgiveness items. This is meaningful because level, spread,
and shape are the three crucial factors influencing the degree of the similarity 2 (Kenny, et al.,
2006). Intraclass correlations can range from being highly positive, indicating similarity, to
being close to zero, indicating neither similarity nor dissimilarity, to being negative,
indicating opposites.
After computing the profile similarity indexes, we adjusted intraclass correlations for the
stereotype effect, following Kenny and Acitelli (1994). We first computed different
stereotypes for engaged women, engaged men, mothers and fathers in order to take into
account gender and generation differences. These stereotypes were operationalized by the
mean response across subjects for each item. Specifically, we computed the mean across
engaged women for each forgiveness item and the mean across engaged men for each
forgiveness item; we performed the same procedure for mothers and fathers as well. Because
engaged women’s, engaged men’s, mothers’ and fathers’ means were highly correlated (r ≥
.92) indicating a considerable overlap in genders’ and generations’ stereotypes about
forgiveness, we finally used a single general stereotype and adjusted intraclass correlations
for the overall sample mean. To control for this stereotype effect, we simply subtracted from
the individual’s score on each item the sample mean for that item before computing the
dyadic indexes3.
To verify whether the average level of unadjusted as well as adjusted similarity was
above chance (Hypothesis 1), we computed for both forgiveness dimensions a one sample t-
test on Fisher r-to-z transformed intraclass correlations4 (see Table 2).
As far as unadjusted scores are concerned, engaged women were significantly similar to
their partners and to their parents in both benevolence and unforgiveness. Engaged men were
similar to their partners in benevolence and unforgiveness and were similar to their fathers in
unforgiveness only.
It is noteworthy that mean levels of similarity were generally modest but were still
significant even after controlling for the stereotype effect, with the exception of woman-
mother similarity in unforgiveness.

2
To see how level, spread, and shape matter in determining similarity, consider the following examples in which,
for simplicity, partner A’s responses are always 2, 3, 5, 5, 3, 2. If partner B’s set of responses is 3, 4, 6, 6, 4, 3,
they are similar in both shape and spread but not in level. If partner B’s responses are 5, 3, 2, 2, 3, 5, partners
are similar in level and spread but not in shape. If partner B’s set is 1, 3, 6, 6, 3, 1, partners are similar in shape
and level but not in spread.
3
The essence of Kenny and Acitelli’s (1994) correction procedure is to remove typical responding from measures
of couple similarity (Acitelli, Kenny & Weiner, 2001). Thus, for example, within the child-partner dyad,
adjusted Benevolence similarity refers to the unique similarity in a benevolent attitude toward the partner
between that person and their own partner, and not the similarity between that person and a general other.
4
Intraclass correlation scores were standardized with the following formula: z = ln[|(r+1)/(r-1)|]/2 (Rosenthal,
1991).
 The Tendency to Forgive in Premarital Couples 201

Table 2. Stereotype adjusted and non-adjusted mean similarities compared with a zero
value and with each other

Similarity in t-test Similarity in t-test

Benevolence Unadj vs Unforgiveness Unadj vs
Unadjusted Stereotype Adj Unadjusted Stereotype Adj
adjusted adjusted
M (SD) M (SD) M (SD) M (SD)
Z score Z score Z score Z score
Engaged .21 (.53) .14 (.56) t=5.31*** .23 (.46) .17 (.48) t=4.70***
woman- .38*** (.90) .30*** .34*** (.70) .27***
Partner (.94) (.72)
Engaged .08 (.55) .04 (.55) ns .09 (.48) .04 (.47) t=4.86***
woman- .18* (.86) .20* (1.10) .13* (.66) .08 (.65)
Mother
Engaged .19 (.53) .14 (.55) t=3.41** .19 (.47) .14 (.48) t=5.38***
woman-Father .30*** (.80) .24** (.82) .26*** (.67) .20** (.68)
Engaged man- .19 (.56) .14 (.59) t=6.11*** .24 (.46) .18 (.48) t=5.04***
Partner .36*** (.92) .29** (.97) .34*** (.68) .27***
(.69)
Engaged .06 (.52) .04 (.53) t=2.29* .05 (.49) .00 (.49) t=4.25***
man– .14 (.75) .11 (.76) .08 (.62) .01 (.63)
Mother
Engaged man- .06 (.51) .02 (.52) t=3.18** .15 (.50) .10 (.51) t=4.43***
Father .11 (.75) .07 (.77) .21 (.68)** .13* (.68)
Note: N=135 for women’s sample and 106 for men’s one.
Mean similarities marked by asterisks are the ones significantly different from zero. Values reported in
italics are Fisher r-to-z transformed intraclass correlations. T-test analyses were performed on
transformed intraclass correlations.
+
p < .055, *p<.05, ** p<..01,*** p<..001

To verify whether adjusted and not adjusted similarity means were significantly different,
we compared them by computing a paired sample t-test on Fisher r-to-z transformed
intraclass correlations (see Table 2). As expected, stereotype-adjusted similarities were
significantly lower than unadjusted ones.
Next we tested whether there was statistically significant variation in profile similarity
indexes across dyads in order to perform subsequent moderating analyses. As Kenny and
colleagues (2006) noted, moderating analyses can be conducted only if there is enough
variation in the similarities indexes, variation which can be tested by analysing the reliability
of dyadic indexes. Except for man – mother unadjusted similarity in benevolence
(reliability=.53) and for man – father unadjusted similarity in unforgiveness (reliability=.49),
all the reliabilities of intraclass correlations were higher than .66 . As indicated by these
satisfactory reliabilities, dyads did vary in their levels of similarity enough to perform further
analyses.
202 F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate et al.

Comparing Similarity across Types of Dyads

To assess whether mean similarity differed across types of dyads (child-mother, child-
father, and child-partner) (Hypotheses 2 and 3) as well as across forgiveness dimensions
(benevolence and unforgiveness), we used the general linear model (GLM) general factorial
procedure with repeated measures. The GLM analyses were performed on Fisher r-to-z
transformed similarity intraclass correlations by entering both the type of dyad and the
forgiveness dimension as within-subjects factors. The sphericity assumption was never met
for dyad type in these analysis (W(2) ranged from .84 to .87 , p < .05), so the Greenhouse-
Geisser correction was applied.
For engaged women’s unadjusted similarities, we found a main effect for dyad type (F(2,
268)=4.77, p=.013, ηp2=.04 (small effect size)). Examination of post hoc comparisons,
performed using Sidak adjustment for multiple comparisons, indicated that this effect was due
to woman-father and woman-partner similarities being significantly higher than the woman-
mother one. No other main effect nor the interaction was significant. However, no main
effects nor interaction effect was found for women’s similarities adjusted for stereotype
effect. This means that women-father and women-partner similarities were higher than the
women-mother one because of a stereotype effect.
For engaged men’s unadjusted similarities, we found a main effect for dyad type (F(2,
210)=6.87, p=.006, ηp2=.05 (small effect size)). Examination of post hoc comparisons,
performed using Sidak adjustment for multiple comparisons, indicated that this effect was due
to man-partner similarity being significantly higher than man-mother one. No other main
effect or interaction was significant.
The same main effect was found for men’s similarities adjusted for stereotype accuracy
(F(2, 210)=4.33, p=.019, ηp2=.04 (small effect size)). This means that man-partner similarities
were higher than men-mother ones even after controlling for stereotype effect. The mean
level of similarity did not differ across forgiveness dimensions (benevolence and
unforgiveness), whereas it differed across types of dyads. In sum, engaged men were more
similar to their partners than to their mothers with respect to their tendency to forgive the
partner and this difference was not due to a stereotype effect. Engaged women were more
similar to their partners and to their fathers than to their mothers with respect to their
tendency to forgive the partner but these differences were due to a stereotype effect.
Next, we examined whether mean similarities differed not only across dyad types and
forgiveness dimensions but also between engaged partners’ gender (Hypothesis 4), by
conducting GLM analyses with repeated measures on a restricted subsample (N=76) in which
all the subjects (the two partners and both their parental couples) returned completed
questionnaires. Dyad type, forgiveness dimension and engaged partners’ gender were entered
as within-subjects factors. As before, GLM analyses were performed on Fisher r-to-z
transformed intraclass correlations and violation of sphericity assumption was corrected by
using Greenhouse-Geisser procedure (see table 3).
 The Tendency to Forgive in Premarital Couples 203

Table 3. Descriptive statistics for Stereotype adjusted and non-adjusted mean

similarities on a restricted subsample in which both parental couples returned
completed questionnaires

Similarity in Benevolence Similarity in Unforgiveness

Unadjusted Stereotype Unadjusted Stereotype
adjusted adjusted
M (SD) M (SD) M (SD) M (SD)
Z score Z score Z score Z score
Engaged woman- .25 (.54) .18 (.58) .28 (.44) .40 .21 (.47)
Partner .44 (.91) .35 (.97) (.68) .32 (.71)
Engaged woman- .12 (.55) .08 (.57) .07 (.46) .02 (.45)
Mother .24 (.87) .26 (1.12) .12 (.65) .06 (.64)
Engaged woman-Father .22 (.54) .19 (.54) .18 (.48) .13 (.49)
.35 (.84) .31 (.83) .25 (.72) .20 (.72)
Engaged man- .25 (.54) .19 (.57) .28 (.44) .21 (.47)
Partner .44 (.91) .36 (.96) .40 (.68) .32 (.71)
Engaged man– .05 (.53) .01 (.54) .06 .05 (.51) .00 (.51)
Mother .10 (.74) (.74) .07(.62) .00 (.63)
Engaged man- .03 (.48) -.01 (.49) .11 (.51) .05 (.51)
Father .06 (.63) .01 (.65) .17 (.71) .09 (.71)
Note: N=76. Values reported in italics are Fisher r-to-z transformed intraclass correlations.

For unadjusted similarities, we found a marginally significant main effect for gender
(F(1, 75)=3.19, p=.078, ηp2=.04 (small effect size)). Observation of means indicated that this
effect was due to women’s similarities being higher than men’s. We also found a main effect
for dyad type (F(2, 150)=7.90, p=.002, ηp2=.10 (moderate effect size)). Post hoc comparisons,
performed using Sidak adjustment for multiple comparisons, indicated that this effect was due
to child-mother similarity being significantly lower than child-father and child-partner ones.
Analogous results were obtained when considering similarities adjusted for stereotype effect,
we found a marginally significant main effect for gender (F(1, 75)=3.66, p=.060, ηp2=.05
(small effect size) and a main effect for dyad type (F(2, 150)=4.93, p=.018, ηp2=.06 (small
effect size).
To verify whether children’s perceptions of parents as models were associated with the
level of parent-child similarity (Hypothesis 5), Pearson’s correlations were performed
between the parents-as-models measure and mother-child and father-child similarity in both
unforgiveness and benevolence. No significant association was found.
A possible explanation of this result could be that, because the forgiveness construct is
highly shaped by one’s own cultural and religious background, children are probably more
sensitive to the fact that parents embody a socially desirable model of forgiveness than to a
general positive evaluation of their parental role. To test this hypothesis we performed post-
hoc analyses in which we verified whether similarity between parents and children was
associated to the actual level of forgiveness displayed by parents (see table 4).
204 F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate et al.

Table 4. Pearson Correlations between parent-child similarity indexes and parents’

forgiveness dimensions

Similarity in Benevolence
Women-mother Women-father Men-mother Men-father
Unad- Stereo- Unad- Stereotype Unad- Stereo- Unad- Stereo-
justed type justed adjusted justed type justed type
adjusted adjusted adjuste
d
Parent .22* .19* .11 .12 .40*** .39*** .24* .24*
Benevolence
Similarity in Unforgiveness
Parent -.26** -.22** -.16 -.16 -.42*** - -.13 -.15
Unforgiveness .44***
Note: N=135 for women’s sample and 106 for men’s one.
* p<.05, ** p<..01,*** p<..001

Results revealed that parent-child similarity, especially mother-child similarity, was

moderated by the level of forgiveness: the more benevolent and less unforgiving were the
parents, the more similar to them were their children, especially sons.

CONCLUSION
Forgiveness research is providing more and more evidence about socio-cognitive,
relational, and dispositional determinants of forgiveness for specific partner’s offences (e.g.,
Allemand, Amberg, Zimprich, & Fincham, 2007; Paleari et al., 2005). Given that the
generalizability of this evidence to a more global and stable tendency to forgive the partner is
by no means assured (McCullough et al., 2000), it is also important to investigate possible
precursors of the tendency itself. Drawing on socialization (e.g., Grusec & Goodnow, 1994;
Zentner & Renaud, 2007) and forgiveness literature (Mullet al al., 2004; 2006), our study
sought to provide further evidence on this issue by investigating in a sample of premarital
couples whether young adults’ tendency to forgive the partner was significantly related to
their partner’s and to their parents’ tendencies. We argued that the tendency to forgive one’s
own partner would be significantly linked to the partner’s typical forgiving or unforgiving
responses to one’s own relational transgressions, as implied by the reciprocity norm, as well
as to the parents’ tendency to forgive one another, as implied by socialization theories
assuming that children internalize parental models.
Specifically, our main objective was to verify the extent to which partners are similar to
each other and to their parents with respect to their forgiveness disposition, using a dyad-
centered approach in order to appropriately analyse the similarity within each dyad and to
control for possible stereotype effects. A unique stereotype for the overall sample was
revealed by our investigation, suggesting that stereotype accuracy did not differ across
genders or generations. Thus, as far as forgiveness toward the partner is concerned, female
and male partners as well as young adult and parents share an overlapping typical view of
forgiveness within the couple. Controlling for stereotype accuracy significantly lowers the
 The Tendency to Forgive in Premarital Couples 205

level of similarities, proving the existence of a stereotypical way of responding to forgiveness

issues among participants.
Consistent with our first hypothesis, however, our results demonstrate that, even after
controlling for stereotype accuracy, there is a significant though small level of similarity
between engaged partners. This evidence mirrors previous studies showing modest levels of
reciprocity between partners’ forgiveness (Hoyt et al, 2005). It can be argued that, as
observed by Clark (1984) romantic relationships are communal bonds in which partners are
not much concerned with ongoing maintenance of equity but rather are more responsive to the
needs of the other and of the relationship.
It is noteworthy that similarity between partners can be explained not only because they
become more and more similar in their reciprocal exchanges of forgiveness, but also because
partners select each other based on similarity in many domains, as studies on assortative
mating suggested (Luo & Klohnen, 2005). Thus, similarity in forgiveness can be part of the
same selection process.
A significant level of similarity in the tendency to forgive was also found between
children and their parents, even after adjusting for stereotype accuracy. In particular,
daughters were found to be similar to their parents in both forgiveness dimensions
(Benevolence and Unforgiveness), whereas sons were similar to their fathers only in the
Unforgiveness dimension. The latter evidence is consistent with the fact that the level of
intergenerational continuity in antisocial behavior is generally stronger for fathers than for
mothers (Farrington, Jolliffe, Loeber, Stouthamer-Loeber, & Kalb, 2001; Thornberry, 2003).
It is noteworthy that, despite the fact that children and parents are referring to different targets
of their forgiveness tendency (i.e. their partners), they are nevertheless uniquely similar about
it. This finding is in line with the assumption of intergenerational transmission of forgiveness
toward the partner, although it is only a first step to come to this conclusion. On the one hand,
the mere similarity between fathers’ and children’s forgiveness does not automatically imply
internalization, a process that requires both an accurate perception of parental dispositions
and their acceptance by children (Grusec & Goodnow, 1994). On the other hand, similarity
doesn’t necessarily mean a parent-to-child transmission but can also stand for a bidirectional
process: by expressing their more or less forgiving tendency, children can also influence
parents’ ongoing socialization of forgiveness (Kuczynski & Parkin, 2007). In line with this
hypothesis, recent evidence on the intergenerational transmission of ideal selves showed the
existence of a child-to-parent effect, even though less frequent than the opposite parent-to-
child one (Zentner & Renaud, 2007).
Partially consistent with our second hypothesis, children were more similar to their
partners than to their mothers in their tendency to forgive, but not to their fathers. For
daughters however this difference was no longer significant when similarity was adjusted for
stereotype accuracy. This indicates that women were not more similar to their own partners’
or fathers’ forgiveness, compared to their mothers’, but to their partner’s and fathers’
responding in a typical fashion about forgiveness. Thus, only engaged men’s tendency to
forgive their partner appears more strongly linked to the forgiveness transactions occurring in
their couple relationship than to the forgiveness model displayed by their mothers. This result
may be partly explained by the fact that males are often reinforced early on to separate
themselves from the family and to establish a sense of individuality (Gilmore, 1990; Philpot,
Brooks, Lusterman, & Nutt, 1997), whereas females are encouraged to connect and please
others with much less emphasis on individuating (Gilligan, 1982). Another possible
206 F. Giorgia Paleari, Silvia Donato, Raffaella Iafrate et al.

explanation is that in our sample mothers, differently from fathers, showed the lowest
tendency to forgive their husbands, thus embodying a socially unacceptable model of
forgiveness. Consequently, children tend not to identify with them. As highlighted in post hoc
analyses, children, and especially sons, are more likely to reproduce parental models as long
as they are positive and socially desirable in the Italian culture.
Daughters and sons were not more similar to their mothers than to their fathers. If
anything, with unadjusted scores, women were more similar to their fathers than to their
mothers, but this difference was no longer significant after stereotype adjustment. This
finding is in contrast with our third hypothesis, which drew upon studies showing that
children are more likely to share maternal rather than paternal ideals, attitudes and feelings
(Harach & Kuczynski, 2005). A possible explanation could be that, compared to the other
variables so far investigated, the tendency to forgive the partner is a more interpersonal
construct, which has a greater likelihood of being manifested during interactions with the
offender. Accordingly, parents’ forgiving or unforgiving intentions toward each other are
more likely to be exhibited (and accurately perceived by children) during their mutual
interactions, thereby resulting in a more equal involvement of fathers and mothers in their
children’s socialization of forgiveness.
As for child gender, results showed a marginally significant effect which confirmed our
fourth hypothesis. Consistent with previous studies on the intergenerational transmission of
individual and relationship variables (e.g., ideals, relational outcomes), daughters are more
similar to their parents in their willingness to forgive the partner than sons (e.g., Caspi &
Elder, 1998; Zentner & Renaud, 2007).
Unexpectedly, children’s perception of parents as models for their lives did not moderate
parent-child similarity, thereby disconfirming our fifth assumption. As highlighted in post-
hoc analyses, when using a more specific measure of the positivity of parents as models (the
actual level of forgiveness reported by parents), a direct association with parent –child
similarity emerged, suggesting that children may be more sensitive to the fact that parents
embody a socially desirable model of forgiveness than to a general positive evaluation of their
parental role.
Interpretation of the present findings must be tempered by several considerations. First,
the use of a convenience sample limits generalizability of results to a broader population.
Second, the cross-sectional nature of the present work makes it impossible to verify the
direction of effects and specifically to disentangle whether parent-child influence is one- or
bi-directional. Moreover, we could not verify the possibility of partners initial selection nor to
address the issue of possible changes in similarity across time, while research suggests that
partners tend to grow more and more similar to each other over time (Blankenship, Hnat,
Hess, & Brown, 1984). Thus, future research should aim at investigating this topic through a
longitudinal design. Third, as already noted, because measuring similarity is only the first step
to assessing internalization, future research should aim at investigating internalization more
closely - especially to verify the role of children’s accuracy in perceiving parents tendency to
forgive as well as their acceptance of such models. Fourth, research on the intergenerational
transmission of dispositions should also aim at distinguishing between biological/genetic and
socialization factors. Finally, only a subset of possible moderators of parent-child similarity
were taken into account. Future research is needed to verify the role of other possible factors,
such as the quality of children’s relationship with each parent or parents’ parenting practices.
 The Tendency to Forgive in Premarital Couples 207

In summary, our study highlights the existence of similarity in partners and parent–child
dyads with regard to forgiveness. Such similarity is due to both a stereotypical way of
responding to forgiveness issues among participants and to a unique similarity between
engaged partners and between parents and children. Partners’ socialisation of forgiveness
seems therefore not only a matter of integrating one’s personal disposition with one’s couple
and parental “culture of forgiveness” but also with a broader societal one.
Our results provide evidence for a reciprocity between partners’ tendency to forgive each
other and for children’s congruence with parents’ tendencies. Thus, even though premarital
engaged couples are strongly involved in defining their own couple identity as a separate
entity from their familial belongings, they are nonetheless permeated by the forgiveness
culture they inherit from their family of origin (Cigoli & Scabini, 2006; Mullet el., 2006).
Young adult children, and especially sons, appear to discriminate the type of forgiveness
models their parents endorse and are more prone to reproduce them as long as they are
positive and socially desirable.

Reviewed by Thomas Bradbury (University of California, Los Angeles, US) and Etienne
Mullet (Ecole Practique des Hautes Etudes, Paris, France). We’d like to express our gratitude
to both of them for their very helpful comments on an earlier version of this chapter.

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Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 10

IS THE SEROTONERGIC SYSTEM ALTERED IN

ROMANTIC LOVE? A LITERATURE REVIEW AND
RESEARCH SUGGESTIONS

Sandra J. E. Langeslag*
Erasmus Affective Neuroscience Lab, Institute of Psychology, Erasmus University
Rotterdam, The Netherlands

ABSTRACT
Infatuated individuals think about their beloved a lot. The notions that these frequent
thoughts resemble the obsessions of obsessive-compulsive disorder (OCD) patients and
that those patients benefit from serotonin reuptake inhibitors (SSRIs), have led to the
hypothesis that romantic love is associated with reduced central serotonin levels. In this
chapter, the literature on this topic is reviewed and suggestions for future research are
made. Previous studies have shown that romantic love is associated with lower blood
serotonin levels and with lower serotonin transporter densities, the latter of which has
also been observed in OCD patients. Further, SSRIs have been found to decrease feelings
of romantic love and the serotonin 2 receptor gene has been associated with the love trait
‘mania’, which is a possessive and dependent form of love. Given that serotonin 2
receptors in the prefrontal cortex have also been implicated in impulsive aggression, this
suggests that stalking behavior may be associated with these receptors. In short, the
serotonergic system appears to be altered in romantic love indeed. Future research is
needed to identify what parts of the serotonergic system, such as which serotonergic
projections, brain areas, transmission stages and receptor types, are affected in romantic
love and in what way they are altered. Furthermore, challenging the serotonergic system
would be useful in determining the causal relationship between central serotonin levels
and feelings of romantic love. In addition, future research should specifically investigate

*
Corresponding author: S. Langeslag. Institute of Psychology, Woudestein, T12-45, P.O. Box 1738, NL-3000 DR
Rotterdam, The Netherlands. Email address: langeslag@fsw.eur.nl; Tel: +31 (0)10 408 2663; Fax: +31 (0)10
408 9009
214 Sandra J. E. Langeslag

the different aspects of romantic love, such as state, trait, requited and unrequited love
and its development in time.

INTRODUCTION
Infatuated individuals and obsessive-compulsive disorder (OCD) patients resemble each
other in the sense that they both have obsessions. In general, obsessions are ideas that haunt,
hover and constantly invade one’s consciousness (Reber & Reber, 2001). Specifically, OCD
patients spend a lot of time thinking about their doubts and fears, whereas infatuated
individuals spend as much as 85 percent of the day thinking about their beloved (Fisher,
Aron, Mashek, Li, & Brown, 2002). This resemblance, combined with the notion that
selective serotonin reuptake inhibitors (SSRIs) can relieve OCD symptoms, led Fisher et al.
(2002) to hypothesize that romantic love is accompanied by reduced levels of serotonin in the
brain. In this chapter, it will be discussed how this hypothesis relates to the existing literature.
In addition, suggestions are made for future research that could put this hypothesis to the test
and would increase our knowledge about both the serotonergic system and the neurobiology
of romantic love.

LITERATURE REVIEW
Kurup and Kurup (2003) have observed that individuals with a predisposition to fall in
love had lower blood serotonin levels than did individuals without such predisposition, as
evident from the fact that they had never fallen in love and had a conventional arranged
Indian marriage. Thus, this study implies that lower serotonin levels are associated with
increased trait romantic love. Furthermore, in a case study of a healthy man it was observed
that state feelings of love were less intense and of shorter duration when taking an SSRI
compared to when taking no medication (Walsh, Victor, & Bitner, 2006). Further, Marazziti,
Akiskal, Rossi and Cassano (1999) have shown that infatuated compared to non-infatuated
participants had a lower density of the serotonin transporter in blood platelets, a measure that
is linked to the density of this transporter in the brain (Rausch et al., 2005). When the same
participants were tested again about a year later, the serotonin transporter density in the
previously infatuated individual had returned to levels equivalent to the non-infatuated
participants. Marazziti et al. also compared the serotonin transporter density in the infatuated
participants with this density in OCD patients, and found that these were undistinguishable.
Yet, because this serotonin transporter is a membrane protein that transports serotonin from
the synaptic cleft back into the presynaptic neuron, a reduced transporter density implies that
an increased number of serotonin molecules would be present in synapses. Still, the finding of
a reduced transporter density in OCD patients is supported by positron emission tomography
(PET) research in which OCD patients compared to control participants had a lower serotonin
transporter density in the thalamus and midbrain (Reimold et al., 2007).
Given the resemblance between OCD patients and infatuated people, these results lead to
the hypothesis that also in infatuated people the density of the serotonin transporter would be
reduced in the thalamus and midbrain. In fact, it is very important to consider the locus of
 Is the Serotonergic System Altered in Romantic Love? 215

serotonergic changes in romantic love because the raphe nuclei in the brainstem have
serotonergic projections to multiple brain structures such as the cerebellum, hippocampus,
amygdala, thalamus, hypothalamus, striatum and neocortex (Kandel, Schwartz, & Jessell,
2000). Changes in the serotonergic system associated with romantic love could occur in all of
these projections, only in some projections or even differently in different projections. Take
schizophrenia for instance, where dopamine is too abundant in the mesolimbic dopaminergic
pathway, but too scarce in the mesocortical dopaminergic pathway (Stahl, 2000).
Interestingly, the serotonergic system has also been implicated in impulsivity and
aggressive behavior. The serotonergic projection to the prefrontal cortex, that would normally
exert inhibitory control, appears dysfunctional in individuals who show impulsive aggression
(Davidson, Putman, & Larson, 2000). Given that romantic love is usually not particularly
associated with aggressive behavior or impulsivity, this suggests that the prefrontal
serotonergic projection may be unaffected by romantic love. Nevertheless, romantic love is
sometimes accompanied by stalking behavior that can involve impulsivity and aggression
directed towards the stalker’s victim (Meloy & Fisher, 2005). So, the serotonergic projection
from the raphe nuclei to the prefrontal cortex may actually play a role in stalking behavior.
Besides considering the changes in different projections or brain structures, it is also
important to evaluate changes in the serotonergic system at the pharmacological level. For
example, serotonergic transmission comprises different stages, such as serotonin synthesis,
serotonin release from the presynaptic neuron, binding of serotonin to receptors, enzymatic
degradation of serotonin in the synaptic cleft, and serotonin reuptake. Moreover, different
receptor types exist, including some autoreceptors that inhibit serotonin release. The SSRIs
that can alleviate OCD symptoms appear to mediate serotonergic transmission in several
ways. Initially, they block the reuptake of serotonin from the synaptic cleft. The therapeutic
effect, however, appears only after a few weeks and is attributed to the subsequent
desensitization of the 1A and 1B autoreceptors that results in disinhibition of serotonin
release from the presynaptic neuron (Stahl, 2000). Alteration or disruption of serotonergic
transmission in romantic love could occur at one or more of the transmission stages and could
involve one or more of the different receptor types. The above mentioned findings regarding
the serotonin transporter imply changes in the reuptake stage during romantic love.
Interestingly, Emanule, Brondino, Pesenti, Re and Geroldi (2007) have not observed an
association between serotonin transporter gene polymorphisms and certain love traits. This
suggests that the observed differences in the serotonin transporter may occur only during state
romantic love. Yet, Emanuele et al. have observed an association between the C516T
polymorphism of the gene encoding the serotonin 2A receptor, which is widely distributed
throughout the brain, and the love trait ‘mania’. Previously, this polymorphism has been
implicated in obsessive-compulsive disorder (Meira-Lima et al., 2004). Moreover, the
serotonin 2 receptors in the prefrontal cortex have been implicated in impulsive aggression
(Davidson et al., 2000). Given that ‘mania’ is characterized as a possessive and dependent
form of love (Lee, 1976), this suggests that stalking behavior may actually be associated with
the serotonin 2 receptors that are located in the prefrontal cortex.
Finally, besides to obsessive-compulsive disorder and possibly romantic love, a
dysfunctional serotonergic system has also been linked to depression (see e.g. D'haenen,
2001). Nevertheless, infatuated participants are rather euphoric than depressed, at least as
long as the relationship is satisfactorily. More research is needed to establish the differences
and similarities between the serotonergic systems of depressed and infatuated individuals.
216 Sandra J. E. Langeslag

INTERIM SUMMARY
Above, four studies regarding the involvement of the serotonergic system in romantic
love have been discussed. The results of these studies suggest that the serotonergic system is
associated with romantic love although it remains unclear whether central serotonin levels are
actually decreased in infatuated individuals as has been hypothesized by Fisher et al. (2002).
In addition, the prefrontal serotonergic projection and the serotonin 2 receptor might be
associated with the manic, stalking aspect of romantic love.

RESEARCH SUGGESTIONS
The review above makes it clear that there are multiple aspects of romantic love that
should be considered explicitly in future research. It is important, for example, to specify
whether the topic of investigation is trait or state romantic love. Obviously, genetic studies
will mostly concern trait romantic love. It is also important to distinguish between requited
and unrequited love, the latter of which may be associated with depressive feelings and even
stalking behavior in some individuals. Further, the time course of serotonergic changes in
romantic love has to be examined, preferably using longitudinal designs. Marazziti et al.
(1999) have already shown that serotonin transporter density returns to normal values after a
year, but it would be interesting to observe changes at the start of the infatuation or after
rejection as well. Hereby it should be kept in mind that changes in the serotonergic system
may take some time to occur, in analogy to the changes underlying the therapeutic effects of
SSRIs.
So how could these issues be investigated? The functioning of the serotonergic system
can be assessed by measuring levels of serotonin or its precursor or metabolites in urine,
blood or cerebrospinal fluid (in order of invasiveness). Also serum prolactin elevation in
response to a single dose of a serotonin agonist or precursor can be used to index central
serotonin activity (e.g. Croonenberghs et al., 2007; Muldoon et al., 2007). Further, any causal
relationship between serotonin and romantic love could be determined by experimentally
manipulating central serotonin levels, for instance by administering a serotonin agonist or
antagonist. Alternatively, central serotonin levels can be decreased by acute tryptophan
depletion, which can be achieved by having participants consume a beverage containing
multiple amino acids except the amino acid tryptophan (e.g. Van der Veen, Evers, Deutz, &
Schmitt, 2007), which is the precursor of serotonin. Likewise, central serotonin levels can be
increased by using a beverage containing high levels of tryptophan compared to other amino
acids (e.g. Bjork, Dougherty, Moeller, Cherek, & Swann, 1999).
Finally, the neuroimaging technique PET would be especially suitable for comparing the
serotonergic system of infatuated individuals with that of non-infatuated individuals or
patients with OCD or depression. In PET studies, a radioactive substance that has a high
affinity for a certain binding site is injected, and detectors then measure where in the brain
that radioactive substance accumulates. In research concerning the serotonergic system and
romantic love, the radioactive substance would be selected for its binding to a certain
serotonin receptor or transporter, thereby making it possible to investigate the locus of
changes in the different aspects of the serotonergic system.
 Is the Serotonergic System Altered in Romantic Love? 217

CONCLUSION
The few studies that have examined the relation between serotonin and romantic love
have shown that the serotonergic system is probably dysfunctional in infatuated individuals.
However, more research is needed to identify the exact locus of these changes, that is to
determine which serotonergic projections, brain areas, transmission stages and receptor types
are altered in romantic love. To this end, crosstalk between the different disciplines such as
neuroimaging, genetics and pharmacology is needed. Finally, future research will have to
specifically investigate the different aspects of love, such as state or trait love, requited and
unrequited love and its development in time.

Reviewed by Dr. F. M. van der Veen, Department of Psychiatry, Erasmus Medical

Center, Rotterdam, The Netherlands

REFERENCES
Bjork, J. M., Dougherty, D. M., Moeller, F. G., Cherek, D. R., & Swann, A. C. (1999). The
effects of tryptophan depletion and loading on laboratory aggression in men: time course
and a food-restricted control. Psychopharmacology, 142, 24-30.
Croonenberghs, J., Wauters, A., Deboutte, D., Verkerk, R., Scharpe, S., & Maes, M. (2007).
Central serotonergic hypofunction in autism: results of the 5-hydroxy-tryptophan
challenge test. Neuroendocrinology Letters, 28, 449-455.
D'haenen, H. (2001). Imaging the serotonergic system in depression. European Archives of
Psychiatry and Clinical Neuroscience, 251, II/76–II/80.
Davidson, R. J., Putman, K. M., & Larson, C. L. (2000). Dysfunction in the neural circuitry
of emotion regulation - A possible prelude to violence. Science, 289, 591-594.
Emanuele, E., Brondino, N., Pesenti, S., Re, S., & Geroldi, D. (2007). Genetic loading on
human loving style. Neuroendocrinology Letters, 28, 815-821.
Fisher, H. E., Aron, A., Mashek, D., Li, H., & Brown, L. L. (2002). Defining the brain
systems of lust, romantic attraction, and attachment. Archives of Sexual Behavior, 31,
413-419.
Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (2000). Principles of neural science (4th ed.).
New York: McGraw-Hill.
Kurup, R. K., & Kurup, P. A. (2003). Hypothalamic digoxin, hemispheric dominance, and
neurobiology of love and attention. The International Journal of Neuroscience, 113, 721-
729.
Lee, J. (1976). The colors of love (1st ed.). Englewood Cliffs: Prentice-Hall.
Marazziti, D., Akiskal, H. S., Rossi, A., & Cassano, G. B. (1999). Alterations of the platelet
serotonin transporter in romantic love. Psychological Medicine, 29, 741-745.
Meira-Lima, I., Shavitt, R. G., Miguita, K., Ikenaga, E., Miguel, E. C., & Vallada, H. (2004).
Association analysis of the cathechol-o-methyltranferase (COMT), serotonin transporter
(5-HTT) and serotonin 2A receptor (5-HT2A) gene polymorphisms with obsessive-
compulsive disorder. Genes, Brain and Behavior, 3, 75-79.
218 Sandra J. E. Langeslag

Meloy, J. R., & Fisher, H. (2005). Some thoughts on the neurobiology of stalking. Journal of
Forensic Sciences, 50, 1472-1480.
Muldoon, M. F., Mackey, R. H., Sutton-Tyrrell, K., Flory, J. D., Pollock, B. G., & Manuck,
S. B. (2007). Lower central serotonergic responsivity is associated with preclinical
carotid artery atherosclerosis. Stroke, 38, 2228-2233.
Rausch, J. L., Johnson, M. E., Li, J., Hutcheson, J., Carr, B. M., Corley, K. M., et al. (2005).
Serotonin transport kinetics correlated between human platelets and brain synaptosomes.
Psychopharmacology, 180, 391-398.
Reber, A. S., & Reber, E. (2001). The Penguin dictionary of psychology (3rd ed.). London:
Penguin Books.
Reimold, M., Smolka, M. N., Zimmer, A., Batra, A., Knobel, A., Solbach, C., et al. (2007).
Reduced availability of serotonin transporters in obsessive-compulsive disorder correlates
with symptom severity - a [11C]DASB PET study. Journal of Neural Transmission, 114,
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Stahl, S. M. (2000). Essential psychopharmacology. Cambridge: Cambridge University Press.
Van der Veen, F. M., Evers, E. A. T., Deutz, N. E. P., & Schmitt, J. A. J. (2007). Effects of
acute tryptophan depletion on mood and facial emotion perception related brain
activation and performance in healthy women with and without a family history of
depression. Neuropsychopharmacology, 32, 216-224.
Walsh, R., Victor, B., & Bitner, R. (2006). Emotional effects of sertaline: Novel findings
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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 11

UPDATE ON PHEROMONE RESEARCH

Donatella Marazziti*, Irene Masala, Stefano Baroni,

Michela Picchetti, Antonello Veltri and Mario Catena Dell’Osso
Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie,
University of Pisa, Pisa, Italy

ABSTRACT
Pheromones are volatile compounds secreted into the environment (in sweat, urine)
by one individual of a species and perceived by another individual of the same species, in
which they trigger a behavioral response or physiological change. Besides insects,
pheromones have been described in several invertebrate and vertebrate animals;
moreover, they have been shown to modulate mating preferences, timing of weaning,
learning ability to distinguish poisoning from not-poisoning food, social recognition and
level of stress.
Several studies suggest that pheromones might play an important role also in
mammals, as it has been demonstrated that they can use chemical signals for mate
attraction, territorial marking, dominance and probably other functions yet to be
identified, amongst which, perhaps, some social behaviors.
In humans, several studies have indicated that pheromones may influence
reproductive endocrinology and have a positive effect on mood. Menstrual synchrony
amongst women sharing the same environment is a long-recognized phenomenon related
to pheromones produced in the armpits; these substances are not perceived as having any
particolar odour, but nonetheless can influence the lenght of the mestrual cycle through
the interference with different hormones. The aim of the present paper is to review the
latest data on pheromones with a specific focus on humans and future developments.

*
Author to whom correspondence and reprint requests should be sent: Dr. Donatella Marazziti. Dipartimento di
Psichiatria, Neurobiologia, Farmacologia e Biotecnologie, University of Pisa, via Roma, 67, 56100 Pisa, Italy.
Telephone: +39 050 835412; Fax: +39 050 21581; E-mail address: dmarazzi@psico.med.unipi.it
220 Donatella Marazziti, Irene Masala, Stefano Baroni et al.

INTRODUCTION
Pheromones are substances which are gaining an increasing attention, given their
important role in intra-species communication. The term “pheromone” is derived from the
Greek “pherein”, to transfer (carry) and “horman” to excite or stimulate. Pheromones are
volatile chemical compounds secreted into the environment by an individual through sweat
and urines and perceived by another member of the same species, in which they trigger a
behavioral or neuroendocrine response, or modulate endocrine states and development
(Karlson and Lüscher, 1959).
Originally, pheromones were distinguished in releaser, which would elicit an immediate
behavioural response, or primer, promoting slower and long-lasting changes to endocrine
state and development (McClintock, 2000). However, such a classification seemed to be too
limited and other categories were soon proposed (McClintock, 2000; Gulyas et al., 2004): that
of signaller pheromones that convey information about the sender, and that of modulator
which would influence mood and cognitive processes in humans (Brennan and Zufall, 2006;
Ngai, 2006; Sheperd, 2006).

PHEROMONES IN INSECTS
The first species where pheromones were described to play a role were insects, as some
of their behaviors appeared to be regulated by these compounds. Releaser pheromones
provoke immediate behavioral responses upon reception, while primer pheromones cause
physiological changes in the animal that ultimately lead to specific behaviors. Chemically
identified releaser pheromones are of three basic types: those which cause sexual attraction,
alarm behavior and recruitment. Sex pheromones elicit the entire pattern of sexual behavior:
therefore a male insect may be attracted to and attempt to copulate even with an inanimate
object that carry sex pheromone (Regner and Law, 1968).
In one of the most studied animals, that is silkworm moths (Bombyx mori), females
attract male mates with the pheromone bombykol, (E,Z)-10,12-hexadecadien-1-ol, which is
also the first chemically-identified pheromone (Butenandt et al., 1959). In the male moth’s
antennae, a pheromone-binding protein conveys bombykol to a membrane-bound receptor on
nerve cells. Males are immediately attracted and move toward females where their excitement
increases and leads to the characteristic wing-fluttering. Some authors have shown that
Bombyx mori males will respond to air streams containing as little as 200 molecules of
bombykol per cm3, so that bombykol results to be one of the most biologically active
substances known up-to-now (Boeckh et al., 1965).
Besides insects, pheromones have been described in several invertebrate and vertebrate
animals; moreover, they have been shown to modulate mating preferences, timing of
weaning, learning ability to distinguish poisoning from not-poisoning food, social recognition
and level of stress (Curtis et al., 1971; Wyatt 2003; Brennan and Keverne, 2004; Brennan and
Kendrick, 2006; Brennan and Zufall, 2006). Vertebrate pheromones present a wide range of
chemical forms. Their size and their polarity represent their most significant features and are
the major factors determining their volatility in air and solubility in water, respectively. In the
terrestrial environment, attractant and alarm pheromones, which by their nature act at a
 Update on Pheromone Research 221

certain distance, are typically small and volatile. By contrast, pheromones that convey
information about specific individuals are likely to be relatively non-volatile, for instance,
proteins or peptides, so that they do not get lost and can be more reliably associated with the
sender. The situation is quite different in the aquatic environment where solubility is the most
important feature, so that even relatively high molecular weight peptides and proteins can
function as attractant (Brennan and Zufall, 2006).

PHEROMONES IN MAMMALS
Several studies suggest that pheromones might play an important role also in mammals,
as it has been demonstrated that they can use chemical signals for mate attraction, territorial
marking, dominance and probably other functions yet to be identified, amongst which,
perhaps, some social behaviors.
In mammals, a specialized region of the olfactory system called the vomeronasal organ
(VNO), also referred to as ‘Jacobson’s organ’, is responsible for pheromone detection. The
VNO contains a sensory epithelium constituted from different cell types than olfactory
epithelium; interestingly, the two epithelia use different transduction mechanisms based on
their expression of G-proteins. The VNO receptors are seven-transmembrane receptors
coupled to GTP-binding protein, but appear to activate inositol 1,4,5-trisphosphate signalling
as opposed to cyclic adenosine monophosphate. Two multigene families of G protein-linked
receptors (V1 and V2), each expressed in a distinct region of the VNO, have been identified.
These two families of putative VNO receptors differ not only in their linkage to distinct G
proteins, but also in the length of their extracellular NH2-terminal domains. The V1 receptors
(V1Rs) are linked to Gαi2, possess a relatively short NH2-terminal, and show a greatest
sequence diversity in their transmembrane domains. The V2Rs are linked to Gα0 and
comprise a family of about 140 genes distinguished by their long extracellular NH2-terminal
that is thought to bind ligands (Keverne, 1999). The neurons of the vomeronasal and olfactory
epithelia project to different parts of the central nervous system through several synapses,
while suggesting that the two systems exert different functions. In particular, the VNO is
located above the hard palate on both sides of the nasal septum and is lined with receptor cells
whose axons project to the accessory olfactory bulb; this, in turn, sends its terminals to the
hypothalamus which modulates reproductive, defensive and eating behaviors, as well as
hormone secretion (Henzel et al., 1988; Keverne, 1999), and also to amygdala, that is
undoubtedly involved in the processing of vomeronasal information (Lanuza et al., 2008).

PHEROMONES IN HUMANS
VNO appears to be vestigial in some primates, and the accessory olfactory bulb is hardly
discernable in humans (Grammer et al., 2005).
Some embryological studies demonstrated that the VNO begins to develop in humans,
but disappears along with the cartilage encapsulating it well before birth. However, it has
been suggested that human VNO is functional and would respond to pheromones (even in
picogram amounts) in a sex-specific manner (Monti-Bloch et al., 1998; Smith et al., 1998;
222 Donatella Marazziti, Irene Masala, Stefano Baroni et al.

Grosser et al., 2000). Not surprisingly, the assumption that humans might communicate
through pheromones is getting an increasing support by experimental data since three decades
(Waltman et al., 1973; Michael et al., 1975, for review: Brennan and Zufall, 2006). The
human VNO has a unique ultrastructure, with elongated bipolar microvillar cells that stain
with several immunomarkers. These cells show physiological properties similar to
chemosensory receptor cells of other mammalian species. The organ's local response, or
electrovomerogram, is followed by gender-specific behavioral changes, modulation of
autonomic nervous system function, or the release of gonadotropins from the pituitary gland.
Functional brain imaging studies revealed consistent activation of the hypothalamus,
amygdala and cingulate gyrus-related structures during adult human VNO stimulation
(Monti-Bloch et al., 1998).
The unique effect attributable to pheromones in humans is the synchronicity of the
menstrual cycles in women living together: in fact, the exposure to axillary secretions from
women in the late follicular and ovulatory phases have been found to shorten and lengthen,
respectively, the cycles of recipient females (Stern and McClintock, 1998). These substances,
although not perceived, because they have no odour, nonetheless can provoke this effect,
probably through the modulation of different hormones (Cutler et al., 1986; Preti et al., 1986,
2003; Stern and McClintock, 1998). Furthermore, men axillary extracts seem to affect women
reproductive state by interference with the frequency of LH release (interestingly, this
parameter is an excellent indicator of the release of GnRH from the hypothalamus). In
women, the positive action of GnRH on LH release influences the length and timing of the
menstrual cycle, and, therefore, fertility. Preti et al., (2003) demonstrated that the application
of extracts of male axillary secretions provoked changes of LH pulsatility and mood of
women, in the sense that they advanced the onset of the next peak of LH, reduced the
subsecutive feeling of tension and increased that of relaxation. These results demonstrate that
male axillary secretions might contain one or more constituents that would act as primer and
modulator pheromones.
From a genetic point of view, different theories of sexual selection have emphasised that
females can obtain good genes for their offspring by mating with males whose genes are
distant, but complementary to their own, while highlightly the importance of the
immunocompetence system (Hamilton et al., 1982; Folstad et al., 1992) and, particularly, of
the major histocompatibility complex (MHC) (Wedekind and Furi, 1997; Wedekind, 2002).
MHC is a large chromosomal region containing closely linked polymorphic genes that play a
role in immunological self/ non-self recognition; the possible mechanism by which this can
be achieved is via body odour perhaps relayed by androgen-based pheromones (Jordan and
Bruford, 1998). Several experimental evidences showed that women prefer odours from
individuals of dissimilar MHC (Jordan and Bruford, 1998). These effects have been
hypothesized to influence even their choice of sexual partner in specific contexts. Wedekind
et al. (1995) demonstrated that women rated the odour of MHC-dissimilar men as ‘more
pleasant’, and this odour was significantly more likely to remind them of their own mate’s
odour. However, it is still premature to draw any conclusion on the effects of pheromones on
attractiveness which, however, have already been suggested (Black and Biron, 1982; Cutler,
1999; Thornhill and Gangstadt, 1999; Thorne et al., 2002).
The main sources of human pheromones are the apocrine glands located in the axillae and
pubic region. The high concentration of apocrine glands found in the armpits led to the term
‘axillary organ’, which is considered an independent ‘organ’ of human odour production
 Update on Pheromone Research 223

(Grammer et al., 2005). Apocrine glands develop in the embryo, but become functional only
with the onset of puberty. At sexual maturation, they produce steroidal secretions derived
from 16-androstenes (androstenone and androstenol) via testosterone, and as such, the
concentrations of several 16-androstenes is significantly higher in men (Brooksbank et al.,
1972). Freshly produced apocrine secretions are odourless, but are transformed into the
odorous androstenone and androstenol by aerobic coryeform bacteria (Gower and Ruparelia,
1993). Androstenone has been hypothesized to be a human pheromone, albeit it was first
identified like a porcine pheromone (Benton and Wastell, 1986; Pierce et al., 2004). In pigs,
an estrus sow tends to respond to exposure to androstenone from a rutting boar by adopting a
mating stance (Kline et al., 2007).
Putative human pheromones are represented by 4,16 androstadien-3-one (AND) and
estra-1,3,5(10),16-tetraen-3-olo (EST): AND, as already mentioned, is a derivate of
testosterone, produced in the armpits and secreted in concentrations which are up to twenty
times higher in men, as compared with women, while EST is a substance resembling naturally
occurring estrogens, synthesized after components present in human sweat (Gower and
Ruparelia, 1993; Monti-Bloch and Grosser, 1991; Sobel et al., 1999).
In the vagina, aliphatic acids (referred to as copulins) are secreted and their odour
changes along the menstrual cycle (Michael et al., 1975). It is now possible to isolate and
manufacture synthetic human pheromones and such compounds are often used in research as
they are relatively easy to make, convenient to store and easy to apply (Grammer et al., 2005).

EXPERIMENTAL EVIDENCE
Experimental evidence supported the involvement of pheromones in some human
reproductive behaviours. In an early report, Kirk-Smith et al. (1978) asked 12 undergraduate
men and women to rate photographs of people, animals and buildings by using a 159-point
bipolar scale (e.g. unattractive–attractive), while wearing surgical masks either impregnated
with androstenol or left plain; mood ratings were also assessed. In the presence of
androstenol, male and female stimuli were judged as being ‘warmer’ and ‘more friendly’.
Van Toller et al. (1983) showed that skin conductance in volunteers exposed to androstenone
was higher than that of non-exposed volunteers, thereby providing evidence of a certain
physiological effect of pheromone exposure. Benton (1982) reported that androstenol
application influenced the self ratings of mood at ovulation, and Grammer (1993) found that
women rated androstenone differently along the phases of their menstrual cycle; as a result, it
has been hypothesized that the link between sensivity to androstenone and these phases may
be related to the evolutionary loss of estrus.
Using positron emission tomography (PET) Gulyàs et al. (2004) measured regional
cerebral blood flow changes in healthy young women during exposure to androstadienone.
The results of this study showed that androstadienone as compared with others odorous
substances, activated two large cortical fields: the anterior part of the inferior lateral
prefrontal cortex and the posterior part of the superior temporal cortex. These brain areas can
be identified as cortical fields underlying other than olfactory function, including various
aspects of social cognition and attention.
224 Donatella Marazziti, Irene Masala, Stefano Baroni et al.

While laboratory studies might exert more control over the varying factors involved, of
potential greater relevance are studies assessing the effects of pheromones in real-life
situations. Cowley and Brooksbank (1991) asked men and women to wear a necklace either
containing an opposite-sex pheromone or a control substance while they slept. The next day,
they found that women who had worn the male pheromones in their necklace reported
significantly more interactions with men than the control group. Two studies employed
double blind, placebo-controlled methods and focussed upon the effects of synthetic
pheromones on self-reported sociosexual behaviors in young men (Cutler et al., 1998) and
women (Mc Coy and Pitino, 2002). The ensuing findings showed that pheromones generally
influences the socio-sexual behaviours, in the sense that more pheromones than placebo users
increased over baseline in sexual intercourse and sleeping with the romantic partner, in
addition, women who used pheromones enhanced also formal date and petting-affection
kissing (Mc Coy and Pitino, 2002). Generally speaking, the results of these studies appear to
provide impressive, albeit preliminary, evidence for the effects of synthetic pheromones on
sexual attractiveness.
Pierce et al. (2004), reported a significant relationship between odorant responsivity and
self-reports of the influence of odors: people able to smell androstenone more commonly
reported odors as having a negative effect on interpersonal relationships than did people
anosmic to androstenone. This could indicate that the responsivity to certain odorants may be
an important factor affecting human social interaction. A relationship of the repressive coping
and defensiveness to the perception to androstenone has also been reported and interpreted as
motives to seek social approval and avoid social disapproval since they may relate to
diminished awareness of androstenone (Kline et al., 2007).
Furthermore, it cannot be ruled out that changes in sexual behavior, attraction drives or
higher mental processes which have been described following airborne chemicals in humans,
might be related to mood fluctuations reported on the same time (Benton and Wastell, 1986;
Cutler et al., 1998; Chen and Haviland-Jones, 1999; Jacob and McClintock, 2000; Bensafi et
al., 2003, 2004; Lundström et al., 2003; Lundström and Olsson, 2005). These, in turn, may be
ascribed to changes of different neurotransmitters, particularly of serotonin (5-HT) which
seems to play a pivotal role in mood regulation (Stahl, 1998; Clark et al., 2005).

CONCLUSION
Human socio-sexual interactions are influenced by pheromones, even if they cannot be
detected consciously. Pheromones have the potential to influence human behavior and
physiology and so there has to be asked the question, in which way the modern striving for
cleanliness and odourlessness affects our everyday social lives and human reproductive
success in the future. What we know at the moment, as many studies in the last few years
have pointed out, is that the human sense of smell has by far been underestimated in the past
and that humans, like other animals, use olfactory signals for the transmission of biologically
relevant information.
 Update on Pheromone Research 225

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 12

NORMAL AND OBSESSIONAL JEALOUSY:

AN ITALIAN STUDY

Donatella Marazziti*, Marina Carlini, Francesca Golia,

Stefano Baroni, Giorgio Consoli, Mario Catena Dell’Osso
Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie,
University of Pisa, Italy

ABSTRACT
Background: Jealousy is a complex emotion spanning from normality to pathology.
The present study aimed to define the boundaries between normal and obsessional
jealousy by utilizing a specific self-report questionnaire.
Methods: The so-called “Questionnaire of Affective Relationships (QAR)” was
administered to 400 university students of both sexes, as well as to 14 outpatients
affected by obsessive-compulsive disorder (OCD). The total scores and the responses to
each of the 30 items were analyzed and compared.
Results: Two hundred and forty-five (approximately 61 %) of the questionnaires
given to the students were returned. Statistical analyses revealed that the OCD patients
had higher total scores than the healthy students. Moreover, we were able to identify an
intermediate group of subjects, consisting of 10 % of the total, who exhibited thoughts of
jealousy regarding their partner, but to a lesser degree than the OCD patients. These were
labeled as “healthy jealous subjects” because no other psychopathological trait could be
observed. in addition, significant intergroup differences in single items were observed.
Conclusion: The present study showed that in our population of university students,
10 % of the subjects, although normal, had excessive jealous thoughts regarding their
partner. In fact, we could clearly distinguish these subjects from the OCD patients and
from the healthy subjects with no jealousy concerns by means of the specific
questionnaire developed by us. Probably, they represent a subgroup of jealous , albeit
normal, subjects.

*
Author to whom correspondence and reprint request are to be sent: Dr. Donatella Marazziti. Dipartimento di
Psichiatria, Neurobiologia, Farmacologia e Biotecnologie, University of Pisa, via Roma, 67, I-56100 Pisa,
Italy. Telephone: +39 050 835412; Fax: +39 050 21581. E-mail address: dmarazzi@psico.med.unipi.it
230 Donatella Marazziti*, Marina Carlini, Francesca Golia et al.

Keywords: jealousy; obsessive-compulsive disorder; healthy conditions; questionnaire of

affective relationships; dimensions

INTRODUCTION
Jealousy is a complex emotion that both psychological and psychiatric research is still
attempting to elucidate; it involves the perception of a threatened or loss of a valued
relationship to a rival, either real or imagined. According to its intensity and persistence, it
can range, from normal to pathological states (Parker & Barret, 1997).
Pathological jealousy can be a reaction to a perceived threat to a relationship (defined as
“reactive” jealousy), or a symptom of some organic/toxic condition, such as alcoholism
(Shrestha et al., 1985; Micheal et al., 1995), or of some underlying psychiatric disorders, in
particular obsessive-compulsive disorder (OCD) or paranoia (Cobb & Marks, 1979; Tarrier et
al., 1990; Parker & Barret, 1997). The attention of most researchers has been mainly focused
on delusional jealousy, a type of jealousy which, according to Kraft-Ebing (1982), can be
distinguished in delusion of infidelity and delusion of jealousy. There is less information on
obsessional jealousy, in which there is a quality of obsessional ideation and egodystonia, a
feature which can, however, vary from patient to patient. There has been a level of success in
treating this category of jealousy as being related to OCD, since standard anti-OCD
treatments, such as selective serotonin (5-HT) reuptake inhibitors (SSRIs), have proven to be
quite effective (Lane, 1990; Gross, 1991; Stein et al., 1994).
Defining the boundary between “normal” and “pathological” jealousy is extremely
difficult, a task which represents “a formidable problem” for clinicians (Mullen, 1991), as
pathological jealousy is easier to recognize than to define (Tarrier et al., 1990). Any definition
of pathological jealousy should include an unfounded suspicion regarding the partner’s
fidelity, a suspicion that modifies thoughts, feelings and behavior. Such modified thoughts
are, however, not based on reliable empirical evidence, and they unavoidably impair the
normal functioning of the individual experiencing them, as well as affect the partner and the
relationship. Pathological jealousy leads the subject to actions aimed to “confirm” the
suspicions, actions which are readily evident to others, especially to the partner, who finds
that his or her whereabouts, actions, and even intentions are constantly being checked
(Docherty & Ellis, 1979). Behavioral avoidance of jealousy-provoking situations are also
quite frequent. Arguments and accusations can result in verbal and physical violence, and, on
occasion, even in murder (Docherty & Ellis, 1979; Tarrier et al., 1990). In addition, the
border between normal and pathological jealousy depends very much on the social customs
and the historical periods as noted by Mullen (1991), in his fundamental review, a century
ago, jealousy was thought of as being socially acceptable, while nowadays, it is perceived as
an embarrassing emotion. It should, therefore, be kept in mind that a society or culture
considers jealousy to be morbid when it exceeds that level of possessiveness which in that
moment is regarded as the norm.
Differing perspectives can lead to different interpretations of jealousy. Freud suggested,
that jealousy is rooted in the Oedipus, or “brother and sister”, complex, and he made a
distinction between “delusional jealousy”, due to homosexual feelings towards the
heterosexual partner, and “neurotic jealousy”, arising from heterosexual feelings towards the
 Normal and Obsessional Jealousy 231

heterosexual partner. Along the evolutionary approach, jealousy is interpreted as an universal

and innate experience and response, with positive, albeit different, values in the two sexes: in
men it is more linked to the certainty of paternity, while in women to the need of a stable and
long-lasting support for child-rearing. The results of a number of studies supported this notion
(Buss, 1989; Buss et al., 1992), while showing that men feel more distress than women at
possibility of sexual infidelity, while women are more concerned by potential emotional
infidelity. However, other studies, which examine the impact of gender on characteristics of
jealousy which might be explained not only by evolutionary processes, but also by the
influence of socio-cultural factors, have raised doubts about these findings (Buunk et al.,
1996).
Besides these factors, there may also be neurobiological mechanisms regulating the
development, expression and degree of jealousy. Kraepelin (1910) and other early authors
claimed that jealousy had its origin in the brain, and he pointed out its presence in cases of
neurological disorders and substance abuse. Very little information is currently available
regarding the biology of jealousy, although there seems to be some involvement of the
attachment system (oxytocin) (Insel & Shapiro, 1992) and of different neurotransmitters, such
as serotonin (5-HT) (Insel & Winslow, 1998; Newman, 1998; Marazziti et al., 2003a).
The aim of the present study was that of contributing to the definition of the boundary
between normal jealousy and obsessional jealousy by means of a specific self-report
questionnaire developed by us.

METHODS
We administered the self-report questionnaire (see appendix) of jealousy to a group of
400 subjects, composed of university students and local residents of both sexes. We had
previously administered a prototypical version of the questionnaire, called “Questionnaire of
Jealousy”, to a pilot sample of 30 students, not included in our larger sample of 400, who
refused to complete it. Subsequently, we changed the label of the questionnaire in
“Questionnaire of Affective Relationships (QAR)”, and immediately all resistance to filling in
it vanished: this, in our view, clearly reflects the negative attitude towards jealousy in our
modern society.
The QAR consists of 30 items; responses are rated on a Likert scale ranging between 1
(least severe) and 4 (most severe). The items were designed in such a way as to assess
specific behavior arising from thoughts of jealousy, such as checking a partner’s explanations,
friends, or clothes, or limiting a partner’s freedom: they, therefore, explored different
features:

1. concerns about a partner’s behavior (# 1, 2, 3, 4, 5, 6);

2. time spent in concerns/thoughts about a partner’s fidelity (# 8);
3. interference with daily activities and a partner’s outside relationships (# 7, 9, 10)
4. characteristics of the concerns/thoughts (# 11, 12)
5. avoidance behavior (# 15, 16, 17)
6. prevention of a partner’s behavior (# 18, 19);
7. level and quality of sexual activity (# 20, 21, 22, 23)
232 Donatella Marazziti*, Marina Carlini, Francesca Golia et al.

8. checking up on a partner’s behavior (# 24, 25, 26, 27, 28, 29, 30).

We specifically directed the subjects to focus on jealousy feelings regarding their current
relationships.
We used the score of the item # 8 (“time spent on concerns/thoughts about a partner’s
fidelity”) as a basis for distinguishing between normal jealousy and obsessive jealousy; more
than 1 hour a day was considered a specific threshold, based on a similar item of the Yale
Brown Obsessive-Compulsive Scale (Y-BOCS) (Goodman et al., 1986).
Fourteen patients with OCD (10 female and 4 male: mean age+SD: 29.4+6.5 years),
whose main obsession was jealousy, were also administered the QAR. These patients were
recruited at the outpatients unit of the “Dipartimento di Psichiatria, Neurobiologia,
Farmacologia e Biotecnologie” at the University of Pisa, and met current DSM-IV (APA,
1994) criteria for OCD, with neither a past nor a current history of mood disorders, as
assessed by the SCID-IV (First et al., 1997). None of the patients had ever taken drugs, except
that three who had taken benzodiazepines and/or neuroleptics in the past. The age (mean+SD)
at the onset of OC symptoms was 18+5, and the duration (mean+SD) of the disorder was
10+9 years. The severity of the OC symptoms was evaluated by means of the Y-BOCS: the
total score (mean+SD) was 27.5+7.3.
The subjects were all free of physical illness, and participated in our study after giving
their informed written consent.
Statistics. We used one-way analysis of variance (ANOVA) to compare the mean score
of Y-BOCS and QAR amongst the groups. Post-hoc comparisons were performed using the
Scheffè method. Analysis of covariance (ANCOVA) was used to control for the effect of
gender and age. All analyses were carried out using SSPS, version 4.0 (Nie et al., 1998).

RESULTS
Two hundred and forty-five (61.2 %) questionnaires, out of the total of 400, were
completed. The remaining 155 (38.8 %) were not returned due to either refusal to complete
them or to the lack of a partner in a current intimate relationship. One hundred and fifty-nine
(64.9%) of the subjects were women while 86 (35.1%) were men, and their age (mean+SD)
was 26.0+6.5 years.
Two hundred and twenty-one (90.2 %) (142 women and 79 men), out of the total of 245,
demonstrated no concerns/thoughts of jealousy: their age (mean+SD) was 25.6+5.9 years.
Two hundred and nine were single and 12 married.
Twenty-four (9.8 %) (17 women and 7 men), out of the total of 245, were shown as being
excessively jealous: their age (mean+SD) was 24.9+4.0 years. Twenty-two were single and 2
married.
The total score on the QAR was 42.8+10.7 (range: 17-76) in the first group, 49.9+14.02
(range: 27-82) in the second and 64.9+16.2 (range: 36-90) in the group of OCD patients. As
shown in Table 1, significant differences amongst the three groups were observed; in
particular, the OCD patients resulted to be more jealous than the excessively jealous subjects,
who, in turn, had higher scores than the non-jealous subjects.
 Normal and Obsessional Jealousy 233

We found also differences amongst the three groups regarding a series of items, except
for # 9 (“these concerns, if present, appear to you excessive and unreasonable”) and # 21
(“frequency of sexual intercourse”). The scores of the OCD patients resulted significantly
higher than those of the normal jealous subjects, who, in turn, had higher scores than the non-
jealous ones, regarding items # 5, 6, 8, 12, 14, 16, 18, 19, 22, 24, 25, 26, 27 and 28. There
were similarities between the OCD and the normal jealous subjects, with both groups
showing significant differences, as compared with the non-jealous ones, concerning items # 7
(an index of egodystonia), # 23 (fear of not being sexually attractive to a partner) and # 30
(checking the partner’s clothes). The normal jealous subjects were similar to the non-jealous
ones, with both groups showing a statistically-significant difference from the OCD patients,
for items # 1, 2, 3, 4, 10, 13, 15, 17 and 29.
These differences were not explained by differences in gender and age.

Table 1. Characteristics of the subjects (mean+SD)

Age (year) Y-BOCS QAR

Healthy Jealous 24.9+4.0 6.2+4.3 49.9+14.0
Subjects17 F, 7 M
OCD Patients 29.+6.5 27.5+7.3 64.9+16.2
10 F, 4 M
Healthy subjects 25.6+5.9 2.1+1.4 42.8+10.7
142 F, 79 M
Analysis of variance of the total score of the questionnaire:
F test: 27.84, p < 0.0001
Post-hoc significant differences:
OCD patients > healthy jealous subjects
OCD patients > healthy controls
Healthy jealous subjects > healthy subjects
OCD patients > healthy jealous subjects > healthy subjects

CONCLUSION
There is a main bias in the present study, that should be acknowledged: it was carried out
in a sample of university students and local residents, which, as has already been pointed out
(Mullen & Martin, 1994), is not representative of the general population; however, most of
the published papers on jealousy report results based on samples consisting of students
(Mathes, 1986; Micheal et al., 1995; Pines & Friedman, 1997).
Notwithstanding this limitation, our study showed some intriguing results. About 10% of
the students had a tendency to harbor excessive thoughts of jealousy concerning their partner.
This is not a finding which can be easily compared to those of previous studies, since we
specifically directed the subjects to focus only on current relationships and the feelings
associated with it, without referring to any past experiences. When past experiences were
taken into consideration, the percentage of jealous subjects rose, but the level of jealousy was
not as extreme (Mathes et al., 1982; Buunk et al., 1985; Mathes, 1986; Paul et al., 1993).
234 Donatella Marazziti*, Marina Carlini, Francesca Golia et al.

More important, our questionnaire enabled us to quite clearly distinguish three groups of
subjects: the normal subjects, those who were excessively jealous and whom we labeled
“normal jealous”, and those patients affected by obsessional jealousy. The results for a
number of the items on the questionnaire were significantly different in the three groups, such
as the time spent in jealous thoughts/concerns (between 1 and 4 hours a day amongst the
normal jealous subjects, and between 4 and 8 hours a day amongst the OCD patients), the
ability to remove jealous thoughts out of the mind, the degree to which the relationship was
impaired, the degree to which there was an attempt to limit the partner’s freedom, and the
checking up on a partner’s behavior. Noteworthy is the fact that healthy jealous subjects were
no different from the OCD patients in terms of egodystonia, which may represent a specific
index of obsessional preoccupation. The OCD patients did, however, show higher scores than
both the normal jealous subjects and the healthy controls with regard to the frequency of
preoccupation, suspicion, interference with daily activities, strategies to avoid jealous
thoughts/concerns, and the checking for traces of sexual intercourse.
It might be concluded that “normal jealous subjects” suffered from a moderate form of
OCD, or had an obsessive-compulsive personality or a positive family history of OCD: but
we excluded all such possibilities by means of a detailed psychiatric interview and the Y-
BOCS total score that was within the normal range. In addition, the percentage of those
“normal jealous” subjects is different from that reported for OCD, which is present in the 2.5
% of the general population (Karno et al., 1988). We believe that, at least in young subjects,
our questionnaire is effective in distinguishing three different forms of jealousy, and that even
normal jealousy is heterogeneous (Mullen & Martin, 1994; Micheal et al., 1995; Stein et al.,
1994). We recently proposed a dimensional model along the “uncertainty/certainty” and
“insight/no insight” dimensions, possibly related to the 5-HT system (Marazziti et al., 1999,
2003a, b), spanning from the pole of normality to the opposite pole of delusional severity,
where a number of different conditions can be located. It is our opinion that the phenomenon
of jealousy may also fit well in this model.

REFERENCES
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Washington, DC: American Psychiatric Press.
Buss, D. M. (1989). Sex differences in human mate preferences: Evolutionary hypotheses
tested in 37 cultures. Behavioural and Brain Science, 12, 1-49.
Buss, D. M., Larsen, R. J., Westen, D., Semmelroth, J. (1992). Sex differences in jealousy:
Evolution, physiology, and psychology. Psychological Science, 3, 251-255.
Buunk, B. P., Angleitner, A., Oubaid, V., Buss, D. M. (1996). Sex differences in jealousy in
evolutionary and cultural perspective: Tests From the Nederlands, Germany and the
United States. Psychological Science, 7, 359-363.
Cobb, J. P., Marks, I. M. (1979). Morbid jealousy featuring as obsessive-compulsive
neurosis; treatment by behavioral psychoterapy. British Journal of Psychiatry, 34, 301-
305.
Docherty, J., Ellis, J. (1979). A new concept and finding in morbid jealousy. American
Journal of Psychiatry, 133, 679-683.
 Normal and Obsessional Jealousy 235

First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B. V. (1997). Structured Clinical
Interview for DSM-IV Axis I disorder-Patient Edition (SCID-I/P, Version 2.0, 4/97
revision). Biometrics Research Department, New York State Psychiatric Institute.
Goodman, W. K., Price, L. H., Rasmussen, S. A. (1986) The Yale Brown Obsessive-
compulsive Scale I: development, use and reliability. Archives of General Psychiatry, 46,
1006-1011.
Gross, M. D. (1991). Treatment of pathological jealousy by fluoxetine. American Journal of
Psychiatry, 148, 683-684.
Insel, T. R., Shapiro, L. E. (1992). Oxytocin receptor distribution reflects social organization
in monogamous and polygamous voles. Proceedings of the National Academy of
Sciences, USA, 89, 5981-5985.
Insel, T. R., Winslow, J. T. (1998). Serotonin and neuropeptides in affiliative behaviors.
Biological Psychiatry, 44, 207-219.
Karno, M., Golding, J. M., Sorenson, S. B. (1988). The epidemiology of obsessive-
compulsive disorder in five US Communities. Archives of General Psychiatry, 45, 1094-
1099.
Kraepelin, E. (1910). Ein Lehrbuch fur Studierende und Aertze. 8th ed. Leipzig, Germany:
Johann Ambrosius Barth.
Kraft-Ebbing, R. (1982). Ueber Eifersuchtswahn beim Männe. Journal of Psychiatry and
Neurology, 10, 212-231.
Lane, R. D. (1990). Successful fluoxetine treatment of pathological jealousy. Journal of
Clinical Psychiatry, 51, 345-346.
Marazziti, D., Akiskal, H. S., Rossi, A., Cassano, G. B. (1999). Alteration of the platelet
serotonin transporter in romantic love. Psychological Medicine, 29, 741-745.
Marazziti, D., Di Nasso, E., Masala, I., Baroni, S., Abelli, M., Mengali, F., Mungai, F., Rucci,
P. (2003b). Normal and obsessional jealousy: a study of a population of young adults.
European Psychiatry, 18, 106-111.
Marazziti, D., Rucci, P., Di Nasso, E., Masala, I., Baroni, S., Rossi, A., Giannaccini, G.,
Mengali, F., Lucacchini, A. (2003a). Jealousy and subthreshold psychopathology: a
serotonergic link. Neuropsychobiology, 47, 12-16.Mathes, E. W., Roterr, M. P., Joerger,
S. M. (1982). A convergence validity study of six jealousy scales. Psychological Reports,
50, 1143-1147.
Mathes, E. V. (1986). Jealousy and romantic love: a longitudinal study. Psychological
Reports, 58, 885-886.
Michael, A., Mirza, S., Mirza, K. A. H. (1995). Morbid jealousy in alcoholism. British
Journal of Psychiatry, 167, 668-672.
Mullen, P. E. (1991). Jealousy: The pathology of passion. British Journal of Psychiatry, 158,
593-601.
Mullen, P. E., Martin, J. (1994). Jealousy: A community study. British Journal of Psychiatry,
164, 35-43.
Newman, J. D. (1998). The physiologic control of mammalian vocalization. New York:
Plenum Press.
Nie, N. H., Hull, C. H., Steinbrenner, K., Bent, D. H. (1998). Statistical Package for the
Social Science (SPSS), (4nd edn), New York: Mc Graw-Hill Company.
Parker, G., Barrett, E. (1997). Morbid jealousy as a variant of obsessive-compulsive disorder.
Australian and New Zealand Journal of Psychiatry, 31, 133-138.
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Paul, L., Foss, M. A., Galloway, J. (1993). Sexual jealousy in young men and women.
Aggressive Behaviour, 19, 401-420.
Pines, A. M., Friedman, A. (1997). Gender differences in romantic jealousy. The Journal of
Social Psychology, 138, 54-71.
Shrestha, K., Reeds, D. W., Rix, K. J. B. (1985). Sexual jealousy in alcoholics. Acta
Psychiatrica Scandinavica, 72, 283-290.
Stein, D. J., Hollander, M. D., Josephson, S. C. (1994). Serotonin reuptake blockers for the
treatment of obsessional jealousy. Journal of Clinical Psychiatry, 55, 30-33.
Tarrier, N., Beckett, R., Harwood, S., Bishay, N. (1990). Morbid jealousy: a review and
cognitive-behavioural formulation. British Journal of Psychiatry, 157, 319-326.
In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 13

JEALOUSY, SEROTONIN
AND SUBTHRESHOLD PSYCHOPATHOLOGY

Donatella Marazziti*, Francesca Golia, Marina Carlini, Stefano

Baroni, Irene Masala, Mario Catena Dell’Osso, Giorgio Consoli
Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie,
University of Pisa, Italy

ABSTRACT
Background: Different studies have suggested that some neurotransmitters may play
a role in the expression of jealousy. In our study, we utilized the specific binding of 3H-
paroxetine (3H-Par) as a peripheral tool to explore the serotonergic system in platelets of
healthy subjects with and without jealousy concerns.
Methods: Twenty-one subjects with thoughts of jealousy and 21 subjects without
jealousy concerns, as revealed by their score at a specific questionnaire (“Questionnaire
of Affective Relationships”, QAR), were included in our study. Subjects in the first group
were administered a battery of self-report instruments designed to detect the presence of
subthreshold psychopathology. The binding of 3H-Par was carried according to a
standardized protocol.
Results: The results showed a reduced density of 3H-Par binding in the “jealous”
subjects, as compared with the “non-jealous” subjects. In addition, most of the subjects
of the first group had one or moresubthreshold psychopathological conditions.
Conclusion: We concluded that jealousy may be considered an expression of subtle
forms of psychopathology, and may provoke an alteration of the serotonergic system, as
reflected by the lower density of the platelet serotonin transporter.

Keywords: Jealousy, Serotonin System, Serotonin transporter, Platelets, Subthreshold

Psychopathology

*
Author to whom correspondence and reprint request are to be sent: Dr. Donatella Marazziti. Dipartimento di
Psichiatria, Neurobiologia, Farmacologia e Biotecnologie, University of Pisa, via Roma, 67, I-56100 Pisa,
Italy. Telephone: +39 050 835412; Fax: +39 050 21581. E-mail address: dmarazzi@psico.med.unipi.it
238 Donatella Marazziti, Francesca Golia, Marina Carlini et al.

INTRODUCTION
Romantic jealousy is a heterogeneous emotion, ranging from normality to pathology,
with different degrees of intensity, persistence and insight (Parker and Barrett, 1997), and can
be defined as a complex emotional state in which a suspicion, or even conviction, of a
partner’s infidelity is the main concern.
How to define exactly the boundaries between “normal” and “pathological” jealousy
represents “a formidable problem” for clinicians (Mullen, 1991), because recognizing
pathological jealousy seems to be easier than defining it (Tarrier et al., 1990). Pathological
jealousy may be an extreme reaction to an abnormally-perceived threat to a relationship, or a
symptom of an underlying organic/toxic condition, such as alcoholism (Shresta et al., 1985;
Michael et al., 1995), or of a psychiatric disorder, such as obsessive-compulsive disorder,
mood disorders, separation anxiety and paranoia (Tarrier et al., 1990). Most researchers have
focussed their efforts on delusional jealousy, while the other forms of pathological jealousy
have received much less attention.
From the evolutionary point of view, jealousy is an experience and a response which is
both universal and innate with different significance in the two sexes: in men it is driven by
the certainty of paternity, while in women by the need of a stable and long-lasting support for
childrearing (Buss et al., 1989; 1992). For this reason, it has been suggested that
neurobiological mechanisms might regulate the development, expression and degree of
jealousy. Early in the last century, Kraepelin (1910) proposed that jealousy has its roots in the
brain, while noting its presence in both neurological and substance abuse disorders. The
literature on the biology of jealousy is quite meager and, perhaps, involves the attachment
system (oxytocin) (Insel and Shapiro, 1992) and different neurotransmitters, such as
norepinephrine, opioid peptides, dopamine and serotonin (5-HT), which play a role in pair-
bonding formation, sexual behavior and the establishment of long-lasting relationships
(Newman, 1998).
We recently proposed a dimensional model along the “uncertainty/certainty” and
“insight/no insight” dimensions, which had permitted the detection of similar reductions in
platelet 5-HT transporter proteins in both patients with different psychiatric disorders and
normal conditions, such as the early phase of a love relationship (Marazziti et al., 1999). In
the current study we applied the same theoretical model to jealousy
Therefore, we measured and compared the platelet 5-HT transporter, by means of the 3H-
paroxetine binding (3H-Par), in both jealous and non-jealous subjects,who were distinguished
on the basis of their scores at a specific self-administered questionnaire (“Questionnaire
ofAffective Relationships”, QAR).

METHODS

Subjects

Our study sample consisted of: a) 21 subjects (14 female and 7 male, mean age +SD:
24.9+4.0 years) who had jealous thoughts; and b) 21 subjects matched by age and gender
with group a), selected from a larger group of medical students and residents who completed
 Jealousy, Serotonin and Subthreshold Psychopathology 239

the QAR and were included in a previous study (Marazziti et al., 2003). These were 14
females and 7 males, with a mean age of 25.1+5 years,and were not jealous.
A psychiatric interview excluded the presence of a personal or family history of major
psychiatric disorders. We then categorized the subjects as “jealous” or “non-jealous”
according to how much time the subject spent on thoughts/concerns regard their partner’s
fidelity: we considered more than 1 hour a day to be a specific hallmark, based on a similar
item in the Yale Brown Obsessive-Compulsive Scale (Y-BOCS) (Goodman et al., 1986). The
subjects in group a) were administered a battery of spectrum questionnaires with the aim of
detecting the presence of a subthreshold psychopathology (Rucci & Maser, 2000).
Furthermore, measurements were repeated in two different years in order to check the
stability of the binding parameters.
None of the subjects was suffering from a physical illness. All gave their informed
written consent to participate in the study, which was approved by the Ethical Committee of
the University of Pisa.

Instruments: Questionnaire of Affective Relationships (QAR)

The QARis composed by 30 items, and all responses to the questions are assigned a
number on a Likert scale from 1 (least severe) to 4 (most severe). The items were specifically
designed to permit an evaluation concerning behaviors arising from thoughts of jealousy,
such as checking a partner’s explanations, friends, or clothes, or limiting a partner’s freedom
(Marazziti et al., 2003). No specific cut-off score has yet been established to discrimate
between “jealous” and “nonjealous” subjects because this questionnaire was not yet validated
. Therefore, for the purposes of the present study we decided to use just a single item,
specifically “time spent on thoughts/ concerns regarding a partner’s fidelity”, to characterize
jealous subjects.

Spectrum Instruments

We used the following four instruments to better characterize jealous subjects: the mood
spectrum self-report (MOODS-SR), the social anxiety spectrum self-report (SHY-SR), the
panic-agoraphobia spectrum self-report (PAS-SR) and the obsessive-compulsive spectrum
self-report (OBS-SR), which were designed to assess the spectrum of 4 psychiatric disorders,
namely mood disorders (unipolar and bipolar disorder), social anxiety disorder, panic disorder
and obsessive-compulsive disorder.
Excellent psychometric properties were demonstrated by these spectrum instruments,
amongst which were high test-retest reliability, good discriminant validity and, for the PAS-
SR, clinical validity in predicting time to response to treatment (Frank et al., 2000; 2002;
Shear et al., 2001; Dell’Osso et al., 2002).
Following a method described in Frank et al. (2001), we employed Receiver Operating
Characteristic Curve (ROC) analysis in determining a cut-off score for these instruments.
Subjects meeting at least one of the four spectrum conditions were identified using these
cut-off scores. The expert clinical judgment of one of the authors was also used to determine
the presence of the spectrum. To define a clinically significant spectrum condition, we
240 Donatella Marazziti, Francesca Golia, Marina Carlini et al.

utilized a combined criterion, defined by exceeding at least one threshold score on the four
instruments and being rated clinically positive for the spectrum.

Preparation of Platelet Membranes

Venous blood (20 ml) was collected between 8 and 9 a.m. during the months of March-
June (to avoid the possible interference of circadian and seasonal rhythms, respectively) from
subjects who had fasted. The sample was then mixed with 1 ml of anticoagulant 0.15 M
EDTA. The biologists who analyzed the blood samples had no knowledge of the subjects’
conditions.
We used low-speed centrifugation (200 x g, for 20 min, at 22°C) to obtain platelet-rich
plasma. Platelets were precipitated from PRP by centrifugation at 10,000 x g for 10 min at
4°C, and then washed with 8 ml buffer (150 mM NaCl, 20 mM EDTA, 50 mM Tris-HCl, pH
7.5, 4°C). We lysed and homogenized the pellets in 8 ml buffer (5 mM Tris-HCl, 5mM
EDTA, pH 7.5, 4°C) with an ultrathurrax homogenizer, which were then centrifuged twice at
30,000 x g for 15 min at 4°C. The ensuing pellet was then stored at -80°C until the assay,
which was performed within a week.

3
H-Par Binding

Platelet membranes were suspended in an assay buffer 50 mM Tris, 120 mM NaCl, 5

mM KCl (pH 7.4), and homogenized. The 3H-Par binding was carried out following the
method of Marazziti et al. (1996). The incubation mixture consisted of 100 µl of platelet
membranes (50-100 µg protein/tube), 50 µl of 3H-Par at six concentrations ranging from 0.01
to 1 nM, and 1850 µl of assay buffer. Specific binding was obtained as the binding remaining
in the presence of 10 µM fluoxetine (a gift from Eli-Lilly Co., Indianapolis, USA) as a
displacer. All samples were assayed in duplicate and incubated at 22°C for 1 hour. The
incubation was halted by adding 5 ml of cold assay buffer. The content of the tubes was
immediately filtered under vacuum through glass fibre filters GF/C (Whatman) 2.5 cm in
diameter, and washed 3 times with 5 ml of assay buffer. Equilibrium-saturation binding data,
the maximum binding capacity (Bmax, fmol/mg) and the dissociation constant (Kd, nM) were
analyzed by means of iterative curve-fitting computer programs EBDA (McPherson, 1985).
Proteins were measured following Peterson’s method (1977).

Statistics

Independent-sample t-test analysis was used to compare the Bmax mean values between
the two study groups. We performed analysis of covariance (ANCOVA) to check for the
effect of gender and age on differences in mean Bmax values between the groups. All analyses
were carried out using SPSS, version 10.
 Jealousy, Serotonin and Subthreshold Psychopathology 241

RESULTS
The mean+SD of the QAR total score was 40+11 and 53+12 in the non-jealous and the
jealous subjects, respectively, significantly lower in the first than in the second group.
Jealous subjects had Bmax values significanly lower than those without jealousy concerns
(833+232 vs 1518+229, t-test= -10, df=38, p<0.001). However, no difference in Kd mean
values was observed between the two groups (Table 1). Neither age nor gender had an effect
on 3H-Par binding parameters.
In the group of 21 jealous subjects, who had blood samples collected on two different
occasions, the mean Bmax was computed to increase the reliability of the measurement.
Of these 21 subjects, 8 had a psychiatric spectrum condition, defined as exceeding at least
one of the cut-off scores of the 4 spectrum questionnaires. Specifically, five of these subjects
were seen to exceed the threshold for the obsessive-compulsive spectrum, two the panic-
agoraphobic spectrum, and one the mood spectrum. Three of these subjects had multiple
spectrum conditions (Table 2). Although the Bmax values in these 8subjects with a spectrum
condition were, on average, lower than in subjects without the spectrum condition, the
difference failed to reach statistical significance (t-test=0.74, df=19, p=0.47).

Table 1. 3H-Paroxetine binding parameters (Bmax and Kd, mean+SD) in subjects without
and with jealousy concerns

Bmax Kd
Subjects without jealousy 1518+229* 0.123+0.075
concerns (14 F, 7 M)
Subjects with jealousy 833+232 0.166+0.130
concerns(14 F, 7 M)
Bmax = fmol/mg protein; Kd = nM; * significant at p<0.001

Table 2. Spectrum conditions in 8 excessively jealous subjects. Subjects 2, 4, 8 exceeded

the cut-off score for more than one spectrum

PAS-SR OBS-SR SHY-SR MOODS-SR

1 1 76 7 6
2 31 96 100 88
3 52 19 8 49
4 57 68 92 84
5 20 64 53 37
6 40 26 6 26
7 27 34 10 85
8 23 61 13 66
Total N 8 8 8 8

PAS-SR = panic agoraphobia spectrum (cut-off score 35)

OBS-SR = obsessive-compulsive spectrum (cut-off score 59)
SHY-SR = social anxiety spectrum (cut-off score 59)
MOODS-SR = mood spectrum (cut-off score 61)
242 Donatella Marazziti, Francesca Golia, Marina Carlini et al.

CONCLUSION
The limitation of the present study is that the healthy subjects were recruited from a
population consisting of university students and local residents, which is not representative of
the general population, as it has already been noted (Mullen and Martin, 1994);
notwithstanding this fact, a large portion of the published material on jealousy has been
collected from studies involving similar groups of subjects (Mathews, 1986; Pines and
Friedman, 1997). In any case, our study, yielded some intriguing preliminary results. The
evaluation of the platelet 5-HT transporter showed that there was a significant decrease of the
platelet 5-HT transporter proteins in subjects with concerns regarding their partner’s fidelity,
as compared with those, with no such concerns: the biological measurements, therefore,
seemed to support the distinction between the two groups. An interesting fact is that the
number of platelet 5-HT transporter proteins in the jealous subjects was similar to that
measured in patients with different psychiatric disorders, such as major depression, panic
disorder, and obsessive-compulsive disorder, as well as in one normal condition, i.e.,
romantic love (Marazziti et al., 1999). These findings, taken together, suggest that all these
different conditions share “something” reflected by the decreased number of the 5-HT
transporter, probably at the level of common dimensions yet to be identified.
Support for this assumption can be found in the fact that five subjects with jealousy
concerns had an OC spectrum pathology, and in three of these there were other subthreshold
symptoms. Two other subjects had panic-agoraphobic spectrum, and one subject had mood
spectrum. It must also be noted that, although our approach in determining the presence of a
clinically significant spectrum condition was very conservative, another 10, out of the total 21
jealous subjects, met either the clinical or the instrument criterion.
Our study, although carried out in a small sample to draw firm conclusions, yielded
intriguing findings which would suggest that excessive jealous thoughts/concerns could be
the expression of underlying, subthreshold forms of psychopathology, which, although not
meeting the full criteria of formal psychiatric disorders, nevertheless impair the normal
functioning of an individual and predispose him/her to the development of doubts regarding
the partner’s fidelity. Therefore, the spectrum conditions may represent factors of a non-
specific vulnerability, a kind of fragile background that, when triggered by the presence of the
love relationship, may lead to excessive jealousy. We tentatively hypothesize that, although
jealousy can in any case be seen as a sign or symptom of subthreshold psychopathology and
an expression of liability factors, it is activated into becoming clinically relevant by the
presence of the different lifetime spectrum symptoms that may shape its presentation
(obsessional, depressive, anxious or delusional). A study aimed at addressing this issue is
currently ongoing. In addition, it could be hypothesized that the 5-HT dysfunction, reflected
by the reduced density of the platelet 5-HT transporter, might be a non-specific biological
indicator of the presence of one or more underlying spectrum conditions or dimensions; the
identification of these conditions or dimensions, crossing normal and pathological states, will
surely be one of the exciting fields of future neuroscientific research.
 Jealousy, Serotonin and Subthreshold Psychopathology 243

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Buss, D. M. (1989). Sex differences in human mate preferences: Evolutionary hypotheses
tested in 37 cultures. Behavioral and Brain Science, 12, 1-49.
Buss, D. M., Larsen, R. J., Westen, D., Semmelroth, J. (1992). Sex differences in jealousy:
Evolution, physiology, and psychology. Psychological Science, 3, 251-255.
Cassano, G. B., Michelini, S., Shear M. K., Coli, E., Maser, J. D., Frank, E. (1997). The
panic-agoraphobic spectrum: A descriptive approach to the assessment and treatment of
subtle symptoms. American Journal of Psychiatry, 154, 27-38.
Dell’Osso, L., Armani, A., Rucci, P., Frank, E., Fagiolini, A., Corretti, G., Shear, M. K.,
Grochocinski, V. J., Maser, J. D., Endicott, J., Cassano, G. B. (2002). Measuring mood
spectrum disorder. Comparison of interview (SCI-MOODS) and self-report (MOODS-
SR) instruments. Comprehensive Psychiatry, 43, 69-73.
Frank, E., Shear, M. K., Rucci, P., Cyranowski, J. M., Endicott, J., Fagiolini, A.,
Grochocinski, V. J., Kupfer, D.J., Maser, J. D., Cassano, G. B. (2000). Influence of
panic-agoraphobic spectrum symptoms on treatment response in recurrent major
depression. American Journal of Psychiatry, 157, 1101-1107.
Frank, E., Cyranowski, J. M., Rucci, P., Shear, M. K., Fagiolini, A., Thase, M. E., Cassano,
G. B., Grochocinski, V. J., Kostelnik, B., Kupfer, D. J. (2002). Clinical significance of
lifetime panic spectrum symptoms in the treatment of bipolar I disorder. Archives of
General Psychiatry, 59, 905-911.
Goodman, W. K., Price, L. H., Rasmussen, S. A. (1986). The Yale Brown Obsessive-
compulsive Scale I: development, use and reliability. Archives of General Psychiatry, 46,
1006-1011.
Insel, T. R., Shapiro, L. E. (1992). Oxytocin receptor distribution reflects social organization
in monogamous and polygamous voles. Proceedings of the National Academy of Sciences
USA, 89, 5981-5985.
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Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 14

ADVANCES IN DYADIC AND SOCIAL NETWORK

ANALYSES FOR LONGITUDINAL DATA:
DEVELOPMENTAL IMPLICATIONS AND APPLICATIONS

William J. Burk
Leiden University, the Netherlands
Danielle Popp, and Brett Laursen
Florida Atlantic University, Boca Raton, Florida, USA

ABSTRACT
Interdependence, a central feature of close relationships, presents contemporary
scholars with theoretical and statistical challenges. Dyadic and social network analytic
techniques have recently been formulated that offer several advantages over previous
statistical methods by accounting for various forms of interdependence for longitudinal
data collected from both relationship partners. We describe two of these methods: the
Actor-Partner Interdependence Model (APIM: Kenny, Kashy, & Cook, 2006) and actor-
based models of network-behavioral dynamics (Snijders, Steglich, & Schweinberger,
2007). The APIM partitions variance into estimates of behavioral stability of both dyad
members (actor effects), and interpersonal influence (partner effects), while adjusting for
initial behavioral similarity between partners. The actor-based models describe dyadic
relationships as embedded within a multitude of interconnected dyadic relationships (i.e.,
social networks). These dynamic models utilize computer simulations to partition
variance into parameters that ascribe similarity based on network, dyadic and individual
behavioral attributes. To illustrate the applicability of both methods, we describe
empirical examples from our recent work using these models techniques.

Relationships with parents and peers are understood to be an important context for
development and psychosocial adjustment of children and adolescents (Hartup & Laursen,
1999). Close relationships are characterized by social interactions between dyadic partners
that are maintained over an appreciable amount of time (Kelley et al., 1983). This definition
246 William J. Burk, Danielle Popp and Brett Laursen

emphasizes interdependence as a central feature of relationships between family members,

friends, and romantic partners (Bugenthal, 2000; Reis, Collins, & Berscheid, 2000). Objective
measures of interdependence, such as closeness, intimacy and social support, have gained
prominence in the developmental literature (Baumeister & Leary, 1995; Berscheid, 1999;
Furman, 1996; Laursen & Bukowski, 1997). Unfortunately, developmental scholars have
been slower to appreciate that relational interdependence necessarily implies statistical
interdependence (Laursen, Popp, Burk, Kerr, & Stattin, in press; Kenny, 1996). Standard
parametric statistical analyses are unable to easily accommodate interdependencies inherent
in data collected from or about both relationship partners. Several dyadic data analytic
methods have been developed that account for nonindependence (Gonzales & Griffin, 1999;
Kashy & Kenny, 2000). In this chapter, we provide an overview of two longitudinal
techniques that offer special promise to developmental scholars: actor-partner
interdependence models (Kenny, Kashy, & Cook, 2006) and actor-based models of social
network and behavioral dynamics (Snijders, Steglich, & Schweinberger, 2007).
It is well known that relationship partners tend to be similar on various attitudes,
behaviors, and physical characteristics (Lazarsfeld & Merton, 1954). While moderate levels
of similarity has been documented for parent-child dyads (Cook & Kenny, 2005; Gonzalez,
Cauce, & Mason, 1996; Kim, Conger, Lorenz, & Elder, 2001; Noller & Callan, 1988; Stice &
Barrera, 1995), more robust levels of similarity have been reported between youth friendship
dyads (Burk & Laursen, 2005; Burk, Steglich, & Snijders, 2007; Kandel, 1978; Popp,
Laursen, Kerr, Stattin, & Burk, 2008), and romantic partner dyads (Capaldi & Crosby, 1997;
Krueger, Moffitt, Caspi, Bleske, & Silva, 1998; Quinton, Pickles, Maughan, & Rutter, 1993;
Rhule-Louie & McMahon, 2007). This similarity, or statistical interdependence, represents
the nonindependent or correlated nature of data collected from both participants in a close
relationship.
Statistical interdependence may be attributed to various distinct sources, including
compositional (selection) effects, unilateral and mutual influences, exogenous factors
common to both individuals, and measurement error (Kenny, Kashy, & Cook, 2006).
Selection and influence have received the lion’s share of empirical attention. Selection
emphasizes similarity prior to the initiation of the relationship. Influence emphasizes
increased similarities acquired after the initiation of the relationship. The patterns of influence
may be further differentiated as unilateral or mutual influence between partners. That is,
interdependence observed between relationship partners may be attributed to similarity prior
to or after the establishment of the relationship, and increased similarity may be the result of
either one partner becoming more similar to the other or both partners become more similar to
each other over time. Delineating the relative contributions of different sources of
interdependence has become increasingly recognized as fundamental to understanding
developmental processes between relationship partners and between dyadic relationships
(Laursen et al., in press).
Unfortunately, statistical interdependence precludes the use of standard correlational and
regression-based methods because these parametric methods assume independent
observations. Violations of the independence assumption introduce systematic biases to the
standard errors of estimates, thus inflating the significance of standardized test statistics
(Kenny, 1995; Kenny, Kashy, & Cook, 2006). Previously, researchers have typically used one
of two strategies to avoid these biases. The first approach utilizes aggregate or difference
scores to examine dyad-level phenomenon. This solution does allow for the appropriate use of
 Dyadic and Social Network Analyses for Longitudinal Data 247

conventional parametric statistics and interpretations at the dyadic level of analysis, but
eliminates the ability to examine variation that might be attributed to the individual. For
example, a parent and child who both report moderate levels of relationship satisfaction have
a similar averge level of satisfaction as dyads consisting of one satisfied and one dissatisfied
participant. The second strategy involves separately analyzed data for each participant in a
relationship. When identical measures are available from both partners, this strategy leads to
four separate analyses: two single-reporter analyses (e.g., both predictor and outcome
variables reported by one of the dyad members) and two cross-reporter analyses (e.g.,
predictor reported by one partner and outcome from the other). This solution also avoids
biases associated with nonindependence and allows for interpretations at the individual level
of analysis, but eliminates the ability to examine variation that might be attributed to the
dyad. So, these strategies limit researchers to interpretations at either the individual or dyadic
level of analysis.
Several analytic techniques have been developed to disentangle similarity attributable to
individuals and dyads (Gonzalez & Griffin, 1999; Kashy & Kenny, 2000; Snijders, 2001).
Longitudinal applications of these methods represent an important step for developmental
researchers, in that, these longitudinal models are capable of delineating specific processes
and mechanisms, such as homophilic selection and social influence. We devote the remaining
text to describing two dyadic data techniques that are capable of modeling interdependence in
longitudinal data, and simultaneously estimating the relative importance of selection and
influence processes in the explanation of similarity between dyadic partners. For each
method, we provide a non-technical overview of basic model specifications, followed by a
description of specific advantages of each modeling technique. To illustrate the applicability
of these methods, we include empirical application of these models from our recent work.

ACTOR-PARTNER INTERDEPENDENCE MODEL

The Actor-Partner Interdependence Model (APIM: Kenny & Cook, 1999; Kashy &
Kenny, 2000) is a dyadic approach that simultaneously estimates the effect of an individual’s
predictor variable on his or her own outcome variable (the actor effect) and on his or her
partner’s outcome variable (the partner effect), controlling for variance shared across
participants (i.e. statistical interdependence). The earliest applications of this method
examined concurrent measures of interactions between family members (Cook & Dreyer,
1984; Kenny & La Voie, 1984). However, these methods have been utilized to a greater
extend to examine peer relations. Previous studies have examined concurrent interactions
among playmates and classmates (Malloy, Sugarman, Montvilo, & Ben-Zeev, 1995; Ross &
Lollis, 1989), the quality of play between friends and nonfriends (Simpkins & Parke, 2002),
features of friendship quality and disagreements (Burk & Laursen, 2005), and social status
within the peer group (Card, Hodges, Little, & Hawley, 2005).
In longitudinal APIM applications, the interpretation of actor and partner effects
somewhat differs from the concurrent model: Actor effects represent autoregressive stability
paths and partner effects represent paths of interpersonal (cross-partner) influence. One of the
first empirical applications of APIM procedures examined mother and child reports of the
child’s attachment security (Cook & Kenny, 2005). A mother-child dyad represents a
248 William J. Burk, Danielle Popp and Brett Laursen

quintessential distinguishable dyad, because the relationship partners can be easily classified
into distinct roles. Procedures for analyzing data from distinguishable dyads are relatively
straightforward compared to dyads that lack attributes that readily distinguish individual
members (Gonzales & Griffin, 1999; Kashy & Kenny, 2000). APIM procedures have been
modified for use with indistinguishable dyads, such as same-sex friends (Olsen & Kenny,
2006; Woody & Sadler, 2005). These procedures include several additional constraints that
add to the statistical complexity of this modeling approach. That is, actor and partner effects
are constrained to be equal, as are means, intercepts, variances, and covariances. In this
manuscript, we focus on APIM procedures for distinguishable dyads. Readers interested in
related procedures for indistinguishable dyads are referred to Olsen and Kenny (2006) and
Laursen et al. (in press).

U W

Person X a1x Person X a2x Person X

Time 1 Time 2 Time 3
p1x p2y
c1 c2 c3
p1y p2x

Person Y a1y Person Y a2y Person Y

Time 1 Time 2 Time 3

V Z

Note: a1x = initial stability of individual behavior for Person X. a1y = initial stability of individual
behavior for Person Y. a2x = subsequent behavioral stability of Person X. a2y = subsequent
behavioral stability of Person Y. p1x = initial partner influence of Person X on behavior of Person
Y. p1y = initial partner influence of Person Y on behavior of Person X. p2x = subsequent partner
influence of Person X on behavior of Person Y. p2y = subsequent partner influence of Person Y on
behavior of Person X. c1 = time 1 dyadic similarity. U = residual variance in behavior of Person X
at time 2. V = residual variance in behavior of Person Y at time 2. c2 = time 2 residual similarity.
W = residual variance in behavior of Person X at time 3. Z = residual variance in behavior of
Person Y at time 3. c3 = time 3 residual similarity.

Figure 1. Longitudinal Actor-Partner Interdependence Model for Distinguishable Dyads.

Figure 1 presents a conceptual longitudinal APIM for distinguishable dyads across three
time points. The paths are labeled according to traditional APIM terminology, where
concurrent estimates of similarity represent dyadic correlations I, stability estimates represent
actor effects (a), and influence estimates represent partner effects (p). Time 1 similarity (c1)
represents the initial correlation between dyad members’ (Person X and Y) reports of a
 Dyadic and Social Network Analyses for Longitudinal Data 249

specific behavior. Time 2 similarity (c2) and time 3 similarity (c3) describe correlations
between dyad members on the residuals of the outcome behavior. Two actor effects are
estimated for each period of change. Initial stability is assessed from time 1 to time 2 for
person X (a1x) and for person Y (a1y). Subsequent stability is assessed from time 2 to time 3
for person X (a2x) and person Y (a2y). Two partner effects are also estimated across adjacent
time points. Initial influence describes cross-paths between the behavior of person X at time 1
and the behavior of person Y at time 2 (p1x) and between the behavior of person Y at time 1
and the behavior of person X at time 2 (p1y). Subsequent influence describes cross-paths
between the time 2 behavior of person X and time 3 behavior of person Y (p2x) and between
the time 2 behavior of person Y and the time 3 behavior of person X (p2y). All these effects
are modeled simultaneously, so each estimate in the model represents unique effects,
partialling out the effects of the other estimates.
Neyer (2002) has formulated a multiple groups structural equation modeling procedure to
compare actor and partner effects across different types of dyads. This application is well-
suited to investigating homophilic processes in close peer relationships because friendships
differ in time of initiation and duration (i.e., they begin and end at different time points). To
assess selection, similarity needs to be estimated prior to the establishment of a friendship. In
contrast, influence effects need to be estimated after the friendship was established. So,
selection and influence cannot be disentangled for friendships reported during the first wave
of data collection, because it is impossible to distinguish friendships that were recently
established from friendships that were longer lived. However, when three time points are
available, selection and influence effects can be estimated for some groups of friendship
dyads. For example, dyads whose members were not friends at time 1, but who nominated
each other as friends at times two and three (new friends). For these dyads, selection effects
are operationalized in terms of dyadic similarity at time 1 (i.e., the time preceding the
initiation of the friendship); influence effects are operationalized in terms of changes in
similarity at times 2 and 3. Furthermore, partner effects may be used to examine whether
changes in similarity may be attributed to unilateral or mutual influence.
For illustrative purposes, we briefly describe some findings from a recent study in which
we utilized this approach to examine homophilic processes in alcohol use among 545
Swedish adolescent friendship dyads (Popp et al., 2008). In this study, dyads were classified
according to initiation and duration of the friendship, and dyad members were distinguished
based on their relative age. Continuing with our example of new friends, youth in these
friendship dyads were similar in their self-reported alcohol intoxication frequency at time
one, thus indicating selection. Similarity increased at times two and three. Initial and
subsequent stability estimates revealed the older friend’s drinking behavior was relatively
more stable than the younger friend’s drinking behavior. Initial influence estimates revealed
the older friend’s drinking behavior at time one predicted changes in their younger friend’s
drinking behavior at time two, but the younger friend’s drinking behavior did not predict
changes in their older friend’s alcohol use. Subsequent influence estimates indicated mutual
influence. That is, the older friend’s drinking behavior at time two predicted changes in the
younger friend’s alcohol use at time three and the younger friend’s time two drinking
behavior predicted changes in the older friend’s alcohol use at time three. So, for these new
friendship dyads, both selection and influence contributed to similarity between friends’
alcohol use. Additionally, influence between dyad members seemed to shift during the course
of the friendship, from unilateral influence during the initial stages of the relationship to
250 William J. Burk, Danielle Popp and Brett Laursen

mutual influence. Different patterns of findings emerged for each of the friendship groups in
the study, collectively indicating similarity prior to the onset of the friendship, unilateral
influence in the initial stages of the friendship, followed by mutual influence between older
and younger friendship partners.
The longitudinal actor-partner model provides an analytic framework that simultaneously
examines interpersonal influences between dyad partners while accounting for the degree of
dyadic similarity in both predictor and outcome measures. Furthermore, distinguishing dyad
members on the basis of meaningful attributes allows for the delineation of unilateral and
mutual influences. We have described models that have been extended to include an
additional measurement point and multiple group analyses. These models may also be
extended to include additional measures, such as between-dyad and within-dyad variables, as
well as various interaction effects including actor-partner interactions (see Kenny, Kashy, &
Cook, 2006). The APIM framework has also been extended to incorporate measures from
more than two relationship partners (Kenny, Mannetti, Pierro, Livi, & Kashy, 2002).
Furthermore, these models may be performed with most standard statistical programs, using
either a pooled-regression approach, structural equation modeling, or hierarchical linear
modeling software (Kenny, Kashy, & Cook, 2006).
Our extensions of the APIM provide additional advantages when investigating close
relationships that may differ as a function of initiation and duration, such as friendships. We
applied this model to the investigation of two well established mechanisms leading to
friendship homophily, and simultaneously examined similarity prior to the relationship
(selection) and similarity acquired after the initiation of the friendship (influence) for
relationships that emerged after the initial data collection. Applications examining different
types of relationships and mechanisms of social influence may also be considered. Overall,
the APIM framework provides researchers with a viable analytic tool for modeling
interdependence and interpersonal influence in longitudinal dyadic data.

ACTOR-BASED MODELS OF NETWORK-BEHAVIORAL DYNAMICS

In some cases, researchers may want to consider dyadic relationships as embedded within
larger relational structures comprised of a multitude of interconnected dyadic relationships,
referred to as social networks. Within the social network literature, analytic methods have
been developed capable of accounting for interdependencies in network data (Carrington,
Scott & Wasserman, 2005; Wasserman & Faust, 1994). We focus our discussion on one of
these methods, actor-based models of network-behavioral dynamics (Snijders, Steglich, &
Schweinberger, 2007; Snijders, Steglich, & Van de Bunt, in press). This modeling approach
simultaneously estimates effects describing changes in relationship ties and individual
behaviors, while accounting for structural features of the social network. That is, this
approach is capable of accounting for statistical interdependence as well as nonindependence
due to structural characteristics of dyadic relations (e.g., individuals are allowed to participate
in more than one dyadic relationship).
The actor-based approach reflects the basic assumption that individuals make decisions
about their own relationship ties and their own behaviors according to short-term preferences
and constraints (Snijders, 2001; 2005). That is, individuals are presumed to make decisions
 Dyadic and Social Network Analyses for Longitudinal Data 251

intended to optimize their position in the overall network. These decisions lead to changes in
ties directed to others (i.e., selection) and changes in their own behaviors (i.e., influence). It is
reasonable to assume that these decisions (and changes) reflect a continuous process, so this
approach incorporates the continuous-time Markov chain model initially proposed by Holland
and Leinhardt (1977) to model network and behavioral dynamics. So, although data are
collected at discrete measurement points, the total observed change between measurement
points is decomposed into probabilistic sequences of many small changes (i.e., micro-steps)
between observed measurements.
These assumptions simplify the dynamic process and reduce the modeling procedure to
two smaller tasks: (a) modeling the frequencies of, and opportunities for network changes
(network micro-steps) and behavioral changes (behavioral micro-steps), referred to as rate
functions; and (b) modeling the preferences and tendencies guiding the types of specific
changes in network or behavioral micro-steps, referred to as objective functions. Models of
network dynamics and individual behavioral dynamics are separately estimated using
transition probabilities associated with all possible combinations of change. The separate
models are integrated by allowing changes in network ties to depend on changes in individual
behaviors and allowing changes in individual behaviors to depend on changes in network ties.
Statistical complexities do not allow for explicit calculations of these models, so parameters
are instead estimated using iterative computer simulations within a Markov Chain Monte
Carlo approach. So, the estimated model parameters indicate which sequence of network and
behavioral micro-steps is most probable, given the observed data.

Network Dynamics

Network dynamics are modeled with rate function parameters that represent the
frequency of changes in network ties and with objective function parameters that estimate the
types of changes. Rate function parameters describe the number of opportunities for change
from one measurement point to the next (i.e., micro-steps). These parameters are typically
constrained to be equal across each successive period of change. However, these estimates
may be permitted to vary as a function of individual attributes or behaviors.
The network objective function includes various parameters modeling endogenous effects
of network structure and exogenous effects of individual and dyadic covariates. Endogenous
network effects include specifications of well-known structural features of network dynamics,
such as reciprocity and transitivity (Carrington, Scott & Wasserman, 2005). Reciprocity
describes the tendency for actors to reciprocate nominations. Transitivity describes transitive
network closure (i.e., the tendency for actors’ nominations to involve triadic relations and
larger cohesive group structures). Transitivity may be specified by in various ways, but the
most common description is a preference for dyadic relationships to be embedded within
cohesive triadic relations (i.e., “my friends are also friends”). Model parameters of transitivity
and other effects modeling structural tendencies of social networks are described elsewhere
(e.g., Snijders, Steglich, & Van de Bunt, in press). While patterns may vary, reciprocity and
some specification of transitivity are well documented as significant predictors of friendship
ties and of ties other relational networks based on advice, liking, trust, and cooperation
(Lazega, Lemercier, & Mounier, 2006; Van de Bunt, Wittek, & de Klepper, 2003).
252 William J. Burk, Danielle Popp and Brett Laursen

The network objective function also includes exogenous effects of dyadic and individual
attributes. Dyadic attributes describe effects specific to pairs of individuals such that each
dyadic covariate constitutes a separate network of ties. A dyadic covariate network may be
constant or may change over time. The basic parameter estimated for each dyadic covariate
describes the tendency for actors with ties in the dyadic covariate network to also have
connections in the overall social network. For each individual attribute, three basic parameters
may be specified. Attribute ego describes the effect of the attribute on outgoing nominations.
Attribute alter describes the effect of the attribute on incoming nominations. Attribute
similarity describes the tendency for ties to occur between individuals with similar levels of
the attribute. Using participant sex as an example (with males = 0 and females = 1), a positive
sex ego effect indicates females have more outgoing nominations than males (i.e., females are
more active in the network). A positive sex alter effect indicates that females receive more
nominations than males (i.e., females are more popular in the network). A positive sex
similarity effect indicates that friendships tend to occur between youth of the same sex (i.e.,
homophilic selection). These three effects may be similarly interpreted for attributes that
consist of more than two levels and for those that change over time.
Interactions may be specified between various endogenous network effects and
parameters associated with two or more dyadic or individual covariates. Using the sex ego
parameter as an example, an interaction between sex ego and reciprocity addresses the
question; do females tend to reciprocate friendships more than males? A positive sex ego by
reciprocity interaction would indicate that females are more likely to reciprocate friendships
than are males. Another potentially interesting set of interactions include the ego parameter of
one attribute and the alter effect of a different attribute. Continuing with the example, an
interaction between sex ego and the alter effect of, say delinquency, examines whether males
or females are more likely to select others with high levels of delinquency. A positive
interaction between sex ego by delinquency alter would indicate that females are more likely
to nominate individuals with higher levels of delinquency than males. Numerous theoretically
interesting questions may be addressed by specifying different interactions between available
parameters.

Behavioral Dynamics

Behavioral dynamics are specified in a similar manner. Rate function parameters

represent the frequency of changes in individual behaviors and objective function parameters
estimate the types of behavioral change. Like the rate function parameters for network
dynamics, these parameters are also typically constrained to be equal across each successive
period of change, but may be permitted to vary as a function of individual attributes or other
behaviors.
The behavioral objective function includes parameters modeling overall behavioral
tendencies, as well as effects of individual attributes that depend on network connections (i.e.,
social influence). Two basic behavioral tendencies are typically modeled. The linear tendency
describes the propensity of individuals to report high levels of a behavior. So, positive values
indicate a tendency for individuals to report high levels of an attribute; negative values
indicate a tendency for individuals to report low levels of an attribute. The curvilinear
tendency describes the quadratic function of the behavior. A positive estimate indicates a self-
 Dyadic and Social Network Analyses for Longitudinal Data 253

reinforcing or addictive behavior; a negative estimate indicates a self-correcting behavior, or

a behavior that provides negative feedback.
Perhaps the most interesting aspect of behavioral dynamics involves estimates of social
influence. Several different parameters representing social influence can be specified within
the actor-based modeling framework. Average influence describes the tendency of actors to
adopt the behavior of affiliates with whom they are tied, regardless of the number of
connections. Total influence, on the other hand, describes this tendency (to adopt the
behaviors of others) as increasing as a function of the number of connections. Finally,
average alter describes the tendency for individuals to adopt the average behavioral level of
those to whom they are connected. While estimates of these three parameters may be similar
within models, each parameter represents different theoretical operationalizations of social
influence.
As with network dynamics, interactions may be specified between behaviors and
endogenous network effects and effects of dyadic and individual attributes. Interactions
between parameters representing social influence and attribute ego effects are perhaps the
most interesting. Returning to the example involving the sex ego parameter, an interaction
between sex ego and average similarity based on delinquency examines whether males or
females are more susceptible to delinquent peer influence. A positive interaction would
indicate females are more likely to adopt the delinquent behaviors of their friends than males
(regardless of the number of friendships). These interactions, as well as the interactions
described for network dynamics, offer researchers a promising tool for testing moderators of
selection and influence processes.
The APIM procedures described earlier may be performed with various statistical
methods and conventional social sciences software, actor-based models of network and
behavioral dynamics require specialized software. One option for performing these models is
the Simulation Investigation for Empirical Network Analyses (SIENA: Snijders et al., 2006).
SIENA is one of the statistical modules of StOCNET (Boer et al., 2006), a family of
statistical programs for social network analysis. The SIENA homepage (http://
stat.gamma.rug.nl/snijders/siena.html) provides links to many of the references cited in this
chapter, as well as technical reports and articles in which actor-based methods are applied to
empirical data. Other software options are available (e.g., Handcock, Hunter, Butts,
Goodreau, & Morris, 2005). Huisman and Van Duijn (2005) provide an excellent review of
the capabilities of these various social network analytic software programs.
We briefly describe findings from one of our first studies utilizing these techniques
(Burk, Steglich, & Snijders, 2007), which may be found on the SIENA website. In this study
we examined selection and influence processes related to minor delinquency in a friendship
network of Swedish youth. Nomination and behavioral data were collected from 260 youth
annually for four measurements. We found evidence for both homophilic selection based on
delinquency (delinquency similarity) and delinquent peer influence (average delinquent
influence), controlling for tendencies for reciprocity and transitivity, selection based on
school and classroom attendance (dyadic covariate similarity), and homophilic selection
based on gender and age (individual attribute similarity). Furthermore, we tested whether
delinquent selection and influence were substantially stronger in reciprocating friendship
dyads compared to unilateral friendships (using interactions involving reciprocity). We found
evidence that homophilic selection did not differ as a function of reciprocity, but delinquent
254 William J. Burk, Danielle Popp and Brett Laursen

influence was significantly stronger in reciprocating friendship compared to unilateral

relationships.
Actor-based models of network and behavioral dynamics provide several advantages over
alternative methods. First, these models do not assume dyads are independent. While dyadic
independence may be a logical conclusion in some situations (e.g., married couples), it is not
necessarily a realistic assumption when examining youth friendships. Second, these models
have been specifically designed to simultaneously estimate homophilic selection and
influence processes using all available information. Unlike the APIM extensions described
earlier, estimates of selection and influence are based on changes in relationship ties and
changes in behaviors of all study participants, thus potentially providing more realistic
estimates of selection and influence. Third, these models utilize Markov processes to model
network and behavioral changes within a continuous time framework. This provides a more
precise estimate of changes in network ties and changes in individual behaviors. Finally, these
models provide the needed flexibility to incorporate a myriad of interaction effects testing
moderators of network and behavioral dynamics.

CONCLUSIONS
Developmental scholars have long appreciated that the dyadic properties of a relationship
are key to understanding its significance in individual development. One of these properties,
namely statistical interdependence, or the degree of dyadic similarity between relationship
partners, biases conventional statistical tests, thus precluding the use of parametric statistical
methods. This has resulted in many researchers to underutilize dyadic data. Fortunately, new
tools have been developed that make it possible for the first time to incorporate
interdependence in developmental research. We have described two such methods that show
particular promise: actor-partner interdependence models and actor-based models of network-
behavioral dynamics.
Actor-partner and actor-based models both offer advantages over previous analytic
strategies for dyadic data, in that, both techniques are capable of accurately modeling
statistical interdependence, and structural dependencies in data collected from dyads or
several members of small groups. Within a distinguishable dyad approach, the longitudinal
actor-partner model provides a framework that allows researchers to delineate unilateral and
mutual influences between relationship partners. Our proposed extensions to the APIM (i.e.,
an additional time point and multiple group analyses) allow for simultaneous assessment of
homophilic selection and social influence processes in (friendship) dyads that differ in the
time of initiation and duration of the relationship. The actor-based models of network-
behavioral dynamics also allow for the simultaneous assessment of selection and influence
processes. In addition, these models account for nonindependence between dyads. That is,
this method also models the degree of structural dependence in dyadic relationships that are
embedded within larger relational network structures. We have provided an overview of these
two techniques, presenting basic definitions and applications of these models. We believe
these two approaches represent substantive advances over alternative modeling procedures.
Both approaches provide a great deal of analytic flexibility to accommodate more complex
models, including multiple predictors and outcomes. Collectively, both methods provide a
 Dyadic and Social Network Analyses for Longitudinal Data 255

complementary analytic framework that offers researchers new tools for the analysis of
dyadic data that better capture the richness and the significance of close relationships.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 15

MOTHER-INFANT INTERACTION IN CULTURAL

CONTEXT: A STUDY OF NICARAGUAN AND
ITALIAN FAMILIES

Ughetta Moscardino, Sabrina Bonichini

and Cristina Valduga
Department of Developmental and Social Psychology,
University of Padua, Italy

ABSTRACT
Although a common goal for parents is to promote their children’s successful
development in a respective society, there is considerable cross-cultural variation in the
beliefs parents hold about children, families, and themselves as parents. Previous research
suggests that in traditional rural areas across the world, parents highly appreciate
interrelatedness in their conceptions of relationships and competence, whereas in urban
settings of Western industrialized societies, parents seem to promote independent parent–
child relationships from early on. The main purpose of this study is to compare
conceptions of parenting and mother-infant interactions in two cultural contexts that may
be expected to hold different beliefs about parent-child relationships: Nicaraguan farmer
families and middle-class Italian families. Fifty-six mothers from central Nicaragua (n =
26) and northern Italy (n = 30) and their infants aged 0-14 months participated in the
study. Mothers were interviewed regarding their childrearing beliefs and behaviors, and
were videotaped interacting with their infants during a free play session. Maternal
responses were qualitatively analyzed using a thematic approach; maternal behaviors
were coded into one of the following categories: social play, object play, motor
stimulation, verbal stimulation, and face-to-face interaction. Findings indicated that: 1)
Nicaraguan mothers emphasized interdependence and connectedness to other people in
their socialization goals, whereas Italian mothers placed greater focus on childrearing
strategies consistent with a more individualistic orientation; 2) Nicaraguan mothers
exhibited a higher overall frequency of behaviors related to motor stimulation and face-
to-face interaction, whereas Italian mothers were more likely to engage in social play,
object play, and to emit a greater overall number of verbal behaviors towards their infants
260 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

during the free-play session. Our results suggest that parents’ conceptions of childcare
reflect culturally regulated norms and customs that are instantiated in parental behavior
and contribute to the structuring of parent-child interactions from the earliest months of
life, thus shaping developmental pathways of infants and children. Implications for
theory on the psychology of relationships as well as for clinical practice are discussed.

INTRODUCTION
A universal goal for parents is to promote their children’s successful development in a
specific eco-cultural context according to their values, norms, and expectations related to
childcare and childrearing (Bornstein, 1991; Harkness and Super, 1996; LeVine, 2002;
Weisner, 2002; Whiting and Edwards, 1988). However, there is considerable cross-cultural
variation in how parents socialize their infants to become competent adults later in life.
Parents’ ideas about children, families, and caregiving, or parental ethnotheories (Harkness
and Super, 2006), reflect broader cultural models that inform parental behavior and contribute
to the structuring of physical settings, daily activities, and social interactions, thus influencing
children’s development from the earliest months of life (Bornstein et al., 1999; Rogoff, 2003;
Super and Harkness, 2002). For the developmental phase of infancy, two major cultural
models have been proposed to study parental beliefs and behaviors in different cultural
communities: the model of “individualism/independence” and the model of
“collectivism/interpedendence” (Hofstede, 1991; Kağitçibaşi, 1997; Markus and Kitayama,
1991; Triandis, 1995). These terms describe differing sociocultural orientations at the cultural
as well as the individual level that may serve as heuristic devices to characterize parental
belief systems and practices (Greenfield and Suzuki, 1998; Shweder et al., 1998).
The model of individualism/independence can be found in educated families living in
Western industrial and post-industrial information societies (Kağitçibaşi, 2005; Keller et al.,
2006; Triandis et al., 1988). In this model, the self is conceived as a unique, autonomous, and
separate entity; personal needs and goals are central, and relationships with others are built
based on personal choice. Societies that have been described as individualistic include the
United States (Harkness, Super, and van Tijen, 2000; Harwood, Schölmerich, Schulze, and
Gonzalez, 1999) and other West European countries, such as Germany (Citlak et al., 2008;
Keller et al., 2005a). The collectivism/interdependence model is common among rural
traditional subsistence-based farmer families in non-Western cultures (Greenfield, Keller,
Fuligni, and Maynard, 2003; LeVine et al., 1994). In this model, the self is defined in terms of
heteronomy and relatedness; group goals are more important than individual goals, and
interpersonal relationships are highly valued. Norms and duties regulate social relationships,
and harmony is maintained through the respect of roles and obligations (Kağitçibaşi, 2005;
Keller et al., 2004). Societies sharing this broad cultural orientation comprise East Asian
countries such as China (Chao and Tseng, 2002), India (Saraswathi, 1999), and Japan
(Rothbaum et al., 2000; Markus and Kitayama, 1991), but also traditional rural areas in Africa
(Keller et al., 2005a; Nsamenang and Lamb, 1994; Ogunnaike and Houser, 2002) and Latin
America (Bornstein and Cote, 2001; Harwood et al., 1999; Triandis et al., 1988). Although
the two models are derived from research conducted in a relatively limited number of
sociocultural settings (Harwood et al., 2002; Nsamenang and Lamb, 1994), and intracultural
variation must be taken into account (Harkness et al., 2000; Harwood, Schölmerich, and
 Mother-Infant Interaction in Cultural Context 261

Schulze, 2000; Palacios and Moreno, 1996), their definitions have been refined and
successfully applied in multiple cultural environments to analyze parents’ conceptions of
relationships and competence (Bornstein and Cote, 2001; Markus and Kitayama, 1991).
Some authors suggest that parents provide different types of stimulation consistent with
their own views of child development and competence during free-play situations with their
infants, thus linking broad cultural models to interactional styles and socialization strategies
(Bornstein et al., 1999; Keller et al., 2004). In particular, the model of independence is
expressed in a distal parenting style characterized by frequent face-to-face interaction,
exclusive dyadic attention, contingency to positive signals, and object play; developmentally,
this pattern leads to an autonomous agency as it enhances the infant’s sense of separateness
and increases the awareness of causality (Keller et al., 2005b). Solitary play with objects also
contributes to the development of an independent self (Harwood et al., 1999). The model of
interdependence is primarily supported by a proximal parenting style characterized by
physical contact and stimulation, warmth, shared attentional focus, and sensitivity to the
infant’s negative signals; these behaviors have been related to the development of a
heteronymous agency, as they enhance relational closeness and a sense of belonging to the
community (Kağitçibaşi, 1997; LeVine et al., 1994).
The present study aims to compare childrearing beliefs and behaviors in two particular
communities within cultures assumed to embody different cultural models: Central
Nicaraguan farmer families and North Italian middle-class families. Based on Hofstede’s
(1991) multinational studies of cultural values, we expect Nicaragua to express a
collectivistic/interdependent orientation, whereas Italy is assumed to represent an
individualistic/independent orientation1. In the following paragraphs we briefly describe the
sociocultural background of the two communities included in our study.

NICARAGUAN FARMERS’ FAMILIES

The Republic of Nicaragua is the largest country in Central America, but it is also the
least densely populated in comparison with neighboring Honduras and Costa Rica. In 2008,
an estimated 5.79 million people lived in Nicaragua (CIA World Factbook, 2008a). Due to
the Spanish conquest and a complex combination of socio-demographic factors, 69% of the
Nicaraguan population is Mestizo (people of mixed European and American Indian ancestry),
with the remaining being Europeans (17%), Creoles and/or Africans (9%), and Amerindians
(5%). Traditionally, the religion of the majority is Roman Catholic, but evangelical
Protestants and Mormons have been rapidly growing since the 1990s. Popular religion centers
around the saints, who are perceived as intermediaries between human beings and God
(Gilbert, 1993).
Economy is primarily based on agriculture, but light industry (maquila), banking, mining,
fisheries, tourism, and general commerce are increasing. Nicaragua’s agrarian economy has

1
Geert Hofstede has developed a classification system in which 50 countries and three geographical regions are
ranked for their national individualism, with lower values indicating higher levels of individualism, and
viceversa (e.g., rank 1 = USA, rank 53 = Guatemala). Although Nicaragua is not included in this system,
neighboring Costa Rica ranks 42, whereas Italy ranks 6. More information is available at
www.clearlycultural.com/geert-hofstede-cultural-dimensions/individualism.
262 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

historically been based on the export of cash crops such as coffee, bananas, sugar, beef, and
tobacco (CIA World Factbook, 2008a). Since 1980, education is free from ages seven to
twelve, but the educational system is underfunded and generally inadequate, with only 18%
of the total national budget invested in primary, secondary, and higher education (Gilbert,
1993). At the time of the Sandinista Revolution in 1979, the educational system was one of
the poorest in Latin America, but a series of large-scale literacy campaigns reduced the
overall illiteracy rate from 50% to 13% (Gilbert, 1993).
In Nicaraguan society the nuclear family forms the basis of family structure, but women
are highly dependent on the support system formed by sisters, mothers, grandmothers, and
other relatives (Espinoza, 2002). The extended family and godparents play a powerful role in
the social, economic, and political relations of Nicaraguans due to the enduring lack of
stability of other societal institutions (Lamontagne, Engle, and Zeitlin, 1998). In particular,
the set of relationships between a child’s parents and his/her godparents (“compadrazgo”)
serves to establish strong bonds of ritual kinship with persons unrelated by blood or marriage,
thus influencing the individual’s status in the larger society. Although stable monogamous
unions and strong patriarchal authority at home are deeply ingrained cultural values, many
Nicaraguan households are headed by women (Gilbert, 1993).
Infants are primarily raised by the mother with the help of the extended kin, whereas the
father rarely participates directly in childcare and childrearing (Espinoza, 2002). Like in other
countries with high infant mortality rates, physical proximity between mother and baby is
fostered through cosleeping and breastfeeding on demand, especially during the infancy
period (LeVine et al., 1994). Traditional parenting beliefs and expectations reflect Hispanic
values emphasizing harmonious relationships between family members, which are achieved
through the early socialization of obedience, respect, and cooperation (Harwood et al., 1999;
Leyendecker, Lamb, Harwood, and Schölmerich, 2002; Moscardino and Bonichini, 2007;
Varela et al., 2004). Previous research reports that Central American mothers frequently
engage in physical stimulation to exercise their infants’ motor skills (Bornstein and Cote,
2001), and consider body contact as a very important means to transmit positive affect (Keller
et al., 2005a).

ITALIAN MIDDLE –CLASS FAMILIES

Today, Italy counts more than 59 million inhabitants and has the 7th –highest GDP among
the world economies (CIA World Factbook, 2008b). After the Second World War, the
country experienced an economic boom that led to substantial migration from rural to
metropolitan areas, with approximately two thirds of the population now living in urban
settings. The literacy rate in Italy is 98% overall, and school is mandatory for children aged 6
to 16. The vast majority of Italians (90%) are Roman Catholic, although only about one-third
of these practice their religion. The Catholic Church is no longer officially the state religion;
however, it still influences the country’s political affairs partly because of the Holy See’s
location in Rome. Italy’s economic system is characterized by the presence of small and
medium-sized companies, with a marked difference between a developed industrial north,
dominated by private companies, and a less developed agricultural south.
 Mother-Infant Interaction in Cultural Context 263

Italians generally live in nuclear families, although frequent contacts with the extended
family are common. A majority of women participate in the labor force and receive support
from health and social services in their everyday lives (Saraceno, 2003). Italian society shares
cultural norms and values of many other Western societies emphasizing individualism and
independence, especially in the northern regions (Bornstein, Cote, and Venuti, 2001). Co-
sleeping is uncommon, as infants are expected from early on to sleep through the night in a
separate room; however, health professionals highly recommend breastfeeding across the first
six months of life to promote children’s physical and psychological well-being (Moscardino,
Nwobu, and Axia, 2006). Family socialization practices and formal schooling are directed to
the promotion of children’s creativity and self-expression. Parents encourage assertiveness,
independence, and social competence during the early years of childhood, since interpersonal
skills and being able to establish social interactions are viewed as desirable characteristics in
this cultural context (Casiglia, Lo Coco, and Zappulla, 1998; Gandini and Edwards, 2001).
Infant liveliness and activity are highly valued as they are considered indicators of good
physical health (Axia and Weisner, 2002; Harkness et al., 2006; Hsu and Lavelli, 2005). In
addition, parents’ childrearing beliefs emphasize emotional closeness, social openness,
autonomy, and serenity in the home environment (Axia, Bonichini, and Moscardino, 2003).
North Italian mothers tend to engage in both social and object play during interactions with
their infants to foster autonomous exploration as well as socio-emotional competence (Axia
and Weisner, 2002; Bornstein et al., 2001).
To summarize, the first goal of this study was to analyze childrearing beliefs and
developmental goals among rural Nicaraguan and middle-class Italian mothers of young
infants. Consistent with previous research suggesting that Central American culture can be
described as more interdependent/collectivistic (Keller et al., 2005a; Leyendecker et al.,
2002), whereas North Italian culture can be described as more independent/individualistic
(Bornstein et al., 2001; Hofstede, 1991), we expected that mothers in the two groups would
differ in their parenting conceptions according to these broad sociocultural constructs. The
second goal of our study was to investigate similarities and differences in both frequency and
duration of maternal behaviors in a free-play session in the two groups. Based on foregoing
comparative studies of mother-infant interaction during free play, we expected that
Nicaraguan mothers representing an interdependent cultural model would engage in physical
and motor stimulation more often and for longer periods of time than the Italian mothers.
Conversely, we expected that Italian mothers supporting an independent cultural model would
engage in face-to-face contact, social stimulation, and object play more often and for longer
periods of time compared to Nicaraguan mothers.

METHOD

Participants

Fifty-six families from the two cultural communities volunteered to participate in the
study. The central Nicaraguan sample consisted of 26 mother-infant dyads, and the north
Italian sample of 30 dyads. The rationale for the selection of the two cultures is based on
264 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

differing cultural conceptions of relationships and competence that may be attributed to

interdependent and independent worldviews.
The 26 Nicaraguan mothers lived in the rural area of Waslala, a municipality located 245
km north of Managua, the capital of Nicaragua. About a quarter of the country’s agriculture
takes place in this region. Most families made their living from farming and trading, and
educational attainment was generally lower than in the Italian sample. This group is assumed
to represent an interdependent cultural model (Kağitçibaşi, 1997; Leyendecker et al., 2002).
The 30 urban Italian mothers lived in Vicenza, a middle-sized industrial city in the
northeastern Veneto region. This area is today among the wealthiest and most industrialized
regions of Italy, with high annual economic growth and a very dynamic economy. Most
participants had achieved a high level of education, were relatively older, and had slightly
fewer children than the Nicaraguan sample. This sociodemographic profile has been
described as characteristic for women with an independent cultural model (Harwood et al.,
1999; Keller et al., 2004).
All mothers had one firstborn infant between the ages of 0 and 14 months. There were no
group differences in the age of each mother’s child (M = 8.43 months), and approximately
equal number of girls and boys were recruited in each sample. The average age of mothers
was 29 (SD = 6.74) years, ranging from 17 to 43 years. An overview of the sociodemographic
characteristics of the samples is presented in Table 1.
Analyses were performed on 9 demographic variables (child’s age, mother’s age, number
of children, percent firstborn infants, percent male infants, mother’s education in years,
maternal employment status, mother’s marital status, and religious background). Results
indicated that participants differed on just three demographic variables: Nicaraguan mothers
were significantly younger (t = -4.8, df = 54, p <.001), received less education (t = -3.81, df =
53, p < .001), and were less likely to report their religious background as Catholic (X2 = 30.6,
df = 2, p < .01) than their Italian counterparts. Although these characteristics differed
markedly between the two groups, they are in line with the standards of the participating
women’s respective populations and thus may be viewed as an integral part of their
sociocultural backgrounds. The selection of equivalent samples would have prevented us
from accurately representing the sociocultural environment of the study participants.

Table 1. Demographic characteristics of participants

Nicaraguan (n = 26) Italian (n = 30)

Characteristic M SD M SD
Child’s age (months) 8.7 3.4 8.2 3.2
Mother’s age 25.1 5.9 32.4 5.5
No. of children 2.1 1.4 1.8 0.9
Firstborn (%) 50 46.7
Male (%) 57.7 36.7
Mother’s education (years) 9.3 2.9 12.3 3.0
Percent mothers employed 50.0 56.7
Percent mothers married 84.6 96.7
Religious background (%)
None 38.5 0
Catholic 30.8 100
Protestant 30.8
 Mother-Infant Interaction in Cultural Context 265

RECRUITMENT AND PROCEDURE

Similar participant recruitment procedures were employed in the two cultural settings.
Specifically, samples were recruited by contacting the local health care centers. A number of
participants were personally contacted by members of the research team and asked to
participate. Parents were informed that we were interested in their ideas about parenting and
childrearing practices in different cultures. Families were then contacted by phone or in
person, and an appointment for the home visit was set up according to the mothers’
preference. In each site, mothers were interviewed and observed at home in their native
language by trained female research assistants. After a warming-up and a familiarization
phase, mothers provided their informed consent, completed a socio-demographic
questionnaire, and were asked to participated in a semi-structured interview concerning their
beliefs and expectations about child health, care, and development. Next, mothers were
videotaped interacting with their infants during a free-play session.
Interviews were administrated to the full sample. The Nicaraguan audiotapes were
transcribed and translated from Spanish into Italian by two bilingual, bicultural research
assistants according to standard back translation techniques. For microanalyses of the
videotaped mother-infant interactions, the data of 41 mothers (n = 23 Nicaraguan, n = 18
Italian) could be used and were included in the present study.

MEASURES
Maternal childrearing beliefs. The Nicaraguan and Italian mothers’ cultural beliefs and
practices were addressed in an in-depth, semi-structured interview used in previous cross-
cultural research on children and families (Harkness et al., 2006; Moscardino et al., 2006).
This technique allows to collect information on ideas, beliefs, opinions, and attitudes
concerning specific topics the investigator is interested in (Axia et al., 2003; Super and
Harkness, 1999). The interview focused on the following areas: family ecology (e.g.,
subsistence base, housing conditions), use of social/health care services, support and social
network, experience of pregnancy and childbirth, childcare beliefs and practices, descriptions
of the infant, and developmental goals. Although the questions were predetermined, length of
time spent discussing each topic and the ordering of questions varied according to participant
verbosity and responses to previously asked questions. Interviews usually lasted an average of
60 min (range = 30-90 min); they were tape-recorded and transcribed verbatim for further
analyses.
All interviews were analysed using a thematic approach to gain insight into caregivers’
subjective experiences relating to infant health, care, and development (Miles and Huberman,
1994). This type of analysis involves a systematic and objective encoding of qualitative data
into categorical data, the extraction of patterns, and the description of observations derived
from the data (Boyatzis, 1998). In particular, for the purpose of this study we will describe
recurrent themes in maternal responses concerning three broad areas of parenting and child
development: conceptions of the infant, daily routines and activities, and developmental
goals. For each interview, the recurrent themes or concepts relating to these areas were
identified. Verbatim quotations are used to illustrate the women’s responses on relevant
266 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

themes. All data were coded by the first author and a graduate-level research assistant. In
cases of disagreement, original transcripts were re-examined and discussed until coding
agreement was reached.
Mother-infant interactions. Since our purpose was to examine a setting in each culture
that allowed us to observe similarities and variations in parent-child relationships, we decided
to focus on mother-infant free-play situations. All mothers were asked to play with their
infants as they normally would when not involved in caregiving or other activities and were
then videotaped for 10 minutes. This time span was chosen because in infants of that age, it
has proven to adequately reflect the ability to sustain attention during a play situation (Keller
et al., 2004). To obtain culturally relevant information on maternal ocializat in the two
cultural environments, we did not give the mothers any indications about the type and content
of play. The videocamera was focused on both the mother’s and the infants’ heads as well as
upper trunks to facilitate subsequent microanalytic coding of the interactions.
The videotaped observations were continuously coded to record the onset and offset of
specific maternal and infant ocializat using coding schemes adapted from previous
comparative research on mother-infant interaction during free play (Bornstein and Cote,
2001; Harwood et al., 1999; Keller et al., 2005a). In this study, we coded: (a) the frequency of
maternal and infant ocializat, defined as the proportion of times each ocializa occurred
during the play session on the total number of observed ocializas; (b) the duration of
maternal and infant ocializat, defined as the proportion of time mothers and their infants
spent in each ocializa on the total duration of all ocializat. The occurrence of discrete
ocializati events was coded with a microanalytic event-sampling technique. Table 2
presents the six ocializati categories for mothers as well as their definitions.

Table 2. Categories used to code mother-infant interactions during free-play in the two
cultural settings

Behavior Description
Social play The mother engages in verbal or physical ocializa to amuse her infant and to elicit
positive vocalizations and smiles. Objects and/or toys may be involved, but only if they
are not used in their original function (e.g., blanket for “peek-a-boo”). It includes
singing, tickling, clapping hands, directing the infant’s attention to herself or others
(e.g., siblings).
Object play The mother attempts to stimulate her infant’s attention with an object/toy; introduces a
new object/toy while the infant is playing; plays with the infant.
Physical/motor The mother physically or verbally encourages her infant to walk, stand, sit, crawl,
stimulation dance, step. It includes holding upright, tossing, shaking, lifting up, positioning, and
massaging the infant.
Verbal The mother encourages her infant to engage in a specific play activity (e.g., “Do you
stimulation want to read a book?”, “Let’s play with the ball”). It does not include maternal requests
to fetch objects/toys to be used during play (e.g., “Go and get the ball”).
Face-to-face The mother is positioned in front of her infant in a way that allows face-to-face
interaction interaction; mother and infant simultaneously look at each other’s face from a close
distance (i.e., within 1 meter) .
Infant plays The mother watches without intervening physically and/or verbally while her infant is
alone involved in some play activity.
 Mother-Infant Interaction in Cultural Context 267

Although we were primarily interested in mothers’ ocializat in this study, to control for
the possibility that group differences in maternal ocializa reflected differences in infant
behavior we also examined the following infant behaviors: (1) cry/fuss; (2); smile; (3)
vocalize; (4) look at mother; (5) look at object; (6) wander away.
Each cultural sample was coded by trained research assistants who were native speakers.
Inter-coder agreements between the research assistants and the first author were calculated on
over 25% of the Nicaraguan and Italian videotapes using Cohen’s Kappa. In the Nicaraguan
sample, interrater reliabilities for maternal and infant behaviors averaged .90 (range = .80-
.99) and .94 (range = .80-.99), respectively; in the Italian sample, Cohen’s Kappas for
maternal and infant behaviors reached a level of .92 (range = .90-.97) and .93 (range = .92-
.94), respectively.

RESULTS

Maternal Childrearing Beliefs

Conceptions of the child. To understand women’s ideas and expectations regarding their
own children, we asked them how they would describe their infants to a person who does not
know him/her. Interestingly, Nicaraguan mothers mostly focused on physical characteristics,
such as “beautiful”, “chubby”, “small”, “big”, “dark-skinned”, “has straight hair”, “moves
around a lot”. However, when explicitly asked to describe behaviours and qualities of their
infants, our study participants also used expressions like “playful”, “friendly”, “happy”,
“cheerful”, “smiling”, “does not cry much”. Overall, their expressions mostly referred to
social and emotional skills. Six mothers used the term “angry” (enohado) in relation to their
child’s difficulty, suggesting that stubbornness, inflexibility, and low manageability were
considered negative characteristics of the infant’s personality. In particular, one mother
explained:

“He has his moments of anger, because when he is holding something and I take it away, he
starts to hit me. Otherwise he likes to play, he laughs a lot, but sometimes he really gets angry
(…) Children are always easy when you love them. But if you do not love them, if you leave
them alone, if you do not care for them, then they will become difficult” (ID 4)

When asked about the ocializa displayed in front of unfamiliar people, most mothers
(14 of 26) said that their children easily approached strangers, whereas another 10 mothers
reported that their infants started to cry, became serious, and searched for physical closeness.
Only in one case, the child needed some time to observe the unfamiliar adult and then
eventually approached him/her.
In comparison with the Nicaraguan mothers, Italian mothers’ descriptions of their infants
were multifaceted and referred to several domains (i.e., physical, social, emotional, and
cognitive). The most frequently mentioned qualities included: “smiling”, “joyful”, “sunny
character”, “good”, “sweet”, “affectionate”, “extrovert”, “strong-willed”, “curious”, “smart”,
“alert”, “active”, “independent”, and “self-confident”. In general, infants were described as
being happy, funny (simpatico), determined, and lively (vivace). Our Italian study participants
particularly emphasized the dimensions of sociability and activity:
268 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

“He is very lively and independent, because he wants to do a lot of things by himself, without
any help…but he also likes to cuddle you, to hug you, although one moment later he is gone
because he needs to do something else, to move around.” (ID 23)

When asked about their infants’ difficulty, only 4 of 30 mothers considered their own
child to be difficult. These infants were described as being persistent, stubborn, and difficult
to manage because of their determination in obtaining something. In contrast, easy infants
were defined as “good-tempered”, “distractable”, and “sociable”. Accordingly, most of our
Italian participants (24 of 30) reported that their infants easily approached strangers. One
mother said:

“She likes to interact with everyone…when we join with the extended family and other
relatives, she does not get scared or cries, but she starts greeting people, and if someone wants
to hold her, she will go!” (ID 7)

Only 6 mothers described their infants as being wary and seeking the mother’s proximity
in front of an unfamiliar adult: “She fist observes the person, then she may even want to be
held, but after a while she starts to cry”; “He looks into people’s eyes, and only if they smile,
he will smile back”.
Daily routines and activities. Another relevant area of parent-child relationships concerns
the organization of daily routines. In particular, we asked our participants to describe their
ideas and practices related to the structuring and scheduling of their infants’ everyday
activities (e.g., feeding, sleeping, playing). In some cases (7 of 26), Nicaraguan mothers
preferred to feed their infants on demand and were not interested in imposing a schedule:
“There are no rhythms because she eats and sleeps, and everytime I nurse her she takes my
milk, so every day is different”; “Sometimes he sleeps in the morning, other times in the
evening…the truth is that he does not have a schedule”. In other cases, mothers emphasized
the importance of putting the baby on a schedule to foster his/her physical health: “My
attention is always devoted to him, because he needs to eat always at the same time”; “I pay
attention that he sleeps and rests, because this will make him grow more”. When asked about
bedtime routines, the vast majority of mothers (20 of 26) preferred to cosleep with their infant
in the same bed for a variety of reasons: “it is more comfortable to feed the baby during the
night”; “in our culture, a mother sleeps with her child until 2-3 years of age”; “they need to
feel the mother’s presence”. Most infants fell asleep during breastfeeding/nursing, but some
mothers used other strategies such as rocking, singing a song, and playing to make their infant
fall asleep. In terms of stimulation and play, most women said that they stayed at home with
their children except for those who were employed in the labor market; these mothers usually
took their infant to the workplace, where they often lay him/her in a hammock to easily
monitor and check on the baby. Only one women talked about play activities in the context of
caregiving:

“Early in the morning when she wakes up, I breastfeed her, and then she falls asleep
again…Then she wakes up, and this is the time we have fun together (…) In the afternoon I
breastfeed her again, then I bath her, change her diaper…when she becomes active it is a
moment of enjoyment for us.” (ID 10)
 Mother-Infant Interaction in Cultural Context 269

Italian mothers’ ideas about regularity and scheduling of their infants’ daily activities
were as diverse as the answers given. The majority of our study participants (17 of 30) put
their babies on a schedule in order to promote a sense of psychological stability and serenity:
“I try to put her on a schedule because I think that this will make her feel more comfortable
and calm”; “You need to give them a schedule so that they learn how to self-regulate”. In
some cases (8 of 30), mothers preferred to adjust to their infants’ biological rhythms, whereas
in others (5 of 30) there was no need to provide any input because the baby seemed to have
autonomously developed his/her own schedule. All mothers highlighted the importance of
teaching the child to sleep in his/her own room from early on, but in particular circumstances
(e.g., mother falls asleep during nighttime breastfeeding, infant wakes up many times during
the night) some infants slept in their parents’ bed. Although daily activities primarily centered
around childcare (i.e., feeding, sleeping, changing diaper), Italian mothers’ descriptions also
referred to play and to moments of reciprocal entertainment:

“In the afternoon my children take a nap, then I wake them up and we go to pick up their
sister at the kindergarten, and then I am there for them…we play, draw, paint, spend time
outside, take walks, and do all kinds of play activities together.” (ID 16)

Developmental goals. When asked about the most important thing for their children’s
development, Nicaraguan mothers’ responses mainly focused on health-related aspects, such
as “nutrition”, “breastmilk”, “preventing sickness”, “cleanliness”, and “clothing”. However,
these women also emphasized warmth and affection, good manners, respect of family
members, and education:

“The most important thing is to give her nutrition and take care of her…then she must learn to
respect the family, to go to school…all these things.” (ID 2)

Interestingly, only one mother highlighted the importance of play in addition to

caregiving: “Health is very important, and I must do everything so that he does not get
sick…but I also would like to provide the opportunity for him to play and have toys”.
Italian mothers’ responses mainly focused on the affective dimension of family
relationships, including serenity of the home environment, socialization/calmness, emotional
closeness between family members, and a good relationship with the partner. One mother
commented:

“The most important thing for her is a serene atmosphere at home…and a positive, optimistic
family climate (…). I want her to have dreams, and to grow up thinking that it is possible to
make dreams come true. I believe that everything comes as a consequence, both physically
and mentally.” (ID 8)

In contrast to the Nicaraguan women, our Italian participants rarely considered health and
nutrition as primary developmental goals.
270 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

MOTHER-INFANT INTERACTIONS
Preliminary analyses. Prior to data analysis, univariate and multivariate distributions of
all dependent variables were examined for normalcy, homogeneity of variance, and outliers
(Tabachnick and Fidell, 1996). Because not all maternal and infant behaviors were normally
distributed, nonparametric tests were used in all analyses. To control for the potentially
confounding effects of (a) infant sociodemographic variables (i.e., infant’s age, gender, and
birth order), and (b) maternal sociodemographic variables (i.e., mother’s age and years of
education) on our dependent variables, Mann Whitney U-tests and Spearman correlations
were performed separately in each cultural group. Since no statistically significant effects
emerged, these variables will not be discussed further.
Infant socialization. Cross-cultural comparisons using Mann-Whitney U-tests revealed
that infant socialization between the two groups differed on just two variables. In particular,
compared to Nicaraguan infants, Italian infants vocalized more (Z = -3.28, p < .001) and spent
more time retreating out of mother’s arm length during free play (Z = -3.23, p < .001). These
few differences suggest that cultural variations in maternal socialization are not attributable to
cultural variations in infant socialization. Given that our primary interest concerns maternal
socialization, the analyses described below will exclusively focus on maternal variables.
Maternal socialization. To investigate cultural differences in mothers’ ocializat with
their infants during free-play, we compared the frequency and duration of each maternal
ocializa across the two groups. Figures 1 and 2 show the average frequency and duration of
each maternal ocializa observed during the free-play session.

0,25
Nicaraguan
Italian
0,2
Mean frequency (%)

0,15

0,1

0,05

0
Social Object Physical Verbal Face-to- Infant
play play stimul. stimul. face plays
alone
Maternal behavior

Figure 1. Mean frequency of maternal behaviors during free play.

 Mother-Infant Interaction in Cultural Context 271

0,4
Nicaraguan
0,35
Italian

0,3

Mean duration (%)

0,25

0,2

0,15

0,1

0,05

0
Social play Object play Physical Verbal Face-to- Infant plays
stimul. stimul. face alone
Maternal behavior

Figure 2. Mean duration of maternal behaviors during free play.

Results of the Mann-Whitney U-tests indicated that, compared to Nicaraguan mothers,

Italian mothers were more likely to engage their infants in social play (Z = -2.40, p < .016)
and object play (Z = -3.33, p < .001), and provided verbal stimulation more often and for
longer periods of time during the observation (Z = -4.42, p < .0001, and Z = -4.77, p < .0001,
respectively). In addition, Italian mothers watched their infants while playing alone more
frequently and for longer periods of time than did Nicaraguan mothers (Z = -4.82, p < .0001,
and Z = -4.90, p < .0001, respectively).
Conversely, compared to Italian mothers, the Nicaraguan mothers physically stimulated
their infants more frequently and for longer periods of time (Z = -3.71, p < .0001, and Z = -
4.05, p < .0001, respectively), and interacted via face-to-face positions more and longer (Z = -
2.67, p < .01, and Z = -1.98, p < .05, respectively).

CONCLUSION AND IMPLICATIONS

The main goals of the present study were to describe parental conceptions of childrearing
and childcare and to evaluate similarities and differences in mothers’ socialization during
free-play in two cultural groups assumed to have differing sociocultural orientations –
Nicaraguan farmer families and Italian middle-class families. Overall, our findings support
the idea that broad cultural values of collectivism/interdependence and
individualism/independence are linked to parents’ beliefs and developmental expectations,
which in turn contribute to variation in observed mother-infant interaction.
Consistent with an interdependent worldview, Nicaraguan mothers’ cultural beliefs and
socialization goals emphasized interconnectedness, socio-emotional competence,
respectfulness, and obedience. Conversely, in accordance with a more individualistic
orientation, Italian mothers emphasized assertiveness, autonomy, self-confidence, and self-
272 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

esteem. These values emerged in mothers’ conceptions of the child as well as in the
description of their everyday activities and developmental expectations. Nicaraguan mothers
highly appreciated infant expressions of positive affect, socio-emotional competence, and
physical characteristics, whereas socialization and anger outbursts were considered two
problematic features associated with low manageability of the child. Daily routines and
activities mainly centered around protection and nurturing, although we found some
heterogeneity in the beliefs and attitudes related to breastfeeding. Indeed, previous studies
reported high variability in the duration of breastfeeding in rural areas of Nicaragua, partly
because of mothers’ differing sociodemographic characteristics (Sakisaka et al., 2006).
Developmental expectations focused on health-related aspects of childcare (i.e., nutrition,
preventing sickness, cleanliness), but Nicaraguan mothers also viewed good manners,
education, and respect of family members as important socialization goals. Overall, this
pattern reflects the values of familismo, respeto, and socialization held by Latino parents of
most national origins (Halgunseth, Ispa, and Rudy, 2006). Familism may be described in
terms of feelings of closeness with family members, strong sense of loyalty to the family,
mutual reliance on extended kin for instrumental and emotional support, and priority of the
family over individual needs (Calzada and Eyberg, 2002). Respect is an important means to
maintain harmonious relationships within the group by showing respectfulness of others and
obedience to authority. The childrearing goal of socialization refers to the importance of
raising a child who has qualities reflective of good manners and high morals, including
honesty, politeness, respectfulness, and responsibility. Together, these values are frequently
described as distinguishing characteristics of Hispanic communities with an interdependent
sociocultural orientation (Halgunseth et al., 2006).
In describing their infants, Italian mothers highly valued the characteristics of liveliness,
activity, sociability, and independence; child difficultness was associated with irritability,
persistence, and low soothability. Daily activities mostly involved caregiving routines, but
infants were also exposed to social and cognitive stimulation, especially during play with
other family members. Although a majority of mothers expected their children to self-regulate
and sleep through the night in their own room from early on, co-sleeping sometimes occurred
on special occasions. Developmental goals included providing a serene home environment,
building emotionally close relationships within the family, and instilling self-confidence
through an optimistic attitude toward the self and others. Together, Italian mothers’
childrearing beliefs reflect the cultural values of personal choice, intrinsic motivation, self-
esteem, and self-maximization, which are common in many cultures that are considered to
emphasize individualism (Tamis-Lemonda et al., 2007). These values are associated with the
overarching goal of autonomy, and describe individuals who assert their personal preferences,
are internally driven to achieve their goals, feel good about themselves, and achieve their full
potential. Parents sharing these childrearing beliefs encourage their children to develop into
unique, autonomous beings through the transmission of optimism and self-esteem as they are
viewed as crucial determinants of happiness and psychological well-being (Miller, Wang,
Sandel, and Cho, 2002).
Despite these differences in broad sociocultural orientations, commonalities also emerged
in Nicaraguan and Italian mothers’ childrearing beliefs. For example, children’s socio-
emotional competence and family connectedness were mentioned as two important aspects in
both groups. This finding may be explained by the fact that cultures can be individualistic in
some aspects and collectivistic in others (Harkness et al., 2000). The case of Italy is
 Mother-Infant Interaction in Cultural Context 273

particularly interesting in this respect. Although in Hofstede’s (1991) classification system

Italy has been ranked almost as individualistic as the United States, several authors suggest
that this individualism primarily refers to interpersonal relationships outside the extended
family (Attili, Vermigli, and Schneider, 1997). Italians’ sense of psychological identity is
strongly related to the extended family and, to some extent, to members of their socialization
or clans (Saraceno, 2003). As a consequence, Italian parents socialize their children to learn
how to manage social relationships, to easily approach others, and to express their emotions
during interpersonal interaction as a means to promote social assertiveness (Casiglia et al.,
1998; Gandini and Edwards, 2001). In addition, the nuclear family is viewed as a ‘secure
base’ that gives the child emotional stability and promotes a sense of psychological well-
being, thus facilitating exploration and openness to the external world (Axia et al., 2003).
Maternal socialization during free-play were coherent with the broad cultural values of
interdependence and individualism expressed in mothers’ childrearing beliefs. In particular,
Nicaraguan mothers engaged more frequently and for longer periods of time in physical and
body stimulation during the observation than did Italian mothers. Conversely, Italian mothers
engaged their infants more frequently and for longer periods of time in verbal stimulation,
and spent more time in both social and object play than did the Nicaraguan mothers. In
addition, Italian mothers watched their infants play alone without intervening more frequently
and for longer periods of time than did the Nicaraguan mothers. This pattern confirms the
findings of previous research indicating that parents who support an interdependent
worldview exhibit a proximal parenting style involving physical closeness and motor
stimulation, whereas parents who support an independent worldview display a distal
parenting style involving increased verbal input and extensive use of objects to direct the
infant’s attention to the external world (Keller et al., 2005b). From this perspective, infant
solitary play can be deemed an expression of the mothers’ effort to encourage autonomy and
foster independent exploration to stimulate the child’s sense of agency and self-efficacy
(Harwood et al., 1999).
Interestingly, we found that Italian mothers engaged their infants in social and object play
for longer periods of time than did the Nicaraguan mothers, but no significant group
difference emerged in the frequency of these socialization during the free-play session. In
other words, the incidence of maternal socialization involving stimulation with objects/toys
and social interaction was similar across the two cultural groups. These results are consistent
with previous research, which found that Central American mothers engaged in both social
and didactic socialization during free play interactions with their infants (Bornstein and Cote,
2001). Contrary to our expectations, Nicaraguan mothers engaged in face-to-face-interactions
with their infants more frequently and for longer periods of time compared to Italian mothers.
This finding may be attributable to the fact that overall Italian infants were more frequently
involved in object and solitary play compared to their Nicaraguan counterparts, and thus their
attention was oriented more toward toys/objects than to the mothers’ eye gaze (see Figure 3).
In contrast, Nicaraguan infants more frequently experienced body stimulation and physical
contact, which often implied face-to-face exchanges and mutual eye contact from a close
distance (see Figure 4). More research would be needed to examine parenting socialization
and their relations to each other in these cultural sites using representative samples.
There are limitations of this study that warrant mention, such as the small sample size of
just 53 mothers, which prevents us from generalizing our results to the Nicaraguan and Italian
population. Since group differences become more robust with sample size, future research in
274 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

this domain may include larger number of mothers to replicate our findings. In addition, there
may be important parenting socialization not emerging from the free-play sessions that
nonetheless play an important role in Nicaraguan and Italian parents’ socialization process.
Indeed, investigators have found that parental beliefs and practices vary across situations
(Harwood et al., 1999; Leyendecker et al., 1997), although these variations often show a
cultural patterning that is consistent with broader socialization goals. Further studies need to
include multiple activity settings (e.g., feeding, social interaction, teaching) to assess whether
maternal socialization differs according to the specific context in which it is observed.
Finally, it is important to remember that individuals in a culture are not uniformly
individualist or collectivist (Oyserman, Coon, and Kemmelmeier, 2002), and that parents in
different cultural environments can endorse similar developmental goals (Harkness et al.,
2000). Despite we focused on particular communities within cultures that can be
characterized by specific sociodemographic profiles and value systems, thus considering the
fact that there is also considerable intracultural variability, researchers need to address the
dynamic coexistence of individualism and collectivism in cultures and individuals across
settings and time (Tamis-LeMonda et al., 2007).

Figure 3. Object play and verbal stimulation during free play in an Italian family.
 Mother-Infant Interaction in Cultural Context 275

Figure 4. Physical stimulation and face-to-face interaction during free play in a Nicaraguan family.

This study contributed to our understanding of the relation between broad cultural values,
parental childrearing beliefs, and mothers’ socialization during free play with their young
infants. We showed that the cultural model of interdependence is reflected in socialization
goals emphasizing social connectedness, respect, and obedience, and is supported by a
proximal parenting style involving physical and motor stimulation. In contrast, the cultural
model of independence is expressed in childrearing beliefs focusing on autonomy,
uniqueness, and separateness, and is supported by a distal parenting style characterized by
verbal, social, and object stimulation. Considering that societies are becoming increasingly
multicultural, our findings have at least two implications for clinicians working with families
from culturally diverse backgrounds. First, parents’ conceptions of relationships and
competence are profoundly influenced by cultural norms and expectations that vary widely
both within and across cultures, thus challenging the notion of “normative” parenting. Health
professionals need to be culturally sensitive and avoid possible misinterpretations due to an
ethnocentric perspective that views differences of ethnic and minority groups in terms of
deficits when compared to the mainstream culture. Second, a methodological approach
276 Ughetta Moscardino, Sabrina Bonichini and Cristina Valduga

combining the use of qualitative (i.e., semi-structured interviewing) and quantitative

assessment techniques (i.e., socialization observations) may be an effective way to identify
cultural patterns in parents’ childrearing beliefs and practices, since self-report questionnaires
are often subject to reporting biases related to social desirability and therefore may provide an
unrealistic picture of parental ideas, expectations, and socialization goals. To conclude, more
intra-cultural and cross-cultural research is needed to study the contextual determinants of
parent-child relationships in order to increase our knowledge of different pathways leading to
children’s successful development in specific ecocultural niches.

ACKNOWLEDGEMENTS
The authors wish to thank all the mothers and infants who participated in the study. We
also gratefully acknowledge Lucia Zurlo for her help in data collection and coding, and
Gianmarco Altoè for statistical assistance.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 16

“IT’S SATURDAY…I’M GOING OUT WITH MY

FRIENDS”: SPENDING TIME TOGETHER IN
ADOLESCENT STORIES

Emanuela Rabaglietti and Silvia Ciairano1

Department of Psychology, University of Torino, Italy

ABSTRACT
During adolescence, peer relationships and friendships are relevant contexts for
cognitive and social development [Bukowski, Newcomb and Hartup, 1996] and for future
adult adjustment [Hartup and Stevens, 1999]. We also know that people, and particularly
adolescents, by way of narration and autobiographic construction, can define and
attribute meaning to their self and their relationships with others. Bruner and colleagues
[Amsterdam and Bruner, 2000; Bruner, 2002] pointed out that individuals construct
stories to attribute meaning and order to daily life events. By narrating one’s own story it
is possible to organise episodic memory, to shape the recollection of events, and to build
reality [Smorti and Pagnucci, 2003]. Specifically in friendship relationships, narrative
autobiographic experiences represent specific interpretative modalities used by
adolescents to give meaning to the self and the others within these relationships.
In this study, which is based on adolescent narrations, we explored adolescent
leisure-time behaviour in the company of friends, specifically on Saturday afternoons.
We were also interested in identifying the self markers [Bruner, 1986; 1997], by which
adolescents perceive themselves and others, and attribute meaning to their own
experiences. Finally, we would like to investigate the relationship between the Self
markers and some indicators of well-being (e.g. positive self-perception and expectations
of success), social self-efficacy, adulthood (e.g. value of autonomy), and discomfort (e.g.
feelings and sense of alienation).
Participants included thirty adolescents (11 girls and 19 boys) aged 14 to 20 years
(M= 15.8; D.S.= 1.4) attending two different types of high school (43% lyceum, 57%
technical and vocational) in the northwest of Italy. The adolescents were asked to write a
essay on the subject: “It’s Saturday…I’m going out with my friends”.

1
emanuela.rabaglietti@unito.it.
282 Emanuela Rabaglietti and Silvia Ciairano

We analysed the essays using thematic analysis of content as well as Bruner’s [1986;
1997] system of self markers. The following profiles summarise our findings. Most of the
adolescents go out on Saturday and they have fun, talk, share convivial activities and
sometimes also illegal activities (particularly boys) with their friends. Adolescents use
frequently especially the Self markers of Agency (97%), Commitment (87%), Coherence
(80%) and Social references (83%). Girls use the subjective aspects of Self markers, such
as Qualia and Evaluation on the bases of expectations, more frequently than boys. Older
adolescents use Agency and Resources more frequently than younger adolescents.
Finally, Resources and Evaluation are related to positive self-perception and Social
references is linked to Social self efficacy. This study has some limitations, such as the
limited number of participants and the specificity of the essay, which make it impossible
to generalise these findings to adolescent social life. Nevertheless, the findings can
contribute to a better understanding of the meaning that peers and friends assume in
adolescence.

INTRODUCTION

Peer Relationships and Friendships in Adolescence

We know that during adolescence, relationships with significant peers are redefined and
assume new meaning. More specifically, adolescents’ relationships with their peers become
increasingly important: these relationships are characterised by greater levels of intimacy
compared to childhood relationships and in the adolescent social network peers and friends
acquire a central position, becoming as important as relationships with parents [Bukowski,
Newcomb and Hartup, 1996].
In the past few years, several studies have shown that being able to build and maintain
satisfactory relationships with peers and friends is a relevant indicator of mental and physical
well-being and an important protective factor against psychosocial risk throughout the entire
life span, and particularly in adolescence [Hartup and Stevens, 1997; Berndt, 2004; Rubin,
Bukowski and Parker, 2006]. According to Hartup [1993], peer relationships and friendships
are one of the most important developmental contexts for adolescents. This scholar [1989;
1993] showed that friendship provides a context in which boys and girls have the opportunity
to develop social, cognitive, and emotional capabilities and experience new types of
relationships characterised by parity and symmetry, and behavior models. Furthermore, high
quality relationships - in terms of support, intimacy, and reciprocity - with friends and peers
in general encourage the maintenance of ties and contribute to psychosocial adjustment
[Fonzi and Tani, 2000]. High quality friendships are related to the regulation of emotions
[Gauze, Bukowski, Aquan-Assee and Sippola, 1996], social competence [Buhrmester, 1990],
problem solving [Brendgen, Bowen, Rondeau and Vitaro, 1999], and school success and
adjustment [Berndt and Keefe, 1995]. Some of our previous research showed that, in
adolescence, supportive friendships, compared to conflictual relationships, are related to
higher levels of psychosocial well-being and lower levels of aggression towards peers. More
specifically, friendship patterns characterized by support and sharing of thoughts, feelings,
and behavior represent a positive social context in which adolescents can strengthen their
self-confidence, expectations for the future, and social competence [Rabaglietti, Roggero,
Settanni and Ciairano, 2007]. However, adolescent friends also share in mild transgression
 “It’s Saturday…I’m Going out with My Friends” 283

against adult rules, such as lying and disobedience [Ciairano, Rabaglietti, Roggero, Bonino
and Beyers, 2007].
Therefore, relationships with peers and friends seems to be the relational experiences
that, through support and social comparison, provide adolescents with an opportunity to learn
new social definitions, to build and/or strengthen their social capabilities, and to experiment
with their own identity and different social roles [Jackson and Rodriguez-Tomé, 1993].
The present study builds on the theoretical framework mentioned previously, which
examines relationships with friends and peers as an adolescent developmental context. We
asked the adolescents who participated in this study to write about themselves and their
friends and how they spend their time together on Saturday afternoons. This activity gave the
adolescents an important opportunity to narrate a portion of their daily lives and focus on
themselves. In particular, they were invited to write a portion of their autobiography
containing relevant self markers.

Narration and Adolescence

In recent years, the construtivistic paradigm of knowledge and the concept of narration
have become increasingly important in various scientific disciplines, such as anthropology,
history, sociology, and psychology. “According to the constructivist paradigm, the process of
acquiring knowledge [...] is a constructive process that takes place always starting from the
inner point of view of the individual [...], likewise a narration that reconstructs events
according the point of view of the narrator [Smorti, 2000, p. 515, translation by the author].
Therefore within the constructivist paradigm, stories become “universal ways” [Smorti, 1997,
p.10] by which individuals convey and attribute meaning to events throughout their lives.
Such stories fulfil a crucial role particularly during adolescence, when boys and girls must
face the universal developmental task of constructing their own identity. While universal, the
developmental task of constructing individual identity may be confronted in many different
ways depending on the characteristics and resources of the individual and his or her life
context [Bonino, Cattelino and Ciairano, 2005].
Some scholars interested in the role of stories and narratives during the life course [see
for instance: Cohler, 1982; Bruner, 1990; and McAdams, 1997] state that, through narration,
human beings define who they are along time, synthesising synchronic and diachronic
elements into a construction that assumes the shape of a story [Aleni Sestito, 2004b]. In the
narration of one’s own experience, the process of re-interpretating events, which individuals
do to maintain a sense of coherence, is very important. According to Cochran [1997],
narration requires “emplotment” that is the process individuals use to place themselves as
actors in significant, productive, and satisfying stories. Thus, it is the process that allows
people to attribute meaning to their identities.
According to this perspective, narration becomes an instrument used to achieve
continuity and, at the same time, adjust to change. More specifically, narration of the self or
self-biography is the main way in which people attribute meaning to the events of their lives,
and, consequently, coherence and continuity to their personal identity. We achieve coherence
and continuity both by modifying our story and by making our actions congruent to the story.
Therefore, a narration “is not only what collects and ocializa the experience, but what
produces it, too” [Smorti, 1997, p. 32; translation by the author]. In fact, “life stories are
284 Emanuela Rabaglietti and Silvia Ciairano

based on biographical facts, but they go considerably beyond the facts as people selectively
appropriate aspects of their experience and imaginatively construe both past and future to
construct stories that make sense to them and to their audiences, that vivify and integrate life
and make it more or less meaningful” [McAdams, 2001, p. 101]. Life stories tell about the
past and are directed at the future, leading human actions.
According to Bruner [1991; 1994], the “life story” represents a “dialogic act” that is the
result of negotiating meaning with others. The efforts of the narrator provide coherence and
construct the plot of his or her own meanings. This negotiation is made possible by the fact
that the narrator and his or her interlocutors share the same cultural context and,
consequently, can share the meanings of experience. People organise their experiences,
especially memories of events, mainly in the form of narratives. These narratives include
human motivations, beliefs, and justifications for behaving or not behaving in a certain way.
In this sense narratives are conventional forms that are culturally transmitted and constrained
by the individual’s level of mastery with personal experience. Through narration, individuals
try to understand, and to interpret their own and others’ actions. In this process, they also try
to link actions to the thoughts of the actor, to face contradictory and unexpected events, and to
re-construct an ordered “canonicity” [Bruner, 1991].
Within this perspective, Trzebiński [1997] stated that knowledge about the self is
organised in narrative schemas and these narrative schemas give people a fundamental
instrument for interpreting the most important events in their reality. This scholar identified
three main features of stories about the Self, defined as processes that put facts, events, and
situations that are relevant for the Self in a narrative plot. First, such stories tell something
about events or actions that is relevant for the individual; therefore, they are strictly linked to
his/her intentions and emotions. Second, people have a central role in the stories they narrate:
they affect the course of events with their actions, and, in turn, are affected by these events.
Finally, the events and the facts of an individual’s story, because of the way they are
described, outline his/her self identity within his/her life context; in other words, they give
meaning and assure continuity to the experiences that are relevant for the self [Trzebiński,
1997, p.62; translation by the author].
Stories about the self lead to the construction of a “narrative representation of self”,
where “the most salient episodes of life […] are organised and mentally represented as
stories. These stories about the self are stored in the memory and can be activated and
reconstructed as real systems of the working memory, in order to elaborate new information
relevant for the self [Trzebiński, 1997, p. 61, translation by the author].
The process of narration is particularly important during adolescence, when boys and
girls must attribute meaning, coherence, and continuity to their lives while facing a rapid
sequence of physical, psychological, and social changes. At the same time, adolescents must
reorganise their self concept, integrating distinctive features of subjective experience with the
evaluation of objective aspects.
As suggested by McAdams [2001], adolescents and youth living in contemporary
societies begin to reconstruct their personal past, to perceive the present, and to anticipate the
future in terms of an internalised and evolving self-story, an integrative narrative of the Self
that provides them with unity and purpose. Adolescents, who are construing their own future,
who are dreaming of tomorrow, who are revising their own childhood dreams, need to test
their potential in the present and they test themselves with the means available to them: one of
these means is self narration. The adolescent reorganises his/her own story by way of self-
 “It’s Saturday…I’m Going out with My Friends” 285

biography, and “constructs the Self like a text” [Smorti, 1997, p.32] in order to recognise and
to preserve his/her sense of identity. The adolescents who participated in this study were all
students and they tried to construct a portion of their reality linking different components.
With their stories, they described a part of the Self that, as in most of human life, takes place
daily within a shared culture.
To narrate one’s own story means to attribute sense and continuity to one’s own
experiences, and the reconstruction of the past promotes the construction of a “platform” of
meanings; this platform is used to both interpret the present experience and to facilitate self
definition [Smorti, 1997]. This narrative process implies the necessity to combine the need for
normalisation with the need for differentiation. Through normalisation, individuals
reconstruct the parts of themselves that they share with others, which Ricoeur [1990] defined
as “idem” identity. On the one hand, normalisation or “idem” identity enables the individual
to experience a sense of belonging (to his/her community, culture, etc). On the other hand, the
individual may risk feeling that his/her story is too predictable or uninteresting. For this
reason, the individual adds some critical events in the self story, which Bruner [1990] called
breaking of “canonicity”: unexpected events are inserted which create a lack of balance and
make the story more interesting, but the individual still perceives the self story as personal. In
this way he/she constructs the other aspect of identity, which Ricoeur [1990] called “ipse”.
The aspects of “idem” and “ipse” identity refer respectively to stability and change of self.
Autobiographical construction is the privileged context in which these aspects integrate and
balance with each other [Smorti, 1997]. When the individual narrates his/her personal story,
he gives meaning to his/her actions. In addition to narrating the self, the individual presents
himself/herself to others in the way he/she perceives to be most appropriate to a particular
situation. For this reason, autobiographical narration can be considered an essential tool for
unravelling the dynamics of the process of identity construction as an expression of the
concept of the Self [Aleni Sestito, 2004b].
As mentioned previously, Bruner’s seminal work [see for example: 1986; 1990; 1997]
highlighted the importance of using narration and particularly autobiography as a possible
methodology for investigating relevant aspects of Self. Furthermore, the constructivistic
theory [Bruner, 1991; 1997] represents an interesting starting point for analysing the self
dimensions that are particularly crucial for the individual during a specific developmental
phase. The present study is based on this theory. Bruner [1997] stated that self markers are
relevant indicators within narrations about the self. These markers are essentially signals
pointing to the way individuals perceive and collocate themselves within their relational,
social, and cultural context. Bruner [1997] proposes the following indicators of selfhood:

1) Agency: refers to acts of free choice, to voluntary actions, and free initiative to
pursue one’s own aims.
2) Commitment: refers to the active participation, which goes beyond impulsive
behaviour, of the actor; as opposed to inconsistency, it signifies perseverance and
delay of gratification.
3) Resources: represented by all the elements (power, goods, privileges) that an actor
has at his/her disposal in order to carry out his/her aims; this includes both external
resources, such as power, social legitimacy, and sources of information, as well as
inner resources, like patience, long term perspective, and forgiveness.
286 Emanuela Rabaglietti and Silvia Ciairano

4) Social references: the features that constitute the actor’s social context; references
used to legitimise or evaluate goals, commitments, and allocation of resources.
5) Evaluation: the actor’s explicit evaluation of events in relation to his/her
expectations.
6) Qualia: delimits feelings, emotions, and other indicators of the subjective self; from
the point of view of other people they range from posture to verbal expression; from
the point of view of the actor they indicate mood, and fatigue.
7) Reflexivity: refers to metacognitive aspects of the Self, or rather the act of reflecting
upon, constructing, and evaluating the Self.
8) Coherence: refers to a kind of integrity between behaviour, commitments,
investments, and evaluation.
9) Positional marker expresses the way in which the individual places himself/herself in
time, space, or social order.

The narrative world places the general human condition in a particular situation, and
“sites the experience in a time and in a space” [Bruner, 2002, p. 36; translation by the author].
One of main tools for constructing the Self in the world is through the narration of the life
story. Narration changes form at different stages of development with the same story being
interpreted in different ways and on different levels by individuals at different ages. Children
explain the plot of a story in terms of actions accomplished, while adolescents linger over the
feelings of the characters in the story [Feldman, Bruner, Kalmar and Renderer, 1994].
Besides, adolescents interpret and organise the story through human complications: the
characters in adolescents’ stories, like their young narrators, face crucial events and moments.

The Present Study

This study is part of a wider longitudinal project aimed at investigating peer relationships,
friendship quality, leisure activity in adolescents, and relationships with both psychosocial
well-being and risk behaviour using both quantitative (self-report questionnaire) and
qualitative (essays and interviews) instruments [Ciairano et al., 2007; Rabaglietti and
Ciairano, in press].
In the present study, we investigated adolescents’ stories about how they spend their
Saturdays with friends, seeking to understand the meanings adolescents attribute to the
different experiences that characterise their friendship relationships.
In particular, we looked at the way the adolescents spent their time together. We
attempted to answer the question: “what does the typical Saturday of an adolescent look
like?”, or more precisely, “what and how do adolescents tell about their Saturday?”. In order
to answer this question, we first identified in the adolescents’ narratives the general context in
which they meet their friends in terms of time, people, activity, and place. This description
gives us the general framework for collocating peer relationships. Second we identified
Bruner’s nine Self markers [1997], which are agency, commitment, resources, social
references, evaluation, qualia, reflexivity, coherence, and positional marker, with the aim of
acquiring, through these descriptions, some significant clues about the way the adolescents
perceive themselves within peer relationships.
 “It’s Saturday…I’m Going out with My Friends” 287

In both cases, we also analysed gender and age differences. With respect to gender, we
hypothesised differences in the way boys and girls tell their stories. More specifically, we
expected to find that boys narrate their leisure time with friends in general terms and that they
refer to the Self markers of commitment and resources more frequently than girls. We
expected to find that girls narrate more emotional and relational aspects of the ways they
spend time with friends and that they would refer more frequently to the Self Markers of
evaluation, social references, qualia, and reflexivity more frequently than boys. Along the
same lines as the previous findings of Haden, Fivush and Reese [1997] and Bruner [1998],
our expectations regarding gender differences were based on differences in socialisation
processes, which still today are more likely to stress emotional aspects in girls and
exploration and commitment in boys. With respect to age, we expect to find differences
between younger and older adolescents not in the general description of the context, but
rather in the way they refer to the Self aspects. More specifically, also based on the findings
of previous studies [Harter, 1985; Roggero, Rabaglietti and Ciairano, 2006], we hypothesise
that, with age, adolescents’ Self-portraits in their relationships with friends become richer in
interpersonal elements in terms of sharing feelings and thoughts.
Finally, we investigate the relationship between the Self markers identified previously
and some indicators of well-being (in terms of positive self-perception and expectations of
success), social self-efficacy, adulthood (expressed by value of autonomy), and discomfort
(depressive feelings and sense of alienation). According to Bruner [1997] and Mc Lean,
Pasupathi and Pais [2007], self story and autobiography represent a way to express the
stability and continuity of Self, especially during adolescence when boys and girls face the
task of constructing an identity. Through the autobiographical construction of a fragment of
their life, adolescents must shape a Self that is coherent for four poles: temporal, biographic,
causal, and thematic [Habermas and Bluck, 2000]. We hypothesise that the Self markers of
agency, commitment, coherence, evaluation, and positional - in other words the markers that
refer to subjectivity in experiences with others - are related to well-being, social self-efficacy,
adulthood, and discomfort in the adolescents.

Participants

Thirty adolescents (11 girls and 19 boys) participated in this study. They ranged in age
from 14 to 19 years (M= 15.8; D.S.= 1.4; median 16 yrs; 47% were younger than 16 yrs), and
attended two different types of high schools (43% lyceum, 57% technical and vocational) in
the northwest of Italy.
In accordance with Italian law and the ethical code of the Association of Italian
Psychologists, we obtained informed consent for participation in the study from the parents of
the underage children and from all the adolescents.
The participants were randomly extracted from the complete list of participants in the
broader study [see: Ciairano et al., 2007], in order to construct a little group balanced for
gender, age and type of high school. We found no differences between the participants
extracted for this qualitative study and the whole sample in terms of relevant socio-
demographic aspects, such as parental education level and employment status and the
integrity of the family.
288 Emanuela Rabaglietti and Silvia Ciairano

The two instruments used in the present study, which are the essays and a self-report
questionnaire, were administered at school by trained researchers. Teachers were not present
during the examination procedure. Finally, no incentive was used to recruit participants.

Procedure and Instruments

To collect the data, we developed and administered an instrument [“It’s Saturday…I am

going out with my friends” Rabaglietti, Roggero and Ciairano, 2005] through which boys and
girls could tell, in a written text, about how they spend their leisure time with friends. To
provide direction for the narration, we selected a title that was broad enough to allow the
participants to tell about how they spend time together, while defining and delimiting the
theme within the established theoretical borders.
The same participants also completed the questionnaire “Being together in adolescence.
My friends, my health and I” [Ciairano, Rabaglietti and Roggero, 2004], the responses to
which provided data about well-being, social self-efficacy, adulthood, and discomfort. In
order to maintain anonymity, adolescents identified their composition and questionnaire with
a personal code. Once completed individually by the adolescents, both instruments were
returned in an unmarked envelope.

Measures

Thematic Content Analysis

We analysed the adolescent compositions by way of thematic content analysis. That is
first we coded each category and second we assembled these categories in descriptive macro-
and micro-categories.
As explained above, we first analysed the general context in which the adolescents meet
their friends in terms of time, people, activity, and place.
The macro-category of “time” consists of the following micro-categories: Saturday
afternoon, Saturday evening, implicit and non-specific references to Saturday. “People” refers
to the people the adolescents usually spend time with: generic friends, best friends, friends
from their neighbourhood, classmates, a non-specific “us”, and family. “Activity” refers to
the activities adolescents take part in and the way they entertain themselves, including:
convivial activities like eating and drinking; playing board games, role games, videogames,
and sports; taking pleasure in spending time together; playing and/or listening to music;
talking about specific subjects like school, romantic relationships, events, their future, and
non-specific topics like culture, science, religion, or silly, unimportant things; and finally,
watching television. Lastly “place” refers to the place where adolescents usually meet. These
can include public places like a bar, pub, disco, or cinema; a private place like their home,
their friends’ home, or the place where they play music; different public places where the
adolescents roam from one to the next; or finally different areas of their own homes of
friends’ homes.
 “It’s Saturday…I’m Going out with My Friends” 289

We identified Bruner’s nine Self markers [1997], defined as follows:

1) Agency refers to free choices and voluntary actions such as: “obviously I’m going to
dress well”, “it always takes me an hour to get to them”.
2) Commitment is represented by those aspects that express adherence to a real or
intended line of action: “My friends and I usually meet at home”, “we all decide
together”.
3) Resources are those elements that can support and promote actions, for example:
“We’re all hoping that summer will bring something good”, “then, with our parents
or on motorcycles.
4) Social references are those elements tied to the social and affective network that
constitute the object in which subjectivity of the Self is reflected and on which the
adolescent bases his/her evaluations: “I’m happy to have been with my
friends..........when the whole group is there”.
5) Evaluation refers to the expression of the adolescents’ judgements: “it is always hard
to meet up”, “but when I go out, I usually have a lot of fun”.
6) Qualia refers to the physical and/or psychological characteristics that contribute to
defining the subjectivity of the Self: “I juggle and make animal shapes out of
balloons and play some “Harry Potter-type” games.”, “I’m not one to go out very
often”, “all of us are good in school”.
7) Reflexivity is shown by the ability to reflect on the Self: “the important thing is to be
together”.
8) Coherence and constancy are the aspects that express Self continuity – in the
individual or group – in the narration: “by now it’s a set date so we don’t even have
to talk about it anymore”, “we always talk a lot because we go to three different
schools”.
9) Positional marker refers to the position of the Self within the individual’s spatial-
temporal or social order: “till now, this [referring to a centre of aggregation] has been
our meeting place”, “the friends I go out with have almost the same tastes as I do”.

Two independent coders categorised the texts. We calculated the proportion of agreement
between the two coders, which was very high (92%). Furthermore, the cases in which there
was disagreement were all resolved. Successively, we calculated the frequency of the
different categories cited by each adolescent.
Well being, social self-efficacy, adulthood, and psychological discomfort
We considered well-being as positive self-perception and expectation for success.
Positive self-perception was assessed with nine items reflecting the adolescents’ perceptions
of their ability to do well in school, to resist peer pressure, to be attractive to the opposite sex,
to cope with problems and to learn new life skills, and of being satisfied with their
relationships with the opposite gender, and with themselves in general. Responses on a 4-
point Likert scale ranged from (1) “not at all”, to (4) “very” Cronbach’s alpha =.70).
Expectation for success (assessed with nine items, reflecting adolescents’ expectations for
success in school, relationships, work, community, and health. Responses on a 5-point Likert
scale ranged from (1) “very low”, to (5) “very high”. Cronbach’s alpha =.79). Social self-
efficacy refers to the ability to become part of and feel at ease in a group. It was assessed with
13 items reflecting adolescents’ ability to participate in group discussions, learn new sports
290 Emanuela Rabaglietti and Silvia Ciairano

and be good at physical activities and individual and team sports, to fulfil friends’
expectations, to accomplish one’s own aims, to make new friends, to state one’s opinion in a
group, to work in a group, to say what one thinks even if others do not agree, to defend one’s
own rights, and to get oneself out of trouble. Responses on a 4-point Likert scale ranged from
(1) “not at all” to (4) “very”. Cronbach’s alpha =.80). Value on autonomy, which we equated
to orientation to adulthood, was assessed with four items reflecting the adolescent’s value on
being autonomous in the use of their free time and money, and in choosing clothes, films, and
books. Responses on a 4-point Likert scale ranged from (1) “not at all” to (4) “very”.
Cronbach’s alpha =.67). We considered adolescent’s discomfort as depressive feelings and
sense of alienation. Depressive feelings was assessed with 5 items reflecting the adolescent’s
feelings of being down, hopeless, worried, depressed, and alone. Responses on a 4-point
Likert scale ranged from (1) “not at all” to (4) “very”. Cronbach’s alpha =.82. Sense of
alienation (assessed with 4 items, reflecting adolescents’ feelings of being left out of things
other kids do, being unsure about who he/she is, not having a clear idea of what other people
expect from him/her, and feeling that hardly anything in life means very much to him/her.
Responses on a 4-point Likert scale ranged from (1) “strongly disagree” to (4) “strongly
agree”. Cronbach’s alpha =.72).

Analysis Strategy

As explained previously, we started by coding the narrative compositions and then

proceeded to explore the adolescents narratives about Saturdays spent with friends in terms of
general context (in terms of time, people, activity, and place), and Self markers (agency,
commitment, resources, social references, evaluation, qualia, reflexivity, coherence,
positional marker. We performed a series of descriptive analyses calculating the frequencies
of the presence (1) or absence (0) of each single micro-category. In other words, we
considered only whether the adolescent referred to this aspect or not and not how many times.
We made this decision in order to minimise the potential biasing effect of the adolescents’
writing capabilities.
Finally, we used t-test analysis to highlight gender and age differences and to investigate
the relationships between Self markers and well-being, social self-efficacy, adulthood, and
discomfort.

Results

The General Context of Going out with Friends on Saturday

With respect to “time”, 57% of the adolescents said they went out on Saturday evening,
2
27% on Saturday afternoon; 37% did not refer specifically to Saturday . We found no gender
differences. However, age differences were found for going out in the afternoon [t-test(28)=-
1.54, p<.005]: older adolescents (M=.44, D.S.=.63) go out more than younger (M=.14,
D.S.=.37).

2
These categories are not reciprocally exclusive. Thus the total percentage is more than one hundred.
 “It’s Saturday…I’m Going out with My Friends” 291

With regard to “people”, 47% of adolescents mentioned going out with friends in general
and 17% with best friends; 23% referred to meeting with friends from their neighbourhood,
and 20% with classmates. 63% of adolescents mentioned generically “our group of friends”.
Finally, 3% said they spent Saturdays with their family, and another 3% 3% said they didn’t
have a group of friends. Girls (M=.45, D.S.=.69 vs. Boys: M=.05, D.S.=.23) [t-test(28)=2.36,
p<.0001], and older adolescents (M=.38, D.S.=.62 vs. Younger: M=.00, D.S.=.00 [t-
test(28)=2.26, p<.005] referred to a best friend more often than the others.
The description of the “activity” carried out with friends varied. The adolescents spend
time with their friends sharing in convivial activities like eating and drinking (37%), joking
around and having fun (50%), just enjoying each other’s company (47%), or playing or
listening to music (17%). Girls (M=.82, D.S.=.98 vs. Boys: M=.42, D.S.=.51; t-test(28)=1.47,
p=.072) and younger adolescents (M=.64, D.S.=.36 vs. Older: M=.50, D.S.=.52; t-
test(28)=.53, p=.087) mentioned to take pleasure in spending time together slightly more
often than the others.
Furthermore, in the company of friends, adolescent discuss a variety of different topics:
school (37%), relationships with peers of the opposite sex and romantic relationships (33%),
and the external side of the self, such as clothes and cars (50%). However, the adolescents
also talk about news, politics, and current events (43%), personal aspects tied to their future
(37%), and cultural, scientific, and religious subjects (20%). Finally, they also talk about silly,
unimportant things (37%). Some age differences were found: younger adolescents talk more
often than older adolescents about silly and unimportant things (M=.57, D.S.=.65 vs. Older:
M=.25, D.S.=.45; F=5.02, t-test(28)=1.60, p<.033).
While fairly uncommon, time with friends may also be spent playing board games and
role games (10%), videogames (13%), or physical and sport activities, like five-a-side
football and ping-pong (10%). Sport activities were mentioned exclusively by boys (M=.16,
D.S.=.38 vs. Girls: M=.00, D.S.=.00; F=11.66, t-test(28)=-1.39, p<.002), while only older
adolescents referred to board and role games (M=.25, D.S.=.58 vs. Younger: M=.00,
D.S.=.00; t-test(28)=-1.62, p<.001).
Another activity, characteristic only of older adolescents was watching shows and films
on television (M=.13, D.S.=.34 vs. Younger: M=.00, D.S.=.00; t-test(28)=-1.37, p<.004), or
renting films (7%).
Finally, some adolescents also referred to illegal activities carried out with friends, such
as racing cars or motorcycles, or using soft drugs (7%). These types of activities were
mentioned exclusively by boys (M=.11, D.S.=.31 vs. Girls M=.00, D.S.=.00; t-test(28)=-1.10,
p<.019).
As for the “place” where they spend their Saturdays with friends, adolescents mentioned
public places such as pubs (33%), coffee bars and ice-cream parlours (37%), pizzerias and
restaurants (33%), the cinema (23%), discos (20%), and video arcades (7%).
Girls referred more often than boys to discos (M=.45, D.S.=.69 vs. Boys M=.11,
D.S.=.32; t-test(28)= 1.91, p<.001), cinemas (M=.45, D.S.=.69 vs. Boys M=.16, D.S.=.38, t-
test(28)=1.54, p<.007), coffee bars and ice-cream parlours (M=.64, D.S.=.67 vs. Boys M=.26,
D.S.=.45; t-test(28)= 1.82, p<.050).
Coffee bars and ice-cream parlours were also mentioned more often by younger
adolescents (M=.57, D.S.=.65 vs. Older M=.25, D.S.=.45; t-test(28)=1.60, p<.033), and video
arcades were mentioned by boys only (M=.11, D.S.=.32 vs. Girls M=.00, D.S.=.00; t-
test(28)=-1.09, p<.019).
292 Emanuela Rabaglietti and Silvia Ciairano

When adolescents said they meet in private places, they referred especially to their own
homes or to their friends’ homes (27%), and in a much smaller percentage, to a practice room
where they play music (3%). Older adolescents mentioned meeting in people’s homes more
often (M=.44, D.S.=.63 vs. Younger: M=.14, D.S.=.36; t-test(28)=-1.54, p<.005); while only
younger adolescents met in music rooms (M=.07, D.S.=.27 vs. Older M=.00, D.S.=.00; t-
test(28)=1.07, p<.028).
When adolescents roam from place to place on Saturday they usually do so in their
neighbourhood (53%), but they also go to towns and villages nearby (27%). No differences
for gender and age were found.

Self Markers in the Adolescent Narratives

Through our second classification we identified units of written text in the adolescents’
narratives about their leisure time spent with friends that we interpreted as referring to
Bruner’s nine Self markers [1997]. We recorded whether each adolescent referred to a
specific Self marker never (0), once (1), or more than once (2).
We can observe through standardised means (Table 1) that the indicators of Self markers
used most frequently are agency, coherence, social reference, positional marker, and
commitment. Agency (I’ll talk about it first [with the girls who are on the bus with me], girl,
16 yrs) was cited by 97% of the adolescents (20% once, 77% more than once), commitment
(in a few minutes it was decided [that we would meet at my house], girl, 15 yrs) by 87% (40%
once, 47% more than once), and coherence ([…to see a film], and to end the night we go to a
pizzeria, girl, 14 yrs) by 80% (20% once, 60% more than once). We found similar
percentages for the indicators of social reference ([and we usually meet up] with the others
from our group, girl, 18 yrs), which were used by 83% (20% once and 63% more than once),
and positional marker ([…who I go out with] they have about the same tastes as I do, girl, 16
yrs; [we talk about everything] that could be of interest to 17-18-years-olds, boy, 17 yrs),
which was cited by 73% (33% once, 40% more than once). The indicator of reflexivity also
deserves attention (I have to be honest…My philosophy on life is like a giraffe: keep your feet
on the ground and your head in the clouds. girl, 16 yrs); this marker was included by 67% of
the adolescents (23% once, 44% more than once).
In terms of gender differences (Table 2), we found that qualia, which refers to the more
subjective aspects of one’s and/or others’ Self (...about how dissatisfied I’ve been feeling
lately, girl, 18 yrs; I’m not one to go out very often, girl, 15 yrs), was emphasised more often
by girls than by boys [t-test=1.60(28), p<.008]. Another sphere of the Self, which evaluates
events based on one’s own expectations (And who says that young people have to go to the
disco to have fun?, girl, 16 yrs), was also referenced more often by girls [t-test=.76(28),
p<.005]. Furthermore, while the difference is tendential and not significant [t-test=.82(28),
p=.090], we found that girls also mentioned social references (Some of my friends and I, [we
made an agreement], girl, 15 yrs) more frequently than boys.
Some age differences in the use of Self markers were also found (Table 3). In particular,
the indicators of agency (Usually, my friends and I meet…, boy, 18 yrs) [t-test=-.01(28),
p<.033], evaluation (To meet is ever difficult, boy, 16 yrs) [t-test=-1.27(28), p<.019], and
resources (“our ‘organization’ [referring to the group of friends] plans to…”, girl, 18 yrs) [t-
test=-1.34(28), p<.006] were more common among older adolescents. We also found a
tendential, though not significant, difference for reflexivity [t-test=-1.45(28), p=.086], (I think
it’s the time that I appreciate the most, , boy, 18 yrs; What is important is to stay together,
 “It’s Saturday…I’m Going out with My Friends” 293

girl, 16 yrs), which is also more frequent among older adolescents, revealing that older
adolescents seem more likely than younger adolescents to refer to metacognitive aspects of
the Self.

Table 1. Mean and standard deviation of quotations for nine Self markers

Self Markers M (SD) M (SD) Range of quotation

standardized
Agency 2.93 (1.74) .42 (.25) 0-7
Commitment 1.67 (1.24) .33 (.25) 0-5
Resources .63 (1.06) .16 (27) 0-4
Social references 2.80 (2.39) .35 (.30) 0-8
Evaluation 1.47 (1.91) .21 (.27) 0-7
Qualia .83 (1.42) .17 (.28) 0-5
Reflexivity 1.93 (2.33) .22 (.26) 0-9
Coherence 1.90 (1.42) .38 (.28) 0-5
Positional marker 1.40 (1.22) .35 (.31) 0-4

Table 2. Mean and standard deviation of quotations for nine Self markers –
Gender differences (t-test)

Self Markers M (DS) t-test (df) p

Male Female

Agency 2.68 (1.80) 3.36 (1.63) 1.03(28) .91

Commitment 1.42 (1.26) 2.09 (1.14) 1.45(28) .75
Resources .42 (1.01) 1.00 (1.09) 1.46(28) .36
Social references 2.53 (2.14) 3.27 (2.83) .82(28) .090+
Evaluation 1.26 (1.45) 1.82 (2.56) .76(28) .050
Qualia .53 (1.02) 1.36 (1.86) 1.60(28) .008
Reflexivity 1.42 (2.27) 2.82 (2.27) 1.63(28) .83
Coherence 1.63 (1.34) 2.36 (1.50) 1.38(28) .38
Positional marker 1.42 (1.31) 1.36 (1.12) -.12(28) .65
Note: Values in bold are significant
+ p<.10

Table 3. Mean and standard deviation of quotations for nine Self markers – Age
differences (t-test)

Self Markers M (DS) t-test (df) p

Younger Elder

Agency 2.92 (2.16) 2.95 (1.34) -.01(28) .033

Commitment 1.93 (1.38) 1.44 (1.09) 1.10(28) .45
Resources .36 (.63) .88 (1.31) -1.34(28) .006
Social references 2.43 (2.41) 3.13 (2.41) -.78(28) .69
Evaluation 1.00 (1.24) 1.88 (2.30) -1.27(28) .019
Qualia .64 (1.39) 1.00 (1.46) -.68(28) .56
Reflexivity 1.29 (1.54) 2.50 (2.78) -1.45(28) .086+
Coherence 2.00 (1.36) 1.81 (1.51) .36(28) .16
Positional marker 1.43 (1.28) 1.38 (1.20) .12(28) .71
Note: Values in bold are significant. + p<.10.
294 Emanuela Rabaglietti and Silvia Ciairano

Relationships between Self Markersand Well-Being, Social Self-Efficacy,

Adulthood, and Discomfort

Using t-tests, we compared the adolescents who cited Self markers with those who did
not in terms of well-being (positive self-perception and expectation for success), social self-
efficacy (belief in their ability to manage and lead a group situation), adulthood (value on
autonomy), and discomfort (depressive feelings and sense of alienation). In Table 4 we
reported all the mean values and statistical indexes. However, in the following section, only
the tendential (p<.10) and significant (p<.05) findings are mentioned.

Table 4. Comparison between adolescents who quote (1) and those who do not quote (0)
a specific Self-Marker: t-test

Self Markers V.D. M(DS) t-test (df) p

1 0
(quote) (no quote)
Positive self- 26.07
25.91 (3.09) .11(28) .43
perception (3.95)
Expectation for 33.15 34.86
.86(28) .20
success (5.00) (2.48)
Social self- 41.02 38.86
-.89(28) .37
efficacy (5.29) (6.73)
Agency
Value on 13.43 12.93
-.62(28) .16
autonomy (1.66) (2.56)
Depressive 11.41 11.93
.37(28) .18
feelings (2.94) (4.18)
Sense of 8.41 9.36
.84(28) .60
alienation (2.56) (2.73)
Positive self- 26.13
25.92 (3.28) .11(28) .94
perception (3.35)
Expectation for 33.60 33.85
-.14(28) .57
success (4.79) (3.01)
Social self- 40.79 38.75
.11(28) .062+
efficacy (5.09) (9.14)
Commitment
Value on 13.13 14.50
1.38(28) .49
autonomy (1.90) (1.23)
Depressive 11.56 11.38
-.11(28) .21
feelings (3.36) (1.79)
Sense of 8.73 8.00
-.52(28) .073+
alienation (2.74) (1.08)
Positive self- 26.15
25.55 (1.69) .47(28) .012
perception (3.81)
Expectation for 35.20 32.73
-1.43(28) .31
success (2.92) (5.06)
Social self- 39.10 41.23
.98(28) .29
efficacy (4.60) (6.03)
Resources
Value on 13.30 13.33
.03(28) .64
autonomy (2.03) (1.84)
Depressive 11.30 11.65
.28(28) .079+
feelings (2.49) (3.53)
Sense of 8.20 8.85
.64(28) .44
alienation (2.39) (2.71)
 “It’s Saturday…I’m Going out with My Friends” 295

Table 4. Continued

Self Markers V.D. M(DS) t-test (df) p

1 0
(cita) (non cita)
Positive self- 25.20
26.10 (3.24) -.56(28) .88
perception (3.44)
Expectation for 33.94 31.60
-1.05(28) .51
success (4.32) (5.75)
Social self- 40.70 39.60
-.39(28) .68
efficacy (5.33) (7.51)
Social references Value on 13.36 13.10
-.28(28) .84
autonomy (1.95) (1.59)
Depressive 11.46 11.90
.28(28) .80
feelings (3.31) (2.70)
Sense of 8.58 8.90
.25(28) .27
alienation (2.70) (1.56)
Positive self- 25.85
26.15 (1.95) -.24(28) .037
perception (3.76)
Expectation for 35.00 32.83
-1.24(28) .28
success (2.89) (5.11)
Social self- 39.35 41.10
Evaluation .80(28) .45
efficacy (5.03) (5.92)
Value on 13.65 13.15
-.69(28) .86
autonomy (1.99) (1.84)
Depressive 10.70 11.95
1.02(28) .58
feelings (3.08) (3.22)
Sense of 8.00 8.95
.75(28) .95
alienation (2.56) (2.65)
Positive self- 26.05
25.77 (5.33) .22(28) .20
perception (3.45)
Expectation for 34.36 33.08
-.74(28) .89
success (3.99) (4.90)
Qualia
Social self- 39.77 40.95
.55(28) .74
efficacy (5.33) (5.87)
Value on 13.45 13.24
-.30(28) .66
autonomy (1.97) (1.86)
Depressive 11.05 11.82
.63(28) .72
feelings (3.55) (3.01)
Sense of 8.59 8.66
.06(28) .58
alienation (3.09) (2.33)
296 Emanuela Rabaglietti and Silvia Ciairano

Table 4. Continued

Self Markers V.D. M(DS) t-test (df) p

1 0
(cita) (non cita)
Positive self- 25.26
26.85 (2.36) -1.34(28) .075+
perception (3.69)
Expectation for 35.38 32.15
-2.03(28) .19
success (2.97) (5.13)
Social self- 40.50 40.53
.01(28) .28
efficacy (4.94) (6.23)
Reflexivity Value on 12.85 12.59
.01(28) .016
autonomy (3.01) (2.97)
Depressive 10.15 11.93
2.21(28) .83
feelings (2.94) (4.18)
Sense of 7.73 9.32
1.73(28) .42
alienation (2.37) (2.59)
Positive self- 24.88
26.67 (2.72) -1.52(28) .21
perception (3.75)
Expectation for 34.44 32.21
-1.33(28) .68
success (4.30) (4.79)
Social self- 41.39 39.21
-1.50(28) .072+
efficacy (4.79) (6.66)
Coherence
Value on 12.97 13.83
1.25(28) .49
autonomy (2.04) (1.49)
Depressive 10.64 12.88
1.98(28) .89
feelings (3.11) (2.91)
Sense of 8.00 9.58
1.69(28) .15
alienation (2.22) (2.88)
Positive self- 23.56
26.82 (2.76) -2.69(28) .41
perception (3.39)
Expectation for 34.55 30.81
-2.10(28) .077+
success (3.52) (6.11)
Social self- 41.55 37.69
-1.72(28) .039
efficacy (4.71) (7.18)
Positional marker
Value on 13.30 13.38
.10(28) .10
autonomy (2.11) (1.03)
Depressive 10.93 13.19
1.78(28) .86
feelings (3.06) (3.09)
Sense of 7.98 10.44
2.51(28) .88
alienation (2.45) (2.13)
Note: Values in bold are significant.
+ p<.10.

DISCUSSION AND CONCLUSIONS

This study contributes to the growing body of research about youth and peer
relationships. We made a precise request, asking a small group of high school students to tell
us how they spend an important part of their leisure time (Saturdays) with their friends.
 “It’s Saturday…I’m Going out with My Friends” 297

From the narrative compositions of the adolescents, we first extrapolated four main
spheres linked to going out with friends, i.e. time, people, activities, and place. Most of the
adolescents mentioned spending time with friends on Saturday, which is implicit in our
request. However, they also specified when (e.g. in the evening), with whom (e.g. friends,
class and schoolmates, and friends from their same or a different neighborhood, and where
(public places like pubs, discos, the cinema, and/or private places like their own house or their
friends’ houses). The common denominator is the desire to be together.
When they are together, the adolescents talk about their school experiences, but school is
not the main topic of conversation; they prefer to talk about music, recent events, sex, and
they really just like to have fun. The adolescents also mentioned, though only a small
percentage, activities that they themselves defined as illegal and non-conventional, like
smoking joints or racing cars and motorcycles. In the adolescents’ stories, these activities are
presented as a way to spend time together and they assume the meaning of testing one’s own
limits, as highlighted by Jessor and colleagues [1991; 1998] and Bonino and colleagues
[2005]. The world depicted in these adolescents’ stories seems to circumscribe the social life
of an individual who deliberately pursues amusement. However, adolescent life cannot be
classified or generalized as superficial, considering the small portion of their lives these
adolescents were asked to describe; this aspect certainly represents one of the major
limitations of our study. In the future, we would like to examine different and broader
portions of adolescent life. Furthermore, considering the limited size of our sample, a greater
number of participants would be needed to collect a sufficient number of narrations and
ensure a representative sample.
Our next step was to extrapolate the indicators of Self Markers from the adolescent
narrations. The findings offered a profile of adolescents who want to be active (agency) and
to commit (commitment), who try to give coherence (coherence) to their Self and life within a
social position, which is typical of adolescence (positional marker) because it is marked by
significant peers and friends (social references). The adolescents showed their desire to be
with peers, to laugh, to joke, and to talk, comparing points of view, and getting to know each
other better.
As hypothesised, sharing pleasant time with friends seems most important for girls; this
finding confirms the findings of numerous previous studies that have pointed out that girls
appreciate friendship relationships characterised by sharing and intimacy more than boys
[Berndt, 1996; Shulman, Laursen, Kalman and Karpovsky, 1997; Crosnoe, 2001]. Moreover,
it can also be hypothesised that the subjective aspects of the Self fit better with feminine
characteristics. In fact, qualia of the Self, evaluation and social references were indicated
more often in girls’ narrations; on the contrary of our hypothesis, reflexivity not is different
by gender. As expected, we also found that the adolescents’ narrations were articulated
differently at different ages. At older ages, the Self-portrait in friendships is enriched with
interpersonal elements and reflection; in fact, among older adolescents we found evidence of
agency, evaluation, resources, and reflexivity more often when compared to younger
adolescents. On one hand, this phenomenon may reflect intentional actions and initiatives and
the pursuit of personal aims while sharing leisure time with friends. On the other hand, this
phenomenon points to individual judgment and metacognitive strategies, and to external or
inner resources, which are part of the Self definition.
Our hypothesis regarding relationships between some of the more subjective Self markers
and well-being, social self-efficacy, adulthood, and discomfort was also, at least in part,
298 Emanuela Rabaglietti and Silvia Ciairano

confirmed. Though we found no associations with agency, the adolescents showed a more
positive self-perception particularly when they mentioned reflexivity and evaluation, and
higher expectations of success when they referred to positional marker. Self-reflection by the
adolescents seemed related to a lower value on autonomy. When the stories were marked by
commitment and coherence, adolescents also showed higher levels of social self-efficacy.
Further, although referring to commitment seems also related to higher sense of alienation, an
association was found between narratives mentioning resources and lower depressive
feelings.
This study clearly has several limitations. In addition to those mentioned previously, we
must also examine the theoretical decision to interpret our findings based on Bruner’s
classification as there may well be alternative explanations.
However, our study also has some merits. First, our study confirmed the findings of
previous researches [see for instance: Palmonari, Pombeni and Kirchler, 1990; Kirchler,
Pombeni and Palmonari, 1991; Larson and Richards, 1998] that, in the process of Self
definition, the adolescents attribute sense, coherence, and continuity to their life, also within
the context of peer and friendship relationships. During this process of Self definition, the
adolescent can also elaborate a hypothetical dimension of Self representation, which drives
him or her to define several possible selves, considered as desired, hoped for, or feared
aspirations, expectations, aims, and ideals [Aleni Sestito, 2004a]. With this in mind, identity
development can be equated to a narrative construction of the Self. Through narration and
autobiography, individuals can represent their own existence, giving it meaning within a
specific cultural context, and they can transform in explicit what is implicit. In addition, in
telling their stories, individuals can be heard and recognised by others [Bruner, 1990, 2002;
Aleni Sestito, 2004b].
In autobiography, individuals aim to construct their own Self while simultaneously
narrating it to themselves or to others. They outline a Self image based on personal
interpretation and their own idea of the world, although their personal interpretations and
ideas are always affected by the symbolic and cultural systems of reference [Bruner, 1991;
Aleni Sestito, 2004b]. In this way, the adolescents who participated in our study, by writing
about Self, leisure time, and friends, attempted to attribute meaning and coherence to both the
events and experiences that characterise their friendship relationships.
To live adolescence means being able to live in the present with the future on the horizon:
taking time today to choose which road to take, without setting a strict itinerary. But, if the
expectations of the outside world become overwhelming, living in the present becomes the
only option, preventing adolescents from developing the ability to fully capture the meaning
of the present. We should be paying close attention to the current generation of adolescents,
because they seem to lack a place in which they can be heard and receive the answers they are
looking for. Particularly it seems important to help the adolescents to build relationships
among the inner dimension (their thoughts and experiences), the external dimension (social
events, and culture), and finally the symbolic dimension (the way people describe and place
value on things they’ve experienced) in order to construct new ways of linking all these
aspects to form mature thoughts and actions.
 “It’s Saturday…I’m Going out with My Friends” 299

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 17

PREVENTION OF THE NEGATIVE EFFECTS OF

MARITAL CONFLICT: A CHILD-ORIENTED PROGRAM

Patricia M. Mitchell, Kathleen P. McCoy, E. Mark Cummings∗,

W. Brad Faircloth and Jennifer S. Cummings
University of Notre Dame, South Bend, Indiana, USA

ABSTRACT
A psycho-educational program for advancing children’s coping skills and reactions
to marital conflict was evaluated. Families with a child between the ages of 4 and 8 were
randomly assigned to one of three groups: 1) parent program only; 2) parent and child
program; or 3) self-study (control group). Parents in the parent-only and parent-child
groups received the same psycho-educational program. Only children in the parent-child
group received the child program which consisted of four visits in which children learned
about marital conflict and family relationships; were taught about emotions and different
levels of emotions; and were given tools for coping with conflict that would help them
react in optimal ways for their development. Analyses suggested the promise of a child
program for older children (ages 6-8) with regard to improved emotional security about
marital conflict. However, consistent with other research, simply educating children
about coping with marital conflict had minimal effects on outcomes associated with
conflict between the parents.

The negative effects of marital conflict on children are well-documented. Children from
high conflict homes are more likely to display externalizing disorders, such as excessive
aggression, non-compliance, and delinquency (Cummings, Goeke-Morey, and Papp, 2003;
Grych and Fincham, 2001), as well as distressed emotional responses, including depression,
anger, and fear in response to marital conflict (Cummings, Goeke-Morey, Papp, and

∗
Correspondence should be addressed to Dr. E. Mark Cummings, Department of Psychology, Haggar Hall,
University of Notre Dame, Notre Dame, IN 46556, phone: (574) 631-3404, fax: (574) 631-1825,
Cummings.10@nd.edu.
304 Patricia M. Mitchell, Kathleen P. McCoy, E. Mark Cummings et al.

Dukewich, 2002; Grych and Fincham, 2001). At the same time, it is how marital conflict is
handled by the parents, rather than the fact that conflict occurs, that has negative
developmental consequences for the child. Specifically, Cummings and Davies (1994)
defined various characteristics of marital conflict that have both negative and positive
consequences on the developmental trajectories of children, which are categorized as
constructive or destructive depending on the children’s reactions (Goeke-Morey, 1999).
The effects of marital conflict are related to how children interpret the conflict and how
they react (emotionally and behaviorally). The emotional security theory (EST; Davies and
Cummings, 1994; Cummings, Schermerhorn, Davies, Goeke-Morey, and Cummings, 2006)
posits that children appraise conflict situations in relation to their own security about their
family and personal well-being. The impact on child adjustment occurs through three
interrelated processes. The first process, emotional reactions to conflict, consists of children’s
overt emotional expressions as well as physiological arousal in the face of conflict. If a
child’s emotional security is threatened by parental discord, for example, children may
respond by expressing emotions such as fear or anger. The second component is children’s
cognitive appraisals of marital conflict. Children may see conflict as a threat to their
representations and expectations of family relationships, raising questions about the security
of their family. Finally, the third component of EST is regulation of exposure to conflict.
Emotionally insecure children, for instance, may attempt to end or reduce their exposure to
conflict by intervening in order to stop the discord. Children may also remove themselves
from the situation to avoid witnessing parental discord (Cummings and Keller, 2005;
Cummings, Davies, and Campbell, 2000). All three components are important aspects of how
marital conflict impacts children and thus are possible targets for intervention.
In light of this evidence of the negative effects of marital conflict on children, a goal is to
develop prevention programs to possibly change these outcomes. One direction is to develop
programs for children to help them cope better with marital conflict. Few efforts have been
made to directly help children by educating them about family conflict. Previous prevention
programs have focused primarily on married couples and the education of parents
experiencing conflict and divorce. The Premarital Relationship Enhancement Program
(PREP; Markman, Jamieson, and Floyd, 1983; Markman, Floyd, Stanley, and Storaasli,
1988), for instance, aims to educate engaged and married couples on the importance of
constructive communication, and to provide approaches towards improvement. PREP
successfully promotes a well-functioning marital relationship for couples to maintain healthy
interactions over time (Stanley, Markman, St. Peters, and Leber, 1995; Markman, et. al,,
1983). However, this program does not focus on the other members of the family outside of
the married couple. Similarly, the Kids in Divorce and Separation Program (K.I.D.S; Shifflett
and Cummings, 1999) provided education on the effects of conflict and divorce for parents.
Again, although this program was successful in improving parents’ knowledge of the effects
of conflict on children and in decreasing destructive conflict over time (Shifflett and
Cummings, 1999), this program was aimed towards parents and did not contain a child
component.
The Family Conflict Intervention Program (FCIP; Lindsay, Pedro-Carroll, and Davies,
2001), however, did contain a child component. This program attempted to directly help
children avoid the negative effects of conflict by teaching children to use optimal coping
skills when witnessing discord between their parents. The primary goals of FCIP were to help
children identify and express conflict-related feelings and to cope with the stress of
 Prevention of the Negative Effects of Marital Conflict 305

interparental conflict by teaching problem-solving skills and enhancing positive self-

perception. This program was successful in helping children to recognize the negative impact
of conflict on their own well-being and teaching them to better express their emotions and
feelings. In a separate program focused on improving the effects of conflict and divorce on
children, Wolchik and colleagues attempted to change children’s “putative mediators” (i.e.
coping skills, parent-child relationship quality, etc.) in relation to adjustment and marital
conflict and divorce (Wolchik, et. al., 2000; Wolchik et. al., 2002). While there was limited
support for the additive benefit of a child component found in this study, they did find some
support for working with children in relation to coping in response to marital conflict and
divorce. They also found working with both mothers and children in prevention programs can
help alleviate the negative outcomes that may result when children witness ongoing
destructive conflict (Wolchik et al, 2002).
The current program is similar to FCIP and the studies by Wolchik and colleagues in that
it focuses on providing children with information about conflict and attempting to teach
children optimal self-regulation. At the same time, the current program is a component of a
larger education program focusing on intervening with both children and parents in relation to
specific processes of the emotional security theory (Cummings, Faircloth, Mitchell,
Cummings, and Schermerhorn, 2008; Faircloth and Cummings, in press). The parent
education portion of the program attempted and succeeded in improving parents’
understanding of the effects of conflict on their children as well as their relationships with one
another (Cummings et al, 2008). The child component directly worked with children to
change and improve their coping skills and responses when witnessing marital discord.
Children learned how to change their own behaviors and emotional reactions to interparental
conflict in order to promote optimal developmental outcomes (Cummings, et. al., 2008). The
combination of both programs was intended to provide additive benefits for the entire family
system.

MARITAL CONFLICT AND CHILDREN’S SELF-REGULATION

Children’s emotional, cognitive, and behavioral reactions to conflict are related to their
overall development (Cummings, et. al., 2006). Thus, teaching children how to better self
regulate in these three domains might be expected to improve their developmental outcomes.
Baumeister (1997) defines self-regulation as the “processes by which the self alters its own
responses, including thoughts, emotions, and behaviors” (p. 146). To impact children’s
outcomes and reactions, it is necessary to teach them how to better handle and interpret their
emotions and behaviors when faced with stressful situations that threaten their emotional
security. In other words, teaching children how to regulate their emotions, cognitions, and
behaviors may improve multiple dimensions of coping, and in turn lead to optimal results for
children. This is the goal of the child component of the present prevention program.
306 Patricia M. Mitchell, Kathleen P. McCoy, E. Mark Cummings et al.

Emotional Regulation

Emotional regulation involves both the act and expression of feelings (Philippot and
Feldman, 2004; Cassidy, 1994). Children are sometimes not explicitly taught how to label
emotions and emotional reactions and may therefore act out in inappropriate ways as a result
of both confusion and arousal. Additionally, children may express emotions that are
immediately beneficial for the situation, but may prove to be detrimental as time goes on.
When witnessing conflict, for example, a child may cry when her parents fight as a way of
distracting her parents from the argument. Although this may be immediately beneficial
because it ends the fight, this coping mechanism could lead to ongoing depressive or anxiety
symptoms as a result of the emotional drain (Cummings, Davies, and Campbell, 2000;
Nicolotti, El-Sheikh, and Whitson, 2003). Finally, many children may conceptualize the
emotional expressions of their parents as proper expressions of emotional arousals. Yet, by
doing so, during periods of heightened negative and intense marital discord, children are
learning less optimal ways to express their own emotions (Crockenberg and Langrock, 2001;
Grych and Cardoza-Fernandes, 2001). Therefore, in order to help children cope both with
their emotions and stressful situations, they must first learn how to label emotions and to
recognize which emotions are beneficial for both short and long term development. Also, they
must gain the ability to separate their own emotions and emotional expressions from that of
others.

Cognitive Regulation

As EST emphasizes, how children perceive marital conflict in relation to their personal
well-being and the family’s functioning plays a large role in both how they feel and react to
conflict situations (Cummings et. al, 2006; Cummings, et. al, 2003; Grych and Fincham,
2001). Children may interpret conflict as a threat to the functioning of the family, which then
causes them to react in negative ways in order to end the conflict (see also Grych and
Fincham, 1990). The properties of the conflict, the context in which it is occurring, and the
child’s initial levels of emotional arousal may each play a role in how the child responds to
the conflict (Cummings, et. al., 2003; Harold, Shelton, Goeke-Morey, and Cummings, 2004;
Cummings and Davies, 1994). Children need to learn how to recognize their cognitions when
faced with conflict and how these cognitions affect both their emotions and behaviors
(Krohne, Pieper, Knoll, and Breimer, 2002). Training in cognitive regulation could provide
children with alternative solutions and various problem-solving skills to better deal with
interparental discord.

Behavioral Self-Regulation

As Lengua and colleagues (1999) explain, “behavioral control would be important for the
planning and effective implementation of coping strategies, which require inhibition of
immediate responding” (p. 18). Self-regulation includes individuals’ abilities to control their
extrinsic reactions to situations and contexts based on input from both emotions and
cognitions. Children high in behavioral self-regulation may be better able to control their
 Prevention of the Negative Effects of Marital Conflict 307

behavior in reaction to stressful situations presented. In order to behave adaptively when

faced with conflict, children must possess the ability to recognize that their parents’ fights are
not their fault and that marital discord is not a problem they can fix or should become
involved in (Nicolotti, et. al, 2003; Cummings et al, 2006; Cummings, et. al, 2000).

CURRENT STUDY
This paper examines the effectiveness of an empirically-based prevention program that
teaches parents how to handle conflict in constructive ways and also teaches children how to
optimally respond to marital conflict. A topical issue for prevention work in the area of
families is whether a child component adds to the benefits of programs geared towards the
parents. As mentioned above, past research has shown limited support for the additive
benefits of a child component aimed at improving children’s coping skills in the face of
adversity. For example, Wolchik and colleagues examined the effectiveness of prevention
programs for families of divorce and compared mother-only programs with combined
programs for mothers and their children. According to longitudinal follow-up studies, there
were few added benefits of programs aimed at teaching children how to cope with conflict
and divorce (Wolchik et. al., 2002; Wolchik et. al., 2000). Particularly, the child components
of these prevention programs did not significantly impact children’s adjustment over time.
Despite these past findings, this paper examines the effectiveness of a psycho-educational
program for children in concert with a psycho-educational program for parents. This child
component is based on theory in relation to children’s emotional, behavioral, and cognitive
reactions to conflict. The teachings of this component aim to positively impact children’s
coping skills in the face of interparental conflict. We hypothesize that prevention education
for children will be beneficial for the adjustment of children over time and in preventing the
negative effects of marital conflict, although we are aware of the limited support for such
findings. Furthermore, we expect that the age of the child participating in the program may
affect the retention of information over time. Therefore, age will be considered as a factor of
analyses in the current report.

Methods

Participants
Families were recruited from the South Bend and Mishawaka, IN, areas by a variety of
means, including: informational flyers posted in day care centers and elementary schools;
recruitment brochures sent home with the children in area schools and day care centers; and
informational booths at family fairs in the community. Criteria for inclusion in the study
required that couples be married or cohabitating for at least 3 years and that they have a child
between the ages of 4 and 8. Interested families were asked to contact the project office to
receive detailed information about the project and to arrange participation. The racial
breakdown for the children in the current sample was as follows: 72% of the children were
Caucasian, 6% were African American, 5% were Asian, and 17% were reported to be
Biracial. Four families did not report on the racial identity of their children. These statistics
308 Patricia M. Mitchell, Kathleen P. McCoy, E. Mark Cummings et al.

are representative of the surrounding counties. Families received monetary compensation for
their participation in the project and free child-care was offered to parents for those children
not participating in the child portion of the project.

Procedure
Approximately one hundred couples were randomly blocked into one of three groups
using a sampling without replacement procedure: 1) a parent-only group (n = 24); 2) a parent-
child group (n = 33); and 3) a self-study group (n= 33). After registering to participate in the
program, parents in all three groups completed the pre-intervention measures. Parents in the
two treatment conditions took part in a manualized psycho-educational program, while
members of the self-study group were given two books titled Not in Front of the Children
(Harold, Pryor, and Reynolds, 2001), and Adventures in Parenting (NICHD, 2001). Parents
assigned to the self-study group were also given a syllabus along with suggested readings
from the books to complete on their own. All adult participants in each group completed the
assessment packets before the program began, and then approximately four weeks after their
initial entry into the program and again at six-months and 1-year follow-up sessions.
Similarly, all participating children in the three groups completed assessments at the pre-
intervention, post-intervention, and follow-up visits. However, only the children in the parent-
child group participated in four educational visits and booster sessions at six-months and one-
year.

Parent Component
The parent educational portions of the parent-only and the parent-child groups were
identical. Multi-media presentations of materials were given, including PowerPoint slides,
videotaped clips, trivia games, and other engaging activities. Information about numerous
topics, including the effects of marital conflict on children, children’s emotional security
about family relationships, parenting behaviors, and optimal communication skills for married
couples was presented to participating parents. Also, at each session, couples practiced
communication skills with a communication coach. These weekly practice sessions focused
on turning destructive arguments into constructive discussions, as well as working towards
conflict resolution. Additionally, at the end of each educational session, couples were asked to
complete weekly diaries about their marital conflicts in the home. The couples were asked to
complete one diary for each of the four weeks.

Child Component
Children in the parent-child group took part in a number of different activities over the
course of four visits in order to promote optimal coping and emotional regulation in response
to marital conflict. Multiple topics were covered over the course of the four visits, including
the labeling and expression of emotions, the normality of marital conflict in all families, and
optimal behavioral, emotional and cognitive reactions to interparental conflict for children.
Multiple methods were used to teach the children these ideas, including coloring, games, and
role plays. Also, a book written primarily for this project, Twilight at Twyckenham, was read
to the children to help explain the concepts of emotions, cognitions, and behaviors in response
to interparental conflict. This book focuses on the different types of conflict that arise
between parents and how children feel about these arguments, as well as how they cope and
 Prevention of the Negative Effects of Marital Conflict 309

react to such discord. Additionally, throughout most of the program, research assistants used
puppets while interviewing the younger children as an age appropriate tool for teaching the
concepts of the program.

Measures

Parent Reports of Children’s Adjustment

The Child Behavior Checklist (CBCL; Achenbach, 1991) was used to asses children’s
internalizing and externalizing symptomatology. Parents are asked to rate a list of behaviors
(i.e. “worries” or “destroys his/her own things”) as being either (0) not true, (1) somewhat
true, or (2) very true of their child over the past six months. In the current project, the mean
test-retest reliability across all subscales is very good (r = .85), while internal consistencies
for the internalizing, externalizing, and total problem subscale scores (α = .89; α = .92; α =
95, respectively) have been well established (Achenbach and Rescorla, 2000).
The Security in the Marital Subsystem-Parent Report inventory (SIMS-PR, Davies, and
Forman, 2002) was used to assess child emotional security from the parents’ perspectives.
This measure consists of a total of 37 items used to assess children’s direct involvement,
behavior dysregulation and negative emotional reactivity in response to interparental conflict.
Each item is assessed using a 5-point ordinal scale from (1) not at all like him/her to (5) a
whole lot like him/her. Mother and father reports were scored for each of the five subscales:
emotional reactivity (i.e. “appears sad”), behavioral dysregulation (i.e. “yells at family
members”), avoidance (i.e. “tries to stay away from us”), involvement (i.e. “tries to distract us
by bringing up other things”), and somantic reactivity (i.e. acts as if he/she feels nauseous).
This measure has good reliability, with α’s ranging from .74 to .88 for both mothers and
fathers in the current project.

Children’s Self-Reports of Adjustment

Children’s internalizing symptoms were assessed using the Child Symptom Inventory
(CSI; Reynolds, 1980). This 15-item measure is a revised version of the Children’s Manifest
Anxiety Scale (CMAS; Castaneda, McCandless, and Palermo, 1956). Children are asked to
answer yes, sometimes, or no to each statement depending on how much each statement
sounds like them. Sample items include, “I get nervous when things do not go the right way
for me” and “I do many things wrong”. For the current project, only the internalizing scale for
this measure was used due to the results of a principal components analysis. The reliability
coefficient for this scale in the current project is .83.

Children’s Self-Reports of Reactions to Marital Conflict

Children’s emotional security in reaction to conflict was assessed using the Security in
the Interparental Subsystem Scale (SIS; Davies, Forman, Rasi, and Stevens, 2002). This is a
27-item measure consisting of five subscales: emotional reactivity (e.g., “When your parents
argue do you feel scared?”), involvement (e.g., “When your parents argue do you try and help
your dad?”), dysregulated involvement (e.g, “When your parents argue do you tell them to
stop?”), avoidance (e.g., “Do you try and be really quiet when your parents argue?”), and
somatic reactivity (e.g., “Does your tummy hurt when your mom and dad argue?”). The
310 Patricia M. Mitchell, Kathleen P. McCoy, E. Mark Cummings et al.

subscales for this measure have shown satisfactory internal consistencies (α’s range from .52
to .89) and test-retest reliabilities (α range from .59 to .87; Davies, Forman, Rasi, and
Stevens, 2002). Internal consistencies for this project range from .75 to .88.
In order to further assess children’s emotional and cognitive responses to marital conflict,
the Children’s Perceptions of Interparental Conflict Scale–Youth (CPIC-Y, Grych et. al.,
1992) was used. This 34 item scale has shown acceptable internal consistency (α range from
.61 to .83) and has three subscales related to children’s perceptions of marital conflict:
conflict properties (e.g., “When my parents have disagreements they yell at each other.”),
threat (e.g, “When my parents argue, I’m afraid that something bad will happen.”), and self-
blame (e.g., “When my parents argue it’s usually because I did something wrong.”). Because
of the age of the children participating in the project, puppets were used to administer this
measure in order to help the children better understand the questions and concepts. Each of
these subscales (conflict properties, threat, and self-blame) has good test-retest reliabilities in
the current project (α = .85; α =.89; α = .64, respectively).

RESULTS

Analysis Plan

Due to the structure of the data, multiple types of analyses were run to examine the
effectiveness of the child component. To begin, multivariate analysis of covariance
(MANCOVA) was used to examine if differences existed between groups on the child
measures. According to Rausch, Maxwell, and Kelley (2003), this test (using the pre-test
score as the covariate) provides the most statistical power to detect treatment effects
compared to other tests of repeated measures designs and gives more “statistically precise
confidence intervals around population group mean differences” (p. 473). Furthermore, to test
if there were any differences between groups while controlling for child age, hierarchical
linear modeling (HLM; Bryk and Raudenbush, 1992) was used.

Tests of Efficacy Using MANCOVA

Tests of differences between the parent-child treatment group and the parent-only
treatment group and the self-study control group using MANCOVA did not yield any
significant results. Each variable for the children’s perceptions of parental conflict and their
adjustment outcomes were examined. The pre-test score for each variable was used as the
covariate to analyze differences between groups for the post-test and follow-up assessments
on the same measure.

HLM

To further examine the possible efficacy of the child program, hierarchical linear models
were run. The main purposes of these models were to examine if children’s perceptions of
 Prevention of the Negative Effects of Marital Conflict 311

conflict between their parents, as well as the parents’ perceptions of their children’s
adjustment, changed based on the group they were in and the age of the participating child.
Because the variables in the current study were expected to vary over time depending on the
group involvement and age of the children, the variables were treated as time-varying
predictors in the level one models and group membership was controlled for in the level two
models. Once these models had been examined, age was then added as a variable of interest
to examine if the older children in the parent-child group were more successful at retaining
the information presented compared to the younger children in the same group. The level one
equation for the models controlling for group took the following general form:

Level 1

Yij = π0 β1 (TIME) + r

Level 2 equations took on the following form:

β0 = γ00 + γ01 (GROUP) + µ0

β1 = γ10

β2 = γ20

Children in the parent-child group did not significantly differ from those children in the
parent-only and self-study groups on self-report or parent report measures of coping and
adjustment. At the same time, children’s self-reports of negative perceptions of marital
conflict (F (88) = -2.84; p < .01); tendencies to engage in behavioral dysregulation in
response to marital conflict (F (88) = -2.65; p < .01); and self-blame in response to marital
conflict (F (88) = -4.9; p < .01), lessened over time for the participants as a whole. Post-hoc
analyses indicated that these variables decreased over time only for the children in the parent-
child group, albeit not significantly. These variables did not decrease over time for the other
groups as indicated by post-hoc analyses.
Further analyses examined whether responding changed over time according to group
and the ages of the children. For example, younger children may not understand and retain the
information presented to them as successfully as the older children in the project. Children
were split into two groups depending on their age: younger children (ages 4 and 5) were put
in one group, while older children (ages 6 to 8) were placed in a second group. Then, age was
included as a variable in the level one linear model:

Level 1 example with age:

Involvement= β1 (TIME) + β2 (AGE) + r

The level two models were the same as above and controlled for group membership.
There were significant differences for some of the variables examining emotional security in
relation to marital conflict depending on the age of the children. For example, children’s self-
reports of dysregulation in response to conflict significantly decreased for older children (ages
312 Patricia M. Mitchell, Kathleen P. McCoy, E. Mark Cummings et al.

6 to 8 at the start of the program) in the parent-child group (F (16) = -2.93, p< .01), but not for
the younger children (ages 4 and 5) in the same group. The same was true for children’s
reports of involvement in conflict for the older children (F(16) = -3.11, p< .01), as well as
self-blame in response to conflict (F (16) = -4.72, p< .01). These results were not found for
younger children in the parent-child groups. Thus, older children in the treatment group were
able to retain and utilize the information presented to them in the program when compared to
younger children. None of these comparisons were significant for the parent-only and self-
study groups.

DISCUSSION
Despite the well-documented impact that conflict has on children’s development, little
has been done to educate children about these effects and to provide them with coping skills
in response to stressful family situations. Because conflict has been found to impact children
through behaviors, cognitions, and emotions (Cummings et al, 2006; Grych and Fincham,
2001), teaching children how to react in these ways may ameliorate impact on their
adjustment. However, the effectiveness of including a child component in addition to a parent
program has been an area of debate. Research has focused on psycho-educational programs
for parents in order to improve marital discord (Markman, et. al, 1983; Goodman, Bonds,
Sandler, and Braver, 2004; Markman, et. al, 1988).
Specifically, the current study examined the effectiveness of a child component within a
larger psycho-educational program for parents aimed at preventing the negative effects of
conflict on the family system. Parents were provided with communication skills training and
information on conflict and family, while a subset of children in one of the prevention groups
were given information and tools regarding optimal coping skills in the face of conflict.
According to results, older children in the parent-child treatment group (ages 6 to 8)
evidenced increased emotional security about marital conflict and less involvement in marital
conflict over time. Moreover, follow-up analyses indicated no benefits in this regard for the
other groups, and younger children in the parent and child group. Thus, information provided
in the child component was successful in helping relatively older children adapt in terms of
feelings of emotional security and reactions in relation to marital conflict. Also, separate
analyses examining the parent component revealed that educating parents about the effects of
marital discord on children can positively impact children’s outcomes over time (Cummings,
et al, 2008).
These findings are consistent with other programs suggesting limited benefits from a
child component for marital conflict and children (Wolchik et al., 2000). Specifically, while
Wolchik and colleagues did not find many additive benefits when including a child
component in the larger prevention programs, they did find that educating children about
coping in the face of family adversity impacted children’s responses to conflict over time
(Wolchik et al, 2002; Wolchik et al, 2000). Several factors may account for the limited
findings. First, children’s adjustment and emotional security is affected by marital conflict
because marital conflict is to some extent an actual threat to children’s safety and well-being.
Relatedly, Bowlby (1973) posited that children’s emotional security about family relations is
based on children’s actual experiences with threatening events or loss. Given this fact, there is
 Prevention of the Negative Effects of Marital Conflict 313

little that children can do to reshape the threat to family posed by marital conflict and it would
be unrealistic for them to view conflict as no longer threatening because of learning about
coping with conflict. Second, relatively advanced cognitive capacities may be needed for
children to understand how to cope better with marital conflict. That is, to the extent that
coping responses are an overreaction or could be improved, children may benefit further as
they get older in terms of learning to use information about putting interparental conflict in
better perspective, such as children understanding that conflict is not their fault. The finding
that children 6-8 (the oldest group) were the only ones to show improvement is consistent
with this interpretation.
At the same time, marital conflict is to some extent related to children’s behavior
problems and how the children handle family conflicts (Jenkins, Simpson, Dunn, Rashbash,
and O’Connor, 2005). Thus, supplementing components to help children cope, older children
may also benefit from training that focuses on how to handle their own conflicts more
constructively. For example, children learning to respond pro-socially, rather than
aggressively or angrily, may also improve marital conflict (Schermerhorn, Cummings, and
Davies, 2005). Given the level of family discord during adolescence, and the relations
between adolescent-parent difficulties and marital conflict (Erel and Burman, 1995),
prevention programs that include components for adolescents to learn how to handle conflicts
better may be especially promising.
Despite the findings to date, there are bases for believing that programs targeting children
as well as parents are more likely to be successful. Although it has been difficult for
researchers to find significant results when adding child components to family prevention or
intervention programs (Wolchik, et. al, 2000) , providing families with additional and
different information for multiple family members is likely to increase the efficacy of
prevention efforts (Borkowski, Smith, and Akai, 2007). Also, because the family is a system
with multiple interacting and functioning parts (Cox and Paley, 2006), intervening with these
different parts is likely to promote a healthy and well-functioning family system.

LIMITATIONS
Although there were interesting results regarding older children participating in the child
component, there were some limitations of the current study that merit mention. To begin, the
sample size of the parent-child group was small and likely contributed to the lack of
significant findings, especially for the comparisons about treatment and control conditions. In
particular, it is difficult to establish enough power for analyses with a small sample size
(Maxwell and Delaney, 2000). Moreover, the lack of significant comparisons between groups
means that the findings should be interpreted with caution. Also, although the older children
seemed to benefit from the program, significant results were not found for the younger
children participating in the program. It could be that older children are better able to
understand the concepts presented and also better able to retain the information due to their
levels of social and cognitive development. This finding indicates that children above the age
of six would be more ideal participants in studies of this nature.
Another limitation that merits attention is in relation to the measures used in the current
study. Because of the nature of the education program for children, one limitation was the
314 Patricia M. Mitchell, Kathleen P. McCoy, E. Mark Cummings et al.

lack of program specific measures. Specifically, because we taught children optimal tools for
coping with conflict and family relationships, it would have been beneficial to measure their
understanding and retention of these concepts over time using measures created specifically
for the project. A measure that asked specific questions regarding the material presented in
the parent-child treatment group may have yielded more significant results in relation to
children’s positive development and marital conflict and family factors. This was the case for
the parent program of the same study. When asked specific questions about what the
participants were taught, their knowledge of the concepts significantly predicted change in
their marital conflict behaviors over time (Cummings, et al, 2008). Finally, a child only group
would help to possibly separate confounds present due to parent treatment and indicate
whether the results were solely from children’s participation in the program, rather than the
combined effects from both parents and children.

FUTURE RESEARCH
Despite these limitations, the current program was successful in helping some children
avoid the negative consequences that may arise in the face of marital discord. Future goals
include adapting this program for older children, including adolescents, and adapting the
information for different groups, including religious and ethnically diverse communities.
Because conflict is an inevitable part of all relationships, children and adolescents could also
learn how to better communicate with their parents, peers, and romantic partners. Therefore,
communication skills training for children, in addition to training for the parents, is a
promising goal for future programs.

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of divorce and conflict on children: An initial evaluation. Family Relations, 48, 79-89.
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Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 18

MOTHER-INFANT BONDS:
THE EFFECTS OF MATERNAL DEPRESSION ON THE
MATERNAL-CHILD RELATIONSHIP

Deana B. Davalos, Alana M. Campbell and Amanda L. Pala

Colorado State University, Colorado, USA

ABSTRACT
The mother infant bond has long been recognized as being crucial in multiple areas
of infant development. The value that is placed on this relationship is recognized across
the world and across groups of varying socioeconomic status. The multitudes of variables
that are thought to be influenced by the mother infant relationship are impressive, even
staggering. Research suggests that, depending on the level of bonding or lack thereof,
infants may suffer outcomes as severe as irreversible neuropsychological deficits or
development of long-standing psychopathology. However, others have argued that the
effects are likely much more subtle, but certainly still important. During the last two
decades there has been an increase in research focusing on the effects of maternal
depression on the mother infant bond. Research in this field has apparently developed out
of; a recognition of a relatively higher prevalence of postpartum maternal depression than
once believed and recurring observations of differences in mother/infant relationships or
infant behavior associated with maternal postpartum depression. The infant behaviors
that have been implicated as resulting from this theoretically compromised mother infant
relationship have included slight, transient effects on sociability and affective sharing to
results suggesting significant increases in irritability, cognitive delays, behavioral
problems, and difficulties with attachment, among others. Longitudinal data suggest that
while some problems appear to resolve relatively quickly, there are some characteristics
that endure long after infancy. Specifically, some researchers have argued that children
and even adolescents who experienced problems bonding with their depressed mothers
are at significantly greater risk of experiencing a variety of psychological symptoms,
including depression, anxiety, and problems with addiction. Again, this view is
controversial and others in the field link these increased risks to other factors such as low
socioeconomic status or marital discord. While there appears to be consensus among
most researchers in recognizing that there are likely effects of postpartum depression on
320 Deana B. Davalos, Alana M. Campbell and Amanda L. Pala

mother infant bonding that affect early development, there is little consensus regarding
the specific details of these effects. In our review, we will systematically analyze research
focusing on the effects of postpartum depression on the mother infant bond and those
variables that are believed to be affected from potential difficulties in this bond.

INTRODUCTION
The mother infant bond has long been recognized as being crucial in multiple areas of
infant development (Beardslee et al., 1983; Cummings and Cicchetti, 1990). The value that is
placed on this relationship is recognized throughout the world and across socioeconomic
status (Narayanan, 1987). The multitudes of variables that are thought to be influenced by the
mother infant relationship are impressive, even staggering. Research suggests that, depending
on the level of bonding or lack thereof, infants may suffer outcomes such as cognitive
deficits, interpersonal difficulties, or the development of long-standing psychopathology
(Downey and Coyne, 1990; Gunning et al., 2004; Orvaschel, Walsh-Allis and Ye, 1988).
Others have argued that the effects are likely much more subtle, but certainly still important.
During the last two decades there has been an increase in research focusing on, possibly one
of the most prevalent threats to the mother infant bond, maternal depression. Research in this
field has apparently developed out of the recognition of a higher prevalence of postpartum
maternal depression than once believed and recurring observations of differences in
mother/infant relationships or infant behavior resulting from maternal postpartum depression.
The infant behaviors which have been implicated as resulting from this theoretically
compromised mother infant relationship have included slight, transient effects on sociability
and affective sharing to results suggesting significant increases in irritability, cognitive
delays, behavioral problems, and difficulties with attachment, among others (Cogill et al.,
1986; Sharp et al., 1995; Murray et al., 1996).
Longitudinal data suggest that while some problems appear to resolve relatively quickly,
there are select characteristics that endure long after infancy. Specifically, some researchers
have argued that children, adolescents, and even young adults who experienced problems
bonding with their depressed mothers are at significantly greater risk of experiencing a
variety of psychological symptoms, including depression, anxiety, and problems with
addiction (Ensminger et al., 2003; Peisah, Brodaty, Luscombe, and Anstey, 2004; Timko et
al., 2008). Again, this view is controversial and others in the field link these increased risks to
factors other than maternal depression, such as low socioeconomic status or marital discord.
While there appears to be consensus among most researchers in recognizing that there are
likely effects of postpartum depression on mother infant bonding that affect early
development, there is little consensus regarding the specific details of these effects. In this
review, we will systematically analyze research focusing on the effects of postpartum
depression on the mother infant bond and those variables which are believed to be affected
from potential difficulties in this relationship. In this report, we will review systematically
postpartum depression and its effect on the mother-infant bond.
Maternal depression has received increasing attention during the past several years due to
interest in the possible implications for both mother and child. However, confounding
variables that may also affect children of depressed mothers present a limitation that
systematically appears in the maternal depression literature. For example, results from various
 Mother-Infant Bonds 321

studies suggest that the following variables may all have an effect on children’s well-being,
regardless of maternal depression; marital status, socio-economic status, low social support,
maternal daily stressors, family adversity, quality of childcare (Belsky, 1984; Downey and
Coyne, 1990; Hall and Farel, 1988; Rutter and Quinton, 1984). Furthermore, there are
difficult issues involved in trying to identify the effects of depression when the onset of
symptoms can be vague or difficult to identify. While some mothers with depression only
experience depressive symptoms during the postpartum period, there are also mothers who
meet diagnostic criteria for depression throughout both the prepartum and postpartum period
(Dietz, Williams, Callaghan, Bachman, Whitlock, and Hornbrook, 2007). Given that there are
distinct consequences for infants and children exposed to maternal depression during the
prenatal period, it is often difficult to ascertain what is a product of postpartum maternal
depression instead of maternal depression with an earlier onset during pregnancy.
While a large number of the outcome variables associated with depression during the
prenatal period have focused on physiological indices related to prenatal exposure to elevated
neurotransmitters and cortisol levels (Davis, et al., 2007; Field, et al., 2004; Field, 1995;
Jones, et al., 1998; Lundy, et al, 1999), the effects of postpartum depression have tended to
emphasize the role of compromised bonding between infant and mother and resulting
psychological and cognitive outcomes.
To understand the importance of identifying maternal depression and the possible effects
on both mother and child, it is critical that one first understands the prevalence of this
condition. While it has been argued that perinatal depression is likely grossly underreported,
estimates suggest that 8% to 52% of women experience postpartum depression. When one
adds those women with children who have experienced depressive symptoms, that estimate
consistently jumps to over 50% of women (Baker-Ericzen et al., 2008; Heneghan, Silver,
Bauman and Stein, 2000; Horowitz, 2007; Lanzi, Pascoe, Keltner and Ramey, 1999;
McLennan and Kotelchuck, 2000; McLennan and Offord, 2002; Moss and Plewis, 1977). The
World Health Organization has posited that for women of child-bearing age, depression is the
leading cause of disease burden worldwide (World Health Organization, 2001). And while
unfortunate, researchers have argued that mothering young children increases the risk of
depression and that, childbirth in particular, is the time when women are most prone to
develop psychiatric disturbance (Brockington and Kumar, 1982; Murray and Lopez, 1996). In
addition, there appears to be specific risk factors associated with those mothers of young
children who endorse the highest rates of depression, including; never being married,
achieving less than a high school education, under 25 years of age, specific racial status, and
low socioeconomic status (Hall, 1990). Surveys focusing on women bringing in children for
pediatric care have estimated that 15% to 40% of mothers report depressive symptoms (Kahn,
Wise, Finkelstein, Bernstein, Lowe, and Homer, 1999; Kemper, 1994).
Given that maternal depression borders on epidemic proportion and considering the fact
that when we are able to recognize depression and treat it effectively, the duration may be
reduced significantly, there is increasing need to understand maternal depression and the
outcomes that may result from depression in both mother and child (Beck and Gable, 2000).
The description of maternal depression varies significantly in the literature. Defining
maternal depression varies from self-reports, subjective ratings from clinicians or family
members, to structured clinical interviews. In addition, women who are included in maternal
depression studies vary from individuals who have suffered from severe depressive symptoms
for years to others who appear to have more transient mild symptoms of depression. Lastly, it
322 Deana B. Davalos, Alana M. Campbell and Amanda L. Pala

is often unclear whether the symptoms of depression that are reported in the women with
depression during the perinatal period are related to their perinatal status or represent long-
term depression that simply carries over into the perinatal period. The unifying theme for the
studies presented in this chapter is that they reflect a wide range of outcome variables that are
thought to result from maternal depression.

MATERNAL DEPRESSION OUTCOME VARIABLES

Physical Health and Injury

Over the years, researchers have uncovered a number of physical differences which
appear to distinguish offspring of depressed mothers compared to those of non-depressed
mothers. Many of these characteristics appear as early as infancy. Among these are elevated
heart rates associated with sympathetic arousal during interactions with their depressed
mothers (Field, 1984) and lower vagal tone suggestive of lowered parasympathetic activity
during interactions (Porges et al., 1982), both suggesting an elevated degree of stress in these
infants with their mothers. While some argue that these characteristics may be inherent in
these children from birth, there are compelling findings suggesting that interaction with the
depressed mother exacerbates physiological deficits. For example, a number of these
physiological indices are not present in infants when they are separated from their mothers
and observed with strangers, even when their external observable behavior is unchanged.
However, there are other measures which appear to be more chronic, regardless of the
presence of the depressed mother during assessment. . For example, infants with depressed
mothers exhibit elevated cortisol levels across multiple measurement times, suggesting that
infants most likely experience chronic stress (Gunnar et al., 1984; Tennes, Downey and
Vemadakis, 1977). Dawson, Frey, Self, et al. (1999) furthered the argument that there are
likely static physiological conditions in these infants leading to increased stress and chronic
negative outcomes. Specifically, the researchers hypothesized that the atypical brain activity
that has been observed in infants of depressed mothers may reflect a tendency to experience
more frequent and possibly more intense negative affect in addition to a lack of appropriate
self-regulatory strategies that are used to modulate negative emotions. Furthermore, the
reduced frontal brain activation (EEG) is likely associated not only with cognitive deficits
that will be addressed later, but also contribute to difficulties with inhibition and emotional
regulation (Ashman, Dawson and Panagiotides, 2008). That infants of depressed mothers may
be predisposed to experience more frequent and greater negative affect while also lacking
sufficient self-regulatory strategies to modulate these negative emotions lends further support
to the idea that there may be multiple factors pointing towards chronic stress in infants of
depressed mothers.
This perceived relationship between maternal depression and increased stress in their
offspring has been of great interest to researchers and has been studied across multiple
physical outcome variables. One condition that has been studied in depth is asthma. Given
that asthma is considered by many to be a stress-sensitive illness, researchers have questioned
the relationship between asthma and psychological distress, specifically focusing on
depression (Shalowitz, Berry, Quinn and Wolf, 2001). The autonomical dysregulation model
 Mother-Infant Bonds 323

of asthma proposed by Miller and Wood (1997) suggests that depressive states involve
autonomic nervous system dysregulation that may be associated with vagally mediated
asthma episodes (Waxmonsky et al., 2006). This model is consistent with past studies which
have found a link between high internalizing symptoms and asthma severity (Goodwin et al.,
2004; Klinnert et al., 2000; Ortega et al., 2002; Padur et al., 1995; Vila et al., 1998;
Wamboldt et al., 1998) and research suggesting higher than average rates of depression in
children and those children’s mothers who present at hospitals for asthma symptoms
(Waxmonsky et al., 2006). Given these findings, a natural question that arises is whether
children of depressed mothers may be at greater risk for developing asthma and/or exhibit
greater asthma activity. While it remains controversial whether there is a direct relationship
between maternal depression and asthma disease activity, research findings suggests that
there is higher prevalence of asthma in children of depressed mothers and that there appears
to be an indirect relationship between maternal depression and increased child internalizing
symptoms (e.g. depressive and anxiety symptomatology) that result in increased asthma
activity (Lim, Wood and Miller, 2008; Shalowitz, Berry, Quinn and Wolf, 2001).
Furthermore, there is strong evidence that maternal depression is associated with internalizing
disorders (Beardslee, Versage and Gladstone, 1998; Weissman et al., 2006), suggesting that
maternal depression may play an important role in child asthma as well as a number of other
conditions which involve internalizing symptoms.
A different, possibly more controversial, area of research in maternal depression focuses
on issues such as the increased prevalence of accidents, injuries, and doctors’ appointments in
children of depressed mothers. There are numerous studies suggesting overall poorer physical
health in children of depressed mothers, greater number of headaches and stomachaches,
higher rates of medical problems, and even higher rates of mortality in the offspring of
depressed parents in longitudinal studies following participants into middle age (Billings and
Moos, 1983; Weissman, Gammon et al., 1987; Weissman, Wickramaratne et al., 2006;
Zuckerman, Stevenson and Bailey,1987). However, there is slightly more controversy
surrounding whether children of depressed mothers have more accidents, more physical
injuries and greater frequency of doctor’s visits.
Lewsinsohn, Olino, and Klein (2005) found that children of mothers with depression had
greater occurrences of treatment for illness. Schwebel and Brezausek (2008) found that
chronic levels of severe maternal depression were associated with increased risk of injury in
infants and toddlers (up to age three). This finding was robust even when the researchers
controlled for SES, sex of the child, child temperament, externalizing behavior, and parenting.
It should be noted, however, that the risk for injury was not noted when mothers endorsed
less severe symptoms of chronic maternal depression. Brown and Davidson (1984) also
demonstrated a higher rate of accidents in children of depressed mothers as compared with
children of nondepressed mothers. However, they point out that other studies noting similar
results have introduced the possible role of maternal psychotropic medication use at the time
of the child’s injury, reporting that 26% of the depressed mothers were receiving prescribed
psychotropic medication at the time of injury (Hyman, 1978). Others have argued that a more
feasible explanation of increased medical care and increased injuries in children of depressed
mothers focuses on the fact that these children may be more likely to have growth failure
(both height and weight) due to “failure to thrive” (O’Brien et al., 2004). Past studies suggest
that low maternal self-esteem and depressive mood are important factors associated with
growth failure (Evans, Reinhart and Succop, 1972). These characteristics often viewed as a
324 Deana B. Davalos, Alana M. Campbell and Amanda L. Pala

failure to thrive appear to be related to poor maternal affect and poor child-rearing. However,
the relationship between maternal depression and infant growth outcomes is poorly
understood with possibilities including; infant growth ‘failure’ may negatively affect maternal
mood, children of mothers with depression may be more likely to be identified with “failure
to thrive” due to increased health-seeking behaviors by the mother, difficulty breastfeeding
and poor mother-child interaction, or the established relationship between antenatal
depression and low infant birth weight (Stewart, 2007).

Cognition and Language

While many of the physical outcome variables studied in the maternal depression
literature are assessed early in development, often at infancy, the outcome measures
associated with cognition and language development are often assessed later in development.
While there appears to be ample evidence suggesting that children of mothers with depression
may exhibit developmental delays and some degree of cognitive and functional impairment,
there is quite a bit of variability in the literature (Beck, 1998). There are clearly certain
situations that may lead to different outcomes or select variables that lead to diverse effects.
Among these, researchers have identified two main variables that may affect outcome the
most: the age of the child at which the onset of maternal depressive symptoms appear and the
gender of the child. Some research results suggest that the first two years are the most critical
in terms of mother/infant bonding and the potential impairment of cognitive development
(Cogill et al., 1986). Others argue that cognitive impairments are less a function of timing and
more likely associated with the gender of the offspring. For example, poor cognitive
performance resulting from maternal depression has been found to be selectively limited to
sons in some studies, specifically finding that boys of depressed mothers have poorer
educational attainment (Ensminger et al., 2003). Others argue that while there are clearly
cognitive and linguistic variables that appear to be affected by maternal depression, it is less
clear whether this relationship is direct or mediated by another variable. For example, some
studies find direct associations between poorer cognitive functioning and maternal depression
(e.g. Teti et al., 1995) but others show an association only in the context of family adversity
or, as mentioned previously, only for boys (e.g., Murray, 1992; Murray et al., 1996; Sameroff
et al.,1993).
More general findings have appeared across genders. There are widespread language
difficulties and specific cognitive deficits that span early childhood to late adolescence. In
terms of language, persistent maternal depression has been associated with delayed language
development (e.g. counting objects, naming colors) in children approximately three years of
age (Kahn, Zuckerman, Bauchner, Homer and Wise, 2002). Other studies assessing the same
age range have noted poor verbal comprehension, poor linguistic functioning, and difficulties
with expressive language (NICHD Early Child Care Research Network, 1999). In addition,
there are a number of cognitive outcome measures that may surface later in development,
possibly after the mother’s depression has resolved. For example, children who have been
exposed to maternal depression at age three exhibit deficient reading even at age eight
(Hopkins, Marcus, and Campbell, 1984). These difficulties can also persist much later, with
studies suggesting that children whose mothers have had persistent depression are more likely
to drop out of high school (Ensminger et al., 2003).
 Mother-Infant Bonds 325

Failure to complete school is not the only education-related variable that has been noted
in the literature. Children of depressed mothers tend to show more difficulty with school-
readiness (NICHD Early Child Care Research Network, 1999). From teacher reports, these
children are more often described as more aggressive, angry, defiant, and uncooperative than
are other children (Alpern and Lyons-Ruth, 1993). However, it has been argued that the more
external, behavioral problems that have been repeatedly noted by teacher ratings in the
literature tend to minimize internalizing symptoms, often reported by family members, such
as fear, anxiety, and physical complaints (Bird, Gould and Staghezza, 1992). Instead, given
the teachers' instructional role, they are more likely to report these children’s behaviors such
as aggression, hostility, and hyperactivity, which disrupt classroom routines.
While there are multiple theories about why maternal depression is related to
compromised cognitive and linguistic development, it has been suggested that it is likely due
to a combination of factors. Many of these include indirect influences that may be more
related to the child’s environment in the home of a depressed mother (e.g. high stress, limited
resources, etc.) while others focus more on the relationship between the mother and child.
These mother/child variables range from poor modeling of enriched language and engaged
problem solving by the depressed mother to more general issues such as reduced maternal
sensitivity to the child’s needs and reduced level of engagement with the child (Hay, 1997;
NICHD Early Child Care Research Network, 1999).

Psychological Effects and Behavioral Correlates

The last facet of development that has arguably received the most attention in the
maternal depression literature is the psychological and behavioral correlates of exposure to
maternal depression.
While there is definite controversy in the literature regarding the types and the extent of
pathology that may be associated with maternal depression, the majority of literature suggests
that there are likely at least transient psychological effects and behaviors that result from
exposure to maternal depression. For decades, researchers have highlighted the relationship
between parental depression and higher rates of depression in their offspring. These rates vary
significantly from study to study, 10% to 33% in some studies, 2-6 times greater than in
control groups in other studies, with all noting a significant increase in the odds of these
children becoming depressed at some point in their life (Beardslee, Keller and Klerman 1985;
Downey and Coyne, 1990; Lieb et al., 2002; McKnew, Cytryn, Efron, Gershon and Bunney,
1979; Weissman, Prusoff, Gammon, Merikangas, Leckman and Kidd, 1984; Weissman et al.,
1987; Welner, Welner, McCrary and Leonard, 1977; Williams and Corrigan, 1992).
However, the increase in psychopathology is not limited to depression. Children of depressed
mothers are also more likely to suffer from other types of clinical disorders including anxiety
disorders, attention deficit hyperactivity disorder, conduct disorder and substance abuse,
among others (Fendrich, Warner and Weissman; 1990; Hammen, Burge, Burney and Adrian,
1990; Orvaschel, Walsh-Allis and Ye, 1988; Weissman, Warner, Wickramaratne, Moreau and
Olfson, 1997; Weissman et al., 1997). In addition, children of depressed mothers, not only
have higher rates of psychopathology, but receive higher levels of treatment for psychiatric
disturbance (Hammen, Gordon, Burge, Adrian, Jaenicke, and Hiroto, 1987; Klein, Clark,
Dansky and Margolis, 1988; Klein et al., 1985; Orvaschel, Welsh-Allis and Weijai, 1988;
326 Deana B. Davalos, Alana M. Campbell and Amanda L. Pala

Weissman, 1988). In longitudinal studies spanning 10-20 years, children of depressed

mothers have been found to use more mental health resources during their lifetime and were
more likely to report that they had obtained mental health assistance in the past year
(Weissman et al., 2006).
Others who have studied the relationship between maternal depression and pathology in
their children agree that there is an increase in psychopathology, however, it appears to vary
as a function of exposure and chronicity. When mothers/offspring are assessed at two separate
time periods (e.g. spanning months to years), children whose mothers reported depressive
symptoms at both ages exhibited significantly elevated rates of hostile behavior problems in
the classroom and at home. However, children of mothers who were previously, but not
currently, depressed exhibited significantly more anxious and withdrawn behavior at school
and at home, while, lastly, children of recently depressed mothers were noted as exhibiting
more hyperactivity and demanding behavior.
These higher rates of psychopathology have been noted not only when compared to
controls, but also when compared to children of non-depressed mothers or mothers with
“medical conditions” (Weisman et al.,1984; Zelner and Rice, 1988). Furthermore, these
differences appear to persist over time, even decades. In studies spanning 25-32 year follow-
ups of adult children of depressed mothers, researchers have found that their risk for specific
disorders such as depression, anxiety, social impairment, and substance disorder were
significantly increased compared to controls (Ensminger et al., 2003; Peisah, Brodaty,
Luscombe and Anstey, 2004). And often, the emergence of pathology did not surface until
years following the initial exposure to maternal depression. For example, the period of
highest incidence for major depressive disorder was found to be between ages 15 and 20
years (Weissman, Wickramaratne, Nomura, Warner, Pilowsky and Verdeli, 2006). Outcome
variables outside the realm of diagnosable mental illness have also been found, specifically in
terms of behaviors that appear to be relatively latent until adolescence when children of
depressed mothers are described as showing elevated patterns of defiant, rebellious, and
withdrawn behavior (Weissman and Siegel, 1972).
One interesting facet of this area of research is the control groups that have been selected
as comparison groups for the mothers with depression. Even when researchers use psychiatric
comparison groups, such as mothers with schizophrenia, poor affect regulation and poor
affective development continue to appear at greater levels in offspring of mothers with
depression (Cytryn, McKnew, Bartko, Lamour and Hamovitt, 1982; Sameroff and Seifer,
1983). While negative affective outcome variables appear to be greater in children of
depressed mothers compared to other psychiatric populations, other studies suggest that the
children of depressed parents cannot usually be distinguished from the children of
schizophrenic parents on behavioral or attentional measures (Orvaschel, Weissman and Kidd,
1980).
These detrimental effects of perceiving one’s mother to be depressed have even been
witnessed when non-depressed mothers have simply simulated depression. The infants of the
mothers with “simulated depression” quickly exhibit high levels of distress. It should be
noted that research in “simulated depression” suggests that the distressed behavior observed
by the infants was selectively limited to the children of the non-depressed mothers, while the
infants of the depressed mothers appeared to be rather unaffected. Results were interpreted as
suggesting that infants of depressed mothers may become accustomed to flattened affect and
lower activity, decreasing their distress over time (Cohn and Tronick, 1983; Field, 1984).
 Mother-Infant Bonds 327

What may be one of the least suspected findings in these studies was that the infants of
clinically depressed mothers were not only negatively affected by the depressed mood of their
mothers, but they also appeared to have a negative effect on the nondepressed mothers
participating in the study (Field et al., 1988). Specifically, the nondepressed mothers (blind to
the infants’ group) appeared to exhibit more depressed symptoms and less optimal interaction
with the infants of depressed mothers.
The finding which suggests that infants of depressed mothers actually affected the non-
depressed mothers in a negative way is not surprising considering the behaviors that often
characterize these offspring. The types of behaviors that have been described in infants and
young children of depressed mothers include; disengaged and intrusive interaction styles,
withdrawn behavior, looking away, and reduced positive affect (Cohn, Matias, Tronick,
Connell and Lyons-Ruth, 1986). A substantial literature has focused on these variables and
how they affect relationships. Specifically, there has been research focusing on the
relationship within and outside of the mother/child dyad, with both types of relationships
thought to be affected by exposure to maternal depression. Within the dyad, depressed
mothers and their infants have been shown to have less positive interaction (Field, 1980).
Unfortunately, the reduction in positive interaction appears to generalize beyond the
interactions between infants with their depressed mothers to others, including non-depressed
mothers with whom the infants were not familiar. These findings suggest that the infants'
depressed style of interacting with their mothers may generalize to nondepressed adults (Field
et al., 1988). There is also evidence that these children have more difficulty in their
relationships with their siblings and peers, specifically, children of depressed mothers have
been described as exhibiting excessive rivalry with peers and siblings for attention
(Weissman, Paykel and Klerman, 1972) and impatient, deviant, and withdrawn behavior in
their interactions (Weintraub, Neale and Liebert, 1975).
Other behaviors that have been noted in offspring of mothers with depression that are
associated with altered patterns of interactions with others include increased self-regulatory
behaviors such as head and gaze aversion which are thought to develop out of a desire to
reduce the negative affect that is experienced when mothers are unresponsive.
Research focusing on children of depressed mothers consistently illustrates this
widespread difficulty regulating emotions. For example, children whose mothers
reportchronically high levels of depression have a difficult time learning to control behavior
and modulate impulses when upset (Zahn-Waxler et al., 1990). This poor modulation of
emotions is exhibited in increased aggression and acting out. Specifically, Zahn-Waxler et al.
(1990) report that toddlers of depressed mothers showed increased out-of-control aggression
when interacting with peers and were rated higher on externalizing problems at the age of
five. These externalizing behaviors have been noted in multiple studies, often characterized
by significantly higher rates of hostile behavior at home and school.
These behaviors appear to persist and have been noted in studies focusing on older
children also, in which offspring of depressed mothers have been found to have more
adjustment problems in early and middle childhood (Hammen, 1992; Lyons-Ruth,
Easterbrooks and Cibelli, 1997).
In terms of the etiology of these aberrant behaviors, there has been ongoing debate
whether psychological symptoms that appear in children of depressed mothers represent
genetic contribution, effects of parenting styles of the depressed mother or whether there may
be modeling in terms of the child adopting traits and attributes from the depressed mother.
328 Deana B. Davalos, Alana M. Campbell and Amanda L. Pala

Recent research suggests that it is likely that multiple factors contribute to psychological
attributes in children of depressed mothers. Lim and colleagues (2008) interviewed children
and adolescents ages 7-17 and found a direct relationship between maternal depression and
increased depressive symptomatology measured using the Children’s Depression Inventory
and the Child Depression Rating Scale-Revised (CDRS–R) and increased anxiety symptoms,
both state and trait, using the State-Trait Anxiety Inventory for Children (STAIC-T; STAIC-
S). In addition, maternal depression indirectly affected these psychological variables via
negative parenting (e.g. intrusiveness, neglect/distancing, and harsh discipline). Kochanska,
Kuczynski, Radke-Yarrow, and Darby-Welsh (1987) have also found that in terms of
parenting, depressed mothers are less effective than nondepressed mothers in setting limits on
their toddlers, and this was reflected in fewer compromise solutions to conflict solutions.
Depressed mothers have also been found to be less likely to follow through when they do set
limits, leading to less compliance and increased conflict between mother and child. This
difficulty with compliance has been noted in a number of studies, with some noting higher
rates of “passive noncompliance” associated with less mature expressions of age-appropriate
interaction and autonomy (Kuczynski and Kochanska, 1990). Lastly, mothers with depression
may tend to use more guilt in their interactions with the children when they are unable to
persuade them to comply via more positive routes. Furthermore, evidence suggests that there
are long-standing effects of these guilt-inducing behaviors. Children of well mothers show
prototypic expressions of “adaptive guilt” which is thought to involve themes of
responsibility and reparation. In contrast, expressions of guilt in children of depressed
mothers have been described as aberrant, distorted, and unresolved, indicating that these
children may develop different patterns of guilt expression, and likely, may be made to feel
guilty for different reasons from the control children (Zahn-Waxler, Kochanska, Krupnick
and McKnew, 1990).
Some have speculated that the lack of consistency in parenting that is often seen in
mothers with depression may exacerbate other behaviors that are often observed in this
population. Specifically, behavioral problems (such as difficulty being managed, difficulty
playing with other children, and having frequent tantrums) may result from both a genetic
predisposition and parenting styles that do not foster proper affect regulation (Kahn,
Zuckerman, Bauchner, Homer and Wise, 2002).
However, there is evidence that suggests that not all mothers with depression exhibit
these deficits in parenting (Frankel and Harmon, 1996), and that the effects of maternal
depression on children can be mediated by interventions and specific parenting techniques.
For example, research suggests that mothers suffering from depression who engaged in
parenting education had children who fared better on certain outcome measures. Specifically,
mothers enrolled in parenting education focusing on anticipatory guidance techniques, or
techniques which focus on anticipating children’s emerging needs at different developmental
stages, are believed to have children with fewer behavioral problems during early school-age
years than mothers not receiving parent education. These mothers were described as more
proactive in their parenting and appeared to exhibit less negative affect, use less guilt in their
parental interactions, have more secure attachments, and appeared to be more consistent with
their young children (Campbell and Cohn, 1997; Zahn-Waxler et al.,1990).
 Mother-Infant Bonds 329

CONCLUSION
During the last decade, there has been increased interest and concern about the
prevalence of maternal depression. Researchers and policy-makers alike appear to recognize
the importance of this condition and the far-reaching effects that maternal depression has on
children and families. While not specific to only maternal depression, the U.S. Surgeon
General has pointed out that the impact of maternal mental health on children is vastly under-
recognized (Office of the Surgeon General, 1999).
It becomes clear when one systematically assesses the literature that there are social and
practical limitations that have made research in the area of maternal depression and the effects
on offspring difficult. One of the primary barriers for researchers in their quest to understand
maternal depression and the prevalence of this condition is the fact that depression, for many,
carries a stigma. When one adds the fact that there are additional expectations about
motherhood, in terms of mothers themselves believing that the period of time following the
birth of their child should be filled with happiness and reward compounded by society placing
these same expectations on mothers, the reporting of depression during this period is likely
vastly underreported (Coleman, Nelson and Sundre, 1999; Douglass and Michaels, 2004;
O’Reilly, 2005). There is a significant amount of literature which reports that even if mothers
would discuss their postpartum depression, there are multiple barriers in terms of having them
adequately assessed by their physicians. There are a number of reasons that are reported by
physicians to explain the lack of screening for depression. Some physicians are not aware of
appropriate screening tools. Others worry that adding depression screening to their visits will
be both time-consuming and expensive and, in the worst case, they may be put in a position
where they have to make decisions about how to treat mothers with depression (Baker-
Ericzen, Mueggenborg, Hartigan, Howard and Wilke, 2008; Seehusen, Baldwin, Runkle and
Clark, 2005). Studies have shown that a large number of pediatricians acknowledge concern
about addressing depression with new mothers due to possible judgments and stigma that may
be associated with maternal depression. Physicians have argued that identification and
assessment may be more feasible and desired if they had services to which they could refer
these mothers. However, these doctors and other researchers have highlighted the point that
even when mothers are successfully identified, they may be hesitant to seek assistance due to
perceived judgment (Heneghan, Morton and DeLeone, 2007; McIntosh, 1993; Richards,
1990).
Even in ideal situations, when mothers are successfully identified and willing to seek
treatment, new barriers arise in terms of accurately diagnosing and providing the proper
treatment. Research suggests that postnatal depression is complex and likely involves a
variety of subtypes that should be considered when determining treatment. Watson et al.
(1984) suggest that women with postnatal depression could be classified into as many as six
categories with others supporting this argument given the vast etiologies of depression during
the postnatal period (Cooper and Murray, 1998).
These proposed different categories of postnatal depression have widespread implications
in terms of treatment and research alike. In terms of treatment, researchers have argued that,
given the different types of depression in this population, personalized client-centered
approaches are the most appropriate rather than a blanket approach of drug treatment paired
with talk therapy (McIntosh, 1993).
330 Deana B. Davalos, Alana M. Campbell and Amanda L. Pala

In terms of research, different types of depression, levels of pathology, and duration of

symptoms have all been found to effect outcome variables in different ways. When one tries
to analyze the literature systematically, it quickly becomes apparent that these variables have
not been well-assessed across studies and have likely led to much of the disparity in the
literature. For example, the aspect of chronicity of symptoms alone is associated with very
different outcomes in the mother/child relationship depending on when the symptoms first
appear and how long those symptoms persist. Many researchers argue that parenting and
bonding appears especially impaired when maternal depression symptoms are chronic; this is
compared to women whose symptoms may be equally long in duration but are intermittent
with breaks during which depressive symptoms remit (Ashman, Dawson, and Panagiotides
2008; Campbell et al., 1995). Similarly, while some researchers have argued that the first six
months of parenting and bonding appear to be selectively involved in poor outcome for
children of depressed mothers, others have argued that negative consequences of maternal
depression are specifically associated with cases in which symptoms persist beyond the
immediate postpartum period, specifically following the first year of life and beyond
(Horwitz, Briggs-Gowan, Storfer-Isser and Carter, 2007).
There are clearly a number of other limitations that enter the picture that may be even
more difficult to extricate from the outcome variables that are associated with maternal
depression. Probably the most notable variable is whether mothers who report postpartum
depression may have had a predisposition for depression existing before the perinatal period.
The question of whether offspring of mothers with postpartum depression may have genetic
predisposition for depression remains (Sullivan, Neale and Kendler, 2000). Depression in the
offspring of depressed parents is generally thought to be due to an interaction between genetic
factors and environmental factors, including stressors in the family and the social context
(Ensminger et al., 2003). However, approximately 40–50% of the relationship between
mothers’ and children’s depressive symptoms are thought to be due to genetic linkage (Rende
et al., 1993; Kendler, 1995). If this is so, one has to wonder what the extent of this
predisposition may have on bonding or other outcome measures that are independent of their
mother’s symptomatology during early development or whether this predisposition is
specifically exacerbated by their mother’s depressive symptoms. The other issue that arises
when this “interaction” between genes and environment is addressed involves the difficulty
that researchers encounter when they attempt to understand this proposed 50-60% of variance
that is not due to genetics. The non-genetic variables that ideally should be assessed in studies
focusing on the effects of maternal depression on mother infant bonding are extensive and
often difficult to assess. For example, multiple studies suggest that the negative effects of
maternal depression on their offspring may be due to what we view as more direct influences,
such as responding to mothers’ sadness or lack of energy or their difficulty parenting
(Downey and Coyne, 1990; Cummings and Davies, 1994; Johnson et al., 2001). However,
children may also exhibit negative symptoms due to secondary variables that not only affect
them negatively but also contribute to their mother’s symptoms. These secondary variables
range from social disadvantage, economic instability, dysfunctional family dynamics, low
social support, maternal daily stressors, or insufficient childcare (Adrian and Hammen, 1993;
Belsky, 1984; Downey and Coyne, 1990; Forehand et al., 1998; Hall and Farel, 1988; Rutter,
1990; Rutter and Quinton, 1984). Last, but not least, is the vastly under-examined role of
marital status, level of marital discord, and the father’s role in both the depressed mother’s
life and in the offspring’s quality of life. Downey and Coyne (1990) once described the
 Mother-Infant Bonds 331

spouses of depressed mothers as “shadowy figures.” There are multiple studies suggesting
that the mates of depressed mothers may, in many cases, contribute to the pathology of the
mother and to their offspring. Specifically, research suggests that mothers with depression
may select mates with mental illness who contribute to pathology in offspring and who also
contribute to marital discord (Downey and Coyne, 1990). However, there is equal, if not
more, empirical support to suggest that “well” fathers may actually provide a buffer between
negative effects of maternal depression on the child (Keller et al., 1986; Tannenbaum and
Forehand, 1994). In addition, there are a wide range of studies suggesting that many of the
negative outcomes associated with maternal depression appear to be selectively associated
with mother’s depression, but not with paternal depression, even when the father had been
diagnosed with clinical depression. For example, behavioral problems, physical injury,
physical illness, and a variety of other negative outcome variables have been found to be
selectively involved in maternal depression but absent in cases of paternal depression (Kahn,
Brandt and Whitaker, 2004; Peisah, Brodaty, Luscombe and Anstey, 2005). While this area of
research is lacking, there is enough empirical support to suggest that future research focusing
on the role of the spouse in both the depressed mother’s life and the life of the offspring is
warranted.

CONCLUDING REMARKS
Maternal depression is a condition that has received increasing attention over the past few
decades. What appears consistent in the literature is the fact that more must be done in terms
of treatment and research in this population. What also appears clear in the literature is that
there are multiple layers of barriers that often stand in the way of achieving research and
treatment goals with this population. Multiple studies suggest that fear of stigma and
embarrassment related to maternal depression may be two of the greatest barriers to getting
assistance to this population. While the ideal solution to these barriers would be to reduce
stigma and be accepting of maternal depression, very little progress towards this goal has
been achieved over the past few decades. As researchers and policy makers work toward
educating the public about maternal depression, the treating clinicians may have to focus on
getting mothers to seek help for the benefit of their offspring and for the benefit of their
relationship with their children. There is substantial evidence, spanning decades, that suggests
that the children of depressed mothers pay a great cost in terms of their physical, cognitive,
and psychological development for untreated maternal depression. There is also a wealth of
literature suggesting that the maternal/child bond is typically compromised whether acutely or
chronically as a result of maternal depression. It becomes quickly apparent that new attempts
at intervention are needed to help get mothers and their offspring get the assistance they need.
Nylen and colleagues (2006) captured the needs of this population when they wrote, “The
challenge now is to devote continued attention to process and outcome variables as well as to
creative manners of designing and implementing interventions such that the propensity of
women and infants in need of help are able to access and receive quality mental health
services.”
332 Deana B. Davalos, Alana M. Campbell and Amanda L. Pala

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 19

SOCIAL NETWORKS AND PSYCHOSOCIAL

FUNCTIONING AMONG CHILDREN AND
ADOLESCENTS COPING WITH SICKLE CELL
DISEASE: AN OVERVIEW OF BARRIERS,
CONSIDERATIONS, AND BEST PRACTICES

Rebecca H. Foster,1 HaNa Kim,1 Robbie Casper,2 Alma Morgan,2

Wanda Brice2 and Marilyn Stern1,2
1
Department of Psychology, Virginia Commonwealth University
2
Department of Pediatrics, Virginia Commonwealth University
Richmond, Virginia, United States of America

ABSTRACT
Over 70,000 individuals in the United States are diagnosed with sickle cell disease,
yet relatively little attention has been paid to this group when compared to those
diagnosed with other chronic illnesses such as asthma, cystic fibrosis, diabetes, or cancer.
Like most major chronic illnesses, sickle cell disease influences familial and social
relationships in numerous and ever-changing ways. Advances in sickle cell disease
treatments and improved survival rates have resulted in dramatic shifts in relationship
networks and psychosocial adaption for each child diagnosed. Several primary areas of
concern have been identified for children and families facing sickle cell disease such as
disruptions to educational and socialization processes, sudden changes in medical
conditions including the persistent threat of pain crises, existential anxieties about death,
the wide range of emotions that are often present in managing with the various stages of
the disease and treatment, the overarching developmental trajectory of the child, and
coping with having a serious illness or caring for a child with a serious illness. Literature
has cited and research continues to find evidence of challenges faced by these children
and adolescents including ways in which family functioning, social acceptance by peers,
interactions with siblings, parenting style used in the home, and daily anxieties and
pressures can play integrated roles in shaping life-long relationships and overall quality
of life. Because sickle cell disease predominantly affects minority groups within the
340 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

United States, families and medical professionals also must consider the cultural needs of
each patient in order to promote best practices for treatment and the development of
sustained, healthy relationships. While these noted challenges tend to be constant foci for
all concerned with caring for and working to develop optimal relationships among
individuals diagnosed with sickle cell disease, many individuals and families coping with
a sickle cell disease diagnosis seem to function quite well when adaptive coping and
supportive networks are present and persistent. This chapter will investigate how the
many relationships that exist within the social context of a child’s world are impacted by
sickle cell disease. An overview will be provided examining dynamics between parents,
the children diagnosed with sickle cell disease, and their peers and siblings in terms of the
challenges faced and the relationship strengths displayed. Cultural influences and means
of improving life-long relationships will be explored. Lastly, currently implemented
interventions promoting positive relationships will be discussed as well as future
directions for research and intervention studies.

INTRODUCTION
Each year in the United States about 1 in every 400 to 500 African Americans born will
be diagnosed with some form of sickle cell disease (Gustafson, Bonner, & Hardy, 2006; Lutz,
Barakat, Smith-Whitley, & Ohene-Frempong, 2004). While African Americans are most
likely to be affected, individuals of Mediterranean, Caribbean, South and Central American,
Arabian, and East Indian descent can be affected as well. Generally speaking, sickle cell
disease constitutes a group of chronic inherited blood disorders caused by an autosomal
recessive genetic deficit in which hemoglobin (Hb) S is atypical (Gustafson et al., 2006).
Certain adverse conditions, such as emotional stress, fever, dehydration, and extreme
temperatures cause the red blood cells to become stiff and rigid, or sickle-shaped. These
sickle-shaped cells are unable to pass through the blood vessels easily, thus blocking blood
flow and oxygen. Such events set the stage for numerous complications to develop including
chronic anemia, recurrent pain (or vaso-occlusive crises), low exercise tolerance, altered
splenic functioning, compromised pulmonary functioning, increased vulnerability to
infection, late onset of puberty, growth delays, enuresis, and poor vascular circulation. Poor
vascular functioning, in turn, may lead to strokes resulting in organ and brain damage
(Gustafson et al., 2006; Mitchell, Lemanek, Palermo, Crosby, Nichols, & Powers, 2007).
Approximately 5-10% of individuals with sickle cell disease will endure cerebrovascular
accidents; another 11-20% will suffer at least one silent stroke. The most common and often
most severe form of sickle cell disease is the homozygous condition known as sickle cell
anemia (Hb SS), which results from two abnormal genes for hemoglobin S. Sickle cell
hemoglobin C (Hb SC) and sickle β-thalassemia are also relatively common. While medical
advances have dramatically improved the life expectancy of what was once considered a fatal
childhood illness, sickle cell disease continues to be considered a life-limiting illness with a
median life expectancy in the mid-40s for those with Hb SS and the mid-60s for those with
Hb SC (Platt et al., 1994).
With increased life expectancy rates comes the need for improving adaptation and quality
of life among children and adolescents with sickle cell disease, their families, and all others
comprising their social networks (Atkin & Uhmad, 2001; Baskin, 1998). Although some
sickle cell disease patients and families adjust relatively well to life coping with sickle cell
 Social Networks and Psychosocial Functioning among Children and Adolescents … 341

disease, nearly all face periodic challenges in various domains of daily living (Barbarin &
Christian, 1999; Baskin et al., 1998; Ohaeri, Shokunbi, Akinlade, & Dare, 1995; Wagner et
al., 2004). While the biomedical challenges associated with sickle cell disease are ongoing
and overwhelming at times, psychosocial and developmental struggles, both chronic and
acute, are equally evident. These struggles come from a broad range of sources including but
not limited to family functioning, peer relationships, interactions with siblings, parenting
styles and emotional states, and daily anxieties and pressures related to communication with
school environments and medical professionals. Any and all of these can play integrated roles
in shaping life-long relationships and overall quality of life. Furthermore, because sickle cell
disease predominantly affects minority groups within the United States, families and medical
professionals also must consider the cultural needs of each patient in order to promote best
practices for treatment and the development of sustained, healthy relationships.
While the potential roadblocks associated with the development of optimal relationships
and daily functioning among individuals diagnosed with sickle cell disease may seem
abundant, many individuals and families coping with a sickle cell disease diagnosis seem to
function quite well when adaptive coping and supportive networks are present and persistent.
This chapter will investigate how the many relationships that exist within the social context of
a child’s world are impacted by sickle cell disease. An overview of the available literature
will be provided, examining patient and family relationship dynamics and adaptation to
chronic illness, perceptions of peer relationships, sickle cell disease within the academic
setting, and relationships in the medical setting. Cultural influences and means of improving
life-long relationships will be explored. The chapter concludes with a discussion of currently
implemented interventions promoting positive familial, peer, academic, and medical
relationships and suggestions for future directions in research and intervention studies.

RELATIONSHIPS IN SICKLE CELL DISEASE:

REVIEW OF THE LITERATURE

Relationship Dynamics within the Family Unit

Coping with Sickle Cell Disease: A Focus on the Patient

Children and adolescents with sickle cell disease face numerous challenges related to
overall development (e.g., Barbarin & Christian, 1999; Battle, 1984; Morgan & Jackson,
1986; Serjeant, 1992; Wright & Phillips, 1988). Because the illness unfolds within the
constantly changing contexts of lifespan development, how sickle cell disease is handled
greatly depends on an individual’s culture and current developmental stage (Gustafson et al.,
2006). Reaching typical developmental markers can be compromised due to pain crises or
other complications at any given time and can result in modified identity and autonomy
development, increased risk of academic setbacks, and disruptions in social skill attainment.
Research suggests that individuals growing up chronically ill are two to three times more
likely to experience difficulties in social relationships (Creswell et al., 2001). Normal
developmental processes become magnified and may result in a heightened propensity for
social isolation (Boice, 1998). Developing the social self-efficacy to create and maintain peer
and romantic relationships can be challenging (Gentry, Varlik, & Dancer, 1998).
342 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

Adolescents with sickle cell disease may be especially likely to experience difficulties in
social adaptation and relationship development. This increased potential for difficulty in
social adaptation is due, in part, to the already complex developmental changes occurring in
these groups within sociodevelopmental domains, which are further disrupted by a sickle cell
experience (Holmbeck, 2002; Ungerer, Horgan, Chaitow, & Champion, 1988). Although
researchers are beginning to understand the importance of conceptualizing children and
adolescents as populations with unique perceptions and needs, study of these individuals
using strong methodologies and analytical techniques remains limited.
Children and adolescents with sickle cell disease may be inundated by psychological
manifestations of the disease such as psychological distress and negative mood (Gil et al.,
2003) and lower levels of self-esteem (Davis, 1995). In a study of urban-dwelling children
with sickle cell disease, approximately one fourth of the sample reported experiencing
feelings of anxiety and depression (Barbarin, Whitten, & Bonds, 1994). Ievers, Brown,
Lambert, Hsu, and Eckman (1998) reported nearly identical outcomes when 30% of parents
of children and adolescents diagnosed with sickle cell disease reported that their children
were less well adjusted than typically developing children. Thompson and colleagues (1999)
also indicated that 25% of their 289 child participants endorsed having some type of
internalizing or externalizing behavior problem. Those reporting behavior problems were
more likely to report poorer family support as well as higher family conflict. Other studies
have acknowledged similar results, but most have been quick to add that the majority of
children and adolescents with sickle cell disease are not clinically depressed (Barlow &
Ellard, 2005; Burlew, Telfair, Colangelo, & Wright, 2000). Burlew and colleagues’ study
(2000) showed somewhat different and additionally optimistic findings when rates of
symptoms of anxiety among adolescents with sickle cell disease were reported to be slightly
lower than norms for high school students.
Child rearing practices can influence reported feelings of depression and anxiety
(Gustafson et al., 2006). Studies have consistently found that parental cognitions including
beliefs, appraisals, expectations, and attributions impact the sociocultural environment within
the household and relate to child and adolescent internalizing and externalizing behaviors
(Barbarin, Whitten, Bond, & Conner-Warren, 1999; Hocking & Lochman, 2005; Ievers et al.,
1998; Thompson et al., 1999). Despite the acknowledgement of these relationships, additional
research points out that parents of children and adolescents with and without sickle cell
disease appear to have similar parenting styles (Noll, McKellop, Vannatta, & Kalinyak,
1998). This findingt further raises the question of whether merely being in a family with a
chronic illness will negatively affect adaptation and relationship development. In general,
children and adolescents with better means of social support are more likely to display
success in developing long-term, healthy relationships and adaptive functioning to stressors
(Hocking & Lochman, 2005; Ievers et al., 1998). Promoting well-being of parents and early
interventions that build self-confidence in social domains may be two important factors that
can increase the likelihood that a child or adolescent with sickle cell disease will develop a
strong, supportive social network.

Coping with Sickle Cell Disease: A Focus on the Parents

Much of the responsibilities of raising a child or adolescent with sickle cell disease
inevitably falls on the parents or caregivers. The balancing act of raising a child, working, and
keeping up with daily expenses are difficult in and of themselves. Because a chronic illness
 Social Networks and Psychosocial Functioning among Children and Adolescents … 343

acts as an ongoing stressor, the added burden of managing a child’s sickle cell diagnosis in
combination with the struggles of daily life can often become overwhelming (Gustafson et al.,
2006). More specifically, parents report that their social and personal life is more limited, and
maintaining employment can be difficult (Mitchell, Lemanek, Palermo, Crosby, Nichols, &
Powers, 2007). Overall, a child or adolescent living with a chronic illness such as sickle cell
disease can dramatically change family dynamics and interrupt marital and parent-child
relationships.
Healthy family functioning can serve to buffer chronically ill children and their healthy
siblings from undesirable outcomes related to associated illness stressors (Barakat, Patterson,
Tarazi, & Ely, 2007). Among caregivers, chronic illness has been found to increase parental
time demands and self-reported exhaustion (Barakat et al., 2007). Parents often report
concerns about the long-term uncertainty of the child’s physical well-being; feelings of
worry, sorrow, and anger; and the limited availability of emotional resources. Due to the
inherited nature of the illness, feelings of guilt and shame may take varying forms on
multigenerational levels (Helps et al., 2003). Caregiver demands and relationship dynamics
with the affected child or adolescent can shift suddenly and dramatically from caring for a
relatively healthy child to coping with severely limiting symptomatology unexpectedly.
Parents must assume the roles of managing pain at home and assisting with the medical
regimen while navigating the child’s responses to and perceptions of the illness.
Studies on parental and overall family functioning when coping with sickle cell disease
report a variety of findings ranging from results suggesting relatively poor functioning to
those reporting that families with sickle cell disease adapt and cope quite well (Barakat et al.,
2007). In general, the literature indicates that those families with lower levels of conflict,
higher levels of organization, and more structure fair better over time. However, differences
in functioning could be based on illness demands, socioeconomic risk, developmental delays,
and/or cultural variations in family functioning. This includes social identity, racial
attributions, experiences with discrimination, religiosity, and support from the extended
family (Barbarin et al., 1999). Furthermore, parent-child relationships change over time. As a
child ages, he or she becomes more autonomous and takes over the role of managing his or
her sickle cell disease. In a 2007 study by Barakat and colleagues, parents of adolescents with
sickle cell disease reported more difficulties with caregiver roles and parent-child
relationships than did parents of preschool-aged children diagnosed with sickle cell disease.
Authors hypothesized that because the parent of a preschool-aged child assumes 100%
responsibility for care, it may be easier for these parents to know how to respond to parenting
stressors and sickle cell crises, whereas the parent of an adolescent may not be certain of how
to balance the adolescent’s responsibility for self-care with the parent’s desire to intervene.
A parent’s sense of control over the quality of the parent-child relationship can be
influenced by a number of factors (Barakat, Lutz, Nicolaou, & Lash, 2005). Having an
internal locus of control (i.e., feeling that control of event outcomes is derived from within) is
related to lower levels of parenting frustration and higher levels of parenting self-efficacy.
Because these parents display higher levels of confidence, they are less likely to rely on
medical professionals for the care of their child in times when they are capable of handling
the illness symptoms. In Barakat and colleagues’ 2005 study of 31 caregivers, parents of a
child diagnosed with sickle cell disease were less likely to report an internal locus of control
as compared to parents of children diagnosed with congenital heart disease. Parents who
reported an internal locus of control also reported better quality of life, especially in terms of
344 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

self-competence and adaptive family functioning. Overall, when the executive parental
system is effective and open to modeling emotional support, the family unit copes better and
maintains stronger cohesive relationships (Barbarin et al., 1999). This system must include
strong leadership, appropriate use of power differentials between parents and children, an
ability to make decisions that are in the best interest of the entire family, and an ability to
distribute resources (e.g., time, attention, money) fairly.
In a related study, family competence was defined by Kell, Kliewer, Erickson, and
Ohene-Frempong (1998) as the “ability of the family to manage the stressors they confront,
including effective emotion management and problem management” (p. 302). Competent
parents are able to make the child feel cared for and safe. In turn, feeling safe reduces
anxieties surrounding the threat of the illness. Competent parents are also better able to
improve self-esteem, which reduces anxieties about the actual illness threat, and convey that
relational support is available. Kell and colleagues (1998) aimed to look at the influence of
family competence in child adjustment using a family systems approach. Eighty adolescents
(ages 12 to 18 years) and their parents participated. Results showed that higher family
competence was associated with fewer internalizing and externalizing behaviors among
adolescents, especially among younger adolescents and girls. Enhanced family competence
also predicted parental reports of fewer somatic complaints in females with sickle cell
disease.
While much remains unknown in terms of parental needs and parent-child relationships
in coping with and adapting to a sickle cell disease diagnosis, the available literature clearly
shows that many factors relate to positive family dynamics and parental functioning among
families coping with sickle cell disease. Unfortunately, many other common factors such as
increased stressors and time demands can hinder long-term secure relationships. Based on
what is known and what remains uncertain, additional studies will be necessary to determine
best practices for accommodating the needs of these families.

Coping with Sickle Cell Disease: A Focus on the Siblings

Just as the patient and parents are affected by a child or adolescent’s sickle cell disease
diagnosis and the course of treatment, the daily lives, experiences, and long-term outcomes of
healthy siblings growing up in a family that has a child or adolescent coping with sickle cell
disease may be altered, for better or for worse, in a variety of ways (Royal, Headings, Molnar,
& Ampy, 1995). Because of the important roles each family member plays within the
overarching family dynamic, examination of how siblings cope with a child or adolescent
family member diagnosed with sickle cell disease may carry serious implications for lifelong
well-being. While many researchers and clinicians have argued the importance of
understanding siblings’ relationships and adaptation to a having a sibling diagnosed with
sickle cell disease, empirical research results are grossly lacking.
One early study explicitly exploring the psychosocial adjustment of siblings without
sickle cell disease took place in 1987 (Treiber, Mabe, & Wilson, 1987). Researchers indicated
that studies conducted over the prior 30 years suggested that healthy siblings of children with
a chronic illness were at greater risk or experiencing guilt, anger, anxiety, and rejection due to
the increased amount of time, resources, and attention given to the ill child (Barlow & Ellard,
2005; Treiber et al., 1987). In Treiber and colleagues’ research (1987), 13 sickle cell disease
patients and their healthy siblings were compared. Results indicated that healthy siblings were
at an increased risk of adjustment problems as compared to the sibling with sickle cell
 Social Networks and Psychosocial Functioning among Children and Adolescents … 345

disease. Levels of distress were associated with the healthy sibling’s reports of adjustment
problems. Maternal depression and anxiety symptomology were associated with sibling
adjustment as well. Healthy siblings displayed higher levels of depression and inability to
cope with the illness as compared to siblings with sickle cell disease, and attempts were made
to avoid coping. However, the sickle cell disease and healthy siblings did not report clinically
significant levels of distress as compared to normative data.
Research conducted within the last 15 years has paralleled the results of Trieber and
colleagues’ 1987 study. Although the research is sparse, there appears to be a consensus that
while some concerns are evident, levels of functioning seem to be comparable to the general
population (e.g., Noll, Yosua, Vannatta, Kalinyak, Bukowski, & Davies, 1995) with some
research going so far as to suggest impressive levels of resilience within the healthy sibling
groups (Royal et al., 1995). A 1995 study by Noll and colleagues examined peer relationships
among healthy siblings of sickle cell disease patients. Social competence of the healthy
siblings was compared to a matched sample of classroom peers. Analyses revealed no
significant differences in social reputation or social acceptance between the two groups.
Another 1995 study discussed the overarching importance of sibling relationships due to
the common genetic background, shared cultural heritage, and common family experiences
(Royal et al., 1995). Healthy siblings growing up in a household with another child coping
with a chronic illness or disability may show enhanced tolerance for human differences,
acknowledgement of the importance of good health, compassion, and knowledge about
societal injustices and stereotypes. Based on this, Royal and colleagues (1995) hypothesized
that healthy siblings may show certain resiliencies that promote more adaptive coping. When
20 healthy siblings were interviewed about coping and family functioning, 90% of those who
displayed a solid knowledge base regarding sickle cell disease were considered very resilient.
Those from smaller, two-parent families of higher socioeconomic status also showed higher
levels of resilience. Healthy siblings reporting more resilient behavior indicated more
favorable attitudes toward their parents’ child rearing practices.
Though much remains unknown about the relationships and overall functioning among
healthy siblings of those with sickle cell disease, several factors have been identified that may
allow healthy siblings to adapt and feel supported within their families and larger social
networks. Culture may be one of the most influential among these factors (Royal et al., 1995).
While African American families may face heightened economic burden and disparities in
health care, they also show extensive strengths within the family unit. Parents often instill a
deep sense of dedication to family members, which includes an expectation that siblings care
for and support one another. While having a sibling with sickle cell disease may cause
additional burdens to the healthy siblings at times, feelings of responsibility to the well-being
of the family may circumvent any hardships associated with chronic illness.

Relationships and Perceptions of Acceptance within Peer Groups

Literature on peer relationships among children and adolescents is varied and, at times, is
contradictory. In social settings, adolescents with sickle cell disease tend to face issues of peer
acceptance and social competency more frequently than their healthy counterparts (Brown,
Armstrong, & Eckman, 1993). Additionally, much of the extant literature shows that
adolescent and child patients exhibit a less positive self-image in terms of their social selves in
346 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

comparison to healthy peers (Ohaeri et al., 1995; Rodrigue, Streisand, Banko, Kedar, & Pitel, 1996).
These individuals may have difficulty making friends and often report lower levels of competence
when developing relationships (Burlew, 2002; Rodrigue et al., 1996). In addition to difficulty
making friends, sickle cell disease patients also have concerns regarding actual and perceived
physical effects of their illness (Ohaeri et al., 1995). Males may be affected more negatively
than females due to delayed growth and inability to engage in certain physical activities that
typically promote bonding among boys and adolescent males (Hocking & Lochman, 2005).
Regardless of gender, disrupted daily activity due to pain may negatively impact the
development of typical social skills and interactions with peers (Rodrigue et al., 1996).
Concerns may influence perceptions of attractiveness and confidence in seeking out and
maintaining peer and romantic relationships.
Among children and adolescents with sickle cell disease, those who feel more stressed by
their chronic illness status often are more anxious in social situations and fear negative
evaluations (Wagner et al., 2004). Limitations in the quantity and quality of social
interactions and poorer development in the ability to read social cues, including a reduced
ability to cope, have been cited as potentially promoting higher levels of social anxiety (Boni,
Brown, Davis, Hsu, & Hopkins, 2001; Wagner et al., 2004). Results of a qualitative study
indicated similar findings suggesting that the burden of disease significantly reduces social
well-being (Thomas & Taylor, 2002). Furthermore, studies with small sample sizes of
children and adolescents reported that those with sickle cell disease feel less accepted by their
peers, socially isolated, and anxious in academic environments (Gentry & Varlik, 1997;
Lemanek, Horwitz, & Ohene-Frempong, 1994). Girls with sickle cell disease were perceived
as being less well-liked, and boys with sickle cell disease were perceived as being less
aggressive than their healthy peers (Noll et al., 1996). However, these children did not seem
to have trouble maintaining their emotional well-being (Barbarin & Christian, 1999; Noll et
al., 1996).
Other studies have reported somewhat opposing findings with teachers, parents, and
health care professionals rating children and adolescents as being as socially competent and
accepted as their healthy peers (Noll, Ris, Davies, Bukowski, & Koontz, 1992; Lemanek et
al., 1994). Noll and his colleagues (1992) reported that when matched by age, gender, and
race, children with sickle cell disease and their healthy peers were rated similarly with respect
to social reputation. In 2007, Noll, Reiter-Purtill, Vannatta, Gerhardt, and Short completed a
controlled replication of their previous social acceptance studies. Thirty-nine children
diagnosed with sickle cell disease, between the ages of 8 and 15, were matched to healthy
classroom peers. When compared to the healthy children, those with the disease were rated by
their teachers to be more prosocial and less aggressive. Although healthy peers reported their
sickle cell counterparts to have fewer friends, to be less athletic, to miss more school, and to
be sick more often, those with sickle cell disease were liked just as well as other healthy
peers. While they were selected less often as the best friend among healthy peers, the children
and adolescents with sickle cell disease were perceived as being just as physically desirable
and academically competent as their healthy peers. Scores for emotional well-being were
similar across groups. At the conclusion, the authors cautioned that results from previous
studies suggesting less aggressive behavior among males may be spurious due to limitations
in sample size. Despite teacher and parents reports of comparable levels of social functioning
between sickle cell children and adolescents and their healthy peers, further investigation into
these complex peer relationships and social networks is warranted.
 Social Networks and Psychosocial Functioning among Children and Adolescents … 347

Relationships with Health Care Professionals

On average, children with sickle cell disease experience pain episodes five to seven times
per year and require hospitalization one to two times per year for pain, fever, or other medical
complications (Walco & Dampier, 1990). Aside from hospitalizations, children must
participate in regular health care maintenance visits specifically designed for children
diagnosed with sickle cell disease. To date, there is no cure for sickle cell disease except for
possible bone marrow transplantation (Todd, Green, Bonhman, Haywood, & Ivy, 2006). A
bone marrow transplant may be difficult to achieve due to problems finding an appropriate
match. If a match is found and transplant occurs, the recipient must successfully survive the
various medical risks such as infection, major bleeding, organ failure, and transplant rejection
(Hsu, 2001). Because bone marrow treatment continues to be somewhat rare, most children
and adolescents with sickle cell disease and their families must learn how to cope with the
burdens of living with a chronic disease throughout their lifespan. While doing so, they must
also try to avoid the pitfalls that often accompany persons of color as they interact within the
health care system. The health care provider (HCP) must be attuned to the various stressors
that go with having a chronic illness and should be aware of how living with sickle cell
disease can add to the health care burden.
A trusting, respectful relationship serves as a springboard for achieving a state of optimal
health and well-being for children and adolescents with sickle cell disease and their families.
It is important for the HCP to have an understanding of components that stimulate a positive
therapeutic alliance between the patients, families, and health care team that is based on
mutual respect, open communication, honesty, and trust. Patients with sickle cell disease
should also be aware of their role and responsibility in achieving a strong partnership with
their HCP as they learn to live with the chronicity of the disease. Though the National Heart,
Lung, and Blood Institute (1995) has published guidelines on the principles and standards of
care for children and adolescents diagnosed with sickle cell disease, families coping with this
chronic illness continue to encounter challenging situations when seeking medical care from
health care providers.
As previously reported, the majority of patients with sickle cell disease in the United
States are of African American descent. Many also hold dual memberships in an economic
underclass as well as a chronic disease group (Barbarin & Christian, 1999). Additional
burdens often coexist in economically distressed groups that serve as barriers to care. Poor
access to health care is one such barrier. For example, non-pharmacologic modalities for
chronic pain and chronic illness may be unavailable, unaffordable, or not covered by health
insurers of sickle cell patients (Shapiro, 1999).
It is important for the health care provider to not only be well versed in the basic
pathophysiology of sickle cell disease but also to be cognizant of the barriers to health care
that often plague patients with sickle cell disease (Barbarin & Christian, 1999). Limited
access to health care is often a primary barrier. Ineffective communication between the HCP
and patient can serve as an obstacle as well. Ineffective communication may result from a
difference in the culture and socioeconomic position of the HCP and patient. In the United
States, most patients with sickle cell disease are of African ancestry whereas the majority of
HCPs in developed nations are not. This socioeconomic difference may contribute to much of
the cross-racial and cross-cultural ineffective communication patterns (Barbarin & Christian,
1999; Shapiro, 1999).
348 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

Another major element contributing to obstacles to health care in the sickle cell disease
population is in the area of pain and pain management. Pain is often the most frequent
incident that brings sickle cell patients into a face-to-face interaction with the HCP. Poor
management of pain can serve as a catalyst in propagating an ineffective, distrustful
relationship between the HCP and patient (Shapiro, 1999; Waldrop & Mandry, 1995). There
are several factors related to pain management that may contribute to the creation of a
distrustful relationship. Many HCPs believe that patients with sickle cell disease who request
narcotic pain relief will become addicted and drug seeking. Waldrop and Mandry (1995)
noted that it is common for HCPs to believe that analgesic addiction is more common among
sickle cell disease patients than among sufferers of other chronic pain conditions. These
beliefs are fueled during occasions when the HCP witnesses seemingly contradictory
behaviors in the report of pain from the patient and his or her level of activity. In other words,
the HCP may witness a patient describing severe pain while simultaneously engaging in
activities that are inconsistent with the image of a person in a severe pain state. For example,
the child or adolescent patient may be observed watching television, talking on the phone, or
playing video games during an inpatient hospitalization. The HCP may perceive that the
patient is exaggerating his or her pain intensity in order to obtain additional narcotics. Though
this may be true for some patients, many patients engage in such activities to cope and
distract themselves through a pain episode. The patient may sleep after receiving pain
medication only to awaken complaining of unrelenting pain. While the act of sleeping is often
equated with pain relief among patients with sickle cell disease, using sleep as a gauge for
pain relief may be inappropriate due to the sedative properties of narcotics (Marlowe &
Chicella, 2002). Although some patients with sickle cell disease do become addicted to
narcotic pain medication, addiction rates coincide with rates observed within the general
population. Despite many HCPs’ beliefs, the frequency of drug addiction in patients with
sickle cell disease is only about 1-3% (Marlowe & Chicella, 2002).
Several published articles on pain management among sickle cell disease patients state
that “the report of pain by any patient must be considered accurate” (Sutton, Atweh,
Cashman, & Davis, 1999, p. 284). However, the American Pain Society Bulletin (1999)
published a statement reporting that “patients with sickle cell disease may have to withstand
accusations of faking the pain or engaging in drug seeking behavior.” When patients receive
suboptimal pain management and encounter stigmatizing care from the HCP, the therapeutic
relationship between the patient and HCP becomes jeopardized (Maxwell, Streetly, & Bevan,
1999). If the patient believes that the HCP doubts or does not take seriously reports of pain, or
if the patient perceives that the HCP is suspicious of the motives for seeking pain
management, an adversarial relationship quickly forms and may be nearly impossible to
overcome (Sutton et al., 1999). The accumulated feelings of mistrust fail to accomplish the
task of heightening the level of rapport necessary to optimize the patient’s quality of life and
may result in a lifelong tendency to avoid seeking needed health care.
Listening to the needs of the patient and the family is crucial in developing the
therapeutic alliance. In a study by Mitchell and colleagues (2007) designed to assess health
care service delivery, 53 parents, who hadchildren between the ages of 7 and 13 with sickle
cell disease, expressed a need for increased support, education, and sensitivity to parents and
patients. The authors recommend that practitioners attempt to understand the patient and
family’s experience of the disease in order to help strengthen patient-practitioner
relationships. Health care practitioners also should receive education and training related to
 Social Networks and Psychosocial Functioning among Children and Adolescents … 349

the care of patients with sickle cell disease based on parents’ expressed need for improved
staff training. Results of the study indicated that during emergency room visits, parents
expressed feelings of anger and frustration at the lack of experience and training of hospital
staff members. Parents were additionally frustrated by the perceived limited attention that
sickle cell disease receives in comparison to other chronic pediatric illnesses. Understanding
the pathophysiology, treatment, and complications of sickle cell disease is important so that
HCPs can provide optimal care (National Heart, Lung, and Blood Institute, 1995). Thus,
physicians, nurses, social workers, and other members of the health care team must equip
themselves with the knowledge and skills needed to treat this population. This
multidisciplinary care must include professionals who are not only knowledgeable about the
medical and physical aspects of sickle cell disease but specifically trained to understand the
numerous individual, family, and societal dynamics involved in comprehensive care (Helps et
al., 2003; Mitchell et al., 2007).
Building a trusting relationship between the HCP and patient that promotes optimal
health and well-being for the patient is a reciprocal effort. Both the HCP and the patient share
a responsibility in this construction process though the HCP bears the responsibility of taking
the first steps toward building a healing and lasting relationship with the patient (Glajchen,
1999). The following are crucial steps that the HCP should take during this relationship
building process.
It is recommended that the HCP:

9. Take a personal inventory of his or her knowledge base regarding the ramifications
of living with a chronic illness, particularly sickle cell disease.
10. Encourage the patient and family to actively participate in their health care program
by offering educational materials on the medical aspects of sickle cell disease,
complications of the disease, and how sickle cell disease symptoms manifest in the
patient (National Heart, Lung, Blood Institute, 1995). Be prepared to offer referrals
for psychosocial, family, and academic resources as well. Patients who actively
adhere to their medical regimens and participate in their care are less likely to utilize
the emergency room in non-emergent situations, and those who engage in positive
thinking practices are more likely to know how to appropriately care for themselves
during pain crises (Barbarin & Christian, 1999).
11. Recognize that African Americans living with the chronicity of sickle cell disease are
also at risk of encountering barriers to health care by virtue of belonging to particular
racial and socio-economic classes.
12. Understand his or her role in influencing the delicate HCP-patient relationship,
especially in the area of pain management.
13. Realize the deleterious effects that sub-optimal pain management can have on the
HCP-patient relationship.
14. Acknowledge that the delivery of sub-optimal pain management to patients with
sickle cell disease has caused undue suffering in this population.
15. Be aware that “compassionate and appropriate analgesic care for sickle cell patients
is consistent with pain relief being a human rights issue and the under treatment of
pain as fundamentally a medical error” (Todd et al., 2006, p. 455).
350 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

The previous recommendations can serve as a platform for the HCP to examine his or her
attitudes and beliefs and to recognize how his or her personal belief system can influence
relationships with patients. Education is the key to altering belief systems and changing
behavior.
The patient and patient’s family must also share the responsibility in forming a mutually
trusting relationship with the HCP. It is recommended that the patient and family:

1. Verbally communicate to provide the HCP with accurate, complete information

about current conditions and symptoms.
2. Participate in the health care process by asking questions about the plan of care. He
or she may benefit from requesting additional educational resources if there are
aspects of care that are not fully comprehended during medical visits.
3. Share thoughts and experiences about what may help with personal care. Most HCPs
are willing to work with the patient and family to create a workable care plan that can
accommodate the patient’s needs and lifestyle.
4. Follow the plan of care developed mutually by the patient, family, and HCP. This
includes showing up for appointments and tests when scheduled. Regular health care
maintenance is imperative in promoting optimal health.
5. Understand that going to the emergency room for treatment during acute pain
episodes and then neglecting follow-up care and maintenance check-ups could
potentially send a negative message to the health care team. Further, non-compliance
with follow-up care may serve to create misconceptions about drug-seeking
behaviors in sickle cell patients.

Both the HCP and patient play an instrumental role in achieving a mutually trusting
relationship with each other. This relationship is reciprocal, dynamic, and often fragile. It
requires ongoing efforts from both the provider and patient in order to be successful. Success
translates to the establishment of a therapeutic relationship that facilitates optimal health and
well-being for children and adolescents living with sickle cell disease and their families.

Relationships within the Academic Setting

The recurrent physical symptoms associated with sickle cell disease, including the
debilitating and recurrent pain crises, may warrant frequent medical attention that can
interfere with regular school attendance (Barlow & Ellard, 2006; Wagner, Connelly, Brown,
Taylor, Rittle, & Wall-Cloues, 2004). Frequent school absences can cause conflict between
families and school personnel (Barakat et al., 2007). Neurological deficits and learning
disabilities, which affect one quarter to one third of individuals with sickle cell disease,
further exacerbate academic difficulties and may help to explain academic differences
between these adolescents and healthy controls beyond school absenteeism (Fowler, Whitt, &
Lallinger, 1988; Noll et al., 2001; Schatz & McClellan, 2006).
Regardless of the severity of disease symptoms or neuropsychological deficits, a child or
adolescent diagnosed with sickle cell disease desires normalcy (The Virginia Sickle Cell
Awareness Program, 2006). One way in which a child finds this normalcy is by attending
school. School provides academic enrichment, offers the opportunity to build relationships
 Social Networks and Psychosocial Functioning among Children and Adolescents … 351

with peers and school staff, and enables the child to participate in extra-curricular activities.
While many of the symptoms or characteristics of sickle cell disease may be apparent as the
child attends school, he or she can still experience academic success and have meaningful
relationships within the school setting (Barbarin & Christian, 1999). By providing educational
in-services to staff and peers, educational plans with appropriate accommodations, and
advocacy training, children are able to attend school on a regular basis and find the normalcy
that they desire while concurrently managing sickle cell disease.
When a child or adolescent with sickle cell begins a new school year, the teachers, school
nurse, administrators, and other support staff working with the child or adolescent should be
educated on sickle cell disease (The Virginia Sickle Cell Awareness Program, 2006). This
educational training should begin when the child enters kindergarten and be repeated at the
beginning of each school year because research suggests cognitive decline over time among
children and adolescents diagnosed with sickle cell disease (Thompson et al., 2003). School
staff cannot be expected to be knowledgeable about the disease if proper education or an in-
service is not provided (The Virginia Sickle Cell Awareness Program, 2006). By educating
teachers and staff working with the child, they will have a basic understanding of the disease
and the proactive measures needed to help the student prevent a pain episode at school. Such
measures include the importance of drinking fluids throughout the day to prevent
dehydration, allowing the student restroom or clinic passes when needed, and making
allowances for a modified workload and extended time to make-up work and complete tests
when experiencing pain or not feeling well. Education also will help physical education
teachers to understand why the child cannot go outside in extreme temperatures or why
strenuous exercises and long distance running can precipitate a pain crisis. In-services are
important in not only providing education about the disease but enabling the child and
teachers to communicate effectively for a successful and positive academic experience.
Through open communication, rapport can be established in which the child feels
comfortable discussing his or her medical condition, and the teachers can be creative in
providing subtle supports that will assist the child while still providing normalcy (The
Virginia Sickle Cell Awareness Program, 2006). Supportive interactions with teachers,
administrators, and staff will help the child or adolescent feel that he or she has someone to
talk with regarding potentially sensitive topics such as necessary school absenteeism or the
physical manifestations of sickle cell disease. Proper education about sickle cell disease to
school staff would also allow the school clinic to serve as a safe haven where the child can
report physical symptoms of pain or discomfort. The school nurse can help to evaluate when a
particular symptom warrants immediate medical or parental attention or if the child simply
needs to rest. Since, in most cases, the school nurse is more knowledgeable about sickle cell
disease than any other school staff member, he or she can help the child educate others and
work with colleagues and child study teams when the child is experiencing academic
difficulty and requiring additional academic support.
Providing educational in-services are important to teachers and support staff as well as
the child’s classmates (The Virginia Sickle Cell Awareness Program, 2006). Ideally, children
and adolescent peers would provide ample support for a fellow classmate dealing with a
chronic illness; however, children often have questions and are inexperienced in managing
their reactions to a classmate who might be perceived as different. When a classmate is absent
from school on a regular basis or for a week or longer several times in a school year, children
start to question why their peer does not have to attend school. They often ask if their peer is
352 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

required to complete his or her class work or homework or whether he or she will fail due to
missing too many days. Other questions may be related to visible physical manifestations of
sickle cell disease: “When he or she does attend school, why are the whites of his or her eyes
yellow?” “Why is he or she smaller than the other kids in his or her class?” “Why is he or she
allowed to carry a water bottle and drink during class?” “Why does he or she go to the
bathroom during class when I have to wait until break or until class is over?” “Why does he
or she not have to run the mile during physical education class?” “Why does he or she get to
wear sweats outside for gym rather than a gym suit?” and “Why is everyone so secretive
when I ask about my friend?” These types of questions represent those that are raised when
classmates are provided in-services regarding the health condition of a classmate with sickle
cell disease.
Adults expect children and adolescents to be supportive; however, when children are not
educated about the disease or illness, they tend to shy away or ask inappropriate questions,
which can be damaging to the child with sickle cell disease and the rest of the class (The
Virginia Sickle Cell Awareness Program, 2006). When in-services are provided in an age-
appropriate manner, sickle cell disease can be explained beginning with diagnosis, symptoms,
treatment, and ways to be supportive. Thus, the child with sickle cell disease and his or her
classmates can be comfortable around one another by dispelling any myths about the disease
(e.g., sickle cell disease is contagious) and helping the child’s classmates understand how to
be a good friend and offer support when needed. In turn, the child with sickle cell disease will
feel more comfortable talking about his or her disease with others and advocating for his or
her needs. Healthy and positive relationships that develop as a result will be sustained
throughout the child’s school career.
In order for the student with sickle cell disease to receive accommodations to be
successful in the school environment, educational plans can be written (The Virginia Sickle
Cell Awareness Program, 2006). Through the Individuals with Disabilities Education Act
(IDEA) or Section 504 of the Rehabilitation Act, students with chronic illnesses such as
sickle cell disease can qualify for special services. Once a referral is made by the parent or
school, the child study team meets to determine the appropriate evaluations or interventions
that should be put in place before finding the child eligible for services. The child study team
meeting is an opportunity for the patient and family to educate others about sickle cell disease
and advocate for services and accommodations needed. This meeting is an important
opportunity for relationships to be established in which team members are working toward
what is in the best interest of the child.
Children and adolescents with sickle cell disease must begin learning at a very young age
about their disease. While the attention and executive functioning deficits that often
accompany a sickle cell disease diagnosis can complicate a child or adolescent’s ability to
manage his or her disease effectively, it is necessary for the child to learn how to self-
advocate (Barakat et al., 2007; The Virginia Sickle Cell Awareness Program, 2006). With
assistance from parents, teachers, and close friends, the child will slowly learn his or her
strengths and weaknesses. The child will learn to identify what causes pain episodes, as well
as alternatives to specific activities that might precipitate a crisis. As the child grows and
matures, he or she will develop skills in communicating effectively with teachers and friends
about the disease and resources and supports needed. In addition, through guidance of
parents, teachers, and others, the child or adolescent will learn that he or she never has to be
embarrassed or ashamed about his or her disease. If a child is expected to fail, he or she most
 Social Networks and Psychosocial Functioning among Children and Adolescents … 353

likely will fail (Barbarin & Christian, 1999). Therefore, academic success, with the
appropriate accommodations and support, should be expected. Close relationships and
successful advocacy training will enable the child or adolescent with sickle cell disease to be
confident, possess self-esteem, and feel good in body, mind, and spirit.

INTERVENTIONS IN SICKLE CELL DISEASE CARE

Biopsychosocial models of adaptation to sickle cell disease highlight the complex
interactions of a variety of factors and resulting effects at the individual and family levels.
The most notable models are the social-ecological system theory (Bronfenbrenner, 1979),
disability-stress-coping model (Wallander & Varni, 1992), and transactional stress and coping
model (Thompson, Gil, Burbach, Keith, & Kinney, 1993). Though these models vary in their
conceptual framework of understanding adaptation in children and adolescents diagnosed
with sickle cell disease, all three acknowledge the importance of family factors in adjustment
to a chronic illness.
The complexity of managing sickle cell disease has fueled research on developing
psychosocial interventions aimed at incorporating contextual, disease, and individual factors.
Families and community members must work fluidly in order to help the child reach
developmental milestones for adequate development. Given the complex nature of
development coupled with managing a chronic illness, parents would greatly benefit from
utilizing the support of community members, friends, and extended family to raise their child.
However, there is lack of research on the effects of pediatric sickle cell disease intervention at
the family, medical, and academic levels (Kaslow & Brown, 1995). Flexible intervention
strategies are especially necessary in the sickle cell disease population to adapt to cultural,
socioeconomic, and individual factors of each family because most intervention studies are
conducted within largely Caucasian populations (Schwartz, Radcliffe, & Barakat, 2007).

Interventions within the Family Context

The complexity of managing sickle cell disease in a child or adolescent falls heavily on
the family, underscoring the importance of implementing family-based interventions. At the
most basic level, family members, particularly parents or main caregivers, must have an
understanding of the disease itself (Kaslow & Brown, 1995). A series of focus groups, part of
a larger mixed method study evaluating perceptions of sickle cell disease awareness, revealed
that health care providers, community members, and sickle cell disease patients alike believed
that there was limited awareness about sickle cell disease in community settings and that most
of the burden of sickle cell disease education fell upon health care providers (Treadwell,
McClough, & Vichinsky, 2006). A helpful guideline in creating and implementing family-
based interventions for sickle cell patients was created by Kaslow and Brown (1995) based on
the identified needs. These guidelines, calling for a more culturally sensitive multidisciplinary
approach, help to alleviate the heavy burden on health care providers of being soley
responsible for disseminating sickle cell disease education to patients and their families.
354 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

Kaslow and Brown’s (1995) manualized intervention, developed under a larger clinical
research study, incorporates cultural and developmental factors in treating families with a
child diagnosed with sickle cell disease. Though the intervention is in a fairly standardized
form for consistent implementation, the authors encourage users to account for differences
among families in sickle cell disease knowledge, psychological and medical sequelae, and
stress management.
Furthermore, because sickle cell disease largely affects African Americans, incorporating
cultural factors into family interventions is crucial. Kaslow and Brown (1995) cite
empowerment as essential to success in implementing interventions in African American
families. By educating families about sickle cell disease and providing useful communication
and problem-solving tools, family members are adequately equipped to successfully manage
having a child with sickle cell disease in a wide variety of settings. Addressing financial
difficulties of families is often a challenge but important in understanding potential issues of
compliance in health care. The multidisciplinary health care team must be aware that some
parents or caregivers may struggle to meet even the basic necessities of the family and thus,
may be forced to forgo a follow-up appointment to manage the demands of the rest of the
family. To address this issue, medical staff members could develop a point system in which
families are rewarded for full medical compliance with basic necessities such as school
supplies (Kaslow & Brown, 1995).
In their guidelines, Kaslow and Brown (1995) recommended 6 to 12 interventions
sessions for each family, with the length and frequency of each session based upon the
content of the meeting. Key members of the family should be encouraged to attend sessions.
Kaslow and Brown break down a typical 6-session format:

1. Session 1: Basic sickle cell disease education is provided for the family members in
attendance using age-appropriate presentations. The family is also given an easy-to-
read pamphlets with helpful illustrations. The language and the way in which the
information is presented may vary slightly depending on the family, allowing
educators to tailor each session.
2. Session 2: This session focuses on prevention of medical issues that may arise in the
child. Family members are supplied with techniques to help lower the chances of a
medical crisis. Games and homework may supplement the session.
3. Session 3: Pain management techniques are addressed as well as ways to successfully
manage and cope with stress. Attention is given to all family members so that each
person can learn how to relax and deal with stressful situations that may arise.
4. Session 4: Family members are asked to communicate their personal thoughts and
feelings with one another during this session. Taking into account cultural and
individual family factors, the educator respects the boundaries of each family
member and the decision not to share thoughts or feelings by a member.
5. Session 5: Through role play, family members learn about the ways in which positive
family relationships can be enhanced through adaptive coping and providing support
to or receiving support from family and friends.
6. Session 6: During the final session, information gathered from the prior five sessions
is reviewed. Progress of the family is also evaluated to emphasize the strengths that
each family member has to offer. Referral sources and an open-door policy are
 Social Networks and Psychosocial Functioning among Children and Adolescents … 355

provided for each family should psychological and education support be needed in
the future.

Kaslow and Brown’s (1995) intervention represents one of the few studies offering a
substantial multi-level intervention to families that promotes both family relationship
development and caring for basic medical needs. While practice-based evidence research has
flourished in adult populations, it is fairly limited in the pediatric chronic disease population
(Collins et al., 1997). As such, little is known about the complexities of creating and
implementing effective psychological interventions in children or adolescents diagnosed with
a chronic illness . A comprehensive family-oriented intervention in the pediatric sickle cell
population was developed by Collins and colleagues (1997) based on recommendations made
by the American Psychological Association’s (1995) guidelines for efficacy studies. Six
treatment sessions were developed for families, covering topics such as disease education,
health care, and effective coping strategies. Families were randomly assigned to the
intervention group or control group and later compared to determine the efficacy of the
intervention. Collins and colleagues discussed the numerous obstacles involved in developing
an intervention for low-income, African American families coping with a chronic illness such
as finding pre-existing efficacious interventions on which to build new interventions, meeting
inclusion criteria, and adherence to manualized treatment. While additional intervention
studies are warranted to further develop efficacious psychoeducational interventions for
children and adolescents with sickle cell disease and their family members, findings from
studies such as Kaslow and Brown (1995) and Collins and colleagues (1997) offer the
beginnings of how to provide quality educational resources and adaptation strategies for these
families.

Interventions within the Academic Domain

To date, no intervention studies were found that examined relationship development and
the promotion of academic success within the academic setting. If such interventions are
developed, it is important to consider that level of socioeconomic status (SES) generally
predicted above and beyond any other factor related to academic achievement (Scott and
Scott, 1999) and likely represents a variable warranting intense investigation. Further,
socioeconomic status levels determined whether adolescents engaged in adaptive or
maladaptive coping mechanisms to manage the stresses of the disease. Scott and Scott (1999)
found that adolescents diagnosed with sickle cell disease who face neuropsychological
problems suffer from cognitive and academic disadvantages related to both medical and
sociocultural variables. Findings by Buchanan and colleagues (1993) corroborates results
found in the Scott and Scott (1999) study, suggesting that academic difficulties are affected
by specific non-health problems such as cultural disparities and socioeconomic status.
Matched healthy controls tended to perform higher in this area, highlighting the need for
psychoeducational support for these students.
356 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

Interventions within the Medical Setting

The history of medical research in African American communities is burdened with

tainted political agendas and mistreatment of African Americans, most notably the notorious
Tuskegee Syphilis Study conducted between 1932 and 1972 (Centers for Disease Control and
Prevention, 2008). Sickle cell trait screening, implemented in the 1970s, was perceived by
African American communities as the basis for discrimination and oppression (Markel,
1992). Because it is unclear how much of a role historical events such as these play into
African American perceptions about the medical community, the underlying goal of
researchers and practitioners should aim to build adequate rapport and trust. Individuals who
are diagnosed with sickle cell disease or have close friends or families affected by the disease
report the need for counselors who are deemed trustworthy (Treadwell et al., 2006) and
appear as a credible resource (Williams, 2003).
Research shows that individuals at high risk for sickle cell disease, specifically African
Americans, lack adequate knowledge about the nature of the disease, leading to many
misconceptions and poor relationships with health care providers. In a community-based
survey evaluating accurate knowledge and information sources on sickle cell disease and trait,
the majority of the 316 participants had accurate basic knowledge about the nature of sickle
cell disease (Treadwell et al., 2006). However, only 13% of participants correctly defined
sickle cell disease and only 16% knew their own sickle cell trait status. Clearly, a greater
emphasis on basic education about the nature of sickle cell disease and sickle cell trait is
needed as the foundation for successful interventions, particularly in hospital settings.
A review of the practice-based evidence in managing physical symptoms show that
cognitive behavioral therapy (CBT) has been widely used with children (Christie & Wilson,
2005). The use of manuals in chronic illness populations have become the norm for
intervention strategies and for good reason. Manuals provide standardized methods of
delivering interventions that allow for groups to be compared, allow for replication of
procedures, increase retention of information presented during the intervention, and allow
ease of training for research staff members. Intervention formats also promote open
discussions on topics that might have been otherwise overlooked.
Currently, there are several manuals that provide how to implement specific behavioral
techniques in adolescent and pediatric populations (Christie & Wilson, 2005). The flexibility
of CBT allows cultural and contextual factors to be taken into account when working with
children and adolescents of various backgrounds, highlighting the adaptability and flexibility
of these techniques. A review study examining the efficacy of CBT interventions in an
adolescentsickle cell disease population demonstrated that behavioral techniques worked
moderately well, especially in managing pain (Chrisie & Wilson, 2005). Anie, Green, Tata,
Fotopoulos, Oni, and Davies (2002) and Gil and colleagues (1997) have published treatment
manuals to help adolescents and children deal with sickle cell disease. Anie and colleagues
(2002) focused on providing psychoeducation in addition to using therapeutic tools to help
challenge negative thought processes whereas Gil and colleagues. focused primarily on pain
management and useful tools to deal with sickle cell crises. Both allow educators to teach
patients new pain management skills and strategies for self-advocacy in addition to building
lasting rapport with patients.
 Social Networks and Psychosocial Functioning among Children and Adolescents … 357

FUTURE DIRECTIONS AND RECOMMENDATIONS

Although the literature on positive adaptation and promoting healthy relationships among
children and adolescents diagnosed with sickle cell disease continues to grow in the pediatric
literature, more work is needed to fully understand and predict the probability of adaptive
outcomes for all patients and family members impacted. Research must be methodologically
rigorous and translatable. Much of the research presented in this chapter utilized small sample
sizes and mixed child and adolescent age groups. Efforts must be made to assess these age
groups independently due to differences in developmental needs concerning relationship
dynamics (Holmbeck, 2002). Measures must be age-appropriate as well. Culture always
needs to be at the forefront of research design and the interpretation of results (Barbarin &
Christian, 1999), especially because many standardizing assessment tools do not have valid
and reliable norms for minority groups (Thompson et al., 1999).
Although the literature continues to support the preface that psychosocial factors such as
family functioning and social relationships are better predictors of adjustment to illness and
quality of life than medical factors (Lutz et al., 2004), little effort has been made to use
knowledge related to specific salient factors to change patient relationship development and
overall functioning for the better. Studies need to ask the children and adolescents for their
perspectives rather than solely relying on parent and teacher reports; parental perspectives of
child and adolescent functioning tend to over-estimate symptoms of mental health disorders
(Barlow & Ellard, 2005). Better means of assessing parent perspectives of self and family
functioning are needed as well. For example, as Barakat and colleagues (2005) noted in their
recommendations, more accurate assessment of parenting beliefs within the clinic setting
related to locus of control would enable health care professionals to intervene in order to
discuss the real and perceived family relationship vulnerabilities that may be at risk.
Therapists need to consider systemic family cognitive patterns that may result to maladaptive
coping patterns (Helps et al., 2003). There exists a need to determine automatic negative
assumptions that hinder family adaptation and to use a cultural milieu to modify patterns in a
culturally sensitive manner. Strengths displayed within families provide just as much valuable
information as identifying barriers to relationship development and quality of life. Efforts
must be made to seek out the positives and learn from families that are doing well.
Christie and Wilson (2005) highlighted the difficulties and efficacy of psychological
interventions in the pediatric chronic illness population, citing the bustling hospital
environment and transportation issues. The authors suggest that interventions implemented in
hospital settings must be flexible in order to adapt to the constantly changing medical
environment. Further, medical staff members who are part of the patient’s care must be
integrated into interventions as a way to help increase the efficacy of psychological
treatments. Cognitive behavioral treatments (CBT) have not been extensively used in
pediatric sickle cell disease populations, and the manualized nature of this therapeutic tool
allows it to be adapted to specific chronic disease populations. Though Christie and Wilson
caution against generalizing techniques found to work in one medical population to another,
the flexible nature of CBT approaches allows for great potential to be used in a wide variety
of populations.
Finally, in a technology dominated society, new methods of meeting patients’ needs are
under ongoing development. Creative websites aimed at increasing basic knowledge about
358 Rebecca H. Foster, HaNa Kim, Robbie Casper et al.

sickle cell disease are beneficial to the family and the child diagnosed with the disease. An
animated website at sicklecellkids.org offers interactive ways for adolescents and children to
learn more about the medical aspects of disease, dispel widespread myths, and provide
resources for patients and their family. In addition, the website offers several quizzes for the
user, which help gauge his or her knowledge about the topic of sickle cell disease. Websites
such as these could offer a fun and creative educational tool for adolescents and children to
use on their own or with a family member to help increase sickle cell knowledge, normalize
the disease, promote peer relationships and academic success, and understand the medical
aspects of sickle cell disease.

CONCLUSIONS
Sickle cell disease is a chronic illness that affects individuals throughout their entire lives.
Children, adolescents, and families managing this disease often face challenging and complex
situations in numerous aspects of relationship formation and psychosocial development.
Healthy relationships with family members, peers, health care practitioners, and school
personnel are of vital importance by providing a significant source of support during the care
of the patient. Developing lasting social networks requires acknowledgement of the barriers
to optimal adjustment and connections with individuals willing to educate themselves to the
medical, socioeconomic, and cultural variables that interact within the patient’s life.
Continued improved outcomes for children and adolescents with sickle cell disease will
require methodologically rigorous research designs to determine additional factors promoting
adaptive social skill development, unconditional familial support, increased involvement
within the school setting, well-trained multidisciplinary care teams, and ongoing self-
advocacy training. The information available to date also clearly suggests the need to develop
additional intervention studies and resources available to families coping with sickle cell
disease.

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Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 20

PARENTING AND CHILDREN’S INVOLVEMENT IN

BULLYING AT SCHOOL

Ken Rigby
University of South Australia

Research into bullying amomg children has suggested that parents can play an important
role in reducing the risk of their children becoming involved in bully/victim problems at
achool .and can take steps to enable their children to cope more effectively (Smith and
Myron-Wilson, 1998; Stelios, 2008; Rigby 2008). At the same time, it should be
acknowledged that parental influence is limited by such factors as their child’s genetic
endowment (Ball et al., 2008) peer pressure at school and unpredictable life events. (Harris,
1998).
What parents can do to reduce the risk or impact of bullying on children can be
considered under these headings:

6) Early childhood parenting

7) Parenting style with older children
8) Parents promoting skills that are helpful in reducing the risk of
9) Parents assisting children who are being bullied at school
10) Parents providing emotional and social support when children are bullied

EARLY CHILDHOOD PARENTING

Early childhood experiences can have a significant effect on the quality of children’s
relations with others at school.. Close and effective parental bonding can make it more likely
that one’s child will subsequently enjoy feelings of confidence and security, as opposed to
feeling generally anxious or distrustful of others. When young children become securely
attached to care-givers, the risk of subsequent involvement in bully/victim problems at
school, is significantly reduced (Troy and Stroufe, 1987). Further, it is known that premature
366 Ken Rigby

exposure for long periods of time to inadequate childcare facilities can produce high levels of
stress in young children with negative consequences for the child’s later peer relations
(Manne, 2005).

PARENTING STYLE
Research has shown that an authoritarian or over-controlling style of parenting, can also
put children at greater risk of becoming bullies at school, especially if the parents who are
seen by their children as uncaring (Rigby, Slee and Cunningham, 1999). ‘Under-controlling’
or unduly permissive parenting can also have undesirable effects. In one US study, reported
by Curtner-Smith et al., (2000) boys aged 10-13 years who reported that their mothers tended
not to monitor or supervise their behaviour, for example in knowing their children’s
whereabouts outside the home, were more likely to be identified by their peers at school as
bullies. A further factor that may result in subsequent bullying behaviour is an incapacity of
some parents to forgive their children for perceived transgressions (Ahmed and Braithwaite,
2006). Children can be ‘overprotected’ by kindly, well-meaning parents who provide a so-
called ‘enmeshed’ family situation. (Bowers, Smith and Binney, 1992) Having little
experience of a diversity of people, such children may find it hard to adjust to school life and
become prominent targets for bullying.

PARENTS PROMOTING APPROPRIATE SKILLS

The development of social skills can help to reduce the likelihood that a child will be
bullied at school (Fox and Boulton, 2005). .These include the capacity to act assertively,
rather than aggressively, during interactions with peers, especially in situations that might
otherwise lead to a child being bullied. Parents may help children to make friends, in part by
modelling ways of behaving positively with others and also by providing children with
opportunities to interact with their peers, for instance by inviting to their home children with
whom their children can make friend under supervised conditions. Repeated conflicts
between siblings in a family are associated with aggressive behaviour at school, and need to
be controlled. However such conflicts can provide opportunities for parents to teach their
children constructive conflict resolution skills that contribute to more armies relations with
peers at school (Duncan, 2005) A frequently suggested antidote to being bullied is for a child
to develop the capacity to act aggressively when challenged. For this reason parents may
encourage their children to participate in power sports such as boxing, weight lifting and
rugby. However, it has been found that children who engage in such sport are more likely
than others to become involved in bully/victim problems at school (Endressen and Olweus,
2005) The development of appropriate social skills can provide a more useful means of
coping with potentially conflictual situations.
 Parenting and Children’s Involvement in Bullying at School 367

PARENTS ASSISTING CHILDREN WHO ARE BEING BULLIED

Parents have the opportunity to assist children who are being bullied at school once they
become aware of it. Unfortunately many children, estimated in England at around 60%, do
not tell their parents (Smith and Shu, 2000). Hence to help such children it is necessary for
parents to establish relationships with them such that they will disclose if they are being
bullied at school. This may occur if the parents are perceived as interested in the matter and
perceived as both motivated and able to help. Parents who simply direct their children to
‘stand up to the bully’ or alternatively offer to protect them by allowing them to stay at home
commonly do not help to improve the situation. Listening sympathetically to a child’s
concerns about being bullied is an essential starting point. Subsequently parents can explore
various strategies such as acting more assertively, avoiding certain threatening situations,
seeking help from friends or teachers . When such strategies fail it becomes necessary to visit
the school and to ask for help.

PARENTS PROVIDING EMOTIONAL AND SOCIAL SUPPORT WHEN

CHILDREN ARE BULLIED
As is well known, children who are repeatedly victimised by peers at school commonly
experience low levels of mental health, as indicated by measures of depression, anxiety and
suicidal ideation (Rigby, 1999; Rigby and Slee, 1999; Bond et al., 2001). Research with
Australian adolescent school children suggests that the provision of social support for
chronically victimised children can reduce the negative health effects. (Rigby, 2000). Such
emotional support can be provided by parents who become aware that their child is being
bullied. This can not only reduce the negative impact of being bullied, but also help to make
children less anxious, depressed or alienated and therefore more capable of resisting attempts
by peers to victimise them.

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368 Ken Rigby

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 21

NEUROBIOLOGY OF SOCIAL BONDING

Donatella Marazziti*, Alessandro Del Debbio, Isabella Roncaglia,

Carolina Bianchi, Liliana Dell’Osso
Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie,
University of Pisa, Pisa, Italy

ABSTRACT
Social bonding development is fundamental for several animals, particularly for
humans who are the most immature at birth, for its relevant impact upon survival and
reproduction. Several neural and endocrine factors, most of which are still largely
unknown, may modulate reproductive behaviors, mother-infant attachment and adult-
adult bonding. Consequently, we aimed to review the neurobiological correlates of
attachment in both animals and humans. MEDLINE and Pub-Med (1970-2008) databases
were searched for English language articles using the keywords attachment,
neuropeptides, neurotrophins, pair bonding, social behavior. We reviewed papers that
addressed the following aspects of attachment neurobiology: 1) Infant-mother
attachment; 2) Mother-infant attachment; 3) Adult-adult pair bonding formation; 4)
Human bonding. Oxytocin and vasopressin, two neurohypophyseal peptides, are known
to be involved in the attachment process. Oxytocin is supposed to facilitate a rapid
conditioned association to maternal odor cues, while linking environmental cues to the
infant's memory of the mother. While oxytocin plays a role in the onset of maternal
behavior in rats, vasopressin seems to influence paternal behavior in praire voles.
Parental behavior development requires also gonadal steroids action. In adults, oxytocin
and vasopressin may contribute to pair bonding process by modulating the
neuroendocrine response, behaviors and emotions associated to preference formation and
pair bonding. Recently, even neurotrophins have been suggested to play a role in social
bonding. In conclusion, although the neurobiological basis of social attachment is mainly
based on animal data, preliminary findings suggest that the same mechanisms may occur
also in humans and would involve multi-sensory processing, complex motor responses

*
Corresponding author: Donatella Marazziti, MD; Dipartimento di Psichiatria, Neurobiologia, Farmacologia e
Biotecnologie, University of Pisa, Via Roma 67, 56100 Pisa, Italy. Tel:+39 050 835412; Fax:+39 050 21581;
E-mail: dmarazzi@psico.med.unipi.it
370 Donatella Marazziti, Alessandro Del Debbio, Isabella Roncaglia et al.

and cognitive functions, such as attention, memory, recognition and motivation. The few
data available in humans are intriguing and seem to open even more exciting perspectives
to the treatment of a broad range of neuropsychiatric disorders.

INTRODUCTION
The attachment theory was first developed by the British psychoanalyst John Bowlby
(1907-1990) [1,2,3] who analized the experience of separation of infants from their parents.
He observed that separation led to distinctive behaviors such as crying, clinging and
protesting in order to restore proximity to their parents. Contemporary psychoanalysts
explained these manifestations as immature defense mechanisms to repress emotional
distress, while Bowlby proposed that they represent adaptive responses to separation from a
primary attachment figure (the so-called “caregiver”) who provides support, protection, and
care..
Feeding, sleeping and locomotion are fundamental, but attachment is probably the most
important process for human survival, as that are very immature at birth and that could not
survive if they were not “social animals”. The brain systems promoting social bonds probably
evolved to mobilize the maternal care in mammals. The helpless of mammal newborns, their
dependence upon maternal nutrition and the necessity of proximity to parental body to keep
warm, therefore, required the evolution of a new motivational system to stimulate and sustain
maternal behavior. According to Bowlby, the quality and quantity of maternal care received
during infancy are fundamental for the development of adult social competence and ability to
cope with stressful situation and aggressiveness. In addition all other types of social bonds
seem to have evolved from motivational systems that stimulate maternal behavior in
mammals.
Bowlby hypothesized that the attachment should have solid genetic and biological bases,
but only in the last three decades, several studies have begun to investigate these aspects.
With the exception of pharmacological studies in maternal monkeys [4] and recent human
imaging studies [5], investigations of neural systems involved in attachment have so far used
non-primate mammals, such as praire voles and precocial ungulates. Recent evidences show
that two neurohypophyseal peptides, oxytocin and vasopressin, are relevant in the formation
of social relationships. Oxytocin seems to be implicated in several physiological, behavioral
and pharmacological aspects of social attachment, such as learning, memory, parturition,
lactation, maternal and sexual behavior. Moreover, the role of these hormones seems to be
gender- specific: oxytocin mediates behavioral aspects in females, while vasopressin in
males. Different neurotransmitters have been also implicated in the attachment process:
prolactin, opioids, dopamine, GABA and serotonin [6,7]. Furthemore, in the last years a
growing body of research has been investigating the role of neurotrophins (NTs) in the
development of attachment.
 Neurobiology of Social Bonding 371

INFANT-MOTHER AND MOTHER-INFANT ATTACHMENT

The newly hatchet chicks show a visual imprinting: they present a long-lasting tendency
to follow the mother or objects similar to the mother. A region within the intermediate medial
part of the hyperstriatum ventrale (IMHV) of their brain is important for the acquisition and
the early consolidation of the memory of an imprinted visual stimulus [8]. An adjacent region,
the mediorostral neostriatum [9], presents exclusively auditory imprinting [10]. Visual or
auditory imprinting provokes an early and persistent increase of the presynaptic release of
amino acids and ultrastructural postsynaptic modifications in specific cortical regions [8]. Rat
pups recognize the mother through an olfactory process which implies noradrenergic
pathways [11] and are conditioned by stimuli associated to maternal odours and care [12],
while oxytocin seems to facilitate the learning of social stimuli (like maternal ones). In
humans, children at the birth form a tie with caregivers which will continue to influence the
emotional relations also in adulthood. Oxytocin and vasopressin systems are influenced by
early social experiences. In mammals, the interaction child-mother has deep effects on
behavior and can determine long-lasting neuro-anatomical and neuro-endocrine
modifications. The early experiences can affect the neurogenetic respose to stress in
adulthood, as a persistent alteration of hypothalamic-pituitary-adrenal (HPA) axis has been
demonstrated as a result of early stressful events [13,14]. Early experiences, like birth, breast-
feeding and other aspects of mother-child interaction, would produce short-term and long-
term behavioral modification probably mediated by oxytocin [15]. Oxytocin and vasopressin
levels are increased by pleasant social experiences like odours and caresses. A marked
production of oxytocin receptors have been found (in rodents and in primates) in limbic areas
during the first two weeks after birth.
Neuroendocrine factors associated with gestation, delivery and breast-feeding induce the
step from avoidance to approach behaviors. In rat brain, several areas seem crucial in
determining maternal behavior: medial preoptic area (MPOA), the overlying bed nucleus of
the stria terminalis (BNST), the lateral habenula and the ventral tegmental area (VTA)
[6,16,17]. In the rat, oxytocin and prolactin have been shown to mediate the maternal
behavior: e.g., it has been demonstrated that oxytocin injection in lateral ventriculi of rat
nulliparous and ovariectomized female induces it [18]. Estrogens are fundamental in
modulating oxytocin neurotransmission. Physiological variations of sexual steroids during
pregnancy provoke, just before delivery, an increase of oxytocin receptors in two limbic
areas, the BNST and the ventro-medial nucleus of hypothalamus, while determining the onset
of maternity [19]. In rat females, the initiation of maternal care is facilitated by lesions that
reduce olfactory processing [20]. During delivery, the oxytocin release reduces mitral and
granule cell firing in the olfactory bulb, while inhibiting the olfactory stimuli processing and
facilitating approach behaviors [21,22]. Up-to-now, the role of oxytocin in the development
of maternal behavior in humans has not been studied systematically. Some authors showed
that breast-feeding, within one hour from birth, when oxytocin levels are elevate, could
induce the formation of a stable and long-term attachment relationship between mother and
child, with a benefical effect on child development [23].
In the post-partum, rat female cares for any pups placed in its nest and shows a generic,
not selective attachment; on the contrary, sheep presents more rigorous and selective models
of maternal attachment, while refusing, in the post-partum, any lamb that is not its own. Until
372 Donatella Marazziti, Alessandro Del Debbio, Isabella Roncaglia et al.

now, brain areas mediating the effects of oxytocin on maternal behaviour have not been
identified, but recent studies suggest a certain region specificity [24,25,26].
The role of olfactory stimuli is supported by a series of experiments: within 24 hours
from the delivery the odour of the own lamb enhances the intracellular concentration of
glutamate and GABA in the olfactory bulb [27]. Such neurochemical modifications within the
olfactory bulb are influenced by sexual steroids [28].
Mother separation is an animal model of early stress, which is used to study the
development of depression-like behaviors in adults [29,30,31]. A growing body of data
suggests the involvement of a neurotrophin (NTs), the Brain-Derived Neurotrophic Factor
(BDNF), in stress-related hippocampal degeneration [32]. BDNF is a protein involved in the
differentiation, survival of peripheral and central neurons, and in the modulation of synaptic
plasticity; recently, it has become the focus of increasing attention, given its putative role in
the pathophysiology of different neuropsychiatric disorders [33,34]. Examination of BDNF
mRNA levels in the brain of rats separated from his mother at birth provoked different effects
in short and long-term, respectively. A short-term increase in gene expression of BDNF has
been observed in prefrontal cortex and hyppocampus [35,36], while a reduced gene BDNF
expression in long-term observations, specifically in prefrontal cortex [36]. The regulation of
BDNF expression in hippocampus of adult rats separated from the mother seems thus, to be
time-dependent. [37].
A recent study examined the effects of early isolation rearing on cell proliferation,
survival and differentiation in the dentate gyrus of the guinea pig, while showing that it
reduces hippocampal cell proliferation, by reducing BDNF expression, and hampers
migration of the new neurons to the granule cell layer, by altering the density and morphology
of radial glia cells [38]. The wide reduction of the number of granular cells following
isolation rearing emphasizes the role of environmental stimuli as key modulators in
neurogenesis.
On the contrary, studies on models of early social enrichment (e.g. being reared in a
communal nest) found a highly stimulating effect on adult neuronal plasticity, which on the
other side seems to be associated with increased anxiety and depression-like behaviors during
the adulthood [39]. On the whole, some data suggest that NTs could act as mediators to
translate the effects of external manipulation on brain development. Changes in the NT level
during the critical stages of development may result in long-term changes of neuronal
plasticity and lead to greater vulnerability to aging and psycopathology [35].

ADULT PAIR BONDING

Approximately 5% of mammals are monogamous and biparental [40,41]. The voles
(microtine rodents) have demonstrated to be an excellent model for molecular and cellular
studies of complex social behaviors [42]; two species of North America have been widely
compared for neuronal differences: prairie voles, that are monogamous and montane voles
that are promiscuous.
Praire voles generally form stable bond after mating [42]. Mating determines the release
of oxytocin and vasopressin that seems to be involved in this process [43]. Oxytocin and
vasopressin injection in the central nervous system facilitates the insorgence of monogamous
 Neurobiology of Social Bonding 373

behaviors in praire voles even when they have not the opportunity to mate [44,45]; on the
contrary, the administration of vasopressin and oxytocin antagonists before mating inhibits
the appearance of long lasting bonds [44,46]. The antagonists do not alter mating itself, but
prevent the development of the partner preference which normally praire voles show after
mating. These observations suggest that in praire voles both neurohypophyseal peptides are
necessary and sufficient to form pair bonding. On the contrary, neither oxytocin nor
vasopressin have relevant effects on social behavior of montane voles [44,47]. Although the
expression of these neuropeptides is similar between the two species, differences have been
found in the regional distribution of their receptors [48,49]. In monogamous voles, in fact the
oxytocin receptors are expressed particularly in the nucleus accumbens, in the pre-limbic
cortex and in the ventral pallidum, regions that are associated with reinforcement and
conditioning. On the contrary, montane voles have a few oxytocin and vasopressin receptors
in these areas, but elevated in the lateral septum. In praire voles, the oxytocin receptor
blockade in the nucleus accumbens inhibits the formation of the partner preference, while the
hyperexpression of V1a receptors for vasopressin in the ventral pallidum facilitates it [50].
This hypothesis is supported by the observation of an analogous distribution of vasopressin
receptors in monogamous rats and in primates, while the regional distribution of such
receptors in rodents and primates, which do not present pair bonding, seems to be different
[51]. Probably, the release of oxytocin and vasopressin during mating leads to the activation
of reward circuits in monogamous species, but not in the promiscuous ones. However, it is
interesting to underline that, in montane voles, there is an increase of the oxytocin receptors
in the post-partum, phenomenon that is associated with the onset of nursing behaviors
towards the pups [48]. Recent studies have highlighted the importance of the nucleus
accumbens and the D2 dopaminergic receptors of this area in determining the formation of
the partner preference in praire voles [52,53]. The administration of D2 agonists sistemically
or directly in the nucleus accumbens seems to facilitate the partner preference, while D2
antagonists would inhibit it. It is possible that these neuropeptides or mating activate the
mesolimbic circuit that is involved in the reward effects of psychostimulants. Recent studies
in rats suggest that dopaminergic effects on reinforcement mechanisms could be mediated by
the potentiation of glutamatergic transmission towards nucleus accumbens [54]. Monogamous
species probably have a selective predisposition to be conditioned by social stimuli, which is
partially mediated by oxytocin and vasopressin. Some authors, while hypothesizing the
existence of a molecular basis of monogamy, focused their attention on the different
neuroanatomical distribution of receptors among different vole species. Regions codifying for
oxytocin and vasopressin receptors are essentially the same in monogamous and in non-
monogamous species, although remarkable differences in the 5’ flanking region of the V1a
receptor gene have been found [55]: these would contribute to the tissue specificity of genic
expression. Therefore, oxytocin and vasopressin could represent the link between the
neuroendocrine response to mating, the formation of partner preference and, finally, pair
bonding. In addition, there is consistent evidence that implicates both oxytocin and
vasopressin in social recognition or social memory [56, 57 ]. Oxytocin knockout mice present
all maternal behaviors, but show a severe social amnesia, without other evident cognitive
deficits [58]. In oxytocin-knockout mice, social stimuli determine a normal level of activation
of c-fos gene in the olfactory bulb, but not in the medial amigdala nor in bed nucleus of stria
terminalis and MPOA. The medial nucleus of amigdala in mouse brain is rich in oxytocin
receptors; in oxytocin-knockout mice, oxytocin injection in this nucleus, but not in the
374 Donatella Marazziti, Alessandro Del Debbio, Isabella Roncaglia et al.

olfactory bulb, restores the social recognition [59]. Therefore, it is possible that the absence of
partner preference in praire voles treated with oxytocin and vasopressin antagonists derives
from the inability to recognize the partner rather than to form pair bonds. It has been
demonstrated that dopamine inhibitor administration before the preference test does not
interfere with the recognition ability, while after mating would inhibit the consolidation of the
partner memory [52].
Male exposure has been proved to modulate the neurogenesis in adult female prairie
voles [60]. Two days of male exposure significantly increased the number of 5-bromo-2'-
deoxyuridine (BrdU)-labeled cells in the amygdala and hypothalamus of female prairie voles
in comparison to a social isolation condition or female exposure. Overall, these data indicate
that the effects of social environment on neuron proliferation in adult female prairie voles
carry out in a stimulus- and site-specific manner.

HUMAN BONDING
In the human brain oxytocin receptors are concentrated in several dopamine-rich regions,
especially the substantia nigra and globus pallidus, as well as the preoptic area [61]. Whereas
this pattern of distribution is similar to that of monogamous species, oxytocin and vasopressin
receptors have not been found in the ventral striatum and in the ventral pallidum, areas that
generally result particularly rich in oxytocin and vasopressin receptors in monogamous voles
and monkeys [62]. The activity in the brain of adult subjects was scanned by means of fMRI,
while they were viewing pictures of their partners, and compared with the activity produced
by pictures of friends of similar age, sex and duration of friendship as their partners. From the
comparison emerged that looking at pictures of the partners evokes a bilateral activation of
the anterior cingulate cortex (Area 24 of Broadman), the medial insula (Area 14 of
Broadman), the caudate nucleus and the putamen [5]. Such pattern of activation differs from
those found in previous studies of visual attention, sexual arousal and other emotional states,
while it is similar to the preliminar results of a a fMRI study on mothers who were listening
to the crying baby [63]. Studies on human attachment show that brain areas activated when
viewing or listening to a loved object are the same that are activated in euphoric states
induced by psychostimulants [64]; this suggests that circuits that regulate attachment perhaps
evolved from reward pathways. A recent study showed that in romantic attachment anxiety
and oxytocin are significantly and positively linked, that is, the higher the oxytocin level the
higher the score of the anxiety scale of the Experiences in Close Relationships (ECR) [65].
This report, in accordance with previous observations in animal studies that showed anxiolitic
properties of oxytocin [66,67], suggests that in humans oxytocin may reduce the anxiety-
related to romantic relationship, while evoking relation and wellbeing sensations
[68,69,70,71].
A recent study investigated for the first time the peripheral levels of NTs in subjects in
love [72]. Subjects who had recently fallen in love and two control groups, consisting of
subjects who were either single or were already engaged in a long-lasting relationship, were
compared for plasma NGF, BDNF, NT-3 and NT-4 levels. NGF levels were significantly
higher in the subjects in love than in the control subjects. A significant positive correlation
was found between NGF levels and the intensity of romantic love, as assessed with the
 Neurobiology of Social Bonding 375

passionate love scale. In 39 subjects who maintained the same relationship after 12-24
months, but were no longer in the same mental state of the first evaluation, plasma NGF
levels were decreased and not different from those of the control groups. Overall, these results
suggest that some behavioral and/or psychological features associated with falling in love
could be related to increased NGF levels. This NT could play a role in molecular mechanism
of romantic love, acting as a modulator of different endocrine functions. From a larger
prospective, NTs may be involved in social relationships, directly or modulating stress-related
symptoms.
Human romantic love has been finally addressed by a genetic perspective [73]. When
looking at the associations between markers in neurotrasmitter genes (the serotonin
transporter gene, 5-HTT; the serotonin receptor 2A, 5HT2A; the dopamine D2 receptor gene,
DRD2; and the dopamine D4 receptor gene, DRD4) and the six styles of love as
conceptualized by Lee [74] (Eros, Ludus, Storge, Pragma, Mania and Agape), it emerged in
both sexes the TaqI A variant of DRD2 was significantly correlated with “Eros” (a loving
style characterized by intense emotional experiences based on the physical attraction to the
partner), as well as the C516T 5HT2A polymorphism correlated significantly with "Mania" (a
possessive and dependent romantic attachment, characterized by self-defeating emotions).
Further studies are warranted to investigate the possible genetic loading on human loving
styles.

CONCLUSION
Social bonding is a complex process that involves several cognitive, behavioral and
emotional variables. From a neurobiological point of view, the neurohypophyseal peptides
oxytocin and vasopressin appear to be crucial for the formation of social relationships,
including infant attachment, parental care and adult pair bonding; the hypothesized
mechanism links oxytocin and vasopressin, stimulated by social interactions, to dopamine
pathways associated with the reward systems. Latest investigations are focusing on NTs,
while suggesting their putative role in translating the effect of social interactions on brain
development and neuroplasticity.

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Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 22

COOPERATIVE AND NON-COOPERATIVE BEHAVIOR

IN PAIRS OF CHILDREN: THE RECIPROCAL EFFECTS
OF SOCIAL INTERACTION IN THE ONGOING
CONSTRUCTION OF A PLAY SEQUENCE

Emanuela Rabaglietti, Fabrizia Giannotta, Silvia Ciairano*

Department of Psychology, University of Torino, Italy

ABSTRACT
We know that some social interactions begin and end cooperatively, while others
start aggressively and end up even more so.
We also know that in some social interactions one of the partners might initially
behave either cooperatively or competitively and aggressively towards the other partner,
who may respond with the opposite type of behavior. However, over time, as the
relationship evolves, behavioral patterns may change as each partner adapts to the
behavior of the other.
We think that as social interactions evolve over time, it is possible to identify two
phases: first, a reciprocal exploration phase, and second, an adjustment phase.
Investigating very short term social interaction sequences of about ten minutes, we
concluded that these two phases last about five minutes each.
The present study investigates the relationships between cooperative and non-
cooperative or competitive behavior in pairs of children in the ongoing process of
interaction during a ten-minute play sequence. To reach our goal, we first divided the
time of the play sequence (10’) in two phases and looked at the differences between the
first and second phase (5’ each). Second, we divided the pairs of children in three groups:
i) initially high in cooperation; ii) initially high in competition; iii) initially high in both.
Third, we looked at the outcomes using both linear and logistic regression analyses. We
hypothesised that: a) initially prevalent cooperative behavior is more likely to end in
cooperation; b) initially prevalent competitive behavior is more likely to end in

*
ciairano@psych.unito.it
382 Emanuela Rabaglietti, Fabrizia Giannotta and Silvia Ciairano

competition; c) initially mixed social interactions (both cooperative and competitive) are
more likely to end in abandonment of the interaction and doing nothing.
Our sample is composed of 125 pairs of children. 69% (N=86) of the pairs were
composed of same-sex children, while the remaining 31% (N=39) were mixed. The
individuals within each pair were the same age. 35% of the pairs (N =44) were eight
years old, 38% (N =48) were ten years old, and 27% (N=33) were twelve years old. We
observed the cooperative and competitive behavior of both the partners. The task was to
finish a puzzle in ten minutes.
Our findings confirmed only our first two hypotheses. We found that initially mixed
situations were also more likely to end in cooperation. These findings underline the
importance of intervention programs aimed at promoting social and cooperative skills in
children to avoid starting negative social cycles or patterns.

INTRODUCTION

Peer Relationships

It is now widely acknowledged that peer relationships can promote an individual’s

cognitive, affective, and social development. However, how and why this happens is still a
topic of discussion in current developmental psychology [Bukowski, Newcom & Hartup,
1996; Fonzi, 1996; Rubin, Bukowski & Parker, 2006].
In fact, despite their high social and psychological relevance we do not know much about
the processes that lead children to choose different interactive strategies and to learn to
modulate their behavior with respect to their peers [Pepitone, 1980; Fonzi, 2003]. The
relevance of a deeper understanding of children’s social relationships with peers has its roots
in the fact that human beings are intrinsically social, or in other words, they are biologically
built to live with other people and to face the challenges of living in a group. As we know, the
social interactive strategies used by people are not always adaptive, but we still lack
knowledge about the underlying processes that lead us to more or less successful social
interactions.
One important reason for this lack of knowledge is that, in developmental psychology,
the importance of peer relationships for individual development emerged only recently. More
precisely, it emerged only after we had abandoned the traditional idea, promoted by both
Piaget and Freud [Rutter & Rutter, 1993], of development that goes from the individual to the
social level, and after we had acknowledged the precocious and complex social competence
of children [Schafer, 2004].
The idea that the child begins life as an essentially asocial and egocentric being and that
through socialization he/she is able to establish successful social relationships has been
surpassed. Rather, we now believe that the child, who is active in establishing social
relationships from the very beginning, enters progressively into wider social networks.
We also know that people construct relationships based on personal goals, cognitive
skills, and social demands. Thus, every change in a relationship can be considered both the
result of ongoing social processes and a factor that can promote further cognitive and social
development [Laursen & Bukowski, 1997]. On one hand, relationships with significant
others, including those between a child and their peers, reflect the psychological needs of the
participants. On the other hand, these relationships contribute to the construction, particularly
 Cooperative and Non-cooperative Behavior in Pairs of Children 383

during childhood, of the patterns and prototypes of future relationships [Bowlby, 1988; Hazan
& Shaker, 1987].
Furthermore, it is known that greater social cognition, in terms of both cognitive
capabilities and perspective-taking skills, facilitates a better understanding of relational
dynamics [Selman, 1980; Youniss, 1980; Dunn & Plomin, 1990].
Finally, we are aware that that wider social experiences and opportunities contribute to
increasing personal interest in social exchanges and attention to their quality and equity
[Kelley & Thibaut, 1978; Laursen & Bukowski, 1997].
Vygotskij’s historical-cultural model strongly contributed to this change in perspective.
In fact, Vygotskij [1978] stated that all psychological functions are first inter-psychic, or
rather they begin within a social relationship, and only later become intra-psychic, meaning
that they belong to the individual. According to this theoretical model, social contexts,
including peer relationships, have a structuring role in development. The constructivist
paradigm incorporated and extended these issues with the neo-Piagetian scholars [Doise &
Mugny, 1981; Mugny & Carugati, 1987; Doise, Deschamps & Mugny, 1991]. Social
interaction became the basic component for acquiring and building new capabilities, based on
the ideas that a child is able to assess the ineffectiveness of his/her thoughts and that he/she
can achieve more advanced thinking through social comparison with peers. Cognitive
development consists of a “social building of intelligence” and inter-individual conflict - in
other words socio-cognitive conflict - fulfils a propulsive role. This conflict, which originates
in social interactions as a result of different ways of thinking, produces an imbalance that is
useful in gaining an awareness of perspectives other than one’s own.
Acknowledging the precocious social competence of children represented a further
crucial contribution. Some ecological studies carried out in children’s life contexts - at home
and in kindergarten - underlined that children, from infancy, are active subjects with
cognitive, behavioral, and emotional competencies, and that they are able to actively interact
with adults and peers [Schneider, 2000]. Social competence is the skill of attaining personal
goals within social interaction and of maintaining positive relationships under different
circumstances [Rubin, Bukowski & Parker, 2006]. We consider social competence as the
result of a compromise between the need for self-realization and social adjustment and as the
expression of the “self-other” dualism of each individual within a social and interpersonal
context [Röhrle & Sommer, 1994; Rubin, Bukowski & Parker, 2006].
Very early on, children are capable of actively participating in social interactions with
peers [Hartup, 1979, 1989; Dunn, 2004]. With time, children build more complex social
relationships, such as friendships [Fonzi, 1996; Bombi, 2000; Bukowski, Newcomb &
Hartup, 1996]. Observational research conducted in kindergartens [Verba, Stambak &
Sinclair, 1982; Bonica, 1983, 1989, 1990; Verba, 1993; Bonica in press] underlined the
complexity and vitality of peer interactions. As opposed to what scholars had previously
hypothesised, this research showed the parallel development of interest by children in both
physical objects and peers. Other research carried out in the family context [see: Dunn, 1988;
Baumgartner & Tallandini, 2002] highlighted that during the third year of life, children are
able to understand even complex emotional states experienced by others and to build a
representation, although partial, of their own and other people’s mental states. Finally, from
an early age, children demonstrate altruistic behavior, such as soothing a crying playmate or
offering him/her one’s own favourite toy [Pines, 1980].
384 Emanuela Rabaglietti, Fabrizia Giannotta and Silvia Ciairano

The progressive increase in knowledge about different features of children’s social lives
has lead scholars to go well beyond the idea of a substantially aggressive and egocentric
child. Children are able to consider the intentions and wishes of other people and to help and
comfort them at a much earlier age than Piaget had hypothesised. Rather than being centred
only on him/herself, the child has the ability, although partial, to decentralize from
him/herself and open up to other people. Therefore, children are clearly characterized by a
very precocious and complex social competence [Dunn, 1988].
This new perspective has encouraged scholars to analyse the characteristics of children’s
interactive strategies and, more specifically, to examine the factors and circumstances that
promote the use of positive sociability strategies, such as altruistic and pro-social behavior
and cooperation [Pepitone, 1980].

Cooperation

Cooperation is a type of social interaction characterised by specific features. It requires

the presence and the definition of a common goal among all the participants in the interaction,
with each participant behaving in order to reach this common goal. This is opposed to
altruistic or pro-social behavior in which one participant works for the benefit of the other,
and to competition, in which the participants work against one another. Moreover,
cooperation requires the coordination of individuals’ actions through planning in pairs or
groups. Individuals’ contributions must be complementary and the partners must assume
correlated roles.
The ability to coordinate one’s actions with the actions of others means that everyone
achieves his/her goal while gaining the perspective of the others in the group. Verbal
communication between people engaged in a common effort may facilitate coordination even
of different personal perspectives. Finally, a cooperative social interaction is characterized by
a positive or at least neutral affective tone among the participants.
During childhood, cooperation has a positive influence and plays a crucial role
particularly in cognitive development [Smith & Craig 2002]. Cooperation with peers is
essential for learning [Perret-Clermont, 1979]. The effort of sharing a goal with a partner
requires a child not simply to adapt to the ideas and competencies of other people, but rather
to work out a solution that considers the needs of all those involved. Cooperation may also
strengthen the ability to work with others and view situations from other perspectives. As a
circular process, the social capabilities the child acquires through cooperation can further
promote his/her social development and adjustment.
Competition differs from cooperation essentially with respect to the nature of its aim:
participants act with only their own interests in mind, working against the other participants.
However, although cooperation and competition lie at opposite ends of the continuum of
human social strategies [Fonzi, 2003] they are not actually opposing realities since
cooperation does not consist only of positive aspects and competition does not include only
negative ones. In fact, sharing a common aim with other individuals using a cooperative
strategy does not imply this aim is intrinsically positive. In the same way, competition does
not necessarily imply overpowering other people. Additionally, the social comparison aspect
of competition can be useful in the development and integration of one’s system of
knowledge about oneself, others, and reality, as well as offering an opportunity to experiment
 Cooperative and Non-cooperative Behavior in Pairs of Children 385

with one’s own abilities. Competition may assume a positive role when it does not involve
fighting against others, but rather fighting against the constraints imposed by reality and
against one’s own limits. Competition may also contribute to self-realization and the
development of personal capabilities and it may teach us how to confront frustrating
situations. However, competition can carry out this positive role only when social comparison
is characterized by both appreciation of the others involved and respect for social rules.
Conversely, competition is maladaptive when the limit to exceed is represented by other
people, when one is unable to consider the equal rights of others to be appreciated and gain
self-realization, and when one is willing to use any means to achieve success.
Peer relationships are privileged scenarios for cooperative strategies, particularly when
children have full responsibility for the interaction. The assumption of personal responsibility
by the children promotes their active role in managing interpersonal dynamics, such as
seeking negotiation strategies and defining a goal that satisfies all the participants.
Furthermore, we know that different factors, such as individual or contextual
characteristics, may alternatively promote the use of cooperative strategies by children, or
interfere with their use.
In general, a distinction can be made between internal factors, like cognitive and affective
factors, and external factors, such as social and situational factors. However, it is always
necessary to bear in mind that these factors constantly interact with one another during the
ongoing course of a social interaction in ways that we only partially understand.

Cognitive, Affective, and Social Factors that Can Promote Cooperation

We know that there is a strong link between cognitive factors, such as thinking, and
cooperative interactive social strategies. Thinking allows people to find a variety of solutions
to the same problem. Furthermore, thinking allows people to distance themselves from reality
on an emotional level as well. The ability to look beyond the reality of the present situation
and come up with new solutions that take into account the needs of different people is
precisely what cooperation requires.
Recent studies have also demonstrated a strong relationship between cooperation and the
capacity for inhibitory control, which is associated with the executive functions of the frontal
and pre-frontal cortex [Nigg, Quamma, Greenberg & Kusché, 1999; Decety, Jackson,
Sommerville, Chaminade & Meltzoff, 2004]. Inhibitory control, as it relates to flexibility in
thinking, is the capacity to go beyond previously acquired or automatic responses and to
modify one’s own behavior when faced with changing situations. Some of our research
showed a positive relationship between flexible thinking and competence in cooperation
during childhood and early adolescence. In their social interactions with peers, children with
high flexibility in thinking use more cooperative, less competitive, and less neutral social
strategies than children with low flexibility. Flexibility in thinking seems to facilitate the re-
construction of the current situation by imagining alternative solutions and overcoming more
rigid, narrow perspectives [Ciairano, Bonino & Miceli, 2006]. Furthermore, flexibility in
thinking also seems to have some long-term effects on the cooperation of children and early
adolescents [Ciairano, Petra & Settanni, 2007].
However, the capacity to decentralise from the current situation and the ability to view
the situation from other perspectives than one’s own are necessary but not sufficient in order
386 Emanuela Rabaglietti, Fabrizia Giannotta and Silvia Ciairano

to behave cooperatively. In fact, these same capabilities are also required when competing.
Cooperation, however, is also influenced by affective and social factors.
Cooperation requires the capacity to find a balance between the internal and external
world, balancing the need for self-realization with the need for social bonds. We know that
some emotional factors in particular may lead to more primitive, less adaptive strategies like
aggression, or to more advanced, adaptive strategies, such as cooperation. For instance a
negative emotional condition, such as the perception of powerlessness due to a specific
danger or to general uncertainty, is more likely to lead to aggression than to cooperation.
When levels of stress, fear, or anxiety are very high, the appearance of primitive, immature,
and/or insufficiently structured actions becomes more probable. Conversely, positive
emotional conditions, such as a feeling of security and mastery, may promote the use of more
advanced and adaptive conduct, like cooperation.
Some situational factors can also carry out a crucial role in modulating cooperation in
children. Among these factors, we know that the availability of physical and psychological
resources, fair distribution of benefits and rewards for personal and collective performance,
and impartial social comparison can promote cooperation. Conversely, lack of resources and
unequal distribution of benefits can contribute to the creation of a highly competitive climate
[Tassi, 2002; Richard, Fonzi, Tani, Tassi, Tomada & Schneider, 2002].
Social comparison is relevant in the definition of individual capacity. Bandura [1997]
showed a link between social comparison and self-efficacy. Self-efficacy emerges both by
testing one’s own capacity to achieve certain tasks, and by having adequate ability levels with
respect to those of the other people. On the one hand, social comparison can promote a
competitive climate. On the other, the comparison between one’s own performance in a task
and the performance of others can promote cooperative solutions when the context values
intrinsic motivation, such as developing new competencies or improving personal
performance, instead of extrinsic motivation.
Intrinsic motives, along with the certainty that all participants will have a turn to be
successful, represent positive experiences for children.
Among the social factors that can promote cooperation in children, we must also consider
the educational style of their parents and teachers, how strict or rigid they are, and the way
these adults typically intervene in children’s peer relationships [Bonino, 2003; Fonzi & Tassi,
2003]. These factors can operate directly, fostering children’s social development by
rewarding some behaviors and punishing others. However, the same social factors can also
operate indirectly by promoting feelings of self-confidence or, conversely, lack of self-
confidence. Furthermore, adults’ educational styles can also affect the cognitive processes of
children by promoting, more or less effectively, the capacity to decentralise from their
personal perspective, and the ability to seek adaptive social responses that are cognitively
mediated and less primitive, as opposed to aggression.
On these theoretical bases, a cooperative form of learning has been extensively
introduced in the schools. Cooperative learning originated from the construct of democratic
education, introduced by Dewey [1916], and is also meant to promote progress in social life.
This educational model is based on peer exchange and the process of “co-construction” of
ideas, which derives from this exchange [Sullivan, 1953; Youniss, 1980]. In a collaborative
context where equality is valued, children can gain new knowledge together and can validate
cognitive strategies consensually. Children can learn by thinking and creating projects
alongside their peers, which require common effort and commitment. Within these
 Cooperative and Non-cooperative Behavior in Pairs of Children 387

relationships children can also experience collaboration and cooperation as modalities of

social interaction: ideas are discovered together, within a cooperative climate, where
everyone can use the ideas of his/her classmates to complete one’s own thinking [Slavin,
1983; Johnson & Johnson, 1987].

THE PRESENT STUDY

Considering the importance of cooperation and its deep roots in human nature, what is
the contribution of the initial phase of the interaction (the partner may start behaving more or
less cooperatively or competitively) in forming either a positive cycle of cooperation or,
conversely, a vicious cycle of competition during children’s social interactions?
Very few, if any, studies have investigated this aspect from a psychological point of
view. We found only some economic and social-biological research on the topic. According
to mathematicians and economists, cooperation is a convenient social strategy only if all the
participants cooperate [to see Game Theory: Fudenberg & Tirole, 1991; Myerson, 1991].
Otherwise, the risk of losing rather than gaining is too high and the individual is more likely
to select different strategies.
According to social-biologists [to see Alcock, 1975, 2001; Freeman, 2002], cooperation
(although in social-biology cooperation is often considered synonymous with altruism or pro-
social behavior) is convenient only when we can gain an indirect advantage for our goodness
of fit, in terms of increasing the probability of the survival of our genes. This can explain why
animals are more willing to help individuals who share part of their genetic inheritance.
In our opinion, these two perspectives are too narrow to be applied to cooperation
between children. Furthermore, they do not help us to understand the underlying processes of
social interaction. We also feel that there are probably great advantages to cooperating with
somebody who appears likely to cooperate. Furthermore, it is not unlikely that children think
it is more appropriate to act competitively when the partner also uses competition. However,
these two perspectives do not help us to disentangle what happens when social interaction
consists of both cooperative and competitive strategies. It seems plausible that under these
particular conditions, the social interaction may end with the participants leaving the
interactive field, for instance doing nothing, as suggested by the Theory of Learned Inactivity
or Learned Helplessness (Peterson, Maier & Seligman, 1993; Overmier, 2002). However, the
intrinsic social nature of human beings cannot be disregarded and different solutions are
certainly possible.
The present study investigated the relationships between cooperative and non-cooperative
or competitive behavior in pairs of children in the ongoing process of interaction during a
play sequence of ten minutes. We know that some social interactions both begin and end
cooperatively. Other interactions start aggressively and end even more aggressively.
In some social interactions one of the partners may initially behave either cooperatively
or competitively and aggressively towards the other partner, who may respond with the
opposite type of behavior.
However, as the relationship evolves, something may change in the behavioral patterns
because each partner may adapt to the behavior of the other and we are interested in
discovering more about this phenomenon.
388 Emanuela Rabaglietti, Fabrizia Giannotta and Silvia Ciairano

More precisely this study is aimed at answering the following three research questions:

1. Are pairs who are cooperative at the beginning of the play sequence more likely to be
cooperative in the second phase of play as well?
2. Are pairs who are non-cooperative or competitive in the beginning of the play
sequence more likely to show non-cooperative behaviors in the second phase of play
as well?
3. How do children who began the sequence with both cooperative and competitive
behaviors behave in the second phase of play?

We hypothesised that: a) initially prevalent cooperative behavior is more likely to end in

cooperation; b) initially prevalent competitive behavior is more likely to end in competition;
c) initially mixed social interactions (both cooperative and competitive) are more likely to end
in abandonment of the task, doing nothing.

Participants

This study is part of wider project about cooperation in childhood [see also Ciairano, et
al., 2007]. In this paper, we will consider only the second wave of this wider project.
125 couples of children participated at the study. The 69% (N=86) was same-sex couples
(38%, N=47 only boys; 31%, N=39 only girls), while the remaining 31% (N=39) consisted of
mixed couples. With regard to the age, the individuals within each couple shared the same
age. Specifically, the 35% (N of couples=44) was eight year old, the 38% (N of couples=48)
was ten year old, and the 27% (N of couples=33) was twelve year old.
All the parents of the children gave informed consent for their children’s participation, in
accordance with the Italian law and the ethical code of the Association of Italian
Psychologists. All the instruments were administered in the school by trained researchers and
teachers were not present during the examination procedure. Finally, no incentive was used to
recruit participants.

Procedure

Within each classroom, children were paired randomly (extracting their names). As
consequence of that, the formed couples were either homogeneous (69%, N=86) or
heterogeneous (31%, N=39) with regard to the gender. The randomization of individuals
within classroom instead of within school was due to the fact that it was the only possible
strategy accepted by the principals. Indeed, we were not allowed to mix people from different
classroom groups. Finally, this is also why the couples were homogeneous as far as age
concerned.
They were asked to build a puzzle together. They had ten minutes to do so. During this
time, they were observed by a researcher (blind to the purpose of the study), who coded their
actions as cooperative, non cooperative o competitive, and neutral. For this purpose a
structured checklist was built up. The checklist contained the temporal information in the
columns, whereas the rows identified the behavioral categories [see for more details,
 Cooperative and Non-cooperative Behavior in Pairs of Children 389

Ciairano, Bonino, & Miceli, 2006]. It was not possible to find a high number of schools that
easily allowed for filming children while playing. As consequence, no objective measure of
inter-rather reliability was available for the whole area of observation. However, we managed
to film the execution of the puzzle task in a school. The videos, representing the 20% of the
total number of observations were coded by two independent observers (blind to the scope of
the study). So that, we can calculate a percentage of consensus, which was very high (95%).

Measures

Cooperation: The Puzzle Task

To measure the degree of cooperation among children, we proposed a task near as much
as possible their normal life: play with a puzzle. This task permitted us to observe the
children’s behavior in a natural context, such as school, and at the same time in a quite
structured situation.
Within the same class group, couples were formed randomly and they were invited to
play with a puzzle. The number of puzzle pieces was different according to the age of
participants: 49 pieces for eight years old children; 60 pieces for ten years old children; 70
pieces for eleven years old children. The researcher presented two different puzzles for each
pair, asking to choose what they preferred to build up. After the choice, the researcher gave
the following instruction: “Now, you have to try to finish the puzzle together. You will have
ten minutes”. After that, the observation started.
We observed both verbal and non-verbal cooperative behavior. However, in this study we
will focus only on the non-verbal cooperative actions, excluding the verbal ones. To
categorize cooperative actions, we used a comprehensive checklist, based on a preliminary
pilot study. The categories we used were: 1) cooperative actions – behavior directed towards
reaching a common goal with the partner (e.g. showing a piece, offering a piece, accepting a
piece); 2) non-cooperative or competitive – behavior directed explicitly against reaching a
common goal with the partner (e.g. removing the piece of the puzzle that the partner has just
built); 3) neutral – behavior involving neither attempts to share with the partner nor fighting
against him/her (e.g. solitary play, watching the other child playing).
An observer (blind to the motive of the study) coded every minute the number of actions
as cooperative, non cooperative, and neutral, using a checklist. So doing, we got 10 indicators
of cooperative, non cooperative or competitive, and neutral actions within a minute. For the
purpose of this study the neutral actions were not used.

Measures

A Typology of Cooperative Behavior

Using the score of cooperative and non cooperative actions in the first phase of the play,
we built up a typology of cooperative behavior for describing the behavior of the couple. First
of all, we summed up the amount of cooperative behavior of each individual within a couple.
So doing, we obtained a score of cooperative behavior of the couple within each minute.
Then, the scores of the first five minutes of observations were summed up. We adopted a
390 Emanuela Rabaglietti, Fabrizia Giannotta and Silvia Ciairano

similar procedure for non cooperative behavior. Moreover, the same modus operandi was
used for the scores of the second five minutes of observations. Afterward, each couple was
classified as high (from half standard deviation above the average to the maximum), low
(from the minimum to half standard deviation below the average), or intermediate (in the
middle, that is from values greater than half standard deviation below the average and values
lower than half standard deviation above the average) with respect to both cooperative and
non cooperative or competitive actions. Then, we created a typology that took together these
informations about cooperative and non cooperative actions in the first five minutes of
playing. We called “non cooperative” couples those ones who had many non cooperative
actions and few or average cooperative actions. “Cooperative couples” were those who had
high levels of cooperative behavior and low or average levels of non cooperative behavior.
“Mixed couples” had high or average levels of both cooperative and non cooperative
behavior. Finally, “no behavior” couples were low both in cooperative and non cooperative
behavior. Finally, we built up the same typology for the observations of the last fifth minutes
of the play.

Analyses
To explore whether cooperative couples at the beginning of the play (T1) were more
likely to show cooperative behavior in the second phase of the play (T2) and whether non
cooperative couples were more likely to show non cooperative behavior, we performed a
MANOVA. The typology of prevalent behavior at T1 was entered as independent variable,
while the couple’s score of cooperative and non cooperative behavior at T2 were entered as
dependent variables. So doing, we explored whether the amount of cooperative behavior at
T2 was higher in the couples that showed cooperative behavior at T1, and vice versa, whether
the amount of non cooperative behavior at T2 was higher in non cooperative couples at T1.
With regard to the third research question, we dichotomised the typology regarding the
first phase of the play. Mixed couple at the beginning of the play were coded as 1, while the
remaining couples were coded as 0. We also dichotomised the typology regarding the second
phase of the play. “No behavior” couples were coded as 1, while the remaining couples were
coded as 0. Then, we performed a logistic regression. We entered, as dependent, the
dichotomous variable of people who gave up playing at T2, while the amount of cooperative
and non cooperative behavior, and the dichotomous variables of mixed couples at T1 were
entered as independent. So doing, we were able to say whether the condition of being a mixed
couple at the beginning of the play influenced to being in the “no behavior” condition at the
end of the play.

RESULTS

Descriptive Information

With regard to the amount of cooperative behavior in the couple, in general the
percentage seemed to decrease in the second part of the play (T1: M=16.28, sd=13.42, T2:
21.32, sd=16.49; t=5.3, p<.00).
 Cooperative and Non-cooperative Behavior in Pairs of Children 391

On the contrary, percentage of non cooperative behavior remained stable in both times
(T1: M=14.58, sd=8.13; T2: M=13.91, sd=10.37; t=1.36, n.s.).
In the typology of behavior at T1, we found out 39 non cooperative couples (31%) at T1,
37 cooperative couples (30%), 20 mixed couples (16%), 29 no behavior couples (23%).

Table 1. Mean and standard deviation of amount of children’ cooperative and non
cooperative behaviour at T2 by typology of behaviour at T1 (MANOVA)

Group Cooperative Non cooperative Sample

behaviour T2 behaviour T2 N
M (SD) M (SD)
Typology at T1
Cooperative 38.83a (14.81) 3.32a (4.14) 37
Non cooperative 9.87 b (6.97) 24.23b (8.01) 39
Mixed 19.55c (12.73) 13.95c (5.81) 20
No behaviour 15.58 bc (11.04) 13.51c (6.92) 29
*
Same letter means equal means

Table 2. Logistic regressions, predictors of being classified a no behaviour couple at T2

Predictors No behaviour couple T2

B coefficient Standard Error Exp(B)
Cooperative behaviour T1 -.08* .03 .92
Non cooperative behaviour T1 -.15* .05 .86
Being classified a mixed couple at T1 .41 .59 1.65
*
p<.05

Table 3. Logistic regressions, predictors of being classified a mixed couple at T2

Predictors Mixed couple T2

B coefficient Standard Error Exp(B)
Cooperative behaviour T1 -.10* .037 .90
Non cooperative behaviour T1 -.12* .056 .88
Being classified a mixed couple at T1 .48 .59 1.61
*
p<.05.

No differences by gender (couple of girls, couple of boys, mixed couples) were found in
the distribution of this typology (Chi square=4.4, n.s.). Finally, no differences by age were
found in typology of behaviors at T1 (Chi square=6.6, n.s.). Thus, the distribution of couples
into the fourth categories was not related to the gender and the age of the couples.
392 Emanuela Rabaglietti, Fabrizia Giannotta and Silvia Ciairano

Cooperative and non Cooperative Couples at T1

A MANOVA model was used to test the first and the second hypotheses. The
multivariate analysis of variance revealed a significant multivariate main effect of the
typology on cooperative and non cooperative behaviors at T2 (F(6, 238)=42.16, p<.00). With
respect to univariate tests, as shown in table 1, cooperative couples at T1 scored higher on
cooperative behavior at T2 than non cooperative, mixed and no behavior couples at T2
(F(3,121)=43.42, p<.00). Moreover, non cooperative couples at T1 scored higher on non
cooperative behavior at T2 than the others couples (F(3,121)=66.39, p<.00). Thus, the amount
of cooperative behavior at the end of the program was found to be related to how individuals
interacted at the beginning of the play: cooperative couples were more likely to remain
cooperative, while non cooperative couples were more likely to keep on with non cooperative
behaviors.

Table 4. Logistic regressions, predictors of being classified

a non cooperative couple at T2

Predictors Non cooperative couple T2

B coefficent Standard Error Exp(B)
Cooperative behaviour T1 -.07 .06 .92
Non cooperative behaviour T1 -.29** .08 .86
Being classified a mixed couple at T1 .59 .75 1.80
*
p<.05
**
p<.01

Table 5. Logistic regressions, predictors of being classified a cooperative couple at T2

Predictors Cooperative couple T2

B coefficent Standard Error Exp(B)
Cooperative behaviour T1 .14* .04 1.15
Non cooperative behaviour T1 -.20+ .10 .81
Being classified a mixed couple 1.35+ .84 3.86
at T1
+
p=.10
*
p<.05

Mixed Couples at T1

To test the third hypothesis, we performed a logistic regression model (see table 2).
Controlling for the initial levels of cooperative and non cooperative behavior, we found out
that being a mixed couple at T1 did not increase the likelihood to be in the no behaviors
condition at T2 (Exp(B)=1.65, n.s.). Then, we performed three other logistic regressions to
explore whether being in the mixed couple at T1 was related to being a cooperative, non
cooperative, or a mixed couple at T2, again controlling for the initial levels of cooperative
 Cooperative and Non-cooperative Behavior in Pairs of Children 393

and non cooperative behaviors (see Tables 3, 4, and 5). We found out that being a mixed
couple at T1 did not predict being a non cooperative couple (see table 4, Exp(B)=1.80, n.s.),
nor a mixed couple at T2 (see Table3, Exp(B)=1.61, n.s.). However, being a mixed couple at
T1 marginally increased the likelihood of being a cooperative couple at T2 (see table 5,
Exp(B)=3.86, p=.10). Thus, our hypothesis was not confirmed, couples who showed both non
cooperative and cooperative behaviors at T1 were slightly more likely to adopt cooperative
behavior at T2.

DISCUSSION AND CONCLUSION

The present study was aimed to investigate the interaction strategies in dyads to reach a
common goal. Particularly, we observed the phenomena of cooperative and non cooperative
behaviors among children’s couples who were assigned the task of building up a puzzle. The
couples who started with cooperative behavior since the very beginning showed the highest
level of cooperation also at the end of the play. On the contrary, non cooperative couples
remained non cooperative also in the second part of the play. Thus, it seemed that the
behaviors chosen at the beginning of the interaction remained stable up to the end of the
interaction.
Regarding to cooperative actions, we know from literature [Pepitone, 1980] that
cooperation is a strategy that promotes sociality. This kind of strategy involves a process of
negotiation resulting in shared behaviors. Those behaviors go beyond the individual needs
and desires in order to get a common goal. This implies cognitive and social abilities. Indeed,
cooperation requires perspective taking [Flavell, 1968; Nelson & Kagan, 1972], the ability to
decentralize oneself [Bearison, Dorval, LeBlanc, Sadow & Plesa, 2002], and flexibility of
thought [Ciairano et al, 2007]. Given that cooperation is the best strategy for the assigned
task, it is reasonable to think that if people are able to cooperate since the beginning, they are
likely to keep on this behavior up to the end. This would explain the stability of cooperative
behavior during the play.
At the same time, couples who were non cooperative at the beginning remained non
cooperative until the end of the play. One may hypothesize that this happened for two
reasons. First, both children in the couples did not have adequate levels of the required
cognitive and social skills to cooperate. Second, one might hypothesize that other
mechanisms related to peer relationship are at work in the stability of competition.
Particularly, one should notice that the couples consisted of children from the same
classroom. That means that children have already got to know each other. As the assignment
in the couples was random, it is also likely that some dyads lacked the minimum level of
“attractiveness” [Abecassis, Hartup, Haselager, Scholte & Van Lieshout, 2002; Gifford-Smith
& Brownell, 2003], which they need to build a positive relationship. This might explain the
presence of non cooperative behavior in the non cooperative couples since the beginning.
Thus, the lack of cooperation and the presence of aversive behavior in some couples might be
due either to cognitive deficit, or to the kind of previous relationship.
Besides, there are couples who showed both cooperative and non cooperative behavior at
the beginning of the play. Unexpected, these couples were likely to end up in the cooperative
condition. However, the amount of cooperative behavior in the second phase of the play was
394 Emanuela Rabaglietti, Fabrizia Giannotta and Silvia Ciairano

higher in couples of children who were cooperative at the beginning of the play than in mixed
couples. Nevertheless, mixed couples at the beginning of the game were likely to increase
their level of cooperative behavior and to decrease the non cooperative actions so that they
ended up as cooperative in the second phase of the play. Initially, children actively tried
different types of strategies. After having experienced both, children turned to cooperation,
probably because they recognised that cooperation was the best solution to reach their goal.
One might hypothesize that a kind of social cognitive conflict [Mugny & Doise, 1978]
occurred in these couples. Children in dyads negotiated and regulated their actions. They
moved from an initial phase where they tried to balance and to experiment “individualistic”
(non cooperative) and “social” (cooperative) behavior. This kind of experimentation
generates a social confrontation [Moscovici, 1976], which on its side leads to raising the
consciousness of the other’s perspective. Being conscious of the different perspective of the
partner is the one of the requirement to start cooperating and it might be responsible of the
shift toward cooperation. Thus, after an initial phase of conflict and after having explored
different possibilities, children in mixed couples chose the cooperative strategies as the best
ones to finish the puzzle. It would have been interesting also to investigate what would
happen in the future social interaction of our mixed couples that is whether or not they will
start with cooperation the next social interaction.
This study has some limitations though. First of all, it was not possible to establish
whether the behavior of one component of the couple influences the behavior of the other.
Future studies should investigate the reciprocal effects of both partners of the interaction.
Second, as abovementioned, it was not possible to know the kind of relationship of members
of the couples before starting the assigned task. The previous relationship between the
partners might have influenced the willingness to cooperate. Future research should
investigate the result of the puzzle task distinguishing clearly between couples of friends and
non friends. This new research might be interesting to know whether the cooperation skills
are related to some features of the previous relationship between the partners or whether a
willingness to cooperate is there independently from previous relational condition.
However, our study has also some strength. It showed that the human social interactions
involve much more than economic immediate gains or genetic advantages. Cooperation is not
only the result of a favourable and cooperative starting: it might be also the result of an initial
experimentation of different social strategies. Thus, a situation of social and cognitive conflict
might be fruitful for the social development and not only for the cognitive development. From
an applied perspective, this finding suggests us that mixing up more or less cooperative
children in the same group is not detrimental for the cooperative individuals, and rather it may
be beneficial for the individuals who are more likely to use aversive social strategies.
Besides, our findings also underlined the negative potential sequence of a non
cooperative starting. When the children used only non cooperative strategies at the beginning
of the interaction, it seems very unlikely that they change their behavioral pattern along the
play. Thus, preventing the starting of these negative social cycles seems very important from
an applied perspective. Children can continue with their competition also when the task
would suggest them to use cooperation in order to finish the construction of the puzzle.
Summarising, human beings are particular social animals: the fact they can think seems
to disentangle kind of preferred social interaction from its gains. Therefore, thinking gives us
a lot of advantages. Unfortunately, it gives us also a lot of responsibility in selecting the most
 Cooperative and Non-cooperative Behavior in Pairs of Children 395

adaptive social strategy and the capacity of assuming this responsibility seems to differ in the
individuals at least from childhood and early adolescence.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 23

SOCIAL RELATIONSHIPS AND PHYSICAL HEALTH:

ARE WE BETTER OR WORSE OFF
BECAUSE OF OUR RELATIONSHIPS?

Julianne Holt-Lunstad
Department of Psychology, Brigham Young University, Provo, Utah 84602, USA
Briahna Bushman
Department of Psychology, Brigham Young University, Provo, Utah 84602, USA

ABSTRACT
When asked, “What is necessary for your happiness?” or “What is it that makes your
life meaningful?” most people mention before anything else-- satisfying close
relationships with family, friends, or romantic partners (Berscheid, 1985). Relationships
with others form a pervasive role in our everyday lives and are generally regarded as
emotionally satisfying. Although it may not be surprising that social relationships are
associated psychological benefits, there is also evidence to suggest that these
relationships have beneficial effects on physical health and/or the lack of meaningful
relationships may be detrimental (Berkman, 1995; Cohen, 1988; House, Landis, &
Umberson, 1988). In fact, reviews of the literature indicate that a lack of meaningful
relationships is associated with increased risk for morbidity and mortality from a variety
of causes (Berkman, 1995; House, Landis, & Umberson, 1988). Importantly, both the
quantity and quality of social relationship can affect health and mortality. Overall,
research suggests that having more and better quality relationships is associated with
beneficial effects on health, while fewer and negative relationships are associated with
detrimental effects on health (see Uchino, 2006 for a review). Therefore, a complete
understanding of health-related consequences of social relationships requires
simultaneous consideration of both the negative and the positive aspects of social
experience.
In this chapter, the health consequences of social relationships will be examined.
This chapter will proceed by first, reviewing definitions of social support; second, a brief
review of the substantial body of evidence that has linked social relationships with health
benefits will be provided; third, the chapter will also include a brief review of the
400 Julianne Holt-Lunstad and Briahna Bushman

evidence showing the negative side of relationships (e.g., negativity and conflict within
relationships is associated with negative health outcomes); and finally, the bulk of the
chapter will focus on a relatively newer line of research that examines relationships that
are characterized by both positive and negative aspects (ambivalent relationships).
Because research has examined the positive and negative aspects of relationships
separately, less is known about relationships that are not entirely positive or negative-but
a mix of both negative and positive feelings. The remainder of this chapter will (1) define
ambivalent relationships and provide theoretical and empirical justification for
examination of ambivalent relationships; (2) summarize evidence linking ambivalent
relationships to both mental and physical health outcomes; (3) provide evidence
regarding maintenance of ambivalent relationships; and (4) propose future research.
Thus, this chapter will summarize empirical research on the health impact of social
relationships characterized by mixed-feelings (ambivalence). This data on ambivalent
relationships will be presented in the context of the larger literature on social
relationships and physical health and highlight the need for new directions in social
relationships research.

SOCIAL SUPPORT DEFINED

The way in which social support has been examined varies considerably across studies.
Despite the vast diversity in methods, social support is usually conceptualized in such a way
as to refer to the structures of an individual’s social life or the more explicit functions that
they may serve (Uchino 2004; Feldman & Cohen, 2000).
Structural aspects of relationships often refer to the size or diversity of one’s social
network. Studies that examine structural aspects often operationalize social support in terms
of one’s marital status, the number of relationships within one’s social network, or the types
of relationships one might have (e.g., family member, coworkers, ties to community, religious
affiliations, etc). Previous research suggests that structural aspects of social support are
important through their provision of a sense of self identity, appropriate norms for behavior,
and greater meaning or worth to life (Umberson, 1987; Stryker & Burke, 2000). One of the
clearest illustrations of the benefit of a social structure is that of marriage. Marriage has
increased benefits for health through a number of possible means. Married individuals tend to
live longer, and are usually happier than single counterparts (Gump, Polk, Karmarck, &
Shiffman, 2001; Ditzen et al., 2007; Grewen, Gridler, Amico, & Light, 2005). One possible
reason for this effect is the sense of identity that the marital role of being a spouse provides,
creating greater meaning and purpose for life. Further, marriage can influence health
behaviors in a positive way through normative influence such as regulating a specific diet,
encouraging doctors visits, or encouraging the avoidance of risky behaviors, just to name a
few.
Although these structural factors of relationships are important, the quality of these
relationships is also important. Relationships serve important functions. For instance,
relationships may be influential by providing good advice (informational support); helping
you feel better about yourself (emotional support); directly providing aid, such as loaning you
money or giving you a ride to the airport (tangible support); or just ‘hanging out” with you
(belonging support). It is important to note, that these functional aspects of social support can
 Social Relationships and Physical Health 401

be assessed in terms of objectively “received support” or the perceptions of others willingness

to help (i.e., perceived support).
Although these are all legitimate ways of measuring social support they are obviously
measuring different sub-constructs. Therefore social support can generally be conceptualized
according to three sub-constructs: (1) the degree of embeddedness or integration in a
supportive network; (2) the actual interactions that are intended to be supportive; (3) the
beliefs and perceptions of support held by the individual. Since these measures are focused on
different sub-constructs it is not surprising that there are low correlations between these types
of measures (typically between .20 and .30; Barrera, 2000). However, while the effects may
differ, all have been associated with physical health outcomes (Uchino, 2004).

THEORETICAL MODELS LINKING SOCIAL SUPPORT TO HEALTH

While a number of different mechanisms underlying this relationship have been
proposed, most of the models linking social support to health outcomes are variants of what
are termed stress-related and direct effect models (Uchino, 2004, Cohen et al., 2000). The
most prominent stress-related perspective is the buffering model which predicts that social
support is health promoting as it diminishes or “buffers” the negative effects of stress in a
person’s life. In comparison, the direct effect models operate across a wide range of
circumstances and suggest that social support is beneficial regardless of life stress (Uchino,
2004; Cohen, 2004).

Stress Related Models of Social Support

The stress buffering hypothesis has been the primary model considered by psychologists
interested in health interventions (Cohen et al., 2000; Cohen, 2004). The buffering model
suggests that social relationships “buffer” or protects individuals from the potentially
pathogenic influence of stressful events. Stress is thought to influence health by both
promoting behavioral coping responses detrimental to health, and by activating physiological
systems such as the sympathetic nervous system and the hypothalamic pituitary-adrenal-
cortical axis (Cohen, Kessler, & Gordon, 1995). This protection can occur in two ways. First,
support may intervene between the event and the stress reaction. Presumably before we would
experience a stress reaction we must first appraise the event as stressful (i.e., harm, threat, or
challenge; Lazarus, 1966). The perception that others may provide resources and/or bolster
one’s perceived ability to cope with the event may alter the appraisal of the situation as being
highly stressful. Likewise, social support may intervene between the stress reaction and any
illness. This can occur by minimizing the impact of the stressful reaction by providing a
solution to the problem, minimizing its perceived importance, encouraging healthy behaviors,
and/or by “tranquilizing the neuroendocrine system so that people are less reactive to
perceived stress” (Cohen and Wills, 1985). However, according to this theoretical model,
when there is little or no stress, social support may have few physical or mental health
benefits. Therefore, this model emphasizes the role of social relationships in coping with
stress.
402 Julianne Holt-Lunstad and Briahna Bushman

Direct Effects Models of Social Support

The second proposed pathway is the main effects model which maintains that social
support is generally beneficial independently of stress. Rather than emphasizing the buffering
effects of support in times of stress, the direct effects models emphasize the overall benefits
of merely being embedded in a social network (Berkman, 1995; Cohen et al., 2000; Cohen
and Wills, 1985; Uchino, 2004; Cohen, 2004). The evidence to support these direct effects
tend to originate from more structural measures of support, as they tap into the existence of a
variety of social roles and ties as well as an individual’s integration within these differing
relationships (Uchino, 2004). One suggested mechanism through which support may directly
affect health is suggested by identity theorists who argue that being part of a social network is
health protective because it gives individuals meaningful roles that provide esteem and
purpose to life (Thoits, 1983; Cohen, 2004).
Reviews suggest there may be evidence consistent with both models (Cohen & Wills,
1985; but also see Barerra, 1986). There is evidence for a buffering model when the social
support measure assesses the perceived availability of interpersonal resources that match the
needs elicited by stressful events. Evidence for a main effects model is found when the
support measure assesses a person’s degree of integration in a large social network.
Suggesting that both conceptualizations of social support may be correct in some respects, but
each represents a different process through which social support may affect well being.
However it should be noted that while the stress-buffering model has received significant
support in cross-sectional studies, it is increasingly being criticized for the failure to find such
effects in prospective studies (Burton, Stice, & Seeley, 2004). Thus, despite the fact that the
stress-buffering hypothesis is widely accepted it may have limited explanatory power relative
to the main effects model.

SOCIAL RELATIONSHIPS AND PHYSICAL ILLNESS

Epidemiological research indicates that supportive relationships may significantly protect
individuals from various causes of mortality (Berkman, Leo-Summers, & Horwitz, 1992;
Brummet et al, 2005). For instance, in a review of several large prospective studies examining
mortality risk from all causes, the evidence indicates that age-adjusted mortality rates are
higher among individuals with relatively low social integration than individuals high in social
integration (House et al, 1988). These associations hold even when controlling for standard
control variables such as age and initial health status.
Importantly, controlling for initial health status helps clarify the direction of the
association between social support and mortality risk. For example, it could be that illness
leads to social isolation either through social withdrawal, because you’re too sick to leave the
house or when you’re sick you just don’t feel like being around others, or through social
rejection (sick people aren’t very fun to be around, or illnesses such as HIV may be
stigmatizing). Therefore, it is possible that illness leads to social isolation. However, the
review found that regardless of initial health status or age, persons with higher social contact
had lower mortality rates. In fact, the evidence linking social relationships to mortality was
 Social Relationships and Physical Health 403

comparable to the evidence linking standard risk factors such as smoking, exercise, and diet
to mortality (House et al, 1988).
Likewise, in a prospective study by Blazer (1982) it was found that the magnitude of the
relationship between social support and risk of mortality was greater when measures of
perceived support were analyzed than were measures of social contact. Thus, it appears that
having many social connections is highly associated with mortality risk, but that perceived
social support is also strongly associated with mortality rates.
There is also considerable evidence suggesting that social support is inversely related to
the prevalence and incidence of the most common cause of death in the U.S.-- cardiovascular
heart disease (Broadhead et al., 1983; House, Landis, & Umberson, 1988). Levels of social
support among myocardial infarction (or Heart attack) patients predicted mortality after
controlling for severity of disease, co-morbidity, functional status, as well as the standard
cardiac risk factors such as smoking and exercise (Berkman, Leo-Summers, & Horowitz,
1992). Likewise, evidence that patients who are socially integrated or receive high social
support are more likely to recover from heart attack, need less time in the hospital, and are
less likely to experience a recurrence of symptoms (Berkman, 1995). Hence, social support
appears to influence the development and clinical impact of CHD.
To summarize, epidemiological studies suggesting that both the quantity and quality of
one’s relationships predicts lower all-cause mortality (see reviews by Berkman et al., 2000;
House et al., 1988, Uchino, 2004). The links between social relationships and health are most
evident for cardiovascular mortality (Berkman et al., 1992; Brummett et al., 2001; Orth-
Gomer, Rosengren, & Wilhelmsen, 1993), with some studies showing links with lower cancer
(Ell, Nishimoto, Medianski, Mantell, & Hamovitch, 1992; Welin et al., 1992) and HIV
mortality (Lee & Rotheram-Borus, 2001). Thus, we have good evidence that an association
between social relationships and physical health does exist.

IMPORTANCE OF RELATIONSHIP QUALITY

These epidemiological data are often taken as evidence for the health benefits of social
relationships; however, even close relationships are not entirely positive. Although social
relationships can be sources of warmth, caring, nurturance, and understanding, they can also
be sources of conflict, criticism, jealousy, and rejection (Major et al, 1997). Research from
the Terman Life Cycle study suggests that past negativity in social relationships predicts
greater mortality (Friedman et al., 1995; Tucker, Friedman, Wingard, & Schwartz, 1996).
Likewise, unhappy marriages are associated with greater morbidity and mortality (Robels &
Kiecolt-Glaser, 2003). Therefore, a complete understanding of health-related consequences of
social relationships requires simultaneous consideration of both the negative and the positive
aspects of social relationships.
Some relationships are characterized by a blend of both positive and negative aspects. For
example, although you may love this person or enjoy this persons company much of the time,
he/she can also be frustrating, demanding, blaming, competitive, or inconsiderate. Whether it
is a colleague, a friend, in-laws, a roommate, or a family member—many individuals have
people in their social network that might fit this description. In fact, prior research among
both college age and older adult samples has found that roughly half of one’s social network
404 Julianne Holt-Lunstad and Briahna Bushman

was made up of such relationships (Uchino et al, 2001). So, where do these relationships fit
within such definitions? They are not entirely positive, nor are they entirely negative.

AMBIVALENT RELATIONSHIPS AND HEALTH

Although it is clear that many relationships are not entirely supportive or positive, the
majority of studies in this area have assumed a sort of homogeneity in regard to the
relationships being studied. Thus relationships have been looked at unidimensionally as either
positive and supportive or negative and unsupportive. The positive and negative aspects of
relationships, however, are separable dimensions (Finch, Okun, Barrerra, Zautra, & Reich,
1989; Fiore, Becker, & Coppel, 1983; Kiecolt-Glaser, Dyer, & Shuttleworth, 1988; Ruehlman
& Karoly, 1991), meaning that they can coexist with one another. Consequently, this accounts
for the mixed feelings of both positivity and negativity that many people experience in their
social relationships (Uchino, Holt-Lunstad, Uno, & Flinders, 2001).
Overall, supportive relationships have been found to have beneficial effects on morbidity
and mortality, while the research suggests that negative relationships do not have the
protective health benefits of positive relationships and have been linked to detrimental effects
on health (Bloor, Uchino, Hicks, & Smith, 2004; House, Umberson, & Landis, 1988; Lepore,
1992). However, there is very little research examining relationships which contain both high
positivity and high negativity and whether people may benefit from the positivity that exists
in these relationships or if the concurrent negativity would be more salient.

Ambivalent Relationships

Theoretical Model and Definitions

Data suggests that any given social network member may differ in the degree to which
they are perceived as being positive and/or negative (Holt-Lunstad, J., Uchino, Smith, Olsen-
Cerny, & Nealy-Moore, 2003; Cacioppo & Berntson, 1994). The following organizational
framework has been proposed (see figure 1). For example, a social network member that is
primarily a source of social support would represent the high positivity / low negativity
corner (e.g., a friend you can always count on). A network member that is primarily a source
of negativity or what we label a socially aversive relationship would represent the low
positivity / high negativity corner (e.g., an unreasonable supervisor). Those low in both
positivity and low negativity are labeled as social indifference and may represent a network
member that is characterized by relatively low levels of social interactions (e.g., fellow
students in a class, fellow church goers). A relatively unique aspect of this conceptualization
for the social relationships and health literature is represented in the high positivity / high
negativity corner or what we label a socially ambivalent network tie. Social ambivalence
refers specifically to a social network member that one feels both positively and negatively
towards (e.g., an overbearing mother, a competitive friend, a volatile romance).
As stated earlier, there is evidence to suggest that more and better relationships have a
positive impact on health, while fewer and negative relationships are associated with
detrimental effects on health. Thus, it was unclear whether we might benefit from the positive
 Social Relationships and Physical Health 405

aspects of ambivalent relationships (e.g., Abbey, Abramis, & Caplan, 1985); or whether a
negativity bias might exist, such that the negative aspects of these relationships is more
salient (e.g., Sandler & Barrera, 1984)—thereby leading to negative effects on health.

Figure 1. Model of social relationships incorporating the positive and negative aspects of social
relationships (Uchino, Holt-Lunstad, Uno, & Flinders, 2001).

Why Ambivalence May Influence HEALTH

Although it may be possible that people may benefit from positivity that exists in these
relationships, there is reason to believe that the negativity may be influential. One important
reason why an examination of ambivalent ties, separate from supportive and aversive ties,
may be important is that a network filled with ambivalent ties may entail significant
interpersonal stress (i.e., stress enhancing hypothesis). If a social network member is
primarily a source of negativity, one may habituate to the aversive relationship by using
specific coping strategies (e.g., discounting or avoidance). However, an ambivalent network
member who you feel particularly positive and negative towards is in theory less predictable
and thus may be associated with more heightened interpersonal stress (Mason,
Frankenhouser, 19??). Likewise, interactions with an ambivalent network member may be
ambiguous and not very clear-cut, so efforts to understand these interactions may lead to
increased ruminative thinking (Gal & Lazarus, 1975; Kaloupek & Stoupakis, 1985).
An additional pathway in which social relationships are thought to have an effect on
health is by buffering the negative effects of stress (i.e., the support interference hypothesis).
It is thought that relationships that are supportive can help one cope with the stresses in their
lives and therefore, one might be less likely to suffer the negative effects of stress. However,
individuals may be less likely to seek support from ambivalent relationships or may not
benefit from support received. Regardless of the explanation there appears to be reason to
believe that ambivalent relationships may not have the same effect as supportive
relationships.
406 Julianne Holt-Lunstad and Briahna Bushman

Ambivalence Studies

I will present a line of studies that has examined the multiple dimensions of social
relationships and its association to health-relevant physiological processes. More specifically,
these studies address the question: “does social ambivalence have unique effects on health
from what is predicted by supportive and aversive social relationships?” It is noteworthy that
this is a relatively new line of research. Social relationships are complex and there are
potentially a number of factors that are involved, including individual differences,
relationship type, etc. Likewise, health is also a very broad concept and there may be a
number of factors contributing to health outcomes, which may also differ depending on the
specific health end-point. Given this, it is important to start by acknowledging that these
factors that are important. However, the studies presented here represent the critical first steps
in this line of research.
Although there are a number of ways in which health outcomes could be examined,
perhaps one of the most compelling first steps would be to examine the impact on
cardiovascular functioning since CHD is the number one cause of death in the U.S. for both
men and women. You may have thought to yourself “how do we get from our day-to-day
interactions with our relationships to dying of heart disease?’ One way this can occur is
through elevations in BP either during the time of the interaction or long term consequences
of repeated interactions. These alterations in cardiovascular function may then impact CHD
risk. Cardiovascular functioning was assessed by either examining cardiovascular reactivity
in the lab (for review see Smith & Ruiz, 2002) or ambulatory blood pressure in one’s
everyday life (Verdecchia et al 1994; Kikuya et al, 2005). Importantly, preliminary research
suggests that the positivity and negativity within social relationships may predict these
changes in cardiovascular functioning.

Network Ambivalence, Age, and Reactivity

In order to test whether ambivalent relationships were beneficial or detrimental, one of
the first studies focused on the association between the extent of ambivalent relationships
within one’s network and age-differences in cardiovascular function. Specifically, we
assessed the different categories depicted in figure 1 using the social relationships index (SRI;
see Uchino et al., 2001; Campo, Uchino, Holt-Lunstad, Vaughn, Reblin, & Smith, under
review; for scale validation information) according to the total listed number of individuals in
one’s network who were only sources of support, aversion, indifference, or ambivalence. The
influence of these categories was examined among a sample of adults between the ages of 30
and 70 (men and women) while they performed an acute stress protocol (Uchino et al., 2001).
Consistent with prior research there was cardiovascular evidence for the benefits of
having socially supportive ties; however, there was also a significant interaction between age
and ambivalent ties. Individuals with high numbers of ambivalent network ties showed
greater heart rate reactivity, and a greater shortening of PEP reactivity (indicating greater
sympathetic activation of the heart) as a function of age. In comparison, age did not predict
heart rate or PEP reactivity for individuals characterized by a relatively low number of
ambivalent network members. These results were independent of demographic variables, task
performance, affect, health behaviors, and other categories of relationships (e.g., number of
supportive ties). Thus, these data provided support for the model depicted in figure 1, as well
 Social Relationships and Physical Health 407

as a developmental process involving social ties, aging, and disease. Of course, longitudinal
evidence will be needed to provide stronger evidence for such a model.

The Influence of Ambivalent Relationships within Daily Life

We were also interested in the link between the different categories of relationships
(supportive, aversive, ambivalent, & indifferent) and cardiovascular functioning by assessing
BP during everyday social interactions (Holt-Lunstad et al., 2003). Ambulatory BP is
somewhat different from blood pressure taken in a clinic or lab in that the monitor is portable
and worn on the participant throughout the day. Rather than 1 or even a few readings taken in
a clinic, several readings are taken in the natural environment that the person normally
experiences. Importantly, studies suggest that elevated ambulatory BP may be a stronger
predictor of cardiovascular outcomes, including overall morbidity and mortality (Perloff,
Sokolow, & Cowan, 1983) than are clinic blood pressure readings. It was predicted that
interactions with supportive network members (i.e. primarily positive relationships) would be
associated with the lowest ambulatory BP, while interactions with ambivalent network
members would be associated with the highest ambulatory BP levels, irrespective of
relationship type.
In this study, male and female volunteers underwent a 3-day ambulatory blood pressure
(ABP) assessment where a reading was taken approximately 5 minutes into each social
interaction. After each interaction, participants completed a standard diary that also included
ratings of the quality of the relationship in terms of how positive and negative they normally
felt toward the interaction partner. Consistent with prior research interactions with people
rated as primarily positive were associated with greater ratings of intimacy, greater self-
disclosure, higher positive affect, and lower negative affect. In comparison, interactions with
negative relationships predicted lower levels of self-disclosure, less positive affect, and higher
negative affect.
Consistent with the framework depicted in figure 1, significant statistical interactions for
relationship positivity and negativity emerged in predicting ambulatory SBP and ambulatory
DBP. The highest ABP was found when participants were interacting with a person they felt
relatively high levels of both positivity and negativity (ambivalence). Importantly, the effect
of ambivalent relationships was not only higher than interactions with supportive
relationships; it was also higher than interactions with aversive relationships. It is also
important to note that this statistical interaction remained significant while statistically
controlling for structural characteristics of the relationship (i.e., familial / non-familial
classification). Thus, ambivalence seems to be bad regardless of the relationship type. These
findings suggest that interactions with ambivalent relationships may have detrimental effects
on ambulatory cardiovascular functioning, and perhaps ultimately, cardiovascular health.

Ambivalent Relationships: Stress Enhancing or Support Interference?

As stated earlier ambivalent relationships might be associated with higher cardiovascular
functioning because they are associated with greater interpersonal stress or because
individuals may not be able to benefit from support from ambivalent relationships.
Unfortunately, although this study did assess the quality of the interaction, the exact nature of
the interaction was unclear-- whether or not the individual was actually seeking support from
the person they were interacting with or having a casual conversation. Therefore, the next
408 Julianne Holt-Lunstad and Briahna Bushman

study utilized a laboratory paradigm to isolate specific dimensions of social relationships and
its relation to psychological and physiological processes.
This study was designed to examine the nature of the interaction. Prior research has
primarily examined social support as a coping resource in times of stress, however, we seek
out our relationships during both the good times and the bad (Gable, Reise, & Impett, 2004),
and it is predicted that the quality of one’s relationship will influence our responses to these
situations. Specifically, (1) if individuals are unable to benefit from support from ambivalent
relationships during times of need or stress then we should see increased reactivity to
disclosing negative events; (2) however, if ambivalence is a general source of stress, then we
would expect increased reactivity to both positive and negative events.
In this study, participants were randomly assigned to bring in either a supportive or
ambivalent friend, and randomly assigned to talk with their friend about either a positive or
negative event. Testing was divided into two sessions. For the first session participants were
asked to complete the Social relationships index (SRI), to assess the participant’s perception
of their friend within negative, positive, and neutral contexts. Based on these ratings we were
able to identify friends in their network that would be classified as either supportive or
ambivalent.
During the second session participants brought their friend (unaware of the assigned
condition) with them to the laboratory. We first got a baseline measure of resting
cardiovascular function. Then, as a neutral comparison to the event discussion, the participant
and friend were instructed to discuss what they do during a normal weekday with each other
for four minutes. After which, a second baseline was obtained. Finally, participants and their
friend discussed either the positive or negative experience (depending on random assignment
to outcome condition) while cardiovascular assessments were obtained. The social interaction
was structured so that participants and their friend alternated speaking for one minute each.
The participant spoke regarding their personal feelings about the event, while the friend was
asked to simply respond as they would naturally.
Preliminary analyses showed that ambivalent friends were viewed as significantly more
dominant than supportive friends. No relationship-based differences in reactivity were found
when participants discussed a neutral topic with their friend. However, there was a significant
interaction between relationship quality and the event topic on SBP reactivity. As predicted
by the support interference hypothesis, participants exhibited the greatest levels of SBP
reactivity when disclosing a negative event to an ambivalent friend.
Although our results appear more consistent with the support interference hypothesis, it is
possible that seeking support from an ambivalent friend during negative life events is in itself
stress-enhancing and can contribute to support interference. In addition, other results
suggested more subtle ways in which ambivalent friends may be stressful. State anxiety was
elevated for individuals who were with an ambivalent friend throughout the entire study
(including relaxation/baseline periods). Also, analyses of baseline levels of cardiovascular
activity showed that participants anticipating interacting with ambivalent friends had
significantly higher heart rate, an effect driven by lower parasympathetic control of the heart
(as indexed by RSA). Thus, these data may indicate a reduced ability to regulate aspects of
the cardiovascular system in the presence of such ambivalent ties.
 Social Relationships and Physical Health 409

Ambivalent Relationship Maintenance

Given the potential negative effects of ambivalent relationships, it may be important to

understand the potential extent of their influence. There is growing evidence that relationships
for which we have mixed feelings may be common and pervasive. Ambivalent relationships
appear to be so common that the vernacular term “frenemy” has become commonplace. For
example, there are television sit-com episodes devoted to “frenemies” and a recent internet
search of the term “frenemy” resulted in over 50,000 hits. When systematically examining
social networks of both undergraduate and community samples, ambivalent relationships are
found among all relationship types (e.g., spouse, family members, friends, co-workers, and
social acquaintances) and individuals report roughly equivalent proportions of supportive and
ambivalent relationships (Uchino et al., 2001). Prior research has also demonstrated that
supportive and ambivalent ties occur more frequently in individuals’ networks than aversive
ties (Fingerman, Hay, & Birditt, 2004; Newsom, Rook, Nishishiba, Sorkin, & Mahan, 2005;
see also Rook, 2001). Likewise, the frequency of contact with ambivalent relationships was
found to be similar to amount of weekly contact with supportive relationships (Holt-Lunstad
et al. 2007). Thus, ambivalent relationships may be both common and detrimental.
If ambivalent relationships are potentially detrimental, why don’t people end these
relationships? While some relationships (e.g., family, work) aren’t as easy to exit as others,
we found similar frequency distributions of supportive and ambivalent friendships (Holt-
Lunstad et al., 2007)—presumably a voluntary relationship. Thus, a recent study was
designed to examine the potential reasons for why individuals would maintain their
ambivalent friendships, as well as how these friendships are maintained (Bushman & Holt-
Lunstad, under review). Specifically we examined the influence of external and internal
maintenance factors, as well as intimacy and distancing in relationship maintenance within
ambivalent and supportive friendships. Participants included male and female undergraduates,
who were randomly assigned to rate either a supportive or ambivalent friend on these
measures of relationship maintenance.
Results suggest that ambivalent relationships are not maintained primarily due to
obligation or external barriers, but rather are viewed as voluntary associations maintained
primarily because of internal factors such as personal commitment to the relationship. Results
also suggest that the positive aspects of ambivalent friendships are either redeeming or
impede termination. Likewise, for women, both ambivalent and supportive friendships were
being maintained in a significantly more intimate manner than were men’s. Due to the
stressful nature of ambivalent relationships, women’s intimacy with their ambivalent friends
may have serious implications for health outcomes.
Despite the positive aspects of ambivalent friendships, this study also found that
relational distancing, both physical (staying away from the individual) and emotional (not self
disclosing), was utilized significantly more frequently as a coping technique within
ambivalent friendships than within supportive friendships. Distancing was originally studied
in regard to aversive or purely negative relationships that would not be categorized as
friendships, thus the finding that distancing was significantly used in ambivalent friendships
is an interesting finding in regard to relationships that are being classified by participants as
“friendships.” Since this study assists in outlining some of the techniques currently used in
coping with these relationships, the above findings help to create a starting point for
410 Julianne Holt-Lunstad and Briahna Bushman

examining the most adaptive and effective relationship maintenance strategies for both men
and women who are interacting in such friendships.

CONCLUSIONS
In summary, these studies were guided initially by two questions regarding the specificity
of the association between social relationships and health. First, are ambivalent relationships
associated with health relevant processes? Our results provide further evidence that blood
pressure is one potential physiological mechanism linking social support and health, and
importantly find that this association is moderated by the extent of concurrent negativity
within the relationship. Also, we were able to find these associations both in a naturalistic
setting and then complemented by our data from a tightly controlled study. Second, under
what conditions does ambivalence seem to be important? Although supportive and
ambivalent relationships are equivalent on perceptions of positivity, our data suggests that
individuals may be unable to benefit when seeking support from ambivalent relationships. In
addition, although more research is needed, these studies suggest that ambivalent social
relationships may have adverse effects. Based on these findings, we next attempted to address
why people might maintain partially negative and potentially detrimental relationships.
Surprisingly, it appears that such relationships are not maintained due to obligation but rather
are maintained willingly; and intimately for women. Given our findings on the extent with
which ambivalent relationships occupy one’s network, level of contact, and maintenance,
suggest that the influence of these relationships may not be isolated but rather may have a
more pervasive impact.
Overall, these data may have important implications for the conceptualization and
assessment of social relationships in the health domain. Much of the prior research on social
relationships and health has only assessed one dimension (typically positivity or social
support). Even in studies where both dimensions were assessed, researchers have typically
examined the effects of one dimension by statistically controlling for the other (e.g., Finch &
Zautra, 1992; Fiore et al., 1983). According to the model presented in figure 1, however, high
negativity includes both social aversion and social ambivalence, whereas high positivity
includes both social support and social ambivalence. This point may be especially important
to consider in developing effective social support interventions (Finch et al., 1989). Our
results suggest that implementing a support intervention (without regard to extent of
positivity and negativity within that relationship) would be a mistake.
Overall, this data suggests that prior conceptualizations of social relationships were
perhaps too simplistic. Rather, a multidimensional approach to the study of social
relationships may be effective in predicting cardiovascular functioning (so as to better
understand the underlying associations between social relationships and morbidity and
mortality).
 Social Relationships and Physical Health 411

IMPORTANT AREAS OF FURTHER RESEARCH

Despite these promising results, there are several important issues that need further
examination. First, prospective studies are needed to track the time course of the
physiological changes that occur as a result of social relationships. Second, at this stage in the
research the classification of ambivalence is very broad. For example, the joint positivity and
negativity could be the result of being given mixed messages during interactions; or, it could
be a summary schema of a long history of some negative interactions and some positive
interaction. Likewise, it is possible that ambivalence may be a result of having specific
aspects of the relationship that are positive and knowing that other specific aspects are
upsetting; or, it may be unpredictable when the person may be positive or upsetting. Given
the broad conceptualization, it may be important to clarify what aspects of ambivalence may
be more detrimental than others. In particular, if upsetting aspects may be identified coping
mechanisms may be better utilized to mitigate any potential adverse influences.
The identification of effective coping may be particularly important given that there is
reason to believe that people do not exit these relationships. Although emotional distancing
was used more among ambivalent than supportive relationships, it is possible that this may
not be effective in reducing negative health effects. For example, prior research has also
shown that individuals were more anxious and less able to relax in the mere presence of their
ambivalent friends (Holt-Lunstad, Uchino, Smith, & Hicks, 2007). Therefore, if individuals
are not limiting contact with ambivalent relationships, it is possible that despite such
strategies relationships still have an impact through cognitive processes (e.g., rumination and
emotional suppression). Future studies that directly test these issues may be able to identify
and elucidate the most effective coping methods.
Third, it may be important to determine whether there are typical relationships in which
ambivalence is more prevalent or more detrimental? Conceivably, some relationships are
easier to exit than are others. It is much harder to sever ties with family members than it is to
leave friendships. Although our findings suggest that ambivalent relationships are maintained
voluntarily rather than out of obligation, because this study focused on friendships we can’t
draw firm conclusions about other relationship types. Likewise, ambivalence within a
marriage or familial ties may be more detrimental than within a friendship due to differences
in importance and amount of contact. Future studies that directly examine these issues are
needed.
Fourth, there are many important individual differences such as gender, age, and
personality all of which are important to examine. For example, women in our culture are
socialized to maintain and nurture interpersonal relationships to a greater extent than are men.
In fact prior research shows that women are more likely to seek out, and give support than are
men (Carver, Scheier, & Weintraub, 1989; Rosario et al., 1988). However, because of this
social pressure to maintain relationships women may be less likely to exit bad relationships.
While currently we have found no evidence of gender differences in terms of the influence of
ambivalent relationships, it does appear that women may attempt to maintain their
relationships more intimately.
Another important point to specify is the physiological pathways. While finding a
significant relationship between the quality of one’s relationships and blood pressure was an
important first step in understanding the pathways in which social relationships influence
412 Julianne Holt-Lunstad and Briahna Bushman

health, blood pressure is a multiply determined end-point. As such it may be useful to identify
particular patterns of cardiovascular functioning (e.g., patterns associated with sympathetic
and parasympathetic activation) which may be useful in understanding more specific
physiological mechanisms.
Finally, the health consequences of psychological, behavioral, and physiological
mechanisms need further examination to clarify the implications for health. There are many
pathways in which social relationships may influence health outcomes. Although we have
focused on the cardiovascular pathway, the immune and endocrine pathways are also
important. Given the immune system is our first line of defense in fighting off disease,
demonstrating a link between ambivalent relationships and immune functioning will provide
strong evidence to support the hypothesis that social ambivalence may influence our health.
Likewise, emerging data on immune-related inflammatory processes also provides a
promising avenue for greater integration among these diverse physiological systems and
disease states. Most research linking social support to immune processes has emphasized its
potential role in cancer, HIV, and infectious diseases more generally (Uchino et al., 1996).
There is now increased emphasis on how inflammatory immune processes may influence the
atherosclerotic processes (Ross, 1999). The establishment of such links will be important due
to the need to model integrative mechanisms (e.g., immune system influencing cardiovascular
risk via inflammation). Such future investigations may help clarify the pathogenic
mechanisms responsible for the long-term health cost and benefits of specific dimensions of
social relationships—such that we can utilize the benefits of social relationships to promote
positive health outcomes.

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Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 24

LIVING IN DISCREPANT WORLDS: EXPLORING

THE CULTURAL CONTEXT OF SEXUALITY AMONG
TURKISH AND MOROCCAN MALE ADOLESCENTS

Barbara C. Schouten* and Chana van der Velden1

Department of Communication, the Amsterdam School of Communications Research,
University of Amsterdam, the Netherlands

ABSTRACT
A high percentage of Turkish and Moroccan male adolescents in the Netherlands is
sexually active. At the same time, they frequently engage in risky sexual behavior, which
makes them vulnerable to HIV/STDs infection. To be able to design culturally
appropriate health promoting interventions, more knowledge about the factors that
influence their sexual behavior is needed. Therefore, this paper reports on a qualitative
study that aims to increase our understanding of the influences on Turkish and Moroccan
adolescent male sexuality within a broader interest in HIV/STD prevention. Seven focus
groups with 29 Moroccan and 20 Turkish boys, aged between 14 and 18 years, were
conducted. Analysis of the data highlighted several factors that may hinder condom use,
such as lack of knowledge, lack of perceived risk, peer norms, lack of parent-adolescent
communication about sexuality, and lack of self-efficacy toward buying condoms.
Results also show some significant differences between the Turkish and Moroccan
adolescents. Turkish adolescents are more conservative toward sexuality, they stick more
strongly to cultural traditions and they have less knowledge about HIV/STDs than
Moroccan adolescents. Moroccan adolescents experiment more frequently with sex.
Therefore, they may be at higher risk of getting infected with HIV/STDs. The findings of
our study provide a fertile starting point for designing culturally appropriate and effective
health education programs in the field of safe sex promotion for ethnic minority
adolescents.

*
Corresponding address: B.C. Schouten. Department of Communication, The Amsterdam School of
Communications Research (ASCoR), University of Amsterdam, Kloveniersburgwal 48, 1012 CX Amsterdam,
The Netherlands. Phone: +31 (0)20 5253879; Fax: +31 (0)20 525 3861; e-mail: b.c.schouten@uva.nl
418 Barbara C. Schouten and Chana van der Velde

Keywords: sexual health; condom use; ethnic minorities; adolescents; HIV/STDs; focus
groups

INTRODUCTION
Within a relatively short time span both the number of adolescents that are sexually
active and the diversity of sexual practice have increased significantly (Feldman & Rosenthal,
2002). In the Netherlands, the percentage of adolescents which has had sexual intercourse is
in particular high among Turkish and Moroccan boys: around 40% of them have had sexual
intercourse between 12-18 years, as compared to 20% of Dutch teenagers (de Graaf, Meijer,
Poelman, & Vanwesenbeeck, 2005). Results of a few studies also indicate that Turkish and
Moroccan males engage in more risk-taking during their sexual activities. For instance,
Turkish men more frequently visit prostitutes and use condoms less frequently than either
Dutch or Surinam men (Hooykaas, van der Velde, van der Linden, van Doorum, & Coutinho,
1991). Furthermore, Turkish and Moroccan adolescents have less knowledge about safe sex
practices, HIV and other sexually transmitted diseases (STDs), and less intention to use
condoms than Dutch adolescents (van Eijk, 2001, Kraemer, van Driel, & van der Sluis, 2005).
Additionally, available epidemiologic data suggest that the number of people infected with
HIV/STDs is rapidly increasing in Turkey and Morocco, in particular among heterosexuals
(Duyan & Yildirim, 2003; Elmir, Naida, Ouafae, Rajae, Amina, & Rajae, 2002), placing
Turkish and Moroccan adolescents who visit their countries of origin during the holidays at
risk of contracting HIV/STDs there. Taken together, these facts make Turkish and Moroccan
male youth in the Netherlands vulnerable to getting infected with HIV/STDs.
Prevention activities targeted at these groups are necessary as they may lead to the
adoption of safer sex practices. However, compared to other recognized high-risk groups,
such as homosexuals, prostitutes and adult migrant groups (Kocken, Voorham, Brandsma, &
Swart, 1996; Martijn, de Vries, Voorham, Brandsma, Meis, & Hospers, 2004), prevention
targeted at Turkish and Moroccan teenagers is still in its infancy. As previous research
indicates that health education campaigns targeted at the general adolescent population are
significantly less effective for Turkish and Moroccan teenagers than for Dutch teenagers (e.g.,
von Bergh & Sandfort, 2000), it is of vital importance to design culturally sensitive health
education programs on the topic of sexuality for Turkish and Moroccan youth. To be able to
develop such programs though, far more in-depth knowledge should be gained about which
factors influence their sexual behavior. Therefore, this paper reports on a qualitative study
that aims to increase our understanding of the influences on Turkish and Moroccan adolescent
male sexuality within a broader interest in HIV/STD prevention among these groups.

ISLAMIC CULTURE AND SEXUALITY

Unlike Christianity, Islam has a mainly positive view of sexuality; the Koran preaches
pleasure for both partners and sexuality is seen as a divine gift (Heemelaar, 2000; Obermeyer,
2000). It is thought that men are more able to devote themselves to Islam when their sexual
desires are fulfilled. Hence, sexuality is regarded as the fulfillment of a religious duty, not
 Living in Discrepant Worlds 419

only in terms of reproduction, but also because it leads to a peaceful and harmonious state of
mind. In the same vein, men should not get too emotionally attached to their spouses, as this
may interfere with their dedication to Islam (Combs-Schilling, 1989). Thus, while sexual
enjoyment takes place between men and women, love is reserved for God. There is, of course,
one major precondition for practicing sexuality in Islam: it should be expressed within the
confines of marriage. Islamic sexual ethic proscribes all premarital sexual activity. Outside
marriage heterosexual encounters are fornication (zina) (Obermeyer, 2000). Hence, both men
and women should remain virgin until marriage.
The positive attitudes toward sexuality as expressed in Islamic religion stand in sharp
contrast with the often fundamentally inegalitarian double standards for men and women
regarding sexual behavior in many Muslim societies (Obermeyer, 2000; Pels, 2000). Most
notable is the double standard with regard to the virginity norm. For men, having sex before
and outside marriage is accepted as long as it is practiced behind closed doors. As many
Islamic societies are also macho cultures, male sexuality is seen as proof of virility and
strength. In contrast, ritual wedding ceremonies display proof of the bride’s virginity (and
groom’s virility), and make it clear that women are to a far greater extent judged by their
sexual conduct and purity of body than men. A clear example of the double virginity standard
is the fact that in Morocco for men their profession is filled out on the marriage certificate
under the heading legal status, while for women it is filled out whether or not they are virgin
(Heemelaar, 2000). Hence, women are under a lot of pressure to keep their virginity until
marriage.
Another double standard in many Muslim societies concerns homosexuality. In Islamic
religion, homosexuality is regarded as sinful. As it does not lead to reproduction, it is
considered a perversion and is forbidden under Muslim law. In practice though, there is a lot
of tolerance toward homosexual activities in Muslim societies, partly because women are
sexually not readily available. As long as it conforms to certain standards, such as the division
of active and passive roles among older men and adolescent boys, it seems to be accepted.
The tolerance toward homosexuality is purely physically oriented though. Having a
homosexual identity is haram and not allowed (Obermeyer, 2000).
Although Turkish and Moroccan youth in the Netherlands are not raised in Muslim
societies and are constantly exposed to western values regarding sexuality, their interpretation
of these values is partly based on interactions with their families. These family relationships
are characterized by experiences that are based in traditional Turkish and Moroccan culture
(Pels, 1998). Furthermore, research has shown that a majority of Moroccan and Turkish
adolescents in the Netherlands identify themselves as Muslim (Phalet & ter Wal, 2004). They
still attach great importance to Islam in their personal and sexual lives. For instance, around
75% of Turkish and Moroccan youth is of the opinion that sex is only allowed within the
confines of marriage. In contrast, only 16% of Dutch adolescents agree with this opinion
(Kraemer et al., 2005).
An obvious similarity between sexuality among Turkish and Moroccan adolescents in
their countries of origin and the Netherlands is the importance attached to virginity before
marriage and the accompanying double standard for girls and boys (Pels, 1998). That is,
while daughters should remain virgin until marriage, parents often turn a blind eye to the
sexual behavior of their sons. As long as their sons deal with sex according to certain rules of
conduct, such as not confronting their parents with their sexual behavior, they are privately
allowed to have sex before marriage. It is equally important to refrain from having sexual
420 Barbara C. Schouten and Chana van der Velde

encounters with girls from their own group (i.e. Moroccan or Turkish girls), as this poses a
threat to the virginity norm and may induce honour-related violence. Dutch girls do not
belong to the in-group and are not seen as marriage candidates for their sons. As a result,
many Turkish and Moroccan boys experiment sexually with Dutch girls before they marry
someone from their own group (Pels, 1998).
Due to sex being forbidden before marriage, sexuality is not a topic of discussion in most
Turkish and Moroccan families in the Netherlands. Not only is it considered indecent and
disrespectful for adolescents to talk about sex with their parents, parents also fear that talking
with their children about sexuality may stimulate sexual activity, which corresponds with the
fact that “Islamic religious authorities strongly oppose the methods of AIDS prevention
adopted in western countries, especially the use of the condom and sex education inasmuch
as they assume and encourage free sex” (Francesca, 2002, p.389). Scarce research indeed
indicates that parent-adolescent communication about sexuality is practically non-existent in
Muslim families in the Netherlands (Kraemer et al., 2005; Schouten, van den Putte, Pasmans,
& Meeuwesen, 2007). Hence, Turkish and Moroccan youth will probably not get the same
amount of education from their family as Dutch youth, and this should be taken into account
when designing HIV/STD prevention programs for them. For instance, it is likely that the
smaller amount of knowledge Turkish and Moroccan teenagers have about safe sex practices
as compared to Dutch youth (see below) is at least partly attributable to the absence of sex
communication within the home. Hence, Turkish and Moroccan adolescents might need to be
given more information about safe sex during HIV/STD prevention programs than their
Dutch counterparts.

DETERMINANTS OF UNSAFE SEX BEHAVIOR

AMONG TURKISH AND MOROCCAN YOUTH

The growing concern about the spread of HIV/STDs among heterosexuals has led to a
substantial body of literature on (determinants of) heterosexual sexual behavior in general and
condom use specifically (for an excellent meta-analysis see Sheeran, Abraham, & Orbell,
1999). In sharp contrast, only scarce research has been carried out which has specifically
focused on the sexual behavior of Turkish and Moroccan youth. The main results of the few
studies carried out so far will be summarized below.
With regard to knowledge levels, previous research has consistently shown that Turkish
and Moroccan teenagers have less knowledge about HIV/STDs than their Dutch counterparts
(von Bergh & Sandfort, 2000; Hendrickx, Lodweijckx, van Royen, & Denekens, 2002;
Kraemer et al., 2005). Although most of them know about the existence of HIV/Aids and the
importance of condom use in preventing infection with HIV, there is far less knowledge about
other STDs. Furthermore, they have many misconceptions about the means of transmission
and symptoms of STDs. Some study results suggest a relation between the lack of knowledge
and a lack of sex communication at home (e.g., Kraemer et al., 2005), but more research is
needed before conclusions about a possible relationship can be drawn. Results of Turkish and
Moroccan studies with regard to knowledge levels are about the same: insufficient knowledge
about HIV/STDs is noticeable, in particular when it comes to modes of transmission and
symptoms (Aral & Fransen, 1995; Gökengin, Yamazhan, Özkaya, Aytuĝ, Ertem, Arda et al.,
 Living in Discrepant Worlds 421

2003, Manhart, Dialmy, Ryan, & Mahjour, 2000; Savaser, 2003; Ungan & Yaman, 2003).
One Moroccan study reported that the various STDs are considered to be different points on a
continuum of severity rather than separate diseases (Manhart et al., 2000). Some positive
associations between knowledge levels and other variables which have been reported in a
couple of Turkish studies are parents’ educational level and more democratic family relations
in which sexuality is more comfortably discussed (Gökengin et al., 2003, Savaser, 2003).
Some misconceptions that center on the perceived vulnerability of Turkish and Moroccan
adolescents seem to be prevalent as well. For instance, condom use is often associated with
prostitutes and casual sex, and is thought to be unnecessary in serious relationships and
marriage (Aral & Fransen, 1995; Manhart et al., 2003). Furthermore, Moroccan adolescents
frequently report that they can know in advance whether a girl is free of disease, based on her
looks (e.g. Hendrickx et al., 2002). The selection of so-called “clean” girls protects them
against STDs and makes the use of condoms during sexual intercourse redundant. Closely
related to the notion of cleanliness is the still popular idea that HIV/STDs merely affect
marginal individuals, such as homosexuals and commercial sex workers (Aral & Fransen,
1995). Biological immunity (e.g. Turkish men are strong) and fatalistic thinking (e.g. you
cannot prevent diseases, as they come from Allah) are also mentioned as reasons not to use
condoms (Aral & Fransen, 1995).
Other barriers toward condom use that have been reported are a negative attitude toward
condom use, costs of buying condoms, and fear of talking about using a condom with a sex
partner (von Bergh & Sandfort, 2000; Gökengin et al., 2003; Manhart et al., 2003; MCA
communicatie, 2002). For instance, Turkish and Moroccan boys mentioned reduced sexual
pleasure when using a condom during sex. Furthermore, they may be hesitant to actually buy
them, not only because of costs but also because of feelings of embarrassment. This hesitancy
might also be present when it comes to bringing condom use during sex up for discussion
(von Bergh & Sandfort, 2000). Hence, the so-called interaction competencies might be lower
among Moroccan and Turkish boys than among Dutch boys, further decreasing the chance of
actually using condoms during sexual intercourse.
Although the studies summarized above have yielded some valuable insight into possible
determinants of unsafe sex among Turkish and Moroccan youth, there are some important
shortcomings that warrant further research. First, most studies cited above were carried out in
Turkey and Morocco. Generalizing the results of these studies to the Turkish and Moroccan
adolescent population in Western countries may be inappropriate. Second, the European
studies were, with the exception of one of them, quantitative in nature. The questionnaires
used in these studies were based on factors that are known to be of influence in Western
populations, but may have left out specific factors that may be relevant within the Turkish and
Moroccan culture. For instance, none of the studies investigated the influence of family
values with regard to condom use, while it is well-known that social norms are more
important than attitudes in influencing behavior in these cultures (Triandis & Trafinow,
2001). To be able to identify culture-specific beliefs, one should make use of qualitative
methods. Third, the only qualitative study on this topic investigated Moroccan adolescents,
but not Turkish adolescents (i.e. Hendrickx et al., 2002), making a comparison between
different ethnic minority groups impossible. To fill these gaps, our study used a qualitative
method to explore and describe the cultural context in which sexuality of Turkish and
Moroccan male adolescents is shaped. In doing so, we aimed to identify similarities and
differences regarding (unsafe) sexual behavior between Turkish and Moroccan adolescents.
422 Barbara C. Schouten and Chana van der Velde

METHODS

Study Context

The study was conducted in Amsterdam, the capital city of the Netherlands, where a
relatively high percentage of inhabitants is of Moroccan and Turkish origin (respectively
around 9% and 5%). The focus groups were conducted at Turkish and Moroccan youth
centers in May and June 2007, all by the same moderator (CvdV). Ethical approval for the
study was obtained by the Ethical Research Committee of the Amsterdam School of
Communications Research.

Table 1. Age and educational level of the participants

Moroccan boys Turkish boys

Age
- 14 3 2
- 15-16 8 5
- 17-18 18 13
Going to school?
- Yes 26 17
- No (unemployed) 3 3
Level of education
- lower secondary professional education 16 12
- intermediate vocational education 8 5
- higher secondary general education 1 -
- higher vocational education 1 -

Participants

Research participants consisted of 29 Moroccan and 20 Turkish boys, aged between 14

and 18 years (see Table 1). The boys were recruited from three Moroccan and two Turkish
youth centers, where group leaders invited the boys to participate. None of the boys refused to
participate. Focus groups were separately run for the Turkish and the Moroccan boys,
resulting in three Turkish groups and four Moroccan groups. All participants belonged to the
second generation immigrants; they were all born in the Netherlands, and could speak the
Dutch language. All boys lived at home with their parents and were unmarried. Each group
consisted of six to eight participants, which is in line with earlier recommendations on
optimal group sizes of focus groups (Bischoping & Dykema, 1999). At the end of each focus
group, participants filled out a brief questionnaire to collect some personal data and were paid
a small amount for their participation (12 Euro).
 Living in Discrepant Worlds 423

Research Method

All focus groups took place in the youth centers where the boys were recruited. Our
choice for running the focus groups in the youth centers was determined both by practical
reasons and by reasons related to the content of our study. First, the boys often gather in these
youth centers after school and are not required to travel to another place to participate,
thereby enhancing the likelihood of partaking in the discussions. Second, the boys are all
familiar with the place and familiar with each other as they constitute pre-existing groups,
which has the advantage that participants share their daily lives and can easily relate to each
other’s comments and stories. Hence, expressed beliefs about sexuality can be more readily
checked against actual behavior and challenged in case there is a gap between the two (for a
similar point of view, see Kitzinger, 1995). Indeed, both the sharing of common experiences
and the challenging of each others comments happened regularly during the discussions.
An important advantage of focus groups over individual interviews is that they are
sensitive to cultural values and group norms, and are therefore particularly suited for research
with ethnic minorities. The interaction inherent of groups facilitates revealing information
about such social norms and enhances the discussion of taboo topics, because the less
inhibited members of the group often break the ice for shyer participants. Focus group
“participants can also provide mutual support in expressing feelings that are common to their
group but which they consider to deviate from mainstream culture” (Kitzinger, 1995, p.299).
For instance, in Islamic culture a well-known “deviation” from Western culture are beliefs
about homosexuality. These views are more likely to be expressed in the context of a group of
like minded people than in the less “safe” setting of an individual interview.
Due to the sensitive nature of the topic and in order to prevent possible macho-behavior,
focus group interviews were moderated by a Dutch female moderator (CvdV). It was decided
to use a non-Moroccan/ non-Turkish moderator, because previous research has indicated that
it might be safer to express feelings about sexuality to people belonging to a different ethnic
group than to people of the own ethnic group (Hendrickx et al., 2002). All interviews were
tape recorded and verbatim transcripts were made. The groups lasted between one and one
and a half hour.

Discussion Topics

The choice of the topics for discussion was based on a literature study (see table 2). Both
authors reviewed all questions for relevance and conclusiveness. The topics were divided in
six themes: knowledge about STDs, attitudes and beliefs about (unsafe) sexual behavior, self-
efficacy, education on sexuality, social norms, and sexual behavior. The order of discussing
the topics was in such a way that less sensitive, more “factual” topics were discussed first (i.e.
knowledge), in order to create an atmosphere in which the boys felt safe to talk about more
personal issues later on. However, the order of topics was not fixed but followed the natural
flow of the discussion. The moderator of the groups ensured that all topics were discussed.
The discussions were concluded with free question sessions, during which the boys could ask
questions (the moderator did not answer any questions during the discussions) and express
their feelings about the discussion. Overall, these sessions revealed that the boys found the
discussions a positive though unusual experience. They felt free to speak about things they
424 Barbara C. Schouten and Chana van der Velde

seldom talk about and some commented that this would be their preferred mode for receiving
education on sexuality.

Table 2. topic list used in the discussions

1. Knowledge
- Which STDs do you know?
- How are STDs transmitted?
- Knowledge about prevention.
2. Attitudes and beliefs
- Risk perception. Is perception of risks different in different situations, with
different sexual partners?
- Advantages/disadvantages of condom use
- Beliefs about carrying condoms
- Fatalism
3. Self-efficacy
- With regard to buying condoms
- With regard to using condoms
- With regard to talking about condom use with girls
4. Social norms
- What do friends think about unsafe sex?
- Is having (unsafe) sex stimulated by friends?
- What are the social norms with regard to having sex with girls from different
ethnic groups (i.e. Dutch, Moroccan, Turkish, other).
- What do parents think about premarital sex?
- Religious norms
5. Sexual behavior
- Risk behavior, when, in which situations?
- Differences in sexual behavior with different kind of partners?
- Homosexual behavior?
- Relationships
- At what age first time sex?
6. Education
- What kind of sexual education did the boys get?
- From whom and when?
- Whom are the boys talking to about sexuality? About which topics, in which
situations?
- Communication about sexuality with family members.
- Which sources do the boys use to inform and educate themselves?
- Preferences and needs for education.

Analysis Method

As qualitative research “is concerned with describing, interpreting and understanding the
meanings which people attribute to their existence and to their world” (Cutcliffe & McKenna,
1999, p.375), the first stage of the analysis involved the close reading and re-reading of the
transcripts of the discussions. The goal of this stage was to arrive at a description of
commonalities and differences between the Turkish and Moroccan groups in terms of the
content of the texts. Thus, a so-called “large-sheet-of-paper” approach was followed by
 Living in Discrepant Worlds 425

breaking the transcripts down into broad content segments and categorizing them in themes
and sub themes (Catterall & Maclaran, 1997). Catterall and Maclaran (1997) refer to this type
of analysis as the “snapshot” approach where data analysis results in “individual photographs
(segments of text)”.
As the value of focus group data to a great extent lies in the interaction between
participants though, in the second stage of the data analysis close attention was paid to how
the boys talked about the topics and how they responded to each other. This analysis of the
process was carried out by both reading the transcripts and listening to the tapes and jotting
down notes about such things as tone of voice, emotional engagement, disagreements,
etcetera. In addition to the categorization of themes or “snapshots”, this results in capturing
the “moving picture” of the story of the focus group discussion (Catterall & Maclaran, 1997),
and allows for a more in-depth interpretation and understanding of the findings.

RESULTS

Sexual Behavior

A majority of the Turkish and Moroccan participants is sexually active. They have had
various sexual partners, mostly Dutch girls. The onset of sexual intercourse is on average
around 14 year, but some of them were as young as 12 years of age or even younger. The
high number of sex partners is partly caused by the fact that it is quite common to visit
prostitutes. One Moroccan boy remarked that “I think the first time is always with a
prostitute”, and a Turkish boy stated that if a boy cannot score a girl on the street because he
is not a player, he has to go to a prostitute. A lot of Turkish boys and some of the Moroccans
confessed that they had unsafe sex sometimes, but most of them said that they use a condom
when having a one-night stand. Within steady relationships, they do not use a condom when
their girlfriend is taking birth control pills. Having a steady relationship does not preclude
sexual activity with others though; most of them admit that they cheat on their girlfriends.
A noticeable difference between the two groups is that Turkish boys more often have
relationships, while the Moroccan teenagers predominantly experiment with casual sex
partners. They say that they hardly ever fall in love with a girl and find it easy to separate sex
from love (“we’re just playing at the playground”, Moroccan boy). This difference might be
related to the fact that the Turkish adolescents are generally more conservative when it comes
to sexuality (see below), and consequently, sex and love more often go hand in hand among
Turkish adolescents than among Moroccan adolescents.
During the group discussions, anal sex was hardly talked about. Like masturbation, it is
clear that it is a taboo topic. Both are forbidden by Islam, and although some boys admit to
masturbate, they all say to regret it afterwards. Some worry about the consequences of
masturbation and think that they will be punished for it in some way:

MB1 (Moroccan boy 1): If a boy masturbates, hairs will grow at his hands. Isn’t that
true?
MB2: Ha ha, no that’s not true.
MB3: Yeah sure man, it’s true.
426 Barbara C. Schouten and Chana van der Velde

Dutch girls are regularly shared among the boys; they are send on to friends, so that
several boys can have sex with the same girl. They feel that friends should have the same
pleasure as they had and girls are therefore easily shared among each other. Such girls have a
reputation at school or in the neighborhood as “easy girls” and are called “love of the
neighborhood” or “ploughers”. They are regarded as whores and not respected by the boys.:

MB1: Love of the neighborhood. The one who hasn’t had sex for the longest time
deserves a slut.
MB2: Yeah, some girls from the neighborhood are taken by everyone.
MB3: They have sex for a packet of cigarettes, a breezer...
MB2: I call them breezer sluts.

When asked whether they think all Dutch girls are like this, most of them indicate that
they indeed do think so:

CvdV: Are a lot of girls like this?

TB: Yes, a lot.
CvdV: But are all Dutch girls whores or can they also be decent girls?
TB: No, not all of them. But most of them are.

Knowledge about HIV/STDs

With regard to knowledge about the transmission and prevention of STDs, most boys
know that they can get infected with HIV/STDs when they have sex without condoms. When
asked which STDs they knew, all Moroccan participants mentioned that they have heard
about HIV and aids from school or the media. Knowledge about other STDs was less,
although Chlamydia was relatively frequently mentioned. In contrast, only some of the
Turkish boys knew about HIV, and none of them could bring up any other STDs. Overall
then, knowledge was worse among the Turkish group as compared to the Moroccan group:

TB1 (Turkish boy 1): I really don’t know what STD means. Perhaps if I get a little bit
more information.
CvdV: Could you help him out?
TB2: Diseases that kill you.
TB3: It means that you get diseases from chicks.

A majority of the Turkish and Moroccan boys was unaware of the fact that unprotected
oral or anal sex can also lead to HIV/STDs. Furthermore, they expressed many
misconceptions about having (unsafe) sex, such as “oral sex can be harmful for the lungs”, “if
you have sex in the snow your sperm cells will die, won’t they?”, “if you kiss people with
pimples on the cheek, you can get sick”, and so on. In addition, some misconceptions about
birth control pills were present in both groups. Some of the boys wrongly assumed that when
a girl takes birth control pills or a morning-after pill, they are protected against contracting
diseases. The fact that they asked a lot of questions to the moderator about modes of
 Living in Discrepant Worlds 427

transmission and prevention indicates that they feel insecure about their knowledge levels and
are motivated to learn more about this topic.

Attitudes and Beliefs

One of the necessary conditions for people to engage in safe sex practices is that they at
least feel personally vulnerable to HIV/STD infections. However, both the Moroccan and the
Turkish boys do not think that the risks in the Netherlands are high. In contrast, perceived risk
about getting infected in Turkey or Morocco is much higher, partly because many boys have
unprotected sex with prostitutes during their holidays in these countries. As one of the
Turkish boys remarked “there [In Turkey], risks are high”. Another boy agreed with him by
stating that risks in Turkey are “very high, they do not use condoms over there”.
In general, when talking about risks, the boys make a sharp distinction between “sluts”
and “decent girls”, and feel confident that they can select a “decent girl”, based on her
appearance and previous sexual behavior. When the girl is not a virgin anymore, some boys
ask her about the number of previous sex partners she has had. When the girl has had several,
she is considered unclean and a slut. In these cases, a condom is often used. Thus, many boys
are convinced that their selection abilities reduce the risk of HIV/STD infections, because
they know with whom they are doing it with:

MB: Two years ago, beach party, nice ladies. I don’t drink, but she did, and one thing
led to another. I didn’t get a test afterwards, but the chance that she was infected
with HIV was 0%.
CvdV: How do you know?
MB: I found out that she had been married. She was recently divorced, and I was the
second one who had had her. I don’t think anything has happened. She was not
one of those chicks who sleep around.

A few did not agree with the low risk perceptions as expressed by the majority, and felt
that they had to correct them in some way:

MB1: Here in the Netherlands, it is safe.

MB2: Safe? Get lost. You cannot trust anyone here. Just use a condom boy.

Besides the low risk perceptions, other factors that might decrease condom use are the
negative beliefs associated with condom use. In both the Turkish and Moroccan groups, the
most frequently mentioned disadvantage of condom use was the reduced feeling during
sexual intercourse and the diminishment of sexual pleasure. Or, as one of the boys remarked:
“It is less pleasant. It feels like my penis is imprisoned”. A lot of the Moroccan boys also
thought condoms are too expensive. Almost none of the Turkish boys mentioned the price of
condoms as a disadvantage, which might be a reflection of the higher socio-economic status
of Turkish people in the Netherlands as compared to the Moroccans.
Both the low perceived vulnerability and the diminished feeling associated with condom
use might function as barriers to actually using condoms during sexual intercourse. However,
both the Turkish and Moroccan boys express a lot of fear of unwanted pregnancies. During
428 Barbara C. Schouten and Chana van der Velde

the group discussions it became clear that condoms are primarily used for preventing
pregnancy, and not so much to prevent HIV/STDs, because when a girl gets pregnant the boy
may be forced to marry her. In fact, a few boys actually had experiences with pregnancies.
Because of their focus on preventing pregnancies, when a girl is on birth control pills,
condom use is sometimes considered over the top. However, condom use may be enhanced
when the girl is not trusted:

TB1: A friend got a blow-job by a desperate girl which was totally in love with him.
She kept the sperm in her mouth and put it into her pussy afterwards. Then, she
got pregnant.
TB2: Don’t take any risks when a girl is in love with you. Sperm stays alive for three
days.

When asked who should be responsible for carrying condoms with them, most
participants think that the boy is mainly the one who should take care that a condom is
available, in particular when they go out during the weekend. “Before you go out, you just
take them with you: perfume, gel, money, condom” (Moroccan boy). They feel that it is not
only necessary to carry a condom for themselves, but also to be able to help out a friend who
might need it. In a steady relationship however, most boys think that both parties share
responsibility for carrying condoms with them.

Self-efficacy

Self-efficacy, or the extent to which one is convinced one can successfully execute
behavior that is required to produce certain outcomes (Bandura, 1977), has been found to be
positively related to actual condom use (e.g. Godin, Gagnon, Lambert, & Conner, 2005;
Sheeran et al., 1999). Besides self-efficacy toward using condoms, the literature on safe sex
behavior has also identified self-efficacy toward buying condoms and self-efficacy toward
talking about using a condom with a sex partner as possible predictors of actual condom use.
The level of Moroccan and Turkish boys’ self-efficacy clearly depends on the specific
behavioral aspect in question. In general, they reported low levels of self-efficacy with
respect to buying condoms, but seemed to have more confidence in using them and discussing
condom use with girls.
Most boys said that buying condoms makes them feel embarrassed, in particular when the
counter-assistant in the drugstore is a Muslim girl wearing a headscarf. Besides feelings of
embarrassment, fear of running into family members or acquaintances was frequently
mentioned too. The Turkish boys reported more hesitancy in this regard than the Moroccan
boys, probably because they are monitored more closely by their parents and other family
members, and hence, are more afraid to get caught. To solve this problem, some send
someone else to buy condoms for them, such as older brothers or friends, while others get
their condoms from condom dispensers. A few Turkish boys mentioned going to other
neighborhoods to buy condoms:
 Living in Discrepant Worlds 429

TB: In multicultural neighborhoods with a lot of Turkish and Moroccan people, I

don’t go there. I have my favorite store, I go to Amsterdam-South, where Dutch
people are.

Technically speaking, using condoms is not regarded as something difficult. After two or
three times practicing, the boys know how it works. However, the Moroccan participants say
that they regularly experience situations in which they have less control over using a condom,
such as when they drink too much alcohol or when they are very horny. In these situations,
the chance of having unsafe sex is much higher than usual.
Contrary to findings of previous research (e.g. von Bergh & Sandfort, 2000), the so-
called interaction competencies of both groups of boys seem to be sufficient. Discussing
condom use with girls is seen as self-evident. Within steady relationships, the boys talk with
their girlfriends about whether or not to use a condom and who is responsible for buying
them. Bringing condom use during sex up for discussion is more difficult among younger
boys and during one-night stands.

Social Norms

The Turkish participants were generally more conservative than the Moroccan
participants, in particular with regard to the virginity standard for women. They could not
imagine marrying someone who is not a virgin. The Moroccan boys were less strict, and some
indicated that it is not necessary for them to marry a virgin. Or, as one of them said: if you
yourself are not a virgin anymore, you cannot demand that your spouse is. In general though,
the double standard with regard to the virginity norm was commonly expressed during the
discussions. Few boys think that they should abstain from sex until marriage, as they feel sex
is normal and natural. Furthermore, they frequently mentioned that there is no objective way
to proof that a man is not a virgin anymore, making it unnecessary to abstain from sex until
marriage: “with girls you will find out that she is not a virgin anymore, with boys this is not
the case” (Moroccan participant).
The double standard toward virginity is also reflected in the fact that most parents give
their sons far more freedom than their daughters. They are allowed to go out late at night,
while their sisters should stay in after dark. Although the participants believe that their
parents hope they will remain virgin until marriage, they also state that their parents are
probably aware of the fact that they are sexually active. As long as sexual activities are not
openly done or discussed, they are tolerated.
As it is strictly forbidden for many Muslim girls to engage in any form of sexual activity
before marriage, most Turkish boys prefer to have sex with Dutch girls. They seem to be very
afraid of the consequences when they get caught with a Turkish girl. A Turkish girl that has
lost her virginity can use this to force the boy into marriage, or even worse, it might induce
honour-related violence. Although exact numbers on honour-induced violence are not
available in the Netherlands, the Dutch media have repeatedly reported on cases in which
people have been attacked because they violated the honour of Turkish families. Hence, the
Turkish boys rather not take any risks:
430 Barbara C. Schouten and Chana van der Velde

TB1: With Turkish girls, you cannot do that much because you are afraid of her parents
and brothers. We will get into trouble then. It can happen that someone beats you
up.
TB2: That will turn into fighting.
TB3: That will turn into war.
TB4: Of course he [the brother] is going to fight with you when you touch his sister; of
course he is going to do some odd things.

The Moroccan boys are less afraid of having sex with Moroccan girls, probably because
in their community honour-related violence does not take place as much as in the Turkish
community. In fact, many believe that more and more Moroccan girls have sex before
marriage, and reported that they secretly had sex with them. However, because Moroccan
girls still like to stay virgin until marriage, they often prefer anal sex, which the boys do not
particularly like, partly because it is forbidden according to Islam. Hence, just like the
Turkish boys, the Moroccan boys mainly have sex with Dutch girls.
When discussing the topic of homosexuality with the focus group participants, some
indications for a double standard emerged among the Moroccan boys, but not among the
Turkish boys. That is, although both groups expressed very negative attitudes toward
homosexuals, they also said homosexual behavior happened frequently among Moroccans,
but not among Turks. Despite the fact that Moroccans openly mention the existence of
homosexual behavior though, the opinions they express about homosexuality are far more
negative than the opinions of the Turkish boys. Almost all say it is unnatural and disgusting,
and one of the Moroccan boys even states that “if you are homosexual you should get a death
sentence and fall down from the highest building there is”. A few disagreed and feel that
everyone should life their own life:

MB1: It’s unacceptable [homosexuality].

MB2: What do you mean with unacceptable? Are you a radical or something? I think it
is acceptable; I have a friend too who is gay.

Among friends, having safe or unsafe sex is not a topic of discussion. A majority of the
boys feel that someone’s sex-life is private, and should not be discussed in detail. The
reluctance to talk about sex was also evident during the group discussions with the Turkish
boys. They were quite timid, in particular the younger ones, and it was obvious that most of
them were not used to talking about sexuality with others. The Moroccan boys were more
assertive, and felt less embarrassed to discuss their sex-lives. Although the participants
claimed that they do not talk about condom use with friends, a few mentioned that they
learned in an indirect way that some friends have unsafe sex. However, they withhold
judgments about it and say that everyone should decide for themselves what they do (what
should I think about it? If he finds it pleasant [sex without condoms], why not; Moroccan
boy).
Although they do not talk much with their friends about their sex-lives, having sex is
mutually stimulated. It is regarded as cool to “score” girls and to have regularly sex with
different girls. The boys also express a lot of macho-behavior toward each other. Not having a
girlfriend seems to be against the norm (“It is normal to have a girlfriend. It’s part of life”.
Turkish boy), and peer-pressure is common:
 Living in Discrepant Worlds 431

MB: If you walk by with a girl, then they will ask: hey, did you already have sex with
her? She looks good! When was the last time you got laid?

Education

The boys hardly discuss sexual matters with their parents. Even if parents know that their
son has a girlfriend (most keep relationships secret from their family), they do not talk about
it. Only one or two Turkish boys said that they can talk with their mother about love, but even
then, sexual topics are taboo. In a few cases, such as when a condom has been found by one
of the parents, the father briefly addresses the topic of safe sex. The boys themselves do not
want to communicate about sexuality with their parents as well, partly out of embarrassment,
partly out of respect for their parents. A few of them are aware that there are no religious
reasons for not talking about sexuality, and that the Koran outlines that young people should
be educated about sexuality to prepare them for marriage. But as a rule, parents do not give
their sons any sexual education.

MB1: Did you know that the Islam says that sexuality should be discussed in order to
educate children?
MB2: My grandpa only says: stay away from girls.

If the boys discuss their sexual lives, it is with their friends or family members from their
own generation and gender, such as older brothers and cousins. However, most do not talk to
others about sex; they feel it is a private matter.
Because of the lack of communication at home, to get some sexual education most of the
Turkish and Moroccan teenagers are dependent upon other information sources. A lot, but not
all of them, have received some sexual education at high school. They are taught about it by
means of books, leaflets, and sometimes video. They discussed the content of the materials
with their teacher, who also often has demonstrated how to use a condom. Most boys liked
the videos and discussions, but the written materials are found quite boring. Furthermore, as a
lot of the boys start early with sex, they feel the school-based education is often too late for
them and should be given earlier.
The internet is an often used medium to gather more information about the technical
aspects of sexuality, such as facts about virginity and pregnancy:

TB: Just open the internet and write “can you get pregnant when you have sex without a
condom?”. And then you read the site which offers the most information.

Almost none of the participants use the internet to search for information about
HIV/STDs. Pornographic sites are regularly visited, which may explain why the internet is
often used secretly. The same holds true for television. Rarely do the boys watch programs
with an educational content; erotic programs are often watched though.
When asked which kind of education they prefer, most participants say that they find
talking about sexuality more effective than reading about it, which might be a reflection of the
fact that Turkey and Morocco are traditionally predominant oral cultures. A woman is
preferred over a man, and a few propose to use prostitutes or people with Aids as educators.
432 Barbara C. Schouten and Chana van der Velde

In general, the younger participants indicate that they have a greater need for education and
information than the older ones. The fact that almost all boys ask a lot of questions during the
group discussions and have low levels of knowledge however, suggests that more specific
education would be no luxury for the older boys as well.

CONCLUSION
The results of our study show that there are a number of noteworthy differences between
Turkish and Moroccan teenagers. For instance, Turkish boys have more conservative views
regarding some aspects of sexuality, such as the virginity of their future bride. Because
Turkish people in the Netherlands strongly identify with their ethnic group (see also Pels,
2004) there is also more social control present, which may result in sticking more strongly to
traditional norms. For instance, having sex with a Turkish girl is perceived as extremely risky,
because of possible acts of revenge from the girl’s family. Moroccan groups on the other hand
are more loosely defined and there is less social control, making honour-induced violence less
likely to take place. Therefore, they can more readily have sex with Moroccan girls, albeit
still in secret. In general, results of our group discussions give the distinct impression that,
overall, Moroccan adolescents more frequently experiment with sex than Turkish boys,
placing them at higher risk of getting infected with HIV/STDs.
Our focus group discussions point to a number of similarities between the Turkish and
Moroccan group as well. The lack of knowledge has been repeatedly found and may be an
important barrier in practicing safe sex. The embarrassment felt when discussing sexual
matters in the Turkish focus groups may not only be an indication that communicating about
sex is taboo, but might also reflect this lack of knowledge. Moreover, the participants asked
many questions about a wide variety of subjects, suggesting that they feel insecure about their
current levels of knowledge and are curious and motivated to learn more. As communication
at home is practically non-existent, information about sexuality should be transferred through
other communication channels, such as peers and mass media. School-based education can be
an effective way to enhance knowledge levels as well, as long as it is brought about in a vivid
and oral manner. As many boys start with sex at an early age, it is recommended to introduce
these programs at an earlier phase in the school curriculum than is usually done though.
Although the focus group participants are aware that having sex without a condom can
result in HIV/STDs infection, their perceptions of the actual risks are rather low. They often
referred to the high risks in Turkey and Morocco to contrast the “safe” situation in the
Netherlands. Furthermore, most boys do not feel personally vulnerable to HIV/STDs
infections, because they have confidence in their ability to select a partner who is clean and
free of disease. This finding corresponds with previous research (Henndrickx et al., 2002),
and may prevent them from using condoms with partners they actually know very little about.
In addition, condom use is often refrained from in relationships in which the girl is on birth
control pills, largely because condom use is more strongly related to preventing unwanted
pregnancies than to prevention of HIV/STDs. As these relationships may very quickly be
judged as steady, and many boys are not faithful to their steady girl, this may augment the
chance of not using condoms in possible high-risk situations. In essence, the sharp and
unrealistic distinction these boys make between decent, clean girls on the one hand and sluts
 Living in Discrepant Worlds 433

on the other hand, may give rise to practicing unsafe sex with so-called “clean” girls and
should be addressed in health prevention programs.
In contrast with previous studies, we did not find much evidence for difficulties in
bringing up condom use with sex partners. The often mentioned lack of interaction
competencies in earlier research (e.g. von Bergh & Sandfort, 2000; de Graaf et al., 2005) did
not seem to be present among our focus group participants. This discrepancy in findings
might be explained by the possibility that the interaction competencies among Turkish and
Moroccan adolescents have actually improved during the last couple of years. Factors that
have been shown to be related to stronger interaction competencies are a better social
integration, more knowledge about HIV/STDs, a strong focus on sex and a positive body
image (de Graaf et al., 2005). It is possible that some of these aspects have increased the last
couple of years, thereby increasing interaction competencies. Equally possible is that the
difference in outcome is attributable to a selection bias: the adolescents who participated in
our study were perhaps more competent with respect to interacting with girls than the average
Turkish/Moroccan teenager. Discussing sexuality during focus group sessions presupposes a
certain ability and willingness to communicate about this topic. As such, the boys who
participated in our study might have been more competent overall in this respect than the
average participant of survey research. Further quantitative research is needed to establish
whether the interaction competencies have actually increased or not.
Some other important factors that were identified during the discussions as possible
barriers to condom use were a negative attitude toward condom use because of reduced
pleasure, financial (mainly mentioned by Moroccan teenagers) and psychological obstacles in
buying condoms, and loss of control when being under the influence of alcohol (mainly
mentioned by Moroccan teenagers). Although the impact of alcohol use on lack of condom
use has been well-documented, it was somewhat surprising to find this to be an aspect of
significance in this particular sample, because drinking alcohol is forbidden in Islam. In
practice though, the Moroccan participants do drink alcohol when going out during the
weekend, and might find themselves in high-risk situations in these cases. Health promotion
programs should therefore address alcohol drinking and sexual activity together, and research
should be conducted to determine the prevalence of drinking and sexual activity among
Moroccan and Turkish youth. Finally, a last aspect that is worth referring to in health
promoting interventions on safe sex is the social pressure of peers to have sex. There seems to
be a social norm that it is cool to score girls, share girls, and have sex on a regular base. In
contrast, there is no social norm toward having safe sex. Condom use is hardly discussed
among peers, as it is considered to be a private affair. This strong focus on macho-behavior
should be addressed and if possible, reversed.
To conclude, our analysis of the focus group discussions with Turkish and Moroccan
teenage boys has pointed to a range of factors that places their sexual health at risk. Some of
the identified factors correspond with previous (survey) evidence, such as the low levels of
knowledge and the absence of perceived vulnerability of getting infected with HIV/STDs.
Other factors are inconsistent with previous findings, such as our results with regard to the
interaction competencies of the Moroccan and Turkish boys. By running focus groups with
both Turkish and Moroccan adolescents, we were able to focus on areas of similarities and
differences between both groups, which may provide health educators with some clues on
how to effectively tailor safe sex programs for these teenagers. To decrease the chance of
HIV/STDs infections among these groups, it is essential to develop such culturally
434 Barbara C. Schouten and Chana van der Velde

appropriate health education programs. The present study can be seen as a first step in getting
closer to this aim.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 25

HIV/AIDS PREVENTION ON MEXICAN

ADOLESCENTS: THE SYNTHESIS OF TWO THEORIES
CONSIDERING THE INTERPERSONAL, INDIVIDUAL,
AND PSYCHOLOGICAL INFLUENCES

Raquel A. Benavides-Torres1, Georgina M. Núñez Rocha2, Esther C.

Gallegos Cabriales1, Claude Bonazzo3, Yolanda Flores-Peña1,
Francisco R. Guzmán Facudo1 and Karla Selene López García1
Universidad Autónoma de Nuevo León; Nuevo León, México 1
Instituto Mexicano del Seguro Social; Nuevo León, México2
University of Texas at Austin; Texas, USA3

ABSTRACT
In Mexico, HIV/AIDS is a complex public health issue that carries significant
psychosocial, socio-political, and economic repercussions. Adolescence is a period of
development that not only encompasses physical and social changes, but also
psychological. Adolescents engaging in unprotected sexual activities during this stage of
development are at risk of contracting HIV infections. This paper posits that the Theory
of Planned behavior has shown to be helpful in guiding research in HIV/AIDS
prevention, but remains limited in the inclusion of ecological influences. Hence, this
limitation is addressed using the Ecodevelopmental Theory. Therefore, this paper aims to
develop a model based on the Theory of Planned Behavior and the Ecodevelopmental
Theory that will explain HIV/AIDS prevention within the context of Mexican adolescents
using concepts from both theories and the empirical evidence available. Three types of
influences were identified during the process of theory synthesis: a) Interpersonal
influences from the microsystem were parent communication about sex and peer
influences; b) Individual influences included HIV/AIDS knowledge, gender (female), and
age; and c) psychosocial influences consisted of perceived behavioral control for sexual
health behaviors, subjective norms (gender roles), positive HIV attitudes, and sexual
intentions. Results provide insight into the complex dynamics of the synthesis of the two
aforementioned theories with respect to HIV/AIDS prevention. Communication about sex
438 R. A. Benavides-Torres, G. M. Núñez Rocha, E. C. Gallegos Cabriales et al.

is positively related to sexual health behaviors for HIV/AIDS prevention, being female,
and knowledge about HIV/AIDS. Peer influence is negatively correlated with sexual
behaviors for HIV/AIDS prevention. It is unclear the relationship of HIV/AIDS
knowledge and sexual behaviors and being female. Gender (female) is positively
correlated with sexual behaviors and perceived behavioral control, but its relationship is
unclear with subjective norms. Age is positively correlated with subjective norms, but
negatively correlated with sexual health behaviors. Perceived behavioral control and
positive attitudes are positively correlated to intentions and sexual health behaviors. In
the case of subjective norms, it was positively correlated with intentions, but not with
sexual behaviors. Finally, high intentions to use condoms influence sexual health
behaviors. The final model allows for a better understanding of the connections among
concepts related to sexual health behaviors in HIV/AIDS prevention. Future research is
recommended regarding the unknown associations between gender, knowledge,
subjective norms, and attitudes for future implementation of preventions programs
against this fatal disease in the Mexican Adolescents.

Keywords: HIV/AIDS prevention, adolescents, interpersonal influences, individual

influences, psychosocial influences

Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus

(HIV) first appeared in the 1980s and quickly became a pandemic illness. Since then, more
than 25 million people have died of AIDS worldwide. Every day around 6,800 people become
infected with HIV (Joint United Nations Program on HIV/AIDS [UNAIDS] and The World
Health Organization [WHO], 2007). In Mexico, as in other Latin American countries,
HIV/AIDS is a complex public health problem which has repercussions in psychosocial,
socio-political, and economic areas (United States Agency for International Development
[USAID], 2005). The proportion of HIV-positive people in Mexico is 4.4 per 100,000 and
has remained stable for 12 years (Secretaría de Salud, 2005). Most HIV/AIDS cases in
Mexico resulted from homosexual and bisexual transmission. However, heterosexual
transmission is increasing at a high rate and now accounts for 39% of total cases (Santos et
al., 2003; Instituto Nacional de Geografia en Informática [INEGI], 2004).
In the last decade, HIV/AIDS was the 17th highest cause of death in Mexicans aged 15 to
29, yet now it is the fourth highest cause of death in this group (INEGI, 2005). Considering
that a person can be infected with HIV for 2 to 10 years without displaying any symptoms of
AIDS, many of these infections may have occurred during adolescence (UNAIDS, PAHO,
UNICEF, & WHO, 2004). Adolescence is a period of development that not only includes
physical and social elements, but also emotional. It is a time when youths are extremely
vulnerable and they must come to grips with their changing bodies. With the development of
secondary sex characteristics, sexuality becomes an increasing concern for adolescents and
the manner in which they respond to these changes contribute to their overall identity and
sexual health. In urban areas, the mean age for first sexual intercourse is 16.7 years (Gayet &
Solis, 2007; González-Garza, Rojas-Martínez, Hernández-Serrato, & Olaiz-Fernández, 2005).
The use of condoms at this age is not a primary concern because the focus tends to center on
unwanted pregnancies rather than HIV/AIDS prevention. It is imperative to better understand
how adolescents become involved in risky sexual behaviors regarding HIV infections, since
the rate of contracting AIDS is increasing rapidly among adolescents (Santos et al., 2003). In
efforts to understand this problem, the Secretaria de Salud (Health Secretariat, 2002) created a
 HIV/AIDS Prevention on Mexican Adolescents 439

program for HIV/AIDS prevention for Mexican adolescents, but the appropriate framework
for Mexican population remains missing in this project.
Nowadays, health professionals’ efforts toward understanding this specific phenomenon
have been meticulous. Some of these efforts have delineated the role of each participant in the
health care team to carry out actions against HIV/AIDS. Using multidisciplinary theories may
help to better understand the phenomenon of HIV/AIDS prevention regarding Mexican
adolescents (Villarruel, Bishop, Simpson, Jemmott, & Fawcett, 2001). A cursory review of
the literature reveals that HIV/AIDS prevention studies frequently used two models to guide
their research: the Theory of Planned Behavior (Ajzen, 1991) and the Ecodevelopmental
Theory (Bronfenbrener, 1979). It is important to mention that most of the work has focused
on people in the United States, but knowledge on how to translate this data with regard to
Mexican adolescents will provide a significant contribution in the fight against HIV/AIDS in
Mexico. Therefore, this paper aims to develop a new model based on the Theory of Planned
Behavior and the Ecodevelopmental Theory that offers an explanation of HIV/AIDS
prevention within the context of Mexican adolescents.

MODEL DEVELOPMENT PROCESS

The process of theory synthesis for theory development described by Walker and Avant
(2005) was used to construct the model of HIV/AIDS prevention in Mexican adolescents.
Prior to carrying out the theory synthesis process, two additional activities were performed.
The first activity consisted on reviewing the two theory analyses conducted by Rew (2005) on
the Theory of Planned Behavior (p. 237) and the Ecodevelopmental Theory (p. 76) in order to
determine if these two theories were suitable to represent this phenomenon. The second
activity focused on the examination of the theoretical prepositions and concepts of interest
from each theory to organize the theory synthesis process.

THEORY OF PLANNED BEHAVIOR

The Theory of Planned Behavior is an extension of the Theory of Reasoned Action
(Ajzen & Fishbein, 1980). The principal assumption in the former theory suggests that a
person’s behavior is determined by his/her intention to perform the behavior; thus the best
predictor of behavior is intention (Ajzen, 1991). Intentions implicitly rely on the motivational
factors that influence the adolescents’ sexual behavior; motivations imply the willingness and
hardiness of the adolescents’ degree of planning regarding performing the sexual behavior
(Ajzen, 1991). This intention is determined by the person's beliefs about the outcomes of the
behavior and beliefs about what other people think the person should do (Ajzen & Fishbein,
1980). A belief is a degree of certainty one has that something is true. Moreover, beliefs
surrounding the carrying out of a particular behavior are a function of the salient information
gathered from the positive and negative evaluations of the consequences of a human behavior
(Ajzen, 1991).
The theory of planned behavior is composed by a limited number of psychological
variables: intentions, attitudes, subjective norms, and perceived behavioral control
440 R. A. Benavides-Torres, G. M. Núñez Rocha, E. C. Gallegos Cabriales et al.

(Albarracin, Johnson, Fishbein, & Muellerleile, 2001). Different studies have shown that the
theory of planned behavior is useful for explaining the phenomenon of HIV/AIDS prevention
(Bennett & Bozionelos, 2000; Bogart, Cecil, & Pinkerton, 2000; Cooke & Sheeran, 2004; De
Wit, Stroebe, De Vroome, Sandfort, & Van Griensven, 2000; Hagger & Chatzisarantis, 2005;
Jemmott, L., Jemmott, J., & Villarruel, 2002).

ECODEVELOPMENTAL THEORY
The Ecodevelopmental Theory was created based on the Social Ecology Theory
(Bronfenbrenner, 1979), the Structural System Theory (Minuchin & Fishman, 1981),
multisystems intervention (Henggeler & Borduin, 1990), and lifespan development
approaches (Baltes, Reese, & Nesselroad, 1977). The theory allows for examining the
influences on sexual behaviors within various environmental and developmental contexts.
The use of this theory is appropriate because it states the protective and risk factors do not
operate in isolation (Rew, 2005). Bronfenbrenner’s theory defines “layers” of environment,
each having an effect on an adolescent’s development. It is important to mention that these
layers interact with each other and that adolescent behaviors may be explained by a
combination and interaction of the various systems. The microsystem contains the structures
with which the adolescent has direct contact. At this level, relationships have an impact in
two directions: from the adolescent and toward the adolescent. These bi-directional influences
occur among all levels of environment. Both the interaction of structures between and within
layers are important to this theory. Bi-directional influences are strongest and have the
greatest impact on the adolescent.
After reviewing both theory analyses, we can conclude that the theory of planned
behavior has shown to be helpful for guiding research in HIV/AIDS prevention, but remains
limited in the inclusion of interpersonal influences. As Walker and Avant (2005) have stated,
one of the purposes of theory analysis is to determine the necessity of creating a new theory.
Hence, this limitation will be addressed using the ecodevelopmental theory. Concepts from
both theories will guide the development of a new model for HIV/AIDS prevention in
Mexican adolescents using the empirical evidence available. The method of theory synthesis
was selected for this development.

LITERATURE REVIEW
This review utilizes the recommendations for literature reviews set out by Cooper (1998).
The literature search included all documents that contained the following words in either
English or Spanish: HIV prevention, AIDS prevention, or HIV/AIDS prevention, and
adolescents and Mexico in the title, abstract, and/or keywords. The search included databases
such as Academic Search Premier, Cinahl, Medline, PsycInfo, PubMed, PsycArticles, Health
Source, Sociological Collection, and Google Scholar. This search identified 91 items of
interest, but after thorough examination of the content, most showed only epidemiologic data
about HIV or AIDS in Mexico and omitted factors associated with sexual behaviors.
Publications should meet the following criteria: a) a publication year from 1995 to 2008, b)
 HIV/AIDS Prevention on Mexican Adolescents 441

the presentation of empirical data associated with sexual health behaviors for HIV/AIDS
prevention, and c) comprise of journal articles with peer review or published governmental
reports. After this process, a total of 50 articles were excluded from the analysis because they
failed to meet the keywords, the criteria above, or did not include Mexican adolescents as a
target population.

DATA EXTRACTION
A total of 41 studies were systematically reviewed, with the publication years ranging
from 1995 to 2008. Twenty five of the studies were carried out in school settings or with
students, and the rest with adolescents in general. The ages of the adolescents ranged from 10
to 20 years. All studies included descriptive statistics in their analyses, more than half (56%)
included inferential statistics in their analyses, three studies had a quasi-experimental design,
and the rest experimental design. Only 11 of the studies were guided by a framework. The
following section will describe the synthesized information according to category influences
(interpersonal, individual, and psychosocial) and their association with sexual health
behaviors for HIV/AIDS prevention.

Note: (+) indicates positive associations, (-) indicates negative associations, and (?) unknown
associations. PBC=perceived behavioral control, SHB=sexual health behaviors, GR=gender roles.

Figure 1. The model of HIV/AIDS prevention on Mexican Adolescents.

442 R. A. Benavides-Torres, G. M. Núñez Rocha, E. C. Gallegos Cabriales et al.

THEORY SYNTHESIS
Theory synthesis is a strategy aimed at constructing theory, i.e. an interrelated system of
ideas from empirical evidence (Walker & Avant, 2005). Sources of empirical evidence
included all studies (41 publications) focused on the concept of sexual behaviors in
HIV/AIDS prevention in the Mexican population. A literature review was conducted to
identify the variables selected from the microsystem of the ecodevelopmental theory
(interpersonal and individual influences) and the theory of planned behavior (psycosocial
influences: attitudes, subjective norms, perceived behavior control, and intentions,) and their
links with HIV/AIDS prevention. The model of HIV/AIDS prevention regarding Mexican
adolescents is presented in Figure 1.

THE MODEL OF HIV/AIDS PREVENTION

REGARDING MEXICAN ADOLESCENTS

Interpersonal Influences

Parent–child communication about sex plays an important role in adolescent sexual

health (Benavides, Bonazzo, & Cruz, 2007). Adolescent girls who had talked frequently with
their mothers about sexual concerns had lower probabilities of begining sexual activity, and
higher probabilities of using contraception for those who were sexually active (Pick & Palos,
1995). Other studies explored the factors associated with sexual experiences in adolescents.
Reported data included a higher percentage of parent–child communication in females as
compared with males and females also perceived it as being more clear and direct than did
males. Communication about sex was found to have a significant influence on the use of
contraceptives (Benavides, Torres, & Bonazzo, 2006; Huerta, 1999). In addition, those
adolescents who received information from their parents about sexuality were more likely to
have higher levels of knowledge about HIV/AIDS (Tapia et al., 2004). From a qualitative
perspective, Stern, Fuentes, Lozano, and Reynoso (2003) reported that male adolescents in
their study received counseling from their mothers about sexuality. Communication about sex
represents an inclination in relation to gender. Females prefer to talk with their mothers
whereas males have a preference to talk with their fathers (Gayet, Rosas, Maguis, & Uribe,
2002). Another study mentioned that most adolescents receive information about sex from
their teachers and when they have specific sexual issues, they look for counseling from their
parents (Pineda, Ramos, Frias, & Cantu, 2000).
Friendship is important in adolescents’ development and peers have a significant
influence on adolescents’ behavior (Pennsylvania State University, 2002). Youths prefer to
receive information from peers rather than from adults because they feel more confident when
talking about sex with adolescents of a similar age (Family Health International, 1997).
Another study involving work with adolescents found that the perception of a permissive
environment was a predictor of sexual activity. Adolescents who were aware of fellow peers
engaging in sexual activity were more likely to engage in sexual risky activities such as the
use of alcohol and unprotected sex (Rasmussen, Hidalgo, & Alfaro, 2003). Adolescents who
were influenced by friends, boyfriend, and/or girlfriend regarding sex had a higher probability
 HIV/AIDS Prevention on Mexican Adolescents 443

of engaging in sexual activity (Stewart et al., 2001). Hence, interpersonal influence such as
communication about sex is positively related to sexual health behaviors in HIV/AIDS
prevention, to being female, and to knowledge about HIV/AIDS. Peer influence was
negatively related to sexual health behaviors for HIV/AIDS prevention.

Individual Influences

Sexual activity has a significant increase related to age. Adolescents at 12 years of age
reported almost no sexual activity, but more than half have had sex at 19 years of age (Gayet,
Juarez, Pedrosa, & Magis, 2003; Gayet & Solis, 2007). Congruent with this finding, Martinez
(2003) and the Population Council (2002) found that older adolescents are more likely to
engage in sexual activity and less likely to use condoms. The use of condoms during first
intercourse was significantly different according to gender. One in two males versus one in
five females used a condom during their first sexual intercourse. Today, however, those
females report higher percentages of condom use than do males (Gayet et al., 2003; Torres,
Walker, Gutiérrez, & Bertozzi, 2006). Another study found that, when controlling for age,
males were more likely to be sexually experienced and to have sexual knowledge than
females. In addition, when controlling for the probability of having had sex over the three
months prior to questioning, females were more likely to have had unprotected sex than were
males (Martinez et al., 2004). Further findings suggest that the mean age at which sex takes
place before 15 years of age is higher for boys than it is for girls (Stewart et al., 2001).
A study reveals that knowledge about HIV/AIDS is a predictor for condom use when
controlling for gender (male) and high socioeconomic status (Villasenor, Caballero, Hidalgo,
& Santos, 2003). Another study shows that males with higher levels of knowledge about
HIV/AIDS increased the likelihood of condom use. On the other hand, females with higher
levels of knowledge were more likely to have only one lifetime sexual partner (Tapia et al.,
2004). This finding was contradictory to another study that found knowledge to be unrelated
to sexual behaviors (Robles, Piña, & Moreno, 2006). In relation to knowledge about sexually
transmitted diseases (STDs) between sexually active adolescents, one quarter of males versus
one half of females know at least one method of protecting against STDs (Caballero,
Villasenor, & Hidalgo, 1997; Gayet, et al., 2003). This was inconsistent with other studies
that affirm that males knew more about HIV and STDs than did females (Givaudan, Van de
Vijver, Poortinga, Leenen, & Pick, 2007; Madrazo, Castellanos, Huerta, Tarazco, & Marco,
2007; Torres, Walker, Gutierrez, & Bertozzi, 2006). Thus, we can conclude from the
individual influences that there is an unclear relationship of HIV/AIDS knowledge and sexual
behaviors and being female. Gender (female) is positively correlated with sexual behaviors
and perceived behavioral control, but their relationship is unclear with subjective norms. Age
was positively correlated with subjective norms, but negatively correlated with sexual health
behaviors.

Psychosocial Influences

Attitudes toward performing a behavior are a function of cognitive belief structures with
two subcomponents: an individual’s beliefs surrounding carrying out a particular behavior
444 R. A. Benavides-Torres, G. M. Núñez Rocha, E. C. Gallegos Cabriales et al.

and the positive and negative evaluations of those consequences (Ajzen, 1991). Males were
more likely to agree somewhat or completely with the perception that condoms make sex less
exciting, romantic, pleasurable, and make them appear too experienced than were females
after controlling for age and sexual experience. In general, males held more negative attitudes
about condoms than did females (Martinez, Melbourne, Hovell, et al., 2004). Another study
involving a focus group showed that adolescents do not believe that AIDS is a homosexual
disease. The focus group believed that AIDS was a fatal disease that could be prevented and
that using condoms was very important. More than half of the participants indicated that
adolescents do not know how to use a condom (Villarruel, Gallegos, Loveland, & Duran,
2003). Adolescents’ attitudes with respect to people living with HIV were related to being
unhealthy and participants did not think that HIV-positive adolescents should continue in
school (Stewart et al., 2001). In addition, adolescents with negative attitudes such as
“condoms reduce pleasure” were less likely to have risky sexual health behaviors than those
with positive attitudes (Gallegos, Villarruel, Loveland, Ronis, & Zhou, 2008; Perez & Pick,
2006; Robles, Piña, & Moreno, 2006). One study found that adolescents with high levels of
sexual knowledge have more positive attitudes about condoms such as “the condom protects
me form HIV” (Posada, 2008).
Subjective norms include the perception of approval or disapproval when performing an
action (Rosengard et al., 2001). Most of the literature that related to subjective norms
explored sexual behaviors in relation to gender. Going beyond biological aspects, gender role
includes masculine and feminine behavioral norms differentiated by sex (Tolman, Striepe, &
Harmon, 2003). In a qualitative study on masculinity and sexual health, male adolescents
described that being seen as “macho” implies being responsible, respecting females, and
providing for their family. Male adolescents described that using condoms depended on their
sexual partner. For example, it is more likely that they will use a condom if they have sex
with “easy” girls than if they have sex with their girlfriend (Stern et al., 2003). Another
qualitative study discussed the aspects related to gender roles and condom use: females are
disadvantaged with an unfavorable reputation if they carry condoms and suggest their use. On
the other hand, boys think that contraception is a feminine matter and stated that “a man can
go as far as a woman wants” therefore, every unwanted consequence is a women’s
responsibility (Castro, 2000). Gayet et al. (2003) in a quantitative study showed that in
general females and males think that boys should propose condom use. The association
between gender roles and gender is unclear because both males and females perceive roles in
relation to gender.
Perceived behavioral control includes an adolescent’s confidence as regards to
performing a specific action (Notani, 1998). Students from an urban area in Mexico had low
levels of self-efficacy in sexual behaviors regarding HIV/AIDS prevention. This study
explored the perceived capacity for abstinence, talking with partners about sexual history, and
the use of condoms. Findings suggested that female adolescents have significantly higher
levels of self-efficacy for the aforementioned activities than do males (Martinez, Blumberg, et
al., 2004; Lopez, 1998). Moreover, after controlling for age and sexual experience males
reported less self-efficacy in refusing to have sex without a condom than did females
(Marinez, Melbourne, et al., 2004). In addition, adolescents with higher levels of self-efficacy
regarding AIDS prevention are more likely to delay sexual activity, use condoms, and
practice abstinence (Lopez & Rubia, 2001). In another study it was reported that adolescents´
 HIV/AIDS Prevention on Mexican Adolescents 445

control beliefs about condom use was associated to adolescent intention for condom use
(Gallegos, Villarruel, Loveland, Ronis, & Zhou, 2008).
The Theory of Planed Behavior affirms that the best predictor of behavior is intention
(Ajzen, 1991; Ajzen & Fishbein, 1980). In Mexico, researchers have focused more on the
study of adolescents’ sexual behaviors and their related factors but only few researches with
Mexican adolescents have studied their intentions for sexual behaviors. Studies reported score
means below the midpoint and reported that in general Mexican students had low intentions
to avoid unprotected sex in future encounters (Martinez-Donate et al., 2004; Pergallo et al.,
2005). Diaz-Loving and Villagran-Vazquez (1999) found that 20% of the variance in sexual
behavior was predicted by adolescents’ intention for condom use. Other studies found that
adolescent’s intentions to use condoms for vaginal, oral, and anal sex was related the sexual
behaviors (condom use) (Patterson, Semple, Fraga, Bucardo, Davila-Fraga, & Strathdee,
2005; Piña, Corrales & Rivera, 2008). Some studies have investigated adolescent’s intentions
in terms of gender. Males have reported less intention to avoid unprotected sex compared to
females however, females tend to engage in risk behaviors despite having stronger intentions
(Givaudan, Van de Vijver, Poortinga, Leenen & Pick, 2007; Martinez-Donate et al., 2004).
One study found that 24% of the variance of the intention of condom use was explained in
females with regular partners (Diaz-Loving & Villagran-Vazquez, 1999). In addition, female
adolescents perceptions of what significant others desired of them, perceptions of general
social norms, and whether they were sexually active predicted intentions to have sex (Flores,
Tschann, & Marin, 2002).
Other studies have focused on adolescent’s intentions for sexual behaviors and their
related factors. Behavioral attitudes, norms, and intentions to engage in sexual behavior vary
depending on both the sexual practice and the belief that condom use makes sex safer. In
addition, behavioral beliefs about the utility of condom use and about the pleasure of condom
use found to be the primary predictor of intentions to use condoms with occasional sex
partners (Diaz-Loving & Villagran-Vazquez, 1999). Moreover, attitudes and subjective norms
about the use of condoms are reliable predictors of intentions to perform healthy behaviors in
adolescents. Adolescents’ self-efficacy and attitudes have a direct effect on adolescent’s
intention to use condoms and partner communication in adolescents with and without sexual
experience (Givaudan, Van de Vijver, Poortinga, Leenen & Pick, 2007). Therefore, from the
analysis of the psychosocial variables we can say that perceived behavioral control and
positive attitudes are positively correlated to intentions and sexual health behaviors. In the
case of subjective norms, it was positively correlated with intentions but not with sexual
behaviors. Finally, high intentions to use condoms influence sexual health behaviors.

CONCLUSIONS AND IMPLICATIONS

This paper hypothesized a more sophisticated representation of HIV/AIDS prevention in
Mexican adolescents. This theory synthesis allows for a better understanding of the
connections among concepts related to sexual health behaviors in HIV/AIDS prevention. In
conclusion, interpersonal, individual, and psychological influences are directly or indirectly
related to sexual health behavior in HIV/AIDS prevention. Future research is recommended
on those unknown factors, from associations between “being female and gender roles” and
446 R. A. Benavides-Torres, G. M. Núñez Rocha, E. C. Gallegos Cabriales et al.

“gender roles and positive attitudes on HIV/AIDS prevention”. There was no association
found in the evidence that showed that subjective norms are related to sexual health
behaviors. This finding is contradictory with Hankins, French, and Horne (2000), who found
that subjective norms are one of the predictors of a behavior. Therefore, more research
including the unknown associations between gender, knowledge, subjective norms, and
attitudes is also recommended.
This theoretical model suggests different possibilities for future research toward
confirmation of those associations reported. In addition, more research should be conducted
into the specific mediators and moderators for the proposed relationships. Variables in the
model were taken from two different theories; hence, explorations regarding their interactions
in one model are suggested. This theory synthesis reviewed recent literature and finds that
there is still a gap between the multiple components that intervene for HIV/AIDS prevention
in adolescents. The Ecodevelopmental Theory was helpful to understand the concepts that are
involved in the adolescents´ social environment to further understand their psychosocial
aspects. Considering that this synthesis used the theory of planned behavior and the
ecodevelopmental theory it may be possible to design different interventions at varying levels
according to the adolescents´ needs to fight against HIV/AIDS in Mexico.

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Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 26

ADOLESCENTS WITH CANCER:

ADJUSTMENT AND SUPPORTIVE CARE NEEDS

Luisa M. Massimo
Department of Pediatric Hematology and Oncology
G. Gaslini Scientific Children’s Hospital, Genoa, Italy

ABSTRACT
Adolescence is a difficult in-between age, even in good health, and any kind of
illness can alter this situation. Living with a high risk disease for several years during
adolescence requires the activation of psychological defense mechanisms, cognitive
functions, perception, acceptance, memory, communication, judgment, and emotions,
which taken together mean good coping. The successful evolution of the coping process
ultimately leads to good quality of life and adaptation. Over the last few years, physicians
and clinical psychologists have endeavored to provide a good psychosocial status to their
patients, especially those with cancer and those undergoing painful and distressing
treatments.
At our institution we chose to use the "narrative" approach with our sick adolescents,
since it would appear to be the most suitable in individual encounters. There is often the
need to overcome an important barrier through a friendly approach. Narrative medicine,
more than others, lends itself to the intimate knowledge of the person being examined.
Listening and talking through a patient/doctor alliance are the first steps towards true
psychological healing. Over the last few years we have chosen this sort of dialogue with
our adolescent patients, since they turn to us both seeking the physicians who know them
well and a space where they can talk openly. The narrative approach requires time,
willingness and an appropriate setting. In addition, the supportive care needs of these
youngsters with cancer are often brought up in these encounters and this suggests the
extent to which these needs may remain unmet. The dialogue that takes place following
the “narrative” approach allows us to obtain detailed personal information and insight
into the values and abilities of each subject. Undoubtedly, some psychosocial disorders
can be prevented. Nowadays, pediatricians, supported by psychologists and other
specialists, can create an alliance with the parents and the sick adolescents in order to
adequately face pitfalls that may become the source of disorders in their physical,
cognitive, emotional and behavioral development, and especially with regards to post-
452 Luisa M. Massimo

traumatic stress. Four different situations of adolescents who were either suffering from
or who were cured of cancer are reported in detail in this chapter, including information
concerning their need for understanding, discrepancy in appearance and insight, crisis in
quality of life and the identity process.

INTRODUCTION
Relationships, mostly with sick persons, are tricky. Some of them need to be constantly
and carefully nurtured, others are scarcely interesting, others work easily, but all of them
require give and take. Physicians must always keep this reality in mind in their daily work
with patients and their families. Healthy and sick people, no doubt, have different ways of
responding to the environment, and for adolescents this mechanism can be more highlighted
and even over-stressed. Adolescence is a very special time of life both in normality and in
particular situations such as illness. Most transformations take place at this time of life, and
there is often a discrepancy in physical and cognitive maturity. Several healthy adolescents
have behavioral difficulties, parents are often very worried, and they become more and more
distressed and lose confidence with their son or daughter. There is also an evolutionary break
down, a period in which somatic and psychic evolution run along different paths and at
different speeds. Both contracting a potentially lethal disease and facing hard treatment create
strong interference in the growth and in the identity process. Adolescents affected by a severe
disease, who undergo high risk treatment may experience stress, pain, extreme frustration,
depression, and anger. In this large spectrum of emotions several conditions and situations
must be taken into account and examined carefully.

ADOLESCENTS WITH CANCER. THEIR NEED FOR UNDERSTANDING

Almost all adolescents and young adults being treated for leukemia and cancer express a
desire or need for information about their illness, treatment and long-term effects, as well as
about family counseling, sexuality and intimacy, infertility and options for having children in
the future [1,2]. They demand detailed explanations in order to achieve better understanding
of their situations. Needs may differ by age and gender, and mostly by the type of cancer and
the severity of therapy. Some of them also wish to receive guidance about physical exercise
and fitness, camp programs, nutrition, social help, transportation. More recent needs for both
patients and parents concern the use of internet sites for cancer education or appropriate
support for their age [3]. Many wish to receive up-to-date news through patient services and
advocacy organizations. Very often adolescents express the need for psychological
counseling for themselves and their families. In addition, they often feel the need for
supportive care that is more suitable for youngsters their age, which suggests the extent to
which these needs may remain unmet. The care provided by the family and by friends,
together with their own personal satisfaction that their needs have been met, play very
important roles in the health status and in the physical functioning of the adolescents 4].
Physicians must look at these many problems from the patient's viewpoint in order to provide
truly total therapy and care to their young cancer patients. In order to achieve good coping
 Adolescents with Cancer: Adjustment and Supportive Care Needs 453

and adjustment, this must include careful planning of resources, supportive care programs and
services, together with a psychosocial assessment of the whole family. It would be important
to carry out detailed investigations on the unmet needs felt by sick adolescents in order to
understand and to facilitate their adjustment and coping with the new condition, and to avoid
post-traumatic stress [5].

ADOLESCENTS AND CANCER:

DISCREPANCY IN APPEARANCE AND INSIGHT
To communicate their feelings, adolescents often choose to write their experiences, just
as young children like to draw. This means of expression may be preferred, not only because
the age allows it, but also because it is easier and more impersonal [6,7]. Nevertheless, we
must bear in mind the self-indulgence, enjoyment and satisfaction that authors derive from
narrating. The use of narrative style allows one to open up and makes it easier to express
one’s own feelings; moreover, the act of writing helps to organize and analyze emotions. The
process of narrating can generate an equilibrium of social, emotional, and behavioral
attitudes. The story creates a fantastic world disjoined from realty, and through symbolism
allows the narrator to assume a new, more impersonal and rational, perspective of real life.
An adolescent is usually at grips with his/her new-found senses of body perception and self-
esteem. A debilitating disease only aggravates this emotional storm [8,9]. Therefore, any
space or vehicle, like a story, becomes an outlet to share their experience. Writings emerging
from these settings have proven both significant and indicative of the perception of the
disease and the associated hopes and fears. Some adolescents tackle their fears and speak
about the impotence and loneliness they feel when faced with the challenge of hospitalization
and treatment, by doing so they feel the possibility and the ability to overcome their ordeal.
Some reveal a deep fear of the future, of abandon and of death. Each story narrated by
adolescents highlights the feeling of impotence they harbor from being faced with the disease
and the lack of any choice. An awareness of and attention to such writings will enhance the
physician’s cultural understanding and will add important elements, thereby allowing a
deeper exploration of feelings and of the adolescents’ coping environment [10,11].
Sometimes, they try to restore some semblance of normality in their own life, inducing an
acceptance of the situation above and beyond the disease. Letting adolescent patients tell their
story with little or no influence or interruption is germane to the physician’s task to grasp a
sense of the cultural and emotional situation they need to share. The stories are fantasy, but
they shed valuable light on the events that evoked them. As said before, adolescents need
both information about their condition and the time and space to elaborate their reactions and
emotions. Understanding this need, and thereby attempting to contain and subdue the
patient’s sense of helplessness, involves the physician’s ability to share and make the patient
feel involved in the decision making process about his/her treatment. This is especially true
when patients who have been ill since a younger age may have grown into more conscious,
discerning individuals, and when recent onset youngsters may have already achieved a certain
degree of self-awareness. Chemotherapy side effects, too, may induce catastrophic feelings
with fantasies. In my experience, several off-treatment adolescents show a high frequency of
panic attacks and post-traumatic stress. In these cases it is very important that physicians and
454 Luisa M. Massimo

other health care professionals improve their listening skills. Interpersonal communication is
an essential tool that demands flexibility of style, in-depth knowledge, and the ability to
recognize and resolve barriers that hinder dialogue. At times, persistence is required. The
adolescent must be made to feel comfortable enough to speak openly. Stories can provide
valuable keys that allow us to know whether or not errors in understanding are a cause of
distress, whether he or she feels alone and whether an atmosphere filled with love, security,
hope, and honesty needs to be created and nurtured. There is a strong need to create
departments which are suitable for patients of that age, and not only for those suffering from
cancer, because in many hospitals adolescents may well be too old for the pediatrician, and
yet too young for the adult practitioner.

CRISIS IN QUALITY OF LIFE AND IDENTITY PROCESS

Our experience with adolescents who have already undergone or are undergoing
treatment for leukemia and cancer also consists of psychodynamic interviews. This is an
active listening technique whereby the doctor is apparently only asking. Interpersonal
communication skills are an essential tool requiring flexibility of style and in depth
knowledge of the matter [12]. In our interviews we follow a patient-centered method. Each
adolescent must feel comfortable enough to speak about him/herself. Many questions are
medically oriented, but at the same time we take the whole family into consideration in order
to obtain a complete scenario including social and psychological information. As I said
before, we always try to recognize and resolve barriers to communication. In many cases
persistence pays off and we overcome the adolescent's reluctance to speak about his/her
feelings, family, past, problems. The literature on the identity process in adolescents with
severe non genetic diseases such as cancer who undergo high risk therapy is very scarce.
Most of the papers written in medical journals and chapters of books on pediatric oncology
are important and reveal personal experiences and feelings. Each of them enriches those who
are dedicated to this field.
Over the last thirty years psychologists have acquired a great deal of experience in Bone
Marrow Transplantation Units, where the long-term, strict isolation, the painful conditions
due both to the illness and to the diagnostic and therapeutic procedures, and the uncertainty
about the results, place a very high degree of stress on the feelings and awareness of
youngsters. The data obtained from observations and interviews reveal that the most
disturbing facts regard the fragmentation of the ego, fantasies about death and above all about
sexual identity when the donor is of the opposite gender. We have observed a high frequency
of panic attacks as well. Some of the patients who had been cured of their malignancy
suffered from persisting psychological distress such as self isolation, failure to engage in
problem-solving efforts, low levels of personal resources concerning their future, behavioral
disengagement, persisting psychological distress and difficulties in coping with uncertainty
about their future as healthy adults. An important relationship with the family environment
was observed, involving psychological maladjustment of the adolescent and parents or
siblings, and behavioral difficulties between the patient and the parent taking care of him/her
during hospitalization. Other important factors are related to the parents’ and siblings'
psychological state when diagnosis and suggestions about treatment are communicated and
 Adolescents with Cancer: Adjustment and Supportive Care Needs 455

discussed. Some problems are linked to the choice of the donor from among family members
or to the obliged choice of an unrelated donor and his/her nationality, blood group, gender,
while others are related to the impossibility of establishing contact between the donor and the
recipient. Some other factors are related to the disease and to hospitalization, such as the
unpredictable duration, altered temporal perception, distance from home and school, and self
isolation. The onset of complications and side effects may induce a catastrophic feeling with
fantasies about them, assuming the worst. The same may happen with the treatment of the
complications, with the fear of having to be admitted to the Intensive Care Unit, and with the
feeling of death. Furthermore, spreading gossip in the ward can play a role in distorting
medical information about the health and death of other patients who are friends of the
adolescent. Patients with low levels of cognitive appraisal and social support are more
threatened, and their coping potential is lower than those who are more competent. Their
reaction may include feelings of great discomfort, followed by difficult adjustment, post-
traumatic stress, and even mental disorders.

THE TRULY HEALTHY ADOLESCENT

AND YOUNG ADULT CURED OF CHILDHOOD CANCER

Treatment approaches over the last 30 years have dramatically increased the survival rate
in childhood cancer which is currently above 75%. Researchers have also investigated the
delayed effects linked both to therapies and to the psychosocial implications of the disease in
an effort to improve the therapeutic protocols and treatment of the sequelae, and to prevent
them. The most commonly identified effects include an increased incidence of organ defects,
growth retardation, sterility, second malignancies, neuropsychological damage, and cognitive
deficits [13]. Published evidence on the quality of life of childhood cancer survivors, albeit
plentiful, mostly measures their current perception of prominent indicators such as social life,
education, occupation, marriage, and fertility [14-17]. Great emphasis is now also being
placed on the post-traumatic stress that both the former patient and his/her parents may suffer
[5,19,20,21]. Through questionnaires and interviews, most interviewers are able to provide
important pictures of the survivors' lives, although the answers may not always depict their
true reality. Only few surveys have longitudinally followed off-treatment patients from
childhood to adulthood in an attempt to detect differences in their perceptions then and now
as compared to the normal population of the same age and status [22]. The relationship
between the physician and the sick child often unveils difficulties regarding understanding.
Long ago, when a high percentage of patients died, the most common approach that
physicians took towards them consisted in general and superficial discussions, without ever
looking carefully at their futures, at their education, or trying to make plans for their
adulthood. Now, several of those cured children are adults who are facing the difficulties of
every-day life.
Recently, our curiosity prompted us to investigate the feelings of a group of adult
survivors of childhood cancer whom we had had the opportunity to know better when they
were sick several years earlier [22]. Through a personal, friendly, narrative approach, we
were able to listen to each one of them talk about their lives now and about their past. The
meetings were conversational, relaxed, and confidential in order to avoid communication
456 Luisa M. Massimo

barriers. This was not a research project designed for any specific purpose, and the encounters
did not have any scientific objectives. The main aim was to establish a new kind of easy
communication with their former physicians. This experience was important to help them get
in touch with their own feelings and behavior. It also taught us the need for a natural, honest,
and direct relationship between the physician and the sick child through empathic exchange
and discussion starting from the very onset of the disease. Talks with our early survivors, now
between 30 and 40 years of age, revealed that they still suffer from distress and anxiety about
something unknown that they had to endure but that they were not able to internalize and to
transform into a positive event that happened during their life. Then we extended our
investigation to more recently cured adolescents and young adults. Our experience taught us
that it is better and easier to speak to the children directly, without any interference from their
parents, and to avoid dangerous fantasies which are often worse than reality itself [14,22].
Sick children and adolescents with cancer therefore deserve increased personal care, mainly
from their physicians. Through careful listening and communication it is possible to actively
involve the child and his/her whole family. It must always be kept in mind that this personal,
narrative approach requires time, willingness and an appropriate setting.
In Europe, teams named ELTEC (Early and Late Toxicity Educational Committee) were
established among experts of the International BFM Study Group to study and follow-up all
the long-term survivors of childhood cancer and leukemia.
In October 2006, at a meeting that took place in Erice (Sicily), we organized an
International Workshop on “Long term survivors of childhood cancer: cure and care. “ At that
time we established the so-called “Erice Statement [23]. This meeting was an attempt to
establish communication among people involved in several areas related to long term
survivors of childhood cancer, i.e., pediatric oncologists, epidemiologists, psychologists,
nurses, parents and Parents’ Associations, and adults cured of childhood cancer, two of whom
were physicians. The workshop involved forty-five experts from 15 European and North
American countries. The combined efforts of the six groups led to the drawing up of the
“Erice Document on cure and care of survivors of childhood cancer” which summarized the
groups' conclusions and included a preamble and 10 statements. Below is a report of the
conclusions given by Prof. JJ Spinetta, who was the coordinator of the last joint Session:
“What happens to survivors of childhood cancer twenty years and more after treatment?
There are three different areas of concern: the medical, the social, and the psychological.
From the medical perspective, there is an increasing concern with the long-term medical and
physical sequelae in young adults and adult survivors of childhood cancer. From the social
perspective, the focus is primarily on how society views survivors of childhood cancer. There
are many countries that view them as damaged goods, less healthy than their peers, less able
to pursue normal careers. These attitudes impose on survivors severe societal restrictions on
work, military service, and health support. The psychological perspective is concerned with
the level of psychological functioning of young adults who were treated for cancer as
children. Do survivors bear the burden of the illness in a way that keeps them from fully
engaging in life or have survivors learned from their experience to be more adaptive and
resilient than their peers?” [24].
In conclusion, as a pioneer of Pediatric Oncology, I suggest we should not look at the
future of survivors who are cured of childhood cancer pessimistically, but rather, we should
look at the entire field in a positive way [25].
 Adolescents with Cancer: Adjustment and Supportive Care Needs 457

I believe that in the future, survivors will have two possible outcomes which will be
related to the risk of disease and treatment. Those who suffered from low and standard risk
disease will achieve and enjoy a normal life, while those who underwent very aggressive
treatment, with or without stem cell transplantation, might have to cope with a more
vulnerable life. I recommend to follow closely the patients and their families, starting from
the time of diagnosis and carrying on throughout the whole treatment period with continuous
psychological support, and to try to empower them and to strengthen their coping ability [25].
Due to the high number of survivors who are already adolescents or in their adult age,
several scientists are now planning how physicians and the whole professional team will have
to behave in the future in order to guarantee the best results when curing and caring for
patients [26,27]. We must emphasize the need to consider this new population as being an
especially vulnerable one. We must provide both survivors and caregivers with better
education about the whole problem, mostly in an effort to prevent and to treat late effects, as
well as to influence at-risk behavior, while always keeping in mind the main aim, which is to
promote health.

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[11] DasGupta, S; Charon R. Personal Illness narratives: Using reflective writing to teach
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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 27

THE QUALITY OF CARING RELATIONSHIPS

Tineke A. Abma*, Barth Oeseburg, Guy A. M. Widdershoven

and Marian Verkerk
University of Maastricht, Netherlands

ABSTRACT
In healthcare, relationships between patients or disabled persons and professionals
are at least co-constitutive for the quality of care. Many patients complain about the
contacts and communication with caregivers and other professionals. From a care-ethical
perspective a good patient-professional relationship requires a process of negotiation and
shared understanding about mutual normative expectations. Mismatches between these
expectations will lead to misunderstandings or conflicts. If caregivers listen to the
narratives of identity of patients, and engage in a deliberative dialogue, they will better be
able to attune their care to the needs of patients. We will illustrate this with the stories of
three women with Multiple Sclerosis. Their narratives of identity differ from the
narratives that caregivers and others use to understand and identify them. Since identities
give rise to normative expectations in all three cases there is a conflict between what the
women expect of their caregivers and vice-versa. These stories show that the quality of
care, defined as doing the right thing, at the right time, in the right way, for the right
person, is dependent on the quality of caring relationships.

INTRODUCTION
It is not uncommon that expectations between patients and their healthcare professionals’
conflict. This creates tensions in the caring relationship. The purpose of this chapter is to
understand these tensions from a care-ethical perspective (Tronto, 1993; Walker, 1998; Held,
2006). From a care-ethical perspective a good patient-professional relationship requires a

*
Correspondence Address: Dr. Tineke A. Abma. University of Maastricht, Health, Ethics and Society/School for
Public Health and Primary Care, PO box 616, 6200 MD Maastricht. Tel: 043-3881132;
Email:T.abma@ZW.UNIMAAS.nl
462 Tineke A. Abma, Barth Oeseburg, Guy A. M. Widdershoven et al.

process of negotiation and shared understanding about mutual normative expectations

(Verkerk and Widdershoven, 2005).Mismatches between these expectations will lead to
misunderstandings or conflicts. If caregivers listen to the narratives of identity of patients, and
engage in a deliberative dialogue they will better be able to attune their care to the needs of
patients (Kagan, 2008).
We will illustrate this with the stories of three women with Multiple Sclerosis (MS): Ann,
Kathy and Jane (pseudonyms). MS is a chronic progressive neurological disease with
profound effects on all facets of life: physical, cognitive and emotional, work, social
activities, financial status and family functioning (Kraft, 1999; Boeije, et.al., 2002). Living
with MS is a matter of balancing different and sometimes conflicting activities. Care for
persons with a chronic disease like MS is complex and healthcare professionals are not
always familiar with the disease and special needs of these patients (Rothman and Wagner,
2003). In the cases presented there is a clash of expectations which leads to tensed
relationships between the disabled women and their professionals.
The chapter consists of the following parts: We start off with sections on the theoretical
framework and methodology. In the following sections the stories of Ann, Kathy and Jane
will be presented. Their narratives illuminate the normative expectations towards themselves,
others and vice versa. In an analysis we will investigate how conflicting normative
expectations are grounded in diverging narratives of identity. Finally, we discuss how the
findings can be used in helping healthcare professionals to build up caring relationships
which are adjusted to the uniqueness of disabled persons.

A CARE ETHICAL PERSPECTIVE ON RELATIONSHIPS

This chapter is based on Margaret Walker’s expressive-collaborative view of morality.
Walker (1998) describes morality as situated in social practices, which makes morality
fundamentally interpersonal. Moral life is centred around relationships. In interactions people
jointly construct and maintain moral orders. This process takes place against a background of
(moral) understandings about what people are supposed to do, expect and understand. Walker
states that these ‘understandings’ – ideas about who we are and how to handle various
situations – are expressed through practices of responsibility.
Walker does not understand responsibility in legal terms, but redefines the concept of
responsibility as ‘whom I care about’. With the emphasis on care as a central element of
responsibility Walker’s view of morality resonates with Joan Tronto’s (1993) normative
theory on the ethics of caring. Responsibility includes the notion of responding; listening,
being attentive and answering in response to the needs of others. Walker does, however, not
describe when and what should be done by whom to whom. The specific interpretation of the
question who is responsible to whom, for what is context-bound and depends on the particular
circumstances and the people involved in the situation.
Commonly we speak about the ‘division’ of responsibilities. This implies a focus on the
outcome of a negotiation process over who does what to whom. Walker rather concentrates
on the process of negotiation over responsibilities between human actors when she talks
about the assignment, acceptance and deflection of responsibilities. Walker’s moral-
epistemology implies that the assignment of responsibilities is shaped and defined by
 The Quality of Caring Relationships 463

normative, often moral expectations. These normative expectations are expressed in

narratives of identity.
Narratives of identity, as Walker (1998) understands them, are the complicated
interactions of the first-person stories by which one makes sense of oneself and the third-
person stories that others use to identify one. Often, the third-person stories are different from
those that figure into one’s self-conception and it is the clash between these different
narratives of identity that creates tensions in the relationships between patients and their
professionals.

MULTIPLE CASE STUDY

Since normative expectations are grounded in stories, we followed a multiple case study
approach in our research on the division of responsibilities for chronically ill. The research
team collected case stories from fifteen MS patients and one or two of their health care
professionals (n=24). These stories were later used as input for two focus groups: one among
MS patients and one among healthcare professionals. We choose to have a mix of cases with
regard to the stage of the illness (MS patients living at home with minimal disabilities; those
going for a treatment to a rehabilitation centre; severely disabled MS patients hospitalized
within a nursing home). The case study ended when no more new insights were added to the
existing data set (‘saturation’).
The interviews had the character of a 'natural' conversation structured by the issues
coming up during conversation (Reissman, 1993). The interviewer did not start with a list of
predefined topics, but began with an open question. MS patients were asked what happened
when they became ill, health care professionals how they handled a specific care situation.
The interviews lasted about two hours. The interviews were tape-recorded, transcribed in their
entirety and analyzed following a narrative approach (Lieblich, et.al., 1998). Besides the
content of the stories, the narrative structure and linguistic elements (discourse, metaphors)
were addressed in the analysis.
It is common within the qualitative research tradition to give respondents the opportunity to
discuss one’s findings and to see whether or not they recognize the interpretation made by the
interpreter(s). This so-called 'member check' is a helpful procedure to check the credibility of
one’s findings (Meadows and Morse, 2001). Ann and Kathy responded to and approved to our
interpretation of their stories. In the case of Jane it was, however, not possible to get a
response, given her bad condition. She preferred not to be consulted and died several months
after the interview in a nursing home.
The verification of the findings was also enhanced because the stories were were
analyzed by various members in the research team and discussed in team meetings. This
strategy for verification is known as ‘inter-rated reliability’ (Meadows and Morse, 2001).
Furthermore, methodological choices were discussed with two independent professors. This is
known in the literature as ‘peer debriefing’ (Guba and Lincoln, 1985) and helps to identify
blind spots.
In the next three sections we describe the normative expectations of the women with MS.
464 Tineke A. Abma, Barth Oeseburg, Guy A. M. Widdershoven et al.

ANN
Ann is a sportive looking woman in her thirties who has MS for more then seventeen
years. Ann presents herself as someone who has learned to live with MS. She talks in terms of
‘decisions’ she has made and makes – as if she is fully in control - and emphasizes the
importance of being able to have freedom of choice. Ann states, for example, that it is very
important for her to choose and decide what she likes. In her words: ‘I will not do the things
that are giving me no energy, that are drowning me.’ She also emphasizes that she has taken
the initiative to select her own caregivers. When she heard the diagnosis she left her
neurologist and GP and went to search for new ones. She explains: ‘I thought if I have to live
with MS then I have to have caregivers who I can live with.’
Ann found health care professionals who she appreciates and with whom she can work
together in a more or less horizontal relationship. She knew what she was looking for –
people she could trust - and was well aware of her own needs. Ann also knows how to
communicate her wishes (‘I am capable to formulate my need for help’ ) and considers this
part of her responsibility in the communication with professionals. Making deliberate choices
and articulating needs are important elements of how Ann sees herself.
For quite some time Ann found satisfaction in becoming an active member of the Dutch
Multiple Sclerosis Association (MSVN), but recently she is more critical of her voluntary
work: ‘Yes, of course, I got many compliments, but you cannot buy your bread with
compliments’. What frustrates her is the fact that she doesn’t have a professional career. Ann
lost her job at the age of 28 years when she was diagnosed with MS. In those days in the
Netherlands it was generally accepted that MS meant getting on insurance. Reintegration was
not considered to be part of the treatment. This was a good solution for her employer, but it
turned out to be a disaster for Ann. She found an alternative in her voluntary work for the
MSVN, but discovered later on that her identity entails more than being a woman with MS: ‘I
am not solely an MS patient I am also Ann who wants to do other things in life, in my spare
time. I do not always want to be involved with MS that is just a part of me.’
Ann’s narrative of identity is thus built around becoming a woman with a profession
again. She wants to be recognized by others as a professional, and not solely as an MS
patient. Finding an appropriate job is, however, complicated. Ann compares it with a ‘real
crusade’. It is here that she expects support from others, among them employers: ‘I need
support from employers for this part in my life … I also need others to support me. Contacts,
networks, information, institutions and whatever is needed.’
In her narrative of identity Ann envisions herself as a professional woman, but she
readily acknowledges her vulnerability as an MS patient. This vulnerability is not only related
to work, in other domains of life she also encounters problems. Ann’s narrative of identity
creates normative expectations towards herself and others. Ann takes on a lot of responsibility
for her own health and welfare. She is the one who make decisions, who is in charge. What is
able to do herself, she will take on. Yet, there are parts in life that she cannot completely
control, and where she expects acknowledgement, help and support from others, especially
from employers. Employers and others, however, have difficulties to identify Ann as
someone who requires support to realize her identity as a professional woman. It is the clash
between the different narratives of identity that creates tensions between Ann and others.
 The Quality of Caring Relationships 465

KATHY
Kathy is in her forties and was diagnosed with MS more than twenty years ago. She lives
alone in the Northern part of the Netherlands. At home she is mobile without using
equipment. Outside her house Kathy uses a wheelchair or a booster. She only makes use of
domestic assistance.
When Kathy was diagnosed with MS she worked fulltime, but over a period of several
years working hours have been gradually reduced. She now works two afternoons per week.
Since the last two years Kathy has frequently been on sickness leave because her condition
has worsened. Due to the spasticity in both hands and her fatigue she wonders whether or not
she is able to continue her work. In Kathy's opinion work is important; it gives her status, a
meaningful place in society. Recently Kathy experiences, however, problems as a result of
her worsening condition. She even cannot maintain social contacts with friends and family.
She wonders what to do, and consults her general practitioner. He has given her the advice to
continue work, because he is worried that Kathy will have no social life anymore, if she is
going to give up her job.
The solution offered by the GP is, however, not satisfying Kathy, because it does not take
into account how important relationships with family and friends are for her. Kathy’s
disappointment also refers to the inattentiveness of the GP to her need for understanding and
support. She does not expect the ready-made solution her GP offers, but assistance to come to
her own solution based on a better understanding of her own situation. A psychologist in a
near-by rehabilitation centre is able to attend to her expectations. After several meetings with
the psychologist Kathy comes to the conclusion that maintaining contacts with friends and
family is more important for her than continuing her job. So she decides that it is better to get
on insurance. The psychologist enabled Kathy to reach a solution that is fine-tuned to Kathy’s
situation and identity.

JANE
Jane is in her fifties, not married, and lives in a one-person room in a nursing home.
Lately she has suffered from various bacterial diseases, so that she almost died. Now she
mainly stays in bed with oxygen, a tube in her nose, a catheter and an anti decubitus mattress.
She is able to drink from a special mug, but can not put up make up herself, is not able to
wash herself, can not move herself from one side to the other. She needs assistance and help
for everything.
Jane was diagnosed with MS at the age of eighteen. The disease is progressive and soon
she gets into a wheelchair. During those years she is very angry, continuously wondering
‘Why does this happen to me?’ What troubled her most was that people were ignoring her
because she was sitting in a wheelchair. She notices: I am perfectly able to talk for myself.
Although she expects he would learn to cope with the situation, she loses her boyfriend. She
also loses her work, although she manages to work as a bookkeeper in the first two years of
her illness. In 1971 she gets on insurance. With the help of a home care nurse and specialized
family help her mother looks after her for many years.
466 Tineke A. Abma, Barth Oeseburg, Guy A. M. Widdershoven et al.

Then a period starts in which she often stays in hospitals, undergoing all kinds of
treatments and cures. In 1979 she is blind for one day and night. Immediately she calls her
doctor at the local hospital. He ensures her she will be hospitalized if the situation lasts for
more than several days. When the situation becomes urgent he, however, informs her he will
do nothing. Jane no longer trusts him and decides to go to a neurosurgeon in an academic
hospital. Jane thus presents herself as someone who knows what she wants and who is able to
make decisions concerning her life. Jane’s self-conceptualization creates certain expectations
towards others, such as the wish to be taken seriously. Conflicts emerge when others identify
her as docile, because she sits in a wheelchair. Yet, she has also satisfying relationships with
others; her mother, family members and recently the residents in the nursing home. She
experiences moral support from these people.
Lately Jane needs extra assistance and help. She experiences a lot of misunderstanding
among the nurses. They do not always understand when she is tired. She also misses respect
and loving attention from the nurses. It is frustrating that she almost always has to wait for
help. She compares it with the way she was treated at home: ‘It is a matter of asking again
and again, and that I can not cope with, because I wasn’t used to that at home.’ She also
notices that nurses get irritated when she asks them, for example, to give her something she
can’t fetch. Besides the lack of attentiveness to her needs Jane is also critical about the
expertise of the health care professionals.
Jane is physically dependent, but does not act in a dependent way. She presents herself –
in line with her story of who she was in the past - as being articulate and critical. Given her
narrative of identity she expects support and help with her daily routine, but also wants
acknowledgement as a person who gives direction to her life. The health care professionals do
not perceive her in the way she sees herself. They identify her as being dependent and expect
her to behave dependent – uncomplaining and grateful for anything that is done for her. Jane
does not live up to these expectations, and the caregivers find her troublesome. Her
demanding nature, her lack of docility and her quite articulate complaints are driving the
nurses crazy. Again we see how conflicting narratives of identity create problems between
MS patients and their caregivers.

IDENTITY AND RELATIONSHIPS

In this analysis we reflect on the above stories and how the narratives of identity of these
women differ from narratives that others use to understand and identity them, and how this
creates tensions in the caring relationships.
Narratives of identity are complex interactions between self-conceptualizations and
perceptions others use to identity us. Ann presents herself as being in charge of her life and
illness. The autonomy and self-determination she enacts in relation with her caregivers does,
however, not work in relation to her employers. This is the other part of Ann’s identity: she is
also vulnerable and dependent on other human beings, information and institutions. This
narrative of identity creates the expectation that others will give her assistance and support,
especially when it comes to finding a job and to realize her future identity as a professional
woman. Ann experiences, however, that others do not identify her as being vulnerable. As a
result, she does not receive the help she expects and needs.
 The Quality of Caring Relationships 467

Kathy presents herself as being independent. She has always worked, is articulate about
her needs and takes the initiative to visit a rehabilitation centre. Autonomy has always been
an important value in her life. Difficulties start when her condition gets worse. Then the
coordination of work and social life becomes complicated. Kathy expects support and
understanding from her GP which he is not able to offer. He identifies Kathy as someone who
cannot make her own decisions, and expects she will be satisfied with his solution to continue
work. Her psychologist is better able to assist her by helping her to make her own conclusion,
thus respecting her identity as an autonomous woman.
Jane also presents herself as being independent, articulate and critical. She is complaining
about the quality of care, expressing her needs and standing up for herself. Autonomy has
always been an important value in her life; Jane, for example, chose her own doctor, which
can be seen as an example of self-determination. Conflicts emerge when others identify her as
docile and dependent. In the nursing-home the nurses and doctor expect Jane to act
uncomplaining and grateful. Her demanding nature and her quite articulate complaints are
considered as troublesome. Again we see how conflicting narratives of identity creates a clash
of expectations. While Ann experiences that others do not identify her as being vulnerable,
Kathy and Jane experience that others are not able to see them as being autonomous. In all
cases normative expectations are in conflict, which creates tensions in the patient-professional
relationship.

CONCLUSION
Walker’s moral epistemology offers an innovative methodology to understand caring
relationships in terms of the coordination of normative expectations between patients and
professionals. The tales of the women with MS show that tensed relationships occur as a
result of conflicting normative expectations, grounded in conflicting narratives of identity.
Sorting out normative expectations in order to reach a shared understanding of who is
responsible to whom and for what, requires that professionals caring for people with MS
listen to their stories. In stories patients express how they see themselves. Walker’s
theoretical perspective also helps professionals to understand the uniqueness of MS patients.
The narratives show that although the women had a similar medical condition, the meaning
they endowed to their situation was very different. There is a tendency in health care to use
protocols and standards. The results of our analysis show that care recommendations must be
tailored according to individual needs of patients.
The particular needs of patients can be understood through interaction and
communication. Health care professionals caring for persons with MS should at least ask
themselves the following questions: a) how do I identify the needs of my patient? and b) what
responsibility do I have for this patient ? In order to answer these questions, they should pay
attention to the way patients see themselves. So, health care professionals should create a
space for patients to develop and tell their stories. The standard-question “How are you?”
should be redefined in terms of “Who are you?” Professionals should ask themselves who the
person is, they encounter, how this person sees him/herself and what kind of expectations this
generates. Professionals have a special responsibility in this regard given the vulnerability and
dependency of patients. Professionals are the ones who should elicit patients’ expectations
468 Tineke A. Abma, Barth Oeseburg, Guy A. M. Widdershoven et al.

thereby showing that this information is a valuable and necessary contribution to their care
(Oeseburg and Abma, 2006).
Furthermore, professionals should be aware and responsive to the fact that the
expectations of similar groups of patients can be very different, as the stories of the women
with MS show. People describe themselves in different ways; even one person can change his
or her image of self during the illness process.
Listening and understanding is very important, but often hard to practice for health care
professionals. Kathy’s GP does not consider listening as part of his job. He wants to act and
finds it very difficult to respond adequately to the uncertainty Kathy experiences. Although he
senses that she is suffering, he is unable to create a space for her feelings of grief and
powerlessness. The psychologist had a very different approach and did not suppress Kathy’s
feelings and emotions. Giving space to suffering implies that one deliberately does not act.
The focus shifts from instrumental values to the intrinsic values of attentiveness, being
present and being related to the patient (Tronto, 1993). This is hard to practice for those
health care professionals who define their identity in terms of being an expert. Creating a
space for emotions and feelings of patients requires that one redefines one’s self-image as a
health care professional. Being a good health care professional is not only a matter of
technical expertise, but includes the moral virtues of being there and listening.

REFERENCES
Boeije HR, Duijnstee MS, Grypdonck MH, Pool (2002) A. Encountering the downward
phase: biographical work in people with multiple sclerosis living at home. Soc Sci Med
55: 881-893.
Held, V. (2006) The Ethics of Care – Personal, Political and Global, Oxford University
Press.
Kagan, P.N. (2008) Listening: Selected perspectives in theory and research, Nurs Sci Q, 21:
105-110.
Kraft GH. (1999) Rehabilitation still the only way to improve function in multiple sclerosis.
The Lancet 354: 2016-2017.
Lieblich, A., R. Tuval-Mashiach and T. Zilber (1998) Narrative analysis, Reading, analysis and
interpretation, Thousand Oaks, Sage.
Meadows, L, M and J. M. Morse (2001). Constructing Evidence within a Qualitative Project,
In: Morse, J.M., J.M. Swanson and A.J. Kuzel (eds), The Nature of Qualitative Evidence
(p. 187-201), Thousand Oaks, Sage.
Oeseburg, B. and T.A. Abma (2006) Care as a mutual endeavour, Medicine, Health Care and
Philosophy, 9: 349-357. DOI 10.1007/s11019-006-0003-6.
Reissman, C.K. (1993) Narrative Analysis, Qualitative Research Methods Series, 30, Newbu-
ry Park, Sage.
Rothman, AA and Wagner, EH (2003) Chronic illness management: what is the role of
primary care?Ann Intern Med. 138(3):256-6).
Stake, R.E. (1994). Case Studies, In: Denzin, N.K. and Y.S. Lincoln (Eds.) The Handbook for
Qualitative Research, Thousand Oaks, SAGE, p. 236-247.
Tronto, J. (1993), Moral Boundaries. New York: Routledge.
 The Quality of Caring Relationships 469

Verkerk, M. and G. Widdershoven (eds.) (2005), Over zorg gesproken, Wiens

verantwoordelijkheid? [Talking about care, Whose responsibility?] NWO/Ethiek en
beleid, Stichting Drukkerij C. Regenboog.
Walker, M.U. (1998) Moral Understandings, New York: Routledge.
In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 28

AN ATTACHMENT-BASED PATHWAYS MODEL

DEPICTING THE PSYCHOLOGY
OF THERAPEUTIC RELATIONSHIPS

Geoff Goodman*
Long Island University, Brookville, New York, USA

ABSTRACT
Throughout the history of psychotherapy, clinical theoreticians have evoked various
metaphors to depict the therapist-patient relationship. With the advent of attachment
theory and other advances in developmental psychology in the 1950s and 1960s, a new
therapeutic metaphor was born: the caregiver-infant attachment relationship. This
metaphor has yielded a number of insights into the process of psychotherapy and the
nature of the interactions in which the therapist and patient engage. The first objective of
this article is to illuminate both the advantages and disadvantages of using this metaphor
to depict the psychology of therapeutic relationships. One distinction between this
metaphor and the therapeutic relationship is the state of development of mental structures
in the infant versus the patient. Whereas the caregiver is behaving in response to the
infant’s emotional cues not contextualized by an interactional history of expectations to
guide these cues, the patient enters into a therapeutic relationship with a complex and
intricate interactional history of expectations. This asynchrony between the caregiver-
infant attachment relationship and the therapist-patient relationship requires the therapist
to behave in sometimes noncomplementary ways to challenge and interpret these
transferential patterns rather than simply responding to emotional cues, as a caregiver
would do. These interactional expectations, typically organized around definable patterns
of behavior in the therapeutic relationship, are “often neither conscious and verbalizable
nor repressed in the dynamic sense” (Lyons-Ruth, 1999, p. 589), and thus pose
challenges to traditional psychotherapy models that rely exclusively on symbolization to
produce therapeutic change. This new understanding of therapeutic change forces

*
Correspondence concerning this article should be addressed to Geoff Goodman, Ph.D., Clinical Psychology
Doctoral Program, Long Island University, 720 Northern Blvd., Brookville, NY 11548 (516-299-4277 (O),
516-299-2738 (F), ggoodman@liu.edu)
472 Geoff Goodman

therapists to focus more intensively on their own attitudes and behaviors vis-à-vis the
patient as the quintessential instruments of change. Various aspects of the therapeutic
relationship, in addition to verbalized interpretations of repressed conflict, have thus
come under increased scrutiny. I present an attachment-based pathways model for
understanding the interrelations among three relationship-based concepts used in
contemporary psychotherapies: working alliance, patient attachment and therapist
caregiving, and transference and countertransference. Thus, the second objective of this
article is to sensitize therapists and psychotherapy process researchers to the structure and
functioning of these interrelated concepts to increase therapeutic effectiveness.

Each of us carries with us into our therapy office a metaphor—conscious and

unconscious—of our relationship with our patients. This metaphor varies from patient to
patient, and varies within the same patient across the span of treatment. Nevertheless, the
broad parameters of this metaphor probably remain constant, both within and across patients,
and depend on the quality of our own attachment patterns and broader influences. Each
theoretical perspective also inaugurates and sanctions its own ready-made therapeutic
metaphors that we also use to help us construct our own. By examining these therapeutic
metaphors, we can learn something about our representations of ourselves as therapists in
relationship with our patients and evaluate whether and in what ways these metaphors serve
or hinder our patient’s interests.
Freud (1912b) offered the therapeutic metaphor of the surgeon-patient relationship to his
disciples and fellow psychoanalysts. Freud (1915) elaborated on this metaphor in his paper on
transference-love, in which he seemed to be defending against the intensity of his female
patients’ professions of love with a sterile, rigid set of technical guidelines. Humanistic
psychologist Carl Rogers (1977) offered a radically different therapeutic metaphor of the
person-person relationship, whose egalitarianism stands in stark contrast to Freud’s
authoritarianism (see also Vitz, 1977). We might consider Rogers’s therapeutic metaphor a
reaction to the rigidity of classical psychoanalytic technique in vogue at the time. With the
advent of attachment theory (e.g., Bowlby, 1973, 1980, 1982, 1988) and the psychoanalytic
study of mother-infant interaction (e.g., Bowlby, 1958, 1973, 1980, 1982; Mahler, Pine, &
Bergman, 1975; Stern, 1977, 1985, 1995; Winnicott, 1960, 1965), a new therapeutic
metaphor was born: the caregiver-infant attachment relationship. Contemporary
psychoanalysts are using this metaphor to illuminate aspects of the therapist-patient
relationship obscured by the Freudian metaphor such as the therapeutic components of
nonverbal interactions between therapist and patient, the corrective emotional experience
(Alexander & French, 1946), and the noncomplementarity of the therapist-patient match
(Bernier & Dozier, 2002).
Bowlby (1977b, 1988) applied his own ideas about human attachment to the metaphor of
the mother-infant relationship. He believed that the primary purpose of the therapist is to
provide the patient with a secure base from which he or she can explore himself or herself and
his or her relationships with others. In attachment theory, the secure base in the person of the
caregiver serves the function of providing protection for the infant as he or she explores the
environment. The caregiver’s safe haven, a complementary concept, serves the function of
comfort when internal or external threats to homeostasis cause the infant to become
distressed. Concepts similar to secure base identified by other writers include conditions of
safety (Weiss & Sampson, 1986), atmosphere of safety (Schafer, 1983), and background of
 An Attachment-Based Pathways Model Depicting the Psychology… 473

safety (Sandler, 1960). The therapeutic relationship proceeds when the patient uses the
therapist to explore oneself and one’s relationships with others and for comfort when
confronted by distressing internal and external threats.
Attachment theory and research have spawned the application of still other facets of the
caregiver-infant attachment relationship to the therapist-patient relationship (Amini et al.,
1996; Diamond et al., 1999; Diamond, Clarkin, et al., 2003; Diamond, Stovall-McClough, et
al., 2003; Farber, Lippert, & Nevas, 1995; Holmes, 1996, 1998; Lyons & Sperling, 1996;
Mackie, 1981; Mallinckrodt, 2000; Mallinckrodt, Gantt, & Coble, 1995; Mallinckrodt, King,
& Coble, 1998; Mallinckrodt, Porter, & Kivlighan, 2005; Mitchell, 1999). Parish and Eagle
(2003) identified seven facets: proximity seeking, separation protest, stronger/wiser,
availability, strong feelings, particularity, and mental representation. Proximity seeking refers
to the infant’s need to seek proximity to the caregiver for protection when faced with an
internal or external danger (Bowlby, 1982). Parish and Eagle (2003) did not define proximity
seeking for the therapist-patient relationship; however, we might regard a patient’s request for
additional sessions after a therapist or patient vacation as an adult form of proximity seeking.
Separation protest refers to the distress experienced by the infant when separated from the
caregiver and the infant’s protest against it (Bowlby, 1982). In the therapist-patient
relationship, the patient might protest against a therapist’s upcoming vacation. One of the
ingredients of an attachment relationship, according to Bowlby (1977a), is that the infant
perceives the caregiver as stronger or wiser than he or she does. Similarly, in the therapist-
patient relationship, the patient perceives the therapist as having knowledge of the patient’s
problems and ways to resolve them that exceed the patient’s own knowledge. Availability
refers to the caregiver’s emotional and physical availability to meet the infant’s attachment
needs (Bowlby, 1982). The therapist also meets the patient’s emotional needs through
attentive listening, regularly scheduled appointments, interpretations that foster a sense of
being understood, and many other manifestations of therapist availability unique to each
therapist-patient dyad.
An infant also expresses strong feelings toward a caregiver (Bowlby, 1982). The infant is
looking for the caregiver to facilitate the regulation of these strong feelings so that he or she
can begin to tolerate them. The patient also looks to the therapist for assistance with strong
feelings stimulated by the therapist-patient relationship. Freud (1915) described the patient’s
strong feelings of romantic love for the therapist, although he did not view them as products
of an attachment relationship. Particularity refers to the preference for the primary caregiver
over other persons, which begins practically from birth. Infants at 10 days have shown a
preference to feed from the primary caregiver over a substitute (Burns, Sander, Stechler, &
Julia, 1972). Patients demonstrate the same preference for their therapists. A therapist
covering for a vacationing therapist meets with the vacationing therapist’s patient only in an
emergency. In other words, therapists are not interchangeable. Mental representation refers to
the child’s reliance on an internalized image of the caregiver for comfort or guidance in the
caregiver’s absence (Bowlby, 1973; Mahler et al., 1975). The patient also relies on this
internalized image of the therapist in certain situations outside therapy. When one of my
patients diagnosed with borderline personality disorder gets an urge to drink alcohol, an
image of my asking her what she is feeling at that moment comes into her mind. Mental
representation resembles safe haven as an internalized image of comfort when internal or
external threats arise.
474 Geoff Goodman

Another clinical concept from the psychoanalytic literature thought to reflect facets of an
attachment relationship between the therapist and patient is the “working alliance” (e.g.,
Greenson, 1965; Mackie, 1981). Freud (1912a) foreshadowed the concept in his discussion of
the dynamics of transference. He defined three components of transference: a negative
component, a positive component, and an “unobjectionable” component (p. 105). The first
two components are unconscious, and serve as resistances to the treatment, while the third
component consists of friendly or affectionate feelings admissible to consciousness, which
serves the treatment as its “vehicle of success” (p. 105). The unobjectionable positive
transference represents “a belief in the value of treatment, based on widely held views of
analysis as a discipline and of the analyst as a professional practitioner [which] facilitates the
work” (Greenberg, 2001, p. 367). Greenberg (2001) has questioned whether Freud’s concept
has stood the test of time and has argued that the patient enters treatment seeking a
relationship rather than a professional practitioner who simply relieves symptoms.
Regardless of whether the patient is seeking a practitioner or a relationship, the concept
seems to encompass a sense of trust in the benevolence of the therapist who “exhibits a
serious interest” in and “sympathetic understanding” for the patient over time and establishes
a “proper rapport” with him or her (Freud, 1913, pp. 139, 140). Using Parish and Eagle’s
(2003) list of attachment concepts applicable to the therapist-patient relationship, strong
feelings, stronger/wiser, secure base, and availability either are implicitly or explicitly present
in Freud’s original idea. Freud (1913) suggested that the patient’s attachment to the therapist
is a prerequisite for the emergence of the unconscious components of transference: “[The
patient] will of himself form such an attachment and link the doctor up with one of the
imagos of the people by whom he was accustomed to be treated with affection” (pp. 139,
140). The link between the unobjectionable positive transference and the caregiver-infant
attachment relationship is implied.
Freud’s (1912a) original concept re-emerged in the literature as “the therapeutic alliance”
(Zetzel, 1956) and “the working alliance” (Greenson, 1965). These terms were defined as
capturing elements of the real relationship to the therapist not distorted by transference.
Horvath and Greenberg (1989) later sought to measure this working alliance by constructing
the Working Alliance Inventory (WAI), which consists of three subscales—task, goal, and
bond. “Task” refers to the level of agreement between the therapist and patient about what to
do in sessions. “Goal” refers to the level of agreement about the desired outcome of
treatment. “Bond” refers to the level of positive personal feelings between patient and
therapist. The “bond” subscale most closely resembles Freud’s (1912a) original definition of
the unobjectionable positive transference. Research has repeatedly identified the working
alliance as highly predictive of successful treatment outcome (Bordin, 1994; Horvath &
Symonds, 1991; Luborsky, 1994; Martin, Garske, & Davis, 2000; Safran & Moran, 2000).
Recently, the concept of the working alliance has been associated with the concepts of secure
attachment and transference because all three concepts seem to reflect similar mental
representations, affects, and strategies for affect regulation (e.g., defensive processes and
interaction structures) activated by the relationship with the therapist and its correspondence
with relationships with past caregivers (Bradley, Heim, & Westen, 2005; Westen & Gabbard,
2002). Whether these concepts conceptually overlap or operate at different levels of
abstraction is a matter of debate (see below).
Of course, every metaphor has a breaking point—a point at which the contours do not
precisely fit. Such is the case with the metaphor of the caregiver-infant attachment
 An Attachment-Based Pathways Model Depicting the Psychology… 475

relationship. The therapist is not a caregiver per se, nor is the patient an infant. The therapist
provides a service paid for by the patient, which takes place in a limited time. These treatment
arrangements ironically both allow the metaphor to exist and immediately invalidate it. One
of my patients diagnosed with borderline personality disorder revealed a fantasy—concretely
experienced by her as an expectation—that therapists should not charge for their services. In
fact, in her mind, therapists have taken a vow of poverty like Mother Theresa to conduct this
work. By informing her that I would be raising my fee next year, I was invalidating this
fantasy. She immediately reminded me that she had abruptly ended her previous treatment
when she discovered that her therapist, who wanted to raise the patient’s fee to $80 per
session, drove a Mercedes-Benz. The fantasy of the all-nurturing, selfless caregiver conflicts
with the reality of the professional aspects of the relationship. We are still working on this
issue of my projected fee increase and its meanings for her.
The therapeutic relationship is unique because of financial, temporal, spatial, logistic, and
ethical boundaries—boundaries that do not exist in the caregiver-infant relationship (Farber et
al., 1995; Goodman, 2006). We can imagine an Orwellian world in which the mother says to
the infant, “Time’s up! You’ve had your fill of milk for the day.” Or, “Stop being a baby and
get off my lap!” Or, “You can’t sleep in my bed; you’ll get too used to that!” Anyone familiar
with ferberization techniques (Ferber, 1990, 2006) will recognize the sound of these
statements offered by some behaviorally oriented psychologists already applying the model of
the therapeutic relationship to child rearing practices well suited to the regimented corporate
world these children are being fitted for. The establishment of boundaries such as time,
money, and perhaps most importantly, therapist availability between sessions structures the
therapeutic relationship in interesting ways. The expectations of contact-maintenance,
caressing, fondling, holding, and primary caregiver preoccupation—all provided to the infant
gratis—do not apply in the therapeutic context.
These arrangements—unique to the therapeutic relationship—might differentially affect
patients according to their quality of attachment. A preoccupied patient (entangled in parental
relationships from childhood) might respond to these boundaries with indignation and
resentment and create an interaction structure in which he or she perceives the
caregiver/therapist as withholding of emotional supplies. A dismissing patient (dismissing of
the importance of parental relationships from childhood), on the other hand, might feel a
sense of relief that strict therapeutic boundaries are in place—at least until the defensive
processes against closeness with the therapist are analyzed. The therapeutic boundaries
established by the therapist—fee, schedule, unavailability outside of session, lack of physical
contact—are unilateral decisions that structure the responses that patients of various
attachment patterns will have toward the therapy. These parameters do not exist in the
caregiver-infant relationship. As therapists, we must be aware of the differential effects of
these parameters on our patients, which can provide us with diagnostic and attachment-related
information and strategies for intervention. The manner in which we establish and maintain
these boundaries reflects our own use of secondary attachment strategies
(deactivating/dismissing vs. hyperactivating/preoccupied), which interact with our patients’
strategies to create unique interaction structures that can facilitate or hinder the treatment.
In addition to the parameters inherent to every therapeutic relationship, factors such as
gender and race also make important contributions to the construction of the therapeutic
relationship that might interact with the patient’s quality of attachment in interesting ways.
Following the work of Jessica Benjamin (1987), the resolution of the Oedipus complex for
476 Geoff Goodman

little boys in Western society often results in a rigid identification with the father and a
wholesale repudiation of the mother, and by extension, women, femininity, and dependency.
Whereas the mother in infancy is typically perceived as the all-powerful primary caregiver—
the secure base and safe haven—this mental representation of the mother changes as the
infant enters the preschool years. Boys no longer perceive her as all-powerful and all-
protecting—the hallmarks of felt security—but rather as a diminished presence in the
household in comparison with the father. This transformation of the maternal representation
could have an impact on the patient’s perception of the female therapist. One might be less
likely to feel secure in a therapeutic relationship with a woman whom society has deemed
“less than.” Farber and Geller (1994) have observed, “Our culture seemingly ‘allows’ women
to serve as protectors of infants and young children but not to inhabit roles that require the
provision of wisdom, strength, or protection of adults” (p. 206).
How might this clinical situation interact with the patient’s attachment pattern to create a
particular interaction structure? Perhaps having a female therapist would exacerbate the
feelings of insecurity of the preoccupied patient and elicit the devaluing tendencies of the
dismissing patient. Alternatively, a female therapist might provide a welcome contrast to a
diminished maternal representation from childhood. These hypotheses need to be submitted to
empirical testing before any definitive conclusions can be drawn regarding the interaction
between the patient’s quality of attachment and the therapist’s gender. It is instructive to
consider these issues, however, as we observe our patients forming specific attachment
relationships to us.
Similarly, the therapist’s race also makes an important contribution to the construction of
the therapeutic relationship. Bowlby’s (1977a) imperative that the infant seek an attachment
figure perceived as stronger or wiser becomes complicated when applied to the therapeutic
relationship because by the time the patient reaches our office, he or she has already had a
series of socialization experiences in the wider world that shape their perceptions of us as
therapists situated in a particular gender, race, and class. Can an African-American therapist
provide a secure base for a white patient who has been chronically exposed to the pervasive
injustices visited upon African-Americans in this country? Certainly, African-American
therapists can provide a secure base and safe haven for white patients, but for some white
patients, their socialization process into the dominant culture—that still contains vestiges of
racism—might present challenges to perceiving a therapist from a historically oppressed
culture as stronger or wiser. The reaction of a white patient to a therapist of color might also
depend on that patient’s attachment quality. A preoccupied patient’s insecurity and a
dismissing patient’s devaluing tendencies might be elicited in this arrangement. Conversely, a
patient from a historically oppressed culture might have difficulty trusting in a white
therapist, who belongs to a culture historically identified with wielding its authority to
oppress rather than to help. This dynamic can be construed in different ways, depending on
the patient’s attachment quality.
Financial disparities between therapists and patients also stimulate both conventional and
idiosyncratic assumptions about social class, privilege, and access to valued commodities
such as education, medical coverage, and an affluent living environment. These disparities
can provoke feelings of admiration, competitiveness, envy, worthlessness, grandiosity,
devaluation, anxiety, or guilt—in us as well as our patients. McWilliams (1999) has solved
this problem for herself by charging her wealthy professional patients whatever fee they
charge in their own professions. Which feelings are likely to emerge in treatment because of
 An Attachment-Based Pathways Model Depicting the Psychology… 477

financial disparities depends in part on the patient’s preferred attachment strategy and our
own. We as therapists need to pay attention to how such nonattachment dynamics interact
with pre-existing attachment patterns in both our patients and ourselves to produce unique
interaction structures.
One of the most important differences between the therapist-patient relationship and the
caregiver-infant attachment relationship is the difference in the mental organization of the
patient versus the infant. Infant internal working models consist of expectations of caregiver
responses to situations that activate the infant’s attachment system (loss, separation, fear,
stress, injury, fatigue, illness, and punishment) as well as the infant’s responses to these
caregiver responses (Bowlby, 1973; Main, Kaplan, & Cassidy, 1985). Episodic memories of
these caregiver responses are consolidated into semantic memory, a more generalized,
abstract memory that permits expectations to form. From these expectations, the infant can
begin to predict future responses and adjust his or her behavior accordingly to increase the
probability of terminating the attachment system when activated and eventually returning to
exploration. These initial expectations, constructed through the accumulation of early
experiences of caregiver-infant interaction when the attachment system is activated, form the
foundation of the internal working model (see also Stern, 1985, pp. 97-99). Eventually, these
expectations become generalized across interactions with other persons over time and become
organized into a personality organization with its own quality of self and object
representations, preferred defensive processes, pattern of relating with others, and affect
regulation strategy (Goodman, 2002). An infant, however, lacks this sophisticated mental
organization.
When a patient enters treatment with us, we are interacting with someone who has
already developed a sophisticated mental organization that that patient wants to change. The
infant, however, has no such historically structured mental organization. The expectations of
caregiver responsiveness are just beginning to form through countless caregiver-infant
experiences day after day. In other words, “the infant is developing his or her past” (Tronick
et al., 1998, p. 297).
This conceptual difference between the infant’s and patient’s mental organizations
becomes problematic when the patient applies his or her historically developed internal
working model to the therapist as caregiver. According to Dozier and Bates (2004),
“Expectations of the therapist may have little to do with the therapist’s actual availability,
thus, the therapist must be more than sensitive to the client’s needs” (p. 173). The patient
signals attachment needs according to the pre-existing template formed during interactions
with the original caregiver, not necessarily according to the way the therapist would be
naturally inclined to respond to those needs. From an attachment perspective, one of the
primary tasks of psychotherapy is to change these expectations so that a patient will develop
new expectations—culminating in a conscious or unconscious awareness—that his or her
wishes and affects will always find containment in the mind of the therapist. The therapist is
not helping an infant develop expectations of containment from scratch but rather helping a
patient change current expectations—already formed over years of experience with the
original caregiver—to facilitate both self-containment of affect and mutual containment of
affect through interdependence with significant others.
Consistent with this reasoning, Dozier and Tyrrell (1998) suggest that “the mother’s task
is easier than the therapist’s because she need not compensate for the failures of other
attachment figures... .The task of therapy is often made more difficult because of the client’s
478 Geoff Goodman

previous experiences with unavailable or rejecting caregivers” (p. 222). Caregivers of infants
placed in foster care most clearly illustrate this conundrum. Often abused or neglected, these
infants are placed with caregivers who need to be not only sensitive to their needs but also
therapeutic; in other words, “[foster] mothers need to see their infants as needy even though
the behavioral evidence might suggest otherwise” (p. 244). Thus, the metaphor of the
caregiver-infant attachment relationship does not precisely fit the parameters of the therapist-
patient relationship because of 1) the patient’s historically determined internal working model
(i.e., mental organization) and 2) the therapist’s therapeutic task that transcends mere
emotional sensitivity and encompasses a corrective emotional experience (Alexander &
French, 1946).
Another difference between the metaphor of the caregiver-infant attachment relationship
and the therapist-patient relationship is the patient’s acquisition and use of language. While
the infant communicates through nonverbal channels such as crying, smiling, frowning, and
gesturing, the patient communicates through symbolic play or language (in most forms of
psychotherapy). Indeed, Freud (1910) labeled his treatment “the talking cure” (p. 13) at the
suggestion of a patient. Of course, interpretation, mediated by language, is also the vehicle he
used to cure the patient. Lacan (1977) believed that the language of the father, or “the third,”
broke up the symbiotic relationship of mother and infant and facilitated differentiation.
Symbolization creates a distance between the signifier—the word or other symbolic
representation—and the signified—the thought or feeling behind the word or other symbolic
representation. The communication that occurs between the caregiver and infant, however, is
presymbolic. The mechanisms by which this presymbolic communication is processed in the
infant’s mind are not precisely known.
Members of the Process of Change Study Group in Boston have attempted to unravel this
mystery. They have classified this early experience of communication as “relational
procedural knowledge” and the later experience of communication as “symbolic knowledge”
(e.g., Lyons-Ruth, 1999; Stern et al., 1998; Tronick et al., 1998). This group has suggested
that relational procedural knowledge—the knowledge about relationships that an infant
acquires in close, face-to-face interactive communication with a caregiver—develops prior to
symbolic knowledge—the knowledge about relationships represented through verbal
communication. Both kinds of knowledge continue to develop throughout the course of
childhood. Classical psychoanalysis has targeted the domain of symbolic knowledge for
therapeutic change; however, this method ignores the domain of implicit procedural
knowledge formed prelinguistically. This presymbolic form of knowledge comprises the
essence of attachment patterns manifested by 12-month-old infants with expressive
vocabulary words numbering in the single digits. Implicit procedural knowledge tends to
reveal itself in therapist-patient interaction structures not readily available to symbolic
representation—known by contemporary psychoanalysts as “enactments” (McLaughlin,
1991). According to this group, sustained therapeutic change occurs primarily within the
domain of implicit relational knowledge, not verbally mediated symbolic knowledge:
“Retranscription of implicit relational knowing into symbolic knowing is laborious, is not
intrinsic to the affect-based relational system, is never completely accomplished, and is not
how developmental change in implicit relational knowing is generally accomplished” (Lyons-
Ruth, 1999, p. 579). Thus, psychotherapy, according to this point of view, needs to conform
to the metaphor of the caregiver-infant attachment relationship by emphasizing change in the
nonsymbolic, procedural forms of knowledge.
 An Attachment-Based Pathways Model Depicting the Psychology… 479

Working from the same assumptions, Eagle (2003) offered a pessimistic view of
therapeutic change occurring within the domain of implicit procedural knowledge:
“Procedural rules are especially recalcitrant....[They] do not change that readily—even in
successful treatment” (pp. 45, 46). Instead, he and Wolitzky (2006) suggested that therapeutic
change through interpretation and acquisition of insight (“second order change,” p. 14) occurs
more frequently than therapeutic change through implicit procedural knowledge (“first order
change,” p. 14). Insight into the causal processes associated with maladaptive patterns of
behavior can serve to limit these behaviors, but the desire to engage in these behaviors usually
remains because first-order change has not occurred.
While these theoreticians have perhaps diminished the exclusive importance of “the
talking cure” in favor of the contributions that therapist-patient enactments can make to
therapeutic change, other theoreticians have argued that caregiver-infant communication can
serve the purposes of intrapsychic connectedness and differentiation for the infant—even
before language acquisition. Benjamin (2002) described a pattern of communication that the
caregiver and infant simultaneously create and surrender to, which Aron (2006) has since
labeled, “a rhythmic third” (p. 356). This third quality of the interaction between the caregiver
and infant creates a sense of connectedness between the dyadic partners.
Benjamin (2004) contrasted this rhythmic sense of connectedness with a sense of
differentiation originating in the caregiver’s marking of the infant’s affective displays.
Gergely (2000; see also Fonagy, Gergely, Jurist, & Target, 2002) has suggested that the
sensitive caregiver mirrors the infant’s negative affective displays in such a way that the
infant “knows” that the caregiver is not actually experiencing the same affect but rather is
recognizing and empathizing with the infant’s affect. He labeled this experience “marking.” A
caregiver’s unmodulated mirroring of the infant’s affective experience (as when the caregiver
expresses fright when the infant expresses a fearful response), or not mirroring the infant’s
affective experience at all (as when the caregiver ignores the infant’s fearful response), would
equally threaten the infant’s sense of security. In other words, the caregiver might exaggerate
some aspect of the infant’s affective display to mark it as belonging to the infant rather than
the mother, but signifying that the mother understands what the infant is experiencing.
Marking is the process through which the caregiver contains and metabolizes the infant’s
dysregulated affects (for an object relations perspective on the same phenomenon, see Bion,
1962, 1967). These repeated experiences of marking facilitate intrapsychic self-object
differentiation and affect regulation for the infant before the acquisition of language occurs.
It is unclear whether marking unarticulated affective displays would have the same
differentiating and affect-regulatory properties after the acquisition of language. Aron (2006)
suggested that the therapist’s verbally mediated reflections on the patient’s thoughts and
feelings—presented in modulated form that resembles marking—allow the patient to identify
with an image of the therapist thinking about her. Fonagy et al. (2002) might modify this
conceptualization by suggesting that the patient identifies instead with a more modulated
image of herself contained in the therapist’s mind, which the patient then internalizes as an
integrated self-representation. Both these conceptualizations apply the idea of marking,
borrowed from the caregiver-infant relationship, to linguistic communication between the
therapist and patient. If marking occurs during the presymbolic period of relational procedural
knowing, then how can language—symbolic communication—“speak” to this layer of human
experience?
480 Geoff Goodman

Lyons-Ruth (1999) tried to answer this question with evidence from the Adult
Attachment Interview (AAI; George, Kaplan, & Main, 1996), which purports to measure
“enactive procedural representations” (Lyons-Ruth, 1999, p. 585). The interviewee reveals
these representations in verbal dialogue on the AAI but does not necessarily symbolically
represent them—“even though they may be symbolically represented by the observing
researcher or psychoanalyst” (p. 585). Therapeutic change, then, would occur when the
therapist uses language as a vehicle to produce the marking of dysregulated affects to
facilitate their modulation and containment. Thus, the metaphor of the caregiver-infant
attachment relationship might still be relevant to the therapist-patient relationship if we view
language as a conduit for communicating both connectedness and differentiation to facilitate
the patient’s affect regulation and self-object differentiation.
The following clinical example illustrates this process in the therapist-patient
relationship. A therapist who marks a patient’s feelings of resentment toward a family
member places the feelings in an intentional frame of reference without himself or herself
becoming resentful. The modulated manner in which the therapist talks about the
resentment—understands the intentions of all parties involved—suggests to the patient that
the therapist both understands the resentment (which facilitates connectedness between
patient and therapist) while not himself or herself reacting with resentment (which facilitates
differentiation between the patient and therapist). The patient begins to identify with either an
image of the therapist thinking about him or her (Aron) or an image of himself or herself
contained in the therapist’s mind (Fonagy and his colleagues). The patient then internalizes
either image or both images to facilitate affect regulation. The therapist’s use of language to
communicate with and change the implicit procedural level of knowledge requires both
symbolic and nonsymbolic mental processing. Although “procedural systems influence and
are influenced by symbolic systems through multiple cross-system connections” (Lyons-
Ruth, 1999, p. 580), these neurocognitive and affective pathways are not clearly understood
by psychoanalysts or attachment researchers. Functional magnetic resonance imaging (fMRI),
positron emission tomography (PET scan), and other neuroimaging techniques are beginning
to reveal these interconnections using clever, sophisticated research methodologies (Schore,
2003).
The final important difference between the metaphor of the caregiver-infant attachment
relationship and the therapist-patient relationship concerns the difference between the infant’s
feelings toward the caregiver and the patient’s feelings toward the therapist. We label the
infant’s feelings “attachment” and the patient’s feelings “transference.” Are these phenomena
conceptually identical, overlapping, or separate? If they are separate, do they mutually
influence each other or operate as parallel systems? While a conceptual relation between the
infant’s attachment to the caregiver and the patient’s working alliance with the therapist has
received a general endorsement in the literature (see above), a conceptual relation between
attachment and transference seems more equivocal.
Whether young children develop transference in psychotherapy stimulated theoretical
battles between the Kleinians and Anna Freudians in London in the middle of the last century.
Melanie Klein (1927) routinely observed transference in her analysis of young children, while
Anna Freud (1946) argued that transference in children does not occur because their
“attachment” to their parents precludes any transfer of libido onto anyone else. This dispute
has been settled in favor of transference; contemporary child psychoanalysts generally
recognize transference phenomena in child psychotherapy (e.g., Altman, Briggs, Frankel,
 An Attachment-Based Pathways Model Depicting the Psychology… 481

Gensler, & Pantone, 2002). If even young children can experience transference in
psychotherapy, then can young children also become attached to their therapists? Or does the
emergence of transference indicate that an attachment relationship has formed?
According to attachment theory (Howes, 1999), infants form attachments to one or a few
persons significantly involved in their care, particularly in the attachment-activating situations
mentioned above. These attachment relationships become hierarchically organized according
to preference. For example, a female toddler might generally prefer sitting on her father’s lap
when her mother and father are present, but she might prefer the mother’s lap instead after a
bad spill or a frightening noise. The infant, however, might prefer the father to the
grandmother or some other ancillary caregiver during similar attachment-activating moments.
Clearly, we would include the mother and father on any short list of attachment figures, who
have provided care for the infant during the organization of the attachment system, which
lasts until 18 to 24 months of age (Ainsworth, Bell, & Stayton, 1974). Can subsequent
attachments form? Dozier and her colleagues (Dozier, Stovall, Albus, & Bates, 2001) found
that infants placed in foster care even after 18 months reorganized their attachment behavior
around the emotional availability of their new caregivers. It is not known, however, whether
these infants reorganize their attachment behaviors yet again when they are placed back with
their biological mothers. Do remnants of these older mental organizations continue to linger
and influence later behaviors?
In psychotherapy, the child patient is entering into a relationship with a potential
attachment figure while maintaining an attachment to the parents. Unlike foster care, in which
biological mothers perform little or no caregiving and foster mothers are solely responsible
for the caregiving, the parents of the child patient continue their secure-base provision. In
other words, the child establishes an attachment relationship with the therapist while
maintaining an attachment relationship with the parents. Where does the child therapist place
on the hierarchy of attachment figures who have been present in the child’s life since the
moment of birth?
I have used child psychotherapy to illustrate this problem of attachment to the therapist
because the child does become attached to the therapist in spite of primary attachments to the
parents. Just this morning, the mother of a 9-year-old male patient with oppositional defiant
disorder in once-per-week psychotherapy called to tell me that a car had run over his dog. The
first thing he said to his mother after learning about the unfortunate news was that he wanted
to speak to me. I characterize this reaction as an attachment behavior to seek vocal proximity
with me. In the same manner, adult patients become attached to therapists even though they
might be involved in emotionally significant relationships. If we acknowledge that attachment
is a regular part of the psychotherapy relationship, then how do we understand transference
and its role in psychotherapy?
Few authors have contributed to our understanding of these phenomena. One group
(Henry & Strupp, 1994; Mackie, 1981; Mallinckrodt et al., 2005) has argued that attachment
and the working alliance are conceptually identical concepts in the sense that the spirit of
“proper rapport” (Freud, 1913, p. 139) attaches the patient to the therapist and allows them to
engage in a common task with a common goal (Horvath & Greenberg, 1989). In addition,
some authors among this group have suggested that the attachment or working alliance
represents aspects of the “real,” ego-based relationship with the therapist, while the
transference represents aspects of the distorted, unconscious fantasies of early caregivers
transferred onto the therapist. The problem with this position, as I see it, is that an insecure
482 Geoff Goodman

attachment to the therapist can include distorted, unconscious processes such as forgetting
payment, coming late to session, or dismissing one’s feelings toward the therapist. In
addition, fantasies of crawling inside the therapist’s womb or blasting off into outer space (a
common fantasy of an anxious-avoidant child patient of mine) seem to contain an obvious
residue of attachment and the defensive processes against it.
A second group (Eagle, 2003; Lyons-Ruth, 1999; Slade, 1999) has hypothesized a
conceptual equivalence between attachment and transference because implicit procedural
knowledge, the essence of internal working models, is attributed to the therapist-patient
relationship and the person of the therapist. For example, Eagle (2003) has regarded
“transference patterns... as most representative of early procedural knowledge and rules” (p.
46), which Lyons-Ruth (1999, p. 585) has characterized as internal working models of
attachment. Slade (1999) has modified the definition of transference so that it refers to the
patient’s “primary mode of relatedness” (p. 588) rather than the classical idea of a transfer of
wishes and fears onto the therapist. The pattern of relating to an attachment figure, rather than
the unacceptable aspects of the patient’s own personality, is transferred onto the therapist and
enacted in the therapist-patient relationship.
A third group (Bordin, 1994; Bradley et al., 2005; Diamond, Clarkin, et al., 2003; Parish
& Eagle, 2003; Szajnberg & Crittenden, 1997) has taken the position that attachment shares
elements of both the working alliance and transference and that, indeed, these phenomena
mutually influence each other. Most of these authors have suggested that a positive working
alliance is conceptually equivalent to a secure attachment, while a negative working alliance
is conceptually equivalent to an insecure attachment. A positive transference usually occurs in
the context of a secure attachment, while a negative transference usually occurs in the context
of an insecure attachment. Yet a secure attachment can protect the treatment from the
destructive effects of the negative transference. Diamond, Clarkin, et al. (2003) distinguished
secure-base behavior in the therapist-patient relationship (the working alliance) from
“recapitulated states of mind with respect to early attachment figures in the relationship with
the therapist” (the transference; p. 170). Bradley et al. (2005) considered all three concepts
virtually interchangeable.
I will present my own theoretical formulation of the relations among these three concepts.
The working alliance includes nonattachment components, such as therapist-patient
agreement on the tasks and goals of treatment, as well as a potential attachment component,
the collaborative bond or rapport between the therapist and patient. This rapport, however, is
not necessarily related to attachment in which the therapist is considered a secure base or safe
haven. During the administration of the AAI, the interviewee’s level of collaboration with the
interviewer contributes to the attachment classification (Main & Goldwyn, 1994). Yet no one
would suggest that the interviewee has formed an attachment to the interviewer, who is
usually a stranger. The level of collaboration between the interviewee and interviewer
depends on the interviewee’s state of mind with respect to his or her attachment history with
the childhood caregivers and on the interviewer’s own level of collaboration, based on his or
her attachment history.
In psychotherapy, a patient can collaborate with the therapist on their common tasks and
goals without developing an attachment to him or her in the sense of relying on the therapist
as a secure base or safe haven. It takes a history of therapist caregiving, delivered over
months of exposure, to form an attachment to the therapist. In my view, treatment approaches
such as cognitive-behavioral therapy offer skills training, not caregiving per se. A working
 An Attachment-Based Pathways Model Depicting the Psychology… 483

alliance is formed, yet only in rare instances would a patient treated in one of these
approaches form an attachment to the therapist. Thus, a working alliance is a necessary but
not sufficient condition for an attachment to form—regardless of whether the attachment is
secure or insecure. The quality of the working alliance depends on the patient’s state of mind
with respect to attachment to the historical caregivers and on the therapist’s own state of mind
with respect to his or her own attachment history (Tyrrell et al., 1999), not on the patient’s
state of mind with respect to attachment to the therapist (see Figure 1). As discussed below,
noncomplementary states of mind between the therapist and patient produce a greater
working alliance than complementary states of mind. The reasons for this finding are not
clearly understood, but one theory is that a therapist with a noncomplementary state of mind
is better equipped to facilitate the patient’s affect regulation than a therapist with a
complementary state of mind.
“Transference” refers to the process of transferring onto a contemporary person feelings
that originally applied, and still unconsciously apply, to a person from childhood in whom the
person had made an emotional investment (Freud, 1912a). The person from childhood,
however, does not have to be a caregiver. Freud (1912a) stated that the “father-imago,” or
father object representation, represents one childhood prototype on which transference is
based, “but the transference is not tied to this particular prototype: it may also come about on
the lines of the mother-imago or brother-imago” (p. 100). We know from attachment theory
that an attachment is formed to a person who gives care in situations in which the attachment
system is activated (see earlier discussion). Unless a sibling is sufficiently older to provide
such care, we would not expect a sibling to use another sibling as a secure base. Thus,
siblings do not form attachments to each other in this restricted sense of the word
“attachment.” Consequently, the phenomenon of transference cannot be conceptually
equivalent to the phenomenon of attachment.
Indeed, there is positive and negative transference and maternal and paternal transference
(Freud, 1912a) and more recently, organizationally based transference: psychopathic,
paranoid, and depressive transference (Kernberg, 1992) and idealizing and mirroring
transference (Kohut, 1971). Furthermore, patients can exhibit different transferences at
different times of the treatment or even in a single session. Kernberg and his colleagues
(1989) have discussed the rapidly oscillating transferences of patients with borderline
personality disorder: at one moment, the patient might be casting the therapist in the role of a
persecutor, the next moment, a longed-for caregiver, and the moment after that, a defiant
child. Kernberg and his colleagues have articulated these oscillations using the language of
projection of and identification with affectively linked pairs of self and object representations
from childhood. Each role portrayed by the therapist also arouses distinct countertransference
reactions because the therapist has temporarily identified with the projected self or object
representation. Bowlby (1980) and others (Grossmann, Grossmann, & Waters, 2005;
Hamilton, 2000; van IJzendoorn, 1995; Waters, Merrick, Treboux, Crowell, & Albersheim,
2000) have characterized the attachment construct as generally stable over time and resistant
to change. Thus, if transference can fluctuate (sometimes rapidly in a single session) and can
consist of feelings originally experienced with noncaregivers, then one must conclude that
transference and attachment are conceptually independent entities. Indeed, therapists’ ratings
of their patients’ negative transference were associated with patients’ ratings of their secure
attachment to the therapist (Woodhouse, Schlosser, Crook, Ligiero, & Gelso, 2003).
484 Geoff Goodman

I want to argue that the attachment to the therapist, developed in the context of a working
alliance (see above), in turn provides a context for the entire range of transference
experiences in the therapist-patient relationship (see Figure 1). Previously (Goodman, 2002), I
argued that the preoccupied/hyperactivating and dismissing/deactivating internal working
models represent two distinctly different personality organizations organized at a borderline
level. According to Kernberg (1986), both borderline personality disorder and most
narcissistic personality disorders (especially antisocial personality disorder) are organized at a
borderline level. Borderline personality organization falls midway between the neurotic and
psychotic levels of personality organization (Kernberg, 1996). What distinguishes the
narcissistic personality disorders from borderline personality disorder is the presence of the
pathological grandiose self. The pathological grandiose self is an admixture of idealized
object representations and real and idealized self-representations that compensates for a lack
of integration of a normal self-concept observed in borderline personality organization, which
accounts for the paradox of relatively good ego functioning and surface adaptation in the
presence of primitive defensive processes, such as splitting, and contaminated, barren object
relationships. I drew comparisons between borderline psychopathology and the
preoccupied/hyperactivating internal working model, and between narcissistic
psychopathology and the dismissing/deactivating internal working model, and provided
modest empirical evidence for these assertions (for recent evidence, see Westen, Nakash,
Thomas, & Bradley, 2006).
Briefly, borderline psychopathology shares with the preoccupied/hyperactivating internal
working model the features of extreme affect dysregulation, caregiver enmeshment, hostile
dependence on significant others, and fear of abandonment. Conversely, narcissistic
psychopathology shares with the dismissing/deactivating internal working model the features
of affect dysregulation, dismissal or devaluation of the emotional importance of object
relationships, counterdependence on others, and denial of vulnerability. These two personality
organizations lack integration and complexity at the representational level and share some of
the same primitive defensive processes such as splitting (Goodman, 2002, p. 66). I also
argued that self and object representations are the building blocks of these personality
organizations; their level of integration and complexity reflects the overall level of the
personality organization.
Transference-countertransference paradigms are affectively linked pairs of self and object
representations, with one representation identified with the patient and the other projected
onto the therapist (Kernberg et al., 1989). These paradigms exist within a particular
personality organization. For example, a psychopathic transference (Kernberg, 1992) is
associated with the pathological grandiose self in a borderline personality organization. This
transference consists of projecting the self-representation onto the therapist, whom the patient
perceives as dishonest, exploitative, and ruthless. I am suggesting that this transference-
countertransference paradigm could exist only within a dismissing/deactivating internal
working model. Other constellations of self and object representations belong to the domain
of a preoccupied/hyperactivating internal working model. For example, the patient’s
projection onto the therapist of an infantile, dependent self-representation compels the patient
to behave toward the therapist in a controlling-caregiving manner.
 An Attachment-Based Pathways Model Depicting the Psychology… 485

Common tasks
of therapy

Patient’s Patient’s
attachment attachment
Transference-
history to therapist
countertransference
Working alliance paradigms
(interaction structures)
Therapist’s Therapist’s
attachment caregiving of
history patient

Situational
Phase of
events
Common goals (e.g., vacation)
treatment
of therapy

Figure. Pathways Model of Working Alliance, Patient's Attachment ot Therapist, Therapist's

Caregiving of Patient, and Transference-Countertransference of Paradigms.

I am proposing that the personality organization constrains the range of representational

pairs and, thus, the transference-countertransference paradigms that could emerge in a
treatment. The personality organization/internal working model is therefore a necessary but
not sufficient condition for a transference-countertransference paradigm to form (Figure 1). In
other words, the personality organization determines the level of quality, complexity, and
integration of the affectively linked pairs of self and object representations manifested in the
therapist-patient relationship; however, other variables such as the therapist’s personality
organization/internal working model, quality of caregiving (see below), phase of treatment,
and situational events (e.g., the therapist’s vacation) also determine which representational
pairs become activated.
I want to add here that the patient’s attachment system both activates and is activated by
the therapist’s caregiving system, reciprocal to and parallel with the attachment system. The
caregiving system, according to George and Solomon (1999), is activated when the caregiver
perceives “internal or external cues or stimuli... as frightening, dangerous, or stressful for the
child” associated with situations such as “separation, child endangerment, and the child’s
verbal and nonverbal signals of discomfort and distress” (p. 652). In the therapist-patient
relationship, this caregiving takes the form of attentive listening; verbalization of affects,
needs, and the processes that inhibit the reception of caregiving; empathy; limit-setting;
affective containment; and mentalization, to name a few. These and other caregiving
behaviors facilitate the patient’s use of the therapist as a secure base and safe haven. George
and Solomon (1999) discovered four patterns of caregiving analogous to the four patterns of
attachment. It is believed that caregivers’ own attachment histories determine the quality of
caregiving for their children. I am arguing that the therapist’s caregiving of the patient
mediates the influence of the therapist’s own attachment history on the patient’s attachment to
him or her. In addition, the patient’s attachment and therapist’s caregiving systems mutually
influence each other (Figure 1).
486 Geoff Goodman

Thus, I am proposing a framework for understanding these relational phenomena (Figure

1). The patient’s and therapist’s attachment histories with childhood caregivers, as well as
their common tasks and goals, determine the quality of the working alliance, which, along
with their attachment histories, determines the formation of an attachment with the therapist
and caregiving of the patient, which, along with other variables such as phase of treatment
and situational events, determines the range of transference-countertransference paradigms
activated in the therapist-patient relationship. These transference-countertransference
paradigms can in turn influence the quality of the working alliance (Bordin, 1994), which in
turn influences the attachment to the therapist and caregiving of the patient. A negative
transference, for example, might disrupt an already tenuous collaboration between the
therapist and patient, contaminate the patient’s perception of the therapist as a secure base and
safe haven and the therapist’s self-perception as these functions, and result in termination of
the treatment. This event is most likely to occur among those patients who rely on extremely
unmodulated dismissing/deactivating or preoccupied/hyperactivating attachment strategies
that dramatically increase the likelihood of affect dysregulation and resultant impulsive
behavior when potentially dysregulating circumstances occur such as a narcissistic injury or a
perceived threat of abandonment.
Psychoanalysis has traditionally targeted the transference-countertransference paradigms
as the intervention point of entry by translating the patient’s enactments, symptoms,
associations, fantasies, dreams, and other clinical material related to the therapist into
symbolic knowledge through their verbal interpretation. As indicated earlier, however, some
psychoanalytic and attachment theoreticians are beginning to question the exclusivity and
even the primacy of symbolic knowledge as a vehicle of therapeutic change:
“Representational change may be set in motion... without necessarily assigning privileged
status to a particular dimension, such as interpretation” (Lyons-Ruth, 1999, p. 601).
According to Lyons-Ruth (1999), “development does not proceed only or primarily by
moving from procedural coding to symbolic coding... .Making the unconscious conscious
does not adequately describe developmental or psychoanalytic change” (pp. 579, 590). Thus,
we might question whether targeting transference-countertransference paradigms is the only
method or even the most efficient method for producing therapeutic change. I am suggesting
that implicit procedural knowledge embodied in the patient’s internal working model—“often
neither conscious and verbalizable nor repressed in a dynamic sense” (Lyons-Ruth, 1999, p.
589)—can also change through the therapist’s reliable provision of a secure base—a
nonsymbolic procedural response aimed at this level of relational knowing. Although the
verbal translation of unconscious, split-off self and object representations can facilitate the
integration of the patient’s internal working model/personality organization and restore affect
regulation, other, nonsymbolic interventions can also target the internal working model for
therapeutic change.
In summary, I have argued that the metaphor of the caregiver-infant attachment
relationship captures only certain features of the therapist-patient relationship—most
importantly, the caregiver functions of secure base and safe haven. The metaphor appears to
break down when the financial, temporal, spatial, logistic, and ethical boundaries of treatment
are considered. I also noted the vast differences between the infant’s and patient’s fund of
implicit procedural knowledge and linguistic knowledge. Finally, I discussed the difference
between the infant’s attachment to the caregiver and the patient’s working alliance and
transference to the therapist. I proposed that the working alliance and transference-
 An Attachment-Based Pathways Model Depicting the Psychology… 487

countertransference paradigms are both conceptually independent of attachment phenomena

embodied in internal working models but reflect the level of personality organization
(psychotic, borderline, or neurotic) and the characteristic secondary attachment strategies
(dismissing/deactivating or preoccupied/hyperactivating) used by the patient as an adult but
originally developed out of caregiving experiences from childhood.

ACKNOWLEDGEMENT
The author gratefully acknowledges the assistance of Valeda Dent in reproducing Figure
1 in Microsoft PowerPoint.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 29

A STUDY OF THE RELATIONSHIP BETWEEN

SELF-CONSCIOUS AFFECTS, COPING STYLES,
AND DEPRESSIVE REACTION
AFTER A NEGATIVE LIFE EVENT

Masayo Uji*, Toshinori Kitamura

Department of Clinical Behavioural Sciences, Kumamoto University Graduate School of
Medical Sciences, Japan
Toshiaki Nagata
Kyushu University of Nursing and Social Welfare, Japan

ABSTRACT
This study aimed to explore how the affects that result from conflictive social
interpersonal relationships influence mental health, as well as to investigate how specific
coping styles mediate between these affects and mental health.
The Test of Self-Conscious Affect-3 (TOSCA-3, Tangney, Dearing, Wagner, &
Gramzow, 2000) assesses six self-conscious affects, namely guilt-proneness, shame-
proneness, externalization, detachment, alpha pride, and beta pride. In this study, we
selected for analysis the four affects that originated from negative evaluations of the
presented scenarios (guilt-proneness, shame-proneness, externalization, and detachment).
We used the Coping Inventory for Stressful Situations (CISS, Endler, and Parker, 1990)
for estimating coping style, specifically task-oriented coping, emotion-oriented coping,
and avoidance-oriented coping.
A structural equation model that makes it possible to explore the causal relationship
between self-conscious affects, coping styles, and mental health, was chosen as a
statistical technique. Among the 394 Japanese university students who agreed to
participate in this study, 298 experienced moderate to severe stressful negative life events

*
E-mail ujimasayo@excite.co.jp; Telephone +81-(0)96-373-5183; Fax + 81-(0)96-373-5181. Address: Department
of Clinical Behavioural Sciences, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo,
Kumamoto, Japan 860-8556.
494 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

during the four-month study. Of those 298 respondents, 268 completed every item of the
TOSCA-3, the CISS, and the Self-rating Depressive Scale (SDS, Zung, 1965). These 268
were subjected to a structural equation model.
Among the four affect categories which occur under stressful situations, only shame-
proneness directly contributed to a depressive reaction, whereas the other three (guilt-
proneness, externalization, and detachment) did not. Individuals with shame-proneness
tended towards an emotional-oriented coping style, but this inhibited task-oriented
coping. Guilt-proneness induced task-oriented coping and avoidance-oriented coping.
Externalization induced task-oriented coping and emotion-oriented coping. Detachment
gave rise only to avoidance-oriented coping. Interestingly, among the three coping styles,
only task-oriented coping induced a depressive reaction, whereas emotion-oriented
coping and avoidance-oriented coping did not.
We discuss these results primarily from the psychological perspective but also look
briefly at how they might be applied to a clinical setting within psychiatry.

Keywords: guilt-proneness, shame-proneness, externalization, detachment, coping style,

depressive reaction

INTRODUCTION
People live within a complex web of interpersonal relationships. These relationships
stimulate various affects, some of which are not experienced at a conscious level. Even when
one is aware of them, it is often difficult to put them into words. One of the aims of
psychotherapy is to use an empathetic relationship with patients to help them become more
aware of their affects and to put those affects in order. We sometimes see patients recognize
affects that had previously been imperceptible to them. Shame and guilt are two primary
examples in this regard. From a clinical perspective is crucial to have a deeper understanding
of these two affects, namely whether they have beneficial properties in maintaining mental
health, or conversely, whether they have negative properties which lead to psychological
maladjustment.
Okada (2006), making reference to Ausubel (1955), mentioned that both guilt and shame
are moral affects that contribute to the maintenance of any given social order. For several
reasons, defining guilt and shame is an extremely difficult task. Guilt and shame differ from
other affects such as anger, fear, pleasure, and sadness because they are not clearly exhibited,
they include diverse moods (Sakuta, 1967, Inoue, 1977), and their definitions may vary across
cultures. Some researchers discuss these two affects from a cultural perspective, while others
explain them as tendencies of a particular person, in which case they are related to the
individual’s psychopathology.
Benedict is a sociologist who compared Western culture and Japanese culture. In “The
Chrysanthemum and the Sword” (Benedict, 1967), she described Western culture as a
“culture of guilt” and Japanese culture as a “culture of shame.” She defined guilt as an
internal sanction, and shame as an external sanction. In other words, guilt is an autonomous
reaction that derives from an internalized conscience, whereas shame occurs when the
individual is criticized or ridiculed by those around them. In some epidemiological studies,
researchers have compared the two cultures: that of guilt and that of shame. Inoue (1977)
pointed out that this had become a somewhat popular trend in the realm of anthropology. He
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 495

criticized anthropologists for having compared these two cultures and having connoted that a
culture of guilt is superior to a culture of shame.
However, many scholars have disputed Benedict’s argument. Sakuta (1967), while
honoring Benedict for having profiled one aspect of the ethnic group, criticized her for
focusing exclusively on the negative aspects of shame. Sakuta (1967) further stated that guilt
is experienced as a recognition of “being bad,” whereas shame is experienced as a recognition
of “being inferior.” He added that people feel shame not only when they are rejected but also
when they are praised in public, which he states is a point that Benedict missed. Sakuta
(1967) also contradicted Benedict’s simple differentiation between guilt as internal sanction
and shame as an external sanction. He wrote that a sense of guilt can be acquired as the result
of external sanction, while shame can control one’s behavior in the absence of external
judgment. Freud (1923) also mentioned that after external sanction is internalized as the
superego, guilt eventually functions as an internal sanction.
Inoue (1977) further developed Sakuta’s (1966) ideas of “private shame” and “public
shame.” He theorized that when people feel private shame, they see themselves as other
people might see them and judge themselves based on the values of the referential group
(Inoue, 1977). They then recognize themselves as being inferior to their ego-ideal (Piers, &
Singer, 1971). Inoue (1977) mentioned that this private shame is very close to guilt, and
therefore shame and guilt are not separate affects but instead exist along a continuum.
Lebra (1983) also refuted Benedict’s description of Japan as embodying a shame culture.
She asserted that, guilt involves far more awareness of others in the Japanese tradition as
compared with the Judeo-Christian theistic tradition. For many Japanese people a sense of
guilt is often accompanied by a deep consideration for the victim, a feeling that they have
caused the other person to suffer as a result of their action. Although Lebra acknowledges that
both shame and guilt are pervasive in the Japanese culture, she argues that guilt comes to the
fore in the Japanese psychic structure. She explains the relative primacy of guilt using the
Japanese moral value of self-denial. Withholding self-expression is regarded as a virtue in
Japan. Both guilt and shame are allocentric, but shame includes an egocentric concern with
one’s self-image. Japanese people may therefore show some ambivalence towards shame.
Guilt sensitivity is always seen as acceptable though shame sensitivity is not.
Through the different theories of guilt and shame in the realms of sociology and cultural
anthropology, we begin to recognize the difficulty in defining and distinguishing between
these two affects.
In the psychiatric and psychological realms, we usually target excessive guilt and shame
under the assumption that they may induce mental disorders or maladjustment. We also
discuss these affects as individual tendencies. Some mental disorders, such as depression and
obsessive-compulsive disorder, are believed to be more closely related to guilt, while others,
such as social phobia and avoidant personality disorder, have been linked more strongly to
shame. Specifically, “taijinkyohusyo” (anthropophobia) is thought to be related to shame
(Lebra, 1983, Inoue, 1977), though Lebra (1983) suggests at the end of her paper that
“taijinkyohusyo” is guilt-related rather than shame-related in terms of patients’ fear of the
discomfort they may arouse in others, not in themselves. Kimura (1972) suggests that
“taijinkyohusyo” is unique to Japanese culture and that no corresponding term exists in
Western languages. It is not a single disease unit and the subject may fear several different
conditions -- i.e., blushing, staring at another, emitting odor, facial expression, looking ugly --
with the underlying concern being the fear of causing discomfort in others. Kasahara (1968)
496 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

points out that among various symptoms of“taijinkyohusyo”, fear of staring at another is quite
unique to Japanese. When these patients make eye contact with another, they become stiff and
tense.
Another discipline that may help deepen our understanding of guilt and shame is
psychoanalysis. Freud discussed guilt and its relation with the superego and Oedipus complex
(Freud, 1923), and also its role as a psychological process in melancholia (Freud, 1917) and
obsessive-compulsive neurosis (Freud, 1909). Klein (1957) has distinguished two types of
guilt: guilt in the paranoid-schizoid position, and guilt in the depressive position. Grinberg
(1964) later called these two types of guilt “persecutory guilt” and “depressive guilt.” The
latter type of guilt is more mature, reparative to the harmed object, and sympathetic. Freud
did not discuss shame to a great extent, but Piers and Singer (1971) later reinterpreted Freud’s
theory and explained that guilt derives from a conflict between the superego and ego, while
shame stems from a conflict between the ego-ideal and ego.
In the area of self-psychology, Kohut explained shame from the viewpoint of the
relationship between self and object (usually the mother). In his paper (Kohut, 1972), he
argued that without the mother’s approval and admiration, a crude and intensely narcissistic
cathexis of the grandiose self cannot be transformed and cannot be integrated with the
remainder of the psychic organization. It is either split off or repressed. When these defense
mechanisms do not function because of archaic claims made by one’s exhibitionistic self, the
ego is flooded by this self and becomes paralyzed, consequently feeling intense shame and
rage. Kohut (1966) also discusses the possibility of the ego inviting an object to participate in
alleviating the narcissistic tension. When the object rejects these attempts, the ego
experiences painful feelings of shame.
Since Lewis (1971) published “Shame and Guilt in Neurosis,” many researchers have
undertaken empirical studies to explore the role of shame and guilt in the development of
psychological maladjustment (Tangney, 1996). This led to the development of inventories
that assess guilt and shame. Tangney has reviewed these inventories and assessed their
strengths and weaknesses (Tangney, 1996).
Feiring and her colleagues demonstrated how “shame feeling” and “abuse-specific
internal attribution” worsen subsequent psychological maladjustment among those who
experience sexual abuse (Feiring, Taska, & Lewis, 1998, Feiring, Coates, & Taska, 2001,
Feiring, Taska, & Chen, 2002a, Feiring, Taska, & Lewis, 2002b, Feiring, & Taska, 2005). To
conduct their research, they invented a questionnaire that assesses shame. It included four
items: (1) “People can tell from looking at me what happened,” (2) “I want to go away by
myself and hide,” (3) “I am the only one in my school who this happened to,” and (4) “What
happened to me makes me feel dirty.” These items seem to cover exposure sensitivity, a
negative evaluation of the entire self, and the impetus to hide oneself. Using the same
questionnaire, Uji, Shono, Shikai, and Kitamura (2007) conducted research on sexual
victimization among Japanese university women, and demonstrated how the feeling of shame
contributed to developing post-traumatic stress disorder (PTSD). This shame-focused
questionnaire is regarded as a tool to assess shame as an emotional state, which alludes to the
emotions an individual feels temporarily and in a particular situation.
Among empirical studies that have assessed both guilt-proneness and shame-proneness as
individual dispositions, the Self-Conscious Affect and Attribution Inventory (SCAAI,
Tangney, 1990) and the Test of Self-Conscious Affect (TOSCA, Tangney, Wagner, Fletcher,
& Gramzow, 1992b) are scenario-based inventories developed by Tangney and her
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 497

colleagues. The development of TOSCA is based on Lewis’s (1971) definition of the two
affects. Lewis (1971) noted that in the case of shame, the central object of negative evaluation
is the entire self, whereas in the case of guilt, it is the thing done or undone. Therefore, we
can see that shame is a more painful affect because the entire self is scrutinized and
negatively evaluated, and moreover it paralyses an individual, driving them to hide
themselves (Tangney, 1996). Furthermore, she (Tangney, 1996) referred to the ameliorative
characteristics of guilt. She wrote, “.… guilt doesn’t affect one’s core identity or self-concept.
In guilt, there’s a sense of tension, remorse and regret over the ‘bad thing done.’ And this
sense of tension and regret often motivates reparative action-confessing, apologizing, or
somehow repairing the damaged one”.
TOSCA is a refined version of SCAAI. SCAAI is applicable only to college students,
whereas TOSCA is applicable to adults of all ages. In addition, scenario items in the SCAAI
were experimenter-generated whereas those in TOSCA were subject-generated for the
purpose of enhancing ecological validity. TOSCA was revised twice to solve a few flaws, and
was superseded by TOSCA-3 (TOSCA-3, Tangney, Dearing, Wagner, & Gramzow, 2000).
TOSCA-3 is composed of 11 negative scenarios and five positive scenarios, which assesses
guilt-proneness, shame-proneness, externalization, detachment, alpha pride, and beta pride.
Tangney and her colleagues verified Lewis’ (1971) idea about the negative property of
shame. They demonstrated that shame-proneness rather than guilt-proneness prompts
psychopathology such as depression, anxiety, obsessive-compulsive disorder, psychoticism,
interpersonal sensitivity, and anger (Tangney, Dearing, Wagner, & Gramzow, 1992a,
Tangney, et al., 1992b). Furthermore, Tangney (1991) showed that guilt was positively
correlated with empathic responses, in contrast to the negative correlation of shame to this
variable.
Based on this previous research, we hypothesized that shame-proneness has more
psychopathology-inducing characteristics than guilt-proneness. As an indicator, we adopted a
depressive reaction which is assessed by the Self-rating Depression Scale (Zung, 1965).
Another interesting aspect of TOSCA-3 is that it does not only take into account the two
more controversial affects, guilt and shame, but also assesses externalization and detachment.
While shame and guilt involve a sense of responsibility (Eisenberg, 2000) and play a role in
maintaining social order, externalization and detachment do not seem to be related to self-
responsibility. They do not motivate moral behaviors. It is interesting to examine these affects
from the perspective of mental health rather than tools for maintaining social order or
morality.
One of the purposes of this study is to examine how these affects (shame, guilt,
externalization, and detachment) correlate with each other and how they might influence a
depressive reaction in those who have experienced a negative life event (NLE). Furthermore,
we wanted to look at which particular coping styles are likely to be adopted by people who
are prone to feeling particular affects in specific conflictive situations. For the purpose of
assessing coping styles, we chose the Coping Inventory for Stressful Situations (CISS,
Endler, & Parker, 1990).
The CISS is a self-report measure to assess an individual’s typical pattern of coping.
There are 48 items with a 5-point scale (1 = not at all, 5 = very much). These include three
orthogonal subscale dimensions: task-oriented coping, emotion-oriented coping, and
avoidance-oriented coping. Task-oriented coping is defined as a strategy in which an
individual attempts to solve or re-conceptualize the problem through some action. Emotional-
498 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

oriented coping is defined as an emotional response, and it includes a preoccupation with

worrying, blaming oneself, tension or other related emotions. Avoidance-oriented coping
refers to strategies where an individual tries to either avoid the difficult situations they are
confronted with or ignore the problems they face by seeking out others or engaging in a
substitute task.
Shikai, Uji, Chen, Hiramura, Tanaka, Shono, and Kitamura (2007) showed significant
correlations between any two of the three coping styles. All three styles assist the individual
in maintaining a sense of balance, even though some of them do not offer a resolution to the
problem.
For instance, previous studies have shown that task-oriented coping is more closely
linked to adaptive health variables (Endler, & Parker, 1990, Endler, Parker, & Butcher, 1993,
Miller, Brody, & Summerton, 1988, Parkes, 1990), whereas the other two coping styles tend
toward maladaptive health variables. With regard to an emotion-oriented coping style,
previous research has suggested that it is linked to negative health variables such as
depression (Shikai et al., 2007), anxiety (Shikai et al., 2007), insufficient ability to recover
from bodily illnesses (Billings, Cronkite, & Moos, 1983, Endler & Parker, 1990, Endler et al.,
1993, McWilliams, Cox, & Enns, 2003, Vollrath, Alnaes, & Torgersen, 1994), and other
maladaptive health variables (Cronkite, Moos, Twohey, Cohen, & Swindle, 1998, Endler, &
Parker, 1990, Holahan & Moos, 1987, Krantz & Moos, 1988, McCrae & Costa, 1986),
though Park and Adler (2003) reported no such link. Avoidance-oriented coping has also been
shown to predict negative health variables (Cronkite, et al., 1998, Endler & Parker, 1990,
Holahan & Moos, 1987, McCrae & Costa, 1986).
This study aims to explore how each coping style mediates between self-conscious
affects and the depressive reaction caused by NLEs. In other words, our goal is to determine
which self-conscious affects cause an individual to adopt a particular coping style, and
whether a depressive reaction is provoked by the adoption of a given coping styles.
We hypothesized that an individual with guilt-proneness is more apt to apply a coping
strategy that relies heavily on problem-solving, namely task-oriented coping. We also
premised that an individual with shame-proneness is apt to apply one of both of the remaining
two coping styles, emotion-oriented coping and avoidance-oriented coping. This is because a
person who exhibits shame-proneness has low self-esteem and may attribute the cause of a
problematic situation to themselves, being unable to deal with the situation efficiently.
Furthermore, we predicted that task-oriented coping has an inhibiting effect on a depressive
reaction, whereas the other two coping styles, emotion-oriented coping and avoidance-
oriented coping precipitate a depressive reaction.
To summarize, the purpose of our study is to determine 1) whether specific self-
conscious affects have an effect on an individual’s depressive reaction, 2) whether these self-
conscious affects prompt an individual to adopt specific coping styles, and 3) as a result,
whether or not these coping styles worsen a depressive reaction caused by a NLE. The
research hypothesis is shown in Figure 1.
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 499

Task-oriented Coping
W3 eSDS
W2 eT

W1
Self-conscious Affect Δ SDS

eE W5
W4

Emotion-oriented Coping

W7
W6 eA

Avoidance-oriented Coping

Figure 1. The hypothesis about the relationship between self-conscious affect, coping styles, and
depressive reaction.

METHOD

Procedure and Participants

As a longitudinal follow-up study on depressive mood and suicidality in a Japanese

university student population, a 9-wave four-month prospective study was performed on
students of two universities in Kumamoto. The anonymity and voluntary participation were
guaranteed. The research protocol was approved by the Ethical Committee of Kumamoto
University. (Institutional Review Board). The number of eligible students was 642, but
because not all students attended class on each occasion and 2% to 3% of the students
declined participation in the study.
The TOSCA-3 was included in the questionnaire given to students on the 6th occasion,
and the CISS was included in the first occasion. The SDS was included in the questionnaire
on all 9 occasions. However, only the scores from the first occasion and the final occasion
were used in the analysis. Therefore, the 394 respondents who agreed to participate in the 1st,
6th, and 9th occasions formed the target population of this study. The population included 68
men and 326 women, with a mean age of 18.8 years (SD 1.28).

Measurements

Test of Self-Conscious Affect-3 (TOSCA-3, Tangney, et al., 2000)

TOSCA-3 is a self-report measure of six self-conscious affects: shame-proneness, guilt-
proneness, externalization, detachment, alpha pride, and beta pride. The TOSCA-3 consists of
500 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

a series of 11 negative and five positive scenarios with four or five responses reflecting one of
the six affects. Each response is rated on a 5-point scale from “not likely” to “very likely.”
We allocated between 1 and 5 points for each item. A bilingual graduate student translated the
TOSCA-3 into Japanese. A second bilingual graduate student familiar with the literature on
shame and guilt back translated the measure and compared it to the original English. In this
study, among the six affect categories, the four affects which originate from negative
evaluations of the presented scenarios (guilt-proneness, shame-proneness, externalization, and
detachment) were used in the analysis.

Coping Inventory for Stressful Situations (CISS, Endler, and Parker, 1991)
The CISS is a self-report measure of coping styles. It consists of 48 items rated on a 5-
point scale (1=not at all, 5=very much). There are three categories: task-oriented coping,
emotion-oriented coping, and avoidance-oriented coping. Its factor structure was confirmed
(Rafnsson, Smari, Windle, Mears, & Endler, 2006). The English version of the CISS was
translated into Japanese by Furukawa and its validity and reliability are well established
(Furukawa, Suzuki, Saito, & Hamanaka, 1993).

Self-rating Depressive Scale (SDS, Zung, 1965)

The SDS was included in the questionnaire on all occasions. The SDS is a self-report
measure of depressive symptoms which consists of items on a 4-point scale from “never”
(scored 1) to “almost always” (scored 4). Using a Japanese university student population,
Kitamura, Hirano, Chen, and Hirata (2004) have reported a three-factor structure for the
scale. They identified the three factors as affective, cognitive, and somatic. We drew our
seven SDS items from the affective category. Among the total scores of the SDS assessed on
nine different occasions, we used the scores from the first and last occasions because their
difference (ΔSDS: the final SDS score – the first SDS score) represents the change in the
mood of the participants during the study period.

Negative Life Event (NLE)

In the questionnaire given to students at the 9th occasion (the final occasion of this study),
participants were asked to recall their most stressful negative experience during the four-
month period of the study. This was assessed by an ad hoc item: “Consider an event you
experienced in this four-month study period which was undesirable, upsetting, depressing, or
that made you sad, and score its impact from 0 (not stressful at all) to 100 (extremely
stressful).” In addition to providing a numeric value, each of the respondents was required to
describe the contents of their NLE in words.

Statistical Methods

Correlations between Subscale Scores of TOSCA-3 and between Subscales of CISS

Responses from 394 students who agreed to participate on all three occasions were used
in the analyses.
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 501

Partial Correlations between Each Subscale of TOSCA-3 and ΔSDS

The NLE score was significantly correlated with ΔSDS [r=.12, (p<.05) ], as well as three
of four self-conscious affects [r=.17 with guilt-proneness, (p<.01), r=.15 (p<.01) with shame-
proneness, r=-.17 (p<.01) with detachment], though it did not correlate significantly with
externalization (r=-.03). Therefore, to remove the influence of the NLE on correlations
between each of the four affects and ΔSDS, partial correlations were estimated by setting the
NLE as a control variable.

The Relationship between Each Self-conscious Affect, Coping Styles, and the
Depressive Reaction Partially Caused by a NLE
To investigate this relationship, we used a structural equation model, which made it
possible to verify whether specific coping styles mediate each self-conscious affect and the
depressive reaction. The goodness of fit of the model to the data was expressed by the
goodness of fit index (GFI), adjusted goodness of fit index (AGFI), and root mean square
error of approximation (RMSEA) (Arbuckle, & Wothke). We premised the hypothesis
schematized in Figure 1. The depressive reaction was calculated by subtracting the 1st SDS
score from the 9th SDS score. Analysis subjects included the 271 respondents who
experienced a moderate to severe NLE (NLE score ≧ 50) and also completed TOSCA-3,
CISS, and SDS.
All the statistical analyses were conducted using the Statistical Package for Social
Science (SPSS) version 12.0 and Amos 5.0.

RESULTS

Correlations between Subscale Scores of TOSCA-3

Guilt-proneness was significantly correlated only with shame-proneness (r=.59, p<.01)

(Table 1). Guilt-proneness did not have a significant correlation with the other two affects,
externalization and detachment. Shame-proneness was significantly correlated with
externalization (r=.21, p<.01) but not with detachment (r=-.08). The correlation between
externalization and detachment was significant (r=.53, p<.01).

Table 1. Correlations between subscales of TOSCA-3

Mean (SD) guilt- shame- externalization detachment

proneness proneness
guilt- 63.9 (8.02) -
proneness
shame- 52.1 (8.88) .59** -
proneness
externalization 35.4 (7.94) -.08 .21** -

detachment 29.0 (6.62) -.09 -.08 .53** -

** p<.01
502 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

Table 2. Correlations between subscales of CISS

Mean (SD) task emotion avoidance

task 43.3 (11.9) -
emotion 37.2 (11.1) 0.18** -
avoidance 42.9 (10.3) 0.36** 0.28** -
** p<.01

Table 3. Partial correlations between each subscale of TOSCA-3 and ΔSDS

(control variable: NLE score)

Partial correlation coefficient with ΔSDS

guilt proneness .01
shame proneness .12*
externalization .04
detachment .01
* p<.05

Correlations between Subscale Scores of CISS

ALL pairs of the three Subscale Scores were Significantly Correlated (Table 2).

Partial correlations between Each Subscale of TOSCA-3 and ΔSDS

Only shame-proneness had a significant partial correlation with ΔSDS (r=.12, p<.05)
(Table 3).

The Description of the most Stressful NLE

Among 374 participants, 180 described their most stressful NLE, but the remaining 214
did not. A total of 298 participants experienced a moderate to severe NLE (the NLE score
was 50 or more). Of these, 145 described the content of their NLE. Whether they described
their NLE varied by subgroup in terms of the NLE intensity [Chi-squared (1) = 4.14, p=.04].
Respondents who experienced a moderate to severe NLE were more likely to describe their
experiences.
The contents of the NLEs were roughly grouped into six categories: distress within a
family, distress concerning a relationship with friends, difficulties regarding a romantic
relationship, hardship due to the participant’s own physical disease or injury, distress about
schoolwork, and other stressful situations.
NLEs within a family were as follows: a family member’s disease (e.g. mother’s cancer,
grandmother’s subarachnoid hemorrhage, etc.), the loss of a family member, the
disappearance of a family member, or a family member’s attempt at suicide. Some reported a
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 503

negative relationship with other family members. One student wrote, “there was a big fight in
my family and glasses were broken; I am afraid that may happen again.”
NLEs involving relationships with their friends were as follows: having been betrayed,
having been told something hurtful, a friend’s cold attitude, having been irritated because of a
friend’s selfish behavior, anxiety over a friend’s reaction to an unintentional mistake (e.g.
having broken or lost a friend’s belongings). One reported that her friend was murdered.
Some had a negative experience with a romantic relationship, such as a “broken heart,”
the breakup of a relationship, or a conflict with their partner. One reported that she was
exhausted because her boyfriend was involved in a traffic accident and was admitted to a
hospital.
Some suffered from their own physical disease or injury. One wrote, “I was about to die
because of chicken pox.” Another wrote, “I suffered from acute bronchitis and was admitted
to a hospital for one week. I worried about my schoolwork because I could not attend classes
during this period.” A few students reported having had a traffic accident.
Some worried about succeeding in their studies and graduating from university as
planned, because they were not confident about submitting many reports or passing all of
their tests. One wrote that a teacher reprimanded her because she missed the deadline for
submitting a report. Some stated that they failed the entrance examination for their first-
choice university and had difficulty motivating themselves to continue their studies at their
current university.

Task-oriented Coping
.13*
.20*** eSDS
eT

Guilt-proneness Δ SDS

eE
.19**

Emotion-oriented Coping

.15*
-.12
eA

Avoidance-oriented Coping

Numerical values in the figure are standardized regression weights between the respective observed
variables.
* p<.05, ** p<.01. *** p<.001.

Figure 2. The relationship between guilt-proneness, coping styles, and depressive reaction.
504 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

Other responses included the loss of a pet, economic distress, a contentious relationship
with seniors, and difficulty in managing their schedule. One student was suspected of stealing
money from work.
Some defined their distress as an inability to come to terms with their own existence or
their own self-image. One female student wrote, “I am always anxious about whether I am
worthy of being loved by other people. I have confided in my friend that I am always scared,
but I do not think that she will ever understand me. As a result, I feel more lonely.” Another
female student wrote, “I am not confident with myself, I hate myself. I always hang out with
two of my friends, they chat very happily, but I cannot join in their conversation and feel
anxious. I do not have anywhere else to go other than this group.” One wrote “I cannot
remember a specific trigger, but I do not want to have contact with other people. I have been
depressed for several months. I am afraid that I am suffering from depression.” One female
student wrote, “I do not want to write about it.” She scored her NLE at 100.

Structural Equation Model

The Relationship between Guilt-Proneness, Coping Styles, and a Depressive Reaction

The model that showed the best fit (GFI: 1.00, AGFI: .99, RMSEA: 0.00) assumed the
following causal coefficients to be zero: from guilt-proneness to ΔSDS, and from emotion-
oriented coping to ΔSDS. The estimates of standardized regression weights are shown in
Figure 2. Individuals with guilt-proneness had a tendency to make use of any of the three
coping styles included in the CISS. The standardized regression weights from guilt-proneness
to each coping style were as follows: .20 to task-oriented coping (p<.001), .19 to emotion-
oriented coping (p<.01), and .15 to avoidance-oriented coping (p<.05). The causal
relationship between task-oriented coping and ΔSDS was significant (p<.05). Emotion-
oriented coping did not influence the ΔSDS. The causal relationship between avoidance-
oriented coping and ΔSDS was not significant (p>.05).

The Relationship between Shame-Proneness, Coping Styles, and Depressive Reaction

The model that showed the best fit (GFI: 1.00, AGFI: 1.00, RMSEA: 0.00) assumed three
of the causal coefficients to be zero: from shame-proneness to task-oriented coping, from
shame-proneness to avoidance-oriented coping, and from emotion-oriented coping to ΔSDS.
The estimates of standardized regression weights are shown in Figure 3. Shame-proneness
prompted an individual to adopt emotion-oriented coping only (the standardized regression
weight from shame-proneness to emotion oriented coping was .42 (p<.001). The causal
relationship between task-oriented coping and ΔSDS was significant (p<.05), whereas
emotion-oriented coping did not influence the ΔSDS. The causal relationship between
avoidance-oriented coping and ΔSDS was not significant (p>.05).
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 505

Task-oriented Coping
.12*
eSDS
eT

.12*
Shame-proneness Δ SDS

eE

.42***
Emotion-oriented Coping

-.12
eA

Avoidance-oriented Coping

Numerical values in the figure are standardized regression weights between the respective observed
variables.
* p<.05, *** p<.001.

Figure 3. The relationship between shame-proneness, coping styles, and depressive reaction.

The Relationship between Externalization, Coping Styles, and Depressive Reaction

The model that showed the best fit (GFI: 1.00, AGFI: .99, RMSEA: 0.00) assumed two
causal coefficients to be zero: from externalization to ΔSDS, and from emotion-oriented
coping to ΔSDS. The estimates of standardized regression weights are shown in Figure 4.
Similar to guilt-proneness, externalization also prompted an individual to adopt all three of
the coping styles in the CISS. The standardized regression weights from externalization to
each coping style were as follows: .15 to task-oriented coping (p<.05), .21 to emotion-
oriented coping (p<.001), and .13 to avoidance-oriented coping (p<.05). The causal
relationship between task-oriented coping and ΔSDS was significant (p<.05), whereas
emotion-oriented coping did not influence the ΔSDS. The causal relationship between
avoidance-oriented coping and ΔSDS was not significant (p>.05).

The Relationship between Detachment, Coping Styles, and Depressive Reaction

The model that showed the best fit (GFI: 1.00, AGFI, .099, RMSEA: 0.00) assumed three
of the causal coefficients to be zero: from detachment to ΔSDS, from detachment to emotion-
oriented coping, and from emotion-oriented coping to ΔSDS. The estimates of standardized
regression weights are shown in Figure 5. The standardized regression weights from
detachment to each coping style were as follows: .17 to task-oriented coping (p<.01) and .21
to avoidance-oriented coping (p<.001). The causal relationship between task-oriented coping
and ΔSDS was significant (p<.05), whereas emotion-oriented coping did not influence the
ΔSDS. The causal relationship between avoidance-oriented coping and ΔSDS was not
significant (p>.05).
506 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

Task-oriented Coping
.13*
.15* eSDS
eT

Externalization Δ SDS

eE

.21***
Emotion-oriented Coping

.13* -.12
eA

Avoidance-oriented Coping

Numerical values in the figure are standardized regression weights between the respective observed
variables.
* p<.05, *** p<.001.

Figure 4. The relationship between externalization, coping styles, and depressive reaction.

Task-oriented Coping
.13*
eSDS
.17** eT

Detachment Δ SDS

eE

Emotion-oriented Coping

.21***
-.12
eA

Avoidance-oriented Coping

Numerical values in the figure are standardized regression weights between the respective observed
variables.
* p<.05, ** p<.01, *** p<.001.

Figure 5. The relationship between detachment, coping styles, and depressive reaction.
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 507

The Relationship between Guilt-proneness, Shame-Proneness, Externalization,

Detachment, Coping Styles, and a Depressive Reaction
As shown in Table 1, significant correlations were observed between guilt-proneness and
shame-proneness, between shame-proneness and externalization, and between externalization
and detachment. To refine our statistical analysis, we put these four affects in the same model
(Figure 6). This made it possible to assess how coping styles and depressive reaction are
affected by the residual portion of guilt-proneness which is not influenced by shame-
proneness, by shame-proneness which is not influenced by guilt-proneness and
externalization, by externalization which is not influenced by shame-proneness and
detachment, and lastly by detachment which is not influenced by externalization. In this
model, we added covariances between guilt-proneness and shame-proneness, between shame-
proneness and externalization, and between externalization and detachment (C1, C2, C3 in
Figure 6).
We inferred from preliminary analyses (Figure 2 – Figure 5) that emotion-oriented
coping did not influence ΔSDS, and therefore the path from emotion-oriented coping to
ΔSDS was dismissed.
In addition, the model which eliminated the following causal coefficients showed the best
fit: from guilt-proneness to ΔSDS, from externalization to ΔSDS, from detachment to ΔSDS,
from guilt-proneness to emotion-oriented coping, from shame-proneness to avoidance-
oriented coping, from externalization to avoidance-oriented coping, from detachment to
emotion-oriented coping, and from emotion-oriented coping to ΔSDS (GFI=.99, AGFI=.97,
RMSEA=0.00) (Figure 7).

Task-oriented coping
Guilt-proneness

eT
C1

Δ SDS

Shame-proneness Emotion-oriented coping eE

C2

Externalization

eA

C3
Avoidance-oriented coping

Detachment

Figure 6. The relationship between four conscious affects, coping styles, and depressive reaction.
508 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

Task-oriented coping
Guilt-proneness
eT

Δ SDS

Shame-proneness
Emotion-oriented coping eE

Externalization
eA

Avoidance-oriented coping

Detachment

Detail estimates were shown in Table 4.

Key: thick lines: causal coefficients and covariances were significant;
narrow lines: causal coefficients were not significant;
solid lines: causal coefficients showed positive values;
dotted lines: causal coefficients showed negative values.

Figure 7. The best-fit model of the relationship between four conscious affects, coping styles, and
depressive reaction.

Table 4. Covariences and Regression weights of Figure 7

Standardized Non-standardized
Covariances
Guilt-proneness ↔ Shame-proneness .58 42.74***
Shame-proneness ↔ Externalization .29 21.70***
Externalization ↔ Detachment .60 33.45***
Regression weights
Guilt-proneness → Task-oriented coping .33 0.47***
Guilt-proneness → Avoidance-oriented coping .18 0.22**
Shame-proneness → Task-oriented coping -.18 -0.23*
Shame-proneness → Emotion-oriented coping .41 0.51***
Externalization → Task-oriented coping .15 0.22*
Externalization → Emotion-oriented coping .11 0.15*
Detachment →Task-oriented coping .10 0.17
Detachment →Avoidance-oriented coping .23 0.34***
Shame-proneness → SDS .13 0.06*
Task-oriented coping → SDS .12 0.05*
Avoidance-oriented coping → SDS -.12 -0.05
*p<.05, **p<.01. ***p<.001
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 509

Standardized covariances and regression weights as well as non-standardized covariances

and regression weights are shown in Table 4. As predicted, the standardized covariances
between the combination of two affects were significant. The standardized covariance
between guilt-proneness and shame-proneness (C1 in Figure 6) was .58 (p<.001), the
standardized covariance between shame-proneness and externalization (C2 in Figure 6) was
.29 (p<.001), and the standardized covariance between externalization and detachment (C3 in
Figure 3) was .60 (p<.001).
As observed in Figure 3, shame-proneness still induced a direct positive effect on ΔSDS
(the standardized causal coefficient from shame-proneness to ΔSDS was .13, p<.05), although
guilt-proneness, externalization and detachment did not. Interestingly, shame-proneness
inhibited task-oriented coping (the standardized causal coefficient from shame-proneness to
task-oriented coping was -.18, p<.05). Guilt-proneness had no effect on emotion-oriented
coping, but it gave rise to one or both of a choice of the other two coping styles: task-oriented
coping (the standardized causal coefficient from guilt-proneness to task-oriented coping was
.33, p<.001) and avoidance-oriented coping (the standardized causal coefficient from guilt-
proneness to avoidance-oriented coping was .18, p<.01). Externalization tended towards both
task-oriented coping (the standardized causal coefficient from externalization to task-oriented
coping was .15, p<.05) and emotion-oriented coping (the standardized causal coefficient from
externalization to emotion-oriented coping was .11, p<.05), but it did not influence
avoidance-oriented coping. Detachment promoted avoidance-oriented coping (the
standardized causal coefficient from detachment to avoidance-oriented coping was .23,
p<.01) whereas it had no effect on emotion-oriented coping. The causal coefficient from
detachment to task-oriented coping was not significant (the standardized causal coefficient
from detachment to task-oriented coping was .10, p=.17).
As shown in Figures 2-5, task-oriented coping reinforced the direction towards ΔSDS
(the standardized causal coefficient was .12, p<.05), and the causal coefficient from
avoidance-oriented coping to ΔSDS was not significant (the standardized causal coefficient
was -.12, p=.06).

DISCUSSION

Correlations between Subscale Scores of TOSCA-3

The definitions of shame and guilt have been debated for many years. The similarity
between these two affects was supported by a strong positive correlation between them in our
analysis (Tables 1 and 4, Figure 7). As mentioned briefly in the Introduction section, both
affects share similar characteristics. Each includes uncomfortable or dysphoric moods that are
derived from an internal attribution. Two other self-conscious affects, externalization and
detachment, do not encompass these characteristics. Both guilt and shame are moral affects,
and are therefore ubiquitous among civilized cultures and play a role in maintaining social
order. As noted in the Introduction, distinguishing between these two affects is extremely
difficult, and it might be appropriate to consider the two not as distinct affects but rather as
existing along a single continuum. Furthermore, they may be experienced simultaneously.
510 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

Our results replicate those of several past studies in terms of the overlap between shame and
guilt (Tangney, 1990, Tangney et al., 1992a, Tangney, et al., 1992b).
Guilt-proneness did not correlate significantly with the other two affects, externalization
and detachment. As noted previously, guilt-proneness and shame-proneness are different from
externalization and detachment. Those who are ashamed blame themselves and those who
feel guilt place the blame on their own actions. However, in the case the other two affects,
individuals do not look introspectively or reflect on their actions. This might be the reason
why guilt-proneness did not correlate with the remaining two affects.
As opposed to guilt-proneness, however, shame-proneness correlated significantly and
positively with externalization (Table 1 and 4, Figure 7). Tangney et al. (1992b) also
concluded that in contrast with guilt-proneness, shame-proneness was consistently correlated
with anger-arousal, resentment, and a tendency to blame others. This might be because shame
includes persecutory feelings. In the Japanese language, there is a common expression, “I was
humiliated in public.” This might be related to a public shame that Sakuta (1967) referred to.
In the psychoanalytic realm, Kohut (1972) mentioned that shame is related to the experience
of being rejected by the mother. From this, we can infer that shame is related to persecutory
feelings and this in turn may be transformed into externalization, since an individual who
exhibits shame-proneness is not able to fully keep their persecutory feelings in themselves.
Externalization and detachment also had a significant positive correlation (Table 1 and 4,
Figure 7). Both of these affects have a role in freeing the individual from responsibility. In
that respect, these affects are markedly different from guilt-proneness and shame-proneness.

Correlations between Subscale Scores of CISS

All three coping styles correlated significantly with positive values. As mentioned briefly
in the Introduction, these coping styles may share in common strategies to both prevent a
situation from becoming worse and to maintain mental balance. People who are likely to
employ one particular coping style tend also to employ the other two coping styles to varying
degrees. The coping styles people use may be interchangeable.

NLE

The intensity of an NLE and ΔSDS correlated significantly (r=.12, p<.05). This might be
interpreted in two ways. First, more stressful NLEs may cause severe depressive reactions.
However, in this study, the intensity of the NLE was assessed subjectively by the individual
at the end of the study. Therefore a second interpretation is possible, namely that a severely
depressed individual assess the NLE as being more stressful.
Interestingly, an individual with higher guilt-proneness and shame-proneness rated the
intensity of the NLE more highly [r=.17 (p< .01) with guilt-proneness, r=.15 (p<.01) with
shame-proneness]. Conversely, an individual with a higher detachment score was more likely
to give a lower rating to the intensity of an NLE [r=-.17 (p<.01) with detachment]. The NLE
score did not correlate significantly with externalization. It goes without saying that the
traumatic effects of an actual NLE are important, but an individual’s perception of the NLE
may also play a role in the aftermath. As noted briefly in the Introduction, externalization and
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 511

detachment are not moral affects, but our results showed that detachment may help an
individual perceive a negative event less seriously. The opposite is true with the two moral
affects, shame-proneness and guilt-proneness, as people experiencing these affects tend to
recognize the NLE as being more serious. Painful perceptions of NLEs are unavoidable
consequences of these moral affects.
An individual who has experienced an NLE which brought about strong distress was apt
to describe their experiences. Whether anonymous or not, the desire to share the experience
seems to be higher among those who have a traumatic experience. One respondent did not
want to describe her NLE and scored it as 100, suggesting that for some people, it is difficult
to talk about their experiences to others because, in this confiding process, they have to
retrace their experience and inevitably recall it vividly. They also may feel fear or shame in
disclosing their experience. This student’s attitude may be related to avoidance or shame.

Partial Correlations between Each Subscale of TOSCA-3 and ΔSDS

By calculating the partial correlations between each subscale of TOSCA-3 and ΔSDS, we
were able to see the relationships between them which were not influenced by the intensity of
the NLE. Similar to Tangney et al. (1992a), only shame-proneness had a significant
correlation with ΔSDS, suggesting its role in developing psychopathology.

Structural Equation Model

Relationship of the Self-conscious Affects to Coping Styles

We first examined the relationship between each affect, coping styles, and depressive
reactions after an NLE (Figures2-5). Significant correlations were identified between guilt-
proneness and shame-proneness, between shame-proneness and externalization, and between
externalization and detachment (Table.1). Therefore, we next constructed a structural
equation model that took into account these significant correlations and examined each
affect’s relationship to coping styles and to depressive reactions (Figure 6).
Figure 7 shows guilt-proneness not influencing emotion-oriented coping, whereas Figure
2 does. We infer that guilt-proneness in Figure 2 shared common features with shame-
proneness and thus exerted a positive effect on emotion-oriented coping.
Shame-proneness that is free from guilt-proneness and externalization inhibited task-
oriented coping (Figure 7). When we examined only shame-proneness, coping styles, and
depressive reactions (Figure 3), we did not observe this inhibition. Shame-proneness in
Figure 3 may include the domains where there is overlap with guilt-proneness and
externalization. It is plausible that these domains cancel the inhibiting impact of shame-
proneness on task-oriented coping (Figure 3).
Similarly, externalization that is free from shame-proneness and detachment did not have
any effect on avoidance-oriented coping (Figure 7), whereas it had a significant positive
effect on avoidance-oriented coping when the correlations between the four affects had not
been into taken account (Figure 4). In Figure 4, externalization may include the part that
512 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

overlaps with detachment and therefore influences the causal relationship between
externalization and avoidance-oriented coping.
In Figure 5, detachment had a positive effect on task-oriented coping (the causal
coefficient from detachment to task-oriented coping was .17 (p<.01). However, in Figure 7
the causal coefficient from detachment to task-oriented coping was .10 (p=.17). We assume
that in Figure 7, the effect of externalization on detachment was removed. This implies that
detachment in Figure 7 is more refined than that of Figure 5.
The main findings in Figure 7 were as follows: individuals with guilt-proneness tended
employ task-oriented coping and avoidance-oriented coping, while those with shame-
proneness were more likely to use emotion-oriented coping and less likely to rely on task-
oriented coping and avoidance-oriented coping. These results were by and large concordant
with our hypothesis. Externalization tended towards task-oriented coping and emotion-
oriented coping, and detachment tended towards avoidance-oriented coping.
These results should be discussed in great deal. Both guilt-proneness and externalization
prompted an individual to use task-oriented coping. However, the quality of task-oriented
coping induced by guilt-proneness might be different from that motivated by externalization.
It is likely that task-oriented coping that is stimulated by guilt-proneness is more focused on
problem solving, is more accommodating of surroundings, and is more reasoned than that the
same type of coping prompted by externalization.
Shame-proneness tended only towards emotion-oriented coping, and it inhibited task-
oriented coping. People who feel shame are overwhelmed with the emotion; thus, it might be
hard to adopt either of the other two coping strategies, even though these individuals might
prefer to adopt avoidance-oriented coping.
One common aspect of externalization and detachment is that people who feel these
affects do not attribute negative events to themselves or to their own actions. Awareness of
negative emotions however, especially anger, may differ. People who externalize the cause of
their situation can recognize their feelings, but those who detach themselves from the cause of
their situation try to avoid feeling anything, and once they fail to avert their attention from
their emotions, the person loses some control of them. Therefore, it is easy to imagine that
people who are prone to detach themselves from the cause of a problematic situation tend to
avoid the situation in order not to arouse disquiet in their mind. On the other hand, people
who are prone to externalize the cause of a dilemma deal with the problem using emotion-
oriented coping, in particular, anger, or task-oriented coping. For them, anger may have a
great healing effect and relieve them from introspection. Task-oriented coping adopted by
these individuals may be characterized by a accusative nature.

Relations of Coping Styles to the Depressive Reaction

We found two phenomena in common in all structural equation models (Figures 2-5,
Figure 7). First, emotion-oriented coping did not affect the depressive reaction. Emotion-
oriented coping in CISS includes several categories of emotion, such as anger, anxiety, worry,
regret, self-blame, tension, and confusion. If the range of emotion-oriented coping in CISS
were limited to self-blame, emotion-oriented coping could precipitate or worsen a depressive
reaction. However, in this study, the range of emotion-oriented coping was broad, therefore
this did not occur. However, previous research that adopted CISS still showed the
maladaptive aspect of an emotion-oriented coping style (Endler &, Parker, 1990, Endler et al.,
1993, Shikai et al., 2007). Our result suggests that emotion-oriented coping could be a way of
 A Study of the Relationship between Self-conscious Affects, Coping Styles… 513

maintaining psychological balance, although it is not a problem-solving strategy. As noted in

the Introduction, all the coping styles are thought of as being beneficial in terms of
maintaining mental balance. Similar to emotion-oriented coping, avoidance-oriented coping
had no effect on depressive reactions. This suggests that this particular coping style enables
an individual to avoid a depressive reaction.
The second common phenomenon is that task-oriented coping prompted a depressive
reaction. This was contrary to what we had hypothesized. Of the three coping styles, task-
oriented coping has been regarded as the most effective strategy in resolving problems, being
both adaptive and mature. It has also been known to minimize the detrimental effects of stress
on mental health. The results of our current study seem to contradict previous research.
However, an individual who is prone to adopt this coping style is better able to face
problematic situations. Furthermore, becoming depressed as a result of facing a difficult
problem is quite a natural phenomenon. If a person becomes hypomanic after adopting this
coping style, this reaction might be seen as psychotic.

Relations of the Self-conscious Affects and the Depressive Reaction

In the current study, shame-proneness directly reinforced the pathway to a depressive
reaction, but guilt-proneness did not. This result supported the study of Tangney et al.
(1992a), which showed a strong relationship between shame-proneness and several mental
disorders, including depression.
Furthermore, detachment and externalization did not directly lead to a depressive
reaction. These affects are generally recognized as being undesirable because they discourage
an individual from taking responsibility. However, they may also temporarily prevent an
individual from undergoing a severe depressive reaction.
One intriguing question relates to which factors determine shame-proneness. Some
researchers attempt to derive an answer from a comparative cultural point of view, while
others argue from the perspective of psychodynamic theory. Among the latter, Kohut (1966,
1972) argues that shame is related to the object’s rejection, in the process of transforming the
narcissistic cathexis of the grandiose self and alleviating the narcissistic exhibitionistic
tension. It could be surmised that patients with shame-proneness have experienced this type
of rejection repeatedly, not only as regards their relationship with their mother, but also in
relationships with other important figures. Therefore, for these patients, it is crucial to be
admired and approved by a significant person, such as a parent or a partner. In a therapeutic
relationship, therapists should be sensitive to the patients’ shame and its manifestation within
this relationship, and deal with it warm-heartedly. This might help raise the patients’ self-
esteem, improve their pathological state, and hopefully, enable them to reconstruct past
painful experiences.

LIMITATIONS
The limitations of this study should be noted. The coping styles assessed by the CISS are
not necessarily those employed by any given subject when dealing with an NLE during the
four-month study. In other words, the coping styles actually adopted might be different from
those scored in the CISS. Similarly, there might be a discrepancy between the affects subjects
514 Masayo Uji, Toshinori Kitamura and Toshiaki Nagata

actually felt in experiencing a NLE and the affects they supposed they might feel when
participating in a given scenario.

CONCLUSION AND APPLICATION IN A CLINICAL SETTING

1. Patients who externalize the cause of a problematic situation sometimes adopt
emotion-oriented coping, in particular anger, or task-oriented coping. In this case,
task-oriented coping may not demonstrate problem solving, may not be reasoned,
may sometimes be accusatory, and can therefore be seen as immature. However,
anger can have a healing effect on patients even though it is temporary. Medical
professionals have to be patient when listening to these patients and also consider
their resources from multiple dimensions, such as socio-economic support or
individual resilience. We should also be aware that we may be a patient resource and
thus help patients solve their problem in a more efficient way.
2. Patients who are apt to detach themselves from the cause of a NLE tend to employ
avoidance-oriented coping. These individuals might not be able to face their
problems for several reasons, such as the traumatic nature of the NLE, severe
pathology, the lack of current social support, and the lack of support from parent-
figures during childhood. We have to understand the reasons for these attribution and
coping styles.
3. Task-oriented coping enhances a depressive reaction. Patients who employ task-
oriented coping try to confront the problem. We have to empathize with and support
them through their difficulties. A depressive reaction due to a stressful situation is a
very natural phenomenon, but if the reaction is too severe, we must consider
pharmacotherapy, making use of family support, or admission.
4. Patients with shame-proneness are more likely to become overwhelmed with their
emotions, and cannot deal with their stressful situation with task-oriented coping and
avoidance-oriented coping. Medical professionals should help patients put their
feelings in order, free from criticism or judgment.

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In: Psychology of Relationships ISBN 978-1-60692-265-1
Editors: Emma Cuyler and Michael Ackhart © 2009 Nova Science Publishers, Inc.

Chapter 30

THE NEUROPSYCHOLOGY OF PASSIONATE LOVE

Elaine Hatfield and Richard L. Rapson

University of Hawaii

ABSTRACT
Throughout history, artists, poets, and writers have been interested in the nature of
passionate love, sexual desire, and sexual behavior. In the 1960s, social psychologists and
sexologists began the systematic investigation of these complex phenomena (see
Berscheid & Hatfield, 1969; Hatfield & Rapson, 1993; Hatfield & Rapson, 2005, for a
review of this research). Yet, only recently have neuroscientists and biochemists begun to
explore these complex phenomena.
In this entry, we will review what these distinguished theorists and researchers have
learned about these processes.

DEFINING PASSIONATE LOVE

Passionate love is a powerful emotional state. It has been defined as:
A state of intense longing for union with another. Passionate love is a complex functional
whole including appraisals or appreciations, subjective feelings, expressions, patterned
physiological processes, action tendencies, and instrumental behaviors. Reciprocated love
(union with the other) is associated with fulfillment and ecstasy. Unrequited love (separation)
is associated with feelings of emptiness, anxiety, and despair (Hatfield & Rapson, 1993, p. 5).
People in all cultures recognize the power of passionate love. In South Indian Tamil
families, for example, a person who falls head-over-heels in love with another is said to be
suffering from mayakkam—dizziness, confusion, intoxication, and delusion. The wild hopes
and despairs of love are thought to “mix you up” (Trawick, 1990).
The Passionate Love Scale (PLS) was designed to tap into the cognitive, emotional, and
behavioral indicants of such longings (Hatfield & Sprecher, 1986). The PLS has been found
to be a useful measure of passionate love for men and women of all ages, in a variety of
cultures, and to correlate well with certain well-defined patterns of neural activation (see
520 Elaine Hatfield and Richard L. Rapson

Bartels & Zeki, 2000, 2004; Doherty, Hatfield, Thompson, & Choo, 1994; Fisher, 2003;
Landis & O’Shea, 2000). Sexual desire (the desire to merge sexually) is assumed to be a
closely related construct. A facsimile of the PLS appears below.

THE PASSIONATE LOVE SCALE

We would like to know how you feel (or once felt) about the person you love, or have
loved, most passionately. Some common terms for passionate love are romantic love,
infatuation, love sickness, or obsessive love.

Please think of the person whom you love most passionately right now. If you are not in
love, please think of the last person you loved. If you have never been in love, think of the
person you came closest to caring for in that way.
Try to describe the way you felt when your feelings were most intense. Answers range
from (1) Not at all true to (9) Definitely true.

Whom are you thinking of?

• Someone I love right now.

• Someone I once loved.
• I have never been in love.

Possible answers range from:

1 2 3 4 5 6 7 8 9
Not at all Moderately Definitely
true true true
Not Definitely
true true
I would feel deep despair if _____ left me. 1 2 3 4 5 6 7 8 9
Sometimes I feel I can’t control my thoughts; they are obsessively on _____. 1 2 3 4 5 6 7 8 9
I feel happy when I am doing something to make _____ happy. 1 2 3 4 5 6 7 8 9
I would rather be with _____ than anyone else. 1 2 3 4 5 6 7 8 9
I’d get jealous if I thought _____ were falling in love with someone else. 1 2 3 4 5 6 7 8 9
I yearn to know all about _____. 1 2 3 4 5 6 7 8 9
I want _____ physically, emotionally, mentally. 1 2 3 4 5 6 7 8 9
I have an endless appetite for affection from _____. 1 2 3 4 5 6 7 8 9
For me, _____ is the perfect romantic partner. 1 2 3 4 5 6 7 8 9
I sense my body responding when _____ touches me. 1 2 3 4 5 6 7 8 9
_____ always seems to be on my mind. 1 2 3 4 5 6 7 8 9
I want _____ to know me—my thoughts, my fears, and my hopes. 1 2 3 4 5 6 7 8 9
I eagerly look for signs indicating _____’s desire for me. 1 2 3 4 5 6 7 8 9
I possess a powerful attraction for _____. 1 2 3 4 5 6 7 8 9
I get extremely depressed when things don't go right in my relationship with _____. 1 2 3 4 5 6 7 8 9
Total: _______

On this scale, the higher the score, the more wildly in love a person is said to be.
 The Neuropsychology of Passionate Love 521

THE NEUROPSYCHOLOGY OF PASSIONATE LOVE

The Ancients

Since antiquity, court physicians and social observers have searched for methods to
detect “lovesickness.” In the 2nd century A. D. Appian of Alexandria (1899) recounted this
“case history.”
During the last years of his life, King Seleucus, appointed his son Antiochus King of
upper Asia in place of himself. Appian notes:

If this seems noble and kingly on his part, even nobler and wiser was his behavior in reference
to his son's falling in love and his self-restraint in suffering; for Antiochus was in love with
Stratonice, the wife of Seleucus, his own step-mother, who had already borne a child to
Seleucus. Recognizing the wickedness of this passion, Antiochus did nothing wrong, nor did
he show his feelings, but he fell sick, took to his bed, and longed for death. Nor could the
celebrated physician, Erasistratus, who was serving Seleucus at a very high salary, form any
diagnosis of his malady. At length, observing his body was free from all the symptoms of
disease, he conjectured that this was some condition of the mind, through which the body is
often strengthened or weakened by sympathy. Grief, anger, and other passions disclose
themselves; love only is concealed by the modest. As Antiochus would confess nothing when
the physician asked him in confidence, he took a seat by his side and watched the changes of
his body to see how he was affected by each person who entered his room. He found that
when others came the patient was all the time weakening and wasting away at a uniform pace,
but when Stratonice came to visit him his mind was greatly agitated by the struggles of
modesty and conscience, and he remained silent. But his body in spite of himself became
more vigorous and lively, and when she went away he became weaker again (pp. 317-318).

Antiochus and Stratonice. In this painting, Jacques-Louis David (1748-1825) depicts the moment
in which Erasistratos diagnosed Antiochus’ love for his stepmother. École des Beaux-Arts at Paris.

Plutarch (1st century, A.D./1920), more medically oriented, detailed Antiochus'

symptoms:
522 Elaine Hatfield and Richard L. Rapson

Accordingly, when any one else came in, Antiochus showed no change; but whenever
Stratonice came to see him, as she often did, either alone, or with Seleucus, lo, those tell-tale-
signs of which Sappho sings were all there in him—stammering speech, fiery flashes,
darkened vision, sudden sweats, irregular palpitations of the heart, and finally, as his soul was
taken by storm, helplessness, stupor, and pallor (pp. 93 and 95).

Appian of Alexandria (1899) continued:

So the physician told Seleucus that his son had an incurable disease. The king was
overwhelmed with grief and cried aloud. Then the physician added, “His disease is love, love
for a woman, but a hopeless love.” (pp. 317-318).

King Seleucus, however, was not one to be stopped by obstacles. Appian of Alexandria
(1899) notes:

Selecus was overjoyed, but it was a difficult matter to persuade his son and not less so to
persuade his wife; but he succeeded finally. Then he assembled his army, which was perhaps
expecting something of the kind, and told them of his exploits and the extent of his empire,
showing that it surpassed that of any of the other successors of Alexander, and saying that as
he was now growing old it was hard for him to govern it on account of its size. “I wish,” he
said, “to divide it and so at the same time to provide for your safety in the future and give a
part of it now to those who are dearest to me. It is fitting that all of you, who had advanced to
such greatness of dominion and power under me since the time of Alexander, should
cooperate with me in everything. The dearest to me, and well worthy to reign, are my grown-
up son and my wife. As they are young, I pray they may soon have children to be an ample
guarantee to you of the permanency of the dynasty. I will join them in marriage in your
presence and will send them to be sovereigns of the upper provinces now. And I charge you
that none of the customs of the Persians and other nations is more worthy of observance than
this one law, which is common of them, “That what the king ordains is always right.” When
he had thus spoken the army shouted that he was the greatest king of all the successors of
Alexander and the best father. Seleucus laid the same injunctions on Stratonice and his son,
then joined them in marriage, and sent them to their kingdom, showing himself even stronger
in this famous act than in his deeds of arms (pp. 319-320).

For a review of the speculations of ancient Greek physicians such as Avicenna,

Erasistratos, and Galen, see M.-Marsel Mesulam and J. Perry (1972).
In ancient China, classical scholars possessed a great deal of scientific information about
sexual response. For example, the 4th century classic, Secret Instructions Concerning the Jade
Chamber, provided information concerning the selection of sexual partners, foreplay, and
positions for intercourse. The text taught men and women how to identify the stage their
partner had reached in the sexual response cycle (Ruan, 1991).
Recently, neuropsychologists have assembled information from neuroanatomical and
neurophysiological investigations, ablation experiments, pharmacologic explorations, clinical
investigations and behavioral research as to the social psychophysiology of passion. These
scientists document that the observations of the ancients are, in part, correct. Passionate love
does produce the autonomic nervous system and skeletal-muscular reactions Plutarch and his
fellow physicians described (Hatfield & Rapson, 1987; Kaplan, 1979; Liebowitz, 1983.) The
early Chinese physicians appear to have been careful observers, too. Their descriptions of the
 The Neuropsychology of Passionate Love 523

stages of sexual response sound much like those described by Alfred Kinsey and his
associates (1948 and 1953) and by William Masters and Virginia Johnson (1966).
The ancients provide a beginning. In spite of the valuable insights that their observations
provide, folklore is often wrong-headed or incomplete. Today’s neuropsychological research
into passionate love and sexual desire makes it clear that men and women’s cognitions,
emotions, and behaviors interact in ways only dreamed of by early court physicians and
scientists.

Modern Day Neuropsychological Explorations into Passionate Love

The Pioneering EEG Research of Niels Birbaumer and his Tübingen colleagues
The first modern-day neuroscientists to study passionate love were Niels Birbaumer and
his Tübingen colleagues (1993). These authors argued that cortical processes in imagery do
not differ from “actual” processing, storage, and retrieval of information. As part of a larger
research project, they interviewed 10 men and women. Participants were asked to complete
six different tasks, which ranged from imaging tasks (imagining a time in their past in which
they had been joyously in love [without sexual imagery] and imagining the same scene [with
sexual imagery]) to sensory tasks (such as determining which of two pieces of sandpaper was
the smoothest). The authors observed:

Subjects in love carry their emotional “burden” like a snail’s house into the laboratory of the
physiologist. The vividness and readiness of their emotional imagery is particularly intense
and easy to create under laboratory conditions (p. 133).

While participants performed these tasks, EEG (electroencephalogram) recordings were

obtained from 15 different brain locations. The authors discovered (on the basis of their EEG
assessments) that the frontal and posterior groupings showed similar dimensions on the
romantic imagery tasks, whereas smaller dimensions were found in the frontal as compared to
the posterior electrode sites on the four sensory tasks. The authors concluded that passionate
imagery involves a significantly higher brain complexity than does sensory stimulation at all
brain sites, but particularly at frontal regions.
In a second experiment, Birbaumer and his group (1993) focused primarily on erotic
images—comparing 10 people who were passionately in love (as assessed by the Passionate
Love Scale described earlier) with a matched group of 10 people who were not emotionally
involved with anyone. Participants were asked to imagine a joyous scene with a beloved
partner, a scene of intense jealousy, and a neutral scene (an empty living room). During these
visualizations, the scientists recorded EEG responses from the midline (Fz, Cz, Pz) and its
fractal dimensions were estimated (using the method described by Graf & Elbert, 1988).
On the bases of these analyses, the authors concluded that passionate love is “mental
chaos.” Passionate imagery employed anatomically more complex and more widespread (less
localized) brain processes than did sensory tasks. Frontal lobe mechanisms, in particular,
seemed to add to imagery-related chaos compared to tactile or visual stimulation. Images,
they note, may be “more than just pictures in the head”( p. 134).
524 Elaine Hatfield and Richard L. Rapson

The authors concluded this preliminary study by calling for more research. It was a full
decade before anyone responded to their plea.

2. Recent fMRI Research: Andreas Bartels and Semir Zeki

In 2000, two London neuroscientists, Andreas Bartels and Semir Zeki, attempted to
identify the brain regions associated with passionate love and sexual desire. The scientists put
up posters around London, advertising for men and women who were “truly, deeply, and
madly in love.” They also recruited participants via the internet. Seventy young men and
women from 11 countries and several ethnic groups responded. Respondents were asked to
write about their feelings of love and to complete the Passionate Love Scale (PLS). Seventeen
men and women, ranging in age from 21-37, were selected for the study. Participants were
then placed in an fMRI (functional magnetic imagery) scanner. This high-tech scanner
constructs an image of the brain in which changes in blood flow (induced by brain activity)
are represented as color-coded pixels. Bartels and Zeki (2000) gave each participant a color
photograph of their beloved to gaze at, alternating the beloved’s picture with pictures of a trio
of casual friends. They then digitally compared the scans taken while the participants viewed
their beloved’s picture with those taken while they viewed a friend’s picture, creating images
that represented the brain regions that became more (or less) active in both conditions. These
images, the researchers argued, revealed the brain regions involved when a person
experiences passionate love and/or sexual desire.
Bartels and Zeki discovered that passion sparked increased activity in the brain areas
associated with euphoria and reward, and decreased activity in the areas associated with
sadness, anxiety, and fear. Activity seemed to be restricted to foci in the medial insula and the
anterior cingulated cortex and, subcortically, in the caudate nucleus, and the putamen, all
bilaterally. Most of the regions that were activated during the experience of romantic love
were those that are active when people are under the influence of euphoria-inducing drugs
such as opiates or cocaine. Apparently, both passionate love and those drugs activate a
“blissed-out” circuit in the brain. The anterior cingulated cortex has also been shown to be
active when people view sexually arousing material. This makes sense since passionate love
and sexual desire are generally assumed to be tightly linked constructs.
Among the regions where activity decreased during the experience of love were zones
previously implicated in the areas of the brain controlling critical thought (i.e., the sort of
mental activity involved when people are asked to make social judgments or to “mentalize”—
that is, to assess other people’s intentions and emotions.) Such brain areas are also activated
when people experience painful emotions such as sadness, anger and fear. The authors argue
that once we fall in love with someone, we feel less need to assess critically their character
and personality. (In that sense, love may indeed be “blind.”) Deactivations were also observed
in the posterior cingulated gyrus and in the amygdala and were right-lateralized in the
prefrontal, parietal, and middle temporal cortices. Once again, the authors found passionate
love and sexual arousal to be tightly linked.
Not surprisingly, the Bartels and Zeki (2000, 20004) research sparked a cascade of fMRI
research.

3. Helen Fisher, Arthur Aron, and Lucy Brown

In Why We Love, Helen Fisher (2004) argued that people possess a trio of primary brain
systems designed to deal with close, intimate relationships. These are: attraction (passionate
 The Neuropsychology of Passionate Love 525

love), lust (sexual desire), and attachment (companionate love).1 Presumably, this trio of
systems evolved during humankind’s long evolutionary history; each is designed to play a
critical role in courtship, mating, and parenting. In theory, attraction evolved to persuade our
ancestors to focus attention on a single favored courtship partner. Sexual desire evolved to
motivate young people to seek a wide range of sexual partners. Attachment evolved to insure
that devoted parents would remain together during the first crucial four years of a child’s life.
According to Fisher (2004) attraction (passionate love) is characterized by a yearning to
win a preferred mating partner. She speculated that three chemicals—dopamine,
norepinephrine, and serotonin—play a crucial role in romantic passion. Sexual desire (lust),
on the other hand, is typified by a general craving for sexual gratification and may be directed
toward many potential partners. In men and women, she observed, the androgens, particularly
testosterone, are central to sparking sexual desire. Attachment (companionate love) is
comprised of feelings of calm, social comfort, emotional union, and the security felt in the
presence of a long-term mate. It sparks affiliative behaviors, the maintenance of close
proximity, separation anxiety when closeness disappears, and a willingness to participate in
shared parental chores. Animal studies suggest that this brain system is primarily associated
with oxytocin and vasopressin in the nucleus accumbens and ventral pallidum.

The Joys of Love

In focusing in on passionate love, Fisher (January 19, 2000) observed:

I speculated that the feelings of euphoria, sleeplessness and loss of appetite as well as the
lover’s intense energy, focused attention and increased passion in the face of adversity might
all be caused in part by heightened levels of dopamine or norepinephrine in the brain.
Similarly, I believed that the lover’s obsessive thinking about the beloved might be due to
decreased brain activity of some type of serotonin. I also knew these three compounds were
much more prevalent in some brain regions than in others. If I could establish which regions
of the brain become active while one is feeling romantic rapture, that might confirm which
primary chemicals are involved (p. 77).

To test these notions, Fisher (2004) and her colleagues Arthur Aron and Lucy Brown
(along with graduate students Deborah Mashek and Greg Strong) conducted a series of fMRI
studies. “Have you just fallen madly in love?” asked the announcement posted on a bulletin
board on the SUNY Stony Brook campus. She received a flood of replies. On the basis of
interviews, Fisher selected 17 young lovers. All of these men and women scored high on the
Passionate Love Scale.
To test her notions, Fisher followed the prototype described by Bartels and Zeki (2000).
She asked lovesick men and women to view pictures of their beloved and “a boring
acquaintance,” while an fMRI imager recorded the activity (blood flow) in the their brains.
Fisher (January 19, 2004) found that when lovesick men and women gazed at their
beloved, activity was sparked in many brain areas. (This should come as no surprise since as
Acevedo, et al., 2008; and Carlson & Hatfield, 1992, noted, passionate love is associated with

1
You will notice that while most social psychologists (see Hatfield & Rapson, 2005) and neuroscientists such as
Birbaumer and his colleagues (1993) and Bartels and Zeki (2004) assume that the emotion of passionate love and
sexual desire are closely linked, Fisher (2004) assumes that passionate love and sexual desire are fueled by very
different brain systems. We will discuss this theoretical difference in greater length in a later section.
526 Elaine Hatfield and Richard L. Rapson

a wider array of related feelings and emotions [guilt, sadness, anger, jealousy, sexual desire,
etc.] than is any other basic emotion.) Two areas, were found to be critically important: the
caudate nucleus (a large, C-shaped region deep in the center of the brain) and the ventral
tegmental area (VTA), a group of neurons at the very center of the brain. “I was astonished,”
Fisher said. The caudate is “a key part of the brain’s ‘reward system,’ the mind’s network for
general arousal, sensations of pleasure and the motivation to acquire rewards” (p. 79). The
VTA is a central part of the reward circuitry of the brain.
Fisher (January 19, 2004) observed:

I had hypothesized that romantic love is associated with elevated levels of dopamine or
norepinephrine. The VTA is a mother lode for dopamine-making cells. With their tentacle-like
axons, these nerve cells distribute dopamine to many brain regions, including the caudate
nucleus. And as this sprinkler system sends dopamine to various parts of the brain, it produces
focused attention as well as fierce energy, concentrated motivation to attain a reward, and
feelings of elation—even mania—the core feelings of romantic love.
No wonder lovers talk all night or walk till dawn, write extravagant poetry and self-revealing
e-mails, cross continents or oceans to hug for just a weekend, change jobs or lifestyles, even
die for one another. Drenched in chemicals that bestow focus, stamina and vigor, and driven
by the motivating engine of the brain, lovers succumb to a Herculean courting urge (p. 79).

Lucy Brown added: “That’s the area that’s also active when a cocaine addict gets an IV
injection of cocaine. It’s not a craving. It’s a high” (Quoted in Blink, 2007, p. 3.)
Blink (2007) observes:

You see someone, you click, and you’re euphoric. And in response, your ventral tegmental
area uses chemical messengers such as dopamine, serotonin, and oxytocin to send signals
racing to a part of the brain called the nucleus accumbens with the good news, telling it to
start craving. [Certain regions] are deactivated—areas as within the amygdala, associated with
fear (p. 3).

(For more detailed descriptions of this research, see Aron, et al, 2005; and Fisher, et al,
2005). Fisher (2004) concluded by observing that the chemistry of romantic attraction
generally elevates sexual motivation.
Alas, other neuroscientists (such as Bartels & Zeki, 2000, who studied the fMRI
responses of joyous lovers), have secured slightly different results than those described by
Fisher and her colleagues (2002). (Bartels & Zeki considered (1) passion to be an emotion
and (2) found a close connection between passionate love and sexual desire). Fisher
speculates that such differences may be due to the fact that while she and her colleagues
studied young people who are in the first throes of love of love, her critics have focused on
men and women who fell in love some time ago. (Fisher’s participants had been in love for an
average of seven months; Bartels and Zeki’s participants for 2.3 years.) In addition, Fisher
studied a homogeneous group of SUNY students, while Bartels and Zeki studied people from
different cultural backgrounds and of a variety of ages.
Whether or not these differences adequately account for these differing results is as yet
unknown.
 The Neuropsychology of Passionate Love 527

fMRI pictures of “The Brain in Love.”

The Dark Side of Love: Anger, Sadness, and Misery

Joyous passionate love is only one-half of the equation, of course. Love is often
unrequited. What kind of brain activity occurs when passionate lovers are rejected?
In a second study, Fisher and her colleagues (2004) studied 15 men and women who had
just been jilted by their beloved. First, they hung a flyer on the SUNY at Stony Brook bulletin
board. “Have you just been rejected in love. But can’t let go?” Rejected sweethearts were
quick to respond. In initial interviews, Fisher found that heartbroken men and women were
caught up in a swirl of conflicting emotions—they were still wildly in love, yet feeling
abandoned, depressed, angry, and in despair.
But what was going on in their brains? To find out, Fisher and her colleagues (2004)
followed the same protocol they’d utilized in testing happily-in-love men and women—i.e.,
528 Elaine Hatfield and Richard L. Rapson

they asked participants to alternately view a photograph of their one-time beloved and a
photograph of a familiar, but emotionally neutral individual. The authors found that when
contemplating their beloved, rejected lovers displayed greater activity in the right nucleus
accumbens/ventral putamen/pallidum, lateral orbitofrontal cortex and anterior
insular/operculum cortex than they did when contemplating neutral images. In short, jilted
lovers’ brains “lit up” in the areas associated with anxiety, pain, and attempts at controlling
anger as well as addiction, risk taking, and obsessive/compulsive behaviors. Jilted lovers did,
indeed, appear to experience a storm of passion—passionate love, sexual desire, plus anguish,
rejection, rage, emptiness, and despair.
Other neuroscientists who have studied the fMRI responses of lovers who are actively
grieving over a recent romantic breakup, have secured slightly different results than those
secured by Fisher and her colleagues (see Najib, et al., 2004). Fisher (2004) speculates that
her critics may have focused on men and women who broke up some time ago and have
presumably adapted to their losses. Instead of at the grief stage, they may have been at a
subsequent stage in the grieving process—experiencing resignation and despair.
In conclusion: Psychologists’ opinions may differ on whether romantic and passionate
love are emotions (Shaver, Morgan, & Wu, 1996) or are not emotions (Reis & Aron, 2008)
and whether passionate love, sexual desire, and sexual motivation are closely related
constructs (psychologically, neurobiologically, and physiologically) (Fehr & Russell, 1991;
Hatfield & Rapson, 1987; Hendrick & Hendrick, 1987a; Regan, 1998, 2004) or very different
in their nature (Diamond, 2004; Reis & Aron, 2008). In addition, scientists have sharply
criticized the widespread use of fMRI techniques to study the nature of love, claiming that
currently the fMRI studies track only superficial changes and lack reliability and validity
(Cacioppo, et al., 2003; Movshon, 2006; Panksepp, 2007; Wade, cited in Wargo, 2005). One
critic observed: “It’s like the Wild West out there. Scientists are working in uncharted
territory; there hasn’t been time for the development of adequate critical standards; and fMRI
research has such status, that everything gets published!” (We might also note that although
in TV shows like House, the administration of fMRIs is an eerily silent procedure, in fact a
real fMRI is a ear-splitting and bone shattering process. Participants staggering out the an
experimental room often report: “I thought I was going crazy! In spite of my earplugs, the
noise was unbelievable. I tried to think of love, but in fact I kept thinking ‘Get me out of
here!’” This technological problem may make the interpretation of fMRI studies somewhat
problematic.) Nonetheless, this path-breaking research (as it grows ever more sophisticated)
has the potential to answer age-old questions as to the nature of culture, love, and human
sexuality.

Adrenalin makes the heart grow fonder

—Elaine Hatfield & Ellen Berscheid

Dopamine. God’s little neurotransmitter. Better known by its street name, romantic love.
Also norepinephrine. Street name, infatuation.
—Neely Tucker
 The Neuropsychology of Passionate Love 529

THE BIO-CHEMISTRY OF LOVE

Researchers are beginning to learn more about the chemistry of passionate love and a
potpourri of related emotions. They are also learning more about the way that various
emotions, positive and negative, interact.

The Ancients

A number of researchers have focused on the chemistry of love—searching for (in effect)
the elusive “Love potion #9.” In 18th century, London physicians crafted love nostrums and
aphrodisiacs from a variety of substances, combining:

. . . crushed toads, salt of vipers, ground garden snails “bruised to a perfect paste,” pulvis
humani cranum (powered human skull), “volatile salt of millipedes,” sal vitrioli (hydrochloric
acid), and copious amount of alcohol (Madeira was favored), rhubarb, and that luckily easily
available substance acqua pluvialis (rain water) (Hunt, 2000-2001, p. 46.)

Pioneering Research: Michael Liebowitz and Helen Singer Kaplan

Psychiatrist Michael Liebowitz (1983) was one of the first to speculate about the
chemistry of love. He argued that passionate love brings on a giddy feeling, comparable to an
amphetamine high. He contended that it was phenylethylamine (PEA), an amphetamine-
related compound, that produces the mood-lifting and energizing effects of romantic love. He
observed that “love addicts" and drug addicts have a great deal in common: the craving for
romance is merely the craving for a particular kind of high. The fact that most romances lose
some of their intensity with time, may well be due to normal biological processes.
The crash that follows a breakup is much like amphetamine withdrawal. Liebowitz
speculates that there may be a chemical counteractant to lovesickness: MAO (monoamine
oxidase) inhibitors may inhibit the breakdown of PEA, thereby “stabilizing" the lovesick.
Liebowitz also offered some speculations about the chemistry of the emotions which
criss-cross lovers' consciousness as they plunge from the highs to the lows of love. The
“highs" include euphoria, excitement, relaxation, spiritual feelings, and relief. The “lows"
include anxiety, terrifying panic attacks, the pain of separation, and the fear of punishment.
His speculations were based on the assumption that non-drug and drug highs and lows
operate via similar changes in brain chemistry.
In excitement, Liebowitz proposed that naturally occurring brain chemicals, similar to the
stimulants (such as amphetamine and cocaine), produce the “rush" lovers feel. In relaxation,
chemicals related to the narcotics (such as heroin, opium and morphine), tranquilizers (such
as Librium and Valium), sedatives (such as barbiturates, Quaaludes and other “downers"), or
alcohol, which acts chemically much like the sedatives, and marijuana and other cannabis
derivatives, produce a mellow state and wipe out anxiety, loneliness, panic attacks, and
depression. In spiritual peak experiences, chemicals similar to the psychedelics (such as LSD,
mescaline and psilocybin) produce a sense of beauty, meaningfulness, and timelessness.
530 Elaine Hatfield and Richard L. Rapson

In the same era, Helen Singer Kaplan (1979) provided some information as to the
chemistry of sexual desire. In both men and women, testosterone (and perhaps LH-RF,
luteinizing hormone-releasing factor) are the libido hormones. The neurotransmitter
dopamine may act as a stimulant, serotonin or 5-HT (5-hydroxtryptamine) as inhibitors, to the
sexual centers of the brain.
Kaplan (1979) observed:

When we are in love, libido is high. Every contact is sensuous, thoughts turn to Eros, and the
sexual reflexes work rapidly and well. The presence of the beloved is an aphrodisiac; the
smell, sight, sound, and touch of the lover—especially when he/she is excited—are powerful
stimuli to sexual desire. In physiologic terms, this may exert a direct physical effect on the
neurophysiologic system in the brain which regulates sexual desire. . . . But again, there is no
sexual stimulant so powerful, even love, that it cannot be inhibited by fear and pain. (p. l4).

Kaplan ended by observing that a wide array of cognitive and physiological factors shape
desire. Although passionate love and the related emotions we have described may be
associated with specific chemical neurotransmitters (or with chemicals which
increase/decrease the receptors' sensitivity), most emotions have more similarities than
differences. Chemically, intense emotions do have much in common. Kaplan reminds us that
chemically, love, joy, sexual desire, and excitement, as well as anger, fear, jealousy, and hate,
are all intensely arousing. They all produce an ANS sympathetic response. This is evidenced
by the symptoms associated with all these emotions—a flushed face, sweaty palms, weak
knees, butterflies in the stomach, dizziness, a pounding heart, trembling hands, and
accelerated breathing.
For a survey of modern research on the biological substrates of human sexuality, see
Hatfield & Berscheid (1971); Hyde (2005); Kauth (2007); and Regan (1999).

Falling in love is a bit like going crazy.

—Donatella Marazziti

Modern Day Neurobiological Research: Donatella Marazziti

Italian psychiatrist Donatella Marazziti (an editor of this collection) has done some of the
most intriguing work on the nature of passionate love. In the popular press, one of Marazziti’s
observations—“Love is insanity”—has sparked intense scientific and journalistic interest.
In the late 1990s, Donatella Marazziti and her colleagues (1999) speculated that
passionate lovers and patients suffering from obsessive-compulsive disorders (OCD) might
have something in common: both may be lacking in a neurotransmitter (serotonin) that has a
soothing effect on the brain. Too little serotonin has been linked to anxiety, depression, and
aggression. Drugs in the Prozac family fight these conditions by boosting the chemicals
presence in the brain.
To test this notion, the authors selected 20 men and women who were passionately in
love, 20 unmedicated OCD patients, and 20 normal controls. Tracking chemicals inside the
brain is difficult (to say the least!), so the authors settled on a simple technique: they
calculated the amount of serotonin in platelets—tiny cells that are easily retrieved from an
 The Neuropsychology of Passionate Love 531

ordinary blood sample. The 5-HT transporter was evaluated with the specific binding of 3H-
Pparoxetine (3H-Par) to platelet membranes. The results supported Marazziti and her
colleagues’ notion. The density of 3H-Par bonding sites was indeed significantly lower in
lovers and those suffering from OCD disorders than in normal controls (people who were
either single or in monogamous, long term relationships) (see also Marazziti & Canale, 2004).
Marazziti and her colleagues (2003) have also investigated the dark side of love—
passionate jealousy. The authors selected 21 Italian university students consumed by jealous
thoughts, 14 OCD patients (whose main obsession was jealousy), and 21 control subjects, not
plagued by jealous concerns. They discovered that men and women who were excessively
jealous suffered from a number of psychopathological traits (as well) and produced reduced
density of 3H-Par binding compared with their healthy peers.
It was these findings that led the Marazziti group to conclude that love is a kind of
insanity.
For additional information, see Marazziti (2005) and chapter 30 in this text.

Odi et amo (I hate and I love)

—Catullus

The Cross-Magnification Process

Scientists have long contended that men and women are most susceptible to passionate
love and sexual desire when their lives are turbulent. It is assumed that although each basic
emotion has its basic chemical signature that an additional supply of adrenalin and
noradrenalin may help fuel the intensity of emotional reactions (Kaplan, 1979; Schachter &
Singer, 1962). Social psychologists have called this phenomenon “the cross-magnification
process” (Carlson & Hatfield, 1992) or the “excitation transfer process” (Zillmann, 1984).
An array of theorists (Freud, 1953; Reik, 1972), for example, have proposed that it is
precisely when people are not at their best—when their self-esteem has been shattered, when
they are anxious and afraid, when their lives are turbulent and stressful—that they will be
especially vulnerable to falling head-over-heels in love. This makes some sense. After all,
infants' early attachments (which motivate them to cling tightly to their mother's side in panic
when danger threatens and to go their own way when it all is safe) are thought to be the initial
prototype of passionate love (Hatfield, Brinton, & Cornelius, 1989; Hatfield, Schmitz,
Cornelius, & Rapson, 1988; Hazen & Shaver, 1987).
Several researchers have demonstrated that children and adults are especially prone to
seek romantic and sexual ties when they are anxious and/or under stress. In a duo of studies,
Hatfield and her Hawaii colleagues (Hatfield, Brinton, & Cornelius, 1989; Hatfield, Schmitz,
Cornelius, & Rapson, 1988), for example, found that children and teen-agers who were either
momentarily or habitually anxious were especially vulnerable to passionate love. Young
people who varied in age from l2 to 16 years of age, and who were of Chinese-, European-,
Japanese-, Korean-American, or mixed ancestry, were asked to complete the Child Anxiety
Scale (Gillis, 1980) or the State-Trait Anxiety Inventory for Children (Spielberger, Gorsuch,
& Lushene, 1970). These scales were designed to measures both state anxiety (how anxious
young people happen to feel at the moment) and trait anxiety (how anxious they generally
532 Elaine Hatfield and Richard L. Rapson

are). The authors found that children and adolescents who were high on either trait or state
anxiety received the highest scores on the Passionate Love Scale.
Donald Dutton and Arthur Aron (1974) also tested the notion that anxiety and fear can
deepen desire in a series of ingenious experiments. In one experiment, they compared
reactions of men who crossed one of two bridges in North Vancouver. The first bridge (the
Capilano Canyon Suspension Bridge) is a five-foot wide, 450-foot-long bridge, composed of
wood slats and wire cable, which is suspended 230 feel above dangerous rocks and shallow
rapids. As people walked over it, the bridge swayed, wobbled, and tilted in a frightening
manner. The second bridge was a solid, safe cement structure.
As each young man crossed one of the bridges, a good-looking college woman
approached him. She explained that she was doing a class project and asked if he would fill
out a questionnaire concerning his attitudes toward conservation. When the man had finished,
she offered to explain her project in greater detail. She scribbled her telephone number on a
scrap of paper, so he could call her if he wanted more information. Which men called? Nine
of the 33 men on the suspension bridge called her; only two of the men on the solid bridge
called!
In subsequent years, researchers have collected a great deal of experimental and
correlational evidence for the intriguing contention that, under the right conditions, a variety
of awkward and painful experiences can deepen passion. These include anxiety and fear
(Brehm et al., 1978; Dienstbier, 1978; Hatfield & Rapson, 1996; Hoon et al., 1977; Meston &
Frohlich, 2003; Riordan & Tedeschi, 1983), embarrassment (Byrne, Przybyla, & Infantino,
1981), the discomfort of seeing others involved in conflict (Dutton, 1979), jealousy (Clanton
& Smith, 1987), loneliness (Peplau & Perlman, 1982), anger (Barclay, 1969 and 1971;
Driscoll, Davis, & Lipetz, 1972), horror (White et al., 1981), or even grief.

The End of the Affair

Fisher (2004) closes her analysis of the brain systems sparking attraction, lust, and
attachment by observing that passionate attachments are by their nature time-bound. She
contends that in the course of evolution our ancestors came to be genetically programmed to
meet, mate, and move on—a strategy designed to create optimal genetic variety in the young.
When she examined the data from 58 human societies selected from the Demographic
Yearbook of the United Nations, she discovered that in the majority of societies, couples
tended to separate and divorce around the fourth year of marriage. Fisher notes that: (1) many
socially monogamous species form pair-bonds that last only long enough to rear the young
through infancy; and (2) in hunting/gathering societies, it generally takes four years to rear a
child. (Children in such societies join in multi-age play groups soon after being weaned,
becoming the responsibility of relatives and older siblings.) (3) Thus she hypothesizes that it
may be “natural” for young couples to meet, court, marry, reproduce, and remain together
only long enough to raise a child. After that period, the chemistry of attraction (the stew of
increased dopamine, decreased serotonin, and increased norepinephrine) swings into action
and men and women begin to feel ancient tugs of attraction, sexual desire, and finally
attachment yet again.
 The Neuropsychology of Passionate Love 533

MAJOR ISSUES
In reviewing this literature, two questions stand out: (1) Is love an emotion? (2) How
tightly linked are passionate love and sexual desire? We will close with a final question: (3)
How useful are cyber-matching sites based on neuroscience models—like Chemistry.com and
ScientificMatch.com?

Is Passionate Love an Emotion?

Most social psychologists would probably agree that passionate love is an emotion.
In a seminal article, Kurt W. Fischer and his colleagues (1990) characterized emotions
this way:

Emotions are complex functional wholes including appraisals or appreciations, patterned

physiological processes, action tendencies, subjective feelings, expressions, and instrumental
behaviours (p. 85).

Scholars have interviewed men and women from a variety of cultures and of different
ages. They have conducted surveys and experiments, utilized prototype analyses, and taken a
social categorical approach to order to determine whether or not love should be classified as a
basic emotion, and if so, what people mean by the terms “in love” and “love.” When Shaver
and his colleagues (1996 and 1991) reviewed all the evidence, pro and con, they concluded
that love is indeed a basic emotion.
In cross-cultural research—in languages as different as English, Italian, Basque, and
Indonesian—ordinary people are able to identify five distinct emotions: love, joy, anger,
sadness, and fear—as prototypic emotions. Generally, passionate love is associated with the
terms “arousal,” “desire,” “lust,” “passion,” and “infatuation. Companionate love is
associated with “love,” “affection,” “liking,” “attraction,” and “caring” (see Shaver et al.,
1987; Shaver, et al., 2001).
After discussing the criteria that various theorists have used to classify emotions, they
concluded that given these criteria, love (which includes passionate and companionate love)
must be classified as an emotion. They observe:

. . . a number of controversies over the status of love can be resolved by distinguishing

between the momentary surge form of love, a basic emotion having properties similar to joy,
sadness, fear, etc., and relational love, a bond that develops between people, associated with
states that include not only surge love, but many other emotions such as distress and anxiety
(p. 81)

In another set of studies, Beverly Fehr and James Russell (1991) used the techniques of
prototype analysis to find out how ordinary people classified emotions. They found that
throughout the world, men and women generally assume that happiness, love, anger, fear,
sadness, and hate are basic emotions. They also discovered that people tend to draw a sharp
distinction between passionate love (i.e., “being in love”) and companionate love (i.e.,
“loving.) Similar results were secured by Berscheid & Meyers (1996), Fehr (1994), Hatfield
534 Elaine Hatfield and Richard L. Rapson

& Rapson (1993), Regan, 1998; Regan & Berscheid (1999); Regan et al. (1999), among a
host of others.
Social psychologists, then, generally assume that love (passionate or companionate) is
indeed a basic emotion.
Yet, some scholars have argued that “being in love” and “loving” are not emotional
experiences. They prefer to call love “a plot” or “script” (as in a story you tell yourself), “a
sentiment,” “a feeling,” “a disposition,” a “syndrome,” or “a motivational state.” (For a
review of these positions, see Shaver, et al., 1996.) Neuroscientists themselves are sharply
divided as to whether or not love is an emotion (see Bartels & Zeki, 2000; Birbaumer, et al.,
1996; Hatfield & Rapson, 2008) or is not an emotion (see Diamond, 2003 and 2004;
Gonzaga, et al., 2006; Reis & Aron, 2008).
Only subsequent research can answer this question. In part it seems like a semantic
question. If forced to hazard a guess, however, we would argue that in the future, love in all
its varieties will be classified as an emotion. When so many scientists and ordinary people
classify love as an emotion, insist they feel the “emotion” of love, and behave emotionally
when in love, it may be impossible for scientists to produce a paradigm shift.

What is love? . . . [I end by] confessing that, in the case of romantic love, I don’t really know.
If forced against a brick wall to face a firing squad who would shoot if not given the correct
answr, I would whisper “It’s about 90% sexual desire as yet not sated.
—Ellen Berscheid

How Tightly Linked Are Passionate Love and Sexual Desire?

Are “passionate love” and “sexual desire” the same thing? Forty years ago, when Ellen
Berscheid and I began our research into the nature of love, we weren't certain. Some social
commentators insisted that the two were one. In the 18th century French erotic novel Histoire
de Dom Bougre, for example, a cynical nun disclosed the true meaning of the expression: “to
be in love.” It meant, she said, to be “in lust”:

When one says, the Gentleman . . . is in love with the Lady . . . it is the same thing as saying,
the Gentleman . . . saw the Lady . . . the sight of her excited his desire, and he is dying to put
his Prick into her Cunt. That's truly what it means (as quoted in Ellrich, 1985, p. 222).

Others insisted that the two were very different. In the 18th century, the Marquis de Sade
(1797/1968) violently opposed the equation of love and pleasure:

I do not want a woman to imagine that I owe her anything because I soil myself on top of her .
. . . I have never believed that from the junction of two bodies could arise the junction of two
hearts: I can see great reasons for scorn and disgust in this physical junction, but not a single
reason for love (p. 148).

In the Victorian era, romantic love was considered to be a delicate, spiritual feeling—the
antithesis of crude, animal lust. Freudians, of course, mocked such pretensions. They irritated
 The Neuropsychology of Passionate Love 535

romantics by insisting that chaste love was simply a sublimated form of carnal love, which
lay bubbling just below the surface.
What about today? In the West, most college students make a sharp distinction between
“being in love” (which embodies sexual feelings) and “loving” someone (which is not
necessarily associated with sexual desire). Ellen Berscheid and her colleagues (Meyers &
Berscheid, 1995) found that most students assumed that although you could “love” someone
platonically, you could only be “in love” with someone you were sexually attracted to and
desired sexually. They concluded: “Thus, our findings suggest that although sexuality may
not be a central feature of love, it is most definitely a central feature of the state of being in
love” (p. 24). In a national survey, Andrew Greeley (1991) interviewed newly married couples
who said they were still in the “falling in love” stage of marriage. He found that passionate
love is a highly sexual state. He described the falling in love stage of marriage this way:

When one is in love, one is absorbed, preoccupied, tense and intense, and filled with a sexual
longing which permeates the rest of existence, making it both glorious and exhausting . . .
Those who are falling in love seem truly to be by love possessed (pp. 122-124).

In the end, Ellen Berscheid and I concluded that passionate love and sexual desire were
“kissing cousins.” Passionate love was defined as “a longing for union” while sexual desire
was defined as “a longing for sexual union” (Hatfield & Rapson, 1987).
Today, this debate seems settled. As Susan and Clyde Hendrick (1987b) noted:

It is apparent to us that trying to separate love from sexuality is like trying to separate fraternal
twins: they are certainly not identical, but, nevertheless, they are strongly bonded. . . . Love
and sexuality are strongly linked to each other and to both the physical and spiritual aspects of
the human condition. For romantic personal relationships, sexual love and loving sexuality
may well represent intimacy at its best (pp. 282 and 293).

There is abundant social psychological evidence in support of the contention that in most
people’s minds, love and sex are tightly related—in fact, most people find it hard to imagine
passionate love absent sexual desire (Hatfield & Rapson, 2005; Regan et al., 1999, 2004;
Regan & Berscheid, 1999; Ridge & Berscheid, 1989). (Naturally, men and women can easily
imagine the converse—sexual desire without passionate love.) As Pamela Regan (2004)
observes:

Theoretical discourse from a number of disciplines suggest that sexual desire is a

distinguishing feature of the passionate love experience . . . Empirical research substantiates
this hypothesis. People believe that sexual desire is part and parcel of the state of being in
love, assume that couples who desire each other sexually are also passionately in love, and
report a similar association when reflecting on their own dating relationships (p. 115).

Of course, culture surely has a powerful impact on how likely young couples are to link
passionate love, sexual desire, and sexual expression (Hatfield & Rapson, 2005). Many men,
for example, are taught to separate sex and love, while many women are taught to connect the
two. The different meanings attributed to sexual activity have been known to cause lovers
much distress (Hatfield & Rapson, 2006).
536 Elaine Hatfield and Richard L. Rapson

Neuroscientists and evolutionary psychologists, however, are still in sharp disagreement

as to whether love and lust are very different systems (Diamond, 2003 and 2004; Gonzaga, et
al., 2006) or are tightly linked (Bartels & Zeki, 2000). These neuroscients do agree, however,
that all of the brain systems for passionate love, sexual desire, and attachment do in fact
communicate and coordinate with one another.
When the dust settles, we suspect neuropsychologists will come to acknowledge that
although love and lust may possess a few distinct features, they are tightly linked. It is hard to
imagine that two phenomena so linked in the public mind could be such disparate entities.
Thus, the contention that love and sexual desire are “kissing cousins” seems to be an
appropriate one.

The Commercialization of Love and Sex Research: The BusinessofLove.com.

Any time a new form of communication is invented—the penny newspaper, Morse code
and the telegraph, the ham-radio, TV, or computers—men and women find ways to use that
technology to find love. In the 1950s, for example, almost as soon as computers appeared,
commercial matchmaking services sprang up (CBC Archives, 1957). Recognized as the first
widespread computer matching service was Operation Match, which was created in the mid
1960s by Harvard students after a discussion of the evils of blind dates and mixers. They
distributed thousands of questionnaires to college students at several universities and asked
them to rate themselves on looks, intelligence, and other dimensions and also to indicate what
they would desire in a partner on these same dimensions. In return for the completed
questionnaire and a fee of three dollars, they were promised a list of compatible matches.
Data were entered on punch cards and analyzed with an Avco #1790 computer (which was
probably the size of a small room). According to media reports, it took the computer six
weeks to generate the lists. Not surprisingly, the business failed miserably (for a description
of this experiment, see Leonhardt, 2006).
Today, while some sites, such as Match.com, are designed for the general population of
singles, other sites target special niches of the population. There are those designed to appeal
to various age groups (HookUp.com, SilverSingles.com), political groups
(ConservativeMatch.com, LiberalHearts.com), religious groups (CatholicSingles.com,
ChristianCafe.com, HappyBuddhist.com, Jdate.com), and sexual orientation (GayWired.com,
superEva.com). Dating sites also exist for people who possess mental and physical
disabilities, unusual sexual preferences, and so forth. Even people who wish to find dates for
themselves and their favorite pets can sign on to a site (DateMyPet.com). At the time this
chapter was written, there had sprung up almost 1,000 dating websites servicing the U.S.
(e.g., Thompson, Zimbardo, & Hutchinson, 2005), and the technology available to create
another one in an afternoon.
Recently, neuroscientists and biochemists have joined the gold rush. They have set up
sites like ScientificMatch.com (people are matched on the basis of DNA) or Chemistry.com,
where scientists use indicators (such as finger length) to classify and match up people, among
a host of others.
What scientific principles are being used to match people on the major relationship
websites, such as eHarmony.com and Perfectmatch.com? Or on the “scientific” websites? Do
 The Neuropsychology of Passionate Love 537

people sign up for these services just for fun or do they truly believe that scientists can match
them with their ideal Prince Charming or Sleeping Beauty?
Almost all of the sites make fantastic claims. ScientificMatch.com, for example,
promises:

DNA Matching and the Magic of Chemistry

When you share chemistry with someone, you significantly increase your chances of
realizing these amazing benefits:

1. You’ll love their natural body fragrance—they’ll smell “sexier” than other people.
2. You’ll have a more satisfying sex life.
3. If you’re a woman, you’ll have a higher rate of orgasms.
4. There will be less cheating in your exclusive relationship.
5. As a couple, you’ll be more fertile.
6. Your children will be healthier.

In support of these contentions, the authors cite a slew of articles published in prestigious
social psychological, neuroscience, evolutionary psychology, and neurobiochemistry journals.
The more popular Chemistry.com asks men and women to answer 56 questions—things
like: “Which image most closely matches your right hand?” The assumption is that people
possess different levels of dopamine, serotonin, estrogen, and testosterone. The scholars
assume that these differences in brain chemistry have a powerful effect on people’s
personalities—determining which of four categories they fit: the explorer, the builder, the
negotiator, and the director. (The site attempts to tell people what type (or combination of
types) they are, based on physical characteristics (i.e., finger length, etc.)
For common folk, computer matching sites have the imprimatur of Science (with a
capital S). In the scientific community there are mixed reactions to claims such as those made
by Science.com. Some argue that no one takes the claims of these sites seriously. People
access the sites in fun. Besides, such sites give people that are shy or live in geographical
locations or work at jobs that make it difficult to find partners (particularly those who share
their values and interests) can access the web to meet dates and mates that might never come
their way.
They also point out that commercial matching services are still in their infancy. Since
social psychologists, neuroscientists, and neurobiologists are working for these sites, in
time—given the money that is being lavished on these commercial enterprises—it is
reasonable to hope that in the future, the BusinessofLove.com sites will craft more complex
versions of relationship science to inform their questionnaire construction, website
construction, and matching algorithms. Thus, in time these matching sites will provide
increased opportunities for men and women to find dating and marital relationships that are
fulfilling.
Other scientists cringe, arguing that these sites can’t possibly fulfill their promises of the
perfect match. Currently, these matching sites—arguing that they are businesses not scientific
enterprises—are reluctant to explain in any detail how they match people and how successful
such matches are.
Critics point out that only charlatans, crooks, and con men sell “elixirs” that cure nothing.
People who join these sites looking for love are being cheated. Worse yet, false claims make
538 Elaine Hatfield and Richard L. Rapson

people who get burned skeptical about the scientific enterprise itself. When people are
disappointed—and they are bound to be—they will blame science for their disappointment
(see Sprecher, et al, 2008, for a longer discussion of these issues.)
Our personal opinion is that an appreciation of science and its methods is a fragile
blossom, easily trampled underfoot, and that scientists participating in these commercial
enterprises should tread with care. They can potentially inflict serious damage to the whole
neuroscientific enterprise when they promise what they cannot deliver. Love may be
wonderful or painful because it is no simple matter.

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 INDEX

adaptability, 356
A adaptation, xxii, 120, 300, 340, 341, 342, 344, 353,
355, 357, 359, 360, 451, 484, 515
aberrant, 327
adaptive functioning, 335, 342
abnormalities, 118, 120, 121, 127
addiction, xvii, 128, 319, 320, 348, 378, 528
abstinence, 128, 444
adenosine, 221
academic, 9, 21, 97, 144, 341, 346, 349, 350, 351,
adipocytes, 114
353, 355, 358, 360, 466
adjustment, ix, x, xii, xiii, xvi, xix, 23, 32, 39, 45, 59,
academic difficulties, 350, 355
60, 77, 78, 144, 145, 148, 149, 150, 169, 170,
academic performance, 9
173, 174, 175, 176, 187, 202, 203, 206, 245, 255,
Academic Search Premier, 440
281, 282, 299, 304, 305, 307, 310, 311, 312, 315,
academic settings, 97
316, 327, 335, 336, 344, 353, 357, 358, 359, 360,
academic success, 351, 353, 355, 358
361, 362, 381, 384, 415, 453, 455
access, 9, 39, 331, 347, 476, 537
administration, 113, 115, 116, 117, 119, 120, 123,
accessibility, 55, 58, 62, 94, 95, 106, 108
124, 128, 373, 376, 482, 528
accidental, 334
administrators, 20, 351
accidental injury, 334
adolescence, xvi, xvii, xxii, 33, 132, 133, 141, 142,
accidents, 323, 332
143, 144, 145, 146, 147, 208, 210, 211, 255, 281,
accommodation, 16, 17, 23, 28, 29, 31
282, 283, 284, 287, 288, 297, 298, 299, 300, 301,
accounting, xv, 163, 245, 250
313, 324, 326, 359, 385, 395, 434, 438, 451, 488,
acculturation, 276
489
accuracy, xiii, 11, 14, 19, 32, 35, 41, 46, 47, 48, 49,
adolescent behavior, 440
50, 51, 52, 53, 54, 60, 61, 62, 64, 191, 195, 196,
adolescent boys, 368, 419
202, 204, 205, 206, 299
adolescent patients, xxii, 451, 453
acetate, 227
adrenocorticotropic hormone, 113, 122
acetylation, 112
adult, ix, xii, xvi, xix, 8, 59, 60, 61, 63, 72, 92, 96,
achievement, 25, 97, 355
97, 102, 106, 107, 108, 115, 116, 121, 124, 131,
acid, 112, 216
133, 141, 142, 143, 144, 146, 169, 186, 194, 196,
Acquired Immune Deficiency Syndrome, 438
199, 204, 207, 222, 227, 256, 267, 268, 281, 283,
ACTH, 113
300, 308, 326, 336, 337, 338, 355, 369, 370, 372,
activation, xxii, 9, 10, 56, 60, 94, 116, 118, 119, 120,
374, 375, 376, 377, 378, 379, 403, 414, 418, 454,
218, 222, 227, 322, 373, 374, 379, 406, 412, 451,
455, 456, 457, 458, 473, 481, 487, 516
519
adult population, 355
acupuncture, 90
adulthood, xii, xiii, xvi, 40, 46, 61, 62, 63, 64, 105,
acute, 81, 106, 113, 118, 120, 216, 218, 341, 350,
106, 107, 108, 115, 131, 132, 133, 141, 142, 143,
406, 416, 458, 503
144, 146, 169, 186, 191, 193, 207, 210, 281, 287,
acute leukemia, 458
288, 289, 290, 294, 297, 359, 371, 372, 455, 489,
acute stress, 81, 113, 406, 416
490, 491
Adams, 132, 133, 134, 142, 145, 146, 458
546 Index

adults, xii, xiii, xix, 37, 42, 76, 95, 102, 115, 119, alters, 305, 376
131, 133, 134, 135, 141, 142, 143, 144, 146, 191, altruism, 11, 13, 21, 387
260, 327, 333, 369, 372, 383, 386, 406, 434, 442, altruistic behavior, 20, 383
446, 454, 455, 456, 476, 491, 497, 531 Alzheimer, 414
advertising, 197, 524 ambiguity, 101, 116
advocacy, 351, 353, 356, 358, 452 ambivalence, xx, 98, 400, 404, 406, 407, 408, 410,
aerobic, 223 411, 412, 414, 495
AFC, 158, 160, 164, 181 ambivalent, xx, 92, 102, 151, 175, 400, 404, 405,
affective dimension, 269 406, 407, 408, 409, 410, 411, 412, 414
affective disorder, 332, 334, 335, 336, 377 American Indian, 261
affective experience, 479 American Psychiatric Association, 77, 126, 169, 186,
affective reactions, 8 234
affective states, 13, 14 American Psychological Association, 29, 30, 31, 32,
affiliates, 253 34, 211, 280, 315, 355, 490, 541
African American, 167, 184, 255, 307, 340, 345, amino, 112, 122, 216, 371
347, 349, 354, 355, 356, 362, 363 amino acid, 112, 122, 216, 371
African Americans, 340, 349, 354, 356, 363 amnesia, 373, 379
African-American, 476 amnion, 113
afternoon, 268, 269, 288, 290, 536 amphetamine, 529
Ag, 79 amygdala, 114, 116, 119, 124, 126, 215, 221, 222,
AGFI, 501, 504, 505, 507 226, 374, 378, 524, 526
aggregation, 289 analgesic, 348, 349
aggression, xiv, 73, 83, 117, 168, 185, 192, 208, 213, analog, 31, 125
215, 217, 255, 282, 299, 303, 325, 327, 386, 516, analysis of variance, 139, 232, 392
530 analytic techniques, xv, 245, 247
aggressive behavior, 78, 109, 215, 346 analytical techniques, 342
aggressiveness, 370 androgen, 222
aging, 33, 40, 128, 372, 407, 414 androgens, 114, 121, 525
agonist, 216 anemia, 340, 360, 361
agoraphobia, xi, 65, 77, 78, 79, 80, 82, 84, 239, 241 anger, 58, 104, 162, 267, 272, 303, 304, 314, 343,
agrarian, 261 344, 349, 452, 487, 494, 497, 510, 512, 514, 516,
agreeableness, 192 521, 524, 526, 528, 530, 532, 533
agricultural, 262 angiotensin, 120, 128
agriculture, 89, 261, 264 angiotensin converting enzyme, 128
aid, 400 animal models, xii, 111, 114, 129
AIDS, xxi, 420, 435, 437, 438, 439, 440, 442, 443, animal studies, 374
444, 445, 446, 447, 448, 450 animal welfare, 96, 103
air, 220, 225, 227, 386 animals, ix, xiv, xviii, 88, 89, 90, 91, 92, 93, 94, 95,
alcohol, x, 2, 70, 120, 150, 249, 429, 433, 442, 473, 96, 99, 100, 101, 102, 103, 105, 107, 108, 109,
529 114, 115, 119, 121, 219, 220, 223, 224, 369, 370,
alcohol abuse, 150 387, 394
alcohol consumption, x, 2 anorexia, 120, 127, 128
alcohol dependence, 70 anorexia nervosa, 127, 128
alcohol use, 249, 433 ANOVA, 232
alcoholics, 120, 128, 208, 236, 244 ANS, 530
alcoholism, 230, 235, 238, 243, 338 antagonism, 127
alexithymia, 490 antagonists, xii, 111, 114, 115, 116, 216, 373
alienation, xvi, 69, 281, 287, 290, 294, 295, 296, 298 anterior cingulate cortex, 9, 374
ALL, 502 anthropology, 283, 494, 495
Allah, 421 anticoagulant, 240
alpha, xxiii, 198, 289, 493, 497, 499 antidepressants, 82, 377
alternative, 20, 254, 298, 306, 385, 464 antisocial, 205, 256, 299, 484, 368
alternatives, 57, 352 antisocial behavior, 205, 256, 299
 Index 547

antisocial personality, 484 421, 423, 434, 435, 437, 439, 442, 444, 445, 446,
antisocial personality disorder, 484 447, 453, 456, 472, 532, 540
antithesis, 534 attractiveness, 21, 167, 184, 222, 224, 225, 227, 346,
anxiety disorder, ix, xi, 65, 66, 70, 71, 72, 74, 75, 77, 393
78, 79, 80, 81, 82, 83, 84, 102, 119, 125, 239, attribution, 19, 496, 509, 514, 515, 517, 539
325, 333 attribution theory, 539
anxiolytic, 118, 119, 127 atypical, 322, 340
APA, 168, 185, 232 audio, 155, 157, 180
appetite, 118, 520 authoritarianism, 472
application, 14, 93, 222, 223, 225, 247, 249, 332, authority, 262, 272, 476
473 autism, 120, 121, 129, 217
appraisals, 304, 342, 519, 533 autonomic, 104, 113, 116, 119, 122, 222, 225, 323,
aquatic, 221 522
arginine, 125 autonomic nervous system, 222, 225, 323, 522
argument, 133, 141, 142, 143, 155, 192, 306, 322, autonomous, 11, 260, 261, 263, 272, 290, 343, 467,
329, 495 494
arithmetic, 100 autonomy, xvi, 11, 12, 263, 271, 272, 273, 275, 281,
arousal, 10, 17, 18, 23, 117, 120, 225, 306, 322, 374, 287, 290, 294, 295, 296, 298, 328, 341, 466
510, 524, 526, 533, 538, 539, 541, 543 autoradiography, 379
artery, 218 autosomal recessive, 340
arthritis, 362 availability, 28, 42, 218, 343, 386, 402, 473, 474,
artificial, 103 475, 477, 481
aspartate, 377 averaging, 157
assertiveness, 13, 263, 271, 273 aversion, 327, 406, 410
assessment, xii, xiii, 146, 148, 149, 150, 152, 154, avoidance, xi, xxiii, xxiv, 33, 63, 69, 75, 87, 93, 94,
158, 161, 166, 167, 168, 170, 171, 173, 174, 175, 97, 98, 99, 117, 119, 230, 231, 309, 371, 400,
176, 177, 183, 184, 185, 187, 188, 189, 243, 244, 405, 493, 494, 497, 498, 500, 502, 504, 505, 507,
254, 255, 276, 308, 316, 322, 329, 335, 336, 357, 509, 511, 512, 513, 514
407, 410, 453, 488, 491, 516, 539 avoidance behavior, 119, 231
assessment techniques, 276 avoidant, 44, 92, 93, 95, 96, 97, 98, 99, 102, 161,
assessment tools, 176, 357 162, 165, 182, 192, 198, 199, 482, 495
assignment, 9, 393, 462 awareness, 11, 14, 69, 224, 261, 353, 362, 383, 453,
associations, xiii, xxi, 12, 19, 37, 43, 44, 70, 129, 454, 477, 495
134, 138, 142, 143, 144, 146, 155, 157, 161, 162, axons, 112, 113, 221, 526
163, 180, 182, 191, 255, 297, 324, 375, 402, 409,
410, 421, 438, 441, 445, 446, 486
assumptions, 12, 13, 101, 251, 357, 476, 479 B
asthma, xviii, 322, 335, 336, 337, 339
babies, 103, 269
atherosclerosis, 218
bacteria, 223
atmosphere, 269, 423, 454, 472
bacterial, 465
attachment theory, xi, xxii, 42, 59, 87, 92, 93, 97,
bad day, 153, 178
102, 103, 104, 370, 471, 472, 481, 483, 487, 488,
bananas, 262
489, 490
banking, 261
attention, xii, xiii, xvii, xix, 5, 12, 28, 36, 51, 54, 69,
barbiturates, 529
101, 148, 149, 150, 154, 166, 173, 174, 175, 177,
barrier, xxii, 347, 432, 451
183, 192, 217, 220, 223, 230, 238, 246, 261, 266,
barriers, 329, 331, 347, 349, 357, 358, 409, 421, 427,
268, 273, 292, 298, 313, 320, 325, 327, 331, 339,
433, 454, 456
344, 349, 350, 351, 352, 370, 372, 373, 383, 425,
basal ganglia, 113, 126
453, 466, 467, 477, 512, 525, 526
basic research, 151, 176
attentional bias, 69
battery, xv, 167, 184, 237, 239
attitudes, xxi, xxiii, 17, 21, 55, 78, 83, 193, 194, 195,
BDNF, 372, 374, 377, 378
206, 211, 246, 265, 272, 332, 334, 345, 350, 413,
beef, 262
behavior modification, 171, 189
548 Index

behavior therapy, xi, 65, 78 blind spot, 463

behavioral aspects, 370 blood, xiii, 100, 102, 112, 114, 115, 121, 213, 214,
behavioral change, 222, 251, 252, 254, 434 216, 240, 241, 262, 340, 406, 407, 410, 411, 414,
behavioral difficulties, 452, 454 415, 455, 524, 525, 531
behavioral dysregulation, 309, 311 blood flow, 340, 524, 525
behavioral modification, 117, 371 blood group, 455
behavioral problems, xvii, 319, 320, 325, 328, 331 blood pressure, 100, 102, 406, 407, 410, 411, 414,
behaviours, xii, 111, 114, 115, 121, 223, 267, 337, 415
533 blood vessels, 340
belief systems, 260, 278, 279, 350 body image, 433
beliefs, xv, 17, 33, 41, 42, 43, 45, 60, 134, 143, 195, bonding, ix, xii, xvii, xviii, 93, 111, 114, 116, 121,
211, 259, 260, 261, 262, 263, 265, 271, 272, 273, 123, 129, 238, 319, 320, 321, 324, 330, 346, 365,
274, 275, 276, 277, 278, 279, 284, 342, 348, 350, 369, 373, 375, 377, 378, 531
357, 401, 421, 423, 424, 427, 435, 439, 443, 445, bonds, 81, 92, 94, 95, 102, 103, 104, 112, 114, 115,
446 116, 117, 205, 262, 370, 373, 386, 487, 488, 532
belongingness, 88 bone, 347, 360, 528
benchmark, 47, 50 bone marrow, 347, 360
beneficial effect, xx, 115, 399, 404 bone marrow transplant, 347, 360
benefits, xx, 62, 88, 100, 101, 102, 103, 105, 106, borderline, 473, 475, 483, 484, 487, 489
192, 305, 307, 312, 386, 399, 400, 401, 402, 403, borderline personality disorder, 473, 475, 483, 484
404, 406, 412, 414, 537 boys, xvi, xxi, 133, 208, 264, 281, 282, 283, 284,
benevolence, 200, 201, 202, 203, 474 287, 288, 291, 292, 297, 324, 346, 366, 388, 391,
benign, 13 417, 418, 419, 421, 422, 423, 424, 425, 426, 427,
benzodiazepines, 67, 232 428, 429, 430, 431, 432, 433, 443, 444, 476
bereavement, 95, 105, 107, 109 bradykinin, 120
best practice, vii, 339 brain, xiv, 9, 10, 113, 115, 116, 119, 120, 122, 123,
beta, xxiii, 113, 128, 493, 497, 499 124, 213, 214, 215, 216, 217, 218, 222, 223, 226,
bias, 35, 46, 47, 48, 49, 50, 51, 52, 53, 54, 60, 61, 69, 227, 231, 238, 322, 333, 340, 370, 371, 372, 373,
78, 82, 135, 169, 186, 233, 332, 405, 433 374, 375, 377, 378, 523, 524, 525, 526, 527, 529,
bilateral, 374 530, 532, 536, 537, 538, 539, 540, 541, 543
bilingual, 265, 500 brain activity, 10, 322, 524, 525, 527, 541
binding, xv, 113, 215, 216, 220, 221, 237, 238, 239, brain chemistry, 529, 537, 539
240, 241, 243, 379, 531 brain damage, 340
biochemical, 114 brain development, 372, 375
biogenesis, 122 brain growth, 115
biological, 119, 192, 206, 242, 269, 370, 387, 444, brain stem, 113
481, 529, 530 brain structure, 215
biological processes, 529 brainstem, 215
biological rhythms, 269 BrdU, 374, 378
biologically, 89, 112, 220, 224, 226, 382 breakdown, 307, 314, 529
biology, 124, 231, 238, 387, 539, 540 breast, 33, 113, 115, 123, 371
biomedical, 341, 359 breast cancer, 33
bipolar, 222, 223, 239, 243, 334 breast feeding, 123
bipolar disorder, 70, 239 breastfeeding, 262, 263, 268, 269, 272, 277, 324
birth, xviii, 82, 114, 115, 123, 221, 270, 322, 324, breathing, 530
329, 369, 370, 371, 372, 377, 425, 426, 428, 432, breeding, 116
473, 481, 490 brick, 534
birth control, 425, 426, 428, 432 bronchitis, 503
birth weight, 324 Bronfenbrenner, 353, 359, 440, 446
births, 333 brothers, 428, 430, 431
blame, 3, 4, 8, 178, 310, 311, 312, 510, 512, 537 buffer, 61, 99, 100, 240, 331, 343, 401, 414
blaming, 403, 498 building blocks, 484
bleeding, 347 buildings, 223
 Index 549

bulimia, 120, 128 cattle, 89

bulimia nervosa, 120 Caucasian, 121, 129, 156, 167, 180, 184, 280, 307,
bullies, 366, 367, 368 353
bullying, xviii, 106, 207, 365, 366, 367, 368 causal relationship, xiv, xxiii, 213, 216, 493, 504,
business, 536, 541 505, 512
causality, 57, 261
cbc, 539
C CBS, 435
CBT, xi, 65, 67, 68, 74, 75, 76, 356, 357, 359
Ca2+, 113
cell, xviii, 113, 221, 339, 340, 341, 342, 343, 344,
campaigns, 262, 418
345, 346, 347, 348, 349, 350, 351, 352, 353, 354,
cancer, x, xviii, xxii, 2, 3, 4, 8, 9, 10, 12, 13, 14, 20,
355, 356, 358, 360, 361, 362, 371, 372
21, 23, 25, 26, 28, 29, 31, 32, 33, 339, 360, 361,
census, 156, 171, 189
403, 412, 413, 451, 452, 454, 455, 456, 457, 458,
Census Bureau, 171, 189
459, 502
Centers for Disease Control, 356, 359
candidates, 115, 420
central nervous system, 221, 372
cannabis, 529
cerebellum, 215
capacity, 5, 14, 16, 132, 137, 141, 145, 240, 366,
cerebral blood flow, 223
385, 386, 395, 444
cerebrospinal fluid, 118, 122, 127, 129, 216
capital, 264, 422, 537
cerebrovascular, 340
cardiac activity, 105
cerebrovascular accident, 340
cardiac arrhythmia, 106
certainty, 231, 234, 238, 386, 439
cardiac risk, 403
certificate, 419
cardiac risk factors, 403
CFA, 37
cardiovascular, 100, 125, 336, 403, 406, 407, 408,
CFI, 83
410, 412, 414, 416
c-fos, 373
cardiovascular function, 406, 407, 408, 410, 412,
channels, 432, 478
414
chaos, 523
cardiovascular risk, 412
cheating, 537
cardiovascular system, 408
check-ups, 350
caregiver, xii, xxii, 32, 92, 94, 95, 111, 114, 121,
chemical, xiv, 219, 220, 221, 227, 526, 529, 530, 531
343, 358, 370, 471, 472, 473, 474, 475, 477, 478,
chemicals, 224, 525, 526, 529, 530
479, 480, 481, 483, 484, 485, 486, 488
chemistry, 526, 529, 530, 532, 537, 539, 541
caregivers, xxii, 40, 92, 96, 97, 265, 342, 343, 353,
chemotherapy, 12, 13, 21, 28, 453
354, 360, 361, 371, 414, 457, 461, 462, 464, 466,
Chi square, 391
474, 478, 481, 482, 483, 485, 486
chicken, 503
caregiving, xi, xxiii, 87, 92, 95, 96, 100, 105, 107,
chicken pox, 503
260, 266, 268, 269, 272, 472, 481, 482, 484, 485,
chicks, 371, 426, 427
486, 487
Child Behavior Checklist (CBCL), 309, 314
caretaker, 488
child development, 261, 265, 315, 316, 334, 371
cartilage, 221
child rearing, 345, 475
case study, 214, 463
childbirth, 126, 265, 321
cash crops, 262
childcare, xvi, 153, 178, 260, 262, 265, 269, 271,
casting, 483
272, 321, 330, 366
catalyst, 348
childhood, xviii, 32, 62, 66, 77, 99, 171, 188, 255,
catalysts, 101
263, 282, 284, 299, 300, 324, 327, 335, 336, 340,
categorization, 425
359, 360, 365, 367, 383, 384, 385, 388, 395, 396,
category a, 136, 288
455, 456, 457, 458, 459, 475, 476, 478, 482, 483,
category d, 92
486, 487, 488, 490, 514
catheter, 465
childrearing, xv, 238, 259, 260, 261, 262, 263, 265,
cathexis, 496, 513
271, 272, 273, 275
Catholic, 191, 195, 197, 199, 261, 262, 264
Chinese, 121, 129, 522, 531, 542
Catholic Church, 197, 262
Chi-square, 502
cats, 88, 89, 90, 91, 93, 98, 99, 100
550 Index

Christianity, 418 codes, 156, 157, 160, 164

chronic, xviii, 56, 58, 66, 97, 120, 126, 322, 323, coding, 149, 152, 158, 163, 165, 171, 174, 176, 188,
330, 336, 339, 340, 341, 342, 343, 344, 345, 346, 266, 276, 290, 434, 486
347, 348, 349, 351, 352, 353, 355, 356, 357, 358, coffee, 262, 291
359, 362, 462 cognition, xii, 30, 55, 62, 89, 94, 111, 121, 129, 279,
chronic disease, 347, 355, 357, 359, 462 324, 447
chronic illness, xviii, 336, 339, 341, 342, 343, 344, cognitive behavioral therapy, 78, 356
345, 346, 347, 349, 351, 352, 353, 355, 356, 357, cognitive capacities, 313
358, 359 cognitive deficit, 320, 322, 324, 373, 393, 455
chronic pain, 347, 348 cognitive deficits, 320, 322, 324, 373, 455
chronic stress, 322 cognitive development, 313, 324, 332, 334, 336, 384,
chronically ill, 341, 343, 360, 361, 463 394
chrysanthemum, 514 cognitive dissonance, 151, 153, 154, 176, 178, 179
CIA, 261, 262, 277 cognitive dysfunction, 120
cigarettes, 3, 426 cognitive function, xix, xxii, 118, 324, 370, 451
cingulated, 524 cognitive impairment, 118, 324
circadian, 240 cognitive performance, 279, 324, 396
circulation, 340 cognitive perspective, 7, 41, 170, 187
citalopram, 377 cognitive process, 220, 315, 335, 386, 411
classes, 22, 91, 135, 349, 503 cognitive reaction, 307, 308
classical, 41, 42, 472, 482, 522, 542 cognitive therapy, 63, 74, 75, 77, 79
classical conditioning, 542 coherence, 208, 283, 284, 286, 287, 290, 292, 297,
classification, 114, 146, 155, 179, 220, 261, 273, 298
292, 298, 407, 411, 482, 490 cohesion, 7, 73
classified, 67, 139, 142, 248, 249, 297, 329, 390, cohort, 82, 334, 336, 458
391, 392, 408, 409, 478, 533, 534 coke, 2, 18, 20, 30
classroom, 7, 23, 253, 325, 326, 345, 346, 388, 393 collaboration, 387, 450, 482, 486
classroom environment, 7 collectivism, 260, 271, 274, 278, 279, 280
cleavage, 112 college students, 39, 107, 137, 146, 448, 497, 535,
cleavages, 119 536
clinical, xiii, xvi, xxii, xxiv, 57, 59, 67, 76, 82, 102, colors, 217, 324, 380
123, 128, 149, 152, 153, 163, 166, 173, 174, 175, combat, 12, 13, 19, 20, 25, 78, 79, 124
176, 177, 182, 183, 239, 242, 260, 315, 321, 325, combined effect, 314
331, 337, 354, 379, 397, 403, 448, 451, 459, 471, commerce, 261
474, 476, 480, 486, 491, 494, 522 commercial, 257, 421, 536, 537
clinical depression, 331 commodities, 476
clinical disorders, 325 communication competence, 22, 33
clinical judgment, 239 communication skills, 31, 34, 308, 312, 314, 396,
clinical psychology, 57, 153, 177 454
clinical trial, 76, 448 communication strategies, 2, 151, 175
clinically significant, 239, 242, 345 communities, 109, 156, 180, 260, 261, 263, 272,
clinicians, 151, 152, 163, 176, 177, 182, 230, 238, 274, 314, 356
275, 321, 331, 344 community, 82, 108, 168, 186, 192, 235, 244, 261,
close relationships, xv, xx, 35, 42, 58, 59, 61, 62, 63, 285, 289, 307, 315, 333, 335, 336, 338, 353, 356,
64, 87, 103, 105, 106, 107, 108, 150, 152, 153, 400, 409, 412, 430
155, 168, 176, 177, 185, 192, 193, 245, 250, 255, community psychology, 412
256, 272, 279, 399, 403, 415, 540, 542 community-based, 108, 356
closure, 97, 108, 251 comorbidity, 84
clothing, 269 companionate love, 525, 533
clouds, 292 comparative research, 266
clusters, 79 compassion, 16, 345
CNS, 126, 379 compensation, 307
cocaine, 120, 128, 379, 524, 526, 529
 Index 551

competence, x, xv, 1, 22, 23, 34, 43, 109, 153, 179, 396, 400, 403, 412, 415, 461, 467, 472, 496, 503,
259, 261, 263, 264, 271, 272, 275, 282, 299, 333, 532
344, 345, 346, 360, 361, 383, 385 conflict resolution, 25, 26, 153, 155, 178, 209, 308
competency, 30, 345 confounding variables, 320
competition, xix, 381, 384, 387, 388, 393, 394, 395, confrontation, 394
397 confusion, 150, 306, 512, 519
competitiveness, 476 congenital heart disease, 343
compilation, 155 congruence, 19, 194, 207, 209, 210
complementarity, 61 consciousness, 214, 394, 474, 529
complementary, 92, 222, 255, 384, 472, 483 consensus, xi, xvii, 53, 65, 76, 319, 320, 345, 389
complex interactions, 353, 466 consent, 232, 239
complexity, 5, 33, 61, 154, 178, 248, 353, 383, 484, conservation, 532
485, 523 consolidation, 57, 117, 119, 127, 371, 374
compliance, 303, 328, 350, 354 constraints, 248, 250, 385
complications, 286, 340, 341, 347, 349, 455 construct validity, 165, 207
components, xi, 2, 7, 9, 14, 15, 16, 17, 18, 35, 36, 41, construction, xvi, 62, 145, 281, 283, 284, 285, 287,
44, 45, 46, 53, 55, 67, 68, 105, 112, 158, 223, 298, 299, 349, 382, 385, 386, 394, 397, 450, 475,
285, 304, 307, 309, 313, 347, 446, 472, 474, 482 476, 537
composite, 17, 37, 46 constructive communication, 192, 208, 304
composition, 107, 288 constructive conflict, 366
compositions, 288, 290, 296 constructivist, 283, 383
compounds, xiv, 219, 220, 223, 225, 525 contamination, 119
comprehension, 324 contempt, 164, 165
compulsive behavior, 126, 528 content analysis, 98, 276, 288
computer, xv, 240, 243, 245, 251, 536, 537 contingency, 261
computer simulations, xv, 245, 251 continuing, 465
computing, 40, 195, 200, 201 continuity, 205, 283, 284, 285, 287, 289, 298
concentrates, 462 contraceptives, 442
concentration, 208, 222, 372 contractions, 117
conceptualization, 14, 36, 37, 42, 44, 45, 46, 54, 58, control condition, 313
133, 141, 154, 178, 194, 404, 410, 411, 479 control group, xvii, 76, 224, 303, 310, 325, 326, 355,
conceptualizations, 41, 402, 410, 479 374
conditioned response, 119 controlled, xiii, 18, 19, 40, 48, 77, 82, 101, 114, 168,
conditioning, 373 186, 191, 224, 311, 317, 323, 338, 346, 366, 410,
condom, xxi, 417, 418, 420, 421, 424, 425, 427, 428, 435
429, 430, 431, 432, 433, 434, 435, 443, 444, 445, convergence, 29, 48, 235
446, 447, 448, 449, 450 conviction, 50, 62, 238
condoms, xxi, 417, 418, 421, 424, 426, 427, 428, coordination, 300, 384, 467
429, 430, 432, 433, 438, 443, 444, 445, 449 coping, vii, xxiii, 339, 341, 342, 344, 414, 415, 493,
conduct disorder, 257, 325 497, 500, 501, 504, 505, 507, 511, 512, 515, 516,
conductance, 227 517
confidence, 43, 91, 92, 102, 153, 178, 310, 343, 346, coping model, 353, 360, 362
365, 386, 428, 432, 444, 452, 521 coping strategies, 306, 355, 405, 413, 512, 515
confidence interval, 310 coping strategy, 498
confidence intervals, 310 coronary artery disease, 413
confirmatory factor analysis, 37 coronary heart disease, 415
conflict, xii, xiii, xvii, xx, xxii, xxiii, 10, 21, 23, 25, corpus luteum, 113
26, 39, 40, 44, 52, 68, 77, 80, 149, 150, 151, 152, correlation, ix, 18, 22, 72, 118, 125, 139, 158, 162,
153, 154, 155, 158, 162, 165, 167, 170, 173, 174, 182, 195, 200, 248, 497, 501, 502, 511
175, 176, 177, 178, 181, 185, 188, 209, 255, 303, correlation coefficient, 502
304, 305, 306, 307, 308, 309, 310, 311, 312, 313, correlational analysis, 255
314, 315, 316, 317, 328, 343, 350, 362, 383, 394, correlations, xii, 18, 37, 138, 139, 145, 149, 156,
157, 158, 160, 161, 162, 165, 174, 180, 181, 198,
552 Index

200, 201, 202, 203, 248, 270, 401, 498, 501, 502, cultural norms, 263, 275
507, 511 cultural perspective, 234, 494, 540
cortex, 114, 115, 116, 215, 223, 372, 373, 524, 528 cultural psychology, 280
cortical, 223, 226, 371, 401, 523 cultural values, 195, 261, 262, 271, 272, 273, 275,
corticosterone, 117 423
corticotropin, 122, 125, 376 culture, 13, 28, 89, 171, 189, 193, 194, 196, 206,
cortisol, 321, 322, 333, 337, 413 207, 210, 230, 263, 266, 268, 274, 275, 276, 278,
co-sleeping, 272 279, 280, 285, 288, 298, 341, 347, 411, 419, 421,
cost-effective, 167, 185 423, 476, 494, 495, 528, 535, 542
costs, 14, 20, 21, 66, 82, 106, 109, 421 curing, 457
counseling, 19, 109, 435, 436, 442, 452 curiosity, 97, 108, 455
counseling psychology, 19 curriculum, 432
couples, ix, xi, xiii, 49, 51, 52, 59, 60, 64, 65, 68, 69, curve-fitting, 240
70, 71, 73, 74, 75, 76, 79, 81, 83, 84, 94, 98, 106, cycles, xx, 222, 382, 394
109, 149, 150, 152, 153, 154, 156, 160, 163, 166, cystic fibrosis, xviii, 339
167, 168, 171, 174, 176, 177, 178, 179, 180, 183,
184, 185, 186, 188, 191, 192, 193, 197, 199, 202,
203, 204, 207, 208, 209, 255, 257, 304, 307, 308, D
315, 388, 389, 390, 391, 392, 393, 394, 532, 535
daily living, 341
coupling, 116, 119
danger, 97, 119, 386, 473, 531
courts, 90
data analysis, 209, 256, 270, 279, 425
covariate, 22, 67, 252, 253, 310
data collection, 249, 250, 276
coverage, 20, 476
data set, 79, 463
covering, 355, 473
dating, xiii, 44, 48, 49, 50, 51, 59, 61, 73, 81, 98,
craving, 525, 526, 529
145, 149, 156, 157, 158, 160, 162, 163, 166, 173,
creativity, 263
174, 179, 180, 181, 182, 183, 193, 209, 535, 536,
credibility, 434, 463
537
credit, 135
DBP, 407
CRH, 113
death, xviii, 6, 90, 95, 339, 361, 403, 406, 414, 430,
criminality, 208
438, 453, 454, 521
criticism, 73, 74, 76, 79, 80, 85, 403, 514
death sentence, 430
cross-cultural, xv, 259, 260, 265, 276, 277, 278, 279,
deception, 91
280, 334, 347, 515, 533
decision making, 32, 73, 453
cross-cultural psychology, 278
decisions, 133, 134, 141, 143, 144, 154, 155, 179,
cross-sectional, 154, 163, 174, 178, 182, 206, 402
250, 329, 344, 464, 466, 467, 475
crosstalk, 217
decoding, 89
crying, 92, 370, 374, 383, 478
defects, 455
CSF, 118, 119, 120, 121
defense, xxii, 55, 370, 412, 451, 496
CSI, 309
defense mechanisms, xxii, 370, 451, 496
cues, xix, xxiii, 6, 11, 22, 23, 69, 82, 89, 115, 346,
defensiveness, 224, 226
369, 471, 485
deficit, 325, 340
cultivation, 8
deficits, xvii, 120, 275, 319, 322, 328, 350, 352
cultural, xv, xviii, xxi, 168, 185, 195, 203, 209, 210,
definition, x, 1, 15, 230, 231, 245, 285, 297, 298,
231, 234, 259, 260, 261, 262, 263, 264, 265, 266,
384, 386, 474, 482, 497
267, 270, 271, 272, 273, 274, 275, 276, 277, 278,
degradation, 215
279, 280, 284, 285, 291, 298, 340, 341, 343, 345,
degree, xiv, 3, 4, 5, 10, 14, 15, 19, 22, 46, 49, 53, 69,
353, 354, 355, 356, 357, 358, 359, 383, 417, 421,
94, 101, 192, 194, 195, 197, 200, 229, 231, 234,
423, 453, 494, 495, 513, 526, 540, 541, 542
238, 250, 254, 322, 324, 389, 401, 402, 404, 439,
cultural beliefs, 265, 271, 277
453, 454
cultural differences, 270
dehydration, 113, 340, 351
cultural factors, 231, 354
delays, xvii, 319, 320, 340
cultural heritage, 345
delinquency, 208, 252, 253, 303
cultural influence, 280
delinquent behavior, 253
 Index
delivery, 348, 349, 371, 372
delusion, 230, 519
demand, 29, 170, 188, 262, 268, 429, 452
demographic, 101, 137, 139, 198, 261, 264, 265,
287, 360, 406
demographic factors, 261
dendrites, 113
denial, 80, 484, 495
density, xv, 114, 118, 214, 216, 237, 242, 372, 531
dentate gyrus, 372, 377
dependent variable, 170, 188, 270, 390
depressed, xvii, 69, 72, 73, 75, 78, 79, 80, 81, 83,
101, 118, 151, 176, 215, 290, 319, 320, 322, 323,
324, 325, 326, 327, 330, 331, 332, 333, 335, 336,
337, 338, 342, 367, 377, 504, 510, 513, 514, 516,
520, 527
depression, xi, xvii, 45, 58, 61, 65, 67, 69, 70, 73, 74,
75, 77, 79, 80, 81, 82, 83, 84, 101, 104, 118, 125,
145, 150, 153, 171, 179, 188, 215, 216, 217, 218,
303, 319, 320, 321, 322, 323, 324, 325, 326, 327,
328, 329, 330, 331, 332, 333, 334, 335, 336, 337,
338, 342, 345, 367, 372, 377, 378, 413, 414, 452,
488, 495, 497, 498, 504, 513, 514, 517, 529, 530
depressive disorder, 82
depressive symptomatology, 328
depressive symptoms, 72, 75, 81, 83, 101, 321, 324,
326, 330, 332, 334, 335, 336, 337, 413, 500
deprivation, 115, 377
derivatives, 529
desensitization, 215
desire, xxiv, 9, 11, 20, 21, 23, 25, 26, 28, 91, 96, 97,
117, 297, 327, 343, 351, 452, 479, 511, 519, 520,
523, 524, 525, 526, 528, 530, 531, 532, 533, 534,
535, 536, 539, 540, 541, 542
desires, 20, 350, 393, 418
detachment, xxiii, 95, 161, 162, 165, 182, 493, 494,
497, 499, 501, 502, 505, 506, 507, 509, 510, 511,
512, 513
detection, 221, 238
devaluation, 73, 81, 476, 484
developed nations, 347
developing brain, 115
developmental change, 342, 478
developmental delay, 324, 343
developmental factors, 354
developmental milestones, 353
developmental process, 132, 246, 341, 407
developmental psychology, xxii, 382, 446, 471, 490,
491
deviation, 390, 423
diabetes, xviii, 339, 360
diabetes mellitus, 360
diagnostic, 66, 70, 321, 454, 475
553
Diagnostic and Statistical Manual of Mental
Disorders, 234
diagnostic criteria, 66, 321
Diagnostic Statistical Manual, 152, 176
Diamond, 473, 482, 488, 528, 534, 535, 539
diet, 101, 400, 403
differential approach, 141, 151, 175
differential treatment, 488
differentiation, 2, 40, 59, 79, 285, 372, 478, 479,
480, 495
disability, 11, 12, 13, 28, 32, 33, 336, 345, 353, 362
disabled, x, xxii, 10, 11, 13, 23, 461, 462, 463
disappointment, 8, 465, 537
disaster, 464
discipline, 209, 328, 474, 496
disclosure, 23, 25, 33, 69, 97, 407, 540
discomfort, xvi, 12, 69, 107, 281, 287, 288, 289, 290,
294, 297, 351, 455, 485, 495, 532
discontinuity, 489
discounting, 405
discourse, 463, 535, 539
discrimination, 33, 343, 356
disease activity, 323, 335, 337
diseases, x, 421, 426
disinhibition, 215
disorder, xi, 65, 66, 67, 70, 79, 83, 119, 120, 121,
126, 127, 129, 232, 235, 243, 244, 325, 326, 337,
358, 360, 361, 481, 484, 489
disposition, xiii, 7, 191, 192, 193, 204, 207, 534
disputes, 79, 83
dissatisfaction, xi, 65, 70, 84, 150
dissociation, 58, 240
distal, 261, 273, 275
distress, x, 1, 3, 4, 5, 9, 10, 17, 18, 20, 21, 23, 24, 25,
26, 27, 28, 29, 30, 66, 70, 71, 72, 75, 83, 91, 95,
96, 129, 150, 151, 152, 154, 156, 163, 167, 169,
171, 174, 175, 177, 179, 182, 184, 186, 188, 189,
231, 316, 326, 335, 345, 414, 454, 456, 473, 485,
502, 504, 511, 516, 533, 535
distribution, 113, 116, 122, 124, 235, 243, 373, 374,
376, 378, 386, 391, 414
divergence, 11
diversity, 221, 279, 366, 400, 418
division, 14, 23, 153, 179, 419, 462, 463
divorce, 52, 54, 70, 72, 73, 150, 167, 169, 171, 184,
186, 188, 304, 305, 307, 315, 316, 317, 532
divorce rates, 167, 184
dizziness, 519, 530
DNA, 536, 537
doctor, xxii, 101, 102, 323, 451, 454, 466, 467, 474
doctors, 67, 323, 329, 400
dogs, 88, 89, 90, 93, 98, 99, 100, 104, 106
DOI, 458, 468
554 Index

domestic violence, 80 educational system, 262

domestication, 89, 105, 106 educators, 354, 356, 431, 433
dominance, xiv, 117, 164, 165, 217, 219, 221 EEG, 322, 333, 523, 540
donor, 225, 227, 454 efficacy, xvi, 68, 74, 75, 76, 77, 78, 82, 105, 167,
donors, 414 184, 282, 287, 298, 310, 313, 355, 356, 357, 386,
dopamine, 113, 120, 128, 215, 238, 370, 374, 375, 395, 424, 428, 434, 444
525, 526, 530, 532, 537 egalitarianism, 472
dopaminergic, 118, 120, 215, 373 ego, 39, 40, 53, 144, 146, 147, 209, 252, 253, 454,
dreaming, 284 481, 484, 495, 496
drinking, 249, 288, 291, 351, 433 ego strength, 146
drowning, 464 egocentrism, 14, 50, 62
drug addict, 348, 529 egoism, 31
drug addiction, 348 ejaculation, 117
drug treatment, 82, 329 elaboration, 4, 27
drugs, 120, 232, 291, 524 elderly, 34, 101, 102, 105, 106, 108, 109, 412, 414
DSM, 66, 81, 84, 152, 169, 176, 186, 232, 235 elderly population, 102
DSM-II, 66, 81, 84 electrical, 227, 333
DSM-III, 66, 81, 84 electroencephalogram, 523
DSM-IV, 66, 152, 232, 235 electrophysiological, 122, 226
dualism, 383 electrophysiological study, 122
duration, 137, 156, 163, 166, 180, 183, 197, 214, elementary school, 197, 307, 396
232, 249, 250, 254, 263, 266, 270, 271, 272, 321, embryo, 223
330, 374, 455 emotion, xiv, xxiii, xxiv, 3, 7, 15, 29, 30, 73, 78, 79,
dust, 536 80, 84, 88, 92, 94, 193, 217, 218, 229, 230, 238,
duties, 12, 260 279, 314, 316, 344, 379, 493, 494, 497, 498, 500,
Dyads, xiii, 191, 202, 248 502, 504, 505, 507, 509, 511, 512, 514, 525, 526,
dysfunctional, 71, 83, 215, 217, 330 531, 533, 534, 538, 541, 542
dysphoria, 84 emotion regulation, 92, 217
dysregulated, 309, 479, 480 emotional disorder, 82, 84
dysregulation, 118, 309, 311, 322, 484, 486 emotional distress, 21, 23, 24, 25, 81, 314, 370
emotional experience, 375, 472, 478, 534
emotional health, 151, 175
E emotional intelligence, 170, 187
emotional processes, 79, 129
eating, 102, 119, 128, 221, 288, 291
emotional reactions, 304, 305, 306, 531
eating behavior, 221
emotional responses, 303
eating disorders, 119, 128
emotional stability, 39, 192, 273
ecological, xxi, 353, 383, 437, 497
emotional state, 4, 8, 11, 13, 23, 238, 341, 374, 383,
ecology, 265, 276, 359, 446
496, 519, 542
economic, xxi, 262, 264, 321, 330, 345, 347, 349,
emotional well-being, 334, 346, 412
387, 394, 427, 437, 438, 504, 514
emotionality, 18, 72, 315
economic boom, 262
emotions, xvii, xviii, xix, xxii, 2, 3, 4, 8, 11, 12, 13,
economic growth, 264
14, 16, 17, 19, 23, 24, 26, 29, 30, 34, 153, 178,
economic status, 321, 427
273, 282, 284, 286, 303, 304, 305, 306, 308, 312,
economies, 262
316, 322, 327, 339, 369, 375, 451, 452, 453, 468,
economy, 261, 264
496, 498, 512, 514, 523, 524, 526, 527, 528, 529,
ecstasy, 519
530, 533, 539
education, 26, 29, 30, 32, 104, 156, 180, 262, 264,
empathy, ix, x, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13,
269, 270, 272, 277, 287, 300, 304, 305, 307, 313,
14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,
315, 321, 325, 328, 348, 350, 351, 353, 354, 355,
27, 28, 29, 30, 31, 32, 33, 34, 192, 194, 211, 458,
356, 363, 386, 396, 418, 420, 422, 423, 424, 431,
485
432, 434, 435, 436, 452, 455, 457, 476
employers, 464, 466
educational attainment, 264, 324, 333
employment, 264, 278, 287, 343, 360
educational programs, 312
 Index 555

employment status, 264, 287 European, 126, 146, 210, 217, 235, 243, 257, 260,
empowerment, 354, 360, 361 261, 279, 300, 334, 337, 396, 421, 435, 456, 531,
encoding, 215, 265 541
endocrine, xviii, 113, 220, 369, 371, 375, 379, 412 Europeans, 261
endocrinology, ix, xiv, 122, 123, 219 euthanasia, 105
endogenous, 114, 251, 252, 253 evening, 268, 288, 290, 297
energy, 330, 464, 525, 526 evolution, xxii, 33, 88, 89, 108, 109, 122, 226, 257,
engagement, 29, 69, 279, 325, 425 258, 370, 451, 452, 532, 541
enhancement, 154, 177, 304 evolutionary, 7, 89, 112, 223, 231, 234, 238, 452,
enterprise, 537, 538 525, 535, 537
entertainment, 269 evolutionary process, 231
enuresis, 340 ewe, 114
envelope, 288 excitability, 113, 122
environment, xiv, 7, 8, 19, 23, 79, 97, 219, 220, 263, excitation, 531, 541
264, 269, 272, 277, 280, 325, 330, 334, 342, 352, excitement, 220, 529, 530
357, 440, 442, 452, 453, 472, 488, 491 exclusion, 109
environmental, xix, 97, 98, 330, 367, 369, 372, 440, excretion, 337
514 execution, 389
environmental factors, 330, 514 executive function, 352, 385
environmental influences, 367 exercise, 101, 118, 262, 340, 395, 403
environmental stimuli, 372 exocytosis, 112
enzymatic, 128, 215 exogenous, 246, 251, 252
enzyme, 119 expenditures, 90
enzymes, 128 experimental design, 441
epidemic, 321 expert, iv, 239, 468
epidemiological, 66, 150, 403, 494 expertise, 466, 468
epidemiology, 81, 235, 412, 434 experts, 456
episodic, xvi, 207, 281 exposure, 33, 67, 74, 75, 76, 79, 82, 83, 118, 119,
episodic memory, xvi, 281 121, 151, 222, 223, 225, 226, 304, 321, 325, 326,
epistemology, 462, 467 327, 333, 366, 374, 482, 496
epithelia, 221 externalization, xxiii, 493, 494, 497, 499, 501, 502,
epithelial cell, 125 505, 506, 507, 509, 510, 511, 512, 513
epithelial cells, 125 externalizing, 257, 303, 309, 323, 327, 342, 344, 361
epithelium, 221 externalizing behavior, 257, 323, 327, 342, 344
equality, 386 externalizing disorders, 303
equilibrium, 9, 453 externalizing problems, 327, 361
equipment, 94, 465 extracellular, 221
equity, 205, 383 extraction, 198, 265
EST, 223, 304, 306 extrinsic, 306, 386
estimating, xxiii, 32, 69, 247, 493 extrinsic motivation, 386
estrogen, 114, 118, 121, 127, 128, 537 extrovert, 267
estrogen, 123, 376 eye, 82, 273, 419, 496
estrogens, 223 eye contact, 273, 496
ethanol, 120, 128 eye movement, 82
ethical, xxii, 287, 388, 434, 461, 475, 486 eyes, 49, 268, 352
ethics, 462
ethnic groups, 424, 524
ethnic minority, xxi, 156, 180, 417, 421 F
ethnicity, 435
face-to-face interaction, xvi, 259, 261, 266, 275, 348
etiology, 8, 316, 327, 413
facial expression, 82, 495
euphoria, 524, 525, 529
factor analysis, 198
factorial, 199, 202
failure, 7, 94, 97, 316, 323, 347, 402, 454
556 Index

failure to thrive, 323 films, 290, 291

fairness, 14 first principles, 538
faith, 62 first-time, 278, 332
false, 537 fitness, 226, 227, 452
familial, xviii, 37, 73, 115, 194, 207, 339, 341, 358, flexibility, 254, 356, 385, 393, 395, 454
407, 411 flood, 525
family conflict, 304, 313, 316, 342 flow, 423
family environment, 300, 454 fluctuations, 6, 15, 19, 224
family factors, 314, 335, 353, 354 fluid, 120, 125, 143
family functioning, ix, xi, xviii, 65, 68, 71, 72, 76, fluid balance, 120
339, 341, 343, 344, 345, 357, 358, 359, 361, 362, fluoxetine, 235, 240
462 fMRI, 374, 379, 395, 480, 524, 525, 526, 527, 528,
family history, 218, 234, 239 539
family interactions, 74, 80 focus group, xxi, 353, 362, 417, 418, 422, 423, 425,
family life, 194 430, 432, 433, 434, 435, 444, 463
family members, 12, 28, 47, 71, 73, 88, 99, 246, 247, focus groups, xxi, 353, 362, 417, 418, 422, 423, 432,
257, 262, 269, 272, 309, 313, 321, 325, 345, 353, 433, 435, 463
354, 355, 357, 358, 409, 411, 424, 428, 431, 455, focusing, xvii, 10, 101, 192, 195, 275, 305, 319, 320,
466, 503 321, 322, 327, 328, 330, 375, 495, 525
family physician, 337 folklore, 523
family relationships, xvii, 210, 269, 303, 304, 308, follicular, 222
314, 316, 354, 368, 419 food, xiv, 89, 115, 127, 217, 219, 220
family structure, 262, 277 food intake, 127
family studies, 153, 177 football, 5, 291
family support, 342, 514 Ford, 37, 59, 101, 108
family system, 208, 305, 312, 313, 344 forebrain, 123, 378, 379
family therapy, 76, 79 forgetting, 482
farming, 264 forgiveness, ix, xiii, 106, 191, 192, 193, 194, 195,
fatalistic, 421 196, 198, 199, 200, 202, 203, 204, 205, 206, 207,
fatigue, 66, 286, 465, 477 208, 209, 210, 211, 285
fatty acids, 227 formal education, 197
faults, 91 foster mothers, 481
fear, xi, 7, 34, 87, 88, 91, 97, 114, 116, 118, 119, Fox, 334, 366, 368
233, 303, 304, 325, 331, 346, 386, 420, 421, 427, fractal dimension, 523
428, 453, 455, 477, 484, 494, 495, 511, 524, 526, fragmentation, 40, 454
529, 530, 532, 533 fraternal twins, 535
fear response, 119 free choice, 285, 289
fears, 91, 97, 214, 453, 482, 520 freedom, 231, 234, 239, 429, 464
fee, 475, 476, 536 freedom of choice, 464
feedback, 48, 103, 167, 184, 253 frequency distribution, 409
feeding, 115, 119, 268, 269, 274, 371, 488 Freud, 193, 209, 230, 382, 472, 473, 474, 478, 480,
feet, 292 481, 483, 488, 489, 495, 496, 515, 531, 540
females, xii, xiii, 66, 116, 117, 118, 131, 132, 133, Friedmann, 225
134, 135, 139, 140, 141, 142, 143, 191, 194, 205, friendship, xvi, 37, 91, 132, 136, 137, 139, 146, 153,
220, 222, 227, 239, 252, 253, 344, 346, 370, 371, 166, 178, 184, 246, 247, 249, 250, 251, 253, 254,
442, 443, 444, 445 255, 276, 281, 282, 286, 297, 298, 299, 300, 301,
femininity, 476 374, 411
fertility, 222, 455 frontal cortex, 385
fetal, 121 frustration, 343, 349, 452
fetus, 333 fulfillment, 39, 61, 96, 418, 519
fever, 113, 340, 347 functional aspects, 400
fidelity, 146, 230, 231, 232, 239, 242, 540, 542
film, 18, 33, 292, 389
 Index 557

glycerol, 113
G glycoprotein, 112
glycosylation, 112
G protein, 113, 221
goals, xvi, 9, 11, 36, 41, 46, 97, 101, 193, 259, 260,
GABA, 370, 372, 377
263, 265, 269, 271, 272, 274, 275, 277, 278, 279,
games, 288, 289, 291, 308
280, 286, 304, 314, 331, 482, 486
gauge, 348, 358
God, 88, 107, 261, 419, 528
GDP, 262
gold, 536
gel, 428
goodness of fit, 387, 501
gender, ix, xii, xxi, 28, 70, 107, 117, 131, 134, 135,
Gore, 42, 59
138, 139, 141, 142, 144, 145, 146, 194, 195, 199,
goslings, 103
200, 202, 203, 206, 211, 222, 231, 232, 233, 238,
gossip, 455
240, 241, 253, 270, 287, 289, 290, 292, 297, 324,
government, iv
346, 370, 378, 388, 391, 411, 431, 435, 437, 441,
G-protein, 221
442, 443, 444, 445, 452, 454, 475, 476
graduate students, 525
gender differences, xii, 131, 134, 135, 139, 141, 142,
grain, 89
144, 146, 287, 290, 292, 411
granules, 122
gender role, xxi, 437, 441, 444, 445
Greenhouse, 202
gene, xiv, 42, 45, 113, 121, 129, 213, 215, 217, 372,
greening, 255
373, 375, 378, 379
grief, 95, 108, 109, 468, 522, 528, 532
gene expression, 113, 372, 378
group identity, 25, 29
gene transfer, 378
group involvement, 311
general education, 422
group membership, 10, 17, 311
general practitioner, 465
group size, 422
generalizability, 156, 166, 179, 183, 204, 206
group work, 360
generalization, 144
groups, xvii, xix, 21, 25, 29, 33, 143, 196, 232, 233,
generalizations, 42, 45
234, 240, 241, 242, 249, 250, 254, 256, 263, 264,
generalized anxiety disorder, ix, 65, 66, 67, 78, 79,
270, 271, 272, 273, 276, 279, 303, 308, 310, 311,
80, 81, 82, 83, 84, 85
312, 313, 314, 316, 319, 326, 342, 345, 346, 347,
generation, 83, 84, 113, 200, 277, 298, 431
356, 357, 375, 381, 384, 388, 418, 421, 422, 423,
genes, 81, 129, 221, 222, 330, 340, 375, 387
424, 425, 426, 427, 429, 430, 432, 433, 456, 468,
genetic, xviii, 72, 120, 121, 192, 206, 216, 222, 327,
532, 536
328, 330, 340, 345, 361, 365, 370, 375, 387, 394,
growth, 7, 120, 147, 323, 336, 337, 340, 346, 378,
454, 532
397, 452, 455
genetic disease, 454
guardian, 90
genetic endowment, xviii, 365
guidance, 328, 352, 452, 473
genetic factors, 192, 330
guidelines, 347, 353, 354, 355, 359, 447, 472
genetic linkage, 330
guilt, xxiii, 32, 104, 328, 338, 343, 344, 476, 493,
genetic load, 120, 375
494, 495, 496, 497, 498, 499, 501, 502, 503, 504,
genetic screening, 361
505, 507, 509, 510, 511, 512, 513, 514, 515, 516,
genetics, 209, 217, 330
526
gestation, 113, 371
guilty, 328
gestures, 11
gyrus, 222, 524
GFI, 501, 504, 505, 507
gift, 135, 240, 418
girls, xvi, 264, 281, 282, 283, 284, 287, 288, 292, H
297, 344, 388, 391, 413, 419, 421, 424, 425, 426,
427, 428, 429, 430, 431, 432, 433, 442, 443, 444 handicapped, 23, 34
gland, 112 handling, 343
glasses, 503 hands, 153, 178, 266, 425, 465, 530
globus, 114, 374 hanging, 400
glucocorticoids, 114, 118 haplotypes, 121
glutamate, 372, 377 happiness, xx, 51, 77, 150, 151, 174, 272, 329, 399,
glutamatergic, 373 533
558 Index

hardships, 345 HIV/AIDS, vii, x, xx, xxi, 30, 363, 402, 403, 412,
harm, 260, 279, 401 415, 417, 418, 420, 421, 426, 427, 428, 431, 432,
harmful, 426 433, 434, 437, 438, 439, 440, 441, 442, 443, 444,
harmony, 260, 279 445, 446, 447, 448, 449, 450
hate, 504, 530, 531, 533 homeostasis, 112, 472
head, 292, 327, 519, 523, 531, 538, 542 homes, 288, 292, 303
Head Start, 335 homogeneity, 256, 270, 404
healing, xxii, 349, 451, 512, 514 homogeneous, 388, 526
health care, 33, 83, 167, 185, 265, 345, 346, 347, homogenized, 240
348, 349, 350, 353, 354, 355, 356, 357, 358, 435, homosexuality, 419, 423, 430
439, 454, 463, 464, 466, 467, 468 homosexuals, 418, 421, 430
health care professionals, 346, 357, 454, 463, 464, honesty, 272, 347, 454
466, 467, 468 Hops, 73, 78, 80
health care system, 347 horizon, 298
health education, xxi, 417, 418, 434 hormone, 112, 114, 115, 120, 221
health effects, 367, 411 hormones, xiv, 113, 114, 120, 126, 128, 219, 222,
health problems, 355 227, 370, 530
health psychology, 434 hospice, 105
health status, 402, 452 hospital, 20, 349, 356, 357, 361, 403, 466, 503
healthcare, xxii, 66, 461, 462, 463 hospital care, 361
heart, 19, 100, 101, 113, 114, 322, 336, 347, 349, hospitalization, 347, 348, 453, 454
403, 406, 408, 413, 503, 522, 528, 530, 540 hospitalizations, 347
heart disease, 403, 406 hospitalized, 102, 107, 463, 466
heart rate, 19, 100, 322, 336, 406, 408, 413 hospitals, 323, 454, 466
heavy smoking, 4 host, 534, 536
hedonic, 77 hostility, 45, 69, 73, 74, 76, 165, 182, 325, 538
height, 323, 348 household, 197, 342, 345, 476
helping behavior, 13, 20, 25, 27 household income, 197
helplessness, 92, 453, 522 households, 90, 262
hemoglobin (Hb), 340 housing, 265
hemorrhage, 113 HPA, 118, 371
heroin, 529 HPA axis, 118
heterogeneity, 272, 278 human actions, 284
heterogeneous, 154, 178, 234, 238, 388 human behavior, 21, 33, 89, 224, 257, 439
heterosexuals, 418, 420, 435 human brain, 114, 129, 226, 374, 379
heterozygosity, 227 human cognition, 88
heuristic, 50, 63, 93, 260 human condition, 286, 535
high risk, xxii, 150, 174, 356, 432, 451, 452, 454 human development, 104, 277, 278, 279, 280, 359,
high school, xvi, 167, 184, 197, 281, 287, 296, 321, 446
324, 342, 431, 435, 447 human experience, xi, 87, 88, 479
high school degree, 197 human motivation, 255, 284
higher education, 262 human nature, 387
high-risk, x, 167, 184, 333, 335, 418, 432, 433 human psychology, ix, xi, 87, 88, 90
high-risk populations, 167, 184 human rights, 349
high-tech, 524 humans, ix, xiv, xviii, 88, 89, 90, 91, 93, 94, 95, 96,
hip, 14, 26, 70, 88, 383, 413, 503 98, 100, 101, 102, 103, 113, 114, 115, 116, 117,
hippocampal, 372, 377 124, 219, 220, 221, 222, 224, 225, 226, 227, 369,
hippocampus, 113, 215, 372, 377 371, 374
hips, xx, 399, 404, 407, 409 humiliation, 104
Hispanic, 156, 171, 180, 189, 262, 272, 280, 446, hunting, 89, 532
448 husband, 69, 75, 80, 162, 180, 208
HIV infection, xxi, 437, 438, 448, 450 hydrochloric acid, 529
hyperactivity, 120, 128, 325, 326
 Index 559

hypersensitivity, 91 in situ, 366, 379, 483

hypertension, 414, 415, 416 in vivo, 79
hypnosis, 107 incentive, 288, 388
hypogonadism, 121 incidence, 119, 273, 326, 403, 415, 455
hypothalamic, 113, 118, 129, 371, 401 inclusion, xxi, 76, 307, 355, 437, 440
hypothalamic-pituitary-adrenal axis, 118 income, 156, 180
hypothalamus, xi, 111, 112, 113, 115, 121, 123, 125, increased access, 56
215, 221, 222, 371, 374, 376 incubation, 240
hypothesis, xii, xiii, xix, 8, 22, 36, 42, 107, 111, 116, incurable, 522
119, 126, 131, 141, 171, 189, 194, 196, 199, 203, independence, 43, 153, 179, 246, 254, 256, 260, 261,
205, 206, 213, 214, 287, 297, 315, 373, 381, 383, 263, 271, 272, 275
384, 388, 392, 401, 402, 405, 408, 412, 413, 415, independent variable, 390
498, 499, 501, 512, 535 Indian, 214, 340, 519
hypothesis test, 199 indication, 10, 22, 432
indicators, xvi, 37, 39, 47, 155, 157, 163, 179, 263,
281, 285, 286, 287, 292, 297, 389, 455, 536
I indices, 19, 158, 181, 321, 322
indirect measure, 19
IBM, 243
individual development, 254, 382
ice, 291, 423
individual differences, 5, 6, 30, 40, 43, 52, 53, 59,
id, 209
160, 161, 162, 165, 182, 208, 406, 411, 516
idealization, 53, 333
individualism, 260, 261, 263, 271, 272, 273, 274,
identification, 10, 27, 195, 242, 329, 411, 476, 483
279, 280
identity, ix, xii, xiii, xxii, 3, 4, 5, 7, 9, 10, 26, 28, 31,
individuality, 205
32, 131, 132, 133, 134, 136, 138, 139, 140, 141,
Individuals with Disabilities Education Act (IDEA),
142, 143, 144, 145, 146, 147, 191, 194, 207, 208,
352
273, 283, 284, 285, 287, 298, 307, 341, 400, 402,
induction, 119, 376
415, 419, 438, 452, 454, 461, 462, 463, 464, 465,
industrial, 260, 262, 264
466, 467, 468, 497
industrialized societies, xv, 259
identity achievement, 133, 143
industry, 90, 104, 261
idiographic approach, 195
ineffectiveness, 383
idiosyncratic, 476
infancy, xvii, 62, 105, 260, 262, 319, 320, 322, 324,
illiteracy, 262
333, 335, 370, 383, 418, 476, 489, 490, 491, 532,
illusion, 62
537
illusions, 45, 57, 59, 60, 62, 170, 187
infant care, 279
imagery, 67, 523, 524
infant mortality rate, 262
images, 49, 50, 480, 523, 524, 528
infants, xv, xvii, 92, 94, 95, 97, 114, 115, 116, 118,
imaging, 222, 370, 523, 538
259, 260, 261, 262, 263, 264, 265, 266, 267, 268,
immigrant mothers, 279
269, 270, 271, 272, 273, 275, 276, 279, 314, 319,
immigrants, 422, 434, 435
320, 321, 322, 323, 326, 327, 331, 332, 333, 336,
immobilization, 118
337, 370, 476, 478, 481, 488, 531
immune function, 412
infection, xx, 340, 347, 417, 420, 432
immune system, 412
infections, 427, 432, 433, 438
immunity, 421
infectious, 412
immunochemistry, 379
infectious diseases, 412
immunocompetence, 222, 226
infertility, 452
immunological, 222
inflammation, 412
immunomarkers, 222
inflammatory, 412, 415
immunoreactivity, 120, 129
inflammatory disease, 415
implementation, xxi, 149, 174, 306, 354, 438
information processing, 55, 56, 69, 108, 359
impotence, 453
informed consent, 265, 287, 388
imprinting, 103, 371, 376
inheritance, 387
impulsive, xiv, 213, 215, 285, 486
inherited, 194, 340, 343
impulsivity, 215, 225
560 Index

inhibition, 114, 117, 127, 225, 306, 322, 511, 541 internalised, 284
inhibitor, 374 internalization, 193, 194, 196, 205, 206, 209
inhibitors, xiii, 67, 213, 230, 529, 530 internalizing, 309, 323, 325, 335, 342, 344, 361
inhibitory, 113, 215, 385, 395, 541 international, 25, 26, 277, 458
initiation, 91, 114, 153, 178, 208, 246, 249, 250, 254, internet, 409, 431, 452, 457, 524, 542
371, 542 interparental conflict, 305, 307, 308, 309, 313, 314,
injection, 114, 115, 117, 119, 371, 372, 526 315
injuries, 323, 336 interpersonal communication, x, 1, 33
injury, iv, 323, 331, 336, 477, 486, 502, 503 interpersonal conflict, 25
inmates, 108 interpersonal interactions, 8, 10, 17, 18, 19, 68, 74
inositol, 113, 221 interpersonal relations, ix, x, xi, xxiii, 1, 14, 15, 26,
insects, xiv, 219, 220 29, 35, 54, 88, 90, 93, 103, 104, 107, 224, 227,
insecurity, 40, 476 260, 273, 411, 493, 494
insight, xxi, xxii, 13, 142, 234, 238, 265, 421, 437, interpersonal relationships, ix, x, xi, xxiii, 1, 15, 29,
451, 479 35, 54, 88, 90, 93, 103, 104, 224, 227, 260, 273,
insomnia, 488 411, 493, 494
inspiration, 103 interpersonal skills, 75, 263
instability, 194, 207, 330 interpretation, 24, 31, 99, 247, 298, 313, 357, 419,
institutions, 262, 464, 466 425, 462, 463, 468, 478, 479, 486, 510, 528
instruction, 389 interrelatedness, xv, 259
instruments, xv, xxiii, 237, 239, 240, 243, 244, 286, interrelations, xxiii, 472
288, 388, 472 intervention, xiii, xviii, xx, 57, 75, 76, 101, 154, 167,
insulin, 128, 360 169, 173, 177, 184, 186, 304, 308, 313, 316, 331,
insurance, 90, 464, 465 332, 340, 341, 353, 354, 355, 356, 358, 360, 362,
insurance companies, 90 382, 410, 413, 440, 448, 450, 475, 486, 488
intangible, 88 intervention strategies, 353, 356
integration, 3, 4, 36, 93, 103, 133, 384, 401, 402, interview, xii, xiii, 149, 152, 154, 155, 158, 161,
412, 435, 458, 484, 485, 486, 487 163, 166, 167, 169, 170, 173, 174, 176, 177, 179,
integrity, 286, 287 180, 182, 183, 184, 186, 187, 188, 234, 239, 243,
intellectual development, 337 265, 423, 463
intellectual functioning, 362 interviews, xii, 149, 150, 152, 153, 155, 156, 157,
intelligence, 18, 383, 396, 397, 536 174, 175, 176, 177, 180, 265, 286, 321, 423, 454,
intensity, 15, 117, 136, 139, 140, 230, 238, 348, 374, 455, 463, 525, 527
472, 502, 510, 511, 529, 531 intimacy, ix, xii, xiii, 77, 92, 131, 132, 133, 134,
intentions, xxi, 9, 13, 192, 206, 230, 284, 384, 437, 136, 137, 138, 139, 140, 141, 142, 143, 145, 146,
439, 442, 445, 446, 447, 448, 449, 480, 524 147, 149, 150, 152, 153, 154, 155, 165, 170, 173,
interaction, vi, vii, 158, 160, 161, 181, 208, 259, 300, 174, 175, 176, 177, 178, 187, 192, 194, 246, 282,
381 297, 301, 407, 409, 452, 535, 540
interaction effect, 202, 250, 254 intoxication, 249, 519
interactivity, 7 intrinsic, 96, 122, 272, 386, 387, 468, 478
interdependence, xv, xvi, 9, 30, 42, 43, 44, 58, 90, intrinsic motivation, 272, 386
103, 107, 146, 153, 178, 193, 245, 246, 247, 250, intrinsic value, 468
254, 255, 256, 257, 259, 260, 261, 271, 273, 275, introspection, 512
477 invasive, 114
interdependence theory, 103 inventories, 151, 496
interdependent self-construal, 59 investment, 3, 146, 483
interference, xiv, 97, 219, 222, 231, 234, 240, 405, investment bank, 3
408, 452, 456, 539 investment model, 146
intergenerational, 193, 194, 205, 206, 211 irritability, xvii, 66, 272, 319, 320
intermediaries, 261 Islam, 418, 419, 425, 430, 431, 433, 434
internal consistency, xii, 149, 174, 310 Islamic, 418, 419, 420, 423, 434
internal working models, 36, 42, 44, 63, 477, 482, island, 89
484, 487 isolation, 116, 372, 377, 402, 440, 454
 Index 561

Italian population, 274 learning disabilities, 350

Italy, xv, xvi, 111, 191, 197, 219, 229, 237, 244, 259, leisure, xvi, 166, 184, 281, 286, 287, 288, 292, 296,
261, 262, 264, 272, 276, 277, 279, 280, 281, 287, 297, 298
369, 381, 395, 396, 397, 451 leisure time, 166, 184, 287, 288, 292, 296, 297, 298
item response theory, 106, 169, 186 lending, 165
lesions, 115, 122, 371, 376
leukemia, 8, 452, 454, 456
J lexical decision, 95
libido, 480, 530
jobs, 526, 537
life course, 208, 283, 300
joints, 297
life expectancy, 340
judge, 47, 64, 495
life experiences, 2, 4, 5, 7
judgment, xxii, 60, 297, 329, 451, 495, 514
life span, 282
justification, xx, 149, 174, 400
life stressors, 337
lifespan, 341, 347, 440
K lifestyle, 350
lifestyles, 526
Kaiser Family Foundation, 457 life-threatening, 13
kidney, 112, 114 lifetime, 66, 242, 243, 326, 335, 443
kindergarten, 269, 351, 383 ligands, 221
kinetics, 218 likelihood, 26, 52, 70, 72, 74, 117, 206, 342, 366,
King, 154, 169, 177, 186, 473, 490, 521, 522 392, 414, 423, 443, 486
knees, 5, 530 Likert scale, 136, 137, 231, 239, 289
knockout, 373 limitation, xxi, 37, 39, 134, 233, 242, 313, 320, 437,
440
limitations, xvi, 9, 101, 150, 154, 176, 178, 273, 282,
L 297, 298, 313, 314, 329, 330, 346, 394, 513
Lincoln, 123, 378, 463, 468, 539
labeling, 308 linear, xix, 199, 202, 250, 252, 310, 311, 314, 381
labor, 115, 263, 268 linear model, 199, 202, 250, 310, 311, 314
labor force, 263 linear modeling, 250, 310
laboratory studies, 224, 379 linguistic, 29, 324, 325, 463, 479, 486
labour, xi, 111, 112 linguistically, 17, 29
lactating, 118, 122 linkage, 221
lactation, xi, 111, 112, 114, 115, 118, 125, 370, 376 links, 39, 45, 57, 144, 253, 375, 403, 412, 416, 442
language, xix, 89, 265, 324, 325, 354, 369, 422, 478, lipid, 227
479, 480, 483, 510, 539, 541 listening, 9, 29, 153, 178, 288, 291, 374, 425, 454,
language acquisition, 479 456, 462, 468, 473, 485, 514
language development, 324 literacy, 262
large-scale, 262 literature, xiii, xx, 31, 36, 41, 44, 57, 72, 73, 76, 99,
Latin America, 260, 262, 438 100, 103, 133, 146, 152, 153, 154, 155, 177, 178,
Latin American countries, 438 192, 194, 196, 204, 213, 214, 238, 246, 250, 277,
Latino, 171, 189, 272, 277, 278, 448, 450 320, 321, 324, 325, 327, 329, 330, 331, 336, 341,
law, 287, 299, 388, 419, 522 343, 344, 345, 357, 359, 393, 399, 400, 404, 420,
laws, 403 423, 428, 434, 439, 440, 442, 444, 446, 454, 463,
lead, x, xxii, 1, 14, 21, 23, 25, 56, 57, 96, 112, 114, 474, 480, 500, 533
116, 117, 132, 134, 143, 154, 166, 178, 183, 214, living arrangements, 91
220, 230, 242, 251, 284, 294, 305, 306, 324, 340, living environment, 476
366, 372, 382, 384, 386, 405, 418, 419, 426, 461, localization, 122
462, 494, 513 location, 89, 227, 262
leadership, 344 locomotion, 370
learning, xiv, 7, 89, 100, 117, 120, 123, 219, 220, locus, 214, 216, 217, 343, 357, 358, 376
306, 313, 327, 350, 352, 370, 371, 376, 384, 386, locus coeruleus, 376
481, 529
562 Index

loneliness, 91, 101, 104, 105, 106, 132, 453, 529, mammalian, 225
532 mammals, xi, xiv, 89, 111, 112, 114, 123, 125, 219,
long distance, 351 221, 370, 371, 372, 378
long period, 366 management, x, xii, xiii, 2, 11, 14, 15, 16, 17, 32, 67,
longevity, 109, 414, 416 149, 150, 151, 152, 153, 158, 162, 165, 167, 173,
longitudinal studies, 57, 208, 323, 326, 489 174, 175, 176, 178, 181, 185, 333, 344, 348, 354,
longitudinal study, 11, 52, 101, 107, 108, 170, 187, 356, 359, 468
208, 210, 235, 243, 278, 395, 396, 491, 515 mania, xiv, 70, 213, 215, 526
long-term, 13, 21, 77, 99, 104, 133, 141, 322, 342, manic, 216
343, 344, 371, 372, 385, 412, 452, 454, 456, 458, manipulation, 372
525 manners, 269, 272, 331
loss of appetite, 525 MANOVA, 139, 390, 391, 392
loss of control, 66, 433 MAO, 529
losses, 528 mapping, 93
love, ix, xiii, xxiv, 5, 48, 51, 56, 58, 60, 62, 63, 90, marijuana, 529
96, 100, 104, 106, 114, 123, 126, 146, 153, 178, marital conflict, xvii, 169, 186, 194, 303, 304, 305,
213, 214, 215, 216, 217, 235, 238, 242, 243, 267, 306, 307, 308, 310, 311, 312, 313, 314, 315, 316,
374, 375, 379, 380, 396, 403, 419, 425, 426, 428, 317
431, 454, 472, 473, 489, 519, 520, 521, 522, 523, marital discord, xvii, 77, 83, 305, 306, 307, 312, 314,
524, 525, 526, 527, 528, 529, 530, 531, 533, 319, 320, 330
534, 535, 536, 537, 538, 539, 540, 541, 542, 543 marital distress, 69, 70, 71, 72, 75, 80, 155, 316
lover, 525, 530 marital quality, 60, 81, 82, 169, 170, 171, 186, 187,
low risk, 427 188, 192, 210
low-income, 355, 448 marital status, 264, 321, 330, 400
loyalty, 272 market, 268
LSD, 529 marketing, 90
lung, 3, 4, 8, 101 Markov, 251, 254
lung cancer, 3, 4, 8 Markov chain, 251
lungs, 426 Markov process, 254
luteinizing hormone, 227, 530 marriage, 45, 54, 60, 61, 63, 68, 70, 76, 80, 84, 151,
lying, 283 156, 161, 165, 166, 167, 168, 169, 170, 171, 176,
180, 183, 184, 185, 186, 187, 189, 194, 197, 207,
208, 209, 214, 262, 400, 411, 415, 416, 419, 420,
M 421, 429, 430, 431, 455, 522, 532, 535
marriages, 51, 60, 169, 186, 317, 403
magnetic, 9, 116, 359, 480, 524
married couples, xiii, 48, 156, 163, 173, 179, 180,
magnetic resonance, 9, 116, 359, 480
193, 209, 254, 304, 308, 535
magnetic resonance imaging, 9, 359, 480
married women, 75, 84
mainstream, 275, 423
marrow, 347
maintenance, xx, 45, 82, 90, 94, 95, 114, 115, 119,
Marx, 106
143, 146, 205, 209, 282, 347, 350, 400, 409, 410,
masculinity, 444
413, 475, 494, 525
mass media, 432
maintenance, 409
mastery, 284, 386
major depression, xi, 65, 81, 84, 118, 125, 126, 242,
maternal, xvi, xvii, xix, 114, 115, 117, 118, 119, 123,
243, 335, 337, 376
195, 206, 211, 259, 263, 264, 265, 266, 267, 270,
major depressive disorder, 72, 81, 326, 332
271, 273, 274, 278, 319, 320, 321, 322, 323, 324,
major histocompatibility complex, 222
325, 326, 327, 328, 329, 330, 331, 332, 333, 334,
maladaptive, 40, 57, 355, 357, 385, 479, 498, 512
335, 336, 337, 362, 369, 370, 371, 373, 375, 376,
males, xii, xiii, 66, 116, 117, 131, 132, 133, 134,
377, 476, 483, 538
135, 139, 141, 142, 191, 194, 205, 220, 222, 226,
maternal care, 114, 118, 123, 370, 371
239, 252, 253, 346, 370, 418, 442, 443, 444
maternal mood, 324
malignancy, 454
maternal support, 211
malnutrition, 120
mathematical, 169, 186
mammal, 370
 Index 563

mathematicians, 387 mental representation, 35, 41, 56, 58, 62, 108, 473,
mathematics, 169, 186 474, 476
matrix, 168, 185 mental retardation, 121
maturation, 2, 5, 7, 23, 223 mental state, 116, 375, 383
MCA, 421, 434, 435 mental states, 383
meanings, 284, 285, 286, 299, 397, 424, 475, 535 messages, 13, 15, 23, 24, 25, 30, 31, 32, 411, 415
measurement, 17, 18, 19, 20, 31, 137, 154, 169, 170, messenger ribonucleic acid, 122
171, 178, 186, 188, 241, 246, 250, 251, 255, 322, messengers, 526
377, 413 meta analysis, 75
measures, xiii, 7, 17, 18, 19, 30, 48, 55, 67, 93, 106, meta-analysis, 67, 80, 420, 435, 446, 447, 448, 489,
121, 136, 137, 139, 140, 149, 150, 151, 154, 156, 491
158, 161, 162, 163, 165, 169, 170, 174, 175, 176, metabolism, 123
178, 179, 180, 181, 182, 186, 187, 188, 198, 199, metabolites, 216
200, 202, 246, 247, 250, 308, 310, 311, 313, 322, metacognitive, 286, 293, 297
324, 326, 328, 330, 351, 367, 401, 402, 403, 409, metaphor, xxii, 471, 472, 474, 478, 480, 486
412, 455, 531 metaphors, xxii, 463, 471, 472
media, x, 1, 18, 19, 28, 308, 426, 429, 449, 536 metropolitan area, 262
medial prefrontal cortex, 10 Mexican, vii, x, xxi, 280, 437, 438, 439, 440, 441,
median, 113, 122, 136, 287, 340 442, 445, 447, 448
mediation, 30 Mexico, xxi, 437, 438, 439, 440, 444, 445, 446, 447,
mediators, 305, 372, 446 448, 449, 450
medical care, 323, 347 MHC, 222, 226, 227
medical school, 516 mice, 118, 120, 128, 373, 378, 379
medical student, 238 microdialysis, 376
medication, 214, 323, 348 microinjection, 126
medications, xi, 65, 67 microsystem, xxi, 437, 440, 442
medicine, xxii, 123, 124, 360, 435, 451, 457 midbrain, 122, 214
meditation, 218 middle class, 167, 184, 363
Medline, xix, 369, 440 middle-aged, 415
membranes, 240, 531 middle-class families, 261, 271
memory, xix, xxii, 99, 117, 119, 124, 127, 151, 176, midlife, 416
225, 284, 369, 370, 371, 373, 376, 451, 477, 487, migrant, 277, 418, 435
489 migrants, 435
memory biases, 151, 176 migration, 262, 372
memory retrieval, 119 military, 456
men, 66, 70, 72, 75, 80, 96, 117, 124, 156, 163, 166, milk, 103, 112, 123, 268, 475
179, 182, 183, 197, 199, 200, 201, 202, 203, 204, mining, 261
205, 211, 217, 222, 223, 224, 225, 226, 227, 231, minorities, 418, 423
232, 238, 406, 409, 410, 411, 415, 418, 419, 421, minority, xviii, 275, 279, 339, 341, 357
447, 499, 519, 522, 523, 524, 525, 526, 527, 528, minority groups, xviii, 275, 339, 341, 357
530, 531, 532, 533, 535, 536, 537, 540 mirror, ix, 278
menstrual, 222, 223, 225, 227 misconceptions, 350, 356, 420, 421, 426
menstrual cycle, 222, 223, 225, 227 misunderstanding, 466
mental activity, 524 mitral, 371
mental arithmetic, 100 mixing, 394
mental disorder, ix, xii, 77, 82, 111, 335, 455, 495, modalities, xi, xvi, 65, 76, 281, 347, 387
513 model specification, 247
mental health, ix, x, xxiii, 59, 64, 67, 82, 207, 277, modeling, 39, 105, 169, 170, 186, 187, 207, 247,
326, 329, 331, 333, 334, 335, 357, 367, 401, 416, 248, 250, 251, 252, 253, 254, 257, 325, 327, 344
493, 494, 497, 513, 516 models, xiii, xv, xxiii, 35, 36, 37, 39, 40, 42, 43, 44,
mental illness, 326, 331, 332, 338 45, 55, 58, 59, 60, 61, 62, 63, 77, 99, 105, 145,
mental model, 59 191, 194, 195, 196, 203, 204, 206, 207, 245, 246,
mental processes, 224 247, 250, 251, 253, 254, 255, 257, 258, 260, 261,
564 Index

278, 280, 282, 310, 311, 353, 371, 372, 401, 402, mouth, 428
412, 413, 414, 439, 446, 447, 471, 482, 533 mRNA, 118, 372
moderates, 541 MSI, 151, 158, 160, 163, 164, 165, 175, 181
moderators, 104, 105, 206, 253, 254, 279, 446 multicultural, 275, 278, 429
modern society, 231, 256 multidimensional, x, xiii, 2, 4, 17, 20, 28, 30, 150,
modulation, 117, 121, 222, 327, 372, 376, 379, 480 151, 152, 173, 175, 176, 185, 410
modules, 253 multidisciplinary, 155, 349, 353, 354, 358, 439, 450
modus operandi, 390 multiple factors, 322, 328
molecular weight, 221 multiple regression analysis, 125
molecules, 214, 220 multiple sclerosis, 468
money, 90, 153, 155, 179, 290, 344, 400, 428, 475, multivariate, 139, 270, 280, 310, 392
504, 537 multivariate distribution, 270
monkeys, 122, 370, 374, 375 multivariate statistics, 280
monoamine, 529 murder, 230
monoamine oxidase, 529 muscle, 66
mood, ix, xiv, 82, 116, 151, 168, 176, 185, 218, 219, music, 288, 291, 292, 297
220, 222, 223, 224, 225, 226, 227, 232, 238, 239, Muslim, 419, 420, 428, 429, 435
241, 242, 243, 286, 323, 327, 337, 360, 377, 499, mutual respect, 347
500, 516, 529 mutuality, 155
mood change, 225 myocardial infarction, 106, 403, 412
mood disorder, 82, 232, 238, 239, 377
moral behavior, 497
moral development, 515 N
morality, 462, 497
NaCl, 240
morals, 272
naming, 324
moratorium, 136, 139, 140, 141, 142
narcissism, 60, 516
morbidity, xx, 81, 337, 399, 403, 404, 407, 410
narcissistic, 53, 484, 486, 489, 496, 513, 516
morning, 268, 426, 481
narcissistic personality disorder, 484, 489
Morocco, 418, 419, 421, 427, 431, 432, 434, 435
narcotic, 348
morphine, 120, 122, 529
narcotics, 348, 529
morphology, 372
narratives, xxii, 276, 283, 284, 286, 290, 292, 298,
morphometric, 120
458, 461, 462, 463, 464, 466, 467
mortality, xx, 323, 336, 399, 402, 403, 404, 407,
National Academy of Sciences, 123, 235, 243
410, 412, 413, 414
National Institutes of Health, 361, 457
mortality rate, 402, 403
national origin, 272
mortality risk, 402, 403
nationality, 455
motherhood, 329, 333, 491
natural, 11, 88, 116, 323, 389, 407, 414, 423, 429,
mothers, xiii, xv, xvii, 103, 119, 191, 195, 197, 198,
456, 463, 513, 514, 532, 537
199, 200, 202, 205, 206, 210, 255, 259, 262, 263,
natural environment, 407, 414
264, 265, 266, 267, 268, 269, 270, 271, 272, 273,
NBC, 88
275, 276, 277, 278, 279, 305, 307, 309, 315, 319,
NCS, 66
320, 321, 322, 323, 324, 325, 326, 327, 328, 329,
negative affectivity, 516
330, 331, 332, 333, 334, 335, 336, 338, 366, 368,
negative attitudes, 73, 430, 444
374, 379, 442, 478, 481
negative consequences, 40, 314, 330, 366
moths, 220
negative emotions, 29, 153, 155, 178, 322, 512
motion, 486
negative life events, xxiii, 408, 493
motivation, xix, 11, 20, 21, 24, 25, 26, 27, 30, 49, 97,
negative mood, 342
115, 279, 370, 378, 526, 538
negative outcomes, 305, 322, 331
motives, x, 1, 55, 97, 224, 348, 386, 538
negative reinforcement, 539, 542
motor skills, 262
negative relation, xx, 56, 399, 404, 407, 409, 503
motor stimulation, xvi, 259, 263, 266, 273, 275
negativity, xx, 400, 403, 404, 405, 406, 407, 410,
motorcycles, 289, 291, 297
411
mouse, 127, 373, 379
neglect, 14, 17, 137, 328
 Index 565

negotiating, 284, 395 neurotrophic, 377

negotiation, xxii, 284, 385, 393, 461, 462 New York Times, 541
neocortex, 215 New Zealand, 83, 235, 244, 336
neonatal, 377 Newton, 123
neonate, 334, 335 Nicaragua, xv, 259, 261, 264, 272, 277, 278, 280
neostriatum, 371, 376 nicotine, 3
nerve, 112, 220, 379, 526 nitric oxide, 112, 122, 377
nerve cells, 220, 526 nitric oxide (NO), 112
nerve growth factor, 379 NLEs, 498, 502, 503, 510, 511
nervous system, 122 noise, 3, 4, 6, 481, 528
Netherlands, x, xx, 93, 213, 218, 245, 257, 417, 418, nomothetic approach, 195
419, 420, 422, 427, 429, 432, 435, 461, 464, 465 non-human, 88, 89, 95, 123
network, xv, 79, 152, 176, 245, 250, 251, 252, 253, non-human primates, 123
254, 256, 257, 258, 289, 400, 401, 402, 403, 404, nonlinear, 169, 186
405, 406, 407, 408, 410, 414, 526 nonparametric, 270
network members, 79, 406, 407 nonverbal, x, 1, 23, 24, 25, 32, 89, 472, 478, 485
neural mechanisms, 31, 376 nonverbal cues, 23
neural systems, 117, 370 nonverbal signals, 485
neuroanatomy, 126 norepinephrine, 67, 238, 376, 525, 526, 528, 532
neurobiological, ix, xix, 114, 115, 116, 124, 231, normal, ix, xiv, 8, 47, 67, 69, 70, 115, 117, 119, 121,
238, 369, 375 129, 156, 180, 216, 229, 230, 231, 232, 233, 234,
neurobiology, xix, 127, 129, 214, 217, 369, 379, 538, 238, 242, 337, 358, 373, 377, 389, 408, 429, 430,
541 455, 456, 457, 484, 515, 529, 530
neuroendocrine, xix, 220, 369, 373, 377, 401 normal conditions, 238
neuroendocrine system, 401 normal distribution, 47, 156, 180
neurogenesis, 372, 374, 376, 377, 379 norms, xvi, xxi, 260, 342, 357, 400, 417, 423, 424,
neuroimaging, 116, 216, 217, 480 432, 435, 437, 439, 442, 443, 444, 445
neuroimaging techniques, 480 North America, 81, 372, 456, 458
neuroleptics, 120, 232 novel stimuli, 98
neurological disease, 462 novelty, 117
neurological disorder, 231 nuclear, 262, 263, 273
neurologist, 464 nuclear family, 262, 273
neuronal plasticity, 372 nuclei, xi, 111, 112, 113, 215
neurons, 112, 113, 115, 117, 118, 121, 122, 125, nucleus, 112, 113, 115, 116, 118, 121, 122, 126, 371,
129, 221, 372, 526 373, 374, 378, 524, 525, 526, 528
neuropeptide, xii, 111, 112, 129 nucleus accumbens, 115, 116, 373, 378, 525, 526,
neuropeptides, xix, 117, 120, 122, 124, 126, 128, 528
235, 369, 373 nulliparous, 114, 371
neuropharmacology, 126 nurse, 268, 351, 465
neuroplasticity, 375 nurses, 349, 456, 466, 467
neuropsychiatric disorders, xii, xix, 111, 118, 121, nursing, 31, 268, 373, 434, 435, 450, 463, 465, 466,
370, 372 467, 516
neuroscience, 491, 533, 537 nursing home, 463, 465, 466
neuroscientists, xxiv, 519, 523, 524, 525, 526, 528, nurturance, 403
536, 537 nutrition, 269, 272, 370, 452
neurosecretory, 112
neurotensin, 120
neurotic, 44, 230, 484, 487 O
neuroticism, 72, 171, 188, 209
obedience, 262, 271, 275
neurotransmission, 118, 371
objective criteria, 47
neurotransmitter, 528, 530
obligation, 96, 409, 410, 411
neurotransmitters, ix, xv, 118, 120, 224, 231, 237,
obligations, 260
238, 321, 370, 377, 530
observable behavior, 322
566 Index

observations, xiii, xvii, 80, 118, 149, 158, 161, 165, outpatients, xiv, 78, 229, 232
174, 180, 181, 246, 265, 266, 276, 319, 320, 372, ovarian, 115
373, 374, 389, 454, 522, 523, 530 ovariectomized, 115, 371
observed behavior, 266 ovariectomized rat, 115
obsessive-compulsive, ix, xiii, xiv, 78, 82, 119, 126, overproduction, 115
127, 213, 214, 215, 217, 218, 229, 230, 234, 235, ovulation, 113, 223, 227
238, 239, 241, 242, 243, 244, 495, 496, 497, 530 ownership, 101, 102, 105, 106, 108, 109
obsessive-compulsive disorder (OCD), ix, xiii, xiv, oxygen, 340, 465
82, 126, 127, 213, 214, 215, 217, 218, 229, 230, oxytocin, ix, xi, xix, 111, 112, 122, 123, 124, 125,
232, 233, 234, 235, 238, 239, 242, 495, 497, 530, 126, 127, 128, 129, 231, 238, 369, 370, 371, 372,
531 374, 375, 376, 377, 378, 379, 525, 526
occupational, ix, xi, 65, 76
odds ratio, 70
odorants, 224, 227 P
odors, 224, 225, 227
packets, 308
Oedipus, 230, 475, 496
pain, xviii, 9, 10, 12, 21, 31, 58, 95, 113, 118, 171,
Oedipus complex, 475, 496
188, 339, 340, 341, 343, 346, 347, 348, 349, 350,
offenders, 208
351, 352, 356, 359, 360, 361, 362, 452, 528, 529,
older adults, 108, 414, 416
530
older people, 108, 109
pain management, 348, 349, 356, 361, 362
olfaction, 227
paints, 67
olfactory, 113, 221, 223, 224, 225, 227, 371, 372,
pairing, 98, 99, 257
373, 376, 377
pallor, 522
olfactory bulb, 114, 221, 371, 372, 373, 376, 377
palpitations, 522
olfactory epithelium, 221, 227
pancreas, 114
olfactory receptor, 225
pandemic, 438
omission, 167, 184
panic attack, 82, 453, 454, 529
omnibus, 151, 175
panic disorder, xi, 65, 78, 82, 118, 119, 125, 239,
oncology, 22, 451, 454, 457
242
one dimension, 150, 176, 410
paradigm shift, 534
one sample t-test, 200
paradox, 484
online, 34, 98, 277, 542
paradoxical, 208
online dating, 542
parameter, 222, 252, 253
ontogenesis, 300
paranoia, 230, 238
openness, 263, 273
parasites, 226
opiates, 120, 524
parasympathetic, 113, 322, 408, 412
opioid, 127, 238, 362
paraventricular, xi, 111, 112, 122, 123, 125, 129
opioids, 114, 370
paraventricular nucleus, 122, 125, 129
opium, 529
parental care, 115, 375, 491
oppression, 356
parental influence, xviii, 365
optimal health, 347, 349, 350
parental relationships, 475
optimism, 11, 44, 48, 51, 272
parent-child, xv, xvii, 93, 194, 195, 203, 204, 206,
oral, 227, 426, 431, 432, 445, 449
207, 209, 246, 259, 266, 268, 276, 277, 303, 305,
orbitofrontal cortex, 528
308, 310, 311, 312, 313, 314, 343, 344, 446
organ, 66, 221, 222, 226, 227, 340, 347, 455
parenthood, 166, 184
organic, 9, 10, 11, 29, 230, 238
parenting, xv, xviii, 80, 206, 209, 257, 259, 261, 262,
organization, xi, 35, 37, 61, 256, 268, 292, 343, 477,
263, 265, 273, 274, 275, 276, 277, 278, 308, 316,
478, 481, 484, 485, 486, 487, 489, 490, 496
323, 327, 328, 330, 332, 335, 339, 341, 342, 343,
organizations, 278, 452, 477, 481, 484
357, 358, 365, 366, 368, 525
orgasm, 117
parenting behaviours, 80
orientation, xvi, 69, 97, 146, 259, 260, 261, 271, 290
parenting styles, 327, 328, 341, 342
oscillations, 483
Parkinson, 378
outliers, 270
parole, 301
 Index 567

paroxetine, xv, 237, 238, 243
partition, xv, 245
partnership, 26, 347
parvicellular, 113
passive, 69, 73, 119, 328, 419
paternal, xix, 206, 331, 369, 483
paternity, 231, 238
pathogenic, 80, 401, 412
pathology, xiv, 76, 229, 235, 238, 242, 243, 325,
326, 330, 331, 514
pathophysiology, ix, 118, 119, 120, 121, 125, 127,
336, 347, 349, 372
pathways, xvi, xxiii, 120, 122, 125, 133, 134, 145,
257, 260, 276, 277, 280, 335, 371, 375, 376, 411,
412, 415, 472, 480
patient care, 434
patient-centered, 454
patients, x, xi, xiii, xiv, xv, xxii, 8, 12, 20, 21, 32, 65,
66, 67, 68, 69, 72, 74, 75, 76, 78, 79, 80, 85, 118,
119, 120, 121, 125, 126, 127, 128, 129, 213, 214,
216, 229, 232, 233, 234, 238, 242, 243, 335, 336,
340, 344, 345, 347, 348, 349, 350, 353, 356, 357,
362, 377, 403, 413, 451, 452, 453, 454, 455, 457,
461, 462, 463, 466, 467, 468, 472, 473, 475, 476,
481, 483, 486, 494, 495, 513, 514, 516, 530, 531
patterning, 274
PBC, 441
peak experience, 529
pediatric, 321, 334, 337, 349, 353, 355, 356, 357,
359, 361, 362, 454, 456
pediatrician, 454
peer, xvi, xviii, xxi, 5, 7, 21, 31, 63, 73, 132, 144,
247, 249, 253, 255, 257, 277, 281, 282, 286, 289,
296, 298, 300, 301, 341, 345, 346, 351, 358, 361,
365, 366, 368, 382, 383, 386, 393, 396, 417, 430,
435, 437, 441, 463
peer group, 132, 247, 300, 301
peer influence, xxi, 253, 437
peer relationship, xvi, 249, 277, 281, 282, 286, 296,
341, 345, 346, 358, 382, 383, 386, 393, 396
peer review, 441
peers, xvii, xviii, 7, 22, 39, 40, 48, 63, 68, 94, 95,
245, 257, 282, 283, 291, 297, 301, 314, 327, 339,
345, 346, 351, 358, 361, 366, 367, 382, 383, 384,
385, 386, 397, 432, 433, 442, 456, 531
penis, 427
PEP, 119, 406
peptide, 112, 115, 129
peptides, xix, 124, 221, 238, 369, 370, 373, 375
perception, xvi, xxii, 36, 47, 60, 61, 64, 69, 79, 80,
152, 176, 194, 195, 205, 206, 218, 224, 226, 230,
281, 282, 287, 289, 294, 295, 296, 297, 305, 386,
401, 408, 424, 442, 444, 451, 453, 455, 476, 486,
510
perceptions, xi, 25, 31, 32, 35, 36, 41, 44, 45, 46, 47,
48, 49, 50, 51, 52, 53, 54, 55, 56, 60, 61, 63, 96,
98, 105, 136, 137, 143, 145, 151, 152, 158, 171,
175, 176, 181, 189, 196, 198, 203, 255, 257, 289,
310, 311, 335, 341, 342, 343, 346, 353, 356, 360,
362, 368, 401, 410, 427, 432, 445, 455, 466,
476, 511
perfectionism, 194, 211
performance, 7, 48, 58, 218, 386
perfusion, 376
perinatal, 321, 322, 330
periodic, 341
permit, 239
perseverance, 285
personal, x, xiii, xxii, 1, 4, 5, 8, 10, 11, 13, 14, 17,
18, 19, 20, 21, 22, 25, 26, 27, 32, 34, 39, 46, 48,
55, 59, 101, 106, 107, 108, 114, 124, 132, 137,
151, 155, 175, 191, 192, 207, 239, 260, 272, 283,
284, 285, 288, 291, 297, 298, 304, 306, 343, 349,
350, 354, 382, 383, 384, 385, 386, 408, 409, 419,
422, 423, 451, 452, 454, 456, 458, 474, 490, 514,
535, 537, 540
personal communication, 458
personal control, 4, 48
personal goals, 11, 382, 383
personal identity, 5, 13, 132, 283
personal life, 343
personal relations, 8, 106, 107, 108, 137, 535, 540
personal relationship, 8, 106, 107, 108, 137, 535, 540
personal responsibility, 385
personality, 5, 22, 32, 50, 55, 57, 58, 59, 60, 61, 63,
64, 72, 84, 105, 145, 161, 162, 171, 188, 192,
208, 209, 210, 234, 256, 267, 411, 477, 482, 484,
485, 486, 487, 488, 489, 491, 495, 516, 524, 538
personality characteristics, 50, 61, 209
personality differences, 5
personality dimensions, 192
personality disorder, 171, 188, 484, 488, 489, 491,
495
personality factors, 32
personality traits, 161, 162
person-centeredness, 23, 32
PET, 214, 216, 218, 223, 480
PET scan, 480
pets, 88, 90, 91, 93, 95, 96, 98, 99, 100, 101, 102,
103, 104, 105, 106, 107, 108, 109, 536
pH, 240
pharmacological, 80, 113, 215, 370
pharmacological treatment, 80
pharmacology, 217
pharmacotherapy, 67, 514
568 Index

phenotypic, 72 369, 375, 381, 387, 388, 389, 390, 392, 393, 394,
pheromone, ix, xiv, 219, 220, 221, 223, 224, 225, 397, 452, 455, 478, 497, 509, 510, 525, 532
226, 227, 228 play activity, 266
philanthropic, 12 pleasure, 288, 291, 418, 421, 426, 427, 433, 444,
philosophy, 292 445, 494, 526, 534
phobia, 72, 80 PLS, 519, 524
phone, 265, 303, 348 poisoning, xiv, 219, 220
phospholipase C, 113 poisons, 541
phosphorylation, 112 polarity, 220
photographs, 223, 425 policy makers, 331
physical abuse, 169, 186 policy-makers, 329
physical activity, 102 politeness, 272
physical aggression, 72, 83, 152, 153, 155, 177, 178, political, xxi, 211, 262, 356, 437, 438, 536
208, 255 politics, 291
physical education, 351, 352 polygraph, 541
physical exercise, 452 polymorphism, 121, 215, 225, 375
physical health, ix, xx, 88, 101, 107, 150, 192, 263, polymorphisms, 121, 215, 217
268, 316, 323, 399, 400, 401, 403, 416 poor, xi, 65, 69, 73, 91, 103, 155, 167, 185, 324, 325,
physical well-being, 282, 343 326, 327, 330, 340, 343, 356, 359
physicians, xxii, 66, 329, 349, 451, 453, 455, 456, poor relationships, 356
457, 489, 521, 522, 523, 529 population, xiv, 29, 47, 66, 76, 81, 101, 113, 121,
physiological, xi, xiv, 7, 19, 67, 100, 102, 111, 113, 206, 229, 233, 234, 235, 242, 243, 261, 262, 310,
114, 117, 119, 219, 220, 222, 223, 304, 321, 322, 328, 329, 331, 345, 348, 349, 353, 355, 356, 357,
370, 401, 406, 408, 410, 411, 412, 416, 519, 530, 412, 418, 421, 439, 442, 455, 457, 499, 500, 536,
533, 538, 542 541
physiological arousal, 304 population group, 310
physiological factors, 530 positive attitudes, x, xxi, 2, 419, 438, 444, 445
physiology, 94, 224, 234, 243, 415 positive behaviors, 20, 21
Piagetian, 383 positive correlation, 18, 374, 509, 510
pig, 372, 377 positive emotions, 29
pigs, 89, 223 positive feedback, 56, 122
pilot study, 179, 389, 448 positive regard, 153, 179
ping-pong, 291 positive relation, xviii, 18, 26, 45, 340, 352, 383,
pituitary, 112, 113, 118, 122, 125, 127, 222, 371, 385, 393, 404, 407
379, 401 positive relationship, xviii, 18, 26, 45, 340, 352, 383,
pituitary gland, 118, 122, 222 385, 393, 404, 407
placebo, 67, 224 positron, 214, 223, 480
placenta, 113 positron emission tomography, 214, 223, 480
plague, 347 Post Traumatic Stress Disorder (PTSD), 71, 72, 74,
planning, 171, 188, 306, 384, 434, 439, 453, 457 79, 81, 83, 84, 119, 124, 496, 517
plasma, 113, 117, 118, 121, 122, 125, 128, 240, 374, posterior cingulated, 524
379 postmortem, 118
plasma levels, 117, 118 postpartum, xvii, 118, 119, 126, 319, 320, 321, 329,
plasma membrane, 125 330, 332, 333, 334, 335, 337
plasticity, 372, 377 postpartum depression, xvii, 319, 320, 321, 329, 330,
platelets, xv, 214, 217, 218, 235, 237, 238, 240, 242, 332, 335, 337
243, 530, 531, 541 postpartum period, 119, 321, 330, 332
play, ix, xiv, xv, xvi, xviii, xix, 5, 36, 40, 41, 44, 52, postsynaptic, 371
73, 102, 108, 113, 114, 215, 219, 220, 221, 222, post-translational, 112
224, 237, 238, 247, 259, 261, 262, 263, 265, 266, post-traumatic stress, xxii , 79, 81, 83, 119, 124, 128,
267, 268, 269, 270, 271, 272, 273, 274, 275, 288, 376, 452, 453, 455, 457, 458, 496
289, 292, 306, 323, 339, 341, 350, 354, 356, 365, posture, 286
potassium, 377
 Index 569

poverty, 475 productivity, 3, 67

power, xii, xiii, 39, 45, 61, 93, 103, 149, 163, 173, profession, 419, 464
174, 178, 183, 285, 310, 313, 344, 366, 367, 368, professions, 472, 476
402, 490, 519, 522 progesterone, 114
preclinical, 218 prognostic value, 415
prediction, 39, 44, 51, 52, 54, 58, 170, 187, 208, 414, program, xvii, 85, 167, 184, 303, 304, 305, 307, 308,
516 310, 311, 312, 313, 314, 315, 316, 317, 332, 335,
predictive validity, 39, 163, 187, 491 349, 392, 439, 447
predictor variables, 139 programming, 7, 8
predictors, 39, 44, 51, 64, 70, 74, 77, 85, 175, 195, progressive, 94, 134, 384, 462, 465
251, 254, 278, 311, 333, 357, 391, 392, 414, 428, prolactin, 113, 216, 370, 371
445, 446, 490, 514 proliferation, 372, 374
pre-existing, 6, 355, 423, 477 prolyl endopeptidase, 119, 128
preference, xix, 97, 116, 117, 124, 251, 265, 369, promote, xv, xviii, 57, 118, 259, 260, 263, 269, 273,
373, 376, 378, 442, 473, 481 289, 305, 308, 313, 340, 341, 345, 346, 356, 358,
prefrontal cortex, xiv, 213, 215, 223, 372 382, 384, 385, 386, 412, 457
pregnancy, 29, 119, 125, 126, 265, 321, 333, 334, property, iv, 93, 116, 497
337, 371, 376, 428, 431 proposition, 39, 40, 54
pregnant, 428, 431 prosocial behavior, 3, 19, 28, 30, 32, 33
prejudice, 33, 34, 195, 211 protection, 93, 115, 272, 370, 401, 472, 473, 476
preschool, 332, 335, 338, 343, 476 protective factors, 153, 167, 184
preschool children, 335, 338 protein, 89, 113, 214, 220, 221, 240, 241, 244, 372
preschoolers, 7, 30, 368 protein synthesis, 113
pressure, xviii, 289, 365, 407, 411, 412, 419, 430, proteins, 112, 221, 238, 240, 242
433 Protestants, 261
presynaptic, 214, 215, 371 protocol, xv, 166, 169, 183, 186, 237, 406, 499, 527
prevention, xiii, xxi, 30, 149, 166, 167, 168, 174, protocols, 152, 176, 455, 467
183, 184, 185, 231, 304, 305, 307, 312, 313, 315, prototype, 51, 483, 525, 531, 533, 539, 542
316, 317, 335, 354, 417, 418, 420, 424, 426, 427, proximal, 44, 261, 273, 275
432, 434, 435, 437, 438, 439, 440, 441, 442, 443, Prozac, 530
444, 445, 446, 447, 448, 450 PRP, 240
preventive, 167, 184, 317, 447 pseudo, 18, 20
primacy, 97, 486, 495 psyche, 2, 24
primary care, 66, 83, 97, 99, 334, 361, 468, 473, 475, psychiatric disorder, xii, 70, 71, 81, 82, 84, 111, 129,
476 230, 238, 239, 242, 332, 336
primary caregivers, 97, 361 psychiatric disorders, xii, 70, 81, 82, 84, 111, 129,
primate, 225, 370 230, 238, 239, 242, 336
primates, 115, 122, 123, 221, 371, 373 psychiatric morbidity, 82
priming, 56, 57, 62 psychiatric patients, 102
prisoners, 79, 83 psychiatrist, 530
prisoners of war, 79, 83 psychiatry, xxiv, 108, 146, 397, 494
private, 105, 262, 288, 292, 297, 430, 431, 433, 495 psychoanalysis, 9, 62, 84, 193, 210, 478, 486, 488,
proactive, 328, 351 489, 491, 496, 515
probability, 51, 357, 387, 442, 443, 477 psychoeducational intervention, 355
probe, 155, 179 psychoeducational program, 315
problem behavior, 300, 338 psychological development, 331, 487
problem-solving, 82, 151, 158, 161, 163, 165, 175, psychological distress, 322, 333, 342, 414, 454
181, 282, 305, 306, 325, 354, 454, 498, 512, 513, psychological functions, 383
514 psychological health, 101, 103
problem-solving skills, 305, 306 psychological problems, 102, 337
procedural knowledge, 478, 479, 482, 486 psychological processes, 55
procedures, 20, 136, 247, 253, 254, 265, 356, 454 psychological resources, 386
production, 223, 371 psychological stress, 102
570
psychological variables, 328, 439
psychological well-being, 40, 209, 263, 272, 273,
415
psychologist, 465, 467, 468, 472, 542
psychologists, xxii, xxiv, 47, 57, 92, 94, 103, 401,
451, 454, 456, 475, 519, 525, 531, 533, 534, 535,
537
psychology, x, xvi, xxiii, 33, 34, 57, 77, 79, 84, 87,
88, 93, 103, 104, 107, 108, 146, 155, 156, 179,
180, 210, 218, 234, 243, 256, 260, 280, 283, 301,
397, 471, 496, 515, 537, 540, 541
psychometric properties, 158, 166, 181, 183, 211,
239
psychopathic, 483, 484
psychopathology, xv, xvii, 77, 112, 119, 235, 237,
239, 242, 315, 319, 320, 325, 326, 333, 334, 335,
337, 484, 487, 494, 497, 511, 516
psychopharmacology, 218
psychophysiological, 94, 105
psychophysiology, 332, 336, 522, 541
psychoses, 120
psychosocial, x, xviii, xxi, xxii, 145, 146, 245, 282,
286, 333, 335, 339, 341, 344, 349, 353, 357, 358,
359, 360, 361, 362, 437, 438, 441, 445, 446, 451,
453, 455, 458
psychosocial development, 358
psychosocial factors, 357, 360
psychosocial functioning, x
psychosocial variables, 360, 445
psychosomatic, 171, 188, 335, 337, 412, 413, 414,
415
psychostimulants, 373, 374
psychotherapy, xxii, 19, 29, 30, 31, 32, 34, 75, 471,
477, 478, 480, 481, 482, 487, 488, 489, 490, 494
psychotic, 484, 487, 513
psychoticism, 497
PsycInfo, 440
puberty, 223, 340
public, x, xxi, 288, 291, 297, 331, 435, 437, 438,
449, 450, 495, 510, 536
public health, x, xxi, 435, 437, 438
PubMed, 440
puerperium, 126
Puerto Rican, 277, 278
pulse, 100
punishment, 477, 529
punitive, 171, 188
PVN, 112, 113, 118, 121
Q reception, 220, 485
Qualia, xvi, 282, 286, 289, 293, 295
qualitative differences, 141, 333
Index
qualitative research, 424, 434, 463
quality of life, xviii, xxii, 13, 66, 84, 101, 107, 330,
339, 340, 343, 348, 357, 358, 362, 451, 452, 455
Quality of life, 82
quantitative research, 433
query, 277
questioning, 143, 443
questionnaire, xiv, xv, 96, 107, 138, 162, 163, 168,
169, 170, 181, 185, 186, 188, 229, 231, 233, 234,
237, 238, 239, 265, 286, 288, 422, 496, 499, 500,
532, 536, 537
questionnaires, xii, xiv, 138, 149, 150, 151, 152, 158,
160, 162, 163, 164, 165, 170, 174, 175, 176, 180,
181, 182, 187, 197, 199, 202, 203, 229, 232, 239,
241, 276, 421, 434, 455, 536
quizzes, 358
R
race, 346, 475, 476
racism, 476
radial glia, 372
radiation, 458
radical, 89, 430
radio, 536
rain, 529
random, xi, 35, 36, 46, 52, 53, 70, 98, 155, 169, 186,
393, 408, 434
random assignment, 408
random errors, xi, 35, 36, 46, 52, 53
range, xviii, xix, 2, 44, 67, 121, 155, 156, 162, 179,
180, 182, 194, 200, 220, 230, 232, 234, 265, 267,
286, 309, 310, 322, 324, 325, 330, 339, 341, 370,
401, 433, 484, 485, 486, 512, 520, 525
raphe, 215
rat, 115, 122, 123, 124, 125, 371, 376, 377
ratings, xii, xiii, 30, 40, 44, 47, 48, 49, 51, 52, 61, 64,
149, 152, 154, 155, 156, 157, 163, 165, 169, 173,
174, 179, 180, 186, 223, 227, 321, 325, 337, 361,
407, 408, 483
rats, xix, 113, 114, 117, 118, 122, 123, 124, 127,
128, 369, 372, 373, 376, 377
reactivity, 18, 100, 102, 115, 118, 276, 309, 406,
408, 416
reading, 64, 89, 102, 324, 407, 424, 425, 431
reality, xvi, 2, 8, 9, 13, 41, 46, 49, 54, 98, 281, 284,
285, 384, 385, 452, 455, 456, 475
reasoning, 477
recall, 500, 511
receptors, xiv, 112, 113, 114, 115, 116, 118, 119,
121, 123, 125, 213, 215, 221, 371, 373, 374, 376,
378, 530
 Index 571

reciprocity, 193, 194, 204, 205, 207, 208, 251, 252, religiosity, 343
253, 256, 282, 299 religious, 107, 136, 203, 264, 291, 314, 400, 418,
recognition, xiv, xvii, xix, 9, 11, 117, 125, 219, 220, 420, 431, 536
222, 225, 319, 320, 370, 373, 376, 487, 495 religious belief, 136
recollection, xvi, 281 religious beliefs, 136
reconcile, 23, 26, 43 religious groups, 536
reconciliation, 25, 32, 33, 207, 367 religiousness, 197
reconstruction, 285 remission, 28, 66
recovery, 29, 102 repair, 490
recruiting, 135, 167, 184 reparation, 328
recurrence, 8, 403 repetitive behavior, 120
red blood cells, 340 replication, 257, 346, 356
reduction, 24, 25, 28, 107, 116, 118, 119, 121, 196, representative samples, 273
208, 327, 363, 372, 448 reproduction, xviii, 369, 419
refining, 68 reproductive organs, 117
reflection, 297, 298, 427, 431 reputation, 277, 345, 346, 426, 444
reflexes, 530 research design, 37, 57, 357, 358
reflexivity, 286, 287, 290, 292, 297 researchers, x, xvii, xxiii, xxiv, 1, 3, 8, 9, 10, 17, 18,
refuge, 92 19, 21, 22, 23, 25, 36, 37, 40, 41, 43, 45, 48, 49,
regional, 223, 373 52, 53, 54, 55, 56, 57, 66, 74, 88, 93, 94, 97, 102,
regression, xix, 144, 163, 246, 250, 381, 390, 392, 103, 134, 137, 141, 151, 152, 154, 176, 177, 178,
503, 504, 505, 506, 509 230, 238, 246, 247, 250, 253, 254, 274, 288, 313,
regression weights, 503, 504, 505, 506, 509 319, 320, 321, 322, 323, 324, 325, 326, 329, 330,
regressions, 391, 392 331, 342, 344, 356, 388, 410, 445, 472, 480, 494,
regular, 347, 350, 351, 433, 445, 481 496, 513, 519, 524, 529, 531, 532
regulation, xi, 111, 113, 115, 120, 122, 224, 282, resentment, 210, 475, 480, 510
304, 306, 308, 314, 315, 316, 322, 326, 328, 372, residuals, 249
376, 378, 379, 473, 474, 477, 479, 480, 483, 486, residues, 112
488, 490, 515 resilience, 345, 514
rehabilitation, 463, 465, 467 resistance, 30, 231
Rehabilitation Act, 352 resolution, 13, 25, 26, 32, 315, 366, 475, 498
reinforcement, 128, 373 resource allocation, 14, 21
rejection, xi, 69, 87, 88, 90, 106, 216, 344, 347, 402, resources, 20, 23, 46, 98, 153, 178, 283, 285, 286,
403, 513, 528 287, 290, 292, 297, 298, 325, 326, 343, 344, 349,
relapse, 80 350, 352, 355, 358, 386, 401, 402, 453, 454, 514
relationship maintenance, 44, 91, 146, 170, 187, 409, responsibilities, 40, 153, 342, 462, 463
410 responsiveness, 3, 42, 118, 123, 170, 188, 376, 377,
relationship quality, ix, xii, xiii, 52, 59, 61, 148, 149, 477, 487, 491
150, 151, 152, 153, 154, 155, 156, 158, 161, 163, restaurants, 291
165, 166, 168, 173, 174, 175, 176, 177, 178, 179, restoration, 120
180, 181, 182, 183, 184, 185, 207, 305, 408, 414 Restorative Justice, 367
relationship satisfaction, xii, xiii, 44, 50, 52, 54, 148, restructuring, 67
149, 150, 152, 153, 160, 161, 163, 164, 165, 173, retardation, 455
174, 175, 177, 179, 182, 207, 209, 247 retention, 307, 314, 356
relatives, 70, 74, 76, 89, 262, 268, 532 returns, 99, 216
relaxation, 67, 120, 222, 408, 529 Revised Conflict Tactics Scale, 171, 188
relevance, 73, 75, 98, 125, 224, 382, 423, 490 reward pathways, 374
reliability, xii, xiii, 136, 137, 149, 152, 155, 156, rewards, 20, 386, 526
157, 165, 166, 170, 173, 174, 176, 179, 180, 183, Reynolds, 171, 188, 308, 309, 316
184, 187, 201, 235, 241, 243, 309, 389, 463, 500, Rho, 138
528 rhythm, 487
religion, 261, 262, 288, 419, 491 rhythms, 240, 268, 300
religions, 193 rigidity, 472
572 Index
rings, 5
risk, xvii, xviii, xx, xxi, 30, 70, 72, 81, 91, 119, 121,
153, 156, 163, 167, 179, 182, 184, 194, 208, 255,
282, 285, 286, 299, 319, 320, 321, 323, 326, 332,
333, 334, 335, 336, 341, 343, 344, 349, 357, 361,
363, 365, 366, 387, 399, 403, 406, 413, 414, 417,
418, 427, 432, 433, 434, 435, 437, 440, 445, 448,
457, 528
risk behaviors, 434, 445
risk factors, 167, 184, 321, 333, 336, 361, 403, 440
risks, xvii, 13, 101, 316, 319, 320, 332, 333, 347,
424, 427, 428, 429, 432
risk-taking, 418, 434
RMSEA, 501, 504, 505, 507
roadblocks, 341
robustness, 40
rodent, 378
rodents, 116, 124, 371, 372, 373, 378
romantic relationship, ix, xii, xiii, 37, 40, 46, 48, 51,
53, 57, 58, 60, 62, 90, 91, 92, 93, 99, 100, 105,
107, 109, 131, 132, 133, 134, 135, 137, 138, 139,
141, 142, 143, 144, 145, 146, 156, 168, 180, 185,
191, 192, 193, 205, 209, 257, 288, 291, 341, 346,
374, 502, 503, 541, 542
routines, 265, 268, 272, 325
rumination, 211, 411
rural, xv, 82, 259, 260, 262, 263, 264, 272
rural areas, xv, 259, 260, 272
S second generation, 422, 435
sacrifice, 20, 434
SAD, 71
sadness, 330, 488, 494, 524, 526, 533
safety, 97, 312, 472, 490, 522
salary, 521
salt, 529
sample, xii, xiii, xix, 39, 54, 70, 72, 74, 75, 76, 80,
81, 98, 121, 131, 135, 144, 154, 155, 157, 158,
160, 161, 162, 163, 166, 178, 180, 181, 182, 183,
191, 195, 199, 200, 201, 204, 206, 231, 233, 238,
240, 242, 263, 264, 265, 267, 273, 287, 297, 307,
313, 335, 338, 342, 345, 346, 357, 382, 406, 414,
433, 434, 516, 531
sample mean, 200
sampling, 122, 266, 308
sanctions, 472
satisfaction, ix, xii, xiii, 39, 40, 44, 45, 51, 52, 54,
61, 62, 64, 77, 149, 150, 151, 153, 155, 161, 163,
165, 167, 168, 169, 170, 171, 173, 174, 175, 176,
178, 182, 183, 184, 185, 186, 187, 189, 211, 247,
452, 453, 464
saturation, 240, 463
savings, 106
SBP, 407, 408
SCD, 359
scheduling, 153, 179, 268, 269
schema, 35, 36, 41, 42, 44, 62, 97, 411
schemas, 42, 44, 45, 58, 63, 97, 99, 104, 284
Schiff, 487
schizophrenia, 120, 129, 215, 326, 333
schizophrenic patients, 120
school, xviii, 32, 169, 186, 207, 253, 262, 269, 282,
288, 289, 291, 297, 299, 307, 325, 326, 327, 328,
332, 335, 341, 346, 350, 351, 352, 354, 358, 360,
362, 365, 366, 367, 368, 386, 388, 389, 395, 422,
423, 426, 431, 432, 434, 441, 444, 447, 449, 450,
455, 496
schooling, 263
science, 19, 114, 123, 135, 217, 255, 288, 314, 435,
537, 542
scientific, 103, 283, 291, 456, 522, 530, 536, 537
scientific community, 537
scientists, 413, 457, 522, 523, 524, 528, 534, 536,
537
scores, xiv, 67, 121, 138, 140, 142, 143, 150, 155,
156, 161, 179, 180, 182, 195, 200, 206, 208, 229,
232, 233, 234, 238, 239, 241, 246, 309, 389, 499,
500, 532
SCP, 435
SDS, xxiii, 494, 499, 500, 501, 508
search, 97, 409, 431, 440, 464
searching, 124, 529
secondary students, 368
secret, 431, 432
secrete, 112
secretion, 113, 221, 227
security, xvii, 5, 20, 40, 51, 61, 62, 83, 87, 95, 98,
99, 247, 257, 303, 304, 305, 308, 309, 311, 312,
315, 316, 365, 386, 454, 476, 479, 491, 525
sedative, 348
sedatives, 529
sedentary, 413
sedentary behavior, 413
selecting, 76, 91, 394
selective serotonin reuptake inhibitor, 214
self, vii, xvi, xxiii, 9, 41, 42, 43, 44, 47, 48, 49, 50,
59, 60, 61, 62, 63, 64, 79, 107, 137, 158, 160,
180, 181, 277, 279, 281, 282, 284, 285, 286, 287,
289, 290, 292, 293, 294, 295, 296, 297, 298, 299,
300, 305, 306, 309, 322, 333, 358, 368, 386, 395,
424, 428, 434, 493, 494, 496, 497, 499, 500,
501, 511, 513, 515, 516, 517
self representation, xi, 35, 40, 41, 42, 43, 44, 45, 48,
56
 Index 573

self worth, 300 serotonin, ix, xiii, xv, 67, 213, 214, 215, 216, 217,
self-awareness, 453 218, 224, 225, 230, 231, 235, 237, 238, 243, 370,
self-care, 343 375, 525, 526, 530, 532, 537, 541
self-concept, 40, 48, 58, 59, 63, 132, 463, 466, 484, serum, 119, 128, 216, 377
497 services, iv, 90, 108, 109, 265, 329, 331, 351, 352,
self-conception, 463 452, 475, 536, 537, 542
self-confidence, 271, 272, 282, 342, 386 SES, 323, 355
self-consciousness, 31, 105 severe stress, xxiii, 493
self-determination theory, 61 severity, 11, 26, 44, 74, 80, 119, 169, 186, 218, 232,
self-efficacy, xvi, xxi, 48, 97, 273, 281, 287, 288, 234, 323, 335, 337, 350, 403, 421, 452
289, 290, 294, 295, 296, 297, 341, 343, 386, 417, sex, xix, xxi, 32, 116, 136, 137, 144, 146, 154, 166,
423, 428, 444, 445, 516 170, 171, 178, 184, 187, 189, 220, 221, 224, 225,
self-enhancement, 45, 48, 60, 61 227, 248, 252, 253, 289, 291, 297, 323, 374, 379,
self-esteem, 39, 40, 42, 44, 45, 48, 55, 56, 60, 81, 83, 382, 388, 417, 418, 419, 420, 421, 424, 425, 426,
132, 272, 323, 342, 344, 353, 453, 498, 513, 531 427, 428, 429, 430, 431, 432, 433, 434, 435, 437,
self-evaluations, 48, 53, 56, 59 438, 442, 443, 444, 445, 446, 447, 448, 535, 537,
self-expression, 263, 495 540
self-image, 55, 345, 468, 495, 504 sex differences, 146, 154, 178
self-monitoring, 31 sexual abuse, 496, 515
self-perceptions, 47, 48, 49 sexual activities, xxi, 418, 429, 437
self-presentation, 55 sexual activity, 125, 132, 153, 178, 231, 419, 420,
self-recognition, 278 425, 429, 433, 442, 443, 444, 535
self-regulation, 193, 305, 306, 316 sexual behavior, xx, xxi, xxiv, 117, 119, 123, 145,
self-report, xii, xiv, xv, 7, 19, 30, 46, 48, 51, 55, 106, 220, 224, 238, 370, 378, 379, 417, 418, 419, 420,
108, 116, 149, 151, 152, 153, 154, 156, 158, 162, 421, 423, 424, 427, 435, 438, 439, 440, 442, 443,
163, 165, 168, 169, 174, 175, 176, 178, 179, 180, 444, 445, 449, 450, 519, 539
181, 182, 185, 186, 224, 229, 231, 237, 239, 243, sexual behaviour, 117, 123, 224
249, 276, 286, 288, 311, 321, 343, 497, 499, 500, sexual contact, 117
516 sexual experiences, 442, 448, 517
self-study, xvii, 303, 308, 310, 311, 312 sexual health, xxi, 418, 433, 437, 438, 441, 442, 443,
self-verification, 60, 61 444, 445, 449
self-view, 53 sexual identity, 454
self-worth, 43 sexual intercourse, 224, 233, 234, 418, 421, 425,
semantic, 151, 175, 477, 534 427, 438, 443
semantic memory, 477 sexual motivation, 526, 528, 539
semi-structured interviews, 152 sexual orientation, 536, 539
sensation, 540 sexuality, xxi, 94, 125, 153, 417, 418, 419, 420, 421,
sensations, 12, 374, 526 423, 424, 425, 430, 431, 432, 433, 434, 435, 438,
sensitivity, 14, 15, 18, 115, 261, 325, 336, 348, 478, 442, 452, 528, 530, 535, 541, 542
495, 496, 497, 530 sexually transmitted diseases (STD), xxi, 417, 418,
sensitization, 120, 128 420, 426, 427, 434, 435, 443
sentences, 97 shame, xxiii, 10, 207, 343, 367, 493, 494, 495, 496,
separate identities, 25 497, 498, 499, 501, 502, 504, 505, 507, 509, 510,
separateness, 261, 275 511, 512, 513, 514, 515, 516, 517
separation, 45, 73, 92, 94, 95, 96, 115, 124, 129, 150, shape, xvi, 57, 105, 200, 242, 281, 283, 287, 476,
238, 370, 372, 377, 473, 477, 485, 519, 525, 529 530
septum, 112, 116, 122, 221, 373 shaping, xvi, xviii, 48, 260, 339, 341
sequelae, 354, 455, 456 shares, 3, 24, 70, 263, 482, 484
series, 71, 89, 94, 126, 137, 154, 179, 233, 262, 290, sharing, xiv, xvii, 3, 4, 7, 14, 16, 17, 25, 26, 108,
353, 372, 476, 500, 525, 532 219, 260, 272, 282, 287, 291, 297, 319, 320, 384,
serotonergic, xiv, xv, 213, 214, 215, 216, 217, 218, 397, 414, 423
235, 237 sheep, 114, 371, 377
shelter, 89, 91
574 Index

shoot, 534 social cognition, 56, 57, 59, 60, 106, 116, 124, 223,
short period, 5 226, 383
short-term, 13, 67, 250, 371, 372 social comparison, 29, 42, 47, 60, 283, 383, 384, 386
shy, 58, 352, 537 social comparison theory, 42
sibling, 344, 345, 483 social competence, 263, 282, 370, 382, 383, 384,
siblings, xviii, 23, 32, 266, 327, 339, 341, 343, 344, 395, 397
345, 359, 361, 362, 366, 396, 454, 483, 532 social construct, 278
sickle cell, x, xvii, 339, 340, 341, 342, 343, 344, 345, social context, xviii, 116, 280, 282, 286, 330, 340,
346, 347, 348, 349, 350, 351, 352, 353, 354, 355, 341, 383
356, 357, 358, 359, 360, 361, 362, 363 social control, 432
sickle cell anemia, 340, 359, 360, 362 social desirability, 151, 153, 154, 169, 170, 176, 178,
side effects, 453, 455 179, 186, 187, 195, 276
sign, 242, 536 social development, xvi, 132, 256, 281, 299, 382,
signalling, 221 384, 386, 394, 397, 487
signals, xii, xiv, 111, 119, 121, 219, 221, 224, 227, social dilemma, 29
261, 285, 377, 477, 487, 526 social environment, 7, 374, 446
signs, 26, 520, 522 social events, 298
silkworm, 220 social exchange, 383
similarity, xv, 15, 17, 19, 42, 50, 51, 53, 54, 61, 64, social exclusion, 90, 104, 106, 109
193, 194, 195, 196, 200, 201, 202, 203, 204, 205, social factors, 386
206, 207, 208, 209, 245, 246, 247, 248, 249, 250, social group, 10, 20, 23, 28, 29, 97
252, 253, 254, 419, 509 social identity, 14, 25, 28, 29, 33, 343
simulation, 255 social identity theory, 25, 29, 33
singular, 40 social impairment, 66, 326
SIS, 309 social influence, 247, 250, 252, 253, 254
sites, 9, 113, 273, 286, 379, 431, 452, 523, 531, 533, social integration, 402, 433
536, 537 social isolation, 14, 124, 341, 374, 402, 415
skills, xvii, xviii, xx, 7, 22, 91, 109, 150, 167, 170, social learning, 117, 170, 187, 194
175, 185, 188, 193, 207, 267, 289, 303, 304, 305, social life, xvii, 255, 282, 297, 386, 400, 455, 465,
307, 308, 312, 349, 352, 356, 360, 365, 366, 382, 467
383, 394, 447, 454, 482 social network, x, xv, 192, 245, 246, 250, 251, 252,
skills training, 360, 482 253, 255, 256, 257, 265, 282, 340, 342, 345, 346,
skin, 100, 223 358, 382, 400, 402, 403, 404, 405, 409, 412, 416
skin conductance, 100, 223 social norms, 421, 423, 424, 445
sleep, 263, 269, 272, 348, 427, 475, 488 social order, 208, 286, 289, 494, 497, 509
smiles, 266 social organization, 116, 124, 235, 243, 378
smoking, x, 2, 3, 297, 403, 413 social perception, 56
smooth muscle, 117 social phobia, 72, 74, 76, 79, 495
snakes, 100 social policy, 280
SNAP, 160, 161, 162, 182 social psychology, 34, 108, 256, 397, 447, 539
sociability, xvii, 267, 272, 319, 320, 384 social relations, ix, xviii, xx, 14, 28, 70, 84, 118, 145,
social acceptance, xviii, 339, 345, 346 193, 255, 256, 257, 260, 273, 339, 341, 357, 370,
social activities, 462 375, 382, 383, 399, 400, 401, 402, 403, 404, 405,
social adjustment, 132, 138, 383 406, 408, 410, 411, 412, 413, 414
social anxiety, 119, 239, 241, 346, 362 social relationships, ix, xviii, xx, 14, 28, 70, 84, 118,
social attitudes, 226 145, 193, 260, 273, 339, 341, 357, 370, 375, 382,
social behavior, xiv, xix, 114, 117, 124, 129, 210, 383, 399, 400, 401, 402, 403, 404, 405, 406, 408,
219, 221, 280, 369, 372, 373, 378, 384, 387, 446 410, 411, 412, 414
social behaviour, 114, 225, 378 social roles, 59, 283, 402
social categorization, 301 social rules, 385
social change, xxi, 284, 396, 437 social sciences, x, 1, 253
social class, 476 social services, 263
social situations, 91, 346
 Index 575

social skills, 91, 120, 346, 366, 368, 393 sports, 288, 289, 366, 368
social standing, 21 spousal support, 154
social status, 247, 255 spouse, 57, 61, 70, 72, 74, 83, 95, 103, 154, 157,
social stress, 379 168, 185, 331, 400, 409, 429
social structure, 400 SPSS, 235, 240, 501
social support, xviii, xx, 30, 34, 68, 95, 100, 101, stability, xv, 52, 56, 57, 60, 81, 82, 99, 105, 109,
102, 105, 106, 109, 162, 168, 170, 171, 185, 186, 137, 153, 170, 171, 177, 187, 188, 192, 239, 245,
188, 189, 246, 321, 330, 342, 360, 365, 367, 368, 247, 248, 249, 262, 269, 285, 287, 393
399, 400, 401, 402, 403, 404, 408, 410, 412, 413, stages, xiv, xviii, 10, 14, 28, 40, 57, 94, 95, 166, 179,
415, 416, 455, 490, 514 184, 213, 215, 217, 249, 286, 328, 339, 372, 523
social withdrawal, 118, 402 STAI, 542
social work, 95, 109, 349 standard deviation, 40, 293, 390, 391
social workers, 349 standard error, 246
socialisation, 207, 287 standardization, 152, 177
socialization, xvi, xviii, 193, 196, 204, 205, 206, standards, 41, 49, 193, 264, 347, 419, 467, 528
207, 209, 210, 256, 259, 261, 262, 263, 271, 274, State-Trait Anxiety Inventory for Children, 328, 531
275, 278, 279, 280, 339, 382, 415, 476 statistical analysis, 255, 256, 507
socially, 50, 91, 116, 203, 206, 207, 230, 313, 346, statistics, 67, 203, 247, 307, 434, 441
379, 403, 404, 406, 413, 532 stem cell transplantation, 457
society, xv, 7, 21, 66, 84, 121, 195, 199, 210, 230, stereotype, xiii, 13, 191, 195, 196, 200, 201, 202,
259, 262, 263, 277, 329, 357, 397, 456, 465, 476 203, 204, 205, 206, 208
sociocultural, 260, 261, 263, 264, 271, 272, 342, 355 stereotypes, 13, 21, 55, 60, 200, 345
socioeconomic, xvii, 279, 319, 320, 321, 343, 345, stereotypical, 205, 207
347, 353, 355, 358, 443 sterile, 472
socioeconomic background, 279 steroid, 225, 227, 379
socioeconomic status, xvii, 319, 320, 321, 345, 355, steroids, xix, 114, 369, 371, 372
443 stigma, 21, 329, 331, 361
socio-emotional, 32, 263, 271, 272 stigmatization, 515
sociologist, 494 stimulant, 3, 530
sociology, 153, 177, 283, 435, 495 stimulus, 18, 20, 374
sociosexual, 224, 225, 226, 378 stomach, 530
software, 250, 253, 255 storage, 89, 122, 523
soil, 534 strain, 25
solitude, 516 strategies, xvi, 2, 25, 29, 96, 105, 153, 155, 162, 178,
solubility, 220 193, 234, 246, 254, 259, 261, 268, 297, 322, 355,
solutions, 113, 306, 328, 385, 386, 387 356, 367, 382, 384, 385, 386, 387, 393, 394, 410,
somatic complaints, 344 411, 450, 474, 475, 486, 487, 498, 510
sounds, 309 streams, 220
spasticity, 465 strength, 20, 137, 167, 184, 193, 196, 394, 419, 476
spatial, 289, 475, 486 stress, xiv, 3, 61, 66, 73, 79, 80, 83, 84, 95, 102, 103,
specialists, xxii, 451 104, 113, 115, 117, 118, 119, 125, 127, 151, 168,
species, xiv, 89, 91, 114, 116, 117, 219, 220, 222, 175, 185, 207, 219, 220, 276, 287, 299, 304, 322,
372, 373, 374, 378, 532 325, 334, 340, 353, 354, 358, 360, 362, 366, 371,
specific knowledge, 12 372, 375, 376, 377, 379, 386, 401, 402, 405, 407,
specificity, xvii, 12, 81, 276, 282, 372, 373, 410 408, 413, 414, 452, 454, 458, 477, 513, 531
spectrum, 3, 129, 239, 241, 242, 243, 244, 452 stressful events, 168, 185, 371, 401, 402
speech, 17, 522 stressful life events, 73
speed, 240 stressors, 73, 321, 330, 342, 343, 344, 347
sperm, 426, 428 stress-related, 61, 118, 372, 375, 377, 401
spheres, 296 striatum, 215, 374
spinal cord, 113, 122 strikes, 10
spiritual, 529, 534, 535 stroke, 340
sporadic, 44 structural characteristics, 250, 407
576 Index

structural equation model, xxiii, 249, 250, 493, 501, sympathy, 2, 521
511, 512 symptom, 32, 79, 80, 84, 218, 230, 238, 242, 351,
structural equation modeling, 249, 250 515
structuring, xvi, 260, 268, 383 symptomology, 345
students, xiv, 7, 32, 107, 155, 179, 229, 231, 233, symptoms, xvii, 11, 26, 66, 67, 72, 74, 75, 76, 80,
285, 296, 342, 352, 355, 404, 434, 435, 441, 445, 81, 83, 118, 119, 120, 126, 167, 184, 214, 215,
449, 450, 499, 500, 503, 516, 526, 535, 536 232, 242, 243, 306, 309, 319, 320, 321, 323, 325,
stupor, 522 327, 330, 334, 335, 342, 343, 349, 350, 351, 352,
subarachnoid hemorrhage, 502 356, 357, 375, 403, 420, 438, 474, 486, 496, 521,
subjective, xvi, xxi, 19, 102, 170, 188, 227, 265, 282, 530
284, 286, 292, 297, 321, 379, 435, 437, 439, 442, synapses, 214, 221
443, 444, 445, 519, 533 synaptic plasticity, 372
subjective experience, 265, 284 syndrome, 79, 119, 121, 124, 127, 129, 534
subjective well-being, 102 synthesis, xxi, 113, 118, 215, 437, 439, 440, 442,
subjectivity, 287, 289 445, 446
subsistence, 260, 265 synthetic, 117, 223, 224, 225
substance abuse, 231, 238, 325 Syphilis, 356
substance use, 257 systematic, xi, xxiv, 35, 36, 44, 46, 47, 53, 55, 56,
substances, xi, xiv, 111, 112, 120, 219, 220, 222, 246, 265, 458, 489, 519
223, 226, 529 systems, 80, 92, 94, 97, 115, 149, 152, 171, 176,
substantia nigra, 114, 374 188, 215, 217, 221, 274, 277, 284, 298, 314, 370,
substrates, 116, 124, 126, 378, 413, 530, 541 371, 375, 376, 401, 412, 440, 480, 485, 490, 524,
suburban, 156, 180 525, 532, 535, 538, 540
suffering, xxii, 18, 70, 76, 125, 239, 328, 349, 360,
361, 452, 454, 468, 504, 519, 521, 530, 531
sugar, 85, 262 T
suicidal, 367
tactics, 80, 315
suicidal ideation, 367
tangible, 153, 155, 178, 400
suicide, 502
target organs, 112
summer, 289
target population, 156, 441, 499
superego, 495, 496
targets, 76, 205, 304, 366
superiority, 51, 63, 64
task performance, 406
supervisor, 93, 404
taste, 228
supply, 531
teachers, 325, 346, 351, 352, 367, 386, 388, 442
support staff, 351
teaching, 30, 269, 274, 304, 305, 307, 309, 312
suppression, 106, 117, 411
team members, 352
Surgeon General, 329, 336
team sports, 290
surgery, 13, 107
technological, 528
surgical, 223
technology, 357, 536
surrogates, 106, 107
teenagers, 367, 418, 420, 425, 431, 432, 433, 447
survival, xviii, 101, 106, 114, 339, 369, 370, 372,
teens, 144, 207
378, 387, 412, 413, 415, 455
telephone, 5, 532
survival rate, xviii, 101, 339, 455
television, 7, 8, 34, 107, 288, 291, 348, 409, 431
survivors, 81, 455, 456, 457, 458, 459
television viewing, 8
susceptibility, 16, 121
temperament, 84, 125, 162, 165, 182, 323, 333
sweat, xiv, 170, 187, 219, 220, 223
temporal, 223, 287, 289, 388, 455, 475, 486, 524
symbiotic, 279, 478
tension, 66, 222, 279, 496, 497, 498, 512, 513
symbolic, 89, 193, 298, 397, 478, 479, 480, 486
terminals, 112, 221
symbolic systems, 480
territorial, xiv, 113, 219, 221
symbols, 106, 208
territory, 116, 528
symmetry, 73, 153, 178, 227, 282
test statistic, 246
sympathetic, 113, 322, 401, 406, 412, 474, 496, 530
testis, 113
sympathetic nervous system, 401
testosterone, 223, 525, 530, 537
 Index 577

test-retest reliability, 137, 239, 309 tourism, 261

thalamus, 113, 214 toxic, 230, 238
thalassemia, 340 toys, 266, 269, 273
theoretical, xv, xx, 16, 34, 36, 57, 75, 99, 102, 103, trading, 264
105, 106, 107, 141, 145, 193, 196, 238, 245, 253, tradition, 78, 199, 463, 490, 495
279, 283, 288, 298, 383, 386, 397, 400, 401, 439, traffic, 503
446, 462, 467, 472, 480, 482, 490, 525 training, 7, 33, 67, 75, 91, 100, 132, 312, 313, 314,
theoretical assumptions, 279 348, 351, 353, 356, 358, 457
theory, xvi, xxi, 16, 23, 28, 31, 36, 39, 40, 41, 42, 52, trait anxiety, 531
59, 60, 63, 81, 82, 87, 88, 90, 92, 93, 95, 98, 100, traits, 61, 64, 82, 128, 161, 182, 215, 327, 531
102, 103, 105, 106, 107, 116, 143, 144, 145, 146, trajectory, xviii, 143, 339
147, 170, 187, 207, 208, 225, 260, 279, 280, 285, tranquilizers, 529
304, 305, 307, 316, 317, 353, 377, 397, 405, 415, transactional stress, 353, 360
434, 437, 439, 440, 442, 445, 446, 447, 448, 450, transactions, 150, 152, 175, 176, 193, 205
462, 468, 473, 483, 487, 488, 489, 490, 491, 496, transcripts, 266, 423, 424, 425
513, 525, 539, 541 transduction, 115, 221
Theory of Planned Behavior, xxi, 437, 439, 447 transfer, 60, 94, 95, 105, 220, 480, 482, 531, 541
therapeutic, xxii, 101, 215, 216, 347, 348, 350, 356, transference, xxiii, 472, 474, 480, 481, 482, 483,
357, 362, 454, 455, 471, 472, 473, 474, 475, 476, 484, 485, 486, 488, 489, 491
478, 479, 486, 487, 488, 489, 490, 513 transformation, 476
therapeutic change, xxiii, 471, 478, 479, 486 transformations, 452, 516
therapeutic goal, 101 transgression, 198, 209, 282
therapeutic process, 488 transition, 132, 166, 171, 184, 188, 194, 207, 251,
therapeutic relationship, xxiii, 348, 350, 471, 473, 359
475, 476, 513 transition to adulthood, 207
therapists, xxiii, 76, 152, 170, 176, 187, 211, 472, transitions, 208
473, 475, 476, 481, 483, 513 translation, 265, 283, 284, 286, 486
therapy, xi, 65, 67, 68, 69, 74, 75, 76, 77, 78, 79, 80, transmembrane, 221
81, 82, 83, 95, 101, 104, 105, 107, 108, 150, 152, transmission, xiv, 101, 125, 193, 205, 206, 207, 209,
166, 169, 170, 171, 176, 177, 183, 186, 187, 189, 210, 211, 213, 215, 217, 224, 272, 279, 335, 337,
225, 329, 358, 361, 448, 452, 454, 472, 473, 475, 373, 420, 426, 427, 438
477, 482 transplant, 101, 107, 347
thinking, 52, 97, 193, 214, 269, 349, 383, 385, 386, transplant recipients, 101, 107
394, 405, 421, 479, 480, 520, 525, 528 transport, 218
threat, xviii, 28, 56, 69, 82, 94, 95, 97, 230, 238, 304, transportation, 357, 452
306, 310, 312, 314, 316, 339, 344, 401, 420, 486, trauma, 71, 81, 119, 127
516, 538 travel, 97, 423
threatened, 3, 50, 97, 230, 304, 455 trees, 58
threatening, 60, 69, 82, 91, 94, 98, 117, 312, 367, trend, 76, 494
368 TRF, 314
threats, 42, 115, 320, 472, 473 trial, 68, 76, 77, 82, 106, 317
threshold, 232, 240, 241 trust, ix, xii, xiii, 25, 26, 33, 44, 92, 97, 116, 124,
thymus, 114 149, 169, 173, 174, 186, 251, 258, 347, 356, 427,
thyrotropin, 112, 120 464, 474
tic disorder, 126 trusts, 90, 466
time frame, 254 tryptophan, 216, 217, 218, 225
time periods, 326 T-test, 201
timing, xiv, 219, 220, 222, 324, 332 tumor, 13
tissue, 373 turbulent, 531
title, 288, 440 two-dimensional, 89, 93
tobacco, 262 two-dimensional space, 93
toddlers, 279, 323, 327, 328 typology, 51, 93, 389, 390, 391, 392
tolerance, 120, 128, 340, 345, 419 tyrosine, 112, 123
578 Index

tyrosine hydroxylase, 112, 123 variable, 6, 8, 20, 23, 40, 139, 140, 161, 163, 181,
195, 211, 247, 310, 311, 324, 325, 330, 355, 390,
497, 501, 502
U variables, xii, xiii, xvii, 5, 32, 37, 39, 52, 76, 83, 101,
139, 142, 148, 149, 150, 161, 173, 174, 181, 195,
ubiquitous, 29, 90, 509
197, 206, 207, 247, 250, 264, 270, 311, 319, 320,
ultrastructure, 222
321, 322, 324, 325, 326, 327, 330, 331, 355, 358,
uncertainty, 13, 14, 28, 50, 97, 234, 238, 343, 386,
360, 367, 375, 390, 402, 406, 421, 442, 447, 449,
454, 458, 468
485, 486, 490, 498, 503, 505, 506
undergraduate, 135, 223, 409
variance, xv, 154, 178, 181, 198, 233, 245, 247, 248,
underlying mechanisms, 416
270, 330, 445
underreported, 321, 329
variation, xv, 4, 40, 53, 61, 201, 247, 259, 260, 271
ungulates, 114, 370
vascular, 113, 340
UNICEF, 438, 450
vascular system, 113
uniform, 2, 521
vasopressin, xix, 112, 122, 123, 124, 125, 127, 128,
unilateral, xi, 87, 90, 246, 249, 250, 253, 254, 475
129, 369, 370, 371, 372, 374, 375, 376, 378, 379,
unions, 262
525
United Nations, 438, 450, 532
vasopressin level, 371
United States, xvii, 81, 87, 121, 123, 171, 188, 234,
vein, 98, 419
260, 273, 279, 339, 340, 341, 347, 438, 439, 450
ventricles, 115
United States Agency for International Development
ventricular, 122
(USAID), 438, 450
vertebrates, xi, 111, 112, 225
units of analysis, xiii, 191
veterans, 71, 78, 81, 83, 124
univariate, 270, 392
victimisation, 368
universities, 499, 536
victimization, 368, 496
university students, xiv, xxiii, 229, 231, 233, 242,
victims, 193, 367, 368
436, 493, 515, 531
video, 291, 348, 389, 431
unpredictability, 91, 92, 97
video games, 348
urban, xv, 259, 262, 264, 342, 359, 434, 438, 444
Vietnam, 78, 81, 124
urban areas, 438
violence, 72, 83, 211, 217, 230, 420, 429, 430, 432
urine, xiv, 216, 219
violent, 208
US Department of Health and Human Services, 457
visible, 11, 352
users, 224, 354
vision, 522
uterus, 113
visual, 22, 371, 374, 523
visual attention, 374
V visual stimulus, 371
vocabulary, 478
vacation, 473, 485 vocalizations, 266
vacuum, 240 vocational, xvi, 211, 281, 287, 422
vagina, 223 vocational education, 422
vaginal, 117, 227, 445, 449 vocational interests, 211
vagus, 113 voice, 145, 425
valence, 124 volatility, 220
validation, 30, 144, 146, 168, 185, 406, 415, 489 voles, xix, 116, 117, 123, 124, 125, 235, 243, 369,
validity, xii, xiii, 17, 18, 19, 37, 108, 137, 149, 152, 370, 372, 374, 378
156, 158, 161, 162, 163, 165, 166, 168, 170, 171, vomeronasal, 221, 226, 227
173, 174, 179, 181, 183, 184, 187, 188, 209, 235, vulnerability, 72, 121, 242, 340, 372, 421, 427, 433,
239, 244, 497, 500, 515, 528 464, 467, 484
values, xxii, 9, 28, 50, 193, 194, 209, 216, 231, 240,
241, 252, 260, 261, 262, 263, 272, 294, 386, 390,
W
419, 421, 449, 451, 468, 495, 503, 505, 506, 508,
510, 537
waking, 540
variability, 40, 43, 53, 113, 129, 200, 272, 274, 324
war, 430
 Index 579

warrants, 143, 351 witnesses, 348

Washington, 29, 30, 31, 32, 34, 77, 78, 169, 186, wives, 69, 75, 156, 157, 158, 162, 163, 165, 180,
234, 255, 280, 315, 316, 361, 490, 541, 542 181, 182, 183
watches, 266 work environment, 516
water, 112, 220, 352, 529 workers, 165, 182, 409, 421, 448
Watson, 42, 44, 46, 47, 48, 49, 50, 63, 64, 72, 82, 84, working hours, 465
158, 329, 337 working memory, 284
weakness, 167, 184 workload, 351
wealth, 175, 331 workplace, 28, 30, 268
wear, 224, 352 World Health Organization (WHO), 321, 338, 438,
web, 494, 537 450
websites, 357, 536 worldview, 271, 273
weight loss, 21 worry, 66, 67, 68, 69, 74, 79, 83, 329, 343, 425, 512
welfare, 3, 464
wellbeing, 45, 374
well-being, xiii, xvi, 39, 55, 59, 61, 64, 88, 100, 101, Y
150, 169, 186, 191, 192, 208, 281, 282, 286, 287,
yield, 154, 175, 310
289, 290, 294, 297, 300, 304, 305, 306, 312, 321,
young adults, xiii, 39, 58, 60, 104, 105, 191, 204,
342, 344, 345, 346, 347, 349, 350, 359, 368, 414,
210, 235, 243, 320, 362, 434, 452, 456, 541
516
young men, 224, 236, 524
western countries, 420, 421
young women, 223, 226
Western culture, 260, 277, 423, 494
younger children, 7, 309, 311, 312, 313
Western societies, 263
wheelchair, 465, 466
wholesale, 476 Z
Wikipedia, x, 1, 34
wisdom, 476 zoonotic, 101
withdrawal, 113, 120, 122, 153, 178, 529
witness, 305, 348