Psychological Bulletin 1991. Vol. 109. No.

1,25-41

Copyright 1991 by the Am rican Psychological Association. Inc. 0033-2909/9I/$3.00

Beyond Attentional Strategies: A Cognitive-Perceptual Model of Somatic Interpretation

Delia Cioffi
University of Houston

The meaning people assign to physical sensations can have profound implications for their physical and psychological health. A predominant research question in somatic interpretation asks if it is more adaptive to distract one's attention away from a potentially unpleasant sensation or to focus one's attention on it. This question, however, has yielded equivocal answers. Many apparent ambiguities in this research can be traced to a failure to distinguish the content of a person's attention from its mere direction or degree. A model of somatic interpretation is discussed, incorporating not only perceptual focus but also the attributions, goals, coping strategies, and prior hypotheses of the perceiver, thus delineating the psychobiological conditions under which various attentional strategies should be adaptive. In contrast to the prevailing concern with when and why somatic distraction doesn't "work," this conceptual analysis also considers when and why somatic attention does. Theoretical and methodological issues are discussed, as is the potential utility of somatic attention in cardiac rehabilitation and multiple sclerosis. He shivered repeatedly as he lay looking out through the wooden arch at the reeking, dripping damp outside, which seemed on the point of passing over into snow. It was strange that with all that humidity his cheeks still burned with a dry heat, as though he were sitting in an over-heated room. He felt absurdly tired from the practice of putting on his rugs; actually, as he held up Ocean Steamships to read it, the book shook in his hands. So very fit he certainly was not.. . ."Iflonlyknew" HansCastorpwenton,and laid his hands like a lover on his heart, "if 1 only knew why I have palpitations the whole time.. . ." (Mann, 1927/1959, p. 103)

Thus young Castorp begins his membership in the society atop The Magic Mountain, a membership denned by the shifting and sometimes chimerical line between health and illness. His initiation into this society occurs in an intensely psychological landscape, where the meaning he assigns to a shiver or a flush determines his identity as either well or ill. Mann's parable reflects an essential characteristic of physical sensations; they are as often socially influenced interpretations as they are the direct output of a biological system. In matters of health and illness, it is difficult to imagine a more fundamental process than that by which we perceive, interpret, and act on the information from our own bodies. Is it better to ignore one's somatic states or to pay attention to them? Researchers studying somatic interpretation have commonly asked this question, exploring the effects of perceptual attention on both subjective and physical response. The corpus of findings has been equivocal. Recent reviews cite mixed results for distracting and attending strategies, and the limiting conditions for each seem far from clear. In this article I recon-

cile some of the equivocations and offer suggestions for moving beyond them. I begin by discussing the development of cognitive-perceptual approaches to somatic interpretation as distinguished from the traditional biomedical model. The findings on attentional strategies are briefly reviewed and are followed by a conceptual analysis of the apparent equivocations. I argue that confusion over the effects of attentional strategies often reflects the failure to distinguish the content of attention from its direction, and I discuss several theoretical and methodological issues that tend to blur this distinction. I describe a model that highlights the interaction between bottom-up and top-down influences on the somato-interpretive process. Current thinking on somatic interpretation is often subtly biased toward viewing awareness of somatic information as necessarily distressing. In contrast, the present discussion punctuates the potential variance between the perception of a physical sensation and any particular interpretation of it while also describing how strong situational or top-down influences may sometimes overdetermine their relationship. This conceptual analysis, rather than concentrating on when and why a d istracting strategy does not "work" also generates hypotheses for when and why attention does. These hypotheses are explored and applied to the clinical exemplars of cardiac rehabilitation and multiple sclerosis, two conditions for which somatic distraction may be neither possible nor desirable. Two Symptomatological Models The Biomedical Model

1 was supported during the early drafts of this article by a National Science Foundation Predoctoral Fellowship. My gratitude goes to Albert Bandura, Kent Harber, Lee Ross, James Pennebaker, Nancy Cantor, and three anonymous reviewers for their most thoughtful comments on the text. Correspondence concerning this article should be sent to Delia Cioffi, Department of Psychology, University of Houston, Houston, Texas 77204-5341.

The traditional biomedical model holds a relatively mechanistic view of physical symptoms. It is assumed that most physical maladies are caused by physical insult or biochemical agents, which in turn produce a cluster of symptoms or signs that are unique to that injury or disease (Lyddon, 1987; Thomas, 1977). Accordingly, a particular constellation of symptoms can be traced to a particular causal biological pro25

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cess. Likewise, close correspondence is assumed between symptom perception and actual biological state; as the physical pathology intensifies, its symptoms become increasingly diagnostic of the relevant underlying pathology and increasingly obvious and distressing to the patient, who consequently seeks medical care (H. Levenlhal, 1983; G. Schwartz, 1982). Medical care consists of administering counteractive biochemical agents and behavioral instructions, both of which, it is supposed, the average patient will understand and follow. In its most rigid form, the biomedical model assumes a direct cause-and-effect relationship between an illness and its symptoms. Critics complain that it underweights psychosocial aspects of the illness process and provides a poor fit to many contemporary health problems (Kaplan, 1984; Karoly, 1985; H. Leventhal, 1983; Lyddon, 1987; G. Schwartz, 1982, 1984). In contrast to the infectious killers of 80 years ago, contemporary diseasessuch as hypertension, coronary heart disease, and cancerare chronic conditions that are rarely linked to a specific cause and that may be managed but not cured. Treatments based solely on biomedical interventions cannot address the significant behavioral components of these and similar diseases (Dingle, 1973; H. Leventhal, Zimmerman, & Gutmann, 1984; G. Schwartz, 1982,1984). In fact, many well-known medical miracles may have been less miraculous than is commonly assumed. For instance, widespread use of penicillin began only after sanitation and public health measures had reduced scarlet fever mortality by 80% (McKinlay & McKinlay, 1981). The most virulent infectious killer in recent history, acquired immune deficiency syndrome (AIDS) makes this point tragically clear: Behavioral prophylaxis, not medical "magic bullets," will save countless lives (Bandura, 1990).

Cognitive-Perceptual Model Medical and psychosocial models often do converge, and their confluenceas in the interdisciplinary treatments for chronic paincan be most effective indeed (cf. Fordyce, 1976; H. Leventhal & Everhart, 1979; Turk & Kerns, 1983; Turk, Meichenbaum, & Genest, 1983). The imperative for this approach is also well illustrated by the so-called compliance problem among people with high blood pressure. A patient who adhered imperfectly to a hypertension prescription was often seen as simply stubborn or uneducated, and the doctor's response just as often was limited to intensifying professional exhortations or, occasionally, referring the patient to a medical psychologist. Patients who take their hypertension medication erratically are not simply being intractable, however. Rather, they are responding to a well-organized subjective representation of their illness. When a group of hypertensive people were asked, "Can people tell when their blood pressure is high?" 80% gave the medically correct response, which is "No." But when asked, "What about you?Can you tell?" 88% said that they could (Baumann & Leventhal, 1985; Meyer, Leventhal, & Gutmann, 1985). Furthermore, these patients based their decisions about taking medication on symptoms such as headaches and flushed face, all of which covaried more reliably with emotions and moods than with actual blood pressure levels (H. Leventhal,

Meyer, & Nerenz, 1980; H. Leventhal, Nerenz, & Steele, 1986; Meyer et al, 1985; Nerenz & Leventhal, 1983). The belief that one can monitor one's blood pressure develops over time and may be a function of our demonstrated need for symmetry between illness labels and symptoms (Easterling & Leventhal, 1989; H. Leventhal, Nerenz, & Strauss, 1982; Pennebaker, 1982; Zimmerman, Linz, Leventhal, & Penrod, 1984). In any case, the hypertension example illustrates that people act on their internal representations of their illness and of their symptoms; that is, they respond to their private, subjective, sometimes idiosyncratic world of interrelated beliefs, fears, competencies, and goals. These construals, although not always accurate in the biological sense, may nonetheless be predictable from a social-psychological point of view (Cioffi, 1990a). Accordingly, one may better serve therapeutic goals by learning more about the patient's illness representation rather than by ever more aggressively defending the physician's (H. Leventhal etal., 1984). Spurred by the practical advances of the psychosocial approach, researchers increasingly turned to people's private theories of diagnostic information (e.g., Bishop, 1987; Cioffi, 1990c, I990b; Ditto, Jemmott, & Darley, 1988; Jemmott, Croyle, & Ditto, 1988; Lau & Hartman, 1983; H. Leventhal et al., 1986; Mechanic, 1980; Pennebaker & Epstein, 1983; G. Schwartz, 1982). Physical symptoms are now viewed as cognitive-perceptual phenomenathat is, as stimuli that are subject to complex psychosocial processes and therefore susceptible to influences beyond those explained by biosensory mechanisms alone (see Pennebaker, 1982, for a review). The social cognition approach was especially germane to the development of this view, demonstrating that the social environment can direct not only an evaluation of one's attitudes and abilities but the labeling of one's somatic arousal as well (Festinger, 1954; Schachter & Singer, 1962). The somatic labeling phenomenon was subsequently observed even in the absence of an actual physiological change. In other words, perceived or inferred physical change is sufficient to set the interpretive process in motion. Invoking the principles of attribution theory (Jones et al., 1971), researchers compiled an impressive collection of studies in which both the perception of a somatic change and the attributions for it were experimentally manipulated (e.g., Dutton & Aron, 1974; Ross, Rodin, & Zimbardo, 1969; Schachter & Rodin, 1974; Valins, 1966; Zanna & Cooper, 1976; see also Holroyd et al., 1984). Taken in sum, this research demonstrated that somatic interpretationindeed, the very "perception" of somatic information itselfwas profoundly influenced by the situation, by the behavior of others, and by the beliefs, assumptions, and attributions of the perceiver. Review of Attentional Strategies Having demonstrated the plasticity of somatic interpretation, researchers turned to what is surely an elementary influence on this process: the effects of attentional focus. The central questions were straightforward. To what extent does a strategy of distraction away from a potentially noxious physical sensation facilitate adaptation to it? And why is distraction occasion ally inferior to the strategy of somatic attention? Recent reviewers have reported an equivocal pattern of results (McCaul

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& Malott, 1984; Mullen & Suls, 1982a; Suls & Fletcher, 1985), and the limiting conditions of each strategy seem far from clear. The response, in terms of new research and theory, has been a collective ennui. In the following section, I briefly review the evidence cited in support of attention and distraction. In subsequent sections, I analyze the apparent equivocations and offer suggestions for moving beyond them. Distraction Competition for attentional capacity. Virtually all research on somatic attention, assumes a necessary division of a fixed amount of attention between relatively strong and weak stimuli (e.g., Kahneman, 1973; Navone & Gopher, 1979). Thus a decrease in the intensity of external stimuli tends to make internal information more salient. This is the principle at work when we experience a sudden "worsening" of an ache or pain in the dead of night; as the house grows still and the events of the day recede, our previously ignored internal state comes into sharp attentional relief. Most models associating the salience of internal information with increased symptom reporting turn on this principle of fixed capacities (Carver & Scheier, 1981; Coburn, 1975; Fenigstein, Scheier, & Buss, 1975; Hansell & Mechanic, 1984; Mechanic, 1983; L. Miller, Murphy, & Buss, 1981; S. Miller, Brady, & Summerton, 1988; Mullen & Suls, 1982a, 1982b; Pennebaker, 1982). Some evidence supports the contention that when the external environment yields relatively little information, the tendency to encode and elaborate on somatic information increases (Pennebaker, 1980; Pennebaker & Brittingham, 1982). For example, in a study in which subjects jogging on a track were compared with subjects running a cross-country route, joggers who were circling the repetitive oval were more aware of their physical fatigue and effort than were runners who navigated the ever-changing course, despite the fact that track joggers ran at the slower pace (Pennebaker & Lightner, 1980). Self-awareness and somatic distress. Other support for distraction's efficacy is indirect, an extrapolation from the correlates of individual differences in self-awareness. Theories of self-consciousness (Buss, 1980), objective self-awareness (Duval & Wicklund, 1972; Wicklund, 1975), and self-focused attention (Carver & Scheier, 1981) are but a few versions of a hypothesized individual difference in the tendency to focus on internal feelings and states. It is suggested that this high degree of selfawareness increases the relative salience of all aspects of the self, including somatic information (Duval & Wicklund, 1972; Wegner & Giuliano, 1982; Wicklund, 1975). Although operational definitions of self-awareness vary, they usually include some tendency to focus on one's feelings and reactions. In some cases, this increased self-awareness induces negative evaluations of private experience and is associated with increased physical symptomatology (Fenigstein et al., 1975; Hansell & Mechanic, 1985; Landers, 1980; Mechanic, 1983; L. Miller et al., 1981; Ward, Leventhal, & Love, 1988). For instance, Hansell and Mechanic (1984) found that introspectiveness, defined as a relatively large degree of attention focused diffusely and inward, was related to symptom reporting by adolescents (see also Mechanic &Cleary, 1980). Another example is the dispositional dimension of monitoring versus blunting (S.

Miller, 1987). S. Miller and her colleagues have suggested that high monitoring, which is defined as a vigilant scanning for threat-relevant clues, induces a greater sensitivity to new and changing physical symptoms. Thus high monitors/low blunters experience subjective symptomatological distress that is equal to that of low monitors/high blunters, even though their conditions are objectively less severe (S. Miller et al, 1988). Finally, several clinical problems have been related to the combination of catastrophizing cognitions and a strong internal focus (Ingram, 1990). A hypochondriacal response, for example, is presumed to reflect the interaction between negative affect and a selective deployment of one's attention to physical symptoms (Barsky & Klerman, 1983; Stretton &Salovey, 1989). Likewise, panic disorders are often characterized by specific patterns of bodily symptoms in combination with symptomrelevantand negativecognitions (Rachman, Levitt, & Lopatka, 1987; see also Beck, 1987; Clark, 1986; Ehlers, Margrat, Roth, Taylor, & Birbaumer, 1988; Morgan, 1983). Similar links between internal focus and somatic distress can be found in "choking under pressure" (Baumeister, 1984; Landers, 1980) and test anxiety (Geen, 1980; Hamilton, 1986; Holroyd & Appel, 1980; Wine, 1980). In summary, two assumptions seem to justify the postulate that self-directed attention increases somatic distress: first, that more somatic information is available to a "self-aware" person as a function of internally directed attention and, second, that it is this increased salience of somatic information that produces physical distress. Whether internally directed attention, sensory or otherwise, necessarily results in somatic distress is addressed in later sections. Active distraction. Willful dissociation from a noxious physical sensation can increase physical tolerance and attenuate both physiological arousal and psychological distress. In a metaanalysis of 16 studies in which attentional coping styles or instructions were compared, Mullen and Suls (1982a) concluded that distraction from an acute noxious stimulus, such as noise or cold-pressor pain, results in better adaptation to the stressor than do strategies of attention to the stressor or to one's own reaction to it. Other reviewers have concurred that distraction by external events or by an absorbing task or event, such as slide shows, waterfalls, or proofreading, often results in a greater forbearance of the stimuli. For instance, in their review of coping with pain, McCaul and Malott (1984) found that for relatively mild and shortlived pain, distraction is more effective than no attentional instructions, and the strategy's efficacy increases with its demands on attentional capacity. Likewise, Suls and Fletcher (1985) agreed that when a stressor is acute, focusing attention on some other absorbing stimulus ameliorates distress and facilitates tolerance more than does no instruction, attention to the self, or attention to the stressor. From exercise science, Morgan, Horstman, Cymerman, and Stokes (1983) found that subjects who focused on the rhythm of their footfalls while on a treadmill exercised 32% longer than did control subjects who were not trained in this distraction. Distraction underlies many psychological interventions for pain management. For example, some techniques require the patient to construct a detailed image of a relaxed and pain-free situation, and its effectiveness is assumed to depend in part on the image's involving qualities (e.g., Avia & Kanfer, 1980; Worth-

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ington & Shumate, 1981). Hypnotic suggestion may act as an aid to sharpening images that are incompatible with and distracting from the painful sensations (e.g., Barber, 1982; Greene & Reyhe, 1972). The evidence discussed in this section supports the following notions: First, when the external environment is undemanding, the relative salience of internal stimuli, which can include somatic information, is boosted, and at least a subset of these situations is associated with high levels of symptom reporting and increased reports of physical and psychological distress. Second, states that presumably reflect a high degree of selfawareness are associated with increased symptomatology and physical discomfort. Finally, active distraction from noxious physical sensations or from one's own reaction to them often facilitates tolerance of and adaptation to the physical stressor. Attention It is intuitively plausible that distraction "works," and the empirical findings converge with commonsense notions for how to cope with many types of physical discomfort. The reason why the effectiveness of a distraction strategy is limited by both the intensity and the length of the stimuli is also fairly transparent: Given only limited willful control over attention, some pain is simply too severe or chronic to ignore, and if one succeeds in doing so, it will not be for long (McCaul & Malott, 1984; Mullen & Suls, 1982a; Suls & Fletcher, 1985). Less clear, however, and worth considering in some detail are the effects of strategies that increase attention to somatic information. Evidence indicates that attention to physical sensations does not necessarily increase distress over those sensations, and under some conditions it may in fact reduce psychological distress and facilitate adaptive outcomes. Sensory monitoring defined. To understand why somatic attention can lessen distress, one must consider the type of attentional strategy used. Such an analysis was offered by Suls and Fletcher (1985), who showed that attention is preferable to distraction, especially when the stressor is chronic and when the strategy focuses on the concrete characteristics of the physical sensation rather than on diffuse physical states, such as fatigue or tension, or on emotional or cognitive responses. This distinction was originally suggested by the work of H. Leventhal and colleagues, which posited that many potentially uncomfortable events can be processed for both their concrete, sensory-informational meaning and for their emotional or threatening value (Ahles, Blanchard, & Leventhal, 1983; H. Leventhal, Brown, Shacham, & Engquist, 1979; H. Leventhal & Mosbach, 1983; see also Melzack, 1973; Melzack & Wall, 1982). Accordingly, instructions to attend to the discrete, sensory aspects of the sensationwhat H. Leventhal called sensory monitoringis presumed to produce a relatively neutral perception of the sensation at the cost of a negative and emotional interpretation of it. Likewise, attention to potentially threatening interpretations or to their frequent concomitants, such as unpleasant emotional reactions or general body tension, biases the processing of all incoming sensory information toward the experience of pain and distress. Sensory monitoring in laboratory and clinical settings. People subjected to experimentally induced pain who had been given

preparatory information about the possible concrete characteristics of their sensations reported reduced distress during the noxious stimulation (Calvert-Boyanosky & Leventhal, 1975; Johnson, 1973; Johnson & Leventhal, 1974; Staub & Kellet, 1972). Subsequently, sensory monitoring was found to be an effective strategy independent of the accuracy of this prior information; this finding thereby ruled out the possibility that a confirmation of expectancies was solely responsible for the effect. In fact, the strategy increased pain tolerance (Ahles et al, 1983; H. Leventhal et al, 1979) and pain threshold (Blitz & Dinnerstein, 1977), even when no preparatory information at all was given. Field studies on clinical pain, distress over chemotherapy, and the discomforts of medical procedures and childbirth suggest that deploying attention to the concrete, sensory aspects of the stressor decreases distress more than does either a focus on one's emotions or a focus on distracting images or tasks (Johnson, Kirchoff, & Endress, 1975; Johnson, Morrissey, & Leventhal, 1973; Kabat-Zinn, 1982, 1984; Love, Nerenz, & Leventhal, 1983; Nerenz, Leventhal, Love, & Ringler, 1984). For instance, women who engaged in sensory monitoring during childbirth registered less pain and reported more positive moods than did women in an attentional control group (E. Leventhal, Leventhal, Shacham, & Easterling, 1989). Willfully focusing on sensory information is rarely a spontaneous or intuitive strategy for dealing with chronic pain. Some evidence suggests, however, that those who use it also recruit other, more active strategies and are more ambulatory and less distressed than those who use diversionary tactics alone (Philips, 1987; Rosensteil & Keefe, 1983). For example, chronic pain patients trained in "mindful meditation"a willful, directed focus on the sensory aspects of painexperienced profound ameliorative effects that generalized beyond the episodes of focused attention. This pain relief was in turn associated with diminished anxiety; fatigue, and confusion (Kabat-Zinn, 1982, 1984). Sensory monitoring during exercise. Exercise researchers have long distinguished between awareness of somatic sensations per se and the various meanings that can be assigned to them. Furthermore, a person's interpretation of physiological arousal is a far better predictor of motor performance and psychological satisfaction than are objective physiological measurements of that arousal (Baumeister, 1984; Borkovec, 1976; Landers, 1980; Mahoney, 1979; Morgan, 1981). Thus a high degree of somatic awareness does not necessarily impair athletic performance, nor does it necessarily produce negative psychological outcomes. For instance, the physical arousal accompanying a platform dive can be interpreted as either fear or readiness, depending on perceived self-efficacy for the maneuver (Feltz, 1982). A broad range of emotions and evaluations can accompany a heightened awareness of physiological activity (Neiss, 1988). Indeed, a high degree of somatic awareness is often the hallmark of the successful athlete. A study of marathon and middle-distance runners is especially provocative. Morgan and Pollock (1977) reported that world-class runners carefully and systematically scan their physical sensations when running, whereas collegiate athletes prefer distracting strategies such as listing their third-grade classmates or solving mathematical

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Behavior
i.e., put on gloves, find distractor

problems. Morgan and Pollock speculated that the elite athletes' monitoring strategy allows them to accurately adduce their physiological status in relation to the demands of the race and thus to realistically fine-tune their pace, whereas the distractors, in an attempt to avoid what for them are sensations of pain and fatigue, are taking a "buy now, pay later" approach. In other words, the price of skirting a psychological wall may be slamming into the physical one. The sports and exercise research shows that successful experience with exercise is far more complex than a simple habitualion to somatic information. Indeed, on the basis of Morgan and Pollock's (1977) interview data, the somatic attention of their world-class runners seems to share many properties with H. Leventhal's sensory monitoring strategy. In an ergometer study of nonathlete college males, I explored this possibility (Cioffi, 1990c). While exercising on a stationary bicycle at a moderate intensity (graded according to fitness level), half the subjects were encouraged to examine their physical sensations in detail, whereas the other half were given control information about the equipment without attentional instructions. The sensory-monitoring subjects were instructed to systematically examine their physical sensations and to actively search for them, whether pleasant, unpleasant, or neutral. These subjects reported a large number of discrete physical sensations, rated them as highly noticeable, but were not at all distressed by them. In fact, these subjects perceived their sensations as predominantly neutral or pleasant. Furthermore, the average correlation between the noticeability of a sensation and its subjective pleasantness was positive (r = .28). In contrast, those given no attentional strategy rated their perceived sensations more negatively and found them more distressing if they were highly noticeable. Interestingly, this nonmonitoring group also attributed a larger proportion of their physical sensations to pathological sources such as possible health problems or to being extremely out of shape, whereas monitoring subjects labeled their sensations as appropriately exercise induced. In summary, one can experience distress over physical sensations even when perceptual awareness of them is not particularly acute. Likewise, a specific type of somatic attentionthat which focuses on the concrete properties of the sensationcan result in an acute somatic perception but little distress over the somatic information that is perceived. Taken in sum, the evidence cited in this section suggests that a quantitative head count of perceived physical sensations is at least indeterminate to psychological distress.

Mediators
goals, affect, coping strategies, dispositions, motivation

Prior Hypotheses
i.e., concerns about illness

Attributions perceived causes and consequences

Somatic Label
i.e., "cold hands"

Physical State
i.e., drop in hand temperature

Figure I. Components of somatic interpretation. (Arrows indicate paths of influence for both [a] meaning assignment, as when a prior hypothesis of illness induces a pathological label fora perceived sensation, and[b] perceptual attention, as when the same hypothesis induces a search for relevant information, thus amplifying somatic awareness in general. Also, perceptual attention has several potential targets; it can be deployed toward or away from any component of the interpretive processes. Finally, situational influencesincluding the relative intensity of internal and external stimuliact on an interpretive system of interrelated components, rather than on any component in isolation. Thus although there are several points of variance between the awareness of a physical sensation and a particular interpretation of it, the relationship is sometimes relatively overdetermined.)

Illustration

A Cognitive-Perceptual Model of Somatic Interpretation

Are the findings on attentional strategies contradictory? It is suggested that if we remain seriously confused over answering the question "Does distraction or attention work?" we have failed to ask the more basic question "Distraction from or attention to what?" More specifically, we must distinguish a person's attention to physical sensations from his or her contemplation of their possible meanings, implications, and sources and consequences. Before discussing specific areas in which this distinction is easily blurred, I turn to an exposition.

Somatic interpretation is a multiprocess elaboration upon a real or perceived physiological state. This elaboration is best characterized as an interaction between stimulus-driven and top-down processes, as depicted in Figure 1. The following scenario illustrates how these processes can interact to produce multiple somatic interpretations, given the same physical stimulus (in the text that follows, the major components of the model appear in italics). While bicycling to the office, my hand temperature drops 0.5 (the objective physical state). If I am obsessing about the lecture I must give, or if my route is marked by potholes, or if an

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old knee injury is acting up, I may never notice the relatively mild physiological change in my hand; the competition for my fixed attentional capacities is, in this case, among several compelling internal and external events. But suppose that both my mind and my path are clear of competing clutter. I will most likely become aware of the physical sensation of cold hands, and this basic somatic label is now part of my attentional field. Once it is noticed, I will almost invariably attributelhe sensation to something. If I believe that my hands are cold because my circulation is bad, then the sensation becomes a symptomevidence that something is wrong with me. I could arrive at this symptomatological attribution in one of two ways. First, the sensation of cold hands could confirm a pre-existing belief ("I've suspected 1 have poor circulation, and this is further proof "). Indeed, if I had been worryingabout my health before beginning my commute, I would be actively searching for information that had a plausible bearing on this concern. In this case, a pre-existing hypothesis about my health affects both my awareness of and my attribution for the sensation. Alternatively, the perceived physical sensation could become the event for which an attributional search is launched. In either case, my sketchy self-diagnosis will include the consequences that I imagine are possible outcomes to my hypothesized malady. My attribution for the sensation need not be symptomatological, however. If I believe that my cold hands are a normal response to the fall chill in the air, the somatic label will not be interpreted as a symptom, as the word is usually understood. Rather, it will be viewed as an appropriate physiological response to the external environment. Likewise, I could believe that all my blood has gone to my hard-working leg muscles, and thus I would be making an attribution that supports a hypothesis of fitness. Even given a fixed somatic perception and an attribution for it (i.e., "my hands are cold, and it is due to poor circulation") my behavioral (and psychological) response to this construal will also depend the mediators of thought and action, such as my mood, my coping repertoire and choices, and my general and situation-specific goals. For example, I may choose (or be prone) to respond to the threat of illness by actively distracting myself, or I may be compelled to do so today because of the importance of the upcoming lecture. Similarly, feeling inefficacious about my dealings with doctors will inspire particular short- and long-term strategies, as well as inform several other cognitive and emotional evaluations that I make. Guiding Principles This illustration makes four critical points. First, a 0.5 change in peripheral temperature can produce no somatic awareness at all or, even given the same basic somatic label of "cold hands," several different interpretations of it. Second, any stage in this processfrom becoming aware of a physical state to labeling, interpreting, and responding to itcould plausibly affect several others; anxiety over the prospect of disease, for example, could constrict blood flow, thus lowering peripheral temperature even more. Third (by extension), the top-down influences of prior hypotheses, attributions, perceived consequences, goals, and coping repertoires can themselves affect, among other things, the degree of subsequent attention that is

deployed to the actual somatic sensation. Fourth, attention itself has several possible targets. Attention can be deployed toward or from any component of the overall processa health hypotheses, an emotional response, an elaborated interpretationnot just toward or away from the somatic sensation itself. Clearly then, failure to distinguish between these multiple processes and their interactions can produce an interpretive tangle to researchers. Unraveling this tangle is aided by the following notions: First, an experimenter may intend or believe that an attentional manipulation (or disposition) operates on "the perception of physical sensations," but if the manipulation inadvertently (or unavoidably) results in an increased salience of an interpretation, then it is that interpretation that is magnified by the attentional manipulation. Second, if a person's health hypothesis is clearly pathological, the perceived consequences are particularly pernicious, and the coping skills are particularly weakin other words, if the top-down bias is strongly negativethen attention to the physical sensation component of this construal is more likely to increase distress, and any attempts at distraction are less likely to succeed. In summary, there are several potential points of variance between the perception of a physical sensation and any particular interpretation of it. Nonetheless, strong situational and topdown influences sometimes overdetermine the relationship between them. Thus one must critically evaluate the assumption that increased internal information is isomorphic to increased somatic information and that increased somatic information is necessarily distressing. I now turn to the components of somatic interpretation in more detail and discuss the methodological and theoretical issues that they raise. Features of the Physical Stimulus The choice of an experimental stimulus defines the range of interpretations that subjects can plausibly make of it. Interpretations of cold-pressor or ischemic pain are relatively overdetermined, and inherently noxious physical sensations are those most easily managed by medical interventions and by distraction strategies (McCaul & Malott, 1984). In contrast, irregular, ambiguous, unpredictable, and diffuse physical sensations are the more common challenge of daily corporeal life, and they may also characterize situations in which a sensory monitoring strategy is most effective (Cioffi, 1990c; Suls & Fletcher, 1985). In the final sections of this article, I briefly discuss cardiac rehabilitation and multiple sclerosis as provocative venues for applied research. In the laboratory, the use of stimuli such as vibration, pressure, and mild exercise broadens the applicability of research findings. Just as critically, they allow one to study situations outside the limited range of experience in which simple distraction is transparently effective. A second stimulus issue pertains to the experimental control of its intensity. As the top-down influences of Figure 1 show, the perceived intensity of a physical stimulation is affected by one's interpretation of it. Thus a confound may result if subjects selfselect a stimulus intensity on the basis of their a priori or manipulated construals. For example, if exercise bouts are not controlled and relativized by fitness levels, fit and sedentary subjects will differ in their physiological activation, and their opportunities for the perception and interpretation of their sen-

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sations will systematically differ. This self-selection, in turn, is intimately related to the somatic interpretation that each subject is prone to make. Statistical covariance analyses or a simple observation of differences on this factor do not replace a firstorder experimental control. In the case of an exercise manipulation, it is possible to relativize workloads in such a way that all subjects are working, for instance, at 60% of their aerobic capacity for a fixed amount of time (Astrand & Rodahl, 1977). The calibration of other physical stimuli is a necessary step toward explicating the microprocesses of somatic interpretation, yet to date this basic methodological research has not been done. The Direction of Attention Attention to the specific concrete properties of a physical sensation has different effects than does attention to its cognitive elaboration, to diffuse inner states, or to one's emotional reaction. Past analyses, however, have not always distinguished between these attentional foci. For instance, Mullen and Suls (1982a) denned attention as "the focusing attention on the stressor and/or one's reaction to if (p. 43; emphasis added). One would expect such a definition to produce variable or perhaps conflicting results. Sensory monitoring might ameliorate distress, whereas attention to one's "own reaction," if that reaction is negative, will amplify it. A related problem exists in interpreting the finding that selffocus results in symptom reporting and somatic distress. Many introspective dispositions share common variance with negative affectivity, depression, and anxiety (Barsky & Klerman, 1983; Costa & McCrae, 1987; Ingram, 1990; Tellegen, 1985; Watson & Clark, 1984; Watson & Pennebaker, 1989). For example, the definition of high monitoring according to S. Miller and colleagues is a vigilant scanning for //irea;-relevant cues (S. Miller, 1987; S. Miller et al, 1988). Thus the disposition may reflect at least as much tendency to construct and attend to pathological somatic interpretations as to somatic sensations per se. This is an important phenomenon to be sure, but it can contaminate rather than illuminate the role of somatic attention in somatic interpretation. Wicklund and Gollwitzer (1987) offered an excellent commentary on the general form of this argument, noting that research on self-focused dispositions often fails to distinguish between the direction of attention and its content. One may raise the question of whether there is indeed such a thing as a "purely directional" attentional manipulation. Is it possible to be aware of a sensation on any level in the absence of some degree of interpretation? The answer is most certainly no. Even a basic somatic label such as "cold hands" is an assignment of meaning to a perceived physical state. This notion is not at all incompatible with the present model, which illustrates that although some categorization has to occur to produce a somatic label, certain other categorizations do not occur if a somatic label is indeed all that is produced. Furthermore, the model specifies that a basic label assignment may be more or less free from top-down influence. Although people often forgo this basic semantic labeling, proceeding almost immediately to a causal attribution, they do so to greater or lesser degrees. Somatic representations are dynamicthey can be created, maintained, and changedand a physical sensation initially

perceived in light of one hypothesis can eventually become evidence for another. Thus primary appraisals such as semantic labeling can and should be distinguished from those processes that result in more elaborated meaning and inference (e.g, Lazarus & Folkman, 1984). In viewing top-down and bottom-up influences as both relative and interactive, the model also reflects much of what is known about perceptual attention in general. People exhibit the ability, and the propensity, to filter their perceptual attention, selectively processing stimuli according to its rudimentary features and meaning (Broadbent, 1958; Treisman, 1964). The perceived context of a stimulus is particularly influential in determining how much attention is deployed to it and the cognitive sets with which it will be interpreted (Norman, 1969; also see Neisser, 1976, 1982). Some theories of attention generate predictions that are particularly relevant to, and testable within, the current model. An example is the effect of physiological arousal on the scope and acuity of perceptual focus. Initial interpretations of an unpleasant sensation can most certainly induce anxiety, which in turn can narrow the attentional field, limit usable cues, and affect the subsequent precision of willful attentional control (Broadbent, 1971; Easterbrook, 1959; Kahneman, 1973). Exercise, illness, drugs, or a medical procedure can also directly affect physiological arousal and thus may influence attentional processes even without the mediation of emotional effects. Whereas these arousal-attention relations have been examined for test anxiety (Geen, 1980; Hollandsworth, Kirkland, Jones, VanNorman, & Glazeski, 1979; Holroyd & Appel, 1980; Wine, 1980) and for skilled performance (Baumeister, 1984; Feltz, 1982, 1988; Neiss, 1988; Nideffer, 1976), the attentional role of physical arousal remains largely unexplored in the domain of somatic interpretation. The Content of Attention Attributions and prior hypotheses. People organize events into causal units and according to their prior theories, beliefs, and expectations (Abelson, 1976,1981; Fiske & Linville, 1980; Kahneman, Slovic, & Tversky, 1982; Lord, Ross, & Lepper, 1979; Nisbett & Ross, 1980; Schank & Abelson, 1977). Manipulating a cognitive set or biasing causal attributions toward a particular somatic hypothesis increases selective attention to information that is hypothesis relevant and often biases the interpretation of that information toward a confirmation of the hypothesis (Snyder&Gangestad, 1981). Selective attention implies that higher order somatic interpretations influence the perception of physical change, as when concerns about one's health induces an active search for hypotheses-relevant clues. The labeling/interpretation bias proceeds from the hypothesisderived somatic perception to a strengthening of the hypothesis itself: namely, by using the already-labeled sensation to confirm a causal hypothesis. Thus, providing an illness label or putting an illness hypothesis in mind causes people to selectively search for sensations associated with that illness and to interpret incoming sensory information relative to it (Anderson & Pennebaker, 1980; H. Leventhal et al., 1980,1982; Pennebaker & Skelton, 1981). For instance, after being toldfalselythat their blood pressure was "a little high for their age," a group of college students

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reported having experienced more hypertensionlike symptoms in the previous 3 months than did those who were told that their readings were normal (Zimmerman et al., 1984). In another study, half the subjects, running in place, were told that it was flu season. After exercising, those given the flu information reported more flulike symptoms in relation to exercise-related symptoms than did subjects who were not given the flu information (Pennebaker, 1982). A positive feedback loop between selective attention and a labeling bias can produce some powerful social phenomena. For instance, "medical students' disease" and "mass psychogenie illness" are situations in which salient environmental factors induce selective attention to and the pathological interpretation of what would otherwise be background or baseline somatic information (Colligan, Pennebaker, & Murphy, 1982). This notion also illuminates some cultural patterns in symptom reporting, in which social norms for the meaning of certain sensations produce different responses to them (Tursky & Sternbach, 1967; Zola, 1973). On the individual level, some theorists view hypochondriasis as the tendency to interpret a large proportion of both internal and external information in illness-related terms (e.g., Barsky & Klerman, 1983; Ladee, 1966; Stretton & Salovey, 1989). Situations! constraints on somatic representations. Once a label has been assigned to a physical sensation, other belief structures follow. People hold fairly elaborate mental representations of their physical states, and these representations provide the basis for coping plans and actions (Becker, 1974; Croyle & Ditto, in press; Lau & Hartman, 1983; E. Leventhal et al, 1989; H. Leventhal et al, 1980; 1982; Safer, Tharps, Jackson, & Leventhal, 1979). As active self-diagnosticians, people use these representations to construct causal, covariational, and consequential inferences from their symptoms. These inferences, in turn, affect what people do in response to the perceived health threat and how they feel about it (Cioffi, 1989, 1990a, 1990b; Ditto et al, 1988; also see Skelton & Croyle, in press). As is the case with any complex cognitive structure, illness representations are closely affiliated with the situation in which they occur (Fiske, 1982; Higgins & McCann, 1984; King & Sorrentino, 1983; Showers & Cantor, 1985). Research on attentional strategies has spanned various clinical and laboratory domains, yet not enough weight has been given to the contextual effects of these experimental venues. Most clinical situations are anything but neutral: Why someone needs physical therapy cannot be trivial to the feelings that it evokes; the representation of physical sensations arising from a gynecological exam necessarily differ for the joyful mother-to-be and the woman at risk for cervical cancer. Situational cues carry considerable power to overdetermine somatic interpretation. Thus contextual features are bound to influence the efficacy of attentional strategies as well. McCaul and Malott (1984) observed that distraction is generally less effective at reducing subjective distress in clinical settings than in laboratory studies, and they suggested that this is because "the emotional context of field and laboratory settings differ widely" (p. 522). Indeed, most clinical settings are strongly associated with schemata of illness or pathology and are also most likely to be accompanied by particularly intense physical stimulation. It is not surprising, then, that the corpus of findings on atten-

tional strategies, across experimental venues, seems weak or equivocal. A major challenge clearly lies in identifying dimensions that are important in this contextual variability. Ideally, laboratory efforts should be directed toward understanding the particular assessments that underlie situational effects, thereafter testing their influence with a degree of a priori theory. In the meantime, a healthy respect for situational influences should be central to any review, meta-analysis, or new research on somatic interpretation. Coping Strategies and Goals The goal in facing laboratory-induced pain is usually transparent and well-defined: namely, to tolerate it as long as possible. In contrast, real-life situations may entail any number of global or situation-specific aims (e.g. Showers & Cantor, 1985). A person in chemotherapy, for example, may plausibly respond to different goal levels at different junctures during treatment. Resisting the sick role may result in the person's collecting information about his or her condition, whereas on another day, or for another person, a more proximal or instrumental goal, such as getting through an important meeting, may identify distraction, reinterpretation, or denial as the strategy of choice (Nerenz & Leventhal, 1983; Nerenz et al, 1984; Safer et al, 1979). Regardless of the goal, personal strategies and competencies in reaching it perforce come into play. Some psychological constructs generate relatively clear predictions for how they might operate in the somatic domain. For instance, a preference for blunting tactics should favor distractive strategies, whereas planful problem solving would probably entail somatic attention, at least to the degree that it facilitates choice and instrumental action (Folkman & Lazarus, 1988; E. Leventhal et al, 1989; S. Miller, 1987). Some constructs, however, have yet to be fully mined for their potentially potent contributions to somatic research. For example, a person may exhibit high tolerance for the cold-pressor task and also exhibit a high degree perceived self-efficacy for "managing cold-pressor pain" (Bandura, 1986). Yet, at least four psychological processes could be responsible for the observed relationship between perceived self-efficacy and the behavioral outcome: (a) As perceived self-efficacy decreases anxiety and its concomitant physiological arousal, the person may approach the task with less potentially distressing physical information to begin with; (b) the efficacious person is able to willfully distract attention from potentially threatening physical sensations; (c) the efficacious person perceives and is distressed by physical sensations but simply persists in the face of them; and (d) physical sensations are neither ignored nor necessarily distressing but rather are relatively free to take on a broad distribution of meanings. Thus, the self-referent mediations of self-efficacy may range from decreasing the intensity or amount of one's initial physiological stimuli, to the ability to distract, to stoicism, to a change in the interpretation of a physical sensation. Each of these processes would have unique implications. For instance, self-efficacy as distraction may facilitate performance in the short run if that performance does not depend on having detailed somatic information (Landers, 1980; Morgan, 1981; Neiss, 1988;

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Nideffer, 1976). Self-efficacy as stoicism may be inappropriate when behavioral perseverance is dangerous (Ewart et al., 1986; Ward et al, 1988), and self-efficacy as a positive interpretive bias may be that mechanism responsible for the instigation and maintenance of long-term behavioral change and the facilitation of coping flexibility (Bandura, 1986, in press-a, in press-b; Calvert-Boyanosky & Leventhal, 1975; F. Cohen & Lazarus, 1973; Folkman & Lazarus, 1988). This example also illustrates that the very definition of an "adaptive" outcome depends on the full implications of various coping strategies and actions. A coping process may address long-term or short-term outcomes, the regulation of behavior or of affect, the influence of instrumental or abstract goals, and the salience of subjective or objective appraisals (Showers & Cantor, 1985). Thus a recovering cardiac patient who runs 3 miles has successfully responded to the challenge to run 2 but will not have coped adaptively if the overexertion is medically dangerous (Ewart et al, 1986). Distraction from arthritic pain may facilitate normal day-to-day functioning, but if the distraction is chronic and unyielding, it may also mask changing physiological conditions that warrant medical attention or an adjustment in activity levels (Folkman & Lazarus, 1988; G. Schwartz, 1979). "Adaptive coping" is more than a behavioral endpoint; executing some action may be no more or no less important than its consequences or than the psychological path that one takes to get there.

Measuring Somatic Awareness The use of symptom checklists as measures of somatic perception may present a pernicious problem: Many symptom labels are already biased toward a negative or pathological interpretation. Arguably, an item such as "pounding heart" is a symptom, not a sensation. It includes subtle but discernible causal inferences and an adjective just this side of negative. Some distress over the perception of accelerated heart rate is already in the item, and those most distressed with what they have felt are most likely to endorse it as something that they have experienced. Researchers in exercise behavior have often noted that athletes have a particularly difficult time with symptom checklists and autonomic perception questionnaires, asking the experimenter for more elaboration and offering more equivocation than do nonathletes. The athlete has not failed to perceive somatic information, yet to the athlete's mind the items primarily concern excessive, inappropriate, or pathological physical responses. Debriefing discussions strongly suggest that they are struggling to accurately report their numerous and detailed somatic sensations and yet cannot honestly endorse items that seem to describe a sick, anxious, or sedentary person.' As measures of somatic awareness, symptom checklists may not allow persons to independently report what they feel and how they feel about it.

findings. A cognitive-perceptual model specifies multiple and interactive processes between a perceived physical state and a psychological or behavioral response to it, and it also illustrates the potential for invariance between them. The model attunes researchers to the following questions: What does an experimenter intendand obtainfrom an "attentional manipulation"? To what aspects of a person's total representation will the attention turn, and through what process? Will a manipulation unavoidably strengthen somatic awareness through a selective search for sensations or as a function of top-down biases? Has the situation overdetermined a particular somatic interpretation? Have we attempted to uniquely quantify and measure physiological stimulation, perceptual awareness, somatic interpretation, psychological distress, and behavioral response? In short, to paraphrase Asch (1952), does an investigation measure or manipulate an attention to the object or, instead, the object of attention? Questions like these are difficult to answer. They require tapping into subjective construals of complex situations, always a formidable task (Ross, 1987). Indeed, explicating the mechanisms of somatic interpretation is, by definition, a most challenging endeavor; it requires a methodological and conceptual partitioning of processes that are often naturally confounded and that frequently occur "all of a piece" in the experiencing person. Continued research into somatic interpretation may in fact require the development of creative and perhaps radically new methodologies. Such an evolution can proceed, however, only from modeling the phenomenon as it is understood to this point. Cognitive-perceptual principles underscore the many possible points of variance between a change in physical state and a judgment or behavior in response to it. In theory, interpretation, and design, psychologists should position themselves to detect and understand this variance, as well as to explain its absence. Many fundamental issues in somatic interpretation lie "beyond attention," namely in exploring the meaning that people assign to their physical sensations and in explicating the processes by which that meaning is assigned. Previous treatments of symptomatology, most notably those of Pennebaker, H. Leventhal, and colleagues, insist on the same presumption (H. Leventhal & Mosbach, 1983; Pennebaker, 1982), and several reviews have touched on similar arguments (McCaul & Malott, 1984; Mullen & Suls, 1982a, 1982b; Suls & Fletcher, 1985). In many respects the discussion to this point has simply made the cognitive-perceptual assumptions explicit and related them in detail to particular methodological and theoretical issues. In doing so, however, central research questions are conceptually reframed as issues of somatic interpretation rather than of mere symptomatology. This reframing also implicates new directions. The assumption that somatic awareness is necessarily distressing tends to support a unidirectional concern with when and why distraction fails. Yet perhaps the richest aspect of the cognitive-perceptual model is in the questions that it generates for when and why attention succeeds.

Summary of the Model

Disambiguating the content of somatic attention from its mere direction and degree clarifies some otherwise equivocal
1

Observations by William Morgan, Deborah Feltz, and myself.

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Sensory Monitoring: Processes and Implications Potential Mechanisms of Sensory Monitoring It is interesting to consider the implied symmetry in somatic interpretation research. Attention to sensations often seems to be that which obtains when distraction from them fails. A fixed attentional-capacities analysis can explain why this is so; when an effortful distraction decomposes, somatic awareness is the necessary result. But are all the effects of sensory attention sufficiently explained by its being viewed simply as distraction's perceptual complement? What, then, is "sensory monitoring"? H. Leventhal and colleagues have suggested that sensory monitoring works to the extent that sensation-distress associations are intercepted or disrupted, thus allowing the formation of more objective schemata (H. Leventhal et al., 1979; H. Leventhal & Everhart, 1979). Although intuitively helpful, this analysis is incomplete, for it does not illuminate the determinants of such a process. Does somatic attention simply segregate incoming somatic awareness from any immediate interpretation? If this is the case, do neutral or positive interpretations necessarily follow? Sensory attention as a type of distraction. H. Leventhal's definition implies that focusing on the objective qualities of a physical stimulus acts as a type of distraction from distressing interpretations and emotions. In terms of Figure 1, this process corresponds to an internal focus on a physical sensation at the expense of attention to any higher order interpretation of it. As a person searches for and examines discrete sensory features, fixed attentional capacities may allow the processing of little else. Thus sensory monitoring may "work" because of what it avoids or replaces. According to this notion, as the engrossing nature of an internal, somatic attention increases, interpretations of an otherwise unpleasant sensation should become less negative (and more positive only in a relative sense). Furthermore, if sensory monitoring operates simply by preventing the formation of any higher order interpretation, then the converse should also be true: namely, that concentrating on concrete somatic components should make an otherwise pleasant sensation less so. This analysis suggests that significant attentional divisions should be represented, not only along internal/external or self/ environment lines, but along a meaningful/meaningless dimension as well and that sensory monitoring drains meaning out of somatic awareness. Yet there is some reason to believe that the effects of sensory monitoring may operate through other, more active processes. For example, the effects of the strategy often generalize beyond the period of focused attention. Subjects trained in the technique during an initial coldpressor trial exhibited better tolerance times in subsequent trials, even though they were not explicitly instructed toward any particular strategy in these later exposures (Ahles et al., 1983). Other research suggests that once sensory monitoring is successfully used, its effectiveness lasts over time (Kabat-Zinn, 1982,1984; E. Leventhal et al., 1989; Suls & Fletcher, 1985). It seems unlikely, then, that all of the effects of the strategy can be accounted for by a strictly inhibitory action. Information and self-regulation. Focused somatic attention may allow for an accrual of information that would not be

available to the distracting person. This is the implied premise behind Morgan and Pollock's findings among athletes, in which an adaptive "buy now, pay now" strategy was possible only if the runner closely monitored his physiological state. To the extent that sensory monitoring provides information about actual physiological status, then, it may result in more appropriate self-regulatory behaviors (F Cohen & Lazarus, 1973; Lazarus, 1983; Lazarus* Folkman, 1984; E. Leventhal et al., 1989; McCaul & Mallot, 1984; G. Schwartz, 1979). Sensory monitoring may have an effect on emotional selfregulation as well. Through attention, one has the opportunity to note an incremental ebbing of discomfort and experience a concomitant sense of relief (E Cohen & Lazarus, 1973; Morgan & Pollock, 1977; N. Schwartz, 1990). This may be especially germane to discomfort that naturally wanes or is tied to changing activity levels, such as arthritic discomfort and some types of injury. It may also be responsible for the strong temporal advantage evinced by sensory monitoring during cold-pressor pain, which for many people gives way after some seconds to a feeling of tingling or numb pressure (Ahles et al., 1983). Someone who is monitoring the sensations may notice the qualitative change and experience both psychological and physical relief, whereas the distracting person may experience less of either. Indeed, sensory monitoring may help discriminate painful sensations from those that are merely associated with them (E. Leventhal et al., 1989). A toothache brings us to the dentist. After a shot of novocaineand as the drill draws nearwe search for distractors from the anticipated pain. Yet with occasional and transient exceptions, the sensations are more often those of pressure or vibration. Sensory monitoring may not make a trip to the dentist a pleasant experience, but it may permit a comparative truce from the effects of fearful anticipation. Perceived control. There are likely to be important psychological differences between a willful and an unwilling awareness of physical sensations, even of those that are experienced as unpleasant. The purposeful search for sensory information could provide one with a degree of perceived control not otherwise likely to occur. Genuine influence over the stimulus is not necessary; the person need only believe or feel that self-monitoring is somehow beneficial (Holroyd et al., 1984; Langer, 1983). The voluminous literature on the psychological and biological benefits of a sense of controland the pernicious effects of its absencemakes this a possibility well worth pursuing (Bandura, Ciolfi, Taylor, & Broullaird, 1988; Litt, 1988; Maier, Laudenslager, & Ryan, 1985; S. Miller, 1979,1980; Tecoma & Huey, 1985; Thompson, 1981; Wallston, Wallston, Smith, & Dobbins, 1987). When distraction fails. Many noxious physical sensations cannot be ignored for long, and attempts to distract from them either ultimately or intermittently fail. Thus sensory monitoring may facilitate adaptation through preparation (Glass, Reim, & Singer, 1971; Glass & Singer, 1972; Houston & Holmes, 1974; Johnson, 1973) and by warding off feelings of helplessness (e.g., Abramson, Seligman, & Teasdale, 1978). The strategy of distancing oneself from distress is often difficult to sustain, and its eventual decomposition can leave one feeling emotionally assaulted and out of control (Folkman & Lazarus, 1988; Lazarus, 1983).

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If there are occasional benefits to active, "confrontational" strategies, then there are occasional costs to distracting or denying ones. Indeed, emergent notions from all quarters are beginning to explicate just what some of these costs might be. Under some circumstances, negative cognitive and emotional states exhibit some benefits (F. Cohen & Lazarus, 1973; Showers, 1988; Showers & Ruben, 1988), whereas repression or denial of them can be psychobiologically pernicious (Jamner, Schwartz, & Leigh, 1988; Pennebaker, 1985; Pennebaker& Bealle, 1986; Shaw et al., 1986; Weinberger, 1990; Wolff, Friedman, Hoffer, & Mason, 1964). Most significantly, suppressing strategies can backfire, exacerbating the very problem that one was trying to avoid. In an intriguing series of experiments, Wegner and colleagues have shown that suppression of an arousing, unwanted thought, although initially effective, produces a rebound effect once the mental inhibition is released (Wegner, 1989; Wegner & Schneider, 1989; Wegner, Schneider, Carter, & White, 1987). Furthermore, the environmental objects used as distractors during suppression become "polluted" with an association to the forbidden thought (Wegner, Schneider, Knutson, & McMahon, 1989). These findings suggest that brute force attempts to distract from uncomfortable sensations, or from accompanying negative cognitions, may ultimately result in an even greater preoccupation with them. Suppression carries other disregulatory consequences. Distracting from the unpleasantness of an event as it occurs may result in memory distortions of it and may bias social perception as well (Harber & Pennebaker, 1990, in press). In addition, suppression is physiologically taxing (Pennebaker & Beall, 1986; Pennebaker & Chew, 1985; Wegner, Shorn, Blake, & Page, 1990; Weinberger, Schwartz, & Davidson, 1979) and may thus directly contribute to the development or the exacerbation of health problems (Pennebaker, 1985; Shaw et al, 1986; Wolff et al, 1964). This psychobiological component of avoidant strategies and dispositions identifies a most provocative area for future study. Levels of thought and action. Several research programs analyze how people experience their actions as a function of how they are categorized (Fiske & Pavelchak, 1986; Pennebaker, 1989; Rosch, 1973; Vallacher & Wegner, 1985,1987; Wegner & Vallacher, 1986). An action such as running 6 miles can be identified along a continuum of low complexity (i.e, "putting one foot in front of the other") to high complexity (i.e., "rehabilitating from a heart attack"). People faced with difficult or stressful task demands tend toward a lower level view of their actions, describing and experiencing them in terms of their concrete, subcomponent parts. Well-learned activities, in contrast, tend to carry larger conceptual or abstract labels (Vallacher & Wegner, 1987). The effect of such categorizations are most certainly germane to the mechanisms of sensory monitoring. It is not yet clear, however, how the constructs map onto many somatic situations. What is the high-level action identification for the act of running a marathon? Do Morgan and Pollock's (1977) data paradoxically suggest that expert athletes hold a low-level identity of their run because they focus on concrete and immediate sensory information? An alternative analysis is that attending to somatic information indicates a comprehensive use

of cues in service of the higher level action of "running a smart race" (Wegner, Vallacher, Macomber, Wood, & Arps, 1984). It is also likely that the effects of different action identifications can be confounded with the content and emotional tone of one's prepotent higher level category. Thus, for example, anxious test takers may benefit from a low-level task focus mainly because the higher level identity for their activity is fraught with anxiety and fear of failure (Geen, 1980; Wine, 1980). Given this self-view, a low-level focus facilitates performance much as sensory monitoring acts as a distractor from negative cognitions and emotions. However, several mediators of agency draw on positive and high-level views of the task and of the self, views that exert a positive top-down influence on behavior and subsequent self-assessment (Ajzen, 1988; Bandura, in press-a; Becker, 1974; Maddux, Scherer, & Rogers, 1982). Thus, intuitive or apparently face-valid definitions of an action level require empirical validation in the somatic domain. More specifically, future researchers should build on the vertical analysis of action identification by adding to it an analysis of content. On what dimensions do disparate high-level identifications differ from one another, and what are the implications of these differences according to the depth-of-processing view? Addressing these questions promises many significant insights into somatic strategies and mechanisms. In sum, there are several mechanisms by which sensory monitoring could contribute to adaptive psychobehavioral outcomes, and they are probably both complementary and interactive in many somatic situations. Active effects may include accrual of self-regulatory information and a sense of efficacy and control, whereas passive effects may provide a diversion from distressing interpretations or may operate by avoiding the pernicious consequences of both successful and failed distraction. Discussion of these mechanisms has been necessarily speculative. It is clear, however, that the speculations generate several hypotheses that marry well with a number of rich theoretical constructs. Sensory Monitoring in Clinical Applications Theoretical considerations aside, the real world awaits. Aging, illness, rehabilitation, medication, and stress often present changing, irregular, ambiguous, unpredictable, and diffuse physical sensations with which the person must cope. In this real world, sometimes it simply is not possible to distract all of the time, and sometimes it is not adaptive to do so. Following is a brief discussion of two clinical problems that may argue against somatic distraction as an exclusive strategy. Both are also promising models within which to explore the adaptive function of a particular type of somatic attention. Misattribution and cardiac rehabilitation. An estimated two thirds of heart attacks are clinically uncomplicated; that is, they leave no permanent heart damage, and within several weeks of the attack, no biological impediments to the patient's full recovery remain (Cohn & Duke, 1987). Many patients, however, never return to full functioning because they can no longer interpret the arousal of exercise, emotion, and sexual excitement in benign or positive ways (Taylor, Bandura, Ewart, Miller, & DeBusk, 1985). Given the hypothesis that they have a

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weak heart, these people reduce many indices of arousal to mere evidence of that weakness. In this situation, avoiding arousal-producing behaviors is clearly maladaptive, such a strategy being the definition of anticipatory disability. Yet distraction from the bothersome physical sensations may be an equally poor solution; imagine a doctor counseling the patient "When you start to notice arousal sensations while havingsex with yourspouse, try doing arithmetic problems, or recall your grade-school teachers." These patients are poor candidates for distraction during exercise as well; the oft-prescribed postattack exercise program is usually the first that the patient has attempted in years, and special risk factors make the consequences for overexercising very serious indeed. An ideal rehabilitation strategy would be to discourage patients from misattributing physical sensations, but to also help them remain able to fully experience and accurately monitor the sensations arising from everyday activity and emotion. Cardiac patients often perform a diagnostic treadmill stress test as part of their medical follow-up. In an interesting set of studies, this event has been used to explore attributional issues in the rehabilitation process. In one study, Ewart, Taylor, Reese, and DeBusk (1983) found that a person's perceived self-efficacy to tolerate physical exertion was more predictive of treadmill performance and of subsequent physical activity than was actual cardiac capacity. Initial self-efficacy judgments were associated with greater effort exerted during the treadmill, which in turn was associated with a greater boost in subsequent perceived self-efficacy and physical activity at home. These results suggest that the efficacious patients were heartenedliterally by signs of their treadmill exertion in that, for them, it was rich with evidence for the robustness of their cardiovascular system. Indeed, all but the most inefficacious patients benefited from a safe completion of the treadmill exercise, especially when they were bolstered by counseling in which the exercise was explained in a positive frame. The positive correlation between stimulus intensity (the degree of treadmill effort) and a strengthening of a patient's perceived self-efficacy is especially interesting; given a positive interpretive bias, more somatic information equaled more evidence for the hypotheses of fitness. In cardiac rehabilitation, then, attention to physical sensations from within a hypothesis of improvement may be more desirable than either sensory distraction or somatic habituation (Bandura, 1986). Multiple sclerosis: Separating symptom from affect. Approximately 200,000 Americans suffer from multiple sclerosis (MS). The condition, which strikes people most commonly between the ages of 15 and 55, progressively destroys the insulation of the central nervous system, and sometimes it cripples and kills. More frequently, however, those afflicted avoid serious organic impairment, but for the remainder of their lives, they are beset by a barrage of confusing and unpredictable symptoms, including sensory and motor disruptions, transient visual disturbances, urinary and sexual dysfunction, problems in balance and coordination, tremor, and profound fatigue (Poser, 1984). One of the most striking characteristics of MS is its unpredictability. A course may run from occasional symptomatological exacerbations to a constant and progressively worsening form, or to several variations in between. In the chronic-relapsing form, for instance, increasingly severe exacerbations are

superimposed on slowly worsening symptomatological baseline. Given such unpredictability, adapting or habituating to one's symptoms is a rare if not impossible achievement. To make matters worse, there are no early, reliable indices predicting which course a particular case will take (Poser, 1984; Rao, 1986). How do people cope with such circumstances? It is most significant to note that how people cope with MS can profoundly affect its course in several ways. First, extreme life stress is associated with the onset of the disease and with its exacerbations, possibly through psychoimmune effects (LaRocca, Scheinberg, & Raine, 1984; Warren, Greenhill, & Warren, 1982). Second, the physical correlates of anxiety and stress can become superimposed onto the already stresslike symptoms of the disease (Rao, 1986). Finally, anxiety or depression about one's limitations can become the source of new functional impairments. An example is the man who experiences transient impotence resulting from neural damage but whose anxiety over this impotence quickly guarantees its chronicity (LaRocca et al, 1984; Rao, 1986). There are several parallels between these phenomena and the cardiac patient, especially in the potential for anticipatory disability. For instance, a woman under emotional stress may assume that her MS is being exacerbated, and she may decide to stay home from work. But there is a unique aspect to the MS situation; not all maladaptive strategies can be traced to somatic misattributions. Exacerbations of symptoms do occur, and unlike the situation of the cardiac patient whose heart has healed, MS symptoms reflect bona fide neurological damage and physical limitation, mandating behavioral adjustments of one sort or another. Under these conditions, it is clearly desirable that patients stay as active as their limitations allow. The scientific and popular literature overwhelmingly acknowledges this imperative and offers much advice on forestalling anticipatory disability (Scheinberg & Holland, 1987; Stewart & Sullivan, 1982). Swimming is highly recommended for patients; MS itself is not accelerated by exercise, and muscle strength is an important hedge against diminishing neurological coordination. The patient who swims is certainly better off than one who does not, inasmuch as the activity is an excellent cardiovascular conditioner and produces moderate gains in muscle tone. One may ask, however, why more progressive resistance activities such as weight training are not widely prescribed, as they would produce even greater skeletomuscular strength and stability. There seem to be two reasons why this is so. First, the more anaerobic exercise of weight training reveals balance and coordination symptoms more than does swimming and, second, a rise in body temperaturewhich is avoided during swimmingtends to exacerbate the symptoms. Yet neither the presence of the symptoms nor the physical exertion worsens the disease! Thus even enlightened advice on how to combat anticipatory disability may ultimately give in to it in some degree. Much research is needed to discover whether, and under what conditions, more muscular exercise is advantageous for the MS patient. However, to the extent that interpretations of one's symptomsrather than an organic impedimentis the limiting condition for vigorous exercise, optimal physical therapies have yet to be devised. An acquaintance of mine, discussing her attempts to maintain a weightlifting regimen despite

SOMATIC INTERPRETATION exacerbated symptoms, adds encouragement for this approach. She describes a coping strategy that separates her perception of the physical severity of her symptoms from her emotional responses to them: References I got tired of telling my boyfriend that my symptoms were either "good" or "bad" that day. Somehow that just didn't convey how I felt and what I wanted to do about it. So we developed this system. When my boyfriend asks how I'm doing, I give him two numbers on a scale of 1 to 10. The first number is for the symptoms: How physically bad are they? The second number is how I feel about them emotionally. They're usually different numbers. So maybe one day my symptoms are only "3" but I'm really bummed out about them, really depressed, and every lift I do just makes me feel worse; I'll probably cut that workout short. But on some other day I might be stumbling around like crazysymptoms "8"but I just don't particularly care about them. They don't bother me all that much, and I'd rather work out. So we go on. I guess I make decisions about what to do not so much hy how badly I'm shaking, but by whether or not it bothers me that 1 am. An intuitive cognitive-perceptual theorist! This woman disambiguates her physical sensations from her psychological response to them by carefully attending to both. In this way she maintains a sense of control over her exercise activity and feels efficacious in both her physical and emotional self-regulation. It would be most instructive to investigate natural strategies such as these and the extent to which attention to potentially distressing physical sensations is a necessary component of an adaptive response to a physical limitation. Indeed, other evidence suggests that MS is an exemplary clinical model for this approach. Many long-term patients exhibit a positive adaptation to their condition, maintaining an optimistic outlook and high self-esteem that persist even in the presence of significant physical impairment (Brooks & Matson 1982). The unpredictable and variable course of MS, the physical and psychological challenges that it presents, the successful self-regulation by at least some of those afflicted, and a strong psychobiological component make this disease a fascinating and important candidate for research efforts.

37

qualify us to make unique and useful contributions to the field of health behavior.

Summary
Many phenomena of health and illness require that we understand the mechanisms and processes of somatic interpretation. The goal of this discussion is to stimulate such research and to exhibit the utility of a cognitive-perceptual model toward this end. Some apparent equivocations in the effects of attentional strategies become more tractable as the content of somatic attention is distinguished from its mere direction or degree. Perhaps of more importance, a cognitive-perceptual analysis poses many questions that await explication. Most interesting among these is how certain types of somatic attention may facilitate adaptive responses to physical stress or limitation. The complexities of somatic experience are surely daunting, and no doubt this subjective construal will defend its opacity quite well. Yet in making the attempt to understand these complexities, we advance our research beyond attentional divisions alone, moving instead toward understanding the meaning of somatic information for the experiencing person. It is there, as psychologists, that we belong; it is there that our traditions best

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Received November 12,1988 Revision received March 12,1990 Accepted Aprill 0,1990