The Oxford Handbook of Stress, Health, and Coping

Susan Folkman (ed.)

https://doi.org/10.1093/oxfordhb/9780195375343.001.0001
Published: 2010 Online ISBN: 9780199940707 Print ISBN: 9780195375343

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CHAPTER

22 Stress, Health, and Coping: Synthesis, Commentary, and

Future Directions 
Susan Folkman

https://doi.org/10.1093/oxfordhb/9780195375343.013.0022 Pages 453–462

Published: 18 September 2012

Abstract
This chapter summarizes the major developments in stress and coping research that are presented in
this volume. Lazarus and Folkman’s (1984) theory of stress and coping provides a framework for
organizing the central themes of the discussion, including problems associated with aspects of the
model, gaps in the original model, and new directions in research that have emerged in the intervening
years. Advances in understanding antecedents of the appraisal process are noted, as are problems with
the original formulation of emotion-focused coping. Future-oriented coping, interpersonal coping,
and religious and spiritual coping are introduced into the stress and coping model. The scope of coping
has been broadened to include the regulation of positive as well as negative emotion states. Meaning-
focused kinds of coping that help motivate and sustain positive well-being in the face of stress are
introduced. Strategies for examining cause-and-e ect relationships between coping and health are
discussed.

Keywords: stress, coping, emotion regulation, positive emotion, meaning-focused coping

Subject: Health Psychology, Social Psychology, Psychology
Series: Oxford Library of Psychology
Collection: Oxford Handbooks Online

Stress and coping research has undergone 30 years of vigorous growth. Earlier ideas are now more fully
developed and, as the chapters in this volume demonstrate beautifully, there is a wealth of exciting new
ideas to pursue. The emphasis in this volume is on coping. Aside from the fact that coping is an inherently
fascinating topic that provides insights into the human capacity to survive both the ordinary and
extraordinary challenges of daily living, it is one of the few variables in the stress process that lends itself to
intervention. As several authors point out, a portion of our response to stress is in uenced by aspects of our
biological heritage and characteristics of the social and physical environment over which we have little or no
 control. But our coping responses—what we think and what we do in response to stress, and to a certain
extent the emotions we feel—are at least potentially under our control. Coping is thus a critical point of
entry for protecting mental and physical health from the harmful e ects of stress and worthy of the time
and e ort the authors of these chapters have invested over the years.

In this chapter I attempt to synthesize the major ideas in this volume, summarizing what we have learned
and how we might continue moving the eld forward. I have chosen to organize these comments within a
theoretical framework. As Stroebe notes in her thoughtful review of theories related to coping and
bereavement (Chapter 8), theories o er the opportunity to test assumptions that guide stress and coping
p. 454 research, and theories also provide guidelines regarding practicalities of research design and measure
development. I nd that theoretical frameworks have an additional practical advantage: they provide a

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structure for connecting ndings from diverse studies, thereby helping to create a coherent data-based
explanatory narrative.

Several important theories are presented in this volume, including Hobfoll’s (Chapter 7) theory of
conservation of resources, Stroebe and Schut’s (1999) dual process model of coping with bereavement
(Chapter 8), Taylor’s (Chapter 5) tend-and-befriend theory, Zautra and Reich’s (Chapter 9) resilience
model, and Lyubomirsky’s (Chapter 11) theory of hedonic adaptation. However, Lazarus and Folkman’s
(1984) cognitive theory of stress, appraisal, and coping appears to have had the major in uence on research
on psychological stress and coping over the past three decades. Conveniently, it is also the model with which
I have the greatest familiarity, and so I shall use it to frame my comments.

Although the Lazarus and Folkman (1984) model has stood the test of time as a useful framework, it was not
free of problems and limitations, many of which are addressed by chapters in this volume. The chapters also
highlight ways in which the model has evolved in the intervening years and introduce new ideas that
broaden the model further. In accord with this framework, I begin with comments about appraisal and then
move on to coping.

Antecedents of Appraisal

The coping process is initiated in response to a cognitive appraisal of a situation as stressful, which means it
is personally signi cant and it taxes or exceeds the person’s resources for coping. A major strength of this
de nition is that it allows for individual di erences in the stressfulness of a given event (e.g., the departure
of the last child may be a relief to one parent and a great sadness to the other). The de nition also allows for
changes in meaning of a given event for a given individual (e.g., a job loss that is experienced once when a
person is single vs. again when he or she is supporting a family).

The appraisal is made by a person with a particular psychosocial and biological heritage at a particular
developmental stage in a particular setting, with particular personal, social, and material resources for
coping, and with other demands competing for those resources. Important theory and research has
developed our understanding of the in uence of some of these variables since Lazarus and Folkman
outlined the antecedents of appraisal in their 1984 book. Others have received less attention. Personality
variables such as optimism, pessimism, and resilience have been included in many studies, but less often
linked to the appraisal process are a number of variables brought forward in the chapters of this volume,
such as:

• “Wired-in” responses of the autonomic nervous system and the genome (e.g., Tugade, Chapter 10;
Taylor, Chapter 5)

• The person’s global belief system (Park, Chapter 12)

 • Developmental stages of control processes, and appraisal and coping skills (Aldwin, Chapter 2; Skinner
& Zimmer-Gembeck, Chapter 3)

• Gender roles (Helgeson, Chapter 4)

• Environmental, social, and material resources (Hobfoll, Chapter 7)

Speci c recommendations for incorporating these variables in research are o ered in the respective
chapters. It is important that these dimensions be considered as they are likely to increase our
understanding of variability in both the appraisal and coping process.

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Challenges of Coping

Lazarus and Folkman (1984) approached coping in terms of thoughts and actions that people used in
stressful situations. As noted in Aldwin’s (Chapter 2) review, this was a departure from earlier approaches in
which coping was de ned in terms of personality styles or defense mechanisms derived from ego
psychology. Lazarus and Folkman de ned two major coping categories: (1) emotion-focused coping, which
refers to the regulation of emotions that are generated by the appraisal process, such as anger or sadness in
response to the appraisal of loss, anxiety, or fear in the case of the appraisal of threat, and eagerness and
excitement, mixed with some worry, in the case of the appraisal of challenge; and (2) problem-focused
coping, which refers to the management of the problem itself. That formulation was the jumping-o point
for many of the chapters in this volume. Here I highlight issues with emotion-focused coping and three
major gaps in the original formulation pertaining to future orientation, religious and spiritual coping, and
interpersonal coping.

Coping with emotion-focused coping

Problems with the formulation of emotion-focused coping became evident when self-report measures were
p. 455 developed to measure it. These problems are discussed in detail by Stanton (Chapter 18). Brie y, one
problem was caused by the heterogeneity of questionnaire items asking about emotion-focused coping.
This problem had its origin in a major tenet of stress and coping theory: The evaluation of the
appropriateness of a given coping strategy should be made in the context of the stressful encounter.
Distancing, for example, is appropriate in a situation where there is nothing that can be done (as when
waiting for the outcome of an exam), but it is inappropriate when action is called for (as when preparing for
the exam). This tenet resulted in measures of emotion-focused coping that combined what on face value
appeared to be maladaptive (e.g., escape-avoidance) and adaptive (e.g., positive reappraisal) strategies. Our
rst version of the Ways of Coping (Folkman & Lazarus, 1980), which had just the two scales for problem-
and emotion-focused coping, illustrates this problem. In subsequent revisions of the Ways of Coping
(Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986), we distinguished among types of emotion-
focused coping, as did other measures of coping that followed, including the COPE (Carver, Scheier, &
Weintraub, 1989) and the Coping Inventory for Stressful Situations (Endler & Parker, 1990). Nevertheless,
many researchers still collapse diverse categories into one emotion-focused scale and one problem-focused
scale, so the problem persists.

Another major tenet of stress and coping theory held (and still holds) that coping, both in its de nition and
its measurement, had to be independent of outcomes. Nevertheless, as Stanton (Chapter 18) points out,
self-report questionnaire items assessing the regulation of emotion were often confounded with outcomes,
especially mood outcomes.
 Stanton’s Emotion Approach Coping (EAC) scale addressed both problems by directing attention to emotion
processing (EP) and emotion expression (EE), without reference to outcomes. Work with this measure has
led to important contributions about the regulation and expression of emotions during stressful
encounters, as summarized by Stanton in her chapter. The care with which the EAC was developed is
exemplary, and it is a valuable addition to the assessment of emotion regulation under conditions of stress.

Although I agree with Stanton about the problems with emotion-focused coping, I do not think those
problems negate the importance of assessing the regulation of emotion along established dimensions such
as distancing, cognitive reframing, or seeking emotional support. What is needed is a careful review of
questionnaire items to assure they are not confounded with outcomes, and careful classi cation processes
that meet both empirical and theoretical standards for coherence.

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Future-oriented coping
Although the major forms of stress appraisal set forth by Lazarus and Folkman (1984)—harm/loss, threat,
and challenge—are oriented to the past, present, and future, most measures of coping tend to be past- or
present-oriented; the future gets short shrift. Fortunately, this situation is improved substantially with the
contributions of Wrosch (Chapter 16) and Aspinwall (Chapter 17).

The pursuit of meaningful goals is by de nition future-oriented; it is also central to well-being. However,
not all goals are feasible, nor do all goals retain their value over time. Adaptive coping requires that people
recognize when goals are no longer tenable or valuable and then disengage from those goals and re-engage
in alternative goals that are realistic and meaningful. Although Lazarus and Folkman (1984) discuss goals,
they did not elaborate the process of goal revision. Wrosch (Chapter 16) provides an excellent review of
theory and research on goal revision with very helpful discussion of the details of the disengagement
process, including withdrawing both e ort and commitment, and the re-engagement process, including
identifying, committing to, and pursuing alternative goals.

A major question, however, still needs explication: How do we decide when to give up a goal? We tend to
value persistence in pursuit of socially approved goals. Our heroes are athletes who overcome physical
handicaps in pursuit of gold medals, entrepreneurs who invest all their resources in a zany new concept,
scientists who pursue a hypothesis that is judged by peers to be absurd. When does persistence turn into
counterproductive obstinacy? How do we know when to quit? I hope that Wrosch and others who are
studying goal processes pursue this perplexing question.

Another form of future-oriented coping is proactive coping, which is based on the assumption that one can
proactively minimize or prevent future stress and promote favorable outcomes. Aspinwall (Chapter 17), who
has done a great deal to develop the theory and research in this area, provides an excellent overview. Some
might question whether it is possible to have coping in the absence of stress. I think of proactive coping as
preventive coping, and consider it an important addition to the stress and coping model.

p. 456 What is particularly appealing about proactive coping is that it lends itself beautifully to prospective
research designs. It is theoretically sensible to ask whether proactive coping at Time 1 a ects the frequency
of unwanted events or states that are the object of the proactive coping at Time 2. The proactive coping
research related to health outcomes reviewed by Aspinwall is a case in point. Below I comment on the
challenges involved in establishing causal links between coping with ongoing stress and future outcomes.
Religious and spiritual coping
Although Lazarus and Folkman (1984) mention religious and spiritual beliefs in relation to coping
resources, very little is said about the use of religion and spirituality for coping. The original Ways of Coping
(Folkman & Lazarus, 1980), for example, did not contain any items pertaining to religious coping.

Pargament’s 1997 book, The Psychology of Religion and Coping: Theory, Research, Practice, changed this
pattern. Pargament not only provided a framework for research on religious coping, but he also seems to
have legitimized the study of religious coping for many psychologists who had previously been squeamish
about researching this topic. In the intervening years research on religious and spiritual coping has
burgeoned, as summarized by Pargament (Chapter 14) and Ironson and Kremer (Chapter 15). Religious

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coping appears to be distinct from secular coping, adding an important dimension to the coping process.
The e ects of religious coping cannot be fully explained by more basic social, physiological, and
psychological variables, although Ironson and Kremer suggest a process through which spirituality can
confer bene ts, especially in the case of serious illness. However, like its secular counterpart, religious
coping can have both bene cial and harmful e ects on mental well-being and physical health. Clearly,
assessments of religious and spiritual coping should be included along with assessments of secular coping.

Interpersonal coping
Any recommendation that is o ered independently by multiple authors in this volume deserves close
attention. One such recommendation concerns interpersonal coping processes, an area that was not fully
addressed in Lazarus and Folkman’s (1984) model. Helgeson (Chapter 4) discusses co-rumination; Skinner
and Zimmer-Gembeck (Chapter 3) talk about social processes involved in the acquisition of mastery coping.
Aspinwall (Chapter 17) o ers compelling reasons for exploring interpersonal aspects of proactive coping, as
does Park (Chapter 12) with respect to meaning-making. Stroebe (Chapter 8) points to the importance of
clarifying features of pre-bereavement relationships in explaining the subsequent adjustment of the
surviving partner, presumably including the ways in which they coped with their shared stressors.
Pargament (Chapter 14) recommends that we turn to interpersonal religious coping.

Revenson and DeLongis (Chapter 6) have developed special expertise in dyadic coping, a topic to which they
devote their chapter. In dyadic coping, the members of the couple participate in an interactive coping
process that plays out in a context of psychological interdependence, or mutual in uences. Revenson and
DeLongis review a bevy of theoretical models of dyadic processes, and it does not take long to realize that
the study of these processes confronts the researcher with formidable challenges. Fortunately, Revenson
and DeLongis and others who conducted research in this area were not daunted, and Revenson and
DeLongis’ review of research in this area is very engaging. Questions raised by Revenson and DeLongis, such
as what are the roles of empathy, engagement, and congruence in dyadic coping, point both to the
complexity of the interactive coping process and to the rich insights it can provide regarding the ways in
which the couple as a dyadic unit confront stressors in their lives. Revenson and DeLongis also provide very
helpful direction regarding measurement and analysis. The work on dyadic coping is an important
contribution to the eld.
 Broadening the Scope of the Stress and Coping Model: Beyond
Negative Emotions

A dramatic shift in thinking about the stress process began to appear in the mid-1990s. Zautra and Reich
(Chapter 9) refer to the shift as “a sea change” that “has now opened up new horizons by bringing to the
fore conceptualizations and measurement of the strengths of people and their societies rather than
attending solely to their weaknesses.” I agree with Zautra and Reich regarding the signi cance of this sea
change; it has had implications for virtually every aspect of the stress process, especially coping and
outcomes.

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p. 457 The sea change had a number of sources: interest in the adaptive functions of positive emotions with
respect to broadening resources for coping and “undoing” the sympathetic arousal created by negative
emotions (Fredrickson, 1998; Fredrickson & Joiner, 2002; Tugade, Chapter 10); observations that positive
emotions co-occurred with negative ones even in the most dire of circumstances (Folkman, 1997; Folkman
& Moskowitz, 2000; Moskowitz, Chapter 20) and contribute independently to adaptational outcomes
(Moskowitz, Chapter 20; Tugade, Chapter 10); and observations that many people nd positive meaning and
perceive growth and bene t as a result of their stress (Helgeson, Reynolds, & Tomich, 2006; Tennen &
A eck, 1998; Pakenham, Chapter 13; Park, Chapter 12).

Zautra and Reich (Chapter 9) place the concept of resilience at the vortex of this swirl of observations.
Resilience is another of those ideas touched upon independently by several authors, including Litt, Tennen,
and A eck (Chapter 19), Lyubomirsky (Chapter 11), Park (Chapter 12), Skinner and Zimmer-Gembeck
(Chapter 3), and Tugade (Chapter 10), re ecting the widespread interest in this response to stress. Despite
the number of di erent discussions about resilience, Zautra and Reich point out that there is widespread
agreement that resilience includes recovery, sustainability, and growth.

Until recently, resilience has been studied primarily in terms of stable aspects of personality and social
network, with reference also to genetic and neural underpinnings (Lyubomirsky, Chapter 11; Tugade,
Chapter 10; Zautra and Reich, Chapter 9). Tugade, for example, reviews evidence of neural and autonomic
correlates of resilience, and there is substantial support for the notion of resilience as a trait.

Now researchers are turning their attention to actual coping processes that sustain positive well-being,
promote recovery, and provide opportunity for growth. The developments in this area are leading to a fuller
understanding of the scope of coping, especially in relation to chronic stress that persists over time, with
the potential for exhausting the person’s coping resources.

Finding positive meaning in the stress

The past 10 years have seen a surge of interest in meaning-making coping strategies for wresting
something good from something bad. Meaning-making coping typically draws on values, goals, and beliefs,
both global and situational (Park, Chapter 12). This coping category is explored in chapters on meaning-
making and made meaning (Park, Chapter 12), bene t- nding and sense-making (Pakenham, Chapter 13;
Tugade, Chapter 10), religious coping (Pargament, Chapter 14), and goal processes (Wrosch, Chapter 16).
Hobfoll’s (Chapter 7) discussion of engagement, de ned by Schaufeli (2002) as “a persistent, pervasive and
positive a ective-motivational state of ful llment in individuals who are reacting to challenging
circumstances,” is an interesting complement to this list. Not all meaning-making processes support
positive emotions, but many do, such as nding resolution, reappraising the meaning of the stressor,
perceiving growth or positive life changes, and pursuing meaningful goals.
 Elsewhere, I have stated that the meaning-making coping described above, which I call “meaning-focused
coping,” is a third function of coping that is distinct from problem- and emotion-focused coping (Folkman,
1997; Folkman & Moskowitz, 2000; Park & Folkman, 1997) and is an important addition to the original
stress and coping framework. I have hypothesized that meaning-focused coping becomes especially
important in stressful situations that are prolonged or chronic, where problem- and emotion-focused
coping fail to make things better. Under these conditions, meaning-focused coping reminds the person of
his or her values, goals, beliefs, and commitments, and this connection helps sustain coping e orts
(Folkman, 1997; Park & Folkman, 1997). Moskowitz (Chapter 20), for example, notes that the more
distressed the person is, the more meaning-focused interventions boost positive a ect. This boost can in
turn motivate subsequent coping.

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These ideas have been incorporated into the stress and coping model (Folkman, 1997; Folkman &
Moskowitz, 2000), and evidence in their support is beginning to accumulate (Folkman, 2008). The timing of
meaning-focused coping e orts may be a key to understanding an individual’s ability to generate and
sustain positive well-being during prolonged periods of stress, as well as his or her ability to recover once it
is in the past. This is another feature of the coping process that should be taken into account, especially
when studying coping with chronic stress.

Attending to the positive while dealing with the negative

Lyubomirsky (Chapter 11) comments that there is a natural process through which people adapt to both
p. 458 positive and negative life changes with fading of the associated positive and negative emotions, the
positive emotions fading more quickly than negative ones. In short, positive emotions, or for that matter
negative emotions, do not sustain themselves.

These observations lead directly to the question of how to keep positive emotions alive while dealing with a
stressor. Tugade (Chapter 10) comments that resilient people may actively cultivate positive emotions to
downregulate distress and describes several practices for this purpose. One general strategy Lyuobmirsky
recommends is to actively try to generate, or be open to, unexpected and variable experiences. Another is to
engage in practices that delay adaptation to positive emotions once they occur. Examples of such practices
include gratitude meditations; appreciative attention, as in savoring a positive moment; and positive
thinking. Moskowitz (Chapter 20) reviews the rapidly expanding literature on these and other practices,
including acts of kindness, forgiveness, reminiscence therapy, positive reappraisal, positive a rmations,
goal-setting, yoga, meditation, and exercise, in her comprehensive review of interventions to boost positive
a ect. This literature is still young, but as Moskowitz’s review indicates, it is growing rapidly with some
promising implications for health.

What is signi cant about the strategies for maintaining positive states described by Lyubomirsky, Tugade,
and Moskowitz is that often these strategies are not directed at the immediate stressors, but elsewhere at
positive events, conditions, or changes in the person’s life—past, present, or anticipated. This approach is
entirely consistent with the idea that positive events and emotions can co-occur with negative ones, and
that the positive emotions can help sustain the individual’s e orts to cope with ongoing stress.

Studies of coping should routinely include questions about positive events or changes happening elsewhere
in people’s lives (Moskowitz, Chapter 20). Such questions may go far in helping us understand how people
are able to persist in stressful situations, such as caregiving for a spouse with Alzheimer’s disease, that do
not improve over time.
 Coping, Health, and Well-Being

An important reason for studying coping is its hypothesized role as a mediator of the e ects of stress on
mental and physical health. The case for a relationship between coping and psychological outcomes is
substantial. Virtually every chapter in this volume provides evidence of this robust connection. The
connection between coping and physical health is less well documented, except in the instances described
earlier in which coping is directly health-related.

Lazarus and Folkman’s (1984) model discussed health outcomes in general terms. The model did not specify
causal mechanisms. Investigations of this question tend to be formulated ad hoc, without much attention to

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approaches that can help forge links among studies.

How do we know when coping has an e ect?

The ultimate demonstration of a cause-and-e ect relationship is a randomized controlled clinical trial.
Such a trial has the advantages of randomization and a control condition to help rule out alternative
hypotheses regarding cause-and-e ect relationships. Fortunately, coping lends itself to intervention.
Coping skills can be taught along the lines of cognitive-behavioral therapy, and the chapters in this volume
provide many examples (e.g., cognitive-behavioral stress management [Antoni, Chapter 21], proactive
coping interventions [Aspinwall, Chapter 17], spiritual and religious coping interventions [Ironson &
Kremer, Chapter 15; Pargament, Chapter 14], and positive meaning coping interventions [Lyubomirsky,
Chapter 11; Moskowitz, Chapter 20; Pakenham, Chapter 13]).

Two tasks must be addressed to determine whether coping a ects outcomes: (1) There needs to be a way to
determine whether coping has changed, and (2) There needs to be a plausible map showing pathways
through which coping can a ect outcomes.

Determining changes in coping

Litt et al. (Chapter 19) comment that the best way to show that coping in uences outcomes is to show that
changes in coping are related to changes in outcomes. This objective is best achieved by assessing coping
that pertains substantively to both the stressful context and the outcome of interest. Litt et al., for example,
review a number of intervention studies in the elds of pain and addiction that failed to produce evidence
that changes in coping were associated with changes in outcome. Based on their review, they developed
coping measures tailored to the nature of the stressor and the outcome of interest, such as thoughts and
actions related to drinking in response to the o er of a drink in the case of alcohol addiction. By tailoring the
p. 459 assessment of coping to the context and a speci c outcome (in the case of alcohol addiction, did the
person draw on the preferred cognitive coping strategies and refuse the drink), it was possible to determine
that in fact changes in coping were related to changes in the outcome.

The design described by Litt et al. (Chapter 19), however, is often not feasible. Many studies have samples
dealing with stressors that are complex and dynamic, such as those associated with bereavement (Stroebe,
Chapter 8), chronic illness (Antoni, Chapter 21; Ironson and Kremer, Chapter 15; Pakenham, Chapter 13),
and existential uncertainty (Pargament, Chapter 14). Under such circumstances it is di cult to measure
changes in coping in a way that is meaningful, because what the person is coping with is also changing. How
do you interpret the change in coping? Is the change due to the intervention, or to change in the stressor, or
to both? For example, Chesney and I and our colleagues (Chesney, Neilands, Chambers, Taylor, & Folkman,
2006) originally tried to measure changes in coping by holding constant what people were coping with, such
as a chronic interpersonal problem. But we found that there was no such thing as holding a stressor
constant. Situations change, and even a transaction that involves the same people in contention over the
 same issue (i.e., one member of a dyad is always late), the situation at Time 1 does not remain frozen in
time; the dynamics will di er at Time 2, even if only minutely.

A way around this problem is to identify surrogate markers of the coping process (variables in which change
must occur if there is to be change in coping) and to examine their shifts over time. For example, in the
study mentioned above (Chesney et al., 2006), we assessed changes in coping self-e cacy regarding the
coping principles we were teaching rather than actual coping processes. These changes were associated with
the intervention and mediated psychological outcomes. In a study of a program for pain coping, Litt et al.
(Chapter 19) note that self-e cacy expectancies explained more pain outcome variance than did coping.
Thus, coping self-e cacy may serve as a surrogate in studies that aim to measure changes in coping.
Another example is provided by Wrosch (Chapter 16), who assesses capacity for goal engagement and

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disengagement rather than the engagement and disengagement processes themselves.

Mapping causal pathways

The second task is to identify plausible pathways of e ect from stress through coping to health outcomes. In
some instances, the path from coping is direct and unambiguous. For example, Aspinwall (Chapter 17)
describes proactive coping in the form of health behaviors, such as being screened for risk factors. Goal-
setting processes described by Wrosch (Chapter 16) can also a ect health directly when the goal is health-
related, as when a person commits to eating a healthier diet with the goal of reducing cholesterol.

In most studies, however, the most common pathway of e ect seems to be indirect, through psychological
or spiritual well-being. To be credible this pathway needs to show that there is stress to begin with, and that
there is reason to believe that stress can harm the health outcome of interest. A case in point is HIV disease.
As Antoni (Chapter 21) and Ironson and Kremer (Chapter 15) point out, HIV carries many stressful burdens,
and physiological stress reactivity has been found to be associated with HIV disease progression. These
features of HIV create a plausible pathway in which the ways people cope with the stress of HIV can
in uence the e ects of stress on HIV progression. Ironson and Kremer summarize the results of
longitudinal studies that show e ects of ve categories of coping on a range of HIV-related health
outcomes, especially CD4 cell levels. They found support for the notion that avoidant coping predicts faster
disease progression. They also found support for e ects between other kinds of coping and HIV-related
outcomes. Antoni’s (Chapter 21) review concurs. Antoni also provides a detailed description of plausible and
testable pathways through which his cognitive-behavioral stress management program can proceed from
psychological adjustment through psychoneuroimmunological pathways to a ect clinically relevant HIV
disease markers.

Until recently, most research focused on a negative a ect pathway on the assumption that its regulation
would reduce the harmful e ects of stress emotions such as hostility, depression, despair, anger, or guilt on
the body’s defenses. Now attention is turning to a positive a ect pathway to determine how it may protect,
restore, and sustain the body’s physical health during periods of stress. Given evidence that positive a ect is
bene cial to health (Lyubormisky, Chapter 11; Moskowitz, Chapter 20; Tugade, Chapter 10), this pathway is
an exciting new direction in stress and coping theory and research. The full picture requires that we pay
attention to both positive and negative a ect, as noted throughout this volume.

p. 460
Methodological Issues

As noted in virtually every chapter of this volume, there are the inevitable methodological issues to
consider. I highlight three here: capturing the dynamic quality of coping, a few comments about measures,
and a concluding observation regarding speci city versus generalizability.
Capturing the dynamic quality of coping
Litt, Tennen, and A eck (Chapter 19) make the important point that most research treats coping in “a
unidirectional, static and deterministic way.” Their concern is that “There is little recognition that changes
in coping lead to changes in adaptational outcomes, which in turn may lead to changes in subsequent
appraisals, coping, or external contingencies on behavior. The transactional nature of coping is not
captured.” They review daily process and momentary assessment technologies and multi-level statistical
techniques that capture the dynamic, mutually reciprocal nature of appraisal and coping outcomes. These
methods might also be useful for capturing the interplay between members of a dyad, or between types of
coping processes such as Wrosch’s (Chapter 16) goal-engagement and goal-disengagement processes,
Tugade’s automatic and controlled coping processes (Chapter 10), and Stroebe and Schut’s (1999) loss and

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restoration orientation within their Dual Process Model of coping.

Measures
The measurement of multidimensional, dynamic subjective phenomena is always complicated and
imperfect. Within this volume, for example, Stanton’s (Chapter 18) discussion of emotion-focused coping
highlights common shortcomings in the assessment of this form of coping and o ers a psychometrically
sound alternative. Stroebe (Chapter 8) reviews the shortcomings of measures of bereavement coping.
Pakenham (Chapter 13) reviews issues in the measurement of bene t- nding and sense-making,
Pargament (Chapter 14) discusses measures of religious coping, and Moskowitz (Chapter 20) o ers clear
direction for improving measures of positive emotions.

Overall, measures need to be appropriate for the question addressed by the research. Aldwin (Chapter 2)
points out that more immediate measures of daily stressors may be better for assessing very variable health
outcomes such as blood pressure or noradrenaline, but it is unlikely that a daily stressor by itself is of
su cient magnitude to a ect long-term health outcomes. Measures of life events and trauma may be more
relevant for studies of morbidity and mortality. Another volume could easily be dedicated to this topic. For
now, researchers contemplating assessing variables related to the stress process should consult the reviews
contained in these chapters.

Creating the stress and coping narrative: Generalizability of findings

Most stress and coping research is conducted in speci c contexts such as chronic illness, divorce, natural
disasters, or terrorism. The introduction to any context-speci c research report usually contains highly
elaborated description of the context, especially the nature of the stressor and its trajectory over time,
context-speci c resources for coping, and context-speci c constraints that might impede coping e orts.

Many people assume that context speci city limits the generalizability of ndings, and indeed caveats to
this e ect are included in most articles. Ironically, in my experience, just the opposite is more often the
case: Well-characterized contexts allow greater precision in de ning correlative or predictive relationships
that turn out to be relevant in diverse contexts. We have many examples. The Dual Process Model that was
developed by Stroebe (Chapter 8) and her colleagues speci cally to characterize the ways people cope with
bereavement contains an important general principle that should apply to any chronic stressor: The person
is likely to oscillate between dual coping orientations to deal with loss and restoration, or to deal with the
stressor while also maintaining well-being. Pakenham (Chapter 13) refers to the adaptive tasks associated
with chronic illness. Adaptive tasks can be de ned in almost any stressful context and, in fact, should be
de ned so that there is a way to determine whether coping has been e ective (Folkman, 2001). Ironson and
Kremer’s (Chapter 15) research on stress and coping in the context of HIV led to the observation that
confronting a stressor and managing it well can lead to increased self-e cacy. This observation happens to
 converge with and add to the general bene t- nding literature discussed by Park (Chapter 12), Pakenham
(Chapter 13), and Moskowitz (Chapter 20). The discovery of positive emotions in the reports of the gay
caregiving partners of men dying of AIDS turned out to echo ndings from a range diverse of settings
(Folkman, 1997; Moskowitz, Chapter 20) and led to the principle that positive and negative emotion co-
occur in the stress process (Folkman & Moskowitz, 2000).

p. 461 Researchers should thus not assume the contextual nature of their research necessarily limits the
generalizability of their ndings; instead, we should look for underlying principles in context-speci c
ndings. These principles can be added to the framework for other researchers to test in their own studies
and make research on the links among stress, health, and coping ever more fruitful.

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Conclusion

Stress and coping research is like the stress process: It is dynamic, multidimensional, complex, and
fascinating. There can be little doubt that we have learned a great deal, but each increment of progress
seems to spawn multiple new questions. So, although we know more than we did in previous years, we have
many new questions enumerated in the chapters that we must now address, especially those linking coping
to health. These questions need to be considered from many di erent perspectives and examined with
carefully designed studies.

Earlier, I mentioned how the stress and coping narrative evolves with the accumulation of research ndings.
We can see this process at work in this volume: Virtually every author draws on work of other authors to
inform the discussion at hand. For example, Pargament cites Ironson, and Ironson cites Moskowitz, who
cites Lyubomirsky, who in turn cites Skinner and Taylor. Skinner and Zimmer-Gembeck cite Stroebe, who in
turn cites Moskowitz, Aldwin, and Skinner. The pattern continues throughout the volume. This cross-talk
solidi es links among ndings and also helps pinpoint work that still needs to be done.

However, stress and coping research requires more than cross-talk among psychologists: The research
requires truly multidisciplinary approaches. Genetics, and now epigenetics, cognitive and a ective
neuroscience, and specialties such as psychoneuroimmunology and psychoneuroendocrinology are all
relevant to the initial response to a stress appraisal and how it plays itself out at every level: biological,
psychological, and social. Taylor’s Tend-and-Befriend theory (Chapter 5) illustrates the interplay among
biological, psychological, and social responses to threats. We must also cross boundaries within the social
and behavioral sciences: Hobfoll’s (Chapter 7) research, for example, on the communal or societal level of
analysis illustrates the importance of resources at these levels for understanding responses at the individual
level. Helgeson’s (Chapter 4) research on gender di erences in stress exposure and vulnerability is another
example of the importance of multi-level models.

We also must learn to take advantage of new technologies for data acquisition and analysis. The new
techniques should allow us to arrive at greater understanding of the momentary ow of stress and coping
processes, which in turn should allow us to derive additional underlying principles that can be used to think
about stress and coping processes at meta-levels.

Multidisciplinary approaches, new methods, and the new ideas and recommendations o ered in this
volume constitute a powerful formula for advancing this exciting eld of research. I would urge us all to
approach the work with open minds, giving special attention to the design of the research and to its
unexpected ndings.
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