Basics of qualitative research: Grounded theory procedures and techniques

Many people are exposed to loss or potentially traumatic events at some point in their lives, and yet they continue to have positive emotional experiences and show only minor and transient disruptions in their ability to function. Unfortunately, because much of psychology’s knowledge about how adults cope with loss or trauma has come from individuals who sought treatment or exhibited great distress, loss and trauma theorists have often viewed this type of resilience as either rare or pathological. The author challenges these assumptions by reviewing evidence that resilience represents a distinct trajectory from the process of recovery, that resilience in the face of loss or potential trauma is more common than is often believed, and that there are multiple and sometimes unexpected pathways to resilience. M ost people are exposed to at least one violent or life-threatening situation during the course of their lives (Ozer, Best, Lipsey, & Weiss, 2003). As people progress through the life cycle, they are also increasingly confronted with the deaths of close friends and relatives. Not everyone copes with these potentially disturbing events in the same way. Some people experience acute distress from which they are unable to recover. Others suffer less intensely and for a much shorter period of time. Some people seem to recover quickly but then begin to experience unexpected health problems or difficulties concentrating or enjoying life the way they used to. However, large numbers of people manage to endure the temporary upheaval of loss or potentially traumatic events remarkably well, with no apparent disruption in their ability to function at work or in close relationships, and seem to move on to new challenges with apparent ease. This article is devoted to the latter group and to the question of resilience in the face of loss or potentially traumatic events. The importance of protective psychological factors in the prevention of illness is now well established (Taylor, Kemeny, Reed, Bower, & Gruenewald, 2000). Moreover, developmental psychologists have shown that resilience is common among children growing up in disadvantaged conditions (e.g., Masten, 2001). Unfortunately, because most of the psychological knowledge base regarding the ways adults cope with loss or potential trauma has been derived from individuals who have experienced significant psychological problems or sought treatment, theorists working in this area have often underestimated and misunderstood resilience, viewing it either as a pathological state or as something seen only in rare and exceptionally healthy individuals. In this article, I challenge this view by reviewing evidence that resilience in the face of loss or potential trauma represents a distinct trajectory from that of recovery, that resilience is more common than often believed, and that there are multiple and sometimes unexpected pathways to resilience.

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Loss, Trauma, and Human Resilience Have We Underestimated the Human Capacity to Thrive After Extremely Aversive Events?

NUDGE: IMPROVING DECISIONS ABOUT HEALTH, WEALTH, AND HAPPINESS by Richard H. Thaler and Cass R. Sunstein Penguin Books, 2009, 312 pp, ISBN 978-0-14-311526-7This book is best described formally as a general explanation of and advocacy for libertarian paternalism, a term coined by the authors in earlier publications. Informally, it is about how leaders, systems, organizations, and governments can nudge people to do the things the nudgers want and need done for the betterment of the nudgees, or of society. It is paternalism in the sense that "it is legitimate for choice architects to try to influence people's behavior in order to make their lives longer, healthier, and better", (p. 5) It is libertarian in that "people should be free to do what they like - and to opt out of undesirable arrangements if they want to do so", (p. 5) The built-in possibility of opting out or making a different choice preserves freedom of choice even though people's behavior has been influenced by the nature of the presentation of the information or by the structure of the decisionmaking system. I had never heard of libertarian paternalism before reading this book, and I now find it fascinating.Written for a general audience, this book contains mostly social and behavioral science theory and models, but there is considerable discussion of structure and process that has roots in mathematical and quantitative modeling. One of the main applications of this social system is economic choice in investing, selecting and purchasing products and services, systems of taxes, banking (mortgages, borrowing, savings), and retirement systems. Other quantitative social choice systems discussed include environmental effects, health care plans, gambling, and organ donations. Softer issues that are also subject to a nudge-based approach are marriage, education, eating, drinking, smoking, influence, spread of information, and politics. There is something in this book for everyone.The basis for this libertarian paternalism concept is in the social theory called "science of choice", the study of the design and implementation of influence systems on various kinds of people. The terms Econs and Humans, are used to refer to people with either considerable or little rational decision-making talent, respectively. The various libertarian paternalism concepts and systems presented are tested and compared in light of these two types of people. Two foundational issues that this book has in common with another book, Network of Echoes: Imitation, Innovation and Invisible Leaders, that was also reviewed for this issue of the Journal are that 1 ) there are two modes of thinking (or components of the brain) - an automatic (intuitive) process and a reflective (rational) process and 2) the need for conformity and the desire for imitation are powerful forces in human behavior. …

Nudge: Improving Decisions about Health, Wealth, and Happiness

Background
People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

Objectives
To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search methods
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria
Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis
Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results
For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions
For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Interventions for enhancing medication adherence.

The Scope of Body Image Disturbance - the Big Picture An Overview of Assessment and Treatment Strategies Sociocultural Theory - the Media and Society Social Comparison Processes Appearance-Related Feedback Interpersonal Factors Peers, Parents and Perfect Strangers Feminist Perspectives Sexual Abuse and Sexual Harassment Behavioural Aspects of Disturbance - Conditioning, Context and Avoidance Cognitive Processing Models Future Directions - Integrative Theories, Multidimensional Assessment and Multicomponent Interventions

Exacting Beauty: Theory, Assessment, and Treatment of Body Image Disturbance

The prevalence of obesity and its associated health problems have increased sharply in the past 2 decades. New revisions to Medicare policy will allow funding for obesity treatments of proven efficacy. The authors review studies of the long-term outcomes of calorie-restricting diets to assess whether dieting is an effective treatment for obesity. These studies show that one third to two thirds of dieters regain more weight than they lost on their diets, and these studies likely underestimate the extent to which dieting is counterproductive because of several methodological problems, all of which bias the studies toward showing successful weight loss maintenance. In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.

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Medicare's search for effective obesity treatments: diets are not the answer.

Past research has shown that strong emotional or motivational states can cause normally restrained eaters to overeat. In this article it is argued that simple cognitive load can also disinhibit eating by restrained eaters. Two studies examined this disinhibition effect. In Study 1, restrained and unrestrained eaters were given the opportunity to consume high-calorie food while performing either a high cognitive-load or low cognitive-load task. Restrained eaters consumed more food when under high cognitive load than when under low cognitive load; unrestrained eaters showed the opposite pattern. Study 2 replicated the disinhibition effect and ruled out stress, diminished awareness of food consumption, and ironic rebound as probable mediators. Results suggest that cognitive load may disinhibit consumption by preventing restrained eaters from monitoring the dietary consequences of their eating behavior. Implications for theories of self-regulation are discussed.

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Don't mind if I do: disinhibited eating under cognitive load.

Stress is implicated in the development and progressionofabroadarrayofmentalandphysicalhealth disorders. Theory and research on the self suggest that self-affirming activities may buffer these adverse effects. This study experimentally investigated whether affirma- tions of personal values attenuate physiological and psychological stress responses. Eighty-five participants completed either avalue-affirmationtaskoracontroltask prior to participating in a laboratory stress challenge. Participants who affirmed their values had significantly lower cortisol responses to stress, compared with control participants. Dispositional self-resources (e.g., trait self- esteem and optimism) moderated the relation between value affirmation and psychological stress responses, such that participants who had high self-resources and had affirmed personal values reported the least stress. These findingssuggestthatreflectingonpersonalvaluescankeep neuroendocrine and psychological responses to stress at low levels. Implications for research on the self, stress processes, health, and interventions are discussed.

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Affirmation of Personal Values Buffers Neuroendocrine and Psychological Stress Responses

Objective The goal of this article is to review and highlight the relevance of social psychological research on self-regulation for health-related theory and practice. Methods We first review research on goal setting, or determining which goals to pursue and the criteria to determine whether one has succeeded. We discuss when and why people adopt goals, what properties of goals increase the likelihood of their attainment, and why people abandon goals. We then review research on goal striving, which includes the planning and execution of actions that lead to goal attainment, and the processes that people use to shield their goals from being disrupted by other competing goals, temptations, or distractions. We describe four types of strategies that people use when pursuing goals. Results We find that self-regulation entails the operation of a number of psychological mechanisms, and that there is no single solution that will help all people in all situations. We recommend a number of strategies that can help people to more effectively set and attain health-related goals. Conclusions We conclude that enhancing health behavior requires a nuanced understanding and sensitivity to the varied, dynamic psychological processes involved in self-regulation, and that health is a prototypical and central domain in which to examine the relevance of these theoretical models for real behavior. We discuss the implications of this research for theory and practice in health-related domains.

Self-regulation of health behavior: social psychological approaches to goal setting and goal striving.

Although persuasive messages often alter people's self-reported attitudes and intentions to perform behaviors, these self-reports do not necessarily predict behavior change. We demonstrate that neural responses to persuasive messages can predict variability in behavior change in the subsequent week. Specifically, an a priori region of interest (ROI) in medial prefrontal cortex (MPFC) was reliably associated with behavior change (r = 0.49, p < 0.05). Additionally, an iterative cross-validation approach using activity in this MPFC ROI predicted an average 23% of the variance in behavior change beyond the variance predicted by self-reported attitudes and intentions. Thus, neural signals can predict behavioral changes that are not predicted from self-reported attitudes and intentions alone. Additionally, this is the first functional magnetic resonance imaging study to demonstrate that a neural signal can predict complex real world behavior days in advance.

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Traci Mann

Papers

Medicare's search for effective obesity treatments: diets are not the answer.

Don't mind if I do: disinhibited eating under cognitive load.

Affirmation of Personal Values Buffers Neuroendocrine and Psychological Stress Responses

Self-regulation of health behavior: social psychological approaches to goal setting and goal striving.

Predicting Persuasion-Induced Behavior Change from the Brain