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Psychological Bulletin1991. 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-PerceptualModel of Somatic Interpretation

Delia CioffiUniversity of Houston

The meaning people assign to physical sensations can have profound implications for their physicaland 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 ambi-

guities in this research can be traced to a failure to distinguish the content of a person's attentionfrom 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 strate-gies should be adaptive. In contrast to the prevailing concern with when and why somatic distrac-

tion 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 woodenarch at the reeking, dripping damp outside, which seemed on thepoint of passing over into snow. It was strange that with all thathumidity his cheeks still burned with a dry heat, as though hewere sitting in an over-heated room. He felt absurdly tired fromthe practice of putting on his rugs; actually, as he held up OceanSteamships to read it, the book shook in his hands. So very fit hecertainly was not.. . ."Iflonlyknew" HansCastorpwenton,andlaid his hands like a lover on his heart, "if 1 only knew why I havepalpitations the whole time.. . ." (Mann, 1927/1959, p. 103)

Thus young Castorp begins his membership in the societyatop The Magic Mountain, a membership denned by the shift-ing and sometimes chimerical line between health and illness.His initiation into this society occurs in an intensely psychologi-cal landscape, where the meaning he assigns to a shiver or aflush determines his identity as either well or ill.

Mann's parable reflects an essential characteristic of physicalsensations; they are as often socially influenced interpretationsas they are the direct output of a biological system. In matters ofhealth and illness, it is difficult to imagine a more fundamentalprocess than that by which we perceive, interpret, and act onthe information from our own bodies.

Is it better to ignore one's somatic states or to pay attention tothem? Researchers studying somatic interpretation have com-monly asked this question, exploring the effects of perceptualattention on both subjective and physical response. The corpusof findings has been equivocal. Recent reviews cite mixed re-sults for distracting and attending strategies, and the limitingconditions for each seem far from clear. In this article I recon-

1 was supported during the early drafts of this article by a NationalScience Foundation Predoctoral Fellowship. My gratitude goes to Al-

bert Bandura, Kent Harber, Lee Ross, James Pennebaker, Nancy Can-tor, and three anonymous reviewers for their most thoughtful com-

ments on the text.

Correspondence concerning this article should be sent to Delia

Cioffi, Department of Psychology, University of Houston, Houston,Texas 77204-5341.

cile some of the equivocations and offer suggestions for movingbeyond them.

I begin by discussing the development of cognitive-percep-tual approaches to somatic interpretation as distinguishedfrom the traditional biomedical model. The findings on atten-tional strategies are briefly reviewed and are followed by a con-ceptual analysis of the apparent equivocations. I argue that con-fusion over the effects of attentional strategies often reflects thefailure to distinguish the content of attention from its direction,and I discuss several theoretical and methodological issues thattend to blur this distinction. I describe a model that highlightsthe interaction between bottom-up and top-down influenceson the somato-interpretive process.

Current thinking on somatic interpretation is often subtlybiased toward viewing awareness of somatic information as nec-essarily distressing. In contrast, the present discussion punc-tuates the potential variance between the perception of a physi-cal sensation and any particular interpretation of it while alsodescribing how strong situational or top-down influences maysometimes overdetermine their relationship. This conceptualanalysis, rather than concentrating on when and why a d istract-ing strategy does not "work" also generates hypotheses forwhen and why attention does. These hypotheses are exploredand applied to the clinical exemplars of cardiac rehabilitationand multiple sclerosis, two conditions for which somatic dis-traction may be neither possible nor desirable.

Two Symptomatological Models

The Biomedical Model

The traditional biomedical model holds a relatively mecha-nistic view of physical symptoms. It is assumed that most physi-cal maladies are caused by physical insult or biochemicalagents, which in turn produce a cluster of symptoms or signsthat are unique to that injury or disease (Lyddon, 1987;Thomas, 1977). Accordingly, a particular constellation ofsymptoms can be traced to a particular causal biological pro-

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26 DELIA CIOFFI

cess. Likewise, close correspondence is assumed betweensymptom perception and actual biological state; as the physicalpathology intensifies, its symptoms become increasingly diag-nostic of the relevant underlying pathology and increasinglyobvious and distressing to the patient, who consequently seeksmedical care (H. Levenlhal, 1983; G. Schwartz, 1982). Medicalcare consists of administering counteractive biochemicalagents and behavioral instructions, both of which, it is sup-posed, the average patient will understand and follow.

In its most rigid form, the biomedical model assumes a directcause-and-effect relationship between an illness and its symp-toms. Critics complain that it underweights psychosocialaspects of the illness process and provides a poor fit to manycontemporary health problems (Kaplan, 1984; Karoly, 1985; H.Leventhal, 1983; Lyddon, 1987; G. Schwartz, 1982, 1984). Incontrast to the infectious killers of 80 years ago, contemporarydiseases—such as hypertension, coronary heart disease, andcancer—are chronic conditions that are rarely linked to a spe-cific cause and that may be managed but not cured. Treatmentsbased solely on biomedical interventions cannot address thesignificant behavioral components of these and similar dis-eases (Dingle, 1973; H. Leventhal, Zimmerman, & Gutmann,1984; G. Schwartz, 1982,1984).

In fact, many well-known medical miracles may have beenless miraculous than is commonly assumed. For instance, wide-spread use of penicillin began only after sanitation and publichealth measures had reduced scarlet fever mortality by 80%(McKinlay & McKinlay, 1981). The most virulent infectiouskiller in recent history, acquired immune deficiency syndrome(AIDS) makes this point tragically clear: Behavioral prophy-laxis, not medical "magic bullets," will save countless lives(Bandura, 1990).

Cognitive-Perceptual Model

Medical and psychosocial models often do converge, andtheir confluence—as in the interdisciplinary treatments forchronic pain—can be most effective indeed (cf. Fordyce, 1976;H. Leventhal & Everhart, 1979; Turk & Kerns, 1983; Turk, Mei-chenbaum, & Genest, 1983). The imperative for this approachis also well illustrated by the so-called compliance problemamong people with high blood pressure. A patient who adheredimperfectly to a hypertension prescription was often seen assimply stubborn or uneducated, and the doctor's response justas often was limited to intensifying professional exhortationsor, occasionally, referring the patient to a medical psychologist.Patients who take their hypertension medication erratically arenot simply being intractable, however. Rather, they are re-sponding to a well-organized subjective representation of theirillness. When a group of hypertensive people were asked, "Canpeople tell when their blood pressure is high?" 80% gave themedically correct response, which is "No." But when asked,"What about you?Can you tell?" 88% said that they could (Bau-mann & Leventhal, 1985; Meyer, Leventhal, & Gutmann,1985). Furthermore, these patients based their decisions abouttaking medication on symptoms such as headaches and flushedface, all of which covaried more reliably with emotions andmoods 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 de-velops over time and may be a function of our demonstratedneed for symmetry between illness labels and symptoms (Eas-terling & Leventhal, 1989; H. Leventhal, Nerenz, & Strauss,1982; Pennebaker, 1982; Zimmerman, Linz, Leventhal, &Penrod, 1984). In any case, the hypertension example illus-trates that people act on their internal representations of theirillness and of their symptoms; that is, they respond to theirprivate, subjective, sometimes idiosyncratic world of interre-lated beliefs, fears, competencies, and goals. These construals,although not always accurate in the biological sense, may none-theless be predictable from a social-psychological point of view(Cioffi, 1990a). Accordingly, one may better serve therapeuticgoals by learning more about the patient's illness representationrather than by ever more aggressively defending the physician's(H. Leventhal etal., 1984).

Spurred by the practical advances of the psychosocial ap-proach, researchers increasingly turned to people's private the-ories of diagnostic information (e.g., Bishop, 1987; Cioffi,1990c, I990b; Ditto, Jemmott, & Darley, 1988; Jemmott,Croyle, & Ditto, 1988; Lau & Hartman, 1983; H. Leventhal etal., 1986; Mechanic, 1980; Pennebaker & Epstein, 1983; G.Schwartz, 1982). Physical symptoms are now viewed as cogni-tive-perceptual phenomena—that is, as stimuli that are subjectto complex psychosocial processes and therefore susceptible toinfluences beyond those explained by biosensory mechanismsalone (see Pennebaker, 1982, for a review).

The social cognition approach was especially germane to thedevelopment of this view, demonstrating that the social environ-ment can direct not only an evaluation of one's attitudes andabilities but the labeling of one's somatic arousal as well (Fes-tinger, 1954; Schachter & Singer, 1962). The somatic labelingphenomenon was subsequently observed even in the absence ofan actual physiological change. In other words, perceived orinferred physical change is sufficient to set the interpretive pro-cess in motion. Invoking the principles of attribution theory(Jones et al., 1971), researchers compiled an impressive collec-tion of studies in which both the perception of a somatic changeand 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 dem-onstrated that somatic interpretation—indeed, the very "per-ception" of somatic information itself—was profoundly in-fluenced by the situation, by the behavior of others, and by thebeliefs, assumptions, and attributions of the perceiver.

Review of Attentional Strategies

Having demonstrated the plasticity of somatic interpreta-tion, researchers turned to what is surely an elementary influ-ence on this process: the effects of attentional focus. The centralquestions were straightforward. To what extent does a strategyof distraction away from a potentially noxious physical sensa-tion facilitate adaptation to it? And why is distraction occasionally inferior to the strategy of somatic attention? Recent re-viewers have reported an equivocal pattern of results (McCaul

SOMATIC INTERPRETATION 27

& 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 acollective ennui. In the following section, I briefly review theevidence cited in support of attention and distraction. In subse-quent sections, I analyze the apparent equivocations and offersuggestions for moving beyond them.

Distraction

Competition for attentional capacity. Virtually all researchon somatic attention, assumes a necessary division of a fixedamount of attention between relatively strong and weak stimuli(e.g., Kahneman, 1973; Navone & Gopher, 1979). Thus a de-crease in the intensity of external stimuli tends to make internalinformation more salient. This is the principle at work when weexperience a sudden "worsening" of an ache or pain in the deadof night; as the house grows still and the events of the dayrecede, our previously ignored internal state comes into sharpattentional relief.

Most models associating the salience of internal informationwith increased symptom reporting turn on this principle offixed capacities (Carver & Scheier, 1981; Coburn, 1975; Fenig-stein, Scheier, & Buss, 1975; Hansell & Mechanic, 1984; Me-chanic, 1983; L. Miller, Murphy, & Buss, 1981; S. Miller, Brady,& Summerton, 1988; Mullen & Suls, 1982a, 1982b; Pennebaker,1982). Some evidence supports the contention that when theexternal environment yields relatively little information, thetendency to encode and elaborate on somatic information in-creases (Pennebaker, 1980; Pennebaker & Brittingham, 1982).For example, in a study in which subjects jogging on a trackwere compared with subjects running a cross-country route,joggers who were circling the repetitive oval were more aware oftheir physical fatigue and effort than were runners who navi-gated the ever-changing course, despite the fact that track jog-gers ran at the slower pace (Pennebaker & Lightner, 1980).

Self-awareness and somatic distress. Other support for dis-traction's efficacy is indirect, an extrapolation from the corre-lates of individual differences in self-awareness. Theories ofself-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 hypothe-sized individual difference in the tendency to focus on internalfeelings and states. It is suggested that this high degree of self-awareness increases the relative salience of all aspects of theself, including somatic information (Duval & Wicklund, 1972;Wegner & Giuliano, 1982; Wicklund, 1975).

Although operational definitions of self-awareness vary, theyusually include some tendency to focus on one's feelings andreactions. In some cases, this increased self-awareness inducesnegative evaluations of private experience and is associatedwith increased physical symptomatology (Fenigstein et al.,1975; Hansell & Mechanic, 1985; Landers, 1980; Mechanic,1983; L. Miller et al., 1981; Ward, Leventhal, & Love, 1988). Forinstance, Hansell and Mechanic (1984) found that introspecti-veness, defined as a relatively large degree of attention focuseddiffusely and inward, was related to symptom reporting by ado-lescents (see also Mechanic &Cleary, 1980). Another example isthe dispositional dimension of monitoring versus blunting (S.

Miller, 1987). S. Miller and her colleagues have suggested thathigh monitoring, which is defined as a vigilant scanning forthreat-relevant clues, induces a greater sensitivity to new andchanging physical symptoms. Thus high monitors/low bluntersexperience subjective symptomatological distress that is equalto that of low monitors/high blunters, even though their condi-tions are objectively less severe (S. Miller et al, 1988).

Finally, several clinical problems have been related to thecombination of catastrophizing cognitions and a strong inter-nal focus (Ingram, 1990). A hypochondriacal response, for ex-ample, is presumed to reflect the interaction between negativeaffect and a selective deployment of one's attention to physicalsymptoms (Barsky & Klerman, 1983; Stretton &Salovey, 1989).Likewise, panic disorders are often characterized by specificpatterns of bodily symptoms in combination with symptom-relevant—and negative—cognitions (Rachman, Levitt, & Lo-patka, 1987; see also Beck, 1987; Clark, 1986; Ehlers, Margrat,Roth, Taylor, & Birbaumer, 1988; Morgan, 1983). Similar linksbetween internal focus and somatic distress can be found in"choking under pressure" (Baumeister, 1984; Landers, 1980)and test anxiety (Geen, 1980; Hamilton, 1986; Holroyd & Ap-pel, 1980; Wine, 1980).

In summary, two assumptions seem to justify the postulatethat self-directed attention increases somatic distress: first,that more somatic information is available to a "self-aware" per-son as a function of internally directed attention and, second,that it is this increased salience of somatic information thatproduces physical distress. Whether internally directed atten-tion, sensory or otherwise, necessarily results in somatic dis-tress is addressed in later sections.

Active distraction. Willful dissociation from a noxious physi-cal sensation can increase physical tolerance and attenuate bothphysiological arousal and psychological distress. In a meta-analysis of 16 studies in which attentional coping styles or in-structions were compared, Mullen and Suls (1982a) concludedthat distraction from an acute noxious stimulus, such as noiseor cold-pressor pain, results in better adaptation to the stressorthan do strategies of attention to the stressor or to one's ownreaction to it. Other reviewers have concurred that distractionby external events or by an absorbing task or event, such as slideshows, waterfalls, or proofreading, often results in a greaterforbearance of the stimuli. For instance, in their review of cop-ing with pain, McCaul and Malott (1984) found that for rela-tively mild and shortlived pain, distraction is more effectivethan no attentional instructions, and the strategy's efficacy in-creases with its demands on attentional capacity. Likewise, Sulsand Fletcher (1985) agreed that when a stressor is acute, focus-ing attention on some other absorbing stimulus ameliorates dis-tress and facilitates tolerance more than does no instruction,attention to the self, or attention to the stressor. From exercisescience, Morgan, Horstman, Cymerman, and Stokes (1983)found that subjects who focused on the rhythm of their footfallswhile on a treadmill exercised 32% longer than did controlsubjects who were not trained in this distraction.

Distraction underlies many psychological interventions forpain management. For example, some techniques require thepatient to construct a detailed image of a relaxed and pain-freesituation, and its effectiveness is assumed to depend in part onthe image's involving qualities (e.g., Avia & Kanfer, 1980; Worth-

28 DELIA CIOFF1

ington & Shumate, 1981). Hypnotic suggestion may act as anaid to sharpening images that are incompatible with and dis-tracting from the painful sensations (e.g., Barber, 1982; Greene& Reyhe, 1972).

The evidence discussed in this section supports the followingnotions: First, when the external environment is undemanding,the relative salience of internal stimuli, which can include so-matic information, is boosted, and at least a subset of thesesituations is associated with high levels of symptom reportingand increased reports of physical and psychological distress.Second, states that presumably reflect a high degree of self-awareness are associated with increased symptomatology andphysical discomfort. Finally, active distraction from noxiousphysical sensations or from one's own reaction to them oftenfacilitates tolerance of and adaptation to the physical stressor.

Attention

It is intuitively plausible that distraction "works," and theempirical findings converge with commonsense notions forhow to cope with many types of physical discomfort. The rea-son why the effectiveness of a distraction strategy is limited byboth the intensity and the length of the stimuli is also fairlytransparent: Given only limited willful control over attention,some pain is simply too severe or chronic to ignore, and if onesucceeds 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 ofstrategies that increase attention to somatic information. Evi-dence indicates that attention to physical sensations does notnecessarily increase distress over those sensations, and undersome conditions it may in fact reduce psychological distressand facilitate adaptive outcomes.

Sensory monitoring defined. To understand why somatic at-tention can lessen distress, one must consider the type of atten-tional strategy used. Such an analysis was offered by Suls andFletcher (1985), who showed that attention is preferable to dis-traction, especially when the stressor is chronic and when thestrategy focuses on the concrete characteristics of the physicalsensation rather than on diffuse physical states, such as fatigueor tension, or on emotional or cognitive responses.

This distinction was originally suggested by the work of H.Leventhal and colleagues, which posited that many potentiallyuncomfortable events can be processed for both their concrete,sensory-informational meaning and for their emotional orthreatening value (Ahles, Blanchard, & Leventhal, 1983; H. Le-venthal, Brown, Shacham, & Engquist, 1979; H. Leventhal &Mosbach, 1983; see also Melzack, 1973; Melzack & Wall, 1982).Accordingly, instructions to attend to the discrete, sensoryaspects of the sensation—what H. Leventhal called sensorymonitoring—is presumed to produce a relatively neutral per-ception of the sensation at the cost of a negative and emotionalinterpretation of it. Likewise, attention to potentially threaten-ing interpretations or to their frequent concomitants, such asunpleasant emotional reactions or general body tension, biasesthe processing of all incoming sensory information toward theexperience of pain and distress.

Sensory monitoring in laboratory and clinical settings. Peoplesubjected to experimentally induced pain who had been given

preparatory information about the possible concrete character-istics of their sensations reported reduced distress during thenoxious stimulation (Calvert-Boyanosky & Leventhal, 1975;Johnson, 1973; Johnson & Leventhal, 1974; Staub & Kellet,1972). Subsequently, sensory monitoring was found to be aneffective strategy independent of the accuracy of this prior in-formation; this finding thereby ruled out the possibility that aconfirmation of expectancies was solely responsible for the ef-fect. 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 atall was given.

Field studies on clinical pain, distress over chemotherapy,and the discomforts of medical procedures and childbirth sug-gest that deploying attention to the concrete, sensory aspects ofthe stressor decreases distress more than does either a focus onone's emotions or a focus on distracting images or tasks (John-son, Kirchoff, & Endress, 1975; Johnson, Morrissey, & Le-venthal, 1973; Kabat-Zinn, 1982, 1984; Love, Nerenz, & Le-venthal, 1983; Nerenz, Leventhal, Love, & Ringler, 1984). Forinstance, women who engaged in sensory monitoring duringchildbirth registered less pain and reported more positivemoods than did women in an attentional control group (E.Leventhal, Leventhal, Shacham, & Easterling, 1989).

Willfully focusing on sensory information is rarely a sponta-neous or intuitive strategy for dealing with chronic pain. Someevidence suggests, however, that those who use it also recruitother, more active strategies and are more ambulatory and lessdistressed than those who use diversionary tactics alone (Phil-ips, 1987; Rosensteil & Keefe, 1983). For example, chronic painpatients trained in "mindful meditation"—a willful, directedfocus on the sensory aspects of pain—experienced profoundameliorative effects that generalized beyond the episodes offocused attention. This pain relief was in turn associated withdiminished anxiety; fatigue, and confusion (Kabat-Zinn, 1982,1984).

Sensory monitoring during exercise. Exercise researchershave long distinguished between awareness of somatic sensa-tions per se and the various meanings that can be assigned tothem. Furthermore, a person's interpretation of physiologicalarousal is a far better predictor of motor performance and psy-chological satisfaction than are objective physiological measure-ments of that arousal (Baumeister, 1984; Borkovec, 1976;Landers, 1980; Mahoney, 1979; Morgan, 1981). Thus a highdegree of somatic awareness does not necessarily impair ath-letic performance, nor does it necessarily produce negative psy-chological outcomes. For instance, the physical arousal accom-panying a platform dive can be interpreted as either fear orreadiness, depending on perceived self-efficacy for the maneu-ver (Feltz, 1982). A broad range of emotions and evaluationscan accompany a heightened awareness of physiological activ-ity (Neiss, 1988).

Indeed, a high degree of somatic awareness is often the hall-mark of the successful athlete. A study of marathon and mid-dle-distance runners is especially provocative. Morgan and Pol-lock (1977) reported that world-class runners carefully and sys-tematically scan their physical sensations when running,whereas collegiate athletes prefer distracting strategies such aslisting their third-grade classmates or solving mathematical


problems. Morgan and Pollock speculated that the elite ath-letes' monitoring strategy allows them to accurately adducetheir physiological status in relation to the demands of the raceand thus to realistically fine-tune their pace, whereas the dis-tractors, in an attempt to avoid what for them are sensations ofpain and fatigue, are taking a "buy now, pay later" approach. Inother words, the price of skirting a psychological wall may beslamming into the physical one.

The sports and exercise research shows that successful experi-ence with exercise is far more complex than a simple habitua-lion to somatic information. Indeed, on the basis of Morganand Pollock's (1977) interview data, the somatic attention oftheir world-class runners seems to share many properties withH. Leventhal's sensory monitoring strategy. In an ergometerstudy of nonathlete college males, I explored this possibility(Cioffi, 1990c). While exercising on a stationary bicycle at amoderate intensity (graded according to fitness level), half thesubjects were encouraged to examine their physical sensationsin detail, whereas the other half were given control informationabout the equipment without attentional instructions. The sen-sory-monitoring subjects were instructed to systematically ex-amine their physical sensations and to actively search for them,whether pleasant, unpleasant, or neutral. These subjects re-ported a large number of discrete physical sensations, ratedthem as highly noticeable, but were not at all distressed bythem. In fact, these subjects perceived their sensations as pre-dominantly neutral or pleasant. Furthermore, the averagecorrelation between the noticeability of a sensation and its sub-jective pleasantness was positive (r = .28). In contrast, thosegiven no attentional strategy rated their perceived sensationsmore negatively and found them more distressing if they werehighly noticeable. Interestingly, this nonmonitoring group alsoattributed a larger proportion of their physical sensations topathological sources such as possible health problems or to be-ing extremely out of shape, whereas monitoring subjects labeledtheir sensations as appropriately exercise induced.

In summary, one can experience distress over physical sensa-tions even when perceptual awareness of them is not particu-larly acute. Likewise, a specific type of somatic attention—thatwhich focuses on the concrete properties of the sensation—canresult in an acute somatic perception but little distress over thesomatic information that is perceived. Taken in sum, the evi-dence cited in this section suggests that a quantitative headcount of perceived physical sensations is at least indeterminateto psychological distress.

A Cognitive-Perceptual Model of Somatic Interpretation

Are the findings on attentional strategies contradictory? It issuggested that if we remain seriously confused over answeringthe question "Does distraction or attention work?" we havefailed to ask the more basic question "Distraction from or at-tention to what?" More specifically, we must distinguish a per-son's attention to physical sensations from his or her contempla-tion of their possible meanings, implications, and sources andconsequences. Before discussing specific areas in which thisdistinction is easily blurred, I turn to an exposition.

Behaviori.e., put on gloves, find

distractor

Mediatorsgoals, affect,

coping strategies, dispositions, motivation

Prior Hypothesesi.e., concerns about

illness

Attributionsperceived causes

and consequences

Somatic Labeli.e., "cold hands"

Physical Statei.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 sensa-

tion, 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 interpre-

tive processes. Finally, situational influences—including the relative

intensity of internal and external stimuli—act on an interpretive sys-

tem of interrelated components, rather than on any component in iso-

lation. 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

Somatic interpretation is a multiprocess elaboration upon areal or perceived physiological state. This elaboration is bestcharacterized as an interaction between stimulus-driven andtop-down processes, as depicted in Figure 1. The following sce-nario illustrates how these processes can interact to producemultiple somatic interpretations, given the same physical stimu-lus (in the text that follows, the major components of the modelappear in italics).

While bicycling to the office, my hand temperature drops0.5° (the objective physical state). If I am obsessing about thelecture I must give, or if my route is marked by potholes, or if an

30 DELIA C1OFFI

old knee injury is acting up, I may never notice the relativelymild physiological change in my hand; the competition for myfixed attentional capacities is, in this case, among several com-pelling internal and external events. But suppose that both mymind and my path are clear of competing clutter. I will mostlikely 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 sensa-tion to something. If I believe that my hands are cold becausemy circulation is bad, then the sensation becomes asymptom—evidence that something is wrong with me. I couldarrive at this symptomatological attribution in one of two ways.First, the sensation of cold hands could confirm a pre-existingbelief ("I've suspected 1 have poor circulation, and this is furtherproof "). Indeed, if I had been worryingabout my health beforebeginning my commute, I would be actively searching for infor-mation that had a plausible bearing on this concern. In thiscase, a pre-existing hypothesis about my health affects both myawareness of and my attribution for the sensation. Alternatively,the perceived physical sensation could become the event forwhich an attributional search is launched. In either case, mysketchy self-diagnosis will include the consequences that I imag-ine are possible outcomes to my hypothesized malady.

My attribution for the sensation need not be symptomato-logical, however. If I believe that my cold hands are a normalresponse to the fall chill in the air, the somatic label will not beinterpreted as a symptom, as the word is usually understood.Rather, it will be viewed as an appropriate physiological re-sponse to the external environment. Likewise, I could believethat all my blood has gone to my hard-working leg muscles, andthus I would be making an attribution that supports a hypothe-sis of fitness.

Even given a fixed somatic perception and an attribution forit (i.e., "my hands are cold, and it is due to poor circulation") mybehavioral (and psychological) response to this construal willalso depend the mediators of thought and action, such as mymood, my coping repertoire and choices, and my general andsituation-specific goals. For example, I may choose (or beprone) to respond to the threat of illness by actively distractingmyself, or I may be compelled to do so today because of theimportance of the upcoming lecture. Similarly, feeling ineffi-cacious about my dealings with doctors will inspire particularshort- and long-term strategies, as well as inform several othercognitive 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 somaticawareness at all or, even given the same basic somatic label of"cold hands," several different interpretations of it. Second, anystage in this process—from becoming aware of a physical stateto labeling, interpreting, and responding to it—could plausiblyaffect several others; anxiety over the prospect of disease, forexample, could constrict blood flow, thus lowering peripheraltemperature even more. Third (by extension), the top-downinfluences of prior hypotheses, attributions, perceived conse-quences, 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 it-self has several possible targets. Attention can be deployed to-ward or from any component of the overall process—a healthhypotheses, an emotional response, an elaborated interpreta-tion—not just toward or away from the somatic sensation itself.

Clearly then, failure to distinguish between these multipleprocesses and their interactions can produce an interpretivetangle to researchers. Unraveling this tangle is aided by thefollowing notions: First, an experimenter may intend or believethat an attentional manipulation (or disposition) operates on"the perception of physical sensations," but if the manipulationinadvertently (or unavoidably) results in an increased salienceof an interpretation, then it is that interpretation that is magni-fied by the attentional manipulation. Second, if a person'shealth hypothesis is clearly pathological, the perceived conse-quences are particularly pernicious, and the coping skills areparticularly weak—in other words, if the top-down bias isstrongly negative—then attention to the physical sensation com-ponent of this construal is more likely to increase distress, andany attempts at distraction are less likely to succeed.

In summary, there are several potential points of variancebetween the perception of a physical sensation and any particu-lar interpretation of it. Nonetheless, strong situational and top-down influences sometimes overdetermine the relationship be-tween them. Thus one must critically evaluate the assumptionthat increased internal information is isomorphic to increasedsomatic information and that increased somatic information isnecessarily distressing. I now turn to the components of so-matic interpretation in more detail and discuss the methodolog-ical and theoretical issues that they raise.

Features of the Physical Stimulus

The choice of an experimental stimulus defines the range ofinterpretations that subjects can plausibly make of it. Interpre-tations of cold-pressor or ischemic pain are relatively overdeter-mined, and inherently noxious physical sensations are thosemost easily managed by medical interventions and by distrac-tion strategies (McCaul & Malott, 1984). In contrast, irregular,ambiguous, unpredictable, and diffuse physical sensations arethe more common challenge of daily corporeal life, and theymay also characterize situations in which a sensory monitoringstrategy is most effective (Cioffi, 1990c; Suls & Fletcher, 1985).In the final sections of this article, I briefly discuss cardiacrehabilitation and multiple sclerosis as provocative venues forapplied research. In the laboratory, the use of stimuli such asvibration, pressure, and mild exercise broadens the applicabil-ity of research findings. Just as critically, they allow one tostudy situations outside the limited range of experience inwhich simple distraction is transparently effective.

A second stimulus issue pertains to the experimental controlof its intensity. As the top-down influences of Figure 1 show, theperceived intensity of a physical stimulation is affected by one'sinterpretation of it. Thus a confound may result if subjects self-select a stimulus intensity on the basis of their a priori or manip-ulated construals. For example, if exercise bouts are not con-trolled and relativized by fitness levels, fit and sedentary sub-jects will differ in their physiological activation, and theiropportunities for the perception and interpretation of their sen-


sations will systematically differ. This self-selection, in turn, isintimately related to the somatic interpretation that each sub-ject is prone to make. Statistical covariance analyses or a simpleobservation of differences on this factor do not replace a first-order experimental control. In the case of an exercise manipula-tion, it is possible to relativize workloads in such a way that allsubjects are working, for instance, at 60% of their aerobic capac-ity for a fixed amount of time (Astrand & Rodahl, 1977). Thecalibration of other physical stimuli is a necessary step towardexplicating the microprocesses of somatic interpretation, yet todate this basic methodological research has not been done.

The Direction of Attention

Attention to the specific concrete properties of a physicalsensation has different effects than does attention to its cogni-tive elaboration, to diffuse inner states, or to one's emotionalreaction. Past analyses, however, have not always distinguishedbetween these attentional foci. For instance, Mullen and Suls(1982a) denned attention as "the focusing attention on thestressor and/or one's reaction to if (p. 43; emphasis added). Onewould expect such a definition to produce variable or perhapsconflicting results. Sensory monitoring might ameliorate dis-tress, whereas attention to one's "own reaction," if that reactionis negative, will amplify it.

A related problem exists in interpreting the finding that self-focus results in symptom reporting and somatic distress. Manyintrospective dispositions share common variance with nega-tive affectivity, depression, and anxiety (Barsky & Klerman,1983; Costa & McCrae, 1987; Ingram, 1990; Tellegen, 1985;Watson & Clark, 1984; Watson & Pennebaker, 1989). For exam-ple, the definition of high monitoring according to S. Millerand colleagues is a vigilant scanning for //irea;-relevant cues (S.Miller, 1987; S. Miller et al, 1988). Thus the disposition mayreflect at least as much tendency to construct and attend topathological somatic interpretations as to somatic sensationsper se. This is an important phenomenon to be sure, but it cancontaminate rather than illuminate the role of somatic atten-tion in somatic interpretation. Wicklund and Gollwitzer (1987)offered an excellent commentary on the general form of thisargument, noting that research on self-focused dispositions of-ten fails to distinguish between the direction of attention andits content.

One may raise the question of whether there is indeed such athing as a "purely directional" attentional manipulation. Is itpossible to be aware of a sensation on any level in the absence ofsome degree of interpretation? The answer is most certainly no.Even a basic somatic label such as "cold hands" is an assignmentof meaning to a perceived physical state. This notion is not at allincompatible with the present model, which illustrates that al-though some categorization has to occur to produce a somaticlabel, certain other categorizations do not occur if a somaticlabel is indeed all that is produced. Furthermore, the modelspecifies that a basic label assignment may be more or less freefrom top-down influence. Although people often forgo thisbasic semantic labeling, proceeding almost immediately to acausal attribution, they do so to greater or lesser degrees. So-matic representations are dynamic—they can be created,maintained, and changed—and a physical sensation initially

perceived in light of one hypothesis can eventually become evi-dence for another. Thus primary appraisals such as semanticlabeling can and should be distinguished from those processesthat result in more elaborated meaning and inference (e.g, Laza-rus & Folkman, 1984).

In viewing top-down and bottom-up influences as both rela-tive and interactive, the model also reflects much of what isknown about perceptual attention in general. People exhibitthe ability, and the propensity, to filter their perceptual atten-tion, selectively processing stimuli according to its rudimen-tary features and meaning (Broadbent, 1958; Treisman, 1964).The perceived context of a stimulus is particularly influential indetermining how much attention is deployed to it and the cog-nitive sets with which it will be interpreted (Norman, 1969; alsosee Neisser, 1976, 1982). Some theories of attention generatepredictions that are particularly relevant to, and testablewithin, the current model. An example is the effect of physiolog-ical arousal on the scope and acuity of perceptual focus. Initialinterpretations of an unpleasant sensation can most certainlyinduce anxiety, which in turn can narrow the attentional field,limit usable cues, and affect the subsequent precision of willfulattentional control (Broadbent, 1971; Easterbrook, 1959;Kahneman, 1973). Exercise, illness, drugs, or a medical proce-dure can also directly affect physiological arousal and thus mayinfluence attentional processes even without the mediation ofemotional effects. Whereas these arousal-attention relationshave been examined for test anxiety (Geen, 1980; Hollands-worth, Kirkland, Jones, VanNorman, & Glazeski, 1979;Holroyd & Appel, 1980; Wine, 1980) and for skilled perfor-mance (Baumeister, 1984; Feltz, 1982, 1988; Neiss, 1988; Ni-deffer, 1976), the attentional role of physical arousal remainslargely unexplored in the domain of somatic interpretation.

The Content of Attention

Attributions and prior hypotheses. People organize eventsinto 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). Manipu-lating a cognitive set or biasing causal attributions toward aparticular somatic hypothesis increases selective attention toinformation that is hypothesis relevant and often biases theinterpretation of that information toward a confirmation of thehypothesis (Snyder&Gangestad, 1981). Selective attention im-plies that higher order somatic interpretations influence theperception of physical change, as when concerns about one'shealth induces an active search for hypotheses-relevant clues.The labeling/interpretation bias proceeds from the hypothesis-derived somatic perception to a strengthening of the hypothesisitself: namely, by using the already-labeled sensation to confirma causal hypothesis.

Thus, providing an illness label or putting an illness hypoth-esis in mind causes people to selectively search for sensationsassociated with that illness and to interpret incoming sensoryinformation relative to it (Anderson & Pennebaker, 1980; H.Leventhal et al., 1980,1982; Pennebaker & Skelton, 1981). Forinstance, after being told—falsely—that their blood pressurewas "a little high for their age," a group of college students

32 DELIA CIOFFI

reported having experienced more hypertensionlike symptomsin the previous 3 months than did those who were told thattheir readings were normal (Zimmerman et al., 1984). In an-other study, half the subjects, running in place, were told that itwas flu season. After exercising, those given the flu informa-tion reported more flulike symptoms in relation to exercise-re-lated symptoms than did subjects who were not given the fluinformation (Pennebaker, 1982).

A positive feedback loop between selective attention and alabeling bias can produce some powerful social phenomena.For instance, "medical students' disease" and "mass psycho-genie illness" are situations in which salient environmental fac-tors induce selective attention to and the pathological interpre-tation of what would otherwise be background or baseline so-matic information (Colligan, Pennebaker, & Murphy, 1982).This notion also illuminates some cultural patterns in symp-tom reporting, in which social norms for the meaning of certainsensations produce different responses to them (Tursky &Sternbach, 1967; Zola, 1973). On the individual level, sometheorists view hypochondriasis as the tendency to interpret alarge proportion of both internal and external information inillness-related terms (e.g., Barsky & Klerman, 1983; Ladee,1966; Stretton & Salovey, 1989).

Situations! constraints on somatic representations. Once alabel has been assigned to a physical sensation, other beliefstructures follow. People hold fairly elaborate mental representa-tions of their physical states, and these representations providethe 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, & Le-venthal, 1979). As active self-diagnosticians, people use theserepresentations to construct causal, covariational, and conse-quential inferences from their symptoms. These inferences, inturn, affect what people do in response to the perceived healththreat 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, illnessrepresentations are closely affiliated with the situation in whichthey occur (Fiske, 1982; Higgins & McCann, 1984; King &Sorrentino, 1983; Showers & Cantor, 1985). Research on atten-tional strategies has spanned various clinical and laboratorydomains, yet not enough weight has been given to the contex-tual effects of these experimental venues. Most clinical situa-tions are anything but neutral: Why someone needs physicaltherapy cannot be trivial to the feelings that it evokes; the repre-sentation of physical sensations arising from a gynecologicalexam necessarily differ for the joyful mother-to-be and thewoman at risk for cervical cancer. Situational cues carry consid-erable power to overdetermine somatic interpretation. Thuscontextual features are bound to influence the efficacy of at-tentional strategies as well. McCaul and Malott (1984) observedthat distraction is generally less effective at reducing subjectivedistress in clinical settings than in laboratory studies, and theysuggested that this is because "the emotional context of fieldand laboratory settings differ widely" (p. 522). Indeed, mostclinical settings are strongly associated with schemata of illnessor pathology and are also most likely to be accompanied byparticularly intense physical stimulation.

It is not surprising, then, that the corpus of findings on atten-

tional strategies, across experimental venues, seems weak orequivocal. A major challenge clearly lies in identifying dimen-sions that are important in this contextual variability. Ideally,laboratory efforts should be directed toward understanding theparticular assessments that underlie situational effects, thereaf-ter testing their influence with a degree of a priori theory. In themeantime, a healthy respect for situational influences shouldbe central to any review, meta-analysis, or new research on so-matic interpretation.

Coping Strategies and Goals

The goal in facing laboratory-induced pain is usually trans-parent and well-defined: namely, to tolerate it as long as possi-ble. In contrast, real-life situations may entail any number ofglobal or situation-specific aims (e.g. Showers & Cantor, 1985).A person in chemotherapy, for example, may plausibly respondto different goal levels at different junctures during treatment.Resisting the sick role may result in the person's collecting in-formation 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 identifydistraction, 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 competenciesin reaching it perforce come into play. Some psychological con-structs generate relatively clear predictions for how they mightoperate in the somatic domain. For instance, a preference forblunting tactics should favor distractive strategies, whereasplanful problem solving would probably entail somatic atten-tion, at least to the degree that it facilitates choice and instru-mental action (Folkman & Lazarus, 1988; E. Leventhal et al,1989; S. Miller, 1987).

Some constructs, however, have yet to be fully mined fortheir potentially potent contributions to somatic research. Forexample, a person may exhibit high tolerance for the cold-pres-sor task and also exhibit a high degree perceived self-efficacyfor "managing cold-pressor pain" (Bandura, 1986). Yet, at leastfour psychological processes could be responsible for the ob-served relationship between perceived self-efficacy and the be-havioral outcome: (a) As perceived self-efficacy decreases anxi-ety and its concomitant physiological arousal, the person mayapproach the task with less potentially distressing physical in-formation to begin with; (b) the efficacious person is able towillfully distract attention from potentially threatening physi-cal sensations; (c) the efficacious person perceives and is dis-tressed by physical sensations but simply persists in the face ofthem; and (d) physical sensations are neither ignored nor neces-sarily distressing but rather are relatively free to take on a broaddistribution of meanings.

Thus, the self-referent mediations of self-efficacy may rangefrom decreasing the intensity or amount of one's initial physio-logical stimuli, to the ability to distract, to stoicism, to a changein the interpretation of a physical sensation. Each of these pro-cesses would have unique implications. For instance, self-effi-cacy as distraction may facilitate performance in the short runif that performance does not depend on having detailed so-matic information (Landers, 1980; Morgan, 1981; Neiss, 1988;


Nideffer, 1976). Self-efficacy as stoicism may be inappropriatewhen behavioral perseverance is dangerous (Ewart et al., 1986;Ward et al, 1988), and self-efficacy as a positive interpretivebias may be that mechanism responsible for the instigation andmaintenance of long-term behavioral change and the facilita-tion 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 variouscoping strategies and actions. A coping process may addresslong-term or short-term outcomes, the regulation of behavior orof affect, the influence of instrumental or abstract goals, andthe salience of subjective or objective appraisals (Showers &Cantor, 1985). Thus a recovering cardiac patient who runs 3miles has successfully responded to the challenge to run 2 butwill not have coped adaptively if the overexertion is medicallydangerous (Ewart et al, 1986). Distraction from arthritic painmay facilitate normal day-to-day functioning, but if the distrac-tion is chronic and unyielding, it may also mask changing physi-ological conditions that warrant medical attention or an adjust-ment 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 importantthan its consequences or than the psychological path that onetakes to get there.

Measuring Somatic Awareness

The use of symptom checklists as measures of somatic per-ception may present a pernicious problem: Many symptom la-bels are already biased toward a negative or pathological inter-pretation. Arguably, an item such as "pounding heart" is asymptom, not a sensation. It includes subtle but discerniblecausal inferences and an adjective just this side of negative.Some distress over the perception of accelerated heart rate isalready in the item, and those most distressed with what theyhave felt are most likely to endorse it as something that theyhave experienced.

Researchers in exercise behavior have often noted that ath-letes have a particularly difficult time with symptom checklistsand autonomic perception questionnaires, asking the experi-menter for more elaboration and offering more equivocationthan do nonathletes. The athlete has not failed to perceive so-matic information, yet to the athlete's mind the items primarilyconcern excessive, inappropriate, or pathological physical re-sponses. Debriefing discussions strongly suggest that they arestruggling to accurately report their numerous and detailed so-matic sensations and yet cannot honestly endorse items thatseem to describe a sick, anxious, or sedentary person.' As mea-sures of somatic awareness, symptom checklists may not allowpersons to independently report what they feel and how theyfeel about it.

Summary of the Model

Disambiguating the content of somatic attention from itsmere direction and degree clarifies some otherwise equivocal

findings. A cognitive-perceptual model specifies multiple andinteractive processes between a perceived physical state and apsychological or behavioral response to it, and it also illustratesthe potential for invariance between them. The model attunesresearchers to the following questions: What does an experi-menter intend—and obtain—from an "attentional manipula-tion"? To what aspects of a person's total representation will theattention turn, and through what process? Will a manipulationunavoidably strengthen somatic awareness through a selectivesearch for sensations or as a function of top-down biases? Hasthe situation overdetermined a particular somatic interpreta-tion? Have we attempted to uniquely quantify and measurephysiological stimulation, perceptual awareness, somatic inter-pretation, psychological distress, and behavioral response? Inshort, to paraphrase Asch (1952), does an investigation mea-sure or manipulate an attention to the object or, instead, theobject of attention?

Questions like these are difficult to answer. They requiretapping into subjective construals of complex situations, alwaysa formidable task (Ross, 1987). Indeed, explicating the mecha-nisms of somatic interpretation is, by definition, a most chal-lenging endeavor; it requires a methodological and conceptualpartitioning of processes that are often naturally confoundedand that frequently occur "all of a piece" in the experiencingperson. Continued research into somatic interpretation may infact require the development of creative and perhaps radicallynew methodologies. Such an evolution can proceed, however,only from modeling the phenomenon as it is understood to thispoint. Cognitive-perceptual principles underscore the manypossible points of variance between a change in physical stateand a judgment or behavior in response to it. In theory, inter-pretation, and design, psychologists should position themselvesto detect and understand this variance, as well as to explain itsabsence.

Many fundamental issues in somatic interpretation lie"beyond attention," namely in exploring the meaning that peo-ple assign to their physical sensations and in explicating theprocesses by which that meaning is assigned. Previous treat-ments of symptomatology, most notably those of Pennebaker,H. Leventhal, and colleagues, insist on the same presumption(H. Leventhal & Mosbach, 1983; Pennebaker, 1982), and sev-eral 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 simplymade the cognitive-perceptual assumptions explicit and re-lated them in detail to particular methodological and theoreti-cal issues. In doing so, however, central research questions areconceptually reframed as issues of somatic interpretation ratherthan of mere symptomatology.

This reframing also implicates new directions. The assump-tion that somatic awareness is necessarily distressing tends tosupport a unidirectional concern with when and why distrac-tion fails. Yet perhaps the richest aspect of the cognitive-per-ceptual model is in the questions that it generates for when andwhy attention succeeds.

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 somaticinterpretation research. Attention to sensations often seems tobe that which obtains when distraction from them fails. A fixedattentional-capacities analysis can explain why this is so; whenan effortful distraction decomposes, somatic awareness is thenecessary result. But are all the effects of sensory attentionsufficiently explained by its being viewed simply as distraction'sperceptual complement? What, then, is "sensory monitoring"?

H. Leventhal and colleagues have suggested that sensorymonitoring works to the extent that sensation-distress associa-tions are intercepted or disrupted, thus allowing the formationof more objective schemata (H. Leventhal et al., 1979; H. Le-venthal & Everhart, 1979). Although intuitively helpful, thisanalysis is incomplete, for it does not illuminate the determi-nants of such a process. Does somatic attention simply segre-gate incoming somatic awareness from any immediate inter-pretation? If this is the case, do neutral or positive interpreta-tions necessarily follow?

Sensory attention as a type of distraction. H. Leventhal's defi-nition implies that focusing on the objective qualities of a physi-cal stimulus acts as a type of distraction from distressing inter-pretations and emotions. In terms of Figure 1, this processcorresponds to an internal focus on a physical sensation at theexpense of attention to any higher order interpretation of it. Asa person searches for and examines discrete sensory features,fixed attentional capacities may allow the processing of littleelse. Thus sensory monitoring may "work" because of what itavoids or replaces. According to this notion, as the engrossingnature of an internal, somatic attention increases, interpreta-tions of an otherwise unpleasant sensation should become lessnegative (and more positive only in a relative sense). Further-more, if sensory monitoring operates simply by preventing theformation of any higher order interpretation, then the converseshould also be true: namely, that concentrating on concrete so-matic components should make an otherwise pleasant sensa-tion less so.

This analysis suggests that significant attentional divisionsshould be represented, not only along internal/external or self/environment lines, but along a meaningful/meaningless di-mension as well and that sensory monitoring drains meaningout of somatic awareness. Yet there is some reason to believethat the effects of sensory monitoring may operate throughother, more active processes. For example, the effects of thestrategy often generalize beyond the period of focused atten-tion. Subjects trained in the technique during an initial cold-pressor trial exhibited better tolerance times in subsequenttrials, even though they were not explicitly instructed towardany particular strategy in these later exposures (Ahles et al.,1983). Other research suggests that once sensory monitoring issuccessfully used, its effectiveness lasts over time (Kabat-Zinn,1982,1984; E. Leventhal et al., 1989; Suls & Fletcher, 1985). Itseems unlikely, then, that all of the effects of the strategy can beaccounted for by a strictly inhibitory action.

Information and self-regulation. Focused somatic attentionmay allow for an accrual of information that would not be

available to the distracting person. This is the implied premisebehind Morgan and Pollock's findings among athletes, inwhich an adaptive "buy now, pay now" strategy was possibleonly if the runner closely monitored his physiological state. Tothe extent that sensory monitoring provides information aboutactual physiological status, then, it may result in more appro-priate self-regulatory behaviors (F Cohen & Lazarus, 1973; Laz-arus, 1983; Lazarus* Folkman, 1984; E. Leventhal et al., 1989;McCaul & Mallot, 1984; G. Schwartz, 1979).

Sensory monitoring may have an effect on emotional self-regulation as well. Through attention, one has the opportunityto note an incremental ebbing of discomfort and experience aconcomitant sense of relief (E Cohen & Lazarus, 1973; Morgan& Pollock, 1977; N. Schwartz, 1990). This may be especiallygermane to discomfort that naturally wanes or is tied to chang-ing activity levels, such as arthritic discomfort and some typesof injury. It may also be responsible for the strong temporaladvantage evinced by sensory monitoring during cold-pressorpain, which for many people gives way after some seconds to afeeling of tingling or numb pressure (Ahles et al., 1983). Some-one who is monitoring the sensations may notice the qualitativechange and experience both psychological and physical relief,whereas the distracting person may experience less of either.

Indeed, sensory monitoring may help discriminate painfulsensations from those that are merely associated with them (E.Leventhal et al., 1989). A toothache brings us to the dentist.After a shot of novocaine—and as the drill draws near—wesearch for distractors from the anticipated pain. Yet with occa-sional and transient exceptions, the sensations are more oftenthose of pressure or vibration. Sensory monitoring may notmake a trip to the dentist a pleasant experience, but it maypermit a comparative truce from the effects of fearful anticipa-tion.

Perceived control. There are likely to be important psycho-logical differences between a willful and an unwilling aware-ness of physical sensations, even of those that are experiencedas unpleasant. The purposeful search for sensory informationcould provide one with a degree of perceived control not other-wise likely to occur. Genuine influence over the stimulus is notnecessary; the person need only believe or feel that self-moni-toring is somehow beneficial (Holroyd et al., 1984; Langer,1983). The voluminous literature on the psychological and bio-logical benefits of a sense of control—and the pernicious effectsof its absence—makes 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 sensationscannot be ignored for long, and attempts to distract from themeither ultimately or intermittently fail. Thus sensory monitor-ing 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 dis-tancing oneself from distress is often difficult to sustain, and itseventual decomposition can leave one feeling emotionally as-saulted and out of control (Folkman & Lazarus, 1988; Lazarus,1983).


If there are occasional benefits to active, "confrontational"strategies, then there are occasional costs to distracting or de-nying ones. Indeed, emergent notions from all quarters are be-ginning to explicate just what some of these costs might be.Under some circumstances, negative cognitive and emotionalstates exhibit some benefits (F. Cohen & Lazarus, 1973;Showers, 1988; Showers & Ruben, 1988), whereas repression ordenial of them can be psychobiologically pernicious (Jamner,Schwartz, & Leigh, 1988; Pennebaker, 1985; Pennebaker&Bealle, 1986; Shaw et al., 1986; Weinberger, 1990; Wolff, Fried-man, Hoffer, & Mason, 1964).

Most significantly, suppressing strategies can backfire, exac-erbating the very problem that one was trying to avoid. In anintriguing series of experiments, Wegner and colleagues haveshown that suppression of an arousing, unwanted thought, al-though initially effective, produces a rebound effect once themental inhibition is released (Wegner, 1989; Wegner &Schneider, 1989; Wegner, Schneider, Carter, & White, 1987).Furthermore, the environmental objects used as distractorsduring suppression become "polluted" with an association tothe forbidden thought (Wegner, Schneider, Knutson, & McMa-hon, 1989). These findings suggest that brute force attempts todistract from uncomfortable sensations, or from accompany-ing negative cognitions, may ultimately result in an even greaterpreoccupation with them.

Suppression carries other disregulatory consequences. Dis-tracting from the unpleasantness of an event as it occurs mayresult in memory distortions of it and may bias social percep-tion 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 maythus directly contribute to the development or the exacerbationof health problems (Pennebaker, 1985; Shaw et al, 1986; Wolffet al, 1964). This psychobiological component of avoidant strat-egies and dispositions identifies a most provocative area forfuture study.

Levels of thought and action. Several research programs ana-lyze how people experience their actions as a function of howthey are categorized (Fiske & Pavelchak, 1986; Pennebaker,1989; Rosch, 1973; Vallacher & Wegner, 1985,1987; Wegner &Vallacher, 1986). An action such as running 6 miles can beidentified along a continuum of low complexity (i.e, "puttingone foot in front of the other") to high complexity (i.e., "rehabili-tating from a heart attack"). People faced with difficult orstressful task demands tend toward a lower level view of theiractions, describing and experiencing them in terms of theirconcrete, subcomponent parts. Well-learned activities, in con-trast, tend to carry larger conceptual or abstract labels (Val-lacher & Wegner, 1987).

The effect of such categorizations are most certainly ger-mane to the mechanisms of sensory monitoring. It is not yetclear, however, how the constructs map onto many somaticsituations. What is the high-level action identification for theact of running a marathon? Do Morgan and Pollock's (1977)data paradoxically suggest that expert athletes hold a low-levelidentity of their run because they focus on concrete and imme-diate sensory information? An alternative analysis is that at-tending to somatic information indicates a comprehensive use

of cues in service of the higher level action of "running a smartrace" (Wegner, Vallacher, Macomber, Wood, & Arps, 1984).

It is also likely that the effects of different action identifica-tions can be confounded with the content and emotional toneof one's prepotent higher level category. Thus, for example,anxious test takers may benefit from a low-level task focusmainly because the higher level identity for their activity isfraught with anxiety and fear of failure (Geen, 1980; Wine,1980). Given this self-view, a low-level focus facilitates perfor-mance much as sensory monitoring acts as a distractor fromnegative cognitions and emotions. However, several mediatorsof agency draw on positive and high-level views of the task andof the self, views that exert a positive top-down influence onbehavior and subsequent self-assessment (Ajzen, 1988; Ban-dura, in press-a; Becker, 1974; Maddux, Scherer, & Rogers,1982).

Thus, intuitive or apparently face-valid definitions of an ac-tion level require empirical validation in the somatic domain.More specifically, future researchers should build on the verti-cal analysis of action identification by adding to it an analysis ofcontent. On what dimensions do disparate high-level identifi-cations differ from one another, and what are the implicationsof these differences according to the depth-of-processing view?Addressing these questions promises many significant insightsinto somatic strategies and mechanisms.

In sum, there are several mechanisms by which sensory mon-itoring could contribute to adaptive psychobehavioral out-comes, and they are probably both complementary and interac-tive in many somatic situations. Active effects may include ac-crual of self-regulatory information and a sense of efficacy andcontrol, whereas passive effects may provide a diversion fromdistressing interpretations or may operate by avoiding the per-nicious consequences of both successful and failed distraction.Discussion of these mechanisms has been necessarily specula-tive. It is clear, however, that the speculations generate severalhypotheses that marry well with a number of rich theoreticalconstructs.

Sensory Monitoring in Clinical Applications

Theoretical considerations aside, the real world awaits. Ag-ing, illness, rehabilitation, medication, and stress often presentchanging, irregular, ambiguous, unpredictable, and diffusephysical sensations with which the person must cope. In thisreal world, sometimes it simply is not possible to distract all ofthe time, and sometimes it is not adaptive to do so. Following isa brief discussion of two clinical problems that may argueagainst somatic distraction as an exclusive strategy. Both arealso promising models within which to explore the adaptivefunction of a particular type of somatic attention.

Misattribution and cardiac rehabilitation. An estimated twothirds of heart attacks are clinically uncomplicated; that is, theyleave no permanent heart damage, and within several weeks ofthe attack, no biological impediments to the patient's full recov-ery remain (Cohn & Duke, 1987). Many patients, however,never return to full functioning because they can no longerinterpret the arousal of exercise, emotion, and sexual excite-ment 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 tomere evidence of that weakness.

In this situation, avoiding arousal-producing behaviors isclearly maladaptive, such a strategy being the definition of an-

ticipatory disability. Yet distraction from the bothersome physi-cal sensations may be an equally poor solution; imagine a doc-tor counseling the patient "When you start to notice arousal

sensations while havingsex with yourspouse, try doing arithme-tic problems, or recall your grade-school teachers." These pa-tients are poor candidates for distraction during exercise aswell; the oft-prescribed postattack exercise program is usuallythe first that the patient has attempted in years, and special riskfactors make the consequences for overexercising very seriousindeed. An ideal rehabilitation strategy would be to discouragepatients from misattributing physical sensations, but to alsohelp them remain able to fully experience and accurately moni-tor the sensations arising from everyday activity and emotion.

Cardiac patients often perform a diagnostic treadmill stresstest as part of their medical follow-up. In an interesting set ofstudies, this event has been used to explore attributional issuesin the rehabilitation process. In one study, Ewart, Taylor, Reese,and DeBusk (1983) found that a person's perceived self-efficacyto tolerate physical exertion was more predictive of treadmillperformance and of subsequent physical activity than was ac-tual cardiac capacity. Initial self-efficacy judgments were asso-ciated with greater effort exerted during the treadmill, which inturn was associated with a greater boost in subsequent per-ceived self-efficacy and physical activity at home. These resultssuggest that the efficacious patients were heartened—literally—by signs of their treadmill exertion in that, for them, it wasrich with evidence for the robustness of their cardiovascularsystem. Indeed, all but the most inefficacious patients bene-fited from a safe completion of the treadmill exercise, espe-cially when they were bolstered by counseling in which theexercise was explained in a positive frame.

The positive correlation between stimulus intensity (the de-gree of treadmill effort) and a strengthening of a patient's per-ceived self-efficacy is especially interesting; given a positive in-terpretive bias, more somatic information equaled more evi-dence for the hypotheses of fitness. In cardiac rehabilitation,then, attention to physical sensations from within a hypothesisof improvement may be more desirable than either sensorydistraction or somatic habituation (Bandura, 1986).

Multiple sclerosis: Separating symptom from affect. Approxi-mately 200,000 Americans suffer from multiple sclerosis (MS).The condition, which strikes people most commonly betweenthe ages of 15 and 55, progressively destroys the insulation ofthe central nervous system, and sometimes it cripples and kills.More frequently, however, those afflicted avoid serious organicimpairment, but for the remainder of their lives, they are besetby a barrage of confusing and unpredictable symptoms, includ-ing sensory and motor disruptions, transient visual distur-bances, urinary and sexual dysfunction, problems in balanceand coordination, tremor, and profound fatigue (Poser, 1984).

One of the most striking characteristics of MS is its unpre-dictability. A course may run from occasional symptomatologi-cal exacerbations to a constant and progressively worseningform, or to several variations in between. In the chronic-relaps-ing form, for instance, increasingly severe exacerbations are

superimposed on slowly worsening symptomatological base-line. Given such unpredictability, adapting or habituating toone's symptoms is a rare if not impossible achievement. Tomake matters worse, there are no early, reliable indices predict-ing 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 MScan profoundly affect its course in several ways. First, extremelife stress is associated with the onset of the disease and with itsexacerbations, possibly through psychoimmune effects (La-Rocca, Scheinberg, & Raine, 1984; Warren, Greenhill, &Warren, 1982). Second, the physical correlates of anxiety andstress can become superimposed onto the already stresslikesymptoms of the disease (Rao, 1986). Finally, anxiety or depres-sion about one's limitations can become the source of new func-tional impairments. An example is the man who experiencestransient impotence resulting from neural damage but whoseanxiety over this impotence quickly guarantees its chronicity(LaRocca et al, 1984; Rao, 1986).

There are several parallels between these phenomena andthe cardiac patient, especially in the potential for anticipatorydisability. For instance, a woman under emotional stress mayassume that her MS is being exacerbated, and she may decide tostay home from work. But there is a unique aspect to the MSsituation; not all maladaptive strategies can be traced to so-matic misattributions. Exacerbations of symptoms do occur,and unlike the situation of the cardiac patient whose heart hashealed, MS symptoms reflect bona fide neurological damageand physical limitation, mandating behavioral adjustments ofone sort or another.

Under these conditions, it is clearly desirable that patientsstay as active as their limitations allow. The scientific and popu-lar literature overwhelmingly acknowledges this imperative andoffers much advice on forestalling anticipatory disability(Scheinberg & Holland, 1987; Stewart & Sullivan, 1982). Swim-ming is highly recommended for patients; MS itself is not accel-erated by exercise, and muscle strength is an important hedgeagainst diminishing neurological coordination. The patientwho swims is certainly better off than one who does not, inas-much as the activity is an excellent cardiovascular conditionerand produces moderate gains in muscle tone. One may ask,however, why more progressive resistance activities such asweight training are not widely prescribed, as they would pro-duce even greater skeletomuscular strength and stability. Thereseem to be two reasons why this is so. First, the more anaerobicexercise of weight training reveals balance and coordinationsymptoms more than does swimming and, second, a rise inbody temperature—which is avoided during swimming—tendsto exacerbate the symptoms. Yet neither the presence of thesymptoms nor the physical exertion worsens the disease! Thuseven enlightened advice on how to combat anticipatory disabil-ity may ultimately give in to it in some degree.

Much research is needed to discover whether, and underwhat conditions, more muscular exercise is advantageous forthe MS patient. However, to the extent that interpretations ofone's symptoms—rather than an organic impediment—is thelimiting condition for vigorous exercise, optimal physical ther-apies have yet to be devised. An acquaintance of mine, discuss-ing her attempts to maintain a weightlifting regimen despite


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 re-

sponses to them:

I got tired of telling my boyfriend that my symptoms were either"good" or "bad" that day. Somehow that just didn't convey how Ifelt 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 numberson a scale of 1 to 10. The first number is for the symptoms: Howphysically bad are they? The second number is how I feel aboutthem emotionally. They're usually different numbers. So maybeone day my symptoms are only "3" but I'm really bummed outabout them, really depressed, and every lift I do just makes mefeel worse; I'll probably cut that workout short. But on some otherday I might be stumbling around like crazy—symptoms "8"—butI just don't particularly care about them. They don't bother me allthat much, and I'd rather work out. So we go on. I guess I makedecisions 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 dis-

ambiguates her physical sensations from her psychological re-

sponse 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 evi-

dence suggests that MS is an exemplary clinical model for this

approach. Many long-term patients exhibit a positive adapta-

tion 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 unpredict-

able 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 can-

didate for research efforts.

Summary

Many phenomena of health and illness require that we un-

derstand the mechanisms and processes of somatic interpreta-

tion. The goal of this discussion is to stimulate such research

and to exhibit the utility of a cognitive-perceptual model to-

ward 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 in-

teresting among these is how certain types of somatic attention

may facilitate adaptive responses to physical stress or limita-

tion.

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 com-

plexities, 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

qualify us to make unique and useful contributions to the field

of health behavior.

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Received November 12,1988Revision received March 12,1990

Accepted Aprill 0,1990 •

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