beyond attentional strategies a cognitive-perceptual

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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 peopleassign to physical sensationscan have profound implications for their physicaland psychological health. A predominant research question in somatic interpretation asks if it ismore adaptive to distract one'sattention away from a potentially unpleasant sensation or to focusone'sattention on it. Thisquestion,however, has yielded equivocal answers. Manyapparentambi-guities in this research can be traced to a failure to distinguish the content of a person'sattentionfrom its mere directionordegree. A model of somatic interpretation isdiscussed, incorporating notonly perceptual focus but also the attributions, goals, copingstrategies,and prior hypothesesof theperceiver, thus delineating the psychobiologicalconditionsunder which various attentionalstrate-gies should be adaptive. In contrast to the prevailing concern with whenand whysomaticdistrac-tion doesn't "work," this conceptual analysisalso considerswhen and why somaticattention does.Theoretical and methodological issues are discussed,as is the potential utilityofsomatic attentionin cardiac rehabilitation and multiple sclerosis.

He shivered repeatedly as he lay looking out through the woodenarch at the reeking, dripping dampoutside,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 upOceanSteamships 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 membershipdenned by the shift-ingand sometimes chimerical line between healthand illness.His initiation into this society occursin an intensely psychologi-cal landscape, where the meaning he assigns to a shiver or aflushdetermines his identity aseither well or ill.

Mann's parable reflects anessential characteristic of physicalsensations; they are as often socially influenced interpretationsastheyare the direct outputof abiological system.Inmattersofhealth and illness,it isdifficult to imaginea more fundamentalprocess than that by which we perceive, interpret, and act onthe information from our own bodies.

Is itbetter to ignoreone's somatic statesor to payattention 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 foreach 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. Mygratitude goes to Al-bert Bandura, Kent Harber, LeeRoss, 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 DeliaCioffi, Department of Psychology, University of Houston, Houston,Texas 77204-5341.

cile some of the equivocationsand offer suggestions formovingbeyond them.

I begin bydiscussing 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 analysisof the apparent equivocations. Iargue that con-fusion over the effects ofattentional strategies often reflects thefailure to distinguish the content ofattention from its direction,and Idiscuss several theoretical and methodological issues thattend to blur this distinction. Idescribe a model that highlightsthe interaction between bottom-up and top-down influenceson the somato-interpretive process.

Current thinking on somatic interpretation is often subtlybiased towardviewingawarenessofsomatic information asnec-essarily distressing. In contrast, the present discussion punc-tuates the potential variance betweenthe perception of a physi-cal sensation and any particular interpretation of it whilealsodescribing howstrong situationalor top-down influences maysometimes overdetermine their relationship. This conceptualanalysis, rather than concentrating on when and whyad istract-ing strategy does not "work" also generates hypotheses forwhen and why attention does. These hypotheses are exploredand applied to the clinical exemplars ofcardiac rehabilitationand multiple sclerosis, two conditions for which somatic dis-traction may be neither possible nor desirable.

Two SymptomatologicalModelsThe Biomedical Model

The traditional biomedical model holds a relatively mecha-nistic viewof physical symptoms. It isassumed 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 biologicalpro-

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26 DELIA CIOFFIcess. Likewise, close correspondence is assumed betweensymptom perception and actual biological state; as the physicalpathology intensifies, itssymptoms 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 issup-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 yearsago,contemporarydiseasessuch as hypertension, coronary heart disease, andcancerare chronic conditions that are rarely linked to aspe-cific cause and that may be managed but not cured. Treatmentsbased solely on biomedical interventions cannot address thesignificant behavioral components of these and similardis-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 ModelMedical and psychosocial models often do converge, and

their confluenceas in the interdisciplinary treatments forchronic paincan be most effective indeed (cf. Fordyce, 1976;H. Leventhal & Everhart,1979;Turk & Kerns, 1983; Turk, Mei-chenbaum, &Genest, 1983). The imperative for thisapproachis also well illustrated by the so-called compliance problemamongpeople with high blood pressure. Apatient whoadheredimperfectly 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, referringthe 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 alwaysaccurate in the biological sense, maynone-theless bepredictable from a social-psychological pointofview(Cioffi, 1990a). Accordingly, one may better serve therapeuticgoals by learning more about the patient'sillness 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 privatethe-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-perceptualphenomenathat is, as stimuli that are subjecttocomplex psychosocial processes and therefore susceptible toinfluences beyond those explained bybiosensory mechanismsalone (seePennebaker, 1982, for a review).

The social cognition approach wasespecially 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 interpretivepro-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 ofa 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;seealso Holroyd etal., 1984). Taken insum, this research dem-onstrated that somatic interpretationindeed, the very"per-ception" of somatic information itselfwas profoundly in-fluenced by the situation, by the behaviorofothers, and by thebeliefs, assumptions, and attributions of the perceiver.

Review of Attentional StrategiesHaving demonstrated the plasticity of somatic interpreta-

tion, researchers turned to what issurely an elementary influ-ence on this process: the effects of attentional focus. The centralquestions were straightforward. To what extent does a strategyofdistraction 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


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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.

DistractionCompetition for attentional capacity. Virtually all research

on somatic attention, assumes a necessary division of a fixedamount ofattention between relatively strong and weak stimuli(e.g., Kahneman, 1973; Navone & Gopher, 1979). Thus a de-crease in the intensity ofexternalstimuli tends to make internalinformation more salient. This is the principle atwork whenweexperienceasudden "worsening" of an acheorpain 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 salienceofinternal informationwith increased symptom reporting turn on this principle offixedcapacities (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 whowere circlingthe repetitive oval were more awareoftheir physical fatigue and effort than were runners whonavi-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 individualdifference in the tendencyto focus oninternalfeelings 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).

Althoughoperational definitionsof 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, wasrelated tosymptom reporting byado-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 isequalto 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 tophysicalsymptoms (Barsky& Klerman, 1983;Stretton &Salovey, 1989).Likewise, panic disorders are often characterized by specificpatterns of bodily symptoms in combination with symptom-relevantand negativecognitions (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 isaddressed in later sections.

Activedistraction. Willful dissociation from anoxious physi-calsensation can increase physical tolerance andattenuate 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 distractionbyexternal 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 whofocusedon the rhythmoftheir 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 toconstruct adetailed 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-


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28 DELIA CIOFF1ington & 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).

Theevidence discussed in this section supports the followingnotions:First,when the external environment is undemanding,the relativesalience 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.

AttentionIt is intuitively plausible that distraction "works," and the

empirical 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 wil l fu l 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 theeffects ofstrategies that increase attention to somatic information. Evi-dence indicates that attention to physical sensationsdoes notnecessarily increase distress over those sensations, and undersome conditions it may in fact reduce psychological distressand facilitate adaptive outcomes.

Sensory monitoringdefined. To understand whysomatic at-tention can lessen distress, one must consider the type ofatten-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 distinctionwas originally suggested by the work of H.Leventhal and colleagues, whichposited that many potentiallyuncomfortableevents can be processed for both theirconcrete,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 sensationwhat H. Leventhal called sensorymonitoringis 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 orgeneral body tension, biasesthe processing of all incoming sensory information toward theexperience of pain and distress.

Sensory monitoringinlaboratory andclinical 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 wasgiven.

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 focusonone'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 israrelya 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 ambulatoryand lessdistressed than those who usediversionary tactics alone (Phil-ips, 1987;Rosensteil &Keefe, 1983). For example, chronic painpatients trained in "mindful meditation"a willful, directedfocus on the sensory aspects of painexperienced 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 areobjective 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 isoften 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


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SOMATIC INTERPRETATION 29problems. 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, paylater" 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 toshare manyproperties 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 weregiven control informationabout the equipment without attentional instructions. The sen-sory-monitoringsubjects were instructed to systematicallyex-amine their physical sensationsand to actively search forthem,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 noticeabilityof a sensation and itssub-jective pleasantness was positive (r = .28). In contrast, thosegiven no attentional strategy rated their perceived sensationsmore negativelyand 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 attentionthatwhich focuses on the concrete properties of the sensationcanresult 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.

ACognitive-Perceptual Model ofSomatic InterpretationAre the findings on attentional strategies contradictory? It is

suggested 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, wemust 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 iseasily blurred, I turn to an exposition.

Behaviori.e., put on gloves, finddistractor

Mediatorsgoals, affect,copingstrategies,dispositions, motivation

Prior Hypothesesi.e., concerns aboutillness

Attributionsperceived causesandconsequences

Somatic Labeli.e., "cold hands"

Physical Statei.e., drop inhandtemperatureFigure I. Components of somatic interpretation. (Arrows indicatepaths of influence for both [a] meaning assignment, as when a priorhypothesis of illness induces a pathological label fora perceived sensa-tion,and[b]perceptual attention,aswhen the same hypothesis inducesa search for relevant information, thus amplifying somatic awarenessin general. Also, perceptual attention has several potential targets; itcan be deployed toward or away from any component of the interpre-tive processes. Finally, situational influencesincluding the relativeintensity of internal and external stimuliact on an interpretive sys-tem of interrelated components, rather than on anycomponent in iso-lation.Thusalthough thereare several pointsofvariance between theawareness of a physical sensation and a particular interpretation of it,the relationship is sometimes relatively overdetermined.)

IllustrationSomatic interpretation is a multiprocess elaboration upon a

real 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 thesame 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 myroute ismarked bypotholes, or if an


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30 DELIA C1OFFIold knee injury is acting up, I may never notice the relativelymild physiological change in my hand; the competition for myfixedattentional capacities is, in this case, among several com-pelling internaland external events. Butsuppose 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 invariablyattributelhe sensa-tion to something. If I believe that myhands are cold becausemy circulation is bad, then the sensation becomes asymptomevidence that something is wrong with me. I couldarrive at this symptomatological attribution in one of twoways.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 mycommute, Iwouldbeactively 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 forthe sensation. Alternatively,the perceived physical sensation could become the event forwhich an attributional search is launched. In either case, mysketchyself-diagnosis willincludethe consequences that Iimag-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 myblood 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, mycoping 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 PrinciplesThis 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 processfrom becoming aware of a physical stateto labeling, interpreting, and responding to itcould 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 processa healthhypotheses, an emotional response, an elaborated interpreta-tionnot just toward or awayfrom the somaticsensation 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 ofphysical 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 weakin other words, if the top-down bias isstrongly negativethen attention to the physicalsensationcom-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 sensationand anyparticu-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 inmore detail anddiscuss themethodolog-ical and theoretical issues that they raise.

Features of the Physical StimulusThe choice of an experimental stimulusdefines the range ofinterpretations that subjects can plausibly make of it. Interpre-

tations ofcold-pressororischemic painare 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 whicha sensory monitoringstrategy ismost 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.

Asecond stimulusissue pertains to the experimental controlof its intensity. As the top-down influences of Figure 1 show, theperceived intensity of a physical stimulation isaffected by one'sinterpretation of it. Thus a confound may result if subjects self-select astimulus intensityon thebasis oftheirapriori ormanip-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 oftheirsen-


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SOMATIC INTERPRETATION 31sations will systematically differ. This self-selection, in turn, isintimately related to the somatic interpretation that each sub-ject ispronetomake. Statisticalcovariance analysesor asimpleobservation of differences on this factor do not replace a first-order experimental control. In the caseofanexercise manipula-tion, it is possible to relativize workloads in such a waythat allsubjectsareworking,for instance,at 60% of their aerobic capac-ity for a fixed amount of time (Astrand & Rodahl, 1977). Thecalibration ofother physical stimuli is a necessary step towardexplicatingthe microprocesses of somatic interpretation, yet todate this basic methodological research has not been done.

The Direction of AttentionAttention to the specific concrete properties of a physical

sensation has different effects than does attention to its cogni-tive elaboration, to diffuse inner states, or to one's emotionalreaction. Past analyses, however, havenot 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; emphasisadded). Onewould expect such a definition to produce variable or perhapsconflicting results. Sensory monitoring might ameliorate dis-tress, whereas attention to one's "own reaction," ifthat reactionisnegative, 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). Forexam-ple, the definition of high monitoring according to S. Millerand colleagues is a vigilant scanningfor //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 dispositionsof-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.Evena basic somatic label such as"coldhands" 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 dynamicthey can be created,maintained, and changedand a physical sensation initially

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

Inviewing 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 itwill 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 directlyaffect physiological arousal and thusmayinfluence 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 AttentionAttributions and prior hypotheses. People organize events

into causal units and according to their prior theories, beliefs,and expectations (Abelson, 1976,1981; Fiske & Linville, 1980;Kahneman, Slovic, & Tversky, 1982; Lord, Ross, & Lepper,1979; Nisbett&Ross, 1980;Schank&Abelson,1977). 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 ofthat information toward aconfirmationof 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 toconfirma causal hypothesis.

Thus, providingan illness label orputting 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 toldfalselythat their blood pressurewas "a little high for their age," a group of college students


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32 DELIA CIOFFIreported havingexperienced 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, weretold 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 salientenvironmentalfac-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 informationinillness-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 fairlyelaborate mental representa-tions of their physical states, and these representations providethe basis for coping plans and actions (Becker, 1974; Croyle &Ditto, inpress; 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 whatpeople 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 forcervical 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 d iffe r widely" (p. 522). Indeed, mostclinical settings arestronglyassociated with schemata ofillnessor 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 bedirected toward understanding theparticularassessments 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 GoalsThe goal in facing laboratory-induced pain isusually 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, forexample, may plausibly respondto different goal levelsat different junctures during treatment.Resisting the sick role mayresult 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 mayexhibit 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 ratherare relatively free to take on a broaddistribution of meanings.

Thus, the self-referent mediationsof self-efficacy may rangefrom decreasing the intensityor amountofone's initial physio-logical stimuli, to the ability todistract, tostoicism, to a changein the interpretation of a physicalsensation. 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;


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SOMATIC INTERPRETATION 33

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-termor 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 ismedicallydangerous (Ewart et al, 1986). Distraction from arthritic painmayfacilitate normal day-to-dayfunctioning, 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 AwarenessThe 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 havea particularly difficult time with symptom checklistsand autonomic perception questionnaires, asking the experi-menter for more elaboration and offe r ing 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 arestrugglingtoaccurately report their numerousand detailed so-matic sensations and yet cannot honestly endorse items thatseem todescribe asick, anxious, orsedentary person.' Asmea-sures of somatic awareness, symptom checklists may not allowpersons to independentlyreport what they feel and how theyfeel about it.

Summary of the ModelDisambiguating the content ofsomatic attention from its

mere 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 intendand obtainfrom 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 intosubjective construals of complex situations, alwaysa formidable task (Ross, 1987). Indeed, explicating the mecha-nisms of somatic interpretation is, by definition, a most chal-lengingendeavor; 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 whydistrac-tion fails. Yet perhaps the richest aspect of the cognitive-per-ceptual model is in the questions that itgenerates forwhen andwhy attention succeeds.

1 Observations by William Morgan, Deborah Feltz, and myself.


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34 DELIA CIOFFISensory Monitoring: Processes and Implications

Potential Mechanisms of Sensory MonitoringIt is interesting to consider the implied symmetry in somatic

interpretation research. Attention tosensations often seems tobe that which obtains when distraction from them fails. A fixedattentional-capacities analysiscan explain whythis is so;whenan effortful distraction decomposes, somatic awareness is thenecessary result. But are all the effects of sensory attentionsufficiently explained by itsbeingviewed simplyasdistraction'sperceptual complement? What, then, is"sensory monitoring"?

H. Leventhal and colleagueshave suggested that sensorymonitoring works to the extent that sensation-distress associa-tionsare intercepted ordisrupted, 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 attentionas a type ofdistraction. H. Leventhal'sdefi-nition implies that focusing on the objective qualities of a physi-cal stimulusactsas 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,fixedattentional 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 (andmore 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. Yetthere 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, itseffectiveness lasts over time (Kabat-Zinn,1982,1984; E. Leventhalet al., 1989; Suls & Fletcher, 1985). Itseems unlikely, then, that all of the effects of the strategycan beaccounted for by a strictly inhibitoryaction.

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 "buynow, 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-regulatorybehaviors (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 naturallywanes 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 giveswayafter some seconds to afeeling of tinglingor numb pressure (Ahleset 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 novocaineand as the drill draws nearwesearch for distractors from the anticipated pain. Yetwith 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 tooccur. Genuine influence over the stimulusis 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 asenseofcontroland the pernicious effectsof its absencemakes this a possibility well worth pursuing(Bandura, Ciolfi, Taylor, & Broullaird, 1988; Litt, 1988; Maier,Laudenslager, & Ryan, 1985; S. Miller, 1979,1980; Tecoma &Huey, 1985;Thompson, 1981; Wallston, Wallston, Smith, &Dobbins, 1987).When distraction fails. Many noxious physical sensationscannot be ignored for long, and attempts todistract from themeither ultimately or intermittentlyfail. Thus sensory monitor-ingmayfacilitateadaptation through preparation (Glass, Reim,&Singer, 1971; Glass&Singer,1972; Houston &Holmes, 1974;Johnson, 1973)and by wardingofffeelings of helplessness (e.g.,Abramson, Seligman, & Teasdale, 1978). The strategy of dis-tancing oneself from distress isoften difficult tosustain, and itseventual decomposition can leave one feeling emotionally as-saulted and out of control (Folkman & Lazarus, 1988; Lazarus,1983).


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SOMATIC INTERPRETATION 35If there are occasional benefits to active, "confrontational"

strategies, then there are occasional costs to distracting or de-nyingones. 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; Shawet 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 asdistractorsduring 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; Wolffetal, 1964). Thispsychobiologicalcomponentofavoidant 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 lowcomplexity (i.e, "puttingone foot infront 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 analysisofaction identification byadding to it an analysisofcontent. 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.

Insum, there are several mechanisms by which sensory mon-itoring could contribute to adaptive psychobehavioral out-comes, and theyare probably both complementary and interac-tive in many somatic situations. Activeeffects may include ac-crual ofself-regulatory information and a sense ofefficacy andcontrol, whereas passive effects may provide a diversion fromdistressing interpretations or mayoperate 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 ApplicationsTheoretical considerations aside, the real world awaits. Ag-

ing, illness, rehabilitation, medication, and stressoften presentchanging, irregular, ambiguous, unpredictable, and di f fusephysical 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. Anestimated twothirdsof 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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36 DELIA C1OFFIweak 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. Yetdistraction from the bothersome physi-cal sensations may be an equally poor solution; imagine a doc-tor counseling the patient "When you start to notice arousalsensations whilehavingsex with yourspouse, trydoingarithme-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 isusuallythe first that the patient has attempted inyears, and special riskfactors make the consequences for overexercising very seriousindeed. An ideal rehabilitation strategy would be to discouragepatients from misattributing physical sensations, but to alsohelpthem remain able to ful ly experienceand 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 heartenedliterallyby 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 isespecially 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-mately200,000Americans 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 besetbya barrage ofconfusing 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. Acourse 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 whichcourse 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 profoundlyaffect itscourse 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, anxietyordepres-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 maydecide 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 limitationsallow. The scientific and popu-lar literatureoverwhelminglyacknowledges this imperative andof fe rs 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 moreanaerobicexercise of weight training reveals balance and coordinationsymptoms more than does swimming and, second, a rise inbody temperaturewhich is avoided during swimmingtendsto exacerbate the symptoms. Yet neither the presence of thesymptoms nor the physical exertion worsens the disease! Thuseven enlightened advice on how tocombatanticipatory disabil-ity mayultimately give in to it in some degree.

Much research is needed to discover whether, and underwhat conditions, more muscular exercise is advantageous forthe MSpatient. However, to the extent that interpretations ofone's symptomsrather than an organic impedimentis thelimitingcondition for vigorous exercise, optimal physical ther-apies have yet to be devised. An acquaintance ofmine, discuss-ing her attempts to maintain a weightlifting regimen despite


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SOMATIC INTERPRETATION 37exacerbated symptoms, addsencouragement forthis approach.She describes a coping strategy that separatesher perception ofthe 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 Iwanted to do about it. So wedeveloped this system.When myboyfriend askshow I'mdoing, Igive him twonumberson 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 probablycut that workout short. But on some otherday I might be stumbling around like crazysymptoms"8"butI just don't particularlycare 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 muchhyhow 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 bycarefully attending to both. In this way shemaintains a senseof control over her exercise activity and feelsefficacious in both her physical and emotional self-regulation.

It would be most instructive to investigate natural strategiessuch as these and the extent to which attention to potentiallydistressing physical sensations is a necessary component of anadaptive response to a physical limitation. Indeed, other evi-dence suggests that MS is an exemplary clinical model forthisapproach. Many long-term patients exhibit a positive adapta-tion to their condition, maintaining anoptimisticoutlook andhigh self-esteem that persist even in the presence ofsignificantphysical impairment (Brooks &Matson 1982). The unpredict-able and variable courseof MS, the physical and psychologicalchallenges that it presents, the successful self-regulation by atleast some of those afflicted, and a strong psychobiologicalcomponent make this diseasea fascinatingand important can-didate forresearch efforts.

SummaryMany phenomena of health and illness require that we un-

derstand the mechanisms and processesofsomatic interpreta-tion. The goal of this discussion is to stimulate such researchand to exhibit the utility of a cognitive-perceptual model to-ward this end. Some apparent equivocations in the effects ofattentional strategiesbecome more tractable as the content ofsomatic attention is distinguished from its mere direction ordegree. Perhaps of more importance, a cognitive-perceptualanalysis poses manyquestions that await explication. Most in-terestingamong these is howcertain types ofsomaticattentionmay facilitate adaptive responses to physical stress or limita-tion.

The complexitiesof somatic experience are surely daunting,and no doubt this subjective construal will defend its opacityquitewell. Yet in making the attempt tounderstand these com-plexities, weadvanceour research beyond attentional divisionsalone, moving instead toward understanding the meaning ofsomatic information for the experiencing person. It is there,aspsychologists, that webelong; it isthere thatour traditions best

qualify us to make unique and useful contributionsto the fieldof health behavior.

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