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AIMS AND SCOPE OF JOURNAL: The Annual Review of Psychology covers the significant developments in the field of psychology, including: biological bases of behavior, sensation and perception, cognitive processes, animal learning and behavior, human development, psychopathology, clinical and counseling psychology, social psychology, personality, environmental psychology, community psychology, and more.  

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The American Journal of Psychology (AJP) was founded in 1887 by G. Stanley Hall and was edited in its early years by Titchener, Boring, and Dallenbach. The Journal has published some of the most innovative and formative papers in psychology throughout its history. AJP explores the science of the mind and behavior, publishing reports of original research in experimental psychology, theoretical presentations, combined theoretical and experimental analyses, historical commentaries, and in-depth reviews of significant books.

• No. 4 Winter 2020 pp. 415-556
• No. 3 Fall 2020 pp. 275-424
• No. 2 Summer 2020 pp. 143-274
• No. 1 Spring 2020 pp. 1-142

• Research article
• Open access
• Published: 13 July 2022

Goal setting with young people for anxiety and depression: What works for whom in therapeutic relationships? A literature review and insight analysis

• Jenna Jacob   ORCID: orcid.org/0000-0003-1006-1547 1 ,
• Milos Stankovic 2 ,
• Inga Spuerck 2 &
• Farhad Shokraneh 3  

BMC Psychology volume  10 , Article number:  171 ( 2022 ) Cite this article

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Goal setting and goal-focused work is widely used in young people’s mental health settings. However, little is known about how, why or for whom this is helpful. This study aims to explore the mechanisms of collaborative goal setting as part of therapeutic relationships: is it helpful for young people experiencing anxiety and/or depression, how and why/not, for whom, and under what circumstances?

Online database searches generated 10,907 records. Seven unique studies are included, combined with insight analysis from directed discussions with international advisors with lived experience of anxiety and/or depression and therapy (N = 8; mean age = 20.8), and mental health academics/clinicians (N = 6).

Findings are presented as a narrative synthesis and suggest that goal setting is helpful to young people experiencing anxiety and/or depression because it helps build good therapeutic relationships through open communication and building trust. Goal setting helps make things more manageable, enabling young people to feel supported and have ownership of their care. Individual preferences, or high levels of distress, trauma, low confidence, hopelessness, negative past experiences of goal setting, perfectionism, and rumination are considered limiting factors to goal setting. Additionally, contextual factors including country and long-term therapy are explored.

Whilst the resultant sample is small, emphasis on the voices of young people in the research is both prominent and of paramount importance. Several key literature gaps are identified, including evidenced links to the reduction in symptoms. Priority must be given to researching unhelpful mechanisms of goal setting for young people experiencing anxiety and/or depression, to avoid any potential iatrogenic effects.

Peer Review reports

Collaborative goal setting within therapeutic mental health settings refers to agreements made between young people and practitioners about specific therapy areas of focus: topics of personalised and meaningful outcome. Goals are concrete representations of intended endpoints, which fill the perceived gap between the current and desired end state [ 1 ]. Goals are usually formulated at the start of therapeutic interventions through a series of discussions. These differ from academic, physical rehabilitation, or general life goals, although there could be overlap. Progress towards these agreed goals may then be tracked over time, often through ratings on numerical scales, and there are tools available to support this. For example, the Goal Based Outcome tool (GBO; [ 2 ]) which comprises setting up to three goals and scoring progress between 0 and 10, is widely used to track progress against goal setting in youth mental health settings. Whilst goal tracking may lead to a shift in practitioners’ work to be goal focused [ 3 ], goals may also sit alongside usual clinical work, to track progress [ 4 ]. Goals set in therapy tend to be focused and specific, e.g., to deal with something in the immediacy, like a phobia [ 5 ], but it is important that these goals attain to more global goals [ 6 ], or are viewed as a “means to an end”.

Goals may take time to set, and can change and become more specific during the therapeutic process, for example, at the beginning of contact with a practitioner, a young person might have a general goal like “to feel less depressed”, but over time the young person, along with the practitioner, may learn more about the mechanisms behind the depression and may define more precise goals like “being able to stop negative thinking” or “being able to cope with flashbacks”. The types of phrases used by practitioners to help young people define goals may include: “what do you want to be different?”, “what will you get off your back?”, “where do you want to get to?”, and “how do you want things to change?” [ 4 , 6 ].

Goal setting and tracking in therapeutic settings is grounded in motivation theory [ 7 , 8 , 9 ] such that working towards goals is a continuous feedback loop which builds on self-efficacy, self-determination and motivation to continue to strive towards goals, acting as a self-regulation strategy [ 10 , 11 ]. Goal setting may be more feasible or acceptable to individuals with particular personality traits e.g., individuals who attribute successes and failures to external factors are less likely to find meaning in striving towards goals than those who attribute successes and failures to their own actions [ 12 ].

Further, young people have described recovery from depression as nested within relationships (e.g., [ 13 ]), portraying recovery as an intentional process, contingent on shared goals and joint action in relationships [ 14 ]. Good therapeutic relationships are considered a key element of effective therapy [ 15 , 16 , 17 , 18 ]. Also known as working relationships, or working/therapeutic alliance, this refers to the connection, bond or partnership between the young person and practitioner. Three key elements of therapeutic alliance have been identified in the literature: bond, tasks, and goals [ 19 ]. In a recent review of the effects of cognitive behavioural therapy (CBT) for young people experiencing anxiety and/or depression, three studies reported small-to-medium effect sizes for the correlational relationship between therapeutic alliance and symptom reduction [ 20 ]. This provides limited evidence linking goal collaboration to reduced anxiety/depression symptoms for young people, despite fair evidence supporting links between goal collaboration and positive adult anxiety and depression outcomes [ 21 ]. It is argued that goal agreement is a fundamental element missing from much work with young people, and it has been referred to as a “social contract” [ 22 ]. This emphasis on relationships is particularly important when working with young people with acute, or multifarious difficulties, where relationships are complex, difficult to develop and maintain (e.g., [ 23 ]).

Existing evidence suggests that there are certain elements of mental health support for young people that are effective, but there is a lack of identification and knowledge about mechanisms to refine and improve this support [ 24 ]. Specifically, there is a paucity of research exploring the mechanisms underpinning why goal setting may be helpful for some young people, and not others. There are likely to be confounding variables which interplay the effectiveness of goals, depression and/or anxiety, cognition, and motivation, yet there is little research that has explored this in clinical settings with young people.

The aim of this study is to summarise existing literature, supplemented by discussions with international advisors to contextualise and aid interpretation of the findings. The research question is:

“Is collaborative goal setting helpful or unhelpful to young people experiencing anxiety and/or depression, as an element of therapeutic relationships? a. Why/why not and how? b. For whom? c. Under what circumstances?”

A mixed methodological approach combined reviews of peer-reviewed, grey literature and additional sources (e.g., websites), with consultation with experts by experience. The risk of expert view biasing the findings was mitigated via the validating steps outlined below. The study was designed by the lead researcher, and other researchers in the team, in collaboration with the peer researchers.

Whilst it is acknowledged that there are important outcome areas such as quality of life and existential factors, aside from symptom reduction, the focus of this study was to specifically explore the research questions in relation to potential anxiety and depression symptom reduction. Anxiety and depression were focused on as the most common mental health difficulties worldwide. This focus on medicalised symptomology differs from quality of life, which is a multi-dimensional construct comprised of several domains, such as psychological, physical, and social wellbeing. Anxiety, depression, therapeutic relationships, and goal progress are routinely measured using self- and proxy-reported outcome measures, with numerical rating scales. It was anticipated that the research question would not be adequately explored through findings from outcome measures alone. Based on some initial scoping work, we determined that there would be more evidence on the effectiveness of goal setting and tracking via qualitative enquiry, including narratives. The exploration of the nuances identified in the research question was key to the study, and so it was important to give precedence to young people’s voices through existing research and youth advisors, combined with findings from any relevant supporting measures. Such explorations would not be possible through quantitative enquiry of outcome measure data.

Goal setting alongside usual clinical work and goals work (goal focused interventions) were differentiated from implicit goal-oriented practice, non-directive approaches and paternalistic approaches to support in this study. This meant that to be included in the literature synthesis, goals needed to be explicitly identified as an approach to progress tracking, and/or informing the work. This study also focused on individual settings, and whilst these relationships may include parents/carers in a triad, the primary focus was on the relationship built between the practitioner and the young person. This was due to the complexities and potential dilution of agreeing goals and developing therapeutic relationships in group work and with parents/carers in addition. Ethical approval was not required because this study did not involve collection nor analysis of primary data, and youth advisors were consulted on in the capacity of being part of the advisory group, rather than within the capacity of research participants [ 25 ].

Literature review

First, search terms and inclusion and exclusion criteria were agreed in collaboration with the academic/clinical and youth advisors (See Additional file 1 : Appendix 1 Inclusion and exclusion criteria and Search Strategies). The project was registered with PROSPERO (number: CRD42021259611).

Second, searches of ten online databases were conducted (PsycINFO (OVID), MEDLINE (OVID), EMBASE (OVID), Web of Science core collection, current contents connect, SciELOCitation Index, Cochrane Library of Systematic Reviews, CINAHL (EBSCO), ERIC (EBSCO), and child and adolescent studies (EBSCO)). The search strategy developed for each database comprised three concepts: anxiety and/or depression (condition), goals (intervention) and therapeutic alliance or general views on goal setting, e.g., perspective, view, narrative (intervention/outcome). Searches were restricted to the past 20 years (2000-present). Citation tracking of included papers was performed. Retrieved hits were exported to EndNote 20 [ 26 ], Rayyan [ 27 ] and Excel for title/abstract screening.

Third, two researchers (FS, JJ) independently screened titles and abstracts. Where one researcher (JJ) was an author in retrieved studies, screening was conducted by the other researcher (FS), to ensure unbiased screening. Fourth, two researchers (JJ, IS) explored resultant literature main texts, extracting and synthesising relevant information. Key literature identified by researchers and advisors was added. The quality of the studies was assessed using criteria for qualitative studies ([ 28 ]; See Additional file 1 : Appendix 2 Core Criteria for Quality Assessment of Qualitative Studies).

Grey literature search

Google and Google Scholar title search, Google Books, PsycEXTRA, PsyArXiv, and ProQuest Dissertations and Theses were used. Google's Site Search was used to search American Psychological Association, British Psychological Society, Australian Psychological Society, European Federation of Psychologists' Associations, International Association of Applied Psychology, Association for Psychological Science, International Union of Psychological Science, Canadian Psychological Association, and UN-affiliated websites (.int domains). To identify more relevant literature, ResearchRabbit.ai was used to track the citations to the included studies. As a result of Google title search, websites were identified and browsed. The searches were restricted to those: (1) written in English, (2) published from January 2000 to August 2021, (3) focused on goal setting with young people experiencing mental health difficulties. Two researchers (FS, JJ) independently screened titles and abstracts of the resultant sources for relevance.

Insight analysis

An advisory group was formed at the study’s outset, comprising: (1) young people with lived experience of anxiety and/or depression and therapy (N = 8; age range 15–26 years; mean age = 20.8; female (includes transgender) N = 5; and male (includes transgender) N = 3; located in Brazil, Pakistan, Spain, Turkey, and UK); and (2) academics and clinicians (N = 6; female N = 1, male N = 5; located in Norway and UK). Criteria for youth advisors to take part where that they were around the age of interest (14–24 years) and had lived experience of anxiety and/or depression and had previously -or currently-experienced receiving a mental health intervention. Youth advisors’ experience of anxiety and/or depression was balanced across advisors. Youth advisors were recruited via adverts circulated by a European network of peer advisors with international reach, and signed an agreement at the outset of the project, by way of consent to participate, which included specific duties and responsibilities of what would be expected of them, as well as hours and reimbursement details. For those under 18 years old, parent/carer consent and agreements were gained. One-to-one meetings between each youth advisor and the participation lead for the study were conducted before and after the study took place. A written agreement was made between the lead research organisation, and the participation organisation which facilitates the network of peer advisors.

Academic/clinical advisors were experienced and specialised in goals work and were recruited via existing networks. Criteria for academic/clinical advisors were that they had research and/or clinical experience in the field of mental health goal setting with young people (academic N = 6; clinical N = 4; categories not mutually exclusive). Written agreements were made between the lead research organisation, and each academic/clinical advisor.

Directed discussions were held at six advisory group meetings (two academic/clinical and four youth) facilitated by two researchers (JJ, MS) and conducted in English. All advisors spoke English, but time was given in the meetings to check understanding, as English was not a native language for many. The academic/clinical and youth advisors met separately, enabling the youth advisors to share openly with their peers. These discussions focused on the research question and drawing inferences about resultant findings, as well as appraising the evidence to identify key literature gaps. The summary of findings from the literature review was presented via PowerPoint to the advisors. The questions asked were broadly: is setting goals an important part of the relationship with the therapist and why/not; do these findings align with your experiences; is there anything you can think of that has not been considered; are there any elements of these findings that do not make sense in your experience; how do you interpret and understand these findings within the context of your own experience? Youth advisors were asked additional questions about the nature of language, for example, what do you think about the term “goal”? Is it the word you use, is it understandable, how does it translate to your national languages?. Field notes were taken, alongside notes in advisors’ own words on the JamBoard interactive workspace, allowing for anonymous contributions. Analysis comprised four stages. First, one researcher (MS) organised field notes and comments into a narrative summary. Second, one researcher (JJ) used the nuanced elements of the research question to organise the summary. Third, feedback was sought from advisors to evaluate and assess whether it was a true reflection of the discussions. Fourth, one researcher (JJ) refined and renamed the themes.

Online searches generated 10,907 records. Ten potentially eligible studies were identified. Upon screening full texts, seven unique studies met the selection criteria (See Fig.  1 and Table 1 ).

PRISMA flow chart of the study selection process. From: Page, M.J., McKenzie, J.E., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(n71)

Included studies comprised three narrative case studies [ 29 , 30 , 31 ] a randomised control trial [ 32 ]; a narrative review [ 33 ] a practitioners’ guidance document [ 34 ]; and a naturalistic study [ 35 ]. Critical appraisal of the evidence (Table 1 ) demonstrates that caution must be exercised when considering the findings. The main strength of the included studies is the voice of young people through verbatim quotes, and for some, strong consideration of the researchers’ impact. However, less strength is attributed to the dependability or generalisability of the findings, mainly due to the high proportion of small-and-homogenous samples. The advisors’ discussion summaries were organised into themes within the nuances of the research question: Why/why not and how? For whom? Under what circumstances?”, and presented as a narrative synthesis.

Why/why not and how (mechanisms)

A conduit for open communication.

Six studies described collaborative goal setting as a conduit for communication [ 29 , 30 , 31 , 33 , 34 , 35 ]. Specifically, agreement on goals leads to open communication, a shared understanding of difficulties and ways forward [ 29 , 31 , 35 ]. Formulating goals was described as key to helping young people to feeling understood, valued and that practitioners are listening to them [ 33 , 34 , 35 ]. Collaborative goal setting enables young people and practitioners to make genuine disclosures, not necessarily otherwise possible [ 30 ] and facilitates mutual support [ 31 ].

Both academic/clinical and youth advisors said that open communication and trust were key, broadly agreeing that goal setting could be helpful to support building trusting relationships. It was agreed that collaboratively agreeing goals may take time and should not happen immediately. Rather, practitioners should work flexibly, aiming to understand what is comfortable for young people experiencing anxiety and/or depression. Some youth advisors said that relationships need to be built first, with trust established prior to goal setting, particularly when goal setting feels complicated. It was agreed by youth and academic/clinical advisors that goal setting should be led by young people and guided by practitioners, sharing responsibility. Youth advisors considered open communication the most crucial factor in therapy, with a sense that much therapeutic work cannot take place without it.

Feel supported and involved

Young people value receiving support to split actions into smaller manageable steps, with encouragement from practitioners stimulating validation that their goals are achievable ([ 35 ], and youth advisors). Being given choice about goal content and how this translates into the options for care was identified as an important part of the process in the literature [ 35 ]. Evidence suggests that this leads to a sense of autonomy and control over what happens to young people and enables them to feel involved in the process and increases engagement [ 30 , 33 , 35 ]. This was not directly addressed by the academic/clinical advisors in their discussions.

Nature of difficulties

All seven studies, and youth and academic/clinical advisors, suggested that goal setting was a helpful element of therapeutic relationships for young people experiencing anxiety and/or depression, and more broadly with other undefined presenting difficulties. Both academic/clinical and youth advisors agreed that there was no need to separate specific attributes of anxiety or depression, due in part, to high proportions of comorbidity.

Age, and previous experiences

Three studies described difficulties for young people engaging in goal setting [ 32 , 33 , 34 ]. These were: age-appropriate quests for independence interfering with establishing collaborative relationships with adults [ 32 ]; significant and repeated traumas impacting development, relationships and challenges ordering thoughts, particularly within the context of long-term therapy [ 34 ]; low confidence or feelings of hopelessness; and poor previous experiences of goal setting [ 33 ]. Youth advisors agreed that previous life experiences were important, e.g., views of goal setting in therapeutic settings were impacted by how successful they had been in achieving past goals, regardless of goal type. Academic/clinical advisors agreed that personal factors such as previous experiences and factors surrounding—or leading to—difficulties, may lead to challenges setting goals in the first instance.

Levels of distress, personality traits and preferences

Youth and academic/clinical advisors suggested that specific unhelpful elements may depend on the young person, and sometimes levels of distress, rather than the nature of difficulties. Some youth advisors expressed preferences for practitioner-directed work, particularly in times of high distress, e.g.,: “If I’m going through something very bad, I can be very frustrated/sad so I can’t think clear” (youth advisor) . It was also agreed that goals may exacerbate anxiety, particularly at times of overwhelm, whilst for others this could be a helpful anxiety reduction approach, e.g., in exposure therapy. Youth advisors said that ensuring goals are achievable is key to building good therapeutic relationships, and the impact on anxiety/depression; the individual’s capacity to set goals should be considered, e.g., someone struggling with day-to-day tasks may find even small goals too challenging. Youth advisors considered perfectionism to be important, where some people may feel pressure to achieve goals. A sense of hopelessness, or procrastination, and rumination also, where delaying tasks may result in delaying work on goals. For some youth advisors, goal setting felt especially important, whilst for others it was not, rather a supportive relationship was identified as most important, and they could not see how that would be developed through goal setting. Academic/clinical advisors said that young people’s preferences to work on goals, or not, was in itself of key importance to the therapeutic relationship. There was no evidence from the included literature to support/oppose these points.

Language and power dynamics

Linked to preferences, youth advisors said that young people tend not to like the term “goal” because they attribute it to work and formal settings, whereas “therapeutic goals” are personal with deeper meaning. Academic/clinical advisors discussed using alternative language for goal setting and goal directed work, and the importance of being led by the young person. Posing questions such as “What do you want to change?” is suggested as an alternative in the literature ([ 33 ]; p.47). Youth advisors said that whilst some young people may feel able to say they do not want to set goals, others may not, due to the young person-practitioner power imbalance, which has implications for relationships, and therapeutic work. There was no further evidence from the included literature to support/oppose these points.

Under what circumstances (contextual factors)

Broadly helpful.

All seven studies suggested that goal setting was a helpful element of therapeutic relationships for young people within the research contexts. This included year-long narrative therapy with interpersonal therapy and CBT techniques in alliance with the family [ 29 ]; multimodal family therapy [ 31 ]; Gestalt therapy [ 30 ]; either CBT, short-term psychoanalytic psychotherapy or brief psychosocial intervention [ 32 ]; UK child and adolescent mental health services [ 33 , 34 ] and UK inpatient settings [ 35 ]. All studies were based in Western high-income countries. Academic/clinical and youth advisors agreed with this assessment.

Review points and referral routes

Reviewing progress towards goals too frequently could give the impression that practitioners are more interested in gauging their own success, rather than in the young person as a whole person, and rating could end up being done by rote, making goals increasingly meaningless [ 34 ] . Academic/clinical and youth advisors agreed with this, discussing the need to work with goals in a flexible manner. Additionally, young people may not recognise the symptoms identified, particularly when referred for treatment by another party (e.g., parents/carers), which is crucial to enable collaborative goal setting [ 32 ]. Challenges associated with thinking of goals in this way was addressed by the academic/clinical and youth advisors in wider discussions elsewhere (see therapy contexts).

Culture and therapy contexts

Youth and academic/clinical advisors located in Western high-income countries agreed that it may depend on types of interventions offered and practitioner’s preferred working style, but young people largely have agency to set goals. However, it was recognised by the youth and academic/clinical advisors that some young people in some countries do not have agency to set goals. There, decisions are made by families, in collaboration with practitioners, and so less consideration is given to young people’s perspectives. It was suggested that, in some countries, there is no concept of setting goals (e.g., a youth advisor discussed their experience in Pakistan), and ongoing stigma associated with mental health difficulties, which may lead to distrust, scepticism in, and a disconnect with practitioners. Youth advisors said that this may also be true in other countries not represented. A youth advisor suggested that young people in Brazil were relaxed towards goal setting and would not mind if goals were not achieved; directed therapy was considered more helpful.

Youth and academic/clinical advisors discussed goals in long-term therapy as potentially feeling restrictive, with challenges associated with thinking of what goals might be. Both long-and short-term goal setting within this context may feel meaningless, which if then pressed by the practitioner, has a negative impact on relationships. Academic/clinical advisors said that the feasibility of goal setting in the first instance is likely to be attributable to the factors young people who might be offered long-term therapy might have, rather than the work itself leading to these challenges. Youth and academic/clinical advisors also said that where there are multiple needs and risks, goals need to be simpler to feel manageable. Youth advisors said that sometimes there were concerns about the achievement of goals equating to treatment ending, which felt unsettling. There was no evidence from the included literature to support/oppose these points.

This study aimed to provide a synthesis of existing literature, identifying knowledge gaps. Whilst much may be drawn from related research, caution must be exercised when translating findings into other contexts [ 11 ], and whilst promising, generalising adult findings to youth must be exercised with an abundance of caution. Evidence suggests that adults and children think differently; as children grow, their cognitive processes develop, and their contexts and perspectives change, impacting on understandings of the self and the world around them. Further, models of recovery from depression are notably different between adults and young people [ 14 ]. As such, we have focused on evidence from the youth field in our discussion, and further highlight the paucity of research with young people in this area.

The included evidence originates from Western high-income and largely specialist settings; further research in majority world countries is urgently required. Many studies identified in initial searches only partially met inclusion criteria. This evidence paucity may suggest goal setting is not embedded in service standards or practice in most countries, or other limiting factors such as the general underfunding of youth mental health research. Some examples were derived from the insight analysis, highlighting the advisors’ value, who helped contextualise and interpret evidence, grounded in lived experience. However, whilst the research question pertained to the effectiveness of goal setting as part of therapeutic relationships, the findings were related to the feasibility, or acceptability of goal setting itself. Links between effective goal setting, good therapeutic relationships and positive outcomes are inferred based on evidence that partially supports the research question, and the discussions with the advisory group, but no evidence relating to anxiety or depression outcomes was found in this study. Future research should consider in depth explorations of mechanisms of goal setting within therapeutic relationships, for young people experiencing anxiety and/or depression.

For many young people, goal setting is a helpful tool for building good therapeutic relationships via open communication. These findings support previous research which partially address the research question: young people find goal setting to be helpful to therapeutic relationships through the development of a shared language and understanding [ 3 ]. It has been suggested that goals are a mechanism of change via a means for “common ground” to be established [ 3 ]. Finding common ground and a shared understanding are particularly pertinent in youth mental health settings, where there are multiple stakeholders involved [ 36 , 37 , 38 ], which can be a balancing act [ 39 ]. Establishing this mutuality of situations is considered the key facilitator of engagement when referred for therapy by others [ 40 ]. Further, ownership of goals located with young people is important [ 41 ], which in turn gives young people ownership of their care, which can be motivational [ 42 , 43 ]. Young people experiencing anxiety may find goal setting an effective strategy due to links with avoidance motivation; such that they have reported pursuing approach goals to avoid negative emotional consequences of not doing so [ 44 ]. The ability of young people to maintain focus on the pursuit of personal goals has also been demonstrated as a moderator of depression and suicide [ 45 ].

One included study explicitly discussed parents/carers within collaborative goals and therapeutic relationships, as a foundation for mutual support [ 31 ]. Stronger relationships between both young people, parents/carers and practitioners and/or involving both young people and parents/carers in decision-making have been demonstrated to predict more positive outcomes [ 39 , 46 ]. Young people are often referred by their parents/carers, which must be considered, particularly where literature highlights challenges of setting goals when young people do not agree with the referral or recognise the difficulties [ 22 , 32 ]. Prior research has demonstrated that young people from minoritized ethnic groups are more likely to be referred for mental health support via social care and the youth justice system compared to their White British counterparts, who are commonly referred via primary care in the UK [ 47 ]. Further, evidence suggests that increases in emotional autonomy result in a shift from dependence on adults in adolescence, to reliance upon peers for support [ 48 ] particularly amongst girls [ 49 ], which may align with the developmental interference with building relationships outside of goal setting found by Cirasola and colleagues [ 32 ]. It has been argued that for young people who have difficulties building and maintaining relationships, the therapeutic relationship is particularly important (e.g., [ 23 ]). It is also noteworthy that young people in some countries may not have agency to set goals, a significant limiting factor. There are cultural and service level factors which were not explored. In some cultures, advice is sought from family and religious leaders over mental health professionals (e.g., [ 50 ]). Organisational level factors have also been found to hinder and influence therapeutic processes [ 40 ]. Further research is needed into referral routes, and intersections between systems, practice, and young people’s preferences.

Several elements of goal setting were identified as unhelpful for young people experiencing anxiety and/or depression, supporting previous literature. These discussions centred on the feasibility/acceptability of goals, rather than goal setting being detrimental to therapeutic relationships per se. Nevertheless, it is suggested that these factors were primarily related to the person, and that “personal” factors may be driven by underlying difficulties. For example, low confidence, hopelessness, levels of distress, perfectionism, and rumination (e.g., [ 51 , 52 , 53 , 54 , 55 ], may all be elements of anxiety and/or depression. Academic/clinical and youth advisors agreed that goals may become clearer over time, particularly for young people experiencing depression and purposeless, and through collaboration, goals could be formulated. The importance of considering specific challenges of goal setting during long-term therapy was highlighted. Academic/clinical and youth advisors discussed challenges associated with identifying priority areas for work, and that goals continue to flex and change, with the potential for goals work to feel too restrictive. This is in support of previous research suggesting that it is important that goals are worked on flexibly [ 3 ] with space for them to change; specifically in relation to depression. Compared to those with low levels of depression, young people with high levels of depression are more able to disengage with unhelpful goals over time and to set new goals, which in turn may predict lower levels of depressive symptoms over a year later [ 56 ]. This sense of goals flexing, feeling unique and changeable has been mirrored in descriptions of therapeutic relationships themselves [ 23 ]. There was a clear steer from youth advisors that the relationship independent of goal setting was key to good outcomes, and that this was a priority; that without the trusting relationship, there is no facilitator for goal setting. This is an important contradiction to the literature, warranting further exploration. One suggestion is that the initial goals for long-term therapy should be on relationship building, but reviewed, so the therapeutic relationship itself does not remain the primary goal [ 34 ]. Another key finding is that goals take time to establish, and pressure to set goals may render them meaningless, which also supports previous research [ 51 ]. Young people often do not know what their goals are [ 57 ], which impacts trust building, relationships and thus, therapeutic work. In support of prior research which defines recovery as contingent on shared goals and joint action in relationships [ 14 ], links found between goals, trust building and therapeutic relationships in the present study align with research on trauma informed care, and emotional and relational safety (see, [ 58 ]). Further consideration should be given to this area, particularly clinical implications, and interactions with levels of distress.

Whilst support approaches that incorporate structured goal setting are often characterised by a greater emphasis on client-centredness, the links between personally meaningful outcomes and the specific behaviour change techniques required to progress towards goals are not clear. Further, the person-centred focus is hypothesised as a conduit to positive ratings of self-efficacy, quality of life and service satisfaction, but evidence is lacking [ 11 ]. Whilst previous literature from within the youth mental health field suggests that working on goals is motivating and increases self-efficacy [ 34 , 42 ], evidence is still limited. Goal setting may be useful to young people because, whilst not necessarily synonymous, it has been demonstrated as a facilitative element of shared decision-making [ 59 , 60 ]. This collaborative way of working through shared understanding and the development of good therapeutic relationships [ 61 ] may be especially helpful to young people experiencing depression as it enables them to exercise control over their own feelings and behaviour [ 43 ] at a time when they may be experiencing feelings of hopelessness and purposeless. Whilst educated links are made to shared decision-making, further research should explore whether there is an embedded link to goals and therapeutic relationships.

Strengths and limitations

The mixed-methodological approach was a particular strength, with literature findings bolstered by lived experience. However, whilst advisors were from diverse demographic groups, not all groups were represented.

Whilst every attempt was made to include as many goal setting search terms as possible, the language is broad and fluid, meaning certain terms may have been missed. Still, the high number of results returned from literature searches suggests the strategy may need refinement. Nevertheless, we chose to ensure a large return given the subject’s broad nature. At the screening stage, the focus on explicitly identified goal setting and goal work made the identification of included studies less ambiguous, but meant that studies focused on implicit goals work would not have been included, reducing the number of studies included in the final synthesis.

Prior assumptions and knowledge of this topic will have influenced the researchers’ interpretation of the findings, even subconsciously. This includes the decision to use the nuanced elements of the research question to organise the findings. The researchers were located in Belgium, Germany, and the UK at the time of the study, which risks the perpetuation of the status quo of Western high-income-originating dominated research. Further, the findings were contextualised and linked to prior theory primarily by a researcher outside the age range of interest (JJ). The impact of both issues was mitigated via advisors, particularly those within majority world countries and the age range of interest, and the peer researchers entrenched in the research team (MS, IS), who provided contextual depth and understanding to the findings.

Literature focused on goal setting as helpful for young people with anxiety and/or depression is overwhelmingly supportive, but this leaves research gaps regarding in which ways, for whom and under what circumstances goal setting might be unhelpful. Priority must be given to researching unhelpful mechanisms of goal setting, to avoid potential iatrogenic effects. Accessibility could be improved through exploration of the intersections between systems/contexts (e.g., country), therapeutic practice (e.g., practitioner’s training/preferences) and young people’s preferences. Further research is also needed to explore mechanisms by which goal setting may help to reduce anxiety and/or depression symptoms, as well as other important areas of outcome, such as quality of life, using e.g., mediation analysis.

Scaling up in countries with well-developed systems could mean embedding goals in guidelines for anxiety and/or depression; in service specifications, including monitoring and reporting change mechanisms; staff training in consistency; and some interagency forums to align goal processes. For majority world countries with less developed systems, largely relying on non-specialist services e.g., NGOs, goals may be paradoxically more important for maximising limited resources. Despite nothing suggesting goal setting could not practically be scaled-up globally, cultural considerations may be a limiting factor in some places.

Preferences to not work on goals may be driven by the limiting factors identified, such as hopelessness or high distress. Practitioners should work through this first, reviewing the option to work on goals over time, respecting young people’s preferences. Flexibility is important, and ownership of goals located with young people is essential, particularly to those experiencing depression, enabling them to exercise control over their feelings and behaviour when they may be feeling hopeless and/or purposeless. Finally, there may be a unique opportunity for goals to facilitate work with young people experiencing high distress levels or who have experienced trauma, due to links to emotional and relational safety and building trusting relationships.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available to protect the confidentiality of the small number of advisors, but may be available from the corresponding author’s organisation, on reasonable request.

Abbreviations

Cognitive behavioural therapy

Goal based outcomes tool

United Kingdom

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Acknowledgements

The authors would like to thank the advisors, for their invaluable contribution from start to finish, including useful comments an early draft: Duncan Law, Elmas Aybike Yılmaz, Hanne Oddli, Isabella Valério, Jacob People, Josh D., Julian Edbrooke-Childs, Katya Proctor, Laura Calomarde Juárez, Mick Cooper, Nick Morgan, Panos Vostanis, Syeda Zeenat R., and Theo Jackson. Thank you to Bernice Appiah, Shade Davies and Shadia Robertson for helpful discussions about the findings, and assistance with evidence synthesis, and to Inês Pote from the Wellcome Active Ingredients team, and Jasmine Harju-Seppanen, for useful comments on a previous draft. The authors also wish to thank Zoe Thomas for incredibly useful advice and guidance regarding literature searches.

This work was funded by a Wellcome Trust Mental Health Priority Area “Active Ingredients” 2021 commission awarded to JJ at the Anna Freud Centre. It was a requirement of the funding team that the research design comprised a literature review, and that the involved and worked collaboratively with young people with lived experience of anxiety and/or depression throughout the course of the project. Members of the funding team provided feedback on an early draft of this manuscript.

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Contributions

JJ conceptualised the study, prepared the first draft protocol and search strategy, refining this with the study authors and advisors. JJ undertook the library database searches for published literature, partially screened the titles and abstracts of literature, screened all full texts, led communication with study authors and advisors, led four advisory group meetings, maintained the databases which were used to extract and manage study data, prepared, and revised the manuscript. MS contributed to the first draft protocol and search strategy, led communication with youth advisors, led two advisory group meetings, created the narrative summaries, and contributed to the manuscript. IS contributed to the first draft protocol and search strategy, supported communication with youth advisors, screened full texts for further relevant literature, and contributed to the manuscript. FS conducted the grey literature searches, screened all potential title and abstracts from all searches (published and unpublished literature), maintained the databases which were used to extract and manage study data, and contributed to the manuscript. All study advisors were invited to comment on the protocol and initial search terms, and were invited to comment on earlier drafts of the manuscript. All authors read and approved the final manuscript.

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Ethical approval for this research was not required because it does not involve collection nor analysis of primary data, and youth advisors were consulted on in the capacity of being part of the advisory group, to discuss their interpretation of the findings, rather than within the capacity of research participants.

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Competing interests

JJ works on the Child Outcomes Research Consortium (CORC) project at the Anna Freud National Centre for Children and Families, which encourages the use of outcome measures in youth mental health settings amongst its members. No other authors report any competing interests.

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Inclusion and exclusion criteria and Search Strategies. Appendix 2 Core Criteria for Quality Assessment of Qualitative Studies.

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Jacob, J., Stankovic, M., Spuerck, I. et al. Goal setting with young people for anxiety and depression: What works for whom in therapeutic relationships? A literature review and insight analysis. BMC Psychol 10 , 171 (2022). https://doi.org/10.1186/s40359-022-00879-5

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• Writing a Literature Review

When writing a research paper on a specific topic, you will often need to include an overview of any prior research that has been conducted on that topic.  For example, if your research paper is describing an experiment on fear conditioning, then you will probably need to provide an overview of prior research on fear conditioning.  That overview is typically known as a literature review.  

Please note that a full-length literature review article may be suitable for fulfilling the requirements for the Psychology B.S. Degree Research Paper .  For further details, please check with your faculty advisor.

Different Types of Literature Reviews

Literature reviews come in many forms.  They can be part of a research paper, for example as part of the Introduction section.  They can be one chapter of a doctoral dissertation.  Literature reviews can also “stand alone” as separate articles by themselves.  For instance, some journals such as Annual Review of Psychology , Psychological Bulletin , and others typically publish full-length review articles.  Similarly, in courses at UCSD, you may be asked to write a research paper that is itself a literature review (such as, with an instructor’s permission, in fulfillment of the B.S. Degree Research Paper requirement). Alternatively, you may be expected to include a literature review as part of a larger research paper (such as part of an Honors Thesis). 

Literature reviews can be written using a variety of different styles.  These may differ in the way prior research is reviewed as well as the way in which the literature review is organized.  Examples of stylistic variations in literature reviews include: 

• Summarization of prior work vs. critical evaluation. In some cases, prior research is simply described and summarized; in other cases, the writer compares, contrasts, and may even critique prior research (for example, discusses their strengths and weaknesses).
• Chronological vs. categorical and other types of organization. In some cases, the literature review begins with the oldest research and advances until it concludes with the latest research.  In other cases, research is discussed by category (such as in groupings of closely related studies) without regard for chronological order.  In yet other cases, research is discussed in terms of opposing views (such as when different research studies or researchers disagree with one another).

Overall, all literature reviews, whether they are written as a part of a larger work or as separate articles unto themselves, have a common feature: they do not present new research; rather, they provide an overview of prior research on a specific topic . 

How to Write a Literature Review

When writing a literature review, it can be helpful to rely on the following steps.  Please note that these procedures are not necessarily only for writing a literature review that becomes part of a larger article; they can also be used for writing a full-length article that is itself a literature review (although such reviews are typically more detailed and exhaustive; for more information please refer to the Further Resources section of this page).

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1. Identify and define the topic that you will be reviewing.

The topic, which is commonly a research question (or problem) of some kind, needs to be identified and defined as clearly as possible.  You need to have an idea of what you will be reviewing in order to effectively search for references and to write a coherent summary of the research on it.  At this stage it can be helpful to write down a description of the research question, area, or topic that you will be reviewing, as well as to identify any keywords that you will be using to search for relevant research.

2. Conduct a literature search.

Use a range of keywords to search databases such as PsycINFO and any others that may contain relevant articles.  You should focus on peer-reviewed, scholarly articles.  Published books may also be helpful, but keep in mind that peer-reviewed articles are widely considered to be the “gold standard” of scientific research.  Read through titles and abstracts, select and obtain articles (that is, download, copy, or print them out), and save your searches as needed.  For more information about this step, please see the Using Databases and Finding Scholarly References section of this website.

3. Read through the research that you have found and take notes.

Absorb as much information as you can.  Read through the articles and books that you have found, and as you do, take notes.  The notes should include anything that will be helpful in advancing your own thinking about the topic and in helping you write the literature review (such as key points, ideas, or even page numbers that index key information).  Some references may turn out to be more helpful than others; you may notice patterns or striking contrasts between different sources ; and some sources may refer to yet other sources of potential interest.  This is often the most time-consuming part of the review process.  However, it is also where you get to learn about the topic in great detail.  For more details about taking notes, please see the “Reading Sources and Taking Notes” section of the Finding Scholarly References page of this website.

4. Organize your notes and thoughts; create an outline.

At this stage, you are close to writing the review itself.  However, it is often helpful to first reflect on all the reading that you have done.  What patterns stand out?  Do the different sources converge on a consensus?  Or not?  What unresolved questions still remain?  You should look over your notes (it may also be helpful to reorganize them), and as you do, to think about how you will present this research in your literature review.  Are you going to summarize or critically evaluate?  Are you going to use a chronological or other type of organizational structure?  It can also be helpful to create an outline of how your literature review will be structured.

5. Write the literature review itself and edit and revise as needed.

The final stage involves writing.  When writing, keep in mind that literature reviews are generally characterized by a summary style in which prior research is described sufficiently to explain critical findings but does not include a high level of detail (if readers want to learn about all the specific details of a study, then they can look up the references that you cite and read the original articles themselves).  However, the degree of emphasis that is given to individual studies may vary (more or less detail may be warranted depending on how critical or unique a given study was).   After you have written a first draft, you should read it carefully and then edit and revise as needed.  You may need to repeat this process more than once.  It may be helpful to have another person read through your draft(s) and provide feedback.

6. Incorporate the literature review into your research paper draft.

After the literature review is complete, you should incorporate it into your research paper (if you are writing the review as one component of a larger paper).  Depending on the stage at which your paper is at, this may involve merging your literature review into a partially complete Introduction section, writing the rest of the paper around the literature review, or other processes.

Further Tips for Writing a Literature Review

Full-length literature reviews

• Many full-length literature review articles use a three-part structure: Introduction (where the topic is identified and any trends or major problems in the literature are introduced), Body (where the studies that comprise the literature on that topic are discussed), and Discussion or Conclusion (where major patterns and points are discussed and the general state of what is known about the topic is summarized)

Literature reviews as part of a larger paper

• An “express method” of writing a literature review for a research paper is as follows: first, write a one paragraph description of each article that you read. Second, choose how you will order all the paragraphs and combine them in one document.  Third, add transitions between the paragraphs, as well as an introductory and concluding paragraph. 1
• A literature review that is part of a larger research paper typically does not have to be exhaustive. Rather, it should contain most or all of the significant studies about a research topic but not tangential or loosely related ones. 2   Generally, literature reviews should be sufficient for the reader to understand the major issues and key findings about a research topic.  You may however need to confer with your instructor or editor to determine how comprehensive you need to be.

Benefits of Literature Reviews

By summarizing prior research on a topic, literature reviews have multiple benefits.  These include:

• Literature reviews help readers understand what is known about a topic without having to find and read through multiple sources.
• Literature reviews help “set the stage” for later reading about new research on a given topic (such as if they are placed in the Introduction of a larger research paper). In other words, they provide helpful background and context.
• Literature reviews can also help the writer learn about a given topic while in the process of preparing the review itself. In the act of research and writing the literature review, the writer gains expertise on the topic .

Downloadable Resources

• How to Write APA Style Research Papers (a comprehensive guide) [ PDF ]
• Tips for Writing APA Style Research Papers (a brief summary) [ PDF ]
• Example APA Style Research Paper (for B.S. Degree – literature review) [ PDF ]

Further Resources

How-To Videos     

• Writing Research Paper Videos
• UCSD Library Psychology Research Guide: Literature Reviews

External Resources

• Developing and Writing a Literature Review from N Carolina A&T State University
• Example of a Short Literature Review from York College CUNY
• How to Write a Review of Literature from UW-Madison
• Writing a Literature Review from UC Santa Cruz  
• Pautasso, M. (2013). Ten Simple Rules for Writing a Literature Review. PLoS Computational Biology, 9 (7), e1003149. doi : 1371/journal.pcbi.1003149

1 Ashton, W. Writing a short literature review . [PDF]     

2 carver, l. (2014).  writing the research paper [workshop]. , prepared by s. c. pan for ucsd psychology.

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STRESS AND HEALTH: Psychological, Behavioral, and Biological Determinants

Stressors have a major influence upon mood, our sense of well-being, behavior, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the long-term effects of stressors can damage health. The relationship between psychosocial stressors and disease is affected by the nature, number, and persistence of the stressors as well as by the individual’s biological vulnerability (i.e., genetics, constitutional factors), psychosocial resources, and learned patterns of coping. Psychosocial interventions have proven useful for treating stress-related disorders and may influence the course of chronic diseases.

INTRODUCTION

Claude Bernard (1865/1961) noted that the maintenance of life is critically dependent on keeping our internal milieu constant in the face of a changing environment. Cannon (1929) called this “homeostasis.” Selye (1956) used the term “stress” to represent the effects of anything that seriously threatens homeostasis. The actual or perceived threat to an organism is referred to as the “stressor” and the response to the stressor is called the “stress response.” Although stress responses evolved as adaptive processes, Selye observed that severe, prolonged stress responses might lead to tissue damage and disease.

Based on the appraisal of perceived threat, humans and other animals invoke coping responses ( Lazarus & Folkman 1984 ). Our central nervous system (CNS) tends to produce integrated coping responses rather than single, isolated response changes ( Hilton 1975 ). Thus, when immediate fight-or-flight appears feasible, mammals tend to show increased autonomic and hormonal activities that maximize the possibilities for muscular exertion ( Cannon 1929 , Hess 1957 ). In contrast, during aversive situations in which an active coping response is not available, mammals may engage in a vigilance response that involves sympathetic nervous system (SNS) arousal accompanied by an active inhibition of movement and shunting of blood away from the periphery ( Adams et al. 1968 ). The extent to which various situations elicit different patterns of biologic response is called “situational stereotypy” ( Lacey 1967 ).

Although various situations tend to elicit different patterns of stress responses, there are also individual differences in stress responses to the same situation. This tendency to exhibit a particular pattern of stress responses across a variety of stressors is referred to as “response stereotypy” ( Lacey & Lacey 1958 ). Across a variety of situations, some individuals tend to show stress responses associated with active coping, whereas others tend to show stress responses more associated with aversive vigilance ( Kasprowicz et al. 1990 , Llabre et al. 1998 ).

Although genetic inheritance undoubtedly plays a role in determining individual differences in response stereotypy, neonatal experiences in rats have been shown to produce long-term effects in cognitive-emotional responses ( Levine 1957 ). For example, Meaney et al. (1993) showed that rats raised by nurturing mothers have increased levels of central serotonin activity compared with rats raised by less nurturing mothers. The increased serotonin activity leads to increased expression of a central glucocorticoid receptor gene. This, in turn, leads to higher numbers of glucocorticoid receptors in the limbic system and improved glucocorticoid feedback into the CNS throughout the rat’s life. Interestingly, female rats who receive a high level of nurturing in turn become highly nurturing mothers whose offspring also have high levels of glucocorticoid receptors. This example of behaviorally induced gene expression shows how highly nurtured rats develop into low-anxiety adults, who in turn become nurturing mothers with reduced stress responses.

In contrast to highly nurtured rats, pups separated from their mothers for several hours per day during early life have a highly active hypothalamic-pituitary adrenocortical axis and elevated SNS arousal ( Ladd et al. 2000 ). These deprived rats tend to show larger and more frequent stress responses to the environment than do less deprived animals.

Because evolution has provided mammals with reasonably effective homeostatic mechanisms (e.g., baroreceptor reflex) for dealing with short-term stressors, acute stress responses in young, healthy individuals typically do not impose a health burden. However, if the threat is persistent, particularly in older or unhealthy individuals, the long-term effects of the response to stress may damage health ( Schneiderman 1983 ). Adverse effects of chronic stressors are particularly common in humans, possibly because their high capacity for symbolic thought may elicit persistent stress responses to a broad range of adverse living and working conditions. The relationship between psychosocial stressors and chronic disease is complex. It is affected, for example, by the nature, number, and persistence of the stressors as well as by the individual’s biological vulnerability (i.e., genetics, constitutional factors) and learned patterns of coping. In this review, we focus on some of the psychological, behavioral, and biological effects of specific stressors, the mediating psychophysiological pathways, and the variables known to mediate these relationships. We conclude with a consideration of treatment implications.

PSYCHOLOGICAL ASPECTS OF STRESS

Stressors during childhood and adolescence and their psychological sequelae.

The most widely studied stressors in children and adolescents are exposure to violence, abuse (sexual, physical, emotional, or neglect), and divorce/marital conflict (see Cicchetti 2005 ). McMahon et al. (2003) also provide an excellent review of the psychological consequences of such stressors. Psychological effects of maltreatment/abuse include the dysregulation of affect, provocative behaviors, the avoidance of intimacy, and disturbances in attachment ( Haviland et al. 1995 , Lowenthal 1998 ). Survivors of childhood sexual abuse have higher levels of both general distress and major psychological disturbances including personality disorders ( Polusny & Follett 1995 ). Childhood abuse is also associated with negative views toward learning and poor school performance ( Lowenthal 1998 ). Children of divorced parents have more reported antisocial behavior, anxiety, and depression than their peers ( Short 2002 ). Adult offspring of divorced parents report more current life stress, family conflict, and lack of friend support compared with those whose parents did not divorce ( Short 2002 ). Exposure to nonresponsive environments has also been described as a stressor leading to learned helplessness ( Peterson & Seligman 1984 ).

Studies have also addressed the psychological consequences of exposure to war and terrorism during childhood ( Shaw 2003 ). A majority of children exposed to war experience significant psychological morbidity, including both post-traumatic stress disorder (PTSD) and depressive symptoms. For example, Nader et al. (1993) found that 70% of Kuwaiti children reported mild to severe PTSD symptoms after the Gulf War. Some effects are long lasting: Macksound & Aber (1996) found that 43% of Lebanese children continued to manifest post-traumatic stress symptoms 10 years after exposure to war-related trauma.

Exposure to intense and chronic stressors during the developmental years has long-lasting neurobiological effects and puts one at increased risk for anxiety and mood disorders, aggressive dyscontrol problems, hypo-immune dysfunction, medical morbidity, structural changes in the CNS, and early death ( Shaw 2003 ).

Stressors During Adulthood and Their Psychological Sequelae

Life stress, anxiety, and depression.

It is well known that first depressive episodes often develop following the occurrence of a major negative life event ( Paykel 2001 ). Furthermore, there is evidence that stressful life events are causal for the onset of depression (see Hammen 2005 , Kendler et al. 1999 ). A study of 13,006 patients in Denmark, with first psychiatric admissions diagnosed with depression, found more recent divorces, unemployment, and suicides by relatives compared with age- and gender-matched controls ( Kessing et al. 2003 ). The diagnosis of a major medical illness often has been considered a severe life stressor and often is accompanied by high rates of depression ( Cassem 1995 ). For example, a meta-analysis found that 24% of cancer patients are diagnosed with major depression ( McDaniel et al. 1995 ).

Stressful life events often precede anxiety disorders as well ( Faravelli & Pallanti 1989 , Finlay-Jones & Brown 1981 ). Interestingly, long-term follow-up studies have shown that anxiety occurs more commonly before depression ( Angst &Vollrath 1991 , Breslau et al. 1995 ). In fact, in prospective studies, patients with anxiety are most likely to develop major depression after stressful life events occur ( Brown et al. 1986 ).

DISORDERS RELATED TO TRAUMA

Lifetime exposure to traumatic events in the general population is high, with estimates ranging from 40% to 70% ( Norris 1992 ). Of note, an estimated 13% of adult women in the United States have been exposed to sexual assault ( Kilpatrick et al. 1992 ). The Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association 2000 ) includes two primary diagnoses related to trauma: Acute Stress Disorder (ASD) and PTSD. Both these disorders have as prominent features a traumatic event involving actual or threatened death or serious injury and symptom clusters including re-experiencing of the traumatic event (e.g., intrusive thoughts), avoidance of reminders/numbing, and hyperarousal (e.g., difficulty falling or staying asleep). The time frame for ASD is shorter (lasting two days to four weeks), with diagnosis limited to within one month of the incident. ASD was introduced in 1994 to describe initial trauma reactions, but it has come under criticism ( Harvey & Bryant 2002 ) for weak empirical and theoretical support. Most people who have symptoms of PTSD shortly after a traumatic event recover and do not develop PTSD. In a comprehensive review, Green (1994) estimates that approximately 25% of those exposed to traumatic events develop PTSD. Surveys of the general population indicate that PTSD affects 1 in 12 adults at some time in their life ( Kessler et al. 1995 ). Trauma and disasters are related not only to PTSD, but also to concurrent depression, other anxiety disorders, cognitive impairment, and substance abuse ( David et al. 1996 , Schnurr et al. 2002 , Shalev 2001 ).

Other consequences of stress that could provide linkages to health have been identified, such as increases in smoking, substance use, accidents, sleep problems, and eating disorders. Populations that live in more stressful environments (communities with higher divorce rates, business failures, natural disasters, etc.) smoke more heavily and experience higher mortality from lung cancer and chronic obstructive pulmonary disorder ( Colby et al. 1994 ). A longitudinal study following seamen in a naval training center found that more cigarette smoking occurred on high-stress days ( Conway et al. 1981 ). Life events stress and chronically stressful conditions have also been linked to higher consumption of alcohol ( Linsky et al. 1985 ). In addition, the possibility that alcohol may be used as self-medication for stress-related disorders such as anxiety has been proposed. For example, a prospective community study of 3021 adolescents and young adults ( Zimmerman et al. 2003 ) found that those with certain anxiety disorders (social phobia and panic attacks) were more likely to develop substance abuse or dependence prospectively over four years of follow-up. Life in stressful environments has also been linked to fatal accidents ( Linsky & Strauss 1986 ) and to the onset of bulimia ( Welch et al. 1997 ). Another variable related to stress that could provide a link to health is the increased sleep problems that have been reported after sychological trauma ( Harvey et al. 2003 ). New onset of sleep problems mediated the relationship between post-traumatic stress symptoms and decreased natural killer (NK) cell cytotoxicity in Hurricane Andrew victims ( Ironson et al. 1997 ).

Variations in Stress Responses

Certain characteristics of a situation are associated with greater stress responses. These include the intensity or severity of the stressor and controllability of the stressor, as well as features that determine the nature of the cognitive responses or appraisals. Life event dimensions of loss, humiliation, and danger are related to the development of major depression and generalized anxiety ( Kendler et al. 2003 ). Factors associated with the development of symptoms of PTSD and mental health disorders include injury, damage to property, loss of resources, bereavement, and perceived life threat ( Freedy et al. 1992 , Ironson et al. 1997 , McNally 2003 ). Recovery from a stressor can also be affected by secondary traumatization ( Pfefferbaum et al. 2003 ). Other studies have found that multiple facets of stress that may work synergistically are more potent than a single facet; for example, in the area of work stress, time pressure in combination with threat ( Stanton et al. 2001 ), or high demand in combination with low control ( Karasek & Theorell 1990 ).

Stress-related outcomes also vary according to personal and environmental factors. Personal risk factors for the development of depression, anxiety, or PTSD after a serious life event, disaster, or trauma include prior psychiatric history, neuroticism, female gender, and other sociodemographic variables ( Green 1996 , McNally 2003 , Patton et al. 2003 ). There is also some evidence that the relationship between personality and environmental adversity may be bidirectional ( Kendler et al. 2003 ). Levels of neuroticism, emotionality, and reactivity correlate with poor interpersonal relationships as well as “event proneness.” Protective factors that have been identified include, but are not limited to, coping, resources (e.g., social support, self-esteem, optimism), and finding meaning. For example, those with social support fare better after a natural disaster ( Madakaisira & O’Brien 1987 ) or after myocardial infarction ( Frasure-Smith et al. 2000 ). Pruessner et al. (1999) found that people with higher self-esteem performed better and had lower cortisol responses to acute stressors (difficult math problems). Attaching meaning to the event is another protective factor against the development of PTSD, even when horrific torture has occurred. Left-wing political activists who were tortured by Turkey’s military regime had lower rates of PTSD than did nonactivists who were arrested and tortured by the police ( Basoğlu et al. 1994 ).

Finally, human beings are resilient and in general are able to cope with adverse situations. A recent illustration is provided by a study of a nationally representative sample of Israelis after 19 months of ongoing exposure to the Palestinian intifada. Despite considerable distress, most Israelis reported adapting to the situation without substantial mental health symptoms or impairment ( Bleich et al. 2003 ).

BIOLOGICAL RESPONSES TO STRESSORS

Acute stress responses.

Following the perception of an acute stressful event, there is a cascade of changes in the nervous, cardiovascular, endocrine, and immune systems. These changes constitute the stress response and are generally adaptive, at least in the short term ( Selye 1956 ). Two features in particular make the stress response adaptive. First, stress hormones are released to make energy stores available for the body’s immediate use. Second, a new pattern of energy distribution emerges. Energy is diverted to the tissues that become more active during stress, primarily the skeletal muscles and the brain. Cells of the immune system are also activated and migrate to “battle stations” ( Dhabar & McEwen 1997 ). Less critical activities are suspended, such as digestion and the production of growth and gonadal hormones. Simply put, during times of acute crisis, eating, growth, and sexual activity may be a detriment to physical integrity and even survival.

Stress hormones are produced by the SNS and hypothalamic-pituitary adrenocortical axis. The SNS stimulates the adrenal medulla to produce catecholamines (e.g., epinephrine). In parallel, the paraventricular nucleus of the hypothalamus produces corticotropin releasing factor, which in turn stimulates the pituitary to produce adrenocorticotropin. Adrenocorticotropin then stimulates the adrenal cortex to secrete cortisol. Together, catecholamines and cortisol increase available sources of energy by promoting lipolysis and the conversion of glycogen into glucose (i.e., blood sugar). Lipolysis is the process of breaking down fats into usable sources of energy (i.e., fatty acids and glycerol; Brindley & Rollan 1989 ).

Energy is then distributed to the organs that need it most by increasing blood pressure levels and contracting certain blood vessels while dilating others. Blood pressure is increased with one of two hemodynamic mechanisms ( Llabre et al.1998 , Schneiderman & McCabe 1989 ). The myocardial mechanism increases blood pressure through enhanced cardiac output; that is, increases in heart rate and stroke volume (i.e., the amount of blood pumped with each heart beat). The vascular mechanism constricts the vasculature, thereby increasing blood pressure much like constricting a hose increases water pressure. Specific stressors tend to elicit either myocardial or vascular responses, providing evidence of situational stereotypy ( Saab et al. 1992 , 1993 ). Laboratory stressors that call for active coping strategies, such as giving a speech or performing mental arithmetic, require the participant to do something and are associated with myocardial responses. In contrast, laboratory stressors that call for more vigilant coping strategies in the absence of movement, such as viewing a distressing video or keeping one’s foot in a bucket of ice water, are associated with vascular responses. From an evolutionary perspective, cardiac responses are believed to facilitate active coping by shunting blood to skeletal muscles, consistent with the fight-or-flight response. In situations where decisive action would not be appropriate, but instead skeletal muscle inhibition and vigilance are called for, a vascular hemodynamic response is adaptive. The vascular response shunts blood away from the periphery to the internal organs, thereby minimizing potential bleeding in the case of physical assault.

Finally, in addition to the increased availability and redistribution of energy, the acute stress response includes activation of the immune system. Cells of the innate immune system (e.g., macrophages and natural killer cells), the first line of defense, depart from lymphatic tissue and spleen and enter the bloodstream, temporarily raising the number of immune cells in circulation (i.e., leukocytosis). From there, the immune cells migrate into tissues that are most likely to suffer damage during physical confrontation (e.g., the skin). Once at “battle stations,” these cells are in position to contain microbes that may enter the body through wounds and thereby facilitate healing ( Dhabar & McEwen 1997 ).

Chronic Stress Responses

The acute stress response can become maladaptive if it is repeatedly or continuously activated ( Selye 1956 ). For example, chronic SNS stimulation of the cardiovascular system due to stress leads to sustained increases in blood pressure and vascular hypertrophy ( Henry et al. 1975 ). That is, the muscles that constrict the vasculature thicken, producing elevated resting blood pressure and response stereotypy, or a tendency to respond to all types of stressors with a vascular response. Chronically elevated blood pressure forces the heart to work harder, which leads to hypertrophy of the left ventricle ( Brownley et al. 2000 ). Over time, the chronically elevated and rapidly shifting levels of blood pressure can lead to damaged arteries and plaque formation.

The elevated basal levels of stress hormones associated with chronic stress also suppress immunity by directly affecting cytokine profiles. Cytokines are communicatory molecules produced primarily by immune cells (see Roitt et al. 1998 ). There are three classes of cytokines. Proinflammatory cytokines mediate acute inflammatory reactions. Th1 cytokines mediate cellular immunity by stimulating natural killer cells and cytotoxic T cells, immune cells that target intracellular pathogens (e.g., viruses). Finally, Th2 cytokines mediate humoral immunity by stimulating B cells to produce antibody, which “tags” extracellular pathogens (e.g., bacteria) for removal. In a meta-analysis of over 30 years of research, Segerstrom & Miller (2004) found that intermediate stressors, such as academic examinations, could promote a Th2 shift (i.e., an increase in Th2 cytokines relative to Th1 cytokines). A Th2 shift has the effect of suppressing cellular immunity in favor of humoral immunity. In response to more chronic stressors (e.g., long-term caregiving for a dementia patient), Segerstrom & Miller found that proinflammatory, Th1, and Th2 cytokines become dysregulated and lead both to suppressed humoral and cellular immunity. Intermediate and chronic stressors are associated with slower wound healing and recovery from surgery, poorer antibody responses to vaccination, and antiviral deficits that are believed to contribute to increased vulnerability to viral infections (e.g., reductions in natural killer cell cytotoxicity; see Kiecolt-Glaser et al. 2002 ).

Chronic stress is particularly problematic for elderly people in light of immunosenescence, the gradual loss of immune function associated with aging. Older adults are less able to produce antibody responses to vaccinations or combat viral infections ( Ferguson et al. 1995 ), and there is also evidence of a Th2 shift ( Glaser et al. 2001 ). Although research has yet to link poor vaccination responses to early mortality, influenza and other infectious illnesses are a major cause of mortality in the elderly, even among those who have received vaccinations (e.g., Voordouw et al. 2003 ).

PSYCHOSOCIAL STRESSORS AND HEALTH

Cardiovascular disease.

Both epidemiological and controlled studies have demonstrated relationships between psychosocial stressors and disease. The underlying mediators, however, are unclear in most cases, although possible mechanisms have been explored in some experimental studies. An occupational gradient in coronary heart disease (CHD) risk has been documented in which men with relatively low socioeconomic status have the poorest health outcomes ( Marmot 2003 ). Much of the risk gradient in CHD can be eliminated, however, by taking into account lack of perceived job control, which is a potent stressor ( Marmot et al. 1997 ). Other factors include risky behaviors such as smoking, alcohol use, and sedentary lifestyle ( Lantz et al. 1998 ), which may be facilitated by stress. Among men ( Schnall et al. 1994 ) and women ( Eaker 1998 ), work stress has been reported to be a predictor of incident CHD and hypertension ( Ironson 1992 ). However, in women with existing CHD, marital stress is a better predictor of poor prognosis than is work stress ( Orth-Gomer et al. 2000 ).

Although the observational studies cited thus far reveal provocative associations between psychosocial stressors and disease, they are limited in what they can tell us about the exact contribution of these stressors or about how stress mediates disease processes. Animal models provide an important tool for helping to understand the specific influences of stressors on disease processes. This is especially true of atherosclerotic CHD, which takes multiple decades to develop in humans and is influenced by a great many constitutional, demographic, and environmental factors. It would also be unethical to induce disease in humans by experimental means.

Perhaps the best-known animal model relating stress to atherosclerosis was developed by Kaplan et al. (1982) . Their study was carried out on male cynomolgus monkeys, who normally live in social groups. The investigators stressed half the animals by reorganizing five-member social groups at one- to three-month intervals on a schedule that ensured that each monkey would be housed with several new animals during each reorganization. The other half of the animals lived in stable social groups. All animals were maintained on a moderately atherogenic diet for 22 months. Animals were also assessed for their social status (i.e., relative dominance) within each group. The major findings were that ( a ) socially dominant animals living in unstable groups had significantly more atherosclerosis than did less dominant animals living in unstable groups; and ( b ) socially dominant male animals living in unstable groups had significantly more atherosclerosis than did socially dominant animals living in stable groups. Other important findings based upon this model have been that heart-rate reactivity to the threat of capture predicts severity of atherosclerosis ( Manuck et al. 1983 ) and that administration of the SNS-blocking agent propranolol decreases the progression of atherosclerosis ( Kaplan et al. 1987 ). In contrast to the findings in males, subordinate premenstrual females develop greater atherosclerosis than do dominant females ( Kaplan et al. 1984 ) because they are relatively estrogen deficient, tending to miss ovulatory cycles ( Adams et al. 1985 ).

Whereas the studies in cynomolgus monkeys indicate that emotionally stressful behavior can accelerate the progression of atherosclerosis, McCabe et al. (2002) have provided evidence that affiliative social behavior can slow the progression of atherosclerosis in the Watanabe heritable hyperlipidemic rabbit. This rabbit model has a genetic defect in lipoprotein clearance such that it exhibits hypercholesterolemia and severe atherosclerosis. The rabbits were assigned to one of three social or behavioral groups: ( a ) an unstable group in which unfamiliar rabbits were paired daily, with the pairing switched each week; ( b ) a stable group, in which littermates were paired daily for the entire study; and ( c ) an individually caged group. The stable group exhibited more affiliative behavior and less agonistic behavior than the unstable group and significantly less atherosclerosis than each of the other two groups. The study emphasizes the importance of behavioral factors in atherogenesis, even in a model of disease with extremely strong genetic determinants.

Upper Respiratory Diseases

The hypothesis that stress predicts susceptibility to the common cold received support from observational studies ( Graham et al. 1986 , Meyer & Haggerty 1962 ). One problem with such studies is that they do not control for exposure. Stressed people, for instance, might seek more outside contact and thus be exposed to more viruses. Therefore, in a more controlled study, people were exposed to a rhinovirus and then quarantined to control for exposure to other viruses ( Cohen et al. 1991 ). Those individuals with the most stressful life events and highest levels of perceived stress and negative affect had the greatest probability of developing cold symptoms. In a subsequent study of volunteers inoculated with a cold virus, it was found that people enduring chronic, stressful life events (i.e., events lasting a month or longer including unemployment, chronic underemployment, or continued interpersonal difficulties) had a high likelihood of catching cold, whereas people subjected to stressful events lasting less than a month did not ( Cohen et al. 1998 ).

Human Immunodeficiency Virus

The impact of life stressors has also been studied within the context of human immunodeficiency virus (HIV) spectrum disease. Leserman et al. (2000) followed men with HIV for up to 7.5 years and found that faster progression to AIDS was associated with higher cumulative stressful life events, use of denial as a coping mechanism, lower satisfaction with social support, and elevated serum cortisol.

Inflammation, the Immune System, and Physical Health

Despite the stress-mediated immunosuppressive effects reviewed above, stress has also been associated with exacerbations of autoimmune disease ( Harbuz et al. 2003 ) and other conditions in which excessive inflammation is a central feature, such as CHD ( Appels et al. 2000 ). Evidence suggests that a chronically activated, dysregulated acute stress response is responsible for these associations. Recall that the acute stress response includes the activation and migration of cells of the innate immune system. This effect is mediated by proinflammatory cytokines. During periods of chronic stress, in the otherwise healthy individual, cortisol eventually suppresses proinflammatory cytokine production. But in individuals with autoimmune disease or CHD, prolonged stress can cause proinflammatory cytokine production to remain chronically activated, leading to an exacerbation of pathophysiology and symptomatology.

Miller et al. (2002) proposed the glucocorticoid-resistance model to account for this deficit in proinflammatory cytokine regulation. They argue that immune cells become “resistant” to the effects of cortisol (i.e., a type of glucocorticoid), primarily through a reduction, or downregulation, in the number of expressed cortisol receptors. With cortisol unable to suppress inflammation, stress continues to promote proinflammatory cytokine production indefinitely. Although there is only preliminary empirical support for this model, it could have implications for diseases of inflammation. For example, in rheumatoid arthritis, excessive inflammation is responsible for joint damage, swelling, pain, and reduced mobility. Stress is associated with more swelling and reduced mobility in rheumatoid arthritis patients ( Affleck et al. 1997 ). Similarly, in multiple sclerosis (MS), an overactive immune system targets and destroys the myelin surrounding nerves, contributing to a host of symptoms that include paralysis and blindness. Again, stress is associated with an exacerbation of disease ( Mohr et al. 2004 ). Even in CHD, inflammation plays a role. The immune system responds to vascular injury just as it would any other wound: Immune cells migrate to and infiltrate the arterial wall, setting off a cascade of biochemical processes that can ultimately lead to a thrombosis (i.e., clot; Ross 1999 ). Elevated levels of inflammatory markers, such as C-reactive protein (CRP), are predictive of heart attacks, even when controlling for other traditional risk factors (e.g., cholesterol, blood pressure, and smoking; Morrow & Ridker 2000 ). Interestingly, a history of major depressive episodes has been associated with elevated levels of CRP in men ( Danner et al. 2003 ).

Inflammation, Cytokine Production, and Mental Health

In addition to its effects on physical health, prolonged proinflammatory cytokine production may also adversely affect mental health in vulnerable individuals. During times of illness (e.g., the flu), proinflammatory cytokines feed back to the CNS and produce symptoms of fatigue, malaise, diminished appetite, and listlessness, which are symptoms usually associated with depression. It was once thought that these symptoms were directly caused by infectious pathogens, but more recently, it has become clear that proinflammatory cytokines are both sufficient and necessary (i.e., even absent infection or fever) to generate sickness behavior ( Dantzer 2001 , Larson & Dunn 2001 ).

Sickness behavior has been suggested to be a highly organized strategy that mammals use to combat infection ( Dantzer 2001 ). Symptoms of illness, as previously thought, are not inconsequential or even maladaptive. On the contrary, sickness behavior is thought to promote resistance and facilitate recovery. For example, an overall decrease in activity allows the sick individual to preserve energy resources that can be redirected toward enhancing immune activity. Similarly, limiting exploration, mating, and foraging further preserves energy resources and reduces the likelihood of risky encounters (e.g., fighting over a mate). Furthermore, decreasing food intake also decreases the level of iron in the blood, thereby decreasing bacterial replication. Thus, for a limited period, sickness behavior may be looked upon as an adaptive response to the stress of illness.

Much like other aspects of the acute stress response, however, sickness behavior can become maladaptive when repeatedly or continuously activated. Many features of the sickness behavior response overlap with major depression. Indeed, compared with healthy controls, elevated rates of depression are reported in patients with inflammatory diseases such as MS ( Mohr et al. 2004 ) or CHD ( Carney et al. 1987 ). Granted, MS patients face a number of stressors and reports of depression are not surprising. However, when compared with individuals facing similar disability who do not have MS (e.g., car accident victims), MS patients still report higher levels of depression ( Ron & Logsdail 1989 ). In both MS ( Fassbender et al. 1998 ) and CHD ( Danner et al. 2003 ), indicators of inflammation have been found to be correlated with depressive symptomatology. Thus, there is evidence to suggest that stress contributes to both physical and mental disease through the mediating effects of proinflammatory cytokines.

HOST VULNERABILITY-STRESSOR INTERACTIONS AND DISEASE

The changes in biological set points that occur across the life span as a function of chronic stressors are referred to as allostasis, and the biological cost of these adjustments is known as allostatic load ( McEwen 1998 ). McEwen has also suggested that cumulative increases in allostatic load are related to chronic illness. These are intriguing hypotheses that emphasize the role that stressors may play in disease. The challenge, however, is to show the exact interactions that occur among stressors, pathogens, host vulnerability (both constitutional and genetic), and such poor health behaviors as smoking, alcohol abuse, and excessive caloric consumption. Evidence of a lifetime trajectory of comorbidities does not necessarily imply that allostatic load is involved since immunosenescence, genetic predisposition, pathogen exposure, and poor health behaviors may act as culprits.

It is not clear, for example, that changes in set point for variables such as blood pressure are related to cumulative stressors per se, at least in healthy young individuals. Thus, for example, British soldiers subjected to battlefield conditions for more than a year in World War II showed chronic elevations in blood pressure, which returned to normal after a couple of months away from the front ( Graham 1945 ). In contrast, individuals with chronic illnesses such as chronic fatigue syndrome may show a high rate of relapse after a relatively acute stressor such as a hurricane ( Lutgendorf et al. 1995 ). Nevertheless, by emphasizing the role that chronic stressors may play in multiple disease outcomes, McEwen has helped to emphasize an important area of study.

TREATMENT FOR STRESS-RELATED DISORDERS

For PTSD, useful treatments include cognitive-behavioral therapy (CBT), along with exposure and the more controversial Eye Movement Desensitization and Reprocessing ( Foa & Meadows 1997 , Ironson et al. 2002 , Shapiro 1995 ). Psychopharmacological approaches have also been suggested ( Berlant 2001 ). In addition, writing about trauma has been helpful both for affective recovery and for potential health benefit ( Pennebaker 1997 ). For outpatients with major depression, Beck’s CBT ( Beck 1976 ) and interpersonal therapy ( Klerman et al. 1984 ) are as effective as psychopharmacotherapy ( Clinical Practice Guidelines 1993 ). However, the presence of sleep problems or hypercortisolemia is associated with poorer response to psychotherapy ( Thase 2000 ). The combination of psychotherapy and pharmacotherapy seems to offer a substantial advantage over psychotherapy alone for the subset of patients who are more severely depressed or have recurrent depression ( Thase et al. 1997 ). For the treatment of anxiety, it depends partly on the specific disorder [e.g., generalized anxiety disorder (GAD), panic disorder, social phobia], although CBT including relaxation training has demonstrated efficacy in several subtypes of anxiety ( Borkovec & Ruscio 2001 ). Antidepressants such as selective serotonin reuptake inhibitors also show efficacy in anxiety ( Ballenger et al. 2001 ), especially when GAD is comorbid with major depression, which is the case in 39% of subjects with current GAD ( Judd et al. 1998 ).

BEHAVIORAL INTERVENTIONS IN CHRONIC DISEASE

Patients dealing with chronic, life-threatening diseases must often confront daily stressors that can threaten to undermine even the most resilient coping strategies and overwhelm the most abundant interpersonal resources. Psychosocial interventions, such as cognitive-behavioral stress management (CBSM), have a positive effect on the quality of life of patients with chronic disease ( Schneiderman et al. 2001 ). Such interventions decrease perceived stress and negative mood (e.g., depression), improve perceived social support, facilitate problem-focused coping, and change cognitive appraisals, as well as decrease SNS arousal and the release of cortisol from the adrenal cortex. Psychosocial interventions also appear to help chronic pain patients reduce their distress and perceived pain as well as increase their physical activity and ability to return to work ( Morley et al. 1999 ). These psychosocial interventions can also decrease patients’ overuse of medications and utilization of the health care system. There is also some evidence that psychosocial interventions may have a favorable influence on disease progression ( Schneiderman et al. 2001 ).

Morbidity, Mortality, and Markers of Disease Progression

Psychosocial intervention trials conducted upon patients following acute myocardial infarction (MI) have reported both positive and null results. Two meta-analyses have reported a reduction in both mortality and morbidity of approximately 20% to 40% ( Dusseldorp et al. 1999 , Linden et al. 1996 ). Most of these studies were carried out in men. The major study reporting positive results was the Recurrent Coronary Prevention Project (RCPP), which employed group-based CBT, and decreased hostility and depressed affect ( Mendes de Leon et al. 1991 ), as well as the composite medical end point of cardiac death and nonfatal MI ( Friedman et al. 1986 ).

In contrast, the major study reporting null results for medical end points was the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial ( Writing Committee for ENRICHD Investigators 2003 ), which found that the intervention modestly decreased depression and increased perceived social support, but did not affect the composite medical end point of death and nonfatal MI. However, a secondary analysis, which examined the effects of the psychosocial intervention within gender by ethnicity subgroups, found significant decreases approaching 40% in both cardiac death and nonfatal MI for white men but not for other subgroups such as minority women ( Schneiderman et al. 2004 ). Although there were important differences between the RCPP and ENRICHD in terms of the objectives of psychosocial intervention and the duration and timing of treatment, it should also be noted that more than 90% of the patients in the RCPP were white men. Thus, because primarily white men, but not other subgroups, may have benefited from the ENRICHD intervention, future studies need to attend to variables that may have prevented morbidity and mortality benefits among gender and ethnic subgroups other than white men.

Psychosocial intervention trials conducted upon patients with cancer have reported both positive and null results with regard to survival ( Classen 1998 ). A number of factors that generally characterized intervention trials that observed significant positive effects on survival were relatively absent in trials that failed to show improved survival. These included: ( a ) having only patients with the same type and severity of cancer within each group, ( b ) creation of a supportive environment, ( c ) having an educational component, and ( d ) provision of stress-management and coping-skills training. In one study that reported positive results, Fawzy et al. (1993) found that patients with early stage melanoma assigned to a six-week cognitive-behavioral stress management (CBSM) group showed significantly longer survival and longer time to recurrence over a six-year follow-up period compared with those receiving surgery and standard care alone. The intervention also significantly reduced distress, enhanced active coping, and increased NK cell cytotoxicity compared with controls.

Although published studies have not yet shown that psychosocial interventions can decrease disease progression in HIV/AIDS, several studies have significantly influenced factors that have been associated with HIV/AIDS disease progression ( Schneiderman & Antoni 2003 ). These variables associated with disease progression include distress, depressed affect, denial coping, low perceived social support, and elevated serum cortisol ( Ickovics et al. 2001 , Leserman et al. 2000 ). Antoni et al. have used group-based CBSM (i.e., CBT plus relaxation training) to decrease the stress-related effects of HIV+ serostatus notification. Those in the intervention condition showed lower distress, anxiety, and depressed mood than did those in the control condition as well as lower antibody titers of herpesviruses and higher levels of T-helper (CD4) cells, NK cells, and lymphocyte proliferation ( Antoni et al. 1991 , Esterling et al. 1992 ). In subsequent studies conducted upon symptomatic HIV+ men who were not attempting to determine their HIV serostatus, CBSM decreased distress, dysphoria, anxiety, herpesvirus antibody titers, cortisol, and epinephrine ( Antoni et al. 2000a , b ; Lutgendorf et al. 1997 ). Improvement in perceived social support and adaptive coping skills mediated the decreases in distress ( Lutgendorf et al. 1998 ). In summary, it appears that CBSM can positively influence stress-related variables that have been associated with HIV/AIDS progression. Only a randomized clinical trial, however, could document that CBSM can specifically decrease HIV/AIDS disease progression.

Stress is a central concept for understanding both life and evolution. All creatures face threats to homeostasis, which must be met with adaptive responses. Our future as individuals and as a species depends on our ability to adapt to potent stressors. At a societal level, we face a lack of institutional resources (e.g., inadequate health insurance), pestilence (e.g., HIV/AIDS), war, and international terrorism that has reached our shores. At an individual level, we live with the insecurities of our daily existence including job stress, marital stress, and unsafe schools and neighborhoods. These are not an entirely new condition as, in the last century alone, the world suffered from instances of mass starvation, genocide, revolutions, civil wars, major infectious disease epidemics, two world wars, and a pernicious cold war that threatened the world order. Although we have chosen not to focus on these global threats in this paper, they do provide the backdrop for our consideration of the relationship between stress and health.

A widely used definition of stressful situations is one in which the demands of the situation threaten to exceed the resources of the individual ( Lazarus & Folkman 1984 ). It is clear that all of us are exposed to stressful situations at the societal, community, and interpersonal level. How we meet these challenges will tell us about the health of our society and ourselves. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. Indeed, individuals who are optimistic and have good coping responses may benefit from such experiences and do well dealing with chronic stressors ( Garmezy 1991 , Glanz & Johnson 1999 ). In contrast, if stressors are too strong and too persistent in individuals who are biologically vulnerable because of age, genetic, or constitutional factors, stressors may lead to disease. This is particularly the case if the person has few psychosocial resources and poor coping skills. In this chapter, we have documented associations between stressors and disease and have described how endocrine-immune interactions appear to mediate the relationship. We have also described how psychosocial stressors influence mental health and how psychosocial treatments may ameliorate both mental and physical disorders. There is much we do not yet know about the relationship between stress and health, but scientific findings being made in the areas of cognitive-emotional psychology, molecular biology, neuroscience, clinical psychology, and medicine will undoubtedly lead to improved health outcomes.

ACKNOWLEDGMENTS

Preparation of this manuscript was supported by NIH grants P01-MH49548, P01- HL04726, T32-HL36588, R01-MH66697, and R01-AT02035. We thank Elizabeth Balbin, Adam Carrico, and Orit Weitzman for library research.

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50+ Research Topics for Psychology Papers

How to Find Psychology Research Topics for Your Student Paper

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.

• Specific Branches of Psychology
• Topics Involving a Disorder or Type of Therapy
• Human Cognition
• Human Development
• Critique of Publications
• Famous Experiments
• Historical Figures
• Specific Careers
• Case Studies
• Literature Reviews
• Your Own Study/Experiment

Are you searching for a great topic for your psychology paper ? Sometimes it seems like coming up with topics of psychology research is more challenging than the actual research and writing. Fortunately, there are plenty of great places to find inspiration and the following list contains just a few ideas to help get you started.

Finding a solid topic is one of the most important steps when writing any type of paper. It can be particularly important when you are writing a psychology research paper or essay. Psychology is such a broad topic, so you want to find a topic that allows you to adequately cover the subject without becoming overwhelmed with information.

I can always tell when a student really cares about the topic they chose; it comes through in the writing. My advice is to choose a topic that genuinely interests you, so you’ll be more motivated to do thorough research.

In some cases, such as in a general psychology class, you might have the option to select any topic from within psychology's broad reach. Other instances, such as in an  abnormal psychology  course, might require you to write your paper on a specific subject such as a psychological disorder.

As you begin your search for a topic for your psychology paper, it is first important to consider the guidelines established by your instructor.

Research Topics Within Specific Branches of Psychology

The key to selecting a good topic for your psychology paper is to select something that is narrow enough to allow you to really focus on the subject, but not so narrow that it is difficult to find sources or information to write about.

One approach is to narrow your focus down to a subject within a specific branch of psychology. For example, you might start by deciding that you want to write a paper on some sort of social psychology topic. Next, you might narrow your focus down to how persuasion can be used to influence behavior .

Other social psychology topics you might consider include:

• Prejudice and discrimination (i.e., homophobia, sexism, racism)
• Social cognition
• Person perception
• Social control and cults
• Persuasion, propaganda, and marketing
• Attraction, romance, and love
• Nonverbal communication
• Prosocial behavior

Psychology Research Topics Involving a Disorder or Type of Therapy

Exploring a psychological disorder or a specific treatment modality can also be a good topic for a psychology paper. Some potential abnormal psychology topics include specific psychological disorders or particular treatment modalities, including:

• Eating disorders
• Borderline personality disorder
• Seasonal affective disorder
• Schizophrenia
• Antisocial personality disorder
• Profile a  type of therapy  (i.e., cognitive-behavioral therapy, group therapy, psychoanalytic therapy)

Topics of Psychology Research Related to Human Cognition

Some of the possible topics you might explore in this area include thinking, language, intelligence, and decision-making. Other ideas might include:

• False memories
• Speech disorders
• Problem-solving

Topics of Psychology Research Related to Human Development

In this area, you might opt to focus on issues pertinent to  early childhood  such as language development, social learning, or childhood attachment or you might instead opt to concentrate on issues that affect older adults such as dementia or Alzheimer's disease.

Some other topics you might consider include:

• Language acquisition
• Media violence and children
• Learning disabilities
• Gender roles
• Child abuse
• Prenatal development
• Parenting styles
• Aspects of the aging process

Do a Critique of Publications Involving Psychology Research Topics

One option is to consider writing a critique paper of a published psychology book or academic journal article. For example, you might write a critical analysis of Sigmund Freud's Interpretation of Dreams or you might evaluate a more recent book such as Philip Zimbardo's  The Lucifer Effect: Understanding How Good People Turn Evil .

Professional and academic journals are also great places to find materials for a critique paper. Browse through the collection at your university library to find titles devoted to the subject that you are most interested in, then look through recent articles until you find one that grabs your attention.

Topics of Psychology Research Related to Famous Experiments

There have been many fascinating and groundbreaking experiments throughout the history of psychology, providing ample material for students looking for an interesting term paper topic. In your paper, you might choose to summarize the experiment, analyze the ethics of the research, or evaluate the implications of the study. Possible experiments that you might consider include:

• The Milgram Obedience Experiment
• The Stanford Prison Experiment
• The Little Albert Experiment
• Pavlov's Conditioning Experiments
• The Asch Conformity Experiment
• Harlow's Rhesus Monkey Experiments

Topics of Psychology Research About Historical Figures

One of the simplest ways to find a great topic is to choose an interesting person in the  history of psychology  and write a paper about them. Your paper might focus on many different elements of the individual's life, such as their biography, professional history, theories, or influence on psychology.

While this type of paper may be historical in nature, there is no need for this assignment to be dry or boring. Psychology is full of fascinating figures rife with intriguing stories and anecdotes. Consider such famous individuals as Sigmund Freud, B.F. Skinner, Harry Harlow, or one of the many other  eminent psychologists .

Psychology Research Topics About a Specific Career

​Another possible topic, depending on the course in which you are enrolled, is to write about specific career paths within the  field of psychology . This type of paper is especially appropriate if you are exploring different subtopics or considering which area interests you the most.

In your paper, you might opt to explore the typical duties of a psychologist, how much people working in these fields typically earn, and the different employment options that are available.

Topics of Psychology Research Involving Case Studies

One potentially interesting idea is to write a  psychology case study  of a particular individual or group of people. In this type of paper, you will provide an in-depth analysis of your subject, including a thorough biography.

Generally, you will also assess the person, often using a major psychological theory such as  Piaget's stages of cognitive development  or  Erikson's eight-stage theory of human development . It is also important to note that your paper doesn't necessarily have to be about someone you know personally.

In fact, many professors encourage students to write case studies on historical figures or fictional characters from books, television programs, or films.

Psychology Research Topics Involving Literature Reviews

Another possibility that would work well for a number of psychology courses is to do a literature review of a specific topic within psychology. A literature review involves finding a variety of sources on a particular subject, then summarizing and reporting on what these sources have to say about the topic.

Literature reviews are generally found in the  introduction  of journal articles and other  psychology papers , but this type of analysis also works well for a full-scale psychology term paper.

Topics of Psychology Research Based on Your Own Study or Experiment

Many psychology courses require students to design an actual psychological study or perform some type of experiment. In some cases, students simply devise the study and then imagine the possible results that might occur. In other situations, you may actually have the opportunity to collect data, analyze your findings, and write up your results.

Finding a topic for your study can be difficult, but there are plenty of great ways to come up with intriguing ideas. Start by considering your own interests as well as subjects you have studied in the past.

Online sources, newspaper articles, books , journal articles, and even your own class textbook are all great places to start searching for topics for your experiments and psychology term papers. Before you begin, learn more about  how to conduct a psychology experiment .

What This Means For You

After looking at this brief list of possible topics for psychology papers, it is easy to see that psychology is a very broad and diverse subject. While this variety makes it possible to find a topic that really catches your interest, it can sometimes make it very difficult for some students to select a good topic.

If you are still stumped by your assignment, ask your instructor for suggestions and consider a few from this list for inspiration.

• Hockenbury, SE & Nolan, SA. Psychology. New York: Worth Publishers; 2014.
• Santrock, JW. A Topical Approach to Lifespan Development. New York: McGraw-Hill Education; 2016.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

What is Parental Monitoring?

• Published: 13 June 2024

Cite this article

• William E. Pelham III 1 ,
• Sarah J. Racz 2 ,
• Isabella S. Davis   ORCID: orcid.org/0009-0000-4397-3863 1 ,
• Isabel R. Aks 1 ,
• Herry Patel 1 ,
• Robert J. McMahon 3 , 4 ,
• Makayla A. Thornburg 1 ,
• Yun-Ting Wendy Huang 1 ,
• Emily M. Schulze 1 ,
• Oscar Gonzalez 5 ,
• Susan F. Tapert 1 &
• Sandra A. Brown 1 , 6  

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Parental monitoring is a construct of longstanding interest in multiple fields—but what is it? This paper makes two contributions to the ongoing debate. First, we review how the published literature has defined and operationalized parental monitoring. We show that the monitoring construct has often been defined in an indirect and nonspecific fashion and measured using instruments that vary widely in conceptual content. The result has been a disjointed empirical literature that cannot accurately be described as the unified study of a single construct nor is achieving a cumulative scientific character. Second, we offer a new formulation of the monitoring construct intended to remedy this situation. We define parental monitoring as the set of all behaviors performed by caregivers with the goal of acquiring information about the youth’s activities and life. We introduce a taxonomy identifying 5 distinct types of monitoring behaviors (Types 1–5), with each behavior varying along five dimensions (performer, target, frequency, context, style). We distinguish parental monitoring from 16 other parenting constructs it is often conflated with and position monitoring as one element within the broader parent-youth monitoring process : the continuous, dyadic interplay between caregivers and youth as they navigate caregivers attempts' to monitor youth. By offering an explicit and detailed conceptualization of monitoring, we aim to foster more rigorous and impactful research in this area.

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We focused on rating scales because nearly all published studies have measured parental monitoring using rating scales, typically completed by parents or youth. Only a handful of studies have measured monitoring instead via coder impressions of videotaped discussions between parents and youth about monitoring (e.g., Pelham & Dishion, 2018 ) or by comparing the simultaneous reports of parents and youth about the youths’ activities on a given day (e.g., Crouter et al., 1999 ).

We write that parental monitoring behaviors are performed with “the goal” of acquiring information for two reasons. First, an instance of the behavior may not be successful at acquiring information, yet it would still be a monitoring behavior. Second, some behaviors that are clearly not monitoring behaviors might incidentally lead to acquiring information. For example, the parent may eat dinner with the youth and incidentally learn something about the youth’s life during their conversation, eating dinner with the youth is itself alone not a monitoring behavior.

The “style” dimension of a monitoring behavior is not to be confused with parenting style more broadly. The former refers to the way a monitoring behavior is performed whereas the latter refers to a constellation of parent attitudes toward the youth (see Table  5 ).

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Pelham was supported by the National Institute on Drug Abuse (DA055935, DA058314) and the National Institute on Alcohol Abuse and Alcoholism (AA030197). Patel and Pelham were supported by the California Department of Cannabis Control (DCC). Patel was supported by the Banting Postdoctoral Fellowship from the Canadian Institutes of Health Research (CIHR). Additional support for the preparation of this work was provided by a LEEF B.C. Leadership Chair award, B.C. Children’s Hospital Research Institute Investigator Grant Award, and a Canada Foundation for Innovation award to Robert J. McMahon.

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Review:  Jude Law rages through ‘Firebrand’ as a mercurial royal while Alicia Vikander hangs on

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The worthy scouring of the past for hidden heroes, underrepresented figures and untapped dramatic potential has always kept historians and novelists dutifully occupied. One might think that England’s well-researched monarchs don’t belong in that category. But “Firebrand,” adapted from Elizabeth Fremantle’s novel “The Queen’s Gambit,” takes the position that Henry VIII’s final wife (of six), Katherine Parr, was more than just a devout, deferential nursemaid to an ailing king. She was also a closet Reformist radical and, in one eye-opening tweak to established history, an abused spouse not to be messed with.

Even if the facts don’t entirely support these notions, they’re not unappealing ones upon which to hang a portrait of a bad marriage at a turbulent time — despite the reality that Henry hardly requires outing as a serial #MeToo offender in need of comeuppance. And while it’s a tad surprising that Brazilian-Algerian art-house iconoclast Karim Aïnouz’s first English-language feature is a costume drama about English royals, it does sport two compelling stars in Alicia Vikander as protofeminist Katherine, and an almost unrecognizably heavy-set Jude Law as the Tudor tyrant.

That pairing, however, comes with drawbacks when the modernist screenplay (credited to Henrietta and Jessica Ashworth, along with Rosanne Flynn) meets Aïnouz’s meandering, atmosphere-thick approach. We drop in on Katherine in 1546 when she’s enjoying some interim power as newly appointed Regent while Henry is fighting France overseas. She risks treason, however, by meeting clandestinely in the forest with rabble-rousing Protestant preacher Anne Askew (Erin Doherty), eager for revolution against a vicious church authority that is afraid of commoners reading the Bible in English.

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Anne is skeptical that her old pal can do anything from within the castle walls, but Katherine’s optimistic rejoinder is, “I’ve lasted longer than any other wife.” That’s hardly the flex that it sounds. As a caring stepmother to Prince Edward (Patrick Buckley) and Princess Elizabeth (Junia Reeves), Katherine has brought a measure of peace to the kids’ traumatized lives but believes she was chosen by God to bring change. When Henry returns in deteriorating health, he brings to an already fearful court the full weight of his madness, paranoia, jealousy and rage, compounded by a festering leg wound. Apart from putting Katherine in immediate danger, it sparks a scramble for survival among his retinue, which includes heretic-hunting conservative bishop Stephen Gardiner (Simon Russell Beale) and Edward Seymour (Eddie Marsan), the Prince’s scheming uncle. Both men would be happy to see Katherine go the way of her beheaded predecessors if it means preserving their own power.

Vikander’s poised, considerate Katherine starts off active, but recedes into the background as the justifiably watchable tornado that is Law’s Oliver-Reed-channeling Henry transforms the movie into a biopic of a ruler’s howling exit. He becomes the central attraction of master cinematographer Hélène Louvart ’s candlelit, sparingly saturated interiors. Previously collaborators on Aïnouz’s Cannes-winning “Invisible Life,” Louvart and the filmmaker work well together, especially when it comes to the rich colors and weighted textures of Michael O’Connor’s period wardrobe, or on any given close-up from a member of the superlative cast.

But Aïnouz, as if understandably drawn to an energy source, seems increasingly preoccupied with a mood of domestic terror at the expense of the story strands intended to paint Katherine as a vital inspirational bridge between her maniacal husband and her stepdaughter Elizabeth’s noteworthy womanhood. At a certain point, it feels as if scenes are missing, and what’s left reads as unconvincing. By the time “Firebrand” reaches its climactic dramatic license about this survivor narrative, we should be better armed to relish it, instead of scratching our heads at a speculative swerve out of nowhere.

'Firebrand'

Rating: R, for some violent content, brief gore and sexuality/nudity Running time: 2 hours Playing: Opens Friday, June 14 in limited release

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