Lawrence A. DiDomenico, DPM, FACFAS

• Adjunct Professor and Director of Reconstructive Rearfoot and
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• Ohio College of Podiatric Medicine
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Over a 2year period visceral pain treatment guidelines purchase maxalt visa, general selfefficacy turned out to be the best single predictor of overall adjustment pain heat treatment maxalt 10 mg without prescription, as assessed by a number of outcomes such as employment status pain medication for dogs tylenol buy maxalt 10mg otc, social integration unifour pain treatment center statesville nc discount maxalt online, physical health pain treatment for ulcers order line maxalt, and subjective well being (Schwarzer & Jerusalem pain treatment video buy maxalt 10 mg online, 1995b). A measure of general selfefficacy proved to be valuable in this study because an assessment of all corresponding domainspecific selfefficacy measures for every coping outcome would not have been possible under the circumstances of this particular study. Measures of general selfefficacy have also been found to relate to a number of mental and physical health outcomes. PhaseSpecific SelfEfficacy In an intervention to increase breast selfexamination, task selfefficacy was associated with intention, whereas maintenance selfefficacy related to planning and behavior (Luszczynska, 2004). There is also evidence that interventions to increase physical activity affect different 610 Lisa Marie Warner and Ralf Schwarzer phasespecific selfefficacy beliefs depending on whether they focus on the adoption or maintenance of physical activity (Higgins, Middleton, Winner, & Janelle, 2014). A longitudinal study with validated scales showed that mastery experience, selfpersuasion, and negative affective states were the most prominent predictors of self efficacy for physical activity in communitydwelling older adults (Warner et al. From a theoretical perspective, selfefficacy is built upon four sources: mastery experiences, vicarious experiences, verbal persuasion, and somatic and affective states (Bandura, 1997). Bandura states that mastery experiences are "the most effective source of efficacy information because they provide the most authentic evidence of whether one can master whatever it takes to succeed" (1997, p. However, metaanalyses have come to the conclusion that graded mastery could also lower selfefficacy. To make the most of newly gained mastery experiences, it is also essential to target a positive attributional style. Interventions can prepare for temporal setbacks and lapses to help individuals avoid what Marlatt and Gordon (1985) called the abstinence violation effect. This effect describes that people tend to see lapses as proof for incapability, which makes them drop all effort so they experience a full relapse. When people learn to attribute lapses to external causes, such as the end of a stressful day or highly tempting situations, selfefficacy can be maintained and trained for future risk situations. Although not always named among the sources of selfefficacy, Bandura also identifies mental imagery as another possible origin of selfefficacy beliefs (Bandura, 1977) and proves its use to treat phobias. Health psychological research shows that imagining the outcomes of a behavior (approach imagery) as well as the steps that need to be fulfilled to attain a goal (process imagery) can also be effective to increase physical activity among sedentary adults (Chan & Cameron, 2012). Vicarious experience, like observing others perform a specific behavior with a specific outcome-be it live or symbolic such as in a video or testimonial-increases the belief in being able to master similar tasks and produce comparable results (Bandura, 1977). Vicarious experiences provide the observer with strategies and techniques needed to attain desired goals or to overcome certain stressors. Usually, it is assumed that role models that resemble the observer in attributes such as background, age, gender, or level of expertise show better effects on self efficacy than dissimilar models (Bandura, 1997). Verbal or social persuasion happens if someone expresses faith in the capabilities of another (Bandura, 1997). Verbal persuasion from credible sources such as health professionals is most effective (Perloff, 1993). If, however, someone already has a strong belief in not being capable to achieve their goal, for example, derived from negative experience in the past, it is easier to lower their selfefficacy than to increase it by attempts of persuasion. Therefore, this source of selfefficacy needs to be addressed with care and experience to avoid reactance. SelfEfficacy and Health 611 Previous to challenging tasks, most people perceive somatic and affective states such as a fast beating heart or sweaty hands. As the natural tendency is to interpret such physiological symptoms as signs of unpreparedness or anticipation of poor performance, people are more likely to feel competent if they do not experience highly aversive arousal (Bandura, 1997). The optimal level of arousal should, however, lay somewhere in the middle, as too high and too low arousal may impede performance. Several metaanalyses have summarized the behavior change techniques that are most effective to increase selfefficacy in physical activity interventions. However, interventionists in this field should keep in mind that there can be "too much of a good thing. Selfefficacy beliefs should hence be realistic to generate motivation and health behavior, as overconfidence could elicit frustration and disappointment along the health behavior change process. His research focuses on various aspects of psychology, including stress and anxiety, coping, social support, health behavior change, and selfefficacy. What is the best way to change selfefficacy to promote lifestyle and recreational physical activity Promoting physical activity with goaloriented mental imagery: A randomized controlled trial. Physical activity interventions differentially affect exercise task and barrier selfefficacy: A metaanalysis. Are measures of selfesteem, neuroticism, locus of control, and generalized selfefficacy indicators of a common core construct Validity of a stage algorithm for physical activity in participants recruited from orthopedic and cardiac rehabilitation clinics. Change in breast selfexamination behavior: Effects of intervention on enhancing selfefficacy. Mediated effects of social support for healthy nutrition: Fruit and vegetable intake across 8 months after myocardial infarction. Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. Predicting physical exercise in cardiac rehabilitation: the role of phasespecific selfefficacy beliefs. University students setting goals in the context of autonomy, selfefficacy and important goalrelated task engagement. Resource loss, selfefficacy, and family support predict posttraumatic stress symptoms: A 3year study of earthquake survivors. Sources of perceived self efficacy as predictors of physical activity in older adults. Maintaining autonomy despite multimorbidity: Selfefficacy and the two faces of social support. The confounded selfefficacy construct: Conceptual analysis and recommendations for future research. Social cognitive theory of posttraumatic recovery: the role of perceived selfefficacy. Functional roles of social support within the stress and coping process: A theoretical and empirical overview. What are the most effective intervention techniques for changing physical activity selfefficacy and physical activity behaviourand are they the same People embraced insights from psychological science concerning the origins and nature of selfesteem, and individuals and governmental organizations alike sought methods for improving selfesteem and reaping the many benefits associated with positive selfregard, including career and academic success, and increased life satisfaction. Many people who hear of this connection may wonder, "How can feelings influence something tangible and physical like health In fact, the mind and the body are intimately connected, and this connection is abundantly evident in the pervasive links between selfesteem and the various dimensions of wellbeing that characterize human health. Before it is possible to understand how and why selfesteem predicts such a seemingly unrelated experience as health, it is essential to first understand how this psychological the Wiley Encyclopedia of Health Psychology: Volume 2: the Social Bases of Health Behavior, First Edition. The first sense of self that coheres during infancy is the sense of being an entity distinct from others, who persists over time and across places. Around the age of 3, as children mature and interact with their social and physical worlds, they gradually develop beliefs about their specific traits and abilities ("I am athletic"), learn the social roles that they are expected to fulfill ("I am a girl"), and develop theories, or scripts, to explain and predict their actions ("If I ask Marjan to play with me, she will say yes"). As children approach puberty, they begin to evaluate their worth and value, and it is this global evaluative component of the self that psychologists call selfesteem. Selfesteem develops in part through a reflected appraisal process, whereby children observe how other people treat them, and from that treatment infer their worth. Being treated with responsive kindness, warmth, and positivity by social partners, especially family, communicates that the self is worthy and valuable. In contrast, being ignored, invalidated, overlooked, or abused by unresponsive or unavailable social partners, especially family, communicates that the self is not worthy of care or deserving of loving kindness. Over time and through repeated exposure, children internalize these social messages, and thus selfesteem is born. Of course, people are not passive tabula rasa onto which their social experiences write. Babies are born with a genetic heritage that shapes the ways in which they interact with the world, and these same forces influence the development of selfesteem. Of particular relevance to the discussion at hand, some people are temperamentally inclined to focus their attention and energy toward seeking rewarding experiences and to experience high levels of positive affect, whereas others are temperamentally inclined to focus their attention and energy toward avoiding punishing experiences and to experience high levels of negative affect. Rewardfocused people who are relatively insensitive to stressors and recover quickly from negative moods will tend to develop higher selfesteem. In contrast, people who are temperamentally attuned to punishments like criticism, who react strongly to stress and take a long time to recover, and who experience frequent negative moods tend to develop lower selfesteem. This association between temperament and selfesteem probably exists because temperament influences the ways in which people experience the world, which in turn informs self evaluations. For example, if someone is very sensitive to rewards, she will be more likely to notice and internalize praise and thus develop higher selfesteem. Conversely, if someone is very sensitive to criticism, he will feel the sting of social rebuff more deeply and thus will be more likely to develop lower selfesteem. Thus, temperament is a lens through which self esteemrelevant experiences and messages must first pass before they are internalized, resulting in selfesteem that is highly subjective in nature. Two people with different temperaments can have the same experiences and from those experiences infer different conclusions about their social worth and thus develop different levels of selfesteem. As this example illustrates, self esteem develops from a true symbiotic interaction between nature and nurture. Once selfesteem crystallizes around the age of 12, it remains remarkably stable across the lifespan. Perhaps due to its high degree of stability, people often rely on their selfesteem to regulate their interactions with their material and social worlds. The lens of selfesteem helps SelfEsteem and Health 617 people to make sense of their past experiences, to determine a present course of action, and to predict future outcomes. In each of these domains, lower selfesteem individuals tend to adopt a more pessimistic and cautious outlook than higher selfesteem individuals, who can be quite optimistic and blithe in many circumstances. For example, a lower selfesteem person may attribute past failures to personal shortcomings and thus avoid situations that call on the skills he believes he does not possess because he anticipates failure. In contrast, a higher selfesteem person is more likely to dismiss past failures as resulting from external factors and thus pursue opportunities that offer rewards he feels equipped to effectively claim. These differing orientations are evident in school and workplace settings and in social contexts ranging from interactions with strangers to interactions with lovers, and they result in differing outcomes for people with lower and higher selfesteem. In many life domains, higher selfesteem individuals tend to experience more positive outcomes than their lower selfesteem counterparts, and this difference extends to the domain of health. Following the World Health Organization, we consider health to be a multifaceted construct comprising psychological, physical, and social wellbeing. Psychological WellBeing Selfesteem is negatively associated with a range of mental health concerns, including depression, anxiety, stress, disordered eating, negative body image, and suicidal ideation. Although it is difficult to determine whether selfesteem is a cause or consequence of these mental health conditions, longitudinal studies that control for third variables and rule out reverse causation can help to tease apart these possibilities. For example, one such study observed that adolescents with low selfesteem and individuals whose selfesteem declined during adolescence were more likely to experience depression fully two decades later (Steiger, Allemand, Robins, & Fend, 2014). Another study that examined selfesteem and mental health outcomes at multiple points in time found that lower selfesteem predicts depression, which, in turn, predicts heightened rates of stressful life events (Orth, Robins, & Meier, 2009). The consensus among psychological scientists is that lower selfesteem is an independent risk factor for the development of numerous mental health conditions. Physical WellBeing Selfesteem is also related to a broad range of physical health conditions. For example, lower selfesteem university students report that they experience worse physical health, visit the doctor more often, and miss more days of school due to illness than their higher selfesteem counterparts (Stinson et al. For example, compared with higher selfesteem individuals, lower selfesteem individuals with asthma or rheumatoid arthritis experience more negative affect, less positive affect, greater stress and symptom severity, and more symptom interference and activity restrictions in daily life (Juth, Smyth, & Santuzzi, 2008). Lower selfesteem individuals report that they receive less social support, experience more interpersonal stress, and suffer from loneliness and social isolation to a greater extent than their higher selfesteem counterparts. Such perceptions may accurately reflect important developmental experiences of acceptance and rejection from family and peers. But with the changing social context of adulthood, appraisals of social wellbeing can diverge from objective reality. Such individual differences are thought to be motivated by concerns about rejection. Lower selfesteem people are extremely risk averse and would rather err on the side of caution and overlook some acceptance cues than risk rejection by perceiving acceptance that is not actually present. In contrast, higher selfesteem people are blithe in the face of rejection and will boldly perceive acceptance from even the most neutral social companions. Thus, selfesteem and social wellbeing are linked throughout the lifespan by a recursive process whereby early social experiences help to forge selfesteem, which later guides social experiences that further reinforce selfesteem. Two dominant models have emerged to explain why selfesteem and health are so intricately woven together. A Resource Model of SelfEsteem and Health Selfesteem and health may be linked because higher selfesteem is a psychological resource on which people can rely in times of adversity. In this model, the same temperamental factors and developmental experiences that give rise to higher or lower selfesteem also give rise to characteristic psychological orientations that benefit, or undermine, health. Specifically, the affective, cognitive, and motivational styles that characterize higher selfesteem may allow such individuals to cope with and recover from stressors more effortlessly and quickly than their lower self esteem counterparts.

It is important to note that the minority stress model emphasizes ways in which multiple minority identities can serve as both protective and risk factors for behaviors and experiences related to health disparities acute chest pain treatment guidelines discount maxalt 10 mg. For example myofascial pain treatment center reviews generic 10mg maxalt visa, sources of stress and health concerns may differ significantly between gay men and lesbian women xiphoid pain treatment discount maxalt 10mg mastercard, or for sexual orientation and gender minority people of color compared with White sexual orientation and gender minority individuals pain treatment center bismarck cheap 10 mg maxalt with mastercard. Indeed pain treatment for pleurisy order maxalt 10mg fast delivery, the minority stress model has been applied several times to understand the experiences of ethnically and racially diverse populations since its conception in 1995 (Meyer pain treatment center of greater washington justin wasserman cheap maxalt 10mg with amex, 1995). The minority stress framework has been instrumental in helping to understand health disparities within their context. Numerous health disparities exist for sexual orientation and gender minority populations. Such disparities are known to begin early, being demonstrated even among adolescents who identify as sexual orientation and gender minorities. Sexual orientation and gender minority youth report higher levels of emotional distress and depressive symptoms than their heterosexual and cisgender counterparts. These symptoms are also associated with elevated levels of suicidal ideation and suicide attempts, as well as selfharm behaviors. Further, these disparities have been replicated across multiple countries, across racial/ethnic groups, and across genders. Transgender youth appear to be at specific and elevated risk for selfharm (McConnell, Birkett, & Mustanski, 2015; Peterson, Matthews, CoppsSmith, & Conard, 2017). Among adults, these health disparities persist and are linked to other negative outcomes for sexual orientation and gender minority individuals. In minority stress theory, stresses are differentiated based on whether they arise from outside or within an individual. Such circumstances speak to the intersectional interactions of multiple minority statuses in considering minority stress. Poverty would impact factors such as access to basic needs such as healthcare, access to food. Unfortunately, limited empirical research has been conducted on the intersection of sexual orientation and gender minority identity and poverty, from within the minority stress framework. Nevertheless, sexual orientation and gender minority persons, especially adolescents, face levels of poverty and homelessness far higher than their heterosexual and cisgender peers (Keuroghlian, Shtasel, & Bassuk, 2014). Other circumstances in the environment may also depend on the specific circumstances of the individuals involved; for example, in considering a samesex couple who wish to adopt, specific state laws regarding samesex adoption may be an especially relevant circumstance in the environment. Such laws may ebb and flow in their relevance to individuals; for example, if a samesex couple has adopted a child in a state in which adoption laws were being called into question, they may worry about the status of their legal rights as adoptive parents. Similarly, such stresses may arise of sexual orientation or gender minority persons when the legality of samesex marriage is called into question. In prior research with sexual orientation minority persons, in states in which constitutional amendments to define marriage as between a man and a woman were on the ballot, sexual orientation minority persons reported higher exposure to negative media, higher negative affect, and higher levels of distress compared with persons in states where such laws were not on the ballot (Fingerhut, Riggle, & Rostosky, 2011). Myriad other circumstances in the environment may ultimately impact the wellbeing of sexual orientation and gender minority persons, including persons with multiple minority statuses or other relevant personal characteristics. Parent and Teresa Gobble Circumstances in the environment are inextricably tied to minority statuses. There are innumerable personal characteristics that a minority of persons may possess, but do not represent socially stigmatized identities. Minority stress theory focuses on stresses that arise due to social influence, and thus categories of stigmatized identities are socially defined and may intersect. For example, recent research has explored ways in which sexual orientation and gender or race may intersect. Such investigations have indicated that there may be some pervasive mental health issues that cut across different groups when faced with minority stress. Thus, specific minority identities, and the interactions among identities, may impact both which circumstances in the environment are relevant and potential outcomes of minority stress processes. Minority Identity Because minority stress theory focuses on socially defined identities, a concept similar to minority status is minority identity and its characteristics. Individuals may differ in the extent to which their identities align with the categories into which researchers or others may desire to put them. For example, the term "men who have sex with men" was coined, in part, to capture the experiences of men who have sex with men but who may not identify as gay or bisexual. Minority identity itself is closely tied to the characteristics of minority identity, such as prominence of that identity or integration of that identity into everyday life. Such processes have implications for the health of sexual orientation and gender minority populations. Other investigations have linked integration of sexual minority identity with lower internalized heterosexism and lower psychological distress. At the same time, outness has also been associated with more experiences of heterosexism, which may exacerbate minority stress processes. In addition, outness has not always clearly been linked to health variables, with some studies finding no relationship between outness and instances of domestic violence among lesbian and bisexual women (Balsam & Szymanski, 2005; Velez, Moradi, & Brewster, 2013). Thus, the relationships among outness or other variables related to identity salience are not straightforward. In minority stress theory, these processes are conceptualized as distal (arising directly from the behaviors of others, such as harassment or discrimination) or proximal (arising directly from within oneself, such as expectations of rejection or internalized homophobia). These proximal and distal stressors have been reliably associated with myriad health concerns for sexual orientation and gender minority persons (Meyer, 2003). Sexual Minority Populations and Health 421 Finally, the minority stress model posits that coping and social support may moderate health outcomes for sexual orientation and gender minority persons. Notably, however, research has not always supported the posited roles of these variables. Some work has supported links between aspects of coping, such as spiritual coping, as a buffer between minority stressors and mental health outcome variables, such as substance use. Other work has demonstrated that emotional regulation mediates the relationship between minority status and depression and anxiety among sexual orientation minority adolescents (but also that sexual orientation minority adolescents demonstrate lower levels of emotional regulation than their heterosexual peers). However, other recent work has called into question the utility of concepts such as "coping" or "resilience" among minority persons who may face social or institutional discrimination, insomuch as those terms may refer to returns to baselines of emotional or cognitive content following experiences of minority stress. By conceptualizing such returns to baseline following experiences of harassment, discrimination, or violence, the impetus for change is placed on an individual experiencing such harassment, discrimination, or violence to deal with the implications of those experiences, rather than emphasizing the need for change in the social or institutional power structures that allow or even encourage those experiences. Experiences of posttraumatic growth, transformative coping, or personal growth following minority stress may be fruitful areas to explore and may lead to a more clear understanding of the relationship between minority stresses and adaptive responses (Meyer, 2015). Regarding social support, a number of studies have supported social support as a buffer of the relationship between experiences of minority stress and negative outcomes. For example, more often attending clubs and parties has been linked to increased body image concerns and substance use among gay and bisexual men (Mattison, Ross, Wolfson, & Franklin, 2001). Minority Stressors and Health Disparities Experiences of bullying appear to be ubiquitous among sexual orientation and gender minority youth, with nearly all reporting some level of bullying or harassment. More severe forms of bullying including persistent bullying, threats of violence, or actual violence, are also common. Some of these instances of violence can result in physical harm, and sexual orientation and gender minority youth report that often these instances are either not reported to school officials or law enforcement, and if they are, that nothing is done about the behavior. Both harassment and violence are known to persist into adulthood, with sexual orientation and gender minority youth reporting workplace harassment and discrimination in housing or employment. Some disparities appear to be particularly relevant for specific groups within the sexual and gender minority umbrella. In particular, transgender persons may be especially vulnerable to experiences of violence (Berlan, Corliss, Field, Goodman, & Austin, 2010; Kim & Leventhal, 2011). Use of substances is also elevated among sexual orientation and gender minority persons, and this finding has been replicated in several countries. Parent and Teresa Gobble elevated among gender and sexual orientation minority adolescents, though rates of hard drugs and club drugs are markedly elevated, and rates of smoking tobacco are also markedly higher among sexual orientation and gender minority adolescents compared with their cisgender counterparts. This elevation is occurring concurrently with marked drops in smoking behaviors in the general population. Regarding substance use in general, among adolescents, girls appear to have somewhat higher risk for substances than boys, and bisexual adolescents appear to be at somewhat greater risk than gay/lesbian adolescents. Among adults, rates of substance use remain elevated, including use of tobacco, alcohol, steroids, recreational drugs, and club drugs. Use of such substances may be related to attempts to cope with stresses such as discrimination and violence but also potentially linked to aspects of community engagement. For example, use of illicit substances is common in clubs and circuit parties (large dance parties). Among femaletomale transgender persons, use of steroids may also facilitate development of a highly masculinized physique, potentially increasing "passing" as male and decreasing risks associated with being perceived as transgender (Guss, Williams, Reisner, Austin, & KatzWise, 2017; Halkitis, Moeller, & DeRaleau, 2008; Lee, Matthews, McCullen, & Melvin, 2014; Marshal et al. Sexual risk behaviors are also relevant to sexual orientation and gender minority individuals. Adolescent gay and bisexual boys report greater risky sexual behaviors than their heterosexual counterparts, with some studies finding bisexual adolescent boys to be at particular risk. These risks persist into adulthood for gay and bisexual men and appear to be exacerbated by use of substances and engaging in sex while intoxicated. This disparity appears to be most prevalent among lesbian and bisexual women and appears to arise relatively early in life as adolescent girls who identify as lesbian and bisexual report higher rates of obesity compared with heterosexual peers. Obesity, and engagement in obesogenic behaviors, may interact with other stressors such as unemployment or underemployment, further complicating health status. However, obesity is not markedly elevated among gay and bisexual men or among transgender persons. The precise cause of specific health disparities among sexual orientation minority women is not known. Indeed, predictors of overweight status and obesity among sexual orientation minority women and heterosexual women are similar (Bowen, Balsam, & Ender, 2008; Yancey, Cochran, Corliss, & Mays, 2003). Some, though not all, transgender persons may seek to undertake aspects of gender transition. Gender transition processes may be social and legal changes, such as legal adoption of a new name; nonmedical alterations of physical appearance, such as changes in hair style, body hair management, or clothing choices; medical and not surgical, such as use of exogenous hormones; and medical and surgical. Sexual Minority Populations and Health 423 Medical and surgical changes also take on a range of manifestations, including breast reductions or breast implants, alterations to facial bone structure, and genital reconfiguration. Importantly, not all transgender persons wish to undergo all aspects of gender transition. Research supports that completing desired aspects of gender transition is associated with improvements in mental health and wellbeing. However, numerous barriers exist to transition processes: primarily, the cost of the procedures and access to competent care providers. Due to these barriers, some gender minority individuals may seek to undergo transition processes outside of professional medical supervision. Such processes may include unsupervised use of illicit hormones or injection with silicone that may result in infection (Murad et al. Discussion Sexual orientation and gender minority persons face a range of health disparities. The study of health disparities within this population has moved beyond views of sexual orientation and gender minority status as intrinsically pathological toward a contextual understanding of social and cultural origins of health disparities within this population. To this end, the minority stress model has been instrumental in framing our understanding of unique, chronic, and socially based stresses that may contribute to health disparities among sexual orientation and gender minority populations. Still, many disparities exist across health behaviors including substance use, obesity, and sexual risk behaviors, and many other disparities affect specific groups within the umbrella of sexual orientation and gender minority, and many opportunities exist for system and individuallevel intervention and future research. It is imperative to understand how public policy related to health impacts the wellbeing of sexual orientation and gender minority populations. Within minority stress theory, such a focus would aim to reduce the institutional or structural supports for distal causes of health disparities for sexual orientation and gender minority individuals. For example, enactment of antisamesex marriage laws in the United States (prior to the Supreme Court ruling in favor of marriage quality across the country) has been associated with negative impacts on the mental health and wellbeing of sexual minority persons (Riggle, Rostosky, & Horn, 2010). Similar research has explored how antibullying legislation impacts experiences of bullying among sexual minority youth (Hatzenbuehler, SchwabReese, Ranapurwala, Hertz, & Ramirez, 2015), though research indicates that specific implementations of such laws by teachers and in schools may affect their impact (Van Wormer & McKinney, 2003). It is important to explore ways in which public policy can be used to reduce health disparities, including ways in which individuals who work in the front lines of implementing such policy may be empowered to better advocate for sexual orientation and gender minority persons. The minority stress model also emphasizes the importance of examining proximal, or withinperson, stressors related to health disparities. Such stressors may include expectations of rejection, internalized stigma, and concealment of sexual orientation (Meyer, 1995). Despite the large body of research on minority stress, very limited empirical research on the treatment of stress among sexual orientation and gender minority populations has been undertaken. Although some treatment guidelines for sexual orientation and gender minority populations have been developed (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015), there have been very few trials of interventions that specifically address constellations of minority stress. Studies that have been conducted have tended to be relatively low quality 424 Mike C. It is important to extend extant work on minority stress beyond theoretical investigations of relations among constructs, which have generally been well established in the literature, and integrate these constructs with empirically supported interventions to provide quality, patientcentered care to sexual orientation and gender minority individuals. Parent earned his PhD in Counseling Psychology from the University of Florida in 2013. He is now an assistant professor in counseling psychology and counselor education at the University of Texas at Austin. His program of research focuses on gender, sexuality, and behavioral health, as well as professional issues in psychology. He is the author of more than 40 peerreviewed publications and has received numerous awards for his research and mentorship of students.

More recently running knee pain treatment cheap 10mg maxalt visa, she has begun to investigate and seek ways to alleviate social psychological barriers to health and wellbeing that affect negatively stereotyped groups jaw pain treatment medications order maxalt 10mg without prescription, including higher bodyweight people and women in highstatus social positions kneecap pain treatment generic 10mg maxalt with mastercard. Fisher is completing her master of science degree in social psychology at the University of Victoria sinus pain treatment natural buy maxalt online, Canada joint & pain treatment center order maxalt, under the supervision of Danu Anthony Stinson pain treatment for rheumatoid arthritis generic maxalt 10 mg mastercard. She studies the social and interpersonal experiences of female breadwinners and other successful women. Specifically, her research examines the stereotypes and impressions that are often formed and applied to female breadwinners and how these impressions may influence close relationship initiation and maintenance processes. The impact of daily stress on health and mood: Psychological and social resources as mediators. Selfesteem moderates neuroendocrine and psychological responses to interpersonal rejection. Selfesteem predicts affect, stress, social interaction, and symptom severity during daily life in patients with chronic illness. Disentangling the effects of low selfesteem and stressful events on depression: Findings from three longitudinal studies. Low and decreasing selfesteem during adolescence predict adult depression two decades later. Selfesteem and autonomic physiology: Parallels between selfesteem and cardiac vagal tone as buffers of threat. Selfregulation plays an important role in health promotion and illness prevention because many of the most common causes of death in the United States have a behavioral component that requires ongoing management. Poor health may result from failing to regulate smoking, drug and alcohol use, eating, exercise, and sexual activity, and many treatments require individuals to adhere to medical regimens or do exercises to manage pain. Other health problems may result from failing to regulate anger, anxiety, or stress. First, individuals have a standard or goal, imposed by themselves or by others, that they wish to obtain. Third, if their current state does not match the desired standard, they make changes to their behaviors, cognitions, or emotions aimed at moving closer to the standard. They may compare their current weight with that goal weight, find that they weigh too much, and therefore change their eating or exercise behavior in an effort to get closer to the goal weight. This conceptualization implies that selfregulation is conscious and deliberate, but that is not always the case. Selfregulation can also be automatic, operating through nonconscious processes, for example, when individuals engage in habitual behaviors, or when goals are primed by situational cues. In addition, the reallife context of selfregulation is considerably more complicated than implied by a simple feedback system. At any given moment, individuals may have multiple competing goals that they are aiming to fulfill simultaneously. Each goal must not only be attended to but also be protected and shielded from distractions, disturbances, and temptations, many of which come from other goals. Lenne and Traci Mann Regardless of the overall conceptualization, most concepts that pertain to the topic can be incorporated in one of two components of the selfregulation process: goal setting and goal striving. Goal Setting Goal setting is the process of deciding what goals to pursue and by what criteria to judge successful goal attainment. These goals can be as small as deciding to take the stairs instead of the elevator or as large as living a more healthy lifestyle. Individuals adopt health goals for different reasons, and the goals themselves have different characteristics that can affect whether goal pursuit is successful. Adopting Health Goals Most people want to live a long and happy life and do not need to be convinced that it is a good idea to take care of their health. However, some form of information is usually the first component to the adoption of a health goal. Accurate health information is not always easy to find in a landscape saturated with oftenconflicting accounts and competing incentives. It can be challenging to know what to believe, which can prevent people from forming health goals. According to theories of health behavior change, once people come to believe that certain behaviors carry health consequences, they are more likely to set goals, particularly if they believe they have the ability to control these behaviors and the behaviors align with what society and significant others deems appropriate (Ajzen, 1991). Goal systems theory makes predictions about the adoption and successful completion of a goal by accounting for how other goals compete with or support each other (Kruglanski et al. According to this perspective, goals can be interrelated such that many goals are associated with a common means (multifinal), or a single goal can be achieved through many means (equifinal). The theory postulates that the more goals are interconnected, the stronger motivational value they carry and the more likely people are to adopt and accomplish them. Goal Characteristics Despite the desire to live a healthy life, people struggle to set goals that will last long enough to make a difference in their health and wellbeing. Certain characteristics of goals have been shown to have meaningful implications for successful goal setting and pursuit. These features include motivational aspects of goals, the level of difficulty of the goal, and the type of goal. People can have goals that are approach oriented, which are focused on moving toward a positive end state, as well as goals that are avoidance oriented, which are focused on preventing a negative end state. Goal orientations are not merely linguistic differences, but they have consequences in terms of whether the goal is likely to be met and for whom. Overall, approachoriented goals tend to lead to more positive outcomes than avoidanceoriented goals (Elliott & Dweck, 1988). Approach goals may be SelfRegulation 625 more effective because it is harder to define success criteria for avoidance goals. There are also individual differences in motivational orientations, with people tending to be oriented toward either approach or avoidance goals, and these differences may have implications for goal pursuit. An important predictor of successful goal setting and pursuit, according to selfdetermination theory (Deci, Koestner, & Ryan, 1999), is whether a person perceives that they have autonomous control over the decision to change their behavior. In fact, social psychologists as early as Lewin (1935) have proposed that selfimposed goals are more motivating than goals imposed by others. Evidence for the importance of selfset goals in the health domain is mixed, however. But other research has found similar outcomes for patient and provider set goals (Alexy, 1985), as well as employee and employer set goals (Locke & Latham, 1990). Goals imposed by others may be less motivating because this undermines the intrinsic value of the goal (Deci et al. Metaanalytic evidence indicates that extrinsic rewards reduce intrinsic motivation (Deci et al. In situations where people lack internal motivation, however, extrinsic motivation may be an effective motivator, such as when external reinforcements are added to employee health promotion programs. Having recognized the cost savings that come from investing in the longterm health of the workforce, many employers have adopted material incentive programs designed to encourage their employees to engage in healthy behaviors, such as exercise and smoking cessation. There is little empirical research on the effectiveness of such programs and what, if any, payment structures are the most effective. Some research suggests that successful goal pursuit requires that the goal is feasible, but other work has found that unrealistic goals may actually inspire goal pursuit (Linde, Jeffery, Finch, Ng, & Rothman, 2004). In support of this view, when the goal is highly desirable but unrealistic, there is evidence that people will take actions to better achieve the goal, instead of changing the goal itself. A person may set a goal to develop the knowledge and cooking skills required to eat a healthy diet. There is evidence that mastery goals lead to better outcomes than performance goals (Elliott & Dweck, 1988). For example, mastery goals lead to deeper processing, whereas performance goals trigger superficial processing (for a review, see Covington, 2000). Mastery goals have also been shown to bolster selfefficacy, increase amount of time spent on task, augment the belief that effort leads to success, and help lead to persistence in the face of obstacles, whereas performance goals have been found to undermine intrinsic motivation and increase avoidance of difficult tasks. While it is reasonable to believe that this distinction applies to health behavior, it has not often been applied. Goal Abandonment Goal abandonment is common and often happens soon after goal setting. People frequently abandon their goals when other goals compete for time and energy or when there are no 626 Richie L. Research tends to focus on ways to bolster goal persistence, but this is not always the most advantageous response. Goal abandonment is also advantageous when goals are beyond personal control, such as the case of those who strive toward the goal of having a "perfect" thin body. Goal Striving Goal striving encompasses all actions, either deliberate or automatic, to achieve goals. This involves not only carrying out actions that directly promote goal attainment but also protecting those goals from being disrupted by competing goals or temptations. Individuals use many strategies in goal striving, which can be loosely categorized into planning strategies, automatic strategies, cognitive strategies, and effortful inhibition. Planning Strategies Planning strategies involve making arrangements before one is in a situation in which goal directed behavior will be needed, so that either (a) temptation to engage in behavior counter to the goal can be avoided or (b) the individual is ready to meet the challenge when it occurs. By thinking ahead of time about potential obstacles that may arise, individuals can plan ways to overcome those obstacles. Mentally rehearsing or simulating a strategy ahead of time is also a form of planning. People may envision themselves engaging in each of the steps necessary to achieve their goal so that they know what to expect and are ready with the appropriate response when the time comes. This strategy has been found effective among students mentally simulating the process of studying and preparing for exams, compared with students imagining the outcome of successful studying (Pham & Taylor, 1999). Focusing on the process rather than the outcome is an important aspect of the strategy, as only a process focus will reveal potential obstacles and challenges that may be encountered. They can operate when individuals are not motivated to comply with their goals and when individuals do not have sufficient attentional resources to dedicate to carefully monitoring and altering their behavior. When goal striving is automated, individuals are less likely to consciously talk themselves out of engaging in the relevant goaldirected behavior and are less susceptible to interference from competing goals. Habits, once formed, operate automatically and can be an effective strategy for reaching a goal. Habits are formed when a behavior is paired with a particular environmental cue many times. After sufficient pairing, the behavior operates automatically whenever that environmental SelfRegulation 627 cue is present. An individual may put on their seat belt when they get into their car so often that this becomes a habit, and they eventually do it without giving it any conscious thought. Behaviors that only happen infrequently are less likely to become habits, as they do not have enough opportunities to be paired with a particular contextual cue. However, they may still be made automatic with the use of implementation intentions. Implementation intentions are ifthen plans that specify a particular action to perform in a particular situation, such as "If I am in the produce section of the store, then I will buy apples. This may be possible by changing which behavioral options are available or possible, or by changing how the options are presented. Using "nudge"type interventions, for example, keeps all options available but makes certain options more likely to be chosen, by, for example, making certain options more salient, closer, easier, more convenient, or cheaper. The fact that people have behaved based on responding to such changes is generally outside of their conscious awareness. There are many ways one might think about the same goal or obstacle, and these different construals affect whether an individual is likely to be successful at attaining the goal. For example, temporal construal theory (Trope & Liberman, 2003) postulates that distantfuture events are evaluated primarily in terms of their desirability, whereas nearfuture events are evaluated primarily in terms of their feasibility. When people set a goal, they tend to focus on desirable outcomes in the distant future, but during goal pursuit, these outcomes lose focus, challenges become more apparent, and persistence becomes more difficult, frequently leading to failure to achieve the goal. Individual differences in the extent to which people focus on proximal or distal goals influence goal attainment, with a more distal focus leading to better outcomes. Individuals can be induced to focus on the future by having them think about possible events that could occur, and this serves as an effective selfregulatory strategy. It should be noted, however, that there is also evidence for the reverse position and that focusing on the means to success rather than on the ends of success leads to more successful goal pursuit and attainment, particularly if the task is difficult. Differences in these perspectives may be explained by the reward value of goaldirected behavior. Individuals also think about temptations and obstacles differently when those challenges are abstract than when they are specific. Challenges that are more vague and abstract seem less daunting than challenges that are concrete and detailed. For example, when children were trained to think about a tempting marshmallow in an abstract way (as "fluffy clouds") instead of as a specific yummy treat, they were able to resist eating it for longer (Mischel, Shoda, & Rodriguez, 1989). Thinking about general categories of animals instead of specific animals led individuals in one study to think more abstractly, and they were more likely to successfully resist a tempting snack (Fujita & Han, 2009). Lenne and Traci Mann Effortful Inhibition of Impulses the final category of goal striving strategies is effortfully inhibiting an impulse that would interfere with goal pursuit, by fighting off or suppressing the counterproductive thoughts, feelings, or behaviors. This subset of selfregulation processes is sometimes specifically referred to as selfcontrol (although in many other cases, the terms selfcontrol and selfregulation are used interchangeably), willpower, or delaying gratification. Effortfully inhibiting an impulse is, by definition, not automatic, as it requires conscious effort, and therefore it is subject to derailment or interference when these resources-whether they are cognitive or motivational-are scarce (for further reading, see Inzlicht & Schmeichel, 2012). Dualprocess models suggest that impulsive behaviors may be automatically enacted when there are not sufficient cognitive resources to challenge them. For example, when cognitive resources are scarce, individuals may not notice that they are violating their standards or may not have the ability to consider another option for how to behave.

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Many studies investigating social support and health have focused on couples dealing with serious or chronic illnesses abdominal pain treatment guidelines order maxalt with mastercard, a useful context for capturing the practical and emotional support provided by close others pain treatment center colorado springs co buy generic maxalt pills. Social support increases patient adherence to medical regimens prescribed by physicians following an illness; the odds of adherence are more than twice as high among patients with greater levels of social support pain treatment in shingles cheap maxalt 10 mg amex. When distinguishing practical and emotional support pain studies and treatment journal proven 10 mg maxalt, studies indicate that the odds of adherence are more than three and a half times greater for patients receiving practical support pain treatment center of illinois new lenox purchase maxalt paypal. Psychosocial interventions with patients and their families designed to increase social support suggest a modestly positive though mixed effect of family involvement; overall evidence indicates that family involvement leads to decreases in depression and mortality (Martire pain treatment center of the bluegrass lexington ky purchase maxalt 10mg on-line, Lustig, Schulz, Miller, & Helgeson, 2004). Mixed findings regarding social support and illness may be due to variation in the match between desired and received support and the extent to which received or enacted support is perceived as support by the receiver. Intimate partners also strive to prevent future health problems by deliberating attempting to promote healthenhancing behaviors and inhibit healthcompromising behaviors. Social Control Like social support, social control can have a positive effect on partner health, but it can also impede health behavior change and have negative effects on partners and relationships. According to the dualeffects hypothesis of social control, deliberate attempts by close others to influence health behavior do sometimes improve health behavior but may also lead to psychological distress, including feelings of irritation, hostility, sadness, and guilt (Lewis & Close Relationships 21 Rook, 1999). Early research guided by this hypothesis, based on general measures of social control, reported mixed results and contributed, in part, to leading researchers to make a distinction between positive and negative social control. Subsequent studies clarified that negative social control (involving tactics such as disapproval, guilt induction, and pressuring) is much less likely to lead to health behavior change and more likely to lead to psychological distress. Negative social control is also much more likely to backfire-resulting in partners hiding behaviors and negatively affecting the relationship. Positive social control (involving tactics such as reinforcing behavior change, modeling, and persuasion) is more likely to positively influence behavior and less likely to lead to psychological or relationship distress. Further, positive social control may even lead to increases in wellbeing (Craddock, vanDellen, Novak, & Ranby, 2015). Researchers have examined the effects of bilateral attempts, such a discussing the issue with the spouse, versus unilateral attempts, such as throwing out unhealthy food, and the effects of direct attempts, such as trying to persuade a partner to make a change, versus indirect attempts, such as inducing guilt. Bilateral and direct attempts are more likely to be associated with health enhancing behavior compared with unilateral and indirect attempts, though the findings have been mixed (Lewis & Butterfield, 2007). Some evidence suggests that direct attempts do not affect partner behavior immediately, but do affect behavior over time. The differential effect of types of attempts can be accounted for, at least in part, by the emotions partners experience in response to social control attempts. Early findings that positive and negative aspects of social control are independent gave rise to the domainspecific model, which posits that positive social control is related to positive affect but not related to negative affect, whereas negative social control is related to negative affect but not positive affect; evidence for this model is mixed and a recent metaanalysis suggests that positive social control is positively related to positive affect and negatively related to negative affect. The same holds for negative social control, that is, that negative social control is positively related to negative affect and negatively related to positive affect (Craddock et al. According to the meditational model of social control, proposed by Tucker and colleagues, variance in behavioral response to social control strategies is significantly reduced when the affective response to attempts is accounted for, indicating that the way a partner feels about a social control attempt is at least partly responsible for how the partner responds behaviorally (Tucker & Anders, 2001). This model, which has been well supported across many studies, explains why the same attempt. Positive emotional responses to social control attempts are more likely to lead to behavior change, whereas negative emotional responses are more likely to backfire-engendering resistance and/or hiding of healthcompromising behavior. Preliminary evidence suggests that health behavior change is more likely when positive social control attempts elicit positive affect and predispose the partner to make the change. Further, reactance has a direct negative effect on the likelihood of making a health behavior change. This effect may be in the form of ignoring the attempts and/or hiding the unhealthy behavior (Logic, Okun, & Pugliese, 2009). Sullivan Cognitions and Readiness to Change Social support and social control are distinct concepts, but they are related to one another. Distinguishing between the two-and when an attempt might be construed as positive and negative-can be challenging, as the same type of attempt to influence health behavior may be considered supportive by one person and controlling by another. Initial evidence suggests that readiness to make a change causes changes in how an attempt is perceived and the emotional reaction to the attempt and that those perceptions and emotions affect how likely the individual will be to make a change. Perceptions of attempts as supportive and subsequent positive emotional responses lead to greater intentions to make a behavior change, and perceptions as controlling and subsequent negative emotional reactions lead to lower intentions to make a health behavior change. Predictors and Consequences of Using of Social Control Much of the research in the area of social control and health focuses on the recipients of control attempts, how they feel, and whether they respond behaviorally. In a seminal study, Butterfield and Lewis (2002) examined characteristics of the partner trying to influence the other (agent) and characteristics of the partner being influenced (target), as well as characteristics of the relationship and the situation to clarify predictors of social tactic use. In terms of consequences of attempts to influence partner behavior, agents experience more stress and more tense interactions when they use social control tactics, but less stress and more enjoyable marital interactions when they employ support tactics. Context the contextual model emphasizes the importance of including situational variables in models of social support and social control and understanding the process by which contextual variables affect partner influence on health behavior. The contextual variables that have received attention to date include relationship satisfaction, gender, ethnicity, personality, history of control attempts, and type of behavior. Close Relationships 23 All but the first two variables have received attention only very recently, and the information provided is based on only one or two studies. Relationship Satisfaction Relationship satisfaction may moderate the effect of social control on health behavior such that partners experiencing social control attempts are much more likely to benefit from those attempts when their relationship satisfaction is high. Partners who are less satisfied with their relationships are less likely to change their behavior in response to social control attempts, have lower levels of positive affect and higher levels of negative affect in response to partner control attempts, and are more likely to hide unhealthy behavior in response to positive and negative social control attempts. In contrast, couples high in satisfaction are much less likely to experience psychological distress and hide unhealthy behaviors only in response to negative social control. Finally, relationship length is positively associated with behavior change in dating relationships. It is important to note, however, that findings regarding relationship satisfaction are mixed, with some studies reporting no effect of relationship satisfaction. Gender Gender appears to be related to the receipt and provision of social control; men are more likely to be the recipients of social control, and women are more likely to attempt to control the health of their partners. There is also evidence of gender differences in affective reactions to and effectiveness of social control attempts. Attempts to influence health are more likely to lead to positive and negative affective responses for women compared with men. As with relationship satisfaction, it is important to note that findings regarding gender effects are mixed, with some studies reporting no gender differences in receipt/provision of social control or the affective reactions to and effectiveness of social control attempts. Gender may also interact with equity in affecting social control attempts, for example, husbands have been shown to use unilateral and positive tactics more frequently when their wives view the relationship as unequal. Ethnicity Few studies have examined ethnic differences in social support or social control of partner health behaviors. One study of dietary behavior in people with diabetes found that partner social support and social control were associated with good dietary behavior in Mexican Americans, but only social support was associated with good dietary behavior in nonHispanic whites. Personality Again, studies here are sparse, but there is evidence that partners who are high in neuroticism experience more social control attempts than partners lower in neuroticism. Further, those high in neuroticism have more negative affective responses to change attempts and are less likely to change their health behavior. Type of Behavior Partners use negative tactics less frequently when trying to initiate a healthenhancing behavior compared with when they are trying to terminate a healthcompromising behavior. Further, healthcompromising behaviors and behaviors with more severe consequences elicit more social control attempts by intimate partners compared with healthenhancing behaviors and behaviors with less serious consequences. Future Directions There are a number of avenues by which the understanding of the relationship between intimate relationships and health behavior can be further illuminated: the first is research on the buffering effect of social support and how it may vary based on type of stressors and characteristics of the situation, the support provider, and the recipient. The second is the continued examination of contextual variables and the role they play in the frameworks provided by major models in the field. Because there is so little work on contextual variables, replication is needed for variables presented here, and additional variables need to be examined. The third is further research on the characteristics of the partners, including readiness and motivation to change, as well as the attributions regarding control attempts and the affect they have on psychological wellbeing and health behavior change. Her current research focuses on support, control, and health behavior in intimate relationships. Social control in personal relationships: Impact on health behaviors and psychosocial distress. Interpersonal relationships and health: Social and clinical psychological mechanisms. Although the prospect of becoming pregnant and having a child is associated with joy and eager anticipation for many couples, it can be associated with sorrow and despair for couples who experience difficulties. Some couples experience infertility, or the inability to conceive after 12 months of regular sexual activity free of birth control. Miscarriage and neonatal loss occur when the embryo or fetus dies before it can live on its own. The term, miscarriage, is typically used when the loss occurs before the 20th week of gestation (sometimes 24th week of gestation in select studies). In contrast, the term neonatal loss (or stillbirth) is typically used when the loss occurs at or after the 20th week of gestation, including instances in which a fetus is carried to term but dies during childbirth. This article describes the phenomenology of, emotional consequences of, and interventions for infertility and perinatal loss. Primary infertility occurs when a woman has never conceived, and secondary infertility occurs when a woman had been previously pregnant, even if the pregnancy resulted in a loss. Although the definition of infertility presented earlier indicates that it is diagnosed after 12 months of trying unsuccessfully to conceive without using birth control, it is often diagnosed after 6 months of trying unsuccessfully to conceive in women over the age of 35. The rationale underlying the use of a different criterion for women the Wiley Encyclopedia of Health Psychology: Volume 3: Clinical Health Psychology and Behavioral Medicine, First Edition. Research shows that among women who have attempted to achieve pregnancy, the rate of infertility varies between 16 and 28%. Approximately 80% of infertility cases can be explained by female factors, male factors, or both, leaving the remaining 20% of cases unexplained by medical causes. Causes of female infertility include factors related to ovulation, the cervix or uterus, and/or the fallopian tubes. Uterine and cervical causes of infertility include fibroids, an abnormally shaped uterus, and cervical stenosis. Women who have endometriosis, a condition in which the uterine lining extends outside the uterus, can have difficulty conceiving because resultant scarring can block the fallopian tubes. Moreover, the fallopian tubes can also be blocked by pelvic inflammatory disease, which is an infection of the uterus and fallopian tubes caused by sexually transmitted infections. Some research demonstrates that anxiety and stress are associated with poorer outcomes in infertility treatment. It is common for people struggling with infertility to report a sense of failure, defectiveness, and incompetence, as well as jealousy of and isolation from others who seem to achieve parenthood easily. Although the prevalence of mental health diagnoses is not elevated in people who struggle with infertility, they often report elevated levels of emotional distress on selfreport inventories of depression, anxiety, and life satisfaction (Greil, Schmidt, & Peterson, 2016). Women tend to report higher levels of infertilityrelated depression, anxiety, and stress than do men. In contrast, people who are characterized by resilience, or the capacity to respond adaptively to negative life events, report comparatively lower levels of infertilityrelated stress, higher quality of life, and more adaptive coping strategies (Sexton, Byrd, & von Kluge, 2010). Over the past 30 years, technology has allowed for the development of sophisticated approaches to medically assisted reproduction. In developed countries, approximately 56% of people who struggle with infertility seek some form of medically assisted reproduction (Boivin, Bunting, Collins, & Nygren, 2007). Many people experience a great deal of stress when they undergo medically assisted reproduction interventions, as these interventions can be unpredictable, ambiguous, and time consuming. In many cases, treatment assumes a central focus in their lives, and it can be difficult to know when to discontinue treatment. Some research suggests that infertility treatment confers stress above and beyond that conferred by infertility itself (Greil, Lowry, McQuillan, & Shreffler, 2011). As might be expected, infertilityrelated emotional distress decreases with successful treatment, and it often persists when treatment is unsuccessful. In addition, infertility and infertility treatment can put great strain on the partner or marital relationship. However, a subset of couples who remain involuntarily childless report that their relationship strengthened because of the shared experience (Peterson, Pirritano, Block, & Schmidt, 2011). When women become pregnant through medically assisted reproduction technology, they view pregnancy as more stressful and report more anxiety than women who did not experience infertility. Moreover, women who became pregnant through infertility treatment report more emotional distress following a pregnancy loss than women who did not become pregnant through infertility treatment. However, there is no evidence that women whose children were born through infertility treatment parent any differently or report differing levels of parenting stress than women whose children were conceived naturally, although parents who had children using medically assisted reproduction technologies endorse stronger feelings toward their children and a high level of gratitude (Sundby, Schmidt, Heldaas, Bugge, & Tanbo, 2007). There are few longterm consequences of infertilityrelated emotional distress in couples who eventually have a successful pregnancy or who adopt children; however, emotional distress persists in a subset of people who remain involuntarily childless. Although the need for infertilityspecific mental health services for people experiencing infertility has been recognized, there is a paucity of research that has examined the efficacy of specific interventions for infertilityrelated emotional distress. In contrast, evidence is mixed regarding the degree to which mental health intervention targeting people struggling with infertility actually improves pregnancy rates. Miscarriage and Neonatal Loss Because the achievement of parenthood is an important developmental task for many adults, a loss can be devastating on many levels. According to perinatal loss experts David and Martha Diamond, In addition to the loss of the fetus or baby, which can be a devastating event in and of itself, there are lost opportunities for progress in adult development, for the repair of old wounds, and for the redefinition of relationships with others. Preexisting psychopathology can be exacerbated, and new disorders can be precipitated (Diamond & Diamond, 2016, p. Perinatal loss is a particularly difficult event for women to endure, given that they are already in a vulnerable state due to fluctuating hormones, shifting their identity to that of being a parent, and perhaps grappling with hurts from their own parentings of which they were reminded during their pregnancy. However, it is important not to underestimate the toll that perinatal loss takes on men as well. The overall incidence of miscarriage is between 15 and 20%, and it increases substantially with age, with as many as 75% of women experiencing a miscarriage after age 45 (Hemminki & Forssas, 1999). Most miscarriages occur in the first 12 weeks of gestation, which is why many people refrain from sharing news of the pregnancy until they have completed the first trimester. Many women are advised to simply allow the miscarriage to proceed naturally; however, in instances in which this does not occur, medical intervention may be necessary.