Problem-focused and emotion-focused coping strategies…

1.2 Stalking victimization

1.3.3 Coping with stalking

1.3.3.2 Problem-focused and emotion-focused coping strategies…

Lazarus and Folkman (1984) distinguished between two coping strategies, i.e. problem-focused coping (focusing on changing problematic aspects of stressful situations) and emotion-focused coping (focusing on managing emotional responses to stressful situations).

An often replicated finding is that emotion-focused coping predominates when stressful conditions are evaluated as resistant to change, while problem-focused coping predominates in stressful situations which are estimated as controllable by action, (Lazarus, 1993). Yet, this fit between coping strategy, stressor controllability and outcomes has achieved mixed support (Folkman & Moskowitz, 2004). Nonetheless, an interesting finding from a stalking point of view concerns the results of a recent meta-analysis (Clarke, 2006), which found that the relationship between active coping and health is different depending on the controllability of the stressor: active coping in response to controllable stressors was positively associated with psychosocial health, and negatively associated with health when used to manage uncontrollable stressors. It is worth noting that there is still an ongoing debate regarding whether emotional or problem-orientated coping is superior and how these strategies are related to well-being (Donellan, Hevey, Hickey & O’Neill, 2006). However, no clear consensus has been reached regarding which coping strategy is most effective in reducing stress and promoting health (Thoits, 1995), as the empirical findings regarding coping strategies and health have been somewhat contradictory (Clarke, 2006; Compas, Connor-Smith, Saltzman, Harding Thomsen & Wadsworth, 2001; Penley, Tomaka & Wiebe, 2002).

Apart from the division between problem-focused and emotion-focused coping emerging from coping theory, also other overlapping, though not conceptually identical categories, have been introduced, e.g. the division between approach and avoidance coping strategies (Lazarus, 1993). The aim of approach coping is to focus on the stressor by seeking

information and planning in order to resolve the stressor. Avoidance coping, by comparison, aims at avoiding the stressor and associated reactions by withdrawal, denial, disengagement (Littleton, Horsley, John & Nelson, 2007). Furthermore, one of the most robust findings across studies regarding coping and health has been the association between avoidance coping and distress.

Recent meta-analysis found a clear association between avoidance coping and distress regarding a variety of traumatic events, while no association between overall approach coping and distress was found (Littleton, et al., 2007). In line with the meta-analysis, trauma-specific avoidance coping was related to poorer health also among university students (Lawler, Ouimette & Dahlstedt, 2005) and in less improvement in PTSD symptoms among female crime victims, while an increase in cognitive restructuring, expressed emotion, and social support led to a decrease in PTSD symptoms (Gutner, Rizvi, Monson & Resick, 2006).

Similarly, passive coping (avoidance and self-blame) was associated to poorer psychological adjustment among female stalking victims (Kamphuis, Emmelkamp & Bartak, 2003) while both passive strategies (self-blame and rumination) and approach strategies (problem solving) were associated with higher symptom levels of depression, anxiety and PTSD (Kraaij, Arensman, Garnefski & Kremers, 2007). Kraaij et al. (2007) proposed that plans to solve a problem do not necessarily lead to action, which in turn may increase emotional distress.

Alternatively, it was suggested that using problem solving in a situation, which is difficult to control (i.e. stalking), might lead to increasing psychological symptoms.

Altogether, it seems that problem-focused strategies are expected to be more beneficial to health outcomes than emotion-focused strategies (Thoits, 1995), even if the study findings are contradictory. This emphasis was also noted in a review across 35 studies (de Ridder &

Schreurs, 2001) on coping interventions in response to chronic diseases. Across the interventions, problem-focused coping appeared to be slightly favored, even if both emotion-focused and problem-emotion-focused coping were promoted. Importantly, the review found the coping approach as a promising framework for intervention development, even if it was not possible to identify the most promising coping interventions, due to the wealth of intervention techniques and diseases (de Ridder & Schreurs, 2001). Recently, coping research and intervention development have searched for new directions and focused for example on reinterpretation of a stressful event in terms of finding meaning, growth or benefit, especially in response to traumatic events or chronic stress (Aldwin & Levenson, 2004; de Ridder, Greenen, Kuijer, Middentorp, 2008; Folkman & Moskowitz, 2004; Janoff-Bulman, 2004).

29 1.4 Violence victimization

1.4.1 The nature and prevalence of violence victimization

As mentioned in the preface of this thesis, the Finnish national crime victimization surveys, carried out between the years 1980-2006, have consistently shown the highest victimization rates for the youngest (15-24 years) age category (Sirén et al., 2007). In the 2003 survey, every fourth (24%) man and every sixth (16%) woman in the above mentioned age category reported exposure to violence or threats, while the figures for physical violence only were 14% for men and 10% for women (Siren et al., 2007; Sirén & Honkatukia, 2005). These results are in line with those reported in the United States (years 1976-2000), which also consistently show the highest violence victimization rates for the youngest age groups (younger than 25 years, Klaus & Rennison, 2002). Furthermore, the rates for violence victimization among United States university students show (based on US national crime victimization surveys during years 1995-2002) that male students were twice as likely to be victims of overall violence compared to female students (80 vs. 43 per 1000), the average annual rate for violent crime being 61 per 1000 students (Baum & Klaus, 2005). More specifically, in the previous 12 months 3.8 per 1000 students had been victims of rape, and 13.5 of aggravated assault, 38.4 of simple assault respectively. Male student were more likely to be victims of both simple and aggravated assault, while female students were more likely to be the victim of rape/sexual assault. College students were most often assaulted (both simple and aggravated assault) by strangers, except for rape/sexual assault where 80% of the victims reported knowing the offender. Furthermore, about 20% of the students had minor injuries, while 3% were seriously injured.

The nature, contexts, mechanisms and offenders of violence differ a great deal for men and women. Men are typically exposed to violence in public places by stranger offenders while women become victims of violence primarily within the home by a person known to them, often an intimate partner (Sundaram, Helweg, Laursen & Bjerregaard, 2004). Studies concerning college students’ experiences of violence have often been focusing on a specific type of victimization (e.g. dating violence, sexual violence, stalking) and carried out on female samples (e.g. Fisher, Cullen & Turner, 2000, 2002; Smith, White & Holland, 2003) which may lead to a tendency to overestimate the effect to the specific type of victimization studied (Gámez-Guadix & Straus, 2008). Moreover, a study including both female and male students, suggests that the proportion of male and female students is remarkably similar in

terms of physically assaulting a partner, both with respect to minor and severe assaults. An extensive International Dating Violence Study carried out in 32 nations (N=13601) showed that almost one third of both male and female university students reported having physically assaulted a dating partner in the previous 12 months (Straus, 2008). Furthermore, almost 7%

of the students had physically injured a dating partner in the previous 12 months at a median university of 31 universities when ranked by injury rates (Straus, 2004). Furthermore, victims of violence have often been exposed to multiple/repeated episodes and various types of violence (Green et al., 2000), which has recently received more research attention (see Finkelhor, Ormrod & Turner, 2007; Winkel, Blaauw, Sheridan & Baldry, 2003) and found to be highly prevalent also among university students (Romito & Grassi, 2007; Sabina & Straus, 2008; Scarpa, 2001).

1.4.2 Violence and health

The experience of a criminal victimization, whether it includes violence or not, has been claimed as one of the most stressful and potentially traumatizing human events (Green &

Pomeroy, 2007). Victimization is often followed with an attempt to adjust to various physical, psychological social, economical damage or loss (Green & Pomeroy, 2007). However, traumatic events, such as exposure to violence, do not only have physical and mental health effects, but also cognitive effects on people's fundamental assumptions/beliefs about the world (Janoff-Bulman, 1992). These various effects of violence victimization do not last for only days or weeks, but can leave many victims with significant long-term psychological distress (Green, Streeter & Pomeroy, 2005; Green & Pomeroy, 2007; Frieze, Hymer &

Greenberg, 1987). Yet, people differ in their adjustment and responses to traumatic events:

some people may recover from in a relatively short period of time while for others the recovery takes years (Janoff-Bulman, 1992).

The significant negative physical and mental health effects of violence are well documented and have been reported across samples and types of victimization (see e.g. Amar

& Gennaro, 2005; Coker et al., 2002; Porcerelli et al. 2003; Resnick, Acierno, & Kilpatrick, 1997). Many of these negative health effects have been combined with violence induced stress leading to an increased risk for psychological problems, such as post traumatic stress disorder, depression or anxiety (Resnick et al. 1997; Green & Roberts, 2008). Similar psychological problems along with somatization, aggression, injuries and problem alcohol use have been reported within the limited amount of research on negative health effects of violence among university students (e.g. Amar & Gennaro, 2005; Fisher et al., 2000, 2002;

Romito & Grassi, 2007; Scarpa, 1991;). Furthermore, violence victimization has been found to be associated with students' problem alcohol use (Romito & Grassi, 2007), as well as bi-directional associations have been reported (Thompson, Sims, Kingree & Windle, 2008).

Furthermore, the effects of violence have been shown to increase when male and female students experienced multiple forms of violence (Amar & Gennaro, 2005; Romito & Grassi, 2007). As a whole, studies concerning the health effects of violence victimization among male and female students are scarce, which is somewhat surprising especially in light of the national violence victimization statistics.

1.4.3 Victims of violence in health care settings

Perceived stress has been found to be associated with frequent health care usage (Báes et al., 1998; Gortmaker, Eckenrode & Gore, 1982), which seems reasonable in the light of studies on stress-related health problems, as outlined above. However, in addition to health problems, stress itself has been found to be associated with increased help-seeking behavior, e.g.

seeking medical help (Mechanic, 1978; Thessler, Mechanic & Dimond, 1976). However, research on victims’ use of health care services is contradictory. Many victims of violence do seek medical care and have higher healthcare usage (e.g. Hulme, 2000; Koss, Woodruff &

Koss, 1991; Walker et al., 1999) while others fail to obtain routine medical care and other positive health care behaviors (Acierno et al, 1997). Thus, although violence victimization is a major problem, it often goes underreported to the police or health care professionals, also among college students (e.g. Amar & Gennaro, 2005; Baum & Klaus, 2005; Carr, 2005;

Fisher et al., 2000). All in all, it is important that the link between victimization-related stress and its potential effects on health and health care usage is acknowledged in health care settings, as failure to detect e.g. PTSD may lead to chronic or comorbid health problems (Acierno et al., 1997; Swizer et al., 1999).

It has been suggested that victims of traumatic events are most apt to turn to primary health care services for help (Chrestman, Prins & Koss, 1996; Koss, Woodruff, Koss, 1990; Polusny et al. 2008), which puts primary health practitioners in a special position to assess and intervene with victims of violence through screening procedures, followed up with a more detailed assessment and intervention when indicated (Kilpatric, Resnick & Acierno, 1997;

Mazza, Dennerstein & Ryan, 1996; Mechanic, 2002). Despite this, issues related to identification of victims of violence have been overlooked in the health care setting (Acierno et al., 1997). At the same time, there has been a debate concerning the acceptability, effectiveness and importance of screening; i.e. screening has been both recommended and

questioned. The recent critique regarding screening stresses that implementation of screening programs in health care settings cannot be justified as a rule. The critique argues that little evidence exists for the effectiveness of screening, i.e. that it would, for example, result in decreased exposure to violence or in subsequent effective interventions or referrals (Ramsay, Richardson, Carter, Davidson & Feder, 2002; Pikarinen, Saaristo, Schei, Swahnberg &

Halmesmäki., 2007). On the other hand, the importance of identifying victims of violence in health care settings has been considered as important because the information might be extremely relevant to the assessment of the patient's health status and treatment (Acierno et al., 1997; Koss et al., 1990). Still, victims of violence do not readily identify themselves.

Common barriers for patients include safety concerns, fear of being offended or embarrassed by the health care provider, or that the health care provider had never asked (Gielen et al., 2000, Mazza, et al., 1996). However, even when expressing their fear and concern about the negative consequences of routine screening, most of the female patients agreed that routine screening would make it easier for abused women to get help and that they would be glad if someone showed interest (Gielen et al., 2000). Thus, positive case identification requires health care professionals to take more initiative (Acierno et al., 1997; Mazza et al., 1996).

Yet, there are barriers also among health care professionals, including a lack of education and experience regarding screening and interventions, being afraid of offending the patient, patient unwillingness to screening, and time limitations (D’Avolio et al., 2001; Erikson, Hill

& Siegel, 2001; Waalen, Goodwin, Spitz, Petersen & Saltzman, 2000).

1.5 Typologies and theoretical frames for stalking and violence

Several perspectives to understanding and explaining violent behavior and violence victimization have been proposed in the literature. From a criminal psychology and victimology perspective, victim and offender characteristics have been an important basis for empirical studies, theory testing and theory building. Moreover, the relationship of these two, i.e. victim-offender relationship, has emerged as one of the key characteristics in understanding violent behavior and victimization; typologies and frameworks have been based on this relationship. The victim-offender relationship also serves as a context for several forms of violence (e.g. dating-violence, sexual violence) and the relationship between the victim and the perpetrator is also a central notion in the WHO typology of violence. Next, theoretical perspectives on stalking and violence victimization are presented starting with

typologies and perspectives on stalking, continuing with a more general perspective focusing on the context of victimization focusing on routine activities, and ending with an overarching perspective on victimization from a stress and coping viewpoint.

1.5.1 Typologies as a form of theory building regarding the stalking phenomenon

Currently, stalking research is prominently grounded on empirical studies, and theoretical approaches to stalking are still in relatively early stages. The early stages of studying any complex phenomenon often start with trying to detect different types of the phenomenon. A typology can be seen as a pre-theoretical framework which can include dimensions that are relevant to explaining the phenomenon in question. There has been extensive research on typologies also regarding stalking. Moreover, research has tried to identify stalking typologies by focusing on the type of underlying psychopathology, the type of stalker-victim relationship or the source of primary motivation in order to explain the stalking phenomenon. Also combinations of these dimensions have been presented in different typologies (Spitzberg &

Cupach, 2007). Furthermore, identifying the types of stalking behavior has also been one of the main concerns of stalking behavior (see e.g. Sheridan & Davies, 2001). As a whole, typologies are considered essential for understanding the stalker, the course of stalking actions and underlying motivations also having important implications for assessing and managing the potential risks regarding stalking (Dressing et al., 2006; Mullen, et al. 2006).

However, typologies have also been criticized for not being definitive explanations or complete theories (Spitzberg & Cupach, 2007). Only a few actual theoretical perspectives have been proposed to explain the development of stalking behavior, i.e. attachment theory and relational goal pursuit theory. The attachment theory perspective on stalking focuses on the pathology of attachment; stalking has been suggested as a behavioral measure for attachment pathology. Relational pursuit theory, in turn, sees stalking as originating from the idea that people pursue relationships because they are desired goals (Meloy, 2007; Spitzberg

& Cupach, 2007). Recently, a neurobiological line of understanding stalking has also been introduced (Meloy & Fisher, 2005).

1.5.2 Routine activity perspective on victimization

Routine activity theory is one of the theoretical frameworks, which have been presented in order to understand victimization in general and why certain individuals, in this case college students, are at increased risk for violence victimization and stalking (Mustaine &

Tewksbury, 1999; Fisher, Cullen, Sloan & Lu, 1998; Fisher et al., 2002; Tewksbury &

Mustaine, 2003). According to routine activation theory (Cohen & Felson, 1979), crime is a result of the following conditions coming together in time and space: motivated/potential offenders, suitable targets, and absence of capable guardians. It focuses on the contextual activities (e.g. lifestyle characteristics, daily activities, personal behaviours and characteristics) that may increase the likelihood that people will come into contact with their perpetrators. The idea of routine activity theory is that when people move into the public domain their risk for victimization increases, i.e. certain victim characteristics and actions make them more accessible and vulnerable for potential offenders (Mustaine & Tewksbury, 1999; Fisher et al. 2002).

1.5.3 Stress and coping perspective on victimization

Literature on violence/criminal victimization has proposed a number of explanations for reactions to victimization of which many have focused on the stress of being victimized, yet differing in their suggestions regarding the source of stress (Frieze et al., 1987; Green &

Roberts, 2008). The stress and coping theory (Lazarus & Folkman, 1984) offers a broader model in understanding both stalking and violence victimization, the variety of reactions to victimization and victim responses to violence. According to the stress and coping theory, stress can be defined as the relationship between a person and the environment that the person appraises as exceeding his/her resources and risking his/her health. Within the above mentioned framework, the meaning of a stressful event is determined by a process named cognitive appraisal. The cognitive appraisal is divided into two major forms of appraisal:

primary and secondary appraisal. In primary appraisal the person evaluates whether the specific situation involves some kind of harm, threat or challenge. If the primary appraisal leads to the conclusion that a situation is stressful, the person evaluates the available resources in secondary appraisal, i.e. what he/she can do to cope in the situation to avoid harm or improve the situation (Folkman 1984; Folkman, Lazarus, Gruen & DeLongis, 1986).

Victimization (including stalking) is likely to be perceived as stressful, because it holds a strong potential to exceed a persons resources, and may thereby endanger a person's health and well-being. When violence is perceived as stressful, secondary appraisal, the evaluation of how to cope with the situation comes in. Coping in turn is defined as cognitions and behaviors that people use to manage the internal and external demands of situations appraised as being stressful (Lazarus & Folkman, 1984; Folkman 1984).

1.5.4 World assumption perspective on victimization

Several coping theorists have suggested that the role of meaning is a critical aspect in how people appraise and cope with stressful events (Lazarus, 1993; Park & Folkman, 1997) and that meaning making may be used especially when coping with traumatic situations (Aldwin, 2007). Park and Folkman (1997) proposed a model where concept of situational and global meaning into the stress and coping frame has been integrated. They stated that the concept of meaning enriches stress and coping theory by making more explicit the role of beliefs/assumptions and the functions of meaning in how people appraise and cope in stressful events. The present thesis perspective concentrates on global meaning (i.e. basic beliefs and assumptions of the world) in the light of Janoff-Bulman's (2002) world assumption model.

The world assumption framework propose that distress caused by victimization is largely due to the challenging or shattering of basic beliefs, i.e. assumptions we hold about ourselves and the world. Victimization calls a person's view of the world and him/herself seriously into question and the assumptions that have enabled him/her to function effectively are no longer able to serve as guides in life. It is this state of disequilibrium that often results in intense stress and anxiety. Moreover, coping with victimization is seen to be coming into terms with these shattered assumptions, i.e. to work towards rebuilding the conceptual system of the world so that the victim would be able to function effectively again. There appear to be three

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