Anxiety, Stress, & Coping

An International Journal

ISSN: 1061-5806 (Print) 1477-2205 (Online) Journal homepage: https://www.tandfonline.com/loi/gasc20

Leveraging the experience of stressors: the role of

adaptive systematic self-reflection

Monique F. Crane, Maria Kangas, Eyal Karin, Ben Searle & Diana Chen

To cite this article: Monique F. Crane, Maria Kangas, Eyal Karin, Ben Searle & Diana Chen
(2020): Leveraging the experience of stressors: the role of adaptive systematic self-reflection,
Anxiety, Stress, & Coping, DOI: 10.1080/10615806.2020.1732359

To link to this article: https://doi.org/10.1080/10615806.2020.1732359

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ANXIETY, STRESS, & COPING
https://doi.org/10.1080/10615806.2020.1732359

Leveraging the experience of stressors: the role of adaptive

systematic self-reflection
a b
Monique F. Crane , Maria Kangas , Eyal Karinc, Ben Searle a
and Diana Chena
a
Department of Psychology, Macquarie University, North Ryde, Australia; bDepartment of Psychology, Centre for
Emotional HealthMacquarie University, North Ryde, Australia; cDepartment of Psychology, eCentre Clinic, Macquarie
University, North Ryde, Australia

ABSTRACT ARTICLE HISTORY

Background: To date, little attention has been paid to the processes by Received 28 May 2019
which resilience is developed, and how the likelihood of a resilient Revised 16 February 2020
outcome may be enhanced over the life course. Accepted 17 February 2020
Objective: This study investigates the potential for adaptive systematic
KEYWORDS
self-reflection to support the development of situation resilience via Resilience; affect; wellbeing;
stressor exposure. randomized controlled trial;
Design: An experimental randomized controlled design was conducted. salivary cortisol
Participants were randomly assigned to either the Systematic Self-
reflection intervention (n = 61) or disengagement control group (n = 60).
Method: Participants were 121 university students (female = 68%) ranging
in age from 18 to 56 years. Participants experienced two psychosocial
stressors and completed a baseline survey, a second survey occurred
post-stressor 1, and a third post-stressor 2. Salivary cortisol was taken pre
stressor 2, immediately post stressor 2, and at 10 min intervals until 30 min.
Results: The intervention was associated with greater reductions in negative
affect, than a disengagement control task, and prevented the continued
reduction in positive affect observed in the disengagement control
condition. Moreover, the intervention promoted a steeper cortisol recovery
trajectory, than the control condition for those with higher pre-stressor cortisol.
Conclusions: This study provides further evidence that certain self-reflective
practices may be involved in the development of resilience from stressor
exposure.

How the capacity for resilience is developed remains empirically underexplored. Resilience is defined
as an emergent outcome characterized by “the maintenance or quick recovery of mental health
during and after exposure to significant stressors” (Kalisch et al., 2017, p. 786). Growing empirical
work suggests a beneficial role for adversity, evidenced across a range of populations (e.g., Lindberg,
Wincent, & Örtqvist, 2013; Seery, Holman, & Silver, 2010) and everyday stressors relating to work or
study (Crane & Searle, 2016). However, exposure to stressors alone is insufficient for the development
of resilience. Yet, the mechanisms by which resilience is developed from exposure to stressors is an
issue of ongoing debate. The Metatheory of Resilience and Resiliency (Richardson, 2002) suggests
that resilient re-integration is triggered by encounters with disruptive life events (e.g., losing a job,
death of a loved one) that require the application of coping skills and resources (e.g., social resources,
creative problem solving) to overcome the disruption (Richardson, 2002). Resilient re-integration is
proposed to occur via an introspective process that allows the identification and nurturing of resilient
qualities, but the introspective process by which resilient transformations occur is not defined.

CONTACT Monique F. Crane monique.crane@mq.edu.au

Supplemental data for this article can be accessed at https://doi.org/10.1080/10615806.2020.1732359
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 M. F. CRANE ET AL.

The Systematic Self-reflection (SSR) model of resilience-strengthening proposes that the develop-
ment of resilient capacities is an experiential learning process where stressors are scaffolded in
five specific adaptive self-reflective practices necessary for the emergence of resilience from everyday
stressors (Crane, Searle, Kangas, & Nwiran, 2019a).

The systematic self-reflection (SSR) model

The five adaptive self-reflective practices (see Crane et al., 2019a for an overview) are drawn from
work highlighting the use of systematic reflection on both current and past success and failure for
the broadening of behavioral options and improving performance outcomes in the workplace
(Ellis, Carette, Anseel, & Lievens, 2014) and reflective practices applied in the educational and pro-
fessional settings (e.g., Bennett-Levy & Padesky, 2014). Emergent evidence suggests that training
adaptive self-reflection may be an alternative or complement to the currently dominant cognitive–
behavioral skills training approaches. A group-randomized controlled trial employing written self-
reflection amongst military Officer Cadets demonstrated reduced anxiety and depression symptoms,
at three-month follow-up, compared to the control group receiving cognitive–behavioral skills train-
ing (Crane et al., 2019b). The effects of the intervention on key outcomes were partially mediated by
lowered frequency of perceived stressors. Crane et al. (2019b) suggested that the self-reflection
process potentially encouraged the reappraisal of stressors as opportunities for growth and
lowered threat, there by decreasing perceived stressor frequency. However, the mediating role of
threat or challenge reappraisals were not directly assessed.
Also plausible is that other resilience capacities specified in the SSR model (such as coping self-
efficacy) mediate this relationship. The reflective process is proposed to have a series of outcomes,
which promote the capacity for resilience, that change with time course and opportunity (Crane
et al., 2019a). In the short term, self-reflection is proposed to promote more adaptive stressor apprai-
sal and reappraisal. Primary (i.e., what is at stake) and secondary (i.e., capacity to cope) appraisal and
reappraisal processes are thought to be responsible for the emergence of adaptive coping and
emotion regulatory practices that may increase or decrease the likelihood of resilience.
In accordance with the SSR model, the reflector is encouraged to consider how the stressors could
be interpreted as an opportunity for growth, rather than loss (i.e., primary appraisal). This is projected
to encourage more adaptive reappraisals (i.e., deliberate cognitive re-evaluation of stressor proper-
ties) and future appraisal (i.e., initial cognitive appraisal of a stressor) depending on context. This prac-
tice may encourage an increase in challenge appraisals (i.e., stressor is viewed as an opportunity for
personal growth). Challenge appraisals have been shown to increase the tendency to experience
positive affective states (Searle & Auton, 2014). Moreover, a less threatening appraisal of the stressor
may also emerge, resulting in lower negative arousal emotions (e.g., fear, anxiety) and perceived
stress (see Moors, Ellsworth, Scherer, & Frijda, 2013 for review). Studies have shown that, threat or
loss appraisals tend to relate to the experience of negative affective states, rather than positive
affective states (Searle & Auton, 2014; Tuckey, Searle, Boyd, Winefield, & Winefield, 2015).
Coping self-efficacy is a form of secondary appraisal and relates to the belief that one has the
capacity to deal with prospective demands and barriers (Bandura, 1982; Schwarzer, 2000). Coping
self-efficacy is related to important psychological outcomes (e.g., Benight & Harper, 2002) and the
application of effective coping strategies (Jensen, Turner, & Romano, 1991). The self-reflective
process is intended to highlight personal strengths for managing the stressor, and reforms in their
coping and emotion regulatory strategies and resources to redress any limitations. Individuals are
proposed to emerge from self-reflection with a renewed coping self-efficacy even from events
that on their private assessment were not successfully handled (Crane et al., 2019a). As individual’s
encounter stressors, the self-reflective process helps to reshape their vision of future coping. In
sum, the reflective process is proposed to yield more adaptive stress appraisals, that in turn lead
to better short-term outcomes (e.g., positive affect), as well as in the longer-term (e.g., adaptations
of coping strategies, developing more supportive relationships).
 ANXIETY, STRESS, & COPING 3

Effects of self-reflection on cortisol reactivity

Healthy cortisol responses are evidenced by an initial moderate elevation in cortisol followed by a
steep recovery trajectory (e.g., Galatzer-Levy et al., 2014; Kunz-Ebrecht, Mohamed-Ali, Feldman,
Kirschbaum, & Steptoe, 2003). Previous work demonstrates that healthy cortisol responsivity predicts
a greater likelihood of downstream resilience, whereas a blunted cortisol response or slow recovery
trajectory predicted a greater likelihood of chronic increasing distress (Galatzer-Levy et al., 2014).
Studies demonstrate that chronic-high or blunted HPA activation (hypocortisolism), is implicated
in mental ill-health (Björntorp, 2001; Gold, Drevets, & Charney, 2002; Holsboer, 2000; McEwen,
Gray, & Nasca, 2015 for review). Thus, both high and low levels of cortisol without adaptation
seem to be associated with adverse outcomes (Kunz-Ebrecht et al., 2003). Elaborative cognitive pro-
cesses are likely important determinates of cortisol regulation (Lam, Dickerson, Zoccola, & Zaldivar,
2009). In particular, Henry (1993) suggests that the repression of emotional information and stressor
disengagement is involved in a down-regulation of the cortisol response. In contrast, active engage-
ment with the stressor is likely to result in an elevated pattern of cortisol responsivity. Consistent with
this perspective, previous work has shown that slow disengagement of attention from a masked
threatening stimulus (indicating greater early automatic processing) predicted elevated acute cortisol
reactivity to a stressor, compared to more rapid early disengagement (Ellenbogen, Carson, & Pishva,
2010; Ellenbogen, Schwartzman, Stewart, & Walker, 2006). Work by Crum, Salovey, and Achor (2013)
provided some initial evidence, albeit not statistically significant, that the way stress is perceived
(stress-as-enhancing vs. stress-as-debilitating) may result in adaptive versus maladaptive cortisol
reactivity to psychosocial stressors. Collectively, this prior research suggests that processes relating
to both attending to the stressor and the way the stressor is perceived has implications for
healthy cortisol responsivity. In this study, we explore the effects of a stressor engagement interven-
tion, specifically, adaptive self-reflection, compared to stressor disengagement (control) on cortisol
recovery trajectories post-stressor event. We tentatively suggest that adaptive self-reflection may
potentiate engagement with stressors that highlights their enhancing role, thereby promoting an
adaptive pattern of cortisol responsivity characterized by a cortisol response to the stressor and
steep recovery trajectory.

The present study

In this study, we explore whether post-stressor self-reflection, on a psychosocial stressor experience,
results in adaptive short-term outcomes when the same type of stressor is re-experienced. The
present study extends previous work in several ways. In accordance with the SSR model, the first
aim was to investigate the potential for adaptive self-reflection as an intervention promoting situa-
tional resilience to an everyday stressor, in a controlled experimental context with a standardized
stressor experience. Using an experimental randomized controlled trial design, participants either
engaged in the intervention consisting of a self-reflective interview where they reflected on the stres-
sor just experienced or were involved in a stressor disengagement task, to control for the passage of
time and promote disengagement from the stressor experience. The primary outcomes, negative
affect, positive affect, and task-related stress were examined and the following predictions were
made:
H1: Condition would be related to a significant change in (a) negative affect and (b) perceived task-
related stress over time. The intervention would demonstrate a decline in negative affect and per-
ceived task-related stress post-intervention, whereas the disengagement control would demonstrate
a non-significant change in these outcomes.
H2: Condition would be related to a significant change in positive affect over time. The interven-
tion would demonstrate an increase in positive affect post-intervention; however, the disengage-
ment control would demonstrate no change.
4 M. F. CRANE ET AL.

The second aim was to investigate the role of primary and secondary appraisals as a mechanism
through which adaptive self-reflection is proposed to contribute to resilience.
H3: Threat reappraisal would mediate the relationships between Condition and (a) negative affect
and (b) perceived task-related stress. The intervention would demonstrate lower threat reappraisal,
which in turn would be related to lower negative affect and task-related stress.
H4: Challenge reappraisal would mediate the relationship between Condition and positive affect.
The intervention would demonstrate greater challenge reappraisal, which would be related to greater
positive affect.
H5: Coping self-efficacy would mediate the relationships between Condition (Intervention/
Control) and (a) negative affect, (b) positive affect, and (c) perceived task-related stress. The interven-
tion would result in more coping self-efficacy, which in turn would be related to higher positive affect,
but lower negative affect and perceived task-related stress.
The third aim of this study is to understand how cognitively processing stressors in a reflective way
relates to the cortisol recovery trajectory.
H6: A two-way interaction between Time and Condition was expected in the prediction of cortisol
recovery. Participants in the intervention would experience a higher initial cortisol level (T2c) that
would return to basal-levels more rapidly than participants in the stressor disengagement control.
By contrast, those in the disengagement control would experience a flatter recovery trajectory.

Method
Participants and design
An experimental randomized controlled design was conducted to explore the effectiveness of the
SSR intervention, compared to a disengagement control. A disengagement control was used
because self-reflection as a tool for enhancing resilience is a newly developed intervention with
only a single trial (Crane et al., 2019b); hence, there is a need to test the effectiveness of the SSR inter-
vention against a no-intervention control condition. The study was approved by the Macquarie Uni-
versity Human Research Ethics Committee (protocol number: 5201700296).
One-hundred and thirty participants completed the initial survey prior to their appointment, but
nine participants did not arrive due to illness. These nine participants were excluded from all further
analyses. The final analyses were based on 121 participants (female = 68% and male = 32%) consist-
ing of undergraduate psychology students (n = 92; 76%) and students from the general university
population (n = 29; 24%) ranging in age from 18 to 56 years (M = 20.94; SD = 5.37). Participants
either received course credit or paid $30 for their time.

Procedure
Three to four days prior to the scheduled individual research session, all participants received the
Time 1 (T1) survey to complete. As part of a screening procedure, participants were asked whether
they were currently diagnosed with a mental health condition and these participants were excluded
to minimize potential risk to wellbeing in line with institutional ethical requirements. Participants who
were pregnant or on medication were also excluded due to the effects on cortisol assays.
Prior to arrival, participants were randomly allocated via coin toss to either the self-reflection inter-
vention (n = 61) or disengagement control (n = 60). On arrival, participants were orientated to the
experimental context. An illustration of the experimental study is provided in Figure S1. After orien-
tation, participants were asked to relax by immersing themselves in a nature image until asked by the
experimenter to stop (three minutes).
Following, participants were moved to a second room with a video camera where they were
exposed to an initial public speaking stressor. There were two public speaking stressors as part of
the procedure. The second stressor needed to be more stressful than the first to reduce potential
 ANXIETY, STRESS, & COPING 5

habituation. Thus, the first public speaking stressor involved five-minutes describing oneself whereas
the second stressor was a job-interview scenario. The two observers in the room were instructed to
provide no verbal or non-verbal feedback to the participant during their speech. Upon arrival to the
room, the experimenter read the following instructions to the participant:
This is the speech preparation portion of the task; you are to mentally prepare a five-minute speech describing
yourself. Your speech will be videotaped and reviewed by a panel of judges trained in public speaking. You have
three minutes to prepare and your time begins now.

When the three-minutes elapsed, the participant was then asked to stand in front of the camera
and deliver their five-minute speech.
Following the stressor task, the participant was escorted back into the initial room where they
completed the second set of self-report measures (T2) on a computer. Participants allocated to the
self-reflection condition then engaged in a 50-minute face-to-face guided self-reflection interview
(description below). This involved the experimenter asking questions related to the initial public
speaking stressor. Participants assigned to the control condition were asked to watch a National Geo-
graphic documentary about hummingbirds titled “Hummingbirds: Jewelled Messengers” streamed
from YouTube (Reddish, 2012) for the same time. This documentary was selected because it was unli-
kely to increase negative or positive arousal emotions (e.g., fear, excitement).
Participants then engaged in an assessment of auditory startle habituation. The startle response
test was part of a nested study exploring the relationship between auditory startle and self-reported
resilience. The detail of these findings is not reported in the present paper. Participants were then
required to relax for five minutes before a pre-stressor saliva cortisol sample was then taken. Cortisol
sample collection occurred after 2pm to avoid the heightened morning cortisol response to awaken-
ing (Bailey & Heitkemper, 1991; Smyth et al., 1998). Participants were asked to chew on a roll-shaped
saliva collector (Salivettes, Sardstedt, Germany) until the collector was saturated with saliva (60 s). The
saliva collector was then placed in a collection tube and frozen at −80 degrees Celsius until analysis.
The participants then returned to the stressor room with the video camera. Again, participants
experienced a public speaking stressor, but this time it involved an interview scenario and declarative
memory task. Initially, they were provided with a list of 24 nouns (e.g., mother, clock) and instructed
to learn the list within three minutes. Participants where then given three minutes to prepare a five-
minute speech explaining why they would be the best candidate for their ideal job. When the three-
minutes expired, the participants were asked to stand in front of the camera and deliver their speech.
After the speech, participants were asked to write down all words beginning with the letters “MO” (of
a possible 10 words) from the previous list in three minutes (Kirschbaum, Wolf, May, Wippich, & Hell-
hammer, 1996).
A second saliva sample was then collected immediately after the declarative memory task. The
third, fourth and fifth saliva samples were collected every ten minutes. After the second saliva
sample, participants completed a final survey (T3). Participants were debriefed about the research
aims and given the opportunity to withdraw consent, none did.

Overview of systematic self-reflection interview

The 50-minute interview session required participants to respond to a key set of questions related to
each facet of self-reflection: Self-awareness, Triggers, (re)Appraisal, Review, and Future-focus – sum-
marized by the acronym STAR-Future. Self-awareness involves inviting participants to become more
self-aware of their own personal goals, values, and their unique stress response. Triggers involves the
identification of what it is about particular situations that leads to one’s stress or distress (e.g., per-
ceived judgement). Reappraisal is about assisting participants to identify how a stressor may be a
positive learning experience or opportunity for growth. Review involves reviewing the effectiveness
of the strategies that were used to cope with the demand in the context of one’s personal goals and
6 M. F. CRANE ET AL.

values. Finally, Future-focus asks participants to consider how they might adapt their coping response
in the future.

Outcome measures
Positive and negative affect
Positive and negative arousal states were measured using the Positive and Negative Affect Scale
(PANAS; Watson, Clark, & Tellegen, 1988). Participants indicated the degree to which they experi-
enced a series of ten positive affective states (e.g., proud) and ten negative affective states (e.g.,
guilty) on a scale from 1 (not at all) to 5 (very much) in the past day at T1 and during the public speak-
ing task at T2 and T3. Internal reliability at all three time points for both positive and negative affect
scales was satisfactory ranging from .76 to .96.

Perceived task-related stress

Perceived task-related stress was based on the global measure of perceived stress (Cohen, Kamarck, &
Mermelstein, 1983). The scale was reduced to seven items reflecting some of the core themes in the
original scale, such as a sense of control, effectiveness in the task, or feelings of stress (e.g., “To what
extent did you feel in control during the task?”, “To what extent was the public speaking task stress-
ful?”). Participants responded on a scale from 1(Not at all) to 5(A great deal). This scale was only
measured at T2 and T3 as items referred to the speech stressor. Reliability was satisfactory at both
time points α T2 = .91 and points α T3 = .91.

Salivary cortisol
The presence of cortisol in saliva provides a snapshot of the activity of the hypothalamic–pituitary–
adrenal (HPA) axis. Pre-stressor cortisol was measured prior to the participants being told they were
going to perform a second speech (pre-stressor cortisol) and then again immediately post the stres-
sor cessation (T2c), and every 10 min for three more times (T3c, T4c, T5c). Pre-stressor cortisol was
measured post-intervention, but prior to the second-stressor, because we aimed to determine
whether the intervention influenced pre-stressor cortisol levels. Moreover, we had concerns about
participant stress related to the uncertainty of the experimental context. Consultation with a stress
physiologist with significant experience in auditory startle also suggested that the auditory startle
test was highly unlikely to affect cortisol.

Mediator variables
Challenge and threat appraisal
The Appraisal of Life Events (ALE) Scale (Ferguson, Matthews, & Cox, 1999) was used to examine the
individual’s cognitive appraisal of their surroundings over three time points. The ALE uses emotions
to infer how an individual’s surroundings have been appraised (Smith & Ellsworth, 1985). Participants
indicated the extent to which various adjectives best described their situation using a 6-point scale
ranging from 0 (Not at all) to 6 (Very much so). The scale includes four challenge emotions (e.g., enjoy-
able, challenging, informative) and four threat-related emotions (e.g., threatening, fearful, worrying,
hostile). Reliability was satisfactory at both time points for both the challenge and threat descriptors
ranging from α = .74 to .89.

Coping efficacy
The five-item coping self-efficacy measure was based on a scale for examining the coping self-
efficacy of head masters (Lindberg et al., 2013). Modifications to the scale were made to capture
coping self-efficacy, for example, “I can handle the challenges that are attributed to being a headmas-
ter,” was changed to “I can handle the challenges that might arise in the future”. Coping self-efficacy
was measured at T1 and T3 and internal reliability was satisfactory at both time points αT1 = .93 and
 ANXIETY, STRESS, & COPING 7

αT3 = .93. In order to check the construct validity of the coping self-efficacy measure, a confirmatory
factor analysis at both time points demonstrated satisfactory fit based on conventional model fit
indices (Time 1: RMSEA = .08; CFI = .99; TLI = .98; SRMR = .01 and Time 2: RMSEA = .04; CFI = .99; TLI
= .99; SRMR = .006). The latent factors demonstrated a strong relationship across time (r = .65, p
< .001). Importantly, values of T1 coping self-efficacy were predictably related to both T3 challenge
(b = 1.93, p = .004) and threat (b = −1.94, p = .003) appraisal when accounting for T1 corresponding
appraisals and T3 coping efficacy.

Baseline control measures

Trait self-reflection
The trait self-reflection scale was adapted from the self-reflection sub-scale of the ruminative
responses scale (Treynor, Gonzalez, & Nolen-Hoeksema, 2003) to measure trait levels of self-reflection
at T1. Trait self-reflection was measured specifically to ensure that there were baseline differences in
self-reflection between conditions that may account for findings. The scale includes five items that
were modified slightly to remove references to mental ill-health (e.g., “depressed” was changed to
“unhappy”), but most items were not modified (e.g., “Analyze recent events to try to understand
why you are unhappy”). Participants were asked to respond to these statements on a 5-point scale
from 1(Never) to 5(Always). Internal reliability was satisfactory αT1 = .87.

Analytic strategy and power

To estimate sample size we identified effects that were previously observed using a similar interven-
tion (e.g., self-reflection), and similar measurement scales (i.e., perceived stressor frequency, anxiety
symptoms). Specifically, Crane et al. (2019b) observed minimal between group effects at longer-term
follow-up ranging from .46 to .69 when comparing a self-reflection group to an active control con-
dition. Thus, to detect a minimal effect we assumed an effect size of d = .46, significance level of α
= 0.05, and power level of .80. The power analysis was conducted using optimal design (v.3; Rauden-
bush, Spybrook, Congdon, Liu, & Martinez, 2011) and determined that a sample of 60 per condition
was necessary to detect between condition effects following the intervention.
One univariate outlier was removed because the participant indicated very low z-scores on two
self-report measures (z < −3.5). Moreover, a single multivariate outlier was identified in all GEE
models and was removed from all self-report analyses. The longitudinal changes between the con-
ditions were tested with the use of generalized estimation equation (GEE) models that emphasizes
the measurement of group change over time (Hubbard et al., 2010). Control variables included sex
and age. Examination of histograms indicated the negative affect, positive affect, threat appraisal
emotions, and emotional interference with performance were all positively skewed and modeled
using a gamma scale with a log-link function. Coping efficacy was negatively skewed, therefore
this scale was initially reverse scored and then a gamma scale was applied.
For the salivary cortisol analysis, multi-level modeling was used to account for the non-indepen-
dence of data. A two-level multi-level model with random intercepts and slopes for the linear
expression of time at Level 2 (individual) was used to assess change in saliva cortisol occurring
during the post-stressor period. Condition was included as a between-person predictor in the
model. Pre-stressor cortisol level was included in the model as it is regarded as an important part
of the endocrine response to the experimental setting that varies between individuals (Wüst, Feder-
enko, van Rossum, Koper, & Hellhammer, 2005). The model included fixed-effects for pre-stressor cor-
tisol (T1c), Condition, Time, their two-way interactions, and three-way interaction were included in a
model as predictors of the rate of cortisol change (T2c-T5c). A single outlier for pre-stressor cortisol
was identified, demonstrating unusually elevated cortisol for that time of day post-awakening.
Given that pre-stressor cortisol sampling commenced at either 2:30pm (approx. 7 h post-awakening)
or 6pm (approx. 10 h post-awakening) those in the bottom 5% typically have a cortisol range
8 M. F. CRANE ET AL.

between 0.027 and 0.069 µ/dL and those in the upper 95% have a range of between 0.25 and 0.35 µ/
dL based on 85 adult day profiles provided by Stratech Scientific APAC Pty Ltd, Sydney, Australia.
Most of the participants in our study demonstrated cortisol levels within those ranges with the excep-
tion of a single case with pre-stressor cortisol of .77. Thus, this case was removed from the cortisol
analysis.
Mediation models were tested using the PROCESS Macro (version 3.3) to test for both direct and
indirect effects (Hayes, 2013). The current analysis employed PROCESS Model 4 (parallel mediation).
Indirect effects were analyzed using bootstrap analyses with 1000 bootstrap samples and 95% bias-
corrected confidence intervals. All analyses were performed in IBM SPSS (v. 25).

Results
Preliminary analyses
Analyses were performed to investigate possible differences at baseline between participants in the
intervention and control condition for all outcome measures, sex, age, trait self-reflection, and pre-
stressor saliva cortisol. There were no statistically significant baseline and pre-stressor differences
in these variables (see supplementary Table S1). Correlations were also performed between the T3
self-report measures and the levels of salivary cortisol for both the intervention and control condition
(Supplementary Table S2).

Primary outcomes
Negative affect
The main effect for age was significant (Wald = 6.22, B = −.009, p = .013) whereby being older was
associated with less reported negative affect. There was a significant main effect for both Time
and Condition (Wald = 16.66, p < .001 and Wald = 3.97, p = .046, respectively). The main effects
were qualified by the predicted (H1a) interaction between Time and Condition (Wald = 12.42, p
= .002; Figure 1(a)). Negative affect did not change between T2 and T3 in the control condition. In
contrast, the intervention condition demonstrated a significant decline in negative affect post-inter-
vention between T2 and T3 (MD = 3.79; 95% CI [2.10, 5.47]; g = .79). Parameter estimates confirmed
that the slopes between T2 and T3 were statistically different for the different conditions (B =
−0.18, p = .003). Moreover, at T3 there was a significant between-group difference (MD = −4.02;
95% CI [−7.04, −1.56]; g = .55) demonstrating that negative affect was significantly lower in the inter-
vention (M = 16.34, SE = 0.65) than compared to the control (M = 20.64, SE = 1.26).

Figure 1. Two-way interaction between Time and Condition for (a) negative affect and (b) positive affect estimated marginal
means. Error bars represent SE ±1.96.
 ANXIETY, STRESS, & COPING 9

Positive affect
The main effect for sex was statistically significant (Wald = 8.30, p = .004) as were the main effects for
Condition and Time (Wald = 6.28, p = .013 and Wald = 97.20, p < .001, respectively). The main effects
were qualified by the predicted (H2) interaction between Time and Condition (Wald = 10.22, p = .006;
Figure 1(b)). The control condition demonstrated a significant decline in average positive affect
between T2 and T3 (MD = −1.33; 95% CI [0.031, 2.64]; g = .15). However, the intervention condition
experienced a non-significant increase in positive affect post-intervention. Parameter estimates indi-
cating that the slopes between T2 and T3 were significantly different between conditions (B = 0.15;
SE = .06; p = .007). Moreover, at T3 there was a statistically significant difference between conditions
(MD = 5.89; 95% CI [2.43, 9.34]; g = −.59) demonstrating that positive affect was higher in the inter-
vention (M = 26.85, SE = 1.29) than compared to the control (M = 20.96, SE = 1.27).

Perceived task-related stress

The main effect for sex and age was statistically significant (Wald = 19.10, p < .001; Wald = 2.91, p
= .089, respectively) as were the main effects for Condition and Time (Wald = 9.13, p = .003 and
Wald = 5.61, p = .018, respectively). The intervention condition demonstrated lower average per-
ceived task-related stress than the control condition (M = 20.34, SE = 0.50; M = 22.27, SE = 0.63,
respectively) and there was an average decline in perceived task-related stress over the two time
points in both conditions (MT2 = 21.92, SE = 0.52; MT3 = 20.67, SE = 0.49). Although there was no pre-
dicted (H1b) statistically significant overall interaction between Time and Condition, pairwise com-
parisons demonstrated a significant between-condition difference at T3 (MD = −2.88; 95% CI
[−4.74, −1.02]; g = .54). Perceived task-related stress was significantly lower in the intervention (M
= 19.28, SE = 0.66) compared to the control condition (M = 22.16, SE = 0.70), despite a non-significant
difference at the preceding time point (T2).

Change in mechanisms over time based on condition

To test the second aim, an analysis of change was conducted for the mediator variables to determine
whether the condition was predictably effecting their change. In brief, for threat appraisal, there was
a significant Time and Condition interaction (Wald = 6.23, p = .044; Figure S2). Between T2 and T3,
only respondents in the intervention condition experienced a significant decline in threat appraisal
(MD = 2.96; 95% CI [1.30, 4.63]; g = .44), whereas there was no change in reported threat appraisal for
the control. For challenge appraisal, there was no statistically significant main effect for Condition or
interaction between Time and Condition. However, coping efficacy demonstrated a significant two-
way interaction between Time and Condition (Wald = 5.67, p = .017). For participants in the control
condition, there was no change in coping self-efficacy between time points. However, for the inter-
vention, there was a significant increase in coping self-efficacy between T1 and T3 (MD = −.31; 95% CI
[−0.46, −0.15]; g = .35). Coping efficacy findings are illustrated graphically in Figure S3.

Mediation analyses
Parallel mediation analyses on the three self-report outcome measures were performed to test
whether the effect of condition on T3 outcomes occurred in-directly via the proposed mechanisms:
coping self-efficacy and threat appraisal. Challenge appraisal did not demonstrate a relationship to
the conditions and therefore was not used as a mediator. The indirect effects for T3 perceived
task-related stress and T3 negative affect were significant and presented in Figures 2 and 3. Mediation
models were also performed for T3 positive affect; however, no evidence of mediation was observed.
Condition initially demonstrated a significant direct effect on T3 task-related stress (Y) when con-
trolling for T2 task-related stress (b = −2.60; SE = 0.95; p = .007). Condition also demonstrated a signifi-
cant relationship to the mediator (a2) T3 perceived threat appraisal (b = −2.52; SE = 1.02; p = .02).
10 M. F. CRANE ET AL.

Figure 2. Parallel mediation model with T3 perceived coping efficacy and threat appraisal as the mediators in the relationship
between intervention and T3 task-related stress. Covariates T1 perceived coping efficacy, T1 threat appraisal, T2 task-related
stress, sex, and age were included in the model, but have been removed from the figure.
Note: Values represent unstandardized coefficients. *p < .05; **p < .01 (two-tailed); c’ values are direct effects post entry of mediators in the model.

However, there was no relationship between condition and the mediator T3 coping efficacy (a1). A
significant relationship also emerged between the mediator T3 perceived threat appraisal (b2) and
T3 task-related stress (b = 0.37; SE = 0.08; p < .001). However, the relationship between T3 coping
efficacy and T3 task-related stress (b1) was not statistically significant. When the mediator T3
threat appraisal was included the in model, the relationship between the intervention condition
and T3 perceived stress became non-significant and the indirect effect (a2b2) was significant (b =
−.94, 95% CI [−2.06, −0.22]). This result supports the hypothesized mediation via threat appraisal
(H3), but not the mediating role for coping efficacy (H5).
A similar mediation model was conducted for T3 negative affect. Condition initially demonstrated
a significant direct effect on T3 negative affect (Y) when controlling for T1 negative affect (b = −3.88,
SE = 1.25; p = .002). Condition also demonstrated a significant relationship to the mediator (a2) T3
threat appraisal (b = −2.78, SE = 1.01; p = .007). As before, there was no relationship between con-
dition and the mediator T3 coping efficacy (a1). A significant relationship also emerged between
the mediator T3 threat appraisal (b2) and T3 negative affect (b = 1.01, SE = .08, p < .001). However,
there was no significant relationship between T3 coping efficacy and T3 negative affect (b1). When
the mediators were included in the model the direct relationship between intervention condition
and T3 negative affect became non-significant. A significant indirect effect emerged via T3 threat

Figure 3. Parallel mediation model with T3 perceived coping efficacy and threat appraisal as the mediators in the relationship
between intervention and T3 negative affect. Covariates T1 perceived coping efficacy, T1 threat appraisal, T2 negative affect,
sex, and age were included in the model, but have been removed from the figure.
Note: Values represent unstandardized coefficients. *p < .05; **p < .01 (two-tailed); c’ values are direct effects post-entry of mediators in the model.
 ANXIETY, STRESS, & COPING 11

appraisal (a2b2) supporting the predicted (H3) mediation relationship via threat appraisal (b = −2.86,
95% CI [−5.01, −.77]), but not coping efficacy (H5).
In parallel mediator models, the mediators are allowed to correlate (Hayes, 2013). Given the
relationship between these mediators (r = −.40, p < .001) to assess whether coping efficacy could
be a mediator without the inclusion of threat appraisal we re-ran models examining the mediators
separately. Coping efficacy still did not appear to mediate the effects of perceived stress or negative
affect.

Cortisol recovery (H6)

A multi-level model of cortisol change over time demonstrated that the anticipated two-way inter-
action between Time and Condition (H6) did not emerge; however, there was a significant three-
way interaction between Condition, pre-stressor cortisol, and Time (F(3, 115) = 3.91, p = .01). This
interaction indicated that the rate of recovery was dependent on both the intervention condition
and the pre-stressor cortisol level. Figure 4 illustrates this interaction using the differentiated cortisol
levels (+−0.5 SD above and below the mean) for the purpose of illustration only. As demonstrated in
Figure 4, the rate of cortisol reduction was steeper for those individuals with a higher pre-stressor
cortisol (T1c), who importantly, reduced at a faster rate within the self-reflection intervention con-
dition, than their control condition counter parts. Parameter estimates demonstrated that the rate
of change between T2c and T5c was greater for those in the intervention condition (Time2c-
*Conditionintervention* Pre-stressor; p = .01, β = −.32) as was the rate of change between T3c and
T5c (Time3c* Conditionintervention*Pre-stressor; p = .004, β = −.34) for individuals with higher pre-stres-
sor cortisol. In contrast, individuals with lower pre-stressor cortisol scores in both conditions demon-
strated low and unchanging cortisol scores over time.

Discussion
Summary of findings
In accordance with the first aim, we investigated whether systematic self-reflection on coping and
emotion regulation in response to stressors would reduce the level of perceived stress and negative
affectivity, but increase positive affect toward a similar stressor event occurring post-reflection com-
pared to a disengagement control condition (watching an unrelated documentary). Consistent with
hypothesis (H1ab), the findings suggest that the self-reflective intervention was more effective in
reducing negative affect and task-related stress, than a disengagement control task. There was

Figure 4. Three-way interaction between pre-stressor cortisol (T1c), Time and Condition for cortisol level (ug/dL) post-stressor. High
and low pre-stressor cortisol defined by 0.5 SD above or below the mean.
12 M. F. CRANE ET AL.

partial support for H2; the self-reflective intervention prevented a continued reduction in positive
affect in response to a similar stressor post-intervention, but did not significantly increase positive
affect. Although there was a tendency to observe an increase in positive affect in the self-reflection
condition, this increase was not statistically significant. Taken together the findings suggest that self-
reflection, in accordance with the SSR model, may reduce negative affect, but perhaps not necessarily
promote an increase in positive outcomes, at least in the short-term and in relation to this stressor
task. Although these outcome variables do not reflect a direct test of the intervention’s capacity to
promote resilience, it is suggestive that reflection on a stressor event may promote a more adaptive
emotional response to a similar stressor event.
A further finding is that although we may expect to observe habituation to the second exposure to
a similar stressor irrespective of the condition (Kant et al., 1985), only perceived task-related stress
demonstrated a significant decline following the second stressor for both conditions. Both conditions
reporting a decline in perceived stress, but at T3 average perceived stress was significantly lower for
the intervention condition. Conversely, for positive affect the control condition reported a continued
significant decline in positive affect in response to the second stressor event.
The second aim was to test potential mediator effects. In support of H3, results indicated that
threat reappraisal mediated the relationship between the intervention condition and both negative
affect and task-related stress. Notably, the intervention reduced threat reappraisals compared to the
control condition, which was related to a decline in negative affect or task-related stress. However,
given threat reappraisal and outcomes were measured at the same time point, this limits the con-
clusions about causal paths. We did not find evidence that challenge reappraisal related emotions
mediated the relationship between the intervention and the primary outcome variables (H4). The
failure to observe this mediation may be related to the stressor task used. It is likely that the
public speaking stressor used in this study was not viewed as an opportunity for personal develop-
ment and therefore less likely to promote challenge reappraisal.
In relation to the present study, the results suggest that threat reappraisal was the most important
mediator in the relationship between the intervention and the affective outcomes. There was no evi-
dence that coping self-efficacy (secondary appraisal) mediated the observed relationships between
condition and outcomes (H5). Thus, at least in the context of this study, threat appraisal was the
mediator with more explanatory value. A possible methodological reason for this is that coping
self-efficacy was measured generally in relation to perceived future capacity to handle the stressors
in one’s life, rather than in relation to the ability to cope with the current stressor. A generic measure
of coping self-efficacy is potentially less likely to mediate the association between the intervention
and task-related outcomes.
For the third aim, we further evaluated the effect of the intervention on modifying post-stressor
cortisol when controlling for pre-stressor cortisol. The overall trend in cortisol levels post-stressor
demonstrated a different pattern compared to previous studies using non-clinical samples. Previous
research has demonstrated that cortisol levels increase and peak 30 min post the Trier Social Stress
Test (TSST; Kudielka, Schommer, Hellhammer, & Kirschbaum, 2004). The TSST is a public speaking and
challenging arithmetic task used to induce stress in the laboratory. In the present study, cortisol levels
did not appear to increase following the second public speaking stressor as has been observed in
other studies using the TSST. This may have been for three reasons. First, pre-stressor cortisol was
elevated already as a consequence of conditions within the experiment (e.g., auditory startle, inter-
vention). However, the average pre-stressor cortisol was comparable to that observed in previous
studies (e.g., Het, Rohleder, Schoofs, Kirschbaum, & Wolf, 2009; Kirschbaum, Pirke, & Hellhammer,
1993). Previous work has demonstrated a mean range in baseline scores across six studies
between 4–9 nmol (Kirschbaum et al., 1993), which is comparable to, the pre-stressor average in
our study of 4.4 nmol (0.16 ug/dL). Moreover, the intervention condition was unrelated to pre-stres-
sor cortisol levels suggesting that the intervention was involved in modifying cortisol recovery, rather
than pre-stressor cortisol. In addition, while there is substantial literature on the effects of cortisol in
acoustic startle response (e.g., Buchanan, Brechtel, Sollers, & Lovallo, 2001) we identified no evidence
 ANXIETY, STRESS, & COPING 13

of the reverse relationship reported in the literature. Second, given the study design required two
public speaking stressor exposures, the second stressor exposure may not have sufficiently promoted
an initial elevation in cortisol as seen in previous work using multiple exposures (Wüst et al., 2005).
Third, it is possible that the TSST is more likely to elicit cortisol elevations than the public speaking
stressor without the challenging arithmetic task. Having noted this, modifications to the TSST para-
digm are common (e.g., Bagley, Weaver, & Buchanan, 2011; Yim, Quas, Rush, Granger, & Skoluda,
2015) and previous work demonstrates that the modified task (e.g., virtual reality simulated scenarios)
is still able to yield an elevation in cortisol (García-León, Pérez-Mármol, Gonzalez-Pérez, del Carmen
García-Ríos, & Peralta-Ramírez, 2019). Finally, our sample was comprised principally of female partici-
pants (68%). Past research has shown female subjects to demonstrate minimal changes in cortisol in
response to achievement stressors (Stroud, Salovey, & Epel, 2002). However, the reverse was found for
a social rejection stressor, females demonstrating increased cortisol in contrast to males. Such differ-
ences may occur because of sex differences in the normative concerns about particular stressors. In
the current study, the framing of the stressor induction may have contributed to the perception of an
achievement-based stressor, thereby limiting the cortisol response from the majority female partici-
pants. In our view, the most plausible account for these findings is that exposure to a stressor for a
second time limited the observable shift in cortisol post-stressor. This had implications for the results
in that the slope of recovery trajectories were limited, which is a probable reason why a predicted
time by condition interaction was not detected.
Although the intervention condition had no effect on pre-stressor cortisol, we identified that pre-
stressor cortisol was critical to determining the effect of condition on cortisol trajectory over time. The
cortisol findings, combined with the findings from the self-report measures, may be interpreted as
suggesting that the intervention promoted a more adaptive physiological stressor response in
those higher (albeit normal) levels of cortisol production at pre-stressor. In Figure 4, we observe
for individuals with high levels of pre-stressor cortisol a steeper decline in cortisol for those in the
intervention condition, compared to the control condition. When pre-stressor cortisol was higher
at T1c, the intervention condition demonstrated a steeper trajectory of recovery and was suggestive
of a continued downward trend, such that if more time points occurred (e.g., 40 min) the level of cor-
tisol would continue to reduce. In contrast, the control condition appeared to demonstrate a flatter
recovery trajectory appearing to plateau at 30 min (T5c). Moreover, at 30 min post-stressor those with
initially higher levels of pre-stressor cortisol demonstrated an average lower cortisol level in the inter-
vention condition, compared to the control condition. A further finding of interest is that when initial
pre-stressor cortisol was low (T1c), condition had little observable effect on post-stressor cortisol
response. This may be the result of a floor effect. However, as noted previously, levels of cortisol
may be as low as between 0.027 and 0.069 for that time of the day post-waking suggesting possible
room for further decline.

Theoretical and applied implications

We have previously proposed that the development of resilience is a, “process of experiential learning
and more specifically learning through reflection on doing” (Crane et al., 2019a, p. 5). Yet, the role of
interactions between meta-cognitive processes that facilitate learning and everyday stressor experi-
ences for the development of resilience is understudied, perhaps because it is challenging to study
nuanced processes that unfold over a life time. In this study, we attempted to capture a small part of
this process in the experimental context to highlight the potential for everyday stressor events to
facilitate the development of situational resilience when scaffolded in nuanced adaptive self-reflec-
tive practices. Specifically, exposure to a target stressor and adaptive self-reflection on that stressor
yielded a more adaptive emotional outcome when re-exposed to a similar stressor, than engaging in
a distraction task. The self-report findings suggest that self-reflection on a stressor emphasizing the
development of resilience, may promote better psychological outcomes on re-exposure to a similar
stressor.
14 M. F. CRANE ET AL.

This extends existing work by proposing a potential mechanism by which resilience may be devel-
oped via exposure to commonly experience stressor events (i.e., psychosocial stressors). Conversely,
stressor disengagement does not necessarily result in habituation or adaptive emotional outcomes
measured via self-report. In the control condition, negative affect, positive affect, threat appraisal,
and coping self-efficacy remained stable on average post both stressors suggesting no average
habituation. Evidence of repeated exposures to a psychosocial stressor in humans demonstrates con-
siderable variability in response to repeated exposure. Using measures of HPA activation (i.e., salivary
and plasma cortisol) Wüst and colleagues (2004) found that habituation is not necessarily an outcome
of repeated exposure to a similar stressor. Rather, there are individual differences in the outcomes of
repeated exposure that may relate to the cognitive processing of events. Adaptive forms of cognitive
stressor processing, that potentially strengthen individual resilience across time, may take the form of
cognitive engagement with the stressor orientated toward development and growth, rather than
cognitive disengagement from the stressor.
A further potential contribution of this work is that adaptive self-reflective practices may be a way
to modify an individual’s stressor mindset or the way people naturally appraise stressor encounters.
Crum et al. (2013) have called for consideration to be given to how people might alter their mindsets
to stressors. Adaptive self-reflection practices during and post-stressor events may achieve this.
However, before engaging self-reflection consideration should be given to the individual’s levels
of stress or distress. Crane et al. (2019a) suggest that stressors eliciting distress are likely to reduce
the capacity for a complex meta-cognitive process and may promote ruminative self-reflection. In
contrast, moderate levels of stress are likely to induce the greatest potential for adaptive self-
reflection.

Limitations, strengths, and future directions

The implications of this research need to be considered in light of some limitations. The control con-
dition was selected to promote disengagement from the stressor and control for the passage of time.
However, the conditions also differed in their social interaction that may have constituted social
support. Perceived social support is an important confound that provides a plausible alternative
explanation for the pattern of results. A large body of literature demonstrating that both emotional
and instrumental social support can reduce the effects of stressor events on the experience of stress
and mental ill-health (e.g., Mathieu & Eschleman, 2019; Rueger, Malecki, Pyun, Aycock, & Coyle, 2016).
The observed effects may have eventuated from a supportive interaction, rather than the reflection
activity. Having noted this, a recent clustered-randomized controlled trial (Crane et al., 2019b) using
only written self-reflections, of a similar nature, with limited social interaction demonstrated signifi-
cant benefits to participants, compared to intervention as usual. Although we are cautious about
drawing conclusions based on a single study, there is cumulating evidence suggesting that a particu-
lar approach to self-reflection may be beneficial to the strengthening of resilience. Future research
could seek to control for the social aspect by exploring self-reflection using writing-tasks where
the control condition is also a writing-task describing a stressor, rather than reflecting on a stressor.
Alternatively, both conditions could involve interviews, but participants in the control condition could
be interviewed about an alternative topic.
A second limitation is that the mediators were measured at the same time point as the outcome
variables, so causal direction cannot be confirmed. Our chosen interpretation of the findings is that
reflective practices emphasizing the development of personal capacities from stressors (stress-as-
enhancing mindset) reduce threat appraisal, that turn promotes less negative affect and task-
related stress. This interpretation is consistent with substantial agreement among scholars that
appraisals precede action tendencies, physiological response and motor expression that are inte-
grated to form nonverbal feelings that are later labeled (Scherer & Moors, 2019). However, bi-direc-
tionality between the appraisal and emotional outcomes is possible. Future research is required to
test the SSR framework using longitudinal design.
 ANXIETY, STRESS, & COPING 15

A further limitation is that the three-way interaction predicting cortisol trajectory was not antici-
pated a priori, and the study may be underpowered to detect the effect. Thus, conclusions about the
role of self-reflection in cortisol recovery are tentative until these findings can be replicated.
Despite these limitations, the study has notable strengths. Perhaps the most critical is that explor-
ing situational resilience to a standardized stressor allows control of the objective magnitude of the
stressor in terms of personal impact and other relevant dimensions. Experimental methodology also
allows the tracking of cortisol recovery trajectories from pre to post stressor exposure. Arguably, such
cortisol recovery trajectories provide critical information about the prospective likelihood of resilient
outcomes (Galatzer-Levy et al., 2014).

Conclusion
To date, little attention has been paid to the processes by which resilience is developed, and how the
likelihood of a resilient outcome may be enhanced over the life course or via interventions. We
propose that resilience is developed via dynamic interactions with everyday stressor events and
adaptive self-reflective practices. This study reflects the first lab-based test of the SSR model of resi-
lience strengthening. Broadly, the findings suggest that self-reflection on a stressor emphasizing the
development of resilience, may promote better psychological outcomes on re-exposure to a similar
stressor. This research is foundational to the advancement of a framework to understand how
common stressor experiences may support resilience development that may eventually inform pre-
vention strategies.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This work was supported by a Macquarie University Research Development Grant Scheme [number: 9201601545].

ORCID
Monique F. Crane http://orcid.org/0000-0002-4943-7962
Maria Kangas http://orcid.org/0000-0001-8693-2949
Ben Searle http://orcid.org/0000-0003-0349-1709

References
Bagley, S. L., Weaver, T. L., & Buchanan, T. W. (2011). Sex differences in physiological and affective responses to stress in
remitted depression. Physiology & Behavior, 104, 180–186. doi:10.1016/j.physbeh.2011.03.004
Bailey, S. L., & Heitkemper, M. M. (1991). Morningness–eveningness and early-morning salivary cortisol levels. Biological
Psychology, 32, 181–192. doi:10.1016/0301-0511(91)90009-6
Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122–147. doi:1037//0003-066X.
37.2.122
Benight, C. C., & Harper, M. L. (2002). Coping self-efficacy perceptions as a mediator between acute stress response and
long-term distress following natural disasters. Journal of Traumatic Stress, 15, 177–186. doi:10.1023/A:1015295025950
Bennett-Levy, J., & Padesky, C. A. (2014). Use it or lose it: Post-workshop reflection enhances learning and utilization of
CBT skills. Cognitive and Behavioral Practice, 21, 12–19. doi:10.1016/j.cbpra.2013.05.001
Björntorp, P. (2001). Do stress reactions cause abdominal obesity and comorbidities? Obesity Reviews, 2, 73–86. doi:10.
1046/j.1467-789x.2001.00027.x
Buchanan, T. W., Brechtel, A., Sollers IIIJ. J., & Lovallo, W. R. (2001). Exogenous cortisol exerts effects on the startle reflex
independent of emotional modulation. Pharmacology Biochemistry and Behavior, 68, 203–210. doi:10.1016/S0091-
3057(00)00450-0
16 M. F. CRANE ET AL.

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social
Behavior, 24, 385–396. doi:10.2307/2136404
Crane, M. F., Boga, D., Karin, E., Gucciardi, D. F., Rapport, F., Callen, J., & Sinclair, L. (2019b). Strengthening resilience in
military officer cadets: A group-randomized controlled trial of coping and emotion regulatory self-reflection training.
Journal of Consulting and Clinical Psychology, 87, 125–140. doi:10.1037/ccp0000356
Crane, M. F., & Searle, B. J. (2016). Building resilience through exposure to stressors: The effects of challenges versus hin-
drances. Journal of Occupational Health Psychology, 21, 468–479. doi:10.1037/a0040064
Crane, M. F., Searle, B. J., Kangas, M., & Nwiran, Y. (2019a). How resilience is strengthened by exposure to stressors: The
systematic self-reflection model of resilience strengthening. Anxiety, Stress, & Coping, 32, 1–17. doi:10.1080/10615806.
2018.1506640
Crum, A. J., Salovey, P., & Achor, S. (2013). Rethinking stress: The role of mindsets in determining the stress response.
Journal of Personality and Social Psychology, 104, 716–733. doi:10.1037/a0031201
Ellenbogen, M. A., Carson, R. J., & Pishva, R. (2010). Automatic emotional information processing and the cortisol response
to acute psychosocial stress. Cognitive, Affective, & Behavioral Neuroscience, 10, 71–82. doi:10.3758/CABN.10.1.71
Ellenbogen, M. A., Schwartzman, A. E., Stewart, J., & Walker, C. D. (2006). Automatic and effortful emotional information
processing regulates different aspects of the stress response. Psychoneuroendocrinology, 31, 373–387. doi:10.1016/j.
psyneuen.2005.09.001
Ellis, S., Carette, B., Anseel, F., & Lievens, F. (2014). Systematic reflection. Current Directions in Psychological Science, 23, 67–
72. doi:10.1177/0963721413504106
Ferguson, E., Matthews, G., & Cox, T. (1999). The appraisal of life events (ALE) scale: Reliability and validity. British Journal of
Health Psychology, 4, 97–116. doi:10.1348/135910799168506
Galatzer-Levy, I. R., Steenkamp, M. M., Brown, A. D., Qian, M., Inslicht, S., Henn-Haase, C., … R, C. (2014). Cortisol response
to an experimental stress paradigm prospectively predicts long-term distress and resilience trajectories in response to
active police service. Journal of Psychiatric Research, 56, 36–42. doi:10.1016/j.jpsychires.2014.08.017
García-León, MÁ, Pérez-Mármol, J. M., Gonzalez-Pérez, R., del Carmen García-Ríos, M., & Peralta-Ramírez, M. I. (2019).
Relationship between resilience and stress: Perceived stress, stressful life events, HPA axis response during a stressful
task and hair cortisol. Physiology & Behavior, 202, 87–93. doi:10.1016/j.physbeh.2019.02.001
Gold, P. W., Drevets, W. C., & Charney, D. S. (2002). New insights into the role of cortisol and the glucocorticoid receptor in
severe depression. Biological Psychiatry, 52, 381–385. doi:10.1016/S0006-3223(02)01480-4
Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis. New York, NY: Guilford Press.
Henry, J. P. (1993). Psychological and physiological responses to stress: The right hemisphere and the hypothalamo-pitu-
itary-adrenal axis, an inquiry into problems of human bonding. Integrative Physiological and Behavioral Science, 28,
369–387. doi:10.1007/BF02690935
Het, S., Rohleder, N., Schoofs, D., Kirschbaum, C., & Wolf, O. T. (2009). Neuroendocrine and psychometric evaluation of a
placebo version of the ‘trier social stress test’. Psychoneuroendocrinology, 34, 1075–1086. doi:10.1016/j.psyneuen.2009.
02.008
Holsboer, F. (2000). The corticosteroid receptor hypothesis of depression. Neuropsychopharmacology, 23, 477–501. doi:10.
1016/S0893-133X(00)00159-7
Hubbard, A. E., Ahern, J., Fleischer, N. L., Van der Laan, M., Satariano, S. A., Jewell, N., … A, W. (2010). To GEE or Not to GEE.
Epidemiology, 21, 467–474. doi:10.1097/EDE.ObOl3e318 lcaeb90
Jensen, M. P., Turner, J. A., & Romano, J. M. (1991). Self-efficacy and outcome expectancies: Relationship to chronic pain
coping strategies and adjustment. Pain, 44, 263–269. doi:10.1016/0304-3959(91)90095-F
Kalisch, R., Baker, D. G., Basten, U., Boks, M. P., Bonanno, G. A., Brummelman, E., & Geuze, E. (2017). The resilience frame-
work as a strategy to combat stress-related disorders. Nature Human Behaviour, 1, 784–790. doi:10.1038/s41562-017-
0200-8
Kant, G. J., Eggleston, T., Landman-Roberts, L., Kenion, C. C., Driver, G. C., & Meyerhoff, J. L. (1985). Habituation to repeated
stress is stressor specific. Pharmacology Biochemistry and Behavior, 22, 631–634. doi:10.1016/0091-3057(85)90286-2
Kirschbaum, C., Pirke, K. M., & Hellhammer, D. H. (1993). The ‘trier social stress test’–a tool for investigating psychobiolo-
gical stress responses in a laboratory setting. Neuropsychobiology, 28, 76–81. doi:10.1159/000119004
Kirschbaum, C., Wolf, O. T., May, M., Wippich, W., & Hellhammer, D. H. (1996). Stress- and treatment-induced elevations of
cortisol levels associated with impaired declarative memory in healthy adults. Life Sciences, 58, 1475–1483. doi:10.
1016/0024-3205(96)00118-X
Kudielka, B. M., Schommer, N. C., Hellhammer, D. H., & Kirschbaum, C. (2004). Acute HPA axis responses, heart rate, and
mood changes to psychosocial stress (TSST) in humans at different times of day. Psychoneuroendocrinology, 29, 983–
992. doi:10.1016/j.psyneuen.2003.08.009
Kunz-Ebrecht, S. R., Mohamed-Ali, V., Feldman, P. J., Kirschbaum, C., & Steptoe, A. (2003). Cortisol responses to mild
psychological stress are inversely associated with proinflammatory cytokines. Brain, Behavior, and Immunity, 17,
373–383. doi:10.1016/S0889-1591(03)00029-1
Lam, S., Dickerson, S. S., Zoccola, P. M., & Zaldivar, F. (2009). Emotion regulation and cortisol reactivity to a social-evalua-
tive speech task. Psychoneuroendocrinology, 34, 1355–1362. doi:10.1016/j.psyneuen.2009.04.006
 ANXIETY, STRESS, & COPING 17

Lindberg, E., Wincent, J., & Örtqvist, D. (2013). Turning stressors into something productive: An empirical study revealing
nonlinear influences of role stressors on self-efficacy. Journal of Applied Social Psychology, 43, 263–274. doi:10.1111/j.
1559-1816.2012.00995.x
Mathieu, M., & Eschleman, K. J. (2019). Meta-Analytic and multiwave comparison of emotional support and instrumental
support in the workplace. Journal of Occupational Health Psychology, 24, 387–409. doi:10.1037/ocp0000135
McEwen, B. S., Gray, J. D., & Nasca, C. (2015). Recognizing resilience: Learning from the effects of stress on the brain.
Neurobiology of Stress, 1, 1–11. doi:10.1016/j.ynstr.2014.09.001
Moors, A., Ellsworth, P. C., Scherer, K. R., & Frijda, N. H. (2013). Appraisal theories of emotion: State of the art and future
development. Emotion Review, 5, 119–124. doi:10.1177/1754073912468165
Raudenbush, S. W., Spybrook, J., Congdon, R., Liu, X., & Martinez, A. (2011). Optimal design software for multi-level and
longitudinal research (version 3.01) [Software]. Retrieved from www.wtgrantfoundation.org
Reddish, P. (2012). Hummingbirds jewelled messengers [Video file]. Retrieved from https://www.youtube.com/watch?v=
pxqIlaVBoH0
Richardson, G. E. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 58, 307–321. doi:10.
1002/jclp.10020
Rueger, S. Y., Malecki, C. K., Pyun, Y., Aycock, C., & Coyle, S. (2016). A meta-analytic review of the association between
perceived social support and depression in childhood and adolescence. Psychological Bulletin, 142, 1017–1067.
doi:10.1037/bul0000058
Scherer, K. R., & Moors, A. (2019). The emotion process: Event appraisal and component differentiation. Annual Review of
Psychology, 70, 719–745. doi:10.1146/annurev-psych-122216-011854
Schwarzer, R. (2000). Social-cognitive predictors of health behavior: Action self-efficacy and coping self-efficacy. Health
Psychology, 19, 487–495. doi:10.1037/0278-6133.19.5.487
Searle, B. J., & Auton, J. C. (2014). The merits of measuring challenge and hindrance appraisals. Anxiety, Stress, and Coping,
28, 1–23. doi:10.1080/10615806.2014.931378
Seery, M. D., Holman, E. A., & Silver, R. C. (2010). Whatever does not kill us: Cumulative lifetime adversity, vulnerability, and
resilience. Journal of Personality and Social Psychology, 99, 1025–1041. doi:10.1037/a0021344
Smith, C. A., & Ellsworth, P. C. (1985). Patterns of cognitive appraisal in emotion. Journal of Personality and Social
Psychology, 48, 813–838. doi:10.1037/0022-3514.48.4.813
Smyth, J., Ockenfels, M. C., Porter, L., Kirschbaum, C., Hellhammer, D. H., & Stone, A. A. (1998). Stressors and mood
measured on a momentary basis are associated with salivary cortisol secretion. Psychoneuroendocrinology, 23, 353–
370. doi:10.1016/S0306-4530(98)00008-0
Stroud, L. R., Salovey, P., & Epel, E. S. (2002). Sex differences in stress responses: Social rejection versus achievement stress.
Biological Psychiatry, 52, 318–327. doi:10.1016/S0006-3223(02)01333-1
Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered: A psychometric analysis. Cognitive
Therapy and Research, 27, 247–259. doi:10.1023/A:1023910315561
Tuckey, M. R., Searle, B., Boyd, C. M., Winefield, A. H., & Winefield, H. R. (2015). Hindrances are not threats: Advancing the
multidimensionality of work stress. Journal of Occupational Health Psychology, 20, 131–147. doi:10.1037/a0038280
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative
affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070. doi:10.1037/0022-3514.54.6.1063
Wüst, S., Federenko, I. S., van Rossum, E. F., Koper, J. W., & Hellhammer, D. H. (2005). Habituation of cortisol responses to
repeated psychosocial stress—further characterization and impact of genetic factors. Psychoneuroendocrinology, 30,
199–211. doi:10.1016/j.psyneuen.2004.07.002
Yim, I. S., Quas, J. A., Rush, E. B., Granger, D. A., & Skoluda, N. (2015). Experimental manipulation of the Trier social stress
test-modified (TSST-M) to vary arousal across development. Psychoneuroendocrinology, 57, 61–71. doi:10.1016/j.
psyneuen.2015.03.021