Coping and Adjustment to Illness

Folkman and Moskowitz define coping as the “thoughts and behaviors used to manage the internal and external demands of situations that are appraised as stressful”. Research on coping largely grew out of and as a result of research on stress (see my post on Stress Processes, Personality and Disease Etiology). Differences in coping is one way to explain the great variability in responses to potentially stressful events as well as results of experiencing a stressor (for example adjustment to a serious illness such as cancer). The majority of the coping literature has focused on coping as something reactive (but see a small literature on proactive coping), which comes as no surprise considering that coping and stress research have been closely linked. At the broadest level, the timeline of typical models is:
\[
stressor \implies coping \implies outcomes
\]

There are many ways to cope and coping need not be “adaptive”. Early coping research tended to categorize coping strategies as problem focused or emotion focused. Under this paradigm, coping strategies were either focused on fixing or changing problems (problem focused) or on dealing (regulating) the emotional response (emotion focused). Many different strategies were theoretically encompassed in each of these groupings; however, only a subset of these were commonly measured. The research from this period generally found that problem focused coping was “adaptive” and emotion focused coping was “maladaptive”. Later on, researchers began to reject the problem versus emotion focused distinction as being adaptive or maladaptive, in part due to the way emotion focused coping was often measured. For example, an item from a common scale asked how often people, “become frustrated and give up” as a coping strategy. Instead of problem vs. emotion, an approach vs. avoidant dichotomy was adopted. Approach-oriented coping relates to “approaching” a stressor whether that is via strategies designed to fix it (e.g., searching for a new job if you get fired) or approaching the emotional response (e.g., expressing or accepting emotions). Conversely, avoidance-oriented coping includes strategies that involve behavioral or emotional disengagement (e.g., I stop trying, I pretend it isn’t real, etc.). In addition to these broad categories of coping strategies, there are numerous more specific coping strategies (e.g., emotional approach coping).

Although the literature on coping is extensive, there are many criticisms. Often, coping strategies are studied and “adaptive” or “maladaptive” strategies are identified. For example, early on, emotion focused coping was generally viewed as ineffective and more recently, avoidance-oriented coping is considered generally unhelpful. One problem with this approach is that “adaptive” and “maladaptive” are relative terms. For example, what is adaptive in one time frame (say shortly before or after a stressor) may be maladaptive in another (say months or years afterward). For example, emotional expression or James Pennebaker’s expressive writing paradigm can lead to increased distress in the short term (immediately after writing), but long term habituation or desensitization to stressors with salutary effects for psychological health and functioning. Another major problem is that coping is necessarily matched to an event—what is adaptive for one stressor may be maladaptive for another. There is evidence that when faced with controllable stressors, problem focused coping may be optimal; however, for uncontrollable stressors, an emotion focused approach may be better. For example, imagine a woman who is at high risk for breast cancer (the stressor). Prior to having cancer, optimal coping may be problem focused going to the doctor for regular screening. However, what if the woman does not have health insurance or easy access to medical care? Is a problem focused approach when she has no resources still beneficial or should she simply try to cope with the emotions and stress? In the absence of sufficient resources to effect a change, an emotional approach may be optimal. After getting cancer while going through chemotherapy, it is largely out of the woman’s control and an emotion focused approach (such as emotional expression or seeking social support) may be more effective than trying to change it.

The picture that emerges is the ideal or adaptive coping strategy depends both on the type of stressor, the timing of the stressor (before or after an event, acute one time stress versus chronic stress, etc.), and an individuals’ resources. It is naïve to assume that a single coping strategy or event set of strategies is ideal for all people for all stressors.

In many ways, the difficulties of the coping literature parallel those of the literature on stress and stressful life events. The same event is not equally stressful for all people, and ignoring the person and the context when assessing coping (just as when assessing stress) misses important detail. Further, measurement is complicated because of the virtually limitless possibilities for coping strategies. In order to consistently measure it, scales have to include every possible coping strategy a person may use (e.g., I don’t think about it, I talk about it, I pray about it, I say to myself this isn’t real, etc.) otherwise you may fail to assess some behavior a person is doing. Consequently, typical measures of coping are quite lengthy, and internal consistency reliability of specific subscales (such as mental disengagement) are low. Again, this is not unlike stressful life event checklists that included lengthy lists of potential stressful life events.

If there are so many problems with it, why study coping? I think that the simple answer is that it matters. Ostensibly similar people in similar environments have a great deal of variability in adjustment. If we can understand what behaviors and strategies are adaptive, we advance basic science about how people function as well as gain valuable tools for intervention. Particularly in a medical setting, there is a unique opportunity to intervene at or before stressful events occur. For example, if we knew effective ways to adjust with a new cancer diagnosis, patients could be given the intervention along with their diagnosis. Chronic disease and illness are associated with decreased quality of life, psychological well-being, and increased risk for psychopathology. Understanding what works, for whom, and under what conditions will enable psychologists to help alleviate the burden of disease on quality of life and well-being.

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