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Psychosocial Adaptation to Cancer: The Role of Coping Strategies.

When confronted with traumatic life events, individuals normally resort to a wide range of coping strategies The German Freudian psychoanalyst Karen Horney defined four so-called coping strategies to define interpersonal relations, one describing psychologically healthy individuals, the others describing neurotic states.  to alleviate the resultant stress. The conceptual underpinnings of much of the recent empirical developments in the field of coping with stress and trauma can be traced to the work of Lazarus and his coworkers (e.g. Lazarus, 1993; Lazarus & Folkman, 1984). These writers viewed the process of coping as comprised of two distinct phases: (a) primary appraisal, which refers to a set of cognitions concerning the significance or impact of the stressful event for the individual, and (b) secondary appraisal, which refers to a set of cognitions regarding the availability of resources or options (e.g., coping skills A coping skill is a behavioral tool which may be used by individuals to offset or overcome adversity, disadvantage, or disability without correcting or eliminating the underlying condition. Virtually all living beings routinely utilize coping skills in daily life. ) for dealing with the stressful situation. These and other (e.g., Billings & Moos, 1981; Pearlin & Schooler, 1978) first generation coping theoreticians and researchers often viewed coping dimensions as comprised of two separate classes, namely, emotion-focused (i.e., efforts directed at affect regulation) and problem-focused (i.e., strategies directed at minimizing or solving the impact of the stressful event) coping. More recent efforts at conceptualizing coping included the addition of a third dimension (i.e., avoidance-orientated coping; Parker & Endler, 1992), as well as other two-dimensional configurations (e.g., approach vs. avoidance, engagement vs. disengagement disengagement /dis·en·gage·ment/ (dis?en-gaj´ment) emergence of the fetus from the vaginal canal.

 coping)(Krohne, 1996; Parker & Endler, 1996; Tobin, Holroyd, Reynolds, & Wigal, 1989).

With the advent of measures that sought to investigate the nature, structure, and correlates of coping, theoreticians and researchers alike have begun to shift their views to focus more on the hierarchical nature of coping. Three broad levels have been implicated im·pli·cate  
tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates
1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.

: (a) coping styles that reflect global, dispositional, macroanalytic tendencies (e.g., monitoring-blunting, vigilance-avoidance, approach-avoidance); (b) coping strategies or modes that reflect an intermediate level in this hierarchy, and are typically indicated by summative Adj. 1. summative - of or relating to a summation or produced by summation

additive - characterized or produced by addition; "an additive process"
 scores on coping scales (e.g., confrontation, seeking social support, planful problem solving problem solving

Process involved in finding a solution to a problem. Many animals routinely solve problems of locomotion, food finding, and shelter through trial and error.
); and (c) coping acts or behaviors that reflect specific, situation-determined, microanalytic responses that are often indicated by individual item endorsement on a coping scale (Endler & Parker, 1990; Krohne, 1996; Schwarzer & Schwarzer, 1996).

The literature on coping with chronic illnesses and disabilities has, likewise, generated much insight into the nature and structure of coping efforts directed at diffusing or removing the stress engendered by the associated trauma, loss, and pain. Among the more commonly investigated disability conditions are cancer, heart diseases, spinal cord injury Spinal Cord Injury Definition

Spinal cord injury is damage to the spinal cord that causes loss of sensation and motor control.

Approximately 10,000 new spinal cord injuries (SCIs) occur each year in the United States.
, amputations, diabetes, rheumatoid arthritis rheumatoid arthritis

Chronic, progressive autoimmune disease causing connective-tissue inflammation, mostly in synovial joints. It can occur at any age, is more common in women, and has an unpredictable course.
, multiple sclerosis, chronic pain, traumatic brain injury Traumatic brain injury (TBI), traumatic injuries to the brain, also called intracranial injury, or simply head injury, occurs when a sudden trauma causes brain damage. TBI can result from a closed head injury or a penetrating head injury and is one of two subsets of acquired brain , and asthma.

Results from these and other studies strongly suggest that coping plays a significant role during the process of psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.

Involving aspects of both social and psychological behavior.
 adaptation to both sudden and gradual onset of chronic illnesses and disabilities. More specifically, these results indicate that: (a) a wide range of coping efforts has been employed by persons with disabilities to deal with the stresses engendered by their conditions; (b) these numerous efforts, both problem-solving and emotional-focused coping, as well as engagement- and disengagement- type coping have been found to be adaptive; (c) different coping efforts assume different roles and are, therefore, differentially employed to regulate stressful emotions and solve problems during the adaptation process; (d) coping efforts have played both a direct role (i.e., are directly linked to measures of psychosocial adaptation to disability) and a mediator mediator n. a person who conducts mediation. A mediator is usually a lawyer, or retired judge, but can be a non-attorney specialist in the subject matter (like child custody) who tries to bring people and their disputes to early resolution through a conference.  role (i.e., act as mediators between sociodemographic variables, personality attributes, disability-related factors, environmental conditions, and outcomes of psychosocial adaptation); and (e) different disabling dis·a·ble  
tr.v. dis·a·bled, dis·a·bling, dis·a·bles
1. To deprive of capability or effectiveness, especially to impair the physical abilities of.

2. Law To render legally disqualified.
 conditions imply different functional (e.g., mobility, manipulation, fatigue, cognitive) limitations, medical courses and prognostic prog·nos·tic
1. Of, relating to, or useful in prognosis.

2. Of or relating to prediction; predictive.

1. A sign or symptom indicating the future course of a disease.

 indicators (e.g., deteriorating, unpredictable, stable), related health problems, treatment modalities treatment modality Medtalk The method used to treat a Pt for a particular condition , and psychosocial reactions.

Among the most extensively researched disabling conditions is cancer. Cancer has been consistently implicated in the coping literature as necessitating a wide range of coping options to deal with shifting functional abilities, medical implications, treatment modalities, and psychosocial reactions. The next section is, accordingly, devoted to a review of those studies that have focused on the role played by coping efforts in adapting to this life-threatening disease.

Coping with Cancer

Earlier investigations of coping with cancer focused on documenting the frequency of use of and the role played by psychological defense mechanisms Defense mechanism
Behavior patterns primarily concerned with protecting ego. Presumably the process is unconscious and the aim is to fool oneself. It is intra psychic processes serving to provide relief from emotional conflict and anxiety.
 (e.g., projection, suppression, denial, displacement, reaction formation) in adapting to the disease (Bahnson & Bahnson, 1969; Heim, Moser, & Adler, 1978; Weisman & Worden, 1976-77). These investigations particularly emphasized the role of psychological defense mechanisms in reducing emotional distress emotional distress n. an increasingly popular basis for a claim of damages in lawsuits for injury due to the negligence or intentional acts of another. Originally damages for emotional distress were only awardable in conjunction with damages for actual physical harm.  and containing fears of death, pain, and disfigurement dis·fig·ure  
tr.v. dis·fig·ured, dis·fig·ur·ing, dis·fig·ures
To mar or spoil the appearance or shape of; deform.

[Middle English disfiguren, from Old French desfigurer
. The data obtained from these studies generally suggested that indicators of ego-strength and problem-solving behaviors were associated with better psychosocial adaptation to cancer. On the other hand, pessimism pessimism, philosophical opinion or doctrine that evil predominates over good; the opposite of optimism. Systematic forms of pessimism may be found in philosophy and religion. , passivity, stoic submission, and self-blame were related to increased emotional distress (Weisman & Worden, 1976-77; Worden & Sobel, 1978).

More recent investigations of coping with cancer have typically employed psychometrically sound measures of coping with life stresses in general (e.g., The Ways of Coping Questionnaire, Billings and Moos Coping Inventory, The COPE Scale) and with cancer more specifically (e.g., the Mental Adjustment to Cancer Scale). These investigations may be conveniently classified into two categories, namely investigations of (a) higher-level hierarchy coping styles (e.g., problem-, emotion-, and cognitive-focused coping; repression/blunting vs. sensitization/monitoring); and (b) intermediate coping strategies (e.g., denial, religiosity re·li·gi·os·i·ty  
1. The quality of being religious.

2. Excessive or affected piety.

Noun 1. religiosity - exaggerated or affected piety and religious zeal
religiousism, pietism, religionism
, fighting spirit Fighting Spirit may refer to:
  • Fighting Spirit (anime), a boxing anime and manga series
  • Victorious Boxers 2: Fighting Spirit, a boxing video game for the PlayStation 2 based on the anime/manga series.
, information seeking Information seeking is the process or activity of attempting to obtain information in both human and technological contexts. Information seeking is related to, but yet different from, information retrieval (IR). )

General Coping Styles with Cancer

The literature on dispositional coping with cancer encompasses a broad range of studies that typically seek to establish a link between general coping styles and measures of psychosocial adaptation to cancer. Among the most frequently researched coping styles are: (a) internal vs. external perceptions of control; (b) optimism vs. pessimism or helplessness; (c) repression or blunting vs. sensitization sensitization /sen·si·ti·za·tion/ (sen?si-ti-za´shun)
1. administration of an antigen to induce a primary immune response.

2. exposure to allergen that results in the development of hypersensitivity.
 or monitoring; and (d) approach vs. avoidance.

Internal versus external control. Several studies have directly addressed the impact of perception of control on psychosocial adaptation to cancer (Ell, Nishimoto, Mantell, & Hamovitch, 1992; Hilton, 1989; Taylor, Lichtman, & Wood, 1984; Thompson, Sobolew-Shubin, Galbraith, Schwankovsky, & Cruzen, 1993; Timko, & Janoff-Bulman, 1985). Results of these studies generally suggest that two perceptions are associated with better psychosocial adaptation and lower depression. The first is that one is capable of controlling cancer (internal or personal locus of control locus of control
A theoretical construct designed to assess a person's perceived control over his or her own behavior. The classification internal locus indicates that the person feels in control of events; external locus
). The second perception is that others, such as medical personnel (typically referred to as powerful others) could control the disease.

Blaming others for the disease occurrence or lack of medical control is more commonly linked to poorer adaptation (Taylor et al., 1984). Some divergent findings, however, were obtained by Jenkins and Pergament (1988) who reported that perceptions of control were differentially associated with measures of self-esteem and nurses' ratings of behavioral upset. Whereas perceptions of control by God were positively related to higher self-esteem and lowered behavioral upset, perceptions of chance control were only related to decreased behavioral upset. Also, higher levels of perceived inability to control emotional reactions were related to lower self-esteem and poorer adjustment to the illness. Similarly, Watson, Greer, Pruyn, and Van Den Borne (1990) reported that higher perception of internal control over the course of the illness (breast cancer) was associated with a "fighting spirit" attitude toward cancer while internal control over the cause of the illness was related to anxious preoccupation with cancer. Perceptions of religious control were associated with expressions of fatalistic fa·tal·ism  
1. The doctrine that all events are predetermined by fate and are therefore unalterable.

2. Acceptance of the belief that all events are predetermined and inevitable.
 attitude toward the disease.

Optimism versus pessimism. Studies of the role of dispositional optimistic op·ti·mist  
1. One who usually expects a favorable outcome.

2. A believer in philosophical optimism.

 outlook in psychosocial adaptation to cancer suggest that optimism is positively related to other coping modes typically perceived as adaptive in nature such as active-behavioral coping (i.e., overt efforts to deal directly with the stressful event) and is negatively related to avoidance coping (i.e., avoidance of the stressful event) (Friedman, Nelson, Baer, Lane, Smith, & Dworkin, 1992). Optimism was also found to be negatively related to psychosocial distress (Stanton & Snider, 1993). Related research, however, suggests that several coping strategies (e.g., acceptance, denial) may play mediating roles in the effect optimism had on distress (Carver et al., 1993). Likewise, optimistic outlook was associated with an increased sense of well-being, increased psychosocial adjustment, decreased psychosocial stress, and renewed vigor among women with breast cancer (Miller, Manne, Taylor, Keates, & Dougherty, 1996; Mishel, Hostetter, King, & Graham, 1984; Stanton & Snider, 1993).

Repression/blunting versus sensitization/monitoring. Several studies investigated the relationships between the defensive dimension of repression--sensitization and psychosocial adaptation to cancer. Repression, or in its alternative form of blunting, minimizing, and rejecting, refers to a defensive maneuver in which the individual employs strategies to avoid or negate ne·gate  
tr.v. ne·gat·ed, ne·gat·ing, ne·gates
1. To make ineffective or invalid; nullify.

2. To rule out; deny. See Synonyms at deny.

 awareness of affects and impulses. Sensitization, or as it is occasionally termed, monitoring, exaggerating ex·ag·ger·ate  
v. ex·ag·ger·at·ed, ex·ag·ger·at·ing, ex·ag·ger·ates
1. To represent as greater than is actually the case; overstate:
, and attending, refers to efforts directed at acknowledging, focusing on, and adopting vigilant attentional style when faced with threatening affects and impulses (Krohne, 1996; Weinberger & Schwartz, 1990). Cancer-specific minimization and denial, as opposed to exaggeration Exaggeration
Bunyon, Paul

legendary giant, hero of tall tales of the logging camps. [Am. Folklore: The Wonderful Adventures of Paul Bunyon]

Jenkins’ ear

trivial cause of a great quarrel. [Br. Hist.
 of the cancer's negative aspects, emerged as the variable most strongly associated with decreased levels of distress among women who underwent mastectomy mastectomy (măstĕk`təmē), surgical removal of breast tissue, usually done as treatment for breast cancer. There are many types of mastectomy. In general, the farther the cancer has spread, the more tissue is taken.  (Meyerowitz, 1983). Ward, Leventhal and Love (1988) reported that repressors had fewer and less severe chemotherapy-induced side effects Side effects

Effects of a proposed project on other parts of the firm.
. Similarly, Lerman and colleagues (Lerman et al., 1990, 1996) investigated the effects of coping style and counseling approach on breast cancer-related psychosocial distress, they reported that: (a) blunting coping style was associated with less anticipatory anxiety anticipatory anxiety Psychiatry Anxiety caused by an expectation of anxiety or panic in a particular situation. See performance anxiety. , less depression, and even less chemotherapy-induced nausea and (b) monitoring, or information-gathering coping style was associated with more anticipatory anxiety, more nausea, and, in general, increased psychosocial distress, regardless of counseling approach undertaken. Finally, research has suggested that people who have cancer tend to resort more to repression and denial as compared to people with other diseases or healthy individuals (Bahnson & Bahnson, 1966, 1969; Grissom, Weiner, & Weiner, 1975; Kneier & Temoshok, 1984).

Approach versus avoidance. Both avoidant (e.g., escape) and approach (e.g., confrontive) coping styles have been reported among survivors of various types of cancer including colostomy colostomy

Surgical formation of an artificial anus by making an opening from the colon through the abdominal wall. It may be done to decompress an obstructed colon, to allow excretion when part of the colon must be removed, or to permit healing of the colon.
, head and neck, and breast cancers (Keyes, Bisno, Richardson, & Marston, 1987; Shapiro, Rodrigue, Boggs, & Robinson, 1994; Shapiro et al., 1997; Steptoe, Sutcliffe, Allen, & Coombes Coombes is a hamlet and civil parish in the Adur District of West Sussex, England. It is located three miles (5km) north of Shoreham by Sea on the River Adur. The 11th century village church has frescoes, some of the most important in England, and painted about 1100 A.D. , 1991). In several studies, researchers reported that persons with cancer who adopted an avoidant, rather than confrontive, coping style had higher levels of depression (Keyes et al., 1987; Mytko, Knight, Chastain, Mumby, Siston, & Williams, 1996), sickness-related or physical symptoms (Keyes et al., 1987, Shapiro et al., 1997), and generalized psychosocial distress (Miller et al., 1996; Mytko et al., 1996; Shapiro et al., 1997). Similarly, Chen et al. (1996) concluded that engagement (i.e., approach) strategies were significantly correlated with a decreased level of psychiatric symptomatology symptomatology /symp·to·ma·tol·o·gy/ (simp?to-mah-tol´ah-je)
1. the branch of medicine dealing with symptoms.

2. the combined symptoms of a disease.

, while emotion-focused disengagement (i.e., avoidance) strategies were related to increased psychiatric distress among women with breast cancer. Manuel, Roth, Keefe, and Brantley (1987), in contrast, reported that among survivors of head and neck cancer, employing either approach or avoidant (rather than neither of these) coping modes was associated with lower levels of emotional distress, both initially and at future time periods.

Specific Coping Strategies with Cancer

In contrast to the more global, macroanalytic, trait-like coping styles that view coping trans-contextually, coping strategies are perceived as more specific, microanalytic, situation-specific, and process-based approaches to dealing with stressful events (Krohne, 1996; Lazarus, 1993). Whereas measures of global coping styles normally request respondents to address how they "usually" or "generally" cope with stress, measures of specific coping strategies require that respondents relate to explicit stressful events encountered by them recently. The latter are, then, inferred from respondents' endorsement of specific coping behaviors on self-report scales such as the Ways of Coping Questionnaire (Folkman & Lazarus, 1988), the COPE Scale (Carver, Scheier, & Weintraub, 1989), and the Coping Strategies Inventory (Tobin et al., 1989), and from cancer-specific coping scales, such as the Mental Adjustment to Cancer (MAC) Scale (Greer, Morris, & Pettingale, 1979).

Within the broader classification system that categorizes coping strategies as operating principally along an engagement (e.g., approach, confrontive) versus disengagement (e.g., avoidance, escape) continuum (Carver et al., 1989; Krohne, 1996; Tobin et al., 1989), a number of specific coping strategies have been identified. This section reviews findings from studies that have focused on these strategies, as applied to coping with the stress of being diagnosed with cancer and with its treatment regimen.

Engagement strategies. These strategies typically include: (a) problem-focusing (solving), (b) planning, (c) information seeking, (d) positive reinterpretation re·in·ter·pret  
tr.v. re·in·ter·pret·ed, re·in·ter·pret·ing, re·in·ter·prets
To interpret again or anew.

 or appraisal, (e) cognitive restraint, (f) confrontation and fighting spirit, (g) seeking social support, and (h) expressing/ventilating emotions. For the purpose of the following discussion, findings from studies on several of those strategies that share common coping elements and principles are combined.

1. Problem-focused/solving coping. This category refers to coping efforts directed at problem (e.g., stressful situations) resolution via focused planning and direct action taking. The available literature suggests that this strategy is frequently used by patients with breast and cervical cancers Cervical Cancer Definition

Cervical cancer is a disease in which the cells of the cervix become abnormal and start to grow uncontrollably, forming tumors.
 (Gotay, 1984; Heim et al., 1987; Hilton, 1989). It was generally found to have salutary sal·u·tar·y
Favorable to health; wholesome.



salutary Healthy, beneficial
 effects on global mental health (Chen et al., 1996), lower levels of depression and anxiety (Mishel & Sorenson, 1993; Morris, 1986), increased vigor (Mishel & Sorenson, 1993), but also was unexpectedly associated with poorer social adjustment (Merluzzi & Martinez-Sanchez, 1997).

2. Information seeking. Factor analytic Adj. 1. factor analytic - of or relating to or the product of factor analysis
factor analytical
 studies of coping scales, administered to people with cancer, have often reported the existence of an information seeking factor (e.g., Friedman, Baer, Lewy, Lane & Smith, 1988; Friedman, Nelson, Baer, Lane, & Smith, 1990; Gotay, 1984; Nelson, Friedman, Baer, Lane, & Smith, 1989). Empirical findings, however, suggest that information seeking was mostly unrelated to a number of indicators of psychosocial adjustment (vocational, social, familial familial /fa·mil·i·al/ (fah-mil´e-il) occurring in more members of a family than would be expected by chance.

, domestic, sexual, psychological distress psychological distress The end result of factors–eg, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with 'significant others'. See Humanistic psychology. ; Filipp, Klauer, Freudenberg, & Ferring, 1990; Friedman et al., 1988, 1990). This factor, however, was found to be positively correlated with active behavioral coping (Nelson et al., 1989), with increased vigor (Stanton & Snider, 1993), and, more recently, also with better self-rated psychological adjustment among survivors of breast cancer (Lavery & Clarke, 1996).

3. Fighting spirit and confrontation. Fighting spirit, typically measured by the Mental Adjustment to Cancer (MAC) Scale (Watson et al., 1988), is described as accepting the diagnosis of cancer while optimistically op·ti·mist  
1. One who usually expects a favorable outcome.

2. A believer in philosophical optimism.

 challenging, tackling, confronting, and recovering from cancer (Greer, 1991; Nelson et al., 1989; Watson et al., 1988). It has been implicated as a factor contributing to longer survival among people diagnosed with cancer (Greer, 1991; Greer, Morris, Pettingale, & Haybittle, 1990; Morris, Pettingale, & Haybittle, 1992; Pettingale, 1984) and, in some studies, inversely related to scores on anxiety and depression (Burgess, Morris, & Pettingale, 1988; Schnoll, Harlow, Stolbach, & Brandt, 1998; Schwartz, Daltroy, Brandt, Friedman, & Stolbach, 1992; Watson et al., 1991; Watson et al., 1994), emotional or psychological distress (Classen, Koopman, Angell, & Spiegel, 1996; Ferrero, Barreto, & Toledo, 1994; Friedman et al., 1988, 1990; Nelson et al., 1989; Nelson, Friedman, Baer, Lane, & Smith, 1994; Schnoll, Mackinnon, Stolbach, & Lorman, 1995), and positively related to active-cognitive coping and optimism (Nelson et al., 1989). Other measures of confrontation (e.g., the Confrontive Coping Scale of the WOC WOC World of Concrete (industry event)
WOC Women of Color
WOC Wound, Ostomy and Continence
WOC World Orienteering Championships
WOC Wizards of the Coast (Hasbro subsidiary) 
 Questionnaire; Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen 1986) failed to replicate these findings and even suggested a positive relationship between confrontive coping and both reported physical symptoms and psychological distress including negative affect (Hannum, Giese-Davis, Harding, & Hatfield, 1991; Manne et al., 1994; Pettingale, Burgess, & Greer, 1988). These discrepant dis·crep·ant  
Marked by discrepancy; disagreeing.

[Middle English discrepaunt, from Latin discrep
 findings might be partially due to the authors' unique conceptualizations and operational definitions of fighting spirit and confrontive coping.

4. Positive reinterpretation. This group of coping strategies has surfaced under a number of different and, at times, slightly variant names such as: cognitive restructuring Cognitive restructuring
The process of replacing maladaptive thought patterns with constructive thoughts and beliefs.

Mentioned in: Cognitive-Behavioral Therapy

cognitive restructuring,
, cognitive (re)appraisal, positive growth, focus on the positive, positive thinking, and reframing reframing (rē·frāˑ·ming),
n the revisiting and reconstruction of a patient's view of an experience to imbue it with a different usually more positive meaning in the
. This coping, among survivors of cancer, has been studied extensively and is reported to be used frequently (Berckman & Austin, 1993; Jarrett, Ramirez, Richards, & Weinman, 1992). It has been linked to higher scores on measures of mental health and psychological well-being psychological well-being Research A nebulous legislative term intended to ensure that certain categories of lab animals, especially primates, don't 'go nuts' as a result of experimental design or conditions  (Ell, Mantell, Hamovitch, & Nishimoto, 1989), positive affect (Manne et al., 1994), lower psychological or emotional distress (Carver et al., 1993; Dunkel-Schetter et al., 1992; Ell et al., 1989; Mishel, Padilla, Grant, & Sorenson, 1991; Mishel & Sorenson, 1991; Schnoll et al., 1995), lower psychiatric symptomatology (Chen, et al., 1996), and increased vigor (Schnoll et al., 1995; Stanton & Snider, 1993). This strategy, along with seeking social support, problem solving, and self-controlling, were also adopted more by those with high threat of cancer reoccurrance and high sense of control (Hilton, 1989).

5. Self/cognitive restraint. Personal control or the ability to use self-restraint is another strategy adopted by survivors of cancer to cope with the stresses evoked by the disease. It was found to be a predictor of positive psychosocial adaptation (Ell et al., 1992; Heim, Valach, & Schaffner, 1997; Manne et al., 1994) and lower distress (Morris, 1986). Others, however (e.g., Wagner, Armstrong, & Laughlin, 1995), reported that a related coping strategy, that of suppression of competing activities, was associated with poorer reported quality-of-life among survivors of cancer.

6. Seeking social support. Another coping strategy directed at defusing de·fuse  
tr.v. de·fused, de·fus·ing, de·fus·es
1. To remove the fuse from (an explosive device).

2. To make less dangerous, tense, or hostile:
 stress among people with cancer is seeking support from others. Results have generally demonstrated a positive association between seeking or reporting satisfaction with social support and decreased emotional/psychological distress (Dunkel-Schetter et al., 1992; Jamison, Wellisch, & Pasnau, 1978; Mishel & Braden, 1987; Rodrigue, Behen, & Tumlin, 1994; Stanton & Snider, 1993), better psychosocial adaptation (Heim et al., 1997), and higher subjective perceptions of well-being, albeit only in a transient manner (Filipp et al., 1990).

7. Expressing feelings. A frequently researched coping strategy, in both the general population and among survivors of cancer, is expressing or venting emotions. Its use has been linked to higher levels of depression (Keyes et al., 1987), greater psychosocial distress (Quinn, Fontana, & Reznikoff, 1986), sickness-related dysfunction (Keyes et al., 1987), and lower perceived quality-of-life (Wagner et al., 1995). However, in two studies, this strategy was also related to decreased psychiatric morbidity as measured by the General Health Questionnaire (Chen et al., 1996) and lower mood disturbance (emotional control, alternatively, was associated with mood disturbance; Classen et al., 1996).

8. Using humor humor, according to ancient theory, any of four bodily fluids that determined man's health and temperament. Hippocrates postulated that an imbalance among the humors (blood, phlegm, black bile, and yellow bile) resulted in pain and disease, and that good health was . Only a single study was found that reported the use of humor. Carver et al. (1993) found in their study that use of humor prospectively predicted lower distress among people with cancer.

Disengagement strategies. These strategies normally refer to mostly maladaptive Maladaptive
Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.

Mentioned in: Cognitive-Behavioral Therapy
 approaches to coping with stress and crisis. Included are: (a) denial (periodically extended to include selective ignoring, threat minimization, and suppression); (b) wishful thinking wishful thinking Psychology Dereitic thought that a thing or event should have a specified outcome  or fantasy; (c) problem avoidance or escape; (d) self-criticism or self-blame; (e) social withdrawal; (f) substance/chemical abuse or more generally behavioral disengagement; and (g) fatalism fa·tal·ism  
1. The doctrine that all events are predetermined by fate and are therefore unalterable.

2. Acceptance of the belief that all events are predetermined and inevitable.
 or resignation.

1.Denial. This extensively researched coping (or defensive) modality modality /mo·dal·i·ty/ (mo-dal´i-te)
1. a method of application of, or the employment of, any therapeutic agent, especially a physical agent.

 implicates cognitions and behaviors that seek toward off anxiety, minimize threat, and alleviate related distressing emotions. It has been found to be prevalent among survivors of cancer (Cooper & Faragher, 1992, 1993; Nelson et al., 1989; Wool & Goldberg, 1986). It has also been linked to: (a) higher levels of psychosocial distress (Carver et al., 1993; Quinn, et al., 1986); and (b) poorer adjustment to health care (Friedman et al., 1988). On the other hand, it has also been linked to increased feelings of well-being and psychological adjustment (Ferrero et al., 1994; Filipp et al., 1990; Heim et al., 1997). Relatedly, denial, often in the form of detachment of the seriousness of cancer diagnosis, was also related to lower mood disturbance and emotional distress (Mishel & Sorenson, 1991; Watson, Greer, Blake, & Shrapnell, 1984). It was not related to social adaptation social adaptation Psychiatry The ability to live and express oneself according to social restrictions and cultural demands  in a study by Heim et al. (1997). Denial was even found to be associated with shorter term survival in one study (Derogatis, Abeloff, & Melisaratos, 1979). A series of longitudinal studies longitudinal studies, the epidemiologic studies that record data from a respresentative sample at repeated intervals over an extended span of time rather than at a single or limited number over a short period.
, however, reversed these findings as deniers had longer survivability sur·viv·a·ble  
1. Capable of surviving: survivable organisms in a hostile environment.

2. That can be survived: a survivable, but very serious, illness.
 (Greer et al., 1990; Morris et al., 1992; Pettingale, 1984).

2. Wishful thinking. This coping strategy, conceptually related to denial, seeks to diminish negative feelings by resorting to fantasy, diversion, and distraction of thoughts (all are forms of mental disengagement) from the problem at hand. This strategy has been linked to: (a) greater psychosocial distress (Quinn et al., 1986; Stanton & Snider, 1993); (b) lower feelings of vigor (Mishel & Sorenson, 1993; Stanton & Snider, 1993); (c) lower perceived quality-of-life (Wagner et al., 1995); and (d) affective affective /af·fec·tive/ (ah-fek´tiv) pertaining to affect.

1. Concerned with or arousing feelings or emotions; emotional.

 distress, including increased depression and anxiety (Mishel & Sorenson, 1991, Mishel, et al., 1991; Parle, Jones, & Maguire, 1996). It was also marginally related to higher (increased symptomatology) scores on the GHQ (Chen et al., 1996).

3. Problem avoidance/escape. The existence of this cognitive-behavioral strategy was demonstrated in several factoral analytic studies of people with cancer (e.g., Dunkel-Schetter et al., 1992; Jarrett, et al., 1992). This strategy resembles wishful thinking and miracle seeking strategies. It also includes praying for restoration of health; preparing for the worst; avoiding other people; resorting to eating, drinking, smoking; and engaging in risky behaviors. This strategy appears to be associated mainly with: (a) increased emotional distress (Dunkel-Schetter et al., 1992; Nelson et al., 1994; Rodrigue et al, 1994; Stanton & Snider, 1993); (b) poor general psychosocial adjustment including the vocational, domestic, familial, and social domains (Friedman et al., 1988, 1990; Heim et al., 1997); (c) increased levels of anxiety (Rodrigue, Boggs, Weiner, & Behen, 1993; Watsen et al., 1994); and (d) lower degree of vigor (Stanton & Snider, 1993). A study by Schwartz et al. (1992), however, failed to detect any relationship between avoidance and measures of depression and anxiety. This strategy was also characteristic of those who demonstrated low commitment, low sense of control, and high perception of uncertainty (Hilton, 1989).

4. Self-criticism/blame. Attribution at·tri·bu·tion  
1. The act of attributing, especially the act of establishing a particular person as the creator of a work of art.

 of blame (e.g., attributing cancer to smoking, poor nutrition etc.) as a coping strategy has been only sporadically studied. Results suggest, however, that it may be associated with: (a) greater emotional distress (Berckman & Austin, 1993; Faller, Schilling, & Lang, 1995; Quinn et al., 1986), (b) increased level of depression (Faller et al., 1995), and (c) decreased general psychosocial adjustment (Heim et al., 1997).

5. Social withdrawal. As a specific form of the behavioral disengagement coping mode, social withdrawal has been seldom studied; it was, however, found to be linked to increased psychiatric symptomatology (i.e., higher GHQ scores) in a single study (Chen et al., 1996).

6. Fatalism, resignation, hopelessness, and helplessness. The coping strategies in this group all suggest passive behavioral disengagement from the source of the stress. In this case, the disengagement is giving up hope and willingness to combat cancer. Use of this set of coping strategies has been associated with: (a) higher levels of depression and anxiety (Burgess, Morris, & Pettingale, 1988; Lavery & Clarke, 1996; Parle et al., 1996; Rodrigue et al., 1993; Rodrigue et al., 1994; Schnoll et al., 1998; Schwartz et al., 1992; Watson et al., 1991; Watson et al., 1994), (b) higher emotional distress (Carver et al., 1993; Ferrero et al., 1994; Schnoll et al., 1995), (c) poorer general psychosocial adjustment (Heim et al., 1997), and (d) lower quality of life (Ferrero et al., 1994; Schnoll et al., 1998). It was even suggested that this strategy may be linked to more severe physical symptoms (Ferrero et al., 1994) and to increased rate of mortality (Greer et al., 1979; Pettingale, 1984).

Two additional coping strategies that defy exact classification into engagement and disengagement coping strategies are: (a) seeking religion and (b) acceptance (of condition, reality, responsibility for condition's management and treatment, future outcomes, etc). These two strategies suggest both recognition of the eventuality e·ven·tu·al·i·ty  
n. pl. e·ven·tu·al·i·ties
Something that may occur; a possibility.


pl -ties
 of facing a life-threatening disease as well as limited effort to directly influence its outcome. They are, therefore, discussed separately.

1. Seeking religion. Seeking comfort in, or actively relying on, religion and praying for reversal of the disease course has been reported to be more common among late stage cancer groups (Gotay, 1984). It has been found to be related to: (a) higher scores on mental health and psychological well-being (Ell et al., 1989) and (b) better adjustment to the medical aspects of cancer (Merluzzi, & Martinez-Sanchez, 1997). However, it has also been related to poorer perceived quality-of-life (Wagner et al., 1995). Searching for meaning in religion was also found to be independent of levels of well being (as an indicator of an affective state) in a sample of German survivors of cancer (Filipp et al., 1990). Finally, other researchers (e.g., Berckman & Austin, 1993) failed to find any relationship between measures of psychosocial adjustment and measures of cognitive control including those of prayer and accepting God's will Noun 1. God's Will - the omnipotence of a divine being
omnipotence - the state of being omnipotent; having unlimited power

2. Acceptance. Acceptance of one's condition, including the reality of its implications, learning to live with it, and at times, its irreversible irreversible (ir´ēvur´sebl),
adj incapable of being reversed or returned to the original state.
 course, has been found to be a common coping strategy among people with cancer (Berckman & Austin, 1993; Carver et al., 1993). It has been linked to lower psychosocial distress in one study (Carver et al., 1993). More frequently, though, it has been linked to (a) higher short-term mood disturbance and state anxiety (Watson et al., 1984), (b) increased depression and anxiety (Parle et al., 1996), (c) increased psychosocial distress (Miller et al., 1996), and (d) decreased feelings of well-being (Miller et al., 1996).

Summary of Findings from Studies of Coping with Cancer

The literature on coping with cancer suggests that:

1. Among the more global coping styles, those of adopting an internal or personal locus-of-control, optimistic outlook, and a more repressive re·pres·sive
Causing or inclined to cause repression.
 or minimizing perspective have been generally linked to lower levels of emotional distress and better psychological adaptation A psychological adaptation, also called an Evolved psychological mechanism or EPM, is an aspect of a human or other animal's psychology that serves a specific purpose, and was created and selected by evolutionary pressures.  to cancer. Avoidance, or escapism es·cap·ism
The tendency to escape from daily reality or routine by indulging in daydreaming, fantasy, or entertainment.
, on the other hand, has been associated with higher emotional distress.

2. Among the more specific coping strategies, those referred to as engagement-oriented, namely problem-focusing, having a fighting spirit, positively reinterpreting problems, using self or cognitive restraint, and seeking social support, were all predominately associated with better psychosocial indices of adaptation to cancer.

3. Coping strategies referred to as disengagement-oriented, namely wishful thinking, blaming oneself, and adopting a fatalistic or resigned attitude, were found to be related to higher levels of emotional distress and poorer psychosocial adaptation to cancer. Likewise, acceptance of cancer diagnosis and its implications, possibly signifying first-step resignation to condition, was found to be associated with poorer psychosocial outcomes.

4. Research on other coping strategies yielded conflicting or mixed results. Coping efforts via expressing feelings, denial, and seeking religion were inconsistently related to measures of psychosocial adaptation. These inconsistent findings extend to results from studies that sought to investigate the relationship between the use of denial and length of survivability following diagnosis of cancer. Further implications of these findings, their empirical validity and clinical utility, will be addressed in the final section of this paper.

Implications for Practice and Research

The reviewed research findings on coping with cancer strongly indicate the supremacy of engagement type coping strategies (e.g., fighting spirit, problem-solving, seeking social support, focusing on the positive) in bettering psychosocial adaptation among survivors of cancer. Disengagement strategies (e.g., wishful thinking, blaming oneself, resigning to the disease impact), in contrast, have been associated with poorer psychosocial outcomes among these survivors.

The findings suggest that rehabilitation rehabilitation: see physical therapy.  practitioners should focus on instilling in·still also in·stil  
tr.v. in·stilled, in·still·ing, in·stills also in·stils
1. To introduce by gradual, persistent efforts; implant: "Morality . . .
 in their clients coping skills that directly seek to: (a) enhance more positive attitudes and beliefs in one's ability to challenge the disease; (b) plan and implement strategies to address daily living problems triggered by the functional limitations (e.g., pain, fatigue, nausea) imposed by cancer and its treatment; (c) establish and maintain a supportive social network that includes the client's family, peers, and, when applicable, coworkers; and (d) reframe Re`frame´   

v. t. 1. To frame again or anew.
 negative thoughts or pessimistic pes·si·mism  
1. A tendency to stress the negative or unfavorable or to take the gloomiest possible view: "We have seen too much defeatism, too much pessimism, too much of a negative approach" 
 outlook to foster a more positive view that focuses on one's remaining abilities, realistic goals, and potential future contributions. Indeed, evidence exists that suggests the benefits of cognitive-behavioral skill training programs to promote effective psychosocial adaptation to cancer (Fawzy et al., 1990; Greer, 1987; Gordon et al., 1980; Telch & Telch, 1986).

For instance, in their landmark study, Gordon and coworkers (1980) studied the efficacy of a multifaceted mul·ti·fac·et·ed  
Having many facets or aspects. See Synonyms at versatile.

Adj. 1. multifaceted - having many aspects; "a many-sided subject"; "a multifaceted undertaking"; "multifarious interests"; "the multifarious
 program for improving the level of psychosocial functioning among cancer survivors Cancer survivors are those individuals with cancer of any type, current or past, who are still living. The National Coalition for Cancer Survivorship (NCCS) pioneered the definition of survivor as from the time of diagnosis and for the balance of life, a person diagnosed with . The interventions were composed of three broad components: (a) education which focused on providing information to patients on cancer and its treatment, on relaxation techniques Relaxation technique
A technique used to relieve stress. Exercise, biofeedback, hypnosis, and meditation are all effective relaxation tools. Relaxation techniques are used in cognitive-behavioral therapy to teach patients new ways of coping with stressful
, and on the recognition of emotional reactions to the disease; (b) counseling which encouraged patients to vent and share feelings with others, to become aware of their feelings, and to act on their environment (i.e., problem solve daily issues); and (c) their environment which assisted patients in gaining referrals to other health care personnel. As compared to a control group of cancer patients who received only psychosocial evaluation, the treatment group evidenced a more rapid decline in negative affect (i.e., anxiety, depression, hostility), experienced a more realistic outlook on life, engaged in more active use of time, and returned to work more often. The results strongly attested at·test  
v. at·test·ed, at·test·ing, at·tests
1. To affirm to be correct, true, or genuine: The date of the painting was attested by the appraiser.

 to the benefits inherent in the use of a comprehensive coping skill training program that focused on providing social and emotional support, problem identification and solving, and in general, on creating a positive, goal-directed rehabilitation atmosphere.

Another comprehensive, coping-based, psychosocial intervention psychosocial intervention Psychology A nonpharmacologic maneuver intended to alter a Pt's environment or reaction to lessen the impact of a mental disorder. See Attention-deficit-hyperactivity syndrome.  model that merits attention is that posited by Meyerowitz, Heinrich, and Schag (1983). In their model, the authors delineated de·lin·e·ate  
tr.v. de·lin·e·at·ed, de·lin·e·at·ing, de·lin·e·ates
1. To draw or trace the outline of; sketch out.

2. To represent pictorially; depict.

 a three-phase competency-based approach for cancer survivors. The phases include: (a) problem-specification, in which daily stressors, including cognitions, emotions, and situations (e.g., physical discomfort, psychological distress, job-related problems) which the client faces are identified; (b) response enumeration 1. (mathematics) enumeration - A bijection with the natural numbers; a counted set.

Compare well-ordered.
2. (programming) enumeration - enumerated type.
, in which the type and spectrum of potential responses to each problem area are determined, followed by a list of all available coping strategies to each specified problem; and (c) response evaluation, where the relative efficacy of each response for alleviating the problem is determined. Meyerowitz et al.'s model, likewise, focuses on instilling in cancer survivors those cognitive-behavioral coping skills necessary for goal setting, confronting, solving, and ultimately alleviating the problems associated with the functional limitations imposed by cancer and its treatment.

More recently, Nezu, Nezu, Friedman, Faddis, and Houts (1998) described a comprehensive problem-solving approach to coping with cancer. This therapeutic model aims at "helping individuals to understand the nature of problems in living and directs their attempts at changing the nature of the problematic situation itself, their reactions to them, or both" (p.71). Goals include: (a) identifying life situations that increase distress, (b) reducing the scope of distressing emotions and their impact on coping efforts, (c) increasing the effectiveness of problem-solving coping efforts to manage problematic situations, and (d) teaching skills that will enable the cancer survivor to deal effectively with distressing emotions and anticipated problems. To this end, the authors developed a 10-week intervention program comprised of the following phases: (a) problem orientation, (b) problem definition and formulation, (c) generation of alternatives, (d) decision making, (e) solution implementation and verification, and (f) practice and termination. This coping-oriented cognitive-behavioral approach, therefore, focuses on the use of engagement-type coping skills to help clients change both the problematic nature of the situation and the stressful emotional responses prompted by it. In sum, these models posit that the psychosocial mechanisms underlying the utility of these interventions revolve around Verb 1. revolve around - center upon; "Her entire attention centered on her children"; "Our day revolved around our work"
center, center on, concentrate on, focus on, revolve about
 enhanced self-efficacy, personal control, problem-solving ability, and realistic appraisals of current and future situations (Andersen, 1992).

Future research on coping with cancer should address the following concerns.

1. Coping is not a static, one-shot effort. Researchers should adopt longitudinal designs to more fully explore the dynamic, evolving nature of coping with cancer, and other life threatening diseases. Previous studies have reported that scores on coping with cancer scales did, indeed, vary over time (Carver et al., 1993; Ferrero et al., 1994; Heim et al., 1987). Longitudinal studies should, then, become the standard by which to assess coping efforts.

2. Failure to control for time since diagnosis. Much of the extant literature Extant literature refers to texts that have survived from the past to the present time. Extant literature can be divided into extant original manuscripts, copies of original manuscripts, quotations and paraphrases of passages of non-extant texts contained in other works,  has failed to report, or control for, variables such as time since diagnosis of disease, occurrence of cancer, and major surgeries. This false assumption, that coping efforts are invariable in·var·i·a·ble  
Not changing or subject to change; constant.

 regardless of disease progression, the effectiveness and side effects of medical interventions, and the unfolding process of psychosocial adaptation to the condition, needs to be challenged.

3. Cancer is comprised of numerous clinical subtypes. Different cancer types (e.g., breast, prostate, lung, head and neck) have been investigated and each appears to mobilize different coping efforts or, at least, different combinations of coping strategies (Dunkel-Schetter et al., 1992; Ell et al., 1989, 1992; Manuel et al., 1987; Mishel & Sorenson, 1993). Researchers should seek to delineate these differences in cancer types and coping modalities Modalities
The factors and circumstances that cause a patient's symptoms to improve or worsen, including weather, time of day, effects of food, and similar factors.
 and to study them accordingly.

4. Coping strategies are partially age-determined. Coping with life stresses and stresses generated by cancer has been determined to be partly influenced by age of respondents (Ell et al., 1992; Keyes et al., 1987; Strack & Feifel, 1996). Coping, therefore, should be assessed within the context of one's age group and information on the differential effects of age should be related to the type, context, and effectiveness of coping.

5. Direct and indirect effects of coping. Coping efforts exert both direct and indirect effects on psychosocial adaptation to disability, in general, and to cancer, more specifically. Research has suggested the role of coping modes as mediators between the individual's sociodemographic and medically-related variables and outcomes of adaptation (Beehr & McGrath, 1996; Mishel & Braden, 1987). The mediating and interactive influences of coping strategies (i.e., coping unique contribution after controlling for other variables; psychosocial adaptation outcomes at different levels of coping and stress) should be more thoroughly investigated so that the proportional contribution of each set of variables (sociodemographic, medical, coping) to psychosocial adaptation can be better understood and appreciated.

6. Unresolved conceptual issues of coping. Perspectives on the nature, function, and structure of coping are widely divergent. Future theoretical developments and empirical research Noun 1. empirical research - an empirical search for knowledge
inquiry, research, enquiry - a search for knowledge; "their pottery deserves more research than it has received"
 should address these issues. For example, Parle and Maguire (1995) suggested a distinction between primary coping or coping efficacy (e.g., coping to relieve pain, to improve level of support) and secondary coping or coping effectiveness (e.g., the impact of coping on mental or physical health). In a similar vein, coping styles or strategies (the actual cognitive-affective-behavioral efforts) should be distinguished from coping resources (the material and social supports available in one's community; Glanz & Lerman, 1992; Pierce, Sarason, & Sarason, 1996). Also, the notion that variant coping strategies (e.g., emotion-focused versus problem-focused, direct or active versus indirect or passive coping) do serve useful purposes, depending on the nature, controllability, and duration of the crisis or stressful event, must be recognized by theoreticians and practitioners.

To summarize, the literature on coping strategies with cancer suggests that, as compared to disengagement-type strategies (e.g., wishful thinking, blaming self, resigning to fate), engagement coping strategies (e.g., problem-solving, fighting spirit, seeking social support) provide the cancer survivor with a useful and often effective mode of attaining a more successful psychosocial adaptation to the disease. Although these findings should be regarded as only preliminary in nature because of conceptual and methodological limitations inherent in several of the studies, they do suggest that the adoption of so-called adaptive coping (and the refraining from the use of maladaptive coping) strategies is, indeed, associated with decreased psychosocial distress and increased personal well-being.


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Hanoch Livneh Portland State University

Hanoch Livneh, Professor and Coordinator, Rehabilitation Counseling rehabilitation counseling,
n counseling started in the United States in 1920 to assist individuals disabled by industrial accidents; originally included physical, psychologic, and occupational training; expanded over the next 70 years and laid the
 Program, School of Education, Portland State University, P.O. Box 751, Portland, OR 97201.
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Author:Livneh, Hanoch
Publication:The Journal of Rehabilitation
Date:Apr 1, 2000
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