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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 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) 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 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: (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 scores on coping scales (e.g., confrontation, seeking social support, planful problem solving); 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, amputations, diabetes, rheumatoid arthritis, multiple sclerosis, chronic pain, traumatic brain injury, and asthma.

Results from these and other studies strongly suggest that coping plays a significant role during the process of psychosocial 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 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 conditions imply different functional (e.g., mobility, manipulation, fatigue, cognitive) limitations, medical courses and prognostic indicators (e.g., deteriorating, unpredictable, stable), related health problems, treatment modalities, 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 (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 and containing fears of death, pain, and disfigurement. 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, 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, fighting spirit, information seeking)

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 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). 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 attitude toward the disease.

Optimism versus pessimism. Studies of the role of dispositional optimistic 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 awareness of affects and impulses. Sensitization, or as it is occasionally termed, monitoring, exaggerating, 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 of the cancer's negative aspects, emerged as the variable most strongly associated with decreased levels of distress among women who underwent mastectomy (Meyerowitz, 1983). Ward, Leventhal and Love (1988) reported that repressors had fewer and less severe chemotherapy-induced side effects. 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, 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, head and neck, and breast cancers (Keyes, Bisno, Richardson, & Marston, 1987; Shapiro, Rodrigue, Boggs, & Robinson, 1994; Shapiro et al., 1997; Steptoe, Sutcliffe, Allen, & Coombes, 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, 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 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 (Gotay, 1984; Heim et al., 1987; Hilton, 1989). It was generally found to have salutary 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 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, domestic, sexual, psychological distress; 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 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 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 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 (re)appraisal, positive growth, focus on the positive, positive thinking, and reframing. 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 (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 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. 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 approaches to coping with stress and crisis. Included are: (a) denial (periodically extended to include selective ignoring, threat minimization, and suppression); (b) wishful thinking 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 or resignation.

1.Denial. This extensively researched coping (or defensive) modality 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 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, however, reversed these findings as deniers had longer survivability (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 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 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 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.

2. Acceptance. Acceptance of one's condition, including the reality of its implications, learning to live with it, and at times, its irreversible 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 or minimizing perspective have been generally linked to lower levels of emotional distress and better psychological adaptation to cancer. Avoidance, or escapism, 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 practitioners should focus on instilling 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 negative thoughts or pessimistic 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 program for improving the level of psychosocial functioning among cancer survivors. 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, 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 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 model that merits attention is that posited by Meyerowitz, Heinrich, and Schag (1983). In their model, the authors delineated 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, 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 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 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 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 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 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 Program, School of Education, Portland State University, P.O. Box 751, Portland, OR 97201.
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