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Psychosocial Adaptation to Heart Diseases: The Role of Coping Strategies.

This paper reviews the literature on the role of coping styles and strategies in psychosocial adaptation to a major threatening disability, namely heart disease. Following a general discussion of the concept of coping and its role within the context of coping with chronic illnesses and disabilities, the research literature on coping with cardiac disease is reviewed. The paper concludes with a summary of the findings on coping with the condition and offers rehabilitation-related clinical and research implications.

Clinicians and researchers have shown increasing interest in the study of the relationship between coping strategies and psychosocial adaptation to stressful life events (Billings & Moos, 1981; Endler, Parker, & Summerfeldt, 1993), loss and trauma (Gass & Chang, 1989; Katz & Florian, 1986), and disease and disability (Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992; Hanson, Buckelew, Hewitt, & O'Neal, 1993). The study of coping, however, has resulted in a fragmented body of theoretical clinical and empirical data often marred by divergent definitions, models, measures, and levels of complexity. Definitions and conceptualization of coping have spanned a wide range of views including: (a) coping as a personality trait or disposition versus coping as a situational-based or state-like effort; (b) coping strategies as inherently adaptive, reality-based, conscious, and purposive approaches versus coping or defense strategies as global, primarily intrapsychic reality-distorting, rigid, and maladaptive processes; and (c) the nature of the coping classification (e.g., approach versus avoidance coping, instrumental/active versus affective/passive coping, adaptive versus maladaptive coping) (Billings & Moos, 1984; Haan, 1977; Holahan, Moos, & Schaefer, 1996; Lazarus & Folkman, 1984).

Similarly, efforts to address global assessment concerns and specific research and measurement issues in the field of coping have encountered numerous obstacles. Most common are those stemming from: (a) the hierarchical nature of coping (i.e., coping assessed as ranging from a global, dispositional level, through intermediate level strategies, to specific, behavioral-level coping acts); (b) the contextual level of coping (i.e., coping as assessed transsituationally versus coping as geared toward specific situational demands); (c) the dimensionality of coping (i.e., the dimensions or groups of coping strategies have been conceived as ranging from 2 to almost 30 separate classes or scales); (d) coping viewed as an independent variable (e.g., a predictor of future adaptation to a stressful event), as a dependent variable (e.g., a criterion or outcome, partially determined by personality or situational characteristics), and as a mediator (e.g., a mediator between disease - or disability-related variables and long-term psychosocial adaptation); and (e) treating the measurement of coping strategies as representing raw scores (i.e., effort frequencies) versus adopting an ipsative scoring system (i.e., relativeness or percentage of efforts of coping strategies) (Endler & Parker, 1990; Krohne, 1993; McCrae, 1984; Vitaliano, Maiuro, Russo, & Becker, 1987).

Despite these varying efforts at conceptualizing, defining, structuring, assessing, and measuring coping, an impressive body of knowledge has accumulated in the past quarter century on the role coping efforts play in psychosocial adaptation to numerous human situations. Representative examples of these situations are: (a) daily stresses and hassles; (b) occupational stresses; (c) personal losses; (d) substance abuse; (e) physical and psychosocial traumas; (f) chronic pain; and (g) chronic illnesses and diseases (e.g., Cole & Reiss, 1993; Moos, 1984, 1986; Zeidner & Endler, 1996).

This paper seeks to: (a) briefly outline the parameters that demarcate the role coping plays in psychosocial adaptation to chronic illnesses and disabilities; (b) review the literature on coping with chronic, life-threatening illnesses and disabilities; and (c) provide clinicians with broad recommendations on how to refine their efforts to better appreciate the role of coping in psychosocial adaptation to chronic illnesses and disabilities.

Coping with Chronic Illnesses and Disabilities

The literature on coping with chronic illnesses and disabilities may be classified according to both modes (often referred to as strategies, ways, or types) of coping and target populations. Modes of coping have been variably conceptualized along a number of dimensions or across several theoretically-based approaches. A review of the extant literature suggests that the most common classification of coping includes three broad classes(1) of approaches: (a) behavioral (e.g., action-oriented, instrumental, problem-focused), (b) affective (e.g., emotion-focused), and (c) cognitive (e.g., planning, mental-oriented) (Hainsworth, Eakes, & Burke, 1994; Kiely, 1972; Lipowski, 1970; Weisman, 1984).

Behavioral coping strategies typically refer to where the person either (a) directly and actively tackles or confronts the source of the stressful situation, or (b) avoids, escapes or withdraws from its presence. Affective coping strategies include individual attempts to regulate emotional reactions (e.g., depression, anxiety, anger, shame) via ventilating feelings, blaming self or others for the situation, accepting one's feelings, or resigning to the impact or permanency of the condition. Cognitive coping strategies include either (a) minimizing, denying, or ignoring the source or impact of the stressful events, or (b) focusing on (e.g., hypervigilance) or attending to it.

Components of these general coping strategies have been clinically and empirically reported among people with a wide range of chronic illnesses and disabilities. This range includes: (a) life-threatening conditions such as cancer and heart diseases (e.g., Dunkel-Schetter et al., 1992; Feifel, Strack, & Nagy, 1987; Keckeisen & Nyamathi, 1990), (b) orthopedic conditions such as spinal cord injuries and amputations (e.g., Dunn, 1996; Hanson et al., 1993; Nieves, Charter, & Espinall, 1991), (c) systemic disorders such as diabetes (e.g., Frenzel, McCaul, Glasgow, & Schaefer, 1988), (d) inflammatory diseases such as rheumatoid arthritis (e.g., Zatura & Manne, 1992), (e) neuromuscular disorders such as Parkinson's disease and multiple sclerosis (e.g., Ehmann, Beninger, Gawel, & Riopelle, 1990; Wineman, Durand, & Steiner, 1994), (f) pain patients (e.g., Brown & Nicassio, 1987; Rosenstiel & Keefe, 1983), and (g) neurological conditions such as traumatic brain injury and epilepsy (e.g., Garske & Thomas, 1992; Kaplan & Wyler, 1983). Results from these studies and from recent reviews of the literature on coping with personal losses, chronic disease, and physical disabilities (Livneh & Antonak, 1997; Maes, Leventhal, & de Ridder, 1996; Katz & Florian, 1986-87) suggest the following:

1. Different chronic illnesses and disabilities necessitate differential use of coping strategies to combat the stress associated with each condition's functional limitations, environmental involvement, and long-term impact. Furthermore, during the course of each chronic disease, different coping strategies are adopted to meet the conditions imposed by each disease's medical status, specific health problems, treatment modalities, psychosocial reactions, and also prognostic indicators (Andersson & Ekdahl, 1992; Felton & Revenson, 1984, 1987; Helgeson, 1992).

2. Models of coping specifically developed to address disability-generated stress typically include the following components: (a) the efforts directed at solving the various problems triggered by these medical conditions; (b) the unfolding process (i.e., time-based) originated by the onset of the condition and its adaptability to fluctuating internal and external conditions; (c) the spectrum of specific coping responses and behaviors directed at dealing with the chronic disease; and (d) the interactive nature of the disease features (e.g., severity, degree of pain, functional involvement), the individual's enduring personality attributes, and the context within which one functions (e.g., work, home, community) (Leventhal & Nerenz, 1983; Maes et al., 1996).

3. Coping with chronic illnesses and disabilities is often viewed as hierarchical in nature, with "superstrategies" or generalized coping styles placed at the top. These are typically categorized into two (e.g., problem - versus emotion-focused, active versus passive, coping versus succumbing, adaptive versus maladaptive), three (e.g., behavioral-focused, cognitive-focused, and emotional-focused), or four (e.g., problem-focused, reappraisal, reorganization, avoidance) higher order coping categories (Billings & Moos, 1981; Krohne, 1996; Lazarus & Folkman, 1984; Mikulincer, & Florian, 1996).

4. Coping efforts are viewed either as directly associated with psychosocial adaptation to chronic illness and disability or as mediating variables between a wide range of disability-related, sociodemographic, other personality attributes, and environmental conditions, and adaptation to chronic illness and disability. The latter is normally depicted along a negative-positive cognitive/affective-based dimension (e.g., negative-positive self-concept, psychological/emotional well-being, degree of psychological distress) (Lipowski, 1970; Maes et al., 1996; McNett, 1987).

Cardiac disease is a primary example of a life-threatening chronic disease (Falvo, 1991). In addition to being the leading cause of death among American adults, it is also one of the most anxiety provoking and, therefore, coping-mobilizing impairments (Johnson & Getzen, 1992). The remainder of this paper, therefore, focuses on those studies that have directly explored the role of coping strategies in dealing with cardiac diseases.

Coping with Cardiac Disease

Earlier research on coping with cardiac disease, and the impact of myocardial infarction (MI) in particular, focused almost exclusively on the role played by denial (typically viewed as a traditional psychodynamic defense mechanism) in warding off death-related anxiety. A secondary goal was to classify patients into "denying" and "nondenying" groups or types. Patients were typically assessed in both the coronary care unit and later at their homes or communities (Croog, Shapiro, & Levine, 1971; Faller, 1990; Gentry, Foster, & Haney, 1972; Hackett & Cassem, 1974; Hackett & Weisman, 1969; Levine & Zigler, 1975; Miller & Rosenfeld, 1975; Olin & Hackett, 1964; Sullivan & Hackett, 1963). Most of these studies relied on Hachett and Cassem's (1974) Denial Scale, or on physicians' interviews with patients, as the sole measure of reporting denial behavior. In an earlier review of cognitive processes inherent in psychosocial adaptation to MI, Krantz (1980) concluded that the use of denial best explains immediate in-hospital reactions to the experience of MI (i.e., denial as a defensive maneuver to minimize anxiety). The effectiveness of denial, however, has not been supported to account for long-term, post-discharge psychosocial outcomes (Krantz, 1980).

In a series of investigations on the effect of denial on mood and on functioning level among survivors of MI, Soloff and his colleagues (Soloff, 1977-78, Soloff, 1980; Soloff & Barrel, 1979) concluded the following: (a) denial may have an instrumental role in decreasing anxiety, and possibly mortality, during the acute phase of convalescence, but its use may be hazardous during the later phases of convalescence, when non-compliance with medical care increases the risk of reinfarction; (b) using the Hackett-Cassem Denial Scale, deniers (as compared to non-deniers) reported less initial mood disturbance on all subscales of the Profile of Mood States (POMS) and those between-groups differences were still maintained following a 6-week cardiovascular rehabilitation program, and at a 3-month follow-up; and (c) no differences were found between deniers and non-deniers on measures of compliance or perceived quality of functioning. Despite its salutary effect on mood level of persons with cardiac disease, the use of denial has also been implicated as a factor in: (a) reducing patients' information gain about heart disease (Shaw, Cohen, Doyle, & Palesky, 1985); (b) augmenting the risk for further coronary disease when coupled with low reported levels of tension (Dimsdale & Hackett, 1982); and (c) increasing non-compliance with medical regimen and duration of rehospitalization at a 1-year follow-up of recovering heart patients (Levine et al., 1987).

More recent research on coping with cardiac disease has broadened in scope to include: (a) investigations of other coping approaches, (b) the use of additional and more psychometrically sound general measures of coping (e.g., the Jaloweic Coping Scale, the Ways of Coping Questionnaire), and (c) coping with heart disease more specifically (the Levine Denial of Illness Scale). Research has, indeed, demonstrated that persons with cardiac disease employ a wide range of global (e.g., active, optimistic) and specific (e.g., confrontive, venting feelings, information-seeking) coping modes (King, 1985; Miller, Garrett, McMahon, Johnson, & Wikoff, 1985; Scherck, 1992). The discussion of the more recent efforts to investigating coping among people with heart disease focuses on reviewing: (a) studies that sought to investigate higher level coping styles and (b) studies directed at more specific, lower level coping strategies employed by individuals with cardiac disease.

General Coping Styles with Cardiac Disease

A growing body of research has accumulated on the relationship between global coping styles and measures of psychosocial adaptation to heart disease. This research has focused mainly on: (a) repression versus sensitization, (b) problem-focused versus emotion-focused coping, (c) adaptive versus maladaptive coping, (d) dispositional optimism, (e) hardiness and sense of coherence, and (f) active versus passive coping.

Repression versus sensitization. In two early studies, Brown and Rawlinson (1976, 1977) sought to investigate the relationship among a variety of medical, psychosocial (including coping style), and demographic variables on the morale (measured by an index of self-satisfaction) and long-term work adjustment of persons following open heart surgery. Repressing (rather than sensitizing) coping style was found to predict long-term morale in both sexes. On the other hand, these coping styles failed to predict work resumption among either males or females.

Shaw et al. (1985) investigated the effect of repressive style on information gain and rehabilitation outcomes in a sample of patients who sustained MI. Their findings suggested that: (a) repressors gained less information about heart disease and its risk factors, (b) high-risk repressors reported more medical complications and lower levels of medical and psychological functioning at 6-month follow-up, and (c) low risk sensitizers reported poorer levels of social functioning.

Denollet and colleagues (Denollet, 1991; Denollet & De Potter, 1992) identified several coping subtypes among a sample of Belgian coronary patients (i.e., negative affectivity, inhibition, and repression). Negative affectivity was viewed in a similar fashion to sensitization (high likelihood of experiencing generalized distress), while repression was seen as manifesting a tendency to avoid distress or threatening information. Results of their studies conveyed that: (a) patients who scored high on negative affectivity (i.e., sensitizers) reported more depression, psychological distress, and health complaints than repressors; (b) those with high degree of negative affectivity also reported more somatic distress (e.g., increased chest pain) than those labeled repressors; (c) repressors had lower scores on a measure of hostility and Type A personality style (e.g., a tendency characterized by open hostility, time urgency and perfectionism) than sensitizers; (d) patients with high negative affectivity were less likely to return to work than their repressive counterparts; and (e) no association was found between coping style and cardiovascular fitness.

Problem-focused versus emotion-focused coping. In a study of patients who survived MI, those who used a more general problem-solving coping style reported better social and psychological adjustment following hospital discharge than those using a more global emotional-focused coping style (Keckeisen & Nyamathi, 1990). In a somewhat related manner, Webster and Christman (1988), and Christman, McConnell, Pheiffer, Webster, Schmitt, and Ries (1988), measured the perceived uncertainty and coping (affective-oriented and problem-oriented) on emotional distress among individuals recovering from MI. Results showed that increased levels of uncertainty or ambiguity were associated with greater use of affective-oriented coping, while decreased uncertainty was linked to greater use of problem-oriented coping. Their results also showed that those who reported using affective-oriented coping more frequently also reported higher levels of emotional distress, notably anxiety and depression. Moreover, those who reported greater use of problem-solving coping experienced lower levels of emotional distress. Finally, a study by Terry (1992) further demonstrated the relationship between emotion-focused coping and increased levels of psychological symptomatology (e.g., state anxiety), disruption of social and recreational activities, and poor personal ratings of global coping effectiveness among individuals who survived MI.

Adaptive versus maladaptive coping. In a study of post-MI patients, participants were cluster analyzed into two groups based on their responses to a structured interview. These two groups were adaptive copers (i.e., those who scored high on a measure of behavioral compensation for stress) and maladaptive copers (i.e., those who scored high on measures of internal anger and hostility). The maladaptive group reported a greater degree of distraction from cardiac symptoms, more relief-seeking behaviors, and increased perceived vulnerability to future heart attacks (Nolan & Wielgosz, 1991). Holahan, Holahan, Moos, and Brennan (1995, 1997) also reported that the use of adaptive coping strategies (i.e., active, approach-oriented coping) predicted a lower level of depressive symptoms, as compared to the use of maladaptive (i.e., avoidant) coping, among older individuals with cardiac illness.

Finally, Bruce, Bruce, Hossack, and Kusumi (1983-84) studied generalized coping strategies in patients before and after coronary bypass surgeries. They reported that those classified as "compartmentalizers" (i.e., reacting realistically to illness, behaving normally; as indicators of adaptive coping) were more frequently working after surgery. Those classified as "generalizers" (i.e., preoccupying with symptoms or illness, performing poorly on life activities, demonstrating inappropriate emotions; as indictors of maladaptive coping), on the other hand, had higher pre-surgery frequency of psychiatric symptoms and showed less post-surgery improvement.

Active versus passive coping. Active coping was found to be associated with an extraversion disposition among survivors of MI (Martin, 1989). More important, however, active coping was successfully indicated by measures of self-reflection, achievement-oriented behaviors, and the ability to revise one's expectations. Passive coping, on the other hand, was suggested by higher levels of denial, evasive reaction, and depression. Contrary to the researcher's expectations, passive coping was not associated with level of anxiety. In a subsequent study (Martin & Lee, 1992), the researchers reported that active coping (as an outcome variable) was best predicted by the survivors' experience with prior stressful life events, while lower socioeconomic status best predicted passive coping. No attempt was made to investigate the relationship between passive coping (viewed as composed of self-devaluation, denial, blame, and evasion) or active coping (perceived as comprised of problem-solving and self-reflection) and psychosocial adaptation to the onset of MI.

Dispositional optimism. In a longitudinal study of persons who underwent coronary bypass surgery, Scheier et al. (1989) reported that optimism was found to be an important predictor of both the use of specific coping strategies and surgical outcomes. Optimism was positively correlated with problem-focused coping and negatively correlated with denial. Optimism was also linked to a faster physical recovery during hospitalization and, subsequently, to a faster return to normal life activities. Finally, optimism was also associated with post-discharge perceived quality-of-life in this group. Other studies also documented the salutary effect of optimism on the lives of persons with cardiac illness (e.g., Chiou, Potempa, & Buschmann, 1997). In a similar manner, lack of optimism or having a pessimistic attitude, as often reflected in negative affectivity, was found to be linked to life dissatisfaction and to feelings of fear and anxiety (Wiklund, Sanne, Vedin, & Wilhelmsson, 1984).

Hardiness and sense of coherence. Three studies have reported the relationship between Kobasa's hardiness construct (as measured by three interrelated sets of beliefs on commitment, control, and challenge), Antonovsky's sense of coherence construct (as measured by the ability to create cognitive and emotional meaningfulness in one's life as well as to problem-solve internal and external demands), and mental health status among Israeli post-MI patients. The authors (Drory & Florian, 1991, 1997, 1998) concluded that: (a) personality hardiness was the most salient predictor of psychosocial adjustment as reflected in higher scores on the health care, vocational, familial, social, and psychological adjustment domains of the Psychosocial Adjustment to Illness Scale (PALS) and (b) a sense of coherence successfully predicted patients' psychological well-being at the end of their convalescence period as well as lower levels of psychological distress (depression and anxiety). A similar psychological construct, self-efficacy, was also found to be associated with decreased level of psychological distress among survivors of MI (Terry, 1992).

Specific Coping Strategies with Cardiac Disease

Within the more global categorization of coping strategies into engagement and disengagement approaches, a number of strategies have been identified that relate directly to coping with cardiac disease. The following discussion focuses on these strategies.

Engagement strategies. Engagement strategies normally refer to strategies that are labeled: (a) problem-focused, (b) information-seeking, (c) confrontation, (d) positive reappraisal, and (e) seeking social support. The relationship between these coping strategies and psychosocial adaptation to cardiac disease is explored in the following paragraphs.

1. Problem-focused coping. Although the use of problem-focused coping has been found to be negatively related to emotional distress and depressive symptomatology in several studies (e.g., Garcia, Valdes, Jodar, Riesco, & De Flores, 1994; Holahan, et al., 1995, 1997), other studies (e.g., Terry, 1992) failed to demonstrate its facilitative impact on psychosocial adaptation among people who sustained MI.

2. Information-seeking coping. In a longitudinal study, information-seeking was found to be the most frequently used coping strategy among patients who underwent coronary bypass surgery (King, 1985). It was rated by these patients as the most helpful strategy during the pre-operative period. Investigators of a direct relationship between information-seeking and psychosocial adaptation to cardiac disease have not been found in the research literature.

3. Confrontive coping. In studies by Christman et al. (1988) and Scherck (1992), confrontive coping was rated by patients as the most or second most frequently used coping mode with the stress engendered by acute MI. It was, however, found to be unrelated to levels of emotional distress, before or after hospital discharge in these patients (Christman et al., 1988).

4. Positive reappraisal. Cognitive efforts to restructure a problem in a positive manner were found to be associated with decreased depressive symptoms among older individuals with cardiac illness (Holahan et al., 1995, 1997). In her previously mentioned research, King (1985), however, reported that the study's sample used positive thinking less frequently than five other coping strategies (e.g., information-seeking, direct action). Moreover, in King's (1985) study, positive-thinking, was the only coping strategy to remain stable over time (from presurgery to follow-up of patients who underwent coronary bypass surgery). This finding is in sharp contrast to the results of Stewart, Hirth, Klassen, Makrides, and Wolf (1997) who found positive reappraisal to be one of the two most frequently used strategies among hospital readmitted patients with heart disease.

5. Seeking social support. King (1985) found that, among persons who underwent coronary bypass surgery, turning to others for social and emotional support changed appreciably from the pre-operative period to the discharge from hospital and, finally, at the follow-up. The use of seeking social support increased steadily during the 3 weeks of the study. Stewart et al. (1997) reported that seeking social support was the most frequently used strategy in their sample of people with heart disease. No studies measuring the effect of seeking social support on psychosocial adaptation to cardiac disease were located. The findings of Holahan et al. (1995, 1997), however, documented the salutatory contribution of social (i.e., work, family, social network) support as an available resource to alleviating patients' level of depression.

Disengagement strategies. Investigations of disengagement strategies have focused primarily on the efforts of persons with cardiac disease to: (a) deny the impact or severity of their condition, (b) avoid or escape the problems or issues necessitated by its onset, (c) seek distraction from the disease's constant presence (e.g., diversion of attention, wishful thinking), and (d) resort to "traditional" (i.e., psychoanalytically derived) defense mechanisms.

1. Denial. Denial has been the most extensively researched coping strategy among people with cardiac disease. Several types of denial appear to exist, such as denial of illness, denial of impact, denial of affect, and suppression of thoughts about the illness (Havik & Maeland, 1986, 1988; Jacobsen & Lowery, 1992). Most research efforts, however, failed to distinguish among these types. Review of the available empirical research yields the following findings: (a) greater level of denial was associated with decreased degree of reported pain but showed no relationship to measures of anxiety and depression among people recovering from MI (Billing, Lindell, Sederholm, & Theorell, 1980); (b) both high and low, but not intermediate, levels of denial (along with compliance with medical regimen) accounted for positive outcomes in psychological symptomatology (as measured by the GHQ) among individuals with heart disease; (c) increased denial of illness was associated with lower levels of previous cardiac disease and less severe medial index of MI (Havik & Maeland, 1986); (d) increased denial of illness was associated with fewer problems in physical activities, work, and sexual activities, and with lower mortality rates (Havik & Maeland, 1988); (e) increased denial of MI impact was associated with better emotional adaptation but also marginally with higher mortality rates (Havik & Maeland, 1988); (f) high level deniers spent less time in the hospital and during that time showed fewer signs of cardiac dysfunction as compared to low level deniers, but at 1-year follow-up the former group demonstrated poorer levels of adaptation than the low denial group (Levine et al., 1987); (g) high levels of denial were associated, but only during earlier phases of recovery from cardiac illness, with lower levels of systolic blood pressure (Warrenburg et al., 1989); and (h) higher levels of denial among Spanish survivors of MI were negatively related to levels of anxiety and depression and also to general measures of psychopathology (Garcia-Esteve, Valdes, Riesco, Jodar, & De Flores, 1992).

2. Avoidance/escapism. Avoidance or evasive coping has been conceptualized as a global dimension of coping (Krohne, 1996). Avoidance coping has also been conceptualized as containing elements involving people-oriented, situation-oriented, and task-oriented avoidance responses (Parker & Endler, 1996). Use of escape-avoidance coping was associated with increased levels of depression among elderly patients with coronary artery disease (Landreville & Vezina, 1994). Avoidant coping strategies were found to be prevalent in a sample of Taiwanese survivors of MI (Chiou et al., 1997). Avoidant coping strategies were also found to be associated with increased severity of psychopathology, mostly symptoms of depression and emotional distress, among Spanish survivors of MI (Garcia et al., 1994). In contrast, avoidant strategies, in another study (De Jong et al., 1994) failed to explain additional variance in levels of anxiety among Dutch patients prior to their undergoing cardiac surgery, after controlling for sociodemographic variables and initial levels of anxiety. Positive correlations, however, were reported between measures of anxiety and avoidant coping strategies.

3. Distraction. Unlike its more passive counterpart of avoidant coping strategies, distraction coping is viewed as a more active form of seeking escape from stressful situations. In the only study located, De Jong et al. (1994) reported that, although distraction coping showed positive correlation with initial (in-hospital) measures of anxiety among patients with cardiac disease, it failed to show any unique contribution to outcome measures of anxiety after controlling for patients' sociodemographic variables and initial levels of anxiety.

4. Use of traditional defense mechanisms. Only one study was located that focused on the relationship between traditionally-defined, psychodynamic defense mechanisms and adaptation to coronary disease. Peglar and Borgen (1984) reported the findings of a 5-year follow-up of responses of males with coronary heart disease to the Defense Mechanisms Inventory (DMI; Gleser & Ihilevich, 1969). Peglar and Borgen found that: (a) principalization (i.e., intellectualization or "splitting off" affect from content) was the most successful defense, while projection the least successful, in lowering level of anxiety; (b) principalization was also correlated with longer survival while projection was associated with higher mortality rate; (c) when patients' responses to the DMI were cluster analyzed, those who were classified under high principalization/low reversal (i.e., intellectualizing while responding positively to frustrating situations) were judged to cope best, based on their health perceptions and 5-year survival rate; and (d) those classified under high projection/high turning against objects (i.e., justifying expression of aggressive tendencies toward frustrating external objects) were the least successful copers.

Summary of Findings from Studies of Coping with Cardiac Disease

The literature on coping with heart disease and MI suggests that:

1. Among the broader, dispositional-like coping approaches, some preliminary support has been obtained to link repressive style, problem- or approach-oriented coping, optimistic outlook and hardy disposition/sense of coherence with indices reflecting increased psychosocial adaptation to cardiac disease. Sensitizing style and an affective-oriented coping style were generally associated with increased degrees of psychosocial and medical distress.

2. Among the specific, behavior-like coping efforts, the scant literature reflects mixed findings on the relationship between engagement-type coping strategies and psychosocial adaptation to cardiac disease. Mixed findings are also found when the relationship between disengagement-type strategies and psychosocial adaptation to cardiac disease has been explored. These mixed findings suggest that neither class of strategies is consistently linked to successful adaptation to the disease.

3. The coping strategy of denial has been studied in numerous research efforts. The findings suggest that denial is generally positively related to increased psychosocial adaptation and decreased levels of physical, medical, and emotional distress in the early phases of convalescence following MI or the impact of other cardiac diseases. The research on the impact of denial upon the distanced periods of psychosocial adaptation to the disease, medical-functional indices, and survival rate generally yielded mixed findings.

Rehabilitation Implications

What are the clinical utility and implications of these findings for rehabilitation practitioners? It could be argued that practitioners who adopt a more skill-building or skill-training approach to the rehabilitation of persons who survive cardiac disease should consider focusing on instilling in their clients more active, problem-focused, and approach-oriented coping skills. But at the same time, clients should not be discouraged from resorting, at least temporarily, to disability minimization or denial coping strategies, to cognitively offset the pernicious impact of the impairment and its potential future implications. Additionally, because coping effectiveness is often enhanced through the use of cognitive-behavioral skill training (Devins & Binik, 1996; Meichenbaum, 1977), rehabilitation practitioners may benefit from employing this skill training. Types of cognitive-behavioral skill training are problem solving, decision making, goal attaining, cognitive restructuring and reframing, self monitoring, progressive relaxation, and stress inoculation. Employing these programs, rehabilitation practitioners may help their clients to improve their skills of managing stress, emotional distress, and enhancing well-being.

For instance, Brown and Munford (1983-84) reported a pilot study in which survivors of MI and their spouses were taught coping skills that included muscle relaxation, imagery-based desensitization, stress and anger management, activity scheduling, and cognitive restructuring. Findings showed that training in a combination of these coping skills resulted in decreased levels of depression, as measured both immediately post-treatment and at 1 year follow-up. Subramanian and Ell (1989) described a coping skill-based approach geared toward meeting the psychosocial needs of lower socioeconomic status, minority group members who sustained MI. Their approach consisted of three main goals including (a) providing participants with information about their disability, availability of community resources, and management of life stressors; (b) increasing participants coping skills, through a primarily group-based, psychoeducational approach that focused on teaching problem-solving skills and assertiveness training; and (c) teaching cognitive coping skills, to assist participants in gaining awareness of dysfunctional thought patterns and developing positive thinking to manage stressful feelings. The authors asserted that this unique program in coping skills is geared toward assisting participants in lowering levels of stress, enhancing feelings of personal control, and attaining overall better psychosocial adaptation. These two examples provide preliminary clinical observations on the strengths inherent in coping-based training programs to foster the use of problem-focused, action-oriented, and social-based coping among survivors of MI and, thus, to foster their psychosocial adaptation.

However, several conceptual and methodological limitations, inherent in the literature reviewed, may compromise these clinical observations. Briefly, these limitations include:

1. Theoretical and operational confounding of definitions and measurements of coping strategies. Frequently, indicators and scale items of coping strategies overlap among conceptually different coping subscales. Also, psychosocial adaptation to disability (e.g., cardiac disease) is perceived and measured rather broadly and inconsistently. Varying indicators of psychosocial adaptation include, but are not limited to: (a) degree of psychological distress, (b) specific psychological symptoms such as anxiety and depression, (c) quality-of-life indicators, and (d) level of life satisfaction.

2. Reliance on isolated or cross-sectional, rather than longitudinal, research designs. This prevalent procedure reduces coping to a static, one-shot event, rather than treating it as a dynamic, evolving construct.

3. Failing to report, or not controlling for, time since diagnosis of disease or occurrence of major surgery. Not considering duration of disabling condition, as a viable research variable, reflects a false assumption that coping efforts are invariable regardless of disease progression, the success of medical intervention, and the unfolding process of psychosocial adaptation to the condition.

4. Confusing internal, psychologically-determined coping efforts (e.g., problem-focusing, venting emotions) with external, environmentally-based coping resources (e.g., availability of financial support, nature of existing social network).

5. Drawing conclusions from small and periodically biased study samples (e.g., using self-selected individuals, relying on data from highly homogenous geographical locations, focusing on narrow age groups).

Taken together, then, these definitional, conceptual, measurement and inferential limitations raise a major concern of the validity of the reported findings. Yet, as is the case with data obtained from research conducted in any new field, these conceptual developments and empirical data should be regarded as the initial and necessary phases toward paving a way to achieving a more useful and empirically sound research on coping with the aftermath of life-threatening physical disabilities.

Author's Note

(1) In Lazarus and his coworker's model (e.g., Lazarus, 1993; Lazarus & Folkman, 1984) the function of emotion-focused coping is viewed as addressing both affective (mitigating stress by emotional means) and cognitive (mitigating stress by attending to the situation with avoidance or vigilance) domains.

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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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Publication:The Journal of Rehabilitation
Date:Jul 1, 1999
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