Introduction
In modern times, chronic illnesses are becoming increasingly common. In the twenty-first century, the leading causes of death in the United States are chronic diseases, as opposed to the beginning of the previous century, when infectious diseases were more rampant. Chronic illnesses are diseases that are long in duration, have multiple risk factors, have a long latency period, are usually noncontagious, cause greater and progressive functional impairment, and are generally incurable. Examples of common chronic illnesses include heart diseases (such as coronary heart disease and hypertension), cancers (malignant neoplasms), chronic obstructive lung diseases (bronchial asthma, emphysema, and chronic bronchitis), cerebrovascular diseases (stroke), diabetes mellitus, kidney diseases (end-stage renal disease and renal failure), musculoskeletal disorders (rheumatoid arthritis and osteoarthritis), chronic mental illnesses, neurological disorders (epilepsy, Alzheimer’s disease, Parkinson’s disease, and multiple sclerosis), and some of the results of accidents or injuries (traumatic brain injury, spinal cord injury, amputations, and burns). Dealing with these illnesses presents numerous challenges for patients and their family members and care providers. “Coping” is a term that is usually used to describe the process by which people manage demands in excess of the resources that are at their disposal. Therefore, in addition to medical treatment, management of chronic illnesses must address lifelong coping with these illnesses.
The interest in coping with chronic illnesses can be traced back to late 1960s, with the work of American physician Thomas Holmes and Richard Rahe, then a medical student, at the University of Washington. They constructed the Social Readjustment Rating Scale (SRRS) to assess the amount of stress to which an individual is exposed. Personal injuries or illnesses were rated as the sixth-most-important events in terms of their intensity in affecting one’s life and increasing the chances of further illness in the subsequent year of life.
Models of Coping
American psychologist Franklin Shontz, in his book The Psychological Aspects of Physical Illness and Disability (1975), described the phases of reaction to any illness. The first stage on being diagnosed with a chronic illness is what he described as the stage of shock, in which the person is in a bewildered state and behaves in an automatic fashion with a sense of detachment from all surroundings. In this stage, patients often describe themselves as observers rather than participants in what is happening around them. The second stage is the stage of encounter or reaction. In this stage, the person is feeling a sense of loss and has disorganized thinking. Emotions of grief, despair, and helplessness are common. In this stage, patients often describe the feeling of being overwhelmed by reality. The third stage is what Shontz calls retreat. In this stage, the feeling of denial becomes very strong, but this state cannot persist and the patient gradually begins to accept reality as the symptoms persist and functional impairments ensue.
In the 1980s, American psychologist Richard Lazarus, an emeritus professor at the University of California at Berkeley, proposed the famous coping model called the transactional model. This model has also been applied widely in understanding coping with chronic illnesses. According to the transactional model, all stressful experiences, including chronic illnesses, are perceived as person-environment transactions. In these transactions, the person undergoes a four-stage assessment known as appraisal. When confronted with a diagnosis of chronic illness, the first stage is the primary appraisal of the event. In this stage, the patient internally determines the severity of the illness and whether he or she is in trouble. If the illness is perceived to be severe or threatening, has caused harm or loss in the past, or has affected someone known to the person, then the stage of secondary appraisal occurs. If, on the other hand, the illness is judged to be irrelevant or poses minimal threat, then stress does not develop and no further coping occurs. The secondary appraisal determines how much control one has over the illness. Based on this understanding, the individual ascertains what means of control are available. This is the stage known as coping. Finally, the fourth stage is the stage of reappraisal, in which the person determines whether the effects of illness have been negated.
According to the transactional model, there are two broad categories of coping. The first one is called problem-focused coping, and the second one is called emotion-focused coping. Problem-focused coping is based on one’s capability to think about and alter the environmental event or situation. Examples of this strategy at the thought-process level include utilization of problem-solving skills, interpersonal conflict resolution, advice seeking, time management, goal setting, and gathering more information about what is causing one stress. Problem solving requires thinking through various solutions, evaluating the pros and cons of different solutions, and then implementing a solution that seems most advantageous to reduce the stress. Examples of this strategy at the behavioral or action level include activities such as joining a smoking-cessation program, complying with a prescribed medical treatment, adhering to a diabetic diet plan, or scheduling and prioritizing tasks for managing time.
In the emotion-focused strategy, the focus is inward and on altering the way one thinks or feels about a situation or an event. Examples of this strategy at the thought-process level include denying the existence of the stressful situation, freely expressing emotions, avoiding the stressful situation, making social comparisons, or minimizing (looking at the bright side of things). Examples of this strategy at the behavioral or action level include seeking social support to negate the influence of the stressful situation; using exercise, relaxation, or meditation; joining support groups; practicing religious rituals; and escaping through the use of alcohol and drugs.
Crisis Theory of Coping
In the 1980s, American psychologist Rudolf Moos proposed the crisis theory to describe the factors that influence the crises of illnesses. He identified three types of factors that influence the coping process in illness. The first category of factors comprises the illness-related factors. The more severe the disease in terms of its threat, the harder is the coping. Examples of such severe threats include conditions such as burns that are likely to produce facial disfigurement, implantation of devices for excreting fecal or urinary wastes, or epileptic seizures. The second category of factors comprises background and personal factors. These factors include one’s age, gender, social class, religious values, emotional maturity, and self-esteem. For example, men are often affected more if the illness threatens their ambition, vigor, or physical power, while children show greater resilience because of their relative naïveté and limited cognitive abilities. The third category of factors identified by Moos comprises physical and social environmental factors. Generally speaking, people who have more social support tend to cope better when compared to people who live alone and do not have many friends.
Moos proposed in his crisis theory that these three factors impinge on the coping process. The coping process begins with cognitive appraisal, in which the patient reflects on the meaning of the illness in his or her life. This leads to formulating a set of adaptive tasks. Moos identified three adaptive tasks for coping directly with the illness: dealing with the symptoms and functional impairment associated with the illness or injury, adjusting to the hospital environment or medical procedures, and developing relationships with care providers. He further identified four adaptive tasks as crucial for adapting to general psychosocial functioning: maintaining a sense of emotional balance and controlling negative affect; preserving a sense of mastery, competence, or self-image; sustaining meaningful relationships with friends and family; and preparing for a future of uncertainty. The family members or long-term care providers who work with such patients also undergo these seven adaptive processes and must make these adjustments for effective coping. These adaptive tasks usually result in specific coping strategies. Moos described the following coping strategies: denial, or minimizing the seriousness of the illness (which is sometimes helpful, especially in the earlier stages); seeking information; learning medical procedures (which is sometimes helpful for self-care, such as taking insulin shots); mastering adaptive tasks; recruiting family support; thinking about and discussing the future to decipher greater predictability; and finding a purpose in and positive impacts of the illness on one’s life.
Heart Diseases
Heart diseases or cardiovascular diseases have been the leading cause of death in the United States since the 1980s. Initial research on coping with heart disease was done on patients with myocardial infarction, or heart attack. The research focused mainly on the role played by denial, which is a defense mechanism, described by the famous Austrian neurologist
Sigmund Freud, who is also called the father of psychoanalysis. Researchers using the “denial scale” classified patients into “denying” and “nondenying” groups and studied the outcomes of recovery. It was found that denial played an important role in decreasing anxiety and even in reducing deaths in the early stages of heart attack recovery. However, during the later phases of recovery, denial added to noncompliance with medical care, decreased seeking of information about the disease, and increased the risk of recurrence of heart attack. Research comparing the specific role of repression (or denial) and sensitization to the presence of disease supports the importance of sensitization in improving the solicitation of information, social functioning, and outcomes through the reduction of complications.
Recent research on coping and heart diseases has broadened its focus, improved coping measurement tools, and studied several other dimensions of coping. The first of these dimensions is the comparison between problem-focused strategies and emotion-focused strategies as described by Lazarus. In general, it has been found that people who use a problem-focused coping strategy report better social and psychological adjustment following hospital discharge, and these approaches are beneficial in the long run for improving disease outcomes. Emotion-focused strategies have been found to be of some utility in the short term in decreasing distress but have not been found to be useful in the long term. Further, people using emotion-focused strategies have reported greater incidence of anxiety and depression as a result of the heart disease.
Another dimension of coping that researchers have studied pertains to optimism. American psychologist Charles S. Carver and his colleagues have found the beneficial effects of being optimistic when recovering from chronic heart disease. Similarly, researchers have found empirical evidence of what American psychologist Suzanne Kobasa described as hardiness, a term that comprises the trinity of control, commitment, and challenge, as being beneficial in improving psychosocial adjustment to heart disease and decreasing chances of anxiety and depression.
Cancers
Cancers are a diverse group of diseases characterized by the uncontrolled growth and spread of abnormal cells in the body. At the start of the twenty-first century, cancers were the second leading cause of death in the United States. The lifetime probability of developing cancer was estimated at one in three, and it was estimated that cancers would soon be the leading cause of death and sickness. Cancers pose special challenges for coping, as these necessitate utilization of a wide range of coping options to deal with changing and often deteriorating functional abilities, medical challenges, treatment modalities (chemotherapy, surgery, and radiotherapy), and psychosocial reactions.
Like the earlier studies on coping with heart diseases, initial work on coping with cancers also focused on the role of defense mechanisms described by Freud. More recent research on coping and cancers has focused on personal disposition styles, coping strategies as described by Lazarus, and other special mechanisms. Results from disposition style studies suggest that internal locus of control and optimistic outlook are linked to lower levels of emotional distress and better psychological adaptation to cancer. On the other hand, avoidance or escapism has been associated with higher emotional distress. Problem-based coping strategies, as described by Lazarus, have also been found to be associated with better psychosocial adaptation to cancer. On the other hand, disengagement-oriented strategies such as wishful thinking, blaming oneself, and adopting a fatalistic or resigned attitude have been found to be associated with higher levels of emotional distress and worse psychosocial adaptation to cancer. Likewise, acceptance of the diagnosis of cancer and resignation to this fact have also been found to be associated with worse psychosocial outcomes. Other coping strategies such as freely expressing feelings, denial, and seeking religion have yielded equivocal results.
Cerebrovascular Diseases
In 2011, cerebrovascular disease (CVD) was the fourth leading cause of death in the United States and represented about 5 percent of deaths from all causes, according to the US Centers for Disease Control and Prevention (CDC). The most severe manifestation of CVD is stroke, with transient ischemic attack being a less severe clinically apparent variant. Stroke is a major cause of disability. Besides the usual generalized coping that goes with any chronic illness, coping with stroke specifically requires speech therapy, occupational therapy, and physiotherapy.
Diabetes
Diabetes mellitus is a disease in which the body is unable to sufficiently produce and/or properly use insulin, a hormone needed by the body to use glucose. The prevalence of this disorder has consistently risen in the United States, and as of 2013, it afflicted about 10 percent of the population, according to the American Diabetes Association. Besides the usual generalized coping that goes with any chronic illness, coping with diabetes specifically requires lifelong dietary changes, changes pertaining to physical activity patterns, and, in most cases, specific medicinal usage and compliance.
Chronic Respiratory Disorders
Chronic lung diseases are a varied group of diseases that were, in 2011, identified as the third leading cause of death in the United States. According to the CDC, as of 2013, approximately fifteen million Americans reported being diagnosed with one of these disorders. The most common chronic respiratory disorders are asthma, emphysema, and chronic bronchitis. Besides the compliance to medical treatment and the usual generalized coping that goes with any chronic illness, coping with respiratory disorders entails gradual buildup of exercise stamina and effective management of stress through relaxation techniques, since many acute attacks are both exaggerated and precipitated by stress.
Chronic Musculoskeletal Disorders
Arthritis and musculoskeletal disorders were the most common causes of physical disability in the United States in 2013, affecting approximately 20 percent of the population, according to the CDC. Besides the usual generalized coping that goes with any chronic illness, these disorders require specific rehabilitative coping through physiotherapy, occupational therapy, and vocational rehabilitation.
Chronic Mental Illnesses
Poor and ineffective coping with stress often leads to persistent depression and anxiety. Besides these two common mental illnesses, other disorders such as schizophrenia, bipolar psychosis, variants of anxiety disorders, organic disorders (such as dementia and Alzheimer’s disease), and other mental illnesses pose special coping challenges for patients and their family members. Besides the usual coping strategies, coping with mental disorders specifically involves long behavioral, psychological, and social challenges and therapies.
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