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Coping with Cancer Interventions for the Family
Cancer & Family  continuing education counselor CEUs

Section 18
Coping with Cancer: Part I

CEU Question 18 | CEU Answer Booklet | Table of Contents | Cancer
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Psychosocial Adaptation/Coping Strategies
This paper reviews the literature on the role of coping styles and strategies in psychosocial adaptation to cancer. Following a brief discussion of coping and its function in the context of coping with chronic illnesses Cope Cancer and Family social work continuing educationand disabilities, the research literature on coping with cancer is reviewed. The paper concludes with a summary of the findings on coping with this life threatening condition and provides rehabilitation-related clinical and research implications.

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.

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.

- Livneh, Hanoch; Psychosocial Adaptation to Cancer: The Role of Coping Strategies; Journal of Rehabilitation; April-June 2000; Vol. 66, Issue 2
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #4
The preceding section contained information regarding general styles of coping with cancer. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 18
What are the three general coping styles for coping discussed by Livneh in the above article? Record the letter of the correct answer the CEU Answer Booklet.

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