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

Section 19
Coping with Cancer: Part II

CEU Question 19 | CEU Answer Booklet | Table of Contents | Cancer
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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).
  1. 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.

  2. 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).
  1. 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.

  2. 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).
  1. 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).
  2. 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 to ward 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).
  1. 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).
  2. 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).
  1. 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).

  2. 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).
-  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 #5
The preceding section contained information regarding specific strategies for 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 19
What is the major difference between engagement and disengagement coping strategies? Record the letter of the correct answer the CEU Answer Booklet.

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