Summary of Findings from Studies of Coping with Cancer
The literature on coping with cancer suggests that:
- 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.
- 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.
- 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.
- 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 selfefficacy, 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.
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.
- 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.
- 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 (DunkelSchetter 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.
- 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.
- 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.
- 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 problemfocused, 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.
-Livneh, Hanoch; Psychosocial Adaptation to Cancer: The Role of Coping Strategies; Journal of Rehabilitation; April-June 2000; Vol. 66, Issue 2
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Reflection Exercise #6
The preceding section contained information
regarding a summary of strategies to cope with cancer. Write three
case study examples regarding how you might use the content of this section in
Online Continuing Education QUESTION 20
What four things does Livneh suggest rehabilitation practitioners should focus on? Record the letter of the correct answer the .