J Chron Dis Vol. 37. No. 6. pp 489-502. 19x4 Printed III Great Britain. All rights reserved
Copyright
0021-9681, X4 S3.00 + 0.00 c’ 1984 Pergamon Press Ltd
COPING WITH CHRONIC ILLNESS: STRATEGY PREFERENCES, CHANGES IN PREFERENCES AND ASSOCIATED EMOTIONAL REACTIONS LINDA L. VINEY’ and MARY T. WESTBROOK’ of Psychology. The University of Wollongong, Wollongong, ?Department of Behavioural Studies, Cumberland College of Health New South Wales. Australia
‘Department
(Receirwi
in rwiseri form
I June
New South Wales and Sciences. Lidcombe,
1983)
Abstract--Coping strategy preferences. changes in those preferences and their associations with different patterns of psychological reaction were investigated in three studies of chronically ill patients. A simple self-appraisal device, consisting of the ranking of six clusters of strategies, was used to assess patients’ coping preferences. In Study I patients were found to prefer optimism, and probably fatalism, more than non-patients. while non-patients preferred action strategies and. to some extent, interpersonal coping. In Study 2 coronary patients were bound to prefer more optimism strategies but fewer escape strategies than other chronically ill patients. All patients also changed some of their coping preferences over time. preferring optimism in hospital and fatalism at home. Study 3 showed preferences for action strategies to be associated with desirable psychological reactlon patterns such as relatively little uncertainty and helplessness. Preferences for escape strategies were linked with patterns which may be less desirable, such as much anxiety and indirectly expressed anger. Optimism and fatalism. although preferred by many patients, were associated with patterns of psychological reaction in which desirable and undesirable elements were mixed. Preferences for control strategies proved to be linked with reactions of patients when in hospital only. while those for interpersonal coping proved to be reaction-linked only when patients were at home.
INTRODUCTION THE MAIN illness-associated fears with which patients have to cope are of pain, body mutilation and death [l-2]. With chronic illness, patients also have more long term concerns: about their future, the loss of their customary social roles, maintaining their self-esteem and their need to develop a new life style [3-41. Hospitalization also brings its own set of stressors [5-61. Just as patients can be aware of these sources of stress, they can be aware of the strategies they use to cope with them. This is one assumption on which this research has been based. The other important assumption has been that patients dealing with chronic illness are not necessarily functioning neurotically or in otherwise abnormal ways. Most of them are well functioning people who have found themselves to be under abnormal stress. What coping strategies do they prefer? Do these differ from illness to illness? Do they differ from situation to situation, say, from hospital to home? No answers to these questions are so far available. Research which would permit predictions of the coping strategies best applied to deal with illness would also be very useful. The studies of coping available to date do not make such predictions with precision; but they do offer some suggestions. There is, for example, agreement on some of the characteristics of coping strategies which should render them
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176
F
should be addressed to: Linda L. Viney, Department P.O. Box 1144, Wollongong, NSW 2500, Australia. 489
of Psychology,
The
University
of
490
LINDA L. VIVEY and MARY T. WESTBROOK
helpful. Strategies that are flexible and reality-oriented, and which facilitate the expression of feelings have been viewed as potentially useful [779]. There is less agreement, however. on the efficacy of specific coping strategies. Is active coping more helpful than passive coping‘? How important is the sense of control patients can develop over themselves and their worlds? Do escape and avoidance preclude effective coping with chronic illness? Fatalism is employed by many patients to protect themselves against false hopes. Does it reduce their quality of life? Or is optimism a better psychological stance with which to receive the blows of chronic illness? What of the use of social supports and other interpersonal coping? The existing research concerning each of these six groups of coping strategies as the means for dealing with illness, is now briefly reviewed. Action strategies, such as information-seeking, are used by some patients coping with illness [2, lo]. They are likely to be flexible and reality-oriented at least. In fact, the evidence relating to the efficacy of this type of strategy so far supports its use. Active coping has been associated with better recovery by patients with severe burns [1 I] and with better adaptation to cancer [12]. Control strategies have also been supported as effective means of coping, although they may not be very flexible nor facilitate the expression of feeling. Sense of control has been reported as especially important to ill people [ 13, 141, in terms of their being able to inhibit both unwanted actions [2] and negative emotion [15]. If feelings of helplessness can lead to illness [2, 161. then feelings of control and mastery should preserve health. Patients who experience more control seem more likely to benefit from rehabilitation [17]. They have been shown to develop more sense of control as successful rehabilitation progresses [ 181. Escape strategies are used by patients in the more obvious forms of avoidance and denial as well as in more subtle ways [3, 10. 1.5, 191. They are generally not flexible, and they can encourage reality distortion. It is not surprising, then, that several independent research programs have provided data which suggest that they are not helpful in the long term [7, 13,201. It is interesting, however, to note in this context the comment of two coping researchers [21] that escape strategies may be helpful in dealing with the threat of danger which, while frightening, has a low probability of occurrence. The threat of death from surgery, for example, which for most patients is relatively unlikely. might be dealt with effectively in this way. The strategies of,futuli,rm and optimism can be viewed as two different ways in which patients can control their internal worlds when much of their external or physical worlds is beyond control. Fatalism involves expecting and accepting the worst; optimism, the best. Both sets of strategies may be flexible and reality-oriented. Each of them, however, precludes the acknowledgement and expression of certain kinds of feelings. It is no surprise to find that the picture of their efficacy which emerges from the literature is a confusing one. Cancer patients employing fatalism have been found to live longer by one research team [22] but, by another, to adapt less well to their illness [12]. Heart patients employing fatalism recover more slowly from myocardial infarction and survive for a shorter time [23-241. Optimism has also produced confusing results. Optimistic or positively-oriented cancer patients have been found to have a shorter life span [22], while patients who are more optimistic prior to surgery have more complicated recoveries [25]. On the other hand, optimism has been associated with good recovery from surgery [26] and with better adaptation to cancer [9]. Interpersonul coping strategies have been considered to be helpful for patients by a number of researchers [2, 10, 141. They can be flexible and reality-oriented: and they do facilitate the expression of feelings. There is now considerable evidence that people who are judged to have social supports have less illness, both disease-related and psychosomatic [27-291. It has also been demonstrated that patients judged to have social supports suffer less severe symptomatology [30-311. Rehabilitation is also more effective with social supports [32]. Having social supports available appears to be helpful. Whether coping by turning to other peoplee-interpersonal coping-- is helpful in comparison with the other types of strategies examined here is a somewhat different question on which little information is available. Investigation of this question seems appropriate in the light of
Coping
with Chronic
Illness
491
the recent finding that people of Anglo-Saxon stock tend not to use interpersonal coping when they are ill [33]. The three studies reported here were carried out to provide information about how patients perceive themselves to be coping with chronic illness. The first compared coping strategy preferences of a sample of chronically ill patients with those of a sample of people free from illness in order to provide information about the utility of a normative approach to coping with chronic illness. If differences were observed, we planned to carry out a second analysis to compare the strategy preferences of two groups of patients with different chronic illnesses. This second study also enabled the testing of hypotheses about changes in patients’ preferences according to whether they were hospitalized in an acute phase of their illness or were living at home. The findings of this comparison were to bear on the much debated question of whether coping can best be considered to be a stable trait or a process varying from situation to situation. The third study was conducted to ascertain whether patients’ preferences for certain coping strategies could be associated with their emotional reactions to their illness. While not directly testing the efficacy of these strategies for coping with chronic illness, it was to provide information relating to this question. SELF-APPRAISAL
OF
COPING
STRATEGIES
Although many measures have already been developed to assess the coping of others [34], for these studies a technique was devised which permits people to appraise their own coping strategies simply and directly. Six clusters of coping strategies were presented to them on six separate cards. Respondents were asked to rank the strategies from the one they were most likely to use (1) to that which they were least likely to use (6), that is, to place the cards in that order from 1 to 6. The context and structure of the interview schedule-of which this request was a part-defined this request as referring to their illness and the implications it had for them. The clusters of strategies were those which have already been discussed: action strategies (e.g. “I try to find out the cause of my problem”, “I take positive action based on my understanding of the problem“), control strategies (e.g. escape strategies (e.g. “I try to reduce tension “I control my feelings”, “I compromise”), e.g. I cry, smoke or eat”, “I become involved in other activities to keep my mind off things“),,fatalism strategies (e.g. “1 am prepared to expect the worst”, “I accept that much of life is difficult”), optimism strategies (e.g. “Things usually work out fine”, “I realise every cloud has a silver lining”) and interpersonal coping (e.g. “When things get difficult in my Very few people life I ask someone to help”, “I talk with friends about the problem”). had problems in following these instructions, although many were observed to have more confidence in their first and last preferences than in their middle rankings. They filled the extreme ranks first, and then added the other items. Consideration was given to using only the extreme ranks; but it was decided that too much valuable data would be lost. The pool of 30 descriptions of coping from which the clusters were derived was developed in part from the research literature [35] and in part from a community-based study of women coping with crises [36]. Multidimensional scaling of the items by a normative sample produced the six-dimension structure employed in this self-appraisal device [37]. This structure has been independently replicated with the same items [38] by another sample. Its dimensions are similar to those of other self appraisal measures of coping [39,40]. The ranking or ipsative scoring method has been retained as more meaningful to respondents than other forms of rating. However, since ipsative scoring results in interdependent scores, it raises problems for the use of statistical techniques which assume independence of measures. We have followed the convention of omitting one of the six coping clusters from such analyses. The reliability of this self-appraisal device over a considerable time period has been found to be only moderate. The overall reliability coefficient for a sample of 45 people with few stresses and relatively stable lives over one month was only 0.70. For each cluster of strategies it was lower: Action, 0.43: Control, 0.30; Escape, 0.30; Fatalism, 0.50; Optimism, 0.38; and Interpersonal Coping, 0.54. Since people are free to vary their self-appraisals
49;
LINDA L. VIMY and Mmy
T. WESTHKOOK
this estimate of reliability seems an accurate one. according to mood and situation, Peoples’ perceptions of their coping strategies varies from occasion to occasion. Estimates of reliability over a shorter period of one day, with a smaller sample (N = IO) have, however, shown higher estimates (overall r = 0.90. with a range from 0.79 to 0.92 for the clusters). Although a few relationships between preferences for certain strategies and the demographic characteristics of the respondents, such as sex, age. education and occupation, have been observed. none has been replicated across samples or across situations. The validity of the cluster scores has been supported in a number of ways. They have been found to discriminate together with other validating measures, between active and passive coping with childbearing [41] and good and poor adjustment to lone parenthood [42]. They have also been used effectively by patients which chronic illness [43]. The device has been applied effectively with chronically ill patients, in order to determine the extent to which factors such as their demographic characteristics, life styles and illness roles, the degree of their disability, their perceived handicaps and their achievement of rehabilitation goals were related to preferences for different coping strategies 1441. Preferences for action strategies were found to be associated with patient related factors (demographic characteristics, life style and illness role). Control strategies were associated with illness-related factors (illness role. degree of disability, perceived handicap and achievement of rehabilitation goals). Escape strategies were related only to the sex of patients (more women than men preferring them). Fatalism was associated with relatively low social status and little interpersonal commitment. Preferences for optimism were related only to patients’ perceptions of their handicaps (patients with less perceived handicap preferring it). Preferences for interpersonal coping strategies were not associated Gth any of these factors. STIJDY
The aim of this study was to test for differences coping with chronic illness and those not coping
1
in strategy preferences with chronic illness.
between
people
Method Chronically ill patients assessed their own coping towards the end of a standardized interview of about an hour’s duration. This interview was conducted on the third, fourth or fifth day of their admission to hospital by their bedside, or, if they were ambulatory, in a day room adjacent to their ward. Only 5 patients who were approached refused to be interviewed. A small number of those interviewed (8) probably because of illnessrelated debilitation, found it too difficult to rank the strategies as required. The remaining sample of 92 patients who participated in this study were all suffering from chronic illness. defined as a condition that would last at least 6 months or had caused a permanent disability [45]. Their disease classification [26] were as follows: circulatory (52”,,), metabolic (1 lo%), respiratory (9’?,), genito-urinary (7”3, nervous system (4”,,) and muscularskeletal (2x)) disorders, with 1.5’): being accident victims. These patients were approached in a hospital in an Australian provincial city. All chronically ill patients (as defined above) admitted to the hospital during a 12 month period were considered for inclusion in the research. Those excluded consisted of those who were too young or too old to fall within the predetermined age range for the study of 18-65 years. Patients who were judged by the hospital staff as too ill to participate were also excluded. Prospective research participants were also excluded if they were judged by the interviewer, a psychologist, as not able to communicate effectively about their coping strategies, for example, because of cognitive impairment or lack of facility with the English language. A summary of some of the relevant characteristics of the resulting sample is available in Table 1. The demographic factors will be examined in detail below. The score distributions for life style variables show the patients to have had considerable interpersonal and community involvement. Descriptions of the ways in which they have defined their illness roles were based on observations noted by hospital staff in the medical records.
Demogruphicarrriahles Men = 57.: women = 43”,, x = 57.26, SD = 14.11 Age: Education: (I = completed primary school: 2 = reached mid-high at tertiary level). x = 1.65. SD = 0.76 Occupatmn: (I=hlgh to 7=low). x=5.22. SD=l.lS Sex:
2.
Life
srde
Yes X = X = (I =
Illness rolf? ~uriahles Nature of onset: Appearance on admission: Estimate of discomfort: Estimate of well-being Estimate
4.
Disohili!,
of patient
6.
= 74”“. No = ?h”;, 2.66, SD = I .71 4.35, SD = 1.70 very dissatisfied to 5 = very satisfied):
X = 4.05, SD = 0.96
(I = gradual,
2 = sudden): x = 1.62, SD = 0.50 (I = distressed to 3 = well-lookmg): x1.73, SD = 0.64 (I = “one to 3 = severe): Tt = 2.25, SD = 0.66 (I = notcopingwell, unhappy to 3 = coping well, cheerful): SD = 0.65 (I =no, 2=yes), X= 1.84, SD=0.43
cooperatmn:
ft = I .63.
~~-iahla
Locomotor: Visual: Communication: Visceral: Inwsible: Aversive: 5.
high school: 4 = qualifications
rmxhles
Current marital relationship: Number of children: Number of pre-illness laaure actwities: Work satisfaction in last job. 3.
school; 3 = completed
X = I .X4. X = 0.08. X=0.15. x = 0.42. x = 0.73, x = 0.34,
Hand~crp percepptrons Mobihty handicap: Self-care handicap: Leisure handicap: Relationships handicap: Goal o~hilwmenr UlrIohle.! Mobdity improvement, Self-care improvement: Lasure improvement: Relatmnshlps Improvement.
SD = I .09 SD = 3.00 SD=046 SD = 0.68 SD = 0.52 SD = 0.64
(I = severe to
6 (I = severe to 4 (I = severe to 4 (I = severe to 4
x x x X
= = = =
~
= = = =
none). none): none): none):
0.37, 0.57. 0.75. 0.03.
SD SD SD SD
x x X x
= = = =
= = = =
4.53, 2.59. I .90. 3.77.
SD SD SD SD
= = = =
1.95 1.20 I .03 1.07
0 79 1.00 1.04 0.54
The majority were, for example, reported to have been in “considerable discomfort” but as “cooperating” with staff. The hospital records also indicated that they each had at least one of the disabilities listed in Agerholm’s classification [47], the modal number being four (with a range up to the possible total of eight). Patients’ ratings of their handicaps showed them to believe that there was least impairment in their interpersonal relations, more in their mobility and self-care and most in their leisure activities. Their later perceptions concerning their achievement of their earlier rehabilitation goals followed the same pattern. In this patient sample men and women were about equally represented. Although their ages ranged from 23 to 86 years, the majority of patients were aged between 50 and 65 years. Their educational level was quite low. About half of them had completed primary school only and a few had completed secondary school. Their occupational status [48] was correspondingly low. The non-patient sample with whom they were compared differed somewhat from them on each of these dimensions. Of the 62 people in this sample, the majority were women. They were younger, their ages ranging from 18 to 56 years with the majority aged between 20 and 35 years. They were all studying at a university, and their occupational levels were correspondingly higher. Their perceptions of their coping, this time “with life as it is for you at the moment”, were tapped towards the end of a standardized interview similar to that for the patients. All of these people were able to rank the selected strategies as requested. Results The means and standard deviations for the coping strategy available in Table 2. (In interpreting those figures the ranking
scores of the two groups are method used should be kept
494
LINDA
L.
VINEYand MAKYT. WESTBKOOK
in mind: low scores show high preferences). Six l-way analyses of variance were carried out to compare the scores of the patients and non-patients on each strategy. Actiotz strategies were found to be differently ranked by them, non-patients being significantly more likely to indicate that they would use them (F = 15.20, ~cf’= I, 162. p < 0.001). The results for control and escupe strategies were not significant. Scores for ,f&/ism showed a trend towards difference, patients placing it higher on their list of strategies (F = 4.25, df’ = I, 162, p < O.OS), while optimism was placed higher by them (F = 1 1.17, df = I. 167. p < 0.001). For interpersonal coping a trend was again indicated, non-patients preferring this strategy more often (F = 5.44. df = I, 167, p < 0.05). The results of Study I suggest that chronically ill patients believed they would employ optimism strategies, that is. expect good things and look for a silver lining, more often than people who were not ill. They also preferred, although to a lesser extent, another strategy which involves a conscious manipulation of their own psychological state-fatalism. There was a tendency for them to prefer interpersonal coping less often than the non-patient group. They may have preferred action strategies less often than non-patients; but this difference may have been due more to age differences between the groups, or even to sex differences. Because there were differences in the sex ratio and age of the two groups which were compared, another parallel series of analyses of variance was run with sex as a second. additional factor and age as a covariate. In none of these analyses did the sex X group effect approach significance. Nor. for five of them. did sex prove to be a significant factor nor age a significant covariate. For acrion strategies only were the sex and age effects significant. When age was run as a covariate for action strategies in the 2-factor design, the results were as follows: group, F = 8.65, &= 1. 149. p -C 0.001; sex, F = 7.23. r(‘f’= 1. 149, p < 0.01; group X sex, F = 0.49, $= I. 149, p = 0.49. In other words, although sex and age were effective predictors of preferences for action strategies so, independently. was group membership. Non-patients continued in this analysis to show a greater preference for action strategies than patients. In spite of these findings, however, interpretation of the group differences as representing reactions to situations must remain tentative. since such differences may be due to the influence of some as yet unknown factor such as a personality characteristic which earlier determined group membership. STlJDY
7
The aims of this study were to test for differences with different types of chronic illness and changes
in preferences of preferences
between people coping in different situations.
Method
This study was of chronically ill patients only. The 46 patients were those from the above sample who completed a coping selfappraisal not only in hospital. as described, but 7 months later when approached in their homes. This sampling made possible comparison of patients’ strategy preferences in two situations over a period. The patients involved in this study included a somewhat higher proportion of men and a slightly younger group than that described above, but this difference was not significant. The educational and occupational attainments remained similar to those of the first sample, as did all the
Coping
with Chronic
495
Illness
variables tapped. The relatively high attrition rate over 7 months is not surprising in view of the vulnerability of the research participants. In spite of a lack of significant differences on measured variables between the remainers and the drop outs, it must be recognised that differences between the groups (in for example, likelihood of death) could have affected the outcomes of this study. This level of attrition also resulted in a relatively small sample of patients, but this sample size problem was somewhat offset by the repeated measures obtained. The other comparison to be made in this study was between patients with different chronic diseases. Thirty of the 46 patients were classified as cardiac patients: 72% with acute myocardial infarction, 20% with other myocardial insufficiences and 8% with symptoms of ischaemic heart disease. They were compared with the remaining 16 patients whose diagnoses were as follows: 35% had disorders of the circulatory system without heart involvement, 170/, endocrine disorders, 13% of the nervous system, 10% genitourinary disorders and 25’/, were suffering from the chronic effects of injuries. Patients’ perceptions of their coping strategies were assessed in the manner already described. Results
The means and standard deviations for the coping strategy scores of these coronary and non-coronary patients both in hospital and at home are available in Table 3. The method of analysis selected to test the significance of the differences-both over time and by patient group-was multivariate analysis of variance. This technique permits comparisons to be made for a set of variables without increasing the probability of error as was the case with the six separate analyses of Study 1. Its main drawback for this research, however, is that it can only be applied to sets of independent variables. It was necessary therefore to select only five strategies for this multivariate analysis. Control strategies were those ommitted on the basis of the observation that these strategies were least often ranked with confidence by these samples of patients as their first or last preference. The two-factor multivariate analysis of variance produced a non-significant multivariate F value for interaction effects but significant multivariate Fs for time (F = 77.46, dJ’= 5,40, p < 0.001) and patient group (F = 3.66, u”= 5, 40 p < 0.01). For time, univariate tests indicated that all patients were preferring significantly more optimism strategies (F = 417.15, LIP= 1, 44, p < 0.001) and fewer fatalism strategies (F = 10.60, @ = 1, 44, p < 0.01) while in hospital than later at home. For patient groups, univariate tests suggested that the coronary patients believed they would use more strategies based on optimism (F = 12.76, df’= 1, 44, p < 0.001) but that the non-coronary patients thought they would use more escape strategies (F = 4.31, df = 1, 44, p < 0.05). The latter effect was a small one. There were differences in strategy preferences, not only between patients and nonpatients, but between patients dealing with different kinds of chronic illness. Coronary patients preferred optimism more often than patients with other chronic illnesses. However they favoured escape-related strategies less than others who were chronically ill. This study also supports the view that patients may change their preferences for coping strategies according to their situation. Hospitalised patients were found to prefer more optimistic strategies like not worrying and believing things usually worked out, but fewer fatalistic
Coronary In hospital X SD Actmn Control Escape Fatahsm Optimsm Interpersonal
coping
2.65 3.15 4.49 4.09 3.12 3.34
I .69 I .54 1.60 I .7b I 65 1.85
patients
Non-coronary
At home R SD 2.39 2.61
4.76 3.50 3.44 3.33
I.12 I .20 1.64 1.89 I .7b
1.83
In hospital ft SD 2.82 3.08 3.62 3.65 3.34 3.65
I s2 I .48 1.98 1.70 I 87 I.81
patienta At home R SD 3.00 3.46 3.62 2.89 3.74 3.38
1.61 1.61 1.78 1.83 1.74 1.94
496
strategies in hospital during home later these preferences
LINDA L. VINEYand MAKY T. WESTBKOOK
an acute phase of their illness. had changed.
When
The aim of this study was to test for associations between strategies and a range of emotional reactions to chronic illness.
they had settled
preferences
in at
for coping
The respondents for this study were those of Study I, where the data analysed had been collected in hospital, or of Study 2, where the data had been collected at home as well. The few cases for which some data were missing had to be excluded. The interview in which they had been engaged had included, not only their self-appraisal for the coping strategies they were likely to use together with demographic and disability-related data, but an open-ended question. This question was posed early in the interview after rapport was established but before any more specific questions were asked. Their responses to this question about their current life experiences revealed how they were structuring these experiences and coming to their own understanding of their illness. They were, with their permission, tape-recorded. These recordings were later transcribed and claused in preparation for content analysis which was to provide measures of a broad range of their emotional reactions. This complex procedure was used to minimize the biases introduced in research in which pre-planned psychometric instruments are used to gauge peoples’ experienced reactions. The extent of the association of patients’ preferences for certain coping strategies with these reactions was then examined. The range of reaction to chronic illness which this research examined contained nine emotional elements. each of which was assessed as in other studies [49--551 by the application of a content analysis scale. Patients‘ uncertainty was appraised. together with their anxiety and depression. Whether they expressed their anger directly or indirectly was assessed, as were their feelings of competence and helplessness. Further positive aspects of their experience which were appraised were the extent to w-hich they perceived themselves to have social supports, as well as the frequency with which they expressed generally good feelings. Studies have supported the validity of the content analysis scales that they have good designed to quantify these experiential elements and indicated interjudge reliability across judges and occasions [56-621. Scores on the scales vary not only from person to person but from situation to situation [63]. They are process measures rather than trait measures. Their application in stress research [64]. as well as in health care [65] and community work [66] has been discussed elsewhere. Four of the scales used were devised in the United States [56-583; but they have been shown to be applicable in Australia where this research was carried out 1671. Scores on the Total Anxiety Scale, for example, were based on content categories which represent a psychoanalytic conceptualization of anxiety. References to fears of death, bodily mutilation and loneliness and loss. as well as guilt and shame and unspecified tensions (e.g. “I was pretty scared”) were scored. Depression was measured by the Hostility In Scale on which reference reflecting purposelessness, disappointment and dissatisfaction with self (e.g. “I felt so useless with only one arm in working order”) were scored. The remaining anger, psychoanalytically viewed as expressed through means other than selfblame, was assessed by the two other American scales. The Hostility Out Scale was used to assess directly expressed anger (e.g. “The food in hospital was terrible”). while the Ambivalent Hostility Scale was used to assess indirectly expressed anger (e.g. “The nurses didn’t like me”). Patients’ uncertainty was also considered to be an important element. This was measured by the Cognitive Anxiety Scale [59]. which was based by the authors on the proposition of personal construct psychology that uncertainty is elicited when people cannot make sense of their own experiences (e.g. “I was a~ a loss for words”). Content of competence and analysis scales have also been developed to assess feelings
Coping
with Chronic
491
Illness
helpnessness-the Origin and Pawn Scales [60]. They have their conceptual roots in attribution theory (e.g. “I was able to take 5 steps today” is an Origin statement compared with “I felt quite overwhelmed by it all” which is a Pawn statement). The measure of awareness of social supports, however-the Sociality Scale [61]-uses content categories derived not from theory but from empirical studies designed to provide a typology of positive interpersonal interactions. “We made the toast together”, for example, suggests the experience of helping, while “The nurses are lovely girls” reflects admiration and acceptance of others. Finally, the Positive Affect Scale [62] was applied to tap generally positive comments by the patients (e.g. “It was so good to be home”). Results The means and standard deviations for the coping strategy scores varied only occasionally from those reported for Studies 1 and 2 because there was inadvertent subject wastage. Those for the content analysis scores making up the psychological reactions of patients are listed in Table 4. Analyses reported elsewhere have indicated that these chronically ill patients, while in hospital, experienced more anxiety, depression, anger expressed both directly and indirectly and helplessness as well as more good feelings than non-patients [15, 531. It has also been shown that these patients, while at home, later, continued to experience much anxiety and helplessness [49, 531. While their directly expressed anger had decreased somewhat at this time, so had the number of good feelings they expressed. There is also evidence available which suggests that early expression of anxiety, depression and anger is associated with later rehabilitation [54]. Multiple regression was the technique used to assess the degree of association between each single coping strategy on the one hand and the set of nine psychological reaction scores on the other. The results of these analyses are shown in Table 5. Findings for hospitalized patients are referred to first. Preferences by patients for action strategies were associated with little uncertainty and, to a lesser extent, directly expressed anger. This relationship was the largest for data obtained in the hospital (R2 = 0.45). Preferences for control strategies, however, were associated with much uncertainty but little indirectly expressed anger or good feeling. Preferences for escape strategies were related to much anger expressed indirectly and to much anxiety. Preferences for fatalism were associated with little good feeling other than competence as well as much anxiety; while preferences for optimism strategies were associated with little anxiety but also little competence and much helplessness and directly expressed anger. The only coping strategy which did not prove to be significantly linked with some aspects of patients’ psychological reaction while in hospital was interpersonal coping. The significant associations between perceived coping strategies and psychological reactions of patients when interviewed at home later are also listed in Table 5. A different set of relationships was revealed by this set of coefficients. Action strategy preferences were associated with little helplessness only, while no significant relationship was found for control strategies. The largest relationship revealed in these data was between escape rankings and the psychological reaction scores. Preferences for escape were associated with little indirectly expressed anger or depression or even sociability but much helplessness. Preferences for fatalism were associated with much indirectly expressed anger and
Uncertamty Anxiety Depression Anger expressed Anger expressed Competence Helplessness Soctability Good feelings
In hospital
At home
X
SD
iC
SD
1.12 2.09
0.76 0.88 0.67 0.51 0.49 0.3s 0.54 0.19 0.57
I .06 2.10 0.99 0.70 0.75 I .05 I .43 0.41 0.83
0.65 0.80 0.59 0.41 0.36 0.47 0.52 O.IX 0.47
1.03 dmctly mdirectly
0.93 0.81 0.85 I .39 0.40 1.10
LINDA
498
L. VIN~Y and
Coping strateg) For patients in hospital Action
Control
Escape
Fatalism
Optimism
MAKY
Psychological reactloll
Uncertainty Anger directly expressed Uncertainty Anger indirectly expressed Good feelings Anger mdirectly expressed AllXiCQ Anxiety Competence Good feelings Anuety Helplessness Competence Anger direc~l) expressed
T. WESTBROOK
Standardised regression coefric1ent* 0.42 0.08
R’ = 0.45
0.28 0 17
R'=0.31
0.12 ~~0.20 R’ = 0.26 ~ 0.09 -0.34 -0.12 0.10 0.46 -0.27 0.20 -0.11
R’= 0.39
R’ = 0.41
Interpersonal copmg For patients at home Action C0Iltrol Escape
Interpersonal c0piIlg
Helples\ness
0.21
Anger mdirectl) expressed Helplessness Soclahility Depreswm Anger indirectly CXpMsed Deprwion Anxiety Helplersness Competence Anger directly exprwed Sociatxht> Competence A11,Uety Aqer indIrectI) expresxd Uncert;iinty Depre%loIl
0.52 -0.30 0.19 0. I4 -0.26
R’= 0.27
R’= 0.56
R’= 0.37 -0.26 0.46 -0.27 0.20 -0.1 I 0.25 0.2x 0.20 -0 I7
R’= 0.41
R'=0.47
-0.15 0.12
*For all reported coclficlenta. p < 0.01.
depression; but those for optimism, while associated with much indirectly expressed anger also, were associated with little anxiety as well as much helplessness and little competence. Interpersonal coping preferences were found to be related to six of the nine psychological reaction elements. They were related to much sociability but also much uncertainty and indirectly expressed anger. There was little anxiety or depression for those who, at home, saw themselves as likely to employ interpersonal coping but also little competence. In this study of how ill people believe themselves to be likely to cope, some associations between their beliefs and certain emotional reactions to chronic illness were demonstrated. The pattern of these relationships varied according to whether patients have been interviewed during hospitalization or later at home, some of their implications will now be discussed. DISCUSSION
The findings of the first study suggest that patients with chronic illness may be more likely to perceive themselves as coping by the use of fatalism and optimism strategies than non-patients. Although this sample showed some preferences for interpersonal coping, these preferences were not so strong as those of non-patients. As previous research has suggested [33], people who are coping with illness in a Western society find it hard to rely
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on interpersonal supports. The main alternative explanation of these data is that the observed differences in coping perceptions are not so much a function of differences between patients and non-patients but of the demographic differences between these groups. Demographic factors were not, however, found to be effective predictors of preferences for differences coping strategies for these samples of research participants, except in the case of action strategies where the group difference prevailed. Generally, the group differences suggest that it may prove useful in the future to conduct a more extensive programme of research to develop normative information about coping with chronic illness. If patients seem to have stronger preferences for certain coping strategies, they also seem to differ in their preferences according to the type of chronic illness with which they are dealing. Study 2 indicates that these coronary patients perceived themselves to be likely to use more optimism strategies and fewer escape strategies than patients with other chronic illnesses. These data too are subject to alternative explanations. It could be that the problems associated with coronary disease are of a kind which elicit optimistic coping and preclude escape strategies [68]. This situation-oriented suggestion finds some support in observations of the interactions of hospital staff with coronary patients through which a cheerfuly aware attitude to illness seems to have been fostered. It could also be that the people who become coronary patients then continue to perceive themselves as employing the same coping strategies as they did before their illness. Considerable optimism with few escape strategies is a coping pattern not dissimilar to the Type A behavior pattern or trait which has been associated with coronary disease [69]. Study 2 also indicates that these patients showed different strategy preferences when interviewed in hospital than they did some seven months later when interviewed in their homes. They believed themselves to be using more optimism on the first occasion and more fatalism on the second. This finding may seem counter-intuitive, until it is remembered that compared with home, where there is no professional expertise nor life-saving equipment readily available, the hospital environment is relatively nurturant and safe for patients. Dealing in hospital with the acute effects of the illness from which some recovery can be anticipated is also very different from dealing at home with the long-term effects of chronic illness which may well last throughout a patient’s remaining life. These findings do not support the person-oriented or trait approach to coping referred to above but rather the situation-oriented or state approach. This is also true of the findings of Study 3 which differed considerably according to whether the patients were in hospital or at home. Evidence is building up which suggests that neither trait- nor situation-oriented accounts of psychological phenomena alone are effective [70-711. The interactionist approach which is now preferred seems likely to be the best for coping too. Turning again to the results of Study 3, it is as meaningful to say that patients who see themselves as using action strategies are likely to keep their uncertainty to a minimum as it is to say that if patients’ uncertainty is minimal they are then able to have a preference for action strategies. Similarly, it can be said either that preferring control strategies raises uncertainty or that high uncertainty makes preferences for control strategies more likely. Both statements have validity as descriptions of different phases of the continuing two-way interaction of person and situation, of patient and illness. The causal relationships between coping and emotions, when we can identify them, will be both complex and multi directional [72]. Coping occurs not only in reaction to stressful situations [73]; it may precede these situations as well as follow from them [40]. Study 3 was designed primarily to find out whether certain coping strategies were associated with certain psychological reactions to illness. As for Studies 1 and 2, its findings too have identified certain patterns of association, not causal relationships. As predicted from the available research, preference for action strategies were associated with relatively benign emotional reactions. There was little uncertainty and directly expressed anger for patients in hospital and little helplessness when they were at home. Such preferences have been found to be associated with certain patient-related characteristics, and so are not readily influenced by psychological interventions [44]. However, preferences for escape
LINDA L. VIWEV and MAKY T. WESTHKOOK
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strategies were associated with more distress, consisting of considerable anxiety and indirectly expressed anger in hospital and considerable helplessness and little sociability at home. These preferences are now the focus of a hospital-based counselling programme designed to help patients cope better with their illness [74]. Preferences for control strategies-which are usually preferred by patients less disabled by their illness [44]proved to be important to the patients’ psychological state when they were in hospital but not when they were at home. Preferences for interpersonal coping, conversely, were linked with patients’ states while at home but not in hospital. These findings fit what is known of the specific stressors of hospitalization. Effective interpersonal coping seems to be prohibited in hospital by patients’ isolation from their usual sources of social support. Strategies involving fatalism and optimism seemed to be of major importance to these chronicaly ill patients who perceived themselves to use them more than non-patients. Perhaps this was because they involve changes in patients’ own internal worlds over which they had some control rather than in their external worlds over which they had little control because of their disabilities. The coronary patients preferred optimism more than other chronically ill patients. This may have been because they saw themselves as less handicapped than other chronical1.y ill patients [44]. All the patients seemed to see themselves as more likely to use optimism while in hospital but fatalism while at home. With what psychological reactions were these strategies associated‘? Optimism was the only strategy for which preferences were found to be related to the same pattern of reaction whether patients were in hospital or at home: much helplessness and little competence with much anger but little anxiety. Preferences for fatalism were found to be associated in hospital with much anxiety and little good feeling but much competence. These findings have, unfortunately, done little to clarify the efficacy of optimism and fatalism as mediators of emotion for the chronically ill. Further investigation of these two strategies which seem so important for them is needed. This research project has indicated that the two assumptions on which it has been based-that chronically ill patients may be regarded as normal people dealing with a stressful situation and that they can be aware of many of the coping strategies which they choose to adopt in that situation-can provide a fruitful framework for research. It has been reported not only to add to the information about how people cope with the stress of chronic illness and so about coping in general, but because of the implications its findings have for both patients and care-givers. Patients who become aware of a wider range of potential strategies are likely to cope better with their illness; and health care professionals who become aware of patients’ experiences and intentions in the face of the stress of chronic illness are likely to be more effective care-givers [75]. Ackno~~,lu~~e~enrsThe work reported here was funded b) the Australian Research Grants Scheme, Grant NO. 7715046R to the authors. They wish to acknowledge the contribution of MS Sue Beattie to the &jt;j collection and analysis and the cooperation of stall’ and patients of the Wollongong Hospital,
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