Coping With Illness and Psychotherapy of the Medically Ill

What Exactly Is Coping?

Coping is best defined as problem-solving behavior that is intended to bring about relief, reward, quiescence, and equilibrium. Nothing in this definition promises permanent resolution of problems. It does imply a combination of knowing what the problems are and how to go about embarking on a correct course that will improve function.

In ordinary language, the term coping is used to mean only the outcome of managing a problem, and it overlooks the intermediate process of appraisal, performance, and correction that most problem-solving entails. Coping is not a simple judgment about how some difficulty was worked out. It is an extensive, recursive process of self-exploration, self-instruction, self-correction, self-rehearsal, and guidance gathered from outside sources.

At virtually every step of patient care, physicians and patients actively assess coping ability. Though this appraisal is not always conscious, the conclusions drawn about how a patient is processing his or her illness have a tremendous impact on therapeutic decisions, on psychological well-being, and indeed on the overall course of illness. However, accurate appraisal of coping skills is hampered by muddled definitions of coping, by competing methods of assessment, by a general lack of conscious consideration of how a patient copes, and by uncertainty about whether particular coping styles are effective.

Early conceptualizations of coping centered around the Transactional Model for Stress Management were put forth first by Lazarus and colleagues in the late 1960s. This conceptualization stressed the extent to which a patient interacts with his or her environment as a means of managing the stress of illness. These interactions involve appraisals of one's medical condition in the context of psychological and cultural overlays that vary from patient to patient. Although this definition of coping persists, it may be too broad to allow for standard assessments of patients. Thus, though multiple studies of patient coping exist, most clinicians favor a more open-ended approach to evaluation that considers the unique backgrounds that the patient and the doctor bring to the therapeutic setting.

Coping with illness and its ramifications cannot help but be an inescapable part of medical practice. Therefore, the overall purpose of any intervention, physical or psychosocial, is to improve coping with potential problems beyond the limits of illness itself. Such interventions must take into account both the problems to be solved and the individuals most closely affected by the difficulties.

How anyone copes depends on the nature of a problem as well as on the mental, emotional, physical, and social resources one has available for the coping process. The hospital psychiatrist is in an advantageous position to evaluate how physical illness interferes with the patient's conduct of life and to see how psychosocial issues impede the course of illness and recovery. This is accomplished largely by knowing which psychosocial problems are pertinent, which physical symptoms are most distressing, and what interpersonal relations support or undermine coping.

Assessment of how anyone copes, especially in a clinical setting, requires an emphasis on the “here and now.” Long-range forays into the past are relevant only if they illuminate the present predicament. In fact, more and more clinicians are adopting a focused and problem-solving approach to therapy with medically ill individuals. For example, supportive therapies for medically ill children and adults in both group and individual settings have reduced psychiatric morbidity, and have had measurable effects on the course of non-psychiatric illnesses.

Who Copes Well?

There are few paragons who cope exceedingly well with all problems. For virtually everyone, psychiatrists included, sickness imposes a personal and social burden, threat, and risk; these reactions are seldom precisely proportional to the actual dangers of the primary disease. Therefore, effective copers may be regarded as individuals with a special skill or with personal traits that enable them to master many difficulties. Characteristics of good copers are presented in Table 36-1 . These characterizations are collective tendencies; they seldom typify any specific individual (except the heroic or the idealized). No one copes exceptionally well at all times, especially with problems that are associated with risk and that might well be overwhelming. However, effective copers appear able to choose the kind of situation in which they are most likely to prosper. In addition, effective copers often maintain enough confidence to feel resourceful enough to survive intact. Finally, it is our impression that those individuals who cope effectively do not pretend to have knowledge that they do not have; therefore, they feel comfortable turning to experts who they trust. The better we can pinpoint which traits a patient appears to lack, the better we can help a patient cope.

Who Copes Poorly?

Bad copers are not necessarily bad people, nor even incorrigibly ineffective people. In fact, it is too simplistic merely to indicate that bad copers have the opposite characteristics of effective copers. As was stressed earlier, each patient brings a unique set of cultural and psychological attributes that impacts the capacity to cope. Bad copers are those who have more problems in coping with unusual, intense, and unexpected difficulties because of a variety of traits. Table 36-2 lists some characteristics of poor copers.

Indeed, structured investigations into the psychiatric symptoms of the medically ill have often identified many of the attributes of those who do not cope well. Problems such as demoralization, anhedonia, anxiety, pain, and overwhelming grief all have been documented in medical patients with impaired coping.

What Interferes With Our Ability to Adapt to Illness?

Adaptation to medical illness is affected by individual factors, by intrahospital factors, and by extrahospital factors; understanding all three is crucial to an assessment of how an individual will adapt to illness. Individual (intrapersonal) factors include psychiatric diagnoses (including, but not limited to, depression, anxiety, neurocognitive disorders, substance use disorders, post-traumatic stress disorder [PTSD], factitious disorders, somatic symptom and related disorders, and sleep–wake disorders; their developmental stage, their experience with trauma, and their understanding of the illness). In addition, personality style and personality disorders (including histrionic, obsessive, paranoid, narcissistic, and borderline personality disorders) affect how a person copes with receiving bad news, how they interact with medical staff, and how they communicate with others in their life. Holland and colleagues described the “Five Ds” when discussing what illness means to a patient (e.g., distance [the interruption of interpersonal relationships]; dependence [having to rely on others]; disability [inability to achieve]; disfigurement; and death). Intrahospital factors include the characteristics of the illness (e.g., its time course, the intensity of pain, its impact on sleep, surgical interventions, and chemotherapy), whereas extrahospital variables (e.g., finances, housing, interpersonal relationships, and sociocultural/language barriers) are also key issues.