OVERVIEW

Coping with illness can be a serious problem for both the patient and the physician. Indeed, the irony of our increasing prowess in healing is our growing discomfort and our profound sense of impotence when a cure cannot be found, and when coping is the order of the day. This dilemma is both consciously realized and unconsciously experienced; both patients and staff feel the ripple effect.^1–3

Fortunately, the psychiatrist is ideally suited to assist both the patient and the physician with the complexities of medical illness, and to pay careful attention to the complex feelings that chronic suffering engenders (in the inpatient consultative setting as well as in the outpatient clinic). In fact, there is a growing body of literature that focuses on the different mechanisms by which patients cope with chronic disease, and the corresponding psychotherapeutic interventions for the patient with chronic illness. This chapter addresses the fundamentals of how patients cope, as well as the art of working psychotherapeutically with the medically ill.

WHAT EXACTLY IS COPING?

At virtually every step of patient care, physicians and patients alike actively appraise patient coping. Though this appraisal is not always conscious, it is clear that conclusions drawn about how a patient is processing his or her illness has great bearing on therapeutic decisions, the psychological well-being of the patient, and indeed of the overall course of the patient’s illness.¹ However, accurate appraisal of coping skills is hampered by muddled definitions of coping, by competing standardized assessments, and by a general lack of conscious consideration of how patients cope and whether their particular coping styles are effective or helpful.^4–7

Early conceptualizations of coping centered around the “Transactional Model for Stress Management,” put forth first by Lazarus and colleagues in the late 1960s.⁸ This conceptualization stressed the extent to which patients interact with their environment as a means of attempting to manage the stress of illness. These interactions involve appraisals of the current medical condition, with psychological and cultural overlay that varies from patient to patient. While this definition of coping persists to this day, many have argued that though it is a useful paradigm, it is also too broad to allow for standardized assessments in patient populations. Thus, while multiple studies of patient coping exist, most clinicians favor a more open-ended evaluation of each patient, taking into consideration the unique backgrounds that patient and doctor bring to the therapeutic setting.⁵

Coping is perhaps best defined as a 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 reaching a correct direction that will help resolution.^1,6,7

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 worked out. It is an extensive, recursive process of self-exploration, self-instruction, self-correction, self-rehearsal, and guidance gathered from outside sources. Indeed, these assertions were central to Lazarus’ initial conceptualizations.⁸

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 past history are relevant only if such investigations are likely to shed light and understanding on the present predicament. In fact, increasingly clinicians are adopting a focused and problem-solving approach to therapy with medically ill patients. For example, supportive and behavioral therapies for medically ill children and adults in both group and individual settings have been found to not only reduce psychiatric morbidity, but also to have favorable measurable effects on the course of nonpsychiatric illnesses.

WHO COPES WELL?

Few of us cope exceedingly well all of the time. For all of us, sickness imposes a personal and social burden, with accompanying significant risk and threat appraisal. Furthermore, 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 9-1.

Table 9-1 Characteristics of Good Copers

These are collective tendencies; they are highly unlikely to typify any specific individual. No one copes superlatively at all times, especially with problems that impose a risk and might well be overwhelming. Notably, however, effective copers seem 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 they trust. The clinical relevance of these characterizations is the extent to which we can assess how patients cope by more accurately pinpointing which traits they seem to lack.

WHO COPES POORLY?

Bad copers are not 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 to his or her 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 9-2 lists some characteristics of poor copers.

Table 9-2 Characteristics of Poor Copers

Indeed, structured investigations into the psychiatric symptoms of the medically ill have often yielded 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 for whom psychiatric attention was indicated.

THE ROLE OF RELIGION

The significance of religious or spiritual conviction in the medically ill deserves special mention. Virtually every psychiatrist works with patients as they wrestle with existential issues (such as mortality, fate, justice, and fairness). Such ruminations cannot help but invoke religious considerations in both patient and the physician; moreover, there is a growing appreciation in the medical literature for the important role that these considerations can play.

In some investigations, being at peace with oneself and with one’s sense of a higher power is predictive of both physical and psychiatric recovery.^9,10 However, other studies have suggested that resentment toward God, fears of God’s abandonment, and a willingness to invoke Satanic motivation for medical illness were all predictive of worsening health and an increased risk of death.¹¹

Inasmuch as the role of the psychiatrist is to identify and to strengthen those attributes that are most likely to aid a patient’s physical and emotional well-being, effective therapy for the medically ill involves exploring the religious convictions of patients; fostering those elements is most likely to be helpful. It is never the role of the physician to encourage religious conviction de novo. At the same time, ignoring religious content risks omitting an important element of the psychotherapeutic armamentarium.

THE MEDICAL PREDICAMENT—BRINGING IT ALL TOGETHER

Coping refers to how a patient responds to and deals with problems that relate to disease, sickness, and vulnerability. In approaching chronically ill patients, it is helpful to conceptualize disease as the categorical reason for being sick, sickness as the individual style of illness and patienthood, and vulnerability as the tendency to be distressed and to develop emotional difficulties in the course of trying to cope.¹

Given these definitions, the psychiatrist needs first to ask why now? What has preceded the request for consultation? How does the patient show his or her sense of futility and despair? How did the present trouble, both medical and the corresponding coping challenges, come about? Was there a time when such problems could have been thwarted? It is also important to note that often the treatment team is even more exasperated than the patient. In these instances, one must guard against the assumption that it is only the patient who is troubled by the medical predicament.

In fact, if there is any doubt about the gap between how the staff and patients differ in their cultural bias and social expectations, listen to the bedside conversation between the patient and all of the clinicians involved in his or her care. Good communication may not only reduce potential problem areas, but also help patients to cope better. Good coping is a function of empathic respect between the patient and the doctor regarding the risks and points of tension in the current treatment. The psychiatrist is by no means alone in professional concern about coping, but the unique skills and mandates of psychiatric care are ideally suited to address the vicissitudes of how patients cope. As already men-tioned, much of chronic disease evokes existential issues (such as death, permanent disability, low self-esteem, dependence, and alienation). These are fundamentally psychiatric considerations.

Given all of this, it is important to remember that psychiatry does not arbitrarily introduce psychosocial problems. If, for example, a patient is found to have an unspoken but vivid fear of death or is noted to suffer from an unrecognized and unresolved bereavement, fear and grief are already there, not superfluous artifacts of the evaluation procedure. Indeed, open discussion of these existential quandaries is likely to be therapeutic, and active denial of their presence is potentially detrimental, risking empathic failure and the poor compliance that accompanies the course of patients who feel misunderstood or unheard.

Being sick is, of course, much easier for some patients than for others, and for certain patients, it is preferred over trying to make it in the outside world. There is too much anxiety, fear of failure, inadequacy, pathological shyness, expectation, frustration, and social hypochondriasis to make the struggle for holding one’s own appealing. At key moments of life, sickness is a solution. Although healthy people are expected to tolerate defeat and to withstand disappointments, others legitimize their low self-esteem by a variety of excuses, denial, self-pity, and symptoms, long after other patients are back to work. Such patients thrive in a complaining atmosphere and even blame their physicians. These are perverse forms of coping.

These complexities substantially complicate the role of the psychiatrist. The clinician must assess the motivation of staff and patient in asking for a psychiatric intervention. For example, the request for psychiatric consultation to treat depression and anxiety in a negativistic and passive-aggressive patient is inevitably more complicated than a simple recognition of certain key psychiatric symptoms. Such patients (through primitive defenses) can generate a profound sense of hopelessness and discomfort in their treaters. It is often an unspoken and unrecognized desire by physicians and ancillary staff that the psychiatrist shifts the focus of negativity and aggression onto himself or herself and away from the remaining treatment team. If the consulting psychiatrist is not aware of these subtleties, the intent of the consultation will be misinterpreted and the psychiatrist’s efforts will ultimately fall short.

COPING AND SOCIAL SUPPORT

Every person needs or at least deserves a measure of support, sustenance, security, and self-esteem, even if they are not patients at all, but human beings encountered at a critical time.

In assessing problems and needs, the psychiatrist can help by identifying potential pressure points (e.g., health and well-being, family responsibility, marital and sexual roles, jobs and money, community expectations and approval, religious and cultural demands, self-image and sense of inadequacy, and existential issues) where trouble might arise.

Social support is not a hodgepodge of interventions designed to cheer up or to straighten out difficult patients. Self-image and self-esteem, for example, depend on the sense of confidence generated by various sources of social success and support. In a practical sense, social support reflects what society expects and therefore demands about health and conduct. There is in fact a burgeoning literature that addresses the necessity of support at all levels of care for patients with chronic illness.

Social support is not a “sometime” thing, to be used only for the benefit of those too weak, needy, or troubled to get along by themselves. It requires a deliberate skill, which professionals can cultivate, in order to recognize, refine, and implement what any vulnerable individual needs to feel better and to cope better. In this light, it is not an amorphous exercise in reassurance but a combination of therapeutic gambits opportunistically activated to normalize a patient’s attitude and behavior. Techniques of support range from concrete assistance to extended counseling.^12,13 Their aim is to help patients get along without professional support. Social support depends on an acceptable image of the patient, not one that invariably “pathologizes.” If a counselor only corrects mistakes or points out what is wrong, bad, or inadequate, insecurity increases and self-esteem inevitably suffers.

THE ASSESSMENT OF VULNERABILITY

Vulnerability is present in all humans, and it shows up at times of crisis, stress, calamity, and threat to well-being and identity.^14–20

How does a patient visualize threat? What is most feared, say, in approaching a surgical procedure? The diagnosis? Anesthesia? Possible invalidism? Failure, pain, or abandonment by the physician or family?

Coping and vulnerability have a loosely reciprocal relationship in that the better one copes, the less distress he or she experiences as a function of acknowledged vulnerability. In general, a good deal of distress often derives directly from a sense of uncertainty about how well one will cope when called on to do so. This does not mean that those who deny or disavow problems and concerns are superlative copers. The reverse may be true. Courage to cope requires anxiety confronted and dealt with, with an accurate appraisal of how much control the patient has over his or her predicament.

Table 9-3 shows 13 common types of distress. Table 9-4 describes how to find out about salient problems, the strategy used for coping, and the degree of the resolution attained.

Table 9-3 Vulnerability

Table 9-4 Coping (To Find Out How a Patient Copes)

Adapted from Weisman AD: The realization of death: a guide for the psychological autopsy, New York, 1974, Jason Aronson.

Many interventions call on the consulting psychiatrist to ask patients to fill out forms that indicate their degree of anxiety, level of self-esteem, perceived illness, and so on. Although such queries are often sources of valuable information, these standardized inquiries are no substitute for careful and compassionate interviews. There is a strong element of social desirability present in any attempt to assess how a patient copes. How a patient deals with illness may not be the same as how he or she wishes to manage it. Vulnerability, except in extreme forms (such as depression, anger, or anxiety), is difficult to characterize, so the astute clinician must depend on a telling episode or metaphor that typifies a total reaction.

HOW TO FIND OUT MORE ABOUT COPING

Thus far, we have discussed the following: salient characteristics of effective and less effective copers; methods by which deficits in patients can be identified and how clinicians can intervene; potential pressure points that alert clinicians to different psychosocial difficulties; types of emotional vulnerabilities; and a format for listing different coping strategies, along with questions about resolution.

The assessment and identification of ways in which a patient copes or fails to cope with specific problems requires both a description by the patient and an interpretation by the psychiatrist. Even so, this may not be enough. Details of descriptive importance may not be explicit or forthcoming. In these situations, the clinician must take pains to elucidate the specifics of each situation. If not, the result is only a soft approximation that generalizes where it should be precise. Indeed, the clinician should ask again and again about a topic that is unclear and rephrase, without yielding to clichés and general impressions.

Psychiatrists have been imbued with the values of so-called empathy and intuition. Although immediate insights and inferences can be pleasing to the examiner, sometimes these conclusions can be misleading and totally wrong. It is far more empathic to respect each patient’s individuality and unique slant on the world by making sure that the examiner accurately describes in detail how problems are confronted. To draw a quick inference without being sure about a highly private state of mind is distinctly unempathic. Like most individuals, patients give themselves the benefit of the doubt and claim to resolve problems in a socially desirable and potentially effective way. It takes little experience to realize that disavowal of any problem through pleasant distortions is itself a coping strategy, not necessarily an accurate description of how one coped.

Patients who adamantly deny any difficulty tend to cope poorly. Sick patients have difficult lives, and the denial of adversity usually represents a relatively primitive defense that leaves such patients unprepared to accurately assess their options. Carefully timed and empathic discussion with patients of a genuine appraisal for their current condition can help them to avoid this maladaptive approach and to address their treatment more effectively.

On the other hand, patients may attempt to disavow any role in their current illness. By seeking credit for having suffered so much, such patients reject any implication that they might have prevented, deflected, or corrected what has befallen them (see Table 9-4). Helping these patients does not necessarily require that they acknowledge their role in their particular predicament. Instead, the empathic listener identifies and provides comfort around the implicit fear that these patients harbor (i.e., that they somehow deserve their debilitation).

Suppression, isolation, and projection are common de-fenses. Effective copers seem to pinpoint problems clearly, whereas poor copers seem only to seek relief from further questions without attempting anything suggesting reflective analysis.

In learning how anyone copes, a measure of authentic skepticism is always appropriate, especially when it is combined with a willingness to correction later on. The key is to focus on points of ambiguity, anxiety, and ambivalence while tactfully preserving a patient’s self-esteem. A tactful examiner might say, for example, “I’m really not clear about what exactly bothered you, and what you really did….”

The purpose of focusing is to avoid premature formulations that gloss over points of ambiguity. An overly rigid format in approaching any evaluation risks overlooking individual tactics that deny, avoid, dissemble, and blame others for difficulties. Patients, too, can be rigid, discouraging alliance, rebuffing collaboration, and preventing an effective physician-patient relationship.

HOW TO BE A BETTER COPER

Coping with illness is only one special area of human behavior. It is important to recognize that in evaluating how patients cope, examiners should learn their own coping styles and, in effect, learn from patients. Clearly, it is not enough to mean well, to have a warm heart, or to have a head filled with scientific information. Coping well requires open-ended communication and self-awareness. No technique for coping is applicable to one and all. In fact, the concept of technique may be antithetical to true understanding. A false objectivity obstructs appraisal; an exaggerated subjectivity only confuses what is being said about whom.

Psychiatrists and patients can become better copers by cultivating the characteristics of effective copers. Coping is, after all, a skill that is useful in a variety of situations, although many modifications of basic principles are called for. Confidence in being able to cope can be enhanced only through repeated attempts at self-appraisal, self-instruction, and self-correction. Coping well with illness—with any problem—does not predict invariable success, but it does provide a foundation for becoming a better coper.