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