Coping with the crisis of illness

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Implications for the outcome of the coping process
Shontz developed these stages from observations of individuals in hospital and suggested
that once at the retreat stage, individuals with a diagnosis of a serious illness can
gradually deal with the reality of their diagnosis. According to Shontz, retreat is only a
temporary stage and denial of reality cannot last for ever. Therefore, the retreat stage acts
as a launch pad for a gradual reorientation towards the reality of the situation and as
reality intrudes the individual begins to face up to their illness. Therefore, this model of
coping focuses on the immediate changes following a diagnosis, suggesting that the
desired outcome of any coping process is to face up to reality and that reality orientation
is an adaptive coping mechanism.
Coping with the crisis of illness
In an alternative approach to coping with illness, Moos and Schaefer (1984) have applied
‘crisis theory’ to the crisis of physical illness.
What is crisis theory?
Crisis theory has been generally used to examine how people cope with major life
crises and transitions and has traditionally provided a framework for understanding
the impact of illness or injury. The theory was developed from work done on grief
and mourning and a model of developmental crises at transition points in the life cycle.
In general, crisis theory examines the impact of any form of disruption on an individual’s established personal and social identity. It suggests that psychological systems
are driven towards maintaining homeostasis and equilibrium in the same way as
physical systems. Within this framework any crisis is self-limiting as the individual
will find a way of returning to a stable state; individuals are therefore regarded as
self-regulators.
Physical illness as a crisis
Moos and Schaefer (1984) argued that physical illness can be considered a crisis as it
represents a turning point in an individual’s life. They suggest that physical illness causes
the following changes, which can be conceptualized as a crisis:
I Changes in identity: illness can create a shift in identity, such as from carer to patient,
or from breadwinner to person with an illness.
I Changes in location: illness may result in a move to a new environment such as
becoming bedridden or hospitalized.
I Changes in role: a change from independent adult to passive dependant may occur
following illness, resulting in a changed role.
I Changes in social support: illness may produce isolation from friends and family
effecting changes in social support.
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I Changes in the future: a future involving children, career or travel can become
uncertain.
In addition, the crisis nature of illness may be exacerbated by factors that are often
specific to illness such as:
I Illness is often unpredicted: if an illness is not expected then the individual will not have
had the opportunity to consider possible coping strategies.
I Information about the illness is unclear: much of the information about illness is
ambiguous and unclear, particularly in terms of causality and outcome.
I A decision is needed quickly: illness frequently requires decisions about action to be
made quickly (e.g. should we operate, should we take medicines, should we take time
off from work, should we tell our friends).
I Ambiguous meaning: because of uncertainties about causality and outcome, the
meaning of the illness for an individual will often be ambiguous (e.g. is it serious?
how long will it effect me?).
I Limited prior experience: most individuals are healthy most of the time. Therefore,
illness is infrequent and may occur to individuals with limited prior experience. This
lack of experience has implications for the development of coping strategies and
efficacy based on other similar situations (e.g. ‘I’ve never had cancer before, what
should I do next?’).
Many other crises may be easier to predict, have clearer meanings and occur to individuals with a greater degree of relevant previous experience. Within this framework,
Moos and Schaefer considered illness a particular kind of crisis, and applied crisis theory
to illness in an attempt to examine how individuals cope with this crisis.
The coping process
Once confronted with the crisis of physical illness, Moos and Schaefer (1984) described
three processes that constitute the coping process: (1) cognitive appraisal; (2) adaptive
tasks; and (3) coping skills. These processes are illustrated in Figure 3.2.
Process 1: Cognitive appraisal At the stage of disequilibrium triggered by the
illness, an individual initially appraises the seriousness and significance of the illness
(e.g. Is my cancer serious? How will my cancer influence my life in the long run?).
Factors such as knowledge, previous experience and social support may influence this
appraisal process. In addition, it is possible to integrate Leventhal’s illness cognitions at
this stage in the coping process as such illness beliefs are related to how an illness will
be appraised.
Process 2: Adaptive tasks Following cognitive appraisal, Moos and Schaefer
describe seven adaptive tasks that are used as part of the coping process. These can be
divided into three illness specific tasks and four general tasks. These are illustrated in
Table 3.1.
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Fig. 3-2 Coping with the crisis of illness
Illness-related tasks
I Dealing with pain and other symptoms
I Dealing with the hospital environment and treatment procedures
I Developing and maintaining relationships with health professionals
General tasks
I Preserving an emotional balance
I Preserving self-image, competence and mastery
I Sustaining relationships with family and friends
I Preparing for an uncertain future
Table 3.1
Adaptive tasks
The three illness-specific tasks can be described as:
1 Dealing with pain, incapacitation and other symptoms. This task involves dealing
with symptoms such as pain, dizziness, loss of control and the recognition of changes
in the severity of the symptoms.
2 Dealing with the hospital environment and special treatment procedures. This
task involves dealing with medical interventions such as mastectomy, chemotherapy
and any related side effects.
3 Developing and maintaining adequate relationships with health care staff.
Becoming ill requires a new set of relationships with a multitude of health
professionals. This task describes the development of those relationships.
The four general tasks can be described as:
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1 Preserving a reasonable emotional balance. This involves compensating for the
negative emotions aroused by illness with sufficient positive ones.
2 Preserving a satisfactory self-image and maintaining a sense of competence
and mastery. This involves dealing with changes in appearance following illness
(e.g. disfigurement) and adapting to a reliance on technology (e.g. pacemaker).
3 Sustaining relationships with family and friends. This involves maintaining social
support networks even when communication can become problematic due to changes
in location and mobility.
4 Preparing for an uncertain future. Illness can often result in loss (e.g. of sight,
lifestyle, mobility, life). This task involves coming to terms with such losses and
redefining the future.
Process 3: Coping skills Following both appraisal and the use of adaptive tasks,
Moos and Schaefer described a series of coping skills that are accessed to deal with the
crisis of physical illness. These coping skills can be categorized into three forms: (1)
appraisal-focused coping; (2) problem-focused coping; and (3) emotion-focused coping
(see Table 3.2).
Appraisal-focused
I Logical analysis and mental preparation
I Cognitive redefinition
I Cognitive avoidance or denial
Problem-focused
I Seeking information and support
I Taking problem-solving action
I Identifying rewards
Emotion-focused
I Affective regulation
I Emotional discharge
I Resigned acceptance
Table 3.2
Coping skills
Appraisal-focused coping involves attempts to understand the illness and represents a
search for meaning. Three sets of appraisal-focused coping skills have been defined:
1 Logical analysis and mental preparation, involving turning an apparently
unmanageable event into a series of manageable ones.
2 Cognitive redefinition, involving accepting the reality of the situation and redefining
it in a positive and acceptable way.
3 Cognitive avoidance and denial, involving minimizing the seriousness of the illness.
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Problem-focused coping involves confronting the problem and reconstructing it as
manageable. Three types of problem-focused coping skills have been defined:
1 Seeking information and support, involving building a knowledge base by accessing
any available information.
2 Taking problem-solving action, involving learning specific procedures and behaviours
(e.g. insulin injections).
3 Identifying alternative rewards, involving the development and planning of events
and goals that can provide short-term satisfaction.
Emotion-focused coping involves managing emotions and maintaining emotional
equilibrium. Three types of emotion-focused coping skills have been defined:
1 Affective, involving efforts to maintain hope when dealing with a stressful situation.
2 Emotional discharge, involving venting feelings of anger or despair.
3 Resigned acceptance, involving coming to terms with the inevitable outcome of an
illness.
Therefore, according to this theory of coping with the crisis of a physical illness,
individuals appraise the illness and then use a variety of adaptive tasks and coping skills
which in turn determine the outcome.
However, not all individuals respond to illness in the same way and Moos and
Schaefer (1984) argued that the use of these tasks and skills is determined by three
factors:
1 Demographic and personal factors, such as age, sex, class, religion.
2 Physical and social/environmental factors, such as the accessibility of social support
networks and the acceptability of the physical environment (e.g. hospitals can be dull
and depressing).
3 Illness-related factors, such as any resulting pain, disfigurement or stigma.
Implications for the outcome of the coping process
Within this model, individuals attempt to deal with the crisis of physical illness via
the stages of appraisal, the use of adaptive tasks and the employment of coping skills.
The types of tasks and skills used may determine the outcome of this process and such
outcome may be psychological adjustment or well-being, or may be related to longevity
or quality of life (see Chapter 16). According to crisis theory, individuals are motivated to
re-establish a state of equilibrium and normality. This desire can be satisfied by either
short-term or long-term solutions. Crisis theory differentiates between two types of
new equilibrium: healthy adaptation, which can result in maturation and a maladaptive
response resulting in deterioration. Within this perspective, healthy adaptation involves
reality orientation and adaptive tasks and constructive coping skills. Therefore,
according to this model of coping the desired outcome of the coping process is reality
orientation.
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