Coping With Chronic Illness: A Study of Illness Controllability and the Influence of Coping Strategies on Psychological Adjustment. Barbara J. Felton. New York ...
Copyright 1984 by the American Psychological Association, Inc.
Journal of Consulting and Clinical Psychology 1984, Vol. 52, No. 3, 343-353
Coping With Chronic Illness: A Study of Illness Controllability and the Influence of Coping Strategies on Psychological Adjustment Barbara J. Felton
Tracey A. Revenson
New York University
Program in Social Ecology University of California, Irvine
Longitudinal data on the coping strategies used by middle-aged and older adults faced with one of four different chronic illnesses (N ~ 151) were used to evaluate the role of coping in the explanation of psychological adjustment. The study distinguished between illnesses that offer few opportunities for control (rheumatoid arthritis and cancer) and those more responsive to individual and medical efforts at control (hypertension and diabetes) and evaluated the emotional consequences of two coping strategies, information seeking and wish-fulfilling fantasy, expected to play different roles in adjustment. Results showed information seeking to have salubrious effects on adjustment and wish-fulfilling fantasy to have deleterious consequences; contrary to expectation, neither strategy's effects were modified by illness controllability. Analyses of the direction of causation between coping and adjustment suggest that wish-fulfilling fantasy is linked to poor adjustment in a mutually reinforcing causal cycle. The modesty of the effects of coping, however, demand replication of results to confirm the conclusions drawn here.
Physical health is closely related to emotional and mental health, particularly among middle-aged and older adults, a fact documented by a multitude of studies (see reviews by Larson, 1978; Palmore & Luikart, 1972). Individuals differ in their adjustment to both acute and chronic illness, however. Coping efforts have been proposed as one means of accounting for these differences in adaptation, and numerous studies have documented the importance of individual coping efforts in helping ill adults maintain reasonable levels of emotional well-being (e.g., Cohen & Lazarus, 1979; Moos, 1982). These studies have found typical coping strategies to include: denial, selective ignoring, information seeking, taking refuge in activity, avoidance, learning specific illness-related procedures, engaging in wish-fulfilling fantasy, blaming others, and seeking comfort from others. Unfortunately, many of the studies arguing the importance
This research was supported by National Institute of Mental Health Grant MH 29822. Requests for reprints should be sent to Barbara J. Felton, Department of Psychology, New York University, 6 Washington Place, Room 766, New York, New York 10003.
of coping efforts have relied on case study methods or have confounded measures of coping and adjustment by a priori defining groups of good versus poor copers (e.g., Hackett & Cassem, 1975; Sanders & Kardinal, 1977). Nonetheless, more recent and more systematically controlled studies have also demonstrated a role for coping in explaining the psychological adjustment of ill adults (Lambert, 1981; Weisman & Worden, 1976). Studies considering stresses other than of physical illness have also provided evidence that adults' choices of coping strategies influence the emotional outcome of stressful events (e.g., Menaghan, 1982; Pearlin, Lieberman, Menaghan, & Mullan, 1981; Pearlin & Schooler, 1978). Pearlin et al. (1981) used longitudinal data to confirm that coping affected depression in reaction to involuntary job disruption: People who coped by making positive comparisons of their situations with others' and by devaluing the importance of monetary success were more successful in avoiding economic strain, loss of self-esteem, and depression. Menaghan (1982) evaluated the role of coping in marital problems over a 4-year period and found that coping by making optimistic comparisons of one's situation relative
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BARBARA J. FELTON AND TRACEY A. REVENSON
to the past and relative to one's peers was as- are basically emotion focused, or palliative, sociated with both lowered distress and with were associated with poorer adjustment, fewer subsequent marital problems. Other whereas active, instrumental strategies were coping strategies were effective in only one do- not. Marrero (1981), on the other hand, found main or actually increased distress. problem-focused coping more characteristic Specific types of coping strategies are more of diabetics in poor metabolic control than of or less effective depending upon the type of well-controlled diabetics. The fact that all of stress being faced. Pearlin and Schooler (1978) the studies of illness to date have been refound that coping strategies involving com- stricted to a single point in time furthers ammitment and engagement with others were biguity: Poor adjustment may be the cause most effective in dealing with stresses arising rather than the consequence of palliative forms in close interpersonal relations. In contrast, of coping. cognitive manipulations that distanced the The current study evaluates the emotional person from the problem were most effective consequences of using palliative and instrufor stresses in occupational and economic mental coping strategies among patients faced areas, domains more impersonal and less with chronic illness. Information seeking was amenable to control (see also Pearlin et al., chosen as the instrumental strategy to be con1981). Folkman and Lazarus (1980) found that sidered and wish-fulfilling fantasy as the pal"palliative," or emotion-focused coping, was liative strategy. Although other coping stratmore likely to be used than "instrumental," egies fit within the instrumental and palliative or problem-focused coping, for health prob- categories, these two strategies were selected lems, especially when the problem was ap- because of their frequent emergence in studies praised as uncontrollable. of the structure of adults' coping (e.g., ChiControllability is suggested as a critical riboga, in press) and because of their centrality property of stressors by this research and by in theories of coping. Information seeking has several theories of coping (e.g., Baum, Singer, been described as one of the most universal & Baum, 1981; Lazarus & Folkman, 1984). forms of coping (Cohen & Lazarus, 1979; Controllability determines whether the strat- Hamburg & Adams, 1967) and one particuegies that prove most effective will be those larly valuable in recovery and adjustment to that directly address the problem or those that illness (Cohen, 1980; Moos & Tsu, 1977). aim at alleviating the emotional distress Wish-fulfilling fantasy was among the emotionaroused by the problem. Uncontrollability focused coping strategies found to be imporlimits the utility of coping efforts directed at tant in explaining psychological adjustment the problematic situation. In stressful situa- among rheumatoid arthritics (Lambert, 1981) tions that are basically immutable, strategies and is theoretically important as a typical "atthat involve compromise with or temporary tention deployment" coping strategy (Lazarus, distortions of reality—strategies that might be Averill, & Opton, 1974). considered inferior by traditional psychological In addition, by examining chronic illnesses theories (e.g., Haan, 1977; Vaillant, 1977)— that vary in controllability, this study addresses might well be effective efforts at adaptation the question of whether the controllability of (Lazarus & Folkman, 1984; Mechanic, 1974; one's illness affects the impact of the instruWhite, 1974). mental strategy of information seeking. We Physical illnesses clearly vary in their expected information seeking to be more psyamenability to efforts at control. Research on chologically adaptive under conditions of conillness, however, has not as yet systematically trol, or conditions in which the information evaluated the impact of variations in illness sought has the capacity to improve directly controllability on the effectiveness of different one's physical well-being. The reprieve from coping strategies. Studies have been largely re- the stress of illness afforded by wish-fulfilling stricted to single illnesses, and findings have fantasy was expected to be more adaptive for been contradictory: In studies by Lambert those with uncontrollable illnesses because (1981) and by Weisman and Worden (1976), wish-fulfilling fantasy may compete with more coping strategies involving avoidance and "at- constructive coping efforts when control is tention deployment," that is, strategies that possible.
COPING WITH CHRONIC ILLNESS
The study also examines whether coping plays a causal role in adjustment to illness, or whether coping behaviors are simply emotional reactions to illness. Although we could not manipulate the use of wish-fulfilling fantasy and information seeking experimentally, we used two panels of data to make tentative inferences about the direction of causation in the relationship between coping and adjustment. Method The study was designed to allow comparisons among nonhospitalized individuals faced with one of four chronic illnesses: hypertension, diabetes mellitus, rheumatoid arthritis, and systemic blood cancers. In selecting the illnesses, those that ran too rapid a course for study or that were not moderately prevalent among middle-aged and older Americans were excluded from consideration; the illnesses chosen were fairly equally "systemic," that is, none was primarily localized in a specific body site. Most important, the four illnesses were selected to represent a 3-point continuum of "controllability" and, in the case of "least controllability," two qualitatively different types of stress. Hypertension is largely controllable by diet and/or medication; both forms of treatment are self-administered and adherence to prescribed treatment is largely the responsibility of the patient (Robbins, 1974). Diabetes mellitus lies in the middle of the continuum: Though the symptoms of diabetes mellitus are usually quite responsive to diet and/or medication, the long-range effects of disease progression, particularly on the circulatory and renal systems, are largely uncontrollable (Cahill, Etzwiler, & Freinkel, 1976; Rifkin, 1978). The diseases characterized in this study as uncontrollable, in contrast, are unpredictable in their prognosis, progression, and responsiveness to treatment. They were distinct from each other in many ways, however. The types of cancer1 included in this study pose a moderate to high degree of life threat. They often require periodic, discomforting, and at times painful therapy and may run a course almost beyond personal and medical control. Rheumatoid arthritis, although not posing the extreme life-threat or metaphorical stigma of cancer (Sontag, 1978), is characterized by extreme pain and decreased joint mobility, symptoms that severely limit one's ability to perform tasks of daily living. For many patients the pain and physical deformity are inevitable, with available drugs offering little relief. Subjects' self-reports of illness controllability led to the decision to dichotomize illnesses into the less controllable illnesses (rheumatoid arthritis and cancer) and the more controllable (hypertension and diabetes). Analysis of variance of a 10-item version of the Health Locus of Control Scale (Wallston, Wallston, Kaplan, & Maides, 1976) showed that cancer (M = 2.70; SD = 0.44) and rheumatoid arthritis (M = 2.78; SD = 0.37) patients perceived themselves as having comparably low levels of control over their illnesses. Diabetic (M = 3.12; SD = 0.43) and hypertensive subjects (M = 3.03; SD = 0.43) reported higher levels of perceived control, according to Tukey (.05) post hoc comparisons, TO, 164)= 11.30, p g
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