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CHAPTER 3 Coping and Social Support SHARON MANNE 51 COPING 51 Theories of Coping 51 The Role of Coping in Health Behaviors and in the Management of Health Risk 54 Coping and Health Outcomes 54 Coping and Psychological Adaptation to Disease 55 Other Coping Processes: Social Comparison 57 Studies of Coping with Chronic Pain 57 Challenges to the Study of Coping with Chronic Illness 58 Conclusions and Directions for Future Research 59 SOCIAL SUPPORT 59 Introduction 59 Social Support Definitions 59 Social Support and Health Outcomes 60 Disease Progression and Mortality 62 Social Support and Psychological Outcomes 64 Cancer 64 Conclusions and Directions for Future Research 67 REFERENCES 68 Coping and social support are among the most widely written about and researched topics in health psychology. Both con- structs have been hypothesized as reasons why particular in- dividuals are at increased risk for developing illnesses such as cardiovascular disease and cancer, why some individuals do not adapt well once they develop a disease, and, more re- cently, linked with disease course and survival once an illness is diagnosed. In this chapter, we explore the historical context of coping and social support in the context of health, as well as the empirical work examining the role of coping and social support in disease etiology, disease management, and out- comes. Each section is divided into a historical discussion, current theoretical perspectives on each construct, and de- scriptive studies. Key challenges and areas for future re- search are also discussed. COPING Over the past two decades, there has been a substantial amount of research devoted to understanding the role of coping in disease etiology, management of health risk, adap- tation to disease, and disease outcomes. In the context of health risk and outcomes, the role of coping in psychologi- cal adaptation to disease has received the most empirical attention. Theories of Coping Stress and Coping Paradigm Research on stress and coping exploded with Lazarus and Folkman•s stress and coping theory (1984). They put forth the transactional stress and coping paradigm and the most widely accepted de“nition of coping. According to Lazarus, coping refers to cognitive and behavioral efforts to manage disruptive events that tax the person•s ability to adjust (Lazarus, 1981, p. 2). According to Lazarus and Folkman, coping responses are a dynamic series of transactions be- tween the individual and the environment, the purpose of which is to regulate internal states and/or alter person- environment relations. The theory postulates that stressful emotions and coping are due to cognitions associated with the way a person appraises or perceives his or her relation- ship with the environment. There are several components of the coping process. First, appraisals of the harm or loss posed by the stressor (Lazarus, 1981) are thought to be important determinants of coping. Second, appraisal of the degree of controllability of the stressor is a determinant of coping strategies selected. A third component is the person•s evalua- tion of the outcome of their coping efforts and their expecta- tions for future success in coping with the stressor. These evaluative judgments lead to changes in the types of coping employed. In addition, they play a role in determining 52 Coping and Social Support psychological adaptation. Two main dimensions of coping are proposed, problem-focused and emotion-focused coping. Problem-focused coping is aimed at altering the problematic situation. These coping efforts include information seeking and planful problem solving. Emotion-focused coping is aimed at managing emotional responses to stressors. Such coping efforts include cognitive reappraisal of the stressor and minimizing the problem. How the elements of coping unfold over time is a key the- oretical issue involved in studies of coping processes. Al- though the theory is dynamic in nature, most of the research utilizing the stress and coping paradigm put forth by Lazarus and colleagues (1981) has relied on retrospective assessments of coping and has been cross-sectional. However, a team of researchers, including Glen Af”eck, Howard Tennen, and Francis Keefe (e.g., Af”eck et al., 1999) have utilized a daily diary approach to assessing coping with pain, a methodology that can examine the proposed dynamic nature of coping. Cognitive Processing Theories In recent years, there has been an expansion in theoretical perspectives on cognitive coping. The literature on cognitive processing of traumatic life events has provided a new direc- tion for coping research and broadened theoretical perspec- tives on cognitive methods of coping with chronic illness. According to cognitive processing theory, traumatic events can challenge people•s core assumptions about themselves and their world (Janoff-Bulman, 1992). For example, the un- predictable nature of many chronic illnesses, as well as the numerous social and occupational losses, can cause people to question the beliefs they hold about themselves. A diagnosis of cancer can challenge a person•s assumptions about being personally invulnerable to illness and/or providing for his or her family. To the extent that a chronic illness challenges these basic assumptions, integrating the illness experience into their preexisting beliefs should promote psychological adjustment. Cognitive processing is de“ned as cognitive ac- tivities that help people view undesirable events in personally meaningful ways and “nd ways of understanding the nega- tive aspects of the experience, and ultimately reach a state of acceptance (e.g., Greenberg, 1995). By “nding meaning or positive bene“t in a negative experience, individuals may be better able to accept the losses they experience. Focusing on the positive implications of the illness or “nding personal signi“cance in a situation are two ways of “nding meaning. Coping activities that help individuals to “nd redeeming fea- tures in an event must be distinguished from the successful outcome of these attempts. For example, people may report that as a result of a serious illness, they have found a new appreciation for life or that they place greater value on rela- tionships. Patients may also develop an explanation for the illness that is more benign (e.g., attributing it to God•s will) or make sense of the illness by using their existing views of the world (e.g., assuming responsibility for the illness because of a lifestyle that caused the illness). While cogni- tive processing theory constructs have been applied to adjustment to losses such as bereavement (e.g., Davis, Nolen-Hoeksema, & Larson, 1998), these processes have re- ceived relatively little attention from researchers examining patients coping with chronic illness. Another coping process that falls under the rubric of cog- nitive processing is social comparison (SC). Social com- parison is a common cognitive process whereby individuals compare themselves to others to obtain information about themselves (Gibbons & Gerrard, 1991). According to SC theory, health problems increase uncertainty; uncertainty increases the desire for information, and creates the need for comparison. Studies of coping with chronic illness have in- cluded social comparison as a focus. A certain type of SC, downward comparison, has been the focus of empirical study among patients with chronic illnesses such as rheumatoid arthritis (RA) (Tennen & Af”eck, 1997). Wills (1981) has suggested that people experiencing a loss can experience an improvement in mood if they learn about others who are worse off. Although there is little evidence that SC increases as a result of experiencing health problems, there is consider- able evidence to suggest this may be the case (Kulik & Mahler, 1997). One proposed mechanism for SC is that downward comparison impacts cognitive appraisal by reduc- ing perceived threat. When another person•s situation appears signi“cantly worse, then the appraisal of one•s own illness may be reduced (Aspinwall & Taylor, 1993). Coping Style Theories Although the majority of coping theories focus on the trans- actional, dynamic aspects of coping, there remains a group of behavioral scientists who consider coping more of a disposi- tion or trait. Although there has been some inconsistency in the use of the term, coping style is typically the term used to refer to characteristic methods individuals use to deal with threatening situations. Coping style theorists propose that in- dividuals differ in a consistent and stable manner in how they respond to threatening health information and how they react to it affectively. Several coping style constructs have been ex- plored in the health psychology literature. The monitoring coping style construct, which has been put forth by Miller (1980; 1987), proposes that individuals have characteristic ways of managing health threats in terms of their attentional Coping 53 processes. According to Monitoring Process Theory, there are two characteristic ways of dealing with health threat, monitoring, and blunting. Monitors scan for and magnify threatening cues, and blunters distract from and downgrade threatening information (Miller, 1995). A similar coping style construct that has received theoret- ical and empirical attention is coping with affective responses to health threats. Two constructs, repressive coping style and emotional control, have been the most studied in the area of health psychology. Repressive coping style, a construct de- rived from psychoanalytic theory is based on the defense of repression (e.g., Kernberg, 1982). Repressive coping style is exhibited by individuals who believe they are not upset de- spite objective evidence to the contrary. Thus, it is inferred that they are consciously repressing threatening feelings and concerns. This style has been variously labeled as attention- rejection (Mullen & Suls, 1982) and repression-sensitization (Byrne, 1961). A second, but related, coping style is the construct of emotional control, which describes an individual who experiences and labels emotions, but does not express the emotional reaction (Watson & Greer, 1983). Both con- structs have sparked particular interest in the area of psy- chosocial oncology, where investigations have focused on the role of emotional repression and suppression in cancer onset and progression (e.g., Butow, 2000; Goldstein & Antoni, 1989; Kneier & Temoshok, 1984; Kreitler, Chaitchik, & Kreitler, 1993). More recently, repressive coping has also been associated with higher risk for poor disease outcome, as physiological and immunological correlates of repressive coping have been identi“ed, including high systolic blood pressure (Broege, James, & Peters, 1997) and reduced im- munocompetence (Jamner & Leigh, 1999). In addition, re- pressive coping has been associated with lower ability to perceive symptoms (Lehrer, 1998). Unfortunately, measure- ment of this construct has been a challenge to behavioral scientists. Although the majority of coping theories treat coping as a situational variable, a subset of investigators have conceptu- alized coping behaviors as having trait-like characteristics. That is, coping is viewed as largely consistent across situa- tions because individuals have particular coping styles or ways of handling stress. In general, the contribution of trait versus states to the prediction of behavior has been a hotly debated topic in the last several decades, starting with the work of Walter Mischel (1968). One response to the trait- situation debate was the development of the interactionist po- sition, which postulates that all behaviors are a function of both the person•s traits and the situation (e.g., Endler & Hunt, 1968). Recent studies investigating coping using daily as- sessments suggest that coping, particularly avoidance and religious coping, has a moderate degree of consistency when multiple daily assessments are utilized (Schwartz, Neale, Marco, Schiffman, & Stone, 1999). Interestingly, these ag- gregated daily reports of coping activities using the Daily Coping Assessment are only moderately associated with self- report measures of trait coping (how one generally copes with stress) (Schwartz, Neale, Marco, Schiffman, & Stone, 1999). Theories of Coping with Health Risk One of the only health belief models that has incorporated coping is Leventhal and colleagues• self-regulatory model of illness behavior (Prohaska, Leventhal, Leventhal, & Keller, 1985). According to this model, symptoms are key factors in how health threats are perceived. Symptoms are also the main targets for coping and symptom reduction is neces- sary for appraising progress with mitigating health threats (Cameron, Leventhal, & Leventhal, 1993). There are multi- ple components to this model: First, the individual perceives a change in somatic activity or a symptom, such as pain. Next, this symptom is compared with the person•s memory of prior symptoms in an attempt to evaluate the nature of the health threat. The person forms a symptom or illness repre- sentation, which has several key components: (a) identity of the health problem that includes its label and its attributes such as severity, (b) duration„an evaluation of how long it will last, (c) consequences„how much it will disrupt daily activity and anticipated long-term consequences or severity of the threat, (d) causes of the symptom, and (e) expecta- tion about controllability of the symptom (Lau, Bernard, & Hartman, 1989). Once the person completes this evaluation then he or she decides how to cope with the symptom. Cop- ing procedures are de“ned in two ways that correspond roughly to Lazarus and Folkman•s emotion- and problem- focused coping. Problem-solving behaviors include seeking medical care and self-care behaviors (e.g., taking insulin for diabetes), as well as attempts to seek information. This model is innovative because care-seeking and self-care behaviors such as adherence to medical regimens for chronic illnesses are de“ned as coping behaviors. Thus, this model would in- clude the study of determinants of adherence to medical reg- imens under the rubric of coping literature. This literature is beyond the scope of the present chapter, so we present only a brief review on this topic. The second aspect of coping is the manner in which the person copes with the affective response to the symptom. An innovative component of the self-regulatory model is that it incorporates how people cope with emotional responses to health threats. Emotional responses such as fear can be 54 Coping and Social Support elicited by symptom-induced pain or by an interpretation that the symptom represents a serious health threat such as cancer (Croyle & Jemmott, 1991). Coping responses to manage emotions have been evaluated in a similar way to Lazarus and colleagues; individuals are asked how they coped with the problem and responses are categorized using similar cat- egories (e.g., direct coping such as seeking information, and passive coping such as distraction). The Role of Coping in Health Behaviors and in the Management of Health Risk As compared to the relatively large literature on coping with illness, there is little published on the role of coping in health behavior change and in the management of health risk. Coping with a health risk is de“ned as those efforts to manage the knowledge that one is at higher risk for disease because of family history of the disease or because of be- havioral risk factors. To date, there have been almost no studies evaluating coping•s role in managing health be- haviors. Barron, Houfek, and Foxall (1997) examined the role of repressive coping style in women•s practice of breast self-examination (BSE). Repressive coping resulted in less frequent BSE and less pro“cient performance of BSE. Indi- viduals who exhibited repressive coping also reported more barriers and fewer bene“ts of BSE. Although it is generally thought that speci“c coping styles (e.g., monitoring) or cop- ing strategies (e.g., denial or avoidance) would predict pa- tients• adherence to medical regimes, the literature linking coping to medical adherence has not supported this hypoth- esis. General coping style has not been consistently linked to adherence (see Dunbar-Jacob et al., 2000). Other investi- gators have evaluated the role of speci“c coping responses in treatment adherence. Catz, McClure, Jones, and Brantley (1999) hypothesized that HIV-positive patients who engaged in spiritual coping may be more likely to adhere to medical regimens for HIV. However, their results did not support this hypothesis. Coping and Health Outcomes Whether psychological characteristics in”uence the devel- opment and course of disease has been a hotly debated topic in the empirical literature. This discussion of the association between coping and health outcomes is organized into two sections: “rst, the association between coping and disease risk; second, the relation between coping and disease pro- gression. Disease Risk The most investigated topic in this area is the association between coping and risk for cancer, particularly breast can- cer. Most scientists view the development of cancer as a multifactorial phenomenon involving the interaction of ge- netic, immunological, and environmental factors (see Levy, Herberman, Maluish, Schlien, & Lipman, 1985). The notion that psychological factors, particularly certain personality characteristics, contribute to the development of cancer, has been proposed by a number of behavioral scientists over the course of the past 30 years (e.g., Greer, Morris, & Pettingale, 1979). Strategies that individuals use to deal with stress, par- ticularly the use of denial and repression when dealing with stressful life events, have been suggested as potential factors in the development of breast cancer (Anagnostopoulos et al., 1993; Goldstein & Antoni, 1989). Studies of women who are at-risk for breast cancer and women undergoing breast biopsy do not consistently report an association. Edwards et al. (1990) used the Ways of Coping Checklist and found no as- sociation between coping and breast cancer risk. Testing for an interaction effect, additional analyses revealed that coping did not modify the effect of life event stress on breast cancer risk, after adjusting for age and history of breast cancer. Some studies have reported counterintuitive “ndings. For ex- ample, Chen et al. found that women who confronted stress by working out a plan to deal with the problem were at higher risk of breast cancer, independent of life events, and adjusted for age, family history, menopausal status, personality, to- bacco and alcohol use. This literature was recently subjected to a meta-analysis by McKenna and colleagues (McKenna, Zevon, Corn, & Rounds, 1999), who found a moderate effect size for denial and repressive coping style in an analysis of 17 studies. Breast cancer patients were more likely to re- spond to stressful life events by using repressive coping. However, such studies cannot prove causation. It is just as likely that having breast cancer may have resulted in changes in use of repressive coping. In addition, biological/immuno- logical mechanisms to account for any association between repressive coping and the development of breast cancer have yet to be elucidated. One study linked coping with outcomes of in vitro fertil- ization (IVF). Demyttenaere and colleagues (1998) examined the association between coping (active, palliative, avoidance, support seeking, depressive coping, expression of negative emotions, and comforting ideas) and the outcome of IVF. Women who had higher than median scores on a palliative coping measure had a signi“cantly greater chance of con- ceiving than women who had a lower than median score on Coping 55 the palliative coping measure. While this is an extremely interesting “nding, the underlying mechanisms were not discussed. Disease Progression One of the most studied areas of psychosocial factors in dis- ease outcomes is the link between coping and HIV outcomes. The HIV to AIDS progression provides a model for studying the connection between psychological factors and immuno- logical outcomes, as well asdisease progression.The majority of studieshave focused on some aspect of avoidant coping and have yielded contradictory results. Reed and colleagues (Reed, Kemeny, Taylor, Wang, & Visscher, 1994) found that realistic acceptance as a coping strategy (de“ned as focusing on accepting, preparing for, and ruminating about the future course of HIV infection) predicted decreased survival time among gay men who had clinicalAIDS at study entry. This ef- fect held after controlling for confounding variables such as CD4 cell counts, use of azidothymidine (AZT), and alcohol or substance abuse.These resultsare inconsistentwith Ironson and colleagues (Ironson et al., 1994) who found that use of de- nial to cope with a newly learned HIV seropositive diagnosis and poorer adherence to behavioral interventions predicted lower CD4 counts one year later and a greater progression to clinical AIDS two years later. Solano et al. (1993) found that having a “ghting spirit was related to less progression to HIV infection one yearlater, after controllingfor baseline CD4 cell count. Mulder, de Vroome, van Griensven, Antoni, and Sanfort (1999) found that the degree to which men avoided problems in general was associated with less decline in CD4 cells and less progression to immonologically de“ned AIDS over a seven-year period. However, avoidance coping was not signi“cantly associated with AIDS-de“ning clinical events (e.g., developing Kaposi•s sarcoma). Contradictory “ndings have been reported by Leserman and colleagues (1999). They followed HIV-infected men for 7.5 years. Results indicated that men who used denial to cope with the threat of AIDS had faster disease progression. In fact, the risk of AIDS was ap- proximately doubled for every 1.5unit increase in denial. This relationship remained signi“cant even after taking into ac- count potential mediators such as age and number of biomed- ical and behavioral factors (e.g., smoking, use of marijuana, cocaine, and other drugs and having had unprotected intercourse). The inconsistency in “ndings across studies is dif“cult to explain. Because these studies are observational in nature, causal inferences cannot be made. Findings from studies linking coping with cancer pro- gression have also been contradictory. Early studies by Buddenberg and colleagues (1996) and Watson and Greer (1983) reported an association between coping style and out- come in early stage breast cancer. However, these early stud- ies did not control for known prognostic indicators such as tumor stage, disease site, and mood. Brown and colleagues (Brown, Butow, Culjak, Coates, & Dunn, 2000) found that melanoma patients who did not use avoidance as a coping strategy experienced longer periods without relapse, after controlling for tumor thickness, disease site, metastatic status, and mood. A similar “nding was reported by Epping- Jordan et al. (1999), who followed a group of cancer patients over a one-year period. Longitudinal “ndings revealed that, after controlling for initial disease parameters and age, avoid- ance predicted disease status one year later; however, neither psychological symptoms nor intrusive thoughts and emotions accounted for additional variance in disease outcomes. Coping and Psychological Adaptation to Disease Cross-Sectional Studies of Coping with Chronic Illness Early studies of coping using the stress and coping paradigm were cross-sectional and used retrospective checklists such as the Ways of Coping Checklist (WOC). The earliest studies divided coping into the overly general categories of problem- and emotion-focused strategies, and focused mostly on psy- chological outcomes rather than pain and functional status outcomes. Later studies have investigated speci“c types of coping. For example, Felton, Revenson, and Hinrichsen (1984) examined two types of coping, wish-ful“lling fantasy and information seeking, using a revision of the WOC. Wish- ful“lling fantasy was a more consistent predictor of psychological adjustment than information seeking. While information seeking was associated with higher levels of pos- itive affect, its effects on negative affect were modest, ac- counting for only 4% of the variance. In a second study, Felton and Revenson (1984) examined coping of patients with arthritis, cancer, diabetes, and hypertension. Wish- ful“lling fantasy, emotional expression, and self-blame were associated with poorer adjustment, while threat minimization was associated with better adjustment. Scharloo and col- leagues (1998) conducted a cross-sectional study of individ- uals with Chronic Obstructive Pulmonary Disease (COPD), RA, or psoriasis. Unlike the majority of studies, this study “rst entered illness-related variables such as time elapsed since diagnosis and the severity of the patient•s medical con- dition into the equation predicting role and social function- ing. Overall, coping was not strongly related to social and 56 Coping and Social Support role functioning. Among patients with COPD, passive coping predicted poorer physical functioning. Among patients with RA, higher levels of passive coping predicted poorer social functioning. Very few studies have examined coping with other chronic illnesses. Several studies have investigated the association between coping and distress among individuals with multiple sclerosis (MS). Pakenham, Stewart, and Rogers (1997) cate- gorized coping as either emotion- or problem-focused, and found that emotion-focused coping was related to poorer ad- justment, while problem-focused coping was associated with better adjustment. In contrast, Wineman and Durand (1994) found that emotion- and problem-focused coping were unre- lated to distress. Mohr, Goodkin, Gatto, and Van Der Wende (1997) found that problem-solving and cognitive reframing strategies are associated with lower levels of depression, whereas avoidant strategies are associated with higher levels of depression. As noted previously, most studies have used instructions that ask participants how they coped with the illness in gen- eral, rather than asking participants how they coped with spe- ci“c stressors associated with the illness. Van Lankveld and colleagues (Van Lankveld, Van•t Pad Bosch, Van De Putte, Naring, & Van Der Staak, 1994) assessed how patients cope with the most important stressors associated with arthritis. When coping with pain was considered, patients with similar degrees of pain who scored high on comforting cognitions and diverting attention scored higher on well-being, and de- creased activity was associated with lower well-being. When coping with functional limitation was examined, patients who used pacing reported lower levels of well-being, and op- timism was associated with higher well-being after func- tional capacity was controlled for in the equation. Finally, when coping with dependence was examined, only showing consideration was associated with higher well-being after functional capacity was controlled for in the equation. Cross-Sectional Studies of Coping with Cancer The earliest work was conducted by Weisman and Worden (1976…1977). In this study, patients were studied during the “rst 100 days after diagnosis. Positive reinterpretation was associated with less distress, and attempts to forget the cancer were associated with high distress. Unfortunately, this study did not evaluate the contribution of severity of disease. Dunkel-Schetter and colleagues (Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992) administered the WOC Inventory, cancer speci“c version, to a sample of patients with varying types of cancer. Participants were asked to select a problem related to their cancer and rate coping responses to that problem. Coping through social support, focusing on the pos- itive, and distancing were associated with less emotional distress, whereas using cognitive and behavioral escape- avoidance was associated with more emotional distress. Although disease severity (e.g., stage) and demographic in- formation were collected, these variables were not included in the analyses. Manne, Al“eri, Taylor, and Dougherty (1994) also admin- istered the WOC to women with early stage breast cancer. In this study, physical symptoms were controlled for in the analysis of associations between coping and positive and neg- ative affect, as measured by the Pro“le of Mood States. Phys- ical symptoms had a greater in”uence on relations between coping and negative affect than on coping and positive affect relations. Escape-avoidance coping and confrontive coping were associated with more negative affect, whereas distanc- ing, positive appraisal, and self-controlling coping were all associated with more positive affect. Epping-Jordan and colleagues (1999) evaluated the associ- ation between coping (assessed with the COPE) and anxiety and depressive symptoms among a sample of 80 women with all stages of breast cancer. Coping was evaluated as a mediator of the relation between optimism and distress. Opti- mism was predicted to predict less emotion-focused dis- engagement, which, in turn, predicted fewer symptoms of anxiety and depression. In addition, this study advanced the literature because cancer stage, patient age, and education were each incorporated into associations between coping and distress rather than simply partialled out of associations. In addition, cross-sectional associations at three separate points were conducted (at diagnosis, three months after diagnosis, and six months after diagnosis), which provided a picture of how coping changed over the course of treatment. At diagno- sis, low optimism predicted more distress, and the relation between optimism and distress was mediated partially by emotion-focused disengagement. Relatively few studies have evaluated coping among patients with advanced disease. Sherman, Simonton, Adams, Vural, and Hanna (2000) used the COPE to study coping by patients with late-stage cancers and found that denial, behav- ioral disengagement, and emotional ventilation were associ- ated with higher distress as assessed by the Pro“le of Mood States. Longitudinal Studies Unfortunately, relatively few studies have employed longi- tudinal designs. Overall, passive coping strategies such as avoidance, wishful thinking, withdrawal, and self-blame have been shown to be associated with poorer psychological Coping 57 adjustment (e.g., Scharloo et al., 1999), and problem-focused coping efforts such as information seeking have been found to be associated with better adjustment among MS patients (e.g., Pakenham, 1999). Two studies have used longitudinal designs to study the re- lation of coping to adaptation to cancer. Carver, Pozo, Harris, Noriega, Scheirer, and Robinson (1993) evaluated coping strategies usedby early-stagebreast cancerpatients, evaluated at two time points, and found that cognitive and behavioral avoidance were detrimental to adjustment, whereas accep- tance was associated with lower distress. Stanton, Danoff- Burg, Cameron, Bishop, and Collins (2000) examined emotionally expressive coping, de“ned as emotional process- ing (delving into feelings), and emotional expression (ex- pressing emotions) among 92 women with early stage breast cancer. Women were assessed at two points, spaced three months apart. The “ndings revealed that coping through emo- tional expression was associated with decreased distress, even after accounting for the contribution of other coping strate- gies. In contrast, women who coped by using emotional pro- cessing became more distressed over time, but only when emotional expression was controlled for in the analysis. This “nding suggests that active engagement in the attempt to talk about cancer-related feelings may be bene“cial, but rumina- tion may exacerbate distress. Other Coping Processes: Social Comparison Social comparison is a common but little-studied process in the context of its use among individuals dealing with a health problem. Stanton and colleagues (2000) evaluated the associ- ation between both upward and downward comparisons and affect among women with breast cancer by using an experi- mental manipulation. Patients listened to tapes of other breast cancer patients, which varied by level of disease prognosis and psychological adaptation. Descriptive data indicated that women extracted positive comparisons from both worse-off and better-off women, reporting gratitude in response to worse-off others and inspiration in response to better-off oth- ers. Negative affect increased and positive affect decreased after patients listened to audiotaped interviews with other pa- tients. Those with better prognosis cancers had a greater decrement in positive mood. These “ndings suggest that so- cial comparison, at least in the short term, may result in mood disruption. Studies of Coping with Chronic Pain The majority of these studies have used longitudinal designs. For example, Brown and Nicassio (1987) studied pain coping strategies among RA patients and found that patients who en- gaged in more passive coping when experiencing more pain became more depressed six months later thandid patients who engaged in these strategies less frequently. Keefe and col- leagues (Keefe, Brown, Wallston, & Caldwell, 1989) con- ducted a six-month longitudinal study of the relationship between catastrophizing(negative thinking) and depression in RA patients. Those patients who reported high levels of cata- strophizing had greater pain, disability, and depression six months later. Similar “ndings have been reported by other investigators (Parker et al., 1989). Overall, studies have sug- gested that self-blame, wishful thinking, praying, catastro- phizing, and restricting activities are associated with more distress, while information seeking, cognitive restructuring, and active planning are associated with less distress. Gil and colleagues (Gil, Abrams, Phillips, & Keefe, 1989; Gil, Abrams, Phillips, & Williams, 1992) have studied Sickle Cell Disease (SCD), which has not been given a great deal of attention by behavioral scientists. Pain is a frequent problem among SCD patients. Adults who used the cognitive coping strategy of catastrophizing reported more severe pain, less work and social activity, more health care use, and more de- pression and anxiety (Gil et al., 1989). SCD patients who coped with pain in an active fashion by using a variety of strategies such as distraction were more active in work and so- cial activities. These associations were signi“cant even after controlling for frequency of pain episodes, disease severity, and demographics. In their later studies, Gil and colleagues (Gil, Phillips, Edens, Martin, & Abrams, 1994) have incorpo- rated laboratory methodologies to provide a better measure of pain reports. Several recent studies have employed prospective daily study designs in which participants complete a 30-day diary for reporting each day•s pain, mood, and pain coping strate- gies using the Daily Coping Inventory (Stone & Neale, 1984). These studies, which have been conducted with RA and OA (Osteoarthritis) patients, have shown that emotion- focused strategies, such as attempting to rede“ne pain to make it more bearable and expressing distressing emotions about the pain, predict increases in negative mood the day after the diary report. The daily design is a promising new method of evaluating the link between coping strategies and mood. More importantly, these studies can elucidate coping processes over time. For example, Tennen, Af”eck, Armeli, and Carney (2000) found that the two functions of coping, problem- and emotion-focused, evolve in response to the out- come of the coping efforts. An increase in pain from one day to the next increased the likelihood that emotion-focused cop- ing would follow problem-focused coping. It appeared that, when efforts to directly in”uence pain were not successful, [...]... 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