more social support as compared to the patients with non-terminal diseases. ... People differ in their adjustment to illness, however various factors have been .... items with five point rating scale ranging from "Not at all" to "quite a lot". For this ...
Cognitive Appraisal and Coping of Patients with Terminal versus Non-terminal Diseases Rukhsana Kausar and Muhammad Akram Department of Applied Psychology ,University of the Punjab, Lahore The present study examined cognitive appraisal and coping of patients with terminal and non-terminal diseases, it was hypothesized that "the patients with terminal disease will differ in their cognitive appraisal and coping strategies from those with non-terminal disease". It was also hypothesized that "more the patients would appraise their disease as controllable, more problem-focused coping strategies they will use. The sample consisted of 120 patients, 60 with terminal illness (Cancer patients) and 60 with non-terminal illnesses, each consisted of equal number of males and females. A self constructed coping strategies questionnaire (CSQ) was used to examine coping strategies. To assess cognitive appraisal, the "Folkman and Lazarus' Scale for Secondary Cognitive Appraisal (1988)" was used. Data was collected from different hospitals in Lahore. Multivariate analysis of variance (MANOVA) and correlation analyses were used to analyze N the data. Results revealed that the patients with terminal illness perceived less control on their illness, used less problem-focused coping, used -more emotion-focused and religious focused coping strategies and sought more social support as compared to the patients with non-terminal diseases. Cognitive appraisal was significantly affected by patients' age, and gender had a significant effect on their coping. It was also found that the appraisal of acceptance was highly associated with the use of emotion-focused and religious focused coping. Findings have implications for patients' adjustment to their disease. They need to appraise their disease as more controllable so that they may use more problem-focused coping strategies rather than having a pessimistic attitude.
Physical health has been closely related to psychological health (Felton & Revenson, 1984). People differ in their adjustment to illness, however various factors have been reported to account for such differences. Coping efforts have been proposed as one of several to account for these differences in adjustment and number of studies, have documented the importance of cognitive factors in helping ill adults maintain their emotional well-being (e.g., Cohen & Lazarus, 1979; Moos, 1982, Felton & Revenson, 1984). Cognitive appraisal refers to the meaning individuals give to a particular stressful encounter. In primary appraisal individual evaluates whether there is anything at stake for him/her particularly in terms of values, goals, commitment or beliefs about oneself. In secondary appraisal, individuals evaluate what, if anything can be done to cope with the
demand. Various coping options are evaluated, such as, controllability, accepting the situation, seeking more information, or holding back from acting impulsively (Folkman, 1982; Folkman et.al; 1986a). After appraising stress, individual does something to handle it, which is commonly known as coping. Coping consists of cognitive and behavioral efforts that are expended by an individual with the intention of reducing the effects of stress (Fleming & Baum, 1984, Kausar & Powell, 1996). Lazarus & Folkman (1984) conceptualize coping as a dynamic process, which will be specific not only to the situation, but also to the stage of encounter. A number of researchers (e.g. Billings & Moos, 1981; Pearlin & Schooler, 1978; Lazarus & Folkman, 1984) have made a distinction between two general forms of coping: Problem-focused and Emotion-focused coping. Problem focused coping involves an attempt to understand and define a problem and to work out possible solutions. Whereas, emotion-focused coping involves the functions that, regulate stressful emotions. Emotion-focused coping strategies include physical exercise, meditation, expressing feelings, and seeking social support. These strategies deal with the associated level of emotional distress. The way a stressor is appraised may either facilitate or impede coping with the event. Individuals use more problem-focused coping in situations that they appraise as changeable, and are more likely to engage in emotion-focused coping when the situations are appraised as uncontrollable (Folkman & Lazarus, 1980, 1984, Kausar, 1994). Several studies have found that coping strategies appear to differ for events appraised as controllable versus uncontrollable. These studies indicate that coping efforts intended to alter the source of stress by acting on it directly, and are used more with events appraised as controllable, while emotion-focused coping strategies intend to moderate emotional reactions and are used more with the events perceived as beyond personel control (Coyne etal., 1981; Felton & Revenson, 1984; Folkman & Lazarus, 1980; Forsythe & Compas, 1987; Parkes, 1984; Stone & Neale, 1984). Acute negative events (e.g. hospitalization) or persistent adverse circumstances (chronic illness) are related to psychological distress (Kessler, Price, & Wortman, 1985). Physical and psychological functioning of individuals with medical conditions varies widely. For many conditions, medical factors alone do not adequately account for the extent of illness related dysfunctions. Functioning of the patients may be significantly affected by psychological factors, including how patients appraise and cope with the stress related to their illness (Holryod & Lazarus, 1982). There has been considerable theoretical and practical interest over the past decade in coping reactions to health problems (Endler & Parker, 1990). Coping plays an important mediating role in the way an individual responds to negative (harmful) situations (Clark, Hovantiz,1989; Hovantiz & Kozara, 1989; Nowack, 1989; Wheaton, 1983, 1985). Avoidance oriented coping strategies may be effective in the short run for reducing pain, stress, or anxiety (Brown, Nicassio & Wallston, 1989; Delamater, Kartz, Bubb, White & Santiago, 1987; Peterson, 1989; Suls & Fletcher, 1985). However, in the long-run, these strategies appear not to be as effective as task-oriented strategies. In a study, Greer, Morris & Pettingale, (1979) interviewed women who had a recent diagnosis of breast cancer and asked them about how they viewed the diagnosis. On the basis of
their responses, the researchers characterized the responses of women to their threatening and potentially stressful diagnosis in one of four ways: the attitude characterized by Fighting spirit; Denial; Stoic acceptance and Giving up. A study by Feifel, Strack & Nagy (1987) attempted to determine whether patients with life threatening illnesses (i.e. cancer, myocardial infarction) differ in coping style from patients with non-lifethreatening or non-terminal illness (i.e. arthritis, dermatitis) and found them using different types of strategies to cope with their illnesses. Weisman & Worden (1976-77) found that less disturbed cancer patients were more likely to confront the problem by taking firm action, accept but redefine the situation, seek medical direction and comply with treatment. More disturbed patients tend to use withdrawal and disengagement from others, externalization or projection of blame, tension reduction through excessive use of alcohol and drugs, and passive acceptance or submission, seeking information, talking with others and thinking about other things (Moos & Billings, 1982). Few studies have investigated relationship of appraisal and coping of patients. Bombardier, Amico & Jordan (1989) found that appraising illness as holding one back predicted greater emotion-focused coping responses. Wallston & Wallston (1981) found that beliefs that one can control one's general health or the course of an illness have been found to be significantly related to greater problem-focused coping strategies. Holm, Holroyd, Hursey & Penzin (1986) examined the role of secondary appraisal in coping to terminal and non-terminal diseases. Results indicated that patients with terminal disease use more emotion-focused strategies and appraised stressors as more harmful and less controllable compared to those with non-terminal disease. In another study by Marrero (1981), it was found that problem-focused coping more characteristic of diabetics in poor metabolic control than of well-controlled diabetics. (Felton & Revenson, 1984). In Pakistan, there is an increasing number of patients both with terminal and nonterminal diseases, and hospitals are flooded with them. However, while treating patients with physical illnesses, psychological factors are completely ignored. The way patients appraise and cope with stress resulted from the disease are not given any importance. Although stress related to disease is a burning issue and may play an important role in the outcome of treatment, but in Pakistan little or no effort has been made to explore this aspect of illness. The present study aimed to find out how the patients with terminal and nonterminal diseases cognitively appraise their disease and cope with it. It was hypothesized that i) the patients with terminal disease would appraise their disease as less controllable compared to those with non-terminal disease; ii) the patients with terminal disease would use more emotion-focused coping and less problem-focused coping compared to patients with non-terminal disease and iii) more the patients would appraise their disease as controllable, more problem-focused coping they II use. Methodology Participants: 120 patients, with equal number having terminal disease (cancer) and those with non-terminal disease (such as minor surgery, headache, orthopedic injuries and blood pressure problems) were the participants. The sample was recruited from Mayo, Inmol and Shaukat Khanum Memorial Hospitals (Lahore, Pakistan). Each group
consisted of equal number of males and females. The participant's age ranged between 17-80 years, with the mean age of 43 years. Majority of the patients was married (71 %). Education level of the majority ranged from middle to matric (59 %), their monthly income ranged from RS. 1,000 to 20,000 per month with the majority having from RS. 2,000 to 5,000 per month (73 %). Duration of disease ranged from one to five years, with the majority having disease from one year (66 %). Demographic characteristics for both groups (terminal and non terminal) are given in table 1. Table 1 Showing Demographic Information of the Sample (Percentages Reported)
Sex Education
Monthly Income
Marital Status
Duration Of Illness
Age
Terminal
Non-terminal
Male Female
50% 50%
50% 50%
Illiterate Middle-Matric F.A. - B.A. M.A.,or Above
26.7 61.7 10.7 1.7
26.7 56.7 16.7 0
Below 2000 2000-5000 5000-10000 above 1 0000
28.3 66.7 1.7 1.7
5 80 10 1.7
Married Unmarried Divorced Widowed
80 6.7 1.7 1.7
61.7 36.7 0 1.7
Year 0-1 Year 1-3 Year 3-5
61.7 31.7 6.7
70 20 10
Mean Minimum Maximum
(14.98) years 18 years 80 years
39.56(1 3.94) years 17 years 65 years
Assessment Measures: To examine cognitive appraisal the "Folkman and Lazarus Scale For Secondary Cognitive Appraisal (1988)" was used. The questionnaire consists of four items with five point rating scale ranging from "Not at all" to "quite a lot". For this study statements were translated into Urdu. To examine coping strategies, a self constructed coping strategies questionnaire (CSQ) was used. CSQ consists of 60 items and the subject has to respond on four point rating scale ranging from "Not at all" to "quite a lot" to show the frequency with which a particular strategy was used by the subject. On the basis of theoretical rational, items on coping questionnaire were categorized into four scales: Emotion-focused (N of items = 33), Problem-focused (N of items = 8), Religious-focused (N for items = 13) and Seeking social support (N of items = 6). Reliability analysis indicated that Cronbach alpha for
these coping scales ranged from .49 to .85 (for seeking social support and religious focused coping respectively, .58 for problem focused coping and .63 for emotion focused coping). Procedure Interview schedule was used as a method for data collection. The questionnaires were filled in by the patients in researchers' presence. For uneducated patients, questions were marked by the researchers.
Results To see the effect of gender, age and nature of the disease on cognitive appraisal and coping, Multivariate analysis of variance (MANOVA) was used. MANOVA was used with terminal by non-terminal, gender, and age category design. Sample was categorized into three age groups. Analysis indicated that nature of the disease had significant effect on patients' cognitive appraisal of their disease. Post hoc tests indicated that the patients with terminal disease appraised their disease as less controllable, as the one that needs to be accepted, realized more need for information and to hold themselves back compared to the patients with non-terminal illnesses. Cognitive appraisal was significantly effected by patients' age. Post hoc analysis revealed that old patients appraised their disease as less controllable, and as the one that needs to be accepted compared to younger patients. Nature of the disease, age and gender had interactive effect on cognitive appraisal. Old female patients with terminal disease appraised their disease as less controllable and the one that they had to accept (see table 2). Table 2 MANOVA results indicating effect of nature of the disease (terminal and non-terminal) gender, and age on patients' cognitive appraisal (only significant results reported).
Source and Dependent variable Nature Need to know Need to accept : Controllability ; To hold self back Age Need to accept Controllability To hold self back Gender* nature* age Need to accept Controllability
df
Mean square
f
Sig
1 1 1 1
37.54 31.91 45.39 12.82
71.32 36.34 56.96 15.99
.001 .001 .001 .001
2 2 2
3.169 6.55 3.53
3.60 8.22 4.40
.05 .001 .01
2 2
5.17 5.83
5.89 7.32
.001 .001
Regarding patients' coping, nature of the disease affected patient's coping significantly. Post hoc analysis (Scheffe's test) indicated that the patients with non-
terminal disease used more problem-focused coping compared to cancer patients. Patients with terminal disease (cancer) used more religious-focused coping, sought more social support and compared to the patients with non-terminal illness. Coping was also effected by gender of the patient. Scheffe's test results indicated that male patients used more problem focused coping compared to their female counterparts, whereas female patients used more emotion-focused, and religious focused coping, and sought more social support compared to male patients. Age of the patient had significant effect on patients' coping. Old patients used more emotion-focused coping compared to younger and middle age patients. Gender of the patient and nature of the disease had an interactive effect on seeking social support. Age and nature of the disease showed an interactive effect on patients' coping. Old patients with terminal disease used more emotion focused strategies and middle age patients sought more social support compared to old patients (see table 3). Table 3 MANOVA results indicating effect of nature of the disease (terminal and non-terminal) gender, and age on patients' coping (only significant results reported).
Source and Dependent variable Nature Emotion-focused Problem-focused Religious-focused Seeking social support Gender Emotion-focused Problem-focused Religious-focused Seeking social support Age Emotion-focused Gender*nature Seeking social support Age * nature Emotion-focused Seeking social support
df
Mean square
f
Sig
1 1 1 1
28997.16 1186.58 22162.79 2886.4
84.71 20.97 120.51 24.63
001 .001 .001 .001
1 1 1 1
1797.43 641 .78 2301.39 2214.06
1797.43 641 .78 2301.39 2214.06
02 .001 .001 .001
1
1094.95
3.19
.05
1
694.15
5.92
.01
2 2
1464.48 352.80
4.28 3.01
.01 .05
To examine relationship between cognitive appraisal and coping strategies, correlation analysis was performed. Results indicated that the patients who appraised their disease as controllable used more problem-focused coping, and those who perceived their disease as less controllable used more emotion-focused, employed more religious-focused coping and sought more social support. Furthermore, results indicated that when the patients perceived their disease as the one they had to accept, they
employed more emotion-focused and religious-focused coping, and used less problemfocused coping. Those patients, who realized more need to hold self back, used more emotion-focused and religious-focused coping and employed less problem-focused coping. In relation to need for information, those patients who realized more need to know, used more emotion-focused, and religious-focused, and employed less problemfocused coping (See table No. 4). Table 4 Correlation analysis indicating the relationship between cognitive appraisal and coping strategies (N =120). Cognitive appraisal Emotion-focused γ
ProblemFocused γ
Religiousfocused γ
Seeking social support γ
Controllability
0.67***
0.53***
-0.42***
-0.17*
Need to accept
0.54***
-0.53***
0.38***
0.208*
To hold self back
0.44***
-0.45***
0.33***
0.15
Need to Know
0.56***
-0.42***
0.42***
0.19
Note: p>0.05 = *, p>0.01 = 0.01, p>0.001 = *** Discussion The present study examined cognitive appraisal and coping of the patients with terminal and non-terminal diseases. The results suggested that specific types of illness appraisal and coping responses were different for patients with terminal disease and those with non-terminal illness. Cancer patients appraised their illness less controllable and utilized more emotion-focused, religious focused and seeking social support coping strategies compared to their counterparts with non-terminal diseases. Patients with non terminal diseases appraised their disease as more controllable, and employed more problem-focused coping compared to those with terminal disease. The results from this study are generally in consensus with findings from previous research (e.g. Greer, Morris & Pettingale, 1979; Feifel, Strack & Nagy, 1987; Folkman & Lazarus, 1980). Excessive use of emotion-focused, religious focus and seeking social support by cancer patients could be for the reason that for such patients These results are also consistent with studies by Coyne, Aldwin & Lazarus, (1981); Parkes, (1984); Stone & Neale, (1984), who found that coping strategies appear to differ for events appraised as controllable versus uncontrollable. The studies indicate that coping efforts intended to alter the source of stress by acting on it directly (problem-focused coping) tend to be used more with events appraised as controllable, while emotion-focused coping strategies are used more with events perceived as beyond personal control (e.g. chronic illness, cancer). Carver and his colleagues (1989), also reported that the use of problem-focused coping strategies characterizes situations judged to be amenable to control, whereas emotion-focused strategies tend to be utilized
in situations where the situation is appraised as having little potential for control. Felton & Revenson, (1984), Folkman & Lazarus, (1980), found that in case of physical illness, the greater the uncertainty, or the less a person can do, the more likely, he or she is to use an emotion-focused coping. Our data suggest that the patients with terminal disease sought more social support compared to the patients with non-terminal illness. These results are consistent with the study by Thoits (1986), who found that social support is associated with reduced risk of psychopathology. Social support promotes adjustment to stress by providing assistance with appraisal and coping processes. In another study by Wethington & Kessler, (1986) reported that social support as a coping resource can mitigate the adverse psychological effects of environmental stressors. The perception, or belief, that others are available to provide emotional comfort or practical assistance in times of distress and need appears to be particularly beneficial for health. Cohen & Wills, (1985) found that individuals with high level of perceived support appear to be more resistant to the adverse psychological effects of environmental stressors than do individuals with low level of perceived support. It was also found from the results that the patients with terminal disease used overall more coping strategies compared to the patients with non-terminal illness. These results are consistent with the study of Ritichie, Judith, Cathy, Suzanne & Ellerton, Marylou, (1988), indicated that patients used more coping behaviors when they are chronically ill and less coping behaviors in patients under low stress. So we see that there is variability in coping in both groups of patients. This variability, according to Folkman & Lazarus (1980) may reflect individuals attempt to match or fit their coping to differences in the perceived demands of stressful situations. Regarding illness appraisal, our data indicates that the patients with terminal disease appraise their disease as less controllable compared to those with non-terminal illness. It was also found that the patients with terminal disease believed their conditions must be accepted and felt that their medical problems held them back from doing what they wanted to do. The patients with terminal disease felt that they needed to know more about the problem before they could act. These findings are consistent with the study of Jenkins & Pargament (1984), who found that the patients’ displaying high perceived control over their disease showed the least negative conditions, while low control subjects showed the most negative conditions. Seeman & Seeman (1983); Folkman, (1984) found that high levels of perceived control are associated with more favourable psychological adjustment and with the use of ameliorative and preventive measures to facilitate health and recovery. Correlation analysis indicated that believing that one can control the conditions is positively related to increased problem-focused coping and negatively related to emotionfocused coping strategies. These results are in agreement with the previous research on the relation between secondary appraisal and coping. For example, Coyne et. al., (1981); Folkman & Lazarus (1980, 1985) examined the relation between secondary appraisal and coping. Results indicated that subjects used more problem-focused forms of coping in conditions they appraised as controllable and more emotion-focused forms of coping in situations where they felt no control on them. Similarly, Bachrach (1983) found that
people who thought something could be done about the situation used more problemfocused coping than people who appraised it as beyond their control. The correlation analysis also revealed that more the patients realize the need to hold them back, more emotion-focused and religion-focused coping they used. The "holding back" appraisal seems to be a particularly maladaptive way of perceiving one's medical condition. Patients who more strongly believe that they must hold back from doing what they want are prone to use more emotion-focused forms of coping, similar results were obtained among chronic pain sufferers by Turner and colleagues; (1987). Bombardier, Amico & Jordan (1989) found that appraising chronic illness as holding one back predicted greater emotion-focused coping responses, and poorer adjustment to illness. The correlation analysis suggest that when the patients realized more need to know, more emotion-focused and religion-focused, and less problem-focused coping strategies were employed. Overall results indicated that both groups of patients used more religious-focused coping. Data collected by McCrae and Costa (1986) suggest that such a coping tactic (religion-focused) may be quite important to many people. One might turn to religion when under stress for widely varying reasons; religion might serve as a source of emotional support, as a vehicle for positive interpretation and growth, or as a tactic of active coping with a stressor. The findings of this study have implications for the patients to change their appraisal of disease as more controllable so that they may use more problem-focused coping rather than having a pessimistic attitude. The patient who appraise his/her disease as controllable may have positive outlook and put more practical efforts compared to those who adapt a passive, fatalistic attitude towards his disease. The findings suggest and provide evidence on the role of psychological factors in cancer and other disease. There is a need of trained staff and family who can help patients in changing their appraisal of their disease. The optimistic appraisal assists in the practical management of the stress and may facilitate adjustment. Although this research has very important implications from medical professionals' point of view, the findings need to be interpreted with caution because of limitations of the study. To make the results more generlizable, a large sample size is required and patients in both groups need to be matched on their demographic characteristics. Furthermore, future research need to examine the effect of cognitive factors on patients' adjustment to their disease and to identify coping strategies which might help patients to come to term with stress related to their illness. References Anderson, R. (1977). Locus of control, coping behaviour, and performance in a stress setting: A Longitudinal study. Journal of Applied Psychology, 62, 446-451. Billings, A. G., & Moos, R. H. (1981). The role of coping responses and social resources in attenuating the impact of stressful life events. Journal of Behavioral Medicine, 4, 739-757. Bombardier, C. H. D., Amico, C. O., & Jordan, J. S. (1990). The relationship of appraisal and coping to chronic illness adjustment. Behavioral Research and
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