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 equilib-rium 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:
■ Changes in identity: Illness can create a shift in identity, such as from carer to patient, or from breadwinner to person with an illness.
■ Changes in location: Illness may result in a move to a new environment such as becoming bed-ridden or hospitalized.
■ Changes in role: A change from independent adult to passive dependant may occur follow-ing illness, resultfollow-ing in a changed role.
■ Changes in social support: Illness may produce isolation from friends and family, effecting changes in social support.
■ 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:
■ Illness is often unpredicted: If an illness is not expected then the individual will not have had the opportunity to consider possible coping strategies.
■ Information about the illness is unclear: Much of the information about illness is ambiguous and unclear, particularly in terms of causality and outcome.
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■ 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).
■ 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 affect me?).
■ 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 ser-iousness 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.
Coping skills
Figure 3.2 Coping with the crisis of illness
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:
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 coping involves attempts to understand the illness and represents a search for meaning. Three sets of appraisal-focused coping skills have been defined:
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Table 3.1 Adaptive tasks Illness-related tasks
■Dealing with pain and other symptoms
■Dealing with the hospital environment and treatment procedures
■Developing and maintaining relationships with health professionals General tasks
■Preserving an emotional balance
■Preserving self-image, competence and mastery
■Sustaining relationships with family and friends
■Preparing for an uncertain future
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.
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.
Table 3.2 Coping tasks Appraisal-focused
■Logical analysis and mental preparation
■Cognitive redefinition
■Cognitive avoidance or denial Problem-focused
■Seeking information and support
■Taking problem-solving action
■Identifying rewards Emotion-focused
■Affective regulation
■Emotional discharge
■Resigned acceptance
2 Physical and social/environmental factors, such as the accessibility of social support net-works 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 17).
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.